Good Shepherd Penn Partners

Purpose: The purpose of this review is to evaluate the literature related to mobilization of the critically ill patient with an emphasis on functional outcomes and patient safety. Methods: We searched the electronic databases of PubMed, CINAHL, Medline (Ovid), and The Cochrane Library for a period spanning 2000-2011. Articles used in this review included randomized and nonrandomized clinical trials, prospective and retrospective analyses, and case series in peerreviewed journals. Sackett's Levels of Evidence were used to classify the current literature to evaluate the strength of the outcomes reported. Results: Fifteen studies met inclusion criteria and were reviewed. According to Sackett's Levels of Evidence, 9 studies were level 4 evidence, one study was level 3, 4 studies were level 2, and one study was level one evidence. Ten studies pertained to patient safety/feasibility and 10 studies pertained to functional outcomes with 5 fitting into both categories. Conclusion: A search of the scientific literature revealed a limited number of studies that examined the mobilization of critically ill patients in the intensive care unit. However, literature that does exist supports early mobilization and physical therapy as a safe and effective intervention that can have a significant impact on functional outcomes.

PURPOSE: The purpose of this review is to evaluate the literature related to mobilization of the critically ill patient with an emphasis on functional outcomes and patient safety. METHODS: We searched the electronic databases of PubMed, CINAHL, Medline (Ovid), and The Cochrane Library for a period spanning 2000-2011. Articles used in this review included randomized and nonrandomized clinical trials, prospective and retrospective analyses, and case series in peer-reviewed journals. Sackett's Levels of Evidence were used to classify the current literature to evaluate the strength of the outcomes reported. RESULTS: Fifteen studies met inclusion criteria and were reviewed. According to Sackett's Levels of Evidence, 9 studies were level 4 evidence, one study was level 3, 4 studies were level 2, and one study was level one evidence. Ten studies pertained to patient safety/feasibility and 10 studies pertained to functional outcomes with 5 fitting into both categories. CONCLUSION: A search of the scientific literature revealed a limited number of studies that examined the mobilization of critically ill patients in the intensive care unit. However, literature that does exist supports early mobilization and physical therapy as a safe and effective intervention that can have a significant impact on functional outcomes.

UNLABELLED: Frozen shoulder or adhesive capsulitis describes the common shoulder condition characterized by painful and limited active and passive range of motion. The etiology of frozen shoulder remains unclear; however, patients typically demonstrate a characteristic history, clinical presentation, and recovery. A classification schema is described, in which primary frozen shoulder and idiopathic adhesive capsulitis are considered identical and not associated with a systemic condition or history of injury. Secondary frozen shoulder is defined by 3 subcategories: systemic, extrinsic, and intrinsic. We also propose another classification system based on the patient's irritability level (low, moderate, and high), that we believe is helpful when making clinical decisions regarding rehabilitation intervention. Nonoperative interventions include patient education, modalities, stretching exercises, joint mobilization, and corticosteroid injections. Glenohumeral intra-articular corticosteroid injections, exercise, and joint mobilization all result in improved short- and long-term outcomes. However, there is strong evidence that glenohumeral intra-articular corticosteroid injections have a significantly greater 4- to 6-week beneficial effect compared to other forms of treatment. A rehabilitation model based on evidence and intervention strategies matched with irritability levels is proposed. Exercise and manual techniques are progressed as the patient's irritability reduces. Response to treatment is based on significant pain relief, improved satisfaction, and return of functional motion. Patients who do not respond or worsen should be referred for an intra-articular corticosteroid injection. Patients who have recalcitrant symptoms and disabling pain may respond to either standard or translational manipulation under anesthesia or arthroscopic release. LEVEL OF EVIDENCE: Level 5.

BACKGROUND: Subacromial impingement syndrome (SAIS) is a painful condition resulting from the entrapment of anatomical structures between the anteroinferior corner of the acromion and the greater tuberosity of the humerus. OBJECTIVE: The aim of this study was to evaluate the short-term effectiveness of high-intensity laser therapy (HILT) versus ultrasound (US) therapy in the treatment of SAIS. DESIGN: The study was designed as a randomized clinical trial. SETTING: The study was conducted in a university hospital. PATIENTS: Seventy patients with SAIS were randomly assigned to a HILT group or a US therapy group. INTERVENTION: Study participants received 10 treatment sessions of HILT or US therapy over a period of 2 consecutive weeks. MEASUREMENTS: Outcome measures were the Constant-Murley Scale (CMS), a visual analog scale (VAS), and the Simple Shoulder Test (SST). RESULTS: For the 70 study participants (42 women and 28 men; mean [SD] age=54.1 years [9.0]; mean [SD] VAS score at baseline=6.4 [1.7]), there were no between-group differences at baseline in VAS, CMS, and SST scores. At the end of the 2-week intervention, participants in the HILT group showed a significantly greater decrease in pain than participants in the US therapy group. Statistically significant differences in change in pain, articular movement, functionality, and muscle strength (force-generating capacity) (VAS, CMS, and SST scores) were observed after 10 treatment sessions from the baseline for participants in the HILT group compared with participants in the US therapy group. In particular, only the difference in change of VAS score between groups (1.65 points) surpassed the accepted minimal clinically important difference for this tool. LIMITATIONS: This study was limited by sample size, lack of a control or placebo group, and follow-up period. CONCLUSIONS: Participants diagnosed with SAIS showed greater reduction in pain and improvement in articular movement functionality and muscle strength of the affected shoulder after 10 treatment sessions of HILT than did participants receiving US therapy over a period of 2 consecutive weeks.

Abstract People form impressions about brands as they do about social groups. The Brands as Intentional Agents Framework (BIAF) a decade ago derived from the Stereotype Content Model (SCM) two dimensions of consumers' brand perception: warmth (worthy intentions) and competence (ability). The BIAF dimensions and their predictive validity have replicated the general primacy of warmth (intentions) and developed the congruence principle of fit to context. BIAF domains include various brands, product design, and countries as origins of products and as travel destinations. Brand anthropomorphism plays a role in perceiving brands' morality, personality, and humanity. Consumer–brand relations follow from anthropomorphism: perceived brand‐self congruence, brand trust, and brand love. Corporate social (ir)responsibility and human relations, especially warm, worthy intent, interplay with BIAF dimensions, as do service marketing, service recovery, and digital marketing. Case studies describe customer loyalty, especially to warm brands, corresponds to profits, charitable donations, and healthcare usage. As the SCM and BIAF evolve, research potential regards the dimensions and beyond. BIAF has stood the tests of time, targets (brands, products, and services), and alternative theory (brand personality, brand relationships), all being compatible. Understanding how people view corporations as analogous to social groups advances theory and practice in consumer psychology.

