Tocilizumab Treatment in COVID-19 Patients: Comparing Cutaneous Disease and Adverse Drug Effects.

Actemra (tocilizumab) received emergency use authorization for the treatment of coronavirus disease 2019 (COVID-19) in June 2021. Literature has linked numerous cutaneous adverse effects to tocilizumab. In this current survey, investigators reviewed and compared these adverse effects to the common cutaneous manifestations of COVID-19. While similarities in patient presentation exist, important distinctions are made to aid dermatologists in their clinical diagnosis.  J Drugs Dermatol. 2023;22(12):e42-e43.     doi:10.36849/JDD.6532e.

Nail Changes Associated With Thyroid Disease.

Nail changes with thyroid disease have not been well studied. Nail findings are helpful in early diagnosis of thyroid disorders and therefore are important for dermatologist education. We reviewed the literature on nail changes in thyroid patients and found that onycholysis and slow-growing, thin nails are associated with hypothyroidism and that onycholysis, koilonychia, and brittle nails changes are associated with hyperthyroidism.

Training "Pivots" from the Pandemic: Lessons Learned Transitioning from In-Person to Virtual Synchronous Training in the Clinical Scholars Leadership Program.

INTRODUCTION: Since the inception of distance-based teaching modalities, a debate has ensued over the quality of online versus in-person instruction. Due to the COVID-19 pandemic, a number of teaching environments-including leadership development trainings for post-graduate learners-have been thrust into exploring the virtual learning environment more thoroughly. One three-year leadership development program for interdisciplinary healthcare professionals transitioned three simultaneous leadership intensives from in-person to online in the spring of 2020. METHODS: Documented changes in overall training length, session length, and session format are described. Further, evaluative data were collected from participants at both retreats via post-session surveys. Ninety-three participants attended the 2019 retreat, and 92 participants attended the 2020 virtual retreat. Quantitative data of three rating questions per session are reported: 1) overall session satisfaction, 2) participants' reported knowledge gain, and 3) participants' reported ability gain. Qualitative data were obtained via two open-ended feedback questions per session. RESULTS: In comparing pre/post scores for knowledge and ability, participants had meaningful (and in some cases higher) self-reported gains in knowledge and ability measures in the online environment, as compared to the in-person environment. Participants reported statistically significant gains in all sessions for both knowledge and ability. Qualitative data of participant feedback identified a number of positive themes similar across the in-person and virtual settings. Negative or constructive feedback of the virtual setting included time constraint issues (eg too much content in one session, a desire for more sessions overall), technical difficulties, and the loss of social connection and networking with fellow participants as compared to in-person trainings. DISCUSSION: While meaningful shifts in knowledge and ability ratings indicate that the transition to successful online learning is possible, several disadvantages remain. The preparation time for both faculty and participants was considerable, there is a need to reduce overall content in each session due to time restraints, and participants indicated feeling the loss of one-on-one connections with their peers in the training. Lessons learned of transitioning leadership training from in-person to an online experience are highlighted.

Reflections on the contributions of self-advocates to an interdisciplinary leadership development program for graduate students in health affairs.

BACKGROUND: To advance equity and to enhance leadership skills, self-advocates with intellectual/developmental disabilities are now part of the cohort of trainees in the University of North Carolina LEND, which means that they fully participate in the Interdisciplinary Leadership Development Program, a collaboration among programs in public health, social work, and LEND, which meets monthly. OBJECTIVE: Given this important new participation by self-advocates, this study analyzes the reflections of graduate students on the contributions of self-advocates to their leadership training. METHODS: At the conclusion of the program each year, graduate students respond to a questionnaire about how self-advocates influenced the content and interactions/discussions of the monthly workshops and are asked to provide specific examples to explain their perceptions. The 12 MCH leadership competencies were used to guide the coding of the comments for this qualitative, directed content analysis. RESULTS: Forty-six of 58 students (79.3%) from two consecutive cohorts responded for this cross-sectional study. Interactions with self-advocates prompted comments on 8 of the 12 leadership competencies, including interdisciplinary team building (29% of the comments); developing others through teaching and mentoring (22%); and self-reflection (18%). CONCLUSIONS: The inclusion of self-advocates throughout an interdisciplinary leadership development program for graduate students in health affairs can strengthen MCH leadership competencies for all participants as they enter an increasingly interdisciplinary workforce.

Partnering with parents in interprofessional leadership graduate education to promote family-professional partnerships.

