Developing a global medicine student pre- and post-travel curriculum.

BACKGROUND: The popularity of short-term global health experiences amongst US medical students has been increasing. However, it remains a challenge for medical schools to comprehensively prepare students to work in an international environment and to contribute in ethically responsible and meaningful ways. Students of the Global Medicine program (GMED) of the UIC College of Medicine Center for Global Health set out to develop a pre-and-post travel curriculum that addresses some of these challenges. METHODS: The students surveyed the literature of 66 published global health curricula and identified aspects of pre-and-post travel training that were found to be under-addressed. They then developed a curriculum in conjunction with GMED faculty that incorporated these identified aspects of pre-and-post travel training. RESULTS: Five aspects of pre-and-post travel training were identified as being under-addressed in the literature while traveling. These domains include: [1] examining power relations associated with neo-colonization between and within countries; [2] training for bi-directional learning; [3] examining motivations and goals for participating in global health; [4] addressing personal resiliency and psychosocial wellbeing related to students' travel, and; [5] reflecting on the challenging aspects of the fieldwork experience. CONCLUSIONS: The student-driven curriculum is being integrated into the GMED program through structured didactic sessions, one-on-one mentor meetings and small group discussions. Once students have traveled, the curriculum will be evaluated with the foreign partners they visited.

Spasticity management and resolution of paroxysmal sympathetic hyperactivity in the acute care setting: a case series.

OBJECTIVE: The aim is to highlight three cases of focal spasticity and/or dystonia as potential noxious triggers and treatment targets of Paroxysmal Sympathetic Hyperactivity (PSH). METHODS: We review the literature, explore pathophysiology, and review treatment options. We discuss the clinical course and management of three unique patients who presented to a teaching hospital with severe traumatic brain injury (TBI) complicated by PSH managed by a physiatry consult team. RESULTS: Three patients, ranging in age from 8 months to 27 years, were admitted with severe TBI complicated by PSH refractory to pharmacologic management. All three patients, however, had resolution of PSH within 24-72 hours of focal spasticity treatments (i.e. casting and botulinum toxin injections). CONCLUSION: PSH is a constellation of physiologic findings and physical symptoms that is incompletely understood. Management is based on addressing predominant symptom features and physiologic responses. In certain cases, ongoing spasticity and/or dystonia may serve as noxious stimuli for persistence of PSH in moderate to severe brain injury. As such, the focal treatment of spasticity and/or dystonia may be considered as a treatment target in the management of refractory PSH.

High sensitivity Troponin-T for prediction of adverse events in patients with COVID-19.

BACKGROUND: High sensitivity cardiac troponin-T (hs-TnT) has been associated with mortality in patients hospitalized with COVID-19. We aimed to determine if hs-TnT levels and their timing are independent predictors of adverse events in these patients. DESIGN: Retrospective chart review was performed for all patients hospitalized at our institution between 23 March 2020 and 13 April 2020 who were found to be COVID-19-positive. Clinical, demographic, and laboratory variables including initial and peak hs-TnT were recorded. Univariable and multivariable analyses were completed for a primary composite endpoint of in-hospital death, intubation, need for critical care, or cardiac arrest. RESULTS: In the 276 patients analysed, initial hs-TnT above the median (≥17 ng/L) was associated with increased length of stay, need for vasoactive medications, and death, along with the composite endpoint (OR 3.92, p < 0.001). Multivariable analysis demonstrated that elevated initial hs-TnT was independently associated with the primary endpoint (OR 2.92, p = 0.01). Late-peaking hs-TnT (OR 2.19 for each additional day until peak, p < 0.001) was also independently associated with the composite endpoint. CONCLUSIONS: In patients hospitalized with COVID-19, hs-TnT identifies patients at high risk for adverse in-hospital events, and trends of hs-TnT over time, particularly during the first day, provide additional prognostic information.

New role of mechanical assist device as bridge to transplant: USA perspective.

