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Patient-centered care for those admitted to a skilled nursing facility is incomplete without a practitioner-patient life-care planning (LCP) conversation to facilitate informed decisions for the plan of care and a named surrogate decision maker. A medical records review of six target areas was used to identify patients who may benefit from an updated LCP conversation. Kaiser Permanente skilled nursing facility teams in the Marin-Sonoma area admitted 429 patients between November 2020 and April 2021. On admission, each patient’s medical record was reviewed for clinical and social indicators to identify patients with LCP needs. In the first month, 45% of patients had their LCP decisions documented prior to discharge, which increased to 74% by the end of the pilot process. By standardizing a process to include LCP as a component of patient-centered care planning, as a department we established practitioner-patient LCP as a routine of care for patients at skilled nursing facilities and their families.

OBJECTIVE The American Academy of Pediatrics (AAP), Advisory Committee on Immunization Practices (ACIP), and Centers for Disease Control and Prevention (CDC) recommend delaying live vaccinations up to 11 months after transfusions of certain blood products due to the risk of immunoglobulins decreasing immunization efficacy. Because vaccination schedules recommend live immunizations at 12 months, infants aged 5 to 12 months who undergo cardiac surgery requiring blood products are potentially at risk for improper vaccination. The objective of this study was to identify the risk of inappropriately timed live vaccination in pediatric patients after cardiovascular surgery. METHODS This single-center, retrospective chart review included 345 patients 5 to 12 months of age who underwent cardiovascular surgery between January 1, 2010, and December 31, 2016. Included patients received packed red blood cells (PRBCs) and/or platelets during the surgical admission and a live vaccine within the first 18 months of life. The primary endpoint was the incidence of live vaccine administration within 7 months of receiving PRBCs and/or platelets. RESULTS Of the 345 included patients, 67% (n = 230) were inappropriately vaccinated after receiving platelets and/or PRBCs during cardiac surgery. CONCLUSIONS Infants who undergo cardiac surgery between the ages of 5 and 12 months are at risk for inappropriate live vaccination timing. A clinically significant percentage of pediatric patients who received blood products during a cardiac surgical admission later received live vaccines at times that were inconsistent with AAP, ACIP, and CDC recommendations. Future interventions aimed at educating providers and patients may be warranted.

Objectives Changes of routine disease management associated with COVID-19 lockdown might have potentially affected the clinical course of juvenile idiopathic arthritis (JIA). Aim of our study was to assess the rate of disease flare before and during COVID-19 lockdown to investigate its impact on disease course in JIA children. Methods A single-center retrospective study was conducted, including patients presenting inactive JIA between September 1st , 2018 and March 9th , 2019 (group A) and between September 1st , 2019 and March 9th , 2020 (group B). For each patient, demographic and clinical data were collected. The rate of JIA flare from March 10th , 2019 to June 30th , 2019 for group A and from March 10th , 2020 to June 30th , 2020 for group B was compared. Results Group A included 126 patients and group B 124 patients. Statistical analysis did not show significant differences among the two cohorts with respect to age, sex, age of JIA onset, JIA subtype, co-occurrence of uveitis, ANA positivity and past or ongoing medications. The rate of disease flare during lockdown at time of first COVID-19 pandemic wave, was significantly higher in comparison to the previous year (16.9% vs 6.3%, p=0.009). Conclusion Our study showed that COVID-19 lockdown was associated with a higher rate of joint inflammation in JIA children. This finding has a considerable clinical implication, since restrictive measures may be necessary in order to contain pandemics. Our data highlight the need for rearrangement in the home and healthcare management of JIA children during lockdowns.

Hepatic trematodes, such as Fasciola hepatica and Fascioloides magna, have variable distribution throughout the United States. F. magna is endemic in the upper midwestern United States, and F. magna infections are diagnosed frequently in weaned calves and adult beef cattle at the North Dakota State University Veterinary Diagnostic Laboratory (NDSU-VDL). Rarely, liver fluke infestation has also been observed in much younger calves, including aborted fetuses. We describe here, in 2 fetal and 7 neonatal beef calves submitted to the NDSU-VDL between 2011 and 2020, parasitic migration tracts in livers, consisting of regionally extensive, random, linear tracts of fibrosis admixed with black porphyrin pigment, along with foci of necrosis and hemorrhage, and mixed inflammatory cells, which were caused presumptively by F. magna infection. Samples were not available from our 9 cases for PCR assay and sequencing, but we did confirm F. magna within liver samples collected from regional cattle in 2020 and 2021. Fetal and neonatal trematodosis was often concurrent with other common causes of fetal abortion and neonatal calf loss in our cases; however, based on the prepatent period of F. magna, fetal and neonatal beef calf trematode infestations occurred in utero.

Doublecortin (DCX) and neuronal nuclear protein (NeuN) can be used as immunomarkers of neuronal progenitor cells and mature neurons, respectively. Increased DCX immunolabeling has been associated with tumor invasion in human gliomas and anaplastic canine meningiomas. These immunomarkers have not been assessed in feline gliomas. Here we characterized the DCX and NeuN immunohistochemistry (IHC) profile in 11 feline gliomas (7 oligodendrogliomas, 4 astrocytomas). Immunolabeling was classified according to intensity (weak, moderate, strong), distribution of neoplastic cell immunolabeling (1 = 70%), and predominant location within the neoplasm (random or at tumor margins). DCX immunolabeling was strong in 6 cases, weak in 4 cases, and moderate in 1 case. The distribution of DCX immunolabeling was characterized as 1 (4 cases), 2 (4 cases), and 3 (3 cases). DCX immunolabeling occurred predominantly in astrocytomas, which had stronger immunostaining at the tumor margins. NeuN immunolabeling was absent in all cases. Our IHC findings are similar to those reported for DCX and NeuN IHC in canine gliomas. The increased DCX immunolabeling at tumor margins is similar to labeling in invasive human gliomas and anaplastic canine meningiomas.

Although Mycobacterium spp. often cause disease in domestic birds (chickens and companion birds), there are few data on avian tuberculosis in wild populations, especially in birds of prey. We describe here a case of a young adult female, free-living Eurasian griffon vulture ( Gyps fulvus) that was found dead. Granulomas were grossly evident in the lungs at autopsy, and tuberculosis was suspected. Ziehl–Neelsen staining revealed large numbers of intracellular acid-fast–positive bacteria within granulomas. Examination on Löwenstein–Jensen medium was negative, but mycobacteria growth indicator tube medium results were positive. For the molecular detection of Mycobacterium spp., the primer set IS901F and IS901R was used. Positive results were observed on gel electrophoresis, indicating the presence of Mycobacterium avium subsp. avium DNA. Although tuberculosis is not considered to be a common cause of death in wild birds, it undoubtedly deserves special attention because vultures are generally considered to be a species resistant to a large number of pathogens. Determination of the cause of death of griffon vultures is important for future conservation measures for this sensitive wild species.

