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Objectives Our institution was the victim of a cyberattack that necessitated use of manual laboratory systems for more than 25 days. These manual processes had to be created not only to enable us to process our case volume without bottlenecks but also to maintain patient safety and allow for billing. Methods Our laboratory needed to create a safe reporting process to ensure ongoing patient safety and error reduction during the downtime. Additionally, we needed to ensure the ability to bill for performed tests in some areas of the lab and maintain compliance with regulatory policies. Results Amendment rates in our system were higher than before the attack, but no patient harm was observed. Intraoperative assessments declined, but high-acuity cases continued with a discrepancy rate comparable with the normal state. Many hours and resources (human and otherwise) were necessary to reconcile the work done to bill for services, but we were able to capture revenue through careful planning. Conclusions This article records the challenges we faced and the successes we achieved in maintaining compliance and a low error rate in the face of manual processes, the steps necessary to bring the cases into the newly restored electronic health record, and how we billed for the services we rendered.

There is a paucity of research concerning the diagnosis and treatment of paediatric vitiligo. This reality parallels published patient reports of profound dissatisfaction with the state of knowledge and available treatments. This study was meant to assess the attitudes of paediatric dermatologists towards the therapeutics of paediatric vitiligo. A survey was designed and approved by the survey committee of the Pediatric Dermatology Research Alliance to be distributed to the members. The study was exempted by the IRB of the Mount Sinai Hospital and posted to an online survey system. A total of 56 dermatologists completed the survey, a majority of whom practiced in the US (n = 44, 78·6%), followed by Mexico (n = 6, 10·7%). Most were board-certified (n = 48, 85·7%). Practitioners reported seeing an average of eight paediatric and adolescent vitiligo patients per month. Providers surveyed reported feeling most comfortable treating older patients 13–17 (n = 48, 85·7%), 9–12 (n = 47, 84%), 5–8 (n = 40, 71·4%), 2–4 years (n = 18, 32·1%), 13–23 months (n = 12, 21·4%), 7–12 months (n = 4, 7·1%), and 0–6 months (n = 1, 1·7%). Among the 8 (14·3%) respondents who used an oral JAK inhibitor, the age of the patients ranged from 4 months to 16 years. Most providers surveyed (n = 50, 89·3%) used an interview with the patient and parents to assess for quality-of-life impairments in children and adolescents. Bloodwork was performed always or usually (n = 25, 44·6%), sometimes (n = 11, 19·6%), and rarely (n = 9, 16·1%). Full thyroid panels (n = 38, 67·8%) and 25-OH vitamin D levels (n = 27, 48·2%) led tests ordered. For children under 8 years with 25% vitiligo +/− eyelid involvement TCI (n = 48, 85·7%; n = 45, 80·3%), TCS (n = 21, 37·5%; n = 30, 53·6%), excimer laser (n = 8, 85·7%; n = 11, 19·6%), NB-UVB (n = 6, 10·7%; n = 7, 12·5%), and cover-up makeup (n = 7, 11·9%; n = 8, 14·3%) were used. For 8+ with body depigmentation

Environmental remediation of polluted sites in developing communities often faces difficulties due to the misalignment of project objectives with the needs and interests of local communities, establishment of unrealistic expectations for the outcome of the project, and failure to account for the available resources in the community itself. Remediation decisions favor technical data and technical solutions as the main means of determining remediation options, requiring significant investment and local capacity that are often not found in developing communities. Often these systems fail to account for the social aspects in environmental management and remediation. In contrast, new approaches in local knowledge-based solutions focus on pre-existing environmental management initiatives to establish objectives that are meaningful to the community itself. “Positive deviance” – or the idea that there are solutions already in communities that are successful at addressing challenges despite the barriers that a community faces – are often overlooked during project design and implementation. Identifying examples of positive deviance and working with community members who are well versed in local challenges, available resources, and local capacity presents opportunities for community members to establish project objectives and provides the foundation for future environmental management projects in the area. We present a case study of artisanal and small-scale gold mining (ASGM) in the Andes municipality, Antioquia, Colombia and local initiatives to overcome community-identified environmental pollutants. Through a series of semi-structured interviews, surveys, and site visits, we identified community perception of environmental pollutants, management techniques for mining waste, and grassroots initiatives that were locally developed to address them. Through key communication and interaction between innovators with identified positive deviance projects, technical experts, and other miners facing similar challenges, innovative projects that account for the social, political, and economic realities of a developing community can become widespread, leading to improved environmental and social conditions.

