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Study Design: Pediatric mandible fractures mandate special consideration because of unerupted teeth, mixed dentition, facial growth and the inability to tolerate maxillomandibular fixation. No consensus exists as to whether resorbable or titanium plating systems are superior with regards to clinical outcomes. Objective: This study aims to systematically review and compare the outcomes of both material types in the treatment of pediatric mandible fractures. Methods: After PROSPERO registration, studies from 1990-2020 publishing on outcomes of ORIF of pediatric mandible fractures were systematically reviewed according to PRISMA guidelines. An additional retrospective review was conducted at a pediatric level 1 trauma center. Results: 1,144 patients met inclusion criteria (30.5% resorbable vs. 69.5% titanium). Total complication rate was 13%, and 10% required a second, unplanned operation. Complication rates in the titanium and resorbable groups were not significantly different (14% vs. 10%; P = 0.07), and titanium hardware was more frequently removed on an elective basis (P < 0.001). Condylar/sub-condylar fractures were more often treated with resorbable hardware (P = 0.01); whereas angle fractures were more often treated with titanium hardware (P < 0.001). Within both cohorts, fracture type did not increase the risk of complications, and comparison between groups by anatomic level did not demonstrate any significant difference in complications. Conclusions: Pediatric mandible fractures requiring ORIF are rare, and hardware-specific outcomes data is scarce. This study suggests that titanium and resorbable plating systems are equally safe, but titanium hardware often requires surgical removal. Surgical approach should be tailored by fracture anatomy, age-related concerns and surgeon preference.

BackgroundIn the context of the SARS-CoV-2 pandemic, reuse of personal protective equipment, specifically that of medical face coverings, has been recommended. The reuse of these typically single-use only items necessitates procedures to inactivate contaminating human respiratory and gastrointestinal pathogens. We previously demonstrated decontamination of surgical masks and respirators contaminated with infectious SARS-CoV-2 and various animal coronaviruses via low concentration- and short exposure methylene blue photochemical treatment (10 µM methylene blue, 30 minutes of 12,500-lux red light or 50,000 lux white light exposure).MethodsHere, we describe the adaptation of this protocol to the decontamination of a more resistant, non-enveloped gastrointestinal virus and demonstrate efficient photodynamic inactivation of murine norovirus, a human norovirus surrogate.ResultsMethylene blue photochemical treatment (100 µM methylene blue, 30 minutes of 12,500-lux red light exposure) of murine norovirus-contaminated masks reduced infectious viral titres by over four orders of magnitude on surgical mask surfaces.Discussion and ConclusionsInactivation of a norovirus, the most difficult to inactivate of the respiratory and gastrointestinal human viruses, can predict the inactivation of any less resistant viral mask contaminant. The protocol developed here thus solidifies the position of methylene blue photochemical decontamination as an important tool in the package of practical pandemic preparedness.

Chronic myeloid leukemia (CML) is a hematological malignancy characterized by BCR-ABL1-derived permanent proliferation of myeloid progenitor cells. BCR-ABL1 tyrosine kinase inhibitors (TKI) are effective first-line therapeutic options to suppress tumor proliferation. However, TKI therapy is not always curative and drug-related side effects as well as drug resistance may evolve over time, necessitating salvage therapies. In this case report we present a 68-year-old woman who developed second- and third-generation TKI therapy resistance with BCR-ABL1T315I and BCR-ABL1E255V mutation. Considering contraindication for hematopoietic stem cell transplantation, we treated the patient in an individual treatment attempt with a third-generation TKI ponatinib in combination with palbociclib, a CDK4/CDK6 inhibitor, which has been shown to effectively inhibit proliferation of BCR-ABL1T315I-mutated cells in vitro. Our case study shows strong antineoplastic effects using this combination in an advanced CML patient resistant to ponatinib monotherapy as a fourth-line treatment. Combined administration of ponatinib/palbociclib at full dose showed almost a tenfold decrease (42.6 to 4.4 IS%) of BCR-ABL1-positive cells but with simultaneous hematopoietic toxicity, necessitating dose reduction. This combination treatment showed high clinical activity. However, biological activity needs to be further characterized in prospective clinical trials.

This article describes a soft robot based on boundary constrained modular subunits. The loop-shaped robot consists of a granule-filled elastic toroidal membrane with a series of modular subunit robots attached to its exterior. The robot can operate both as a soft robot to conform to external objects or navigate through narrow corridors and as a rigid robot by jamming its internal granules using a vacuum. The jammed state is useful for exerting forces on the environment in object manipulation or locomotion tasks. This article describes the robot’s design, object handling capabilities, locomotion, shape formation, and ability to navigate narrow corridors. We also present computationally efficient control methodologies used for self-reconfiguration and target tracking, which enable scaling the number of subunits to create larger systems. The robot’s scalability and the control methodologies are verified through simulation with ProjectChrono, a multibody dynamic simulation platform. All other results are obtained experimentally.

Autoimmune conditions can occur in a temporary relationship with any malignant lymphoma. In many instances, treatment at diagnosis is not required, but symptomatic autoimmune conditions represent an indication for treatment, particularly in chronic lymphoproliferative diseases. Treatment is selected depending on the predominant condition: autoimmune disease (immunosuppression) or lymphoma (antilymphoma therapy). Steroids and anti-CD20 antibodies are effective against both conditions and may suppress the autoimmune complication for a prolonged period. The efficacy of B-cell receptor inhibitors has provided us with novel insights into the pathophysiology of antibody-producing B cells. Screening for underlying autoimmune conditions is part of the lymphoma workup, because other drugs, such as immunomodulators and checkpoint inhibitors, should be avoided or used with caution. In this article, we discuss diagnostic challenges and treatment approaches for different situations involving lymphomas and autoimmune cytopenias.

Significance\ud \ud Communicating in ways that motivate engagement in social distancing remains a critical global public health priority during the COVID-19 pandemic. This study tested motivational qualities of messages about social distancing (those that promoted choice and agency vs. those that were forceful and shaming) in 25,718 people in 89 countries. The autonomy-supportive message decreased feelings of defying social distancing recommendations relative to the controlling message, and the controlling message increased controlled motivation, a less effective form of motivation, relative to no message. Message type did not impact intentions to socially distance, but people’s existing motivations were related to intentions. Findings were generalizable across a geographically diverse sample and may inform public health communication strategies in this and future global health emergencies.\ud \ud \ud \ud Abstract\ud \ud Finding communication strategies that effectively motivate social distancing continues to be a global public health priority during the COVID-19 pandemic. This cross-country, preregistered experiment (n = 25,718 from 89 countries) tested hypotheses concerning generalizable positive and negative outcomes of social distancing messages that promoted personal agency and reflective choices (i.e., an autonomy-supportive message) or were restrictive and shaming (i.e., a controlling message) compared with no message at all. Results partially supported experimental hypotheses in that the controlling message increased controlled motivation (a poorly internalized form of motivation relying on shame, guilt, and fear of social consequences) relative to no message. On the other hand, the autonomy-supportive message lowered feelings of defiance compared with the controlling message, but the controlling message did not differ from receiving no message at all. Unexpectedly, messages did not influence autonomous motivation (a highly internalized form of motivation relying on one’s core values) or behavioral intentions. Results supported hypothesized associations between people’s existing autonomous and controlled motivations and self-reported behavioral intentions to engage in social distancing. Controlled motivation was associated with more defiance and less long-term behavioral intention to engage in social distancing, whereas autonomous motivation was associated with less defiance and more short- and long-term intentions to social distance. Overall, this work highlights the potential harm of using shaming and pressuring language in public health communication, with implications for the current and future global health challenges.

