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Activating autophagy may be therapeutically beneficial, and we have previously shown that azathioprine (AZA), an immunomodulatory drug, induces autophagy. Here, we evaluated the induction of autophagy by the thiopurines AZA, mercaptopurine (6-MP) and thioguanine (6-TG) in THP-1 macrophages and investigated the mechanism of action in the context of this cellular process. The cytotoxicity of thiopurines was evaluated using an LDH assay. Induction of endogenous LC3 by thiopurines was evaluated using immunostaining. To confirm autophagy activation by thiopurines, a GFP-RFP-LC3 reporter plasmid was used to monitor the maturation of autophagosomes to autolysosomes. Induction of apoptosis by thiopurines was evaluated using Annexin V/PI staining, and ER stress was assessed via RT‒PCR analysis of XBP1 splicing. To gain insight into the mechanism of action of thiopurines, mTORC1 activity and eIF2α-S51 phosphorylation were evaluated by immunoblotting. Thiopurines were not cytotoxic to cells and induced strong time- and concentration-dependent autophagy. Thiopurines activate autophagy with complete progression through the pathway. Induction of autophagy by thiopurines occurred independently of apoptosis and ER stress. Immunoblotting revealed that AZA inhibited mTORC1 activity, and AZA and 6-TG increased eIF2α-S51 phosphorylation. In contrast, 6-MP had a minor effect on either signalling pathway. Thiopurines are strong inducers of autophagy, and autophagy induction should be considered among the mechanisms responsible for patient response to thiopurines., (© 2024. The Author(s).)

The Clinical and Laboratory Standards Institute (CLSI) M27 guidelines are the recommended and most commonly used protocols for broth microdilution antifungal susceptibility testing of yeasts. However, these guidelines are limited to the use of 96-well assay plates, limiting assay capacity. With the increased risk of fungal resistance emerging in the community, it is important to have alternative protocols available, that offer higher throughput and can screen more than eight to ten potential antifungal compounds per plate. This study presents an optimised broth microdilution minimum inhibitory concentration (MIC) method for testing the susceptibility of yeasts in an efficient high throughput screening setup, with minimal growth variability and maximum reproducibility. We extend the M27 guidelines and optimise the conditions for 384-well plates. Validation of the assay was performed with ten clinically used antifungals (fluconazole, amphotericin B, 5-fluorocytosine, posaconazole, voriconazole, ketoconazole, itraconazole, caspofungin diacetate, anidulafungin and micafungin) against Candida albicans and Cryptococcus neoformans., (© 2024. Crown.)

The plethora of genome sequences produced in the postgenomic age has not resolved many of our most pressing biological questions. Correlating gene expression with an interrogatable and easily observable characteristic such as the surrogate phenotype conferred by a reporter gene is a valuable approach to gaining insight into gene function. Many reporters including lacZ , amdS, and the fluorescent proteins mRuby3 and mNeonGreen have been used across all manners of organisms. Described here is an investigation into the creation of a robust, synthetic, fusion reporter system for Cryptococcus neoformans that combines some of the most useful fluorophores available in this system with the versatility of the counter-selectable nature of amdS . The reporters generated include multiple composition and orientation variants, all of which were investigated for differences in expression. Evaluation of known promoters from the TEF1 and GAL7 genes was undertaken, elucidating novel expression tendencies of these biologically relevant C. neoformans regulators of transcription. Smaller than lacZ but providing multiple useful surrogate phenotypes for interrogation, the fusion ORF serves as a superior whole-cell assay compared to traditional systems. Ultimately, the work described here bolsters the array of relevant genetic tools that may be employed in furthering manipulation and understanding of the WHO fungal priority group pathogen C. neoformans .

Background: Optic disc drusen (ODD) represent an important differential diagnosis of papilledema caused by intracranial hypertension, but their distinction may be difficult in clinical practice. The aim of this study was to train, validate, and test a dedicated deep learning system (DLS) for binary classification of ODD vs papilledema (including various subgroups within each category), on conventional mydriatic digital ocular fundus photographs collected in a large international multiethnic population., Methods: This retrospective study included 4,508 color fundus images in 2,180 patients from 30 neuro-ophthalmology centers (19 countries) participating in the Brain and Optic Nerve Study with Artificial Intelligence (BONSAI) Group. For training and internal validation, we used 857 ODD images and 3,230 papilledema images, in 1,959 patients. External testing was performed on an independent data set (221 patients), including 207 images with ODD (96 visible and 111 buried), provided by 3 centers of the Optic Disc Drusen Studies Consortium, and 214 images of papilledema (92 mild-to-moderate and 122 severe) from a previously validated study., Results: The DLS could accurately distinguish between all ODD and papilledema (all severities included): area under the receiver operating characteristic curve (AUC) 0.97 (95% confidence interval [CI], 0.96-0.98), accuracy 90.5% (95% CI, 88.0%-92.9%), sensitivity 86.0% (95% CI, 82.1%-90.1%), and specificity 94.9% (95% CI, 92.3%-97.6%). The performance of the DLS remained high for discrimination of buried ODD from mild-to-moderate papilledema: AUC 0.93 (95% CI, 0.90-0.96), accuracy 84.2% (95% CI, 80.2%-88.6%), sensitivity 78.4% (95% CI, 72.2%-84.7%), and specificity 91.3% (95% CI, 87.0%-96.4%)., Conclusions: A dedicated DLS can accurately distinguish between ODD and papilledema caused by intracranial hypertension, even when considering buried ODD vs mild-to-moderate papilledema., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by North American Neuro-Ophthalmology Society.)

Background:  Pectus excavatum deformities are usually repaired with a minimally invasive approach in which a metal bar is used to correct the chest wall abnormality. We aimed to evaluate long-term outcomes and patient satisfaction after surgical correction., Methods:  Patients who underwent pectus excavatum repair and subsequent bar removal at a single tertiary care center from January 2000 to December 2020 were identified. A retrospective chart review was performed, and a telephone survey was conducted to evaluate perceived inward chest movement, need for surgeon reevaluation, surgical reintervention, and overall satisfaction. Data are presented as medians with interquartile ranges (IQRs) and frequencies with percentages., Results:  A total of 583 patients were included. The survey response rate was 26.2% ( n  = 153). The respondents were predominantly male (80.4%, n  = 123) with a median age at surgical correction of 14.9 years (IQR 12.9, 16.1) and a median Haller index (HI) of 3.8 (IQR 3.4, 4.5). Median time to bar removal was 2.9 years (IQR 2.5, 3.0) with a median age at removal of 17.7 years (IQR 15.5, 19.0). Median time from surgery to survey follow-up was 9.6 years (IRQ 5.0, 11.4) with respondents having a median age at follow-up of 25 years (IQR 22.0, 28.4). The satisfaction rate was 96.7% ( n  = 148) with a reintervention rate of 2.0% ( n  = 3). The perceived inward chest movement was 30.7% ( n  = 47) with 12.8% ( n  = 6) of those requesting surgical reevaluation., Conclusion:  There is a high level of satisfaction many years after correction of pectus excavatum and bar removal. With the advent of cryoablative therapy since 2017, patient satisfaction improved by experience of less postoperative pain. Reintervention rate is low despite some patients reporting a perceived chest wall inward movement., Competing Interests: None declared., (Thieme. All rights reserved.)

