Counseling Veterans with Chronic Pain During the COVID-19 Pandemic: A Secondary Analysis of a Randomized Controlled Trial.

INTRODUCTION: Veterans with chronic pain could be vulnerable during the COVID-19 pandemic. We qualitatively explored the impact of the COVID-19 pandemic on a sample of veterans receiving brief counseling focused on pain management in an ongoing clinical trial and discuss how the pandemic affected the process of motivating veterans with chronic pain to engage in interdisciplinary multimodal pain treatment at the Department of Veteran Affairs. METHODS: Segments of audio-recorded counseling sessions containing content about the pandemic were transcribed and coded to identify key concepts emerging from individual counselor-participant transactions. Themes that emerged were examined with constant comparison analysis. RESULTS: Three major themes emerged. 1) The pandemic caused a disruption in pain management service delivery, resulting in changes to the way veterans receive services or manage their pain symptoms. 2) The pandemic offered opportunities for resilience and personal growth as veterans with chronic pain reflected on their lives and personal goals. 3) The pandemic brought veterans' mental health issues to the forefront, and these should be addressed as part of a comprehensive pain management approach. DISCUSSION: Discussion of the COVID-19 pandemic during pain treatment counseling sessions highlighted negative and positive ways participants were affected by the pandemic. These discussions provided counselors with a unique opportunity to facilitate behavior change by focusing on characteristics of resilience to motivate individuals with chronic pain to adapt and adopt positive behaviors and outlooks to improve their pain experience and quality of life. CONCLUSIONS: Counselors can leverage feelings of resilience and personal growth to motivate veterans' use of adaptive coping skills and a wider array of pain management services.

Integrating Early Brain Science and Skills Into Prelicensure Nursing Curriculum to Promote Parent-Child Interaction.

BACKGROUND: Research shows that the number of loving words children hear in their first 3 years of life has a tremendous impact on their health, developmental, and literacy outcomes. Early language transactions should be rich in engagement, quantity, quality, and context-a term called language nutrition. PROBLEM: The curriculum in most nursing programs does not emphasize the importance of early language exposure and ways to empower families to talk with their babies. APPROACH: The Talk With Me Baby Curriculum for Nurses, which includes techniques to empower families to better engage conversationally with their babies, was integrated into the prelicensure nursing curriculum. OUTCOMES: More than 1,300 nursing students have received knowledge and skills on early language exposure and ways nurses can promote parent-child interactions. CONCLUSION: Nurses have the opportunity to empower families to engage with their babies socially, emotionally, and linguistically as a means of promoting healthy brain development.

A multicentre outbreak of ST45 MRSA containing deletions in the spa gene in New South Wales, Australia.

BACKGROUND: Early identification of MRSA by diagnostic medical microbiology laboratories enables improved antimicrobial choice and outcomes. The Cepheid Xpert® MRSA/SA BC test rapidly identifies Staphylococcus aureus bloodstream infections through spa gene detection and methicillin resistance via mecA gene detection. Recent emergence of S. aureus with deletions in the spa gene has resulted in false-negative results for this test, leading to misidentification of infections with this organism, particularly MRSA ST45. OBJECTIVES: To investigate the emergence and prevalence of ST45 MRSA in New South Wales (NSW), Australia. METHODS: WGS read data from six NSW hospitals were collected for 131 ST45 MRSA isolates and analysed. RESULTS: Of the 131 ST45 MRSA investigated, 88.5% (116/131) contained a deletion in the spa gene that appeared to have arisen once in approximately 2010 followed by clonal expansion. Given the successful establishment of this 'spa-deletion' MRSA clone, the Cepheid Xpert® MRSA/SA BC test became unreliable for confirming S. aureus bacteraemia in NSW. Subsequently, the algorithm used by this test has been updated and evaluated to take into account the presence of S. aureus with either a spa deletion or SCCmec target variations. CONCLUSIONS: This study highlighted the applied use of WGS for assessing diagnostic assays and informing necessary changes to ensure the viability of the Cepheid Xpert® MRSA/SA BC test in the context of the new 'spa-deletion' MRSA clone. It demonstrated how continued surveillance through WGS can reveal evolutionary events that may impact diagnostic assays, allowing corrective modifications to be made in real time.

Mechanisms of Action of Instillation and Dwell Negative Pressure Wound Therapy with Case Reports of Clinical Applications.