Background: The impact of adjuvant radiotherapy (RT) to the vulva with regard to prognosis and local recurrence in patients with vulvar squamous cell cancer (VSCC) is poorly described.Patients and methods: In the AGO-CaRE-1 study 1618 patients with primary VSCC FIGO stage ≥ IB, treated between 1998-2008, were documented. In this retrospective subanalysis, 360 patients were included based on the following criteria: nodal involvement (pN+), known RT treatment and known radiation fields.Results: The majority had pT1b/pT2 tumors (n=299; 83.1%). In 76.7%, R0 resection was achieved. 57/360 (15.8%) N+ patients were treated with adjuvant RT to the groins/pelvis and 146/360 (40.5%) received adjuvant RT to the vulva and groins/pelvis. 157/360 (43.6%) patients did not receive any adjuvant RT. HPV status was available in 162/360 patients (45.0%), 75/162 tumors were HPV+(46.3%), 87/162 (53.7%) HPV-. During a median follow-up of 17.2 months, recurrence at the vulva only occurred in 25.5% of patients without adjuvant RT, in 22.8% of patients with adjuvant RT to groins/pelvis and in 15.8% of patients with adjuvant RT to the vulva and groins/pelvis respectively. The risk reducing effect of local RT was independent of the resection margin status. 50% disease free survival time (50% DFST) indicated a stronger impact of adjuvant RT to the vulva in HPV+ compared to HPV- patients (50% DFST 20.7 months vs. 17.8 months).Conclusion: Adjuvant RT to the vulva was associated with a lower risk for local recurrence in N+ VSCC independent of the resection margin status. This observation was more pronounced in patients with HPV+ tumors in comparison to HPV– tumors.

Background: We review the efficacy and safety of dexmedetomidine and clonidine as perineural or systemic adjuvants for brachial plexus blocks (BPB). Methods: We included randomised controlled trials on upper limb surgery with BPBs in adults, comparing dexmedetomidine with clonidine or either drug with placebo. The primary outcome was duration of analgesia. Secondary outcomes included adverse and serious adverse events. The review was conducted using Cochrane standards, trial sequential analyses (TSA) and Grading of Recommendations Assessment, Development and Evaluation (GRADE). Results: We included 101 trials with 6248 patients. Overall, duration of analgesia was prolonged with both clonidine (176 min [TSA adj. 95% CI: 118, 205, p

Tisagenlecleucel is indicated for pediatric and young adult patients with relapsed/refractory (r/r) B-cell acute lymphoblastic leukemia (B-ALL) and adult patients with r/r diffuse large B-cell lymphoma (DLBCL). The tisagenlecleucel chimeric antigen receptor (CAR) contains a murine single-chain variable fragment domain; we examined the effects of humoral and cellular immune responses to tisagenlecleucel on clinical outcomes using 2 validated assays. Data were pooled from the ELIANA (registered at www.clinicaltrials.gov as #NCT02435849) and ENSIGN (#NCT02228096) trials in r/r B-ALL (N = 143) and the JULIET trial (#NCT02445248) in r/r DLBCL (N = 115). Humoral responses were determined by flow cytometric measurement of anti-murine CAR19 (mCAR19) antibodies in serum. Cellular responses were determined using T-cell production of interferon-γ in response to 2 different pools of mCAR19 peptides. Pretreatment anti-mCAR19 antibodies were detected in 81% of patients with r/r B-ALL and 94% of patients with r/r DLBCL. Posttreatment anti-mCAR19 antibodies were higher than patient-specific baseline in 42% of r/r B-ALL and 9% of r/r DLBCL patients. Pretreatment and posttreatment anti-mCAR19 antibodies did not affect tisagenlecleucel cellular kinetics, including maximum concentration and persistence (r2 < 0.05), clinical response (day-28 response, duration of response, and event-free survival), and safety. T-cell responses were consistent over time, with net responses

BREST and PREDICA scores have recently emerged for the diagnosis of acute heart failure (AHF) in the emergency department (ED). This study aimed to perform a head-to-head comparison in a large contemporary cohort. BREST and PREDICA scores were calculated from, respectively, 11 and 8 routine clinical variables recorded in the ED in 1386 patients from the PArADIsE cohort. The diagnostic performance of the scores for adjudicated AHF diagnosis was assessed by the area under the ROC curve (AUC). Acute HF diagnosis was adjudicated according to the European Society of Cardiology criteria and BNP levels. A BREST score ≤ 3 or PREDICA score ≤ 1 was associated with low probabilities of AHF (5.7% and 2.6%, respectively). Conversely, a BREST score ≥ 9 or PREDICA score ≥ 5 was associated with a high risk of AHF diagnosis (77.3% and 66.9%, respectively) although more than half of the population was within the "gray zone" (4-8 and 2-4 for the BREST and PREDICA scores, respectively). Diagnostic performances of both scores were good (AUC 79.1%, [66.1-82.1] for the BREST score and 82.4%, [79.8-85.0] for the PREDICA score). PREDICA score had significantly higher diagnostic performance than BREST score (increase in AUC 3.3 [0.8-5.8], p = 0.009). Our study emphasizes the good diagnostic performance of both BREST and PREDICA scores, albeit with a significantly higher diagnostic performance of the PREDICA score. Yet, more than half of the population was classified within the "gray zone" by these scores; additional diagnostic tools are needed to ascertain AHF diagnosis in the ED in a majority of patients. Clinical trial registration: NCT02800122.

BACKGROUND AND OBJECTIVES High recurrence rates of Stages II and IIIA melanoma make close follow-up essential, especially with new adjuvant therapies for metastatic disease. However, there are currently no consensus guidelines for routine imaging for Stages IIB, IIC, and IIIA melanoma. The study's aim is to determine the utility of 18 F-fluorodeoxyglucose (18 F-FDG) positron emission tomography/computed tomography (PET/CT) for detecting asymptomatic recurrence of melanoma after primary surgical resection. METHODS This retrospective cohort study included 158 patients with the American Joint Committee on Cancer 8th edition Stages IIB, IIC, or IIIA cutaneous melanoma who underwent an 18 F-FDG PET/CT from 2010 to 2020. We retrospectively analyzed clinical data after a median follow-up time of 39 months. RESULTS We calculated a positive predictive value (PPV) of 32% (95% confidence interval: 11%-53%) for 154 routine PET/CTs, including six true positives and 13 false positives (FPs). PPV was 33% for Stage IIB, 50% for Stage IIC, and 14% for Stage IIIA. FPs were mostly benign or inflammatory foci (75%), and some other malignancies were found (21%). CONCLUSIONS This cohort of patients imaged for high-risk melanoma demonstrated a high FP rate and low PPV. These findings suggest that routine surveillance with 18 F-FDG PET/CT may not be indicated for monitoring recurrence in this population.

