bluuebunny/crossref_metadata_2025 huggingface dataset:
Structures of 1:1 and 2:1 complexes of BMVC and MYC promoter G-quadruplex reveal a mechanism of ligand conformation adjustment for G4-recognition
Authors: Liu Wenting , Lin Clement , Wu Guanhui , Dai Jixun , Chang Ta-Chau , Yang Danzhou
Published: November 2019

BMVC is the first fluorescent probe designed to detect G-quadruplexes (G4s) in vivo. The MYC oncogene promoter forms a G4 (MycG4) which acts as a transcription silencer. Here, we report the high-affinity and specific binding of BMVC to MycG4 with unusual slow-exchange rates on the NMR timescale. We also show that BMVC represses MYC in cancer cells. We determined the solution structures of the 1:1 and 2:1 BMVC–MycG4 complexes. BMVC first binds the 5′-end of MycG4 to form a 1:1 complex with a well-defined structure. At higher ratio, BMVC also binds the 3′-end to form a second complex. In both complexes, the crescent-shaped BMVC recruits a flanking DNA residue to form a BMVC-base plane stacking over the external G-tetrad. Remarkably, BMVC adjusts its conformation to a contracted form to match the G-tetrad for an optimal stacking interaction. This is the first structural example showing the importance of ligand conformational adjustment in G4 recognition. BMVC binds the more accessible 5′-end with higher affinity, whereas sequence specificity is present at the weaker-binding 3′-site. Our structures provide insights into specific recognition of MycG4 by BMVC and useful information for design of G4-targeted anticancer drugs and fluorescent probes.
Mapping RNA–capsid interactions and RNA secondary structure within virus particles using next-generation sequencing
Authors: Zhou Yiyang , Routh Andrew
Published: November 2019

To characterize RNA–capsid binding sites genome-wide within mature RNA virus particles, we have developed a Next-Generation Sequencing (NGS) platform: viral Photo-Activatable Ribonucleoside CrossLinking (vPAR-CL). In vPAR-CL, 4-thiouridine is incorporated into the encapsidated genomes of virus particles and subsequently UV-crosslinked to adjacent capsid proteins. We demonstrate that vPAR-CL can readily and reliably identify capsid binding sites in genomic viral RNA by detecting crosslink-specific uridine to cytidine transitions in NGS data. Using Flock House virus (FHV) as a model system, we identified highly consistent and significant vPAR-CL signals across virus RNA genome, indicating a clear tropism of the encapsidated RNA genome. Certain interaction sites coincide with previously identified functional RNA motifs. We additionally performed dimethyl sulfate mutational profiling with sequencing (DMS-MaPseq) to generate a high-resolution profile of single-stranded genomic RNA inside viral particles. Combining vPAR-CL and DMS-MaPseq reveals that the predominant RNA–capsid interaction sites favored double-stranded RNA regions. We disrupted secondary structures associated with vPAR-CL sites using synonymous mutations, resulting in varied effects to virus replication, propagation and packaging. Certain mutations showed substantial deficiency in virus replication, suggesting these RNA–capsid sites are multifunctional. These provide further evidence to support that FHV packaging and replication are highly coordinated and inter-dependent events.
Double-frequency Aharonov-Bohm effect and non-Abelian braiding properties of Jackiw-Rebbi zero-mode
Authors: Wu Yijia , Liu Haiwen , Liu Jie , Jiang Hua , Xie X C
Published: November 2019

Ever since its first proposal in 1976, Jackiw-Rebbi zero-mode has been drawing extensive attention for its charming properties including charge fractionalization, topologically protected zero-energy and possible non-Abelian statistics. We investigate these properties through the Jackiw-Rebbi zero-modes in quantum spin Hall insulators. Though charge fractionalization is not manifested, Jackiw-Rebbi zero-mode's zero-energy nature leads to a double-frequency Aharonov-Bohm effect, implying that it can be viewed as a special case of Majorana zero-mode without particle-hole symmetry. Such relation is strengthened for Jackiw-Rebbi zero-modes also exhibiting non-Abelian properties in the absence of superconductivity. Furthermore, in the condition that the degeneracy of Jackiw-Rebbi zero-modes is lifted, we demonstrate a novel non-Abelian braiding with continuously tunable fusion rule, which is a generalization of Majorana zero-modes’ braiding properties.
Incomplete information and iterated strict dominance
Authors: Bach Christian W , Perea Andrés
Published: November 2019

The solution concept of iterated strict dominance for static games with complete information recursively deletes choices that are inferior. Here, we devise such an algorithm for the more general case of incomplete information. The ensuing solution concept of generalized iterated strict dominance is characterized in terms of common belief in rationality as well as in terms of best response sets. Besides, we provide doxastic conditions that are necessary and sufficient for modelling complete information from a one-person perspective.
Clinical Outcomes Associated With Escherichia coli Infections in Adults With Cystic Fibrosis: A Cohort Study
Authors: Edwards B D , Somayaji R , Greysson-Wong J , Izydorczyk C , Waddell B , Storey D G , Rabin H R , Surette M G , Parkins M D
Published: November 2019

Background

Analysis of “emerging” pathogens in cystic fibrosis (CF) lung disease has focused on unique pathogens that are rare in other human diseases or are drug resistant. Escherichia coli is recovered in the sputum of up to 25% of patients with CF, yet little is known about the epidemiology or clinical impact of infection.