Introduction: The American Urological Association guidelines recommend against the performance of ultrasound and other imaging modalities in the evaluation of patients with cryptorchidism before expert consultation. We aimed to examine our institutional experience with cryptorchidism and measure adherence to currently available guidelines., Methods: An institutional review board-approved retrospective review of ultrasound utilization in the evaluation of patients with cryptorchidism was performed from June 1, 2016, to June 30, 2019, at a single tertiary level pediatric hospital., Results: We identified 1796 patients evaluated in surgical clinics for cryptorchidism. Surgical intervention was performed in 75.2% (n = 1351) of the entire cohort. Ultrasound was performed in 42% (n = 754), most of which were ordered by referring physicians (91% n = 686). Of those who received an ultrasound, surgical intervention was performed in 78% (n = 588). Those 166 patients (22%) who did not undergo surgical intervention were referred with ultrasounds suggesting inguinal testes; however, all had normal physical examinations or mildly retractile testes at the time of consultation and were discharged from the outpatient clinic. There were 597 patients referred without an ultrasound, 81% (n = 483) were confirmed to have cryptorchidism at the time of specialist physical examination and underwent definitive surgical intervention, the remainder (19%, n = 114) were discharged from the outpatient clinics., Conclusions: Ultrasound evaluation of cryptorchidism continues despite high-quality evidence-based guidelines that recommend otherwise, as they should have little to no bearing on the surgeon's decision to operate or the type of operation. Instead, physical examination findings should guide surgical planning., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Pectus bar stabilizers are routinely used for bar fixation in the repair of pectus excavatum. We aimed to determine the optimum technique for bar fixation by reviewing our institutional experience with the use of bilateral, unilateral, and no stabilizer placement. Methods: Retrospective single pediatric center review of patients who underwent minimally invasive bar placement for pectus excavatum and subsequent bar removal between December 2001 and July 2019 was performed. Demographic data, details about the surgery, the number of bars and stabilizers used, and follow-up information were collected. Stabilizer-related complications included pain requiring stabilizer removal, surgical site infections (SSIs), and bar displacement. Data are presented as medians with interquartile ranges (IQRs) and frequencies with percentages. Results: A total of 561 patients were included. The cohort was predominantly male (83.1%, n  = 466) with a median age at the time of bar placement of 15 years (IQR 12.4, 16.3) and a median Haller index of 3.8 (IQR 3.4, 4.5). Pain attributed to the stabilizer site that required removal was observed only in the bilateral stabilizer group (2.5%, n  = 13). SSI related to the stabilizer site occurred in 1.8% ( n  = 9) of the bilateral stabilizer cases and 2.1% ( n  = 1) of the unilateral stabilizer cases. Bar displacement was observed in 0.6% ( n  = 3) of the bilateral stabilizer cases and 2 of those patients also had an SSI. There were no complications in the no stabilizer group. Conclusion: As the trend moves toward unilateral and no stabilizer use, we observe fewer cases of pain requiring stabilizer removal with no increase in bar displacements.

Competing Interests: M. W. D. Thorne has received honoraria from Biogen, Novartis, EMS Serono, and Roche to participate in Ad boards and attend medical conferences. S. M. Mirsattari has received honoraria for speaking engagements for UCB Canada Inc, Eisai Co. Ltd (Canada), and Sunovion Pharmaceuticals Canada Inc. He has been a member of the Epilepsy National Advisory Board for UCB Canada Inc, Eisai Co Ltd (Canada), Sunovion Pharmaceuticals Canada Inc, Jazz Pharmaceuticals Inc, and Paladin Labs Inc. The other authors report no conflicts of interest.

Importance: The travelers' gut microbiome is potentially assaulted by acute and chronic perturbations (e.g., diarrhea, antibiotic use, and different environments). Prior studies of the impact of travel and travelers' diarrhea (TD) on the microbiome have not directly compared antibiotic regimens, and studies of different antibiotic regimens have not considered travelers' microbiomes. This gap is important to be addressed as the use of antibiotics to treat or prevent TD-even in moderate to severe cases or in regions with high infectious disease burden-is controversial based on the concerns for unintended consequences to the gut microbiome and antimicrobial resistance (AMR) emergence. Our study addresses this by evaluating the impact of defined antibiotic regimens (single-dose treatment or daily prophylaxis) on the gut microbiome and resistomes of deployed servicemembers, using samples collected during clinical trials. Our findings indicate that the antibiotic treatment regimens that were studied generally do not lead to adverse effects on the gut microbiome and resistome and identify the relative risks associated with prophylaxis. These results can be used to inform therapeutic guidelines for the prevention and treatment of TD and make progress toward using microbiome information in personalized medical care., Competing Interests: The authors declare no conflict of interest.

With the emergence of the human pathogen Candida auris as a threat to human health, there is a strong demand to identify effective medicines to prevent the harm caused by such drug-tolerant human fungi. Herein, a series of 33 new derivatives of bensulfuron methyl (BSM) were synthesized and characterized by 1 H NMR, 13 C NMR, and HRMS. Among the target compounds, 8a possessed the best K i value of 1.015 μM against C. auris acetohydroxyacid synthase (CauAHAS) and an MIC value of 6.25 μM against CBS10913, a clinically isolated strain of C. auris. Taken together the structures of BSM and the synthesized compounds, it was found that methoxy groups at both meta-position of pyrimidine ring are likely to provide desirable antifungal activities. Quantum calculations and molecular dockings were performed to understand the structure-activity relationships. The present study has hence provided some interesting clues for the discovery of novel antibiotics with this distinct mode of action., (© 2023 John Wiley & Sons Ltd.)

The Spt-Ada-Gcn Acetyltransferase (SAGA) complex is a highly conserved co-activator found across eukaryotes. It is composed of a number of modules which can vary between species, but all contain the core module. Hfi1 (known as TADA1 in Homo sapiens ) is one of the proteins that forms the core module, and has been shown to play an important role in maintaining complex structural integrity in both brewer's yeast and humans. In this study we successfully identified the gene encoding this protein in the important fungal pathogen, Cryptococcus neoformans , and named it HFI1 . The hfi1 Δ mutant is highly pleiotropic in vitro, influencing phenotypes, ranging from temperature sensitivity and melanin production to caffeine resistance and titan cell morphogenesis. In the absence of Hfi1, the transcription of several other SAGA genes is impacted, as is the acetylation and deubiquination of several histone residues. Importantly, loss of the gene significantly impacts virulence in a murine inhalation model of cryptococcosis. In summary, we have established that Hfi1 modulates multiple pathways that directly affect virulence and survival in C. neoformans , and provided deeper insight into the importance of the non-enzymatic components of the SAGA complex.

