Surfacing and addressing hospitalized patients' needs: Proactive nurse rounding as a tool.

AIMS: This paper reports on rounding interventions employed at high performing hospitals, and provides three case studies on how proactive nurse rounding was successfully implemented to improve patient-centredness. BACKGROUND: Proactive nurse rounding is a popular form of rounding that has shown promise for improving patient outcomes, yet, little evidence exists on how to implement it successfully. METHODS: We identified high-performing hospitals in the domains of staff responsiveness and nurse communications in the Hospital Consumer Assessment of Health Providers and Systems survey nationally, and conducted case studies at three of these hospitals exploring their implementation of proactive nurse rounding. We partnered with leaders from these hospitals to describe the associated challenges and lessons learned. RESULTS: Twenty-six high performing hospitals in the domains of staff responsiveness and/or nurse communication were identified. The majority of nursing units reported proactive nurse rounding as their main rounding intervention (96%). CONCLUSIONS: Proactive rounding interventions are a feasible approach to help surface and address hospitalized patients' needs in a timely manner. IMPLICATIONS FOR NURSING MANAGEMENT: The information and tools provided in this paper build upon the learning from high performing hospitals' experiences and are useful to nurse leaders in their efforts to improve the patient-centeredness in the hospital.

Declining invasive prenatal diagnostic procedures: A comparison of tertiary hospital and national data from 2012 to 2015.

BACKGROUND: In recent years, the superior accuracy of maternal plasma cell-free DNA-based prenatal screening has resulted in >50% national decline in amniocenteses and chorionic villus sampling (CVS), creating new implications for specialist training. OBJECTIVE: To compare the annual figures on amniocenteses and CVS in a tertiary hospital with national population-based trends between 2012 and 2015. METHODS: Retrospective study examining the amniocentesis and CVS procedures performed in a tertiary hospital between 2012 and 2015. Numbers of procedures, indications for testing, type of test and diagnostic results were analysed. Trends in the annual numbers of procedures were compared to national population-based data from Medicare Benefits Schedule database. RESULTS: The annual numbers of diagnostic procedures in our tertiary centre fell from 267 to 215 over the study period, representing a 19.5% decline. This was significantly smaller than the corresponding national decline of 53.7% for the same period (P < 0.0001). In 2015, ultrasound abnormality (including nuchal translucency ≥ 3.5 mm) surpassed high-risk screening results as the most common indication for invasive testing. Thirty percent of procedures performed for an ultrasound abnormality occurred prior to 18 weeks gestation. CONCLUSION: Our tertiary centre experienced a relatively smaller decline in prenatal diagnostic procedures compared with national figures, largely due to an increase in testing for ultrasound abnormalities. Our results demonstrate the increasing contribution of first trimester ultrasound in the detection of fetal abnormalities in the cell-free DNA era and the continued viability of specialist training in invasive procedures.

Patient Perceptions of Telemental Health: Systematic Review of Direct Comparisons to In-Person Psychotherapeutic Treatments.

BACKGROUND: Although there is growing empirical support for the clinical efficacy of telemental health (TMH) treatments, questions remain about how patient perceptions of the TMH treatment process may compare with those of traditional in-person psychotherapy treatments. MATERIALS AND METHODS: Through a systematic review, we specifically examine measures of patient treatment satisfaction and therapeutic alliance in studies that included direct comparisons of video teleconferencing or telephone-based psychotherapeutic TMH treatments with in-person treatment delivery. We performed a comprehensive search of the PsychINFO and MEDLINE databases for articles published in the last 10 years (2004-2014) on TMH treatments that included in-person comparison groups, yielding 552 initial results with 14 studies meeting our full inclusion criteria. RESULTS: The findings generally show comparable treatment satisfaction as well as similar ratings of therapeutic alliance. Some results suggested the potential for decreased patient comfort with aspects of group treatment delivered via TMH. CONCLUSIONS: We discuss implications for providing psychotherapeutic treatments via TMH and review practice recommendations for assuring and enhancing satisfaction with TMH services.