Methods

We studied patients attending a Canadian adult CF clinic who had positive sputum cultures for E coli from 1978 to 2016. Infection was categorized as transient or persistent (≥3 positive sputum cultures, spanning >6 months). Those with persistent infection were matched 2:1 with age, sex, and time-period controls without history of E coli infection, and mixed-effects models were used to assess pulmonary exacerbation (PEx) frequency, lung function decline, hospitalization, and intravenous antibiotic days.

Results

Forty-five patients (12.3%) had E coli recovered from sputum samples between 1978 and 2016, and 18 patients (40%) developed persistent infection. Nine patients (24%) had PEx at incident infection, and increased bioburden was predictive of exacerbation (P = .03). Risk factors for persistent infection included lower nutritional status (P < .001) and lower lung function (P = .009), but chronic infection with Pseudomonas aeruginosa was protective. There was no difference in annual lung function decline, need for hospitalization or intravenous antibiotics, or risk of PEx in patients with persistent infection.

Conclusions

Persistent E coli infection was frequent and was more common in CF patients with low nutritional status and lung function. However, this does not predict clinical decline. Multicenter studies would allow better characterization of the epidemiology and clinical impact of E coli infection.
Formal infectious diseases specialist consultation improves long-term outcome of methicillin-sensitive Staphylococcus aureus bacteremia
Authors: Forsblom E , Frilander H , Ruotsalainen E , Järvinen A
Published: November 2019

Background

Formal infectious diseases specialist (IDS) consultation has been shown to improve short-term outcome of Staphylococcus aureus bacteremia (SAB) but its effect on long-term outcome lacks evaluation.

Methods

Retrospective study of 367 methicillin-sensitive (MS) SAB patients followed for 10 years. The impact of formal IDS consultation on risk for new bacteremia and outcome during long-term follow-up were evaluated. Patients who died within 90 days were excluded to avoid interference from early deceased patients.

Results

304 (83%) patients had formal IDS consultation whereas 63 (17%) received informal or no IDS consultation. Formal consultation, compared to informal or lack of consultation, associated to a reduced risk for a new bacteremia caused by any pathogen within 1-year (OR, 0.39; 95% CI, .18-.84; p=.014; 8% vs. 17%), and within 3-years (OR, 0.39; 95% CI, .19-.80; p=.010; 9% vs. 21%) whereas a trend towards a lower risk was observed within 10-years (OR, 0.56; 95% CI, .29-1.08; p=.079; 16% vs. 25%). Formal consultation, compared to informal or lack of consultation, improved outcome at 1-year (OR, 0.16; 95% CI, .06-.44; p<0.001; 3% vs. 14%), at 3-years (OR, 0.19; 95% CI, .09-.42; p<.001; 5% vs. 22%) and at 10-years (OR, 0.43; 95% CI, .24-.74; p=.002; 27% vs. 46%). Considering all prognostic parameters formal consultation improved outcome (HR, 0.42; 95% CI, .27-.65, p<.001) and lowered risk for any new bacteremia (OR, 0.45; 95% CI, .23-.88, p=.02) during 10-years follow-up.

Conclusion

MS-SAB management by formal IDS consultation, compared to informal or lack of IDS consultation, reduces risk for any new bacteremia episodes and improves long-term prognosis up to ten years.
Far-Lateral Craniotomy for Posterior Inferior Cerebellar Artery to Occipital Artery Bypass: 2-Dimensional Operative Video
Authors: Hendricks Benjamin K , Spetzler Robert F
Published: November 2019

Posterior inferior cerebellar artery (PICA) aneurysms are infrequent compared with other intracranial aneurysms and are more commonly distal in origin (35% of PICA aneurysms are distal vs 6.5% of other aneurysms). This makes PICA aneurysms a surgical challenge that requires careful consideration of the patient's angiographic anatomy and perfusion needs before deciding on the appropriate intervention. This patient had a highly calcified left PICA p2 segment aneurysm, which was not favorable for endovascular intervention. An end-to-side anastomosis of the occipital artery to the p3 PICA segment was performed. This anastomosis was achieved with 11-0 suture. A permanent clip was then placed along the vertebral artery occluding both the proximal PICA and the aneurysm. Indocyanine green angiography was performed to demonstrate bypass and PICA patency. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.
High-Level Mobility Assessment Tool Normative Values for Children
Authors: Eldridge Beverly J , Galea Mary P , Kissane Anne L , Broder Jonathan C , Brilleman Samuel L , Wolfe Rory , Williams Gavin
Published: November 2019

Background

Physical therapists need to be able to evaluate high-level gross motor skills of children to determine their capacity to engage in activities such as running, jumping, hopping, and stair climbing. The High-Level Mobility Assessment Tool (HiMAT) has excellent interrater and retest reliability and is less susceptible to a ceiling effect than existing mobility scales in children who are 6 to 17 years old and have traumatic brain injury.

Objective

The purposes of this study were to develop normative HiMAT score ranges for Australian children and to investigate the relationship between children’s HiMAT scores and their age, height, weight, and body mass index (BMI).

Design

This study used a cross-sectional design.

Methods

Children included in this study were 5 to 12 years old, had no condition affecting their mobility, could follow 2-stage instructions, and had written informed consent from their parent or guardian. A total 1091 children were assessed at their local school, where their height, weight, and HiMAT score were recorded. The relationships between children’s age, height, weight, and BMI were summarized using Spearman rank correlations. Truncated regression models were used to determine the most appropriate predictor variable for developing sex-specific normative ranges.

Results

There was a positive correlation between children’s HiMAT scores and their age, height, weight, and BMI. Age explained the most variability in HiMAT scores for both boys and girls.

