Post-COVID Sequelae: From Lung Disease to Long Disease.

COVID-19 can have both an acute phase and post-acute phase of illness termed post-COVID sequelae, or "long Covid." In this case, a 66-year-old woman with a past medical history of reactive airway disease was admitted for shortness of breath twice. The first episode occurred in the setting of active COVID-19 infection. However, the second episode took place seven weeks later in the absence of COVID-19 as evidenced by a rapid antigen test. It is unclear why she re-developed shortness of breath after being discharged symptom-free from her initial admission. After treatment with prednisone, albuterol, and ipratropium she experienced symptomatic relief yet again and outpatient pulmonary function testing demonstrated a mildly obstructive pattern reversed with an inhaled bronchodilator. She has remained symptom-free since finishing an outpatient prednisone course. It is possible she developed post-COVID sequelae resembling an acute asthma exacerbation. Though the exact mechanism of post-COVID sequelae is not known, it is thought to be due to a combination of immune activation, dysregulation, and suppression. It is an important presentation for internists to know given the prevalence of COVID-19.

The Effect of Elexacaftor/Tezacaftor/Ivacaftor on Hospitalizations and Intravenous Antibiotic Use.

INTRODUCTION: Elexacaftor/tezacaftor/ivacaftor (ETI) is a highly effective cystic fibrosis transmembrane conductance regulator modulator. It has been shown to improve lung function and decrease pulmonary exacerbations in short-term clinical trials. The effect of ETI on hospitalization and intravenous (IV) antibiotic rates is not known. We performed a single-institution, retrospective review comparing these rates before and after the initiation of ETI. METHODS: Among patients taking the cystic fibrosis modulator ETI, we compared the cumulative number of days per month hospitalized and cumulative number of days per month on IV antibiotics before and after the initiation of ETI. Electronic medical records from 37 patients were reviewed from 2016 through 2020 to identify demographic data, hospitalizations, and antibiotic use. Results were then stratified by severity of lung disease. RESULTS: Following the initiation of ETI, there was a decline in days per month hospitalized and on IV antibiotics. The cumulative average number of days per month patients were hospitalized decreased 86% from 27 to 4 after starting ETI. The cumulative average number of days per month on IV antibiotics decreased by 80% (32.5 to 6.4). Most of these reductions occurred among patients with severe lung disease. DISCUSSION: At our institution, we saw a decline in cystic fibrosis-related hospitalizations and in the use of outpatient IV antibiotics following the initiation of ETI. These reductions were most pronounced among patients with severe lung disease. CONCLUSION: The initiation of ETI was associated with a decline in days hospitalized and days on IV antibiotics.

Measuring Knowledge of Community Health Workers at the Last Mile in Liberia: Feasibility and Results of Clinical Vignette Assessments.

INTRODUCTION: Community health workers (CHWs) can provide lifesaving treatment for children in remote areas, but high-quality care is essential for effective delivery. Measuring the quality of community-based care in remote areas is logistically challenging. Clinical vignettes have been validated in facility settings as a proxy for competency. We assessed feasibility and effectiveness of clinical vignettes to measure CHW knowledge of integrated community case management (iCCM) in Liberia's national CHW program. METHODS: We developed 3 vignettes to measure knowledge of iCCM illnesses (malaria, diarrhea, and pneumonia) in 4 main areas: assessment, diagnosis, treatment, and caregiver instructions. Trained nurse supervisors administered the vignettes to CHWs in 3 counties in rural Liberia as part of routine program supervision between January and May 2019, collected data on CHW knowledge using a standardized checklist tool, and provided feedback and coaching to CHWs in real time after vignette administration. Proportions of vignettes correctly managed, including illness classification, treatment, and referral where necessary, were calculated. We assessed feasibility, defined as the ability of clinical supervisors to administer the vignettes integrated into their routine activities once per year for each CHW, and effectiveness, defined as the ability of the vignettes to measure the primary outcomes of CHW knowledge of diagnosis and treatment including referrals. RESULTS: We were able to integrate this assessment into routine supervision, facilitate real-time coaching, and collect data on iCCM knowledge among 155 CHWs through delivery of 465 vignettes. Diagnosis including severity was correct in 65%-82% of vignettes. CHWs correctly identified danger signs in 44%-50% of vignettes, correctly proposed referral to the facility in 63% of vignettes including danger signs, and chose correct lifesaving treatment in 23%-65% of vignettes. Both diagnosis and lifesaving treatment rates were highest for malaria and lowest for severe pneumonia. CONCLUSION: Administration of vignettes to assess knowledge of correct iCCM case management was feasible and effective in producing results in this setting. Proportions of correct diagnosis and lifesaving treatment varied, with high proportions for uncomplicated disease, but lower for more severe cases, with accurate recognition of danger signs posing a challenge. Future work includes validation of vignettes for use with CHWs through direct observation, strengthening supportive supervision, and program interventions to address identified knowledge gaps.

Resilience to emotional distress in response to failure, error or mistakes: A systematic review.

Perceptions of failure have been implicated in a range of psychological disorders, and even a single experience of failure can heighten anxiety and depression. However, not all individuals experience significant emotional distress following failure, indicating the presence of resilience. The current systematic review synthesised studies investigating resilience factors to emotional distress resulting from the experience of failure. For the definition of resilience we used the Bi-Dimensional Framework for resilience research (BDF) which suggests that resilience factors are those which buffer the impact of risk factors, and outlines criteria a variable should meet in order to be considered as conferring resilience. Studies were identified through electronic searches of PsycINFO, MEDLINE, EMBASE and Web of Knowledge. Forty-six relevant studies reported in 38 papers met the inclusion criteria. These provided evidence of the presence of factors which confer resilience to emotional distress in response to failure. The strongest support was found for the factors of higher self-esteem, more positive attributional style, and lower socially-prescribed perfectionism. Weaker evidence was found for the factors of lower trait reappraisal, lower self-oriented perfectionism and higher emotional intelligence. The majority of studies used experimental or longitudinal designs. These results identify specific factors which should be targeted by resilience-building interventions. Resilience; failure; stress; self-esteem; attributional style; perfectionism.