Dogs with infectious arthritis may occasionally exhibit positive serum antinuclear antibody (ANA) and rheumatoid factor (RF) titers; however, relevant data are sparse for arthritis secondary to canine leishmaniosis (CanL) caused by Leishmania infantum. We determined the prevalence of positive serum ANA and RF titers in dogs with arthritis secondary to CanL. Blood samples from adult, client-owned dogs with purulent arthritis secondary to CanL, without any comorbidities, were collected for diagnostic purposes. Serum ANA titers were measured by immunoperoxidase test and RF titers by the Rose–Waaler latex test. Twelve of 23 dogs enrolled prospectively in our study had clinical arthritis, and 11 of 23 had subclinical arthritis. Based on LeishVet clinical staging, 7 dogs had clinical stage II disease, 11 had clinical stage III disease, and 5 had stage IV. None of the 23 dogs was seropositive for ANA; 3 of 23 were positive for RF. ANA and/or RF seropositivity, in dogs with CanL-associated arthritis, appears to be weak, if present at all. Based on our results, positive serum ANA and RF titers should not be expected in dogs with arthritis secondary to CanL.

BACKGROUND: Pediatric palliative care (PPC) consultation is infrequent among children on extracorporeal membrane oxygenation (ECMO). OBJECTIVE: Investigate intensive care unit (ICU) team members' perceptions of automatic PPC consultation for children on ECMO in an ICU in the United States. METHODS: Cross-sectional survey assessing benefits, barriers to PPC, and consultation processes. RESULTS: Of 291 eligible respondents, 48% (n = 140) completed the survey and 16% (n = 47) answered an open-ended question. Benefits included support in decision-making (n = 98; 70%) and identification of goals of care (n = 89; 64%). Barriers included perception of giving up on families (n = 59; 42%) and poor acceptability by other team members (n = 58; 41%). Respondents endorsed communication with the primary ICU team before (n = 122; 87%) and after (n = 129; 92%) consultation. Open-ended responses showed more positive (79% vs. 13%) than negative statements. Positive statements reflected on expanding PPC to other critically-ill children where negative statements revealed unrecognized value in PPC. CONCLUSIONS: Results demonstrate opportunities for education about the scope of PPC and improvements in PPC delivery.

BACKGROUND: Unlike fee-for-service Medicare, the Veterans Health Administration (VHA) allows for the provision of concurrent care, incorporating cancer treatment while in hospice. METHODS: We compared trends of aggressive care at end of life between Medicare and VHA decedents with advanced nonsmall cell lung cancer from 2006 to 2012, and the relation between regional level end-of-life care between Medicare and VHA beneficiaries. RESULTS: Among 18,371 Veterans and 25,283 Medicare beneficiaries, aggressive care at end of life decreased 15% in VHA and 4% in SEER (Surveillance, Epidemiology, and End Results)-Medicare (p

In veterinary medicine, measurement of canine C-reactive protein (cCRP) is used widely to detect inflammatory diseases. We evaluated the precision of Randox and Fuji assays for cCRP, as well as accuracy, correlation, and agreement compared to a reference ELISA. Blood samples from 71 client-owned dogs (20 healthy, 51 diseased) were analyzed with the 3 assays. Inter-assay CVs were ~3.5% with both the Randox and Fuji assays. The mean biases were −1.90% for the Randox and −5.93% for the Fuji test; the targeted biases were ~8.5% for both assays. The CV, bias, and observed total error were acceptable for the 2 assays compared to ASVCP recommendations based on biological variation studies. The Spearman correlation coefficient for cCRP concentration compared with the reference ELISA was 0.83 for the Randox test and 0.92 for the Fuji test. Both assays measured cCRP precisely at intermediate and increased concentrations. Correlation with the reference ELISA was good, and both assays could be used to evaluate cCRP concentrations in veterinary practice. However, the assays did not reach analytical agreement; hence the results obtained by these assays are not interchangeable, and serial monitoring of cCRP requires the use of the same assay.

Background COVID-19 has negatively impacted the mental health of frontline health care workers, including pharmacists. Objective(s) The aim of this longitudinal study was to assess the psychological impact of the COVID-19 outbreak in French owner community pharmacists. Methods We carried out a postal-based survey to assess the psychological difficulties of the COVID-19 outbreak in French owner community pharmacists based on three psychologically validated self-report questionnaires: Perceived Stress Scale (PSS), Impact of Event Scale-revised (IES-R) and Maslach Burnout Inventory. The baseline assessment was during the first sanitary lockdown period and the second one 5 months later. Results The sample consists of 135 owner community pharmacists. At follow-up, 67 answered the questionnaires (response rate: 49.6%). The mean scores of the PSS and IES-R significantly decreased (p=0.002). Fifteen pharmacists reported significant posttraumatic stress symptoms (23.1%) at baseline and eleven at follow-up (16.4%, p=0.02). Age and sex were not significantly associated with persistent posttraumatic stress or burnout symptoms. Conclusion This is the first longitudinal study that showed the psychological impact of owner community pharmacists as health care workers dealing with their community's COVID-19 outbreak. Based on validated self-report questionnaires, stress, posttraumatic stress and burnout symptoms decreased during follow-up. It is necessary to continue monitoring psychological difficulties for health care workers, especially during consecutive waves of the COVID-19 outbreak.

OBJECTIVE The utility of routine therapeutic drug monitoring (TDM) in children living with HIV has not been extensively studied. The purpose of this study was to assess this strategy. METHODS This was a single-center, prospective observational study of routine TDM for protease inhibitors (PIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs), and integrase strand transfer inhibitors (INSTIs) in children living with HIV who were receiving antiretroviral therapy (ART) between February and December 2014. Outcome measures included the proportion of serum antiretroviral (ARV) medication concentrations in the therapeutic range (target values extrapolated from adult data) and the effect of serum concentrations on virologic control, medication adherence, and toxicity. RESULTS Forty-eight children with a median age of 13 years (interquartile range, 3–18) were included. Median viral load (VL) and CD4% were CONCLUSIONS This study does not support routine TDM in healthy children living with HIV who are well controlled on antiretroviral medication regimens. A more targeted strategy, such as when adherence is questioned or when there are suspected drug interactions, may be more appropriate.

Ependymoma, one of the most common gliomas in cats, occurs most often in the lateral and third ventricles and has variable histologic patterns that often form rosettes and pseudorosettes. Oligodendrocyte transcription factor (OLIG2) is expressed in oligodendrocyte precursor cells and mature oligodendrocytes. Although widely used as a diagnostic marker for most gliomas, OLIG2 is reported to have minimal immunolabeling in ependymomas. Here we characterize the OLIG2 immunolabeling pattern in 19 cases of feline ependymoma, which occurred predominantly in the lateral and third ventricles. Immunohistochemistry for GFAP was variable in 14 cases and was typically localized in the cytoplasmic processes of the neoplastic ependymal cells, especially in the rosettes and pseudorosettes. Nuclear OLIG2 immunolabeling was present in 17 cases and varied in intensity from weak (4 cases) to strong (13 cases). The distribution of OLIG2 immunolabeling within the neoplasms included none (2 cases), 75% (3 cases). OLIG2 immunolabeling intensity and distribution is widespread in feline ependymoma, in contrast to ependymomas in other species, and should not be relied upon as a specific marker for feline oligodendroglioma.

