Lymphedema Symptom Intensity and Distress Surveys-Truncal and Head and Neck, Version 2.0.

Background: A comparison of symptom prevalence, intensity, and distress for participants with truncal lymphedema, head and neck lymphedema, and no lymphedema identified a need for a truncal-specific, lymphedema-related symptom assessment tool and a revision of the Lymphedema Symptom Intensity and Distress Survey-Head and Neck (LSIDS-H&N). The purpose of this study was to institute the development of the Lymphedema Symptom Intensity and Distress Survey-Truncal (LSIDS-T) and revise the LSIDS-H&N. Methods and Results: A comprehensive midline measure and subsequent series of analyses were used to develop the LSIDS-T and revise the initial LSIDS-H&N. Participants included 97 without lymphedema, 82 with truncal lymphedema, and 72 with head and neck lymphedema. Cluster analysis for the LSIDS-T resulted in five clusters with a total of 21 items. Cluster analysis for the LSIDS-H&N resulted in seven clusters with a total of 31 items. Key correlations in expected directions were found with the validated measures for both surveys, and correlations with the Marlowe Crown Social Desirability Scale did not indicate issues with social desirability of response. Conclusion: The 24-item LSIDS-T and the 31-item revised LSIDS-H&N v.2 are promising additions to the suite of other LSIDS measures for use in clinical environments.

Critical Care Clinician Reports on Coronavirus Disease 2019: Results From a National Survey of 4,875 ICU Providers.

IMPORTANCE: Global cases of coronavirus disease 2019 infection continue to increase, and significant numbers of patients are critically ill, placing an immense burden on ICU resources. Understanding baseline resource needs and surge capacity in the ICU will be essential to meet current and projected healthcare needs. Continued appraisal of the state of readiness for healthcare systems at individual, regional and national levels will be paramount to ensure we are poised to continue the fight against coronavirus disease 2019. OBJECTIVES: This study queried U.S. ICU clinician perspectives on ICU preparedness and concerns regarding delivering coronavirus disease 2019 patient care. DESIGN SETTING AND PARTICIPANTS: An anonymous web-based survey administered from March 18, 2020, to March 25, 2020 (email and newsletter) used survey methodology to query members of U.S. national critical care organizations. MAIN OUTCOMES AND MEASURES: Through a 12-item descriptive questionnaire, ICU clinicians were assessed regarding preparedness, techniques employed to augment critical care capacity, and concerns related to caring for coronavirus disease 2019 patients. RESULTS: A total of 4,875 ICU clinicians responded to the survey. Respondents included ICU nurses (n = 3,470, 71.3%), physicians (n = 664, 13.6%), advanced practice providers (nurse practitioners and physician assistants; n = 334, 6.9%), respiratory therapists (n = 236, 4.9%), and pharmacists (n = 79, 1.6%). Over half (n = 2,552, 52.5%) reported having cared for a presumed or confirmed coronavirus disease 2019 patient. The majority (n = 4,010, 82.9%) identified that their hospital was employing techniques to augment critical care capacity. However, 64.5% (n = 3,125) believed that their ICU facility and team were inadequately prepared to treat coronavirus disease 2019 patients. The majority (n = 4,547, 93.9%) anticipated ICU personal protective equipment shortages based upon their current use profile. The chief reported concerns include ICU resource shortages such as supplies, medications, beds, ICU staffing shortages, and patient surge leading to overcrowding. CONCLUSIONS AND RELEVANCE: This national ICU clinician survey indicates that hospitals are expanding ICU bed capacity to prepare for coronavirus disease 2019 patient surge. Importantly, amid this preparation, ICU clinicians harbor concerns regarding preparedness, staffing, and common use resources that merit specific education as well as resource allocation and utilization planning.

Coronavirus Disease 2019 Pandemic Measures: Reports From a National Survey of 9,120 ICU Clinicians.