Enhancing health care worker ability to detect and care for patients with monkeypox in the Democratic Republic of the Congo.

BACKGROUND: Monkeypox (MPX) is an endemic disease of public health importance in the Democratic Republic of the Congo (DRC). In 2010, the DRC Ministry of Health joined with external partners to improve MPX surveillance in the Tshuapa Health District of DRC. A pivotal component of the program is training of health zone personnel in surveillance methods and patient care. In this report we evaluate outcomes of the training program. METHODS: Health care worker knowledge of key concepts in the MPX training curriculum was assessed using an anonymous self-administered survey. Additionally, evaluators collected feedback about the capacity of participants to perform the surveillance tasks. Training impacts were determined by assessing various surveillance performance metrics. RESULTS: Correct trainee responses to questions about MPX symptoms and patient care increased significantly upon completion of training events. During the 12 months after the initial training, the proportion of suspected cases investigated increased significantly (from 6.7 to 37.3%), as compared to the 5 months prior. However, the proportion of reported cases that were ultimately confirmed remained unchanged, 20.1% (5/24) vs 23.3% (60/257). CONCLUSIONS: We have demonstrated that the MPX curriculum developed for this initiative was effective in transferring knowledge and was associated with improved detection of human MPX cases.

Investigation of a prolonged Group A Streptococcal outbreak among residents of a skilled nursing facility, Georgia, 2009-2012.

BACKGROUND: Group A Streptococcus (GAS) is an important bacterial cause of life-threatening illness among the elderly. Public health officials investigated a protracted GAS outbreak in a skilled nursing facility in Georgia housing patients requiring 24-hour nursing or rehabilitation, to prevent additional cases. METHODS: We defined a case as illness in a skilled nursing facility resident with onset after January 2009 with GAS isolated from a usually sterile (invasive) or nonsterile site (noninvasive). Cases were "recurrent" if >1 month elapsed between episodes. We evaluated infection control practices, performed a GAS carriage study, emm-typed available GAS isolates, and conducted a case-control study of risk factors for infection. RESULTS: Three investigations, spanning 36 months, identified 19 residents with a total of 24 GAS infections: 15 invasive (3 recurrent) and 9 noninvasive (2 recurrent) episodes. All invasive cases required hospitalization; 4 patients died. Seven residents were GAS carriers. All invasive cases and resident carrier isolates were type emm 11.0. We observed hand hygiene lapses, inadequate infection documentation, and more frequent wound care staff turnover on wing A versus wing B. Risk factors associated with infection in multivariable analysis included living on wing A (odds ratio [OR], 3.4; 95% confidence interval [CI], .9-16.4) and having an indwelling line (OR, 5.6; 95% CI, 1.2-36.4). Cases ceased following facility-wide chemoprophylaxis in July 2012. CONCLUSIONS: Staff turnover, compromised skin integrity in residents, a suboptimal infection control program, and lack of awareness of infections likely contributed to continued GAS transmission. In widespread, prolonged GAS outbreaks in skilled nursing facilities, facility-wide chemoprophylaxis may be necessary to prevent sustained person-to-person transmission.

Autism spectrum disorders.

Autism spectrum disorders are being diagnosed with increasing frequency. The likelihood that a primary care provider will see a patient with autism spectrum disorder in their clinic is high. In this article, current diagnostic criteria and expected changes in DSM criteria, as well as prevalence rates and epidemiologic studies are reviewed. Recommendations for screening, including early warning signs, and best practices for diagnosis are discussed. Comprehensive evidence based intervention for ASD as well as the findings of the National Standards Project are reviewed. Medication management is also described, as are the roles of other treating professionals.

Teaching applied behavior analysis knowledge competencies to direct-care service providers: outcome assessment and social validation of a training program.

Staff training is a critical performance improvement objective within behavioral health care organizations. This study evaluated a systematic training program for teaching applied behavior analysis knowledge competencies to newly hired direct-care employees at a day and residential habilitation services agency for adults with intellectual and developmental disabilities. Three content areas--measurement, behavior support, and skill acquisition--were trained in a group format using Powerpoint® presentations that featured didactic instruction, practice exercises, and video demonstrations. The employees completed an assessment of knowledge test before and after training in each content area. Across five training groups, the average correct posttraining test scores were consistently higher than pretraining test scores. A social validity assessment revealed that the employees judged the training program favorably along several dimensions. Issues pertaining to staff training and performance improvement initiatives are discussed.

Turning sexual science into news: sex research and the media.

In this article we report on the findings of a two-part project investigating contemporary issues in sexuality researchers' interaction with journalists. The goal of the project was to explore best practices and suggest curricular and training initiatives for sexuality researchers and journalists that would enhance the accurate dissemination of sexuality research results in the media. We present the results of a survey of a convenience sample of 94 sexuality researchers about their experiences and concerns regarding media coverage and a summary of the main themes that emerged from an invitational conference of sexuality researchers and journalists. In addition, we present some preliminary recommendations for training and best practices. Topics assessed include reporting accuracy; sex researchers' comfort with various topics, media, and journalists; researchers' perceptions of the purpose and content of articles; concern about the impact of media coverage; and training for sexuality researchers.