The Sticky Standard of Care

The problem at the heart of “Stemming the Standard‐of‐Care Sprawl: Clinician Self‐Interest and the Case of Electronic Fetal Monitoring,” an article by Kayte Spector‐Bagdady and colleagues in the November‐December 2017 issue of the Hastings Center Report, is the persistence of a suboptimal standard of care long after evidence‐driven approaches would dictate a change. That problem is not simply defensive medicine, or what the authors call “standard‐of‐care sprawl.” Instead, it is that, in some cases, the standard of care lags behind best practices. It gets stuck. The authors point to the genesis of the stickiness problem in their passing reference to a core truth: “The problem is that standard of care is not synonymous with best or evidence‐based medicine.” In my view, we might best understand the persistence of ineffective and even harmful medical interventions by acknowledging the regulatory vacuum in which such practices thrive. It is by default, not by design, that the profession relies on medical malpractice law to set the boundaries on acceptable practice.     

Queensland tick typhus in rural New South Wales

We report five cases of Rickettsia australis infection from southern coastal New South Wales, Australia. All patients presented with a cutaneous eruption of erythematous papules and pustules and systemic features of malaise, headache, lymphadenopathy and myalgia. Acute kidney injury (AKI) was present in two of five cases and one of five cases had acute delirium. Improvement was only seen after treatment with doxycycline 100 mg b.i.d. Positive serology for R. australis was present in four of five cases and a positive polymerase chain reaction (PCR) was seen in one of five cases. Histology showed varying features, from neutrophilic vasculitis to Sweet's syndrome and lymphocytic vasculitis. Recent significant advances in the diagnosis of R. australis infection include an eschar swab or biopsy PCR and isolation of specific Rickettsia on serology. These investigations should be considered in the presence of any of the following features: eschar at site of a tick bite or lymphadenopathy and fever with an eruption of erythematous papules and pustules.     

Vesiculobullous Hailey-Hailey disease: Successful treatment with oral retinoids

A 56-year-old male presented with a pruritic, generalized vesiculobullous eruption. His past history revealed classical symptoms of limited Hailey-Hailey disease for 34 years. Clinically, vesicles, bullae and occasional pustules were present and multiple biopsies confirmed this to be an unusual presentation of Hailey-Hailey disease. Various therapeutic modalities including topical and oral antibiotics, oral prednisone and dapsone failed to achieve sustained remission. Treatment with lowdose oral etretinate (25 mg daily) produced marked clinical improvement with complete suppression of new vesicle formation after 6 weeks.     

COVID-19 vaccine uptake and intention during pregnancy in Canada

ObjectiveTo investigate COVID-19 vaccine uptake and intent among pregnant people in Canada, and determine associated factors.MethodsWe conducted a national cross-sectional survey among pregnant people from May 28 through June 7, 2021 (n = 193). Respondents completed a questionnaire to determine COVID-19 vaccine acceptance (defined as either received or intend to receive a COVID-19 vaccine during pregnancy), factors associated with vaccine acceptance, and rationale for accepting/not accepting the vaccine.ResultsOf 193 respondents, 57.5% (n = 111) reported COVID-19 vaccine acceptance. Among those who did not accept the vaccine, concern over vaccine safety was the most commonly cited reason (90.1%, n = 73), and 81.7% (n = 67) disagreed with receiving a vaccine that had not been tested in pregnant people. Confidence in COVID-19 vaccine safety (aOR 16.72, 95% CI: 7.22, 42.39), Indigenous self-identification (aOR 11.59, 95% CI: 1.77, 117.18), and employment in an occupation at high risk for COVID-19 exposure excluding healthcare (aOR 4.76, 95% CI: 1.32, 18.60) were associated with vaccine acceptance. Perceived personal risk of COVID-19 disease was not associated with vaccine acceptance in the multivariate model.ConclusionVaccine safety is a primary concern for this population. Safety information should be communicated to this population as it emerges, along with clear messaging on the benefits of vaccination, as disease risk is either poorly understood or poorly valued in this population.     

Optimization of scan parameters in pulmonary partial pressure oxygen measurement by hyperpolarized 3He MRI.

The dependence of hyperpolarized (HP) (3)He T(1) on local oxygen concentration provides the basis for measuring the partial pressure of oxygen (pO(2)) and oxygen depletion rate (R) in the lungs. Precise measurements of this type are difficult because the oxygen effect manifests itself through a decay of signal, leading to noisy images at the end of the series. The depolarization caused by RF excitation pulses further complicates the problem. It is therefore important to optimize scan parameters, such as measurement timing and flip angle, to obtain accurate and reproducible measurements. This work presents a new single-acquisition technique in conjunction with the multiple regression fitting method for data evaluation. Analytical expressions for the measurement uncertainties are derived. A total of four types of single-acquisition timing schemes are investigated; simulation shows a large uncertainty variation between these schemes (pO(2): 7.5-30.2%; R: 47.4-173.7%). A basic procedure for optimizing scan parameters is then described. A phantom experiment was conducted to verify the simulation results. Repeated in vivo measurements with the optimal scheme in a rabbit experiment showed that average variation of global mean is 6.2% for pO(2) and 12.0% for R, and that the average variation of percentiles (10th, 25th, 50th, 75th, and 90th) is 8.7% for pO(2) and 19.0% for R.