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Lisa Marie Shook,1,2 Christina Bennett Farrell,1 Cami Mosley1 1Cincinnati Comprehensive Sickle Cell Center, Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA; 2Department of Pediatrics, College of Medicine University of Cincinnati, Cincinnati, OH, USACorrespondence: Lisa Marie Shook, Cincinnati Comprehensive Sickle Cell Center, Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave., MLC 7015, Cincinnati, OH, 45229, USA, Tel +1-513-636-7541, Email Lisa.Shook@cchmc.orgPurpose: Healthcare providers faced numerous knowledge gaps and challenges with adapting practice behaviors in light of the COVID-19 pandemic. In response, an established virtual sickle cell disease (SCD) telementoring program rapidly expanded from monthly evidence-based didactic sessions focused on medical and psychosocial complications of sickle cell disease, to additional supplemental COVID-19 sessions with emerging pandemic topics and forums for shared experiences to address this timely educational need among multidisciplinary healthcare providers.Methods: In March 2020, the COVID-19 and Sickle Cell Disease Project ECHO® telementoring series was launched with a rapidly evolving curriculum of contemporary topics and case presentations. Topics included COVID-19 specific management for children and adults with sickle cell disease and strategies to adapt care and communication during the pandemic. Participants completed evaluations after each session.Results: From March 2020 to February 2022, there were 20 COVID-19 and SCD Project ECHO® sessions held with an average of 43 participants per session, which is over a 170% increase from the average SCD ECHO monthly attendance pre-pandemic. Participants represented 21 states and 3 countries. A majority of participants (91%) self-reported significantly improved knowledge of COVID-19.Conclusion: Project ECHO® is a successful educational strategy to diffuse knowledge using a virtual platform during a public health emergency, by facilitating shared learning among a community of practice that specializes in the management of sickle cell disease.Keywords: sickle cell disease, COVID-19, telementoring, project ECHO®, continuing education

We report on the generation of high-power narrow-bandwidth terahertz (THz) pulses by cryogenic cooling of hand-made periodically poled lithium niobate (PPLN) wafer stacks. As a proof-of-concept, we cool stacks with up to 48 wafers down to 97 K and achieve few-percent bandwidths at a center frequency of 0.39 THz, with pulse energy up to 0.42 mJ and average power of 21 mW. Supported by modeling, we observe effective cooling of PPLN wafer stacks that not only reduces terahertz absorption but critically maintains the micrometer-scale inter-wafer gaps for optimal terahertz transmission. Our results unlock the potential for scaling these large-area sources to greater numbers of wafers to push both the energy and bandwidth beyond current capability, opening up possibilities in areas such as terahertz-driven particle acceleration, terahertz imaging, and control over material properties. [ABSTRACT FROM AUTHOR]

Colossal magnetoresistance (CMR) is demonstrated at terahertz (THz) frequencies by using terahertz time-domain magnetospectroscopy to examine vertically aligned nanocomposites (VANs) and planar thin films of La0.7Sr0.3MnO3. At the Curie temperature (room temperature), the THz conductivity of the VAN was dramatically enhanced by over 2 orders of magnitude under the application of a magnetic field with a non-Drude THz conductivity that increased with frequency. The direct current (dc) CMR of the VAN is controlled by extrinsic magnetotransport mechanisms such as spin-polarized tunneling between nanograins. In contrast, we find that THz CMR is dominated by intrinsic, intragrain transport: the mean free path was smaller than the nanocolumn size, and the planar thin-film exhibited similar THz CMR to the VAN. Surprisingly, the observed colossal THz magnetoresistance suggests that the magnetoresistance can be large for alternating current motion on nanometer length scales, even when the magnetoresistance is negligible on the macroscopic length scales probed by dc transport. This suggests that colossal magnetoresistance at THz frequencies may find use in nanoelectronics and in THz optical components controlled by magnetic fields. The VAN can be scaled in thickness while retaining a high structural quality and offers a larger THz CMR at room temperature than the planar film. [ABSTRACT FROM AUTHOR]