Background: Initial treatment of hypertrophic pyloric stenosis (HPS) is correction of electrolyte disturbances with fluid resuscitation. In 2015, our institution implemented a fluid resuscitation protocol based on previous data that focused on minimizing blood draws and allowing immediate ad libitum feeds postoperatively. Our aim was to describe the protocol and subsequent outcomes., Methods: We conducted a single-center retrospective review of patients diagnosed with HPS from 2016 to 2023. All patients were given ad libitum feeds postoperatively and discharged home after tolerating three consecutive feeds. The primary outcome was the postoperative hospital length of stay (LOS). Secondary outcomes included the number of preoperative labs drawn, time from arrival to surgery, time from surgery to initiation of feeds, time from surgery to full feeds, and re-admission rate., Results: The study included 333 patients. A total of 142 patients (42.6%) had electrolytic disturbances that required fluid boluses in addition to 1.5x maintenance fluids. The median number of lab draws was 1 (IQR 1,2), with a median time from arrival to surgery of 19.5 hours (IQR 15.3,24.9). The median time from surgery to first and full feed was 1.9 hours (IQR 1.2,2.7) and 11.2 hours (IQR 6.4,18.3), respectively. Patients had a median postoperative LOS of 21.8 hours (IQR 9.7,28.9). Re-admission rate within the first 30 postoperative days was 3.6% ( n = 12) with 2.7% of re-admissions occurring within 72 hours of discharge. One patient required re-operation due to an incomplete pyloromyotomy., Discussion: This protocol is a valuable tool for perioperative and postoperative management of patients with HPS while minimizing uncomfortable intervention., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: To determine whether acromegaly is associated with increased extraocular muscle (EOM) size at time of presentation., Methods: Patients with a new diagnosis of acromegaly in a single tertiary care clinic with a CT scan that adequately delineated the EOMs were included. Control subjects were age- and sex-matched patients with a new diagnosis of nonfunctioning pituitary adenoma. Retrospective chart review was performed to extract baseline clinical and laboratory parameters including growth hormone, insulin-like growth factor 1, thyroid stimulating hormone, free T3, and free T4. A single neuroradiologist analyzed all CT scans and measured the maximum diameter and cross-sectional area of the superior rectus, inferior rectus, medial rectus, and lateral rectus in both eyes of all patients., Results: We evaluated 17 patients with acromegaly and 18 control subjects. Mean maximum diameter of the superior, inferior, medial, and lateral recti were 4.80 mm (SD = 0.81), 4.67 mm (SD = 0.54), 4.86 mm (SD = 0.77), and 4.53 mm (SD = 0.70) respectively, in the acromegaly group. In the control group, they were 3.62 mm (SD = 0.58),3.71 mm (SD = 0.46), 3.66 mm (SD = 0.32), and 3.21 mm (SD = 0.44), respectively. The maximum diameter and cross-sectional area of all 4 EOMs measured in the acromegaly group were significantly larger ( P < 0.001) compared with the control group., Conclusions: Patients with acromegaly present with significantly enlarged EOMs compared with control subjects with nonfunctioning pituitary adenomas., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by North American Neuro-Ophthalmology Society.)

Introduction: Clinical remission has been achieved with infliximab in patients with refractory ulcerative colitis (UC). However, there is conflicting data regarding its effectiveness as rescue therapy in adult acute severe colitis. Furthermore, pediatric inflammatory bowel disease (IBD) is associated with more severe disease that may be less amenable to attempted rescue. We reviewed our experience and outcomes with pediatric severe colitis after attempted inpatient rescue with infliximab., Methods: A single-institution, retrospective review was conducted of pediatric patients with UC or indeterminate colitis who received inpatient rescue infliximab therapy from 1/2000 to 1/2019. Rescue infliximab therapy was considered if a child failed non-biologic therapy or progressed to fulminant or toxic colitis. Primary outcome was failed therapy resulting in colectomy. A p-value of <0.05 determined significance., Results: Thirty patients met inclusion criteria. The median age at administration of rescue infliximab treatment was 14 years [IQR 13,17]. Rescue therapy with infliximab was successful in 33% (n = 10), while 67% (n = 20) underwent colectomy. Children on maintenance steroids were less likely to be successfully rescued with infliximab and require colectomy (p = 0.03). Children requiring colectomy had a longer hospital stay (p = 0.03), more abdominal radiographs (p = 0.01), and were on a longer duration of antibiotics (p = <0.01) compared to children who were successfully rescued with infliximab. There was no difference in baseline vital signs or laboratory abnormalities between the two groups., Conclusion: In severe acute ulcerative or indeterminate colitis cases where infliximab has not been previously used, rescue infliximab can be used to avoid colectomy but has a high failure rate., Level of Evidence: IV., Type of Study: Retrospective study., (Copyright © 2023 Elsevier Inc. All rights reserved.)

The optimal approach to COVID-19 surveillance in congregate populations remains unclear. Our study at the US Naval Academy in Annapolis, Maryland, USA, assessed the concordance of antibody prevalence in longitudinally collected dried blood spots and saliva in a setting of frequent PCR-based testing. Our findings highlight the utility of salivary-based surveillance.

Background: The Arizona-Texas-Oklahoma-Memphis-Arkansas Consortium practice management guideline was created to standardize management of blunt liver or spleen injury across pediatric trauma centers. We describe our outcomes since guideline adoption at our institution and hypothesize that blunt liver or spleen injury may be managed more expeditiously than currently reported without compromising safety., Methods: A retrospective cohort study was conducted on patients younger than 18 years presenting with blunt liver and/or splenic injuries from March 2016 to March 2021 at one participating center., Results: A total of 199 patients were included. There were no clinically relevant differences for age, body mass index, or sex among the cohort. Isolated splenic injuries (n = 91 [46%]) and motor vehicle collisions (n = 82 [41%]) were the most common injury and mechanism, respectively. The overall median length of stay (LOS) was 1.2 days (interquartile range, 0.45-3.3 days). Intensive care unit utilization was 23% (n = 46). There was no statistically significant difference in median LOS among patients with isolated solid organ injuries, regardless of injury grade. There were no readmissions associated with non-operative management., Conclusion: The Arizona-Texas-Oklahoma-Memphis-Arkansas Consortium guideline fosters high rates of nonoperative management with low intensive care unit utilization and LOS while demonstrating safety in implementation, irrespective of injury grade., Level of Evidence: Therapeutic/Care Management; Level IV., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Revisional bariatric surgeries are increasing for weight recurrence and return of co-morbidities. Herein, we compare weight loss and clinical outcomes following primary Roux-en-Y Gastric Bypass (P-RYGB), adjustable gastric banding to RYGB (B-RYGB), and sleeve gastrectomy to RYGB (S-RYGB) to determine if primary versus secondary RYGB offer comparable benefits., Methods: Participating institutions' EMRs and MBSAQIP databases were used to identify adult patients who underwent P-/B-/S-RYGB from 2013 to 2019 with a minimum one-year follow-up. Weight loss and clinical outcomes were assessed at 30 days, 1 year, and 5 years. Our multivariable model controlled for year, institution, patient and procedure characteristics, and excess body weight (EBW)., Results: 768 patients underwent RYGB: P-RYGB n = 581 [75.7%]; B-RYGB n = 106 [13.7%]; S-RYGB n = 81 [10.5%]. The number of secondary RYGB procedures increased in recent years. The most common indications for B-RYGB and S-RYGB were weight recurrence/nonresponse (59.8%) and GERD (65.4%), respectively. Mean time from index operation to B-RYGB or S-RYGB was 8.9 and 3.9 years, respectively. After adjusting for EBW, 1 year %TWL (total weight loss) and %EWL (excess weight loss) were greater after P-RYGB (30.4%, 56.7%) versus B-RYGB (26.2%, 49.4%) or S-RYGB (15.6%, 37%). Overall comorbidity resolution was comparable. Secondary RYGB patients had a longer adjusted mean length of stay (OR 1.17, p = 0.071) and a higher risk of pre-discharge complications or 30-day reoperation., Conclusion: Primary RYGB offers superior short-term weight loss outcomes compared to secondary RYGB, with decreased risk of 30-day reoperation., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: The Midwest Pediatric Surgery Consortium (MWPSC) suggested a simple aspiration of primary spontaneous pneumothorax (PSP) protocol, failing which, Video-Assisted Thoracoscopic Surgery (VATS) should be considered. We describe our outcomes using this suggested protocol., Methods: A single institution retrospective analysis was conducted on patients between 12 and 18 years who were diagnosed with PSP from 2016 to 2021. Initial management involved aspiration alone with a ≤12 F percutaneous thoracostomy tube followed by clamping of the tube and chest radiograph at 6 h. Success was defined as ≤2 cm distance between chest wall and lung at the apex and no air leak when the clamp was released. VATS followed if aspiration failed., Results: Fifty-nine patients were included. Median age was 16.8 years (IQR 15.9, 17.3). Aspiration was successful in 33% (20), while 66% (39) required VATS. The median LOS with successful aspiration was 20.4 h (IQR 16.8, 34.8), while median LOS after VATS was 3.1 days (IQR 2.6, 4). In comparison, in the MWPSC study, the mean LOS for those managed with a chest tube after failed aspiration was 6.0 days (±5.5). Recurrence after successful aspiration was 45% (n = 9), while recurrence after VATS was 25% (n = 10). Median time to recurrence after successful aspiration was sooner than that of the VATS group [16.6 days (IQR 5.4, 19.2) vs. 389.5 days (IQR 94.1, 907.0) p = 0.01]., Conclusion: Simple aspiration is safe and effective initial management for children with PSP, although most will require VATS. However, early VATS reduces length of stay and morbidity., Level of Evidence: IV. Retrospective study., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Same-day discharge (SDD) after laparoscopic appendectomy for acute nonperforated appendicitis is safe, without an increased rate of postoperative complications, emergency department visits, or readmissions. We aimed to evaluate caregiver satisfaction with this protocol., Methods: Patients discharged on the day of laparoscopic appendectomy for nonperforated acute appendicitis were identified between January 2022 and August 2022. Surveys to evaluate satisfaction with the protocol were distributed to the caregivers via email or text message 96 h after discharge. Telephone surveys were conducted if there were no responses to the initial online survey. The surveys assessed comfort with SDD, postoperative pain control adequacy, postoperative provider contact, and overall satisfaction. The protocol focused on avoidance of narcotics in the postoperative period and immediate return to a regular diet., Results: A total of 255 cases of nonperforated acute appendicitis underwent SDD. The survey response rate was 50.6% (n = 129). Most respondents were Caucasian (69.0%, n = 89) and male (51.9%, n = 67) with a median age of 12.0 y (IQR 8.9,14.7). The median postoperative length of hospital stay was 3.8 h (interquartile range [IQR] 3.2,4.8). The overall satisfaction rate was 91.5%, with 118 caregivers feeling satisfied with SDD. Most caregivers felt comfortable with the SDD protocol (89.9%, n = 116), with 22.5% (n = 29) calling a medical provider postoperatively. Approximately nine out of 10 caregivers reported that pain was adequately controlled (91.5%, n = 118). In contrast, those that were dissatisfied reported issues with pain control and anxiety with SDD after a surgical procedure., Conclusions: Caregiver satisfaction and comfort with same-day discharge following laparoscopic appendectomy is high with appropriate anticipatory guidance and preoperative education., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Family support is offered to Australian parents of young children using a mix of targeted and universal child and family health services including nurse-home-visiting programmes. These rely on the voluntary engagement of families. In this study, the capacity to engage and retain families, including those at risk of becoming involved with child protection services, was examined. The broad objective was to identify nursing practices used at the interface of health and child protection services and to articulate those practices. Child and Family Health Nurses (CFHN) ( n = 129) participated in a pragmatic, multilevel mixed-methods study. A questionnaire was used to identify nursing practices in the first phase of this study followed by focus groups in the second phase to describe these practices in more detail. Three practice themes were identified and described: enrolment, retention and conclusion of the nurse-family relationship. Universal child and family health services feature flexible, advanced, and multidimensional family support services including child protection practices. This paper focuses on practices employed by nurses to engage and retain families where child protection concerns are identified.