Wounds on wheels: implementing a specialized wound clinic within an established syringe exchange program in Baltimore, Maryland.

People who inject drugs (PWID) experience a high incidence of abscesses and chronic wounds. However, many PWID delay seeking care for their wounds. In 2012, the Baltimore Needle Exchange Program (BNEP) in Baltimore, Maryland, partnered with the Johns Hopkins Wound Healing Center to establish a mobile BNEP Wound Clinic. This clinic provided specialized wound care for BNEP patients. In sixteen months, the clinic treated 78 unique patients during 172 visits overall. On average, each visit cost the program $146.45, which was substantially less than clinic-based treatment. This program demonstrates that specialized wound care can be effectively provided through mobile outreach. A community-based service delivery approach might serve as a model for local health departments looking to improve the health of PWID.

Self-care and risk reduction habits in older injection drug users with chronic wounds: a cross-sectional study.

BACKGROUND: We surveyed a population of injection drug users (IDUs) frequenting the mobile Baltimore City Needle Exchange Program (BNEP) to investigate self-care factors associated with chronic wounds, a significant cause of morbidity especially among older IDUs. METHODS: Participants ≥18 years old completed a survey regarding chronic wounds (duration ≥8 weeks), injection and hygiene practices. Study staff visually verified the presence of wounds. Participants were categorized into four groups by age and wound status. Factors associated with the presence of chronic wounds in participants ≥45 years were analyzed using logistic regression. RESULTS: Of the 152 participants, 19.7% had a chronic wound. Of those with chronic wounds, 18 were ≥45 years old (60.0%). Individuals ≥45 years old with chronic wounds were more likely to be enrolled in a drug treatment program (Odds ratio (OR) 3.4, 95% Confidence interval (CI) 1.0-10.8) and less likely to use cigarette filters when drawing up prepared drug (OR 0.2, 95% CI 0.03-0.7) compared to the same age group without chronic wounds. Compared to individuals <45 years old without chronic wounds, individuals ≥45 with a chronic wound were more likely to report cleaning reused needles with bleach (OR 10.7, 95% CI 1.2-93.9) and to use the clinic, rather than an emergency room, as a primary source of medical care (OR 3.4, 95% CI 1.1-10.4). CONCLUSIONS: Older IDUs with chronic wounds have different, and perhaps less risky, injection and hygiene behaviors than their peers and younger IDUs without wounds in Baltimore City. Because of these differences, older IDUs with wounds may be more receptive to community-based healthcare and substance abuse treatment messages.

Comparison of chronic wound culture techniques: swab versus curetted tissue for microbial recovery.

Health-care professionals are increasingly relying on wound cultures as part of their clinical assessment. Tissue viability nurses in the UK use wound swabbing as the standard specimen-taking technique, but others are used globally and there is no worldwide standard. This study compares two wound culture techniques in uninfected chronic wounds of active and former injection drug users seeking care through a civic needle exchange mobile wound clinic. For each wound, two sampling approaches were applied during the same visit: swab culture and curetted tissue culture. A total of 12 chronic wounds were assessed among 9 patients, including 19 swab cultures and 19 tissue cultures. These 38 cultures grew a total of 157 individually identified bacterial organisms, including 27 anaerobic organisms (17.2%), 63 Gram-positive species (40.1%), and 67 Gram-negative species (42.7%). The swab technique yielded a greater percentage recovery rate of anaerobic (55.6%), Gram-positive (52.4%), and all species (51.6%) compared to tissue culture (P>0.05). Recovery of common wound species, such as methicillin-sensitive Staphylococcus aureus, methicillin-resistant Staphylococcus aureus, and Pseudomonas aeruginosa was the same using either method (50.0%). Swab and curetted tissue cultures yielded similar recovery rates for common wound bacteria. Therefore, swabs (including a vacuum transport container) may offer an advantage in the recovery of anaerobes. Based upon this analysis, the swabbased culture method for chronic wounds currently used in the UK is reasonable.