Limitations

The reliability, validity, and responsiveness of the HiMAT have not been tested across a broad range of children with mobility limitations. Normative data reported in this study are for Australian children only.

Conclusions

HiMAT scores for children in this study increased with age, height, weight, and BMI. Age was the most appropriate variable for developing a normative dataset of HiMAT scores for children of primary school age.
DIOPHANTINE APPROXIMATION WITH GAUSSIAN PRIMES
Authors: Harman Glyn
Published: November 2019

In this paper we prove that the exact analogue of the author’s work with real irrationals and rational primes (G. Harman, On the distribution of $\alpha p$ modulo one II, Proc. London Math. Soc. (3) 72, 1996, 241–260) holds for approximating $\alpha \in \mathbb{C}\setminus \mathbb{Q}[i]$ with Gaussian primes. To be precise, we show that for such $\alpha $ and arbitrary complex $\beta $ there are infinitely many solutions in Gaussian primes $p$ to $$\begin{equation*} ||\alpha p + \beta|| <| p|^{-7/22}, \end{equation*}$$where $||\cdot ||$ denotes distance to a nearest member of $\mathbb{Z}[i]$. We shall, in fact, prove a slightly more general result with the Gaussian primes in sectors, and along the way improve a recent result due to Baier (S. Baier, Diophantine approximation on lines in $\mathbb{C}^2$ with Gaussian prime constraints, Eur. J. Math. 3, 2017, 614–649).
Geography, Climate, and Genes in Development Studies
Authors: Klitgaard Robert , Fedderke Johannes W , Napolioni Valerio
Published: November 2019

Over the coming decade, much more genetic data will enter into the study of economic development. This paper provides an example and emphasizes the uses and misuses of such information. It has assembled for the first time national frequencies of the ACP1 genetic polymorphism and the Interleukin-6 (IL6-174G) and Interleukin-10 (IL10-1082G) cytokines. These three respond over the centuries to ultraviolet radiation and infectious diseases. The study also looks at a national measure of heterozygotic diversity. In particular, it finds that ACP1 frequencies are significantly related to national outcomes ranging from GDP per capita to type and quality of governance, to measures of national “competitiveness,” to health, to fertility, to measures of satisfaction with life. These associations do not seem explainable by reverse causation nor by the influence of some of the usual variables in studies of long-run development. Nonetheless, these results do not mean that a few genes have a direct causal effect on world development. The ACP1*B variable is surely picking up the influences of many genetic and cultural adaptations over evolutionary time in response to ultraviolet exposure and pathogen burdens. This study's findings thus support other research indicating the importance of disease environments in shaping both genetic and sociocultural adaptations that have influence on development outcomes today. The paper concludes with a discussion of what such strong associations mean and do not mean, in hopes of guiding future studies of genes and other deep roots of economic development.
Development of Nationwide Recommendations to Support Prenatal Counseling in Extreme Prematurity
Authors: Geurtzen Rosa , van Heijst Arno F. J. , Draaisma Jos M. T. , Kuijpers Lindie J. M. K. , Woiski Mallory , Scheepers Hubertina C. J. , van Kaam Anton H. , Oudijk Martijn A. , Lafeber Harrie N. , Bax Caroline J. , Koper Jan F. , Duin Leonie K. , van der Hoeven Marc A. , Kornelisse René F. , Duvekot Johannes J. , Andriessen Peter , van Runnard Heimel Pieter J. , van der Heide-Jalving Marja , Bekker Mireille N. , Mulder-de Tollenaer Susanne M. , van Eyck Jim , Eshuis-Peters Ellis , Graatsma Margo , Hermens Rosella P. M. G. , Hogeveen Marije
Published: November 2019

(Abstracted from Pediatrics 2019;143(6):e20183253)

Guidelines on management of extreme prematurity differ regarding the lowest limits of gestation for which active support can or should be offered the recommendations for the role of parents in the decision making. In addition, the use of gestational age (GA) as a cutoff has been debated because other factors also determine prenatal outcome.
Role of Interventional Radiology in Pregnancy Complicated by Placenta Accreta Spectrum Disorder: Systematic Review and Meta-analysis
Authors: D'Antonio F. , Iacovelli A. , Liberati M. , Leombroni M. , Murgano D. , Cali G. , Khalil A. , Flacco M.E. , Scutiero G. , Iannone P. , Scambia G. , Manzoli L. , Greco P.
Published: November 2019

(Abstracted from Ultrasound Obstet Gynecol 2019;53:743–751)

The increase in cesarean sections performed in the last 20 years has also led to a large increase in the incidence of placenta accreta spectrum (PAS) disorders. Prenatal diagnosis of a PAS disorder, by ultrasound or magnetic resonance imaging, has been shown to improve maternal outcome by letting providers plan surgical treatment for these disorders.
Compartment Syndrome in Tibial Plateau Fractures: Do Previously Established Predictors Have External Validity?
Authors: Marchand Lucas S. , Working Zachary M. , Rane Ajinkya A. , Elliott Iain S. , Gilbertson Ellen , Rothberg David L. , Higgins Thomas F. , Haller Justin M.
Published: November 2019

Objective:

To test previously established radiographic predictors of compartment syndrome in tibial plateau fractures and determine whether novel measurements may further improve a surgeon's ability to identity patients at high risk for developing this outcome.

Design:

Retrospective review.

Setting:

Academic Level I trauma center.

Patients:

Five hundred thirteen patients with tibial plateau fractures treated operatively over a 10-year period (OTA/AO 41B1-3 & 41C1-3; Schatzker I-VI).

Intervention:

Previously established plain film radiographic measurements and novel computed tomography soft tissue measurements.

