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Objectives: Dog bites occur frequently in the United States, yet there are no clear guidelines for prescribing antibiotic prophylaxis in healthy children after a dog bite. The aim of our study was to assess antibiotic prophylaxis and subsequent rates of infection after dog bites in children. We hypothesized a negative association between prophylactic prescription of any antimicrobial and return visit within 14 days for infection., Methods: In this retrospective cohort study, we assessed the frequency of antibiotic prophylaxis prescribed after dog bite injuries in patients 0 to 18 years old and subsequent return visits for infection using 2016 to 2017 medical and pharmacy claims derived from the IBM MarketScan Research Databases. We used the International Classification of Diseases-10 code W54 for dog bites then used keyword searches to find diagnoses (including infection), wound descriptions, and medications., Results: Over the 2-year period, 22,911 patients were seen for dog bites that were not coded as infected. The majority, 13,043 (56.9%), were prescribed an antibiotic at the initial visit and 9868 (43.1%) were not. Of those prescribed antibiotics, 98 (0.75%; 95% confidence interval [CI], 0.60-0.90) returned with an infection, compared with 59 (0.60%; 95% CI, 0.44-0.75) of those not prescribed antibiotics. Receiving an antibiotic prescription at the initial visit was associated with a reduced rate of return for wound infection only among children whose wounds were repaired or closed. Children not receiving a prescription whose wounds were repaired were more than twice as likely to return with an infection in the subsequent 14 days as children whose wounds were not repaired (odds ratio, 2.2; 95% CI, 1.2-4.0)., Conclusions: Most children are prescribed antibiotics at an initial emergency department visit after a dog bite. However, very few return for infection independent of antimicrobial prophylaxis, which suggests antibiotics are overprescribed in this setting., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Antiretroviral therapy (ART) extends the life of people with HIV (PWH), but these individuals are at increased risk for obesity, dyslipidemia, diabetes, and cardiovascular disease. These comorbidities may be a consequence of HIV-related chronic inflammation and/or adverse effects of ART on tissue regulatory adipose tissue macrophages (ATMs). We sought to determine the effects of HIV/ART on metabolically beneficial ATM populations and functions., Design: We examined subcutaneous ATMs from PWH on integrase inhibitor-containing ART ( n  = 5) and uninfected persons ( n  = 9). We complemented these studies with ex vivo and in vitro analyses of peripheral blood mononuclear cell (PBMC) and murine macrophage lipid metabolism and fatty acid oxidation gene expression., Methods: ATM populations were examined by flow cytometry. Macrophage lipid metabolism and fatty acid oxidation gene expression were examined by Seahorse assay and quantitative PCR., Results: Adipose tissue from PWH had reduced populations of metabolically activated CD9 + ATMs compared to that of uninfected controls ( P  < 0.001). PBMCs of PWH had lower fatty acid metabolism compared to those of uninfected controls ( P  < 0.01). Analysis of murine macrophages revealed that dolutegravir reduced lipid metabolism ( P  < 0.001) and increased expression of the fatty acid beta-oxidation enzyme enoyl-CoA hydratase, short chain 1 ( P  < 0.05)., Conclusions: We report the loss of metabolically beneficial ATM populations in PWH on ART, altered fatty acid metabolism of blood immune cells, and evidence that dolutegravir alters macrophage fatty acid metabolism. Future studies should examine direct or indirect effects and mechanisms of dolutegravir, and other integrase inhibitors and ART classes, on fatty acid beta-oxidation., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Despite successful legislative efforts by the American Society of Plastic Surgeons (ASPS), the Plastic Surgery Political Action Committee remains underused. Participation in advocacy and financial contributions of ASPS members fall below those of similar surgical subspecialties. This study aims to perform a data-driven investigation into the impact of Plastic Surgery Political Action Committee efforts on the practicing plastic surgeon., Methods: A retrospective review of the ASPS procedural database from 1992 to 2018 and Plastic Surgery Political Action Committee contributions from 2012 to 2018 was performed. Postmastectomy breast and congenital anomaly reconstructions were analyzed. To determine significant variations in trends, change-point analyses were conducted. Changes in surgical volume were correlated to implementation of federal legislative efforts., Results: Three significant trends of increased breast reconstruction volume were detected with associations to three specific legislative changes: 1992 to 1998, which correlates with the Women's Health and Cancer Rights Act; 2006 to 2009, which correlates with the U.S. Food and Drug Administration's approval of silicone breast implant use; and 2013 to 2015, which correlates with the Breast Cancer Patient Education Act. During the study period, breast reconstruction procedures increased substantially compared with all reconstructive procedures (146.6 percent versus 3.6 percent). There were no significant trends detected for birth defect reconstructions. Although contributions were relatively stagnant, resident member contributions increased after 2015, correlating with formation of the Political Action Committee's Resident's Club., Conclusions: This study demonstrates a correlation in timing between Plastic Surgery Political Action Committee legislative accomplishments and the resulting case volume increase in some areas of plastic surgery. The data highlight the importance of political advocacy and how political action committee activities can directly impact patient access to care and the practice of plastic surgery., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Purpose of Review: The aim of this review is to discuss the current evidence regarding the development of eosinophilic esophagitis (EoE) in individuals undergoing oral and sublingual immunotherapy (SLIT) for both food and environmental allergens. Cumulative incidence of EoE in patients on allergen immunotherapy for peanut, milk, and egg is estimated., Recent Findings: De novo development of EoE in patients undergoing oral and SLIT has been demonstrated on the scale of case reports and prospective randomized trials. However, few individuals with EoE-like symptoms during immunotherapy undergo endoscopy, and the long-term outcomes of immunotherapy-associated EoE are unknown., Summary: Evidence exists to suggest that allergen immunotherapy could place individuals at risk for the development of EoE, the true incidence of which may vary depending on antigen exposure and methods used to define the condition.

