Measles in the vaccinated host.

A woman in her 40s known to have systemic lupus erythematosus presented with a maculopapular rash on her face, neck and chest following measles exposure. She had received a single-dose measles vaccine as a child in the 1970s and was therefore presumed to be immune, and thus not infectious. As a result, she was initially managed in an open bay. Measles virus IgM antibody in serum was undetectable; however, measles virus RNA was subsequently detected in throat swab by PCR, which is consistent with current infection. Measles is one of the most transmissible diseases in the world and cases are rising both in the UK and globally. Our case and literature review highlight the risk of vaccine failure in measles, especially in people who have not received two doses of the measles, mumps and rubella vaccine. It also highlights the challenges in diagnosing measles in previously vaccinated individuals.

The Bering Strait was flooded 10,000 years before the Last Glacial Maximum.

The cyclic growth and decay of continental ice sheets can be reconstructed from the history of global sea level. Sea level is relatively well constrained for the Last Glacial Maximum (LGM, 26,500 to 19,000 y ago, 26.5 to 19 ka) and the ensuing deglaciation. However, sea-level estimates for the period of ice-sheet growth before the LGM vary by > 60 m, an uncertainty comparable to the sea-level equivalent of the contemporary Antarctic Ice Sheet. Here, we constrain sea level prior to the LGM by reconstructing the flooding history of the shallow Bering Strait since 46 ka. Using a geochemical proxy of Pacific nutrient input to the Arctic Ocean, we find that the Bering Strait was flooded from the beginning of our records at 46 ka until [Formula: see text] ka. To match this flooding history, our sea-level model requires an ice history in which over 50% of the LGM's global peak ice volume grew after 46 ka. This finding implies that global ice volume and climate were not linearly coupled during the last ice age, with implications for the controls on each. Moreover, our results shorten the time window between the opening of the Bering Land Bridge and the arrival of humans in the Americas.

Burnout, compassion fatigue, and vicarious trauma among wildfire responders.

Firefighting is an essential occupation that is hazardous and stressful. While researchers have established that firefighters are likely to experience burnout, compassion fatigue (CF), and vicarious trauma (VT), no studies to date have focused on these variables in a context specific to wildfire response. As wildfires and their intensity continue to be a growing concern in the Western United States, there is a need to understand the extent of burnout, CF, and VT among firefighters, particularly those who respond to wildfires. This study was conducted at a large metropolitan fire department located in Colorado (n = 186). There were three scales used for this study: the Maslach Burnout Inventory-General Survey, the Vicarious Trauma Scale, and the Compassion Fatigue Self-Test. Survey results indicated that the firefighters experienced emotional exhaustion (µ = 16.99), moderate depersonalization (µ = 11.12), low reduced personal accomplishment (µ = 29.29), extremely high CF (µ = 22.60), and moderate VT (µ = 29.15). There were no significant differences between wildfire responders and nonwildfire responders. However, firefighters who were midcareer (11-15 years of service) and those who were between the ages of 35 and 55 were statistically more likely to experience emotional exhaustion and depersonalization than their younger and older peers, thus suggesting that further research is warranted to understand midcareer and midlife stressors among firefighters.

Necessity is the mother of invention: how the COVID-19 pandemic could change medical student placements for the better.

COVID-19 led to the widespread withdrawal of face-to-face hospital-based clinical placements, with many medical schools switching to online learning. This precipitated concern about potential negative impact on clinical and interprofessional skill acquisition. To overcome this problem, we piloted a 12-week COVID-19 safe face-to-face clinical placement for 16 medical students at the Hospital for Tropical Diseases, London, during the first wave of the COVID-19 pandemic. COVID-19 infection control measures necessitated that students remained in 'social bubbles' for placement duration. This facilitated an apprenticeship-style teaching approach, integrating students into the clinical team for placement duration. Team-based learning was adopted to develop and deliver content. Teaching comprised weekly seminars, experiential ward-based attachments and participation in quality improvement and research projects. The taught content was evaluated through qualitative feedback, reflective practice, and pre-apprenticeship and post-apprenticeship confidence questionnaires across 17 domains. Students' confidence improved in 14 of 17 domains (p<0.05). Reflective practice indicated that students valued the apprenticeship model, preferring the longer clinical attachment to existent shorter, fragmented clinical placements. Students described improved critical thinking, group cohesion, teamwork, self-confidence, self-worth and communication skills. This article describes a framework for the safe and effective delivery of a longer face-to-face apprenticeship-based clinical placement during an infectious disease pandemic. Longer apprenticeship-style attachments have hidden benefits to general professional training, which should be explored by medical schools both during the COVID-19 pandemic and, possibly, for any future clinical placements.

Bariatric surgery: a viable treatment option for patients with severe mental illness.

BACKGROUND: Although bariatric surgery has become a recognized treatment for obesity, its utility among patients with severe psychiatric disorders has not been extensively studied. A few studies have reported similar weight loss outcomes in these patients, but psychiatric status after bariatric surgery has been studied only minimally, and it is unknown if exacerbation of the mental illness affects weight loss. OBJECTIVES: The aim of this study was to shed greater light on the issue of serious mental illness and bariatric surgery. Specifically, do patients with a diagnosis of schizophrenia, bipolar I, and bipolar II have poorer weight loss outcomes postbariatric surgery than the general bariatric surgery population? Also, do patients with these diagnoses experience an exacerbation of psychiatric symptoms after bariatric surgery, and if so, is the exacerbation of these disorders linked to poorer weight loss results? SETTING: Midwest university medical center. METHODS: A medical record review of approximately 1500 bariatric patients in a Midwest university medical center was conducted to identify those patients with diagnoses of schizophrenia, bipolar I, and bipolar II. Information was gathered on bariatric surgery outcomes and changes in psychiatric status postsurgery. RESULTS: Eighteen patients were identified as undergoing bariatric surgery and having a diagnosis of schizophrenia, bipolar I, or bipolar II. Weight loss in this group was significant and comparable to expected outcomes of absolute weight lost, changes in body mass index, and percentage excess weight loss for patients in the typical bariatric population. Postsurgery psychiatric status was known on 10 patients. All 10 patients experienced some exacerbation of psychiatric problems yet weight loss outcomes were still as expected. CONCLUSION: Bariatric surgery is a viable obesity treatment option for patients with schizophrenia, bipolar I, and bipolar II disorders. Symptom exacerbations occurred postsurgery, although it is not clear if these were due to the surgery or would have occurred in the normal course of the illness.

