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PURPOSE: Prior studies on compressive optic neuropathy (CON) have come from large tertiary centers, which may contain referral bias toward more severe or atypical disease. To our knowledge, there are no studies to determine the population-based etiologies and clinical outcomes of compressive optic neuropathy (CON). This study aims to bridge that gap using the Rochester Epidemiology Project database. DESIGN: Retrospective, population-based cohort METHODS: Medical records of all residents living in Olmsted County, Minnesota from January 1, 2000 through December 31, 2018 were screened for CON. Demographic and clinical information were collected before and after treatment. RESULTS: 23 patients had a confirmed diagnosis of CON during our study period, which provided an overall incidence of 1.14 per 100,000 per year. Average age at onset of CON was 51 years (SD 24), and 39% were male. The most common etiologies were pituitary adenoma and meningioma. There was significant improvement in visual fields (p < 0.003) but not in visual acuity (p = 0.08) after patients underwent treatment for CON. There was also a significant relationship between the time until treatment and the degree of visual field improvement at follow-up (Pearson correlation rho = −0.58, p < 0.047). CONCLUSION: To our knowledge, this study provides the first population-based incidence of CON. The finding that earlier treatment leads to better visual outcomes stresses the importance of having CON on the differential diagnosis of patients with optic neuropathy.

Procalcitonin (PCT) levels rise in systemic inflammation, especially if bacterial in origin. COVID-19, caused by the novel coronavirus SARS-CoV-2, presents with acute respiratory distress syndrome. Elevated procalcitonin in COVID-19 is considered as a marker for severity of disease. There is no study available that indicates whether elevated PCT in COVID-19 is associated with inflammation or superimposed bacterial infection. The objective of this study is to evaluate the association between PCT levels and superadded bacterial infection, and the effect of discontinuation of antibiotic in the low PCT (0.25 ng/ml) group on patients' outcomes.A retrospective chart review of patients admitted with COVID-19 pneumonia at a single tertiary care centre. We collected information on demographics, co-morbidities, PCT level, antibiotic use, culture results for bacterial infection, hospital length of stay (LOS) and mortality.Continuous variables were summarized with the sample median, interquartile range, mean and range. Categorical variables were summarized with number and percentage of patients.We studied a total of 147 patients with COVID-19 pneumonia. 101 (69%) patients had a low PCT level (0.25 ng/ml). Bacterial culture results were negative for all patients, except 1 who had a markedly elevated PCT level (141.ng/ml). In patients with low PCT, 42% received no antibiotics, 59% received antibiotics initially, 32 (57%) patients antibiotic discontinued early (within 24 hours) and their culture remained negative for bacterial infections during hospitalizations. LOS was shorter (6 days in low PCT group compared to 9 days) in high PCT group. LOS was 1 day shorter (5 days vs 6 days) in no antibiotic group compared to antibiotic group. Our study examines the association between PCT level and superadded bacterial infection in COVID-19 pneumonia. Our results demonstrate that most patients admitted with COVID-19 have a low PCT (0.25 ng/ml), which suggests no superadded bacterial infection and supports the previously published literature regarding low PCT in viral pneumonia.Procalcitonin level remains low in the absence of bacterial infection. Early de-escalation/discontinuation of antibiotics is safe without adverse outcomes in COVID-19 pneumonia. Early de-escalation/discontinuation of antibiotics is associated with lower LOS.

Author(s): Correa, Kelly; Craver, Scott; Sandhu, Amar | Abstract: Introduction: Meningitis is a serious and potentially life-threatening infection of the central nervous system. Cryptococcus neoformans is a rare fungal cause of meningitis that commonly presents with atypical symptoms. Although this infection is most common in immunocompromised patients, it also occurs in immunocompetent patients. This case report describes an atypical presentation of cryptococcal meningitis in a seemingly immunocompetent patient.Case Report: A 40-year-old immunocompetent patient with no significant past medical history had visited the emergency department (ED) five times within a span of 30 days reporting dental pain and headache. Throughout each of the visits, no clear symptoms signaling the need for a meningitis workup were observed, as the patient had been afebrile, displayed no nuchal rigidity, and his presenting symptoms subsided within the ED after treatment. A lumbar puncture was performed after emergency medical services brought the patient in for his sixth ED visit, initially for stroke-like symptoms and altered mental status. Spinal fluid was indicative of cryptococcal meningitis.Conclusion: This case highlights the challenge of identifying cryptococcal meningitis in the ED, particularly in immunocompetent patients who do not display classic meningitis symptoms. It also highlights the importance of keeping a broad differential and carefully ruling out diagnoses when patients return to the ED multiple times for the same complaint.

Received 12th May 2021. Accepted 17th May 2021. Published online 28th May 2021. Issue published 1st August 2021.

Background: Cardiac damage is frequently referred to in patients with SARS-CoV-2, is usually diagnosed by enzyme elevations, and is generally thought to be due to underlying coronary artery disease. There are references to cardiomyopathies accompanying coronavirus, but there has been no histologic confirmation. Case report: A previously healthy 17 year male old presented in full cardiac arrest to the emergency department after a 2 day history of headache, dizziness, nausea and vomiting. Autopsy demonstrated an enlarged flabby heart with eosinophilic myocarditis. There was no interstitial pneumonia or diffuse alveolar damage. Postmortem nasopharyngeal swabs detected severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) known to cause coronavirus disease 2019 (COVID-19). No other cause for the eosinophilic myocarditis was elucidated. Conclusion: Like other viruses, SARS-CoV-2 may be associated with fulminant myocarditis.