Evidence supports the benefits to families of relationships with professionals that build on the concept of partnership, but there are few studies in the literature of strategies involving joint education for parents and professionals to enhance the capacity of parents of children with special healthcare needs to be effective interprofessional partners. Since 2007, parents of children with special healthcare needs have participated alongside graduate students from five different profession-based training programmes in a structured interprofessional leadership programme. The aims of this summative evaluation study were to elicit the influences of this training model on parents' capacity to partner with both health professionals and other parents and explore features of the training that facilitated these partnership skills. Using qualitative analysis, a semi-structured interview, guided by sensitising concepts informing leadership development, was conducted with 17 of the 23 parents who participated in the training. Transcriptions of the interviews were used for creating codes and categories for analysis. Parents described how the programme enhanced abilities to see other points of view, skills in communicating across professions, skills in conflict management, and feelings of confidence and equality with providers that influenced their relationships with their own providers and their capacity to assist other parents in addressing challenges in the care of their children. Parents reported that building concrete skills, organised opportunities to hear other viewpoints, structured time for learning and self-reflection, and learning in the context of a trusting relationship facilitated the development of partnership skills. These findings suggest that the leaders of interprofessional training programmes should involve parents and graduate students as equal partners to enhance partnership skills.

Advancing MCH Interdisciplinary/Interprofessional Leadership Training and Practice Through a Learning Collaborative.

Purpose The Interdisciplinary Leadership Learning Collaborative (ILLC), under the sponsorship of AUCD and the Maternal and Child Health Bureau, brought together six teams, composed of 14 MCHB and UCEDD training programs to enhance their leadership training. Description Using adult learning principles, interactive training methods, and skill-focused learning, the ILLC built upon the evidence-based Interdisciplinary Leadership Development Program of the University of North Carolina at Chapel Hill. The program began with a 4-day on-site intensive and then continued through monthly conference calls, a mid-term on-site workshop, and a summary virtual workshop to present programmatic accomplishments and share plans for sustainability. Coaching/consultation for the teams around particular challenges was also part of the program. Assessment All teams reported enhancements in intentional leadership training, threading of leadership concepts across clinical, didactic, and workshop settings, and new collaborative partnerships for leadership training. Teams also identified a number of strategies to increase sustainability of their intentional leadership training efforts. Conclusion for Practice The learning collaborative is a productive model to address the growing need for interdisciplinary MCH leaders.

Fostering intentional interdisciplinary leadership in developmental disabilities: the North Carolina LEND experience.

This study describes the effects of interdisciplinary leadership training on a retrospective cohort (2001-2009) of the University of North Carolina MCH Leadership Education in Neurodevelopmental and Related Disabilities (UNC-CH LEND) program, including LEND graduates who were selected to participate in a focused Interdisciplinary Leadership Development Program (ILDP) in addition to their LEND training. Specifically, the study examined graduates' reports of the relationship between LEND training and their attitudes/beliefs about interdisciplinary practice, as well as their reported use of interdisciplinary skills in their post-fellowship practice settings. Using a post-test design, participants in the LEND and ILDP programs were contacted to complete an on-line survey. Using a Conceptual Model guided by EvaluLEAD, respondents were asked to rate the influence of the UNC-LEND training program on their attitudes/beliefs and skills using a 5-point Likert scale, as well as through open-ended descriptions. The 49 LEND respondents represented a 56% overall response rate from years 2001-2009. ILDP participants reported greater agreement with interdisciplinary attitudes/beliefs and more frequent use of interdisciplinary skills than did the non-participants. Graduates of LEND as well as ILDP reported the influence of training through a range of qualitative responses. Response examples highlight the influence of LEND training to promote outcomes at the individual, organizational and systems level. Findings from this study illustrate that MCHB funded LEND training has a strong influence on the future employment and interdisciplinary practices of graduates for the MCH workforce as well as services for individuals with developmental disabilities, their families and systems of care.

A new method for precise determination of iron, zinc and cadmium stable isotope ratios in seawater by double-spike mass spectrometry.

The study of Fe, Zn and Cd stable isotopes (δ(56)Fe, δ(66)Zn and δ(114)Cd) in seawater is a new field, which promises to elucidate the marine cycling of these bioactive trace metals. However, the analytical challenges posed by the low concentration of these metals in seawater has meant that previous studies have typically required large sample volumes, highly limiting data collection in the oceans. Here, we present the first simultaneous method for the determination of these three isotope systems in seawater, using Nobias PA-1 chelating resin to extract metals from seawater, purification by anion exchange chromatography, and analysis by double spike MC-ICPMS. This method is designed for use on only a single litre of seawater and has blanks of 0.3, 0.06 and <0.03 ng for Fe, Zn and Cd respectively, representing a 1-20 fold reduction in sample size and a 4-130 decrease in blank compared to previously reported methods. The procedure yields data with high precision for all three elements (typically 0.02-0.2‰; 1σ internal precision), allowing us to distinguish natural variability in the oceans, which spans 1-3‰ for all three isotope systems. Simultaneous extraction and purification of three metals makes this method ideal for high-resolution, large-scale endeavours such as the GEOTRACES program.

