Draping in Dermatology: A Physician's Perspective.

BACKGROUND: Patient dignity is a core component of medicine and health care, yet maintaining patient dignity can be challenging in clinical settings in dermatology, specifically during a total body skin examinations (TBSE) for appropriate assessment and diagnosis. A recent study evaluated patient perspectives in dermatology. The purpose of this study was to investigate current draping practices and perspectives from a physicians' perspective. METHODS: A cross-sectional study was performed with the use of study-specific questionnaire distributed to staff dermatologists and dermatology residents across Canada. RESULTS: A total of 117 physicians were included (84 attending dermatologists and 33 dermatology residents). Nearly all staff and resident dermatologists (90.6%) indicated that draping was important. Specific practices differed between residents and staff (P = .03). Only 3.1% of residents indicated that they did not receive any form of teaching on draping during their training compared to 21.4% of attending physicians (P = .03). DISCUSSION: This study confirms that draping practices in dermatology are perceived as important by dermatologists, consistent with other reports emphasizing approaches to protect patient privacy and dignity. There is a shared value for draping and consistent integration of this within current practice of Canadian dermatologists. Formal and informal education incorporated in medical education and dermatology training is becoming more prominent. Major study limitations include sampling bias, convenience bias and nonresponse bias. CONCLUSION: This is the first study to evaluate physician perspectives on draping in dermatology or other areas in medicine. Findings from this study support a focus on draping in medical education.

A case of drug-induced bullous pemphigoid secondary to immunotherapy treated with upadacitinib: A case report.

Bullous pemphigoid is an acquired autoimmune subepidermal blistering disease that can arise following exposure to systemic medication, referred to as drug-induced bullous pemphigoid. Drug-induced bullous pemphigoid is a rare but potentially serious immune-related adverse event that should be considered in patients with advanced malignancies undergoing immunotherapy, with immune checkpoint inhibitors emerging in particular as a well-documented drug association in drug-induced bullous pemphigoid. We present a 74-year-old female with recurrent metastatic programmed cell death-ligand 1-positive squamous cell carcinoma of the head and neck area who developed drug-induced bullous pemphigoid in the setting of immunotherapy with a novel immunoglobulin-like transcript 4 inhibitor (MK-4830) in combination with pembrolizumab. Treatment with upadacitinib, a Janus-associated kinase-1 inhibitor, was pursued for significantly disabling disease that was recalcitrant to standard therapies and ultimately transition to palliative care. Follow-up at 4 weeks demonstrated good response. This is the first report describing the use of a Janus-associated kinase inhibitor for the treatment of bullous pemphigoid.

Multicenter Surveillance of Antimicrobial Resistance among Gram-Negative Bacteria Isolated from Bloodstream Infections in Ghana.