Effects of HIV-1 and herpes simplex virus type 2 infection on lymphocyte and dendritic cell density in adult foreskins from Rakai, Uganda.

BACKGROUND: Male circumcision reduces human immunodeficiency virus (HIV) and herpes simplex virus type 2 (HSV-2) acquisition, and HSV-2 infection is associated with an increased risk of HIV acquisition. To assess the cellular basis for these associations, we estimated immunologic cellular densities in foreskin tissue. METHODS: Immunostained CD1a(+) dendritic cell and CD4(+) and CD8(+) T cell densities were quantified in foreskin samples obtained from medical circumcision in Rakai, Uganda (35 HIV-infected, HSV-2-infected men; 5 HIV-infected, HSV-2-uninfected men; 22 HIV-uninfected, HSV-2-infected men; and 29 HIV-uninfected, HSV-2-uninfected men. RESULTS: CD1A(+) dendritic cell densities did not vary by HIV or HSV-2 status. Compared with densities in HIV-uninfected, HSV-2-uninfected men (mean, 26.8 cells/mm(2)), CD4(+) T cell densities were similar in the HIV-infected, HSV-2-infected group (mean, 28.7 cells/mm(2)), were significantly decreased in the HIV-infected, HSV-2-uninfected group (mean, 11.2; P < .05), and were increased in the HIV-uninfected, HSV-2-infected group (mean, 68.7; P < .05). Dermal CD8(+) T cell densities were higher in the HIV and HSV-2-coinfected group (mean, 102.9) than in the HIV-uninfected, HSV-2-uninfected group (mean, 10.0; P < .001), the HIV-infected, HSV-2-uninfected group (mean, 27.3; P < .001), and the HIV-uninfected, HSV-2-infected group (mean, 25.3; P < .005). DISCUSSION: The increased CD4(+) cellular density in the HIV-uninfected, HSV-2-infected men may help to explain why HSV-2-infected men are at increased risk of HIV acquisition. The absence of this increase in men coinfected with both HIV and HSV-2 is likely in part the result of the progressive loss of CD4(+) cells in HIV infection. Conversely, HIV and HSV-2 coinfection appears to synergistically increase CD8(+) T cell densities.

Using high-fidelity simulation to develop nurse-physician teams.

BACKGROUND: This study was undertaken to determine whether interdisciplinary high-fidelity simulation training improves group cohesion in nurse-physician teams. In addition, perceptions of collaboration and satisfaction with patient care decisions were measured in nurse-physician participants. METHODS: Clinical scenarios relevant to the general surgical urology inpatient unit were conducted in an interdisciplinary high-fidelity simulation center. Participants included physicians and staff nurses. RESULTS: Participants reported a positive shift in group cohesion over time. In addition, the results suggested a positive shift in perceptions of collaboration and satisfaction with patient care decisions over time. The youngest participants (Millennial Generation, born in the 1980s and 1990s) showed the most significant growth in response to the training. CONCLUSION: This study provides evidence of benefits of high-fidelity simulation that extend beyond the training. Simulation training may be a strategy to build and strengthen relationships across nurse-physician teams. In addition, this type of training may positively affect collaboration and satisfaction with patient care decisions. When data were analyzed by generational grouping, the most significant growth occurred in the Millennial Generation participants. These influences need to be explored further.

Use of High-Fidelity Simulation to Enhance Interdisciplinary Collaboration and Reduce Patient Falls.