Effects of interdisciplinary training on MCH professionals, organizations and systems.

We studied the effects of the Interdisciplinary Leadership Development Program (ILDP) on MCH trainees from five MCHB-funded training programs at the UNC-Chapel Hill from the years 2001-2008. Specifically, we examined attitudes/beliefs about interdisciplinary practice and the frequency of use of interdisciplinary skills; identified effects of interdisciplinary training on career choices; and, examined the ways in which graduates used their interdisciplinary skills to effect change in MCH organizations and systems, up to 8 years after completion of training. Using a post-test design, participants in the ILDP were contacted to complete a web-based survey. Non-participating LEND and public health graduates were recruited for comparison. Guided by EvaluLEAD, we designed questions that asked graduates to rate the influence of their programs on their attitudes/beliefs and skills (on 5-point Likert scales), and to describe those influences in some detail in open-ended questions. The 208 respondents represented 59.6 % of the graduates from 2001 through 2008. Model-predicted mean levels of frequency of use of interdisciplinary skilIs was associated with ILDP participation (p = 0.008) and nearly so for interdisciplinary attitudes/beliefs (p = 0.067). There is an association between four domains of systems changes and frequency of skill use: develop/improve a program (3.24 vs. 2.74, p < 0.0001); improve the way an organization works (3.31 vs. 2.88, p < 0.0001); develop/improve a partnership (3.22 vs. 2.83, p < 0.0003); and, develop a policy (3.32 vs. 2.98, p < 0.0013). Graduates used interdisciplinary training to improve outcomes for families and to effect change in MCH systems. MCH leaders should disseminate, more broadly, rigorous assessments of the training intended to develop leadership competencies that underpin effective interdisciplinary practice.

Looking at graduates of Title V MCHB-funded training programs through the lens of the MCH pyramid.

OBJECTIVES: To examine the distribution of professional responsibilities as reflected in each level of the MCH Pyramid for 208 graduates of five Maternal and Child Health Bureau (MCHB)-funded training programs-Leadership Education in Neurodevelopmental and Related Disabilities, nutrition, pediatric dentistry, public health, and social work-at the University of North Carolina at Chapel Hill. METHODS: Graduates completed a web-based survey, 1-8 years after graduation. For each program, we constructed means of the reported percentages of total work time spent in infrastructure-building, population-based, enabling, and direct health care services. RESULTS: Although generally consistent with the goals of the training programs, the percentages of time spent in each level of the Pyramid varied substantially among the five programs. For example, for a clinically focused program like pediatric dentistry, 80.2 % of time is spent in direct care services in contrast to 14.8 % for public health graduates. For each program, however, graduates report responsibilities among the different levels of the Pyramid. CONCLUSIONS: Reporting job responsibilities within the MCH Pyramid provides a more informative picture of the contributions of training program graduates than do conventional metrics such as institutional or agency appointments. The fact that graduates from all five programs engage multiple roles is consistent with the MCHB workforce training goal to develop leaders in the field of MCH. Given the central role of the MCH Pyramid in planning and reporting for the MCH Services Block Grant, MCH training programs should include metrics such as graduates' roles according to the MCH Pyramid to assure that training goals are more closely aligned with workforce needs.

"Dance Dance Revolution" Used by 7- and 8-Year-Olds to Boost Physical Activity: Is Coaching Necessary for Adherence to an Exercise Prescription?

OBJECTIVE: To increase opportunities for physical activity (PA) for children in children's homes, we used a "Dance Dance Revolution" (DDR) (Konami of America, Redwood City, CA) coaching protocol for 7- and 8-year-olds. SUBJECTS AND METHODS: We randomly assigned youth to either an Enhanced (coaching) or Basic (no coaching) group. A DDR prescription of 120 minutes/week was provided to 40 children. Motor learning principles guided the coaching protocol, provided by adult graduate students, which took place weekly during weeks 1-5. PA was measured with accelerometry, DDR logs, and Sony (New York, NY) Playstation(®)2 memory cards at baseline and at week 10. RESULTS: Total accelerometer-measured PA was not significantly different between the groups at baseline or week 10; however, vigorous PA increased significantly in both groups at week 10. DDR logs showed a large range from 0 to 660 minutes/week of dance time. Respective playing time for each week (1 and 10) averaged 149 and 64 minutes for the Basic group and 184 and 47 minutes for the Enhanced group. Coaching significantly increased DDR use patterns in this population of youngsters during weeks 1 through 5 (P<0.001). CONCLUSION: Adult coaching deserves further study to determine how to maintain high levels of participation in exergames for youth who live in an obesogenic environment.