IMPORTANCE: Recent reports identify that among hospitalized coronavirus disease 2019 patients, 30% require ICU care. Understanding ICU resource needs remains an essential component of meeting current and projected needs of critically ill coronavirus disease 2019 patients. OBJECTIVES: This study queried U.S. ICU clinician perspectives on challenging aspects of care in managing coronavirus disease 2019 patients, current and anticipated resource demands, and personal stress. DESIGN, SETTING, AND PARTICIPANTS: Using a descriptive survey methodology, an anonymous web-based survey was administered from April 7, 2020, to April 22, 2020 (email and newsletter) to query members of U.S. national critical care organizations. MEASUREMENTS AND MAIN RESULTS: Through a 16-item descriptive questionnaire, ICU clinician perceptions were assessed regarding current and emerging critical ICU needs in managing the severe acute respiratory syndrome coronavirus 2 infected patients, resource levels, concerns about being exposed to severe acute respiratory syndrome coronavirus 2, and perceived level of personal stress. A total of 9,120 ICU clinicians responded to the survey, representing all 50 U.S. states, with 4,106 (56.9%) working in states with 20,000 or more coronavirus disease 2019 cases. The 7,317 respondents who indicated their profession included ICU nurses (n = 6,731, 91.3%), advanced practice providers (nurse practitioners and physician assistants; n = 334, 4.5%), physicians (n = 212, 2.9%), respiratory therapists (n = 31, 0.4%), and pharmacists (n = 30, 0.4%). A majority (n = 6,510, 88%) reported having cared for a patient with presumed or confirmed coronavirus disease 2019. The most critical ICU needs identified were personal protective equipment, specifically N95 respirator availability, and ICU staffing. Minimizing healthcare worker virus exposure during care was believed to be the most challenging aspect of coronavirus disease 2019 patient care (n = 2,323, 30.9%). Nurses report a high level of concern about exposing family members to severe acute respiratory syndrome coronavirus 2 (median score of 10 on 0-10 scale). Similarly, the level of concern reached the maximum score of 10 in ICU clinicians who had provided care to coronavirus disease 2019 patients. CONCLUSIONS: This national ICU clinician survey identifies continued concerns regarding personal protective equipment supplies with the chief issue being N95 respirator availability. As the pandemic continues, ICU clinicians anticipate a number of limited resources that may impact ICU care including personnel, capacity, and surge potential, as well as staff and subsequent family members exposure to severe acute respiratory syndrome coronavirus 2. These persistent concerns greatly magnify personal stress, offering a therapeutic target for professional organization and facility intervention efforts.

A Comparison of Symptoms Among Patients with Head and Neck or Truncal Lymphedema and Normal Controls.

Background: Symptoms associated with midline lymphedema are not fully understood and it is unclear if symptoms associated with swelling in the head and neck are similar to those associated with swelling in the truncal region of the body. Objectives: Describe symptoms experienced by those with head and neck and truncal lymphedema. Compare symptom presence, intensity, and distress among those two groups and participants with no lymphedema. Methods: Cross-sectional descriptive study administered by online survey. Results: Nonlymphedema participants were younger than the lymphedema groups. Those with truncal lymphedema took more diuretic medications than the other groups. Participants with truncal lymphedema experienced a greater number of symptoms than the other groups (p < 0.001). These symptoms were also more severe and intense (p < 0.001). Fourteen symptoms distinguished the truncal group from the other two groups (p < 0.001). Nine symptoms differentiated the head and neck group from the other groups (p < 0.001). Conclusion: These preliminary findings support that symptom profiles differ among those with lymphedema and those without lymphedema. The number, type, severity, and intensity of symptoms vary based upon the location of lymphedema. The need to use two lymphedema anatomical classifications (head and neck and truncal) instead of one classification (midline) when assessing lymphedema-related symptoms is also supported.

A Retrospective Review of Patients With Acute Stroke With and Without Palliative Care Consultations.

Despite advances in stroke care, patients continue to incur significant disability, are at risk for future events, and are inconsistently comanaged with palliative care (PC) specialty teams. The purpose of this study was to review patients with stroke admitted to our institution, comparing patients with and without PC consultation. We retrospectively reviewed medical record data of all patients with stroke admitted to our neurosciences ICU (NICU) in July 2014 to June 2015 with and without PC consultation. Review focused on stroke type, patient demographics, median days to discharge and death, and posthospitalization discharge. Of 463 patients admitted to the NICU with a stroke diagnosis, 27% (125/463) had (PC) consultation. A higher percentage of the patients with PC consult presented with hemorrhagic stroke than those without PC consult (38% vs 21%, P < .001). Patients with PC consult had longer median days to discharge and death ( P < .001) and a higher percentage of mortality (32% vs 11%). Of the 301 patients without PC consult who discharged (89.1%), 36.5% discharged to inpatient rehab while 10% discharged to a skilled nursing facility. In comparison, of the patients with PC consultation who discharged alive (41.1%), 15.7% discharged to inpatient rehab whereas 39% discharged to skilled nursing ( P < .001). The uncertainty of which patients with stroke benefit most from specialty PC is highlighted in that although sicker patients are referred to PC, a substantial portion (41%) of these patients discharge alive, of which 39.2% discharged to skilled nursing. Future research should focus on which patients with stroke would benefit from specialty PC.