BACKGROUND AND PURPOSE: Long-term acute care hospitals (LTACHs) have emerged for patients requiring medical care beyond a short stay. Minimal data have been reported on functional outcomes in this setting. The purposes of this study were: (1) to measure the clinical utility of the Functional Status Score for the Intensive Care Unit (FSS-ICU) in an LTACH setting and (2) to explore the association between FSS-ICU score and discharge setting. PARTICIPANTS: Data were obtained from 101 patients (median age=70 years, interquartile range [IQR]=61-78; 39% female, 61% male) who were admitted to an LTACH. Participants were categorized into 1 of 5 groups by discharge setting: (1) home (n=14), (2) inpatient rehabilitation facility (n=26), (3) skilled nursing facility (n=23), (4) long-term care/hospice/expired (n=13), or (5) transferred to a short-stay hospital (n=25). METHODS: Data were prospectively collected from a 38-bed LTACH in the United States over 8 months beginning in September 2010. Functional status was scored using the FSS-ICU within 4 days of admission and every 2 weeks until discharge. The FSS-ICU consists of 5 categories: rolling, supine-to-sit transfers, unsupported sitting, sit-to-stand transfers, and ambulation. Each category was rated from 0 to 7, with a maximum cumulative FSS-ICU score of 35. RESULTS: Cumulative FSS-ICU scores significantly improved from a median (IQR) of 9 (3-17) to 14 (5-24) at discharge. Median (IQR) cumulative discharge FSS-ICU scores were significantly different among the discharge categories: home=28 (22-32), inpatient rehabilitation facility=21 (15-24), skilled nursing facility=14 (8-21), long-term care/hospice/expired=5 (0-11), and transfer to a short-stay hospital=4 (0-7). DISCUSSION AND CONCLUSIONS: Patients receiving therapy at an LTACH demonstrate significant improvements from admission to discharge using the FSS-ICU. This outcome tool discriminates among discharge settings and successfully documents functional improvements of patients in an LTACH setting.

Importance: From late 2016 through August 2017, US government personnel serving on diplomatic assignment in Havana, Cuba, reported neurological symptoms associated with exposure to auditory and sensory phenomena. Objective: To describe the neurological manifestations that followed exposure to an unknown energy source associated with auditory and sensory phenomena. Design, Setting, and Participants: Preliminary results from a retrospective case series of US government personnel in Havana, Cuba. Following reported exposure to auditory and sensory phenomena in their homes or hotel rooms, the individuals reported a similar constellation of neurological symptoms resembling brain injury. These individuals were referred to an academic brain injury center for multidisciplinary evaluation and treatment. Exposures: Report of experiencing audible and sensory phenomena emanating from a distinct direction (directional phenomena) associated with an undetermined source, while serving on US government assignments in Havana, Cuba, since 2016. Main Outcomes and Measures: Descriptions of the exposures and symptoms were obtained from medical record review of multidisciplinary clinical interviews and examinations. Additional objective assessments included clinical tests of vestibular (dynamic and static balance, vestibulo-ocular reflex testing, caloric testing), oculomotor (measurement of convergence, saccadic, and smooth pursuit eye movements), cognitive (comprehensive neuropsychological battery), and audiometric (pure tone and speech audiometry) functioning. Neuroimaging was also obtained. Results: Of 24 individuals with suspected exposure identified by the US Department of State, 21 completed multidisciplinary evaluation an average of 203 days after exposure. Persistent symptoms (>3 months after exposure) were reported by these individuals including cognitive (n = 17, 81%), balance (n = 15, 71%), visual (n = 18, 86%), and auditory (n = 15, 68%) dysfunction, sleep impairment (n = 18, 86%), and headaches (n = 16, 76%). Objective findings included cognitive (n = 16, 76%), vestibular (n = 17, 81%), and oculomotor (n = 15, 71%) abnormalities. Moderate to severe sensorineural hearing loss was identified in 3 individuals. Pharmacologic intervention was required for persistent sleep dysfunction (n = 15, 71%) and headache (n = 12, 57%). Fourteen individuals (67%) were held from work at the time of multidisciplinary evaluation. Of those, 7 began graduated return to work with restrictions in place, home exercise programs, and higher-level work-focused cognitive rehabilitation. Conclusions and Relevance: In this preliminary report of a retrospective case series, persistent cognitive, vestibular, and oculomotor dysfunction, as well as sleep impairment and headaches, were observed among US government personnel in Havana, Cuba, associated with reports of directional audible and/or sensory phenomena of unclear origin. These individuals appeared to have sustained injury to widespread brain networks without an associated history of head trauma.

BACKGROUND: The primary aims of this hybrid Type 1 effectiveness-implementation trial were to quantitatively assess whether an evidence-based exercise intervention for breast cancer survivors, Strength After Breast Cancer, was safe and effective in a new setting and to qualitatively assess barriers to implementation. METHODS: A cohort of 84 survivors completed measurements related to limb volume, muscle strength, and body image at baseline, 67 survivors completed measurements 12 months later. Qualitative methods were used to understand barriers to implementation experienced by referring oncology clinicians and physical therapists who delivered the program. RESULTS: Similar to the efficacy trial, the revised intervention demonstrated safety with regard to lymphedema, and led to improvements in lymphedema symptoms, muscular strength, and body image. Comparison of effects in the effectiveness trial to effects in the efficacy trial revealed larger strength increases in the efficacy trial than in the effectiveness trial (P < .04), but few other differences were found. Qualitative implementation data suggested significant barriers around intervention characteristics, payment, eligibility criteria, the referral process, the need for champions (ie, advocates), and the need to adapt during implementation of the intervention, which should be considered in future dissemination and implementation efforts. CONCLUSIONS: This trial successfully demonstrated that a physical therapy led strength training program for breast cancer survivors can be implemented in a community setting while retaining the effectiveness and safety of the clinical trial. However, during the translation process, strategies to reduce barriers to implementation are required. This new program can inform larger scale dissemination and implementation efforts.

OBJECTIVE An improved understanding of carbapenem-resistant Klebsiella pneumoniae (CRKP) in long-term acute care hospitals (LTACHs) is needed. The objective of this study was to assess risk factors for colonization or infection with CRKP in LTACH residents. METHODS A case-control study was performed at a university-affiliated LTACH from 2008 to 2013. Cases were defined as all patients with clinical cultures positive for CRKP and controls were those with clinical cultures positive for carbapenem-susceptible K. pneumoniae (CSKP). A multivariate model was developed to identify risk factors for CRKP infection or colonization. RESULTS A total of 222 patients were identified with K. pneumoniae clinical cultures during the study period; 99 (45%) were case patients and 123 (55%) were control patients. Our multivariate analysis identified factors associated with a significant risk for CRKP colonization or infection: solid organ or stem cell transplantation (OR, 5.05; 95% CI, 1.23-20.8; P=.03), mechanical ventilation (OR, 2.56; 95% CI, 1.24-5.28; P=.01), fecal incontinence (OR, 5.78; 95% CI, 1.52-22.0; P=.01), and exposure in the prior 30 days to meropenem (OR, 3.55; 95% CI, 1.04-12.1; P=.04), vancomycin (OR, 2.94; 95% CI, 1.18-7.32; P=.02), and metronidazole (OR, 4.22; 95% CI, 1.28-14.0; P=.02). CONCLUSIONS Rates of colonization and infection with CRKP were high in the LTACH setting, with nearly half of K. pneumoniae cultures demonstrating carbapenem resistance. Further studies are needed on interventions to limit the emergence of CRKP in LTACHs, including targeted surveillance screening of high-risk patients and effective antibiotic stewardship measures. Infect. Control Hosp. Epidemiol. 2015;37(1):55-60.