OBJECTIVES: This pilot study aimed to determine the effect of nurse/physician interdisciplinary team training on patient falls. Specifically, we evaluated team training in a simulation center as a method for targeting and minimizing breakdowns in perceptions of respect, collaboration, communication, and role misunderstanding behaviors between care disciplines. METHODS: Registered nurses (RNs) were randomly assigned to participate. Residents were divided into groups and assigned based on their availability and clinical responsibility. All participants completed a demographic form, the Professional Practice Environment Assessment Scale (PPEAS), and the Mayo High Performance Teamwork Scale (MHPTS) after consenting and before participation in simulation training. The PPEAS and the MHPTS were readministered at 2 and 6 months after the simulation experience. Differences in MHPTS and PPEAS scores between the baseline and 2- and 6-month assessments were analyzed; fall rates over time were evaluated using Cochran-Armitage trend tests. RESULTS: After the team training exercises, teamwork as measured by the MHPTS improved significantly at both 2 and 6 months (P = 0.01; P < 0.001) compared with baseline measurement. Practice environment subscores, with the exception of positive organizational characteristics, also increased when measured 6 months after training. The primary outcome, reduction in anticipated patient falls, improved significantly (P = 0.02) over the course of the study. CONCLUSIONS: Results of this pilot study show that team training exercises result in improvement in both patient safety (anticipated patient falls) and team member perception of their work environment. If validated by other studies, improvement in this patient safety metric would represent an important benefit of simulation and team training.

Pyrophilous fungi detected after wildfires in the Great Smoky Mountains National Park expand known species ranges and biodiversity estimates.

Following a late fall wildfire in 2016 in the Great Smoky Mountains National Park, pyrophilous fungi in burn zones were documented over a 2-y period with respect to burn severity and phenology. Nuc rDNA internal transcribed spacer (ITS1-5.8S-ITS2 = ITS) barcodes were obtained to confirm morphological evaluations. Forty-one taxa of Ascomycota and Basidiomycota were identified from burn sites and categorized as fruiting only in response to fire or fruiting enhanced by fire. Twenty-two species of Pezizales (Ascomycota) were among the earliest to form ascomata in severe burn zones, only one of which had previously been documented in the Great Smoky Mountains National Park. Nineteen species of Basidiomycota, primarily Agaricales, were also documented. Among these, only five species (Coprinellus angulatus, Gymnopilus decipiens, Lyophyllum anthracophilum, Pholiota carbonicola, and Psathyrella pennata) were considered to be obligate pyrophilous taxa, but fruiting of two additional taxa (Hygrocybe conica and Mycena galericulata) was clearly enhanced by fire. Laccaria trichodermophora was an early colonizer of severe burn sites and persisted through the winter of 2017 and into spring and summer of 2018, often appearing in close association with Pinus pungens seedlings. Fruiting of pyrophilous fungi peaked 4-6 mo post fire then diminished, but some continued to fruit up to 2.5 y after the fire. In all, a total of 27 previously unrecorded taxa were added to the All Taxa Biodiversity Inventory (ATBI) database (~0.9%). Most pyrophilous fungi identified in this study are either cosmopolitan or have a Northern Hemisphere distribution, but cryptic endemic lineages were detected in Anthracobia and Sphaerosporella. One new combination, Hygrocybe spadicea var. spadicea f. odora, is proposed.

An atypical case of fatal zygomycosis: simultaneous cutaneous and laryngeal infection in a patient with a non-neutropenic solid prostatic tumor.

We describe what we believe is the first reported case of simultaneous highly invasive cutaneous and laryngopharyngeal zygomycosis in a non-neutropenic, nondiabetic but immunosuppressed patient with prostate cancer. An invasive fungal process was not suspected until late in the patient's hospital course; when it was, a tracheotomy and direct laryngoscopic biopsies were performed. Unresectable invasive zygomycosis with Rhizopus rhizopodiformis was diagnosed. The patient was managed with liposomal amphotericin B initially and later with palliative medical therapy until he died. This case emphasizes the need for a rapid and specific diagnosis with timely introduction of appropriate antifungal management, particularly now that voriconazole is frequently used as empiric prophylaxis against aspergillosis in high-risk patients.

Impact of maternal HIV coinfection on the vertical transmission of hepatitis C virus: a meta-analysis.