BACKGROUND: Antimicrobial resistance (AMR) in Gram-negative bacteria-causing bloodstream infections (BSIs), such as Klebsiella pneumoniae and non-typhoidal Salmonella (NTS), is a major public health concern. Nonetheless, AMR surveillance remains scarce in sub-Saharan Africa, where BSI treatment is largely empirical. The aim of the study was to determine the distribution and AMR patterns of BSI-causing NTS, K. pneumoniae, and other Gram-negative bacteria in Ghana. METHODS: A cross-sectional study was conducted between April and December 2021 at eleven sentinel health facilities across Ghana as part of a pilot study on the feasibility and implementation of the human sector AMR surveillance harmonized protocol in sub-Saharan Africa. Gram-negative bacteria recovered from blood specimens of febrile patients were identified using MALDI-TOF and evaluated for antimicrobial resistance using the BD Phoenix M50 analyzer and Kirby-Bauer disc diffusion. The Department of Medical Microbiology at the University of Ghana served as the reference laboratory. RESULTS: Out of 334 Gram-negative blood isolates, there were 18 (5.4%) NTS, 85 (25.5%) K. pneumoniae, 88 (26.4%) Escherichia coli, 40 (12.0%) Acinetobacter baumannii, 25 (7.5%) Pseudomonas aeruginosa, and 77 (23.1%) other Gram-negative bacteria. As a composite, the isolates displayed high resistance to the antibiotics tested-amoxicillin (89.3%), tetracycline (76.1%), trimethoprim-sulfamethoxazole (71.5%), and chloramphenicol (59.7%). Resistance to third-generation cephalosporins [ceftriaxone (73.7%), cefotaxime (77.8%), and ceftazidime (56.3%)] and fluoroquinolones [ciprofloxacin (55.3%)] was also high; 88% of the isolates were multidrug resistant, and the rate of extended-spectrum beta-lactamase (ESBL) production was 44.6%. Antibiotic resistance in K. pneumoniae followed the pattern of all Gram-negative isolates. Antibiotic resistance was lower in NTS blood isolates, ranging between 16.7-38.9% resistance to the tested antibiotics. Resistance rates of 38.9%, 22.2%, and 27.8% were found for cefotaxime, ceftriaxone, and ceftazidime, respectively, and 27.8% and 23.8% for ciprofloxacin and azithromycin, respectively, which are used in the treatment of invasive NTS. The prevalence of multidrug resistance in NTS isolates was 38.9%. CONCLUSIONS: Multicenter AMR surveillance of Gram-negative blood isolates from febrile patients was well-received in Ghana, and the implementation of a harmonized protocol was feasible. High resistance and multidrug resistance to first- or second-choice antibiotics, including penicillins, third-generation cephalosporins, and fluoroquinolones, were found, implying that these antibiotics might have limited effectiveness in BSI treatment in the country. Continuation of AMR surveillance in Gram-negative blood isolates is essential for a better understanding of the extent of AMR in these pathogens and to guide clinical practice and policymaking.

Safety and efficacy of autologous cell vaccines in solid tumors: a systematic review and meta-analysis of randomized control trials.

We conducted a systematic review and meta-analysis of randomized control trials to formally assess the safety and efficacy of autologous whole cell vaccines as immunotherapies for solid tumors. Our primary safety outcome was number, and grade of adverse events. Our primary efficacy outcome was clinical responses. Secondary outcomes included survival metrics and correlative immune assays. We searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials for studies published between 1946 and August 2020 using any autologous whole cell product in the treatment of any solid tumor. The Cochrane Randomized Controlled Trial risk of bias tool was used to assess risk of bias. Eighteen manuscripts were identified with a total of 714 patients enrolled in control and 808 in vaccine arms. In 698 patients receiving at least one dose of vaccine, treatment was well tolerated with a total of 5 grade III or higher adverse events. Clinical response was reported in a minority (n = 2, 14%) of studies. Autologous cell vaccines were associated with improved overall (HR 1.28, 95% CI 1.01-1.63) and disease-free survival (HR 1.33, 95% CI 1.05-1.67) over thirteen and ten trials respectively. Where reported, immune assays correlated well with clinical outcomes. Our results suggest that autologous whole cell vaccination is safe and efficacious in increasing survival in patients undergoing treatment for solid tumors.Registration: PROSPERO CRD42019140187.

Draping in Dermatology: A Patient's Perspective.

BACKGROUND/OBJECTIVES: Patient dignity is a core component of the Canadian health care system; however, there may be challenges to maintaining patient dignity in clinical settings requiring total body skin examination (TBSE) for adequate assessment and diagnosis. As standardized TBSE draping practices have not been investigated in a dermatology setting, we sought out to investigate subjective patient experiences of draping practices. METHODS: A cross-sectional study was performed using a paper survey in dermatology hospital clinics over a 6-month period to 150 patients. RESULTS: Draping was considered important by over 50% of patients surveyed (54.7%). Respondents who indicated that draping impacted their comfort level "a lot" or "very much" had a mean age of 52 and were more likely to be females (P < .05). Females were also more likely to answer that their body weight/shape (P < .05), physician of same (P < .01) or opposite sex (P < .001), and the degree of privacy offered by drapes (P < .001) impacted their comfort level when undressing for a TBSE. Respondents who reported that any assessed factor impacted their comfort during a TBSE were also younger (P < .05), suggesting that younger and female patients were more likely to have comfort concerns than males. CONCLUSIONS: Our study confirmed that most patients surveyed considered draping to be important. Our findings highlight the importance of adequate draping practices to maintain patient privacy and dignity for all patients, with special attention to younger female patients to ensure they feel as comfortable as possible. Future research should focus on how these identified patient comfort factors can be implemented into medical education.