Negative pressure wound therapy (NPWT) has revolutionized the care of complex wounds since 1997. The addition of instillation (NPWTi-d) adds several potential benefits and challenges to clinicians dealing with complex wounds in a hospital setting. We surveyed the literature regarding the mechanism of action of these devices and reviewed our clinical experience to date. Potential mechanisms of action include the removal of microorganisms from the wound surface, dilution of cytotoxic molecules, upregulation of angiogenesis pathways, and maintenance of a moist wound environment. As we have extended our use of these devices to more complex wounds, we have taken advantage of and observed potential mechanisms of action, including facilitated removal of microorganisms, dilution of inflammatory and cytotoxic macromolecules, additional wound hydration, and enhanced angiogenesis through an intermittent application of NPWT. We have also observed complications, including bleeding, loss of a seal along the wound, and pain. NPWTi-d provides additional options for clinicians caring for complex wounds with favorable responses in wounds with significant contamination and those with poor inherent vascularity. Further studies to clarify the mechanisms of action, better define the wound types that would benefit, and techniques to manage complications using this device should further advance this field.

Cutaneous Breast Radiation-associated Angiosarcoma: Anterior Chest Wall Reconstruction Options Following Extra-radical Resection.

BACKGROUND: Radiation-associated angiosarcoma (RAAS) of the breast is a rare complication following breast irradiation with high rates of recurrence and death. To improve survival, we have advocated for an extra-radical resection where the entire irradiated skin and subcutaneous tissue is excised. This results in very large chest defects for which we describe our reconstructive experience. METHODS: We performed a retrospective review of patients diagnosed with RAAS and treated with extra-radical resection followed by immediate reconstruction between 1999 and 2017. We analyzed reconstructive options, complications rates, length of stay, and operative times. RESULTS: Extra-radical resections were performed in 35 patients. We reconstructed these large defects with abdominal advancement flaps with split-thickness skin grafting in 25 patients and added a pedicled latissimus dorsi or omental flap in the 10 other patients. Skin grafts took well over the irradiated pectoralis major muscle with a median take rate of over 90%. Average operative times were 150 minutes for those treated with an abdominal advancement flap and skin grafting with a median length of stay of 5 days for all patients. CONCLUSION: Large anterior chest soft-tissue defects caused by extra-radical resections leaves defects too large to be covered by traditional breast reconstruction flaps. Abdominal advancement, latissimus dorsi muscle, and omental flaps along with skin grafts can be safely performed while leaving other traditional options open for future breast reconstruction.

Plastic Surgery Complications from Medical Tourism Treated in a U.S. Academic Medical Center.

BACKGROUND: Medical tourism is a growing, multi-billion dollar industry fueled by improvements in the global transportation infrastructure. The authors studied patients living in the United States who travel to other countries for plastic surgical procedures and returned to have their complications treated in the authors' center. METHODS: A retrospective patient evaluation was performed. Patients who had presented to an urban tertiary academic hospital plastic surgery service with complications or complaints associated with plastic surgery performed in a developing country were studied. The authors collected demographic information, types of surgery performed, destinations, insurance coverage, and complications. RESULTS: Seventy-eight patients were identified over 7 years. Most commonly, complications were seen following abdominoplasty (n = 35), breast augmentation (n = 25), and foreign body injections (n = 15). Eighteen patients underwent multiple procedures in one operative setting. The most common destination country was the Dominican Republic (n = 59). Complications included surgical-site infections (n = 14), pain (n = 14), and wound healing complications (n = 12). Eighty-six percent of patients (n = 67) relied on their medical insurance to pay for their follow-up care or manage their complications, with the most common type of health insurance coverage being Massachusetts Medicaid (n = 48). CONCLUSIONS: Cosmetic surgery performed in developing countries can carry substantial risks of complications that can be challenging to patients, primary care providers, insurers, and plastic surgical teams not associated with the original surgery. These complications pose significant burdens on our public health systems.

Longitudinal and Source-to-Tap New Orleans, LA, U.S.A. Drinking Water Microbiology.

The two municipal drinking water systems of New Orleans, LA, U.S.A. were sampled to compare the microbiology of independent systems that treat the same surface water from the Mississippi River. To better understand temporal trends and sources of microbiology delivered to taps, these treatment plants and distribution systems were subjected to source-to-tap sampling over four years. Both plants employ traditional treatment by chloramination, applied during or after settling, followed by filtration before distribution in a warm, low water age system. Longitudinal samples indicated microbiology to have stability both spatially and temporally, and between treatment plants and distribution systems. Disinfection had the greatest impact on microbial composition, which was further refined by filtration and influenced by distribution and premise plumbing. Actinobacteria spp. exhibited trends with treatment. In particular, Mycobacterium spp., very low in finished waters, occurred idiosyncratically at high levels in some tap waters, indicating distribution and/or premise plumbing as main contributors of mycobacteria. Legionella spp., another genus containing potential opportunistic pathogens, also occurred ubiquitously. Source water microbiology was most divergent from tap water, and each step of treatment brought samples more closely similar to tap waters.