A 21-mo-old Japanese Black beef cow had swollen mandibular and superficial cervical lymph nodes. Fine-needle aspiration cytology of the superficial cervical lymph node revealed large lymphoblasts with mitoses present. The bovine leukemia virus (BLV) proviral load was relatively high, and phylogenetic analysis of the whole BLV genome classified the BLV strain as one with high viral replication activity. Genotyping of bovine leukocyte antigen genes indicated that the cow was susceptible to enzootic bovine leukosis (EBL). The bone morphogenetic protein 6 ( BMP6) gene promoter region was hypermethylated. Monoclonal proliferation of B cells and monoclonal integration of the BLV provirus in the bovine genome were detected by a clonality test of B cells and an inverse PCR assay, respectively. At autopsy, generalized swelling of lymph nodes and spinal canal invasion by tumor tissue at vertebrae L5-6 were observed. Histologic analysis revealed diffuse proliferation of large round neoplastic cells that were positive for BLA36 and negative for CD3. The cow was definitively diagnosed with EBL based on these findings. Infection with a highly pathogenic strain of BLV, susceptibility of the BoLA-DRB3 alleles, and hypermethylation of the BMP6 gene may have contributed to the development of EBL in our case.

Although systemic bacterial infection (SBI) is a common cause of sepsis and death in dogs, the neuropathology of canine SBI has been poorly characterized. Here we describe the neuropathologic features of SBI in a retrospective series of 28 dogs. The mean age of affected dogs was 5.5 y, and there was no sex or breed predisposition. Gross lesions in the brain were reported in 13 cases (46%) and consisted mainly of leptomeningeal hemorrhages in 10 of these cases (77%). Associated extraneural lesions included suppurative mitral valve endocarditis (12 cases; 43%) and pneumonia (10 cases; 36%). The main neurohistologic findings were neutrophilic (suppurative) and/or fibrinous meningoencephalitis with hemorrhage, vasculitis, thrombosis, and neuronal necrosis. Intralesional bacteria were observed in neutrophils or macrophages in 10 cases (77%). The putative primary site of infection was determined in 16 cases (57%) and consisted of pneumonia (6 cases; 38%), pyelonephritis (4 cases; 25%), and skin lesions (3 cases; 19%). Bacterial culture of fresh or frozen tissue samples yielded bacterial growth in 26 cases (93%), including Streptococcus canis (6 cases; 23%), Escherichia coli (4 cases; 15%), and Staphylococcus intermedius (3 cases; 12%).

BACKGROUND: Telenovelas show significant promise as a mode of education that could potentially enhance hospice family caregivers' (HFCG) ability to manage distress or pain for themselves and the care recipient. OBJECTIVES: We sought to understand HFCGs' perceived benefits and challenges of NOVELA using the Levels of Kirkpatrick as a conceptual framework. SETTING/SUBJECTS: HFCGs from two hospices in the Mid-Atlantic region of the United States. MEASUREMENTS: Semistructured interviews were conducted to understand perceptions of HFCGs on the benefits and challenges of the NOVELA intervention. RESULTS: Participants (N = 20) in our study were mainly homebound, well educated, White female, and adult children of people with advanced cancer who reported mild anxiety and moderate self-efficacy at baseline. Three unique themes were identified: acceptability of NOVELA, usability and relevance of NOVELA, and the effect of NOVELA. According to our conceptual model, the intervention positively affects all three adult learning categories: reaction, learning, and behavior. CONCLUSION: Our findings suggest that HFCGs support the proposed NOVELA intervention and it appears to be an acceptable educational tool during hospice care (NCT04533594).

Metastrongylosis is an infection of the respiratory tract of pigs caused by parasites of the genus Metastrongylus, whose eggs are similar to other Strongylida through light microscopy; species-specific identification can be performed with molecular tools. We explored the species composition and the genetic diversity of Metastrongylus infecting pigs in close contact with humans in impoverished rural communities in the state of Piauí, in northeastern Brazil. Fecal samples (n = 78) were collected for parasitologic tests. Egg morphometry and molecular characterization, using the cytochrome c oxidase subunit 1 (cox1) gene, were performed. For strongyliform eggs, 62 of 78 (80%) pigs were positive and 6 of 99 (6%) eggs had dimensions compatible with Metastrongylus. Of the 37 samples submitted to PCR, 10 were identified as M. salmi. We found 3 M. salmi haplotypes, including 2 new and 1 described previously in Europe. Overall, M. salmi demonstrated lower intraspecific genetic diversity: diversity index (H) ± SD = 0.318 ± 0.164, n = 12, compared with published M. pudendotectus sequences (1.000 ± 0.272, n = 3). To our knowledge, M. salmi DNA sequences have not been published previously from pigs in South America.

A 5-y-old spayed female Golden Retriever dog was referred because of severe normocytic normochromic nonregenerative anemia and thrombocytopenia. Serum analysis revealed hyperproteinemia and monoclonal or oligoclonal gammopathy. Fine-needle aspiration of the spleen revealed a highly erythrophagocytic population of neoplastic round cells, morphologically suggestive of plasma cells. After euthanasia, histologic assessment of the spleen and liver revealed an erythrophagocytic round cell tumor. Immunohistochemical analysis of the tumor population was positive for MUM1p and negative for CD3, CD20, and Iba-1, confirming the plasma cell origin of the tumor. Erythrophagocytic multiple myeloma is a very rare neoplastic condition in dogs.

HoBi-like pestivirus (HoBiPeV) is an emerging virus that has been detected in cattle and other ruminants. We diagnosed 2 cases of fatal bovine respiratory disease complex (BRDC) associated with infection with HoBiPeV in a feedlot in Argentina. The main findings in 2 steers autopsied were interstitial bronchopneumonia (case 1) and fibrinous bronchopneumonia (case 2). HoBiPeV was detected by RT-PCR in lungs of both animals and by immunohistochemistry in case 2. Phylogenetic analysis showed that both strains clustered within the “Brazilian-Italian” clade. In case 2, Mannheimia haemolytica was isolated from the lung. There is scant information about the contribution of HoBiPeV to the pathogenesis of BRDC. To our knowledge, HoBiPeV has not been reported previously in association with M. haemolytica pneumonia. Our findings further support the involvement of HoBiPeV in cases of BRDC and contribute to understanding the synergy of this etiologic agent in the pathogenesis of BRD, which is critical for the development of appropriate preventive strategies.

