Search

Objectives/hypothesis: To determine whether there is a scientific basis for the routine use of contrast-enhanced computed tomography (CECT) in the evaluation of suspected deep neck infection (DNI). Study Design: We conducted a prospective, blinded comparison of clinical examination and CECT in DNI. Methods: Thirty-five consecutive patients with suspected DNI were prospectively assessed by clinical examination and CECT for the presence and extent of surgically drainable purulent collections. Before CECT a surgeon recorded clinical data and predicted the extent of infection. A head and neck neuroradiologist, blinded to the clinical evaluation, predicted the extent of infection based on CECT. Final outcome (the presence of a purulent collection) was determined at surgery or in long-term follow-up. The clinical and CECT findings were compared with the final outcome to determine the sensitivity, specificity, and accuracy of each modality. Results: Twenty patients had purulent drainable collections. The accuracy of clinical examination alone in identifying a drainable collection was 63%, the sensitivity was 55%, and the specificity was 73%. The accuracy of CECT alone was 77%, the sensitivity was 95%, and the specificity 53%. When CECT and clinical examination were combined, the accuracy in identifying a drainable collection was 89%, the sensitivity was 95%, and the specificity 80%. If fluid collections with volumes of 2 mL or greater on CECT were considered, the accuracy of CECT would have been 85%, the sensitivity 89%, and the specificity 80%. Conclusion: CECT and clinical examination are both critical components in the evaluation of suspected DNI. [ABSTRACT FROM AUTHOR]

Background: Interrupted aortic arch (IAA) is associated with left ventricular outflow tract obstruction (LVOTO) and DiGeorge syndrome. High-risk infantile surgery is required to address IAA, with limited data available on long-term outcomes. We used the Pediatric Cardiac Care Consortium, a multicenter US-based registry for pediatric cardiac interventions, to assess long-term outcomes after IAA repair by patient characteristics and surgical approach., Methods: This is a retrospective cohort study of patients undergoing IAA repair between 1982 and 2003. Kaplan-Meier plots and Cox proportional hazards regression were used to examine associations with postdischarge deaths tracked by matching with the US National Death Index., Results: Of 390 patients meeting inclusion criteria, 309 (79.2%) survived to discharge. During a median follow-up of 23.6 years, 30-year survival reached 80.7% for patients surviving hospital discharge after initial IAA repair. Adjusted analysis revealed higher risk of death for type B vs type A (adjusted hazard ratio [aHR], 3.32; 95% CI, 1.48-7.44), staged repair (aHR, 2.50; 95% CI, 1.14-5.50), and LVOTO interventions during initial hospitalization (aHR, 4.12; 95% CI, 1.83-9.27) but not for LVOTO without need for interventions or presence of DiGeorge syndrome. There was a trend toward improved in-hospital and long-term survival over time during the study period., Conclusions: Staged repair, type B IAA, and need for LVOTO intervention during initial hospitalization for repair are associated with high risk of death out to 30 years. Survival outcomes are improving, but further efforts need to minimize staged approach and risks associated with LVOTO relief procedures., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Aquaporin-1 (Aqp1), a water channel, has garnered significant interest for cell-based medicine and in vivo synthetic biology due to its ability to be genetically encoded to produce magnetic resonance signals by increasing the rate of water diffusion in cells. However, concerns regarding the effects of Aqp1 overexpression and increased membrane diffusivity on cell physiology have limited its widespread use as a deep-tissue reporter. In this study, we present evidence that Aqp1 generates strong diffusion-based magnetic resonance signals without adversely affecting cell viability or morphology in diverse cell lines derived from mice and humans. Our findings indicate that Aqp1 overexpression does not induce ER stress, which is frequently associated with heterologous expression of membrane proteins. Furthermore, we observed that Aqp1 expression had no detrimental effects on native biological activities, such as phagocytosis, immune response, insulin secretion, and tumor cell migration in the analyzed cell lines. These findings should serve to alleviate any lingering safety concerns regarding the utilization of Aqp1 as a genetic reporter and should foster its broader application as a noninvasive reporter for in vivo studies., (© 2024. The Author(s).)