Effect of monochloramine treatment on the microbial ecology of Legionella and associated bacterial populations in a hospital hot water system.

Opportunistic pathogens, including Legionella spp. and non-tuberculous mycobacteria, can thrive in building hot water systems despite municipal and traditional on-site chlorine disinfection. Monochloramine is a relatively new approach to on-site disinfection, but the microbiological impact of on-site chloramine use has not been well studied. We hypothesized that comparison of the microbial ecology associated with monochloramine treatment versus no on-site treatment would yield highly dissimilar bacterial communities. Hot water samples were collected monthly from 7 locations for three months from two buildings in a Pennsylvania hospital complex supplied with common municipal water: (1) a hospital administrative building (no on-site treatment) and (2) an adjacent acute-care hospital treated on-site with monochloramine to control Legionella spp. Water samples were subjected to DNA extraction, rRNA PCR, and 454 pyrosequencing. Stark differences in the microbiome of the chloraminated water and the control were observed. Bacteria in the treated samples were primarily Sphingomonadales and Limnohabitans, whereas Flexibacter and Planctomycetaceae predominated in untreated control samples. Serendipitously, one sampling month coincided with dysfunction of the on-site disinfection system that resulted in a Legionella bloom detected by sequencing and culture. This study also demonstrates the potential utility of high-throughput DNA sequencing to monitor microbial ecology in water systems.

Molecular analysis of point-of-use municipal drinking water microbiology.

Little is known about the nature of the microbiology in tap waters delivered to consumers via public drinking water distribution systems (DWDSs). In order to establish a broader understanding of the microbial complexity of public drinking waters we sampled tap water from seventeen different cities between the headwaters of the Arkansas River and the mouth of the Mississippi River and determined the bacterial compositions by pyrosequencing small subunit rRNA genes. Nearly 98% of sequences observed among all systems fell into only 5 phyla: Proteobacteria (35%), Cyanobacteria (29%, including chloroplasts), Actinobacteria (24%, of which 85% were Mycobacterium spp.), Firmicutes (6%), and Bacteroidetes (3.4%). The genus Mycobacterium was the most abundant taxon in the dataset, detected in 56 of 63 samples (16 of 17 cities). Among the more rare phylotypes, considerable variation was observed between systems, and was sometimes associated with the type of source water, the type of disinfectant, or the concentration of the environmental pollutant nitrate. Abundant taxa (excepting Cyanobacteria and chloroplasts) were generally similar from system to system, however, regardless of source water type or local land use. The observed similarity among the abundant taxa between systems may be a consequence of the selective influence of chlorine-based disinfection and the common local environments of DWDS and premise plumbing pipes.

Universal newborn screening: knowledge, attitudes, and satisfaction among public health professionals.

OBJECTIVE: Assess knowledge, attitude, and satisfaction with the newborn screening (NBS) system among pediatric public health leaders in the state of Florida. METHODS: Online surveys and open-ended telephone interviews were administered to 10 county medical directors for a state-funded program that oversees NBS. Survey questions examined basic knowledge regarding NBS, views on provider and parent access to NBS information, and recommendations for improving the information distribution system. RESULTS: Providers learn about NBS from the American Academy of Pediatrics, the Department of Health, and continuing medical education; however, 80% of providers were concerned about receiving inadequate information. Thirty percent of the providers surveyed reported that it takes >14 days to receive NBS results. The majority (80%) were concerned that parents may not receive adequate information about their infant's condition, treatment, or prognosis. No provider reported being confident in his or her ability to assess how well a parent understands a positive NBS result. Eighty percent of those surveyed believe that the pediatric primary care provider is responsible for providing NBS information to parents and almost all of the providers (90%) believed parents should be notified of normal NBS results. CONCLUSIONS: This study indicates dissatisfaction with and confusion about NBS. Addressing this problem requires action at the levels of medical education, clinical care, health policy, and information systems.

Phototrophic phylotypes dominate mesothermal microbial mats associated with hot springs in Yellowstone National Park.