Thrombosis is a major cause of mortality in patients with myeloproliferative neoplasms (MPNs), though there is currently little to offer patients with MPN beyond aspirin and cytoreductive therapies such as hydroxyurea for primary prevention. Thrombogenesis in MPN involves multiple cellular mechanisms, including platelet activation and neutrophil-extracellular trap formation; therefore, an antithrombotic agent that targets one or more of these processes would be of therapeutic benefit in MPN. Here, we treated the JAK2V617F knockin mouse model of polycythemia vera with N-acetylcysteine (NAC), a sulfhydryl-containing compound with broad effects on glutathione replenishment, free radical scavenging, and reducing disulfide bonds, to investigate its antithrombotic effects in the context of MPN. Strikingly, NAC treatment extended the lifespan of JAK2V617F mice without impacting blood counts or splenomegaly. Using an acute pulmonary thrombosis model in vivo, we found that NAC reduced thrombus formation to a similar extent as the irreversible platelet inhibitor aspirin. In vitro analysis of platelet activation revealed that NAC reduced thrombin-induced platelet-leukocyte aggregate formation in JAK2V617F mice. Furthermore, NAC reduced neutrophil extracellular trap formation in primary human neutrophils from patients with MPN as well as healthy controls. These results provide evidence that N-acetylcysteine inhibits thrombosis in JAK2V617F mice and provide a pre-clinical rationale for investigating NAC as a therapeutic to reduce thrombotic risk in MPN.

Hyperkalemia, defined as a serum or plasma potassium greater than 5.5 mEq/L, while an uncommon occurrence in children, is a serious medical problem that warrants immediate attention as it can result in serious cardiac arrhythmias and death. Although hyperkalemia may occur in the critically ill patient or in the setting of renal failure and insufficiency, there are limited reports of its occurrence during intraoperative care. The authors report a previously healthy, 18-year-old patient, who developed hyperkalemia intraoperatively during posterior spinal fusion to treat adolescent idiopathic scoliosis. The potential etiologies of hyperkalemia are reviewed, a differential diagnosis for the possible etiologies presented, and treatment modalities discussed. J Med Cases. 2020;11(6):152-156 doi: https://doi.org/10.14740/jmc3470

Introduction Existing research on postabortion emergency room visits is sparse and limited by methods which underestimate the incidence of adverse events following abortion. Postabortion emergency room (ER) use since Food and Drug Administration approval of chemical abortion in 2000 can identify trends in the relative morbidity burden of chemical versus surgical procedures. Objective To complete the first longitudinal cohort study of postabortion emergency room use following chemical and surgical abortions. Methods A population-based longitudinal cohort study of 423 000 confirmed induced abortions and 121,283 subsequent ER visits occurring within 30 days of the procedure, in the years 1999-2015, to Medicaid-eligible women over 13 years of age with at least one pregnancy outcome, in the 17 states which provided public funding for abortion. Results ER visits are at greater risk to occur following a chemical rather than a surgical abortion: all ER visits (OR 1.22, CL 1.19-1.24); miscoded spontaneous (OR 1.88, CL 1.81-1.96); and abortion-related (OR 1.53, CL 1.49-1.58). ER visit rates per 1000 abortions grew faster for chemical abortions, and by 2015, chemical versus surgical rates were 354.8 versus 357.9 for all ER visits; 31.5 versus 8.6 for miscoded spontaneous abortion visits; and 51.7 versus 22.0 for abortion-related visits. Abortion-related visits as a percent of total visits are twice as high for chemical abortions, reaching 14.6% by 2015. Miscoded spontaneous abortion visits as a percent of total visits are nearly 4 times as high for chemical abortions, reaching 8.9% of total visits and 60.9% of abortion-related visits by 2015. Conclusion The incidence and per-abortion rate of ER visits following any induced abortion are growing, but chemical abortion is consistently and progressively associated with more postabortion ER visit morbidity than surgical abortion. There is also a distinct trend of a growing number of women miscoded as receiving treatment for spontaneous abortion in the ER following a chemical abortion.

Patients with vascular Ehlers–Danlos syndrome (vEDS) have a defect in the formation of type III collagen. This defect puts patients at risk of vascular rupture, uterine rupture, and bowel perforations. The segmental absence of intestinal musculature is a rare histopathologic finding, wherein there is a lack of a muscularis propria layer in the intestinal wall. Although typically documented in the literature in neonates or adults, it can be seen in children of other ages. This is a case report of a patient who exhibits both rare entities, which has not been described in the literature to date.

Serologic testing of residual blood samples from 812 children from a hospital in New Orleans, LA, between March and May 2020, demonstrated a SARS-CoV-2 seroprevalence of 6.8% based on S and N protein IgG; Black and Hispanic children, and children living in zip codes with lower household incomes were over-represented.

Introduction: The prevalence of induced abortion among women with children has been estimated indirectly by projections derived from survey research. However, an empirically derived, population-based conclusion on this question is absent from the published literature. Objective: The objective of this study was to describe the period prevalence of abortion among all other possible pregnancy outcomes within the reproductive histories of Medicaid-eligible women in the U.S. Methods: A retrospective, cross-sectional, longitudinal analysis of the pregnancy outcome sequences of eligible women over age 13 from the 17 states where Medicaid included coverage of most abortions, with at least one identifiable pregnancy between 1999 and 2014. A total of 1360 pregnancy outcome sequences were grouped into 8 categories which characterize various combinations of the 4 possible pregnancy outcomes: birth, abortion, natural loss, and undetermined loss. The reproductive histories of 4,884,101 women representing 7,799,784 pregnancy outcomes were distributed into these categories. Results: Women who had live births but no abortions or undetermined pregnancy losses represented 74.2% of the study population and accounted for 87.6% of total births. Women who have only abortions but no births constitute 6.6% of the study population, but they are 53.5% of women with abortions and have 51.5% of all abortions. Women with both births and abortions represent 5.7% of the study population and have 7.2% of total births. Conclusion: Abortion among low-income women with children is exceedingly uncommon, if not rare. The period prevalence of mothers without abortion is 13 times that of mothers with abortion.

