bluuebunny/crossref_metadata_2025 huggingface dataset:
Antimicrobial Prescribing during Infant Hospital Admissions in a Birth Cohort in Dhaka, Bangladesh
Authors: Boone Katherine , Morris Shaun K , Doshi Sejal , Black Jason , Mohsin Minhazul , Ahmed Tahmeed , Al Mahmud Abdullah , Roth Daniel E
Published: October 2020

Empirical antimicrobial use is common in hospitalized infants and may contribute to antimicrobial resistance in low- and middle-income countries. In this observational birth cohort study nested in a randomized controlled trial in Dhaka, Bangladesh, inpatient antimicrobial prescription data were extracted from serious adverse event forms completed for hospitalizations of infants (0–12 months of age). The primary outcome was the proportion of inpatient admissions where systemic antimicrobials were prescribed. Infant and hospitalization-related factors associated with antimicrobial prescriptions were determined. Among 1254 infants, there were 448 admissions to 32 facilities from 2014 to 2016. Antimicrobials were prescribed in 73% of admissions with a mean antimicrobial exposure rate of 0.25 antimicrobials per day of admission [95% confidence intervals (95% CIs): 0.24–0.27]. The most common antibiotics were aminoglycosides (29%), penicillins (26%) and third-generation cephalosporins (25%). In all, 58% of antibiotics were classified as ‘access’, 38% ‘watch’ and 1% ‘reserve’ using the World Health Organization (WHO) Essential Medicines List classification. WHO-recommended antimicrobial regimens were used in 68% of neonatal sepsis and 9% of lower respiratory tract infection (LRTI) admissions. ‘Watch’ antimicrobials were used in 26% of neonatal sepsis and 76% of LRTI admissions. Compared with private facilities, antimicrobial prescription rates were lower at government [rate ratio (RR) 0.71; 95% CI: 0.61–0.83] and charitable facilities (RR 0.39; 95% CI: 0.28–0.53), after adjustment for household wealth index and parental education. Younger infant age, older maternal age and longer admission were associated with higher prescription rates. These findings highlight the need for paediatric antimicrobial stewardship programs in Bangladesh.
Tolerance mechanisms in allergen immunotherapy
Authors: Celebi Sözener Zeynep , Mungan Dilsad , Cevhertas Lacin , Ogulur Ismail , Akdis Mübeccel , Akdis Cezmi
Published: October 2020

Purpose of review

Allergen immunotherapy is the only treatment modality which alters the natural course of allergic diseases by restoring immune tolerance against allergens. Deeper understanding of tolerance mechanisms will lead to the development of new vaccines, which target immune responses and promote tolerance.

Recent findings

Successful allergen immunotherapy (AIT) induces allergen-specific peripheral tolerance, characterized mainly by the generation of allergen-specific Treg cells and reduction of Th2 cells. At the early phase, AIT leads to a decrease in the activity and degranulation of mast cells and basophils and a decrease in inflammatory responses of eosinophils in inflamed tissues. Treg cells show their effects by secreting inhibitory cytokines including interleukin (IL)-10, transforming growth factor-β, interfering with cellular metabolisms, suppressing antigen presenting cells and innate lymphoid cells (ILCs) and by cytolysis. AIT induces the development of regulatory B cells producing IL-10 and B cells expressing allergen-specific IgG4. Recent investigations have demonstrated that AIT is also associated with the formation of ILC2reg and DCreg cells which contribute to tolerance induction.

Research done so far, has shown that multiple molecular and cellular factors are dysregulated in allergic diseases and modified by AIT. Studies should now focus on finding the best target and ideal biomarkers to identify ideal candidates for AIT.
Acid-sensing Ion Channel 3 Overexpression in Incisions Regulated by Nerve Growth Factor Participates in Postoperative Nociception in Rats
Authors: Li Hao , Li Huiping , Cheng Jing , Liu Xicheng , Zhang Zhongjun , Wu Chaoran
Published: October 2020

Background

Acid-sensing ion channel 3 (ASIC3) upregulation has been reported in dorsal root ganglion neurons after incision and contributes to postoperative nociception. This study hypothesized that upregulation of ASIC3 in incised tissues is induced by nerve growth factor through the phosphoinositide 3–kinase/protein kinase B signaling pathway.

Methods

A plantar incision model was established in adult male and female Sprague–Dawley rats. ASIC3 was inhibited by APETx2 treatment, small interfering RNA treatment, or ASIC3 knockout. Sciatic nerve ligation was performed to analyze ASIC3 transport. A nerve growth factor antibody and a phosphoinositide 3–kinase inhibitor were used to investigate the mechanism by which nerve growth factor regulates ASIC3 expression.

Results

Acid-sensing ion channel 3 inhibition decreased incisional guarding and mechanical nociception. ASIC3 protein levels were increased in skin and muscle 4 h after incision (mean ± SD: 5.4 ± 3.2-fold in skin, n = 6, P = 0.001; 4.3 ± 2.2-fold in muscle, n = 6, P = 0.001). Sciatic nerve ligation revealed bidirectional ASIC3 transport. Nerve growth factor antibody treatment inhibited the expression of ASIC3 (mean ± SD: antibody 2.3 ± 0.8-fold vs. vehicle 4.9 ± 2.4-fold, n = 6, P = 0.036) and phosphorylated protein kinase B (mean ± SD: antibody 0.8 ± 0.3-fold vs. vehicle 1.8 ± 0.8-fold, n = 6, P = 0.010) in incised tissues. Intraplantar injection of nerve growth factor increased the expression of ASIC3 and phosphorylated protein kinase B. ASIC3 expression and incisional pain–related behaviors were inhibited by pretreatment with the phosphoinositide 3–kinase inhibitor LY294002.