Background: Signs of tachypnea after sedation of febrile horses with α2-agonists have been noted previously but have not been further investigated. Objectives: To examine the effects of xylazine and detomidine on respiratory rate and rectal temperature in febrile horses and to investigate if either drug would be less likely than the other to cause changes in these variables. Animals: Nine febrile horses and 9 healthy horses were included in the study. Methods: Horses were randomly assigned to sedation with xylazine 0.5 mg/kg or detomidine 0.01 mg/kg. Heart rate and respiratory rate were recorded before sedation and at 1, 3, and 5 minutes after injection. Hourly measurements of rectal temperature were performed starting before sedation. Results: All febrile horses experienced an episode of tachypnea and antipyresis after sedation. Rectal temperature in the febrile group was significantly lower at 1, 2, and 3 hours after sedation. In several measurements, the decrease was >1°C. Respiratory rate in the febrile group was significantly increased after sedation. All febrile horses were breathing >40 breaths/min and 3 horses >100 breaths/min 5 minutes after sedation. No differences were noted between the 2 treatments. No significant changes in respiratory rate or temperature were noted in the reference group. Conclusions and Clinical Importance: Febrile horses can become tachypneic after sedation with detomidine or xylazine. The antipyretic properties of α2-agonists need consideration when evaluating patients that have been sedated several hours before examination. [ABSTRACT FROM AUTHOR]

ABSTRACT Patients with end-stage renal disease (ESRD) and pre-ESRD require higher utilization of health care resources. Current reimbursement modalities contribute to the fragmentation of care, and inadequate financial information obscures the fiscal impact disease management's coordination of care can have for this population. Ignoring the extreme costs of the first 3 months of hemodialysis underestimates costs by as much as 16%. Potential areas of coordination and the financial benefits are discussed. In each venue of the care settings of a patient with chronic renal failure (CRF) they may receive excellent service. Too often there is not optimal coordination of care between these venues, and in fact the fragmentation of care can cause unnecessary wear and tear on the patient, and increases the overall expense to a health care system. Understanding sources of fragmentation, reimbursement effects, and potential corrections will enhance the patient's voyage through the system. This article provides some examples of the discoordination that presently exists and financial implications especially during the transition onto dialysis. In patients with end-stage renal disease (ESRD), each arena of care has criteria established to quantitate quality. None of the settings, whether it is the dialysis unit, the hospital, the skilled nursing facility, or the physician's office, exists in the absence of regulations. These may be state or federal, National Council on Quality Assurance (NCQA), Health Plan Employer Data and Information Set (HEDIS), water standards, Occupational Safety and Health Administration (OSHA), fire codes, physician peer review, Medicare billing, Health Care Finance Administration (HCFA), the ESRD networks, credentialing, health maintenance organization (HMO) insurance requirements, pharmacy benefits and formularies, safe harbors, “antikickback,” or National Kidney Foundation Dialysis Outcomes Quality Initiative (NKF-DOQI) guidelines. For all the providers of care, the other critical component is the ability to have adequate income to stay in business, and make a profit. Each becomes very astute at working within the confines of the regulatory restrictions to provide good care. However, the continuity of care cannot be the overwhelming issue for many of the providers. The only person that is involved in every arena is the patient. The only provider that currently crosses over most arenas is the nephrologist. But the other element that exists in each arena is a payer. [ABSTRACT FROM AUTHOR]

Presents information on the mechanisms of metronidazole on cholesterol and trigylceride levels. Purpose of metronidazole; Side effects of the drug; Clinical and laboratory features of patients treated with metronidzole.

This capsule review is a discussion of myofascial pain syndrome in small animals. The history of myofascial pain syndrome is discussed as well as facts and theories behind the aetiology and treatment of this syndrome. Diagnostic techniques are both discussed and illustrated. Accepted treatments including dry needling, photobiomodulation, manual therapy and thermal therapy are outlined., (© 2024 British Small Animal Veterinary Association.)