Many plasma membrane receptors and ligands form nanoscale clusters on the plasma membrane surface. However, methods for directly and precisely manipulating nanoscale protein localization are limited, making understanding the effects of this clustering difficult. DNA origami allows precise control over nanoscale protein localization with high fidelity and adaptability. Here, we describe how we have used this technique to study how nanoscale protein clustering affects phagocytosis. We provide protocols for conjugating DNA origami structures to supported lipid bilayer-coated beads to assay phagocytosis and planar glass coverslips for TIRF microscopy. The core aspects of this protocol can be translated to study other immune signaling pathways and should enable the implementation of previously inaccessible investigations., (© 2023. The Author(s), under exclusive license to Springer Science+Business Media, LLC, part of Springer Nature.)

Pleural effusions are a common complication of orthotopic liver transplantation (OLT), and chronic post-OLT pleural effusions have been associated with worse outcomes. Furthermore, "trapped lung" (TL), defined as a restrictive fibrous visceral pleural peel preventing lung re-expansion, may have prognostic significance. We performed a retrospective analysis of adult OLT recipients over a 9-year period at UCLA Medical Center. Post-OLT patients with persistent pleural effusions, defined by the presence of pleural fluid requiring drainage one to 12 months after OLT, were included for analysis. Outcomes for patients with and without TL were compared using univariate and multivariate analysis. Of the 1722 patients who underwent OLT, 117 (7%) patients met our criteria for persistent postoperative pleural effusion, and the incidence of TL was 21.4% (25/117). Compared to patients without TL, those with TL required more surgical pleural procedures (OR 59.8, 95%CI 19.7-181.4, p < 0.001), spent more days in the hospital (IRR 1.56, 95%CI 1.09-2.23, p = 0.015), and had a higher risk of mortality (HR 2.47, 95%CI 1.59-3.82, p < 0.001) following transplant. In sum, we found that post-OLT TL was associated with higher morbidity, mortality, and healthcare utilization. Future prospective investigation is warranted to further clarify the risk factors for developing postoperative pleural effusions and TL., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Cuk, Melamed, Vangala, Salah, Miller, Swanson, Dai, Antongiorgi, Wang, Agopian, Dinorcia, Farmer, Yanagawa, Kaldas and Barjaktarevic.)

Rationale: Crisis standards of care (CSCs) guide critical care resource allocation during crises. Most recommend ranking patients on the basis of their expected in-hospital mortality using the Sequential Organ Failure Assessment (SOFA) score, but it is unknown how SOFA or other acuity scores perform among patients of different races. Objectives: To test the prognostic accuracy of the SOFA score and version 2 of the Laboratory-based Acute Physiology Score (LAPS2) among Black and white patients. Methods: We included Black and white patients admitted for sepsis or acute respiratory failure at 27 hospitals. We calculated the discrimination and calibration for in-hospital mortality of SOFA, LAPS2, and modified versions of each, including categorical SOFA groups recommended in a popular CSC and a SOFA score without creatinine to reduce the influence of race. Measurements and Main Results: Of 113,158 patients, 27,644 (24.4%) identified as Black. The LAPS2 demonstrated higher discrimination (area under the receiver operating characteristic curve [AUC], 0.76; 95% confidence interval [CI], 0.76-0.77) than the SOFA score (AUC, 0.68; 95% CI, 0.68-0.69). The LAPS2 was also better calibrated than the SOFA score, but both underestimated in-hospital mortality for white patients and overestimated in-hospital mortality for Black patients. Thus, in a simulation using observed mortality, 81.6% of Black patients were included in lower-priority CSC categories, and 9.4% of all Black patients were erroneously excluded from receiving the highest prioritization. The SOFA score without creatinine reduced racial miscalibration. Conclusions: Using SOFA in CSCs may lead to racial disparities in resource allocation. More equitable mortality prediction scores are needed.