BACKGROUND: Observational studies suggest that maternal human immunodeficiency virus (HIV)-hepatitis C virus (HCV) coinfection is associated with increased odds of vertical HCV transmission. We performed a meta-analysis to summarize current evidence. METHODS: We systematically searched for relevant articles published during the period from January 1992 through July 2006 and independently abstracted articles that met our inclusion criteria. Under a random effects model, we calculated the pooled odds ratio for vertical HCV transmission according to maternal HIV-HCV coinfection status and performed sensitivity analyses. RESULTS: Ten articles met our inclusion criteria. Study quality varied widely, and study estimates displayed high statistical heterogeneity. Restriction of the analysis to studies that included >50 HIV-HCV-coinfected women provided our most reliable estimate: maternal HIV-HCV coinfection increases the odds of vertical HCV transmission by approximately 90% (odds ratio, 1.9; 95% confidence interval, 1.36-2.67), compared with maternal HCV infection alone. When we restricted analyses to HIV-infected mothers with HCV viremia, the odds of vertical HCV transmission were 2.82-fold (95% confidence interval, 1.17-fold to 6.81-fold) greater than the odds for HIV-infected mothers without HCV viremia. CONCLUSIONS: HIV-HCV-coinfected women have significantly higher odds of transmitting HCV to their infants than do women who are infected with HCV alone.

The emerging clinical importance of non-O157 Shiga toxin-producing Escherichia coli.

In 1982, hemorrhagic colitis and hemolytic-uremic syndrome were linked to infection with Escherichia coli O157:H7, a serotype now classified as Shiga toxin-producing E. coli (STEC). Thereafter, hemorrhagic colitis and hemolytic-uremic syndrome associated with non-O157 STEC serogroups were reported, with the frequency of non-O157 STEC illness rivaling that of O157:H7 in certain geographic regions. In the United States, non-O157 E. coli may account for up to 20%-50% of all STEC infections. A high index of suspicion, paired with options to test for non-O157 STEC infection, are necessary for early recognition and appropriate treatment of these infections. Supportive care without the use of antibiotics is currently considered to be optimal treatment for all STEC infections. This commentary provides a perspective on the non-O157 STEC as human pathogens, how and when the clinician should approach the diagnosis of these organisms, and the challenges ahead.

GIS habitat analysis for lesser prairie-chickens in southeastern New Mexico.

BACKGROUND: We conducted Geographic Information System (GIS) habitat analyses for lesser prairie-chicken (LPCH, Tympanuchus pallidicinctus) conservation planning. The 876,799 ha study area included most of the occupied habitat for the LPCH in New Mexico. The objectives were to identify and quantify: 1. suitable LPCH habitat in New Mexico, 2. conversion of native habitats, 3. potential for habitat restoration, and 4. unsuitable habitat available for oil and gas activities. RESULTS: We found 16% of suitable habitat (6% of the study area) distributed in 13 patches of at least 3,200 ha and 11% of suitable habitat (4% of the study area) distributed in four patches over 7,238 ha. The area converted from native vegetation types comprised 17% of the study area. Ninety-five percent of agricultural conversion occurred on private lands in the northeastern corner of the study area. Most known herbicide-related conversions (82%) occurred in rangelands in the western part of the study area, on lands managed primarily by the US Bureau of Land Management (BLM). We identified 88,190 ha (10% of the study area) of habitats with reasonable restoration potential. Sixty-two percent of the primary population area (PPA) contained occupied, suitable, or potentially suitable habitat, leaving 38% that could be considered for oil and gas development. CONCLUSION: Although suitable LPCH habitat appears at first glance to be abundant in southeastern New Mexico, only a fraction of apparently suitable vegetation types constitute quality habitat. However, we identified habitat patches that could be restored through mesquite control or shin-oak reintroduction. The analysis also identified areas of unsuitable habitat with low restoration potential that could be targeted for oil and gas exploration, in lieu of occupied, high-quality habitats. Used in combination with GIS analysis and current LPCH population data, the habitat map represents a powerful conservation and management tool.