Development and Validation of the Lymphedema Symptom Intensity and Distress Survey-Lower Limb.

BACKGROUND: Lymphedema is a chronic, incurable condition that occurs most commonly in lower limbs (legs and feet). Increased morbidity is seen with this form of lymphedema, but there are few studies and even fewer tools intended to assess symptom burden in patients impacted by this condition. A questionnaire, the Lymphedema Symptom Intensity and Distress Survey-Lower Limb (LSIDS-L), was developed to fill this gap. The measure is composed of several clusters of symptoms thought to characterize lower limb lymphedema. The initial work was conducted to propose and assess the face validity of the clusters. Subsequently, work was undertaken to empirically evaluate the presence of the symptom clusters, assess the reliability of the cluster scores, and evaluate the validity of the scores by studying associations with other valid measures. METHODS AND RESULTS: During the initial work, the LSIDS-L was tested with lower limb lymphedema patients only, and in the subsequent work the LSIDS-L and valid measures were administered to patients with no lymphedema and with lower limb lymphedema. A total of 388 volunteers participated, 111 of whom indicated no diagnosis of lymphedema, and 277 indicated a diagnosis of lower limb lymphedema. Cluster analysis resulted in the exclusion of 5 items, yielding 8 clusters with a total of 31 items. Cluster scores demonstrated acceptable internal consistency, distinguished nonlymphedema patients from lower lymphedema patients, and demonstrated expected convergent and divergent validity with other valid measures. CONCLUSION: The LSIDS-L is a valid tool for detecting and quantifying symptom burden in patients with lower limb lymphedema.

A Prospective Study of L-Dex Values in Breast Cancer Patients Pretreatment and Through 12 Months Postoperatively.

BACKGROUND: Data regarding pretreatment, bioimpedance spectroscopy (BIS) L-Dex® values for patients newly diagnosed with breast cancer, and longitudinal data 12 months postoperatively are lacking. This study describes L-Dex values at the time of breast cancer diagnosis and maximum L-Dex change within 12 months of surgery. METHODS AND RESULTS: Patients were enrolled in a parent, clinical trial that compares the effectiveness of BIS for early detection of breast cancer-related lymphedema to tape measurement. A total of 280 women with a pretreatment and at least one postoperative L-Dex measurement (within 12 months of surgery) were included. Pretreatment L-Dex readings were compared with population norms and maximum L-Dex changes within 12 months were examined. An L-Dex U400 device was used to obtain BIS measurements. The documented normative mean value using this device is 0.00, which is at the 49th percentile for this sample. Approximately 6% of patients had a pretreatment L-Dex value of ≥7.0; 1.8% had an L-Dex value ≥10.0. For 12 months, 17.1% (n = 48) of patients had a maximum change in L-Dex value from pretreatment of ≥7.0 L-Dex units, suggestive of clinical lymphedema. CONCLUSIONS: At the time of breast cancer diagnosis, L-Dex values are similar to normative values. Identified maximum changes in L-Dex values 12 months postoperatively suggest that frequent L-Dex measurements during that time frame are of potential clinical benefit. Our findings are consistent with research supporting an L-Dex value of ≥7 as indicative of clinical lymphedema with subclinical lymphedema logically occurring at somewhat lower likely, near ≥6.5.

Mindfulness in a Graduate Nursing Curriculum: A Randomized Controlled Study.

This study evaluated a mindfulness-based stress reduction intervention for graduate nursing students. Forty-four participants engaged in 20 weekly, 1.5-hour sessions of mindfulness training. There were no statistically significant effects on participants' stress levels or quality of life, yet there was a statistically significant increase in overall mindfulness (P < .05).

Electronic Informed Consent to Facilitate Recruitment of Pregnant Women Into Research.