Sepsis has been characterized as a dysregulated host response to infection, and the role of the microbiome as a key influencer of this response is emerging. Disruption of the microbiome while treating sepsis with antibiotics can itself result in immune dysregulation. Alterations in the gut microbiome resulting from sepsis and its treatment have been implicated in organ dysfunction typical of sepsis across multiple tissues including the lung, kidney, and brain. Multiple microbiota-directed interventions are currently under investigation in the setting of sepsis, including fecal transplant, the administration of dietary fiber, and the use of antibiotic scavengers that attenuate the effects of antibiotics on the gut microbiota while allowing them to concentrate at the primary sites of infection. The emerging evidence shows that the gut microbiome interacts with various elements of the septic response, and provides yet another reason to consider the judicious use of antibiotics via antibiotic stewardship programs., (© The Author(s) 2021. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Importance: Crisis Standards of Care (CSC) are guidelines for rationing health care resources during public health emergencies. The CSC adopted by US states ration intensive care unit (ICU) admission using the Sequential Organ Failure Assessment (SOFA) score, which is used to compare expected in-hospital mortality among eligible patients. However, it is unknown if Black and White patients with equivalent SOFA scores have equivalent in-hospital mortality., Objective: To investigate whether reliance on SOFA is associated with bias against Black patients in CSC., Design, Setting, and Participants: This cohort study was conducted using data from the eICU Collaborative Research Database of patients admitted to 233 US ICUs in 2014 to 2015. Included individuals were Black and White adult patients in the ICU, who were followed up to hospital discharge. Data were analyzed from May 2020 through April 2021., Exposure: SOFA scores at ICU admission., Main Outcomes and Measures: Hierarchical logistic regression with hospital fixed effects was used to measure the interaction between race and SOFA as a factor associated with in-hospital mortality, as well as the odds of death among Black and White patients with equivalent priority for resource allocation according to the SOFA-based ranking rules of 3 statewide CSC (denoted A, B, and C) under shortage conditions that were severe (ie, only patients with the highest priority would be eligible for allocation), intermediate (ie, patients in the highest 2 tiers would be eligible for allocation), or low (ie, only patients with the lowest priority would be at risk of exclusion)., Results: Among 111 885 ICU encounters representing 95 549 patients, there were 16 688 encounters with Black patients (14.9%) and 51 464 (46.0%) encounters with women and the mean (SD) age was 63.3 (16.9) years. The median (interquartile range) SOFA score was not statistically significantly different between Black and White patients (4 [2-6] for both groups; P = .19), but mortality was lower among Black individuals compared with White individuals with equivalent SOFA scores (odds ratio [OR], 0.98; 95% CI, 0.97-0.99; P < .001). This was associated with lower mortality among Black patients compared with White patients prioritized for resource allocation in 3 CSC under shortage conditions that were severe (system A: OR, 0.65; 95% CI, 0.58-0.74; P < .001; system B: OR, 0.70; 95% CI, 0.64-0.78; P < .001; system C: OR, 0.73; 95% CI, 0.67-0.80; P < .001), intermediate (system A: OR, 0.73; 95% CI, 0.67-0.80; P < .001; system B: OR, 0.83; 95% CI, 0.77-0.89; P < .001; system C: OR, 0.82; 95% CI, 0.77-0.89; P < .001), and low (system A: OR, 0.83; 95% CI, 0.77-0.89; P < .001; system C: OR, 0.86; 95% CI, 0.81-0.92; P < .001; not applicable for system B, which had fewer tiers). When SOFA-based ranking rules were adjusted for Black patients to simulate equitable allocation based on observed mortality, the proportion upgraded to higher priority ranged from 379 Black patient encounters (2.3%) in low shortage conditions to 2601 Black patient encounters (15.6%) in severe shortage conditions., Conclusions and Relevance: This study found that SOFA scores were associated with overestimated mortality among Black patients compared with White patients, and this was associated with a structural disadvantage for Black patients in CSC allocation systems. These findings suggest that guidelines should be revised to correct this inequity and alternative methods should be developed for more equitable triage.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is currently causing a global pandemic. The antigen specificity of the antibody response mounted against this novel virus is not understood in detail. Here, we report that subjects with a more severe SARS-CoV-2 infection exhibit a larger antibody response against the spike and nucleocapsid protein and epitope spreading to subdominant viral antigens, such as open reading frame 8 and nonstructural proteins. Subjects with a greater antibody response mounted a larger memory B cell response against the spike, but not the nucleocapsid protein. Additionally, we revealed that antibodies against the spike are still capable of binding the D614G spike mutant and cross-react with the SARS-CoV-1 receptor binding domain. Together, this study reveals that subjects with a more severe SARS-CoV-2 infection exhibit a greater overall antibody response to the spike and nucleocapsid protein and a larger memory B cell response against the spike. IMPORTANCE With the ongoing pandemic, it is critical to understand how natural immunity against SARS-CoV-2 and COVID-19 develops. We have identified that subjects with more severe COVID-19 disease mount a more robust and neutralizing antibody response against SARS-CoV-2 spike protein. Subjects who mounted a larger response against the spike also mounted antibody responses against other viral antigens, including the nucleocapsid protein and ORF8. Additionally, this study reveals that subjects with more severe disease mount a larger memory B cell response against the spike. These data suggest that subjects with more severe COVID-19 disease are likely better protected from reinfection with SARS-CoV-2., (Copyright © 2021 Guthmiller et al.)

