C1-C2 Posterior Screw-Rod Fixation.

Multiple approaches for instrumentation of the upper cervical spine have evolved to treat atlantoaxial instability which, until the 20th century, was largely considered to be inoperable and managed nonsurgically with immobilization. Surgeons set out to provide safe and effective approaches in a clearly dangerous and technically complex anatomic region. It is important to provide a historical analysis of the evolution of techniques that have shaped C1-C2 instrumentation, and how the diligent efforts of surgeons to improve the biomechanical stability and fusion rates of their constructs eventually led to the prevailing Harms technique. This technique is explored by describing its surgical steps, alternative techniques, and associated outcomes. For successful instrumentation of the atlantoaxial joint, a comprehensive understanding of spinal biomechanics, surgical techniques, and anatomic variations is imperative for surgeons to develop a tailored plan for each patient's individual pathology and anatomy.

Standardizing Opioids Prescribed at Discharge in Trauma Surgery.

INTRODUCTION: Excessive opioid use after sustaining trauma has contributed to the opioid epidemic. Standardizing the quantity of opioids prescribed at discharge can improve prescribing behavior. We hypothesized that adopting new electronic medical record order sets would be associated with decreased morphine milligram equivalents (MME) prescribed at discharge for trauma patients. METHODS: This was a quasi-experimental study examining opioid prescribing practices at a Level 1 Trauma Center. All patients ages 18-89 admitted to the Trauma Service from January 2017 through March 2021 and hospitalized for at least 2 d were included. In November 2020, new trauma admission and discharge order sets were implemented with recommended discharge opioid quantity based on inpatient opioid usage the day prior to discharge multiplied by five. Postintervention prescribing practices were compared to historical controls. The primary outcome was MME at discharge. RESULTS: Baseline characteristics between preintervention and postintervention cohorts were comparable. There was a significant reduction in median MME prescribed at discharge postintervention (112.5 versus 75.0, P < 0.0001). Median inpatient MME usage also significantly reduced postintervention (184.1 versus 160.5; P < 0.0001). There were trends toward increased ideal prescribing per order set recommendation and a reduction in overprescribing. Patients receiving the recommended opioid quantity at discharge had the lowest opioid refill prescription rate (under: 29.6%, ideal: 7.3%, over: 19.7%, P < 0.0001). CONCLUSIONS: For trauma patients requiring inpatient opioid therapy, a pragmatic and individualized intervention was associated with a reduced quantity of discharge opioids without negative outcomes. Reduction in inpatient opioid use was also associated with standardizing prescribing practices of surgeons with electronic medical record order sets.

Learning from national implementation of the Veterans Affairs Clinical Resource Hub (CRH) program for improving access to care: protocol for a six year evaluation.

BACKGROUND: The Veterans Affairs (VA) Clinical Resource Hub (CRH) program aims to improve patient access to care by implementing time-limited, regionally based primary or mental health staffing support to cover local staffing vacancies. VA's Office of Primary Care (OPC) designed CRH to support more than 1000 geographically disparate VA outpatient sites, many of which are in rural areas, by providing virtual contingency clinical staffing for sites experiencing primary care and mental health staffing deficits. The subsequently funded CRH evaluation, carried out by the VA Primary Care Analytics Team (PCAT), partnered with CRH program leaders and evaluation stakeholders to develop a protocol for a six-year CRH evaluation. The objectives for developing the CRH evaluation protocol were to prospectively: 1) identify the outcomes CRH aimed to achieve, and the key program elements designed to achieve them; 2) specify evaluation designs and data collection approaches for assessing CRH progress and success; and 3) guide the activities of five geographically dispersed evaluation teams. METHODS: The protocol documents a multi-method CRH program evaluation design with qualitative and quantitative elements. The evaluation's overall goal is to assess CRH's return on investment to the VA and Veterans at six years through synthesis of findings on program effectiveness. The evaluation includes both observational and quasi-experimental elements reflecting impacts at the national, regional, outpatient site, and patient levels. The protocol is based on program evaluation theory, implementation science frameworks, literature on contingency staffing, and iterative review and revision by both research and clinical operations partners. DISCUSSION: Health systems increasingly seek to use data to guide management and decision-making for newly implemented clinical programs and policies. Approaches for planning evaluations to accomplish this goal, however, are not well-established. By publishing the protocol, we aim to increase the validity and usefulness of subsequent evaluation findings. We also aim to provide an example of a program evaluation protocol developed within a learning health systems partnership.