Conclusions

Acid-sensing ion channel 3 overexpression in incisions contributes to postoperative guarding and mechanical nociception. Bidirectional transport of ASIC3 between incised tissues and dorsal root ganglion neurons occurs through the sciatic nerve. Nerve growth factor regulates ASIC3 expression after plantar incision through the phosphoinositide 3–kinase/protein kinase B signaling pathway.

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Slower Speaking Rate Reduces Listening Effort Among Listeners With Cochlear Implants
Authors: Winn Matthew B. , Teece Katherine H.
Published: October 2020

Objectives:

Slowed speaking rate was examined for its effects on speech intelligibility, its interaction with the benefit of contextual cues, and the impact of these factors on listening effort in adults with cochlear implants.

Design:

Participants (n = 21 cochlear implant users) heard high- and low-context sentences that were played at the original speaking rate, as well as a slowed (1.4× duration) speaking rate, using uniform pitch-synchronous time warping. In addition to intelligibility measures, changes in pupil dilation were measured as a time-varying index of processing load or listening effort. Slope of pupil size recovery to baseline after the sentence was used as an index of resolution of perceptual ambiguity.

Results:

Speech intelligibility was better for high-context compared to low-context sentences and slightly better for slower compared to original-rate speech. Speech rate did not affect magnitude and latency of peak pupil dilation relative to sentence offset. However, baseline pupil size recovered more substantially for slower-rate sentences, suggesting easier processing in the moment after the sentence was over. The effect of slowing speech rate was comparable to changing a sentence from low context to high context. The effect of context on pupil dilation was not observed until after the sentence was over, and one of two analyses suggested that context had greater beneficial effects on listening effort when the speaking rate was slower. These patterns maintained even at perfect sentence intelligibility, suggesting that correct speech repetition does not guarantee efficient or effortless processing. With slower speaking rates, there was less variability in pupil dilation slopes following the sentence, implying mitigation of some of the difficulties shown by individual listeners who would otherwise demonstrate prolonged effort after a sentence is heard.

Conclusions:

Slowed speaking rate provides release from listening effort when hearing an utterance, particularly relieving effort that would have lingered after a sentence is over. Context arguably provides even more release from listening effort when speaking rate is slower. The pattern of prolonged pupil dilation for faster speech is consistent with increased need to mentally correct errors, although that exact interpretation cannot be verified with intelligibility data alone or with pupil data alone. A pattern of needing to dwell on a sentence to disambiguate misperceptions likely contributes to difficulty in running conversation where there are few opportunities to pause and resolve recently heard utterances.
The Association of Preoperative Duration of Symptoms With Clinical Outcomes and Minimal Clinically Important Difference Following Anterior Cervical Discectomy and Fusion
Authors: Jenkins Nathaniel W. , Parrish James M. , Lynch Conor P. , Cha Elliot D.K. , Mohan Shruthi , Geoghegan Cara E. , Jadczak Caroline N. , Singh Kern
Published: October 2020

Study Design:

This was a retrospective cohort study.

Objective:

The purpose of this study is to examine whether the time duration from symptom onset to operative treatment is associated with postoperative clinical improvement after anterior cervical discectomy and fusion (ACDF).

Summary of Background Data:

There is a paucity of literature regarding the influence of preoperative symptom duration on patient-reported outcomes (PROs) following ACDF.

Methods:

Patients who underwent primary, single-level ACDF were retrospectively reviewed and stratified according to preoperative symptom duration (<12 and ≥12 mo). Demographic and perioperative characteristics were compared using χ2 analysis and linear regression. Subgroup mean scores were compared and achievement of minimal clinically important difference (MCID) was assessed for the Neck Disability Index (NDI), Visual Analogue Scale (VAS) neck pain, VAS arm pain, and 12-Item Short-Form Physical Component Score.

Results:

A total of 109 patients underwent primary, single-level ACDF: 68 had duration of symptoms (DOS) <12 months and 41 had a DOS ≥12 months. When comparing DOS subgroup preoperative PROs, there was no preoperative difference in NDI, VAS arm or neck pain, and 12-Item Short-Form Physical Component Score. In the postoperative period, there were no significant differences in the improvement of PROs throughout the 12-month timepoint. A significantly larger proportion of the <12 months DOS cohort achieved NDI MCID at the 3-month (66.1% vs. 43.8%, P=0.039) and 6-month (76.8% vs. 53.6%, P=0.030) postoperative period.

Conclusions:

Among the patient subgroups with <12 and ≥12 months DOS, there were no statistically significant differences observed in any of the measured PRO means at any timepoint. When assessing MCID, however, patients with shorter DOS (<12 mo) were observed to attain NDI MCID at the 3- and 6-month timepoints more often than patients with DOS ≥12 months. Our findings suggest that delayed surgical intervention may impair functional recovery to MCID in patients with degenerative cervical disease.
Evaluating the Cost-Effectiveness of the ABCDE Bundle: Impact of Bundle Adherence on Inpatient and 1-Year Mortality and Costs of Care*
Authors: Collinsworth Ashley W. , Priest Elisa L. , Masica Andrew L.
Published: October 2020

Objectives:

Growing evidence supports the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility (ABCDE) bundle processes as improving a number of short- and long-term clinical outcomes for patients requiring ICU care. To assess the cost-effectiveness of this intervention, we determined the impact of ABCDE bundle adherence on inpatient and 1-year mortality, quality-adjusted life-years, length of stay, and costs of care.