Diabetic kidney disease (DKD) is the most frequent cause of kidney failure (KF). There are large variations in the incidence rates of kidney replacement therapy (KRT). Late referral to nephrology services has been associated with an increased risk of adverse outcomes. In many countries, when patients reach severely reduced glomerular filtration rate (GFR), they are managed by multidisciplinary teams led by nephrologists. In these clinics, efforts will continue to halt chronic kidney disease (CKD) progression and to prevent cardiovascular mortality and morbidity. In patients with diabetes and severely reduced GFR and KF, treating hyperglycemia is a challenge, since some drugs are contraindicated and most of them require dose adjustments. Even more, a decision-making process will help in deciding whether the patient would prefer comprehensive conservative care or KRT. On many occasions, this decision will be conditioned by diabetes mellitus itself. Effective education should cover the necessary information for the patient and family to answer these questions: 1. Should I go for KRT or not? 2. If the answer is KRT, dialysis and/or transplantation? 3. Dialysis at home or in center? 4. If dialysis at home, peritoneal dialysis or home hemodialysis? 5. If transplantation is desired, discuss the options of whether the donation would be from a living or deceased donor. This review addresses the determinant factors with an impact on DKD, aiming to shed light on the specific needs that arise in the management and recommendations on how to achieve a comprehensive approach to the diabetic patient with chronic kidney disease

Evaluate utilization of MRI-directed breast ultrasound (US) in patients with newly diagnosed breast cancer and refine practices to increase success of sonographic lesion detection.This retrospective single-institution review was restricted to women with breast cancer who underwent MRI from November 2006 to January 2017. Enhancing breast lesions, separate from the index tumor, recommended for MRI-directed US were assessed to see which were detected and which characteristics predicted success in detection. Univariate mixed-effects logistic modeling predicted likelihood of finding breast lesions with US, with odds ratios reported. All tests were two-sided with p 0.05 considered significant.A total of 275 patients underwent MRI-directed US for 361 breast lesions, of which 187 (51.8%) were found on US. Of those detected, 171 (91.4%) were masses and 16 (8.6%) were nonmass enhancement (NME), with masses 14 times more likely to be seen (p 0.001). Size alone was not a significant predictor but achieved significance when associated with lesion type (mass size, p 0.001). Masses with irregular shapes or margins and invasive carcinomas were more frequently detected. Patient age, internal enhancement pattern, and distribution of NME were not significant predictors in sonographic detection. A presumed sonographic correlate for NME was found for 16 (16.2%) of 99 attempted lesions.As MRI access expands, utilization of MRI-directed US should be scrutinized to avoid downstream practice inefficiencies. Sonographic detection rates for NME remain low for women undergoing MRI for disease extent, with NME often better suited for MRI-guided biopsy.

Patients with myeloproliferative neoplasms (MPN) have high levels of inflammatory cytokines, some of which drive many of the debilitating constitutional symptoms associated with the disease and may also promote expansion of the neoplastic clone. We report here that monocytes from patients with MPN have defective negative regulation of Toll-like receptor (TLR) signaling that leads to unrestrained production of the inflammatory cytokine tumor necrosis factor α (TNF-α) after TLR activation. Specifically, monocytes of patients with MPN are insensitive to the anti-inflammatory cytokine interleukin 10 (IL-10) that negatively regulates TLR-induced TNF-α production. This inability to respond to IL-10 is a not a direct consequence of JAK2V617F, as the phenotype of persistent TNF-α production is a feature of JAK2V617F and wild-type monocytes alike from JAK2V617F-positive patients. Moreover, persistent TNF-α production was also discovered in the unaffected identical twin of a patient with MPN, suggesting it could be an intrinsic feature of those predisposed to acquire MPN. This work implicates sustained TLR signaling as not only a contributor to the chronic inflammatory state of MPN patients but also a potential predisposition to acquire MPN.

We describe a posterior wall intratracheal embryonal rhabdomyosarcoma (RMS) arising in a 6-year-old tracheostomized child masquerading as reactive granulation tissue and review all reported cases of pediatric intratracheal RMS. The child underwent laser debulking of the tumor and postoperative radiation and chemotherapy with no evidence of recurrence at 2-year follow-up. A literature review revealed four previous cases of pediatric primary tracheal or intratracheal RMS, and remission was achieved in all but one case with surgery, chemotherapy, and radiation. Pathologic evaluation of tracheal mucosal granulation tissue may merit consideration, particularly in patients with increased risk factors.

Animal relocation programs seek to balance the animal population and resources between source and destination communities to promote positive outcomes, though little objective evidence has been reported on their physical and behavioral implications. The objective of the current report is to describe the incidence and predictors of canine parvovirus (CPV) diagnoses in 8- to 19-week-old puppies reported by destination shelters participating in a large scale, long-distance, structured animal relocation program. The incidence of post-transport CPV diagnoses in the study population of 4088 puppies was 2.3%. The number of pre-transport vaccinations, length of stay at the source shelter, and time between pre-transport vaccination and transport was not associated with the expected difference in count of post-transport CPV diagnoses (p &gt, 0.05), and was lower in those 13–17 weeks of age (IRR = 0.08, 95% CI = 0.02–0.34, p = 0.001), 18–19 weeks of age (IRR = 0.11, 95% CI = 0.02–0.80, p = 0.029), transferred in to the source shelter (IRR = 0.31, 95% CI = 0.10–0.96, p = 0.043), and transported in the summer season (IRR = 0.07, 95% CI = 0.01–0.53, p = 0.010). When basic biosecurity practices and vaccination protocols were in place, post-transport CPV cases in puppies were few, suggesting that the timing of transport should take into account factors other than the number or timing of pre-transport vaccinations.