Main Outcome Measure:

Acute compartment syndrome (ACS).

Results:

Schatzker VI fractures (odds ratio 5.72, confidence interval 2.55–12.83, P < 0.001), high-energy mechanism (3.10, 1.26–7.58, P = 0.0096), fibular fracture (8.14, 3.33–19.96, P < 0.0001), fracture length (9.70, 2.45–37.69, P = 0.0014), and plateau-shaft combined injury (2.97, 1.15–7.70, P = 0.019) were all associated with the development of compartment syndrome. The depth of the posterior compartment was also predictive of CS (1.06, 1.02–1.09, P = 0.0025). Patients with 3 and 4 predictive markers demonstrated a 20% and 27% chance of developing ACS respectively.

Conclusions:

This study confirms that several factors are associated with the development of ACS. The presence of each independent predictor had a cumulative effect such that when more than one variable is present, the chance of ACS increases. This information may be used to alert providers regarding injuries that require vigilant evaluation.

Level of Evidence:

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Multiple Cranial Tuberculomas Without Meningitis in Two Infants With Miliary Tuberculosis
Authors: St. Cyr Grace , Starke Jeffrey R.
Published: November 2019

Magnetic resonance imaging may detect central nervous system involvement even when cerebrospinal fluid is normal and tests to detect Mycobacterium tuberculosis are negative. We describe 2 cases of miliary tuberculosis in young children with clinically unexpected central nervous system involvement. Magnetic resonance imaging of the brain should be considered part of the initial diagnostic workup for miliary tuberculosis in very young children.
Extrapulmonary Coccidioidomycosis Among Children in Central California
Authors: Naeem Fouzia , McCarty James , Mhaissen Mohammad Nael , Ha Sandie , Rongkavilit Chokechai
Published: November 2019

Background:

The literature on pediatric extrapulmonary coccidioidomycosis is limited. We reviewed the clinical course, diagnostic studies, treatment and outcomes of children with extrapulmonary coccidioidomycosis followed at a tertiary care center in central California.

Methods:

Retrospective study of 78 patients ≤21 years old with extrapulmonary coccidioidomycosis diagnosed over 10 years (1/1/07–12/31/16).

Results:

The median age was 9.7 years (interquartile range, 4.5–14.8). The majority of patients were males (55%), Hispanic (65%) and without comorbid conditions (85%). Over two-thirds (68%) had concurrent pulmonary disease. Organ involvements included bones and joints (33%), mediastinum (19%), central nervous system (19%), cervical lymph nodes (15%), larynx (6%) and skin (5%). Most cases (84%) resolved and/or became stable on maintenance therapy, 14% experienced relapse and/or progressive disease, and 2% were fatal. Children ≥10 years of age tended to have >1 site of involvement (47% vs. 25%, P = 0.06), and more relapsed/progressive/fatal disease (21% vs. 5%, P = 0.06) compared with those <10 years. They also required longer durations of treatment (median, 611 vs. 349 days, P = 0.02). Non-Hispanics were more likely to require >1 drug therapy (85% vs. 70%, P = 0.04) and tended to have Coccidioides complement fixation titers ≥1:32 (89% vs. 72%, P = 0.04) compared with Hispanics.

Conclusions:

Extrapulmonary coccidioidomycosis in children can be severe and spread to multiple sites and requires prolonged treatment. Non-Hispanics and those ≥10 years of age are more likely to experience severe disease, suggesting a need for early recognition and intervention in these populations.
Epstein-Barr Virus Seroprevalence and Force of Infection in a Multiethnic Pediatric Cohort, Singapore
Authors: Setoh Johnson Weng Sung , Ho Clement Kam Man , Yung Chee Fu , Tam Clarence , Yelen  , Tee Nancy Wen Sim
Published: November 2019

Background:

Epstein-Barr virus (EBV) spreads through bodily fluids, especially saliva, and can cause infectious mononucleosis. EBV immunity and infection status can be assessed by testing EBV viral capsid antigen and nuclear antigen (EBNA) antibodies in blood. In this study, we investigated the seroprevalence and force of infection (FOI) of EBV antibodies among children and young people in 3 ethnic groups in Singapore.

Methods:

Eight hundred ninety-six residual serum samples at a tertiary hospital were tested for viral capsid antigen (IgG and IgM) and EBNA IgG antibodies using Abbott Architect assays. We calculated the EBV seroprevalence using catalytic models to estimate the EBV force of infection from age-stratified seroprevalence data, both overall and by ethnic group.

Results:

Overall seropositivity was 68.3% (n = 612). Seropositivity was higher in Malays (81.8%) compared with both Chinese (64.2%) and Indians (58.4%). EBV FOI was consistently higher in Malays, with an estimated annual rate of seroconversion of 25% in children 1 year, of age compared with 14% among Chinese and Indians at the same age.