Survey of Postpartum People in the United States During the First Wave of the COVID-19 Pandemic to Explore Their Perspective on Support After Discharge.

INTRODUCTION: The purpose of this study was to capture the experiences of postpartum people during the first wave of COVID-19, specifically their access to contraception and lactation support. METHODS: This cross-sectional study surveyed individuals in the United States who used the Ovia Pregnancy and Parenting app. The survey was administered via an email Web link sent to postpartum people who gave birth between March 1, 2020, and June 11, 2020. Quantitative and qualitative analyses were conducted. RESULTS: A total of 388 postpartum people completed the survey. Most participants had just given birth to their first baby (68.5%; n = 261) at term gestation (37-41 weeks) (92.9%; n = 355). From the qualitative data, using content analysis, we derived 6 themes and 2 subthemes: quarantine, changes in postpartum care, loneliness and isolation, stress, resource changes, and positive impact. The theme loneliness and isolation had 2 subthemes: depression/sadness/hopelessness and anxiety. DISCUSSION: The experience of being postpartum during the COVID-19 pandemic brought unforeseen challenges. Providing care and support to postpartum people during a pandemic, specifically during a time of quarantine, should be reimagined. Increased use of virtual postpartum care services and expanded mental health support could serve to fill the gaps identified by participants.

DNA sensor-associated type I interferon signaling is increased in ulcerative colitis and induces JAK-dependent inflammatory cell death in colonic organoids.

DNA sensor pathways can initiate inflammasome, cell death, and type I interferon (IFN) signaling in immune-mediated inflammatory diseases (IMIDs), including type I interferonopathies. We investigated the involvement of these pathways in the pathogenesis of ulcerative colitis (UC) by analyzing the expression of DNA sensor, inflammasome, and type I IFN biomarker genes in colonic mucosal biopsy tissue from control (n = 31), inactive UC (n = 31), active UC (n = 33), and a UC single-cell RNA-Seq dataset. The effects of type I IFN (IFN-ß), IFN-γ, and TNF-α on gene expression, cytokine production, and cell death were investigated in human colonic organoids. In organoids treated with cytokines alone, or in combination with NLR family pyrin domain-containing 3 (NLRP3), caspase, or JAK inhibitors, cell death was measured, and supernatants were assayed for IL-1ß/IL-18/CXCL10. The expression of DNA sensor pathway genes-PYHIN family members [absent in melanoma 2 (AIM2), IFI16, myeloid cell nuclear differentiation antigen (MNDA), and pyrin and HIN domain family member 1 (PYHIN1)- as well as Z-DNA-binding protein 1 (ZBP1), cyclic GMP-AMP synthase (cGAS), and DDX41 was increased in active UC and expressed in a cell type-restricted pattern. Inflammasome genes (CASP1, IL1B, and IL18), type I IFN inducers [stimulator of interferon response cGAMP interactor 1 (STING), TBK1, and IRF3), IFNB1, and type I IFN biomarker genes (OAS2, IFIT2, and MX2) were also increased in active UC. Cotreatment of organoids with IFN-ß or IFN-γ in combination with TNFα increased expression of IFI16, ZBP1, CASP1, cGAS, and STING induced cell death and IL-1ß/IL-18 secretion. This inflammatory cell death was blocked by the JAK inhibitor tofacitinib but not by inflammasome or caspase inhibitors. Increased type I IFN activity may drive elevated expression of DNA sensor genes and JAK-dependent but inflammasome-independent inflammatory cell death of colonic epithelial cells in UC.NEW & NOTEWORTHY This study found that patients with active UC have significantly increased colonic gene expression of cytosolic DNA sensor, inflammasome, STING, and type I IFN signaling pathways. The type I IFN, IFN-ß, in combination with TNF-α induced JAK-dependent but NLRP3 and inflammasome-independent inflammatory cell death of colonic organoids. This novel inflammatory cell death phenotype is relevant to UC immunopathology and may partially explain the efficacy of the JAKinibs tofacitinib and upadacitinib in patients with UC.