Effects of reduced time in bed on daytime sleepiness and recovery sleep in fibromyalgia and rheumatoid arthritis.

OBJECTIVES: Fibromyalgia (FM) and rheumatoid arthritis (RA) are associated with sleep disturbance and daytime sleepiness. We sought to determine whether sleep homeostatic mechanisms are blunted in FM by assessing the effects of reduced time in bed (4h) on next day sleepiness and recovery sleep. METHODS: Fifty women (18 with FM, 16 with RA, and 16 HC) had a baseline 8h time-in-bed (TIB) and Multiple Sleep Latency Test (MSLT) the following day, and 3-7 days later bedtime was reduced (4h) followed by MSLT and an 8h TIB recovery night. RESULTS: Following reduced bedtime the MSLT was reduced relative to baseline in the FM group by an amount (4.3+/-4.8 min) similar to that of the RA (3.1+/-5.2 min) and HC (4.8 +/-3.1 min) groups. Relative to the baseline on the recovery night the FM group showed increased sleep efficiency (83.7+/-7.8 to 88.1+/-9.2%) relative to the RA (83.9+/-8.6 to 80.9+/-13.3%) and HC (90.1+/-5.0 to 87.4+/-7.6%) groups due primarily to reduced wake after sleep onset. The groups did not differ in recovery night sleep stages with the exception that the FM group showed REM rebound (21.6+/-6.5 to 25.2+/-6.0%), which was not found in the RA (20.4+/-7.4 to 17.8+/-6.5%) or HC (16.6+/-6.6 to 17.5+/-6.0%) groups. CONCLUSIONS: Compared to RA and HC, people with FM responded to reduced bedtime with a comparable increase in sleepiness and greater recovery sleep efficiency, suggesting that homeostatic sleep mechanisms are functional in FM. People with FM uniquely showed REM rebound on recovery from reduced bedtime suggesting underlying REM pressure.

Nocturnal sleep, daytime sleepiness and fatigue in fibromyalgia patients compared to rheumatoid arthritis patients and healthy controls: a preliminary study.

OBJECTIVE: Fibromyalgia (FM) and rheumatoid arthritis (RA) are pain disorders, both of which are associated with complaints of sleep disturbance, non-refreshing sleep, and daytime sleepiness and fatigue. Given the putative differential central versus peripheral nervous system involvement in these disorders, subjective and objective measures of nocturnal sleep, daytime sleepiness, fatigue and pain were compared between patient groups and to healthy controls (HC). METHODS: Fifty women (18 with FM, 16 with RA, and 16 HC) completed an 8h nocturnal polysomnogram (NPSG), Multiple Sleep Latency Test (MSLT) the following day, and self-reports of sleepiness, fatigue, and pain. RESULTS: FM and RA patients were similar to each other and had less total sleep time than HC, primarily due to more wake after sleep onset. In an analysis of sleep and wake bouts, both patient groups had longer duration of wake bouts than HC. Nocturnal sleep was judged to be non-restorative for both patient groups. Although reporting the greatest subjective sleepiness and fatigue, FM patients had less objective (MSLT) daytime sleepiness than HC, whereas RA patients were intermediate in objective sleepiness. Unlike the RA and HC, FM patients also showed no association between their subjective and objective sleepiness. CONCLUSIONS: Women with FM have similar nocturnal sleep disturbance as those with RA, but FM patients report greater self-rated daytime sleepiness and fatigue than RA and HC, which did not correspond to the relatively low level of objectively determined daytime sleepiness of FM patients. These findings suggest a generalized hyperarousal state in FM.

An Emotional Exposure-Based Treatment of Traumatic Stress for People with Chronic Pain: Preliminary Results for Fibromyalgia Syndrome.

Emotional trauma occurs in many patients with chronic pain, particularly fibromyalgia syndrome (FMS). Current cognitive-behavioral treatments for chronic pain have limited effects, perhaps because the trauma is not addressed, whereas emotional exposure-based treatments improve post-traumatic stress, but have not been tested on chronic pain. We present a novel, brief treatment protocol for people with chronic pain and unresolved trauma (Multi-Stimulus, Multi-Technique Emotional Exposure Therapy), which involves detecting avoidance of a range of emotion-related stimuli, implementing exposure techniques tailored to the patient's avoidances, and negotiating the process and therapeutic alliance. This treatment was pilot tested on 10 women with intractable FMS and trauma histories. Three months post-treatment, the sample showed moderate to large effects on stress symptoms, FMS impact, and emotional distress; and small to moderate improvements on pain and disability. Two patients showed substantial improvement, four made moderate gains, two showed modest improvement, and two did not benefit. This pilot study suggests that emotional exposure treatment for unresolved trauma may benefit some patients with FMS. Controlled testing of the treatment for FMS and other chronic pain populations is indicated.