Neuroprognostication following diffuse axonal injury (DAI) has historically relied on neuroimaging techniques with lower spatial resolution and contrast than techniques currently available in clinical practice. Since the initial studies of DAI classification and prognosis in the 1980s and 1990s, advances in neuroimaging have improved detection of brainstem microbleeds, a hallmark feature of Grade 3 DAI that has traditionally been associated with poor neurologic outcome. Here, we report clinical and radiologic data from two patients with severe traumatic brain injury and grade 3 DAI who recovered functional independence and returned to work within 4 months of injury. Importantly, both patients were scanned using 3 Tesla MRI protocols that included susceptibility-weighted imaging (SWI), a technique that provides enhanced sensitivity for detecting brainstem microbleeds. These observations highlight the importance of developing approaches to DAI classification and prognosis that better align with contemporary neuroimaging capabilities.

This article characterizes 2 cases of longitudinally extensive transverse myelitis (LETM) that did not respond to immunotherapy and were diagnosed by biopsy as primary central nervous system (CNS) malignancies. Diffuse H3 K27M-mutant glioma is a recently described entity with very few cases of isolated spinal disease described in adults. Primitive neuroectodermal tumor is similarly uncommon in the spinal cord. Malignancies should be considered in patients who fail to improve with immunomodulatory therapy. We believe the experiences of our center will raise awareness about that point, broaden the existing understanding of the diagnostic approach to LETM, and highlight the need for additional studies.

Neurological involvement occurs in 5 to 15% of patients with sarcoidosis. It rarely represents the sole manifestation of the disease, a condition called isolated neurosarcoidosis. Objectives: To describe patients with definite isolated central neurosarcoidosis. To compare their characteristics to a group of systemic sarcoidosis with central neurologic involvement. Methods: Monocentric retrospective study of all patients presenting with central neurosarcoidosis (NS) over a 10 year period, subsequently divided into 2 groups: isolated neurosarcoidosis (INS) and systemic neurosarcoidosis (SNS). Results: We report 10 cases of INS and subsequently, we compared their characteristics to a group of 30 patients with SNS. INS patients exhibited brain parenchymal involvement (8/10), meningeal disease (8/10), myelitis (3/10), cranial neuropathy (3/10), neuroendocrine impairment (1/10). Cerebro-spinal fluid (CSF) analysis was conducted in 8/10 patients and showed pleocytosis in 6/8 (75%), elevated protein level in (4/8) 50%, oligoclonal intrathecal synthesis in 1/5 (20%). All patients received steroids, 7/10 (70%) required associated immunosuppressive therapy, 5 of which TNFα inhibitors. When compared to patients with SNS, INS patients were more likely to experience seizures (60% vs 23.3%); display encephalic parenchymal enhancing lesions (80% vs 39.3%) or encephalic leptomeningeal involvement (80% vs 35.7%). Serum angiotensin converting enzyme (ACE) was elevated in a third of patients with SNS but none of those with INS. Conclusion: The phenotypes of patients with INS are similar to the ones described in SNS. Serum ACE should not be regarded as a diagnostic test in patients with isolated neurosarcoidosis but could be useful in detecting subclinical extra neurologic involvement during follow up.

Introduction In 2016, California enacted a law (T21) prohibiting tobacco product sales to individuals under 21 years of age. Given tobacco use disparities among sexual minority (SM) youth, this study investigated whether California’s T21 law was differentially associated with changes in tobacco use for SM and non-SM adolescents. Aims and Methods Secondary analyses of California Healthy Kids Survey data from 2013–2014 to 2018–2019 for 7th, 9th, and 11th graders (N = 2 229 401). Results Multilevel mixed-effects logistic regression analyses showed that SM students were more likely than non-SM students to report past-30-day and lifetime cigarette (odds ratio (OR) = 2.47; OR = 2.37), e-cigarette (OR = 1.21; OR = 1.10), smokeless tobacco use (OR = 1.95; OR = 1.56), and use of any tobacco product (OR = 1.94; OR = 1.61). Among SM youth, T21 was associated with significant reductions in lifetime e-cigarette use (OR = 0.66), and lifetime use of any tobacco products (OR = 0.75). These decreases generally were greater than or equivalent to those observed for non-SM youth. For 30-day e-cigarette and any tobacco use, SM youth showed no significant increases, whereas non-SM youth showed significant increases (OR = 1.06; OR = 1.11) following T21. T21 was associated with smaller increases in lifetime cigarette use (OR = 1.34), and larger increases for past-30-day and lifetime smokeless tobacco use (OR = 1.34; OR = 1.28) among SM students, to those observed for non-SM students. Conclusions California’s T21 policy may help reduce tobacco use disparities among SM students who are more at risk for tobacco use than their non-SM peers. Implications Research on associations of T21 laws with tobacco use among sexual minority (SM) adolescents is lacking. The potential for unintended consequences of T21 for these adolescents raises concerns about increased health disparities. Importantly, our study generally found California’s T21 was associated with reductions in tobacco use among SM students that were equivalent to or greater than those for non-SM students. Future research should investigate whether T21 laws and similar policies have differential effects for other marginalized groups and, if so, identify mechanisms that can be targeted in prevention efforts.

Introduction Fluctuations in ovarian hormones have been associated with changes in cigarette smoking behavior, which can be measured through both serum or less invasive salivary procedures. The primary aim of this exploratory study is to characterize the progesterone profiles of salivary progesterone measurements and to compare that with the profiles estimated from a previously measured serum sample. Aims and Methods Nontreatment-seeking, cigarette smoking women (n = 82; ages 18–45 years) provided daily salivary hormone samples every morning for 14 consecutive days. Time-dependent random effects functions were used to approximate daily salivary progesterone (ng/mL) levels over the course of a standardized menstrual cycle. Serum measures of progesterone from a previous study of female cigarette smokers were examined for consistency with established profiles and compared with the salivary profile using the same methodology. Results The salivary model fit exhibits relative stability during the follicular phase and a clear unimodal peak during the luteal phase. Parameter estimates from the non-linear function show correspondence to serum data. Although the profiles estimated from salivary and serum data agree in functional form, we observed larger between-subject heterogeneity both in the follicular level and the peak luteal level in salivary measures. Conclusions The pattern of salivary and serum progesterone measured across the menstrual cycle is similar in form, which is noteworthy given that the saliva and serum samples were drawn from independent sample of female smokers. Inter- and intra-individual variation in salivary measures may be greater than in serum measures. Implications Measuring progesterone level variation across the menstrual cycle via saliva samples has several benefits relative to serum sampling methods in that they are easily obtained, noninvasive, and low-cost. Inter- and intra-individual variation in measurements may be greater than those in serum measurements. However, the functional form of the salivary progesterone profile is isomorphic to serum progesterone.

BACKGROUND: Exercise and physical therapy (PT) can improve motor function and quality of life in individuals with Parkinson's disease (PD), but their role in hospitalization avoidance is not well‐studied. OBJECTIVES: To determine the longitudinal and temporal association of exercise and PT use with hospital encounter. METHODS: Longitudinal regression and χ(2) analyses were performed on Parkinson's Foundation Parkinson's Outcome Project exercise and PT use data from 4674 and 9259 persons with PD, respectively. RESULTS: Greater exercise duration and intensity were associated with reduced odds of hospital encounter, whereas both PT and occupational therapy use were associated with increased odds. In the 2 years before a hospital encounter, there was an increased frequency of PT use, but not reductions in exercise. CONCLUSIONS: Consistent exercise may reduce hospitalization risk whereas PT referral may identify at‐risk individuals without preventing this outcome. Further work to incentivize consistent exercise in PD may reduce healthcare use.