PURPOSE OF REVIEW: Cardiac transplant remains the gold standard of care for patients with end-stage heart failure. Unfortunately, due to the limited availability of donor hearts in the United States, not all eligible candidates are able to be transplanted. Since the introduction of mechanical assist devices for the treatment of advanced heart failure, patients gain a significant survival benefit while awaiting transplant. With rapidly evolving technology, it is important to appreciate the advances in the current use of mechanical assist devices. RECENT FINDINGS: Following a comprehensive analysis of novel therapies in end-stage heart failure, there is an enhancement in quality of life and life expectancy following implantation of left ventricular (LV) assist devices (LVADs). When implanted in suitable patients as bridge-to-transplant or 'destination therapy', recipients demonstrate superior outcomes and survival compared with those who remain on optimal medical therapy. SUMMARY: The use of LV assist devices (LVADs) as bridge to transplantation has gained popularity over the last decade. It is recognized as an integral treatment modality in end-stage heart failure to those awaiting heart transplantation. When implanted in the appropriately chosen patient, it is superior to medical treatment alone and has shown noninferiority to heart transplantation while allowing for optimal functional status and preservation of end organ function.

Altered fear learning across development in both mouse and human.

The only evidence-based behavioral treatment for anxiety and stress-related disorders involves desensitization techniques that rely on principles of extinction learning. However, 40% of patients do not respond to this treatment. Efforts have focused on individual differences in treatment response, but have not examined when, during development, such treatments may be most effective. We examined fear-extinction learning across development in mice and humans. Parallel behavioral studies revealed attenuated extinction learning during adolescence. Probing neural circuitry in mice revealed altered synaptic plasticity of prefrontal cortical regions implicated in suppression of fear responses across development. The results suggest a lack of synaptic plasticity in the prefrontal regions, during adolescence, is associated with blunted regulation of fear extinction. These findings provide insight into optimizing treatment outcomes for when, during development, exposure therapies may be most effective.

Adolescent-specific patterns of behavior and neural activity during social reinforcement learning.

Humans are sophisticated social beings. Social cues from others are exceptionally salient, particularly during adolescence. Understanding how adolescents interpret and learn from variable social signals can provide insight into the observed shift in social sensitivity during this period. The present study tested 120 participants between the ages of 8 and 25 years on a social reinforcement learning task where the probability of receiving positive social feedback was parametrically manipulated. Seventy-eight of these participants completed the task during fMRI scanning. Modeling trial-by-trial learning, children and adults showed higher positive learning rates than did adolescents, suggesting that adolescents demonstrated less differentiation in their reaction times for peers who provided more positive feedback. Forming expectations about receiving positive social reinforcement correlated with neural activity within the medial prefrontal cortex and ventral striatum across age. Adolescents, unlike children and adults, showed greater insular activity during positive prediction error learning and increased activity in the supplementary motor cortex and the putamen when receiving positive social feedback regardless of the expected outcome, suggesting that peer approval may motivate adolescents toward action. While different amounts of positive social reinforcement enhanced learning in children and adults, all positive social reinforcement equally motivated adolescents. Together, these findings indicate that sensitivity to peer approval during adolescence goes beyond simple reinforcement theory accounts and suggest possible explanations for how peers may motivate adolescent behavior.

Stereotype confirmation concerns predict dropout from cognitive behavioral therapy for social anxiety disorder.

