The Use and Teaching of Telemedicine in Allergy/Immunology Training Programs.

PURPOSE OF REVIEW: The use of telemedicine has greatly increased since the onset of the coronavirus disease 2019 (COVID-19) pandemic. This review discusses the types of telemedicine, current telehealth curricula in medical education, and benefits and disadvantages of incorporation of telemedicine into Allergy/Immunology training programs. RECENT FINDINGS: The majority of Allergists/Immunologists use telemedicine in their clinical practice with leaders in graduate medical education recommending inclusion of telemedicine in training. Fellows-in-training reported that use of telemedicine in Allergy/Immunology training during the pandemic mitigated some concerns for lack of adequate clinical experience. Still, no standardized curriculum for telemedicine training in Allergy/Immunology exists, although curricula from internal medicine and primary care residencies can provide a framework for incorporation of telemedicine training into fellowship. Benefits of telemedicine in Allergy/Immunology training include enhanced immunology training, home environment monitoring, and flexibility to reduce physician burnout while disadvantages include limited physical examination skill building and lack of a standardized curriculum. As telemedicine has been widely accepted in medicine with high patient satisfaction, it is necessary to incorporate a standardized telehealth curriculum in Allergy/Immunology fellowship training, both as a tool for patient care as well as trainee education.

Is It Really the Foley? A Systematic Review of Bladder Management and Infection Risk.

Background: The belief that intermittent catheterization results in fewer infections than indwelling catheters is commonly expressed in the spinal cord injury literature. Some practice guidelines strongly recommend intermittent over indwelling catheterization due to concerns about infections and other complications. However, studies on this topic are of low quality. Guidelines from the Consortium for Spinal Cord Medicine suggest the data regarding infection risk are mixed, and they do not recommend one bladder management method over the other. Objectives: To compare risk of bias in studies reporting higher rates of urinary tract infection (UTI) with indwelling catheters to studies that found equal rates of UTI between indwelling and intermittent catheterization, and to describe implications in clinical decision-making. Methods: A systematic search of PubMed, CINAHL, Embase, and SCOPUS databases from January 1, 1980, to September 15, 2020, was conducted. Eligible studies compared symptomatic UTI rates between indwelling and intermittent catheterization. We used a risk of bias assessment tool to evaluate each study. Results: Twenty-four studies were identified. Only three of these reported significantly higher UTI risk with indwelling catheters, and all three demonstrated a critical risk of bias. More than half of the studies reported differences in UTI risk of less than 20% between the two methods. Studies with larger (nonsignificant) differences favoring intermittent catheterization were more susceptible to bias from confounding. Conclusion: The hypothesis that indwelling catheters cause more UTIs than intermittent catheterization is not supported by the scientific literature. Most studies failed to demonstrate a significant difference in UTI risk, and studies with nonsignificant trends favoring intermittent catheterization were more susceptible to bias from confounding. Perceived risk of infection should not influence a patient's choice of catheter type.

The impact of asthma on COVID-19 disease severity in children and adolescents.

BACKGROUND: Atopy and allergic asthma have been found to be protective against coronavirus disease (COVID-19) in adults but have not been studied in children. OBJECTIVE: To identify whether children and adolescents with asthma had less severe disease and lower morbidity from COVID-19 than their counterparts without asthma. METHODS: This was a retrospective chart review from March 1, 2020, through January 31, 2021. Charts were eligible for inclusion if patients were over 6 years of age and below 20 years of age and tested positive for COVID-19 by PCR or antigen testing or were COVID-19 antibody positive when they presented to the emergency department (ED). Patients were grouped according to disease severity and divided into two groups, those with asthma and those without. A total of 1,585 patients were included-1,492 without asthma and 93 with asthma. RESULTS: Children and adolescents with asthma are less likely to be seen in the ED for COVID-19-related disease (p value< 0.0001, but if they presented to the ED, they were significantly more likely to be hospitalized, require oxygen, and have more severe forms of COVID-19 than children and adolescents without asthma (p value< 0.0001). CONCLUSIONS: Children and adolescents with asthma, though less likely to be seen in ED with COVID-19, were more likely to have severe disease than patients without asthma, once they presented to the ED.

