Rising Prevalence of Pneumocystis jirovecii Pneumonia Amongst the Non-HIV Immunosuppressed

INTRODUCTION Fungal Pneumonia caused by Pnemocystis Jirovecci (PCP) has long been associated with morbidity and mortality in HIV-positive patients. With the widespread use of high dose corticosteroids and biologic therapies, the prevalence of PCP infection in the non-HIV immunosuppressed population has increased significantly. A lack of formalized prophylaxis guidelines in these specific populations has lead to increasing rates of preventable infection and death. CASE PRESENTATION The patient is a 63-year-old man, admitted to the hospital for persistent shortness of breath following a seven-day course of Levofloxacin taken as an outpatient. Two months prior, the patient was found by his hematologist to have a hemoglobin level of 5.5g/ dL, and was diagnosed with autoimmune hemolytic anemia. He was started on a 12 week Prednisone taper following an initial blood transfusion. Three weeks prior to admission, the patient began to develop shortness of breath worse with ambulation, a non-productive cough, and he denied fevers. At time of admission, the patient was taking Prednisone 40mg daily. The patient’s past medical history was significant for Hodgkin’s Lymphoma in 2001 treated with Adriamycin, Bleomycin, Vinblastine and Dacarbazine (ABVD) and radiation therapy, with recurrence in the nasopharanx and lung requiring further ABVD cycles and left pneumonectomy in 2005. Patient also had renal cell carcinoma requiring nephrectomy in 2007. Social history was significant for a 5-year pack history of cigarette smoking. Family history was significant for myocardial infarction in his father at age 69. Vital signs at presentation were temperature of 99.4 F, blood pressure of 157/70, pulse of 105 beats per minute and oxygen saturation of 90% on room air. Pertinent positive physical exam findings were sinus tachycardia and diffuse wheezing in all right lung fields and lack of breath sounds on the left. Patient was resting comfortably and able to answer questions without distress. On admission, patient had a normal white blood cell count and a hemoglobin level of 9.8g/dL. Computed tomography scan of the thorax showed mild diffuse, nonspecific ground glass opacities

Interpersonal Relationships as Sources of Medical Student Stress

Introduction The issue of physician impairment, that is , decreased ability or quality of functioning due to intemperate use of drugs or alcohol, emotional or psychiatric dysfunction, has recently received attention (1,5) . Studies have indicated the risks physicians face of substance abuse problems(6,7), marital discord(8,9), suicide (lO,ll), and psychiatric problems (l2-14). studies have also addressed the difficulties faced by medical students (15-20). A group of medical students at the University of North Carolina came together to investigate the subject of medical student impairment . A survey was constructed in order to ascertain the sources of stress in medical school. The results were used to develop a second survey instrument that was distributed to all students in the medical school and is presently being analyzed. A portion of the results are presented in this paper because of their unique focus on interpersonal relationships as sources of stress

Total Body Skin Exam and Number Needed to Screen

Introduction/Background: Skin cancer screening could impact mortality and morbidity in US adults; however, the effectiveness of widespread screening remains unclear. Further research is necessary to determine what age groups, with what risk factors, might benefit from routine total body skin exams (TBSE) in the US. Objective: This study sought to determine, on average, the number of patients, per decade, needed to screen via TBSE to identify one person with skin cancer. Methods: A retrospective review of Jefferson Dermatology outpatient data in Epic was conducted. All patient charts from 1/1/2017 - 1/1/2018 were reviewed if they received a TBSE. The type of skin cancer diagnosed after each visual skin exam was documented and data on the results of the patient interview and biopsy were collected in RedCap and analyzed in SPSS. Results: 3153 patients received a TBSE. Skin cancer was identified in 180 people; 8 people were found to have melanoma. By decade, the number needed to screen to identify 1 person with skin cancer was as follows: 20s: 331, 30s: 64, 40s: 60, 50s: 22, 60s: 12, 70s: 10, 80s: 6, 90s: 5. By decade, the number needed to screen to identify 1 person with melanoma was as follows: 20s: 331, 30s: Undefined, 40s: Undefined, 50s: 559, 60s: 153, 70s: 452, 80s: undefined, 90s: undefined. Conclusion: As patient age increases, less people need to be screened to detect skin cancer. It may be beneficial for Americans over 50 to obtain routine TBSEs. This data can contribute to the growing body of evidence needed for the USPSTF to provide skin cancer screening guidelines

Population Pharmacokinetic and Pharmacodynamic Analysis of Buprenorphine for the Treatment of Neonatal Abstinence Syndrome

Neonatal abstinence syndrome (NAS) is a condition affecting newborns exposed to an opioid in utero. Symptoms of NAS include excessive crying, poor feeding, and disordered autonomic control. Up to 2/3 of infants will require pharmacologic therapies to reach symptom control. Opioids including morphine and methadone are the current first-line treatments. Buprenorphine is being investigated as a treatment of NAS. The purpose of this analysis was to evaluate the pharmacokinetics (PK) and pharmacodynamics (PD) of BUP in infants with NAS. Poster presented at American Society for Clinical Pharmacology and Therapeutics (ASCPT) 2017 Annual Meeting, March 15-18, 2017 in Washington DC.https://jdc.jefferson.edu/petposters/1004/thumbnail.jp