BACKGROUND: There are high attrition rates observed in efficacy studies for social anxiety disorder, and research has not identified consistent nor theoretically meaningful predictors of dropout. Pre-treatment symptom severity and demographic factors, such as age and gender, are sometimes predictive of dropout. The current study examines a theoretically meaningful predictor of attrition based on experiences associated with social group membership rather than differences between social group categories--fear of confirming stereotypes. METHODS: This is a secondary data analysis of a randomized controlled trial comparing two cognitive behavioral treatments for social anxiety disorder: virtual reality exposure therapy and exposure group therapy. Participants (N = 74) with a primary diagnosis of social anxiety disorder who were eligible to participate in the parent study and who self-identified as either "African American" (n = 31) or "Caucasian" (n = 43) completed standardized self-report measures of stereotype confirmation concerns (SCC) and social anxiety symptoms as part of a pre-treatment assessment battery. RESULTS: Hierarchical logistic regression showed that greater stereotype confirmation concerns were associated with higher dropout from therapy--race, age, gender, and pre-treatment symptom severity were not. Group treatment also was associated with higher dropout. CONCLUSIONS: These findings urge further research on theoretically meaningful predictors of attrition and highlight the importance of addressing cultural variables, such as the experience of stereotype confirmation concerns, during treatment of social anxiety to minimize dropout from therapy.

Efficacy of Lateral View Needle Placement for Sacroiliac Joint Injections.

Introduction: Sacroiliac joint (SIJ) pathology is typically diagnosed and treated with fluoroscopy-guided intraarticular injections. Most practitioners use only an anteroposterior (AP) or oblique view. Although injection into the periarticular space may yield adequate pain relief, intraarticular needle placement is imperative to identify SIJ pathology and plan future management. This study highlights the importance of obtaining an additional lateral view during fluoroscopy to better evaluate SIJ disease. Methods: A retrospective review of 38 patients who underwent fluoroscopy guided SIJ injection was conducted, for which IRB approval was granted by the MetroWest Medical Center Institutional Review Board. Patient demographics (age, sex, BMI) and pre- and post-operative numerical rating scale (NRS) scores were collected, and initial needle location was reviewed. Patients were placed into groups according to initial needle location. Statistical analysis was conducted using a Mann-Whitney U-test with significance defined as p < 0.05. Results: The 21 females and 17 males had a mean age and BMI of 70.5 years and 27.8 kg/m2, respectively. Thirty-one patients had initial intraarticular needle placement confirmed with lateral arthrogram, and 7 patients had initial periarticular needle placement, requiring needle readjustment in lateral confirmatory view. Both groups had similar demographic characteristics. No statistically significant differences were found between the two groups' mean NRS score improvement (p=0.108). Conclusion: Using only the AP or oblique view during needle placement results in miss rates of nearly 20% while adding a lateral view can lower miss rates to near 0%. While pain relief may be adequate in either case, proper diagnosis and future management relies upon accurate needle placement.

Telemedicine and the environment: life cycle environmental emissions from in-person and virtual clinic visits.

Concern over climate change is growing in the healthcare space, and telemedicine has been rapidly expanding since the start of the COVID19 pandemic. Understanding the various sources of environmental emissions from clinic visits-both virtual and in-person-will help create a more sustainable healthcare system. This study uses a Life Cycle Assessment with retrospective clinical data from Stanford Health Care (SHC) in 2019-2021 to determine the environmental emissions associated with in-person and virtual clinic visits. SHC saw 13% increase in clinic visits, but due to the rise in telemedicine services, the Greenhouse Gas emissions (GHGs) from these visits decreased 36% between 2019 and 2021. Telemedicine (phone and video appointments) helped SHC avoid approximately 17,000 metric tons of GHGs in 2021. Some departments, such as psychiatry and cancer achieved greater GHG reductions, as they were able to perform more virtual visits. Telemedicine is an important component for the reduction of GHGs in healthcare systems; however, telemedicine cannot replace every clinic visit and proper triaging and tracking systems should be in place to avoid duplicative care.

Characterization of novel canine bocaviruses and their association with respiratory disease.

We report the first identification, genetic characterization and disease association studies of several novel species of canine bocaviruses (CBoV). Evolutionary analysis confirmed that CBoV are genetically distinct from the only other known canine bocavirus, minute virus of canines, with which they share less than 63, 62 and 64 % protein identity in NS, NP and VP genes, respectively. Comparative genetic analysis of 37 VP gene variants found in diseased and healthy animals showed that these novel viruses are genetically highly diverse and are common in canine respiratory infections that have remained undetected until now. Interestingly, we observed that a CBoV genotype with a unique deletion in the VP2 gene was significantly more prevalent in animals with respiratory diseases compared with healthy animals.