Methods to obtain informed consent digitally or electronically may increase the participation of racially and geographically diverse pregnant women in prospective research, which is essential to improve the evidence base for maternity care. We evaluated the feasibility and utility of e-consent in the first year of a multiyear clinical trial involving pregnant women. Of the 86 women screened, 71 were eligible, 65 (93% of eligible) agreed to review the e-consent form, and 61 (86% of eligible) completed the e-consent process. Of the interested women who were sent the e-consent link, all were able to complete the e-consent process, even those who reported low health literacy. Women of all racial and ethnic groups were equally likely to consent, and the sample of women who consented was consistent with practice demographics. E-consent is feasible and easy to use with pregnant women and may expedite enrollment of a representative sample.

Evaluation of CT Changes in the Head and Neck After Cancer Treatment: Development of a Measurement Tool.

BACKGROUND: The late effect continuum of lymphedema and fibrosis (LEF) affects more than 70% of patients after treatment for head and neck cancer (HNC). LEF is associated with symptom burden and decreased function and quality of life. Although surveillance imaging is common posttreatment, objective assessment of soft tissues is not, likely due to the lack of objective evaluation methods and understanding of the significance of LEF. We undertook the development of a tool to measure LEF using CT scans in HNC patients. METHODS AND RESULTS: We developed a CT measurement tool assessing sites of soft tissue damage secondary to tumor, surgery, or radiation. The tool was applied to pre- and posttreatment CT scans for 10 HNC patients. The data were reviewed, and the initial tool was modified. Ten additional patients' scans were assessed using the revised tool. The tool was modified further after data review by an expert panel and was then applied to scans from all 20 patients. The final tool included 11 items as follows: grading of fat stranding at 6 sites (axial reconstruction images, scale 0-2), measurement of epiglottic thickness (sagittal images, scale mm), and measurement of prevertebral soft tissue thickness at C3 (sagittal images, scale mm). A total of 176 CT scans were evaluated from 20 patients (range 4-14 examinations/patient). Preliminary data demonstrated face validity. CONCLUSIONS: The final LEF assessment tool (CT-LEFAT) provides a standardized method for assessing critical sites that are involved by LEF. Studies to assess reliability and validity are ongoing.

A pilot randomized trial evaluating lymphedema self-measurement with bioelectrical impedance, self-care adherence, and health outcomes.

BACKGROUND: Less than half of breast cancer survivors with lymphedema perform self-care as directed. Effective lymphedema self-care is required to obtain acceptable health outcomes. Self-Regulation Theory suggests that objective self-measurement of physiological conditions is necessary to promote self-regulation/self-care. Bioelectric Impedance Spectroscopy (BIS) represents a potential self-measurement method for arm lymphedema. The purpose of this pilot study was to examine the impact of arm self-measurement on daily self-care activities and health outcomes in breast cancer survivors with lymphedema. METHODS AND RESULTS: A pilot randomized clinical trial compared outcomes between breast cancer survivors with lymphedema who self-monitored for 3 months and breast cancer survivors with lymphedema who did not self-monitor. Data were collected at baseline, months 1, 2, 3, and 4. Eighty-six women with lymphedema were screened: 62 were eligible, 50 were enrolled, 10 withdrew, and 1 had incomplete data, thus N=39. No between group differences were noted in participant characteristics. The self-monitored group had higher days of garment use (p=0.005) that remained stable after self-monitoring stopped. The median number of days of simple manual lymphatic drainage increased in the intervention group (p=0.004) with a downward trend after self-monitoring ceased. CONCLUSIONS: Objective self-monitoring of arms using BIS is possible. Self-monitoring may positively impact self-care behaviors. Highly symptomatic patients may require coaching or other psychological support to improve their self-care. Studies that combine a cognitive behavioral therapy component along with self-measurement should be considered as potential interventions to impact lymphedema self-care. Other applications of self-monitoring warrant investigation.

Bioelectrical impedance self-measurement protocol development and daily variation between healthy volunteers and breast cancer survivors with lymphedema.