Changing demographics, the shift to community prevention and health promotion, complexity of medical care advances, and chronicity requires nursing professionals who are attuned to the diverse healthcare needs of communities. Nursing schools are beginning to build on holistic admission procedures that are being used by other healthcare disciplines to be more inclusive in the evaluation of applicants. This article outlines the background of holistic admissions and a State University implementation for prospective prelicensure nursing student admissions that reflect institutional mission and goals to create a more inclusive learning environment. The School of Nursing has five years of experience in holistic admissions of a second baccalaureate entry program and now is applying those procedures to high school entry nursing applicants. This article shares the complex vetting required in obtaining statewide academic and local stakeholder approval to change freshmen admission procedures across a University system. New applicant holistic admission appraisal included aptitude, characteristics, and experiences along with academic metrics. Recruitment, selection, and admission procedures are multifaceted and require change at the University and State levels to achieve the goal of a more diverse student population. Implementing creative holistic admissions processes will better align the future-nursing workforce with communities they serve.

Objectives Our institution was affected by a multi-institution, systemwide cyberattack that led to a complete shutdown of major patient care, operational, and communication systems. The attack affected our electronic health record (EHR) system, including all department-specific modules, the laboratory information system (LIS), pharmacy, scheduling, billing and coding, imaging software, internet access, and payroll. Downtime for the EHR lasted 25 days, while other systems were nonfunctional for more than 40 days, causing disruptions to patient care and significantly affecting our laboratories. As more institutions transition to network EHR systems, laboratories are increasingly vulnerable to cyberattack. This article focuses on the approaches we developed in the anatomic pathology (AP) laboratory to continue operations, consequences of the prolonged downtime, and strategies for the future. Methods Our AP laboratory developed manual processes for surgical and cytopathology processing, redeployed staff, and used resources within the department and of nearby facilities to regain and maintain operations. Results During the downtime, our AP laboratory processed 1,362 surgical pathology and consult cases as well as 299 cytology specimens and outsourced 1,308 surgical pathology and 1,250 cytology cases. Conclusions Our laboratory successfully transitioned to downtime processes during a 25-day complete network outage. The crisis allowed for innovative approaches in managing resources.

Technical advancements in mine tailings recycling have led to the production of construction products such as bricks, cement, road pavers, and mortars in artisanal and small-scale mining (ASM) communities. Although such efforts show promise, the environmental, health, and social implications of such practices are often overlooked by stakeholders including researchers, miners, and community members. This paper summarizes and evaluates the environmental and health implications of mine tailings recycling activities (MTRAs) in ASM. A comprehensive review was conducted using both academic and gray literature to analyze the current state of practice linked with environmental and health considerations. From the fifty-three analyzed MTRAs, twenty-three articles considered aspects of environmental concerns, and three studied aspects of health in mine tailings recycling processes. When included, environmental and health considerations mainly focused on toxicity leaching protocols or analyzing health risks and exposure routes of facilities constructed out of mine tailings construction materials. Results suggest that studies mostly focus on lab-scale experiments evaluating the material properties of the MTRAs products and have limited consideration of field application and social concerns. No study considered environmental, health and social implications in unison. To comprehensively address these concerns, a Comprehensive Approach to Recycling Tailings (CART) framework is proposed that can assist communities and researchers to better understand the possible environmental and health implications of MTRAs and to incorporate such understanding into practice.

Pollution remediation decisions in developing communities are often made with limited technical data and stakeholder engagement. Local knowledge of contamination is oftentimes neglected, resulting in efforts that fail to align with community objectives. In this work, we propose a new approach for incorporating local knowledge on contamination into remediation efforts, resulting in a community-informed conceptual site model framework for pollution remediation. This framework uses qualitative and quantitative social science methods to develop a holistic view of contamination as defined by the community, pairing social knowledge with existing technical information about a site. An example of the application of this framework is provided from a field study conducted in a mercury-contaminated artisanal and small-scale gold mining community in Andes, Colombia. We conducted qualitative unstructured and semi-structured interviews and surveys to elicit local knowledge on mercury contamination. We combined this stakeholder input with limited scientific published literature on mercury contamination in artisanal mining communities to develop different conceptual site models that vary based on the level and type of stakeholder input. Our findings demonstrate how local knowledge on contamination varies due to contextual factors within the community, revealed through the engagement. This work also demonstrates how the new framework can be utilized by environmental practitioners to define the needs, wants, and priorities of stakeholder groups throughout a remediation project, ensuring maximum participation in solution development.