Effect of CHRFAM7A Δ2bp gene variant on secondary inflammation after spinal cord injury.

The α7 neuronal nicotinic acetylcholine receptors (α7nAChRs) are essential for anti-inflammatory responses. The human-specific CHRFAM7A gene and its 2bp deletion polymorphism (Δ2bp variant) encodes a structurally-deficient α7nAChRs that may impact the anti-inflammatory function. We studied 45 spinal cord injury (SCI) patients for up to six weeks post SCI to investigate the role of the Δ2bp variant on multiple circulating inflammatory mediators and two outcome measures (neuropathic pain and risk of pressure ulcers). The patient's SCI were classified as either severe or mild. Missing values were imputed. Overall genetic effect was conducted with independent sample t-test and corrected with false discovery rate (FDR). Univariate analysis and regression analysis were applied to evaluate the Δ2bp effects on temporal variation of inflammatory mediators post SCI and their interaction with outcome measures. In severe SCI, the Δ2bp carriers showed higher levels of circulating inflammatory mediators than the Δ2bp non-carriers in TNF-α (FDR = 9.6x10-4), IFN-γ (FDR = 1.3x10-3), IL-13 (FDR = 1.6x10-3), CCL11 (FDR = 2.1x10-3), IL-12p70 (FDR = 2.2x10-3), IL-8 (FDR = 2.2x10-3), CXCL10 (FDR = 3.1x10-3), CCL4 (FDR = 5.7x10-3), IL-12p40 (FDR = 7.1x10-3), IL-1b (FDR = 0.014), IL-15 (FDR = 0.024), and IL-2 (FDR = 0.037). IL-8 and CCL2 were negatively associated with days post injury (DPI) for the Δ2bp carriers (P = 2x10-7 and P = 2x10-8, respectively) and IL-5 was positively associated with DPI for the Δ2bp non-carriers (P = 0.015). Neuropathic pain was marginally positively associated with IL-13 for the Δ2bp carriers (P = 0.056). In mild SCI, the Δ2bp carriers had lower circulating levels of IL-15 (FDR = 0.04) than the Δ2bp non-carriers. Temporal variation of inflammatory mediators post SCI was not associated with the Δ2bp variant. For the mild SCI Δ2bp carriers, risk of pressure ulcers was positively associated with circulating levels of IFN-γ, CXCL10, and CCL4 and negatively associated with circulating levels of IL-12p70. These findings support an important role for the human-specific CHRFAM7A Δ2bp gene variant in modifying anti-inflammatory function of α7nAChRs following SCI.

Creation of a contractile biomaterial from a decellularized spinach leaf without ECM protein coating: An in vitro study.

Myocardial infarction (MI) results in the death of cardiac tissue, decreases regional contraction, and can lead to heart failure. Tissue engineered cardiac patches containing human induced pluripotent stem cell-derived cardiomyocytes (hiPS-CMs) can restore contractile function. However, cells within thick patches require vasculature for blood flow. Recently, we demonstrated fibronectin coated decellularized leaves provide a suitable scaffold for hiPS-CMs. Yet, the necessity of this additional coating step is unclear. Therefore, we compared hiPS-CM behavior on decellularized leaves coated with collagen IV or fibronectin extracellular matrix (ECM) proteins to noncoated leaves for up to 21 days. Successful coating was verified by immunofluorescence. Similar numbers of hiPS-CMs adhered to coated and noncoated decellularized leaves for 21 days. At Day 14, collagen IV coated leaves contracted more than noncoated leaves (3.25 ± 0.39% vs. 1.54 ± 0.60%; p < .05). However, no differences in contraction were found between coated leaves, coated tissue culture plastic (TCP), noncoated leaves, or noncoated TCP at other time points. No significant differences were observed in hiPS-CM spreading or sarcomere lengths on leaves with or without coating. This study demonstrates that cardiac scaffolds can be created from decellularized leaves without ECM coatings. Noncoated decellularized leaf surfaces facilitate robust cell attachment for an engineered tissue patch.

Association of a Functional Polymorphism in the CHRFAM7A Gene with Inflammatory Response Mediators and Neuropathic Pain after Spinal Cord Injury.