Design:

We conducted a 2-year, prospective, cost-effectiveness study in 12 adult ICUs in six hospitals belonging to a large, integrated healthcare delivery system.

Setting:

Hospitals included a large, urban tertiary referral center and five community hospitals. ICUs included medical/surgical, trauma, neurologic, and cardiac care units.

Patients:

The study included 2,953 patients, 18 years old or older, with an ICU stay greater than 24 hours, who were on a ventilator for more than 24 hours and less than 14 days.

Intervention:

ABCDE bundle.

Measurements and Main Results:

We used propensity score-adjusted regression models to determine the impact of high bundle adherence on inpatient mortality, discharge status, length of stay, and costs. A Markov model was used to estimate the potential effect of improved bundle adherence on healthcare costs and quality-adjusted life-years in the year following ICU admission. We found that patients with high ABCDE bundle adherence (≥ 60%) had significantly decreased odds of inpatient mortality (odds ratio 0.28) and significantly higher costs ($3,920) of inpatient care. The incremental cost-effectiveness ratio of high bundle adherence was $15,077 (95% CI, $13,675–$16,479) per life saved and $1,057 per life-year saved. High bundle adherence was associated with a 0.12 increase in quality-adjusted life-years, a $4,949 increase in 1-year care costs, and an incremental cost-effectiveness ratio of $42,120 per quality-adjusted life-year.

Conclusions:

The ABCDE bundle appears to be a cost-effective means to reduce in-hospital and 1-year mortality for patients with an ICU stay.
Respiratory hospitalizations and wildfire smoke: a spatiotemporal analysis of an extreme firestorm in San Diego County, California
Authors: Aguilera Rosana , Hansen Kristen , Gershunov Alexander , Ilango Sindana D. , Sheridan Paige , Benmarhnia Tarik
Published: October 2020

Background:

Wildfire smoke adversely impacts respiratory health as fine particles can penetrate deeply into the lungs. Epidemiological studies of differential impacts typically target population subgroups in terms of vulnerability to wildfire smoke. Such information is useful to customize smoke warnings and mitigation actions for specific groups of individuals. In addition to individual vulnerability, it is also important to assess spatial patterns of health impacts to identify vulnerable communities and tailor public health actions during wildfire smoke events.

Methods:

We assess the spatiotemporal variation in respiratory hospitalizations in San Diego County during a set of major wildfires in 2007, which led to a substantial public health burden. We propose a spatial within-community matched design analysis, adapted to the study of wildfire impacts, coupled with a Bayesian Hierarchical Model, that explicitly considers the spatial variation of respiratory health associated with smoke exposure, compared to reference periods before and after wildfires. We estimate the signal-to-noise ratio to ultimately gauge the precision of the Bayesian model output.

Results:

We find the highest excess hospitalizations in areas covered by smoke, mainly ZIP codes contained by and immediately downwind of wildfire perimeters, and that excess hospitalizations tend to follow the distribution of smoke plumes across space (ZIP codes) and time (days).

Conclusions:

Analyzing the spatiotemporal evolution of exposure to wildfire smoke is necessary due to variations in smoke plume extent, particularly in this region where the most damaging wildfires are associated with strong wind conditions.
Perimenopausal contraception
Authors: Voedisch Amy J. , Ariel Danit
Published: October 2020

Purpose of review

Perimenopause is a time of reduced fertility, and yet unintended pregnancies can occur making comprehensive contraceptive counseling essential for these women. Concern over potential contraceptive risks has unnecessarily limited access and use of certain hormonal methods in this population. This review summarizes the available data on the use and effectiveness of contraceptive options during perimenopause.

Recent findings

All contraceptive options may be appropriate during perimenopause and no method is contraindicated based on age alone. Combined hormonal contraception has the added benefit of relieving perimenopausal symptoms including controlling menstrual irregularities. Progestin-only methods have the advantage of being taken either alone or in combination with estrogen replacement therapy to address both perimenopausal symptoms and contraceptive needs. Nonhormonal options exist for those wishing to avoid hormonal methods.

Extensive contraceptive options are available for perimenopausal women as they transition into menopause. Consideration of patient preference, medical co-morbidities, and perimenopausal symptoms will allow women to use the option that best serves her needs.
Temporal improvements in perioperative stroke rates following coronary artery bypass grafting
Authors: Weiss Aaron J. , Svensson Lars G. , Bakaeen Faisal G.
Published: October 2020

Purpose of review

Perioperative stroke remains one of the most dreaded complications following coronary artery bypass grafting. In this review, we highlight the significant advances in understanding and preventing stroke in patients undergoing bypass surgery and offer our center's current best-practice recommendations to help avoid this debilitating outcome.

Recent findings

The incidence of stroke has significantly reduced since the advent of coronary artery bypass graft surgery. Improvements in our understanding of the cause, mechanisms, risk factors, and diagnosis of stroke as well as refinements in medical optimization, surgical technique, and perioperative care all have contributed to making coronary artery bypass grafting safer even as patients have become increasingly complex.

