Differential Screening for Nonviral Sexually Transmitted Infections by Type of Vaginitis Testing.

BACKGROUND: Data are lacking on adherence to Centers for Disease Control and Prevention testing guidelines among insured US women presenting with vaginal health complaints; thus, we quantified vaginitis testing frequency and assessed the co-testing rate for causes of vaginitis and Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG). METHODS: This was a retrospective analysis of deidentified data from a medical database. Information from women aged 18 to 50 years was obtained from the Truven MarketScan Commercial Database (2012-2017) using Current Procedural Terminology ( CPT ) codes; χ2 testing was applied to determine co-testing differences for CT/NG based on vaginitis test type. Odds ratios were calculated to determine the association with CT/NG screening across vaginitis testing categories. RESULTS: Approximately 48% of 1,359,289 women received a vaginitis diagnosis that involved a laboratory-based test. Of these women, only 34% were co-tested for CT/NG. CT/NG co-testing was highest for those with nucleic acid amplification testing for vaginitis and lowest for those with no vaginitis testing CPT code (71% vs. 23%, respectively; P < 0.0001). CONCLUSIONS: The vaginitis nucleic acid amplification test, indicated by CPT code, was associated with statistically significantly higher CT/NG testing rates. Molecular diagnostics may support vaginitis testing in settings that have limited opportunities for microscopy and clinical examinations and offer greater opportunity to offer comprehensive women's health care that includes testing for chlamydia and/or gonorrhea infections.

Clinical Utility of Advanced Microbiology Testing Tools.

Advanced microbiology technologies are rapidly changing our ability to diagnose infections, improve patient care, and enhance clinical workflow. These tools are increasing the breadth, depth, and speed of diagnostic data generated per patient, and testing is being moved closer to the patient through rapid diagnostic technologies, including point-of-care (POC) technologies. While select stakeholders have an appreciation of the value/importance of improvements in the microbial diagnostic field, there remains a disconnect between clinicians and some payers and hospital administrators in terms of understanding the potential clinical utility of these novel technologies. Therefore, a key challenge for the clinical microbiology community is to clearly articulate the value proposition of these technologies to encourage payers to cover and hospitals to adopt advanced microbiology tests. Specific guidance on how to define and demonstrate clinical utility would be valuable. Addressing this challenge will require alignment on this topic, not just by microbiologists but also by primary care and emergency room (ER) physicians, infectious disease specialists, pharmacists, hospital administrators, and government entities with an interest in public health. In this article, we discuss how to best conduct clinical studies to demonstrate and communicate clinical utility to payers and to set reasonable expectations for what diagnostic manufacturers should be required to demonstrate to support reimbursement from commercial payers and utilization by hospital systems.

Preparing for a face transplant: development of a comprehensive nursing educational program.

To date, more than 30 face transplants have been performed worldwide. This innovative procedure has restored the functional and aesthetic aspects of the face in patients with cancer, congenital, and trauma-related deformities where the results of traditional reconstructive surgery have been deficient. The importance of nursing involvement in the care of these patients is undeniable; however, little has been published about how to properly prepare a nursing department to undertake such an important role. Although the care of patients undergoing face transplants has many similarities to the care of patients undergoing traditional head and neck flap procedures, patients undergoing face transplant provide unique challenges, including immunosuppression, allograft rejection, communication impairment, and psychosocial needs. Staff at New York University's Langone Medical Center have devised a specific plan of action to properly inform, educate, and prepare the nursing staff for this exciting endeavor.

Prevalence of Bandemia in Respiratory Viral Infections: A Pediatric Emergency Room Experience.

Objective: The aim of this study was to examine the prevalence of bandemia in confirmed respiratory viral infections in febrile infants and children presenting to the emergency department. Methods: An observational retrospective study from January 1, 2016, through December 31, 2016, was conducted in patients between the ages of ≥ 1 month and ≤ 5 years presenting to the emergency room with fever and who had a complete blood cell count performed. Patients were separated into seven groups based on the type of respiratory viral infection. Inclusion criteria strictly counted children with viral infections and absence of clinical and laboratory evidence of a bacterial coinfection. Results: A total of 419 patients had a documented viral infection. A significant proportion of these children were found to have bandemia; children with adenovirus (17%), respiratory syncytial virus (RSV) (14.9%), human metapneumovirus (hMPV) (13%), and parainfluenza virus (7.9%) had the highest prevalence when the cutoff for bandemia was set at 10%. The prevalence increased to 35.3, 30.9, 40.3, and 15.8% for adenovirus, RSV, hMPV, and parainfluenza virus, respectively, when this cutoff was lowered further to 5%. Conclusion: Band neutrophils are detected frequently in confirmed respiratory viral infections particularly during early stages.

