Healthcare Workers Beliefs about COVID-19; a Longitudinal, Mixed Methods Analysis.

The psychological impact of COVID-19 on Health Care Workers (HCWs) has been widely reported. Few studies have sought to examine HCWs personal models of COVID-19 utilising an established theoretical framework. We undertook a mixed methods study of beliefs about COVID-19 held by HCWs in the Mid-West and South of Ireland during the first and third waves of COVID-19. Template analysis was undertaken on the free text responses of 408 HCWs about their perceptions of the Cause of COVID-19 as assessed by the Brief Illness Perception Questionnaire (B-IPQ). Responses were re-examined in the same cohort for stability at 3 months follow-up (n = 100). This analytic template was subsequently examined in a new cohort (n = 253) of HCWs in the third wave. Female HCWs perceived greater emotional impact of COVID-19 than men (t = -4.31, df405, p < 0.01). Differences between occupational groups were evident in relation to Timeline (F4,401 = 3.47, p < 0.01), Treatment Control (F4,401 = 5.64, p < 0.001) and Concerns about COVID-19 (F4,401 = 3.68, p < 0.01). Administration staff believed that treatment would be significantly more helpful and that COVID-19 would last a shorter amount of time than medical/nursing staff and HSCP. However, administration staff were significantly more concerned than HSCP about COVID-19. Template analysis on 1059 responses to the Cause items of the B-IPQ identified ten higher order categories of perceived Cause of COVID-19. The top two Causes identified at both Waves were 'individual behavioural factors' and 'overseas travel'. This study has progressed our understanding of the models HCWs hold about COVID-19 over time, and has highlighted the utility of the template analysis approach in analysing free-text questionnaire data. We suggest that group and individual occupational identities of HCWs may be of importance in shaping HCWs responses to working through COVID-19.

Identifying the essential knowledge and skills for Neonatal-Perinatal Medicine: a systematic analysis of practice.

The knowledge and skills expected for board certification in Neonatal-Perinatal Medicine (NPM) should reflect the clinical practice of neonatology. First, a 14-member panel of practicing neonatologists, convened by the American Board of Pediatrics (ABP), drafted a practice analysis document which identified the practice domains, tasks, knowledge, and skills deemed essential for clinical practice. NPM fellowship program directors provided feedback via online survey resulting in revisions to the document. During the second phase of the project, the panel organized testable knowledge areas into content domains and subdomains to update the existing ABP NPM content outline. All ABP board-certified neonatologists were asked to review via online survey, and results were used to guide final revisions to the content outline. The NPM practice analysis document and the updated NPM content outline should serve as helpful resources for educators, trainees, and practicing neonatologists.

Genetic investigation of equine recurrent uveitis in Appaloosa horses.

Equine recurrent uveitis (ERU) is characterized by intraocular inflammation that often leads to blindness in horses. Appaloosas are more likely than any other breed to develop insidious ERU, distinguished by low-grade chronic intraocular inflammation, suggesting a genetic predisposition. Appaloosas are known for their white coat spotting patterns caused by the leopard complex spotting allele (LP) and the modifier PATN1. A marker linked to LP on ECA1 and markers near MHC on ECA20 were previously associated with increased ERU risk. This study aims to further investigate these loci and identify additional genetic risk factors. A GWAS was performed using the Illumina Equine SNP70 BeadChip in 91 horses. Additive mixed model approaches were used to correct for relatedness. Although they do not reach a strict Bonferroni genome-wide significance threshold, two SNPs on ECA1 and one SNP each on ECA12 and ECA29 were among the highest ranking SNPs and thus warranted further analysis (P = 1.20 × 10-5 , P = 5.91 × 10-6 , P = 4.91 × 10-5 , P = 6.46 × 10-5 ). In a second cohort (n = 98), only an association with the LP allele on ECA1 was replicated (P = 5.33 × 10-5 ). Modeling disease risk with LP, age and additional depigmentation factors (PATN1 genotype and extent of roaning) supports an additive role for LP and suggests an additive role for PATN1. Genotyping for LP and PATN1 may help predict ERU risk (AUC = 0.83). The functional role of LP and PATN1 in ERU development requires further investigation. Testing samples across breeds with leopard complex spotting patterns and a denser set of markers is warranted to further refine the genetic components of ERU.