Zusammenfassung Anamnese Ein 49-jähriger Mann stellte sich in der chirurgischen Notfallsprechstunde mit seit neun Tagen progredienten, thorakolumbalen Rückenschmerzen vor. Symptome eines respiratorischen Infektes zeigte er nicht, insbesondere lagen weder Fieber noch Husten vor. Untersuchungen Bei der Untersuchung fiel im Rahmen der Entkleidung eine Dyspnoe auf, die sich bei genauerem Nachfragen etwa im selben Zeitraum progredient zeigte, den Patienten subjektiv aber nicht sehr beeinträchtigte. Zudem bestand ein deutlicher Gewichtsverlust. Ein daraufhin ambulant erfolgtes Röntgen des Thorax zeigte bilaterale, ubiquitär verteilte, feinfleckig konfluierende Verschattungen. Die im Anschluss durchgeführte PCR des Nasopharynxabstriches war positiv für SARS-CoV-2. Therapie und Verlauf Bei progredienter Dyspnoe erfolgte noch am selben Tag eine stationäre Einweisung. Hier wurden im Zuge einer zunehmenden hypoxämischen, respiratorischen Insuffizienz sowie kompromittierter Atemmechanik mit drohender muskulärer Erschöpfung die intermittierende nichtinvasive Beatmung sowie eine nasale High-Flow-Therapie notwendig. Probatorisch erfolgte eine virostatische Therapie mit Remdesivir. Zudem wurde aufgrund des Verdachts auf eine bakterielle Superinfektion eine antibiotische Therapie notwendig. Nach 13 Tagen stationärer Behandlung konnte der Patient entlassen werden. Die Rückenschmerzen sistierten im Verlaufe der stationären Behandlung spontan und ohne spezifische Therapie. Schlussfolgerungen Rückenschmerzen können ein Symptom von COVID-19 sein, im vorliegenden Kasus waren sie sogar der einzige Grund für die ärztliche Vorstellung. Auch wenn Rückenschmerzen im ärztlichen Alltag sehr häufig vorkommen, sollten auch seltene bzw. ungewöhnliche Differenzialdiagnosen bedacht werden.

Personalized medicine aims to match the right drug with the right patient by using specific features of the individual patient's tumor. However, current strategies of personalized therapy matching provide treatment opportunities for less than 10% of patients with cancer. A promising method may be drug profiling of patient biopsy specimens with single-cell resolution to directly quantify drug effects. We prospectively tested an image-based single-cell functional precision medicine (scFPM) approach to guide treatments in 143 patients with advanced aggressive hematologic cancers. Fifty-six patients (39%) were treated according to scFPM results. At a median follow-up of 23.9 months, 30 patients (54%) demonstrated a clinical benefit of more than 1.3-fold enhanced progression-free survival compared with their previous therapy. Twelve patients (40% of responders) experienced exceptional responses lasting three times longer than expected for their respective disease. We conclude that therapy matching by scFPM is clinically feasible and effective in advanced aggressive hematologic cancers. Significance: This is the first precision medicine trial using a functional assay to instruct n-of-one therapies in oncology. It illustrates that for patients lacking standard therapies, high-content assay-based scFPM can have a significant value in clinical therapy guidance based on functional dependencies of each patient's cancer. See related commentary by Letai, p. 290. This article is highlighted in the In This Issue feature, p. 275

Bone marrow (BM) lymphocyte subsets are evaluated by flow cytometry or immunohistochemistry for diagnostic purposes; however, CD4:CD8 T lymphocyte ratios are often erroneously interpreted using peripheral blood ranges. There are few and no recent studies describing the composition of lymphocytes within the marrow space, or normal reference ranges. Lymphocyte subsets in cytopenic patients and hospital autopsy BM specimens were evaluated to better characterize CD4:CD8 ratios. Ten patients with a history of cytopenia were identified from 2017 to 2021. Clinical history, cytogenetic testing, and results of a next generation sequencing panel were reviewed to rule out hematolymphoid disease. Thirty-five decedents who underwent a hospital autopsy from 2018 to 2019 were identified. History of hematolymphoid disease was ruled out by chart review. Immunohistochemical staining for CD3, CD20, CD4, and CD8 was evaluated with digital image analysis. Findings were compared to peripheral blood flow cytometry in a group of 20 living patients. BM CD4:CD8 ratios by image analysis were significantly lower than peripheral blood, mean in cytopenic patients 0.37:1 and mean in decedents 0.51:1 versus 2.6:1 (p = 0.99). Lymphoid aggregates were encountered with increasing frequency in older individuals. These findings aid in the evaluation of BM lymphocyte subsets and distribution both in living patients and autopsy evaluation. We also present a practical approach to image analysis.

Integrating photonics with CMOS electronics in silicon is essential to enable chip-scale, electronic-photonic systems that will revolutionize classical and quantum communication and computing systems. However, the lack of an on-silicon isolator, capable of blocking unwanted back reflections and ensuring the stable operation of the laser, precluded many previous demonstrations from providing single-chip solutions. For most optical systems employing a laser, magneto-optic isolators have been indispensable, but such isolators are incompatible with silicon. To stabilize on-chip lasers, reflections-cancellation circuits were proposed as a way to reduce the reflections going back to the laser. Yet, a stable laser against time-varying back reflections was never demonstrated. Here we demonstrate a stable quantum well-distributed feedback (QWDFB) laser against slowly time-varying reflections using a reflections-cancellation circuit (RCC) on a foundry-produced, silicon-photonic (SiP) chip. The optical spectrum and the relative intensity noise (RIN) of the laser when the RCC was running is comparable to when an isolator was used. By accurately locking the laser in a stable optical feedback regime, the RCC further enhances the QWDFB laser performance by reducing its linewidth by a factor of 100, down to 3 kHz. Both results are enabled using novel techniques in the design, calibration, tuning, and control of the proposed SiP RCC. The optical insertion loss of the RCC is less than 1.5 dB for reflections smaller than −20 dB and can yield isolation ranges of up to 64 dB. Our device paves the way towards the mass production of fully integrated, low-cost electronic-photonic silicon chips without attaching magneto-optic isolators between the laser and the SiP chip.