The alpha 7 nicotinic acetylcholine receptor, α7 nAChR, plays a central role in regulating inflammatory responses. Previous studies showed that pharmacological inhibitors of α7nAChR have a pro-inflammatory effect, increasing the circulating levels of cytokines such as tumor necrosis factor alpha (TNFα). This study focused on how genetic polymorphisms of the partially duplicated α7nAChR gene (CHRFAM7A), which is highly expressed in peripheral blood cells, contribute to functional outcome after spinal cord injury (SCI). In a cohort of 27 SCI patients and 25 emergency room consented controls (% F/M: 15/85, 24/76; mean ± SE age: 35 ± 1.38 and 35 ± 2.0 respectively), a panel of circulating cytokines, noradrenergic metabolite (normetanephrine [NMN]) levels, and clinical data were available within the first 7 days post-injury (DPI) up to 90 DPI, and were investigated in the acute/subacute (DPI 1-21) and intermediate (DPI 22-90) temporal periods. Cytokine and NMN plasma levels on different DPI were analyzed as a function of CHRFAM7A genotype. TNFα levels, as a representative of some elevated inflammatory mediators, were nearly threefold higher in individuals carrying the del-2bp variant of the CHRFAM7A gene compared with that in the no-deletion genotype (p = 0.001 analysis of variance [ANOVA]) 3 weeks DPI, and twofold higher than genotype-matched acute/subacute non-SCI injury controls within 7 days DPI. In contrast, NMN levels were initially unchanged, although after 3 weeks, NMN levels were significantly decreased in SCI individuals carrying the del-2bp variant compared with non-carriers (p = 0.011 ANOVA). Numerical pain scores over this same period post-injury were significantly elevated in SCI patients carrying the del-2bp variant relative to non-carriers (p = 0.001 ANOVA). Taken together, these data reveal that pro-inflammatory responses associated with CHRFAM7A gene variation may also be associated with differences in pain experience in patients following SCI, at least during the intermediate phase.

Programs to locate missing and critically wandering elders: a critical review and a call for multiphasic evaluation.

As America ages, greater numbers of older adults will be living with Alzheimer's disease or a related dementia, leading to increased incidence of wandering. Currently there are several initiatives to assist older adults who go missing. We describe and critically examine three prominent and widespread programs: Safe Return, Project Lifesaver, and Silver Alert. Despite their emergence, there has been little research on their effectiveness. More fundamentally, the nature and scope of the missing elder problem is understudied. We call for further research into this issue, as well as assessments of how well such programs balance individual liberties with safety concerns.

Which benefits of research participation count as 'direct'?

It is widely held that individuals who are unable to provide informed consent should be enrolled in clinical research only when the risks are low, or the research offers them the prospect of direct benefit. There is now a rich literature on when the risks of clinical research are low enough to enroll individuals who cannot consent. Much less attention has focused on which benefits of research participation count as 'direct', and the few existing accounts disagree over how this crucial concept should be defined. This disagreement raises concern over whether those who cannot consent, including children and adults with severe dementia, are being adequately protected. The present paper attempts to address this concern by considering first what additional protections are needed for these vulnerable individuals. This analysis suggests that the extant definitions of direct benefits either provide insufficient protection for research subjects or pose excessive obstacles to appropriate research. This analysis also points to a modified definition of direct benefits with the potential to avoid these two extremes, protecting individuals who cannot consent without blocking appropriate research.

Silver alerts and the problem of missing adults with dementia.

In the months following the introduction of the National AMBER (America's Missing: Broadcast Emergency Response) Alert plan used to locate missing and abducted children, Silver Alert programs began to emerge. These programs use the same infrastructure and approach to find a different missing population, cognitively impaired older adults. By late 2008, 17 states had enacted Silver Alert policies, and several more planned to take advantage of National Silver Alert grant funding to initiate policies in 2009. To date, however, no research has examined the efficacy of such programs, which have widely varying parameters and criteria to initiate the alerts. In this study, we empirically examine the 17 existing state Silver Alert and related policies. The analysis includes an examination of the varieties of programs: dementia related and AMBER extension, the dates of enactment, the criteria for activation, and the process of activation. We conclude with two salient questions that emerged from the analysis. We examine these questions and make recommendations for future research, including examining whether Silver Alerts are an appropriate response to address the problem of missing adults with dementia or cognitive impairments and examining the costs and benefits of the programs including determining how best to balance efforts to keep cognitively impaired elders safe while keeping their basic human rights of autonomy and empowerment intact.