EARLY ASSESSMENT OF RENAL TRANSPLANTS USING BOLD-MRI: PROMISING RESULTS.

Non-invasive evaluation of renal transplant function is essential to minimize and manage renal rejection. A computer-assisted diagnostic (CAD) system was developed to evaluate kidney function post-transplantation. The developed CAD system utilizes the amount of blood-oxygenation extracted from 3D (2D + time) blood oxygen level-dependent magnetic resonance imaging (BOLD-MRI) to estimate renal function. BOLD-MRI scans were acquired at five different echo-times (2, 7, 12, 17, and 22) ms from 15 transplant patients. The developed CAD system first segments kidneys using the level-sets method followed by estimation of the amount of deoxyhemoglobin, also known as apparent relaxation rate (R2*). These R2* estimates were used as discriminatory features (global features (mean R2*) and local features (pixel-wise R2*)) to train and test state-of-the-art machine learning classifiers to differentiate between non-rejection (NR) and acute renal rejection. Using a leave-one-out cross-validation approach along with an artificial neural network (ANN) classifier, the CAD system demonstrated 93.3% accuracy, 100% sensitivity, and 90% specificity in distinguishing AR from non-rejection . These preliminary results demonstrate the efficacy of the CAD system to detect renal allograft status non-invasively.

Genetic risk for squamous cell carcinoma of the nictitating membrane parallels that of the limbus in Haflinger horses.

Squamous cell carcinoma (SCC) is the most common cancer affecting the equine eye, with a higher incidence documented in Haflinger horses. Recently, a missense variant in the gene damage specific DNA binding protein 2 (DDB2, p.Thr338Met) on ECA12 was identified as a risk factor for the development of limbal SCC in Haflinger horses. SCC also occurs on the nictitating membrane; therefore, investigating the role of this missense variant in nictitating membrane SCC is warranted. In this study, a common ancestor was identified among Haflinger horses affected with limbal SCC or with nictitating membrane SCC, thus supporting a recessive risk factor for the development of cancer at both ocular locations. Analysis of genotype data from Haflinger horses with and without nictitating membrane SCC revealed that the same region on ECA12 associated with limbal SCC was also associated with nictitating membrane SCC (P < 2.04 × 10-5 ). Fine mapping of this locus using 25 cases and 49 controls supported the hypothesis that DDB2:c.1013C>T, p.Thr338Met, is a risk factor for nictitating membrane SCC, as 88% of our cases were homozygous for this variant and no other polymorphism was more strongly associated (P = 4.13 × 10-14 ). These data indicate that the genetic risk is the same for the development of both limbal and nictitating membrane SCC in Haflinger horses and validates utilization of genetic testing of the DDB2 variant for both clinical management and the guidance of mating decisions.

Genetic testing facilitates prepubertal diagnosis of congenital hypogonadotropic hypogonadism.

Neonatal micropenis and cryptorchidism raise the suspicion of congenital hypogonadotropic hypogonadism (CHH), a rare genetic disorder caused by gonadotropin-releasing hormone deficiency. Low plasma testosterone levels and low gonadotropins during minipuberty provide a clinical diagnostic clue, yet these tests are seldomly performed in general practice. We report a male neonate with no family history of reproductive disorders who was born with micropenis and cryptorchidism. Hormonal testing at age 2.5 months showed low testosterone (0.3 nmol/L) and undetectable gonadotropins (luteinizing hormone and follicle-stimulating hormone both <0.5 U/L), suggestive of CHH. Genetic testing identified a de novo, heterozygous mutation in fibroblast growth factor receptor 1 (FGFR1 p.L630P). L630 resides on the ATP binding cleft of the FGFR1 tyrosine kinase domain, and L630P is predicted to cause a complete loss of receptor function. Cell-based assays confirmed that L630P abolishes FGF8 signaling activity. Identification of a loss-of-function de novo FGFR1 mutation in this patient confirms the diagnosis of CHH, allowing for a timely hormonal treatment to induce pubertal development. Therefore, genetic testing can complement clinical and hormonal assessment for a timely diagnosis of CHH in childhood.

A review of 145 234 ophthalmic patient episodes lost to follow-up.