The field of cardiothoracic surgery endures in its quest to eliminate the risk of perioperative stroke. By incorporating the lessons of the past into our innovations of the future, cardiac surgeons will continue to strive for safer coronary artery bypass grafting and afford patients to not only live longer but better as well.
Epidemiological characteristics and related factors of frailty in older Chinese adults with hypertension: a population-based study
Authors: Ma Lina , Chhetri Jagadish K. , Liu Pan , Ji Tong , Zhang Li , Tang Zhe
Published: October 2020

Objectives:

Hypertension is highly prevalent in the elderly and represents a major risk factor for cardiovascular complications such as coronary heart disease, stroke, and cognitive dysfunction. Frailty is a common geriatric syndrome characterized by increased risk of disability, hospitalization, and mortality. However, little is known about the frailty status in older adults with hypertension. Thus, we aimed to explore the epidemiological characteristics and related factors of frailty in older Chinese adults with hypertension.

Methods:

The current study included data collected from participants in the China Comprehensive Geriatric Assessment Study. Frailty was defined using the frailty index. Hypertension was defined as SBP at least 140 mmHg, DBP at least 90 mmHg, current treatment with antihypertensive medication, or a self-reported diagnosis of hypertension.

Results:

Frailty index was positively correlated with age. The prevalence of frailty was significantly higher in hypertensive patients than in normal controls. The prevalence of frailty in older adults with hypertension was 13.8% in China. The awareness and treatment of hypertension was higher in frail individuals than in nonfrail individuals. The control rate of hypertension did not differ significantly between the two groups. Logistic analysis showed that older age, poor marital status, coronary heart disease, chronic obstructive pulmonary disease, cerebrovascular disease, diabetic mellitus, osteoporosis, hearing loss, lack of exercise, depression, cognitive impairment, and higher white blood cell count were factors independently related with frailty in older participants with hypertension.

Conclusion:

The current study provides the first evidence regarding the status of frailty in older Chinese adults with hypertension.
Chronic Myeloid Leukemia in 2020
Authors: Hehlmann Rüdiger
Published: October 2020

New insights have emerged from maturing long‐term academic and commercial clinical trials regarding optimum management of chronic myeloid leukemia (CML). Velocity of response has unexpectedly proved less important than hitherto thought, does not predict survival, and is of unclear relevance for treatment‐free remission (TFR). Serious and cumulative toxicity has been observed with tyrosine kinase inhibitors that had been expected to replace imatinib. Generic imatinib has become cost‐effective first‐line treatment in chronic phase despite chronic low‐grade side‐effects in many patients. Earlier recognition of end‐phase by genetic assessment might improve prospects for blast crisis (BC). TFR has become an important new treatment goal of CML. To reflect this new situation ELN has recently revised and updated its recommendations for treating CML. After a brief review of 175 years of CML history this review will focus on recent developments and on current evidence for treating CML in 2020.
Age-dependent Interactions Among Clinical Characteristics, Viral Loads and Disease Severity in Young Children With Respiratory Syncytial Virus Infection
Authors: Brenes-Chacon Helena , Garcia-Mauriño Cristina , Moore-Clingenpeel Melissa , Mertz Sara , Ye Fang , Cohen Daniel M. , Ramilo Octavio , Mejias Asuncion
Published: October 2020

Background:

Age-dependent differences in clinical presentation and viral loads in infants and young children with respiratory syncytial virus (RSV) infection, and their correlation with disease severity are poorly defined.

Methods:

Previously healthy children <2 years old with mild (outpatients) and severe (inpatients) RSV infection were enrolled and viral loads measured by polymerase chain reaction in nasopharyngeal swabs. Patients were stratified by age in 0–<3, 3–6 and >6–24 months, and multivariable analyses were performed to identify clinical and viral factors associated with severe disease.

Results:

From 2014 to 2018, we enrolled 534 children with RSV infection, 130 outpatients with mild RSV infection and 404 inpatients with severe RSV disease. Median duration of illness was 4 days for both groups, yet viral loads were higher in outpatients than in inpatients (P < 0.001). In bivariate analyses, wheezing was more frequent in outpatients of older age (>3 months) than in inpatients (P < 0.01), while fever was more common in inpatients than outpatients (P < 0.01) and its frequency increased with age. Adjusted analyses confirmed that increased work of breathing and fever were consistently associated with hospitalization irrespective of age, while wheezing in infants >3 months, and higher RSV loads in children >6–24 months were independently associated with reduced disease severity.

