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Objective: To describe the prescription of hydrocodone-containing products (HCPs) and codeine-containing products (CCPs) by patient and provider race and ethnicity at two pediatric emergency departments (EDs) before and after the US Drug Enforcement Administration (DEA) rescheduling of HCPs in 2014. Design and setting: The authors performed a secondary analysis of data describing the prescription of HCPs and CCPs for 6 months before and after the DEA rescheduling of HCPs in two academic, urban pediatric EDs. Patients, participants: The authors included all children for whom race and ethnicity data were available and who were prescribed HCPs or CCPs at the time of discharge from the ED during a 12-month period (n = 1,246). The authors sent a three-question survey soliciting name, race, and ethnicity to all providers who prescribed an HCP or a CCP during the study period. Main outcome measures: Chi-square comparisons were made between the number of HCP and CCP prescriptions for primary ED diagnosis and patient ethnicity or race. The number of HCP and CCP prescriptions before and after the DEA rescheduling were compared to patient and provider race and ethnicity using the Breslow-Day test for homogeneity. Results: There were no significant differences in the number of HCP and CCP prescriptions between the pre- and post-DEA rescheduling periods across all racial and ethnic groups. When comparing the number of HCP and CCP prescriptions to patient race, Caucasian patients (84.4 percent) were prescribed more HCPs and CCPs than African Americans (15.6 percent) for abdominal pain (p value = 0.02). Non-Hispanic providers prescribed CCPs more often (n = 38, 55.2 percent) than Hispanic providers (n = 0, 0.0 percent) after DEA rescheduling (Breslow-Day p value = 0.01). Providers of all races wrote similar numbers of HCP and CCP prescriptions before and after the DEA rescheduling (Breslow-Day p value = 0.99). Conclusions: Pediatric patients of all races and ethnicities received fewer HCP prescriptions after the 2014 DEA rescheduling of HCPs. However, Caucasian patients were prescribed HCPs and CCPs for abdominal pain more frequently than African American patients. There were no significant differences in the number of prescriptions of HCPs and CCPs by provider race.

Purpose Few guidelines exist regarding the selection of a particular type or size of tracheostomy tube. Although nonstandard tubes can be placed over the percutaneous kit dilator, clinicians often place standard tracheostomy tubes and change to nonstandard tubes only after problems arise. This practice risks early tracheostomy tube change, possible bleeding, or loss of the airway. We sought to identify predictors of nonstandard tracheostomy tubes. Materials and methods In this matched case-control study at an urban, academic, tertiary care medical center, we reviewed 1220 records of patients who received a tracheostomy. Seventy-seven patients received nonstandard tracheostomy tubes (cases), and 154 received standard tracheostomy tubes (controls). Results Sex, endotracheal tube size, severity of illness, and computed tomography scan measurement of the distance from the trachea to the skin at the level of the superior aspect of the anterior clavicle were significant predictors of nonstandard tracheostomy tubes. Specifically, trachea-to-skin distance > 4.4 cm and endotracheal tube sizes ≥ 8.0 were associated with nonstandard tracheostomy. Conclusions The findings suggest that clinicians should consider using nonstandard tracheostomy tubes as the first choice if the patient is male with an endotracheal tube size ≥ 8.0 and has a trachea-to-skin distance > 4.4 cm on the computed tomography scan.

Bronchogenic cysts are congenital malformations of the tracheobronchial tree. We describe a 20-month-old male who presented with persistent non-bilious emesis; manometry and imaging were consistent with esophageal achalasia. During a planned laparoscopic Heller myotomy, an intramural bronchogenic cyst was discovered in the anterior esophagus at the level of the gastroesophageal junction and successfully resected with resolution of his symptoms.