Importance: During the coronavirus disease 2019 pandemic, there may be too few ventilators to meet medical demands. It is unknown how many US states have ventilator allocation guidelines and how these state guidelines compare with one another., Objective: To evaluate the number of publicly available US state guidelines for ventilator allocation and the variation in state recommendations for how ventilator allocation decisions should occur and to assess whether unique criteria exist for pediatric patients., Evidence Review: This systematic review evaluated publicly available guidelines about ventilator allocation for all states in the US and in the District of Columbia using department of health websites for each state and internet searches. Documents with any discussion of a process to triage mechanical ventilatory support during a public health emergency were screened for inclusion. Articles were excluded if they did not include specific ventilator allocation recommendations, were in draft status, did not include their state department of health, or were not the most up-to-date guideline. All documents were individually assessed and reassessed by 2 independent reviewers from March 30 to April 2 and May 8 to 10, 2020., Findings: As of May 10, 2020, 26 states had publicly available ventilator guidelines, and 14 states had pediatric guidelines. Use of the Sequential Organ Failure Assessment score in the initial rank of adult patients was recommended in 15 state guidelines (58%), and assessment of limited life expectancy from underlying conditions or comorbidities was included in 6 state guidelines (23%). Priority was recommended for specific groups in the initial evaluation of patients in 6 states (23%) (ie, Illinois, Maryland, Massachusetts, Michigan, Pennsylvania, and Utah). Many states recommended exclusion criteria in adult (11 of 26 states [42%]) and pediatric (10 of 14 states [71%]) ventilator allocation. Withdrawal of mechanical ventilation from a patient to give to another if a shortage occurs was discussed in 22 of 26 adult guidelines (85%) and 9 of 14 pediatric guidelines (64%)., Conclusions and Relevance: These findings suggest that although allocation guidelines for mechanical ventilatory support are essential in a public health emergency, only 26 US states provided public guidance on how this allocation should occur. Guidelines among states, including adjacent states, varied significantly and could cause inequity in the allocation of mechanical ventilatory support during a public health emergency, such as the coronavirus disease 2019 pandemic.

