Bell Palsy: Rapid Evidence Review.

Bell palsy should be suspected in patients with acute onset of unilateral facial weakness or paralysis involving the forehead in the absence of other neurologic abnormalities. The overall prognosis is good. More than two-thirds of patients with typical Bell palsy have a complete spontaneous recovery. For children and pregnant women, the rate of complete recovery is up to 90%. Bell palsy is idiopathic. Laboratory testing and imaging are not required for diagnosis. When other causes of facial weakness are being considered, laboratory testing may identify a treatable cause. An oral corticosteroid regimen (prednisone, 50 to 60 mg per day for five days followed by a five-day taper) is the first-line treatment for Bell palsy. Combination therapy with an oral corticosteroid and antiviral may reduce rates of synkinesis (misdirected regrowth of facial nerve fibers manifesting as involuntary co-contraction of certain facial muscles). Recommended antivirals include valacyclovir (1 g three times per day for seven days) or acyclovir (400 mg five times per day for 10 days). Treatment with antivirals alone is ineffective and not recommended. Physical therapy may be beneficial in patients with more severe paralysis.

Extinct in the wild: The precarious state of Earth's most threatened group of species.

Extinct in the Wild (EW) species are placed at the highest risk of extinction under the International Union for Conservation of Nature Red List, but the extent and variation in this risk have never been evaluated. Harnessing global databases of ex situ animal and plant holdings, we report on the perilous state of EW species. Most EW animal species-already compromised by their small number of founders-are maintained at population sizes far below the thresholds necessary to ensure demographic security. Most EW plant species depend on live propagation by a small number of botanic gardens, with a minority secured at seed bank institutions. Both extinctions and recoveries are possible fates for EW species. We urgently call for international effort to enable the latter.

Tinnitus: Diagnosis and Management.

Tinnitus is the sensation of hearing a sound in the absence of an internal or external source and is a common problem encountered in primary care. Most cases of tinnitus are benign and idiopathic and are strongly associated with sensorineural hearing loss. A standard workup begins with a targeted history and physical examination to identify treatable causes and associated symptoms that may improve with treatment. Less common but potentially dangerous causes such as vascular tumors and vestibular schwannoma should be ruled out. A comprehensive audiologic evaluation should be performed for patients who experience unilateral tinnitus, tinnitus that has been present for six months or longer, or that is accompanied by hearing problems. Neuroimaging is not part of the standard workup unless the tinnitus is asymmetric or unilateral, pulsatile, associated with focal neurologic abnormalities, or associated with asymmetric hearing loss. Cognitive behavior therapy is the only treatment that has been shown to improve quality of life in patients with tinnitus. Sound therapy and tinnitus retraining therapy are treatment options, but evidence is inconclusive. Melatonin, antidepressants, and cognitive training may help with sleep disturbance, mood disorders, and cognitive impairments, respectively. Avoidance of noise exposure may help prevent the development or progression of tinnitus. Providing information about the natural progression of tinnitus and being familiar with the causes that warrant additional evaluation, imaging, and specialist involvement are essential to comprehensive care.

Engaging Family Medicine Residents in a Structured Patient Panel Reassignment Process.

BACKGROUND AND OBJECTIVES: The patient panels of graduating residents must be reassigned by the end of residency. This process affects over 1 million patients annually within the specialty of family medicine. The purpose of this project was to implement a structured, year-end reassignment system in a family medicine residency program. METHODS: Our structured reassignment process took place from December 2017 through June 2020. Panel lists of current, active patients were generated and residents were responsible for reassigning their own panels during a panel reassignment night. We created a tip sheet that addressed patient complexity and continuity, a risk stratification algorithm based on patients' medical and social complexity, and a tool that tracked the number of patients assigned to each future provider. Outcome measures included a resident satisfaction survey administered in 2018-2020 and patient-provider continuity measured with a run chart from December 2016 through August 2020. RESULTS: The resident survey response rate was 75%. Seventy-three percent felt the panel reassignment night was very helpful; 87% thought the reassignment timeline was extremely reasonable, and 87% indicated that they had the necessary information to reassign their patients. Residents also felt confident that their patients were reassigned appropriately (33% extremely confident, 67% somewhat confident). Patient continuity improved with a 13-point run above the median, indicating nonrandom variation. Patient continuity remained above the median until the impact of COVID-19 in April 2020. CONCLUSION: Our structured reassignment process was received positively by residents and resulted in improved patient continuity.