Objective: To assess the clinical implications of cryoanalgesia for pain management in children undergoing minimally invasive repair of pectus excavatum (MIRPE)., Background: MIRPE entails significant pain management challenges, often requiring high postoperative opioid use. Cryoanalgesia, which blocks pain signals by temporarily ablating intercostal nerves, has been recently utilized as an analgesic adjunct. We hypothesized that the use of cryoanalgesia during MIRPE would decrease postoperative opioid use and length of stay (LOS)., Materials and Methods: A multicenter retrospective cohort study of 20 US children's hospitals was conducted of children (age below 18 years) undergoing MIRPE from January 1, 2014, to August 1, 2019. Differences in total postoperative, inpatient, oral morphine equivalents per kilogram, and 30-day LOS between patients who received cryoanalgesia versus those who did not were assessed using bivariate and multivariable analysis. P value <0.05 is considered significant., Results: Of 898 patients, 136 (15%) received cryoanalgesia. Groups were similar by age, sex, body mass index, comorbidities, and Haller index. Receipt of cryoanalgesia was associated with lower oral morphine equivalents per kilogram (risk ratio=0.43, 95% confidence interval: 0.33-0.57) and a shorter LOS (risk ratio=0.66, 95% confidence interval: 0.50-0.87). Complications were similar between groups (29.8% vs 22.1, P =0.07), including a similar rate of emergency department visit, readmission, and/or reoperation., Conclusions: Use of cryoanalgesia during MIRPE appears to be effective in lowering postoperative opioid requirements and LOS without increasing complication rates. With the exception of preoperative gabapentin, other adjuncts appear to increase and/or be ineffective at reducing opioid utilization. Cryoanalgesia should be considered for patients undergoing this surgery., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Study Objective: There is little guidance for managing pubertally identified Mullerian anomalies in patients with anorectal malformations (ARMs). We sought to assess these unique issues., Design: Retrospective review SETTING: Single-institution study PARTICIPANTS: Natal female patients aged 10-25, with an ARM, cloaca, or exstrophy, who presented from 2009 to 2019 with a gynecologic concern were included., Intervention: Data collection was performed and included the presenting problem, psychological evaluation, fertility and sexuality concerns, and management strategies for these problems., Main Outcome Measures: The main outcome was unique needs that had to be addressed in the young adult population and the type of colorectal and gynecological procedures needed on representation., Results: Twelve patients were identified; all had gynecologic concerns. Ten had ARMs, including cloaca (n = 3) and cloacal exstrophy (n = 5). Median age at representation was 14.6 years (IQR = 12.7, 15.3). Colorectal revisions included posterior sagittal anorectoplasty (n = 1), resection of bowel attached to urogenital sinus (n = 1), and appendicostomy revision (n = 1). Gynecologic issues included dysmenorrhea (n = 8), obstructed Mullerian anomaly (n = 6), and introital stenosis (n = 5). Behavioral health concerns (n = 9) and fertility/sexuality concerns (n = 4) were identified. Median time from first visit to reconstruction was 1.5 years (IQR = 0.5, 1.5), providing multiple visits to achieve consensus among patients and providers before intervention, including vaginal or introital repair (n = 5) and hysterectomy of obstructed uterine horns (n = 3)., Conclusions: Goal-directed follow-up is required before surgical management to identify psychological and reproductive issues in patients with ARMs who have gynecologic concerns. Patient input and psychologic consultation are helpful for patients requiring staged reconstruction., Competing Interests: Conflict of Interest Statement No authors have any conflicts of interest to declare., (Copyright © 2022. Published by Elsevier Inc.)