Conclusions:

The seroprevalence patterns of EBV antibodies in the Chinese and Indian, but not Malay children in Singapore by 19 years of age resemble those previously reported in developed countries. Ideally, any future EBV vaccination strategy would need to target infants <1 year of age for maximum population benefit.
Lifetime Changes in CD4 T-cell count, Viral Load Suppression and Adherence Among Adolescents Living With HIV in Urban Peru
Authors: Rodriguez Carly A. , Kolevic Lenka , Ramos Alicia , Wong Milagros , Munoz Maribel , Patel Kunjal , Franke Molly F.
Published: November 2019

We quantified longitudinal changes in CD4 T-cell count, viral load suppression and combined antiretroviral therapy adherence from childhood to adolescence among patients living with HIV in urban Peru. Mean CD4 count and viral load suppression decreased dramatically in early adolescence (13 years of age) in tandem with increases in nonadherence.
Predictors of Mortality Among HIV-exposed Infants Through 18 Months of Age in Kenya: A Retrospective Review of Programmatic Data
Authors: Sandbulte Matthew R. , Nazir Niaman , Goggin Kathy , Wexler Catherine , Maloba May , Gautney Brad J. , Khamadi Samoel , Lwembe Raphael , Finocchario-Kessler Sarah
Published: November 2019

We identified mortality predictors among HIV-exposed uninfected infants and infants living with HIV in Kenyan early infant diagnosis services between 2012 and 2017. Younger maternal age and absence of antenatal antiretroviral therapy among HIV-exposed uninfected infants (n = 2366) and travel time to hospital and delayed infant testing among infants living with HIV (n = 130) predicted mortality, highlighting the importance of supporting engagement in maternal/pediatric HIV services.
Impact of Baseline Tuberculin Skin Test and Isoniazid Chemoprophylaxis on Subsequent Quantiferon-TB Gold In-Tube Performance in Young Children Assessed After Tuberculosis Contact in Catalonia
Authors: Velasco-Arnaiz Eneritz , Soriano-Arandes Antoni , Espiau María , Altet Neus , Fortuny Clàudia , Monsonís Manuel , Tebruegge Marc , Noguera-Julian Antoni
Published: November 2019

We investigated the impact of baseline tuberculin skin tests (TSTs) and preventive isoniazid chemoprophylaxis on subsequent QuantiFERON-TB Gold In-Tube (QFT-GIT) assays performed after a 10- to 12-week window period in 114 children <5 years of age. Previous TSTs and chemoprophylaxis had no impact on the magnitude of subsequent antigen-induced responses in QFT-GIT. Furthermore, previous TSTs did not induce conversion from a negative to a positive QFT-GIT result.
Chlamydia pneumoniae Infections in an Immunocompetent Patient Compared With a Neutropenic Cancer Patient
Authors: Abraham Abel Mundakakuzhiyil , Greene John N.
Published: November 2019

Chlamydia pneumoniae, an uncommon cause of respiratory tract infections, is difficult to diagnose in most patients. Its signs, symptoms, laboratory values, and imaging are nonspecific, and historically, culture or serology was required to implicate the organism. Because many physicians begin treatment of bacterial pneumonia with antibiotics ineffective against C. pneumoniae, cases of atypical pneumonia caused by this organism require greater time, resources, and analysis before positive diagnoses and the start of effective treatment. However, the emergence and widespread use of polymerase chain reaction have led to quicker recognition of respiratory tract infections caused by C. pneumoniae. This is especially relevant for immunosuppressed cancer patients, who must be quickly treated to prevent the development of serious complications. This article reviewed the limited literature regarding C. pneumoniae and immunosuppressed cancer patients, concluding that prompt diagnosis and standard recommended treatment of C. pneumoniae will provide favorable outcomes.
A Case of Kaposi Sarcoma–Related Immune Reconstitution Inflammatory Syndrome
Authors: Walde Charles , Merritt Karissa , Trotman Robin
Published: November 2019

Immune reconstitution inflammatory syndrome is a complication of antiretroviral therapy in advanced human immunodeficiency virus infection and acquired immunodeficiency syndrome. We describe the uncommon presentation of undiagnosed Kaposi sarcoma after antiretroviral therapy initiation. Kaposi sarcoma can manifest after initiation of antiretroviral therapy and may necessitate cytotoxic chemotherapy.
Cellulitis and Sepsis Secondary to Serratia marcescens in a Patient With HIV
Authors: Dhariwal Ankush , Serafino Wani Robert , Martin-Lazaro Juan F. , Cevallos Morales Joaquim
Published: November 2019

We describe a case of bullous leg cellulitis secondary to Serratia marcescens in a patient with a complex background including well-controlled HIV and venous insufficiency secondary to multiple deep vein thrombosis. Despite appropriate antibiotic therapy with meropenem, her condition deteriorated, requiring intensive care unit support. She was reviewed multiple times by the surgical teams, who felt that surgical intervention was not warranted. After a switch in antibiotics to ciprofloxacin, she made a sustained and complete recovery.

S. marcescens cellulitis is a rare entity, but certain clinical features are common to most reported cases, including an immunocompromised host, bullous lesions, and a severe illness, all of which are demonstrated here. Optimal antibiotic therapy is not established, and our experience suggests that perhaps quinolones are superior to carbapenems, for reasons which remain unclear. Surgery is an important consideration in S. marcescens cellulitis; however, our experience suggests that in selected cases, watchful waiting may be appropriate.
Oral Antimicrobial Agents for Urinary Tract Infections Due to Enterobacteriales Species
Authors: Bader Mazen S. , Irfan Neal , Leto Daniela , Brooks Annie
Published: November 2019

Background

Urinary tract infections (UTIs) due to Enterobacteriales continue to pose a challenge because of increasing resistance rate to antimicrobial agents. The aim of this study was to evaluate in vitro susceptibility of oral antimicrobial agents against urinary isolates of Enterobacteriales species in patients with suspected UTIs at Hamilton Health Sciences hospitals in 2016.

Methods

Positive urine cultures for Enterobacteriales species in all patients 18 years or older with diagnosis of UTIs from 2 acute care hospitals in 2016 were included. Susceptibility rates were calculated for first- and second-line oral antimicrobial agents commonly used to treat UTIs.