Marketing mobile influenza vaccine clinics on a college campus.

BACKGROUND: Influenza vaccination rates fall below public health targets. Compared with the general population, vaccination rates on college campuses are even lower. Since 2013, the University of Georgia College of Pharmacy and University Health Center (UHC) Pharmacy have collaborated to increase access to influenza vaccines by holding clinics at locations across campus. In an effort to increase awareness, this partnership expanded to include the UHC Marketing Department. Through this initiative, a coordinated marketing campaign was implemented to promote immunization opportunities. OBJECTIVES: To examine the impact of a collaborative, multimodal marketing campaign on individuals receiving the influenza vaccine at mobile clinics on a college campus and explore reasons why recipients chose to get vaccinated. METHODS: A 7-item survey was developed and administered at mobile influenza vaccine clinics across campus during the fall of 2018. The survey asked participants for basic demographics, the marketing strategies that they encountered, the strategy had the most impact on their decision to get vaccinated at the clinic, and their motivation for receiving the vaccine. RESULTS: The survey was administered at 11 campus-based clinics, with a 71% response rate. A total of 59% respondents were students, and 41% were faculty or staff. The most common marketing strategies recognized by participants were e-mail (45%), friend or colleague (35%), paper/digital flyers (24%), UHC website (9%), and mobile clinic signage (7%). The most common motivating factors for getting vaccinated were lowering the risk of getting sick (87%), protecting others (64%), and being encouraged by a relative or friend (34%). The number of people vaccinated after the marketing campaign was 1150, a 69% increase compared with the previous year. CONCLUSION: The marketing strategies described in this paper resulted in an increase in the number of vaccine recipients at campus-based mobile clinics. Implementing a multimodal, coordinated marketing campaign can help universities improve their vaccination efforts.

Brief Cognitive-Behavioral Therapy for Suicide Prevention (BCBT-SP) via Video Telehealth: A Case Example During the COVID-19 Outbreak.

Although veterans living in remote/rural areas are at elevated risk for suicide, there is very little research specific to treating suicidal veterans who present with barriers to in-person care. The current study aims to examine the delivery of brief cognitive-behavioral therapy for suicide prevention (BCBT-SP) via Clinical Video Telehealth (CVT) to the home of a veteran discharged from the psychiatric inpatient unit after a recent suicide attempt. Preliminary data on acceptability, feasibility, and changes in symptoms were gathered. The veteran received treatment during the 2020 COVID-19 outbreak and additional adaptations were made accordingly. The veteran did not engage in any suicidal behavior during the course of treatment, and suicidal ideation, depression, and anxiety decreased as treatment progressed. The results provide initial support for the feasibility of BCBT-SP via CVT to the home.

Treatment with a CD40 Antagonist Antibody Reverses Severe Proteinuria and Loss of Saliva Production and Restores Glomerular Morphology in Murine Systemic Lupus Erythematosus.