An academic-community outreach partnership: building relationships and capacity to address childhood lead poisoning.

BACKGROUND: Although academic institutions are rich resources for improving public health, academic partnerships with community organizations can be challenging. We describe a successful academic-community partnership composed of the Dartmouth Toxic Metals Research Program, the Manchester (New Hampshire) Health Department, and the Greater Manchester Partners Against Lead Poisoning (GMPALP). OBJECTIVE: Partners collaborated to translate science and best practices into social action and policy change to address childhood lead poisoning. METHODS: Using the evolution of a childhood lead poisoning prevention initiative, we discuss how an academic-community relationship can be created and sustained. LESSONS LEARNED: Our experience demonstrates that broad-based partnerships are enhanced by the attributes of community-based participatory research (CBPR). We observe that engaging in community collaborations that are not driven by research eliminates potential conflicts for academic and community partners. CONCLUSION: We identify four core values, namely, (1) adaptability, (2) consistency, (3) shared authority, and (4) trust, as being constructive when working in such partnerships.

Promoting active engagement in health research: lessons from an undergraduate gerontology capstone course.

With National Institutes of Health/National Institute of Aging (NIH/NIA) (R15/AREA) funding, the authors offered a four-credit hour undergraduate research course that was cross-listed in gerontology and sociology. This capstone course was aimed at providing students with the opportunity to (1) gain knowledge about diabetes and racial/ethnic disparities in the management of the illness and (2) develop expertise in secondary data analysis, using the Behavioral Risk Factor Surveillance System (BRFSS) data set. Each student designed and conducted her or his own research project and, working in teams, created a team poster and presentation. The authors examine student pretest/posttest questionnaire data, rubric-based assessment of students' work, and mid- and end-of-the-semester student evaluations to highlight three distinct aspects of the course: (1) skills acquired by students, (2) students' evaluation of the course, and (3) successes and challenges of implementing the course.

Perinatal choline deficiency produces abnormal sensory inhibition in Sprague-Dawley rats.

Adequate choline levels in rodents during gestation have been shown to be critical to several functions, including certain learning and memory functions, when tested at adulthood. Choline is a selective agonist for the alpha7 nicotinic receptor which appears in development before acetylcholine is present. Normal sensory inhibition is dependent, in part, upon sufficient numbers of this receptor in the hippocampus. The present study assessed sensory inhibition in Sprague-Dawley rats gestated on normal (1.1 g/kg), deficient (0 g/kg) or supplemented (5 g/kg) choline in the maternal diet during the critical period for cholinergic cell development (E12-18). Rats gestated on deficient choline showed abnormal sensory inhibition when tested at adulthood, while rats gestated on normal or supplemented choline showed normal sensory inhibition. Assessment of hippocampal alpha-bungarotoxin to visualize nicotinic alpha7 receptors revealed no difference between the gestational choline levels. These data suggest that attention to maternal choline levels for human pregnancy may be important to the normal functioning of the offspring.

Sensory gating impairment associated with schizophrenia persists into REM sleep.

Physiological measures of sensory gating are increasingly used to study biological factors associated with attentional dysfunction in psychiatric and neurologic patient populations. The present study was designed to assess sensory gating during rapid eye movement (REM) sleep in patients with schizophrenia, a population bearing a genetic load for gating impairment. Auditory event-related potentials (ERPs) were recorded in response to paired clicks during separate waking and overnight sleep recording sessions in controls and schizophrenia patients. Suppression of ERP component P50 was significantly impaired in the patient group during both waking and REM sleep, whereas the difference between groups for N100 gating was dependent on state. These results suggest that REM sleep is an appropriate state during which to assess P50 gating in order to disentangle the effects of state and trait on sensory gating impairment in other clinical populations.