Synergistic use of deep TMS therapy with IV ketamine infusions for major depressive disorder: a pilot study.

OBJECTIVE: Major Depressive Disorder (MDD) is a pervasive psychiatric condition effecting approximately 21 million adults in the U.S. (8.4%). An estimated 30-60% of patients are resistant to traditional treatment approaches (medications and talk-therapy), alluding to the need for additional options. Two promising treatment modalities include transcranial magnetic stimulation (TMS) and ketamine infusions; both have shown efficacy in standalone studies but have scarcely been investigated synergistically in the same group of participants. METHOD: In the current study, 169 participants with treatment-resistant MDD received 36 treatments of Deep TMS-only (H1 + H7 protocols), while 66 received 36 treatments of Deep TMS (H1 + H7 protocols) and 6 IV infusions of ketamine over the course of 9 weeks. Depressive symptoms were compared pre- and -post treatment in both conditions using the PHQ-9. RESULTS: In both treatment groups, depressive symptoms were significantly reduced from pre-to-post and there were no significant differences in response between the TMS + ketamine condition and the TMS-only condition. The TMS + ketamine condition had an 80.30% response rate (53 out of 66) and 43.42% remission rate (28 out of 66) compared to a 76.92% response (130 out of 169) and 39.64% remission (67 out of 16) in the TMS-only condition. CONCLUSION: These results support the notion that TMS treatments yield high response rates in treatment-resistant cases; however, in this investigation there was no added benefit for including 6 sessions of IV ketamine in conjunction with TMS. Future investigations using randomized-control designs and robust outcome measures are warranted.

Inter-rater reliability of a novel objective endpoint for benign central airway stenosis interventions: Segmentation-based volume rendering of computed tomography scans.

OBJECTIVES: To evaluate the reliability of a novel segmentation-based volume rendering approach for quantification of benign central airway obstruction (BCAO). DESIGN: A retrospective single-center cohort study. SETTING: Data were ascertained using electronic health records at a tertiary academic medical center in the United States. PARTICIPANTS AND INCLUSION: Patients with airway stenosis located within the trachea on two-dimensional (2D) computed tomography (CT) imaging and documentation of suspected benign etiology were included. Four readers with varying expertise in quantifying tracheal stenosis severity were selected to manually segment each CT using a volume rendering approach with the available free tools in the medical imaging viewing software OsiriX (Bernex, Switzerland). Three expert thoracic radiologists were recruited to quantify the same CTs using traditional subjective methods on a continuous and categorical scale. OUTCOME MEASURES: The interrater reliability for continuous variables was calculated by the intraclass correlation coefficient (ICC) using a two-way mixed model with 95% confidence intervals (CI). RESULTS: Thirty-eight patients met the inclusion criteria, and fifty CT scans were selected for measurement. The most common etiology of BCAO was iatrogenic in 22 patients (58%). There was an even distribution of chest and neck CT imaging within our cohort. The average ICC across all four readers for the volume rendering approach was 0.88 (95% CI, 0.84 to 0.93), suggesting good to excellent agreement. The average ICC for thoracic radiologists for subjective methods on the continuous scale was 0.38 (95% CI, 0.20 to 0.55), suggesting poor to fair agreement. The kappa for the categorical approach was 0.26, suggesting a slight to fair agreement amongst the raters. CONCLUSION: In this retrospective cohort study, agreement was good to excellent for raters with varying expertise in airway cross-sectional imaging using a novel segmentation-based volume rendering approach to quantify BCAO. This proposed measurement outperformed our expert thoracic radiologists using conventional subjective grading methods.

Traumatic Sternoclavicular Dislocations in Athletes: Diagnosis, Indications for Surgical Reconstruction, and Guide for Return to Play.

Injuries to the sternoclavicular (SC) joint are rare, however, when they occur prompt recognition, evaluation, and treatment are crucial. SC joint injuries can occur following high-energy mechanisms such as motor vehicle collisions and contact sports. Injury to the SC joint can be evaluated with the use of plain radiographs as well as computed tomography. If an injury to the SC joint is suspected, injury to vital mediastinal structures must be evaluated. SC joint dislocations can be treated by either closed reduction or open reduction and stabilization. Many stabilization methods have been described including plate stabilization and ligament reconstruction.

Navigating Challenging Conversations: The Interplay Between Inquiry and Knowledge Drives Preparation for Future Learning.