Titanium associated risks have led to interest in resorbable hardware for open reduction and internal fixation (ORIF) of pediatric facial fractures. This study aims to systematically review and compare the outcomes of titanium/resorbable hardware used for ORIF of upper/midfacial fractures to determine which hardware carries a higher complication rate in the pediatric patient.Studies published between 1990 and 2020 on the ORIF of pediatric upper/midfacial fractures were systematically reviewed. A retrospective institutional review was also conducted, and both arms were compiled for final analysis. The primary predictor value was the type of hardware used and the primary outcome was the presence of a complication. Fisher's exact test and 2-proportion 2-tailed z-test calculations were used to determine statistical significance, which was defined as a P value.05. The low quality of published evidence precluded meta-analysis.Systematic review of 23 studies identified 659 patients, and 77 patients were identified in the institutional review. A total of 736 patients (299 resorbable, 437 titanium) were included in the final analysis. Total complication rate was 22.8%. The titanium group had a higher complication rate (27 vs 16.7%; P.01), and more often underwent elective hardware removal (87.3 vs 0%, P.01). In each hardware subgroup, the incidence of complications was analyzed by fracture site. In the titanium group, complication incidence was higher when treating maxillary fractures (32.8 vs 22.9%, P = .03). When comparing the 2 hardware groups by fracture site, maxillary fractures had a higher rate of complications when treated by titanium hardware compared with resorbable hardware (32.8 vs 18%, P.01).Upper/midfacial pediatric fractures requiring ORIF, especially maxillary fractures, may be best treated with resorbable hardware. Additional hardware-specific outcomes data is encouraged.

Purpose We conducted a patterns-of-care survey on chemoradiation for locoregionally confined anal cancer in Austria to evaluate areas of disagreement and to identify possible targets for further standardization. Methods An anonymous questionnaire comprising 38 questions was sent to all Austrian radiation oncology departments. Results were analyzed descriptively and compared to two international guidelines. Results The response rate was 93%. Work-up generally includes DRE, endoscopy, and cross-sectional imaging of chest/abdomen and pelvis. PET-CT is used by 38%. Screening for HIV and biopsies of suspicious lymph nodes are infrequently used. All centers perform IMRT, mainly with daily IGRT. Median doses to the primary are 54.7 Gy (T1–2) and 59.4 Gy (T3–4). Suspicious nodes receive a boost (median dose 54 Gy), while elective nodal areas are mainly treated with 45–50.4 Gy. Target delineation of elective nodal areas seems generally uniform, although disagreement exists regarding inclusion of the common iliac nodes. No agreement was found for OAR-delineation and dose constraints. Concurrent chemotherapy is mitomycin and 5‑FU/capecitabine. Supportive care beyond skin care is infrequently offered. Intensive follow-up is performed for at least 5 years. Treatment of T1N0 shows considerable disagreement. Conclusion We found a high rate of agreement between the centers and concordance with major guidelines. PET-CT, routine HIV testing, and biopsies of suspicious LN seem underrepresented. The largest controversy regarding target volumes concerns inclusion of the common iliac nodes. Prescribed doses are generally in line with the recommendations or higher. OAR delineation, dose constraints, supportive care, and treatment of early anal cancer represent areas for further standardization.

Immune evasion is a hallmark of cancer and therapies that restore immune surveillance have proven highly effective in cancers with high tumor mutation burden (TMB) (for example, those with microsatellite instability). Whether low TMB cancers, which are largely refractory to immunotherapy, harbor potentially immunogenic neoantigens remains unclear. Here, we show that tumors from all patients with microsatellite stable colorectal cancer express clonal predicted neoantigens despite low TMB. Unexpectedly, these neoantigens are broadly expressed at lower levels compared to those in colorectal cancer with microsatellite instability. Using a versatile platform for modulating neoantigen expression in colorectal cancer organoids and transplantation into the distal colon of mice, we show that low expression precludes productive cross-priming and drives immediate T-cell dysfunction. Notably, experimental or therapeutic rescue of priming rendered T cells capable of controlling tumors with low neoantigen expression. These findings underscore a critical role of neoantigen expression level in immune evasion and therapy response. Jacks and colleagues demonstrate the effects of neoantigen expression level on T-cell priming and immune surveillance during tumor development and progression and explore implications for immunotherapies, using in vivo models of colorectal cancer.

BACKGROUND AND OBJECTIVE: Monitoring recovery process of coronavirus disease 2019 (COVID-19) patients released from hospital is crucial for exploring residual effects of COVID-19 and beneficial for clinical care. In this study, a comprehensive analysis was carried out to clarify residual effects of COVID-19 on hospital discharged patients. METHODS: Two hundred sixty-eight cases with laboratory measured data at hospital discharge record and five follow-up visits were retrospectively collected to carry out statistical data analysis comprehensively, which includes multiple statistical methods (e.g., chi-square, T-test and regression) used in this study. RESULTS: Study found that 13 of 21 hematologic parameters in laboratory measured dataset and volume ratio of right lung lesions on CT images highly associated with COVID-19. Moderate patients had statistically significant lower neutrophils than mild and severe patients after hospital discharge, which is probably caused by more efforts on severe patients and slightly neglection of moderate patients. COVID-19 has residual effects on neutrophil-to-lymphocyte ratio (NLR) of patients who have hypertension or chronic obstructive pulmonary disease (COPD). After released from hospital, female showed better performance in T lymphocytes subset cells, especially T helper lymphocyte% (16% higher than male). According to this sex-based differentiation of COVID-19, male should be recommended to take clinical test more frequently to monitor recovery of immune system. Patients over 60 years old showed unstable recovery process of immune cells (e.g., CD45 + lymphocyte) within 75 days after discharge requiring longer clinical care. Additionally, right lung was vulnerable to COVID-19 and required more time to recover than left lung. CONCLUSIONS: Criterion of hospital discharge and strategy of clinical care should be flexible in different cases due to residual effects of COVID-19, which depend on several impact factors. Revealing remaining effects of COVID-19 is an effective way to eliminate disorder of mental health caused by COVID-19 infection.

Overgrowth syndromes encompass a number of rare genetic diseases with heterogeneous clinical phenotypes. Accordingly, there is a strong imperative to collect data and classify these disorders to aid in diagnosis and management. Recent advances in the genetics of overgrowth syndromes have identified mutations in the PIK3CA gene. These somatic mutations manifest in progressive segmental overgrowth of fibrous and adipose tissue and bone, vascular malformations, and in some cases, increased risk for malignancy. Targeted medical therapy is under investigation for the management of PROS, but treatment of overgrowth relies on surgical debulking. Macrotia in PIK3CA-related overgrowth spectrum (PROS) has not been reported in the literature. In this case, we discuss a novel approach to reductive otoplasty and facial soft tissue debulking in a pediatric patient with PROS.

Android recently introduced the scoped storage defense to better protect application use of shared external storage. This article examines the evolution of Android external storage defenses leading to scoped storage and assesses the impact of the scoped storage defense for limiting opportunities for exploitation.