Women's Health and Gender-Specific Considerations.

Women's health is largely influenced by cultural beliefs, local traditions, and access to care across the world. Immigrant and refugee women experience health in varied ways; prior experiences with health care and beliefs about health should be explored with women on their arrival to the United States. Topics that should be discussed include menstrual practices, contraception and beliefs about family planning, prior screening for preventable diseases, pregnancies and experiences with childbirth, sexual assault and trauma, and history of traditional practices, including female genital mutilation (dependent on area of origin).

Climate suitability as a predictor of conservation translocation failure.

The continuing decline and loss of biodiversity has caused an increase in the use of interventionist conservation tools, such as translocation. However, many translocation attempts fail to establish viable populations, with poor release site selection often flagged as an inhibitor of success. We used species distribution models (SDMs) to predict the climate suitability of 102 release sites for amphibians, reptiles, and terrestrial insects and compared suitability predictions between successful and failed attempts. We then quantified the importance of climate suitability relative to 5 other variables frequently considered in the literature as important determinants of translocation success: number of release years, number of individuals released, life stage released, origin of the source population, and position of the release site relative to the species' range. Probability of translocation success increased as predicted climate suitability increased and this effect was the strongest among the variables we considered, accounting for 48.3% of the variation in translocation outcome. These findings should encourage greater consideration of climate suitability when selecting release sites for conservation translocations and we advocate the use of SDMs as an effective way to do this.

Idoneidad Climática como Pronosticador del Fracaso de la Reubicación por Conservación Resumen La continua declinación y pérdida de la biodiversidad ha ocasionado un incremento en el uso de herramientas intervencionistas de conservación como la reubicación. Sin embargo, muchos intentos de reubicación fracasan en el establecimiento de poblaciones viables, y generalmente se identifica a la mala selección de sitios de liberación como el inhibidor del éxito. Usamos modelos de distribución de especies (MDE) para predecir la idoneidad climática de 102 sitios de liberación para anfibios, reptiles e insectos terrestres y comparamos las predicciones de idoneidad entre los intentos fallidos y los exitosos. Después cuantificamos la importancia de la idoneidad climática en relación a otras cinco variables consideradas frecuentemente en la literatura como determinantes importantes del éxito de la reubicación: el número de años de liberaciones, el número de individuos liberados, la etapa de vida durante la liberación, la fuente de la población de origen y la posición del sitio de liberación en relación a la extensión de la especie. La probabilidad del éxito de la reubicación incrementó conforme aumentó la idoneidad climática pronosticada y este efecto fue el más fuerte entre las variables que consideramos, representando el 48.3% de la variación del resultado de la reubicación. Estos hallazgos deberían promover una mayor consideración de la idoneidad climática cuando se seleccionan sitios de liberación para reubicaciones por conservación y abogamos que el uso de los MDE es un método efectivo para hacer esto.

Ex situ collections and their potential for the restoration of extinct plants.