Introduction: While some physicians hone their skills through informal learning in clinical practice, others do not. There is a lack of understanding of why some physicians seek improvement and how they use the workplace context to build their capabilities. Because physicians rarely pursue formal professional development activities to improve communication skills, examining physician-patient communication offers a powerful opportunity to illuminate important aspects of preparation for future learning in the workplace. Methods: This qualitative observational study involved over 100 hours of observation of eight pediatric rehabilitation physicians as they interacted with patients and families at an academic teaching hospital in 2018-2020. Detailed field notes of observations, post-observation interviews, and exit interviews were the data sources. Data collection and analysis using a constructivist grounded theory approach occurred iteratively, and themes were identified through constant comparative analysis. Results: Through their daily work, experienced physicians employ 'habits of inquiry' by constantly seeking a better understanding of how to navigate challenging conversations in practice through monitoring and attuning to situational and contextual cues, taking risks and navigating uncertainty while exploring new and varied ways of practicing, and seeking why their strategies are successful or not. Discussion: Engaging in communication challenges drives physician learning through an interplay between habits of inquiry and knowledge: inquiry into how to improve their communication supported by existing conceptual knowledge to generate new strategies. These 'habits of inquiry' prompt continual reinvestment in problem solving to refine existing knowledge and to build new skills for navigating communication challenges in practice.

Deep transcranial magnetic stimulation alters resting-state neurophysiological traits in major depressive disorder.

OBJECTIVE: Major depressive disorder (MDD) is one of the most prevalent and debilitating health conditions worldwide; unfortunately, many patients do not respond to traditional antidepressant medication or talk therapy approaches. Deep transcranial magnetic stimulation (Deep TMS) has emerged as an effective treatment option for such "treatment-resistant" cases; however, the mechanisms by which Deep TMS attenuates depressive symptoms are still ambiguous. METHODS: In the current study, resting-state quantitative electroencephalography (QEEG) measures were assessed pre-and-post treatment to illustrate neurophysiological changes resulting from Deep TMS. RESULTS: The results showed reduced slow-frequency brain activity (delta and theta waves) in the prefrontal cortex following 36 treatments. Additionally, baseline QEEG measures predicted treatment response with 93 % accuracy. CONCLUSIONS: These findings provide preliminary evidence that TMS improves depressive symptoms by mitigating slow-wave brain activity in the prefrontal cortex. SIGNIFICANCE: Deep TMS paired with QEEG should continue to be utilized for treatment of MDD in clinical practice and future studies should explore its potential for other neuropsychiatric conditions.

Multiple Flesh-Colored Nodules: A Patient with Multiple BAP 1-Inactivated Melanocytic Tumors.

A 22-year-old man without previously known skin disease presented with multiple asymptomatic, skin-brown to red-brown papules on the head and neck for 1 year (Figure 1). The diagnoses considered included benign intradermal or compound nevi, atypical nevi, and neurofibromas. Shave biopsies of three lesions revealed intradermal melanocytic lesions comprising large epithelioid melanocytes flanked by small banal melanocytes (Figure 2). All nevi had a low proliferation index, absent junctional component as demonstrated by a dual Ki-67/Mart-1 immunostain, and no dermal mitotic figures. Immunostaining demonstrated lesional melanocytes positive for p16, but the larger epithelioid melanocytes in these lesions lacked nuclear expression of ubiquitin carboxyl-terminal hydrolase protein (BAP-1; Figure 3). The diagnosis of a BAP-1-inactivated nevus was made, and the patient was referred for genetic counseling and screening for associated malignancies. Given that the lesions involved deep margins, the same were completely excised.

Multisystem Inflammatory Syndrome in an Adult With COVID-19.

Multisystem inflammatory syndrome (MIS) in children is a severe illness characterized by fever, laboratory evidence of inflammation, and multisystem organ dysfunction resulting from severe acute respiratory syndrome coronavirus 2 infection in a patient younger than 21 years. We present the case of a 39-year-old man with evidence of prior COVID-19 who seemed to meet all non-age-related criteria for MIS in children as well as criteria for the working definition of MIS in adults, and who improved after treatment with aspirin, corticosteroids, and intravenous immunoglobulin. Clinicians should be aware of this new inflammatory illness, not only in children but potentially also in adults with antecedent or concurrent COVID-19.

Revisiting the "leading edge" of hospital privacy curtains in the medical intensive care unit.

BACKGROUND: Privacy curtains within medical intensive care unit (MICU) rooms are a potential contributor to health care associated infections. The "leading edge" of a hospital curtain, estimated to be the edge most frequently touched, likely plays a role in health care associated infections at hospitals. The aims of this study were to (1) compare the bacterial load of the edge vs the middle of curtains in the MICU, and (2) determine the identity and distribution of relevant pathogens colonizing them. METHODS: The edge and middle sections of 8 curtains in MICU rooms (4 contact precaution and 4 noncontact precaution) were sampled for culture on patient and staff sides. Bacterial loads of edges and middles were compared. Select isolates were further analyzed for species identification. RESULTS: There was a statistically significant difference for the contact (t = 2.10, P = .047) and noncontact (t = 2.62, P = .016) rooms, with the edges having a significantly higher median than the middles. Pathogens such as methicillin-resistant Staphylococcus aureus, Enterococcus, Klebsiella, and Acinetobacter were found on the curtains, though at lower rates than in previous studies. Opportunistic fungi were also found on all curtains. CONCLUSIONS: Results of this study confirm that hospital curtains, most notably the edge but also the middle, are contaminated with pathogens, and that these areas are frequently touched by health care workers in between hand hygiene.