Results

A total of 2773 urinary isolates of Enterobacteriales species were included in the analysis. The rates of susceptibility to nitrofurantoin were 96.3% (1925/1999) and 46.9% (188/401), respectively, for Escherichia coli and Klebsiella pneumoniae. The rates of susceptibility to trimethoprim-sulfamethoxazole and ciprofloxacin were 73.9% (1478/1999) and 84% (337/401), and 72.3% (1446/1999) and 86.3% (346/401), respectively, for E. coli and K. pneumoniae. The rate of E. coli susceptibility to oral cephalosporins was approximately 83%. The proportions of Enterobacteriales isolates that produced extended-spectrum β-lactamases (ESBLs) for E. coli and K. pneumoniae were 11.6% (231/1999) and 11.2% (45/401), respectively. The rates of ESBLs E. coli susceptibility to nitrofurantoin, trimethoprim-sulfamethoxazole, and ciprofloxacin were 91.3% (211/231), 30.3% (70/231), and 16% (37/231), respectively.

Conclusions

Oral antimicrobial agents have a limited role as empiric treatment of UTIs due to antibiotic-resistant Enterobacteriales species, with the exception of nitrofurantoin for E. coli including ESBL-producing strains. Oral cephalosporins were the second most susceptible agents to E. coli.
Fusobacterium-Associated Pylephlebitis Complicated by Hepatic Abscess Following Roux-en-Y Gastric Bypass Surgery–Gastrointestinal Variant of Lemierre Syndrome
Authors: Tariq Tooba , Badwal Karun , Wilt Jeffrey , Boapimp Pimpawan
Published: November 2019

Acute pylephlebitis is a suppurative thrombosis of the portal vein that arises as a complication of intra-abdominal infections. This report describes a rare case of acute pylephlebitis complicated by hepatic abscess formation secondary to Fusobacterium nucleatum. The patient is a 48-year-old woman who presented with worsening abdominal pain and malaise for 3 weeks. She had a Roux-en-Y gastric bypass surgery 4 months earlier that showed a phlegmon at the surgical site on a contrast computed tomography scan postsurgery. Physical examination revealed right upper quadrant tenderness, and magnetic resonance imaging of the liver showed portal vein thrombosis with multiple hepatic abscesses. The patient was started empirically on cefepime and metronidazole. A tagged white blood cell scan showed an infected portal vein thrombosis. The abscess was aspirated and grew F. nucleatum. The patient was discharged on rivaroxaban and a 6-week course of ceftriaxone and metronidazole. The pathophysiology of acute pylephlebitis is hematogenous dissemination into the portal system from a remote enteric infection. Fusobacterium nucleatum is a commensal anaerobe in the oral cavity, but emerging evidence suggests that it can also colonize the gastrointestinal mucosa and can lead to pylephlebitis and hepatic abscess. In the literature, only a handful of Fusobacterium pylephlebitis complicated by hepatic abscess have been reported. This is the first known case of Fusobacterium-associated pylephlebitis complicated by hepatic abscess post–Roux-en-Y gastric bypass surgery.
Salmonella enteritidis Endocarditis and Recurrent Urinary Tract Infections in an Immunocompromised Renal Transplant Patient
Authors: Pervin Najwa , Antonacci Dominic , Sundareshan Vidya
Published: November 2019

Complicated nontyphoidal Salmonella infections and its recurrences have been reported infrequently in transplant patients. As such, there is no standard consensus regarding treatment options and prevention of recurrences in this population. We present a renal transplant patient who developed recurrent urinary tract infections with Salmonella enteritidis, complicated by bacteremia and endocarditis, and discuss our management for this challenging case.
Pain behavior without pain sensation: an epileptic syndrome of “symbolism for pain”?
Authors: Hagiwara Koichi , Garcia-Larrea Luis , Tremblay Léon , Montavont Alexandra , Catenoix Hélène , Rheims Sylvain , Guénot Marc , Isnard Jean
Published: November 2019

“Asymbolia for pain” has shown the potentiality of diseased insular networks to dissociate sensory from affective-behavioral dimensions of pain, resulting in the lack of appropriate motor and affective responses despite preserved sensory aspect of pain. Here, we describe 4 patients with an inverse phenomenon of asymbolia for pain, namely an isolated “symbolism for pain” triggered by epileptic seizures, characterized by pain behavior without declarative pain sensation despite fully preserved contact and vigilance. Stereoelectroencephalography demonstrated in each case focal seizure discharges within the posterior insulo-opercular cortex, with little or no propagation to other cortical structures, especially those considered to drive subjective pain experiences. The pain behavior might reflect seizure propagation from the insula to brain networks serving for behavioral responses associated with pain, including the cingulate motor region and possibly also the basal ganglia. We propose that the isolated symbolism for pain is a novel epileptic syndrome of dissociation between pain perception and behaviors associated with the insular nociceptive-related networks.
The Dyadic Experience of Managing Heart Failure
Authors: Kim Juliah Shay Ryann , Risbud Rashmi , Gray Caroline , Banerjee Dipanjan , Trivedi Ranak
Published: November 2019

Background:

Self-management of heart failure (HF) is often a joint venture between patients and their friends and family (“framily”). However, this joint experience is often overlooked in clinical care.

Objectives:

The aim of this study was to understand the cognitive, emotional, and relational elements affecting the experience of patient-framily member dyads managing HF.

Methods:

Participants were patients with HF receiving care at a university hospital and their framily. Dyads participated in 30- to 45-minute semistructured interviews before their clinic visit. Transcribed interviews were analyzed using thematic analyses. Interviews were coded independently and checked for interrater agreement before the final coded data set was developed. Participants were recruited until thematic saturation was attained.