OBJECTIVE: To analyze insulin delivery and glycemic metrics throughout the menstrual cycle for women with type 1 diabetes using closed loop control (CLC) insulin delivery. METHODS: Menstruating women using a CLC system in a clinical trial were invited to record their menstrual cycles through a cycle-tracking application. Sixteen participants provided data for this secondary analysis over three or more complete cycles. Insulin delivery and continuous glucose monitoring (CGM) data were analyzed in relation to reported cycle phases. RESULTS: Insulin delivery and CGM metrics remained consistent during cycle phases. Intraparticipant variability of CGM metrics and weight-based insulin delivery did not change through cycle phases. CONCLUSIONS: For this sample of menstruating women with type 1 diabetes using a CLC system, insulin delivery and glycemic metrics remained stable throughout menstrual cycle phases. Additional studies in this population are needed, particularly among women who report variable glycemic control during their cycles. TRIAL REGISTRATION: NCT03591354.

There are limited data for letermovir as primary cytomegalovirus (CMV) prophylaxis in patients less than 18 years of age. We report 9 adolescent patients who received letermovir following hematopoietic cell transplantation. No patients developed clinically significant CMV while taking letermovir. Letermovir was well tolerated and efficacious in preventing CMV infections.

Introduction: Recently, a large study concluded that certain brands of vaccines may increase the risk of Bell’s palsy and Guillain Barre Syndrome (GBS). As to whether vaccination after COVID-19 modify the risk of Bell’s palsy or GBS has not yet been studied. Case: Here we report a 35 years old COVID-19 survivor whom in less than 2 weeks after his second dose of inactivated SARS-CoV2 vaccine, developed bilateral facial nerve paralysis. In addition, he had hyperacusis, dysgeusia and decreased lacrimation without any signs of sensory and motor deficits in the limbs. His limb nerve conduction study (NCS) was unremarkable in contrast to bilaterally abnormal facial NCS and blink reflexes. Although he had negative anti-GM1 IgG and IgM antibodies, he has marked albuminocytologic dissociation, classic of acute inflammatory demyelinating polyneuropathy. Conclusion: To date, there were no similar case reports which published the occurrence of facial diplegia as sole manifestation of GBS in a post COVID-19 patient who recently completed vaccination. We believe that molecular mimicry, induced by magnified immune response from both COVID-19 and vaccination may have caused the symptom.

Here we characterize the neuroanatomic distribution, neuropathology, and immunophenotype of 10 cases of primary nervous system lymphoma in cats. Cases were retrospectively searched from 2 academic institutions. Selected cases were reviewed and subjected to immunohistochemistry (IHC) for CD3, CD20, and Pax5. The mean age of affected cats was 9.1 y, and no sex or breed predilection was observed. The most common clinical sign was ataxia (8 cases). Gross changes reported in 8 cases consisted of white-to-tan masses (7 cases) or swelling (1 case) within the neuroparenchyma (5 cases) or epidural spaces (3 cases). Histologically, intraparenchymal lymphomas occurred in the gray and white matter or perivascular spaces (7 cases); extraparenchymal lymphomas (6 cases) consisted of neoplastic cell infiltration of the perivascular spaces in the leptomeninges, choroid plexus, or epidural spaces. Nerve lymphomas were diffusely infiltrative. Tumors occurred in the brain (4 cases), spinal cord and nerves (3 cases), spinal cord (2 cases), and brain, spinal cord, and nerves (1 case). IHC was consistent with a B-cell lymphoma in 5 cases and with a T-cell lymphoma in 5 cases.

Objective: To investigate the differences in self-efficacy (SE) for walking tasks between older patients with knee osteoarthritis (OA) and older adults without knee OA. Methods: A cross-sectional design was employed. Older patients with radiographic knee OA and community-dwelling older adults without knee OA as controls were enrolled in the study. SE for the walking task was assessed using the modified gait efficacy scale (mGES). A Wilcoxon rank-sum test was used to compare the mGES between the groups of participants. A Tobit regression model was used to estimate the difference in mGES. The presence of radiographic knee OA was used as an independent variable. Sex (women), age, and body mass index were used as potential confounding variables in the model. Results: After exclusion, 78 participants (n=40 with knee OA, n=38 controls) were included. The mGES was lower in patients with knee OA than in controls. In the Tobit regression model adjusted for confounding factors, mGES in patients with knee OA was estimated to be 26.8 (95% confidence interval [CI]: 15.8-37.8) points lower than in controls. Conclusion: This study demonstrated that mGES was lower in older patients with knee OA than in older adults without knee OA.

Introduction This study examines the proportion of the United States adolescents and adults who are variable (ie, at least one change in gender identity) versus stable in their gender identities over time, and whether they differ significantly in their nicotine/tobacco use after adjusting for key covariates. Methods We fit multivariable logistic regression models to data from Waves 2–4 (2014/15–2016/18) of the Population Assessment of Tobacco and Health (PATH), a nationally representative study (n = 33 197 U.S. adolescents and adults aged ≥14 years). We examined associations of gender stability/variability over three waves with tobacco use at wave 4 (2016–2018). Differences in any past 30-day tobacco, cigarette, e-cigarette, other tobacco, and poly-tobacco use were assessed among cisgender-stable, transgender-stable, and gender-varying respondents. Results An estimated 1.0% of adolescents and adults were classified as gender-varying. Prevalence of any past 30-day tobacco use was higher among gender-varying individuals (42.7%) than among gender-stable individuals (transgender-stable, 37.8% and cisgender-stable, 26.7%). There were no significant differences in the odds of nicotine/tobacco use between the two gender-stable groups. However, gender-varying respondents had significant increased odds of any past 30-day tobacco use (adjusted odds ratio [AOR] = 2.0, 95% confidence interval [CI] = 1.3 to 3.0), cigarette use (AOR = 1.7, 95% CI = 1.1 to 2.5), e-cigarette use (AOR = 2.2, 95% CI = 1.4-3.5), other tobacco use (AOR = 2.2, 95% CI = 1.4 to 3.4), and poly-tobacco use (AOR = 2.0, 95% CI = 1.3 to 3.1) compared with cisgender-stable individuals. Conclusions Gender-varying individuals are at higher risk for nicotine/tobacco use, placing them at greater risk for tobacco-related health consequences. Implications Despite increased knowledge about transgender health in recent years, there remains a paucity of research about gender-varying individuals. This study is the first to examine the proportion of gender-varying individuals in the United States using a longitudinal, nationally representative sample and to explore differences in nicotine/tobacco use among gender-varying and gender-stable individuals. Our findings suggest that gender-varying people have an increased risk for nicotine/tobacco use, placing them at higher risk for tobacco-related health consequences. This study increases knowledge about nicotine/tobacco use among this under-represented population in research and underscores the importance of developing an awareness of gender diversity.