Pregnancy loss, natural or induced, is linked to higher rates of mental health problems, but little is known about its effects during the postpartum period. This study identifies the percentages of women receiving at least one postpartum psychiatric treatment (PPT), defined as any psychiatric treatment (ICD-9 290-316) within six months of their first live birth, relative to their history of pregnancy loss, history of prior mental health treatments, age, and race. The population consists of young women eligible for Medicaid in states that covered all reproductive services between 1999–2012. Of 1,939,078 Medicaid beneficiaries with a first live birth, 207,654 (10.7%) experienced at least one PPT, and 216,828 (11.2%) had at least one prior pregnancy loss. A history of prior mental health treatments (MHTs) was the strongest predictor of PPT, but a history of pregnancy loss is also another important risk factor. Overall, women with a prior pregnancy loss were 35% more likely to require a PPT. When the interactions of prior mental health and prior pregnancy loss are examined in greater detail, important effects of these combinations were revealed. About 58% of those whose first MHT was after a pregnancy loss required PPT. In addition, over 99% of women with a history of MHT one year prior to their first pregnancy loss required PPT after their first live births. These findings reveal that pregnancy loss (natural or induced) is a risk factor for PPT, and that the timing of events and the time span for considering prior mental health in research on pregnancy loss can significantly change observed effects. Clinicians should screen for a convergence of a history of MHT and prior pregnancy loss when evaluating pregnant women, in order to make appropriate referrals for counseling.

The negative impact of COVID-19 on adults with underlying chronic kidney disease, including kidney transplant recipients, has been well documented. Children have a less severe presentation and better prognosis compared to adults. However, little is known regarding the spectrum of COVID-19 infection in children and adolescents with underlying autoimmune disorders necessitating solid organ transplant and long-term immunosuppressive therapy. Case Report. An adolescent male developed end-stage kidney disease secondary to microscopic polyangiitis requiring a living-donor kidney transplant. Six years later, he developed antibody-mediated rejection of his kidney transplant. During his rejection treatment course, he contracted SARS-CoV-2 and developed new-onset nephrotic syndrome with severe acute kidney injury. Kidney transplant biopsy revealed de novo collapsing focal segmental glomerulosclerosis on a background of chronic active antibody mediated rejection. Immunostaining for SARS-CoV-2 on the biopsy specimen demonstrated positive staining of the proximal tubular epithelium consistent with intra-renal viral infection. Pulse corticosteroids, intravenous immunoglobulin, and temporary reduction of anti-metabolite therapy resulted in successful recovery with return of graft function back to pre-infection baseline. This case highlights the clinical conundrum of treating kidney transplant recipients with active rejection in the midst of the COVID-19 pandemic. Pediatric kidney transplant recipients can develop severe COVID-19-related kidney complications. Judicious immunosuppression modulation is necessary to balance infection and rejection risk.

Background The Madrid Acute Kidney Injury Prediction Score (MAKIPS) is a recently described tool capable of performing automatic calculations of the risk of hospital-acquired acute kidney injury (HA-AKI) using data from from electronic clinical records that could be easily implemented in clinical practice. However, to date, it has not been externally validated. The aim of our study was to perform an external validation of the MAKIPS in a hospital with different characteristics and variable case mix. Methods This external validation cohort study of the MAKIPS was conducted in patients admitted to a single tertiary hospital between April 2018 and September 2019. Performance was assessed by discrimination using the area under the receiver operating characteristics curve and calibration plots. Results A total of 5.3% of the external validation cohort had HA-AKI. When compared with the MAKIPS cohort, the validation cohort showed a higher percentage of men as well as a higher prevalence of diabetes, hypertension, cardiovascular disease, cerebrovascular disease, anaemia, congestive heart failure, chronic pulmonary disease, connective tissue diseases and renal disease, whereas the prevalence of peptic ulcer disease, liver disease, malignancy, metastatic solid tumours and acquired immune deficiency syndrome was significantly lower. In the validation cohort, the MAKIPS showed an area under the curve of 0.798 (95% confidence interval 0.788–0.809). Calibration plots showed that there was a tendency for the MAKIPS to overestimate the risk of HA-AKI at probability rates ˂0.19 and to underestimate at probability rates between 0.22 and 0.67. Conclusions The MAKIPS can be a useful tool, using data that are easily obtainable from electronic records, to predict the risk of HA-AKI in hospitals with different case mix characteristics.

Aims/Objectives/BackgroundRapid risk stratification of patients is vital for Emergency Department (ED) streaming during the COVID-19 pandemic. Ideally, patients should be split into red (suspected/confirmed COVID-19) and green (non COVID-19) zones in order to minimise the risk of patient-to-patient and patient-to-staff transmission. A robust yet rapid streaming system combining clinician impression with point-of-care diagnostics is therefore necessary.Point of care ultrasound (POCUS) findings in COVID-19 have been shown to correlate well with computed tomography (CT) findings, and it therefore has value as a front-door diagnostic tool. At University Hospital Lewisham (a district general hospital in south London), we recognised the value of early POCUS and its potential for use in patient streaming.Methods/DesignWe developed a training programme, ‘POCUS for COVID’ and subsequently integrated POCUS into streaming of our ED patients. The training involved Zoom lectures, a face to face practical, a 10 scan sign off process followed by a final triggered assessment. Patient outcomes were reviewed in conjunction with their scan reports.Results/ConclusionsCurrently, we have 21 ED junior doctors performing ultrasound scans independently, and all patients presenting to our department are scanned either in triage or in the ambulance. A combination of clinical judgement and scan findings are used to stream the patient to an appropriate area.Service evaluation with analysis of audit data has found our streaming to be 94% sensitive and 79% specific as an indicator of COVID 19. Further analysis is ongoing.Here we present both the structure of our training programme and our integrated streaming pathway along with preliminary analysis results.

Electronic cigarettes (E-cigs) generate nicotine containing aerosols for inhalation and have emerged as a popular tobacco product among adolescents and young adults, yet little is known about their health effects due to their relatively recent introduction. Few studies have assessed the long-term effects of inhaling E-cigarette smoke or vapor. Here, we show that two months of E-cigarette exposure causes suppression of bone marrow hematopoietic stem and progenitor cells (HSPCs). Specifically, the common myeloid progenitors and granulocyte-macrophage progenitors were decreased in E-cig exposed animals compared to air exposed mice. Competitive reconstitution in bone marrow transplants was not affected by two months of E-cig exposure. When air and E-cig exposed mice were challenged with an inflammatory stimulus using lipopolysaccharide (LPS), competitive fitness between the two groups was not significantly different. However, mice transplanted with bone marrow from E-cigarette plus LPS exposed mice had elevated monocytes in their peripheral blood at five months post-transplant indicating a myeloid bias similar to responses of aged hematopoietic stem cells (HSC) to an acute inflammatory challenge. We also investigated whether E-cigarette exposure enhances the selective advantage of hematopoietic cells with myeloid malignancy associated mutations. E-cigarette exposure for one month slightly increased JAK2V617F mutant cells in peripheral blood but did not have an impact on TET2&minus, /&minus, cells. Altogether, our findings reveal that chronic E-cigarette exposure for two months alters the bone marrow HSPC populations but does not affect HSC reconstitution in primary transplants.