Knowledge and preventive behaviors towards tick-borne diseases in Delaware.

Delaware is among the top 10 states in the United States with the highest incidence for Lyme disease. The Delaware Division of Public Health (DPH) therefore has been working diligently to prevent and control tick-borne diseases through a variety of interventions including awareness campaigns and educational programs. To assess if tick-borne disease related information is reaching Delawareans through these programs, DPH in collaboration with Delaware State University administered an anonymous survey to 1755 participants in all three of Delaware counties during May 2017. The questionnaire assessed individuals' general knowledge about tick-borne diseases and performance of selected tick-borne disease prevention methods Overall, participants' knowledge of tick-borne diseases was poor; only 38.4% of respondents stated that ticks were problematic in Delaware and only 12.7% of respondents "strongly agreed" that Lyme disease is a problem in Delaware. A little over half of the respondents (51.6%) indicated having seen advertisements/infomercials/flyers for protection from ticks or the disease agents spread by ticks; the most common places for viewing these advertisements were doctor's offices and through social media. The reported frequency of performing preventive behaviors was variable and disparities were observed by age, race, gender and county of residence. Existing public health communication efforts on tick-borne diseases in Delaware do not appear to be having the desired effect. This study provides important baseline information to rethink communication channels for education and more effectively guide future tick-borne disease awareness campaigns.

Pharmacological and neurosurgical interventions for managing dystonia in cerebral palsy: a systematic review.

AIM: To systematically review evidence for pharmacological/neurosurgical interventions for managing dystonia in individuals with cerebral palsy (CP) to inform a care pathway. METHOD: Searches included studies with a minimum of five participants with dystonia in CP receiving oral baclofen, benzodiazepines (clonazepam, diazepam, lorazepam), clonidine, gabapentin, levodopa, trihexyphenidyl, botulinum toxin, intrathecal baclofen (ITB), or deep brain stimulation (DBS). Evidence was classified according to American Academy of Neurology guidelines. RESULTS: Twenty-eight articles underwent data extraction: one levodopa, five trihexyphenidyl, three botulinum toxin, six ITB, and 13 DBS studies. No articles for oral baclofen, benzodiazepines, clonidine, or gabapentin met the inclusion criteria. Evidence for reducing dystonia was level C (possibly effective) for ITB and DBS; level C (possibly ineffective) for trihexyphenidyl; and level U (inadequate data) for botulinum toxin. INTERPRETATION: For dystonia reduction, ITB and DBS are possibly effective, whereas trihexyphenidyl was possibly ineffective. There is insufficient evidence to support oral medications or botulinum toxin to reduce dystonia. There is insufficient evidence for pharmacological and neurosurgical interventions to improve motor function, decrease pain, and ease caregiving. The majority of the pharmacological and neurosurgical management of dystonia in CP is based on clinical expert opinion. WHAT THIS PAPER ADDS: Intrathecal baclofen and deep brain stimulation are possibly effective in reducing dystonia. Current evidence does not support effectiveness of oral medications or botulinum toxin to reduce dystonia. Evidence is inadequate for pharmacological/neurosurgical interventions impact on improving motor function, pain/comfort, and easing caregiving. The majority of the care pathway rests on expert opinion.

Periodontal Referral Patterns in Australia: 2000 Versus 2015.

BACKGROUND: A previous study investigated differences in the severity of periodontal disease on referral for specialist care between 1980 and 2000 across the United States. The present study finds patients referred in 2000 had greater severity of periodontal disease than those referred 20 years ago. METHODS: A retrospective analysis of 384 charts was completed from three periodontal practices across the east coast of Australia. Two time periods were investigated: 2000 to 2001 and 2015 to 2016. From these charts, the following data were recorded: 1) age; 2) sex; 3) smoking status; 4) number of missing teeth; and 5) number of teeth planned for extraction as part of a treatment plan at initial examination. Additionally, degree of periodontal severity was determined and recorded. The classification system was based on that used by the previous study, wherein case Types I to IV defined increasing severity of periodontal disease, and Type V defined referrals for needs other than periodontal disease (e.g., crown lengthening and implants). RESULTS: Overall, patients seen in 2015 presented with a greater percentage of Type IV and Type V cases. Smoking prevalence reduced significantly across the three locations between the two time periods. No consistent or noteworthy trends were identified with regard to number of missing teeth or number of teeth planned for extraction. CONCLUSIONS: Consistent with the results of a similar previous study, there appears to be a trend for more severe periodontal conditions being referred to periodontists. This is concerning given that more severe periodontal conditions tend to be more difficult to manage conservatively and reliably.