Conclusions:

Age had a significant impact defining the interactions among viral loads, specific clinical manifestations and disease severity in children with RSV infection. These observations highlight the importance of patient stratification when evaluating interventions against RSV.
Timeline of pain before dementia diagnosis: a 27-year follow-up study
Authors: Kumaradev Sushmithadev , Fayosse Aurore , Dugravot Aline , Dumurgier Julien , Roux Christian , Kivimäki Mika , Singh-Manoux Archana , Sabia Séverine
Published: October 2020

This study examines the importance of length of follow-up on the association between pain and incident dementia. Further objective was to characterize pain trajectories in the 27 years preceding dementia diagnosis and compare them with those among persons free of dementia during the same period. Pain intensity and pain interference (averaged as total pain) were measured on 9 occasions (1991-2016) using the Short-Form 36 Questionnaire amongst 9046 (women = 31.4%) dementia-free adults aged 40 to 64 years in 1991; 567 dementia cases were recorded between 1991 and 2019. Cox regression was used to assess the association between pain measures at different time points and incident dementia and mixed models to assess pain trajectories preceding dementia diagnosis or end point for dementia-free participants. Results from Cox regression showed moderate/severe compared with mild/no total pain, pain intensity, and pain interference not to be associated with dementia when the mean follow-up was 25.0, 19.6, 14.5, or 10.0 years. These associations were evident for a mean follow-up of 6.2 years: for total pain (hazard ratio = 1.72; 95% confidence intervals = 1.28-2.33), pain intensity (1.41; 1.04-1.92), and pain interference (1.80; 1.30-2.49). These associations were stronger when the mean follow-up for incidence of dementia was 3.2 years. Twenty-seven–year pain trajectories differed between dementia cases and noncases with small differences in total pain and pain interference evident 16 years before dementia diagnosis (difference in the total pain score = 1.4, 95% confidence intervals = 0.1-2.7) and rapidly increasing closer to diagnosis. In conclusion, these findings suggest that pain is a correlate or prodromal symptom rather than a cause of dementia.
Hemolytic Disease of the Fetus and Newborn Caused by Anti-Group A IgG From a Group B Mother
Authors: Wang Ruyao , Li Yang , Tong Yingna , Su Nailun
Published: October 2020

ABO incompatibility has emerged as the premier reason for hemolytic disease of the fetus and newborn (HDFN). It always occurs in the offspring of blood group O mother. We present a rare case that the fetus of group A got HDFN caused by the anti-group A immunoglobulin G from a group B mother. The direct Coombs test of the fetus blood was negative, but the indirect Coombs test on A1 standard blood cells was strong positive (4+). The acid release test of antibody on the membrane of red blood cells to A1 standard blood cells was also strong positive (4+). Bilirubin of the fetus reached the threshold of exchange transfusion, but she just received 4 days’ phototherapy and 2.2 g albumin intravenous injection, with no packed blood cells transfusion, because her family refused, and came to a favorable outcome. This case reminds us not to ignore the possibility of HDFN in offspring of mothers with non-O blood group.
Subcutaneous Panniculitis-like T-Cell Lymphoma With Hemophagocytic Lymphohistiocytosis Syndrome in Children and Its Essential Role of HAVCR2 Gene Mutation Analysis
Authors: Chaweephisal Phumin , Sosothikul Darintr , Polprasert Chantana , Wananukul Siriwan , Seksarn Panya
Published: October 2020

Background:

We identified 3 adolescents with alpha-beta subtype subcutaneous panniculitis-like T-cell lymphoma.

Case Presentation:

Three patients presented with prolonged fever, abnormal skin lesions, and cytopenia described in the context. All had the same disease entity, which showed the prolonged duration of B systemic symptoms till diagnosis, difficulty to distinguish from autoimmune diseases, presence of hemophagocytic lymphohistiocytosis syndrome, good response, and remained on long-term remission with nonchemotherapy treatment, which included oral corticosteroid and cyclosporin.

Conclusions:

Although diagnosis can only be “highly suspected” with pathologic review, some cases may need multiple serial skin biopsy to clarify diagnosis because of the discrete distribution of specific histology. T-cell receptor gene rearrangement, which demonstrates a monoclonal pattern of alpha and beta chain gene, is the essential requirement for specific diagnosis. The role of molecular analysis by identification of germline hepatitis A virus cellular receptor 2 (HAVCR2) gene mutation can be much valuable in classifying susceptible patients.
Suppurative Thyroiditis
Authors: Pereira Kevin D. , Highstein Mallory J. , Greenwell Ariana G. , Isaiah Amal , Valdez Tulio A.
Published: October 2020

Objective

The aim of this study was to determine if microbiological cultures can guide management of suppurative thyroiditis.

Design

This study is a retrospective case series set in 2 tertiary care academic hospitals.

Methods

The microbiological cultures from patients with suppurative thyroiditis who underwent incision and drainage from July 2004 to June 2018 were reviewed. Those who had confirmed pyriform sinus tracts and underwent surgical intervention were included in the study.

Results

Fifteen patients satisfied the criteria for inclusion. All had confirmed pyriform sinus tracts and underwent successful intervention. Endoscopic cautery was the most common intervention followed by complete open excision. Five cultures grew alpha Streptococcus, 6 had Eikenella, and 4 Prevotella. Combinations of Eikenella + Prevotella were seen in 3, and 1 sample had all 3 bacteria. Two cultured methicillin-susceptible Staphylococcus aureus alone. One culture was sterile.

