Achromobacter cluster related to COVID-19 supply chain issues.

Isolation of an unusual organism, Achromobacter xylosoxidans, from 2 cardiac surgical patients on the same day prompted an investigation to search for cases and cause. An extensive review demonstrated a pseudo-outbreak related to practices to conserve laboratory saline due to short supply resulting from supply chain shortage from the coronavirus disease 2019 pandemic.

National resident survey in dermatopathology: The role of slide scanners in resident learning.

BACKGROUND: Dermatology residents gain exposure to dermatopathology through a variety of educational modalities. While virtual pathology applications have risen dramatically, resident utilization of digital libraries, slide scanner availability, and comfort with virtual slides are not well-known. This study aims to assess the current landscape of educational resources used by dermatology residents. METHODS: A 17-question survey was sent to dermatology residents through a national email database. The survey was a self-assessment of their experience in dermatopathology education and the use of departmental slide scanners. RESULTS: The use of digital dermatopathology is high among trainees, despite only half of respondents reporting slide scanner access. Residents report using virtual images more often in non-clinical dermatopathology didactics and independent studies compared to clinical dermatopathology rotations. Public slide set use was common, while professional society and departmental slide sets may be underutilized. Over half of respondents report being extremely or very comfortable navigating interactive scanned slides. CONCLUSIONS: Survey data suggests digital slides are currently predominantly used in non-clinical dermatopathology rotations and independent studies. Incorporation of slide scanners into departments may benefit resident education through the development of high-quality, curated departmental slide sets.

What are the unsupervised exercise adherence rates in clinical trials for knee osteoarthritis? A systematic review.

BACKGROUND: Exercise is an effective intervention for knee osteoarthritis (OA), and unsupervised exercise programs should be a common adjunct to most treatments. However, it is unknown if current clinical trials are capturing information regarding adherence. OBJECTIVE: To summarize the extent and quality of reporting of unsupervised exercise adherence in clinical trials for knee OA. METHODS: Reviewers searched five databases (PubMed, CINAHL, Medline (OVID), EMBASE and Cochrane). Randomized controlled trials where participants with knee OA engaged in an unsupervised exercise program were included. The extent to which exercise adherence was monitored and reported was assessed and findings were subgrouped according to method for tracking adherence. The types of adherence measurement categories were synthesized. A quality assessment was completed using the Physiotherapy Evidence Database (PEDro) scores. RESULTS: Of 3622 abstracts screened, 176 studies met criteria for inclusion. PEDro scores for study quality ranged from two to ten (mean=6.3). Exercise adherence data was reported in 72 (40.9%) studies. Twenty-six (14.8%) studies only mentioned collection of adherence. Adherence rates ranged from 3.7 to 100% in trials that reported adherence. For 18 studies (10.2%) that tracked acceptable adherence, there was no clear superiority in treatment effect based on adherence rates. CONCLUSIONS: Clinical trials for knee OA do not consistently collect or report adherence with unsupervised exercise programs. Slightly more than half of the studies reported collecting adherence data while only 40.9% reported findings with substantial heterogeneity in tracking methodology. The clinical relevance of these programs cannot be properly contextualized without this information.

Oncofertility patient navigation: The frontlines of fertility and reproductive health care in cancer.

Oncofertility is an emerging field that incorporates diverse disciplines working together to care for oncology patients from birth to adulthood who are facing surgery, radiation therapy, or chemotherapy that may impact their fertility potential and reproductive function. Providing this care to newly diagnosed oncology patients in an expedited manner can be challenging. There is currently a paucity of published data about how this care is provided, training and education of individuals providing this care, and patient-reported outcomes related specifically to oncofertility care. The role of the oncofertility patient navigator is to bridge the institutional and disciplinary boundaries so oncology patients of all ages can receive timely information regarding fertility risk and preservation options at diagnosis and throughout survivorship care. The purpose of this paper is to define the role of the oncofertility patient navigator within diverse models of care and health care systems, and provide a framework for ongoing efforts to improve reproductive care for those affected by cancer in their years of child-bearing potential.

Pediatric pyoderma gangrenosum associated with leukocyte adhesion deficiency type 1: A case report and review of the literature.

Pyoderma gangrenosum is a rare neutrophilic dermatosis characterized by painful skin ulcers with necrotic, undermined margins. In severe cases, particularly in pediatric patients, work-up for an associated autoimmune, inflammatory, malignant, or genetic disorder should be considered based on the clinical presentation. We report a unique case of pediatric pyoderma gangrenosum with a leukemoid reaction, secondary to an autosomal recessive leukocyte adhesion deficiency type 1.

Assent in applied behaviour analysis and positive behaviour support: ethical considerations and practical recommendations.