Given its unusual lymphatic drainage system, the tonsil is a rare site of metastasis, with few reports in the human and veterinary literature. Prognosis in cases of tonsillar metastasis is reportedly poor. We describe here a unique case of urinary bladder urothelial carcinoma (UC) with metastasis to the tonsil in an 11-y-old, spayed female, mixed-breed dog. At presentation, the patient had a history of a growing neck mass and increasing lethargy, hyporexia, weight loss, drooling, and diarrhea for 2 wk. A carcinoma was diagnosed by cytology. Given the poor prognosis, the patient was euthanized. Postmortem examination revealed masses in the inguinal region, cranioventral neck region including tonsil, and urinary bladder. Histologically, the masses were composed of large polyhedral cells arranged in dense sheets and nests with occasional large, clear, intracytoplasmic vacuoles. Neoplastic cells were multifocally positive for uroplakin III and cytokeratin 8/18 by immunohistochemistry. UC with metastasis to tonsil and lymph nodes was diagnosed.

OBJECTIVES The objective of this study was to develop and validate an approach to accurately identify incident pediatric neuropsychiatric events (NPEs) requiring hospitalization by using administrative data. METHODS We performed a cross-sectional, multicenter study of children 5 to 18 years of age hospitalized at two US children’s hospitals with an NPE. We developed and evaluated 3 NPE identification algorithms: (1) primary or secondary NPE International Classification of Diseases, 10th Revision diagnosis alone, (2) NPE diagnosis, the NPE was present on admission, and the primary diagnosis was not malignancy- or surgery-related, and (3) identical to algorithm 2 but without requiring the NPE be present on admission. The positive predictive value (PPV) of each algorithm was calculated overall and by diagnosis field (primary or secondary), clinical significance, and NPE subtype. RESULTS There were 1098 NPE hospitalizations included in the study. A total of 857 confirmed NPEs were identified for algorithm 1, yielding a PPV of 0.78 (95% confidence interval [CI] 0.76–0.80). Algorithm 2 (n = 846) had an overall PPV of 0.89 (95% CI 0.87–0.91). For algorithm 3 (n = 938), the overall PPV was 0.86 (95% CI 0.83–0.88). PPVs varied by diagnosis order, NPE clinical significance, and subtype. The PPV for critical clinical significance was 0.99 (0.97–0.99) for all 3 algorithms. CONCLUSIONS We identified a highly accurate method to identify neuropsychiatric adverse events in children and adolescents. The use of these approaches will improve the rigor of future studies of NPE, including the necessary evaluations of medication adverse events, infections, and chronic conditions.

South American camelids (SACs) have become increasingly popular as livestock and companion animals in the Midwestern United States. With increased ownership, postmortem evaluations and samples available for diagnostic assessment are being submitted more frequently to veterinary diagnostic laboratories. We searched archived pathology records at the Wisconsin Veterinary Diagnostic Laboratory (WVDL) between 2009–2019 for SAC cases. Postmortem records from 166 alpacas and 27 llamas were included, with an average of 1.42 diagnoses per animal. The overall average diagnostic rate was 79.8%. Abortion and neonatal cases (fetus to 1-wk-old) had the lowest diagnostic rate (33.3%) and was the only group with a diagnostic rate statistically significantly lower than the average. The most common diagnoses were gastrointestinal parasitism and suboptimal nutritional status or inanition; 78% of cases diagnosed with suboptimal nutritional status were also parasitized. The gastrointestinal parasites identified most frequently were Eimeria sp. and strongyles, especially Nematodirus sp. Our findings may aid allocation of diagnostic resources to better serve regional SAC populations and provide a framework for practitioners who send samples to laboratories for analysis. Submission of whole bodies, euthanized animals, fresh tissue, and inclusion of placental tissues in abortion cases are recommended for optimal diagnostic outcome.

PURPOSE: Ethnic disparities in childhood cancer survivor (CCS) mental health have been identified, although prior survivorship research has focused predominantly on non-Hispanic/Latinx (H/L) white survivors. METHODS: This study examined the association of acculturation with depressive symptoms and wellbeing among 582 young adult H/L CCS recruited to a population-based study of CCS in Southern California. RESULTS: In multivariable regression models adjusted for covariates, greater identification with both the Hispanic and Anglo cultures was positively associated with wellbeing (p = 0.007 and p

We assessed predictors of rising hemoglobin A1c (HbA1c) during long-term use of closed-loop control (CLC) in children aged 6–13 years with type 1 diabetes. Participants used a CLC system during a 16-week randomization phase followed by a 12-week extension phase. We compared an “Increased-HbA1c” group (n = 17, ≥0.5% rise in HbA1c between randomization and extension phases) to a “Maintained-Improvement” group (n = 18, had stable or improved HbA1c). The Increased-HbA1c group had higher pre-CLC HbA1c (8.42% ± 0.80 vs. 7.45% ± 0.93, P = 0.002). Contrary to a-priori hypotheses, there were no differences in Δ-height-for-age z-score, a surrogate for a pubertal growth spurt (+0.16 vs. −0.15, P = 0.113), or number of carbohydrate boluses per day, a surrogate for missed boluses (4.4 ± 2.2 vs. 5.2 ± 2.1, P = 0.263). Both groups maintained high rates in closed-loop. Thus, some children exhibit meaningful rise in HbA1c after initial CLC use, likely from multiple contributing factors, and may benefit from added encouragement during ongoing use.

OBJECTIVE: This study aimed to identify and describe healthful and youth-oriented qualities of the restaurant food environment around high schools. METHODS: Using direct observation data from 58 restaurants located within a half-mile (804.5 meters) of all high schools in a single district, two index measures of the restaurant food environment were created: healthfulness index and youth-oriented index. Wilcoxon signed-rank order was used to examine differences in restaurant features according to index scores. RESULTS: Mean healthfulness score was 8.9 (range = 2–14, max = 19) and mean youth-oriented score was 5.5 (range = 0–11, max = 12). Differences were found in signed-rank order of healthfulness and youth-oriented index restaurant scores (p = 0.02). CONCLUSION: Results suggest that restaurants have room for improvement in offering customers a healthful environment, some restaurants are more likely to appeal to youth, and that youth-oriented restaurants were different than restaurants with high healthfulness scores. Further qualitative exploration of food environment features will help contextualize the influence of restaurants on youth eating behaviors.