Background: A noninvasive biomarker that could accurately diagnose acute rejection (AR) in heart transplant recipients could obviate the need for surveillance endomyocardial biopsies. We assessed the performance metrics of a novel high-sensitivity cardiac troponin I (cTnI) assay for this purpose., Methods and Results: Stored serum samples were retrospectively matched to endomyocardial biopsies in 98 cardiac transplant recipients, who survived ≥3 months after transplant. AR was defined as International Society for Heart and Lung Transplantation grade 2R or higher cellular rejection, acellular rejection, or allograft dysfunction of uncertain pathogenesis, leading to treatment for presumed rejection. cTnI was measured with a high-sensitivity assay (Abbott Diagnostics, Abbott Park, IL). Cross-sectional analyses determined the association of cTnI concentrations with rejection and International Society for Heart and Lung Transplantation grade and the performance metrics of cTnI for the detection of AR. Among 98 subjects, 37% had ≥1 rejection episode. cTnI was measured in 418 serum samples, including 35 paired to a rejection episode. cTnI concentrations were significantly higher in rejection versus nonrejection samples (median, 57.1 versus 10.2 ng/L; P<0.0001) and increased in a graded manner with higher biopsy scores (P(trend)<0.0001). The c-statistic to discriminate AR was 0.82 (95% confidence interval, 0.76-0.88). Using a cut point of 15 ng/L, sensitivity was 94%, specificity 60%, positive predictive value 18%, and negative predictive value 99%., Conclusions: A high-sensitivity cTnI assay seems useful to rule out AR in cardiac transplant recipients. If validated in prospective studies, a strategy of serial monitoring with a high-sensitivity cTnI assay may offer a low-cost noninvasive strategy for rejection surveillance., (© 2014 American Heart Association, Inc.)

Germline mutations in DICER1 are associated with increased risk for a wide variety of neoplastic conditions, including pleuropulmonary blastoma (PPB), cystic nephroma, nasal chondromesenchymal hamartoma, ovarian Sertoli-Leydig cell tumors, botryoid embryonal rhabdomyosarcoma of the uterine cervix, ciliary body medulloepithelioma, pineoblastoma, pituitary blastoma and nodular thyroid hyperplasia or thyroid carcinoma. These tumors may be seen in isolation or in constellation with other characteristic tumor types in individuals or family members. Here we describe the medical history of a child with a heterozygous, loss of function germline DICER1 mutation and multiple tumors associated with the syndrome.. Although germline mutations in DICER1 are rare, tumors of these types will be seen by practicing pathologists and should prompt consideration of an underlying DICER1 mutation.

