Cutaneous Fungal Infections in Patients Experiencing Homelessness and Treatment in Low-Resource Settings: A Scoping Review.

Patients experiencing homelessness (PEH) suffer from a high burden of cutaneous fungal infections. Preventative treatment is important as such infections can lead to harmful complications such as cellulitis and even osteomyelitis. There are sparse data regarding cutaneous fungal infections of homeless populations and management in low-resource settings. A MEDLINE search was conducted using the key terms "cutaneous," "fungal," "infections," "dermatophytes," and "homeless." The search included case-control, cohort, and randomized controlled trials published in the English language. This scoping review of studies yielded information with regard to practical treatment advice for providers in low-resource settings, including medical, hygiene, prevention, and treatment options for PEH with cutaneous fungal infections, the most common of which were tinea pedis (3-38%) and onychomycosis (1.6-15.5%). Few studies have been conducted on the differences between sheltered and unsheltered homeless patients, which can have treatment implications. Systemic antifungal therapy should be carefully considered for diffuse, refractory, or nail-based cutaneous fungal infections if there is a history of alcohol use disorder or liver disease. While PEH have a high risk of alcohol use disorder, this can make definitive treatment challenging.

Resource-Limited Management of Presumptive Pyoderma Gangrenosum in an Unsheltered Patient.

Pyoderma gangrenosum (PG) is an ulcerating dermatosis associated with various chronic medical conditions. Its exact etiology is unknown but likely a function of inflammation and immune dysregulation. Treatment of PG generally follows a stepwise approach which involves extensive testing, biopsies, and potentially systemic therapy. However, patients with presumptive PG in an unsheltered homeless (USH) environment require a different approach, especially in a resource-limited setting. Our 65-year-old USH patient with an extensive medical history presented with an initial, irregular salmon-colored plaque measuring approximately 10 cm × 6 cm that eventually ulcerated with pain and purulent discharge. The consistent and judicious management of his wound in terms of gentle irrigation and appropriate dressing was performed over the course of seven months starting in April 2021. In November 2021, his wound margins shrunk by roughly 1 cm circumferentially, and the ulcer had scant serosanguinous discharge, a noticeable improvement from baseline. The previously impaired wound healing may have been due to pathergy, which was indirectly addressed by protective wound dressings. Management of chronic wounds and ulcers in patients otherwise lacking access to reliable care should avoid systemic immunosuppressants due to the inherently high-risk conditions on unsheltered streets.

Patient Perspectives toward Undergoing Same-Day Discharge for Apical Pelvic Organ Prolapse Repair Surgery during the COVID-19 Pandemic.

INTRODUCTION: To ensure patient satisfaction during the COVID-19 pandemic, hospitals implemented changes to elective surgeries while upholding safety and quality of care. This includes a growing trend toward same-day discharge (SDD) following apical pelvic organ prolapse (POP) repair surgery, which previously involved overnight hospitalization for some institutions. We assessed patient perspectives following SDD after transvaginal and minimally invasive apical POP repair during the pandemic. METHODS: This was a cross-sectional study of women who underwent apical POP surgery. Preoperatively, we assessed preference for SDD. A postoperative survey evaluated perceived safety, pain control and satisfaction using the "Core questionnaire for the assessment of Patient Satisfaction for general Day-care" and the "Patient Global Impression of Improvement." Postoperative complications were identified. RESULTS: Of 36 recruited patients, 83.3% preferred SDD preoperatively. When rating the influence of COVID-19 on their preference (1-10, 10=high), 13 reported level 10 and 11 reported level 1 (mean 5.9±4.0). A total of 34 postoperative surveys were collected, 29 of which were SDD (85.3%); 89.7% of patients reported feeling safer with SDD, and 40% (2/5) of admitted patients would have preferred SDD. Pain control satisfaction for SDD was assessed on a Likert scale (1-10, 10=very satisfied), with a mean of 9.1 (±1.8); 82.8% of SDD patients rated their overall experience as "very satisfied" and consistently rated individual components highly. CONCLUSIONS: During the pandemic, our patient population preferred SDD after an apical POP repair with a high success and satisfaction rate with minimal complications. In the absence of a pandemic, SDD should be considered to increase patient satisfaction.