Ultrasound and Clinical Measures for Lymphedema.

BACKGROUND: Treatment for breast cancer has increased patient survivorship exponentially over the past few decades. With increased survivorship, more women are living with the longstanding effects of breast cancer treatment, such as lymphedema. Patients, health care providers, and payers depend on practical and efficient clinical measures to accurately diagnose and monitor disease progression or regression. However, current clinical measures do not include objective measures that assess lymphedetamous tissue accurately. This study compared current measures to a novel use of ultrasound (US) imaging to quantify tissue texture. METHODS AND RESULTS: Seventeen women diagnosed with lymphedema completed self-report questionnaires and then were tested twice by two lymphedema physical therapists who measured edema, fibrosis, and limb volume differences. One therapist measured subjects' limbs using US imaging and derived measures of entropy and average pixel intensity. Volume measures were consistent between therapists (p < 0.01) but palpation was not (0.01 < p < 0.72). Therapists' measures correlated better to subjects' self-report of edema (0.01 < p > 0.32) as compared to fibrosis (0.23 < p > 0.90). US measures were reliable (Cronbachs's α = 0.7 and 0.91 for entropy and API, respectively). Entropy measures demonstrated significant differences between subjects' involved versus uninvolved forearms (p = 0.03). CONCLUSIONS: Therapists were not consistent with each other when rating edema or fibrosis; however, they were consistent when measuring limb volume differences. US measures (entropy) demonstrated a significant difference between involved and uninvolved. US imaging, as a tool to quantify subcutaneous tissues, holds promise to be a safe, mobile, and effective method to measure lymphedema tissue texture.

High rates of abscesses and chronic wounds in community-recruited injection drug users and associated risk factors.

OBJECTIVES: Abscesses and chronic wounds are common among injection drug users (IDUs) though chronic wounds have been understudied. We assessed the risk factors associated with both acute and chronic wounds within a community-based population of IDUs frequenting the Baltimore City Needle Exchange Program (BNEP). METHODS: We performed a cross-sectional study of BNEP clients aged 18 years or more who completed an in-person survey regarding active or prior wounds including abscesses (duration <8 weeks) and chronic wounds (duration ≥8 weeks), injection practices, and skin care. Factors associated with wounds were analyzed using univariate and multivariate logistic regressions. RESULTS: Of the 152 participants, 63.2% were men, 49.3% were white, 44.7% were African American, 34.9% had any type of current wound, 17.8% had an active abscess, and 19.7% had a current chronic wound. Abscesses were more common in women (odds ratio [OR], 2.56; 95% confidence interval [CI], 1.10-5.97) and those reporting skin-popping (OR, 5.38; 95% CI, 1.85-15.67). In a multivariate model, risk factors for an abscess included injecting with a family member/partner (adjusted OR [AOR], 4.06; 95% CI, 0.99-16.58). In a multivariable analysis of current chronic wounds, cleaning skin with alcohol before injection was protective (AOR, 0.061; 95% CI, 0.0064-0.58). CONCLUSIONS: Abscesses and chronic wounds were prevalent among a sample of IDUs in Baltimore. Abscesses were associated with injection practices, and chronic wounds seemed linked to varying skin and tool cleaning practices. There is a pressing need for wound-related education and treatment efforts among IDUs who are at greatest risk for skin-related morbidity.

Human Placenta-derived Cells (PDA-001) for the Treatment of Moderate-to-severe Crohn's Disease: A Phase 1b/2a Study.