Using a participatory research approach, we enlisted 12 U.S. Centers for Independent Living (CILs) to recruit and enroll 170 adults with intellectual disability (ID) to be randomized to either The Safety Class, an abuse prevention group program, or usual care. Participants were asked to complete pre, post, and 3-month follow-up questionnaires. CIL staff members facilitated the eight-session, interactive program. Quantitative and qualitative findings suggest that participation in a brief safety program may improve safety protective factors among men and women with ID. The Safety Class serves as one model for delivering an abuse prevention and education intervention to adults with significant safety needs but extremely limited access to relevant community resources.

Environmental risk mitigation strategies employed in developing communities to address mercury pollution from artisanal and small-scale gold mining (ASGM) have largely failed to meet community needs, resulting in their abandonment. In contrast, the water and wastewater treatment sector has gained more traction, introducing sustainable and community supported water treatment strategies. This paper discusses why initiatives in water and wastewater treatment in developing communities are succeeding while initiatives in ASGM environmental risk mitigation are falling short. Selected case studies illustrate that water and wastewater treatment project success is contingent on the inclusion of a fully comprehensive approach that considers the socio-economic and ecological context of communities and individuals along with behavior change interventions. These elements of successful WASH projects were then applied to past ASGM environmental projects to determine their applicability to the sector. By adopting the core traits of successful water and wastewater treatment projects in developing communities, a framework can be developed for ASGM projects that, when applied correctly, could lead to measurable impact and long-term sustainability.

Dermoscopy is a non-invasive diagnostic technique that facilitates the visualization of surface and subsurface structures of the skin. It has been proven to be an essential tool in the diagnosis of both malignant and benign cutaneous lesions. In this article, we review some of the most recent and noteworthy advances in dermoscopy. In addition, we discuss Reflectance Confocal Microscopy (RCM) and Optical Coherence Topography (OCT), two non-invasive imaging devices that may be used alongside dermoscopy to improve diagnostic accuracy.

Optical coherence tomography (OCT), an emerging noninvasive imaging modality, recently received category III Current Procedural Terminology (CPT) codes from the American Medical Association, enabling tracking of its use in the medical community. In this article, we review OCT imaging and its variant systems, discussing its applications and limitations for clinical use. Future directions of OCT technology and goals for obtaining category I CPT codes and reimbursement also are discussed.

Objective: The objective of this study was to assess the ability of optical coherence tomography to detect clinical and subclinical actinic keratoses confirmed by histopathology. The efficacy of ingenol mebutate treatment of actinic keratosis was also evaluated using optical coherence tomography, and correlation of treatment efficacy with severity of local skin reactions was determined. Design: Single-arm, open-label, split-face study. Setting: Hospital outpatient clinic. Participants: Male subjects (N=30) with seven actinic keratoses. Measurements: A suspected actinic keratosis and the normal-appearing, perilesional skin were imaged, biopsied for histopathologic analysis, and the results compared with the clinical and a blinded optical coherence tomography diagnosis. Treatment with ingenol mebutate gel 0.015% was randomly administered to three clinically suspected actinic keratoses and the perilesional skin; three additional, suspected actinic keratoses lesions and perilesional areas were left untreated. Clinical and optical coherence tomography images were obtained for all lesions. Severity of local skin reactions was recorded to evaluate the relationship between local skin reaction and treatment effect. Results: Optical coherence tomography analysis had a 100-percent (28/28) correlation with the clinical diagnosis of actinic keratosis and detected 16 of 22 (73%) histopathologically confirmed subclinical lesions from perilesional skin sites. By optical coherence tomography assessment, the clearance rate for clinically observed lesions was 76 percent for ingenol mebutate-treated areas versus 11 percent for untreated areas; the clearance rate for treated subclinical lesions was 88 percent versus 43 percent for untreated areas. Clearance rates did not vary with the severity of the local response. Conclusion: Optical coherence tomography is effective at detecting clinical and subclinical actinic keratoses and monitoring their response to treatment.