Vehicle-to-grid (V2G) technology utilizes the batteries of electric vehicles (EV) to provide services to the electric power grid. One use of V2G technology is demand charge management, which applies bidirectional DC fast chargers to deploy stored electricity from EV batteries to a site during periods of maximum power usage. Satisfying a portion of electricity demand of a building or system using EV batteries can incrementally reduce the need for power distribution infrastructure, and can provide value to building and facilities managers by reducing utility bills. This paper develops a protocol to evaluate the installation of advanced charging stations at various locations based upon factors such as duty cycles, fleet locations, and the potential for generating revenue from demand charge management. The revenue relies partly on the development of a predictive algorithm used to forecast electricity demand with a specified lead time that can enable the V2G operator to communicate with the vehicles and signal them to charge and discharge in order to mitigate peak demand incidents. The combined energy storage capacity and power output of EV fleet batteries placed behind the meter will be able to decrease the net energy supplied by the grid, thereby reducing load at the meter. The effort has suggested how demand charge management can be a viable energy storage service performed by batteries of electric vehicles with appropriate communications and systems integration. The paper builds on previous work which monetized the relatively small effects of frequency regulation on battery life cycles and simulated the duty cycle of a typical EV in a fleet to evaluate the additional value electric vehicles can provide to the electricity generation market. Based on the above results, several needs for future research are identified and prioritized.

Copyright © Taylor & Francis Group, LLC. Sexual communication is a principal means of transmitting sexual values, expectations, and knowledge from parents to their children and adolescents. Many parents seek information and guidance to support talking with their children about sex and sexuality. Parent education materials can deliver this guidance but must use appropriate readability levels to facilitate comprehension and motivation. This study appraised the readability of educational materials to support parent sexual communication with their children. Fifty brochures, pamphlets, and booklets were analyzed using the Flesch-Kincaid, Gunning Fog, and Simple Measure of Gobbledygook (SMOG) index methods. Mean readability grade-level scores were 8.3 (range = 4.5–12.8), 9.7 (range = 5.5–14.9), and 10.1 (range = 6.7–13.9), respectively. Informed by National Institutes of Health–recommended 6th to 7th grade levels and American Medical Association–recommended 5th to 6th grade levels, percentages falling at or below the 7.0 grade level were calculated as 38%, 12%, and 2% and those falling at or below the 6.0 grade level were calculated as 12%, 2%, and 0% based on the Flesch-Kincaid, Gunning Fog, and SMOG methods, respectively. These analyses indicate that the majority of educational materials available online to support parents’ communication with their children about sex and sexuality do not meet the needs of many or most parents. Efforts to improve the accessibility of these materials are warranted.

Object The object of this study was to evaluate surgical outcome in a select group of patients with medically refractory epilepsy who had undergone corpus callosotomy combined with bilateral subdural electroencephalography (EEG) electrode placement as the initial step in multistage epilepsy surgery. Methods A retrospective chart review of 18 children (ages 3.5–18 years) with medically refractory symptomatic generalized or localization-related epilepsy was undertaken. A corpus callosotomy with subdural bihemispheric EEG electrode placement was performed as the initial step in multistage epilepsy surgery. All of the patients had tonic and atonic seizures; 6 patients also experienced complex partial seizures. All of the patients had frequent generalized epileptiform discharges as well as multifocal independent epileptiform discharges on surface EEG monitoring. Most of the patients (94%) had either normal (44%) MR imaging studies of the brain or bihemispheric abnormalities (50%). One patient had a suspected unilateral lesion (prominent sylvian fissure). Results Of the 18 patients who underwent corpus callosotomy and placement of subdural strips and grids, 12 progressed to further resection based on localizing data obtained during invasive EEG monitoring. The mean patient age was 10.9 years. The duration of invasive monitoring ranged from 3 to 14 days, and the follow-up ranged from 6 to 70 months (mean 35 months). Six (50%) of the 12 patients who had undergone resection had an excellent outcome (Engel Class I or II). There were no permanent neurological deficits or deaths. Conclusions The addition of invasive monitoring for patients undergoing corpus callosotomy for medically refractory epilepsy may lead to the localization of surgically amenable seizure foci, targeted resections, and improved seizure outcomes in a select group of patients typically believed to be candidates for palliative surgery alone.

