Telehealth in PM&R: Past, present, and future in clinical practice and opportunities for translational research.

Telehealth refers to the use of telecommunication devices and other forms of technology to provide services outside of the traditional in-person health care delivery system. Growth in the use of telehealth creates new challenges and opportunities for implementation in clinical practice. The American Academy of Physical Medicine and Rehabilitation (AAPM&R) assembled an expert group to develop a white paper to examine telehealth innovation in Physical Medicine and Rehabilitation (PM&R). The resultant white paper summarizes how telehealth is best used in the field of PM&R while highlighting current knowledge deficits and technological limitations. The report identifies new and transformative opportunities for PM&R to advance translational research related to telehealth and enhance patient care.

Food rationing affects dietary selenium bioaccumulation and life cycle performance in the mayfly Centroptilum triangulifer.

Selenium effects in nature are mediated by the relatively large bioconcentration of aqueous Se by primary producers and smaller, yet critical, dietary transfers to primary consumers. These basal processes are then propagated through food webs to higher trophic levels. Here we quantified the movement of dissolved Se (as selenite) to periphyton, and used the resultant periphyton as a food source for conducting full life-cycle dietary Se exposures to the mayfly Centroptilum triangulifer. Periphyton bioconcentrated Se ~2,200-fold from solution in a log-linear fashion over dissolved Se concentrations ranging from 1.1 to 23.1 µg L(-1). We examined the influence of two feeding ration levels (1x and 2x) on trophic transfer, tissue Se concentrations, maternal transfer, and functional endpoints of mayfly performance. Mayflies fed a lesser ration (1x) displayed greater trophic transfer factors (mean TTF, 2.8 ± 0.4) than mayflies fed 2x rations (mean TTF, 1.1 ± 0.3). In 1x exposures, mayflies exhibited significant (p < 0.05) reductions in survivorship and total body mass at dietary [Se] ≥ 11.9 µg g(-1), reduced total fecundity at ≥ 4.2 µg g(-1), and delayed development at ≥ 27.2 µg g(-1). Mayflies fed a greater ration (2x) displayed reduced tissue Se concentrations (apparently via growth dilution) relative to 1x mayflies, with no significant effects on performance. These results suggest that the influence of Se on mayfly performance in nature may be tied to food resource availability and quality. Furthermore, nutritional status is an important consideration when applying laboratory derived estimates of toxicity to risk assessments for wild populations.

Audit of the consultation process on general internal medicine services.

OBJECTIVE: To determine the proportion of consultations requested by general internal medicine services that communicate key components of the consultation process to medical subspecialists. DESIGN: Retrospective chart review by two researchers, using a standardised chart abstraction instrument (93.1% agreement, kappa 0.85). SETTING: Calgary, Alberta, Canada. SAMPLE: A random sample of medical consultations was selected from those generated on two medical teaching units (MTUs) from 2003 to 2004. MEASUREMENTS: The primary measure of interest was whether a "clear clinical question" was posed to the subspecialist, a binary variable. RESULTS: Two hundred consultations were sampled from the 2885 subspecialty consultations. Of the selected consultations, 94.0% (188/200) were available for review. A clear clinical question was posed in 69.7% (131/188) of consultations (CI 0.63 to 0.74). In a secondary analysis involving a larger sample permitting comparison across subspecialties, 95.1% (368/387) of the consultations, representative of the subspecialties, were available for review. An MTU member contacted the subspecialist for 74.2% of consultations. If a consultation was urgent, a member of the MTU contacted the subspecialist in 81.0% of consultations. Of these urgent consultations, 63.3% had a clear clinical question. CONCLUSION: More than one in four consultations does not contain a clear clinical question, illustrating suboptimal communication between physicians. Innovative strategies that provide a sustainable solution for overcoming barriers to communication could have a significant impact on quality of care.

Volatile anesthetics give a false-positive reading in chemical agent monitors in the "H" mode.