The alarming current and predicted species extinction rates have galvanized conservationists in their efforts to avoid future biodiversity losses, but for species extinct in the wild, few options exist. We posed the questions, can these species be restored, and, if so, what role can ex situ plant collections (i.e., botanic gardens, germplasm banks, herbaria) play in the recovery of plant genetic diversity? We reviewed the relevant literature to assess the feasibility of recovering lost plant genetic diversity with using ex situ material and the probability of survival of subsequent translocations. Thirteen attempts to recover species extinct in the wild were found, most of which used material preserved in botanic gardens (12) and seed banks (2). One case of a locally extirpated population was recovered from herbarium material. Eight (60%) of these cases were successful or partially successful translocations of the focal species or population; the other 5 failed or it was too early to determine the outcome. Limiting factors of the use of ex situ source material for the restoration of plant genetic diversity in the wild include the scarcity of source material, low viability and reduced longevity of the material, low genetic variation, lack of evolution (especially for material stored in germplasm banks and herbaria), and socioeconomic factors. However, modern collecting practices present opportunities for plant conservation, such as improved collecting protocols and improved cultivation and storage conditions. Our findings suggest that all types of ex situ collections may contribute effectively to plant species conservation if their use is informed by a thorough understanding of the aforementioned problems. We conclude that the recovery of plant species currently classified as extinct in the wild is not 100% successful, and the possibility of successful reintroduction should not be used to justify insufficient in situ conservation.

Colecciones Ex Situ y su Potencial para la Restauración de Plantas Extintas Resumen Las alarmantes tasas de extinción actuales y pronosticadas han incitado a los conservacionistas a esforzarse para evitar las futuras pérdidas de biodiversidad, pero para las especies que ya se encuentran extintas en vida silvestre existen pocas opciones. Nos preguntamos si estas especies pueden ser restauradas, y de ser así, qué papel pueden desempeñar las colecciones ex situ de plantas (es decir, jardines botánicos, bancos de germoplasma, herbarios) en la recuperación de la diversidad genética de las plantas. Revisamos la literatura relevante para evaluar la factibilidad de la recuperación de la diversidad genética perdida y la probabilidad de supervivencia subsecuente de las reubicaciones. Encontramos 13 intentos por recuperar especies extintas en vida silvestre, la mayoría de los cuales usó material preservado en jardines botánicos (12) y en bancos de semillas (2). También hubo un caso de una población eliminada localmente que fue recuperada con material de un herbario. Ocho (60%) de estos casos fueron reubicaciones exitosas o parcialmente exitosas de la especie o población focal; los otros cinco fallaron o era demasiado pronto para poder determinar el resultado. Los factores que limitan el uso de material proveniente de colecciones ex situ para la restauración de la diversidad genética de las plantas en vida silvestre incluyen la escasez de material original, la baja viabilidad y la longevidad reducida del material, la baja variación genética, la falta de evolución (especialmente para el material almacenado en herbarios y bancos de germoplasma) y los factores socioeconómicos. A pesar de esto, las prácticas modernas de colección representan una oportunidad para la conservación de las plantas, como los protocolos mejorados de recolección y las condiciones acrecentadas de cultivo y almacenamiento. Nuestros hallazgos sugieren que todos los tipos de colecciones ex situ pueden contribuir efectivamente a la conservación de especies de plantas si su uso está respaldado por un entendimiento a fondo de los problemas antes mencionados. Concluimos que la recuperación de especies de plantas que actualmente están clasificadas como extintas en vida silvestre no es 100% exitosa y que la posibilidad de una reintroducción exitosa no debería utilizarse para justificar una conservación in situ insuficiente.

Treatment of the Common Cold.

Acute upper respiratory tract infections are extremely common in adults and children, but only a few safe and effective treatments are available. Patients typically present with nasal congestion, rhinorrhea, sore throat, cough, general malaise, and/or low-grade fever. Informing patients about the self-limited nature of the common cold can help manage expectations, limit antibiotic use, and avoid over-the-counter purchases that may not help. Treatments with proven effectiveness for cold symptoms in adults include over-the-counter analgesics, zinc, nasal decongestants with or without antihistamines, and ipratropium for cough. Lower-quality evidence suggests that Lactobacillus casei may be beneficial in older adults. The only established safe and effective treatments for children are acetylcysteine, honey (for children one year and older), nasal saline irrigation, intranasal ipratropium, and topical application of ointment containing camphor, menthol, and eucalyptus oils. Over-the-counter cold medications should not be used in children younger than four years. Counseling patients about the importance of good hand hygiene is the best way to prevent transmission of cold viruses.