BACKGROUND: One goal for older adults with Parkinson disease (PD) and multiple sclerosis (MS) is community ambulation; however, the best way for clinicians to measure this has not been established. Self-report questionnaires rely on the participant's cognitive function and reporting accuracy, while the association between clinical timed walk tests and community ambulation may not be strong. Progress toward the identification of an appropriate clinical tool to measure strides in PD and MS populations is hampered by the lack of meaningful research and reference standards in this area. PURPOSE: The objective of the present study was to explore the validity of the StepWatch Step Activity Monitor (SAM) in assessing stride count in persons with PD or MS. The SAM is a 2-dimensional accelerometer that counts strides and is calibrated for individual participants. METHODS: A convenience sample of 20 participants completed a health history interview. Participants ambulated approximately 15 m while wearing the SAM to establish appropriate baseline calibrations, matching their stride with the device settings. Next, participants took 3 passes over the GaitMat II (GM II) while wearing the SAM. Strides counted by the GM were compared with the strides counted by the SAM. RESULTS: The Pearson correlation coefficients (r) for MS and PD, respectively, were 0.99 and 1.0. CONCLUSIONS: Our investigation presents preliminary data that shows the concurrent validity of the SAM when compared with the gold standard GM. The SAM appears to be a valid tool for use in persons with PD and MS. The validity was apparent in a population of widely varying impairment levels.

Patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for coronavirus disease 2019 (COVID-19), may experience lasting sequelae following the acute phase of their index infection.1 The post-acute sequelae of SARS-CoV-2 infection (PASC) can manifest as a wide-ranging constellation of disabling symptoms. These symptoms are sometimes referred to as being part of long COVID, post-acute COVID-19 syndrome, long-haul COVID, chronic COVID, or other terms, but for the purposes of this report, the term PASC will be used. Respiratory symptoms are among the most common symptoms reported by patients, and include shortness of breath, impaired exercise tolerance, cough, and chest pain.2-7 Although the incidence of PASC is not yet fully known, estimates suggest varying length of symptoms post-initial infection and expected recovery. In a study of patients with incident cases of COVID-19 in which individuals self-reported their symptoms prospectively in the COVID Symptom Study, a total of 558 participants (13.3%) reported symptoms lasting ≥28 days, 189 (4.5%) for ≥8 weeks, and 95 (2.3%) for ≥12 weeks.8 Persistent respiratory symptoms, in particular, may be more common among patients who required hospitalization, as dyspnea was present in 30% of previously hospitalized patients at 12-month follow-up in one longitudinal cohort.9 Despite the prevalence of these sequelae and emerging data on the longevity of symptoms, limited guidance exists regarding the assessment and treatment of PASC. The American Academy of Physical Medicine and Rehabilitation (AAPM&R) Multi-Disciplinary PASC Collaborative ("PASC Collaborative") was convened to address the pressing need for guidance in the care of patients with PASC. This document is part of a larger series addressing PASC, and specifically addresses the assessment and treatment of breathing discomfort and respiratory sequelae. 1 Consider evaluation by a pulmonologist for any of the following, based on assessment recommendations: Referral to a pulmonologist for breathing discomfort in the absence of these abnormalities can be considered on an individual basis when persistent or unexplained. We acknowledge that the definition of PASC is evolving, and there are various factors that contribute to the diagnosis. The PASC Collaborative sought input from patient representatives and patient-led research initiatives to inform recommendations. Literature available at the time of our consensus process suggested that PASC be defined as the persistence of symptoms beyond 3 or 4 weeks from the onset of acute infection.1 Alternative definitions of PASC include symptoms lasting longer than 3 months.10 Following the completion of our consensus process for this report, World Health Organization (WHO) released a definition of "post-COVID condition," including describing the timing as "usually 3 months from the onset of COVID-19" and lasting "for at least 2 months."11 Based on patient feedback during our consensus process, we believe that earlier evaluation, diagnosis, and management can improve access to beneficial interventions. For the purposes of this guidance statement, we recommend expanded assessment if symptoms are not improving 1 month after acute symptom onset. The PASC Collaborative was created, in part, to develop expert recommendations and guidance from established PASC centers with extensive experience in managing patients with PASC. The PASC Collaborative is following an iterative modified Delphi approach to achieve consensus on assessment and treatment recommendations for a series of Consensus Guidance Statements focused on the most prominent PASC symptoms.12, 13 The collaborative is composed of 34 established post-COVID-19 or PASC centers, the first of which were established in April to June 2020; over 50 experts spanning clinical disciplines and specialties participate in the monthly meetings. Areas of expertise included physical medicine and rehabilitation, pulmonology, cardiology, primary care, physical therapy, speech therapy, and respiratory therapy, among others. Individual guidance statements include acknowledgement of the total number of centers participating in the Collaborative at the time of the publication, given the evolving nature of this group. Participating PASC centers were asked to designate one expert to be the voting member to assess consensus. Patient representatives were also permitted to vote. These statements were developed by a diverse team of experts, with patient input, and integrate current experience and expertise with available evidence to provide tools to clinicians treating patients. There is an intentional focus on health equity because disparities in care and outcomes are critically important to address. Beyond offering recommendations for assessment and treatment based on experience with care of patients presenting with PASC symptoms, the hope is that a broadened understanding of current patient care practices will help identify areas of future research. As with other PASC Collaborative documents, a detailed literature review was performed prior to initiation of the modified Delphi approach, the full description of our methodology has been published in detail previously.14 These Guidance Statements are intended to reflect current practice in patient assessment, testing, and treatments. At the time of development, must of the literature focused on patients who were not vaccinated, and the incidence and trajectory of PASC in vaccinated patients with "breakthrough" cases (including but not limited to current and emerging variants of the virus) is evolving. The PASC Collaborative took this into account during the development process, and these guidance statements generally apply to individuals who develop PASC regardless of their vaccination status. It is important to note that the recommendations provided in the Guidance Statements should not preclude clinical judgment and must be applied in the context of the specific patient, with adjustments for patient preferences, comorbidities, and other factors. As with any treatment plan, clinicians treating patients with PASC are encouraged to discuss the unknowns of PASC treatments and prognosis, as well as the benefits and risks of any treatment approach. This document specifically addresses post-acute persistent breathing discomfort and respiratory sequelae in the outpatient setting and does not apply to the acute assessment or management of breathing discomfort in urgent or emergency care settings. In addition, the PASC Collaborative recognizes that patients with PASC typically present with a cluster of symptoms that cross multiple body systems, such as fatigue and dysautonomia, which might limit their ability to participate fully in some of these assessment and treatment recommendations. These co-existing conditions must always be considered when suggesting a test or treatment, such as physical rehabilitation. Assessment and treatment of these co-existing conditions has15 and will be addressed in additional AAPM&R consensus statements. Breathing discomfort and respiratory sequelae of COVID-19 may include disabling symptoms, abnormal clinical exam findings, and abnormalities on cardiopulmonary testing or chest imaging studies.16-18 Common symptoms include shortness of breath at rest; disproportionate shortness of breath with activity; chest discomfort that may manifest as pain, tightness, constriction, and/or pressure; inability to take a full deep breath; new or progressive cough; and chest congestion.17-19 These symptoms frequently result in limited activity tolerance.16, 19, 20 Clinical examination may be normal or reveal abnormalities including tachypnea, tachycardia, hypoxemia at rest or with exertion, wheezing, rales, or abnormalities on cardiac exam. On further evaluation, some patients may have evidence of lung disease, such as abnormal pulmonary function tests (PFTs) and/or abnormalities on chest imaging, inclusive of but not limited to chest radiographs and computed tomography (CT) of the chest.16-18 The severity of lung disease and abnormalities in pulmonary function in individuals with PASC appears to be associated with severity of the acute COVID-19 episode. It has been established previously that patients surviving acute respiratory distress syndrome (ARDS) can have persistent abnormalities in pulmonary function.21 Similarly, 4 or more months after severe, or less commonly, moderate COVID-19 infection, changes in pulmonary function and chest imaging have been described, although data on the time course of this process are limited.22-25 The most common abnormality described is impaired diffusion capacity on pulmonary function testing—found in ~40% of patients at 1-year follow up after hospitalization for COVID-19 in China.26 A systematic review of studies examining pulmonary function abnormalities after acute COVID-19 similarly found diffusion capacity impairments in 39% of patients across seven studies.20 Six months after hospitalization for severe COVID-19, one cohort study identified changes concerning for pulmonary fibrosis in approximately one-third of patients—these changes were most common in older patients and those who experienced ARDS.27 At this time, the time course of pulmonary fibrosis identified in individuals with PASC is unknown and it is unclear whether the condition will persist, progress, improve, or resolve. Patients who initially had mild COVID-19, and did not experience hypoxemia or require hospitalization, are less likely to have post-acute pulmonary function or imaging abnormalities.22 However, shortness of breath and breathing discomfort remain common aspects of PASC among patients with initial mild acute COVID-19 and warrant close evaluation, as described in this report.28 As noted in the AAPM&R Multi-Disciplinary PASC Consensus Guidance Statement methodology,14 the recommendations (Tables 1 and 2) are based on expert consensus. Specific guidance recommendations that have been approved by consensus will be noted in the recommendation tables and are accompanied by additional discussion when appropriate. During the initial evaluation of breathing discomfort in the post-acute period, health care providers should determine whether lung disease is present and whether pulmonology evaluation is warranted. The severity of acute COVID-19 may help to initially stratify the risk of lung disease. Thus, history should include a detailed accounting of a patient's acute illness and the trajectory of symptoms since that time, in addition to history of pulmonary or cardiac disease. Characterizing the sensations and severity of breathing discomfort may also help guide further testing and treatment, as discussed in the section that follows. As noted previously, ARDS survivors are more likely to have impairments in pulmonary function testing and persistent interstitial lung abnormalities, when compared to those with less severe acute illness.21, 22 However, when estimating initial severity, clinicians must also account for resource limitations and inequities in care that may confound the characterization of the acute illness—for instance, patients who remained at home and were not hospitalized may have had hypoxemia that was not identified and treated in the acute phase, or may not have had access to inpatient hospitalization or home pulse oximetry (refer to Table 3: Health Equity Considerations and Examples in Patients with PASC: Breathing Discomfort). Understanding that the experience and individual response to breathing symptoms may, in part, be subjective, it should be recognized that sociocultural influences may impact variations in how these symptoms are reported by individuals with PASC. A detailed review of breathlessness as it applies to historical, cultural, and existential relationships is beyond the scope of this report; however, it is important to note that these may play a role in the clinical evaluation.29 Disability Example: People with spinal cord injuries (SCI) Insurance Example: Individuals who are uninsured, underinsured, or cannot afford access to recommended healthcare services Racial / Ethnic Minority Groups Example: People who identify as Black (including African-American), American-Indian/Alaska Native, Pacific Islander, Asian-American, and Mixed Race, and/or Latino/Hispanic (ethnicity) People who identify with minority groups may be at higher risk for COVID-19 infection, severe disease, and mortality. For example, one retrospective study of acute COVID-19 patients found that Hispanic individuals had a 2.76 odds ratio of decompensation and transfer to the intensive care unit within 24 hours of admission.83 As COVID-19 disproportionately affects the case count and severity of disease in Hispanic patients, this cohort may require more respiratory related rehabilitation after hospitalization. In comparison, a cross-sectional study showed that amid patients diagnosed with COVID-19, both Black race and poverty were associated with higher risk of hospitalization, but only poverty was associated with higher risk of intensive care unit admission.84 Similarly, non-Hispanic American Indian and Alaska Native (AI/AN) persons account for 0.7% of the United States population, yet 1.3% of COVID-19 cases.85 Not only diagnosis but assessment and treatment related to breathing can be influenced by race and ethnicity. In two large cohorts, Black patients had nearly three times the frequency of occult hypoxemia that was not detected by pulse oximetry as White patients.31 Although a discrepancy between measurements of pulse oximetry and arterial blood gas oxygen saturation was not found for all Black patients, unadjusted analysis found a discordance in 17% of Black patients and 6.2% in White patients.31 Age Example: Younger individuals and older individuals Younger: Breathing problems may occur in children due to underlying conditions such as asthma and this may be exacerbated by acute COVID-19 infection. The American Academy of Pediatrics has made general recommendations regarding return to play for young athletes, and these are generally based on expert opinion with much of the advice focused on when to refer to cardiology or get cardiac testing.86 Children infected with acute COVID-19 are susceptible to Multisystem Inflammatory Syndrome in Children (MIS-C). Reports have found that some minority groups, such as Black and Hispanic children are disproportionately affected.87 Depending on clinical cardiopulmonary symptoms related to MIS-C, some children will require a gradual return to usual activities and play.88 Older: Patients in older age categories often have worse outcomes. For example, one report notes that individuals over age 55 have had increased hospitalization, delayed clinical recovery, increased pulmonary involvement, and faster disease progression.89 Younger: Clinicians should be prepared to provide medical clearance, complete school forms, pre-participation sports physical examinations, and provide additional prescriptions for medication when needed (eg, rescue inhalers - one to be kept at school, one to be kept at home, one to be kept on their person if maturity level allows). Older: Elderly individuals may need long term services and support after COVID-19 infection. Responsibility for this care can fall to unpaid and untrained family members at home.90 Coordination of safe return to community care after hospitalization in the elderly population is recommended. Environmental exposure Example: People who live in low socioeconomic environments that expose them to various types of environment-related stressors Cough can persist for weeks or months after COVID-19 infection, often accompanied by chronic fatigue, cognitive impairment, dyspnea,93 or pain. Elevated levels of air pollution have shown a positive association with COVID-19 mortality rates after considering area-level confounders.94 Air pollution may also have a negative impact on the immune system as well as exacerbations of asthma and chronic obstructive pulmonary disease.95 Biologic sex Example: Pregnant women At the time of office evaluation, physical examination should include a detailed cardiac and pulmonary exam. Vital sign measurement should include pulse oximetry measurement at rest and with ambulation around the office or the individual's current environment if the visit is conducted virtually and this testing is feasible. This can serve as a simple and widely available screen to guide clinicians when prioritizing the next steps in diagnostic evaluation. Overnight oximetry testing may also be considered for individuals with documented exertional or resting hypoxemia or those with daytime supplemental oxygen requirements, to determine overnight oxygen requirement. Further details regarding sleep disorders and evaluation will be addressed in forthcoming PASC Consensus Guidance Statements. It is notable that clinicians should be aware that patients with darker skin pigmentation may have pulse oximetry readings that are falsely higher than their actual arterial oxygen saturation, and thus experience occult hypoxemia30—previously described as oxygen saturation greater than 92% on pulse oximetry yet less than 88% on concurrent arterial blood testing.31 In a recent retrospective analysis of hospitalized adults who underwent arterial blood gas measurements, Black patients had nearly three times the frequency of occult hypoxemia (11.4%) not detected by pulse oximetry, compared to White patients (3.6%).31 Therefore, if mild hypoxemia accompanies dyspnea in patients with darker skin pigmentation, clinicians should consider repeat testing with an alternative oximeter, ambulatory oximetry, and potentially arterial blood gas if there is concern for occult hypoxemia. Pregnant patients may also have unique explanations for breathing discomfort and testing considerations that differ from those for non-pregnant patients (Table 3: Health Equity Considerations and Examples in Patients with PASC: Breathing Discomfort). Prompt evaluation and workup of new shortness of breath during pregnancy should be considered. For patients with persistent symptoms that are not improving ~8 weeks after symptom onset, or are worsening prior to that time, further evaluation with PFTs should be considered. This serves as a screen for pulmonary disease that may require additional evaluations in consultation with a pulmonologist and may direct specific treatment approaches. Although the exact timing of testing may be individualized, it is our experience that waiting ~8 weeks provides adequate recovery from the acute phase of COVID-19 and reduces the overuse of testing in individuals who would otherwise recover within this time. Given that some degree of breathing discomfort is common in the early post-acute period of COVID-19,5 a period of observation of the trajectory of recovery, prior to extensive testing, may be appropriate when history and examination is otherwise reassuring. Where available, PFTs performed in a dedicated pulmonary function lab are recommended, providing comprehensive and accurate testing, including spirometry, lung volumes, and diffusion capacity. In settings where this is not available, in-office spirometry can be obtained. As discussed later, interpretation and further evaluation of abnormal PFTs can be undertaken in consultation with a pulmonologist. The need for repeat or serial assessment if patients have worsening symptoms can also be considered in consultation with a pulmonologist. Chest imaging is an important additional step for patients with abnormal oxygen saturation, persistent productive or dry cough, abnormal pulmonary exam, and/or impairment on pulmonary function testing. A chest radiograph should be considered as an initial step when performing imaging for most patients. However, if a chest radiograph does not explain the aforementioned abnormalities, in the presence of ongoing signs or testing abnormalities concerning for pulmonary disease, a chest CT scan should be considered to exclude or further characterize a possible pulmonary disorder. This chest CT can be performed as a high-resolution non-contrast scan in most patients, whereas a contrast-enhanced study is indicated if there is clinical concern for acute pulmonary embolism. In addition, a high-resolution non-contrast chest CT should be considered when abnormalities are identified on initial chest radiograph, to better define these abnormalities. Finally, clinicians can consider ordering a chest radiograph in settings where respiratory symptoms are not accompanied by other objective findings yet remain otherwise unexplained. Decisions regarding chest imaging may also be guided by a dedicated PASC clinic or a pulmonologist familiar with PASC, where available. If patients have chest imaging available from the acute phase of this should be when for to follow-up Clinicians should be aware that imaging findings following may persist beyond 4 to and the trajectory of findings with clinical trajectory are important in this Although follow-up imaging may be in the setting of persistent or new symptoms, follow up chest imaging for is of limited in the absence of persistent symptoms or other clinical patients who not have evidence of lung disease, cardiac of dyspnea should also be considered. testing is of limited in patients with breathing discomfort who not have a history or physical examination of a cardiac and is considered on an than Assessment and treatment of of COVID-19 will be addressed in a consensus by our Clinicians may consider the approach to testing in consultation with a PASC clinic or where available. Breathing discomfort may be associated with chest that can be to chest reported with disease in some patients with PASC. For these patients, clinicians should direct testing to exclude cardiac on an individual basis prior to considering rehabilitation discussed Breathing discomfort can be severe and regardless of whether an can be identified on testing or distress associated with breathing discomfort has been and a and approach by clinicians is to achieve from these disabling symptoms. and factors for dyspnea include following acute medication and Patients who are referred for rehabilitation should be with objective of activity These should be to the patient's including of to impairment, fatigue with dysautonomia, or other During a initial office evaluation, consider in-office such as and step In a physical more extensive such as test may be Alternative tests for patients more Individuals with PASC may present with a of pulmonary from shortness of breath and breathing discomfort with or objective abnormalities on pulmonary testing, to pulmonary and Patients with more severe initial COVID-19 more often manifest objective abnormalities on pulmonary to survivors of dyspnea is among the most common symptom of PASC, and patients may have objective abnormalities in cardiopulmonary health and including a and impaired diffusion capacity on pulmonary function with or oxygen on cardiopulmonary exercise and persistent or changes on cross-sectional Following initial evaluation, as discussed in the assessment patients with objective resting or exertional abnormal and/or abnormal imaging should be by a pulmonologist to guide additional assessment and evaluation should also be considered if abnormal breath as rales, or remain or after management in the primary care Although progressive or lung disease following COVID-19 appears the trajectory of lung disease for those patients who develop these changes is not yet patients may also present with treatment with patients with objective abnormalities in pulmonary testing or chest imaging warrant further evaluation with a pulmonologist. The of oxygen in patients with hypoxemia is from evidence that supplemental oxygen in patients with chronic obstructive pulmonary disease with severe Symptom is also with of resting or hypoxemia with appropriate oxygen in patients with any of lung disease that in chronic oxygen should be to established These refer to at and may be modified for conditions such as We recommend for the of supplemental oxygen for individuals with PASC who have or hypoxemia. During activity and rehabilitation, oxygen should be to rehabilitation and oxygen As patients home pulse should be to and for Although adequate can be at low rates if higher rates are a should be considered. oxygen can symptoms and exercise capacity in individuals with PASC and or oxygen can community ability to participate in rehabilitation, and of and are for home should be considered for home on the of oxygen is in a setting of pulmonary rehabilitation or in a exercise of oxygen with pulse and of oxygen can also be to individuals with PASC who require oxygen to for better and appropriate of oxygen in a home or rehabilitation Rehabilitation for individuals with PASC who are limited by respiratory sequelae can address dyspnea and breathing abnormalities, fatigue, and pulmonary and and return to In individuals with PASC and lung sequelae who also have fatigue and/or dysautonomia, the most should be considered when whether these to rehabilitation are appropriate. For example, if fatigue is the most clinicians should refer to previously published guidance regarding the assessment and treatment of The of simple measurements of as previously, can for of and over time in response to the rehabilitation we rehabilitation for multiple patient including patients with breathing discomfort with and impairment in pulmonary 1 provides considerations for these rehabilitation based on the initial assessment The for rehabilitation management is an home or activity or exercise Individuals with PASC who have persistent respiratory symptoms and are limited and have abnormal that for pulmonary rehabilitation or respiratory services should be The of pulmonary rehabilitation and respiratory services for patients with chronic lung conditions is well and it appears from early studies that there is also in individuals with PASC with lung Insurance between pulmonary rehabilitation and respiratory Rehabilitation for obstructive lung is for individuals with and medical by the for and the For individuals with and who have lung Respiratory or and Respiratory for both obstructive and lung rehabilitation also provide respiratory services and determine the appropriate based on diagnosis and