Arboviral infections, including dengue (DNV), chikungunya (CHIKV), and Zika (ZIKV), impact both travelers and native populations of endemic regions. We sought to assess the disease burden of arboviral infections in the Military Health System, the validity of arboviral diagnostic codes, and the role of pretravel counseling on insect avoidance precautions. We searched for diagnostic codes consistent with arboviral infection and grouped them into DNV, CHIKV, ZIKV, Japanese encephalitis virus (JEV), and Other. Demographic data were evaluated. A subset of charts in each category were reviewed for diagnostic validity and travel characteristics. In all, 10,547 unique subjects carried 17,135 arboviral diagnostic codes, including 1,606 subjects (15.2%) coded for DNV, 230 (2.2%) for ZIKV, 65 (0.6%) for CHIKV, and 4,317 (40.9%) for JEV. A chart review was performed on 807 outpatient charts, yielding outpatient diagnostic code positive predictive values of 60.5% (DNV), 15.3% (ZIKV), and 64.5% (CHIKV); there were no valid cases of JEV. Dengue represented the greatest burden of arboviral infections with 2.2 cases per 100,000 military healthcare enrollees over the 2012-2019 fiscal years. More than 80% of subjects with arboviral infection did not have documented pretravel counseling. Arboviral infections represent a significant disease burden in young travelers to endemic regions. After adjustment for diagnostic validity, DNV represented the greatest burden. Diagnostic codes for ZIKV and JEV overestimate the burden of these diseases. Low rates of pretravel visits represent an opportunity for increased emphasis on insect exposure precautions.

Purpose: To identify the most accurate diagnostic imaging modality to detect optic disc drusen (ODD) between B-scan ultrasonography (US), fundus photography, fundus autofluorescence (FAF), and enhanced depth imaging optical coherence tomography (EDI-OCT)., Design: Comparative diagnostic analysis., Methods: Two hundred five eyes of 105 patients referred to 2 tertiary care neuro-ophthalmology clinics for suspected ODD were recruited: 108 eyes had ODD and 97 did not have ODD. All eyes received a full in-person ophthalmic exam with 3D view of the optic nerve and all 4 imaging modalities. Images were independently reviewed by 3 masked neuro-ophthalmologists to determine the presence or absence of ODD. Final interpretation was made through consensus. The reference standard was defined as the attending ophthalmologist's clinical judgement based on open chart review, with access to all image modalities and clinical information, including disease course. Main outcome measures were sensitivity, specificity, accuracy, and precision for each imaging modality. Examiner confidence was quantified as the proportion of eyes in which the reviewers were certain of their decision., Results: The EDI-OCT had the highest sensitivity and accuracy (95%, 97%) to detect ODD, compared with FAF (84%, 92%), US (74%, 86%), and fundus photography (38%, 66%), respectively. All image modalities had high specificity (> 97%) and precision (> 93%). The EDI-OCT also had highest examiner confidence (96%) compared with all others (88%)., Conclusions: Among all modalities, EDI-OCT was the imaging modality with the highest diagnostic utility for the detection of ODD and should be considered as the preferred initial diagnostic modality., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Verb and action knowledge deficits are reported in persons with Parkinson's disease (PD), even in the absence of dementia or mild cognitive impairment. However, the impact of these deficits on combinatorial semantic processing is less well understood. Following on previous verb and action knowledge findings, we tested the hypothesis that PD impairs the ability to integrate event-based thematic fit information during online sentence processing. Specifically, we anticipated persons with PD with age-typical cognitive abilities would perform more poorly than healthy controls during a visual world paradigm task requiring participants to predict a target object constrained by the thematic fit of the agent-verb combination. Twenty-four PD and 24 healthy age-matched participants completed comprehensive neuropsychological assessments. We recorded participants' eye movements as they heard predictive sentences (The fisherman rocks the boat) alongside target, agent-related, verb-related, and unrelated images. We tested effects of group (PD/control) on gaze using growth curve models. There were no significant differences between PD and control participants, suggesting that PD participants successfully and rapidly use combinatory thematic fit information to predict upcoming language. Baseline sentences with no predictive information (e.g., Look at the drum) confirmed that groups showed equivalent sentence processing and eye movement patterns. Additionally, we conducted an exploratory analysis contrasting PD and controls' performance on low-motion-content versus high-motion-content verbs. This analysis revealed fewer predictive fixations in high-motion sentences only for healthy older adults. PD participants may adapt to their disease by relying on spared, non-action-simulation-based language processing mechanisms, although this conclusion is speculative, as the analyses of high- vs. low-motion items was highly limited by the study design. These findings provide novel evidence that individuals with PD match healthy adults in their ability to use verb meaning to predict upcoming nouns despite previous findings of verb semantic impairment in PD across a variety of tasks., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Aveni et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: The survival of traumatic cardiopulmonary arrest (TCA) requiring pre-hospital cardiopulmonary resuscitation (P-CPR) is abysmal across age groups. We aim to describe the mechanisms of injury and outcomes of children suffering from TCA leading to P-CPR at our institution., Methods: A retrospective review was conducted to identify children ages 0-17 years who suffered TCA leading to P-CPR at our institution between 5/2009 and 3/2020. For analysis, patients were stratified into those still undergoing CPR at arrival and those who attained pre-hospital return of spontaneous circulation (ROSC). Primary outcome was discharge alive from the hospital., Results: P-CPR was initiated for 48 patients who had TCA; 23 had pre-hospital ROSC. Of the 25 children undergoing CPR at presentation, none survived to discharge. The median duration of CPR, from initiation to time of death declaration was 34 min [29,50]. Seventeen patients died after resuscitation attempts in the ED, while 8 died after admission to the PICU. Of the 23 patients who attained pre-hospital ROSC, 6 survived to discharge. All survivors required intensive rehabilitation services at discharge and at most recent follow-up, 5 had residual deficits requiring medical attention., Conclusion: There are poor outcomes in children with pre-hospital traumatic cardiopulmonary arrest, particularly in those without pre-hospital ROSC. These data further support the need for standardized guidelines for resuscitation in children with traumatic cardiopulmonary arrest., Competing Interests: Declarations of Competing Interest None., (Copyright © 2022. Published by Elsevier Ltd.)

Background: Same-day discharge (SDD) after laparoscopic gastrostomy tube (G-tube) placement, using written and video-based preoperative education, has been our standard institutional practice since 2017. We aim to evaluate caretaker satisfaction with this protocol., Methods: All patients planned for SDD after G-tube placement from February 2021-February 2022 were identified. Chart review was performed to identify demographic information, successful same-day discharge or reason for postoperative admission, time to first postoperative feed, length of stay (LOS), and complications requiring emergency department evaluation, readmission, or reoperation. Telephone follow-up at two weeks postoperatively was conducted to evaluate satisfaction with the SDD protocol., Results: Forty-nine patients were eligible for SDD with a median age of 1.1 years [0.7, 4.4]. Forty-two (86%) patients were successfully discharged the same day with a median LOS of 7.5 h [6.7, 8.1], and 7 (14%) were admitted postoperatively for further education or emesis with a median LOS of 30.4 h [26.9, 31.2]. Median time to initiation of feeds was 2.3 h [1.7, 2.9]. 8 (16%) patients were evaluated in the emergency department within 30 days postoperatively, resulting in two re-admissions: one for peri‑stomal erythema and fever requiring oral antibiotics at 21 days and one for G-tube dislodgement requiring reoperation and replacement at 28 days. On two-week telephone follow-up, 42 caretakers (100%) felt that their education was adequate for same-day discharge and felt comfortable with the same-day discharge protocol. Six (14%) caretakers stated their child's pain was not well controlled at some point between discharge and survey follow-up, and three caretakers (7%) called a provider within the first 24 h for issues with pain. Forty-one caretakers (98%) expressed satisfaction going home the day of surgery., Conclusion: Caretaker satisfaction and comfort with same-day discharge following laparoscopic G-tube placement are high, ascribed to comprehensive preoperative education and anticipatory guidance., Type of Study: Prognostic., Level of Evidence: Level 1., Competing Interests: Declaration of Competing Interest None., (Copyright © 2022. Published by Elsevier Inc.)