The UNC-CH MCH Leadership Training Consortium: building the capacity to develop interdisciplinary MCH leaders.

This article describes the UNC-CH MCH Leadership Consortium, a collaboration among five MCHB-funded training programs, and delineates the evolution of the leadership curriculum developed by the Consortium to cultivate interdisciplinary MCH leaders. In response to a suggestion by the MCHB, five MCHB-funded training programs--nutrition, pediatric dentistry, social work, LEND, and public health--created a consortium with four goals shared by these diverse MCH disciplines: (1) train MCH professionals for field leadership; (2) address the special health and social needs of women, infants, children and adolescents, with emphasis on a public health population-based approach; (3) foster interdisciplinary practice; and (4) assure competencies, such as family-centered and culturally competent practice, needed to serve effectively the MCH population. The consortium meets monthly. Its primary task to date has been to create a leadership curriculum for 20-30 master's, doctoral, and post-doctoral trainees to understand how to leverage personal leadership styles to make groups more effective, develop conflict/facilitation skills, and identify and enhance family-centered and culturally competent organizations. What began as an effort merely to understand shared interests around leadership development has evolved into an elaborate curriculum to address many MCH leadership competencies. The collaboration has also stimulated creative interdisciplinary research and practice opportunities for MCH trainees and faculty. MCHB-funded training programs should make a commitment to collaborate around developing leadership competencies that are shared across disciplines in order to enhance interdisciplinary leadership.

Parental and environmental factors associated with physical activity among children participating in an active video game.

PURPOSE: Parental and intervention-specific environmental supports were examined as potential reinforcers for physical activity and use of a video game, Dance Dance Revolution (DDR), among a cohort of 7- to 8-year-old children. METHODS: Sixty children were randomized to an intervention (n = 40) or a control (n = 20) group. Physical activity was measured with accelerometry and DDR logs. Parental support for their child's physical activity was assessed via a questionnaire. DDR-specific environmental supports were captured on an environmental home screen and the DDR log. RESULTS: At baseline, the absence of other video games and parent DDR participation was associated with child participation in DDR. At follow-up, DDR participation of siblings and friends was associated with child participation in DDR. CONCLUSION: The primary findings of this study suggest that parental and peer participation in DDR may play a role in children's initial and sustained participation in DDR.

Methods for assessing neurodevelopment in lysosomal storage diseases and related disorders: a multidisciplinary perspective.

UNLABELLED: Lysosomal storage diseases and related disorders (LSRDs) are a heterogeneous group of rare diseases caused by genetic mutations that result in deficiencies of specific lysosomal enzymes. Some of these enzymes are necessary for normal development of the central and peripheral nervous systems. Because of the heterogeneity in clinical presentation and complexity of these disorders, evaluation of disease progression poses unique challenges. In recent years, recombinant enzyme replacement therapy and haematopoietic stem cell transplantation have been developed to treat some of these diseases. With the development of specific therapies and screening programmes, there is a need to systematically follow the natural course and effects of treatment in these disorders with standardized and validated tools. This review describes the limitations of currently available neurobehavioural tools in longitudinally tracking disease outcomes in patients with neurodegenerative LSRDs. A multidisciplinary team reviewed over 750 evaluations in 274 patients. These patients were found to have neurological, sensory and somatic problems that considerably influence the results of neurobehavioural testing. CONCLUSION: Treatment effects in patients with neurodegenerative LSRDs are best evaluated by repeated measures and longitudinal analysis of each domain of function.

A pilot of a video game (DDR) to promote physical activity and decrease sedentary screen time.