Conclusions

The presence of oral flora in an intrathyroidal abscess is confirmatory evidence of a pyriform sinus tract. Further investigations are not needed, and early definitive intervention can be planned.
Fever Without Source in Unvaccinated Children Aged 3 to 24 Months
Authors: Finkel Leah , Ospina-Jimenez Camila , Byers Michael , Eilbert Wesley
Published: October 2020

Fever is the most common complaint for infants and children brought to the emergency department. Most febrile children younger than 3 years will have a clinically apparent source of infection. However, in approximately 20% of these children, a source cannot be identified by history and physical examination alone. The recommended diagnostic approach to children younger than 3 years presenting with fever without source (FWS) has changed dramatically over the past 30 years because of the widespread use of the Haemophilus influenza type b and polyvalent pneumococcal vaccines. The percentage of children in the United States unvaccinated at 24 months is now over 1% and seems to be increasing. This article will review what is currently known about FWS in children aged 3 to 24 months in the modern era and how it pertains to unvaccinated children treated in the emergency department. An algorithm for the treatment of unvaccinated young children presenting with FWS is proposed.
Judging an Expander by Its Cover: A Propensity-Matched Analysis of the Impact of Tissue Expander Surface Texture on First-Stage Breast Reconstruction Outcomes
Authors: Chiu Wen-Kuan , Fracol Megan , Feld Lauren N. , Qiu Cecil S. , Kim John Y. S.
Published: October 2020

Background:

There is increased scrutiny of texturing on implants and a paucity of data looking at texturing on expanders. Because of the difficulty in controlling potential confounders with these comparative studies, the authors performed propensity matching between smooth and textured tissue expander cohorts to provide definitive insight into the impact of expander texture on breast reconstruction outcomes.

Methods:

A single-surgeon experience with immediate two-stage breast reconstruction was reviewed for 90-day postoperative complications after mastectomy and expander placement. Variables extracted included demographics, comorbidities, tissue expander texturing, mastectomy type, infection, seroma, skin flap necrosis, dehiscence, explantation, and overall complication rates. Subjects were 1:1 propensity matched using the nearest neighbor matching algorithm with caliper (maximum propensity score difference) of 0.2, and chi-square test was performed for statistical analysis.

Results:

After 1:1 propensity matching, 282 reconstructed breasts were analyzed (141 textured versus 141 smooth expanders). Textured expanders had higher minor infection rates than smooth expanders (5.0 percent versus 0 percent; p = 0.024). Smooth expanders had higher seroma rates than textured expanders (5.0 percent versus 0.7 percent; p = 0.031). Smooth expanders also had longer drain retention (20.4 days versus 16.8 days; p = 0.001). There was no difference in other complications, including major infection, explantation, or any complication, between textured and smooth expanders.

Conclusions:

Textured expanders are associated with increased minor infection risk, whereas smooth expanders are associated with increased seroma formation. However, these differing complication profiles coalesce to equal explantation rates.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.
Hyaluronic Acid Filler Longevity and Localization: Magnetic Resonance Imaging Evidence
Authors: Master Mobin
Published: October 2020

Hyaluronic acid is the most commonly used facial dermal filler in aesthetic medicine. Identification of placement, longevity, and localization of hyaluronic acid fillers are becoming increasingly important. This article proposes a practical approach to monitoring the location and longevity of hyaluronic acid, using magnetic resonance imaging.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, V.
Improvement Initiative to Develop and Implement a Tool for Detecting Drug-Drug Interactions During Oncology Clinical Trial Enrollment Eligibility Screening
Authors: Marcath Lauren A. , Coe Taylor D. , Shakeel Faisal , Reynolds Edward , Bayuk Mike , Haas Steven , Redman Bruce G. , Wong Siu-Fun , Hertz Daniel L.
Published: October 2020

Objectives

Screening subjects for drug-drug interactions (DDIs) before enrollment in oncology clinical trials is integral to ensuring safety, but standard procedures or tools are not readily available to screen DDI in this setting. Our objectives were to develop a DDI screening tool for use during oncology clinical trial enrollment and to test usability in single-center and multicenter pilot studies.

Methods

A multistage approach was used for this quality improvement intervention. Semistructured interviews with individuals responsible for DDI screening were conducted to develop a prototype tool. The tool was used for screening DDI in subjects enrolling in National Clinical Trials Network trials of commercially available agents during a single-center 3-month pilot. Improvements were made, and a 3-month multicenter pilot was conducted at volunteer SWOG Cancer Research Network sites. Participants were surveyed to determine tool usability and efficiency.

Results

A tool was developed from semistructured interviews. A critical feature was reporting which medications had specific pharmacokinetic and pharmacodynamic characteristics including transporter and cytochrome P450 substrates, inhibitors, or inducers and QT prolongation. In the 12-site study, average (SD) DDI screening time for each patient decreased by 15.7 (10.2) minutes (range, 3–35 minutes; P < 0.001). Users reported the tool highly usable, with >90% agreeing with all positive usability characterizations and disagreeing with all negative complexity characterizations.

Conclusions

A DDI screening tool for oncology clinical trial enrollment was created and its usability confirmed. Further testing with more diverse investigator sites and study drugs during eligibility screening is warranted to improve safety and data accuracy within clinical trials.
Prevalence of Abnormal Coronary Findings on Coronary Computed Tomography Angiography Among Young Adults Presenting With Chest Pain
Authors: Burt Jeremy R. , O’Dell Matthew Cody , Yacoub Basel , Chamberlin Jordan , Waltz Jeffrey , Wallace Charlotte , Kocher Madison , Sacerdote Michael , Gonzalez Antonio , Feranec Nicholas , Hernandez Manuel , Agha Ali , Liu Bo
Published: October 2020

Purpose:

We evaluated the prevalence of coronary stenosis on coronary computed tomography angiography (CCTA) in patients aged 18 to 30 years, who presented to the emergency department with chest pain. We also examined the risk factors potentially associated with abnormal coronary findings on CCTA in this age group.