Leadership Development for Future Medical School Deans: Outcomes of the AAMC Council of Deans Fellowship Program.

PURPOSE: To determine the outcomes of the Association of American Medical Colleges (AAMC) Council of Deans (COD) Fellowship Program with respect to participants' achieving the goals of becoming a medical school dean and developing leadership skills, and to ascertain fellows' views about the program's value, beneficial aspects, and areas for improvement. METHOD: The 37 COD fellows from 2002 to 2016 were invited to participate in a 2017 survey addressing demographics, training, current leadership position, and value of the program. The survey also included 3 open-ended questions. A 2018 web-based search was conducted to determine fellows' senior leadership roles since their program participation. RESULTS: The survey response rate was 73% (27/37). The majority of respondents were male (82%, 22), aged 51-70 (89%, 25), and white (82%, 22). The top 5 medical specialties reported were internal medicine, pediatrics, anesthesiology, psychiatry, and surgery. Most respondents (63%, 17) reported having a graduate degree. All reported being in leadership positions in academia and/or health care. The web-based search found that 27% (10/37) of the fellows became medical school deans (average tenure 5.6 years); 2 fellows became deans of other types of schools. Overall, survey respondents perceived the program as valuable. Respondents identified shadowing a dean mentor, attending COD meetings, and attending the AAMC Executive Development Seminar for Deans as the most valuable program components. The majority (88%, 23/26) indicated their fellow experience persuaded them to pursue being a dean; 2 (8%) indicated it did not. Respondents identified 4 key opportunities for program improvement: more sponsorship by deans, development of a learning community, enhanced mentoring, and coaching. CONCLUSIONS: The COD Fellowship Program appears to be successful in preparing senior faculty to become deans and assume other senior leadership roles in academia and/or health care. Fellows' feedback will be used to inform future revisions to the program.

Outcomes of Maternal-Newborn Dyads After Maternal SARS-CoV-2.

BACKGROUND AND OBJECTIVES: Infection with a novel coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has become a global pandemic. There are limited data describing the impact of SARS-CoV-2 infection on pregnant mothers and their newborns. The objective of this study is to describe characteristics and outcomes of maternal-newborn dyads with confirmed maternal SARS-CoV-2. METHODS: This was a multicenter, observational, descriptive cohort study with data collection from charts of maternal-newborn dyads who delivered at 4 major New York City metropolitan area hospitals between March 1 and May 10, 2020, with maternal SARS-CoV-2 infection. RESULTS: There were a total of 149 mothers with SARS-CoV-2 infection and 149 newborns analyzed (3 sets of twins; 3 stillbirths). Forty percent of these mothers were asymptomatic. Approximately 15% of symptomatic mothers required some form of respiratory support, and 8% required intubation. Eighteen newborns (12%) were admitted to the ICU. Fifteen (10%) were born preterm, and 5 (3%) required mechanical ventilation. Symptomatic mothers had more premature deliveries (16% vs 3%, P = .02), and their newborns were more likely to require intensive care (19% vs 2%, P = .001) than asymptomatic mothers. One newborn tested positive for SARS-CoV-2, which was considered a case of horizontal postnatal transmission. CONCLUSIONS: Although there was no distinct evidence of vertical transmission from mothers with SARS-CoV-2 to their newborns, we did observe perinatal morbidities among both mothers and newborns. Symptomatic mothers were more likely to experience premature delivery and their newborns to require intensive care.

Facial Transplantation for an Irreparable Central and Lower Face Injury: A Modernized Approach to a Classic Challenge.

BACKGROUND: Facial transplantation introduced a paradigm shift in the reconstruction of extensive facial defects. Although the feasibility of the procedure is well established, new challenges face the field in its second decade. METHODS: The authors' team has successfully treated patients with extensive thermal and ballistic facial injuries with allotransplantation. The authors further validate facial transplantation as a reconstructive solution for irreparable facial injuries. Following informed consent and institutional review board approval, a partial face and double jaw transplantation was performed in a 25-year-old man who sustained ballistic facial trauma. Extensive team preparations, thorough patient evaluation, preoperative diagnostic imaging, three-dimensional printing technology, intraoperative surgical navigation, and the use of dual induction immunosuppression contributed to the success of the procedure. RESULTS: The procedure was performed on January 5 and 6, 2018, and lasted nearly 25 hours. The patient underwent hyoid and genioglossus advancement for floor-of-mouth dehiscence, and palate wound dehiscence repair on postoperative day 11. Open reduction and internal fixation of left mandibular nonunion were performed on postoperative day 108. Nearly 1 year postoperatively, the patient demonstrates excellent aesthetic outcomes, intelligible speech, and is tolerating an oral diet. He remains free from acute rejection. CONCLUSIONS: The authors validate facial transplantation as the modern answer to the classic reconstructive challenge imposed by extensive facial defects resulting from ballistic injury. Relying on a multidisciplinary collaborative approach, coupled with innovative emerging technologies and immunosuppression protocols, can overcome significant challenges in facial transplantation and reinforce its position as the highest rung on the reconstructive ladder. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Perioperative Nursing Management of Donor and Recipient Patients Undergoing Face Transplantation.