CD40 is a costimulatory receptor on APCs that is critical for the induction and maintenance of humoral and cell-mediated immunity. Accordingly, CD40 and its ligand, CD40L, have long been considered targets for the treatment of autoimmune diseases. We developed a rat/mouse chimeric anti-mouse CD40 antagonist mAb, 201A3, and evaluated its ability to alleviate murine lupus. Treatment of NZB/W-F1 mice with 201A3 after the onset of severe proteinuria rapidly reversed established severe proteinuria and nephritis and largely restored normal glomerular and tubular morphology. This coincided with a normalization of the expression of genes associated with proteinuria and injury by kidney parenchymal cells. Anti-CD40 treatment also prevented and reversed loss of saliva production and sialadenitis. These effects on kidney and salivary gland function were confirmed using mice of a second strain, MRL/Mp-lpr/lpr, and extended to alleviating joint inflammation. Immunologically, anti-CD40 treatment disrupted multiple processes that contribute to the pathogenesis of systemic lupus erythematosus (SLE), including autoreactive B cell activation, T effector cell function in target tissues, and type I IFN production. This ability to disrupt disease-critical immunological mechanisms, to reverse glomerular and tubular injury at the cellular and gene expression levels, and to confer exceptional therapeutic efficacy suggests that CD40 is a central disease pathway in murine SLE. Thus, a CD40 antagonist Ab could be an effective therapeutic in the treatment of SLE.

Acute Intramyocardial Right Ventricular Hematoma After Coronary Artery Bypass Graft.

A 50-year-old woman underwent coronary artery bypass graft (CABG) for multivessel coronary artery disease. Due to hemodynamic instability, the patient could not be weaned from cardiopulmonary bypass without mechanical support, even after multiple attempts. Subsequently, a right ventricular intramyocardial hematoma (IH) was found during postoperative coronary angiography. The IH was felt to be the main contributing factor leading to right ventricular failure and cardiogenic shock, which, to the authors' knowledge, has not been previously reported after CABG. An IH is a rare complication postoperatively that often requires a high level of suspicion to identify on transesophageal echocardiogram. It should be suspected when there is hemodynamic instability intraoperatively or postoperatively in the intensive care unit that cannot be explained easily. There currently is no standard treatment. Treatment often is based on the individual patient and degree of hemodynamic instability.

Adapting training in real time: An empirical test of adaptive difficulty schedules.

Adaptive Training (AT) has been shown to be an effective technique for training tasks in multiple domains. Despite the promise AT has shown as a training technique, researchers remain unsure of the specific qualities that improve learning. In this experiment, we examined how adaptation schedule affects the efficacy and efficiency of difficulty adaptation in computer-based training. We used Cognitive Load Theory to guide our predictions about performance gains. In the reported study, we hypothesized that an adaptation schedule that adapts more frequently would lead to superior performance. To test this, we examined two types of difficulty adaptation (i.e., Within-Adaptive & Between-Adaptive) schedules using an audio-visual change detection task over five 10-minute scenarios. The Within-Adaptive condition adapted difficulty throughout the scenario based on trainee performance in real time. The Between-Adaptive condition adapted difficulty of subsequent scenarios based on previous scenario performance. We compared these two conditions to a Control condition, which maintained a constant difficulty throughout the experiment. We identified performance benefits for the Within-Adaptive condition, particularly for individuals whose performance was initially poor. A closer examination of the results suggested that average difficulty was the driving factor for performance gains in the Between-Adaptive condition. The data support that a within-scenario adaptation schedule effectively manages cognitive load to facilitate learning gains.

The Role of Regional versus General Anesthesia on Arteriovenous Fistula and Graft Outcomes: A Single-Institution Experience and Literature Review.