Sickle cell disease (SCD), which occurs primarily in individuals of African descent, has been identified as a preexisting health condition for COVID-19 with higher rates of hospitalization, intensive care unit admissions, and death. National data indicate Black individuals have higher rates of vaccine hesitancy and lower COVID-19 vaccination rates. Understanding the key predictors of intention to receive a COVID-19 vaccine is essential as intention is strongly associated with vaccination behavior. This multisite study examined attitudes, beliefs, intentions to receive COVID-19 vaccines, and educational preferences among adolescents, young adults, and caregivers of children living with SCD. Participants completed an online survey between July 2021 and March 2022. Multivariate logistic regression was used to examine the association between participant age and COVID-19 vaccine attitudes, beliefs, and vaccine intentions. Of the 200 participants, 65.1% of adolescents, 62.5% of young adults, and 48.4% of caregivers intended to receive a COVID-19 vaccine for themselves or their child. Perception that the vaccine was safe was statistically significant and associated with patient and caregiver intention to receive the COVID-19 vaccine for themselves or their child. Participant age was also statistically significant and associated with the intent to get a booster for patients. Study findings highlight key concerns and influencers identified by patients with SCD and their caregivers that are essential for framing COVID-19 vaccine education during clinical encounters. Study results can also inform the design of messaging campaigns for the broader pediatric SCD population and targeted interventions for SCD subpopulations (eg, adolescents, caregivers)., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Sickle cell disease (SCD) is a group of chronic, genetic disorders of the red blood cells with significant gaps in access to evidence-based clinical care. Sickle Treatment and Outcomes Research in the Midwest (STORM), a provider network, utilized Project ECHO (Extension for Community Health Outcomes), a telementoring model, to deliver evidence-based education about SCD management. The purpose of this mixed-methods study is to evaluate the utility of Project ECHO as an educational strategy for healthcare providers treating children and adults with SCD. Annual evaluations were administered to STORM TeleECHO participants from 2016 to 2021. Survey data showed a statistically significant change in self-reported provider confidence in the ability to provide care for adult patients with SCD; identify suitable candidates for disease-modifying therapies; and confidence to prescribe disease-modifying therapies. Participants who attended at least 10 sessions were invited to participate in a semi-structured interview. Qualitative data were analyzed using thematic analysis and several themes emerged about the benefits, including (1) increased confidence, (2) integrated best-practice care, (3) connection to provider network and access to experts, (4) high-quality educational presentations and (5) opportunities for collaboration and a sense of community. This suggests that Project ECHO is accessible and leads to increased confidence in providers caring for individuals with SCD. Overall, participant knowledge gains successfully demonstrated the utility of Project ECHO as an educational resource for providers.

Background: Mandatory training is considered fundamental to establishing and maintaining high standards of professional practice. There is little evidence however, of the training either achieving its required learning outcomes, or delivering improvement in outcomes for patients. Whist organisations may be hitting their compliance target for mandatory training, is the purpose missing the point? This systematic review aims to synthesize and evaluate the efficacy of statutory and mandatory training., Methods: PubMed, EMBASE, CNAHL, ERIC and Cochrane Central registers were searched on 23 rd May 2023. All research designs were included and reported training had to specify an organisational mandate within a healthcare setting. Data was coded using a modified Kirkpatrick (KP) rating system. Critical appraisal was undertaken using the Modified Medical Education Research Study Quality Instrument, Critical Appraisal Skills Programme Qualitative Studies checklist and Mixed Methods Assessment Tool., Results: Twenty-five studies were included, featuring 9132 participants and 1348 patient cases audited. Studies described evaluation of mandatory training according to Kirkpatrick's outcomes levels 1-4b, with the majority (68%) undertaken in the UK and within acute settings. Training duration varied from 5 min to 3 days. There is a lack of consensus regarding mandatory training rationale, core topics, duration, and optimum refresher training period. Currently, mandatory training does not consistently translate to widescale improvements in safe practice or improved patient outcomes., Conclusions: Due to the lack of international consensus regarding the need for mandated training, most papers originated from countries with centrally administered national health care systems. The rationale for mandating training programmes remains undefined. The assumption that mandatory training is delivering safe practice outcomes is not supported by studies included in this review. The findings of this review offer a basis for further research to be undertaken to assist with the design, facilitation, and impact of mandatory training.

Background: Uptake of COVID-19 vaccines remains problematically low in the USA, especially in rural areas. COVID-19 vaccine hesitancy is associated with lower uptake, which translates to higher susceptibility to SARS-CoV-2 variants in communities where vaccination coverage is low. Because community pharmacists are among the most accessible and trusted health professionals in rural areas, this randomized clinical trial will examine implementation strategies to support rural pharmacists in delivering an adapted evidence-based intervention to reduce COVID-19 vaccine hesitancy., Methods: We will use an incomplete stepped wedge trial design in which we will randomize 30 rural pharmacies (unit of analysis) to determine the effectiveness and incremental cost-effectiveness of a standard implementation approach (consisting of online training that describes the vaccine hesitancy intervention, live webinar, and resource website) compared to adding on a virtual facilitation approach (provided by a trained facilitator in support of the delivery of the vaccine hesitancy counseling intervention by pharmacists). The intervention (ASORT) has been adapted from an evidence-based vaccine communication intervention for HPV vaccines through a partnership with rural pharmacies in a practice-based research network in seven southern US states. ASORT teaches pharmacists how to identify persons eligible for COVID-19 vaccination (including a booster), solicit and address vaccine concerns in a non-confrontational way, recommend the vaccine, and repeat the steps later if needed. The primary trial outcome is fidelity to the ASORT intervention, which will be determined through ratings of recordings of pharmacists delivering the intervention. The secondary outcome is the effectiveness of the intervention, determined by rates of patients who agree to be vaccinated after receiving the intervention. Other secondary outcomes include feasibility, acceptability, adoption, reach, and cost. Cost-effectiveness and budget impact analyses will be conducted to maximize the potential for future dissemination and sustainability. Mixed methods will provide triangulation, expansion, and explanation of quantitative findings., Discussion: This trial contributes to a growing evidence base on vaccine hesitancy interventions and virtual-only facilitation of evidenced-based practices in community health settings. The trial will provide the first estimate of the relative value of different implementation strategies in pharmacy settings., Trial Registration: NCT05926544 (clinicaltrials.gov); 07/03/2023., (© 2023. The Author(s).)