BACKGROUND: PDA-001 (cenplacel-L), a preparation of placenta-derived mesenchymal-like adherent cells with immunomodulatory effects, previously demonstrated safety and tolerability in an open-label Crohn's disease (CD) study. The current phase 1b/2a study evaluated the safety and efficacy of PDA-001 in subjects with moderate-to-severe CD. METHODS: Subjects had active inflammation on colonoscopy or elevated fecal calprotectin and inadequate response to conventional therapy. Concomitant therapy with stable doses of immunomodulators and/or biologics was permitted. Subjects received 8 units of PDA-001 (1.5 × 10 cells per unit) in the phase 1b open-label study. In the phase 2a double-blind study, subjects were randomly assigned placebo, 1 unit, or 4 units of PDA-001 (2 infusions 1 wk apart). The primary endpoint was induction of clinical response (≥100 points and/or 25% decrease in Crohn's Disease Activity Index) at 4 and 6 weeks. RESULTS: Fifty subjects were enrolled (safety analysis, 50 subjects; efficacy analysis, 48 subjects). Four subjects received 8 units of PDA-001 (phase 1b study); 46 subjects were subsequently randomized to 1 or 4 units of PDA-001 or placebo (phase 2a study). The primary endpoint was achieved in 10/28 (36%) of PDA-001 subjects compared with placebo (0%, P = 0.026). Clinical remission was achieved in 4/28 (14%) of PDA-001 subjects compared with placebo (0%, P = 0.3). One treatment-related serious adverse event occurred (systemic hypersensitivity reaction at 8 units). In the phase 2a study, serious adverse events occurred in 9/28 (32%) of PDA-001 subjects and 1/16 (7%) of placebo subjects. CONCLUSIONS: A 2-infusion regimen of PDA-001 induced clinical response in subjects with moderate-to-severe CD. Additional studies are warranted.

Clinical measurements of lymphedema.

Patients, health care providers, and payers depend on practical, efficient, and useful tests that can be performed in a clinical setting in order to measure accurately and to diagnose lymphedema. Accurate measures are also necessary to monitor progression or regression of the disease, as well as treatment effects. This article reviews clinical measures of lymphedema that are currently being utilized. In addition, this article proposes an alternative objective measure, different from limb volume, that quantifies tissue texture.

Suicide risk management during clinical telepractice.

The effective assessment and management of suicidal patients is an essential component of telehealth-based care. With this article, we describe how we have implemented procedures for the ongoing assessment and management of suicide risk in a clinical trial that compares in-office treatment to home-based treatment delivered via web-cam to U.S. military service members and veterans with depression. We describe our safety protocol and how it was adapted from current recommended best practices, published guidelines, and local requirements for managing patient safety during home-based telepractice. We conclude with discussion of other key safety issues associated with telepractice. The topics discussed are relevant to all mental health practitioners who are interested in clinical telepractice services.

Resolution of a fungal mycotic aneurysm after a contaminated steroid injection: a case report.

BACKGROUND: In the past ten years there have been three separate outbreaks of fungal contaminated steroid injections from compounding pharmacies. The 2012 outbreak of central nervous system fungal infections associated with contaminated methylprednisolone produced by a United States compounding pharmacy has led to 750 infections (151 with meningitis and paraspinal infections and 325 cases with paraspinal infections without meningitis) and 64 deaths as of October 23, 2013. Exserohilum rostratum has been the predominant pathogen identified by culture, polymerase chain reaction or antibody tests. According to previous reports, cerebral involvement with phaeohyphomycosis has a high risk of morbidity and mortality. CASE PRESENTATION: We report a 41 year-old Caucasian woman who received a lumbar methylprednisolone injection from a contaminated lot in August 2012. She was diagnosed with fungal meningitis by cerebrospinal fluid pleocytosis and positive (1, 3) beta-D-glucan after cultures and polymerase chain reaction were negative. Two weeks after onset of therapy, she developed a 4.1 mm superior cerebellar artery mycotic aneurysm associated with new stroke symptoms, which resolved with thirty-two weeks of antifungal treatment. CONCLUSIONS: This is the rare case report of successful medical management of a cerebral mycotic aneurysm with stroke symptoms related to a presumed phaeohyphomycosis in an immunocompetent individual. Further studies are needed to determine the utility of cerebrospinal fluid (1, 3) beta-D-glucan in diagnosing and monitoring patients with meningitis thought to be related to fungal infection.