Chemical agent monitors (CAMs) are routinely used by the armed forces and emergency response teams of many countries for the detection of the vesicant sulfur mustard (HD) and the G series of organophosphate nerve agents. Ambient operating room isoflurane levels were found to produce strong positive signals in the "H" mode when the CAM was used to monitor the efficacy of decontamination procedures during routine surgical procedures on HD-poisoned animals requiring up to 8 hours of general anesthesia. Subsequent testing showed that isoflurane, as well as desflurane, sevoflurane, halothane and methoxyflurane, produce two ionization peaks in the CAM response. One of these peaks is interpreted by the CAM processing software as HD, resulting in a CAM "H" mode bar response. No interference was encountered with isoflurane, desflurane, and sevoflurane when the CAM was set to the "G" mode, although extremely high (nonclinical) concentrations of halothane and methoxyflurane yielded a weakly positive bar response. These findings have potentially serious ramifications for the medical management of patients resulting from terrorist, military, or chemical agent decommissioning activity when concomitant chemical injuries are also possible.

A comparison of the effects of sarin and succinylcholine on respiratory parameters in anesthetized domestic swine.

Differences in the "respiratory paralysis" caused by sarin (GB) and succinylcholine (SDC) were observed in a domestic swine model using a bedside pulmonary dynamics monitor. GB was administered intravenously (9 micrograms/kg/30 min) and compared with SDC administered intravenously (20 mg/30 min). All animals developed respiratory insufficiency indicated by decreased respiratory frequency. Minute ventilation was relatively maintained in animals that received GB by increasing tidal volume, whereas both of these parameters decreased in animals that received SDC. GB animals showed an increase in airway resistance and work of breathing. The former was unchanged and the latter was decreased in animals that received SDC. Mouth occlusion pressure at 100 milliseconds and tidal volume were relatively maintained in GB animals but decreased in SDC animals, suggesting a central mechanism for respiratory paralysis with GB and a peripheral mechanism for respiratory paralysis with SDC.

A primary germ cell tumor of the anterior mediastinum: a case report and discussion.

The anterior mediastinum is the most common extragonadal location for germ cell tumors and accounts for about 50% to 70% of such neoplasms. Embryonal cell carcinomas are one of the rarest forms and account for less than 2%. We present the case of a 19-year-old, white male who was found to have a primary embryonal cell carcinoma of the anterior mediastinum. This case illustrates the subtle complaints that these patients present with, some of the problems and decisions that go into making the diagnosis, and the response to the appropriate therapy. The following discussion takes a look at the variety of germ cell tumors, the vast differential of an anterior mediastinal mass, the workup of such a mass, and the various treatments and outcomes of extragonadal germ cell tumors.

Domestic swine model for the assessment of chemical warfare agent-anesthetic interactions: some effects of sulfur mustard.

A domestic swine model was developed to examine the interaction of chemical warfare agents with anesthetics and other drugs used during general anesthesia. Animals were fully instrumented, and clinically relevant physiological parameters were monitored throughout the experimental procedures. Exposure of animals under halothane anesthesia to the chemical warfare agent sulfur mustard (HD; 1 mg/kg intravenous) produced mild signs of systemic intoxication during the subsequent 5 hours. Induction doses of ketamine 1 hour after HD exposure resulted in periods of profound apnea, with continued respiratory distress for the next 2 hours. When animals were treated with HD 1 hour after the initiation of ketamine anesthesia, severe and persistent convulsion-like muscular activity was observed within 45 minutes of HD administration. This nonpurposeful activity was not ameliorated by diazepam but was dramatically reduced or eliminated by resumption of halothane anesthesia. Treatment of HD-intoxicated pigs with succinylcholine produced a prolonged apnea resulting in death. In these apparently mildly HD-intoxicated animals, the introduction of ketamine or succinylcholine can rapidly induce potentially life-threatening situations.