PurposeLost to follow-up and delays in follow-up care are a major problem in chronic diseases, particularly when irreversible progression precedes symptoms. The NPSA Glaucoma Safety Alert in 2009 highlighted the risk and requirements for consistent robust review systems in ophthalmology. In response, Moorfields Eye Hospital reviewed the records of all patients in all subspecialties without review appointments booked. The purpose of this study was to determine whether ophthalmic patients lost to follow-up had come to harm and develop investigation techniques to optimise safety, which do not put excessive demands on clinical staff time.MethodsThe health records of all patients lost to follow-up (LTFU) between July 2007 and November 2012 were reviewed for evidence of clinical harm using a risk-based strategy involving an initial administrative review, then a clinician led electronic patient record review, followed by a review of paper records by clinicians. The final stage was a clinical outpatient review where required determined by clinical risk.ResultsPatients identified as lost to follow-up were 145 234; 79 562 episodes were closed following administrative review; 50 519 were discharged following clinician examination of paper records; 12 316 patients required clinical review; and 16 serious incidents were identified, of which 14 patients had glaucoma, 1 a medical retinal condition with secondary glaucoma, and 1 an oculoplastic condition. A number of actions implemented hospital wide are described which minimise future risk.ConclusionRisk from delays or lost to follow-up care continue and require better capacity and more accurate data nationally.

The KICA Carer: informant information to enhance the Kimberley Indigenous Cognitive Assessment.

BACKGROUND: A quality dementia-screening tool is required for older remote Aboriginal Australians who have high rates of dementia and limited access to appropriate medical equipment and clinicians. The Kimberley Indigenous Cognitive Assessment (KICA Cog) is a valid cognitive test for dementia in Aboriginal and Torres Strait Islander peoples. The KICA cognitive informant questionnaire (KICA Carer) had yet to be analyzed to determine validity alone or in combination with the KICA Cog. METHODS: The KICA Carer was completed by nominated informants of 349 remote-living Aboriginal Australians in the Kimberley region, Western Australia. Validity was assessed by comparing KICA Carer with Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and International Classification of Diseases (ICD-10) consensus diagnoses based on a blinded specialist review. KICA Carer and KICA Cog were then compared to determine joint validity. RESULTS: A KICA Carer score of ≥3/16 gave optimum sensitivity (76.2%) and specificity (81.4%), area under curve (AUC) 0.89 (95% CI = 0.85, 0.94) with positive predictive value (PPV) of 35.8%, and negative predictive value (NPV) of 96.2%. A KICA Cog score of ≤33/39 gave a sensitivity of 92.9% and specificity of 89.9%, AUC 0.96 (95% CI = 0.94, 0.98), with PPV of 55.6% and NPV of 98.9%. Cut-off scores of KICA Cog ≤ 33/39 and KICA Carer ≥ 2/16 in series indicate possible dementia, with sensitivity of 90.5% and specificity of 93.5%. In this setting, PPV was 66.5% and NPV was 98.6%. CONCLUSIONS: The KICA Carer is an important tool to accurately screen dementia in remote Aboriginal Australians when the KICA Cog is unable to be used for a patient. It is readily accepted by caregivers. KEY POINTS: • For the best practice in the cognitive assessment of an Aboriginal Australian aged over 45 years, KICA Cog should be utilized. • In cases where Aboriginal patients are not assessed directly, KICA Carer should be conducted with an informant. A cut-off score of ≥3/16 should be used (these tools can be downloaded from www.wacha.org.au/kica.html).

[Transition in diabetology]. / Transition en diabétologie.

For patients with type I diabetes, transition from pediatric to adult care is a challenge due to complex treatment requirements and the physical, psychological and social changes of adolescence. Members of the care team must recognize that while these emerging adults need to develop self-management skills, this may conflict at times with the developmentally appropriate desire for increasing autonomy. The role of nursing in coordinating a successful transition is critical for maintaining continuity of patient-centered care that responds to the specific needs of these young adults.

Mindfulness-based cognitive therapy for psycho-oncology patients: an exploratory study.