Joanna Emilio,1 Michelle Schwartz,2–4 Eleanor Feldman,2–4 Amy Kalowitz Bieber,2–4 Amanda Bienenfeld,2–4 Min-Kyung Jung,1 Daniel M Siegel,2,3 Orit Markowitz2–4 1Department of Dermatology, NYIT College of Osteopathic Medicine, Old Westbury, 2Department of Dermatology, SUNY Downstate Medical Center, 3Department of Dermatology, NY Harbor Healthcare System, Brooklyn, 4Department of Dermatology, Mount Sinai Medical Center, New York, NY, USA Abstract: Actinic keratoses (AKs), especially on areas of the face, have a negative impact on a patient's quality of life (QoL). These lesions manifest on sun-damaged skin and have the potential to progress to squamous cell carcinoma. Field-directed therapy alone and in combination with lesion-directed treatment is effective in clearing both visible and nonvisible AK lesions. Topical treatments of AKs thus have the potential to improve a patient's well-being. However, evidence demonstrating improvements in patient QoL is limited, and is mostly based on observational or retrospective studies. Some prospective studies have reported unchanged or even worsening QoL despite excellent treatment outcomes. Our prospective, pilot study demonstrated a significant increase in QoL in 28 subjects with AKs of the face treated with ingenol mebutate gel 0.015%. QoL was assessed at days 0 and 60 using the Skindex-16 survey. Mean overall scores improved from 24.5% at baseline to 15.5% at day 60 (P=0.031). Improvements in QoL were consistent with an 80% reduction in AK lesion number at day 60. These improved QoL findings are in line with those from a recent retrospective study using ingenol mebutate 0.015% gel. This study therefore further demonstrates the potential for field therapy to improve both treatment outcomes and patient satisfaction. Keywords: actinic keratosis, squamous cell carcinoma, ingenol mebutate gel, local skin reaction, quality of life, Skindex-16

There is increased emphasis on self-determination as an important outcome for youth with disabilities if they are to achieve positive adult outcomes after they leave school. However, the causal link between self-determination and positive adult outcomes has remained untested. The Arc conducted a follow-up study of students with mental retardation or learning disabilities for whom data regarding self-determination had been collected prior to their high school exit. Data regarding adult outcomes for these students nearly 1 year after graduation were collected. The resulting analysis determined that self-determined students were more likely to have achieved more positive adult outcomes, including being employed at a higher rate and earning more per hr than peers who were not self-determined. A framework for promoting self-determination as an educational outcome is presented.

BACKGROUND Stage-specific survival for colon cancer improves when more lymph nodes are reported in the surgical specimen. This has led to a minimum standard of identifying 12 lymph nodes as a quality indicator. OBJECTIVE The aim of this study was to determine whether the addition of Schwartz solution increases node yield and impacts pathologic staging. DESIGN This is a prospective cohort study. SETTING The study was conducted in an academic medical center. PATIENTS Included were 104 consecutive patients with colorectal cancer. MAIN OUTCOME MEASURES Lymph node counts before and after specimen treatment with Schwartz solution and incidence of upstaging were measured. RESULTS An additional 20 minutes (interquartile range, 15-40 minutes) was spent searching for lymph nodes, increasing the median number of nodes from 22.5 to 29.0 nodes. However, only 1 patient was upstaged. Schwartz solution decreased the number of specimens with less than 12 lymph nodes from 15 to 6. The following factors were associated with Schwartz solution leading to the detection of additional nodes: number of nodes detected initially with formalin only (p < 0.000), mesenteric fat volume (p < 0.000), mesenteric fat weight (p < 0.000), length of specimen (p < 0.016), tumor greatest dimension (p < 0.016), patient body surface area (p < 0.034), and patient age (p < 0.003). LIMITATIONS Clinical data for this study were obtained retrospectively and were not available for all of the patients. CONCLUSIONS Although Schwartz solution increased the number of nodes detected in 95% of patients and improved compliance with the 12-node standard for colon resection, there was minimal impact on cancer staging. Upstaging is unlikely to explain the increase in overall survival in patients with higher lymph node counts, casting doubt on the validity of this process measure as a meaningful quality indicator. Rather, the lymph node count may be a reflection of inherent tumor biology or host-related factors.