BACKGROUNDChildren (≤18 years) account for ∼20% of the US population but currently represent METHODSDuring the March 18th-May 15th 2020 Louisiana Stay At Home Order, 1690 blood samples from 812 individuals from a Children’s Hospital were tested for antibodies to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spike protein. Demographics, COVID-19 testing, and clinical presentation abstracted from medical records were compared with local COVID-19 cases.RESULTSIn total, 62 subjects (7.6%) were found to be seropositive. The median age was 11 years with 50.4% female. The presenting complaint of seropositive patients was chronic illness (43.5%). Only 18.2% had a previous positive COVID-19 PCR or antibody test. Seropositivity was significantly associated with parish (counties), race, and residence in a low-income area. Importantly, seropositivity was linearly correlated with cumulative COVID-19 case number for all ages by parish.CONCLUSIONIn a large retrospective study, the seropositivity prevalence for SARS-CoV-2 in children in Louisiana during the mandated Stay At Home Order was 7.6%. Residence location, race, and lower socioeconomic factors were linked to more frequent seropositivity in children and correlated to regional COVID-19 case rates. Thus, a significant number of children in Louisiana had SARS-CoV-2 infections that went undetected and unreported and may have contributed to virus transmission.

The authors regret that the name of the author Randall Craver was incorrectly rendered as “Randall Carver.” The original article has been corrected.

The authors regret that the name of the author Randall Craver was incorrectly rendered as "Randall Carver." The original article has been corrected.

Timely and accurate agricultural information is needed to inform resource allocation and sustainable practices to improve food security in the developing world. Obtaining this information through traditional surveys is time consuming and labor intensive, making it difficult to collect data at the frequency and resolution needed to accurately estimate the planted areas of key crops and their distribution during the growing season. Remote sensing technologies can be leveraged to provide consistent, cost-effective, and spatially disaggregated data at high temporal frequency. In this study, we used imagery acquired from unmanned aerial vehicles to create a high-fidelity ground-truth dataset that included examples of large mono-cropped fields, small intercropped fields, and natural vegetation. The imagery was acquired in three rounds of flights at six sites in different agro-ecological zones to capture growing conditions. This dataset was used to train and test a random forest model that was implemented in Google Earth Engine for classifying cropped land using freely available Sentinel-1 and -2 data. This model achieved an overall accuracy of 83%, and a 91% accuracy for maize specifically. The model results were compared with Rwanda’s Seasonal Agricultural Survey, which highlighted biases in the dataset including a lack of examples of mixed land cover.

OBJECTIVE To determine the feasibility of short-term cardiovascular responses to postural change as a screening tool for mild traumatic brain injury (mTBI), using heart rate metrics that can be measured with a wearable electrocardiogram sensor. SETTING Military TBI clinic. DESIGN Data collected from active-duty service members who had sustained a medically diagnosed mTBI within the prior 72 hours and from age- and sex-matched controls. Cardiac data collected while participants performed a sequence of postural changes. MAIN MEASURES Model classification compared with clinical mTBI diagnosis. RESULTS Cardiac biomarkers of mTBI were identified and logistic regression classifiers for mTBI were developed from different subsets of biomarkers. The best model achieved 90% sensitivity and 69% specificity using data from 2 different postural changes. CONCLUSION Noninvasive measurement of cardiovascular response to postural change is a promising approach for field-deployable post-mTBI screening.

Introduction: The number and outcomes of pregnancies experienced by a woman are consequential determinants of her health status. However, there is no published research comparing the patterns of subsequent pregnancy outcomes following a live birth, natural fetal loss, or induced abortion. Objectives: The objective of this study was to describe the characteristic patterns of subsequent pregnancy outcomes evolving from each of three initiating outcome events (birth, induced abortion, natural fetal loss) occurring in a Medicaid population fully insured for all reproductive health services. Methods: We identified 7,388,842 pregnancy outcomes occurring to Medicaid-eligible women in the 17 states which paid for abortion services between 1999-2014. The first known pregnancy outcome for each woman was marked as the index outcome which assigned each woman to one of three cohorts. All subsequent outcomes occurring up to the fifth known pregnancy were identified. Analyses of the three index outcome cohorts were conducted separately for all pregnancy outcomes, three age bands (Results: Women with index abortions experienced more lifetime pregnancies than women with index births or natural fetal losses and were increasingly more likely to experience another pregnancy with each subsequent pregnancy. Women whose index pregnancy ended in abortion were also increasingly more likely to experience another abortion at each subsequent pregnancy. Both births and natural fetal losses were likely to result in a subsequent birth, rather than abortion. Women with natural losses were increasingly more likely to have a subsequent birth than women with an index birth. All age and racial/ethnic groups exhibited the characteristic pattern we have described for all pregnancy outcomes: abortion is associated with more subsequent pregnancies and abortions; births and fetal losses are associated with subsequent births. Other differences between groups are, however, apparent. Age is positively associated with the likelihood of a birth following an index birth, but negatively associated with the likelihood of a birth following an index abortion. Hispanic women are always more likely to have a birth and less likely to have an abortion than Black or White women, for all combinations of index outcome and the number of subsequent pregnancies. Similarly, Black women are always more likely to have an abortion and less likely to experience a birth than Hispanic or White women. Conclusion: Women experiencing repeated pregnancies and subsequent abortions following an index abortion are subjected to an increased exposure to hemorrhage and infection, the major causes of maternal mortality, and other adverse consequences resulting from multiple separation events.