OBJECTIVE: We examined the feasibility of Dance Dance Revolution (DDR), a dance video game, in participants' homes, to increase physical activity (PA) and to decrease sedentary screen time (SST). METHODS AND PROCEDURES: Sixty children (7.5 +/- 0.5 years) were randomized in a 2:1 ratio to DDR or to wait-list control (10-week delay). DDR use was logged, PA was measured objectively by accelerometry. SST was self-reported at weeks 0 and 10. At week 28, after both groups had access to DDR, accelerometry and SST were repeated. RESULTS: Mean use of DDR was 89 +/- 82 (range 0-660 min) min per week (mpw). The DDR group showed increased vigorous PA and a reduction in light PA; the control group showed no increase in moderate and/or vigorous PA (MVPA) although they also had a reduction in light PA. Differences between the groups were not observed. The DDR group also reported a decrease in SST of -1.2 +/- 3.7 h per week (hpw) (P < 0.05), whereas the controls reported an increase of +3.0 +/- 7.7 hpw (nonsignificant). The difference in SST between the groups was significant, with less SST in the DDR group. Between weeks 10 and 28, numeric reductions in SST were reported in both groups. In the DDR group, SST at week 28 (8.8 +/- 6.0 hpw) was lower than baseline (10.5 +/- 5.5 hpw; P < 0.03). DISCUSSION: This pilot study suggests that DDR reduces SST and may facilitate slight increases in vigorous PA. Further study is needed to better characterize children and contexts in which DDR may promote a healthy lifestyle.

Gross motor development of children with hurler syndrome after umbilical cord blood transplantation.

BACKGROUND AND PURPOSE: Little is known about the gross motor development of children with Hurler syndrome who have undergone umbilical cord blood transplantation (UCBT). The purpose of this study was to provide a description of gross motor development in children with Hurler syndrome after UCBT. SUBJECTS AND METHOD: Longitudinal changes in gross motor abilities were documented on the gross motor subtests of the Peabody Developmental Motor Scales, second edition (PDMS-2) for 21 children with Hurler syndrome. Each child was assessed between 1 and 6 times after UCBT. The participants had a mean age (+/-SD) of 32.2+/-16.0 months at the time of the first assessment. The mean time (+/-SD) between UCBT and the first assessment was 16.2+/-16.5 months. RESULTS: The participants had marked gross motor delays, with a mean gross motor quotient 2 standard deviations below the mean for children who were developing typically. The rate of development differed between the subtests of the PDMS-2. The participants gained abilities at the slowest rate on the stationary subtest and at the fastest rate on the locomotor subtest. DISCUSSION AND CONCLUSION: The participants had varying degrees of delay in different gross motor domains. While gaining new gross motor abilities over time, these children continued to have delays up to 48 months after UCBT. Physical therapists treating children with Hurler syndrome after UCBT should use assessment tools that will capture these differences and should individualize treatment plans accordingly. Additional research is needed to document the efficacy of physical therapy intervention with this population.

Temporal and spatial gait characteristics of children with Hurler syndrome after umbilical cord blood transplantation.

BACKGROUND AND PURPOSE: Recent medical advances are increasing the life expectancy of children with Hurler syndrome; however, little is known about the motor abilities of children who have received these medical interventions. The purpose of this study was to describe the temporal and spatial gait parameters of children with Hurler syndrome following umbilical cord blood transplantation (UCBT) in reference to gait parameters of children with typical development. SUBJECTS: The group with Hurler syndrome consisted of 18 children between 19.6 and 96.8 months of age who were examined 1 to 4 times between 2.9 and 72.2 months after UCBT. Four hundred thirty-eight children with typical development between the ages of 14.4 and 131.8 months served as a comparison group. METHODS: Temporal and spatial gait parameters were assessed using a GAITRite electronic walkway. Step length, gait speed, and cadence were normalized for body stature. RESULTS: Children with Hurler syndrome had slower gait speeds and shorter step lengths than children with typical development at 2 and 3 years of age. Time since transplantation was a predictor of gait speed and step length. DISCUSSION AND CONCLUSION: Children with Hurler syndrome after UCBT were delayed in maturation of temporal and spatial gait parameters.

Gross motor abilities in children with Hurler syndrome.

Hurler syndrome is the most severe form of mucopolysaccharidosis type I. There is a paucity of literature reporting the gross motor abilities of children with untreated Hurler syndrome. The purpose of this case series is to describe the gross motor abilities of one male and three female children (mean age 11.4mo [SD 3.1]; range 9.5-16mo) diagnosed with Hurler syndrome. The children were assessed using the Peabody Developmental Motor Scales, 2nd edition. Gross motor delays were present in all four children at the time of assessment, and were most evident in locomotor abilities for three of the children. All four children had range of motion limitations at multiple joints. This case series provides evidence for early gross motor delays in this population, as well as evidence for specific gross motor abilities of children with untreated Hurler syndrome. It is recommended that children diagnosed with Hurler syndrome be referred to physical therapy services upon diagnosis and that physical therapists be part of the interdisciplinary team involved in the care of children with Hurler syndrome.