Safety and efficacy of autologous whole cell vaccines in hematologic malignancies: A systematic review and meta-analysis.

Autologous cell vaccines use a patient's tumor cells to stimulate a broad antitumor response in vivo. This approach shows promise for treating hematologic cancers in early phase clinical trials, but overall safety and efficacy remain poorly described. We conducted a systematic review assessing the use of autologous cell vaccination in treating hematologic cancers. Primary outcomes of interest were safety and clinical response, with secondary outcomes including survival, relapse rate, correlative immune assays and health-quality related metrics. We performed a search of MEDLINE, Embase and the Cochrane Register of Controlled Trials including any interventional trial employing an autologous, whole cell product in any hematologic malignancy. Risk of bias was assessed using a modified Institute of Health Economics tool. Across 20 single arm studies, only 341 of 592 enrolled participants received one or more vaccinations. Primary reasons for not receiving vaccination included rapid disease progression/death and manufacturing challenges. Overall, few high-grade adverse events were observed. One death was reported and attributed to a GM-CSF producing allogeneic cell line co-administered with the autologous vaccine. Of 58 evaluable patients, the complete response rate was 21.0% [95% CI, 10.4%-37.8%)] and overall response rate was 35.8% (95% CI, 24.4%-49.0%). Of 97 evaluable patients for survival, the 5-years overall survival rate was 64.9% (95% CI, 52.6%-77.2%) and disease-free survival was 59.7% (95% CI, 47.7%-71.7%). We conclude that, in hematologic malignancies, based on limited available data, autologous cell vaccines are safe and display a trend towards efficacy but that challenges exist in vaccine manufacture and administration.

An evidence-based guide to SARS-CoV-2 vaccination of patients on immunotherapies in dermatology.

Immune-mediated diseases and immunotherapeutics can negatively affect normal immune functioning and, consequently, vaccine safety and response. The COVID-19 pandemic has incited research aimed at developing a novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine. As SARS-CoV-2 vaccines are developed and made available, the assessment of anticipated safety and efficacy in patients with immune-mediated dermatologic diseases and requiring immunosuppressive and/or immunomodulatory therapy is particularly important. A review of the literature was conducted by a multidisciplinary committee to provide guidance on the safety and efficacy of SARS-CoV-2 vaccination for dermatologists and other clinicians when prescribing immunotherapeutics. The vaccine platforms being used to develop SARS-CoV-2 vaccines are expected to be safe and potentially effective for dermatology patients on immunotherapeutics. Current guidelines for the vaccination of an immunocompromised host remain appropriate when considering future administration of SARS-CoV-2 vaccines.

Policy and Science for Global Health Security: Shaping the Course of International Health.

The global burden of infectious diseases and the increased attention to natural, accidental, and deliberate biological threats has resulted in significant investment in infectious disease research. Translating the results of these studies to inform prevention, detection, and response efforts often can be challenging, especially if prior relationships and communications have not been established with decision-makers. Whatever scientific information is shared with decision-makers before, during, and after public health emergencies is highly dependent on the individuals or organizations who are communicating with policy-makers. This article briefly describes the landscape of stakeholders involved in information-sharing before and during emergencies. We identify critical gaps in translation of scientific expertise and results, and biosafety and biosecurity measures to public health policy and practice with a focus on One Health and zoonotic diseases. Finally, we conclude by exploring ways of improving communication and funding, both of which help to address the identified gaps. By leveraging existing scientific information (from both the natural and social sciences) in the public health decision-making process, large-scale outbreaks may be averted even in low-income countries.