Individuals with debilitating facial injuries and deformities have achieved significant improvement of aesthetic form and function after undergoing a face transplantation. The involvement of surgical technologists and perioperative nurses in the care of the recipient and donor plays a critical role in the success of these procedures. There are unique challenges that staff members may be presented with when caring for a donor and recipient undergoing a face transplantation, including less comfort with and knowledge of the surgical procedure and instrumentation, an increased amount of equipment and personnel in the OR, donor and recipient admission and discharge care, and increased shift length. At New York University Langone Medical Center, New York, we have developed a comprehensive process to prepare staff members to care for patients undergoing face transplantation.

Total Face, Eyelids, Ears, Scalp, and Skeletal Subunit Transplant Research Procurement: A Translational Simulation Model.

BACKGROUND: Cadaveric face transplant models are routinely used for technical allograft design, perfusion assessment, and transplant simulation but are associated with substantial limitations. The purpose of this study was to describe the experience of implementing a translational donor research facial procurement and solid organ allograft recovery model. METHODS: Institutional review board approval was obtained, and a 49-year-old, brain-dead donor was identified for facial vascularized composite allograft research procurement. The family generously consented to donation of solid organs and the total face, eyelids, ears, scalp, and skeletal subunit allograft. RESULTS: The successful sequence of computed tomographic scanning, fabrication and postprocessing of patient-specific cutting guides, tracheostomy placement, preoperative fluorescent angiography, silicone mask facial impression, donor facial allograft recovery, postprocurement fluorescent angiography, and successful recovery of kidneys and liver occurred without any donor instability. Preservation of the bilateral external carotid arteries, facial arteries, occipital arteries, and bilateral thyrolinguofacial and internal jugular veins provided reliable and robust perfusion to the entirety of the allograft. Total time of facial procurement was 10 hours 57 minutes. CONCLUSIONS: Essential to clinical face transplant outcomes is the preparedness of the institution, multidisciplinary face transplant team, organ procurement organization, and solid organ transplant colleagues. A translational facial research procurement and solid organ recovery model serves as an educational experience to modify processes and address procedural, anatomical, and logistical concerns for institutions developing a clinical face transplantation program. This methodical approach best simulates the stressors and challenges that can be expected during clinical face transplantation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Total Face, Eyelids, Ears, Scalp, and Skeletal Subunit Transplant: A Reconstructive Solution for the Full Face and Total Scalp Burn.

BACKGROUND: Reconstruction of extensive facial and scalp burns can be increasingly challenging, especially in patients that have undergone multiple procedures with less than ideal outcomes resulting in restricting neck and oral contractures, eyelid dysfunction, and suboptimal aesthetic appearance. METHODS: To establish a reconstructive solution for this challenging deformity, a multidisciplinary team was assembled to develop the foundation to a facial vascularized composite allotransplantation program. The strategy of developing and executing a clinical transplant was derived on the basis of fostering a cohesive and supportive institutional clinical environment, implementing computer software and advanced technology, establishing a cadaveric transplant model, performing a research facial procurement, and selecting an optimal candidate with the aforementioned burn defect who was well informed and had the desire to undergo face transplantation. RESULTS: Approval from the institutional review board and organ procurement organization enabled our face transplant team to successfully perform a total face, eyelids, ears, scalp, and skeletal subunit transplant in a 41-year-old man with a full face and total scalp burn. CONCLUSIONS: The culmination of knowledge attained from previous experiences continues to influence the progression of facial vascularized composite allotransplantation. This surgical endeavor methodically and effectively synchronized the fundamental principles of aesthetic, craniofacial, and microvascular surgery to restore appearance and function to a patient suffering from failed conventional surgery for full face and total scalp burns. This procedure represents the most extensive soft-tissue clinical face transplant performed to date. CLINICAL QUESTION/LEVEL OF EVIDEMCE: Therapeutic, V.

Assessment and treatment of excessive straightening and destructive behavior in an adolescent diagnosed with autism.

Repetitive behaviors such as excessive straightening are commonly observed among individuals with autism. Attempts to prevent these behaviors may increase the likelihood of other problem behaviors. The present study was designed to assess and treat the excessive straightening and associated destructive behaviors of a 16-year-old boy who had been diagnosed with autism and moderate mental retardation. Following a series of functional analyses, an intervention that incorporated functional communication, extinction of destructive behavior, and blocking of repetitive straightening was demonstrated to be effective in reducing straightening and destructive behavior.