A consumer study was administered in order to test the effects of utilizing augmented reality in online shopping for an apparel item. A theoretical model was developed as a framework for the analysis and included telepresence, attitude, and product knowledge as independent variables, and purchase intent as the dependent variable. The results of the analysis suggested that only attitude predicted purchase intent. Attitude was affected directly by the stimulus, telepresence, and product knowledge. This implied that augmented reality has the potential to positively impact purchase intent, if and only if it can positively impact attitude.

OBJECTIVE Describe the development and preliminary evaluation of a safety awareness program for women with disabilities. DESIGN Baseline and postintervention questionnaires administered to a sample of women who completed a safety awareness program. PARTICIPANTS Seven women with diverse disabilities. INTERVENTION Eight interactive sessions designed to increase protective factors. SETTING Community site for persons with disabilities. MAIN OUTCOMES Safety self-efficacy, safety skills, social support/isolation, and safety promoting behaviors. RESULTS Significant increases from baseline to postintervention were found on measures of self-efficacy and safety skills. Although not statistically significant, improvements were also found in safety promoting behavior. CONCLUSION Despite the small sample, findings suggest that participation in a safety awareness program may improve protective factors.

The intended purpose of this monograph is to provide a general overview of allergy diagnostics for health care professionals who care for patients with allergic disease. For a more comprehensive review of allergy diagnostic testing, readers can refer to the Allergy Diagnostic Practice Parameters. A key message is that a positive allergy test result (skin or blood) indicates only the presence of allergen specific IgE (called sensitization). It does not necessarily mean clinical allergy (ie, allergic symptoms with exposure). It is important for this reason that the allergy evaluation be based on the patient's history and directed by a health care professional with sufficient understanding of allergy diagnostic testing to use the information obtained from his/her evaluation of the patient to determine (1) what allergy diagnostic tests to order, (2) how to interpret the allergy diagnostic test results, and (3) how to use the information obtained from the allergy evaluation to develop an appropriate therapeutic treatment plan.

Non-invasive imaging devices are currently being utilized in research and clinical settings to help visualize, characterize, anddiagnose cancers of the skin. Speckle-variance optical coherence tomography (svOCT) is one such technology that offers considerable promise for non-invasive, real time detection of skin cancers given its added ability to show changes in microvasculature. We present four early lesions of the face namely sebaceous hyperplasia, basal cell skin cancer, pigmented actinic keratosis, and malignant melanoma in situ that each display different important identification markers on svOCT. Up until now, svOCT has mainly been evaluated for lesion diagnosis using transversal (vertical) sections. Our preliminary svOCT findings use dynamic en face (horizontal) visualization to differentiate lesions based on their specific vascular organizations. These observed patterns further elucidate the potential of this imaging device to become a powerful tool in patient disease assessment.

We used a murine monoclonal antibody to herpes simplex virus (HSV) type 2 (HSV-2) glycoprotein G (gG) to develop an enzyme immunoassay that detected HSV-2 type-specific antibodies in human sera. Antibodies to HSV-2 gG were detected in 98 (96%) of 102 sera from pregnant women with culture-proved HSV-2 infection. Sixty-five percent of the women had serological evidence of past HSV-2 infection by the Rawls index, based on titers of neutralizing antibody to HSV type 1 and HSV-2. Thirty (88%) of 34 infants exposed to maternal HSV infection at delivery had antibodies to HSV-2 gG and remained well. One infant exposed to primary maternal HSV-2 infection lacked antibodies to HSV-2 gG and developed neonatal HSV-2 infection. The mean +/- SD optical density by HSV-2 gG enzyme-linked immunosorbent assay for sera obtained from 17 infants within one week after onset of neonatal HSV-2 infection was 0.25 +/- 0.12, compared with 1.15 +/- 0.34 in cord blood sera from exposed infants who did not develop symptoms (P less than .0001 by t test).