Construction and characterization of monoclonal antibodies against western equine encephalitis virus.

A repertoire of mouse monoclonal antibodies (MAbs) against western equine encephalitis virus (WEE) was constructed and characterized. Anti-WEE antibodies were expressed from hybridomas and purified by protein G chromatography. Each of the antibodies was functionally assessed by indirect enzyme-linked immunosorbent assays (ELISAs), Western blotting, and immunoprecipitations. All antibodies bound to WEE antigen in ELISAs, whereas only a subgroup of antibodies was found to be active in Western blotting and immunoprecipitations. A subset of antibodies was found to cross-react with other alphaviruses, such as Sindbis virus (SIN), Venezuelan equine encephalitis (VEE), and eastern equine encephalitis (EEE). Because many of the antibodies were highly reactive to WEE antigen in one or more of the assays, these antibodies are excellent candidates for immunodetection and immunotherapy studies.

Evidence of declining STD prevalence in a South African mining community following a core-group intervention.

OBJECTIVES: To reduce the prevalence of curable sexually transmitted diseases (STDs) in a South African mining community through provision of STD treatment services, including periodic presumptive treatment and prevention education to a core group of high-risk women living in areas around the mines. METHODS: Women at high risk for STDs attended a mobile clinic monthly for examination and counseling, and were treated presumptively for bacterial STDs with a directly observed 1-g dose of azithromycin. Gonococcal and chlamydial infection rates were measured by urine ligase chain reaction, and genital ulcers were assessed by clinical examination. Changes in STD prevalence among local miners were assessed through comparison of prevalence in two cross-sectional samples of miners taken 9 months apart, and through routine disease surveillance at mine health facilities. RESULTS: During the first 9 months of the intervention, 407 women used the services. Baseline prevalence of Neisseria gonorrhoeae and/or Chlamydia trachomatis in women was 24.9%; 9.7% of these women had clinical evidence of genital ulcer disease (GUD). The proportion of women with incident gonococcal or chlamydial infections at the first monthly return visit (69% follow-up rate) was 12.3%, and genital ulcers were found in 4.4% of these women. In the miner population, the prevalence of N gonorrhoeae and/or C trachomatis was 10.9% at baseline and 6.2% at the 9-month follow-up examination (P<0.001). The prevalence of GUD by clinical examination was 5.8% at baseline and 1.3% at follow-up examination (P< 0.001). Rates of symptomatic STDs seen at mine health facilities decreased among miners in the intervention area compared with miners living farther from the site and with less exposure to the project. DISCUSSION: Provision of STD treatment services to a core group of high-risk women may significantly reduce their burden of disease, and may contribute to a reduction in community STD prevalence. In the absence of sensitive and affordable screening tests for STDs in women, periodic presumptive treatment coupled with prevention education is a feasible approach to providing STD services in this population.

PIP: This intervention-linked study was conducted to reduce the prevalence of curable sexually transmitted diseases (STDs) in a South African mining community through provision of STD treatment services, including periodic presumptive treatment and prevention education to a core group of high-risk women living in areas around the mines. In this article, the impact of such an intervention is assessed on the women as well as the male migrant community in the intervention area. During the 9 months of the intervention, 407 women used the services. Baseline prevalence of gonococcal or chlamydial infections in women was 24.9%; 9.7% of these women had clinical evidence of genital ulcer disease (GUD). At the first monthly return, baseline for gonococcal or chlamydial infected women was 12.3%, and genital ulcers were found in 4.4% of the women. In the miner population, the overall result was similar to the result observed in the women: a decrease in rate of baseline prevalence of gonococcal or chlamydial infections and GUD was noted. In addition, rates of symptomatic STDs seen at mine health facilities decreased more among miners living closer within the intervention area than among those living farther away. In conclusion, provision of STD treatment services to a core group of high-risk women may significantly reduce their burden of disease, and may contribute to a reduction in community STD prevalence.