BACKGROUND: Multiple studies have demonstrated the benefits of creating arteriovenous fistulas (AVFs) under regional anesthesia. This is most likely because of the avoidance of hemodynamic instability and stress response of general anesthesia, as well as the sympathectomy associated with brachial plexus blockade. As vein diameter is the major limiting factor for primary AVF creation and maturation, our aim is to investigate if the vasodilation that accompanies regional anesthesia leads to improved patency and maturation rate of autologous AVF and improved patency of arteriovenous graft (AVG) compared with those placed under general anesthesia. METHODS: This retrospective study was approved by the institutional review board. A total of 238 patients who had either an AVF or an AVG placed at the Mayo Clinic, Florida, between 2012 and 2017 were analyzed. Demographics, access type, preoperative vein diameter, anesthesia type, change of plan after regional versus general anesthesia, and outcomes were assessed. All statistical tests were 2 sided, with the alpha level set at 0.05 for statistical significance. RESULTS: Among 238 patients, 120 (50.4%) had regional anesthesia. Differences between the 2 groups in risk factors and 30-day or long-term outcomes (failure, abandonment, or reoperation) were not statistically significant. Of the accesses placed under general anesthesia, 58.5% were abandoned compared with 45.2% of those placed under regional anesthesia. Owing to loss of patency, 25.8% of accesses placed under general anesthesia were abandoned compared with 19.2% of those placed under regional anesthesia. Two-month failure was higher in the general anesthesia group than that in the regional anesthesia group (P = 0.076). After preoperative vein mapping, 22 patients were originally intended to have an AVG placed under regional anesthesia. After brachial plexus blockade, 9 of these patients (41%) were successfully switched to AVF, while the other 13 followed the original surgical plan and received an AVG. Of these, 0 failed and 0 were abandoned because of loss of patency. CONCLUSIONS: This study showed possible improvements in failure rates for vascular accesses placed under regional anesthesia compared with those placed under general anesthesia. In addition, we showed an impact of regional anesthesia on the surgical plan by transitioning from a planned AVG to an AVF, intraoperatively. Giving patients with originally inadequate vein diameter the chance to have the preferred hemodialysis access method by simply switching anesthesia type could reduce the number of grafts placed in favor of fistulas.

Electronic medical record-based interventions to encourage opioid prescribing best practices in the emergency department.

OBJECTIVE: Overdose from opioids has reached epidemic proportions. Large healthcare systems can utilize existing technology to encourage responsible opioid prescribing practices. Our study measured the effects of using the electronic medical record (EMR) with direct clinician feedback to standardize opioid prescribing practices within a large healthcare system. METHODS: This retrospective multicenter study compared a 12 month pre- and post-intervention in 14 emergency departments after four interventions utilizing the EMR were implemented: (1) deleting clinician preference lists, (2) defaulting dose, frequency, and quantity, (3) standardizing formulary to encourage best practices, and (4) creating dashboards for clinician review with current opioid prescribing practices. Outlying clinicians received feedback through email and direct counseling. Total number of opioid prescriptions per 100 discharges pre- and post-intervention were recorded as primary outcome. Secondary outcomes included number of prescriptions per 100 discharges/clinician exceeding 3-day supply (defined as 12 tablets), number exceeding 30 morphine equivalent daily dose (MEDD)/day, and number of non-formulary prescriptions. RESULTS: There were >700,000 discharges during pre- and post-intervention periods. Percentage of total number opioid prescriptions per 100 discharges decreased from 14.4% to 7.4%, a 7.0% absolute reduction, (95% CI,6.9%-7.2%). There was a 5.9% to 0.7% reduction in prescriptions exceeding 3-days, (95% CI, 5.1%-5.3%), a 4.3% to 0.3% reduction in prescriptions exceeding 30 MEDD, (95% CI, 3.9%-4.0%), and a 0.3% to 0.1% reduction in non-formulary prescriptions, (95% CI, 0.2%-0.3%). CONCLUSIONS: A multi modal approach using EMR interventions which provide real time data and direct feedback to clinicians can facilitate appropriate opioid prescribing.

Regional improvements in lumbosacropelvic Hounsfield units following teriparatide treatment.