Background Currently available hand-held dynamometers (HHD) offer a more objective and reliable assessment of muscle force production as compared to a manual muscle test (MMT). Yet, their clinical utility is limited due to high cost. The ActivForce (AF) digital dynamometer is a new low-cost HHD with unknown psychometric properties, and its utilization may benefit clinical practice. Hypothesis/Purpose This study aimed to determine the AF intra- and inter-tester reliabilities, standard error of measurement (SEM), minimal detectable change (MDC), and criterion validity for assessing shoulder isometric force as compared to the microFET2 (MF2) across testers with different experiences. Design Descriptive observational study. Methods A convenience sample of 29 healthy adults were assessed twice by each of three testers (two experienced clinicians and a novice PT student) on shoulder external rotation (ER), internal rotation (IR), and forward elevation (FE) using both the AF and MF2 devices. Tester, HHD, and shoulder motion assignment orders were randomized. All testing was performed in a standardized seated position. ER and IR were tested with the shoulder fully adducted. FE was tested at 45° at the scapular plane. All testing and rest periods between testers and tested motions were standardized and monitored via a stopwatch. Results Both devices had high intra- [ ER (.95-.98), IR (.97 - .99), FE (.96 - .99)] and inter-tester [ ER (.85-.96), IR (.95 - .97), FE (.88 - .95)] intraclass correlation coefficient (ICC) with comparable intra- (1.68-1.80) and inter-tester (2.36-2.98) SEM, and intra- (4.64-4.97) and inter-tester (6.50-8.24) MDC values across all motions. Tester experience did not affect these values. High (.89-.93) statistically significant Pearson correlations were found between HHDs for all shoulder motions. Conclusion Both the AF and MF2 HHDs were found to have high reliability levels across all shoulder motions regardless of tester clinical experience. The AF was also found to be valid for measuring shoulder isometric force production compared to the criterion standard device, the MF2. Its low-cost and electronic accessibility features may promote better compliance for clinicians using dynamometry to objectively assess and store muscle force data in a cost-effective manner. Level of Evidence 3