Longitudinal Stability of Cognition in Early-Phase Relapsing-Remitting Multiple Sclerosis: Does Cognitive Reserve Play a Role?

BACKGROUND: Up to 70% of people with multiple sclerosis (MS) experience cognitive impairment. Some remain cognitively intact despite advanced disease. Cognitive reserve (CR) theory postulates that individuals with higher levels of intellectual enrichment can tolerate more pathology than others before exhibiting cognitive impairment. METHODS: Thirty-two individuals with early-phase relapsing-remitting MS with mild physical disability and disease duration less than 10 years and 32 controls were recruited. At baseline and after 3 years, participants completed neuropsychological tests evaluating several cognitive domains. The CR was assessed via a cognitive reserve index (CRI) using educational levels and North American Adult Reading Test scores. Change in cognition was assessed using a reliable change index. RESULTS: At baseline, people with MS performed worse than controls on visual memory. There were no significant group differences on information processing speed, learning, language, and executive functions. Most cognitive domains showed no change over time, and CRI was not a significant predictor in the regression model. CONCLUSIONS: People with MS performed worse on memory tasks at baseline compared with controls. Cognitive change differed between people with MS and controls in executive functions. Although people with MS and controls improved over time, beyond practice effects, people with MS improved less than controls. Overall, no cognitive deterioration was noted over time, and CR did not predict change in cognition. Sample homogeneity in terms of disease stage and CR may explain these findings.

Sexual Health of Adolescent Patients Admitted to a Psychiatric Unit.

OBJECTIVE: To review sexual health screening practices during admission to an adolescent psychiatry unit. METHOD: Retrospective chart review of randomly selected youth admitted over a one-year period (2013). Data extracted included demographics, reasons for admission, sexual health history, as well as any comorbid behaviours noted. The main outcome measure was whether sexual health details were documented at any time during admission; if so, this information was extracted for analysis. Statistical analysis was done using univariate associations and logistic association. RESULTS: Mean age of subjects (n=99, 79 females and 20 males) was 15.24 years (SD = 1.30). Most common reasons for admission were suicidal gestures/self harm (n=57, 58%) and mood disorders (n=53, 54%). Thirty-seven patients (37%) had sexual health information documented in their charts. No demographic variables were significantly associated with being asked sexual health questions. Patients who had mood disorder diagnoses had 6 times the odds (95%CI: 1.18 to 29.96, P=0.03) of sexual health questions being documented compared to those not diagnosed with mood disorders. CONCLUSIONS: Screening for sexual health concerns is not being documented in the majority of adolescent psychiatry inpatients. Omitting sexual health screening during hospitalizations represents a missed opportunity for investigation and management of sexual health issues in this high-risk group. As many adolescents, particular those struggling with mental illness, do not attend preventative health visits, screening for pregnancy risk and other reproductive health needs is recommended at every adolescent encounter and in all settings.

OBJECTIF: Examiner les pratiques de dépistage de la santé sexuelle durant l'hospitalisation dans une unité de psychiatrie pour adolescents. MÉTHODE: Une revue rétrospective de dossiers d'adolescents choisis au hasard ayant été hospitalisés sur une période d'un an (2013). Les données extraites comprenaient des données démographiques, les raisons de l'hospitalisation, les antécédents de santé sexuelle, et tout comportement comorbide observé. La principale mesure de résultat était si les détails de la santé sexuelle étaient documentés à un moment de l'hospitalisation, si c'était le cas, cette information était extraite aux fins d'analyse. L'analyse statistique a été effectuée à l'aide d'associations univariées et d'association logistique. RÉSULTATS: L'âge moyen des sujets (n = 99, 79 filles et 20 garçons) était de 15,24 ans (ET = 1,30). Les raisons les plus communes de l'hospitalisation étaient les gestes suicidaires ou l'automutilation (n = 57, 58 %) et les troubles de l'humeur (n = 53, 54 %). Trente-sept patients (37 %) avaient de l'information sur la santé sexuelle documentée dans leur dossier. Aucune variable démographique n'était significativement associée au fait d'être interrogé sur la santé sexuelle. Les patients ayant des diagnostics de troubles de l'humeur avaient 6 fois plus de probabilités (IC à 95 % 1,18 à 29,96, P = 0,03) d'avoir des questions de santé sexuelle documentées que ceux n'ayant pas de ces diagnostics. CONCLUSIONS: Le dépistage des problèmes de santé sexuelle n'est pas documenté chez la majorité des adolescents hospitalisés en psychiatrie. L'omission du dépistage de la santé sexuelle durant les hospitalisations représente une occasion ratée d'investigation et de prise en charge des questions de santé sexuelle dans ce groupe à risque élevé. Comme bon nombre d'adolescents, en particulier ceux qui sont aux prises avec la maladie mentale ne font pas de visites de santé préventives, le dépistage du risque de grossesse et d'autres besoins de santé reproductive est recommandé pour toute rencontre avec un adolescent et dans tous les contextes.