Background: Childhood-onset systemic lupus erythematosus (cSLE) is an autoimmune disease with variable disease expression but noted association with significant disease-related damage, morbidity, and mortality. The European Alliance of Associations for Rheumatology (EULAR) recommends routine monitoring of SLE through validated disease activity and chronicity indices, including the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI). Despite this, physician adherence with SLEDAI documentation remains elusive at various academic institutions. The aim of our study was to determine baseline SLEDAI documentation rates at our center and assess the change in adherence in SLEDAI documentation rate with electronic clinical decision support (CDS) reminders facilitated through the electronic medical record (EMR) over a 2-year period., Methods: All SLE encounters over a 24-month period at a pediatric academic center were reviewed in order to obtain baseline SLEDAI documentation percentages. Physicians subsequently received monthly email reminders, initiated at month 4 of project initiation, with subsequent CDS reminder 13 months after project initiation prompted by anti-dsDNA lab result. Chart review was repeated continuously for each provider, and SLEDAI documentation rates were emailed to each provider monthly. Physicians completed a post-intervention survey regarding barriers to SLEDAI documentation at the end of the study., Results: A total of 1980 SLE encounters were reviewed for this study. Baseline SLEDAI documentation rates were 10%. Following the introduction of monthly emails reminding physicians to document SLEDAI, rates increased to 55%. After the initiation of electronic in-basket reminders prompted by lab results, rates increased to 60%. Noted barriers to documentation were cited to be forgetfulness (67%) and lack of time (33%)., Conclusion: Our study demonstrates that monthly email reminders as well as EMR-mediated electronic in-basket reminders increased SLEDAI documentation rates at an academic center. Noted barriers to documentation were reported to be forgetfulness (67%) and lack of time (33%)., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background/purpose: Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease, with a potential for significant disease damage, morbidity, and mortality. In comparison to the adult population, childhood-onset SLE (cSLE) tends to be more aggressive given the higher preponderance of renal and neuropsychiatric disease and increased disease activity. There is a paucity of literature examining relationship between disease activity, rheumatology follow-up visits, and health care utilization. The objective of this study is to determine whether adherence with outpatient clinic visits would affect disease activity in patients with childhood-onset systemic lupus erythematosus (cSLE)., Methods: 41 children <18 years of age at time of diagnosis with SLE who met Systemic Lupus International Collaborative Clinics (SLICC) criteria and not evaluated in clinic within the previous 120-day period were identified as eligible for inclusion. Patients were continuously searched between December 2021 and July 2022 for eligibility evaluation. Through retrospective chart review, we assessed disease activity (SLE Disease Activity Index) at the last clinic visit. The patients were stratified into two cohorts of lower and higher disease activity, with SLE disease activity index (SLEDAI) ≤ 3 and SLEDAI ≥ 4, respectively. Descriptive statistics and Willcox Rank Sum (numerical variables) and Fisher's test (categorical variables) were used to compare these two groups., Results: Clinical, epidemiological, and serological data were compared between the two groups, with observed statistically significant differences to include current use of high dose prednisone associated with higher SLEDAI scores ( p = 0.019). In nonparametric analysis, time to follow-up ( p < 0.001), hospitalizations ( p = 0.017), and Emergency Department visits (ED) ( p < 0.001) were found to be associated with higher SLEDAI scores., Conclusion: Our findings suggest that cSLE patients with higher disease activity are at risk for increased health care utilization with respect to ED visits as well as hospitalizations in the setting of follow-up nonadherence. While further studies are required to enhance our understanding of this association, this links the importance of disease-related outcome and routine outpatient visits in this particularly vulnerable patient population.