Cancer-related fatigue (CRF) is the most common side effect of cancer treatment. Regular surveillance is recommended, but few clinical practice guidelines transparently assess study bias, quality, and clinical utility in deriving recommendations of screening and assessment methods. The purpose of this clinical practice guideline (CPG) is to provide recommendations for the screening and assessment of CRF for health care professions treating individuals with cancer. Following best practices for development of a CPG using the Appraisal of Guidelines for Research and Evaluation (AGREE) Statement and Emergency Care Research Institute (ECRI) Guidelines Trust Scorecard, this CPG included a systematic search of the literature, quality assessment of included evidence, and stakeholder input from diverse health care fields to derive the final CPG. Ten screening and 15 assessment tools supported by 114 articles were reviewed. One screen (European Organisation for Research and Treatment of Cancer-Quality of Life Questionnaire-30 Core Questionnaire) and 3 assessments (Piper Fatigue Scale-Revised, Functional Assessment of Chronic Illness Therapy-Fatigue, and Patient Reported Outcome Measurement Information System [PROMIS] Fatigue-SF) received an A recommendation ("should be used in clinical practice"), and 1 screen and 5 assessments received a B recommendation ("may be used in clinical practice"). Health care providers have choice in determining appropriate screening and assessment tools to be used across the survivorship care continuum. The large number of tools available to screen for or assess CRF may result in a lack of comprehensive research evidence, leaving gaps in the body of evidence for measurement tools. More research into the responsiveness of these tools is needed in order to adopt their use as outcome measures. IMPACT: Health care providers should screen for and assess CRF using one of the tools recommended by this CPG.

BACKGROUND: Unplanned rehospitalizations (UR) within 30 days of discharge are common after lung transplantation. It is unknown whether UR represents preventable gaps in care or necessary interventions for complex patients. The objective of this study was to assess the incidence, causes, risk factors, and preventability of UR after initial discharge after lung transplantation. METHODS: This was a single-center prospective cohort study. Subjects completed a modified short physical performance battery to assess frailty at listing and at initial hospital discharge after transplantation and the State-Trait Anxiety Inventory at discharge. For each UR, a study staff member and the patient's admitting or attending clinician used an ordinal scale (0, not; 1, possibly; 2, definitely preventable) to rate readmission preventability. A total sum score of 2 or higher defined a preventable UR. RESULTS: Of the 90 enrolled patients, 30 (33.3%) had an UR. The single most common reasons were infection (7 [23.3%]) and atrial tachyarrhythmia (5 [16.7%]). Among the 30 URs, 9 (30.0%) were deemed preventable. Unplanned rehospitalization that happened before day 30 were more likely to be considered preventable than those between days 30 and 90 (30.0% versus 6.2%, P = 0.04). Discharge frailty, defined as short physical performance battery less than 6, was the only variable associated with UR on multivariable analysis (odds ratio, 3.4; 95% confidence interval, 1.1-11.8; P = 0.04). CONCLUSIONS: Although clinicians do not rate the majority of UR after lung transplant as preventable, discharge frailty is associated with UR. Further research should identify whether modification of discharge frailty can reduce UR.