OBJECTIVE: Opportunistic Hounsfield unit (HU) determination from CT imaging has been increasingly used to estimate bone mineral density (BMD) in conjunction with assessments from dual energy x-ray absorptiometry (DXA). The authors sought to compare the effect of teriparatide on HUs across different regions in the pelvis, sacrum, and lumbar spine, as a surrogate measure for the effects of teriparatide on lumbosacropelvic instrumentation. METHODS: A single-institution retrospective review of patients who had been treated with at least 6 months of teriparatide was performed. All patients had at least baseline DXA as well as pre- and post-teriparatide CT imaging. HUs were measured in the pedicle, lamina, and vertebral body of the lumbar spine, in the sciatic notch, and at the S1 and S2 levels at three different points (ilium, sacral body, and sacral ala). RESULTS: Forty patients with an average age of 67 years underwent a mean of 20 months of teriparatide therapy. Mean HUs of the lumbar lamina, pedicles, and vertebral body were significantly different from each other before teriparatide treatment: 343 ± 114, 219 ± 89.2, and 111 ± 48.1, respectively (p < 0.001). Mean HUs at the S1 level for the ilium, sacral ala, and sacral body were also significantly different from each other: 124 ± 90.1, -10.7 ± 61.9, and 99.1 ± 72.1, respectively (p < 0.001). The mean HUs at the S2 level for the ilium and sacral body were not significantly different from each other, although the mean HU at the sacral ala (-11.9 ± 52.6) was significantly lower than those at the ilium and sacral body (p = 0.003 and 0.006, respectively). HU improvement occurred in most regions following teriparatide treatment. In the lumbar spine, the mean lamina HU increased from 343 to 400 (p < 0.001), the mean pedicle HU increased from 219 to 242 (p = 0.04), and the mean vertebral body HU increased from 111 to 134 (p < 0.001). There were also significant increases in the S1 sacral body (99.1 to 130, p < 0.05), S1 ilium (124 vs 165, p = 0.01), S1 sacral ala (-10.7 vs 3.68, p = 0.04), and S2 sacral body (168 vs 189, p < 0.05). CONCLUSIONS: There was significant regional variation in lumbar and sacropelvic HUs, with most regions significantly increasing following teriparatide treatment. The sacropelvic area had lower HU values than the lumbar spine, more regional variation, and a higher degree of correlation with BMD as measured on DXA. While teriparatide treatment resulted in HUs > 110 in the majority of the lumbosacral spine, the HUs in the sacral ala remained suggestive of severe osteoporosis, which may limit the effectiveness of fixation in this region.

Osteoporosis in spine surgery patients: what is the best way to diagnose osteoporosis in this population?

OBJECTIVE: The goal of this study was to compare different recognized definitions of osteoporosis in patients with degenerative lumbar spine pathology undergoing elective spinal fusion surgery to determine which patient population should be considered for preoperative optimization. METHODS: A retrospective review of patients in whom lumbar spine surgery was planned at 2 academic medical centers was performed, and the rate of osteoporosis was compared based on different recognized definitions. Assessments were made based on dual-energy x-ray absorptiometry (DXA), CT Hounsfield units (HU), trabecular bone score (TBS), and fracture risk assessment tool (FRAX). The rate of osteoporosis was compared based on different definitions: 1) the WHO definition (T-score ≤ -2.5) at total hip or spine; 2) CT HU of < 110; 3) National Bone Health Alliance (NBHA) guidelines; and 4) "expanded spine" criteria, which includes patients meeting NBHA criteria and/or HU < 110, and/or "degraded" TBS in the setting of an osteopenic T-score. Inclusion criteria were adult patients with a DXA scan of the total hip and/or spine performed within 1 year and a lumbar spine CT scan within 6 months of the physician visit. RESULTS: Two hundred forty-four patients were included. The mean age was 68.3 years, with 70.5% female, 96.7% Caucasian, and the mean BMI was 28.8. Fracture history was reported in 53.8% of patients. The proportion of patients identified with osteoporosis on DXA, HUs, NBHA guidelines, and the authors' proposed "expanded spine" criteria was 25.4%, 36.5%, 75%, and 81.9%, respectively. Of the patients not identified with osteoporosis on DXA, 31.3% had osteoporosis based on HU, 55.1% had osteoporosis with NBHA, and 70.4% had osteoporosis with expanded spine criteria (p < 0.05), with poor correlations among the different assessment tools. CONCLUSIONS: Limitations in the use of DXA T-scores alone to diagnose osteoporosis in patients with lumbar spondylosis has prompted interest in additional methods of evaluating bone health in the spine, such as CT HU, TBS, and FRAX, to inform guidelines that aim to reduce fracture risk. However, no current osteoporosis assessment was developed with a focus on improving outcomes in spinal surgery. Therefore, the authors propose an expanded spine definition for osteoporosis to identify a more comprehensive cohort of patients with potential poor bone health who could be considered for preoperative optimization, although further study is needed to validate these results in terms of clinical outcomes.