Coincident climatic and human effects strongly influence water-quality properties in estuarine-coastal ecosystems around the world. Time-series data for a number of ecosystems reveal high spatio-temporal variability superimposed on secular trends traceable to nutrient over-enrichment. In this paper, we present new analyses of long-term data for Chesapeake Bay directed at several goals: (1) to distinguish trends from spatio-temporal variability imposed by climatic effects; (2) to assess long-term trends of water-quality properties reflecting degradation and recovery; (3) to propose numerical water-quality criteria as targets for restoration; (4) to assess progress toward attainment of these targets. The bay has experienced multiple impairments associated with nutrient over-enrichment since World War II, e.g., low dissolved oxygen (DO), decreased water clarity, and harmful algal blooms (HAB). Anthropogenic eutrophication has been expressed as increased chlorophyll-a (chl-a) driven by accelerated nutrient loading from 1945 to 1980. Management intervention led to decreased loading thereafter, but deleterious symptoms of excess nutrients persist. Climatic effects exemplified by irregular "dry" and "wet" periods in the last 30+ years largely explain high inter-annual variability of water-quality properties, requiring adjustments to resolve long-term trends. Here, we extend these analyses at a finer temporal scale to six decades of chl-a, Secchi depth, and nitrite plus nitrate (NO 2  + NO 3 ) data to support trend analyses and the development of numerical water-quality criteria. The proposed criteria build on a conceptual model emphasizing the need to distinguish climatic and human effects in gauging progress to reverse eutrophication in estuarine-coastal ecosystems.

Objective: We sought to determine if any histopathologic component of the pulmonary microcirculation can distinguish systemic sclerosis (SSc)-related pulmonary fibrosis (PF) with and without pulmonary hypertension (PH)., Methods: Two pulmonary pathologists blindly evaluated 360 histologic slides from lungs of 31 SSc-PF explants or autopsies with (n = 22) and without (n = 9) PH. The presence of abnormal small arteries, veins, and capillaries (pulmonary microcirculation) was semiquantitatively assessed in areas of preserved lung architecture. Capillary proliferation (CP) within the alveolar walls was measured by its distribution, extent (CP % involvement), and maximum number of layers (maximum CP). These measures were then evaluated to determine the strength of their association with right heart catheterization-proven PH., Results: Using consensus measures, all measures of CP were significantly associated with PH. Maximum CP had the strongest association with PH ( P = 0.013; C statistic 0.869). Maximum CP 2 or more layers and CP % involvement 10% or greater were the optimal thresholds that predicted PH, both with a sensitivity of 56% and specificity of 91%. The CP was typically multifocal rather than focal or diffuse and was associated with a background pattern of usual interstitial pneumonia. There was a significant but weaker relationship between the presence of abnormal small arteries and veins and PH., Conclusion: In the setting of advanced SSc-PF, the histopathologic feature of the pulmonary microcirculation best associated with PH was capillary proliferation in architecturally preserved lung areas., (© 2019 The Authors. ACR Open Rheumatology published by Wiley Periodicals, Inc. on behalf of American College of Rheumatology.)

Background: Significant effort has been directed at developing prediction tools to identify patients at high risk of unplanned hospital readmission, but it is unclear what these tools add to clinicians' judgment. In our study, we assess clinicians' abilities to independently predict 30-day hospital readmissions, and we compare their abilities with a common prediction tool, the LACE index., Methods: Over a period of 50 days, we asked attendings, residents, and nurses to predict the likelihood of 30-day hospital readmission on a scale of 0-100% for 359 patients discharged from a General Medicine Service. For readmitted versus non-readmitted patients, we compared the mean and standard deviation of the clinician predictions and the LACE index. We compared receiver operating characteristic (ROC) curves for clinician predictions and for the LACE index., Results: For readmitted versus non-readmitted patients, attendings predicted a risk of 48.1% versus 31.1% (p < 0.001), residents predicted 45.5% versus 34.6% (p 0.002), and nurses predicted 40.2% versus 30.6% (p 0.011), respectively. The LACE index for readmitted patients was 11.3, versus 10.1 for non-readmitted patients (p 0.003). The area under the curve (AUC) derived from the ROC curves was 0.689 for attendings, 0.641 for residents, 0.628 for nurses, and 0.620 for the LACE index. Logistic regression analysis suggested that the LACE index only added predictive value to resident predictions, but not attending or nurse predictions (p < 0.05)., Conclusions: Attendings, residents, and nurses were able to independently predict readmissions as well as the LACE index. Improvements in prediction tools are still needed to effectively predict hospital readmissions.