Purpose of Review: Acute cardiac allograft rejection surveillance has historically been based on serial endomyocardial biopsy (EMB). Limitations with this approach have stimulated interest in identifying noninvasive surrogate markers of rejection. This review summarizes the evidence assessing the use of direct cardiac markers B-type natriuretic peptide (BNP) and cardiac troponins in detecting acute allograft rejection., Recent Findings: BNP, its amino-terminal fragment NT-proBNP, and cardiac troponins T and I have all been extensively evaluated for this purpose, and so far have demonstrated inadequate diagnostic accuracy to replace EMB. Longitudinal surveillance of BNP and NT-proBNP appears to offer promise for improved accuracy, but has not been adequately evaluated in prospective studies. Preliminary investigations into highly sensitive troponin assays suggest a potential role in rejection surveillance, but prospective validation in larger studies is needed., Summary: EMB remains the gold standard for cardiac allograft rejection surveillance. However, recent data indicate potential clinical utility for serial monitoring of natriuretic peptides. If further investigation into highly sensitive troponin assays confirms the positive data so far reported, further efforts directed toward a longitudinal-based rejection surveillance algorithm incorporating both troponin and BNP may identify a strategy that could serve as an alternative to EMB.

Background: Epidemiologic studies are consistent in finding that women who have had at least one birth are less likely to develop endometrial cancer. Less clear is whether timing of pregnancies during reproductive life influences risk, and the degree to which incomplete pregnancies are associated with a reduced risk., Methods: We evaluated pregnancy history in relation to endometrial cancer risk using data from a series of 4 population-based endometrial cancer case-control studies of women 45-74 years of age (1712 cases and 2134 controls) during 1985-2005 in western Washington State. Pregnancy history and information on other potential risk factors were collected by in-person interviews., Results: Older age at first birth was associated with a reduced risk of endometrial cancer after adjustment for number of births and age at last birth (test for trend P = 0.004). The odds ratio comparing women at least 35 years of age at their first birth with those younger than 20 years was 0.34 (95% confidence interval = 0.14-0.84). Age at last birth was not associated with risk after adjustment for number of births and age at first birth (test for trend P = 0.830). Overall, a history of incomplete pregnancies was not associated with endometrial cancer risk to any appreciable degree., Conclusions: In this study, older age at first birth was more strongly associated with endometrial cancer risk than was older age at last birth. To date, there remains some uncertainty in the literature on this issue.

A 17-year-old with acute myeloid leukemia M4 and hyperleukocytosis developed fulminant hypoxemic respiratory failure at presentation. After failing to respond to conventional mechanical ventilation and leukapheresis, he was started on inhaled nitric oxide (iNO) with dramatic improvement in oxygenation. Following graduated chemotherapy, his pulmonary status again deteriorated coincident with tumor lysis. After failing to respond to increases in iNO, he was placed in prone position with immediate improvement. The patient was successfully extubated. Patients with myelomonocytic leukemias are at risk for early death due to pulmonary complications. The use of adjuvant therapies directed by specific pathophysiology might decrease this risk.

Osteosarcoma arising in soft tissues is exceedingly rare in children. The tumor most often affects older adults, involves the lower extremity, responds poorly to chemotherapy, and carries a grave prognosis. The authors describe a 12-year-old girl with an extraosseous osteosarcoma of the left sternocleidomastoid muscle with pulmonary metastases. The patient responded well to neoadjuvant chemotherapy and remains disease-free nearly 3 years after her initial diagnosis. The authors review available information about this disease in children and adults. Children with extraosseous osteosarcoma may have a more favorable response to treatment than adults; thus, a curative approach using combined modality therapy appears warranted.

Congenital mesoblastic nephroma (CMN) is usually cured by surgery. The sensitivity of this tumor to chemotherapy is unknown. The recent description of a t(12;15)(p13;q25) chromosomal translocation in both cellular CMN and congenital infantile fibrosarcoma suggests that these entities have a common pathogenesis, and that cellular CMN might respond to chemotherapy like congenital infantile fibrosarcoma does. The authors describe three patients with recurrent cellular CMN who showed a complete response to chemotherapy. Based on these patients and a review of the literature, the authors suggest that chemotherapy be considered as a part of the therapy for recurrent or unresectable cellular CMN.

Metastatic rhabdoid tumor of the kidney (RTK) is a highly lethal malignancy; only one survivor with stage 4 disease has been reported. The authors reviewed the cases of two patients with metastatic RTK who had excellent responses to therapy. Both patients were treated with radiation therapy and alternating courses of ifosfamide, carboplatin, and etoposide (ICE) and vincristine, doxorubicin, and cyclophosphamide (VDC). The patients are without evidence of disease at 24 months and 12 months from the detection of metastasis. Alternating courses of ICE and VDC have activity against metastatic RTK. This combination of agents warrants prospective investigation in clinical trials.