Materials and Methods:

A total of 884 patients were retrospectively evaluated. Indication for CCTA was guided by our hospital’s chest pain protocol based on ACC/AHA guidelines. These were performed using the standard technique and interpreted based on CAD-RADS guidelines. Scans were identified as abnormal if atherosclerotic coronary artery disease (CAD), myocardial bridging (MB), or any anatomic coronary artery anomaly were present.

Results:

Twenty-two percent of patients had a coronary abnormality on CCTA. The most common abnormality was MB (17.3%), followed by CAD (4.4%) and coronary anomalies (1.5%). A small minority had stenosis (2.8%), most commonly caused by CAD. Most cases with stenosis were minimal to mild (72%) with 0.8% having coronary stenosis ≥50%. Age and male sex were risk factors for both coronary artery stenosis (odds ratio: 1.32 and 4.50, 95% confidence interval: 1.03-1.69, and 1.23-16.46, P=0.028 and 0.023, respectively) and CAD (odds ratio: 1.52 and 3.67, 95% confidence interval: 1.14-2.04, and 1.26-10.66, P=0.005 and 0.017, respectively).

Conclusions:

Epicardial coronary stenosis is rarely the cause of chest pain among young adult patients presenting to the emergency department. Age and male sex were both risk factors for coronary artery stenosis/disease in this age group.
Thoracoscopy or Thoracotomy for Esophageal Atresia
Authors: Drevin Gustaf , Andersson Björn , Svensson Jan F.
Published: October 2020

Objective:

This systematic review with meta-analysis compares health- and provider-based outcomes of thoracoscopic to thoracotomy repair of esophageal atresia.

Summary of Background Data:

Thoracoscopic surgery has become a routine operation for esophageal atresia repair. However, large studies comparing the safety and efficacy of thoracoscopy to thoracotomy are scarce. Current reviews are obscured with institutional experiences or pool small samples.

Methods:

PRISMA-compliant search in Medline/PubMed, EMBASE, Web of Science, and Cochrane Library (PROSPERO #CRD42019121862) for original studies comparing thoracoscopy to thoracotomy for esophageal atresia. Quality assessments were performed using the Joanna Briggs Institute Critical Appraisal Tool. Meta-analyses were presented as odds ratios and standardized mean differences.

Results:

This is the largest published meta-analysis, including 17 studies and 1043 patients. Thoracoscopy produce shorter hospital stay [standardized mean differences (SMD) −11.91; 95% confidence interval (CI) 23.49–6.10; P = 0.0440], time until extubation (SMD −3.22; 95% CI 5.93–0.51; P = 0.0198), time until first oral feeding (SMD −2.84; 95% CI 4.62–1.07; P = 0.0017), and fewer musculoskeletal complications [odds ratio (OR) 0.08; 95% CI 0.01–0.58; P = 0.0133). Thoracoscopy is as safe as thoracotomy regarding leakage (OR −1.92; 95% CI 0.97–3.80; P = 0.0622), stricture formation (OR 2.66; 95% CI 0.86–3.23; P = 0.1339), stricture dilatation (OR 1.90; 95% CI 0.16–3.88; P = 0.0767), and mortality (OR 1.18; 95% CI 0.34–4.16; P = 0.7934). However, thoracoscopy take longer (SMD +27.69; 95% CI 12.06–43.32; P = 0.0005) and necessitate more antireflux surgery (OR 2.12; 95% CI 1.06–4.24; P = 0.0343).

Conclusion:

Thoracoscopy is effective and safe, with similar or better outcomes than thoracotomy for patients and providers. The only significant drawback is the need for antireflux surgery in the first years of life. Comparative randomized long-term studies are needed.
Is laparoscopic approach still a risk factor for postappendectomy intra-abdominal abscess?
Authors: Fernández-Moreno María-Carmen , Pérez Santiago Leticia , Martí Fernández Rosa , León Espinoza Carlos , Ortega Serrano Joaquín
Published: October 2020

BACKGROUND

The impact of laparoscopic appendectomy (LA) on the incidence of intra-abdominal abscess (IAA) remains controversial. We aimed to identify risk factors for postappendectomy IAA and assess the impact of appendectomy approach in postoperative morbidity.

METHODS

A retrospective single-center study including consecutive patients who underwent appendectomy for acute appendicitis between 2015 and 2018 was performed. Demographic, clinical, intraoperative, and perioperative variables were collected. Univariate and multivariate analyses was performed to detect independent risk factors for IAA. Comparison of LA and open appendectomy was conducted, and propensity score model (PSM) was used to overcome differences between groups. Independent risk factors for IAA were identified by univariate and multivariate analyses in the PSM cohort.

RESULTS

A total of 532 appendectomies were included. The median age was 35 years. Three hundred two patients (56.7%) underwent LA. The most frequent operative finding was American Association for the Surgery of Trauma (AAST) grade 1 appendicitis in 303 patients (57%). Peritonitis was found in 109 patients (20.5%). Postoperative morbidity and mortality were 14.4% and 0%, respectively. Intra-abdominal abscess rate was 6.2%. An AAST grade of ≥2, a preoperative C-reactive protein level of >100 mg/dL, and diabetes mellitus were identified as independent risk factors for IAA in the multivariate analysis. Comparing LA and open appendectomy, there were no differences in IAA rates. After PSM, LA showed lower morbidity and shorter hospital stay.