Summary Background COVID-19 can lead to multiorgan failure. Dapagliflozin, a SGLT2 inhibitor, has significant protective benefits for the heart and kidney. We aimed to see whether this agent might provide organ protection in patients with COVID-19 by affecting processes dysregulated during acute illness. Methods DARE-19 was a randomised, double-blind, placebo-controlled trial of patients hospitalised with COVID-19 and with at least one cardiometabolic risk factor (ie, hypertension, type 2 diabetes, atherosclerotic cardiovascular disease, heart failure, and chronic kidney disease). Patients critically ill at screening were excluded. Patients were randomly assigned 1:1 to dapagliflozin (10 mg daily orally) or matched placebo for 30 days. Dual primary outcomes were assessed in the intention-to-treat population: the outcome of prevention (time to new or worsened organ dysfunction or death), and the hierarchial composite outcome of recovery (change in clinical status by day 30). Safety outcomes, in patients who received at least one study medication dose, included serious adverse events, adverse events leading to discontinuation, and adverse events of interest. This study is registered with ClinicalTrials.gov , NCT04350593 . Findings Between April 22, 2020 and Jan 1, 2021, 1250 patients were randomly assigned with 625 in each group. The primary composite outcome of prevention showed organ dysfunction or death occurred in 70 patients (11·2%) in the dapagliflozin group, and 86 (13·8%) in the placebo group (hazard ratio [HR] 0·80, 95% CI 0·58–1·10; p=0·17). For the primary outcome of recovery, 547 patients (87·5%) in the dapagliflozin group and 532 (85·1%) in the placebo group showed clinical status improvement, although this was not statistically significant (win ratio 1·09, 95% CI 0·97–1·22; p=0·14). There were 41 deaths (6·6%) in the dapagliflozin group, and 54 (8·6%) in the placebo group (HR 0·77, 95% CI 0·52–1·16). Serious adverse events were reported in 65 (10·6%) of 613 patients treated with dapagliflozin and in 82 (13·3%) of 616 patients given the placebo. Interpretation In patients with cardiometabolic risk factors who were hospitalised with COVID-19, treatment with dapagliflozin did not result in a statistically significant risk reduction in organ dysfunction or death, or improvement in clinical recovery, but was well tolerated. Funding AstraZeneca.

Background Performance validity and test-retest reliability of ReVeRe.D, an iPad-administered cognitive test battery in major depressive disorder (MDD) were analyzed. Methods Participants aged 18-59 years had DSM-5 diagnosis of MDD with adequate visual and hearing acuity. All had responded to oral antidepressant treatment for a major depressive episode within the most recent 24-months and were stable with no greater than mild depressive symptoms as evidenced by Montgomery Asberg Depression Rating Scale total score 17. Participants were randomly assigned to 1 of 2 test sequences (AABB or BBAA; A=ReVeRe.D; B=examiner-administered tests) in a crossover design. Results 244 randomized participants (AABB: n=123; BBAA: n=121) had mean age of 38.3 years; 54.9% had a college, baccalaureate, or higher education. At first administration, Pearson correlation coefficients (PCC) for 6/10 pairs of corresponding ReVeRe.D vs examiner-administered tests exceeded the pre-specified acceptance criterion (PCC=0.53) for the primary analysis; 8 test score pairs had PCC exceeding 0.40. At second administration, PCC for 9/10 test scores pairs exceeded PCC=0.53. Together, the series of PCCs supports the concurrent validity for ReVeRe.D. Test-retest reliability for ReVeRe.D test scores was generally moderate to high. Limitations The study included stable participants with MDD who had responded to oral antidepressant treatment, with most in at least partial remission. The sample was limited to English-speaking participants, and skewed towards white, college-educated women. Further studies in acutely ill MDD patients who represent a broader demographic, are warranted. Conclusions iPad-administered ReVeRe.D is a valid and reliable computerized test battery for assessment of cognitive performance in MDD.

Background The 2017 American College of Cardiology/American Heart Association blood pressure (BP) guideline recommends using 10-year predicted atherosclerotic cardiovascular disease (ASCVD) risk to guide decisions to initiate antihypertensive medication. Methods We included adults aged 40-79 years from the National Health and Nutrition Examination Survey 2013-2018 (n = 8803). We computed 10-year predicted ASCVD risk using the Pooled Cohort risk equations. Clinical CVD was self-reported. Analyses were conducted overall and among those with stage 1 hypertension, defined by a mean SBP of 130-139 mmHg or DBP of 80-89 mmHg. In subgroups defined by diabetes, chronic kidney disease (CKD), and age at least 65 years, we estimated the proportion of United States adults with high ASCVD risk (i.e. 10-year predicted ASCVD risk ≥10% or clinical CVD) and estimated age-adjusted probability of having high ASCVD risk. Results Among United States adults, an estimated 72.3, 64.5, and 83.9 of those with diabetes, CKD, and age at least 65 years had high ASCVD risk, respectively. Among United States adults with stage 1 hypertension, an estimated 55, 36.7, and 72.6% of those with diabetes, CKD, and age at least 65 years had high ASCVD risk, respectively. The probability of having high ASCVD risk increased with age and exceeded 50% for United States adults with diabetes and CKD at ages 52 and 57 years, respectively. For those with stage 1 hypertension, these ages were 55 and 64 years, respectively. Conclusion Most United States adults with diabetes, CKD, or age at least 65 years had high ASCVD risk. However, many with stage 1 hypertension did not.

Background The value of pelvic lymphadenectomy (LAE) has been subject of discussions since the 1980s. This is mainly due to the fact that the relation between lymph node involvement of the groin and pelvis is poorly understood and therewith the need for pelvic treatment in general. Patients and Methods N = 514 patients with primary vulvar squamous cell cancer (VSCC) FIGO stage ≥ IB were treated at the University Medical Center Hamburg-Eppendorf between 1996 and 2018. In this analysis, patients with pelvic LAE (n = 21) were analyzed with regard to prognosis and the relation of groin and pelvic lymph node involvement. Results The majority had T1b/T2 tumors (n = 15, 78.9%) with a median diameter of 40 mm (11–110 mm). 17/21 patients showed positive inguinal nodes. Pelvic nodal involvement without groin metastases was not observed. 6/17 node-positive patients with positive groin nodes also had pelvic nodal metastases (35.3%; median number of affected pelvic nodes 2.5 (1–8)). These 6 patients were highly node positive with median 4.5 (2–9) affected groin nodes. With regard to the metastatic spread between groins and pelvis, no contralateral spread was observed. Five recurrences were observed after a median follow-up of 33.5 months. No pelvic recurrences were observed in the pelvic nodal positive group. Patients with pelvic metastasis at first diagnosis had a median progression-free survival of only 9.9 months and overall-survival of 31.1 months. Conclusion A relevant risk for pelvic nodal involvement only seems to be present in highly node-positive disease, therefore pelvic staging (and radiotherapy) is probably unnecessary in the majority of patients with node-positive VSCC.