The Case of Flecainide Toxicity: What to Look for and How to Treat.

BACKGROUND: Flecainide is a class Ic antidysrhythmic agent used to prevent and treat both ventricular and supraventricular tachycardias, including atrial fibrillation, atrioventricular nodal re-entrant tachycardia, and Wolff-Parkinson-White syndrome. Flecainide can cause serious side effects, including cardiac arrest, dysrhythmias, and heart failure. Despite its growing use, the presenting signs and symptoms of flecainide toxicity are not familiar to most clinicians. In particular, our patient's particular presentation of acute kidney injury (AKI) resulting in flecainide accumulation is high risk for missed diagnosis in the emergency department. CASE REPORT: A 58-year-old woman presented with altered mental status and hypoxia that was later found to be secondary to sepsis. Medical history was notable for atrial fibrillation, for which she was on flecainide. Laboratory results were notable for hypokalemia and an AKI. Her wide complex tachycardia on admission was ultimately attributed to flecainide toxicity in the setting of AKI. Six days after presentation, it was found that her flecainide level was in the toxic range at 2.02 µg/mL (normal range 0.20-1.00 µg/mL, toxic >1.50 µg/mL). WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Flecainide intoxication is rare but serious due to the potential for cardiogenic shock. Its diagnosis can be difficult, as the flecainide serum level may take days to result. This case demonstrates the necessity of keeping flecainide toxicity on the physician's differential for patients who are taking the drug, as well as what electrocardiogram findings suggest it as the etiology. Treatment can be lifesaving if initiated promptly.

Telemental health training in the Veterans Administration Puget Sound Health Care System.

As a pioneer of training in the field of psychology, the Veterans Affairs (VA) HealthCare System serves as a leader in the training in and provision of Telemental Health (TMH) services in the United States. To meet goals toward continued expansion of these services, the VA TMH training program includes both web-based didactic courses and a skills competency test at a basic level with supervision and consultation in TMH for more advanced training and is available to staff psychologists and psychologist trainees. Despite these efforts, barriers for training in and implementation of TMH occur at the provider, system, and patient level. At the national level, the VA is actively working to resolve these barriers and we share site-specific examples implemented by the VA Puget Sound Health Care System promoting access through TMH team to further address barriers to training and implementation.

The Vaginal Microbiota and Behavioral Factors Associated With Genital Candida albicans Detection in Reproductive-Age Women.

BACKGROUND: Vulvovaginal candidiasis is commonly diagnosed and has been associated in prospective studies with the acquisition of HIV. Little data is available on how the composition of the vaginal microbiota, and other risk factors, are associated with the molecular detection of Candida albicans-a common cause of vulvovaginal candidiasis. METHODS: In a cross-sectional study, self-collected vaginal swabs were obtained from 394 nonpregnant, reproductive-age women. C. albicans was detected using polymerase chain reaction targeting C. albicans ITS1/2 region. Vaginal microbiota was characterized by 16S rRNA gene amplicon sequencing of the V3 to V4 hypervariable regions and clustered into community state types (CSTs). Multiple logistic regression identified factors associated with C. albicans detection. RESULTS: Twenty-one percent had C. albicans detected and 46% reported vaginal symptoms in the prior 60 days. There was a 2-fold increase in the odds of C. albicans if a woman was in a L. crispatus-dominated CST compared to CSTs with low-Lactobacillus levels (adjusted odds ratio, 2.05; 95% confidence interval, 0.97-4.37). History of self-treatment with antifungals, L. crispatus relative abundance, and receptive oral sex were also significantly associated with C. albicans detection. CONCLUSIONS: A L. crispatus-dominated vaginal microbiota is thought to protect women from both development of bacterial vaginosis and incidence of sexually transmitted infections; however, our data suggest that L. crispatus is associated with increased C. albicans detection. Receptive oral sex may also be a risk factor for vaginal C. albicans colonization.