STUDY DESIGN: Case study. OBJECTIVE: We present an unusual case of cauda equina syndrome due to a penetrating injury in which the brake caliper of a motorcycle lodged in the lumbar canal of the operator of the vehicle after a road accident and provide a review of the literature on penetrating injury to the spine. SUMMARY OF BACKGROUND DATA: While the large majority of penetrating spinal injuries are due to gunshot wounds, penetrating injury to the spine causing cauda equina syndrome is rare. METHODS: We report the case of a 42-year-old man involved in a motorcycle accident in which the brake caliper penetrated the lumbar region and entered the lumbar canal through the interlaminar space between L2 and L3. He had a complete motor and sensory deficit in the lower extremities with absent rectal tone. The patient was taken urgently to the operating room and underwent removal of the foreign object and repair of a dural laceration. He was treated with a course of intravenous antibiotics. RESULTS: The wound healed without evidence for cerebrospinal fluid leakage or infection. The patient made a good neurologic recovery, becoming ambulatory with bowel and bladder continence at 5 months following the injury. CONCLUSIONS: Surgical removal of foreign object resulted in resolution of cauda equina syndrome injury. Language: en

The web has unique potential for adolescents seeking comprehensive sexual health information. As such, it is important to understand the nature, scope, and readability of the content and messaging provided by sexuality educational websites. We conducted a content analysis of 14 sexuality education websites for adolescents, based on the 7 essential components (sexual and reproductive health and HIV, relationships, sexual rights and sexual citizenship, pleasure, violence, diversity, and gender) of the International Planned Parenthood Framework for Comprehensive Sexuality Education. A majority of content across all sites focused on sexual and reproductive health and HIV, particularly pregnancy and STI prevention, and other information about STIs and HIV. No other topic comprised more than 10% of content coverage across a majority of sites. The authors found little discussion of gender issues, sexual rights, sexual diversity, or sexual violence. Most sites provided brief references to sexual pleasure, generally moderated with cautionary words. Language used implied a heterosexual female audience. Reading levels for most sites were above the 9th-grade level, with several at the college level. These findings have implications for enhancing online sexuality education and broadening the coverage of essential topics.

A 34-year-old woman with chronic sinusitis and nasal polyps was treated with bilateral pansinusotomy. Postoperatively, she had a unilateral superior oblique paresis. We suspect that superior oblique damage occurred without involvement of the medial rectus because of inadvertent entry of the endoscopic probe through the superior lamina into the left orbit.

Reversible interactions between DNA and silica are utilized in the solid phase extraction and purification of DNA from complex samples. Chaotropic salts commonly drive DNA binding to silica, but inhibit DNA polymerase amplification. We studied DNA adsorption to silica using conditions with or without chaotropic salts through bulk depletion and Quartz Crystal Microbalance (QCM) experiments. While more DNA adsorbed to silica using chaotropic salts, certain buffer conditions without chaotropic salts yielded a similar amount of eluted DNA. QCM results indicate that under stronger adsorbing conditions, the adsorbed DNA layer is initially rigid, but becomes viscoelastic within minutes. These results qualitatively agreed with a mathematical model for a multiphasic adsorption process. Buffer conditions that do not require chaotropic salts can simplify protocols for nucleic acid sample preparation. Understanding how DNA adsorbs to silica can help optimize nucleic acid sample preparation for clinical diagnostic and research applications.

