Search

UNSTRUCTURED We examined the representation of people with skin of colour in patient information resources from multiple dermatological bodies around the world. We found a stark under-representation of skin of colour, which can lead to deleterious consequence on health outcomes. Dermatological communities must join the global effort to eliminate racial disparities, to improve approachability, inclusiveness and trust within our specialty.

Acute vocal fold edema (VFE) is often a consequence of illness, allergy, or voice overuse, causing dysphonia. Although VFE typically resolves with voice rest and treatment of predisposing causes, oral glucocorticoids are often considered for performers with imminent performance demands. There are limited data about performers' perceptions of vocal change during treatment and how this relates to their ability to perform. This study aims to examine performers' self-perceptions of vocal function with steroid treatment.Fifty-five performers (34 F; 21 M) diagnosed with VFE who chose treatment with a 6-day methylprednisolone taper were prospectively assessed. They completed the Evaluation of the Ability to Sing Easily (EASE) and reported on their voice use, regimen, performance obligations, and ability to perform. Findings were compared between Day 1 and Day 6 using paired t-tests and nonparametric Wilcoxon signed-rank tests.Nearly all subjects completed scheduled performances without interruption. Following treatment, all subscales of the EASE were decreased at Day 6 (Vocal Function 29.78-20.59; Pathologic Risk Indicator 26.60-17.33; Vocal Concerns 6.10-4.20). These differences were statistically significant (p 0.0001) and greater in subjects with performances scheduled and subjects who consistently completed vocal warmups. These findings demonstrate significant improvement in several facets of performers' self-perception of function.Subjects reported significant improvement in vocal function with oral steroid treatment and were able to meet performance obligations. It remains important that steroids are not prescribed without laryngeal examination. Examination should be repeated when dysphonia persists, recurs swiftly, or when patients seek repeated treatment, as there may be increased risk of adverse outcomes, and continued steroid use may mask underlying chronic pathology that is best treated by other means.4 Laryngoscope, 132:2434-2441, 2022.

In 2017, The Ottawa Hospital initiated a unique‐in‐Canada quality improvement initiative by opening a novel, multi‐specialist limb‐preservation clinic. We sought to describe the structure, processes, and initial outcomes of the clinic and evaluate whether it is achieving its mandate of providing high‐quality wound clinical care, education, and research. We conducted a descriptive prospective cohort study alongside a nested study of 162 clinic patients requiring serial assessments. There have been 1623 visits, mostly (72.2%) from outpatients. During 17.8% of visits, patients were evaluated by >1 specialist. Therapies provided most often included negative‐pressure wound therapy (32.7%), biological wound dressings (21.6%), and total contact casting (18.5%). Furthermore, 1.2% underwent toe/ray amputations or skin grafting in clinic and 22.8% were initiated on antimicrobials. Mixed‐effects models suggested that mean wound volumes for those requiring serial assessments decreased by 1.6 (95% confidence interval = −0.86 to −2.27) cm3 between visits. The clinic provided seven rotations to vascular surgery, infectious diseases, dermatology, and palliative care physicians; three nursing preceptorships; and two educational workshops. It also initiated provincial and national vascular health and wound care research initiatives. This study may be used to guide development of other limb‐preservation clinics and programmes. Findings support that our programme is achieving its mandate.

Objective To raise awareness of the role of environmental biofilm in the emergence and spread of antibiotic resistance and its consideration in antimicrobial stewardship. Background Antibiotic resistance is a major threat to public health. Overuse of antibiotics, increased international travel, and genetic promiscuity amongst bacteria have contributed to antibiotic resistance, and global containment efforts have so far met with limited success. Antibiotic resistance is a natural mechanism by which bacteria have adapted to environmental threats over billions of years and is caused either by genetic mutations or by horizontal gene transfer. Another ancient survival strategy involves bacteria existing within a self-produced polymeric matrix, which today is termed biofilm. Biofilm similarly enables bacterial tolerance to environmental threats, and also encourages the transfer of antibiotic resistance genes between bacterial species. This natural and ubiquitous mode of bacterial life has not been considered amongst strategies to tackle antibiotic resistance in healthcare facilities, despite its ability to significantly enhance bacterial survival and persistence, and to encourage antibiotic resistance. Conclusion Biofilm must be considered synonymously with antibiotic resistance because of its proficiency in transferring resistance genes as well as its innate phenotypic tolerance to antibiotics. Although biofilm falls outside of the current definition of antimicrobial stewardship, greater awareness of the existence, ubiquity, and consequences of environmental biofilm amongst healthcare practitioners is crucial to improving hygiene practices and controlling the emergence and spread of antibiotic resistance in healthcare facilities.