The term positive behaviour support (PBS) is used to describe the integration of the contemporary ideology of disability service provision with the clinical framework of applied behaviour analysis (ABA). Assent, the participation consent of those not legally able to consent, has gained recent popularity in the fields of ABA and PBS. The goal of assent-based ABA and PBS is a person-centered approach to assessment, intervention, and all other decision-making. In this model, the learner's assent withdrawal for participation is honored, whether it be a vocal 'no' or a non-vocal expression of verbal behaviour. There is currently a limited subset of studies that mention or utilize assent with learners in ABA or PBS. The lack of published research can make assent-based practices seem to be a choice of the practitioner. The authors of this manuscript seek to further define assent, illuminate the necessity of assent-based practices, and offer assent-based procedures in ABA- and PBS-based intervention.

Telehealth Services for Primary Care and Urgent Care to Support Rural Schools and Students.

Background: School-based health services, particularly those available to underserved and rural communities, remain in high demand. Advancements in telehealth services present clinical resources otherwise typically unavailable to students from rural communities. Methods: Data were collected during 4 semesters on all students receiving primary care or urgent care health services from 8 school-based telehealth programs delivering care to 40 schools across the United States. Results: Across the 4 semesters, 2,769 students received primary care telehealth and 2,238 students received urgent care telehealth. The primary care telehealth services were delivered by a primary care provider with a registered nurse also involved in half of the encounters. In contrast, the urgent care telehealth services were delivered almost exclusively by a registered nurse. Primary care telehealth delivered a variety of services including medication management, counseling, and sports physicals in addition to assessments and evaluations. Urgent care telehealth primarily involved an assessment. Both services returned most students to the classroom without the need for further follow-up, thus reducing or eliminating the need for seeking health care outside of the school setting. Notably, 67.7% of students seeking primary care telehealth services did not have a primary care provider outside of the school, clearly demonstrating the importance of these school-based services in increasing access to basic health care services for these students in rural and underserved communities. Conclusions: Telehealth provides a reliable solution and immediate access to care for students in need of health care, which, in turn, presents advantages to educators and parents.

Lupus erythematosus-specific bullous lesions.

Lupus erythematosus (LE)-specific bullous lesions are often difficult to distinguish from other bullous diseases presenting in patients with systemic lupus erythematosus. Herein, we describe a 49-year-old woman with systemic lupus erythematosus with recurrent tense bullae on the forearms. Clinical, histopathologic, and serologic findings led to the diagnosis of LE-specific bullous lesions. We also summarize the diagnostic clues for distinguishing LE-specific bullous lesions, bullous systemic lupus erythematosus, and erythema multiforme-like lesions in LE (Rowell syndrome).

Intermittent Hypoxia Differentially Regulates Adenosine Receptors in Phrenic Motor Neurons with Spinal Cord Injury.

Cervical spinal cord injury (cSCI) impairs neural drive to the respiratory muscles, causing life- threatening complications such as respiratory insufficiency and diminished airway protection. Repetitive "low dose" acute intermittent hypoxia (AIH) is a promising strategy to restore motor function in people with chronic SCI. Conversely, "high dose" chronic intermittent hypoxia (CIH; ∼8 h/night), such as experienced during sleep apnea, causes pathology. Sleep apnea, spinal ischemia, hypoxia and neuroinflammation associated with cSCI increase extracellular adenosine concentrations and activate spinal adenosine receptors which in turn constrains the functional benefits of therapeutic AIH. Adenosine 1 and 2A receptors (A1, A2A) compete to determine net cAMP signaling and likely the tAIH efficacy with chronic cSCI. Since cSCI and intermittent hypoxia may regulate adenosine receptor expression in phrenic motor neurons, we tested the hypotheses that: 1) daily AIH (28 days) downregulates A2A and upregulates A1 receptor expression; 2) CIH (28 days) upregulates A2A and downregulates A1 receptor expression; and 3) cSCI alters the impact of CIH on adenosine receptor expression. Daily AIH had no effect on either adenosine receptor in intact or injured rats. However, CIH exerted complex effects depending on injury status. Whereas CIH increased A1 receptor expression in intact (not injured) rats, it increased A2A receptor expression in spinally injured (not intact) rats. The differential impact of CIH reinforces the concept that the injured spinal cord behaves in distinct ways from intact spinal cords, and that these differences should be considered in the design of experiments and/or new treatments for chronic cSCI.

Impact of Skin Biopsy and Clinical-Pathologic Correlation in Dermatology Inpatient Consults.

Background While studies of hospital dermatology have demonstrated diagnostic discordance between primary teams and dermatology consultants, little is known about the impact of biopsy and clinical-pathologic correlation (CPC) in consultation. This study compares biopsy performance based on diagnostic discordance and evaluates the impact of CPC on the diagnosis. Methods This was a retrospective review of 376 dermatologic consultations at a single academic medical center between July 1, 2017, and June 27, 2018. Results Biopsy was significantly less likely to be performed when the diagnosis by the referring primary team was unspecified (p < 0.001). In 24 percent of cases, the diagnosis based on histopathology alone differed from the diagnosis reached by formal CPC consensus review with either potential or significant impact on management. Conclusion Dermatologists who perform inpatient consultations and rely on hospital-based pathology services may consider a consensus review for CPC. Requests to perform a biopsy may be interpreted as a request for diagnostic assistance rather than pressure to perform a procedure.