Unlabelled: We studied gastric emptying, using acetaminophen absorption, in 105 women in labor divided into three equal groups of 35 each, after intrathecal (i.t.) (25 micrograms, Group S) or extradural (50 micrograms, Group E) fentanyl in combination with bupivacaine and compared with a control group (Group C) receiving extradural bupivacaine only. The time to maximal acetaminophen concentration (tCamax), maximal acetaminophen concentration (Camax), and areas under the acetaminophen concentration-time curve at 90 and 120 min (AUC90 and AUC120, respectively) were determined. Median (range) tCamax values were 120 (15-180), 82.5 (15-180), and 90 (15-180) min in Groups S, E, and C, respectively (P < 0.05). Mean +/- SD Camax was 13.4 +/- 8.82, 17.9 +/- 8.06, and 15.0 +/- 6.22 micrograms/mL in Groups S, E, and C, respectively (P < 0.05). Mean +/- SD AUC90 and AUC120 were also significantly smaller in Group S than in the other two groups (430 +/- 616, 736 +/- 504, and 672 +/- 453; and 649 +/- 592, 1063 +/- 627, and 1053 +/- 616 micrograms.mL-1.min-1 in Groups S, E, and C, respectively). We conclude that the administration of fentanyl 25 micrograms i.t. delays gastric emptying in labor compared with both extradural fentanyl 50 micrograms with bupivacaine and extradural bupivacaine alone., Implications: We examined emptying of the stomach in women in labor after administration of analgesics by the spinal or the epidural route. We observed that the analgesic, fentanyl, administered by the spinal route, although relieving pain rapidly, may delay emptying of the stomach. In theory, delayed gastric emptying may increase the chance of vomiting and aspiration of gastric contents.

Background: Atracurium has four chiral centers and the marketed product is a mixture of ten optical and geometric isomers. Six of the isomers were prepared and evaluated for neuromuscular blocking activity and autonomic effects in anesthetized cats. This study reports the comparative pharmacology of the six isomers and atracurium that led to the selection of one isomer, cisatracurium (Nimbex, 51W89) for clinical development., Methods: Purpose bred cats, anesthetized with alpha-chloralose (80 mg/kg) and pentobarbital sodium (7 mg/kg) administered intraperitoneally, were used in this study. Neuromuscular blocking effects were assessed from the effects on the tibialis anterior twitch evoked at 0.15 Hz. Inhibition of the autonomic nervous system was assessed from the effects on the nictitating membrane contraction, in response to preganglionic sympathetic nerve stimulation and the bradycardia/vasodepressor responses to vagal nerve stimulation. Cardiovascular effects and plasma histamine concentrations were determined after a bolus injection of cisatracurium or atracurium., Results: Like atracurium, all six isomers produced dose-dependent neuromuscular block (NMB). The calculated ED95NMB values varied approximately tenfold (43 +/- 2 microgram/kg -488 +/- 56 microgram/kg. The "R-series" isomers were more potent than the corresponding "S-series" isomers. With the exception of the S,Trans-S', Trans isomers, the NMB effects, i.e., onset times (range 2.6 +/- 0.2 min to 4.7 +/- 0.3 min) and total durations (range 9.9 +/- 1.4 min to 14 +/- 0.9 min), of the other five isomers were very similar to that atracurium. The former isomers had relatively short duration of action. The 25-75% recovery times after cisatracurium at 1 x ED95 (4.4 +/- 0.4 min), 4 x ED95 (4.5 +/- 0.4 min), and continuous infusions lasting at least 60 min that maintained 95-99% NMB (4.8% +/- 0.4 min) indicated a noncumulative effect. The vagal ID50:NMB ED95 ratios for atracurium and the six isomers ranged from 2 to 27. The sympathetic ID25:NMB ED95 ranged from 2.7 to 60. Atracurium and all of the isomers, except cisatracurium, produced cardiovascular effects after intravenous bolus administration at large doses (700-4,800 micrograms/kg). In contrast to atracurium, there were no changes in plasma histamine concentrations associated with the administration of doses of cisatracurium equivalent to 60X the NMB ED95 (62 +/- 8 micrograms/kg)., Conclusions: Cisatracurium has neuromuscular blocking effects identical to those of atracurium, is more potent, and does not produce cardiovascular effects or increase plasma histamine concentrations.