Results:

A total of 16 patient-framily member dyads and 1 triad (n = 35) participated in the study; 47.1% of patients and 77.8% of framily members were female. Patients were 66 years old (SD, 14 years) and framily members were 59 years old (SD, 12.3 years). Three aspects of the dyadic experience emerged in the themes: (1) health beliefs of dyads were characterized by acceptance and optimism, but also pessimism; (2) negative emotions influenced the dyadic experience; (3) the closeness of their interpersonal relationships influenced their contributions to managing HF.

Conclusions:

Our study suggests that greater attention to the experience and interpersonal relationships of dyads has the potential for improving HF self-management and facilitating patient-centered care.
Helping parents choose treatments for young children with autism: A comparison of applied behavior analysis and eclectic treatments
Authors: Stanislaw Harold , Howard Jane , Martin Carolyn
Published: November 2019

Background:

Nurse practitioners (NPs) increasingly meet with families of young children who have been recently diagnosed with autism spectrum disorder (ASD). These families face a bewildering variety of treatment options and can benefit from working with NPs who can help them better understand those options and the likely outcomes for their children.

Purpose:

This study describes outcomes for young children with autism, who were treated with either applied behavior analysis (ABA) or eclectic treatment. Nurse practitioners can use this information to help families choose treatments for their children.

Methods:

Children diagnosed with autism received ABA (n = 50) or eclectic treatment (n = 32). Age-appropriate assessments in a variety of domains were made before and after up to 7 years of treatment.

Results:

Initial scores were below normal in every domain except motor skills. Sixty percent of children had normal cognitive scores after ABA, compared with only 25% of children after eclectic treatment. Other domains also showed better outcomes after ABA than eclectic treatment.

Implications for practice:

Nurse practitioners should be prepared to help families understand treatment options and their likely outcomes. The present study suggests that young children diagnosed with ASD can achieve normal levels of functioning in a variety of domains. These outcomes are much more likely after ABA than eclectic treatment.
Enhancing migraine self-efficacy and reducing disability through a self-management program
Authors: Short A. Laurel
Published: November 2019

Background:

Chronic migraine is a primary headache disorder affecting approximately 3–7 million individuals in the United States. This condition is associated with significant individual and societal consequences, causing impaired function and high levels of health care utilization.

Purpose:

The aim of this quasi-experimental single cohort study was to determine if an 8-week outpatient self-management program for chronic migraine would decrease migraine disability and enhance self-efficacy.

Methods:

This was a prospective, single cohort, pre- and postintervention pilot study. Fifteen adults aged 18–65 years who met the criteria for diagnosis of chronic migraine were enrolled in the study through convenience sampling. Participants participated in an evidence-based self-management program with multimodal formats including verbal, written, video, and online materials. Outcome measures included migraine disability (using Migraine Disability Assessment tool [MIDAS]), headache self-efficacy (using Headache Management Self-Efficacy Scale [HMSE]), acute medication use, and migraine frequency. Participants also completed a postintervention survey to assess satisfaction.

Results:

Findings showed a reduction in MIDAS scores, acute medication use, and frequency of migraine. Outcomes also included an increase in HMSE scores and a trend of improved health behaviors. Acute medication use decreased by more than 50%, and frequency of migraine and headache days reduced by close to 40%.

Implications for practice:

Despite high rates of disability, patient education and self-management programs for chronic migraine are not readily available. The findings of this study encourage use of a hybrid clinic and web-based self-management model to improve migraine disability and self-efficacy.
Monitoring respiratory mechanics during assisted ventilation
Authors: Grasselli Giacomo , Brioni Matteo , Zanella Alberto
Published: November 2019

Purpose of review

Accurate monitoring of the mechanical properties of the respiratory system is crucial to understand the pathophysiological mechanisms of respiratory failure in mechanically ventilated patients, to optimize mechanical ventilation settings and to reduce ventilator-induced lung injury. However, although the assessment of respiratory mechanics is simple in patients undergoing fully controlled ventilation, it becomes quite challenging in the presence of spontaneous breathing activity. Aim of the present review is to describe how the different components of respiratory mechanics [resistance, static compliance, and intrinsic positive end-expiratory pressure (PEEP)] can be measured at the bedside during assisted modes of ventilation.

Recent findings

Available techniques for bedside measurement of resistance during assisted ventilation are complex and not commonly implemented. On the contrary, an increasing number of reports indicate that measurement of static compliance and intrinsic PEEP can be easily obtained, both with advanced monitoring systems (esophageal and gastric manometry, diaphragm electromyography, electrical impedance tomography) and, with some limitations, with simple airways occlusion maneuvers.

Assessment of respiratory mechanics in spontaneously breathing patients, with some limitations, is feasible and should be included in everyday clinical practice; however, more data are needed to understand the clinical relevance of the measures obtained during assisted ventilation.
Searching for the optimal positive end-expiratory pressure for lung protective ventilation
Authors: Sahetya Sarina K.
Published: November 2019

Purpose of review

The optimal strategy for setting positive end-expiratory pressure (PEEP) has not been established. This review examines different approaches for setting PEEP to achieve lung-protective ventilation.