Investigating the role of stigma on fertility desire among HIV-positive women in Bangkok, Thailand: a qualitative study.

OBJECTIVES: The Thai Ministry of Public Health is committed to reaching the United Nations' goal of zero new HIV infections, zero AIDS-related deaths, and zero discrimination towards people living with HIV by 2030. While significant progress has been made towards the first two targets, stigma against women living with HIV (WLHIV), particularly in the context of their desire to have and raise children, remains an issue. METHODS: We conducted interviews with WLHIV (n=10) who expressed a desire to have a child or delivered an infant within 2 years of the study date, and key informants (KI) involved in their medical care and social support. We asked women about their HIV diagnosis, thoughts about pregnancy, desires to have children, and perceived stigma. KIs were asked about their perceptions of stigma towards WLHIV and policies or recommended actions to reduce discrimination towards this population. RESULTS: While the WLHIV reported that their healthcare providers had generally been supportive of them having children, internalised stigma and the perceived risk of or actual discrimination by community members negatively impacted fertility desire and peripartum experiences among the study participants. KIs confirmed similar sources of discrimination, emphasising more internalised and community-based stigma rather than from healthcare providers. Both groups highlighted the importance of increasing community education and awareness about HIV to reduce stigma. CONCLUSIONS: Complex issues around stigma and discrimination specific to women with HIV should be addressed at the community level in order to reach the goal of zero discrimination against all people living with HIV in Thailand.

Strain-dependence of the Angelman Syndrome phenotypes in Ube3a maternal deficiency mice.

Angelman syndrome (AS) is a genetic neurodevelopmental disorder, most commonly caused by deletion or mutation of the maternal allele of the UBE3A gene, with behavioral phenotypes and seizures as key features. Currently no treatment is available, and therapeutics are often ineffective in controlling AS-associated seizures. Previous publications using the Ube3a maternal deletion model have shown behavioral and seizure susceptibility phenotypes, however findings have been variable and merit characterization of electroencephalographic (EEG) activity. In this study, we extend previous studies comparing the effect of genetic background on the AS phenotype by investigating the behavioral profile, EEG activity, and seizure threshold. AS C57BL/6J mice displayed robust behavioral impairments, spontaneous EEG polyspikes, and increased cortical and hippocampal power primarily driven by delta and theta frequencies. AS 129 mice performed poorly on wire hang and contextual fear conditioning and exhibited a lower seizure threshold and altered spectral power. AS F1 hybrid mice (C57BL/6J × 129) showed milder behavioral impairments, infrequent EEG polyspikes, and fewer spectral power alterations. These findings indicate the effect of common genetic backgrounds on the Ube3a maternal deletion behavioral, EEG, and seizure threshold phenotypes. Our results will inform future studies on the optimal strain for evaluating therapeutics with different AS-like phenotypes.

The Risk of Cardiovascular Disease, Diabetes, Liver-Related Outcomes, and Death Over 10 Years in HIV/HCV-Coinfected Patients With and Without Steatosis.