A Systematic Review of Racial/Ethnic Disparities in Female Pelvic Floor Disorders.

Numerous studies have investigated the influence of health disparities among women with pelvic floor disorders with varied results. Racial/ethnic disparities, in particular, inconsistently indicate differences in prevalence of disease, disease severity, and treatment outcomes. We aim to review the body of literature examining racial/ethnic disparities in pelvic floor disorders, including overactive bladder, stress urinary incontinence, pelvic organ prolapse, and interstitial cystitis. A better understanding of these disparities may help guide clinicians, researchers, and advocates in providing improved education, outreach opportunities, and access to care in minority women with pelvic floor disorders.

Role of IgG against N-protein of SARS-CoV2 in COVID19 clinical outcomes.

The Nucleocapsid Protein (N Protein) of severe acute respiratory syndrome Coronavirus 2 (SARS-CoV2) is located in the viral core. Immunoglobulin G (IgG) targeting N protein is detectable in the serum of infected patients. The effect of high titers of IgG against N-protein on clinical outcomes of SARS-CoV2 disease has not been described. We studied 400 RT-PCR confirmed SARS-CoV2 patients to determine independent factors associated with poor outcomes, including Medical Intensive Care Unit (MICU) admission, prolonged MICU stay and hospital admissions, and in-hospital mortality. We also measured serum IgG against the N protein and correlated its concentrations with clinical outcomes. We found that several factors, including Charlson comorbidity Index (CCI), high levels of IL6, and presentation with dyspnea were associated with poor clinical outcomes. It was shown that higher CCI and higher IL6 levels were independently associated with in-hospital mortality. Anti-N protein IgG was detected in the serum of 55 (55%) patients at the time of admission. A high concentration of antibodies, defined as signal to cut off ratio (S/Co) > 1.5 (75 percentile of all measurements), was found in 25 (25%) patients. The multivariable logistic regression models showed that between being an African American, higher CCI, lymphocyte counts, and S/Co ratio > 1.5, only S/Co ratio were independently associated with MICU admission and longer length of stay in hospital. This study recommends that titers of IgG targeting N-protein of SARS-CoV2 at admission is a prognostic factor for the clinical course of disease and should be measured in all patients with SARS-CoV2 infection.

Implementation of a medical student-run telemedicine program for medications for opioid use disorder during the COVID-19 pandemic.

OBJECTIVES: The COVID-19 pandemic led to the closure of the IDEA syringe services program medical student-run free clinic in Miami, Florida. In an effort to continue to serve the community of people who inject drugs and practice compassionate and non-judgmental care, the students transitioned the clinic to a model of TeleMOUD (medications for opioid use disorder). We describe development and implementation of a medical student-run telemedicine clinic through an academic medical center-operated syringe services program. METHODS: Students advertised TeleMOUD services at the syringe service program on social media and created an online sign-up form. They coordinated appointments and interviewed patients by phone or videoconference where they assessed patients for opioid use disorder. Supervising attending physicians also interviewed patients and prescribed buprenorphine when appropriate. Students assisted patients in obtaining medication from the pharmacy and provided support and guidance during home buprenorphine induction. RESULTS: Over the first 9 weeks in operation, 31 appointments were requested, and 22 initial telehealth appointments were completed by a team of students and attending physicians. Fifteen appointments were for MOUD and 7 for other health issues. All patients seeking MOUD were prescribed buprenorphine and 12/15 successfully picked up medications from the pharmacy. The mean time between appointment request and prescription pick-up was 9.5 days. CONCLUSIONS: TeleMOUD is feasible and successful in providing people who inject drugs with low barrier access to life-saving MOUD during the COVID-19 pandemic. This model also provided medical students with experience treating addiction during a time when they were restricted from most clinical activities.