Introduction: We evaluate the incidence, outcomes, and management of peri‑umbilical hernias after sutured or sutureless gastroschisis closure., Methods: A retrospective, longitudinal follow-up of neonates with gastroschisis who underwent closure at 11 children's hospitals from 2013 to 2016 was performed. Patient encounters were reviewed through 2019 to identify the presence of a peri‑umbilical hernia, time to spontaneous closure or repair, and associated complications., Results: Of 397 patients, 375 had follow-up data. Sutured closure was performed in 305 (81.3%). A total of 310 (82.7%) infants had uncomplicated gastroschisis. Peri-umbilical hernia incidence after gastroschisis closure was 22.7% overall within a median follow-up of 2.5 years [IQR 1.3,3.9], and higher in those with uncomplicated gastroschisis who underwent primary vs. silo assisted closure (53.0% vs. 17.2%, p< 0.001). At follow-up, 50.0% of sutureless closures had a persistent hernia, while 16.4% of sutured closures had a postoperative hernia of the fascial defect (50.0% vs. 16.4%, p< 0.001). Spontaneous closure was observed in 38.8% of patients within a median of 17 months [9,26] and most frequently observed in those who underwent a sutureless primary closure (52.2%). Twenty-seven patients (31.8%) underwent operative repair within a median of 13 months [7,23.5]. Rate and interval of spontaneous closure or repair were similar between the sutured and sutureless closure groups, with no difference between those who underwent primary vs. silo assisted closure., Conclusion: Peri-umbilical hernias after sutured or sutureless gastroschisis closure may be safely observed similar to congenital umbilical hernias as spontaneous closure occurs, with minimal complications and no additional risk with either closure approach., Levels of Evidence: Level II., Competing Interests: Declarations of Competing Interest None., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: There are disparate findings in the literature on the impact of race and insurance status on gonadal loss in testicular torsion. We sought to determine if race or levels of social vulnerability influence the rate of torsion or gonadal loss., Methods: Retrospective cross-sectional review between December 2017 and September 2019. Social vulnerability index was dichotomized using the 75th percentile. Primary outcome was the diagnosis of testicular torsion., Results: 515 patients were included. There was no difference in median age, torsion diagnosis, and orchiectomy rate between the two institutions. Black/African American patients were >3 times more likely than Caucasian patients to be diagnosed with TT when controlled for dichotomized SVI, insurance, and age (OR 3.39, 95% CI 1.74 - 6.61, p < 0.01)., Conclusion: Black/African American children have an increased risk of testicular torsion. Despite these patients having higher levels of social vulnerability, it was not associated., (Copyright © 2022 National Medical Association. Published by Elsevier Inc. All rights reserved.)

Competing Interests: The authors report no conflicts of interest.

Introduction: Umbilical access in laparoscopic surgery has been cited as a factor for increased complications in low-birth-weight infants and those less than three months old. In a previous series, 10.6% of pediatric surgeons reported complications in this population associated with umbilical access, citing carbon dioxide (CO 2 ) embolism as the most common complication. To further examine the safety of this technique, we report our outcomes with blunt transumbilical laparoscopic access at our institution over four years., Methods: A retrospective review was performed of patients less than three months of age who underwent laparoscopic pyloromyotomy or inguinal hernia repair from 2016 to 2019. Operative reports, anesthesia records, and postoperative documentation were reviewed for complications related to umbilical access. Complications included bowel injury, vascular injury, umbilical vein cannulation, CO 2 embolism, umbilical surgical site infection (SSI), umbilical hernia requiring repair, and death., Results: Of 365 patients, 246 underwent laparoscopic pyloromyotomy, and 119 underwent laparoscopic inguinal hernia repairs. Median age at operation was 5.9 weeks [4.3,8.8], and median weight was 3.9 kg [3.4,4.6]. Nine complications (2.5%) occurred: 5 umbilical SSIs (1.4%), 1 bowel injury upon entry requiring laparoscopic repair (0.2%), 1 incisional hernia repair 22 days postoperatively (0.2%), and 2 cases of hypotension and bradycardia upon insufflation that resolved with desufflation (0.5%). There were no intraoperative mortalities or signs/symptoms of CO 2 embolism., Conclusion: In this series, umbilical access for laparoscopic surgery in neonates less than three months of age was safe, with minimal complications. Although concern for umbilical vessel injury, cannulation, and CO 2 embolism exists, these complications are not exclusively associated with umbilical access technique., (Copyright © 2021. Published by Elsevier Inc.)

The fungal pathogen Cryptococcus neoformans is a leading cause of meningoencephalitis in the immunocompromised. As current antifungal treatments are toxic to the host, costly, limited in their efficacy, and associated with drug resistance, there is an urgent need to identify vulnerabilities in fungal physiology to accelerate antifungal discovery efforts. Rational drug design was pioneered in de novo purine biosynthesis as the end products of the pathway, ATP and GTP, are essential for replication, transcription, and energy metabolism, and the same rationale applies when considering the pathway as an antifungal target. Here, we describe the identification and characterization of C. neoformans 5-aminoimidazole-4-carboxamide ribonucleotide (AICAR) transformylase/5'-inosine monophosphate cyclohydrolase (ATIC), a bifunctional enzyme that catalyzes the final two enzymatic steps in the formation of the first purine base inosine monophosphate. We demonstrate that mutants lacking the ATIC-encoding ADE16 gene are adenine and histidine auxotrophs that are unable to establish an infection in a murine model of virulence. In addition, our assays employing recombinantly expressed and purified C. neoformans ATIC enzyme revealed K m values for its substrates AICAR and 5-formyl-AICAR are 8-fold and 20-fold higher, respectively, than in the human ortholog. Subsequently, we performed crystallographic studies that enabled the determination of the first fungal ATIC protein structure, revealing a key serine-to-tyrosine substitution in the active site, which has the potential to assist the design of fungus-specific inhibitors. Overall, our results validate ATIC as a promising antifungal drug target., Competing Interests: Conflict of interest The authors declare that they have no conflicts of interest with the contents of this article., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction: We previously developed an institutional, evidence-based fluid resuscitation protocol for neonates with infantile hypertrophic pyloric stenosis (HPS) based on the severity of electrolyte derangement on presentation. We aim to evaluate this protocol to determine its efficacy in reducing the number of preoperative lab draws, time to electrolyte correction, and overall length of stay., Methods: A single center, retrospective review of 319 infants with HPS presenting with electrolyte derangement from 2008 to 2020 was performed; 202 patients managed pre-protocol (2008-2014) and 117 patients managed per our institutional fluid resuscitation algorithm (2016-2020). The number of preoperative lab draws, time to electrolyte correction, and length of stay before and after protocol implementation was recorded., Results: Use of a fluid resuscitation algorithm decreased the number of infants who required four or more preoperative lab draws (20% vs. 6%) (p < .01), decreased median time to electrolyte correction between the pre and post protocol cohorts (15.1 h [10.6, 22.3] vs. 11.9 h [8.5, 17.9]) (p < .01), and decreased total length of hospital stay (49.0 h [40.3, 70.7] vs. 45.7 h [34.3, 65.9]) (p < .05)., Conclusion: Implementation of a fluid resuscitation algorithm for patients presenting with hypertrophic pyloric stenosis decreases the frequency of preoperative lab draws, time to electrolyte correction, and total length of hospital stay. Use of a fluid resuscitation protocol may decrease discomfort through fewer preoperative lab draws and shorter length of stay while setting clear expectations and planned intervention for parents., Level of Evidence: III - Retrospective comparative study., Competing Interests: Declarations of Competing Interest None., (Copyright © 2021. Published by Elsevier Inc.)