OBJECTIVES: Mindfulness-based cognitive therapy (MBCT) is a group-based intervention similar to mindfulness-based stress reduction, but which includes cognitive therapy techniques. This study investigates its usefulness in the treatment of depressive, anxiety and stress/distress symptoms in cancer patients referred to a psycho-oncology service. It also examines whether effect on depression is mediated by self-compassion. METHOD: In phase 1 of this study, 16 cancer patients with mild/moderate psychological distress were randomised to MBCT (n=8) or treatment as usual (TAU; n=8), and assessed pre- and post-treatment. Analysis of variance was performed to examine the effect of treatment on anxiety and depression. In phase 2, the TAU group received the intervention, and results of pre- and post-MBCT assessments were combined with those receiving MBCT in phase 1. Finally, both groups were followed up at 3 months. RESULTS: In phase 1, the MBCT group had a significant improvement in mindfulness and a decrease in anxiety. Statistically significant improvements in both depression and anxiety were found at 3 month follow-up. Self-compassion appeared to mediate the effect on anxiety/depression. CONCLUSION: This small pilot study suggests that MBCT may have a beneficial effect on psychological variables often adversely affected in cancer in a heterogeneous cancer population.

Adaptation of the chronic disease self-management program for cancer survivors: feasibility, acceptability, and lessons for implementation.

Self-management in chronic disease has been shown to improve patient-reported and health care-related outcomes. However, relatively little information about its utility in cancer survivorship is known. We evaluated the feasibility and acceptability of the delivery of an adaptation of the evidence-based Chronic Disease Self-management Program (Stanford) called Cancer Thriving and Surviving (CTS). Triangulated mixed methods were used to capture baseline characteristics and post-program experiences using a combination of closed- and open-ended survey items; emergent coding and simple descriptive statistics were used to summarize the data. Twenty-seven workshops were delivered by 22 CTS leaders to 244 participants between August 2011 and January 2013 in a variety of settings (48 % community, 30 % health care, 22 % regional/community cancer center). Representing a variety of cancer types, about half the participants were 1-3 years post-diagnosis and 45 % were 4 or more years from diagnosis. Program attendance was high with 84 % of participants attending four or more of the six sessions in the workshop. Overall, 95 % of the participants were satisfied with the program content and leaders, and would recommend the program to friends and family. These results confirm the feasibility and acceptability of delivery of a high-fidelity, peer-led model for self-management support for cancer survivors. Expansion of the CTS represents a powerful tool toward improving health-related outcomes in this at-risk population.

Co-prescribing of linezolid and serotonergic agents in a general hospital setting.

BACKGROUND: Co-prescription of linezolid and serotonergic agents (SSRIs, SNRIs, NaSSA, TCAs) can lead to serotonin syndrome, this study seeks to identify prescribing practise of these agents. METHODS: Study of all general hospital inpatients prescribed intravenous linezolid in a 3-month period, using drug charts and clinical notes. RESULTS: Co-prescription occurred in 20% with SSRIs most frequently concurrently used. There were no cases of serotonin syndrome. There was no evidence in clinical notes of vigilance for potential interaction. CONCLUSION: Co-prescription is common; awareness of potentially serious interaction is not evident in current practice.

[Caring for patients with pediatric endocrinopathies and diabetes into adulthood: challenges of an often difficult transition]. / Prise en charge des jeunes patients avec endocrinopathies pediatriques chroniques: les défis d'une transition souvent difficile.

The success of therapies for a number of pediatric disorders has posed new challenges for the long-term follow-up of adolescents with chronic endocrinopathies. Unfortunately, too many patients are lost during the transfer from pediatric to adult clinics. The transition process should be well-organized and include the young person and family. Recognizing the special needs of these adolescents is an important step in developing patient-centered approaches to care that enable patients to develop autonomy and self care skills. Key elements in this process include structured policies and guidelines, communication and close collaboration between pediatric and adult clinics, and integrating nurse clinicians in the transition process to help close the gaps in care.

Preliminary evaluation of the prevalence of falls, pain and urinary incontinence in remote living Indigenous Australians over the age of 45 years.

AIMS: To report on the prevalence of falls, urinary incontinence, pain and associated factors in remote living Indigenous Australians over the age of 45 years. METHODS: A cross-sectional, semi-purposeful sample of 363 indigenous men and women aged over 45 years living in six remote communities and one town in Kimberley, Australia. Participants were assessed for self- or informant-reported rates of falls, urinary incontinence and pain. RESULTS: The prevalence of self- or informant-reported falls was 31% (95% CI 25.3, 36.7), pain 55% (95% CI 47.4, 62.6) and urinary incontinence 9% (95% CI 5.9, 12.1%). Associations with falls after adjustment for age, sex and education included alcohol use (OR 2.4, 95% CI 1.4, 4.2), stroke (OR 2.4, 95% CI 1.1, 5.0), epilepsy (OR 3.5, 95% CI 1.1, 11.6), head injury (OR 2.1, 95% CI 1.3, 3.3) and poor hearing (OR 2.5, 95% CI 1.4, 4.1); for urinary incontinence epilepsy (OR 6.0, 95% CI 1.7, 21.2) and stroke (OR 16.7, 95% CI 6.0, 46.3); and for pain, poor hearing (OR 1.9, 95% CI 1.0, 3.3) and female sex (OR 1.8, 95% CI 1.2, 2.7). CONCLUSIONS: Falls, urinary incontinence and pain are common and reported for the first time in older indigenous people living in remote regions. The presence of these syndromes in ages over 45 may be due to accumulation of health insults during the life course.