An 8-y-old intact male Labrador Retriever dog developed cutaneous masses over the entire body. On histologic evaluation, the masses were composed of bundles of fusiform neoplastic cells arranged around adnexa, with mild atypia and no mitoses, consistent with peripheral nerve sheath tumors (PNSTs). Immunohistochemically, neoplastic cells were immunoreactive for vimentin, glial fibrillary acidic protein (GFAP), and S100, confirming their perineurial origin. The dog was euthanized because of deteriorating clinical signs. In addition to the cutaneous masses, a cardiac mass was identified at postmortem examination. The histopathologic and immunohistochemical features of the cardiac mass were similar to those of the cutaneous masses. To our knowledge, the combination of multiple cutaneous masses with features of PNSTs and a concurrent cardiac lesion has not been reported previously in a dog. We suggest “neurofibromatosis type 1–like” presentation for this unique combination of cutaneous and cardiac masses. Further studies are required to investigate the etiopathogenesis of this condition and explore its genetic background.

Introduction Tobacco product packaging is an influential industry marketing tool, but research on cigar packaging characteristics is limited. This study leveraged a pack archive of the top-selling, mass-market cigar products in the US and their corresponding sales data to assess the prevalence of common pack features in the marketplace. Methods The 50 cigar products with the highest national unit sales in 2018 were identified using Nielsen’s Scantrack data. A content analysis captured common packaging features within four domains: physical, textual, graphical, and promotional elements. Descriptive statistics, weighted by each pack’s 2018 unit sales, documented the market share of pack characteristics overall and by brand. Results Products in the sample constituted 62% of all convenience store cigar sales in 2018. Black & Mild, the most popular brand, did not display warning labels on its single stick, cellophane-wrapped products, which constituted nearly all of its sales (96.3%). Resealable foil pouches were the most common packaging style across other brands, and were most often sold in predominantly red, green, or silver packaging. Common flavor categories included concept (eg, “Jazz”, 32.4%), fruit (15.7%), and sweet (14.5%). Prepricing (eg, “2 for 99 cents”) was a popular promotional strategy, appearing on 74% of all packs sold. Conclusions Cigar packaging features such as small pack sizes, innovative materials, flavor names, bright colors, and cost-saving promotions are prevalent among the top-selling products. Stronger packaging-focused policies at the federal and local levels may help reduce appeal and potentially curb cigar use. Implications Sales of mass-market cigars in the US have remained strong over the past decade, propelled by lax product regulations. This study demonstrated that cigar packaging features that may enhance consumer appeal, such as small pack sizes, flavor names, sensory descriptors, bright colors, and cost-saving promotions, are prevalent among the top-selling products. Stronger packaging-focused policies at the federal and local levels may help curb cigar use, reduce youth appeal, and potentially minimize existing disparities in cigar use.

Introduction The number of cigarettes smoked per day (CPD) is a component of commonly used nicotine dependence measures and often used as a smoking cessation treatment outcome. Yet relighting (ie, smoking used cigarette butts) is not usually considered when CPD is assessed, which may underestimate nicotine dependence and result in an inaccurate picture of smoking behaviors. Aims and Methods Data from a randomized controlled trial of a smoking cessation intervention were used. Fagerström Test for Cigarette Dependence (FTCD), CPD, and the frequency of smoking (number of smoking episodes/day) assessed at baseline and 3-month follow-up were used. Results Participants were 49 adults with mood disorders who smoke daily receiving outpatient psychiatric treatment. At baseline, 27 (55.1%) participants reported relighting cigarettes, and 6 (27.3%) of those who did not report relighting at baseline reported relighting at 3-month follow-up. Replacing CPD with the frequency of smoking to recalculate the total FTCD score increased the score for 21 participants (43%). The mean FTCD scores increased from 4.61 to 5.16, from a classification of low to medium dependence, and 16 participants (33%) moved up in the dependence classification. Of the 31 participants who reported a >=50% reduction in CPD at 3-month follow-up, 5 (16%) did not achieve the outcome of >=50% reduction in the frequency of smoking per day. Conclusions In this sample of adults with mood disorders who smoke, over half reported relighting cigarettes. Results underscore the importance of incorporating the frequency of smoking/relighting when assessing nicotine dependence and patterns of smoking behaviors in high-risk populations. Implications This is the first study to investigate the patterns of relighting behavior and its impact on nicotine dependence and smoking cessation treatment outcome measures among treatment-seeking adults with mood disorders who smoke. The majority were relighting, and over a quarter of those who did not report relighting at baseline subsequently reported relighting in the context of a quit attempt. The findings demonstrate that overlooking relighting may underestimate nicotine dependence and overestimate the rates of those who have made meaningful changes in smoking behavior. Incorporating the frequency of smoking/relighting may help to more accurately capture nicotine dependence and patterns of smoking behavior among high-risk populations.

Two central bearded dragons ( Pogona vitticeps), a 3-y-old male and a 5-y-old female, were diagnosed with different manifestations of lymphoma at the Kansas State Veterinary Diagnostic Laboratory between 2019 and 2020. The 3-y-old male was presented for postmortem evaluation and was in poor body condition. Microscopically, nearly all examined organs contained variable numbers of neoplastic round cells. Neoplastic cells in the stomach and liver had moderate immunoreactivity to CD3 consistent with multicentric T-cell lymphoma, and non-neoplastic lymphocytes infiltrating the stomach mass had strong immunoreactivity to Pax5. The 5-y-old female had an ulcerated oral mass located in the right lingual gingiva submitted as an excisional biopsy. Microscopically, the mass was composed of large numbers of neoplastic round cells in the epithelium and connective tissue that were strongly and diffusely positive for CD3 and frequently positive for Pax5, consistent with a dual-positive, localized, epitheliotropic T-cell lymphoma. Neoplastic and non-neoplastic lymphocytes did not stain with CD20 or CD79a. Neoplasms are increasingly reported as a cause of morbidity and mortality in reptiles. Our 2 cases illustrate various presentations of T-cell lymphoma and the effectiveness of CD3 and Pax5 immunohistochemistry in bearded dragons.

Better understanding of mast cell tumors (MCTs) in miniature pigs is needed to guide diagnosis and establish clinical significance. We characterized the gross pathology, histopathology, histochemical staining, and KIT immunoreactivity of cutaneous MCTs in a retrospective descriptive study of 11 miniature pigs ( Sus scrofa domesticus). Tumors were single or multiple papules, small nodules, or plaques. In one pig, lymph nodes and internal organs were affected. Histologically, all MCTs involved the dermis, and some extended to the subcutis (4 of 11) and skeletal muscle (1 of 11). Most tumors were well-demarcated, unencapsulated, nodular or multinodular masses (8 of 11) and fewer were poorly demarcated plaques (3 of 11). Neoplastic cells were often well-differentiated with pale amphophilic-to-eosinophilic faintly granular cytoplasm, occasional binucleation, rare multinucleation, and a low mitotic count (

The alien limb is a phenomenon characterized by a cluster of clinical features wherein the limb behaves autonomously and as separated from a person’s identity. We herein report a 36-year-old Indian female with multiple comorbidities who presented with recurrent episodes of limb-shaking transient ischemic attacks for 1 year, followed by left-sided hemiplegia. During recovering, the patient noticed a feeling that as if her left hand did not belong to herself and acted autonomously (alien limb phenomenon) along with visuospatial deficits. Magnetic resonance imaging of the brain revealed ischemic stroke diffusely involving corpus callosum. Magnetic resonance angiography was suggestive of compromised right-sided anterior circulation. This was corroborated by digital subtraction angiography that revealed reduced flow in right internal carotid artery. Diffuse infarction of the corpus callosum requires involvement of both the anterior and the posterior circulation. Due to the lack of clinical features suggestive of chronic internal carotid artery dissection, occlusive atherosclerotic disease of the anterior cerebral circulation associated with possible steal phenomenon from the posterior circulation was the most probable underlying mechanism for the callosal stroke. Steal phenomenon has been proposed as a compensatory mechanism in hemodynamically compromised ischemic parenchyma and it can explain the co-existence of anterior and posterior circulation strokes. This case also highlights how both anterior and posterior types of the alien limb phenomenon can co-exist in a background of vascular insult, resulting from intra-cranial atherosclerotic disease.