Purpose: Malone antegrade continence enemas (MACE) provide a conduit in which the patient can achieve improved continence, be clean of stool, and gain independence in maintaining bowel function. The Mini-ACE® is a low-profile balloon button that is used to facilitate the administration of antegrade enemas. We sought to describe our practice and short-term outcomes., Methods: This work is a retrospective review of the Mini-ACE® appendicostomy button from April 2019 to March 2021, with follow-up concluding in October 2021. Patient demographics, colorectal diagnoses, and outcomes were examined., Results: Forty-three patients underwent Mini-ACE® placement; 22 (51%) were male. The average age at Mini-ACE® insertion was 9.2 years (range 3-20 years). The most common diagnoses were functional constipation in 19 (44%), anorectal malformation in 15 (35%), and Hirschsprung disease in 3 (7%), spinal differences 3 (7%). There were no intra-operative complications, but 5 (12%) required prolapse resection. The median length of stay was two days (IQR 1, 4). Patients achieved self-catheterization at 4.5 [3,7] months from MACE creation, with 38 children (88%) reporting excellent success in remaining clean of stool., Conclusion: The Mini-ACE® appears to be a safe and low-profile option for antegrade continence enema access. Further research is needed directly comparing complications and patient satisfaction rates between different MACE devices and overall quality of life., Level of Evidence: Level IV., (Copyright © 2021. Published by Elsevier Inc.)

Flecainide, a cardiac class 1C blocker of the surface membrane sodium channel (NaV1.5), has also been reported to reduce cardiac ryanodine receptor (RyR2)-mediated sarcoplasmic reticulum (SR) Ca2+ release. It has been introduced as a clinical antiarrhythmic agent for catecholaminergic polymorphic ventricular tachycardia (CPVT), a condition most commonly associated with gain-of-function RyR2 mutations. Current debate concerns both cellular mechanisms of its antiarrhythmic action and molecular mechanisms of its RyR2 actions. At the cellular level, it targets NaV1.5, RyR2, Na+/Ca2+ exchange (NCX), and additional proteins involved in excitation-contraction (EC) coupling and potentially contribute to the CPVT phenotype. This Viewpoint primarily addresses the various direct molecular actions of flecainide on isolated RyR2 channels in artificial lipid bilayers. Such studies demonstrate different, multifarious, flecainide binding sites on RyR2, with voltage-dependent binding in the channel pore or voltage-independent binding at distant peripheral sites. In contrast to its single NaV1.5 pore binding site, flecainide may bind to at least four separate inhibitory sites on RyR2 and one activation site. None of these binding sites have been specifically located in the linear RyR2 sequence or high-resolution structure. Furthermore, it is not clear which of the inhibitory sites contribute to flecainide's reduction of spontaneous Ca2+ release in cellular studies. A confounding observation is that flecainide binding to voltage-dependent inhibition sites reduces cation fluxes in a direction opposite to physiological Ca2+ flow from SR lumen to cytosol. This may suggest that, rather than directly blocking Ca2+ efflux, flecainide can reduce Ca2+ efflux by blocking counter currents through the pore which otherwise limit SR membrane potential change during systolic Ca2+ efflux. In summary, the antiarrhythmic effects of flecainide in CPVT seem to involve multiple components of EC coupling and multiple actions on RyR2. Their clarification may identify novel specific drug targets and facilitate flecainide's clinical utilization in CPVT., (© 2022 Salvage et al.)

Introduction: Infants with intra-abdominal pathology necessitating open abdominal surgery may also require placement of a gastrostomy tube (GT). Use of laparoscopy provides better visualization for gastrostomy placement and lowers the risk of complications compared with an open approach. We describe a series of patients who underwent laparoscopic GT placement at the time of an open abdominal procedure. Methods: All patients who underwent an open abdominal procedure with concurrent laparoscopic gastrostomy from January 2010 to June 2020 were reviewed. Descriptive statistics were performed with categorical variables reported as proportions and continuous variables reported as medians with interquartile range [IQR]. Results: Twelve patients were included; 8 (67.5%) were male. The median age at time of surgery was 10 weeks [IQR 6, 14], with a median weight of 4.1 kg [IQR 3.4, 4.8]. Ten patients had the laparoscope placed through the open incision, whereas 2 had the laparoscope placed through a separate incision. Median operative time was 106 minutes [IQR 80, 125]. There were no intraoperative complications. Postoperative complications included surgical site infection in 5 (41.7%), leaking around the GT in 3 (25%), and malfunction of the tube in 1 (8.3%). One patient required reoperation 28 days postoperatively due to malfunction. Conclusion: Laparoscopic GT can be safely performed at the time of an open abdominal procedure, and frequently through the same incision, harnessing the benefits of a laparoscopic approach even when an open incision is needed.

Paleoproteomics typically involves the destructive sampling of precious bioarchaeological materials. This analysis aims to investigate the proteins identifiable via nanoLC-MS/MS from highly degraded 26th Dynasty Egyptian mummified human remains (NMR.29.1-8) after non-destructive sampling with commercially available dermatology-grade skin sampling tape strips. A collection of cranial and other bone fragments were sampled with the tape strips then subsequently analysed using a shotgun proteomics approach. The number of proteins identified using this method ranged from 18 to 437 at a peptide FDR of <1%. Deamidation ratios were assessed using an in-house R script, with asparagine deamidation averaging ∼20-30% and glutamine deamidation averaging ∼15-25%., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Author(s). Published by Elsevier Inc.)

Introduction: We previously conducted a randomized trial that showed a lack of need for esophagocrural (EC) sutures during fundoplication when no esophageal dissection was performed. There was no difference in wrap herniation or other complications in the group without EC sutures at a median 1.5 years of follow-up. In this follow-up study, we aim to evaluate long-term symptom control and complication profiles in these patients., Methods: 106 patients were randomized and participated in the original trial. We were primarily concerned with identification of late complications and persistence of symptoms. Presently, we conducted a retrospective chart review and a telephone follow-up survey at a minimum of 6.5 years after fundoplication., Results: 100 patients were alive at late follow-up and 70% of caregivers responded to the telephone survey. 53% of patients were male; 76% were Caucasian. Of these children, 39 (56%) received four EC sutures, while 31 (44%) did not. Follow-up was conducted at a median of 8.7 years [IQR 8.2,9.7] post-fundoplication. Late wrap herniation was not demonstrated radiographically on chart review or caregiver report in either group. The rate of residual reflux symptoms, post-operative hospitalizations for pneumonia, failure to thrive (FTT), and brief resolved unexplained event (BRUE) were also similar between groups., Conclusion: Long-term follow-up in children who underwent fundoplication without esophagocrural sutures demonstrates no difference in symptom management or subsequent hospitalizations at a minimum of 6.5-year follow-up., Level of Evidence: II (follow-up of a randomized controlled trial)., Competing Interests: Declaration of Competing Interest None of the authors have any financial or commercial interests to disclose. No financial support was used to conduct this research., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Introduction: Hirschsprung's-associated enterocolitis (HAEC) is a common post-operative problem for patients with Hirschsprung disease (HSCR). However, treatment strategies remain variable among providers, institutions, and even nations. The purpose of this study was to identify differences in treatment patterns for HAEC., Methods: A questionnaire was distributed to members of the International Pediatric Endoscopic Group (IPEG) community that focused on HSCR and HAEC management strategies. Questionnaire responses were collected via the Research Electronic Data Capture (RedCap)., Results: 178 responses were obtained: 30% from North America, 20% South America, 20% Europe, 26% Asia, and 4% from Australia. 37% had a dedicated pediatric colorectal center. After diagnosis, 53% send patients home with irrigations, while 29% perform a primary PT before discharge; the type of PT varied between Soave (50%), Swenson (25%) and Duhamel (13%). Only 29 respondents (17%) stated their institution had guidelines for HAEC management; however, inpatient treatments were fairly consistent: 95% performed rectal irrigations, 93% obtained an abdominal radiograph, and 72% held feeds; 55% taught families irrigations before discharge. Utilization of Botulinum (BT) injections was mixed: 36% never utilized BT injections, 33% only used BT if irrigations were not tolerated, and 16% only injected BT for recurrent episodes. Preventative HAEC measures were also varied and included anal dilations (44%), prophylactic antibiotics (34%), probiotics (29%), and routine home irrigations (22%)., Conclusion: There is wide variation of care in managing enterocolitis episodes in patients with Hirschsprung disease. Further research leading to consensus guidelines and standardization practices can help improve the care for these patients., Level of Evidence: V TYPE OF STUDY: Treatment study/ survey., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: We report the findings of a three-year prospective observational study elucidating long-term symptoms and complications of patients who underwent minimally invasive pectus excavatum repair with intercostal nerve cryoablation with specific attention to postoperative pain control associated with the cryoablation technique., Methods: Surveys were administered to patients who underwent bar placement for pectus excavatum with intercostal nerve cryoablation from 2017 to 2021 regarding pain scores, pain medication usage, and limitations to activity beginning on the day of surgery, on the day of discharge, and at two-week and three-month follow-up., Results: Of 110 patients, forty-eight (44%) completed the discharge survey; sharp pain and pressure on the first postoperative night were the most described pain characteristics, most frequently in the middle of the chest. On follow-up, 55% of patients reported tolerable residual pain at two weeks and 41% at three months, with 25% requiring intermittent pain medication at three months. There were three readmissions for inadequate pain control and 110 calls to the surgery clinic by three-month follow-up, most commonly for persistent pain and frequent popping sensation with movement., Discussion: Although cryoablation is an excellent pain control modality, these data suggest that patients underreport functional symptoms and experience more frequent discomfort and alteration of daily living activities., Competing Interests: Declarations of Competing Interests None, This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors., (Copyright © 2022. Published by Elsevier Inc.)