Aims Myocardial infarction (MI) is the most common cause of heart failure (HF) worldwide. G protein-coupled receptor kinase 5 (GRK5) is upregulated in failing human myocardium and promotes maladaptive cardiac hypertrophy in animal models. However, the role of GRK5 in ischemic heart disease is still unknown. In this study, we evaluated whether myocardial GRK5 plays a critical role post-MI in mice and included the examination of specific cardiac immune and inflammatory responses. Methods and results Cardiomyocyte-specific GRK5 overexpressing transgenic mice (TgGRK5) and non-transgenic littermate control (NLC) mice as well as cardiomyocyte-specific GRK5 knockout mice (GRK5cKO) and wild type (WT) were subjected to MI and, functional as well as structural changes together with outcomes were studied. TgGRK5 post-MI mice showed decreased cardiac function, augmented left ventricular dimension and decreased survival rate compared to NLC post-MI mice. Cardiac hypertrophy and fibrosis as well as fetal gene expression were increased post-MI in TgGRK5 compared to NLC mice. In TgGRK5 mice, GRK5 elevation produced immuno-regulators that contributed to the elevated and long-lasting leukocyte recruitment into the injured heart and ultimately to chronic cardiac inflammation. We found an increased presence of pro-inflammatory neutrophils and macrophages as well as neutrophils, macrophages and T-lymphocytes at 4-days and 8-weeks respectively post-MI in TgGRK5 hearts. Conversely, GRK5cKO mice were protected from ischemic injury and showed reduced early immune cell recruitment (predominantly monocytes) to the heart, improved contractility and reduced mortality compared to WT post-MI mice. Interestingly, cardiomyocyte-specific GRK2 transgenic mice did not share the same phenotype of TgGRK5 mice and did not have increased cardiac leukocyte migration and cytokine or chemokine production post-MI. Conclusions Our study shows that myocyte GRK5 has a crucial and GRK-selective role on the regulation of leucocyte infiltration into the heart, cardiac function and survival in a murine model of post-ischemic HF, supporting GRK5 inhibition as a therapeutic target for HF., Graphical Abstract

Management of the axilla in the era of neoadjuvant chemotherapy for breast cancer is evolving. The aim of this study is to determine if conventional gadolinium-enhanced breast MRI can aid in evaluation of the response to neoadjuvant chemotherapy in the axilla. A retrospective review of a prospectively maintained database of patients undergoing neoadjuvant chemotherapy for breast cancer was performed. Pre and post-neoadjuvant chemotherapy MRI reports for node-positive patients were examined in conjunction with demographic data, treatment type, and final histopathology reports. One-hundred and fourteen patients with breast cancer undergoing neoadjuvant chemotherapy were included in the study. The sensitivity of magnetic resonance imaging in detecting nodal response post-neoadjuvant chemotherapy was 33.93% and the specificity was 82.76%. Magnetic resonance imaging had a positive predictive value of 65.52% and a negative predictive value of 56.47%. MRI was found to be most specific in the detection of triple-negative cancer response. Specificity was 100% in this group and sensitivity was 75%. Magnetic resonance imaging has a relatively high specificity in detecting nodal response post-neoadjuvant chemotherapy but has a low sensitivity. Alone it cannot be relied upon to identify active axillary malignancy post-neoadjuvant chemotherapy. However, given its increased specificity among certain subgroups, it may have a role in super-selecting patients suitable for sentinel lymph node biopsy post-neoadjuvant chemotherapy.

Introduction There has been limited study of patient-reported outcomes (PROs) in patients at risk of limb loss. Our primary objective was to estimate the prevalence of disability in this patient population using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). Materials and methods We recruited patients referred to a limb-preservation clinic. Patients self-reported their disability status using the 12-domain WHODAS 2.0. Severity of disability in each domain was scored from 1 = none to 5 = extreme and the total normalized to a 100-point scale (total score ≥25 = clinically significant disability). We also asked patients about wound-specific concerns and wound-related discomfort or distress. Results We included 162 patients. Reasons for clinic referral included arterial-insufficient (37.4%), postoperative (25.9%), and mixed etiology (10.8%) wounds. The mean WHODAS 2.0 disability score was 35.0 (standard deviation = 16.0). One-hundred-and-nineteen (73.5%) patients had clinically significant disability. Patients reported they had the greatest difficulty walking a long distance (mean score = 4.2), standing for long periods of time (mean score = 3.6), taking care of household responsibilities (mean score = 2.7), and dealing with the emotional impact of their health problems (mean score = 2.5). In the two-weeks prior to presentation, 87 (52.7%) patients expressed concern over their wound(s) and 90 (55.6%) suffered a moderate amount or great deal of wound-related discomfort or distress. In adjusted ordinary least squares regression models, although WHODAS 2.0 disability scores varied with changes in wound volume (p = 0.03) and total revised photographic wound assessment tool scores (p Discussion The majority of people at risk of limb loss report suffering a substantial burden of disability, pain, and wound-specific concerns. Research is needed to further evaluate the WHODAS 2.0 in a multicenter fashion among these patients and determine whether care and interventions may improve their PROs.