What do patients referred to physical therapy for a musculoskeletal condition expect? A qualitative assessment.

BACKGROUND: Patient expectations related to physical therapy outcomes are commonly collected through surveys and close-ended questionnaires. These methods may not optimally capture patients' expectations for physical therapy, especially in the patients' own words. Louis Gifford identified four questions attempting to guide clinicians' understanding of patients' expectations for physical therapy. However, a qualitative assessment mapping the expectations that patients have prior to starting physical therapy appears to be undocumented. OBJECTIVES: The aim of this study was to determine patient expectations prior to beginning physical therapy for individuals with musculoskeletal conditions. DESIGN: Qualitative analysis with structured interviews and open-ended participant responses. METHODS: Twenty-five people (18 female, 7 male; mean age: 47.04 years) were interviewed prior to their initial physical therapy evaluation using a pragmatic approach rooted in phenomenology. Data were transcribed, coded, and thematized using qualitative data analysis software. RESULTS: Outcome, education, exercise, evaluation, and cause of pain were key themes expressed by participants. Participants appear to want to better understand their symptoms, how they can improve symptoms, what the clinician will do, and how long they will attend physical therapy. Many participants were not certain where physical therapy fit within their overall healthcare plan, and perceptions of manual therapy were vague. CONCLUSIONS: These identified themes highlight what patients may expect from a physical therapy experience and clinicians should work to identify and satisfy each patient's individual expectations to optimize outcomes.

Fertility Preservation During the COVID-19 Pandemic: Modified But Uncompromised.

Purpose: Throughout COVID-19, our clinic remained operational for patients requiring urgent fertility preservation (FP). This study aimed to characterize changes to clinical protocols during the first wave of COVID-19 and compare outcomes to historical controls. Methods: We performed a retrospective cohort study at a university fertility center examining all patients who underwent medically indicated FP cycles during the American Society for Reproductive Medicine (ASRM) COVID-19 Task Force-recommended suspension of fertility treatment (March 17-May 11, 2020) and patients from the same time period in 2019. FP care was modified for safety during the first wave of COVID-19 with fewer monitoring visits and infection control measures. FP cycle characteristics and outcomes were compared across years. Results: The volume of cycles was nearly 30% higher in 2020 versus 2019 (27 vs. 19). Diagnoses, age, and anti-Mullerian hormone were similar between cohorts. More patients elected to pursue embryo cryopreservation over oocyte cryopreservation in 2020 versus 2019 (45.8% vs. 5.2%, p < 0.005). Patients managed during COVID-19 had fewer monitoring visits (5 ± 1 vs. 6 ± 1, p = 0.02), and 37.5% of cycles utilized a blind trigger injection. There was no difference in total days of ovarian stimulation (11 ± 1 vs. 11 ± 2, p > 0.05), but 2020 cycles utilized more gonadotropin (4770 ± 1480 vs. 3846 ± 1438, p = 0.04). There was no difference in total oocytes retrieved (19 ± 14 vs. 22 ± 12, p > 0.05) or mature oocytes vitrified (15 ± 12 vs. 17 ± 9, p > 0.05) per cycle. Conclusions: FP continued during COVID-19, and more cycles were completed in 2020 versus 2019. Despite minimized monitoring, outcomes were optimal and equivalent to historical controls, suggesting FP care can be adapted without compromising outcomes.

Two rare cases of bullous pemphigoid associated with immune checkpoint inhibitors.

Bullous pemphigoid is a rare and severe adverse reaction to immune-checkpoint inhibitors that can be life-threatening. Here, we present two cases of bullous pemphigoid secondary to nivolumab and ipilimumab+nivolumab therapy, respectively. Both cases presented months after discontinuation of immunotherapy. Our first case highlights the life-threatening nature of bullous pemphigoid due to its potential to cause laryngeal oedema. Our second case illustrates that cytotoxic T-lymphocyte-associated protein-4 inhibitors can rarely lead to bullous pemphigoid, in addition to programmed cell death-1 (PD-1) and programmed cell death ligand-1 (PD-L1) inhibitors. Both cases emphasise the importance of skin examinations and dermatological follow-up for patients during and even after discontinuation of immunotherapy.

Is nighttime bracing effective in the treatment of adolescent idiopathic scoliosis? A meta-analysis and systematic review based on scoliosis research society guidelines.