Variable climatic conditions strongly influence phytoplankton dynamics in estuaries globally. Our study area is Chesapeake Bay, a highly productive ecosystem providing natural resources, transportation, and recreation for nearly 16 million people inhabiting a 165,000-km(2) watershed. Since World War II, nutrient over-enrichment has led to multiple ecosystem impairments caused by increased phytoplankton biomass as chlorophyll-a (chl-a). Doubled nitrogen (N) loadings from 1945-1980 led to increased chl-a, reduced water clarity, and low dissolved oxygen (DO), while decreased N loadings from 1981-2012 suggest modest improvement. The recent 30+ years are characterized by high inter-annual variability of chl-a, coinciding with irregular dry and wet periods, complicating the detection of long-term trends. Here, we synthesize time-series data for historical and recent N loadings (TN, NO2 + NO3), chl-a, floral composition, and net primary productivity (NPP) to distinguish secular changes caused by nutrient over-enrichment from spatio-temporal variability imposed by climatic conditions. Wet years showed higher chl-a, higher diatom abundance, and increased NPP, while dry years showed lower chl-a, lower diatom abundance, and decreased NPP. Our findings support a conceptual model wherein variable climatic conditions dominate recent phytoplankton dynamics against a backdrop of nutrient over-enrichment, emphasizing the need to separate these effects to gauge progress toward improving water quality in estuaries.

In this paper, we describe the design, fabrication, calibration, and deployment of an airborne multispectral polarimetric imager. The motivation for the development of this instrument was to explore its ability to provide information about water constituents, such as particle size and type. The instrument is based on four 16 MP cameras and uses wire grid polarizers (aligned at 0°, 45°, 90°, and 135°) to provide the separation of the polarization states. A five-position filter wheel provides for four narrow-band spectral filters (435, 550, 625, and 750 nm) and one blocked position for dark-level measurements. When flown, the instrument is mounted on a programmable stage that provides control of the view angles. View angles that range to ±65° from the nadir have been used. Data processing provides a measure of the polarimetric signature as a function of both the view zenith and view azimuth angles. As a validation of our initial results, we compare our measurements, over water, with the output of a Monte Carlo code, both of which show neutral points off the principle plane. The locations of the calculated and measured neutral points are compared. The random error level in the measured degree of linear polarization (8% at 435) is shown to be better than 0.25%.

A practical method for palladium-catalyzed cyanation of aryl halides using Pd/C is described. The new method can be applied to a variety of aryl bromide and active aryl chloride substrates to effect efficient conversions. The process features many advantages over existing cyanation conditions and the practical utility of the process has been demonstrated on scale.

Context: This article reviews and updates the evidence base informing four recommendations of the Robert Wood Johnson Foundation Commission to Build a Healthier America (the commission) that address the creation of healthy, vital neighborhood and community environments., Evidence Acquisition: Reviews of published research, consultation with experts in housing, community development policy, and site visits by the commission were conducted between 2006 and 2009. The literature reviews and national statistics were updated with publications appearing through the first half of 2010., Evidence Synthesis: The physical, social, and economic environments of local communities affect residents' health and exacerbate health disparities. Public and private decision makers are increasingly recognizing the importance of investing in cross-cutting strategies to reduce exposures harmful to health and to establish conditions that support healthful daily practices. Pilot and demonstration projects that engage community members in identifying priorities and implementing interventions that improve health and quality of life show promise in terms of their overall impact and effect on health disparities., Conclusions: Consistent with the broad policy directions outlined in the commission's recommendations, an effective population health improvement strategy requires enlisting new partners among public agencies including housing, transportation, recreation, community development, and planning, and joint efforts between private sector business and voluntary organizations. Evaluation research of community-based interventions is needed to generate strong evidence of impact in order to guide policy and secure future investments in such measures., (Copyright © 2011 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Higher educational attainment is associated with better health status and longer life., Purpose: This analysis estimates the annual dollar value of the benefits that would accrue to less-educated American adults if they experienced the lower mortality rates and better health of those with a college education., Methods: Using estimates of differences in mortality among adults aged ≥ 25 years by educational attainment from the National Longitudinal Mortality Survey and of education-based differentials in health status from published studies based on the Medical Expenditure Panel Survey, combined with existing estimates of the economic value of a healthy life year, the economic value of raising the health of individuals with less than a college education to the health of the college educated is estimated., Results: The annual economic value that would accrue to disadvantaged (less-educated) Americans if their health and longevity improved to that of college-educated Americans is $1.02 trillion., Conclusions: This modeling exercise does not fully account for the social costs and benefits of particular policies and programs to reduce health disparities; rather, it provides a sense of the magnitude of the economic value lost in health disparities to compare with other social issues vying for attention. The aggregate economic gains from interventions that improve the health of disadvantaged Americans are potentially large., (Copyright © 2011 American Journal of Preventive Medicine. All rights reserved.)