An 8-y-old, castrated male Siberian Husky dog was admitted to an emergency clinic with acute collapse and severe swelling of both forelimbs, ventral thorax, and axillary region. The clinical assessment, with laboratory tests and radiologic investigation, confirmed severe subcutaneous emphysema and multi-organ failure. The animal died while receiving emergency treatment. On postmortem examination, Clostridium perfringens was isolated from the subcutaneous fluid and the effusion from the thoracic and abdominal cavities. Relevant histopathology findings included subcutaneous emphysema and multi-organ perivascular and intravascular, intralesional myriad 0.5–3-µm gram-positive rod bacteria, with no associated inflammation. Whole-genome sequencing and phylogenetic analysis identified C. perfringens type A. Virulence genes detected included cpa (alpha toxin), cadA (v-toxin), colA (collagenase A), nagH (hyaluronidase), nanH, nanI, nanJ (sialidases), and pfoa (perfringolysin). These virulence genes have previously been reported to act synergistically with alpha toxin in C. perfringens–mediated gas gangrene.

The coronavirus disease 2019 (COVID-19) pandemic likely affected youth with type 1 diabetes (T1D). We used electronic health record-extracted data to compare continuous glucose monitoring (CGM) metrics during 1 year of the pandemic with those of the previous year. The sample comprised CGM users, aged 1 to

INTRODUCTION: Black patients have a higher incidence of heart failure (HF) and worse outcomes than white patients. Guidelines recommend palliative care for patients with advanced HF, but no studies have examined outcomes in a black patient cohort. METHODS: This is a post hoc analysis of the Palliative Care in Heart Failure trial, which randomized patients to usual care plus a palliative care intervention (UC+PAL) or usual care (UC). Quality of life (QoL) was measured using Kansas City Cardiomyopathy Questionnaire (KCCQ) and Functional Assessment of Chronic Illness Therapy-Palliative Care scale (FACIT-Pal). RESULTS: Black patients represented 41% of the 148 patients. At six months, QoL improved more in UC+PAL than UC for both racial subgroups. The difference was greater for black than white patients (difference: KCCQ 10.8 vs. 2.5; FACIT-Pal: 14.8 vs. 3.9). However, the findings were not statistically significant. CONCLUSIONS: Larger studies are needed to assess the benefits of palliative care for black patients with HF. ClinicalTrials.gov Identifier: NCT01589601.

Objective We aimed to explore the impact of telehealth in the setting of COVID-19 on patient access to ambulatory rheumatologic care at our academic public health system and to determine whether telemedicine visits had a beneficial impact on access to our rheumatology ambulatory clinics. Methods We compared completed, no-show, and cancellation rates between in-person clinic visits and telemedicine appointments over a 10-week time period before Ohio's initial executive order responding to COVID-19 (premandate period) and a 10-week time period afterward (postmandate period). Scheduling and appointment data were retrospectively extracted from the medical center's electronic health record. Results During the premandate period, when all visits were in-person, the total number of completed visits was 930. The percentages of cancellations, no-shows, and completed appointments of all appointment activities were 31.43%, 13.12%, and 55.46%, respectively. During the postmandate period, when telemedicine visits were added, the overall total number of completed visits was 1038. The percentages of cancellations, no-shows, and completed appointments of all appointment activities were 53.45%, 13.91%, and 32.64%, respectively, for in-person appointments and 0.12%, 8.48%, and 91.39%, respectively, for telemedicine appointments. Conclusion Telemedicine during the COVID-19 pandemic resulted in higher rates of completed appointments and lower rates of missed appointments in the rheumatology outpatient clinic compared with in-person visits during and prior to the pandemic.

BACKGROUND: National Consensus Project for quality palliative care guidelines emphasizes the importance of a comprehensive assessment of all care domains, including physical, psychosocial, and spiritual aspects of care, for seriously ill patients. However, less is known about how real-world practice compares with this guideline. OBJECTIVE: To describe clinicians' assessment practices and factors influencing their approach. DESIGN: This is a two-part web-based survey of palliative care clinicians from five academic groups in the United States. RESULTS: Nineteen out of 25 invited clinicians (physicians, nurse practitioners, and physician assistants) completed the survey. A majority (62%) reported that, although some elements of assessment were mandatory, their usual practice was to tailor the focus of the consultation. Time limitations and workload received the highest mean scores as reasons for tailored assessment (6.1 on a 0–9 importance scale), followed by beliefs that comprehensive assessment is unnecessary (4.8) and absence of the full interdisciplinary team (4.4). All participants cited symptom acuity, and 91% cited reason for consult as factors influencing a tailored approach. Among domains “always” assessed, physical symptoms were reported most commonly (81%) and spiritual and cultural factors least commonly (24% and 19%, respectively). Although a majority of clinicians reported usually tailoring their consultations, mean importance scores for almost all assessment elements were high (range 3.9–8.8, mean 7.1); however, there was some variation based on reason for consult. Spiritual elements received lower importance scores relative to other elements (5.0 vs. 7.4 mean score for all others). CONCLUSION: Although clinicians placed high importance on most elements included in comprehensive palliative care, in practice they often tailored their consultations, and the perceived relative importance of domains shifted depending upon the type of consultation.

A 4-y-old, spayed female, mixed-breed domesticated rabbit ( Oryctolagus cuniculus domesticus) was presented because of progressive bilateral exophthalmos, with a large mediastinal mass in the cranial thorax. Palliative radiation therapy was elected, and 4 fractions of 5 Gy were delivered twice weekly under general anesthesia using 3-dimensional conformal radiation therapy for a total dose of 20 Gy, guided by an on-board cone beam CT scan. Quality-of-life and respiratory rate improved before sudden death that followed an episode of dyspnea. The overall survival time following initial diagnosis was 93 d, with 68 d after the first dose of radiation. An autopsy was performed, and the mass was diagnosed as a type A thymoma. The diagnosis was confirmed with positive immunohistochemical labeling of the neoplastic cells for cytokeratin 5/6 and cytokeratin 7.