CONCLUSIONS

Laparoscopic appendectomy is a safe approach and not related to a higher risk of IAA. Patients with an AAST grade of ≥2, a preoperative C-reactive protein level of >100, and diabetes mellitus have higher risk for postappendectomy IAA.

LEVEL OF EVIDENCE

Therapeutic/care management, level IV.
Metagenome-assembled genome binning methods with short reads disproportionately fail for plasmids and genomic Islands
Authors: Maguire Finlay , Jia Baofeng , Gray Kristen L. , Lau Wing Yin Venus , Beiko Robert G. , Brinkman Fiona S. L.
Published: October 2020

Metagenomic methods enable the simultaneous characterization of microbial communities without time-consuming and bias-inducing culturing. Metagenome-assembled genome (MAG) binning methods aim to reassemble individual genomes from this data. However, the recovery of mobile genetic elements (MGEs), such as plasmids and genomic islands (GIs), by binning has not been well characterized. Given the association of antimicrobial resistance (AMR) genes and virulence factor (VF) genes with MGEs, studying their transmission is a public-health priority. The variable copy number and sequence composition of MGEs makes them potentially problematic for MAG binning methods. To systematically investigate this issue, we simulated a low-complexity metagenome comprising 30 GI-rich and plasmid-containing bacterial genomes. MAGs were then recovered using 12 current prediction pipelines and evaluated. While 82–94 % of chromosomes could be correctly recovered and binned, only 38–44 % of GIs and 1–29 % of plasmid sequences were found. Strikingly, no plasmid-borne VF nor AMR genes were recovered, and only 0–45 % of AMR or VF genes within GIs. We conclude that short-read MAG approaches, without further optimization, are largely ineffective for the analysis of mobile genes, including those of public-health importance, such as AMR and VF genes. We propose that researchers should explore developing methods that optimize for this issue and consider also using unassembled short reads and/or long-read approaches to more fully characterize metagenomic data.
Time-series clustering for home dwell time during COVID-19: what can we learn from it?
Authors: Huang Xiao , Li Zhenlong , Lu Junyu , Wang Sicheng , Wei Hanxue , Chen Baixu
Published: October 2020

In this study, we investigate the potential driving factors that lead to the disparity in the time-series of home dwell time, aiming to provide fundamental knowledge that benefits policy-making for better mitigation strategies of future pandemics. Taking Metro Atlanta as a study case, we perform a trend-driven analysis by conducting Kmeans time-series clustering using fine-grained home dwell time records from SafeGraph, and further assess the statistical significance of sixteen demographic/socioeconomic variables from five major categories. We find that demographic/socioeconomic variables can explain the disparity in home dwell time in response to the stay-at-home order, which potentially leads to disparate exposures to the risk from the COVID-19. The results further suggest that socially disadvantaged groups are less likely to follow the order to stay at home, pointing out the extensive gaps in the effectiveness of social distancing measures exist between socially disadvantaged groups and others. Our study reveals that the long-standing inequity issue in the U.S. stands in the way of the effective implementation of social distancing measures. Policymakers need to carefully evaluate the inevitable trade-off among different groups, making sure the outcomes of their policies reflect interests of the socially disadvantaged groups.

Highlights

We perform a trend-driven analysis by conducting Kmeans time-series clustering using fine- grained home dwell time records from SafeGraph.

We find that demographic/socioeconomic variables can explain the disparity in home dwell time in response to the stay-at-home order.

The results suggest that socially disadvantaged groups are less likely to follow the order to stay at home, potentially leading to more exposures to the COVID-19.

Policymakers need to make sure the outcomes of their policies reflect the interests of the disadvantaged groups.
LUNG ULTRASOUND FINDINGS IN PATIENTS WITH COVID-19 IN AN URBAN EMERGENCY DEPARTMENT IN THE UK – AN OBSERVATIONAL STUDY
Authors: Burkert Julia , Dunlop Hannah , Stewart Rachel , Treacy Adam , Jarman Robert , Deol Paramjeet
Published: October 2020

COVID-19 can present with respiratory symptoms ranging from mild cough to viral pneumonia and ARDS. Lung ultrasonography has emerged as a promising imaging modality during the pandemic, but there is still a paucity of systematic analysis of lung ultrasound findings.

In this retrospective observational study, 12 Zone ultrasound scans of COVID-19 positive patients were systematically analysed for pleural irregularities, subpleural consolidations, B lines, deep consolidations and effusions. Lung abnormalities were analysed according to overall frequency, frequency distribution in coronal and sagittal lung planes and were also correlated to clinical severity groups as determined by oxygenation deficit.

Our results show that lung zones with abnormalities can occur juxtaposed to normal lung. Irregular pleural and small subpleural consolidations appear ubiquitously distributed throughout both lungs and occur early in the disease process. Wide B-lines are a predominant feature in COVID-19 infection. B-lines are found in a variety of patterns with number and width correlated to disease severity. In our analysis we also describe a previously unrecognised finding of small peri-pleural effusions in 8.7% of scans occurring in all areas of the lung.

The current results form the basis for a more thorough understanding of the lung changes occurring in COVID-19 and the incorporation of lung ultrasound in the setting of COVID-19 infection including triage, diagnosis, treatment approach and prognosis.