Objective: The literature indicates that trauma center pedestrian mortality rates approximate twice that of injured car occupants. This study was performed to test the hypothesis that outcomes will be similar given similar degrees of injury severity if analyzed from an epidemiologic perspective. Differences are expected in the cause and place of death because of different injury profiles., Design: Prospective population-based study., Methods: The study group consisted of all adult car occupants and pedestrians sustaining major injury -- Injury Severity Score (ISS) of >15 -- in a defined area of central Sydney from mid-1991 to mid-1994., Main Results: The study included 65 car occupants (median ISS,32) and 101 pedestrians (median ISS,34). Major abdominal injury (p = 0.003) and thoracic aortic disruption (p = 0.06) were more common in car occupants, but major injury to the brains (p = 0.004), lower extremity long bone fractures (p = 0.0005), and thoracolumbar fractures (p = 0.01) occurred more frequently in pedestrians. The overall car occupant mortality was 38% compared with 46% in the pedestrians (p = 0.37). Seventy-two percent of car occupant fatalities occurred in the field, most commonly from ruptured thoracic aorta, whereas 63% of pedestrian deaths occurred in hospital (p = 0.005), most commonly from head injury., Conclusion: These findings have important implications for prehospital care. A policy of "scoop and run" is advocated for injured car occupants in shock because of the high frequency of aortic and abdominal injuries. Advanced life support measures are appropriate at the scene to stabilize the airway and to protect the entire spine in pedestrians with multiple injuries because of the high frequency of brain and vertebral trauma.

To estimate the prevalence of human immunodeficiency virus type 1 (HIV-1) among parturients in an area with a high cumulative incidence of AIDS, an HIV seroprevalence study was conducted in 1988 in Los Angeles County. Test results were available from 8485 (86.1%) of the 9860 women delivering at four public hospitals. The test results were linked to demographic and medical information available from routinely collected delivery records. Three specimens were HIV-positive, for a seroprevalence of 3.5 per 10,000. The seropositive women were all Latina. The prevalence of HIV among women delivering at all hospitals in Los Angeles County has been shown to be relatively low compared with that of other metropolitan areas with a high number of AIDS cases, such as New York city, but appears to be even lower among women delivering at public hospitals during this time period. This low prevalence is attributed to the predominance of Latinas, who may have lower levels of infection, among public hospital parturients. The relatively low prevalence of HIV among injection drug users in Los Angeles County may contribute to the overall lower prevalence among women in Los Angeles County compared with those in New York city. This study supplements county-specific data obtained from statewide blinded neonatal testing by providing details on HIV seroprevalence among the catchment populations of public hospitals in Los Angeles County.

We examined the onset of atrial epicardial excitation by recording unipolar potentials from 360 electrodes arranged in templates affixed to the superior vena cava and right atrium in dogs. Both activation sequence and potential distribution maps were obtained for the period of impulse origin beginning before the surface P wave and continuing through the first 15-20 msec of atrial depolarization. The activation maps demonstrated impulse origin from multiple widely separated sites, resulting in two to three individual wavefronts that merged to form a single widely disseminated wavefront spread over a 50 X 20 mm area by 10-15 msec. Atrial potential maps obtained for the same time periods revealed multiple sites of primary negativity corresponding to the points of impulse origin in the activation maps. The potential distributions and evolution of these maps also indicated the presence of multiple wavefronts originating from widely separated locations, and suggested an extensively dispersed source of impulse origin. One of these sites at the superior cavo-appendicular junction corresponded to the rostral portion of the sinus node and the site of classical unifocal origin. Additional sites of impulse origin and primary negativity distant to the sinus node were noted either concurrently in the same map or in other maps associated with different patterns of impulse initiation. Classical physiological and pharmacological interventions were used to alter adrenergic and cholinergic input to the atrium, and resulted in coincident changes of both the patterns of impulse origin and heart rate. In addition, we examined spontaneous changes in the patterns of impulse initiation which accompanied beat-to-beat changes in cycle length (sinus arrhythmia). There was close agreement between activation and potential maps over the entire steady state and dynamic range of impulse origin. The data can be explained by the concept of a widely distributed system of functionally differentiated but coordinated atrial pacemakers.