Practical and Regulatory Considerations of Teleprescribing via CVT.

PURPOSE OF REVIEW: Clinical video teleconferencing (CVT) represents a robust mechanism for more accessible medical care. Providers who practice medicine via CVT, including teleprescribing, should understand a number of core practical and regulatory factors. This paper aims to review these core factors, such that providers new to CVT may offer teleprescribing services in a manner consistent with current clinical standards and regulatory requirements. RECENT FINDINGS: A number of practical factors relate to the setup and delivery of teleprescribing services that are contextually influenced by federal and state law. This review will elucidate the practical and regulatory factors relevant to teleprescribing and encourage the use of CVT for patient care. Through consideration of these factors, providers may better implement teleprescribing and prepare for future technology and policy changes relevant to practice.

Pediatric vascularized composite allotransplantation: What is the landscape for obtaining appropriate donors in the United States?

Listing the world's first pediatric bilateral hand transplant patient for a donor posed many challenges including matching the appropriate donor age, bone size, skin tone, and growth potential in an already limited donor population. This study describes the prevalence and distribution of potential pediatric VCA donors in the United States. We assessed the UNOS database from 2008 to 2015 to identify the prevalence of potential pediatric VCA donors. Standard VCA inclusion and exclusion criteria were applied to the dataset for all pediatric solid organ donors. Frequency analyses were performed of characteristics important for VCA matching. The dataset began with 57 300 brain-dead donors and after applying the inclusion and exclusion criteria including age <18, decreased to 4663 (8.1%). The number of pediatric potential VCA donors per UNOS region ranged from 11 to 112/year. The majority of pediatric potential VCA donors were blood type O Whites, with the least common profile being blood type AB of "other" ethnicity. The present study confirmed that pediatric VCA donors are rare and may require longer travel times for procurement and listing at multiple centers in order to find a suitable donor. This will be a limiting factor for the expansion of pediatric VCA.

Patient perceptions of student pharmacist-run mobile influenza vaccination clinics.

OBJECTIVE: To assess patients' perceptions of student pharmacist-run mobile influenza immunization clinics, including satisfaction, comfort, comparison to other experiences, and the views of pharmacists as immunizers. METHODS: A 7-item survey was designed to assess patient satisfaction with receiving influenza vaccinations from student pharmacists, to compare the experience with vaccines received in nonpharmacy settings, and to determine the impact of the experience on patients' views of pharmacist-administered vaccines. The anonymous survey was provided to patients in the postvaccination monitoring area for campus and non-campus mobile clinics from September through October of 2017. RESULTS: Student pharmacists administered 1303 immunizations to patients at 27 campus or community-based mobile clinics. Of 928 patients (71.2% response rate) completing the survey, 90.9% had previously received at least 2 prior influenza vaccinations. More than 98% of patients were very satisfied or satisfied with the student pharmacist-run mobile flu clinic. Similarly, more than 98% of patients were very comfortable or comfortable receiving immunizations from a student pharmacist, and 99.9% of patients rated the experience as either better or similar to previous vaccinations received in nonpharmacy settings. Although 53.4% already used pharmacists as an immunization resource, an additional 38.5% reported they were more comfortable with pharmacists providing vaccinations as a result of the experience. Only 8.1% of patients reported that they would rather receive vaccinations from a physician or nurse. Reasons cited for choosing the mobile clinic for vaccination included convenience (92.2%), cost (35.8%), and positive past experience (28.9%). CONCLUSION: Patients were very satisfied with influenza vaccinations provided by student pharmacists in mobile clinics. The experience appeared to positively affect participants' views of pharmacists as vaccine providers. Proper training, education, and skill development of student pharmacists are essential for ensuring patient safety and for obtaining and maintaining the trust of the patient and health care community.