Unhealthy behaviors, notably tobacco use; unhealthy diets; and inadequate physical activity are major contributors to chronic disease in the U.S. and are more prevalent among socioeconomically disadvantaged groups. Differences in the prevalence of unhealthy behaviors among communities with different physical, social, and economic resources suggest that contextual environmental factors play an important causal role. Yet health promotion interventions often are undertaken in isolation and with inadequate attention to these holistic social and economic influences on lifestyle. For example, clinicians' advice to patients to stop smoking or lose weight can help motivate people to change behaviors, but their ability to take subsequent action can benefit from coordination with community-based and public health programs that offer intensive counseling services, and from modified environmental conditions to facilitate behavior change where people live, work, learn, and play. Reshaping these environmental conditions to support healthier living is the subject of six recommendations from the Robert Wood Johnson Foundation Commission to Build a Healthier America. Changing the conditions of daily life to make them conducive to healthy behaviors--what is here called citizen-centered health promotion--requires a concerted effort by clinical, educational, business, civic and governmental partners within communities. Linkages among clinical practices and community-based programs have been demonstrated to be effective, but moving from demonstration projects to sustainable community collaborations nationwide will require a proactive effort to establish the necessary infrastructure and financing., (Copyright © 2011 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Context: The Robert Wood Johnson Foundation Commission to Build a Healthier America recommended that substantial resources be committed to ensure all children have high-quality developmental experiences through family support, child care, and early education. This article reviews and updates the evidence base informing that recommendation and explores federal and state policy challenges involved in implementing it., Evidence Acquisition: Reviews of published research, analyses of federal child health data sets, consultation with early development and state and local program experts, and site visits were conducted between 2006 and 2009, with statistics and literature reviews updated through mid-2010., Evidence Synthesis: The economic and social conditions of children's lives, especially in the early years, affect their health and development in childhood and across the life course. Forty percent of children in the U.S. live in families with incomes <200% of the federal poverty level and consequently are at higher risk of poor health and development. Recent advances in neuroscience and life course epidemiology reveal that these children are more likely to experience chronic or "toxic" stress resulting from frequent or sustained adverse experiences, increasing their lifetime risk of chronic disease. Intervening early in childhood by providing a safe, stable, nurturing, and stimulating environment can improve cognitive, emotional, and behavioral development and health outcomes in children--particularly socially and economically disadvantaged children--and both their health and social and economic well-being as adults., Conclusions: Coordination of multiple programs and funding sources, along with higher standards of accountability for services, outcomes, and ongoing evaluation of effectiveness, are needed to ensure more effective state and local programs providing early developmental support. Federal leadership and funding are needed to ensure that children at high risk for multiple adverse exposures and their families receive attention and services as early as possible., (Copyright © 2011 American Journal of Preventive Medicine. All rights reserved.)