BACKGROUND: Coinfection with HIV/HCV is associated with more severe liver disease, including increased frequency of steatosis and significant fibrosis, compared to patients mono-infected with HCV or HIV. We sought to explore the impact of steatosis on cardiovascular disease (CVD), liver-related outcomes, and survival. METHODS: An IRB-approved, single-center retrospective cohort study was undertaken to analyze 10-year clinical outcomes in HIV/HCV-coinfected patients. Liver biopsy was performed at study entry for the evaluation of HCV disease; a study pathologist graded samples for fibrosis and steatosis. Clinical outcomes, including cardiac events, liver function with FIB-4, AST to Platelet Ratio Index, and survival were assessed over 10 years. RESULTS: At cohort entry N = 105, mean age 45 ± 7 years, 70% male, and 56% had steatosis present on biopsy. During the 10-year follow-up, no association was found between incident CVD, changes in noninvasive liver fibrosis measures, or survival in the steatosis group compared to nonsteatosis group. However, nonsignificant trends were noted. Overall, mortality for this coinfected population was 25% over 10 years, with liver disease as the most common cause of death. CONCLUSIONS: Given the prevalence of steatosis in approximately half of coinfected patients, larger studies are warranted to determine if steatosis is associated with cardiac disease, diabetes, or liver disease progression in this population. Furthermore, 10-year mortality for this population was very high, underscoring the importance of HCV treatment and need for a better understanding of other variables responsible for decreased survival in this population.

Association of parental ADHD and depression with externalizing and internalizing dimensions of child psychopathology.

OBJECTIVE: To study the independent association of parental depression and ADHD on three dimensions of child psychopathology among 178 children aged 5 to 10 years. METHOD: Self-reported measures of parental depression and ADHD as well as rating scales and structure diagnostic interviews of child internalizing, ADHD, and externalizing problems were obtained. RESULTS: Structural equation modeling indicated that parental ADHD was positively associated with a broad child problems factor after a second-order factor of child problems best accounted for the high intercorrelations among the internalizing, ADHD, and externalizing child psychopathology factors. Parental depression did not significantly predict the second-order child problems factor, but it specifically predicted the child internalizing factor. CONCLUSION: These results suggest that parental ADHD may be a nonspecific risk factor for child psychopathology broadly, whereas parental depression may function as a specific risk factor for child internalizing problems.

Does engagement with exposure yield better outcomes? Components of presence as a predictor of treatment response for virtual reality exposure therapy for social phobia.

Virtual reality exposure (VRE) has been shown to be effective for treating a variety of anxiety disorders, including social phobia. Presence, or the level of connection an individual feels with the virtual environment, is widely discussed as a critical construct both for the experience of anxiety within a virtual environment and for a successful response to VRE. Two published studies show that whereas generalized presence relates to fear ratings during VRE, it does not relate to treatment response. However, presence has been conceptualized as multidimensional, with three primary factors (spatial presence, involvement, and realness). These factors can be linked to other research on the facilitation of fear during exposure, inhibitors of treatment response (e.g., distraction), and more recent theoretical discussions of the mechanisms of exposure therapy, such as Bouton's description of expectancy violation. As such, one or more of these components of presence may be more strongly associated with the experience of fear during VRE and treatment response than the overarching construct. The current study (N=41) evaluated relations between three theorized components of presence, fear ratings during VRE, and treatment response for VRE for social phobia. Results suggest that total presence and realness subscale scores were related to in-session peak fear ratings. However, only scores on the involvement subscale significantly predicted treatment response. Implications of these findings are discussed.

Identification and characterization of a new bocavirus species in gorillas.

A novel parvovirus, provisionally named Gorilla Bocavirus species 1 (GBoV1), was identified in four stool samples from Western gorillas (Gorilla gorilla) with acute enteritis. The complete genomic sequence of the new parvovirus revealed three open reading frames (ORFs) with an organization similar to that of known bocaviruses. Phylogenetic analysis using complete capsid and non structural (NS) gene sequence suggested that the new parvovirus is most closely related to human bocaviruses (HBoV). However, the NS ORF is more similar in length to the NS ORF found in canine minute virus and bovine parvovirus than in HBoV. Comparative genetic analysis using GBoV and HBoV genomes enabled characterization of unique splice donor and acceptor sites that appear to be highly conserved among all four HBoV species, and provided evidence for expression of two different NS proteins in all primate bocaviruses. GBoV is the first non-human primate bocavirus identified and provides new insights into the genetic diversity and evolution of this highly prevalent and recently discovered group of parvoviruses.