Dear Editor,In this retrospective IRB-approved case series, we describe two acetaminophen (APAP) toxic patients reported to a regional poison center who manifested arterial acidemia after fluid res...

Biofilm has been implicated as a barrier to wound healing and it is widely accepted that the majority of wounds not following a normal healing trajectory contain biofilm. Therefore, strategies that inform and engage clinicians to reduce biofilm and optimise the wound tissue environment to enable wound progression are of interest to wound care providers. In March 2019, an advisory board was convened where experts considered the barriers and opportunities to drive a broader adoption of a biofilm-based approach to wound care. Poor clarity and articulation of wound terminology were identified as likely barriers to clinical adoption of rigorous and proactive microbial decontamination that is supportive of wound healing advancement. A transition to an intuitive term such as ‘wound hygiene’ was proposed to communicate a comprehensive wound decontamination plan with an associated message of expected habitual routine. ‘Wound hygiene’, is a relatable concept that supports meticulous wound practice that addresses barriers to wound healing, such as biofilm, while aligning with antimicrobial stewardship programmes.

Chan Koonchung's second novel, The Unbearable Dreamworld of Champa the Driver, like his first, The Fat Years (Chen and Duke 2011), is banned in mainland China for its dystopian and realist depiction of racial discrimination, economic inequality, government corruption, and public dis-ease in contemporary Chinese society. Tracing the adventures of the quintessential anti-hero in the form of Champa, a young Tibetan man from Lhasa on his way to Beijing, a city of wealth, adventure, and opportunity in his mind, Koonchung effectively constructs a depiction of modern youth and masculinity in an economically perilous period, as well as a broader narrative of the difficult relationship between Tibetan and Chinese identity. ...

Thank you for the response to our letter. Our interest in fomepizole as an adjunct therapy for severe acetaminophen toxicity is grounded in preclinical investigations and initial human reports. Unf...

INTRODUCTION: Gadolinium-based contrast agents (GBCA) have been used to enhance magnetic resonance imaging (MRI) since 1985. Recently, the media and online groups have voiced concerns about gadolinium deposition in patients with normal renal function based on “elevated” urinary gadolinium levels. The determination of increased urinary gadolinium levels is based on reference ranges developed in individuals with normal renal function who were never exposed to GBCA. Studies suggest an elevated gadolinium urinary elimination greater than 72 h post GBCA scan. We evaluated urine gadolinium concentrations over a 30-day period in patients administered GBCA. METHODS: In this prospective, observational pilot study, we enrolled subjects between 18 and 65 years of age with normal renal function who received GBCA for the first time. Urinary gadolinium was measured at days zero (prior to GBCA exposure), 3, 10, and 30 after GBCA exposure. We compared urinary gadolinium levels after GBCA exposure to the current reference range and calculated an estimated duration of “elevated” gadolinium urine levels in the average patient. RESULTS: All 13 subjects had 24-h urinary gadolinium levels higher than 0.7 μg/24 h with means of 1944 (± 1432) μg/24 h on day 3, 301 (± 218) μg/24 h on day 10, and 34 (± 33) μg/24 h on day 30. Based on calculated urinary gadolinium elimination kinetics, we estimate urinary gadolinium levels will often remain above the current reference range for > 50 days. CONCLUSION: The current reference range of 0.7 μg/24 h for 24 h urinary gadolinium is not applicable to patients for at least 30 days following GBCA exposure.

Tibetan Folktales brings a welcome addition to the well-respected World Folklore Series, published by Libraries Unlimited, an imprint of ABC-CLIO LLC. The primary author, Haiwang Yuan, Professor of Library Public Services at Western Kentucky University, has also written two other texts in the series, The Magic Lotus Lantern and Other Tales from the Han Chinese, and Princess Peacock: Tales from the Other Peoples of China, winner of the 2009 Aesop Accolade Award for the Children's Section of the American Folklore Society. ...