It is demonstrated that hyperspectral imagery can be used, without atmospheric correction, to determine the presence of accessory phytoplankton pigments in coastal waters using derivative techniques. However, care must be taken not to confuse other absorptions for those caused by the presence of pigments. Atmospheric correction, usually the first step to making products from hyperspectral data, may not completely remove Fraunhofer lines and atmospheric absorption bands and these absorptions may interfere with identification of phytoplankton accessory pigments. Furthermore, the ability to resolve absorption bands depends on the spectral resolution of the spectrometer, which for a fixed spectral range also determines the number of observed bands. Based on this information, a study was undertaken to determine under what circumstances a hyperspectral sensor may determine the presence of pigments. As part of the study a hyperspectral imager was used to take high spectral resolution data over two different water masses. In order to avoid the problems associated with atmospheric correction this data was analyzed as radiance data without atmospheric correction. Here, the purpose was to identify spectral regions that might be diagnostic for photosynthetic pigments. Two well proven techniques were used to aid in absorption band recognition, the continuum removal of the spectra and the fourth derivative. The findings in this study suggest that interpretation of absorption bands in remote sensing data, whether atmospherically corrected or not, have to be carefully reviewed when they are interpreted in terms of photosynthetic pigments.

This retrospective review of children surgically treated for King Type II or IV curvature of the spine required a minimum lumbar Cobb angle of 40 degrees and a minimum lumbar inclination (the angle formed between a line through the spinous processes of the three most caudal lumbar vertebrae and a line perpendicular to the floor) of 10 degrees. Twenty children had combined anterior thoracolumbar and posterior instrumentations whereas 20 had only posterior instrumentation. Children who had combined surgery had significantly better corrections of their lumbar Cobb angles. They had a mean correction of 43.3 degrees compared with 26.7 degrees in children with posterior instrumentation only. These superior corrections of the lumbar Cobb angles did not result in significantly better improvements in the lumbar inclinations. Patients who had the combined procedures had a mean improvement of 10.1 degrees, whereas patients who had posterior instrumentation only had a mean improvement of 8.0 degrees in lumbar inclination. Instead of having superior corrections of the lumbar inclinations, the combined surgeries resulted in a significant worsening of the angle between the end plates of the last instrumented vertebra and the next most caudal end plate. In patients who had combined surgery this angle averaged 8.4 degrees, whereas in patients who had posterior instrumentation only this angle averaged 4.1 degrees.

Purpose: This report describes an episode of malignant hyperthermia (MH) in a ten year old boy receiving desflurane anaesthesia., Clinical Features: Following induction of general endotracheal anaesthesia with thiopentone and succinylcholine, desflurane was administered for maintenance of anaesthesia. Ten minutes after commencing desflurane administration, heart rate and PETCO2 increased to 165 bpm and 50 mmHg, respectively. Initially, the tachycardia was attributed to a sympathetic response secondary to desflurane. Desflurane was discontinued and isoflurane was started. Minute ventilation was increased to decrease PETCO2. Over the next five minutes, temperature increased to 38.4 degrees C as the PETCO2 increased to above 60 mmHg. Venous and arterial blood gases were drawn which showed acidosis and hypercapnia. Temperature and PETCO2 continued to increase, reaching peak values of 41 degrees C and 77 mmHg, respectively. Efforts to cool the patient were made. A total of 220 mg dantrolene sodium was administered iv. Following dantrolene, the temperature increase and acidosis subsided. Heart rate and PETCO2 decreased to 130 bpm and 36 mmHg, respectively. The surgical procedure was expeditiously performed. Postoperatively, in the Paediatric Intensive Care Unit, a dantrolene infusion of 20 mg.hr-1 was administered for 12 hr. The trachea was extubated the following morning. Several days later, the patient underwent another surgical procedure without complications using MH-safe anaesthetics., Conclusion: Onset of tachycardia in a patient receiving desflurane may initially be attributed to desflurane-induced sympathetic hyperactivity. This poses a clinical challenge in the diagnosis of MH during desflurane anaesthesia.

As a guide for how to select a new executive director, a family agency adopted the search committee process from higher education. The approach included clarifying agency goals and the director's qualifications, a board-staff screening, and interviews held jointly with public representatives before final board selection.