Invasive species and emerging infectious diseases are two of the greatest threats to biodiversity. American Bullfrogs (Rana [Lithobates] catesbeiana), which have been introduced to many parts of the world, are often linked with declines in native amphibians via predation and the spread of emerging pathogens such as amphibian chytrid fungus (Batrachochytrium dendrobatidis [Bd]) and ranaviruses. Although many studies have investigated the potential role of bullfrogs in the decline of native amphibians, analyses that account for shared habitat affinities and imperfect detection have found limited support for clear effects. Similarly, the role of bullfrogs in shaping the patch-level distribution of pathogens is unclear. We used eDNA methods to sample 233 sites in the southwestern USA and Sonora, Mexico (2016-2018) to estimate how the presence of bullfrogs affects the occurrence of four native amphibians, Bd, and ranaviruses. Based on two-species, dominant-subordinate occupancy models fitted in a Bayesian context, federally threatened Chiricahua Leopard Frogs (Rana chiricahuensis) and Western Tiger Salamanders (Ambystoma mavortium) were eight times (32% vs. 4%) and two times (36% vs. 18%), respectively, less likely to occur at sites where bullfrogs occurred. Evidence for the negative effects of bullfrogs on Lowland Leopard Frogs (Rana yavapaiensis) and Northern Leopard Frogs (Rana pipiens) was less clear, possibly because of smaller numbers of sites where these native species still occurred and because bullfrogs often occur at lower densities in streams, the primary habitat for Lowland Leopard Frogs. At the community level, Bd was most likely to occur where bullfrogs co-occurred with native amphibians, which could increase the risk to native species. Ranaviruses were estimated to occur at 33% of bullfrog-only sites, 10% of sites where bullfrogs and native amphibians co-occurred, and only 3% of sites where only native amphibians occurred. Of the 85 sites where we did not detect any of the five target amphibian species, we also did not detect Bd or ranaviruses; this suggests other hosts do not drive the distribution of these pathogens in our study area. Our results provide landscape-scale evidence that bullfrogs reduce the occurrence of native amphibians and increase the occurrence of pathogens, information that can clarify risks and aid the prioritization of conservation actions., (© 2022 The Ecological Society of America. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

The proposed life cycle of fungi in the genus Pneumocystis has typically included both an asexual cycle via binary fission and a sexual cycle. Until recently, the strategy used for sexual replication was largely unknown, but genomic and functional assays now support a mode known as primary homothallism (self-fertilization). The question of whether an asexual cycle contributes to the growth of these fungi remains. Treatment of Pneumocystis pneumonia in immunosuppressed rodent models with the class of drugs known as echinocandins is challenging the historical concept of asexual replication. The echinocandins target 1,3-β-D-glucan (BG) synthesis resulting in death for most fungi. Because Pneumocystis species have both non-BG expressing life cycle stages (trophic forms) and BG-expressing asci, treatment with anidulafungin and caspofungin resulted in elimination of asci, with large numbers of non-BG expressing organisms remaining in the lungs. Transcriptional analyses of anidulafungin treated Pneumocystis murina-infected lungs indicated that these agents were blocking the sexual cycle. In the present study, we explored whether there was an asexual or alternative method of replication that could rescue P. murina survival and growth in the context of anidulafungin treatment. The effects of anidulafungin treatment on early events in the sexual cycle were investigated by RT-qPCR targeting specific mating genes, including mam2 , map3, matMi, matPi, and matMc . Results from the in vivo and gene expression studies clearly indicated there was no rescue by an asexual cycle, supporting these fungi's reliance on the sexual cycle for survival and growth. Dysregulation of mating-associated genes showed that anidulafungin induced effects early in the mating process. IMPORTANCE The concept of a sexually obligate fungus is unique among human fungal pathogens. This reliance can be exploited for drug development and here we show a proof of principle for this unusual target. Most human fungal pathogens eschew the mammalian environment with its battery of immune responses. Pneumocystis appear to have evolved to survive in such an environment, perhaps by using sexual replication to help in DNA repair and to introduce genetic variation in its major surface antigen family because the lung is the primary environment of these pathogens. The concept of primary homothallism fits well into its chosen ecosystem, with ready mating partners expressing both mating type receptors, and a sexual cycle that can introduce beneficial genetic variation without the need for outbreeding.