Recent findings

PEEP titration strategies commonly focus either on achieving adequate arterial oxygenation or reducing ventilator-induced lung injury from repetitive alveolar opening and closing, referred to as the open lung approach. Five recent trials of higher versus lower PEEP have not shown benefit with higher PEEP, and one of the five trials showed increased harm for patients treated with the open lung strategy. Evidence suggests that some patients may respond beneficially to higher PEEP by recruiting lung, whereas other patients do not recruit lung and merely overdistend previously open alveoli when higher PEEP is applied. A PEEP titration approach that differentiates PEEP responders from nonresponders and provides higher or lower PEEP accordingly has not been prospectively tested.

When compared, no method for setting PEEP has been proven superior to another. Based on recent studies, higher compared with lower PEEP has not improved clinical outcomes and worsened mortality in one study. Future research should focus on identifying feasible methods for assessing lung recruitability in response to PEEP to enrich future trials of PEEP strategies.
Emergency Laboratory Evaluations for Patients With Inborn Errors of Metabolism
Authors: Gold Nina B. , Kritzer Amy , Weiner Debra L. , Michelson Kenneth A.
Published: November 2019

Background

Children with inborn errors of metabolism (IEM) are at risk for metabolic crises triggered by acute illnesses. Crises are identified through laboratory evaluations.

Objectives

Our objective was to determine national adherence to minimum laboratory evaluations for patients with IEM in emergency departments (EDs), as well as factors associated with laboratory evaluation adherence.

Methods

Using the Pediatric Health Information System, we identified visits to 48 EDs from 2012 to 2017 by children with IEM. We analyzed visits for catabolic conditions (dehydration, gastroenteritis, or vomiting) and determined variation in minimum laboratory evaluation adherence. Multivariable models were created to determine predictors of adherence.

Results

Among the visits by children with disorders of the urea cycle, organic acid metabolism, and fatty acid oxidation, 1457 (76.3%) of 1909 adhered to the minimum laboratory evaluation. Median ED-level adherence was 78.2% (interquartile range, 67.4–92.5). Factors associated with adherence were disorder [fatty acid oxidation vs urea cycle disorder; adjusted odds ratio (aOR), 9.35; 95% confidence interval (CI), 4.07–21.47], annual ED volume of patients with IEM (quartile 4 vs 1; aOR, 3.58; 95% CI, 1.51–8.49), and presence of a biochemical genetics fellowship (aOR, 0.29; 95% CI, 0.14–0.62).

Conclusions

Patients with IEM frequently did not receive minimum laboratory evaluations for catabolic conditions. Measures to improve laboratory use in children with IEM should be undertaken.
Recommendations for Enhancing Sports Medicine Fellowship Training
Authors: Jain Nitin B. , Borg-Stein Joanne , Miranda-Comas Gerardo , Micheo William , Visco Christopher , Fredericson Michael
Published: November 2019

Physical medicine and rehabilitation–trained physicians are increasingly interested in caring for patients with musculoskeletal and sports disorders. Sports medicine fellowships are designed to provide competency in sports medicine and musculoskeletal care. The authors, with endorsement from the Association of Academic Physiatrists, provide a framework and tools that Accreditation Council for Graduate Medical Education accredited sports medicine fellowship programs can use to enhance and meet the Accreditation Council for Graduate Medical Education program requirements. Based on the position statement from the American Medical Society for Sports Medicine, we propose recommendations for Accreditation Council for Graduate Medical Education–accredited sports medicine programs to achieve standards of excellence. We also provide recommendations for research requirements during the course of a sports fellowship. With the proposed recommendations, a sports medicine fellowship program can achieve excellence and enhance fellowship training by increasing proficiency in physical medicine and rehabilitation–based skills relevant to sports and musculoskeletal medicine. Given the multidisciplinary nature of musculoskeletal and sports medicine, it is also key that fellowship programs (regardless of the department that they are accredited through) have faculty members that represents these disciplines and accept applicants with residency training in physical medicine and rehabilitation, internal medicine, family medicine, pediatrics, and emergency medicine.
Interactive Relations Across Dimensions of Interpersonal-Level Discrimination and Depressive Symptoms to Carotid Intimal-Medial Thickening in African Americans
Authors: Beatty Moody Danielle L. , Leibel Daniel K. , Pantesco Elizabeth J. , Wendell Carrington R. , Waldstein Shari R. , Evans Michele K. , Zonderman Alan B.
Published: November 2019

Objective

This study aimed to examine within-race interactions of multiple dimensions of self-reported discrimination with depressive symptoms in relation to carotid intimal-medial thickness (IMT), a subclinical marker of atherosclerosis prospectively implicated in stroke incidence, in middle-aged to older African American and white adults.

Methods

Participants were a socioeconomically diverse group of 1941 African Americans (56.5%) and whites from the Healthy Aging in Neighborhoods of Diversity across the Life Span study (30–64 years old, 47% men, 45.2% with household income <125% federal poverty threshold) who underwent carotid IMT measurement. Discrimination was assessed across four dimensions (everyday, frequency across various social statuses, racial, and lifetime burden). The Center for Epidemiologic Studies Depression scale was used to assess depressive symptoms.

Results

In cross-sectional hierarchical regression analyses, two interactions were observed in African Americans: more frequent discrimination across various social statuses (b < 0.001, p = .006) and a higher lifetime discrimination burden (b < 0.001, p = .02) were each related to thicker carotid IMT in those with greater depressive symptoms. No significant findings were observed within whites.

Conclusions

Among African Americans, those reporting high levels of discrimination and depressive symptoms have increased carotid atherosclerosis and may be at greater risk for clinical end points compared with those reporting one or neither of these risk factors. Findings suggest that assessment of interactive relationships among social and psychological factors may elucidate novel pathways for cardiovascular disease, including stroke, among African Americans.