The mesothermal outflow zones (50-65°C) of geothermal springs often support an extensive zone of green and orange laminated microbial mats. In order to identify and compare the microbial inhabitants of morphologically similar green-orange mats from chemically and geographically distinct springs, we generated and analyzed small-subunit ribosomal RNA (rRNA) gene amplicons from six mesothermal mats (four previously unexamined) in Yellowstone National Park. Between three and six bacterial phyla dominated each mat. While many sequences bear the highest identity to previously isolated phototrophic genera belonging to the Cyanobacteria, Chloroflexi, and Chlorobi phyla, there is also frequent representation of uncultured, unclassified members of these groups. Some genus-level representatives of these dominant phyla were found in all mats, while others were unique to a single mat. Other groups detected at high frequencies include candidate divisions (such as the OP candidate clades) with no cultured representatives or complete genomes available. In addition, rRNA genes related to the recently isolated and characterized photosynthetic acidobacterium "Candidatus Chloracidobacterium thermophilum" were detected in most mats. In contrast to microbial mats from well-studied hypersaline environments, the mesothermal mats in this study accrue less biomass and are substantially less diverse, but have a higher proportion of known phototrophic organisms. This study provides sequences appropriate for accurate phylogenetic classification and expands the molecular phylogenetic survey of Yellowstone microbial mats.

Shock wave therapy in wound healing.

BACKGROUND: Recently, shock wave therapy has been investigated as an adjuvant therapy in the treatment of acute and chronic wounds. There are several devices with focused and unfocused shock waves that have been administered to a heterogenous group of wounds. Encouraging preclinical and clinical studies suggest that shock wave therapy may promote wound healing with little or no adverse events, prompting investigations into the mechanism of action and additional clinical trials. METHODS: The peer-reviewed literature within the past 10 years was studied using an evidence-based approach. RESULTS: Preclinical studies demonstrate that shock wave therapy affects cellular function and leads to the expression of several genes and elaboration of growth factors known to promote wound healing. Limited clinical trials are encouraging for the use of shock wave therapy in the treatment of acute and chronic wounds. Serious complications, including wound infections, bleeding, hematomas, seromas, and petechiae, have not been reported in the largest of these studies. CONCLUSIONS: Shock wave therapy is an intriguing physical modality that may play an important role as an adjuvant therapy in wound healing. To date, there is no consensus on which wounds are most likely to benefit from shock wave therapy and what the optimal power, degree of focus, and frequency or number of cycles should be. Well-designed preclinical and clinical studies are necessary to better understand shock wave therapy in wound healing.

Single-strand-specific exonucleases prevent frameshift mutagenesis by suppressing SOS induction and the action of DinB/DNA polymerase IV in growing cells.

Escherichia coli strains carrying null alleles of genes encoding single-strand-specific exonucleases ExoI and ExoVII display elevated frameshift mutation rates but not base substitution mutation rates. We characterized increased spontaneous frameshift mutation in ExoI- ExoVII- cells and report that some of this effect requires RecA, an inducible SOS DNA damage response, and the low-fidelity, SOS-induced DNA polymerase DinB/PolIV, which makes frameshift mutations preferentially. We also find that SOS is induced in ExoI- ExoVII- cells. The data imply a role for the single-stranded exonucleases in guarding the genome against mutagenesis by removing excess single-stranded DNA that, if left, leads to SOS induction and PolIV-dependent mutagenesis. Previous results implicated PolIV in E. coli mutagenesis specifically during starvation or antibiotic stresses. Our data imply that PolIV can also promote mutation in growing cells under genome stress due to excess single-stranded DNA.

The involvement of low-income African American fathers in their children's lives, and the barriers they face.

OBJECTIVE: To examine the involvement of fathers in the lives of low-income African American 8-year-old children, and the barriers they face. METHODS: The sample was comprised of 117 fathers or father figures of 8-year-olds in families participating in a longitudinal study of child development and maltreatment. The men were asked a series of open-ended questions pertaining to their involvement in the children's lives. Their responses were audiotaped and transcribed. Major themes and subthemes were identified and coded on NVIVO software. RESULTS: The men conveyed a strong sense of commitment to the children, identifying many issues reported by white and middle class men, such as providing support and affection and teaching values and skills. They raised the need to protect the children and help take care of them when sick, some adding that they did not feel confident doing so. They saw discipline as one of their roles, but described this as difficult for them. The men faced challenges of not having financial resources, not living with the child, and lacking knowledge or skills. CONCLUSIONS: This group of fathers appears to be clearly committed to their children, despite significant challenges. There are a variety of ways that pediatricians can help facilitate their positive involvement in children's lives, and they may well contribute to the health and development of such high-risk children.