Short open reading frame (sORF)-encoded peptides (sPEPs) have been found across a wide range of genomic locations in a variety of species. To date, their identification, validation, and characterisation in the human fungal pathogen Cryptococcus neoformans has been limited due to a lack of standardised protocols. We have developed an enrichment process that enables sPEP detection within a protein sample from this polysaccharide-encapsulated yeast, and implemented proteogenomics to provide insights into the validity of predicted and hypothetical sORFs annotated in the C. neoformans genome. Novel sORFs were discovered within the 5' and 3' UTRs of known transcripts as well as in "non-coding" RNAs. One novel candidate, dubbed NPB1, that resided in an RNA annotated as "non-coding", was chosen for characterisation. Through the creation of both specific point mutations and a full deletion allele, the function of the new sPEP, Npb1, was shown to resemble that of the bacterial trans-translation protein SmpB., (Copyright © 2022. Published by Elsevier Inc.)

Background: The Deployment and Travel Medicine Knowledge, Attitudes, Practices, and Outcomes Study (KAPOS) evaluates health outcomes and provider practices associated with travel and deployments within the US Military Health System. We analyzed prescribing errors for chloroquine malaria chemoprophylaxis between travel medicine specialists and non-specialists over a five-year period., Methods: A sample of 291 chloroquine prescriptions were reviewed to determine if malaria chemoprophylaxis was appropriate for destination of travel based on both transmission and chloroquine resistance risk. We included non-active-duty beneficiaries of all ages seeking care at military treatment facilities., Results: 10.3% (n = 30) of patients were prescribed chloroquine inappropriately. Non-travel medicine specialists prescribed chloroquine inappropriately more frequently than travel medicine specialists with 16.5% vs 2.3% error, respectively. Physicians were less likely to erroneously prescribe chloroquine as compared to non-physicians with 6.4% vs 22.2% error, respectively. 93.3% of prescribing errors were due to chloroquine-resistance presence at the travel destination. Africa was the most common destination of erroneous prescriptions, creating significant risk for travelers., Conclusions: While chloroquine is infrequently prescribed, this analysis demonstrates travel medicine proficiency is associated with reduced errors, highlighting the need to supply travel medicine education and decision support tools to non-specialists, to safeguard patients who seek pre-travel medical care., (Published by Elsevier Ltd.)

The pathogenic yeast Cryptococcus neoformans causes nearly 200,000 deaths annually in immunocompromised individuals. Cryptococcus cells can undergo substantial morphological change during mammalian infection, including increased capsule and cell size, the release of shed capsule, and the production of titan (>10 μm), micro (<2 μm)-, and irregular cells. We examined phenotypic variation under conditions designed to simulate in vivo stress in a collection of nine lineages derived from the C. neoformans type strain H99. These lineages are highly genetically similar but have a range of virulence levels. Strains from hypervirulent lineages had a larger average capsule size, greater variation in cell size, and an increased production of microcells and shed capsule. We tested whether disruption of SGF29 , which encodes a component of the SAGA histone acetylation complex that has previously been implicated in the hypervirulence of some lineages, also has a role in the production of morphological variants. Deletion of SGF29 in a lineage with intermediate virulence substantially increased its production of microcells and released capsule, consistent with a switch to hypervirulence. We further examined SGF29 in a set of 52 clinical isolates and found loss-of-function mutations were significantly correlated with patient death. Expansion of a TA repeat in the second intron of SGF29 was positively correlated with cell and capsule size, suggesting it also affects Sgf29 function. This study extends the evidence for a link between pleomorphism and virulence in Cryptococcus, with a likely role for epigenetic mechanisms mediated by SAGA-induced histone acetylation. IMPORTANCE Cryptococcosis is a devastating cause of death and disease worldwide. During infection, Cryptococcus cells can undergo substantial changes to their size and shape. In this study, we used a collection of C. neoformans strains that are highly genetically similar but possess differing levels of virulence to investigate how morphological variation aligns with virulence. We found hypervirulent strains on average had larger capsules and greater variation in cell size and produced more microcells and shed capsule. These hypervirulent strains possessed a mutation in SGF29 , which encodes a component of the SAGA complex involved in epigenetic regulation. Analysis of the SGF29 gene in a set of clinical isolates found strains with loss-of-function mutations were associated with higher patient death rates. The capacity to vary appears to be linked with virulence in Cryptococcus, and this can occur in the absence of genetic variation via epigenetic mechanisms.

Introduction: Little is known about psychosocial and behavioral factors that impact the quality of life of patient's with anorectal malformations (ARM) and Hirschsprung disease (HSCR). We aimed to highlight the psychosocial, emotional, and behavioral themes that affect these patients., Methods: A qualitative literature review of articles published between 1980 and 2019 was performed. Articles that reported quality of life (QoL) measures not directly related to bowel function and incorporated data on patients aged 0-21 years old were included. Data were separated based on distinct developmental time points., Results: In the neonatal period, parents relayed uncertainty about the future and feeling overwhelmed by lack of social support. Difficulties with anxiety, peer rejection, and behavioral problems were noted in primary grades, while adolescents experienced low self-confidence, poor body image, and depression. Young adults expressed hesitancy to engage in romantic relationships or sexual activity. Lack of long-term follow-up, an incomplete transition to adult healthcare, and lack of psychology services leave young adults without guidance to manage a chronic condition., Conclusion: Multiple psychosocial stressors are present in the lives of ARM and HSCR patients. Provision of developmentally matched medical, psychological, and community-based supports for ARM and HSCR patients and their families can lead to improved QoL., (Copyright © 2021. Published by Elsevier Inc.)