PM&RAccepted Articles Clinical GuidanceFree Access Multi-Disciplinary Collaborative Consensus Guidance Statement on the Assessment and Treatment of Cardiovascular Complications in Patients with Post-Acute Sequelae of SARS-CoV-2 Infection (PASC) Jonathan Whiteson MD, Jonathan Whiteson MD Department of Rehabilitation Medicine and Department of Medicine, Rusk Rehabilitation, NYU Langone Health, New York, NYSearch for more papers by this authorAlba Azola MD, Alba Azola MD Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MDSearch for more papers by this authorJohn T. Barry PT, DPT, John T. Barry PT, DPT Good Shepherd Penn Partners, Penn Therapy & Fitness – University City, Philadelphia, PASearch for more papers by this authorMatthew N. Bartels MD, MPH, Matthew N. Bartels MD, MPH Professor and Chairman Department of Rehabilitation Medicine, Montefiore Health System, Albert Einstein College of Medicine, Bronx, New YorkSearch for more papers by this authorSvetlana Blitshteyn MD, Svetlana Blitshteyn MD Department of Neurology, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NYSearch for more papers by this authorTalya K. Fleming MD, Talya K. Fleming MD orcid.org/0000-0002-2034-8253 JFK Johnson Rehabilitation Institute at Hackensack Meridian Health, Edison, NJSearch for more papers by this authorMark D. McCauley MD, PhD., Mark D. McCauley MD, PhD. Department of Medicine, Section of Cardiology, University of Illinois at Chicago and Jesse Brown VA Medical Center, Chicago, ILSearch for more papers by this authorJacqueline D. Neal MD, Jacqueline D. Neal MD Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, IL Physical Medicine and Rehabilitation, Jesse Brown VA Medical Center, Chicago, ILSearch for more papers by this authorJayasree Pillarisetti MD, Jayasree Pillarisetti MD Division of Cardiology, Department of Medicine, University of Texas Health San Antonio, San Antonio, TXSearch for more papers by this authorSarah Sampsel MPH, Corresponding Author Sarah Sampsel MPH slsampsel@ssampselqlty.com orcid.org/0000-0002-7496-8482 SLSampsel Consulting, LLC (Corresponding Author), Albuquerque, NM Correspondence Contact Information: Sarah Sampsel, MPH, Email: slsampsel@ssampselqlty.com, Phone: 505-977-0332, SLSampsel Consulting, LLC, 5008 Noreen Dr. NE, Albuquerque NM 87111Search for more papers by this authorJulie K. Silver MD, Julie K. Silver MD Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Boston, MASearch for more papers by this authorCarmen M. Terzic MD, PhD, Carmen M. Terzic MD, PhD Department of Physical Medicine and Rehabilitation and Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MNSearch for more papers by this authorJenna Tosto PT, DPT, NCS, Jenna Tosto PT, DPT, NCS Department of Rehabilitation and Human Performance, Abilities Research Center, Icahn School of Medicine at Mount Sinai, New York, NYSearch for more papers by this authorMonica Verduzco-Gutierrez MD, Monica Verduzco-Gutierrez MD orcid.org/0000-0003-0964-5908 Department of Rehabilitation Medicine, UT Health San Antonio, San Antonio, TXSearch for more papers by this authorDavid Putrino PT, PhD, David Putrino PT, PhD Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NYSearch for more papers by this author Jonathan Whiteson MD, Jonathan Whiteson MD Department of Rehabilitation Medicine and Department of Medicine, Rusk Rehabilitation, NYU Langone Health, New York, NYSearch for more papers by this authorAlba Azola MD, Alba Azola MD Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MDSearch for more papers by this authorJohn T. Barry PT, DPT, John T. Barry PT, DPT Good Shepherd Penn Partners, Penn Therapy & Fitness – University City, Philadelphia, PASearch for more papers by this authorMatthew N. Bartels MD, MPH, Matthew N. Bartels MD, MPH Professor and Chairman Department of Rehabilitation Medicine, Montefiore Health System, Albert Einstein College of Medicine, Bronx, New YorkSearch for more papers by this authorSvetlana Blitshteyn MD, Svetlana Blitshteyn MD Department of Neurology, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NYSearch for more papers by this authorTalya K. Fleming MD, Talya K. Fleming MD orcid.org/0000-0002-2034-8253 JFK Johnson Rehabilitation Institute at Hackensack Meridian Health, Edison, NJSearch for more papers by this authorMark D. McCauley MD, PhD., Mark D. McCauley MD, PhD. Department of Medicine, Section of Cardiology, University of Illinois at Chicago and Jesse Brown VA Medical Center, Chicago, ILSearch for more papers by this authorJacqueline D. Neal MD, Jacqueline D. Neal MD Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, IL Physical Medicine and Rehabilitation, Jesse Brown VA Medical Center, Chicago, ILSearch for more papers by this authorJayasree Pillarisetti MD, Jayasree Pillarisetti MD Division of Cardiology, Department of Medicine, University of Texas Health San Antonio, San Antonio, TXSearch for more papers by this authorSarah Sampsel MPH, Corresponding Author Sarah Sampsel MPH slsampsel@ssampselqlty.com orcid.org/0000-0002-7496-8482 SLSampsel Consulting, LLC (Corresponding Author), Albuquerque, NM Correspondence Contact Information: Sarah Sampsel, MPH, Email: slsampsel@ssampselqlty.com, Phone: 505-977-0332, SLSampsel Consulting, LLC, 5008 Noreen Dr. NE, Albuquerque NM 87111Search for more papers by this authorJulie K. Silver MD, Julie K. Silver MD Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Boston, MASearch for more papers by this authorCarmen M. Terzic MD, PhD, Carmen M. Terzic MD, PhD Department of Physical Medicine and Rehabilitation and Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MNSearch for more papers by this authorJenna Tosto PT, DPT, NCS, Jenna Tosto PT, DPT, NCS Department of Rehabilitation and Human Performance, Abilities Research Center, Icahn School of Medicine at Mount Sinai, New York, NYSearch for more papers by this authorMonica Verduzco-Gutierrez MD, Monica Verduzco-Gutierrez MD orcid.org/0000-0003-0964-5908 Department of Rehabilitation Medicine, UT Health San Antonio, San Antonio, TXSearch for more papers by this authorDavid Putrino PT, PhD, David Putrino PT, PhD Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NYSearch for more papers by this author First published: 03 June 2022 https://doi.org/10.1002/pmrj.12859 This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1002/pmrj.12859. AboutPDF ToolsExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Accepted ArticlesAccepted, unedited articles published online and citable. The final edited and typeset version of record will appear in the future. This article also appears in:Long COVID (PASC) Clinical Guidance Statements RelatedInformation