Purpose: Computed tomography (CT) scans obtained in the setting of facial trauma often report aberrations in neural anatomy, such as optic nerve stretching. While these findings have not yet been correlated with clinical findings, they raise concern for traumatic optic neuropathy (TON). This study aims to correlate radiographic optic nerve abnormalities with clinical findings in the setting of craniomaxillofacial trauma. Methods: Patient charts were queried based on ICD-9 codes for the presence of an orbital fracture. Patients were included if the CT report mentioned an anatomic abnormality of the optic nerve. Patients who expired within 24 hours of arrival, had an open globe injury, or who were not able to participate in a visual exam were excluded. An additional matched cohort of patients with orbital fractures and without optic nerve abnormalities was selected. The primary endpoint was a clinical diagnosis of TON, and secondary endpoints included the need for ophthalmologic intervention and the presence of abnormal visual acuity. Results: One-hundred and eight patients were included in the study (54 per group). Radiographic optic nerve stretching was not associated with an increased risk of TON (OR: 2.22, 95% CI: 0.71-7.02); however, it was associated with increased risk for abnormal visual acuity (OR: 2.24, 95% CI: 1.01-4.99). There was no increased need for any ophthalmologic intervention (OR: 1.93, 95% CI: 0.86-4.31). Conclusions: Alterations in orbital anatomy on CT are common after orbital fracture and may inappropriately raise concern for TON. This in turn may prompt interfacility transfer and/or emergent ophthalmology consultation. This study demonstrates that radiographic stretching of the optic nerve does not increase the odds for TON in the setting of orbital fractures. While patients with abnormal optic nerve findings did have a higher rate of abnormal visual acuity, this is a common, multifactorial finding in this setting.

PurposePublic debates and scholarly literature on football fandom are often characterised by generalisation and lacking differentiation. The changing ethnography of fans, affected by the rapid commercialisation and internationalisation of the game, reinforces the demand for contemporary classification criteria and fan typologies that take the complexity and heterogeneity of fans into account and draw a more differentiated picture of fans and sub-groups.Design/methodology/approachBased on the grounded theory methodology and a systematic literature review on stakeholder theory, stakeholder classification criteria and football fandom, the authors conduct and analyse 14 semi-structured expert interviews with fan managers employed by German professional football clubs. Building on the analysis, the authors identify, present and discuss ten contemporary criteria and five corresponding typologies for the classification of football fans.FindingsThe grounded theory analysis suggests that football fans can be characterised according to ten classification criteria. Building on the analysis, the authors derive five fan typologies that differ in their characteristics along the continua of the identified criteria. Typologies comprise (1) active fans, (2) consuming fans, (3) event fans, (4) corporate fans and (5) passive followers.Originality/valueThe paper enlarges prior knowledge on the behavioural and attitudinal characteristics of fans as individuals and adds knowledge regarding relationships within fan groups, and regarding formal and non-formal relations between fans and clubs. The results provide scholars with a framework for further scientific investigation and practitioners with a concept for a more sophisticated and differentiated approach to managing fan relations.

International audience; Background: Verticality perception is frequently altered in Parkinson’s disease (PD) with Pisa syndrome (PS). Is it the cause or the consequence of the PS? Objective: We tested the hypothesis that both scenarios coexist. Methods: We performed a double-blind within-person randomized trial (NCT02704910) in 18 individuals (median age 63.5 years) with PD evolving for a median of 17.5 years and PS for 2.5 years and treated with bilateral stimulation of the subthalamus nuclei (STN-DBS) for 6.5 years. We analyzed whether head and trunk orientations were congruent with the visual (VV) and postural (PV) vertical, and whether switching on one or both sides of the STN-DBS could modulate trunk orientation via verticality representation. Results: The tilted verticality perception could explain the PS in 6/18 (33%) patients, overall in three right-handers (17%) who showed net and congruent leftward trunk and PV tilts. Two of the 18 (11%) had an outstanding clinical picture associating leftward: predominant parkinsonian symptoms, whole-body tilt (head –11°, trunk –8°) and transmodal tilt in verticality perception (PV –10°, VV –8.9°). Trunk orientation or VV were not modulated by STN-DBS, whereas PV tilts were attenuated by unilateral or bilateral stimulations if it was applied on the opposite STN. Conclusion: In most cases of PS, verticality perception is altered by the body deformity. In some cases, PS seems secondary to a biased internal model of verticality, and DBS on the side of the most denervated STN attenuated PV tilts with a quasi-immediate effect. This is an interesting track for further clinical studies.

Novel minimally invasive therapies like the prostatic urethral lift are among the many endoscopic options for the treatment of benign prostatic enlargement and lower urinary tract symptoms (BPE/LUTS). To further understand the relative uptake, complications and retreatment rates of contemporary endoscopic procedures for BPE/LUTS across diverse practice types, we performed a retrospective study of inpatient and ambulatory surgery encounters in the Premier Healthcare database.We included men who underwent endoscopic procedures for BPE/LUTS between 2000 and 2018. We determined the utilization of endoscopic therapies for BPE/LUTS, 30-day and 90-day readmission rates, and retreatment rate. Multivariable logistic regression was used to assess the association of procedure type with outcomes for the 3 most commonly performed procedures.We identified 175,150 men treated with endoscopic surgery for BPE/LUTS. The annual percent utilization of the prostatic urethral lift increased from1% in 2014 to 10.4% in 2018. Compared to transurethral resection of the prostate and prostate photovaporization, prostatic urethral lift was associated with a lower odds of readmission at 30 (OR 0.58, p0.01) and 90 (OR 0.55, p0.01) days and a higher odds of retreatment within 2 years of followup (OR 1.78, p0.01).Providers have rapidly adopted prostatic urethral lift which accounted for more than 1 in 10 endoscopic procedures captured for BPE/LUTS in 2018. Men treated with prostatic urethral lift are readmitted less within 30 and 90 days but are more likely to be retreated within 2 years of their index procedure as compared to men treated with transurethral resection of the prostate or prostate photovaporization.

We report on a patient who presented with refractory subacute cutaneous lupus erythematosus. The scaly annular and polycyclic patches/plaques, and hyperkeratotic lesions on multiple fingers improved rapidly after treatment with baricitinib.