Background Evasion from programmed cell death is a hallmark of cancer and can be achieved in cancer cells by overexpression of inhibitor of apoptosis proteins (IAPs). Second mitochondria-derived activator of caspases (SMAC) directly bind to IAPs and promote apoptosis; thus, SMAC mimetics have been investigated in a variety of cancer types. particularly in diseases with high inflammation and NFĸB activation. Given that elevated TNFα levels and NFĸB activation is a characteristic feature of myeloproliferative neoplasms (MPN), we investigated the effect of the SMAC mimetic LCL-161 on MPN cell survival in vitro and disease development in vivo. Methods To investigate the effect of the SMAC mimetic LCL-161 in vitro, we utilized murine and human cell lines to perform cell viability assays as well as primary bone marrow from mice or humans with JAK2V617F–driven MPN to interrogate myeloid colony formation. To elucidate the effect of the SMAC mimetic LCL-161 in vivo, we treated a JAK2V617F–driven mouse model of MPN with LCL-161 then assessed blood counts, splenomegaly, and myelofibrosis. Results We found that JAK2V617F-mutated cells are hypersensitive to the SMAC mimetic LCL-161 in the absence of exogenous TNFα. JAK2 kinase activity and NFĸB activation is required for JAK2V617F-mediated sensitivity to LCL-161, as JAK or NFĸB inhibitors diminished the differential sensitivity of JAK2V617F mutant cells to IAP inhibition. Finally, LCL-161 reduces splenomegaly and may reduce fibrosis in a mouse model of JAK2V617F-driven MPN. Conclusion LCL-161 may be therapeutically useful in MPN, in particular when exogenous TNFα signaling is blocked. NFĸB activation is a characteristic feature of JAK2V617F mutant cells and this sensitizes them to SMAC mimetic induced killing even in the absence of TNFα. However, when exogenous TNFα is added, NFĸB is activated in both mutant and wild-type cells, abolishing the differential sensitivity. Moreover, JAK kinase activity is required for the differential sensitivity of JAK2V617F mutant cells, suggesting that the addition of JAK2 inhibitors to SMAC mimetics would detract from the ability of SMAC mimetics to selectively target JAK2V617F mutant cells. Instead, combination therapy with other agents that reduce inflammatory cytokines but preserve JAK2 signaling in mutant cells may be a more beneficial combination therapy in MPN.

Rounded intraplacental hematomas (RIH) have a distinct rounded hemorrhagic appearance located within the placental parenchyma. Hemorrhagic villous infarctions (infarcts that when sectioned have hemorrhagic centers) are probably older RIH. RIH have been associated with acute abruptions.We describe multiple RIHs and hemorrhagic villous infarctions in various stages of development that arose between 20 and 27 weeks gestation, demonstrated by ultrasound, that developed an acute abruption and fetal death.The findings of RIHs, hemorrhagic infarcts, and lesions in between support the evolution of hemorrhagic villous infarctions from RIHs. These lesions can arise in the second trimester, and can be detected by ultrasound. These multiple lesions in various stages of evolution suggest an ongoing rather than a discrete insult.

With product customization an emerging business opportunity, organizations must find ways to collaborate and enable sharing of information in an inherently trust-less network. In this paper, we propose – “FabRec”: a decentralized approach to handle manufacturing information generated by various organizations using blockchain technology. We propose a system in which a decentralized network of manufacturing machines and computing nodes can enable automated transparency of an organization’s capability, third party verification of such capability through a trail of past historic events and automated mechanisms to drive paperless contracts between participants using ‘smart contracts’. Our system decentralizes critical information about the manufacturer and makes it available on a peer-to-peer network composed of fiduciary nodes to ensure transparency and data provenance through a verifiable audit trail. We present a testbed platform through a combination of manufacturing machines, system-on-chip platforms and computing nodes to demonstrate mechanisms through which a consortium of disparate organizations can communicate through a decentralized network. Our prototype testbed demonstrates the value of computer code residing on a decentralized network for verification of information on the blockchain and ways in which actions can be autonomously initiated in the physical world. This paper intends to expose system elements in preparation for much larger field tests through the working prototype and discusses the future potential of blockchain for manufacturing IT.

Introduction We evaluated a multi-parametric approach to seizure detection using cardiac and activity features to detect a wide range of seizures across different people using the same model. Methods Electrocardiogram (ECG) and accelerometer data were collected from a chest-worn sensor from 62 children aged 2–17 years undergoing video-electroencephalogram monitoring for clinical care. ECG data from 5 adults aged 31–48 years who experienced focal seizures were also analyzed from the PhysioNet database. A detection algorithm was developed based on a combination of multiple heart rhythm and motion parameters. Results Excluding patients with multiple seizures per hour and myoclonic jerks, 25 seizures were captured from 18 children. Using cardiac parameters only, 11/12 generalized seizures with clonic or tonic activity were detected as well as 7/13 focal seizures without generalization. Separately, cardiac parameters were evaluated using electrocardiogram data from 10 complex partial seizures in the PhysioNet database of which 7 were detected. False alarms averaged one per day. Movement-based parameters did not identify any seizures missed by cardiac parameters, but did improve detection time for 4 of the generalized seizures. Conclusion Our data suggest that cardiac measures can detect seizures with bilateral motor features with high sensitivity, while detection of focal seizures depends on seizure duration and localization and may require customization of parameter thresholds.