IMPORTANCE: United States government personnel experienced potential exposures to uncharacterized directional phenomena while serving in Havana, Cuba, from late 2016 through May 2018. The underlying neuroanatomical findings have not been described. OBJECTIVE: To examine potential differences in brain tissue volume, microstructure, and functional connectivity in government personnel compared with individuals not exposed to directional phenomena. DESIGN, SETTING, AND PARTICIPANTS: Forty government personnel (patients) who were potentially exposed and experienced neurological symptoms underwent evaluation at a US academic medical center from August 21, 2017, to June 8, 2018, including advanced structural and functional magnetic resonance imaging analytics. Findings were compared with imaging findings of 48 demographically similar healthy controls. EXPOSURES: Potential exposure to uncharacterized directional phenomena of unknown etiology, manifesting as pressure, vibration, or sound. MAIN OUTCOMES AND MEASURES: Potential imaging-based differences between patients and controls with regard to (1) white matter and gray matter total and regional brain volumes, (2) cerebellar tissue microstructure metrics (eg, mean diffusivity), and (3) functional connectivity in the visuospatial, auditory, and executive control subnetworks. RESULTS: Imaging studies were completed for 40 patients (mean age, 40.4 years; 23 [57.5%] men; imaging performed a median of 188 [range, 4-403] days after initial exposure) and 48 controls (mean age, 37.6 years; 33 [68.8%] men). Mean whole brain white matter volume was significantly smaller in patients compared with controls (patients: 542.22 cm3; controls: 569.61 cm3; difference, -27.39 [95% CI, -37.93 to -16.84] cm3; P < .001), with no significant difference in the whole brain gray matter volume (patients: 698.55 cm3; controls: 691.83 cm3; difference, 6.72 [95% CI, -4.83 to 18.27] cm3; P = .25). Among patients compared with controls, there were significantly greater ventral diencephalon and cerebellar gray matter volumes and significantly smaller frontal, occipital, and parietal lobe white matter volumes; significantly lower mean diffusivity in the inferior vermis of the cerebellum (patients: 7.71 × 10-4 mm2/s; controls: 8.98 × 10-4 mm2/s; difference, -1.27 × 10-4 [95% CI, -1.93 × 10-4 to -6.17 × 10-5] mm2/s; P < .001); and significantly lower mean functional connectivity in the auditory subnetwork (patients: 0.45; controls: 0.61; difference, -0.16 [95% CI, -0.26 to -0.05]; P = .003) and visuospatial subnetwork (patients: 0.30; controls: 0.40; difference, -0.10 [95% CI, -0.16 to -0.04]; P = .002) but not in the executive control subnetwork (patients: 0.24; controls: 0.25; difference: -0.016 [95% CI, -0.04 to 0.01]; P = .23). CONCLUSIONS AND RELEVANCE: Among US government personnel in Havana, Cuba, with potential exposure to directional phenomena, compared with healthy controls, advanced brain magnetic resonance imaging revealed significant differences in whole brain white matter volume, regional gray and white matter volumes, cerebellar tissue microstructural integrity, and functional connectivity in the auditory and visuospatial subnetworks but not in the executive control subnetwork. The clinical importance of these differences is uncertain and may require further study.

With encouraging signs of pandemic containment nationwide, the promise of return to a full range of clinical practice is on the horizon. Clinicians are starting to prepare for a transition from limited evaluation of emergent and urgent complaints to resumption of elective surgical procedures and routine office visits within the next few weeks to months. Otolaryngology as a specialty faces unique challenges when it comes to the COVID-19 pandemic due to the fact that a comprehensive head and neck examination requires aerosol-generating endoscopic procedures. Since the COVID-19 pandemic is far from being over and the future may hold other highly communicable infectious threats that may require similar precautions, standard approaches to the clinical evaluation of common otolaryngology complaints will have to be modified. In this communication, we present practical recommendations for dysphagia evaluation with modifications to allow a safe and comprehensive assessment.

INTRODUCTION: Frailty at listing for lung transplant has been associated with waitlist and post-transplant mortality. Frailty trajectories following transplant, however, have been less well characterized, including whether recipient frailty improves. The objective of this study was to identify prevalence and risk factors for frailty at discharge and to evaluate changes in frail recipients enrolled in an outpatient physical therapy program. METHODS: This was a single-center prospective cohort study of lung transplant recipients. Enrollees completed a short physical performance battery (SPPB) to assess frailty at listing and at initial hospital discharge. RESULTS: Of the 111 enrolled recipients, none were frail at listing and 18 (16.2%) were prefrail. At discharge, however, 60 (54.1%) patients were frail. Discharge frailty was associated with prefrailty at listing, acute kidney injury post-transplant, and longer intensive care unit stay. Among the 35 patients who were frail at discharge and who were enrolled in an outpatient PT program, the median improvement in SPPB was 6 points (IQR = 5-7 points), and 85.7% became not frail over a median of 6 weeks. CONCLUSION: Discharge frailty is common following lung transplantation. In most frail patients, an intensive outpatient physical therapy program is associated with improvement in frailty, as assessed by the SPPB.

This research examined the transition from occupational therapy student to practicing occupational therapist over the course of one's first year of professional employment, as recalled by a sample of occupational therapists. Surveys were mailed to 500 occupational therapists randomly selected from membership in the American Occupational Therapy Association resulting in 202 returned surveys. Median year of graduation was 1998, ranging from 1967 to 2014. In general, respondents indicated the transition was positive. Having a mentor was related to high job satisfaction and good clinical fit, while supervising an occupational therapy assistant and low self-confidence were viewed as negative impact factors. Recent graduates presented with lower ratings of a positive transition and higher ratings of likelihood of experiencing burnout and initial job stress than earlier graduates. Recommendations for improving the transition experience are presented.

Early reliable, valid screening, diagnosis, and treatment improve peripheral arterial disease outcomes, yet screening and diagnostic practices vary across settings and specialties. A scoping literature review described reliability and validity of peripheral ischaemia diagnosis or screening tools. Clinical studies in the PUBMED database January 1, 1970, to August 13, 2018, were reviewed summarising ranges of reliability and validity of peripheral ischaemia diagnostic and screening tools for patients with non-neuropathic lower leg ischaemia. Peripheral ischaemia screening and diagnostic practices varied in parameters measured such as timing, frequency, setting, ordering clinicians, degree of invasiveness, costs, definitions, and cut-off points informing clinical and referral decisions. Traditional ankle/brachial systolic blood pressure index <0.9 was a reliable, valid lower leg ischaemia screening test to trigger specialist referral for detailed diagnosis. For patients with advanced peripheral ischaemia or calcified arteries, toe-brachial index, claudication, or invasive angiographic imaging techniques that can have complications were reliable, valid screening, and diagnostic tools to inform management decisions. Ankle/brachial index testing is sufficiently reliable and valid for use during routine examinations to improve timing and consistency of peripheral ischaemia screening, triggering prompt specialist referral for more reliable, accurate Doppler, or other diagnosis to inform treatment decisions.