This study explores how researchers' analytical choices affect the reliability of scientific findings. Most discussions of reliability problems in science focus on systematic biases. We broaden the lens to emphasize the idiosyncrasy of conscious and unconscious decisions that researchers make during data analysis. We coordinated 161 researchers in 73 research teams and observed their research decisions as they used the same data to independently test the same prominent social science hypothesis: that greater immigration reduces support for social policies among the public. In this typical case of social science research, research teams reported both widely diverging numerical findings and substantive conclusions despite identical start conditions. Researchers' expertise, prior beliefs, and expectations barely predict the wide variation in research outcomes. More than 95% of the total variance in numerical results remains unexplained even after qualitative coding of all identifiable decisions in each team's workflow. This reveals a universe of uncertainty that remains hidden when considering a single study in isolation. The idiosyncratic nature of how researchers' results and conclusions varied is a previously underappreciated explanation for why many scientific hypotheses remain contested. These results call for greater epistemic humility and clarity in reporting scientific findings. ispartof: PROCEEDINGS OF THE NATIONAL ACADEMY OF SCIENCES OF THE UNITED STATES OF AMERICA vol:119 issue:44 ispartof: location:United States status: published

Information fusion has become a powerful tool for challenging ap- plications such as biological prediction problems. In this paper, we apply a new information-theoretical fusion technique to HIV-1 protease cleavage site prediction, which is a problem that has been in the focus of much interest and investigation of the machine learning community recently. It poses a difficult classification task due to its high dimensional feature space and a relatively small set of available training patterns. We also apply a new set of biophysical features to this problem and present experiments with neural networks, support vector machines, and decision trees. Application of our feature set results in high recognition rates and concise decision trees, pro- ducing manageable rule sets that can guide future experiments. In particu- lar, we found a combination of neural networks and support vector machines to be beneficial for this problem.

Despite an intensive mechanization trend in German forest operations since the early 1990s, many sites restrict the efficient implementation of fully mechanized harvesting systems. Trafficability and singletree selection harvest-based silviculture, focusing on high stem volume broadleaves, such as European beech, are the main limitations. Thus, motor-manual operations are still prevalent but need to be adapted to stay efficient and improve safety in a changing work environment. Recent developments of new felling techniques and aiding tools and advances in training and work organization improved occupational health and safety. Also, these achievements help to avoid log devaluation due to felling damages. The general digitalization trend did not ignore motor-manual operations either. Smartphone applications can already contribute to more efficient bucking, operation planning and fleet management. Yet, motor-manual operations will remain cost-intensive, and expose worker directly to occupational hazards. Therefore, operations should take as much advantage of mechanized systems as possible for feasible and applicable silvicultural objectives.

Sowohl die intraepitheliale Neoplasie der anogenitalen Region als auch das Plattenepithelkarzinom der Vulva (VSCC) sind immer noch seltene Erkrankungen, wenngleich innerhalb der letzten Jahrzehnte ein kontinuierlicher Anstieg der Inzidenz sowohl der vulvaren intraepithelialen Neoplasien (VIN) als auch des VSCC beobachtet werden konnte. Rund 85 % aller VIN-Lasionen und ca. 40 % aller VSCC weisen eine Assoziation mit „high-risk“ humanen Papillomviren (HPV) auf und konnten damit potenziell durch eine prophylaktische HPV-Impfung verhindert werden. Die Standardtherapie der VIN ist nach wie vor operativer Natur und erfolgt bis auf wenige Ausnahmen idealerweise mittels CO2-Laser im Sinne einer Vaporisation. Die topische Therapie mit Imiquimod gewinnt aufgrund ihrer Effektivitat aber zunehmend an Stellenwert. Bezuglich des VSCC wird ein stadienadaptiertes Behandlungskonzept verfolgt: Wahrend im Fruhstadium die Therapie im Sinne einer radikalen lokalen Exzision und einem chirurgischen Lymphknoten-Staging weitestgehend standardisiert und sehr effektiv ist, werden im fortgeschrittenen Stadium sowohl radikale chirurgische Eingriffe als auch eine primare Radio(chemo)therapie, eine (neo)adjuvante Radio(chemo)therapie oder eine (zumeist palliativ intendierte) alleinige Chemotherapie in Betracht gezogen. Nach Abschluss der Therapie sowohl einer VIN als auch eines VSCC wird eine lebenslange Nachsorge empfohlen, um rezidivierende Dysplasien oder Karzinome der Anogenitalregion fruhzeitig zu detektieren und zu therapieren. Etwa 25 % aller Rezidive treten erst nach 5 Jahren auf, sodass die Nachsorge uber die 5‑Jahres-Intervalle hinaus angeraten wird.

The US Military Joint Trauma System has been developed to mitigate the harsh conditions under which medical providers care for combat casualties and provide continuity of care from the battlefield to US medical centers. We review the components of this system with emphasis on combat trauma care under fire and the role of the anesthesiologist and intensivist in this continuum of care. An important link in the chain of survival is the Air Force Critical Care Aeromedical Transport Team, which provides critical care while transporting casualties from the theater to higher levels of care outside the war zone and home.

High blood pressure (BP) based on measurements obtained in the office setting has been associated with the presence and level of coronary artery calcification (CAC)—a measure of subclinical atherosclerosis. We studied the association between out-of-office BP and CAC among 557 participants who underwent 24-hour ambulatory BP monitoring at visit 1 in 2000–2004 and a computed tomography scan at visit 2 in 2005–2008 as part of the JHS (Jackson Heart Study)—a community-based cohort of African American adults. Mean awake, asleep, and 24-hour BP were calculated for each participant. Among participants included in this analysis, 279 (50%) had any CAC defined by an Agatston score >0. After multivariable adjustment including office systolic BP (SBP), the prevalence ratios for any CAC comparing the highest versus the lowest quartiles of SBP on ambulatory BP monitoring were 1.08 (95% CI, 0.84–1.39) for awake SBP, 1.32 (95% CI, 1.01–1.74) for asleep SBP, and 1.19 (95% CI, 0.91–1.55) for 24-hour SBP. After multivariable adjustment including office diastolic BP, the prevalence ratios for any CAC comparing the highest versus the lowest quartiles of awake, asleep, and 24-hour diastolic BP were 1.27 (95% CI, 1.02–1.59), 1.29 (95% CI, 1.02–1.64), and 1.25 (95% CI, 0.99–1.59), respectively. The current results suggest that higher asleep SBP and higher awake and asleep diastolic BP may be risk factors for subclinical atherosclerosis and underscore the potential role of ambulatory BP monitoring in identifying individuals at high risk for coronary artery disease.

Given the role of comorbid conditions in the pathophysiology of HFpEF, we aimed to identify and rank the importance of comorbid conditions associated with post-hospitalization outcomes of older adults hospitalized for HFpEF. We examined data from 4605 Medicare beneficiaries hospitalized in 2007–2014 for HFpEF based on ICD-9-CM codes for acute diastolic heart failure (428.31 or 428.33). To identify characteristics with high importance for prediction of mortality, all-cause rehospitalization, rehospitalization for heart failure, and composite outcome of mortality or all-cause rehospitalization up to 1 year, we developed boosted decision tree ensembles for each outcome, separately. For interpretability, we estimated hazard ratios (HRs) and 95% confidence intervals (CI) using Cox proportional hazards models. Age and frailty were the most important characteristics for prediction of mortality. Frailty was the most important characteristic for prediction of rehospitalization, rehospitalization for heart failure, and the composite outcome of mortality or all-cause rehospitalization. In Cox proportional hazards models, a 1-SD higher frailty score (0.1 on theoretical range of 0–1) was associated with a HR of 1.27 (1.06–1.52) for mortality, 1.16 (1.07–1.25) for all-cause rehospitalization, 1.24 (1.14–1.35) for HF rehospitalization, and 1.15 (1.07–1.25) for the composite outcome of mortality or all-cause rehospitalization. In conclusion, frailty is an important predictor of mortality and rehospitalization in adults aged [Formula: see text] 66 years with HFpEF.