Wearable activity monitors in oncology trials: Current use of an emerging technology.

BACKGROUND: Physical activity is an important outcome in oncology trials. Physical activity is commonly assessed using self-reported questionnaires, which are limited by recall and response biases. Recent advancements in wearable technology have provided oncologists with new opportunities to obtain real-time, objective physical activity data. The purpose of this review was to describe current uses of wearable activity monitors in oncology trials. METHODS: We searched Pubmed, Embase, and the Cochrane Central Register of Controlled Trials for oncology trials involving wearable activity monitors published between 2005 and 2016. We extracted details on study design, types of activity monitors used, and purpose for their use. We summarized activity monitor metrics including step counts, sleep and sedentary time, and time spent in moderate-to-vigorous activity. RESULTS: We identified 41 trials of which 26 (63%) involved cancer survivors (post-treatment) and 15 trials (37%) involved patients with active cancer. Most trials (65%) involved breast cancer patients. Wearable activity monitors were commonly used in exercise (54%) or behavioral (29%) trials. Cancer survivors take between 4660 and 11,000 steps/day and those undergoing treatment take 2885 to 8300steps/day. CONCLUSION: Wearable activity monitors are increasingly being used to obtain objective measures of physical activity in oncology trials. There is potential for their use to expand to evaluate and predict clinical outcomes such as survival, quality of life, and treatment tolerance in future studies. Currently, there remains a lack of standardization in the types of monitors being used and how their data are being collected, analyzed, and interpreted. PRECIS: Recent advancements in wearable activity monitor technology have provided oncologists with new opportunities to monitor their patients' daily activity in real-world settings. The integration of wearable activity monitors into cancer care will help increase our understanding of the associations between physical activity and the prevention and management of the disease, in addition to other important cancer outcomes.

The human-animal interface and zoonotic threats: the Russian Federation approach.

Zoonotic pathogens have caused the majority of emerging infectious disease events in the past 6 decades. With most emerging infectious diseases arising from animal origins, including many of the select agents identified as most likely candidates for bioterrorism, linking human and animal surveillance systems will be critical to effective disease identification and control in the future. Lack of this linkage has been the focus of a number of important policy papers in recent years. These have expressed concern over the continued lack of preparedness for addressing zoonotic threats and have called for a new approach to integrating biosurveillance. However, these studies have been mainly Western-centric in viewpoint and have overlooked the example of the Russian Federation (RF) Anti-Plague System (AP system). In this article we submit that the RF AP system has select components that effectively address recent concerns and inform the US and UK intersectoral efforts on human-animal health surveillance, forming a basis for US, UK, and RF collaboration.

Creating a global dialogue on infectious disease surveillance: connecting organizations for regional disease surveillance (CORDS).