The object of this study was to evaluate surgical outcome in a select group of patients with medically refractory epilepsy who had undergone corpus callosotomy combined with bilateral subdural electroencephalography (EEG) electrode placement as the initial step in multistage epilepsy surgery.A retrospective chart review of 18 children (ages 3.5-18 years) with medically refractory symptomatic generalized or localization-related epilepsy was undertaken. A corpus callosotomy with subdural bihemispheric EEG electrode placement was performed as the initial step in multistage epilepsy surgery. All of the patients had tonic and atonic seizures; 6 patients also experienced complex partial seizures. All of the patients had frequent generalized epileptiform discharges as well as multifocal independent epileptiform discharges on surface EEG monitoring. Most of the patients (94%) had either normal (44%) MR imaging studies of the brain or bihemispheric abnormalities (50%). One patient had a suspected unilateral lesion (prominent sylvian fissure).Of the 18 patients who underwent corpus callosotomy and placement of subdural strips and grids, 12 progressed to further resection based on localizing data obtained during invasive EEG monitoring. The mean patient age was 10.9 years. The duration of invasive monitoring ranged from 3 to 14 days, and the follow-up ranged from 6 to 70 months (mean 35 months). Six (50%) of the 12 patients who had undergone resection had an excellent outcome (Engel Class I or II). There were no permanent neurological deficits or deaths.The addition of invasive monitoring for patients undergoing corpus callosotomy for medically refractory epilepsy may lead to the localization of surgically amenable seizure foci, targeted resections, and improved seizure outcomes in a select group of patients typically believed to be candidates for palliative surgery alone.

PURPOSE To study the circadian (24-hour) change in intracranial pressure (ICP) in conscious, freely moving rats and to project the circadian change in translaminar pressure difference. METHODS Telemetric pressure transmitters were implanted to monitor ICP in the lateral ventricle in nine light-dark-entrained Sprague-Dawley rats. ICP and locomotor activity data were collected. The mean results for the 12-hour light period and the 12-hour dark period were compared. The light-dark change in ICP was also determined in six rats under an acute 24-hour constant dark condition. The circadian translaminar pressure difference was projected based on the ICP data and the previously established circadian pattern of intraocular pressure (IOP). RESULTS Under the standard light-dark condition, the hourly average ICP was relatively constant (7.47-10.90 mm Hg). The light-dark ICP difference was -0.11 ± 1.45 mm Hg (mean ± SD, P = 0.823), whereas the locomotor activity was significantly higher during the dark period (P < 0.01). Under the acute constant dark condition, the subjective light-dark ICP difference remained small. Compared with a significant light-dark IOP elevation of 5.15 ± 4.47 mm Hg (P = 0.037) in rats housed under the same laboratory conditions, the light-dark ICP variation was considered minimal. The translaminar pressure difference was projected to be 5.26 mm Hg higher in the dark period (mean, 17.10 mm Hg) than in the light period (mean 11.84 mm Hg). CONCLUSIONS There is no significant circadian ICP variation in Sprague-Dawley rats. The translaminar pressure difference is projected to be higher during the dark period because of the change in IOP.

Thalamic deep brain stimulation (DBS) is proven therapy for essential tremor, Parkinson's disease and Tourette's syndrome. We tested the hypothesis that high-frequency electrical stimulation results in local thalamic glutamate release. Enzyme-linked glutamate amperometric biosensors were implanted in anesthetized rat thalamus adjacent to the stimulating electrode. Electrical stimulation was delivered to investigate the effect of frequency, pulse width, voltage-controlled or current-controlled stimulation, and charge balancing. Monophasic electrical stimulation-induced glutamate release was linearly dependent on stimulation frequency, intensity and pulse width. Prolonged stimulation evoked glutamate release to a plateau that subsequently decayed back to baseline after stimulation. Glutamate release was less pronounced with voltage-controlled stimulation and not present with charge balanced current-controlled stimulation. Using fixed potential amperometry in combination with a glutamate bioprobe and adjacent microstimulating electrode, the present study has shown that monophasic current-controlled stimulation of the thalamus in the anesthetized rat evoked linear increases in local extracellular glutamate concentrations that were dependent on stimulation duration, frequency, intensity and pulse width. However, the efficacy of monophasic voltage-controlled stimulation, in terms of evoking glutamate release in the thalamus, was substantially lower compared to monophasic current-controlled stimulation and entirely absent with biphasic (charge balanced) current-controlled stimulation. It remains to be determined whether similar glutamate release occurs with human DBS electrodes and similar charge balanced stimulation. As such, the present results indicate the importance of evaluating local neurotransmitter dynamics in studying the mechanism of action of DBS.