PURPOSE: Standard treatment for skeletally immature adolescents with moderate Adolescent Idiopathic Scoliosis (AIS) is a full-time spinal orthosis. However, adherence to full-time wear (≥ 18 h/day) is often challenging for these patients. Nighttime bracing is an alternative option that may improve patient adherence and/or satisfaction. This systematic review and meta-analysis assessed the effectiveness of nighttime bracing in patients with AIS. METHODS: A systematic review of studies evaluating nighttime bracing was performed. PubMed, Medline, Embase, CINAHL and Cochrane library databases were searched (01/1975-03/2020); two reviewers assessed eligibility. Eligible articles were peer reviewed, in English, and reported outcomes for patients who met Scoliosis Research Society (SRS) criteria. The primary outcome was curve progression ≥ 6°. Pooled progression rates were calculated from random effects meta-analyses with inverse-variance weights; 95% CIs were calculated. RESULTS: Nine studies (n = 595) were included. The overall pooled progression rate to ≥ 6° was 40.7% (95% CI: 30.4-51.5%). The pooled progression rate to surgical magnitude was 24.8% (95% CI: 4.5-53.6%). The most successful outcomes were in subjects with thoracolumbar/lumbar curves and subjects who initiated bracing at Risser 1/2 (pooled progression rates were 27.8% (95% CI: 17.0-40.0%) and 16.5% (95% CI: 11.7-21.8%), respectively). Univariate sub-analyses were conducted due to sample sizes. CONCLUSIONS: Progression rates in patients with primary thoracolumbar/lumbar curves and in patients who initiated nighttime bracing at Risser 1/2 were comparable to published progression rates for full-time bracing, indicating that nighttime bracing may be equally effective for these patients. However, the strength of these conclusions is limited by the sample size and the overall quality of included studies.

Second Job Holding Among Direct Care Workers and Nurses: Implications for COVID-19 Transmission in Long-Term Care.

One reason that nursing homes are a primary source of COVID-19 infections and deaths in the United States may be that workers hold multiple jobs. We use 2010-2019 Current Population Survey data to document the rate of second jobholding among nursing and long-term care workers. On average, 6.41% of personal care and nursing aides and 6.23% of licensed practical nurses and registered nurses hold second jobs; second job holding rates are 35% and 32% higher than those of other workers, respectively. Both wages and hours in the primary job are negatively associated with the probability of holding a second job for personal care and nursing aides, while lower hours are more strongly correlated with a second job for registered nurses and licensed practical nurses. Many of these workers move across health settings from their first to second jobs, and 15% of second jobs for personal care and nursing aides are in other "essential" occupations.

Daily acute intermittent hypoxia enhances serotonergic innervation of hypoglossal motor nuclei in rats with and without cervical spinal injury.

Intermittent hypoxia elicits protocol-dependent effects on hypoglossal (XII) motor plasticity. Whereas low-dose, acute intermittent hypoxia (AIH) elicits serotonin-dependent plasticity in XII motor neurons, high-dose, chronic intermittent hypoxia (CIH) elicits neuroinflammation that undermines AIH-induced plasticity. Preconditioning with repeated AIH and mild CIH enhance AIH-induced XII motor plasticity. Since intermittent hypoxia pre-conditioning could enhance serotonin-dependent XII motor plasticity by increasing serotonergic innervation density of the XII motor nuclei, we tested the hypothesis that 3 distinct intermittent hypoxia protocols commonly studied to elicit plasticity (AIH) or simulate aspects of sleep apnea (CIH) differentially affect XII serotonergic innervation. Sleep apnea and associated CIH are common in people with cervical spinal injuries and, since repetitive AIH is emerging as a promising therapeutic strategy to improve respiratory and non-respiratory motor function after spinal injury, we also tested the hypotheses that XII serotonergic innervation is increased by repetitive AIH and/or CIH in rats with cervical C2 hemisections (C2Hx). Serotonergic innervation was assessed via immunofluorescence in male Sprague Dawley rats, with and without C2Hx (beginning 8 weeks post-injury) exposed to 28 days of: 1) normoxia; 2) daily AIH (10, 5-min 10.5% O2 episodes per day; 5-min normoxic intervals); 3) mild CIH (5-min 10.5% O2 episodes; 5-min intervals; 8 h/day); and 4) moderate CIH (2-min 10.5% O2 episodes; 2-min intervals; 8 h/day). Daily AIH, but neither CIH protocol, increased the area of serotonergic immunolabeling in the XII motor nuclei in both intact and injured rats. C2Hx per se had no effect on XII serotonergic innervation density. Thus, daily AIH may increases XII serotonergic innervation and function, enhancing the capacity for serotonin-dependent, AIH-induced plasticity in upper airway motor neurons. Such effects may preserve upper airway patency and/or swallowing ability in people with cervical spinal cord injuries and other clinical disorders that compromise breathing and airway defense.