Author Correction: Ex situ seed banks and the IUCN Red List.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Using an interprofessional team to provide refugee healthcare in an academic medical centre.

INTRODUCTION: The International Family Medicine Clinic (IFMC) was established in 2002 by the University of Virginia Department of Family Medicine to provide comprehensive, timely, culturally sensitive and high-quality healthcare to the growing refugee and special immigrant population in Central Virginia, USA. METHODS: The purpose of this paper is to describe the IFMC, with a specific focus on interprofessional roles, interprofessional collaboration, community partnerships and the services and resources available to IFMC patients. RESULTS: The clinic has served over 3100 refugees from 60 countries in its 16-year history. In 2019, the clinic staff now includes 4 attending physicians, 2 nurse practitioners and 14 residents who have dedicated clinic time to see refugees; a registered nurse care coordinator and a social worker dedicated to the IFMC refugee population; 2 clinical psychologists and doctoral students in clinical psychology; and a clinical pharmacist. The IFMC also provides onsite psychiatric care. A process flow map depicts the interconnectivity of interprofessional team members working together with other specialty care providers within the medical centre and with community partners on behalf of refugee patients through the resettlement process. CONCLUSION: Individuals who arrive in the USA as refugees are a particularly vulnerable patient group and often require an interprofessional team approach. The IFMC may serve as a model for other institutions interested in starting a similar interprofessional, refugee-centred medical home.

Analysis of a large cohort of cystic fibrosis patients with severe liver disease indicates lung function decline does not significantly differ from that of the general cystic fibrosis population.

Previous reports of lung function in cystic fibrosis (CF) patients with liver disease have shown worse, similar, or even better forced expiratory volume in 1 second (FEV1), compared to CF patients without liver disease. Varying definitions of CF liver disease likely contribute to these inconsistent relationships reported between CF lung function and liver disease. We retrospectively evaluated spirometric data in 179 subjects (62% male; 58% Phe508del homozygous) with severe CF liver disease (CFLD; defined by presence of portal hypertension due to cirrhosis). FEV1 values were referenced to both a normal population (FEV1% predicted) and CF population (CF-specific FEV1 percentile). We utilized a linear mixed model with repeated measures to assess changes in lung function (before and after diagnosis of CFLD), relative to both the normal and CF populations. At diagnosis of CFLD, the mean FEV1 was 81% predicted, or at the 53rd percentile referenced to CF patients without CFLD. There was a significant difference in post-CFLD slope compared to pre-CFLD slope (post-pre) using FEV1% predicted (-1.94, p-value < 0.0001). However, there was insignificant evidence of this difference using the CF-specific FEV1 percentile measure (-0.99, p-value = 0.1268). Although FEV1% predicted values declined in patients following CFLD diagnosis, there was not significant evidence of lung function decline in CF-specific FEV1 percentiles. Thus, the observed study cohort indicates diagnosis of severe CFLD was not associated with worsened CF lung disease when compared to a large CF reference population.

Isolation of microsatellite primers for Melampyrum sylvaticum (Orobanchaceae), an endangered plant in the United Kingdom.

PREMISE OF THE STUDY: Microsatellite markers were developed for the hemiparasitic plant Melampyrum sylvaticum to investigate the breeding system, genetic diversity, and structure of populations in the United Kingdom, Sweden, and Norway. METHODS AND RESULTS: Microsatellites were isolated from genomic DNA using an enrichment protocol. Twenty-nine loci were characterized in two individuals from each of 15 geographically disparate populations ("global"). Seven polymorphic loci were further characterized in one population ("local"). The number of alleles per locus ranged from two to 12 in the global sample and one to seven in the local sample. The expected heterozygosity ranged from 0-0.75, the observed heterozygosity from 0-0.1, and the inbreeding coefficient from 0.84-1 in the local sample. CONCLUSIONS: The results show the utility of these novel polymorphic microsatellite markers for further conservation genetic analyses. The strong deficit of heterozygosity across all loci in the local sample suggests the species may be inbreeding.