ObjectivesThe psychological impact of the COVID-19 pandemic on doctors is a significant concern. Due to the emergence of multiple pandemic waves, longitudinal data on the impact of COVID-19 are vital to ensure an adequate psychological care response. The primary aim was to assess the prevalence and degree of psychological distress and trauma in frontline doctors during the acceleration, peak and deceleration of the COVID-19 first wave. Personal and professional factors associated with psychological distress are also reported.DesignA prospective online three-part longitudinal survey.SettingAcute hospitals in the UK and Ireland.ParticipantsFrontline doctors working in emergency medicine, anaesthetics and intensive care medicine during the first wave of the COVID-19 pandemic in March 2020.Primary outcome measuresPsychological distress and trauma measured using the General Health Questionnaire-12 and the Impact of Events-Revised.ResultsThe initial acceleration survey distributed across networks generated a sample of 5440 doctors. Peak and deceleration response rates from the original sample were 71.6% (n=3896) and 56.6% (n=3079), respectively. Prevalence of psychological distress was 44.7% (n=1334) during the acceleration, 36.9% (n=1098) at peak and 31.5% (n=918) at the deceleration phase. The prevalence of trauma was 23.7% (n=647) at peak and 17.7% (n=484) at deceleration. The prevalence of probable post-traumatic stress disorder was 12.6% (n=343) at peak and 10.1% (n=276) at deceleration. Worry of family infection due to clinical work was the factor most strongly associated with both distress (R2=0.06) and trauma (R2=0.10).ConclusionFindings reflect a pattern of elevated distress at acceleration and peak, with some natural recovery. It is essential that policymakers seek to prevent future adverse effects through (a) provision of vital equipment to mitigate physical and psychological harm, (b) increased awareness and recognition of signs of psychological distress and (c) the development of clear pathways to effective psychological care.Trial registration numberISRCTN10666798.

BACKGROUND The number of pregnancies and interval between pregnancies can have significant impact on a woman's reproductive, psychological, and general health. Exposure to multiple reproductive losses is especially associated with higher rates of negative outcomes. MATERIAL AND METHODS Medical records from 1999-2012 for all Medicaid beneficiaries born after 1982 in the 17 states that provide coverage for all reproductive services (N=2 162 600) were examined to identify the timing of subsequent pregnancies and their outcomes within 3 years of a first known pregnancy. RESULTS One year after their first pregnancy outcomes, 22.6%, 17.8%, and 11.7% of women who had an induced abortion, a natural loss, or a birth, respectively, conceived at least 1 additional pregnancy. By the second year, the percentage of repeat pregnancies rose to 37.5% after an abortion, 25.6% after a natural loss, and 23.1% after a birth. Graphing the weekly conception rates revealed that women who had abortions and natural losses showed similar patterns of rapid repeat pregnancy, with the rate of second conception spiking quickly within 3 to 4 months after the first pregnancy outcome. CONCLUSIONS These findings support the clinical evidence that pregnancy loss may contribute to rapid repeat pregnancies and may better inform interventions to reduce rapid repeat pregnancies.

Introduction: Historically, perioperative hemoglobin monitoring has relied on calculated saturation, using blood gas devices that measure plasma hematocrit (Hct). Co-oximetry, which measures total hemoglobin (tHb), yields a more comprehensive assessment of hemodilution. The purpose of this study was to examine the association of tHb measurement by co-oximetry and Hct, using conductivity with red blood cell (RBC) transfusion, length of stay (LOS) and inpatient costs in patients having major cardiac surgery. Methods: A retrospective study was conducted on patients who underwent coronary artery bypass graft (CABG) and/or valve replacement (VR) procedures from January 2014 to June 2016, using MedAssets discharge data. The patient population was sub-divided by the measurement modality (tHb and Hct), using detailed billing records and Current Procedural Terminology coding. Cost was calculated using hospital-specific cost-to-charge ratios. Multivariable logistic regression was performed to identify significant drivers of RBC transfusion and resource utilization. Results: The study population included 18,169 cardiovascular surgery patients. Hct-monitored patients accounted for 66% of the population and were more likely to have dual CABG and VR procedures (10.4% vs 8.9%, p=0.0069). After controlling for patient and hospital characteristics, as well as patient comorbidities, Hct-monitored patients had significantly higher RBC transfusion risk (OR=1.26, CI 1.15-1.38, pConclusions: tHb monitoring during cardiovascular surgery could offer a significant reduction in RBC transfusion, length of stay and hospital cost compared to Hct monitoring.

Multilayer vertical production systems using sole-source (SS) light-emitting diodes (LEDs) can be an alternative to more traditional methods of microgreens production. One significant benefit of using LEDs is the ability to select light qualities that have beneficial impacts on plant morphology and the synthesis of health-promoting phytochemicals. Therefore, the objective of this study was to quantify the impacts of SS LEDs of different light qualities and intensities on the phytochemical content of brassica (Brassica sp.) microgreens. Specifically, phytochemical measurements included 1) total anthocyanins, 2) total and individual carotenoids, 3) total and individual chlorophylls, and 4) total phenolics. Kohlrabi (Brassica oleracea var. gongylodes), mustard (Brassica juncea ‘Garnet Giant’), and mizuna (Brassica rapa var. japonica) were grown in hydroponic tray systems placed on multilayer shelves in a walk-in growth chamber. A daily light integral (DLI) of 6, 12, or 18 mol·m−2·d−1 was achieved from SS LED arrays with light ratios (percent) of red:blue 87:13 (R87:B13), red:far-red:blue 84:7:9 (R84:FR7:B9), or red:green:blue 74:18:8 (R74:G18:B8) with a total photon flux from 400 to 800 nm of 105, 210, or 315 µmol·m−2·s–1 for 16 hours, respectively. Phytochemical measurements were collected using spectrophotometry and high-performance liquid chromatography (HPLC). Regardless of light quality, total carotenoids were significantly lower under increasing light intensities for mizuna and mustard microgreens. In addition, light quality affected total integrated chlorophyll with higher values observed under the light ratio of R87:B13 compared with R84:FR7:B9 and R74:G18:B8 for kohlrabi and mustard microgreens, respectively. For kohlrabi, with increasing light intensities, the total concentration of anthocyanins was greater compared with those grown under lower light intensities. In addition, for kohlrabi, the light ratios of R87:B13 or R84:FR7:B9 produced significantly higher anthocyanin concentrations compared with the light ratio of R74:G18:B8 under a light intensity of 315 µmol·m−2·s−1. Light quality also influenced the total phenolic concentration of kohlrabi microgreens, with significantly greater levels for the light ratio of R84:FR7:B9 compared with R74:G18:B8 under a light intensity of 105 µmol·m−2·s−1. However, the impact of light intensity on total phenolic concentration of kohlrabi was not significant. The results from this study provide further insight into the selection of light qualities and intensities using SS LEDs to achieve preferred phytochemical content of brassica microgreens.