The aim of this study was to compare changes in wound size and appearance and health complication rates in patients with vasculopathy and lower-extremity wounds treated with or without low-frequency contact ultrasound debridement (LFCUD) This study was a randomised controlled trial. The study was conducted in a vascular surgery service, including outpatient wound clinic and inpatient ward, in a tertiary care academic centre. In total, 70 patients with vasculopathy and lower-extremity wounds of mixed aetiology were enrolled in the trial; 68 completed the study. Patients were randomised to receive LFCUD plus usual care (n = 33) or usual care (n = 37) at 4 weekly visits, and were followed thereafter for up to 12 wk. The main outcome measures included closed wounds, change in wound surface area (WSA), and wound appearance by the revised Photographic Wound Assessment Tool (revPWAT). After 4 weekly LFCUD treatments, patients in the LFCUD group had significantly better wound appearance (total revPWAT score) compared with the control group treated only with usual care (P =

Aim: Nitromethane, found in fuels used for short distance racing, model cars, and model airplanes, produces a falsely elevated serum creatinine with standard creatinine analysis via the Jaffe method. Erroneous creatinine elevation often triggers extensive testing, leads to inaccurate diagnoses, and delayed or inappropriate medical interventions. Multiple reports in the literature identify “enzymatic assays“ as an alternative method to detect the true value of creatinine, but this ambiguity does not help providers translate what type of enzymatic assay testing can be done in real time to determine if there is indeed false elevation.Methods: We report seven cases of ingested nitromethane where creatinine was determined via Beckman Coulter® analyser using the Jaffe method, Vitros® analyser, or i-Stat® point-of-care testing. Nitromethane was detected and semi-quantified using a common clinical toxic alcohol analysis method, and quantified by headspace-gas chromatography-mass spectrometry.Results: When...

In this case, an 18-year-old male presents to the emergency department with status asthmaticus. He subsequently developed hyperlactemia during the first 8 h of his hospitalization. This chapter reviews causes of hyperlactemia, including specific discussions on propofol infusion syndrome, toxic alcohol-related hyperlactemia, clenbuterol exposure, and mitochondrial toxins.

Many exposures can cause liver injury. This case involves a 46-year-old patient with fever, nausea, vomiting, and signs of hepatic injury. In this chapter, we review pharmaceutical and supplement causes of hepatitis and hepatocellular necrosis.

In this case, a patient is envenomated by his friend’s exotic pet snake. The patient rapidly develops signs of neurotoxicity, including blurred vision, ptosis, and difficulty swallowing. He ultimately develops respiratory arrest and bradycardia. In this chapter, we review some of the toxins that can cause progressive neurologic symptoms including botulinum toxin, neurotoxic snakes in the US, and some of the exotic snakes that can cause neurologic effects.

A 21-year-old male presented to the emergency department in status epilepticus. He was hyperthermic, tachycardic, and hypertensive with hyperreflexia and clonus. Laboratory workup revealed a metabolic acidosis with associated hyperlactatemia. He was admitted to the intensive care unit where he was sedated, mechanically ventilated, and externally cooled. His hospital course was complicated by an aspiration pneumonia and rhabdomyolysis but he fully recovered.

This case involves a 2-year-old female who ingested some of her father’s prescribed medication. She presented early to the emergency department where she received activated charcoal. On a follow-up call from the local poison control center 3 days later, she had developed vomiting, agitation, and appeared to have increased work of breathing. We review possible causes for the patient’s symptoms including thyroid hormone toxicity, lithium toxicity, and management guidelines for her specific overdose.

In this chapter, we discuss the case of a toddler who acutely vomited following ingestion of a small container of liquid on his father’s nightstand. He subsequently developed ataxia and lethargy. This chapter explores possible causes of his symptoms, including GHB intoxication and nicotine exposure.

A 34-year-old female developed itching and jaundice after taking a “cultural medication” given to her by a friend. Laboratory studies from her initial emergency department evaluation suggest a cholestatic process. This chapter reviews herbal medications associated with hepatic injury and drugs that cause hepatic injury.

A 3-year-old male ingested several tablets of his mother’s diet supplement, which had been obtained from Mexico. While he did not develop clinical signs of toxicity, exposure to this product was concerning based on the active ingredient it reportedly contained. This chapter reviews some of the agents found in “diet pills,” how they cause toxicity, and clinical symptoms associated with toxicity.

This chapter delves into the case of an 8-year-old male who develops withdrawal symptoms after a chronic headache medication is discontinued. Multiple withdrawal syndromes are reviewed, as well as general management principles of withdrawal.