BACKGROUND: A significant percentage of breast cancer survivors are at risk for lymphedema for which lifelong self-care is required. Previous studies suggest that less than 50% of breast cancer survivors with lymphedema (BCS-LE) perform prescribed self-care tasks and that even wearing a compression sleeve, the most commonly reported self-care activity, is done irregularly. Reasons for poor self-care adherence include perceived lack of results from self-care (no available arm volume data) and perceived inability to manage the condition. METHODS AND RESULTS: A two-part pilot study was conducted to: 1) develop and determine the feasibility of a self-measurement protocol using a single frequency bioelectrical impedance device; and 2) examine daily variation in extracellular volume in healthy and lymphedematous limbs. Healthy and BCS-LE volunteers were recruited to refine and test a self-measurement protocol. Volunteers were trained in the use of the device and measured for 5 consecutive days in a laboratory setting. They were then given the device to use at home for an additional 5 consecutive days of self-measurement. All volunteers completed each scheduled home measurement. Daily variability in both groups was noted. CONCLUSIONS: Home self-measurement using bioelectrical impedance is feasible, acceptable, and captures change. This has implications for both self-care support and for the possibility of incorporating self-measurement using bioelectrical impedance in future clinical trials examining effectiveness of lymphedema treatment.

A pilot randomized trial evaluating low-level laser therapy as an alternative treatment to manual lymphatic drainage for breast cancer-related lymphedema.

PURPOSE/OBJECTIVES: To examine the impact of advanced practice nurse (APN)-administered low-level laser therapy (LLLT) as both a stand-alone and complementary treatment for arm volume, symptoms, and quality of life (QOL) in women with breast cancer-related lymphedema. DESIGN: A three-group, pilot, randomized clinical trial. SETTING: A private rehabilitation practice in the southeastern United States. SAMPLE: 46 breast cancer survivors with treatment-related lymphedema. METHODS: Patients were screened for eligibility and then randomized to either manual lymphatic drainage (MLD) for 40 minutes, LLLT for 20 minutes, or 20 minutes of MLD followed by 20 minutes of LLLT. Compression bandaging was applied after each treatment. Data were collected pretreatment, daily, weekly, and at the end of treatment. MAIN RESEARCH VARIABLES: Independent variables consisted of three types of APN-administered lymphedema treatment. Outcome variables included limb volume, extracellular fluid, psychological and physical symptoms, and QOL. FINDINGS: No statistically significant between-group differences were found in volume reduction; however, all groups had clinically and statistically significant reduction in volume. No group differences were noted in psychological and physical symptoms or QOL; however, treatment-related improvements were noted in symptom burden within all groups. Skin improvement was noted in each group that received LLLT. CONCLUSIONS: LLLT with bandaging may offer a time-saving therapeutic option to conventional MLD. Alternatively, compression bandaging alone could account for the demonstrated volume reduction. IMPLICATIONS FOR NURSING: APNs can effectively treat lymphedema. APNs in private healthcare practices can serve as valuable research collaborators. KNOWLEDGE TRANSLATION: Lasers may provide effective, less burdensome treatment for lymphedema. APNs with lymphedema certification can effectively treat this patient population with the use of LLLT. In addition, bioelectrical impedance and tape measurements can be used to assess lymphedema.

Duration of virus shedding after trivalent intranasal live attenuated influenza vaccination in adults.

OBJECTIVE: To characterize the probability and duration of viral shedding among adults given trivalent live attenuated influenza vaccine (LAIV). DESIGN: Prospective surveillance study. METHODS: Nasal wash samples were collected from adult volunteers at baseline and on days 3, 7, and 10 and between days 17 and 21 following intranasal LAIV vaccination. The presence, titer, and identification of each specific strain of influenza virus shed were determined by standard methodology. RESULTS: Twenty subjects received LAIV. No samples were positive for influenza virus at baseline. After LAIV vaccination, influenza virus was recovered from 10 of 20 vaccinees on day 3, from 1 of 18 vaccinees on day 7, and from none of the samples on days 10 or 17 through 21. Vaccinees who shed vaccine virus were significantly younger than those who did not (mean age, 26.4 vs 38.6 years; P < .01). Although the presence of specific mucosal immunoglobulin A to influenza B was associated with significantly less shedding of influenza B after vaccination (P = .02), associations of shedding with other measures of immunity were not detected. CONCLUSION: The duration of shedding of vaccine virus after LAIV in adults i s limited and may be associatedwith an individual's prior influenza vaccination history.

Risk of vaccinia transfer to the hands of vaccinated persons after smallpox immunization.