Introduction/Objective Extrarenal rhabdoid tumor is a high-grade soft-tissue predominately pediatric malignancy with a frequency of 0.15 per million children less than 15 years. It is associated with del(22) (q11.2) with SMARCB1 loss, recognized by loss of INI-1 staining. It has distinct perinuclear hyaline inclusions; however, this feature can be present in other tumors. We describe a malignant extrarenal rhabdoid tumor involving the heart and great vessels to highlight the multiple modalities required for the diagnosis of this tumor in this unusual location. Methods We utilized routine histology, immunohistochemistry, and electron microscopy. Results This 5 -month -old male presented with respiratory distress due to a mass that invaded the heart, surrounding the great vessels. The tumor was composed of sheets of polygonal large cells with light pink to clear cytoplasm, eccentric nuclei with mild anisonucleosis, peripherally marginating chromatin, prominent nucleoli, with 2 mitoses per 10 high power field. Hyaline perinuclear inclusions were inapparent. There were frequent clusters of lymphocytes and eosinophils, with 10 percent necrosis and moderately increased vascularity. The tumor was positive for vimentin, SMA, EMA, MSA, S-100, keratin, and WT1, and negative for INI-1, CD34, ALK, AFP, PLAP, CD30, myogenin, NeuN1, synaptophysin, chromogranin, and NSE. Electron microscopy demonstrated occasional cells with perinuclear collections of intermediate filaments, some with whorls. The strong positivity for vimentin, keratin, SMA, MSA, S-100, negative staining for INA-1 and CD34, and visualization of perinuclear intermediate filament whorls by electron microscopy helped make the diagnosis of extrarenal rhabdoid tumor. Conclusion Malignant extrarenal rhabdomyosarcomas may occur in the middle mediastinum, invade the heart, occur in the first 6 months of life, and not have the typical rhabdoid cells. Diagnoses depend on multiple modalities

Chondromyxoid fibroma-like osteosarcoma (CMF-OS) is a low-grade osteosarcoma, often misdiagnosed on initial biopsy as a benign lesion, with five cases previously described. We report a 13-year-old male with an intramedullary lytic CMF-OS of the right tibial proximal metaphysis with cortical destruction and soft tissue extension. Diagnosis was based on malignant new bone formation, increased mitotic figures, lamellar bone permeation with bony destruction, and correlation with imaging studies. There were no metastasis at presentation and the tumor showed good response to standard chemotherapy with >95% necrosis.

Poor adherence to treatment is a common cause of medical treatment failure. Studying adherence is complicated by the potential for the study environment to impact adherence behavior. Studies performed without informing patients about adherence monitoring must balance the risks of deception against the potential benefits of the knowledge to be gained. Ethically monitoring a patient’s adherence to a treatment plan without full disclosure of the monitoring plan requires protecting the patient’s rights and upholding the fiduciary obligations of the investigator. Adherence monitoring can utilize different levels of deception varying from stealth monitoring, debriefing after the study while informing the subject that some information had been withheld in regard to the use of adherence monitoring (withholding), informed consent that discloses some form of adherence monitoring is being used and will be disclosed at the end of the study (authorized deception), and full disclosure. Different approaches offer different benefits and potential pitfalls. The approach used must balance the risk of nondisclosure against the potential for confounding the adherence monitoring data and the potential benefits that adherence monitoring data will have for the research subjects and/or other populations. This commentary aims to define various methods of adherence monitoring and to provide a discussion of the ethical considerations that accompany the use of each method and adherence monitoring in general as it is used in clinical research., Video abstract

Although Rwanda has accomplished significant improvements in food production in recent years, one fifth of its population remains food insecure. Agricultural information is currently collected through seasonal agricultural surveys, but more frequent and timely data collection is needed to adequately inform public and private decision-makers about the status of crops during the growing season. Sentinel-1 and -2 data are freely available with new images provided every 4-5 days. While analysis of these multispectral images has been used for agricultural applications, there are few applications to smallholder agriculture. Major challenges for satellite image analysis in the context of Rwanda include heavily clouded scenes and small plot sizes that are often intercropped. Sentinel-2 scenes corresponding to mid-season were analyzed, and spectral signatures of maize could be distinguished from those of other crops. Seasonal mean filtering was applied to Sentinel-1 scenes, and there was significant overlap in the spectral signatures across different types of vegetation. Random Forest models for classification of Sentinel scenes were developed using a training dataset that was constructed from high-resolution multispectral images acquired by unmanned aerial vehicles (UAVs) in several different locations in Rwanda and labeled as to the crop type by trained observers. The models were applied to satellite images of the whole country of Rwanda and validated using a test dataset from the UAV images. The Sentinel-2 model had the user’s accuracy for maize classification of 75%, while the Sentinel-1 model overestimated the maize area resulting in a user’s accuracy of

Currently, the most common method for detecting prosthetic implant loosening is imaging. Unfortunately, imaging methods are imprecise in detecting the early signs of implant loosening. This paper describes a new wireless inductive proximity sensor system for detecting early implant loosening. The loosening of the implant is accurately detected by analyzing the electromagnetic field generated by the passive sensors located around the implant. The sensor system was modeled and simulated using COMSOL, and then tested experimentally. The inductive proximity sensor and the metallic implant form a coupled circuit is tuned to oscillate at a designed frequency. The circuit’s integrated controller measures and records specific sensor’s parameters such as resistance and inductance of the sensor that are directly related to the distance between the sensor system and the implant. A prototype has been developed and the results show that the designed proximity sensor is capable of measuring the loosening of the hip implant at $\text{50}\ \mu$ m resolution at distances of less than $\text{8 mm}$ , and of $\text{100}\ \mu$ m resolution at a distance of $\text{15 mm}$ . Furthermore, there is a good correlation between the simulated and experimental results.