Purpose A high expression of fibroblast activation protein (FAP) was observed in multiple sarcomas, indicating an enormous potential for PET/CT using 68Ga-radiolabeled inhibitors of FAP (FAPI). Therefore, this retrospective study aimed to evaluate the role of the novel hybrid imaging probe for sarcomas as a first clinical evaluation. Methods A cohort of 15 patients underwent 68Ga-FAPI-PET/CT for staging or restaging. The acquisition of PET scans was performed 60 min after administration of 127 to 308 MBq of the tracer. The uptake of 68Ga-FAPI in malignant tissue as well as in healthy organs was quantified by standardized uptake values SUVmean and SUVmax. Results Excellent tumor-to-background ratios (> 7) could be achieved due to low background activity and high SUVmax in primary tumors (median 7.16), local relapses (median 11.47), and metastases (median 6.29). The highest uptake was found for liposarcomas and high-grade disease (range 18.86–33.61). A high SUVmax (> 10) was observed for clinically more aggressive disease. Conclusion These preliminary findings suggest a high potential for the clinical use of 68Ga-FAPI-PET/CT for patients diagnosed with sarcoma.

Previous scholarship on Virginia Woolf’s classicism has acknowledged her debt to Vergil primarily in the context of the Eclogues or Georgics, and her debt to classical epic as a genre rarely and sparsely. Tremper (1992) and Tudeau-Clayton (2006) have both suggested a reading of “The Lighthouse,” the third part of To the Lighthouse, as an example of modernist epic. This paper, conversely, proposes that the novel in its entirety functions as a satirical critique of epic, specifically of Vergil’s Aeneid, with the goal of demonstrating the pitfalls of epic ideology as it impacted English society during the First World War.

Background: Orbital floor fractures constitute roughly 20% of all pediatric facial fractures. Reconstructive techniques are broadly subdivided into alloplastic and autologous. While pediatric literature exists for alloplastic orbital reconstruction, autologous orbital reconstruction studies are limited. Here we present several cases of posttraumatic pediatric orbital reconstruction utilizing autologous split rib graft. Methods: After IRB approval, a retrospective chart review was conducted at Monroe Carell Jr. Children’s Hospital at Vanderbilt from 2003 to 2019. A review of relevant published literature was also performed. Results: From 2003 to 2019, 5 pediatric patients underwent orbital reconstruction with split rib graft. Of the 5 patients, 3 were female and 2 were male with an age range of 4 to 8 years old (mean 4.8). Two patients had isolated orbital blow-out fractures while 3 presented with concurrent midfacial fractures. In each patient, the orbit was reconstructed by contoured split rib corticocancellous graft. Average length of stay was 5.2 days. There were no postoperative pneumothoraces. Mean follow-up length was 18.7 months, with no rib donor site complications. Each patient had adequate orbital volume restoration with no postoperative globe malposition or persistent diplopia. Conclusion: Pediatric orbital fractures are complex and challenging injuries. While alloplastic reconstruction is common and reliable, the risks of foreign body implantation and fixation must be carefully considered in patients who have not yet reached skeletal maturity. This is especially pertinent in younger patients as orbital growth continues until approximately 9 years of age. Rib graft use for adult orbital reconstruction has been explored. Data in the pediatric literature has not been identified. Corticocancellous rib graft harvest mandates a second surgical site; however, it is relatively inconspicuous with low postoperative morbidity. Corticocancellous rib grafting is a safe and durable option for orbital reconstruction and should be considered for use in the pediatric patient with a growing facial skeleton.

Purpose Prognostication of refractory out-of-hospital cardiac arrest (OHCA) is essential for selecting the population that may benefit from extracorporeal cardiopulmonary resuscitation (ECPR). We aimed to examine the prognostic value of signs of life before or throughout conventional CPR for individuals undergoing ECPR for refractory OHCA. Methods Pooling the original data from three cohort studies, we estimated the prevalence of signs of life, for individuals with refractory OHCA resuscitated with ECPR. We performed multivariable logistic regression to examine the independent associations between the occurrence of signs of life and 30-day survival with a CPC score ≤ 2. Results The analytical sample consisted of 434 ECPR recipients. The prevalence of any sign of life was 61%, including pupillary light reaction (48%), gasping (32%), or increased level of consciousness (13%). Thirty-day survival with favorable neurological outcome was 15% (63/434). In multivariable analysis, the adjusted odds ratios of 30-day survival with favorable neurological outcome were 7.35 (95% confidence interval [CI], 2.71–19.97), 5.86 (95% CI, 2.28–15.06), 4.79 (95% CI, 2.16–10.63), and 1.75 (95% CI, 0.95–3.21) for any sign of life, pupillary light reaction, increased level of consciousness, and gasping, respectively. Conclusion The assessment of signs of life before or throughout CPR substantially improves the accuracy of a multivariable prognostic model in predicting 30-day survival with favorable neurological outcome. The lack of any sign of life might obviate the provision of ECPR for patients without shockable cardiac rhythm.

Objective To report and compare presentation and management of Fournier's Gangrene (FG) in female vs male patients at a single tertiary care center. Methods Patient demographics, clinical characteristics, treatments and outcomes were summarized and compared between males and females who were treated for FG from 2011 to 2018 at a single institution. Results Of the 143 patients treated for FG at our institution, 33 (23%) were female. Female patients were predominantly white (82%), with a median (IQR) age of 55 (46, 59). Median female boby mass index (BMI) was 42.1 (32, 50.4). Female patients’ wound cultures were polymicrobial mix of gram positive and gram negative organisms. Median number of debridements for females was 2 ( 1 , 3 ). The most common anatomic region of gangrene involvement in females was labia (76%) followed by perineum (55%) and gluteus/buttocks (42%). Mortality rate during initial admission was 6% for females. Female patients had a higher median BMI than males (42.1 vs 33.7 respectively; P = .003). FG severity index, length of hospital stay, number of debridements, and wound cultures were comparable to males. The surgical team managing initial debridements differed with females managed primarily by general surgery and males primarily by urology. Mortality rate was comparable to men (6% vs 7%, P >.05). Conclusion Female patients with FG have greater BMI but similar clinical presentation, microbiologic characteristics and mortality rate compared to men. Urologists have little involvement during initial management for females at our institution.

Although mean blood pressure (BP) increases with age, there may be a subset of individuals whose BP does not increase with age. Characterizing the population that maintains normal BP could inform hypertension prevention efforts. We determined the proportion of Jackson Heart Study participants that maintained normal BP at 3 visits over a median of 8 years. Normal BP was defined as systolic BP