The use of intra-operative fluoroscopy for tibial tunnel placement in anterior cruciate ligament reconstruction.

OBJECTIVES: Our aim was to assess the use of intra-operative fluoroscopy in the assessment of the position of the tibial tunnel during reconstruction of the anterior cruciate ligament (ACL). METHODS: Between January and June 2009 a total of 31 arthroscopic hamstring ACL reconstructions were performed. Intra-operative fluoroscopy was introduced (when available) to verify the position of the guidewire before tunnel reaming. It was only available for use in 20 cases, due to other demands on the radiology department. The tourniquet times were compared between the two groups and all cases where radiological images lead to re-positioning of the guide wire were recorded. The secondary outcome involved assessing the tibial interference screw position measured on post-operative radiographs and comparing with the known tunnel position as shown on intra-operative fluoroscopic images. RESULTS: Of the 20 patients treated with fluoroscopy, the imaging led to repositioning of the tibial guide wire before reaming in three (15%). The mean tourniquet time with intra-operative fluoroscopy was 56 minutes (44 to 70) compared with 51 minutes (42 to 67) for the operations performed without. Six patients (30%) had post-operative screw positions that were > 5% more posterior than the known position of the tibial tunnel. CONCLUSION: Intra-operative fluoroscopy can be effectively used to improve the accuracy of tibial tunnel positions with minimal increase in tourniquet time. This study also demonstrates the potential inaccuracy associated with plain radiological assessment of tunnel position.

Factitious disorder as a differential diagnosis for recurrent skin graft failure.

This case report presents the history of a 43-year-old man who sustained a relatively minor burn to his face but who subsequently suffered significant morbidity. Although the wound was grafted on a number of occasions, it failed to heal. Multiple investigations were carried out to determine the cause of recurrent wound breakdown. It had been suspected that the patient was interfering with the wound but this could not be proven initially. He was eventually diagnosed with factitious disorder and it was only when this was managed in the multi-disciplinary setting that his wound finally healed.

Fractura triplana de tobillo relacionada con fractura tibial homolateral en un adolescente. Caso clínico / Triplane fracture of the ankle associated with homolateral tibial fracture in a teenager. A case report

Introducción: las fracturas de la diáfisis tibial relacionadas con fracturas isolaterales triplanas son atípicas y son el resultado de fuerzas de torsión que producen fracturas espiroideas u oblicuas en la unión de los tercios medio y distal de la tibia. Caso clínico: niña de 13 años con síndrome de Gilbert que acudió a urgencias después de sufrir una caída cuando jugaba al baloncesto; se torció el tobillo cuando pisó el balón. Presentaba inflamación en el tercio distal de la pierna y el tobillo derechos, sin déficit neurovascular. En la radiografía simple se observó una fractura oblicua en la unión del tercio medio y distal de la tibia junto con una fractura triplana intraarticular del tobillo del mismo lado. Conclusiones: en nuestro caso fue necesario una reducción abierta de la fractura diafisaria debido a que era oblicua, desplazada e inestable, con el objetivo de obtener una reducción anatómica. Esto ayudó, a su vez, a obtener una reducción anatómica de la fractura triplana del tobillo que no precisó fijación interna (AU)

Introduction: Tibial shaft fractures associated with ipsilateral triplanar fractures are atypical and result from torque forces that cause spiral or oblique fractures at the junction between the mid and the distal tibia. Conclusion: sIn our case we had to perform an open reduction of the diaphyseal fracture since it was oblique, displaced and unstable; the purpose was to obtain an anatomical reduction. This also helped secure an anatomical reduction of the triplanar ankle fracture, which did not require internal fixation (AU)