Interview with Edith Irby Jones

An oral history interview with Dr. Edith Irby Jones, MD

The Usefulness of Neutrality

Recently, the idea of therapeutic neutrality has been attacked. Many observers have suggested that the neutral therapist is inhuman and unempathic. Actually, being a neutral therapist means being especially human and empathic. The neutral therapist\u27s empathic contact with the patient is the most extensive in that it includes not only contact with feelings and thoughts of which the patient is aware, but also contact with all those intolerable thoughts and feelings of which the patient prefers to be unaware. Such awareness in the therapist is possible only when the therapist remains, as Anna Freud (I) recommends, equidistant from the patient\u27s id, ego and superego, that is equidistant from the forces generating the patient\u27s psychic conflict. Such objectivity does not preclude warmth, rather it directly evolves from warm and authentic contact with the patient

Exercise-Induced Hypoalgesia in Healthy Individuals and People With Chronic Musculoskeletal Pain: A Systematic Review and Meta-Analysis

Exercise-induced hypoalgesia (EIH) is a reduction in pain that occurs during or following exercise. Randomized controlled studies published from 1980 to January 2020 that examined experimentally induced pain before and during/following a single bout of exercise in healthy individuals or people with chronic musculoskeletal pain were systematically reviewed. Data were analyzed using random-effects meta-analyses and studies were appraised using the Cochrane Risk of Bias tool and GRADE. Five thousand eight hundred twenty-nine records were screened, with 13 studies ultimately included. In healthy individuals, aerobic exercise caused large EIH (7 studies, 236 participants; g = −.85 [−1.58, −.13]), dynamic resistance exercise caused small EIH (2 studies, 23 participants; g = −.45 [−.69, −.22]), and isometric exercise did not cause EIH (3 studies, 177 participants; g = −.16 [−.36,.05]). In chronic musculoskeletal pain, isometric exercise did not cause EIH (3 studies, 114 participants; g = −.41 [−1.08,.25]); aerobic (0 studies) and dynamic resistance (1 study) exercise were not analyzed. We conclude that, based on small studies with unclear risk of bias, aerobic and dynamic resistance exercise reduce experimental pain in healthy individuals. Further research is needed to determine whether EIH exists for experimental and clinical pain in people with chronic musculoskeletal pain. Registration: PROSPERO ID: CRD42018085886. Perspective: Based on low-quality data from small samples, a single bout of aerobic exercise reduces experimental pain in healthy individuals. The evidence is unclear in people with chronic musculoskeletal pain but warrants further investigation due to the limited number of studies in these populations

Magic at the Movies: Positive Psychology for Children, Adolescents and Families

Children learn in part from what they see and hear, whether modeling parents’ or peers’ behavior, reading books, or viewing movies. Parents and their children share the same and often unspoken goal—to live “the good life”—in a state of well-being. Character strengths are foundational to well-being, and movies are a rich source with which to build character strengths and hence flourishing. However, even though movies are considered efficacious (and more rigorous studies are needed), there are minimal resources for parents on how to use this powerful tool with their children and teenagers. Movies are presented here as an educational force, with the ability to promote altruism and self-improvement. The power of the narrative stimulates emotions, and these emotional responses influence learning and behavior. Immersion into a character in a movie increases empathy, and allows the viewer to live the experiences of the character without having to experience the real-life consequences. The following paper will discuss: movies as positive media, the rationale for how movies build character strengths, the benefits of building character strengths from movies in particular, and curriculum/criteria for “Positive Psychology at the Movies for Families, Children, and Teenagers.” The 24 character strengths will be reviewed, and an exemplar movie presented for each, followed by discussion points and potential positive interventions. A literature review of positive psychology and character strengths can be found in the Appendix

Directional Next-Generation RNA Sequencing and Examination of Premature Termination Codon Mutations in Endoglin/Hereditary Haemorrhagic Telangiectasia

Hereditary haemorrhagic telangiectasia (HHT) is a disease characterised by abnormal vascular structures, and most commonly caused by mutations in ENG, ACVRL1 or SMAD4 encoding endothelial cell-expressed proteins involved in TGF-β superfamily signalling. The majority of mutations reported on the HHT mutation database are predicted to lead to stop codons, either due to frameshifts or direct nonsense substitutions. The proportion is higher for ENG (67%) and SMAD4 (65%) than for ACVRL1 (42%), p < 0.0001. Here, by focussing on ENG, we report why conventional views of these mutations may need to be revised. Of the 111 stop codon-generating ENG mutations, on ExPASy translation, all except one were premature termination codons (PTCs), sited at least 50-55 bp upstream of the final exon-exon boundary of the main endoglin isoform, L-endoglin. This strongly suggests that the mutated RNA species will undergo nonsense-mediated decay. We provide new in vitro expression data to support dominant negative activity of stable truncated endoglin proteins but suggest these will not generate HHT: the single natural stop codon mutation in L-endoglin (sited within 50-55 nucleotides of the final exon-exon boundary) is unlikely to generate functional protein since it replaces the entire transmembrane domain, as would 8 further natural stop codon mutations, if the minor S-endoglin isoform were implicated in HHT pathogenesis. Finally, next-generation RNA sequencing data of 7 different RNA libraries from primary human endothelial cells demonstrate that multiple intronic regions of ENG are transcribed. The potential consequences of heterozygous deletions or duplications of such regions are discussed. These data support the haploinsufficiency model for HHT pathogenesis, explain why final exon mutations have not been detected to date in HHT, emphasise the potential need for functional examination of non-PTC-generating mutations, and lead to proposals for an alternate stratification system of mutational types for HHT genotype-phenotype correlations