Connecting Organizations for Regional Disease Surveillance (CORDS) is an international non-governmental organization focused on information exchange between disease surveillance networks in different areas of the world. By linking regional disease surveillance networks, CORDS builds a trust-based social fabric of experts who share best practices, surveillance tools and strategies, training courses, and innovations. CORDS exemplifies the shifting patterns of international collaboration needed to prevent, detect, and counter all types of biological dangers - not just naturally occurring infectious diseases, but also terrorist threats. Representing a network-of-networks approach, the mission of CORDS is to link regional disease surveillance networks to improve global capacity to respond to infectious diseases. CORDS is an informal governance cooperative with six founding regional disease surveillance networks, with plans to expand; it works in complement and cooperatively with the World Health Organization (WHO), the World Organization for Animal Health (OIE), and the Food and Animal Organization of the United Nations (FAO). As described in detail elsewhere in this special issue of Emerging Health Threats, each regional network is an alliance of a small number of neighboring countries working across national borders to tackle emerging infectious diseases that require unified regional efforts. Here we describe the history, culture and commitment of CORDS; and the novel and necessary role that CORDS serves in the existing international infectious disease surveillance framework.

Computerized bioterrorism education and training for nurses on bioterrorism attack agents.

BACKGROUND: Biological agents have the ability to cause large-scale mass casualties. For this reason, their likely use in future terrorist attacks is a concern for national security. Recent studies show that nurses are ill prepared to deal with agents used in biological warfare. Achieving a goal for bioterrorism preparedness is directly linked to comprehensive education and training that enables first-line responders such as nurses to diagnose infectious agents rapidly. METHODS: The study evaluated participants' responses to biological agents using a computerized bioterrorism education and training program versus a standard bioterrorism education and training program. RESULTS: Both programs improved participants' ability to complete and solve case studies involving the identification of specific biological agents. CONCLUSION: Participants in the computerized bioterrorism education and training program were more likely to solve the cases critically without reliance on expert consultants. However, participants in the standard bioterrorism education and training program reduced the use of unnecessary diagnostic tests.

Trust across borders: responding to 2009 H1N1 influenza in the Middle East.

Disease surveillance networks in the Middle East, Southeast Asia, and Africa are models for the kind of transnational cooperation that can mount the needed flexible and coordinated response to the spread of 2009 H1N1 influenza and future pandemic threats. For example, members of the Middle East Consortium on Infectious Disease Surveillance (MECIDS), a regional disease surveillance network of public health experts and ministry of health officials from Israel, the Palestinian Authority, and Jordan, have coordinated the screening, laboratory testing, and risk communication strategies to detect and control 2009 H1N1 influenza. This coordination is made possible by trust and by well-exercised national and regional pandemic preparedness policies. The consortium illustrates the value of regional disease surveillance networks in shaping and managing cohesive policies on current and future threats. The MECIDS alliance partnership also exemplifies to other parts of the world that are experiencing conflict-like South Asia-that finding common ground is imperative to promoting health security and cooperation where it is most lacking and needed and that developing cohesive infectious disease control policies can build trust across the most difficult boundaries in the world. This article provides an overview of the history of MECIDS and similar networks and of the MECIDS response to 2009 H1N1 influenza.

Conflict management training and nurse-physician collaborative behaviors.

Collaboration between nurses and physicians continues to be elusive although it is a desirable goal for most in health care. This study used a quasi-experimental design to evaluate the outcomes of a conflict resolution (management) training program on nurses' perception of their collaboration with the physicians with whom they work. Results showed no differences between the experimental and control groups following the intervention. Individual readiness and evaluation of the antecedents of collaboration should be determined before implementing such an intervention.

Fetal sex and maternal asthma control in pregnancy.

Asthma is a prevalent chronic disorder that might substantially complicate pregnancy. Some recent reports suggest that the presence of a female fetus might be associated with worse maternal asthma symptoms during pregnancy. We tested this hypothesis using the sample of 719 pregnant women with asthma prospectively enrolled in the OTIS study. The presence of a female fetus was associated with a higher incidence of hospitalizations for asthma during pregnancy (OR = 1.84; 95% CI: 1.05; 3.21) independent of maternal age, BMI, ethnicity, smoking, and socioeconomic status. The current study suggests that pregnant asthmatic women carrying a girl might be more susceptible to asthma exacerbations.