A 30-year-old male presented to the emergency department after undergoing ultra-rapid opioid detoxification. He was awake but nonverbal for the 8 h following the procedure. With this case, the process of and possible complications associated with ultra-rapid opioid detoxification are reviewed. Potential causes of the patient’s symptoms are reviewed, including carbon monoxide poisoning, ibogaine exposure, and spongiform leukencephalopathy.

Clinicians have limited experience with assessment and treatment of overdose from newer anticonvulsant medications. The aim of this investigation was to evaluate clinical effects of newer anticonvulsant overdose, determine if a relationship exists between dose and clinical effect, and if a particular agent appears more toxic in overdose. This was a retrospective study using electronic poison center data, evaluating clinical outcomes from newer anticonvulsant overdose. The Toxicall™ database from January 1, 2002 to December 31, 2011 was queried using key words: "gabapentin," "lamotrigine," "levetiracetam," "tiagabine," "topiramate," "zonisamide," "pregabalin," and "oxcarbazine." Polypharmacy overdose and children less than 15 years of age were excluded. Charts were reviewed by two abstractors for pharmaceutical, self-reported dose, clinical effect score, and clinical signs, symptoms, and vital signs recorded in the chart. Ordinal logistic regression was used to evaluate the relationship between drug type, dose, age, and sex to clinical effect score. Out of 501 cases identified, 347 met the final inclusion criteria. There were 116 gabapentin, 67 lamotrigine, 15 levetiracetam, 15 tiagabine, 56 topiramate, 23 pregabalin, and 55 oxcarbazepine cases. Overdose of newer anticonvulsants frequently results in altered mental status. Seizures may be more common with tiagabine, lamotrigine, and oxcarbazepine. There was one death reported from intentional overdose of topiramate. An information index was created to rank drug toxicity based on reported signs and symptoms for each overdose. There was no significant effect of dose on severity of outcome (β = 0.12, p = 0.23). However, the risk of a more severe outcome score was significantly increased with tiagabine relative to other drugs (β = 2.8, p = 0.001). Lamotrigine ranked highest in terms of toxicity (HT = 1.66) and number of interventions performed (HI = 1.17), and levetiracetam the lowest (HT = 0.98; HI = 0.88). We could not identify a dose-effect in these data which likely reflects the limitations of self-reported doses. Despite limitations of these data, the risk of more severe outcome scores appear to be higher with tiagabine overdose while lamotrigine overdose appears to result in more reported signs, symptoms, and interventions.

This chapter consists of two main sections. The first section is concerned with a brief and broad overview of the emergence and development of Buddhism during different periods, namely, those of the Mongol Empire, the colonial Qing rule in Mongolia, and the establishment of the Autonomous Mongolian State. This is followed by descriptions of the demise of institutional Buddhism in Mongolia, prohibition of religious freedom during the communist period, and the re-emergence of Buddhism in the early 1980s. The first section of the chapter focuses on the challenges of the early phase of the revitalization of Buddhism and on the current progress made in the effort to rebuild Buddhism as a genuine Mongolian tradition. The second section of the chapter is dedicated to the development of modern interpretations of Buddhism within contemporary Mongolia. Looking specifically at the relationship between sexuality and monasticism in contemporary Mongolia and at the tradition of married monastics, we develop a fuller understanding of contemporary Buddhist practices and identity in contemporary Mongolian Buddhism.

Purpose – The paper aims to report on the experiences moderating an interdisciplinary graduate-level sustainability seminar. Initiated in Fall 2002, the seminar has explored diverse sustainability topics and reached approximately 150 faculty and students. The paper describes how the course shaped participants' perceptions of sustainability and influenced their viewpoints on interdisciplinarity. The paper discusses the implications of this seminar format for communicating about sustainability and provides suggestions for replicating the course at other institutions. Design/methodology/approach – Information about the course is complemented by analyses of the results of 15 in-depth interviews of students and faculty who have participated in the course. Findings – The course facilitated positive outcomes for students and faculty by expanding their familiarity with interdisciplinary perspectives on sustainability and environmental issues, increasing respect for other disciplinary perspectives, learning the basic vocabulary of disciplines outside their area of expertise, and strengthening collaborations between faculty. The course can be strengthened with more involvement from colleagues from the humanities and social sciences, and with attention to equal participation from all involved. Originality/value – The experience is unique in that it represents a nearly decade-long initiative to teaching about sustainability and biocomplexity from an interdisciplinary perspective. The innovative format, content, and pedagogical approach used for this course can be easily implemented in other disciplines. The learning community has facilitated other teaching and research endeavors. This model of sustainability education can advance understanding of complex environmental issues at a time when both interdisciplinarity and sustainability are becoming more common in higher education.