Transmission of vaccinia virus after smallpox vaccination is a concern. We conducted a prospective examination of the protection afforded by vaccination-site bandages in recently vaccinated individuals. After smallpox vaccination, inoculation sites were covered with 2 occlusive dressings. Site assessment and bandage changes occurred every 3-5 days until the site was healed. At each visit, specimens from the vaccination site, outer dressing surface, and contralateral hand were obtained for vaccinia culture. For 148 vaccinated subjects, vaccinia was detected from vaccination lesions of every subject on several occasions. Only 6 (0.65%) of 918 dressing (95% CI, 0.24%-1.4%) and 2 (0.22%) of 926 hand (95% CI, 0.03%-0.78%) specimens tested positive for vaccinia. The mean number of bandage changes was 9.6 (95% CI, 9.17-10.0). Vaccinia autoinoculation did not occur. The rate of vaccinia recovery outside occlusive bandages covering smallpox vaccination sites was remarkably low, suggesting excellent protection against inadvertent transmission.

Activities of temporin family peptides against the chytrid fungus (Batrachochytrium dendrobatidis) associated with global amphibian declines.

Temporin A and structurally related peptides produced in amphibian dermal granular glands and in wasp venom were tested for growth inhibition of Batrachochytrium dendrobatidis, a pathogen associated with global amphibian declines. Two natural amphibian temporins, a wasp temporin, and six synthetic analogs effectively inhibited growth. Differences in potency due to amino acid substitution suggest that ability to penetrate membranes and form an alpha-helical structure is important for their effectiveness against this pathogen.

Activity of antimicrobial skin peptides from ranid frogs against Batrachochytrium dendrobatidis, the chytrid fungus associated with global amphibian declines.

Accumulating evidence suggests that a chytrid fungus, Batrachochytrium dendrobatidis, is responsible for recent declines in amphibian populations in Australia, Central America, Europe, and North America. Because the chytrid infects the keratinized epithelium of the skin, we investigated the possible role of antimicrobial peptides produced in the skin as inhibitors of infection and growth. We show here that 10 peptides representing eight families of peptides derived from North American ranid frogs can effectively inhibit growth of this chytrid. The peptides are members of the ranatuerin-1, ranatuerin-2, esculentin-1, esculentin-2, brevinin-2, temporin, palustrin-3, and ranalexin families. All the tested peptides inhibit growth of mature fungal cells at concentrations above 25 microM, and some of them inhibit at concentrations as low as 2 microM. A comparison of the sensitivity of infectious zoospores with that of mature cells showed that the zoospores are inhibited at significantly lower concentrations of peptides. To determine whether cold temperature interferes with the inhibitory effects of these peptides, we tested their effectiveness at both 22 and 10 degrees C. Although the peptides inhibit at both temperatures, they appear to be more effective against zoospores at the lower temperature. These results suggest that the ranid frogs have, within their repertoire of antimicrobial substances, a number of skin peptides that should be a deterrent to chytrid infection. This may provide some natural resistance to infection, but if environmental factors inhibit the synthesis and release of the skin peptides, the pathogen could gain the advantage.

Antimicrobial peptide defenses against pathogens associated with global amphibian declines.

Global declines of amphibian populations are a source of great concern. Several pathogens that can infect the skin have been implicated in the declines. The pathogen most frequently associated with recent die-offs is a chytrid fungus, Batrachochytrium dendrobatidis. A second fungus, Basidiobolus ranarum, was isolated from declining populations of Wyoming toads. A third pathogen, Aeromonas hydrophila, is an opportunistic bacterium found in healthy frogs, but capable of inducing disease. Among the immune defense mechanisms used by amphibians is the production of antimicrobial peptides in granular glands in the skin. These packets of natural antibiotics can be emptied onto the skin when the amphibian is injured. To determine whether antimicrobial skin peptides defend against these amphibian pathogens, six peptides (magainin I, magainin II, PGLa, CPF, ranalexin, and dermaseptin), from three species, and representing three structurally different families of peptides, were tested in growth inhibition assays. We show here that the peptides can kill or inhibit growth of both fungi but not Aeromonas. Although each peptide varied in its effectiveness, at least one from each species was effective against both fungi at a concentration of about 10-20 microM. This is the first direct evidence that antimicrobial peptides in the skin can operate as a first line of defense against the organisms associated with global amphibian declines. It suggests that this innate defense mechanism may play a role in preventing or limiting infection by these organisms.