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BackgroundEpithelial remodeling is a histopathologic feature of chronic inflammatory airway diseases including chronic rhinosinusitis (CRS). Cell type shifts and their relationship to CRS endotypes and severity are incompletely described.ObjectiveThe purpose of this study was to understand the relationship of epithelial cell remodeling to inflammatory endotypes and disease outcomes in CRS.MethodsUsing cell type transcriptional signatures derived from epithelial single cell sequencing, we analyzed bulk RNA sequencing data from sinus epithelial brushes obtained from patients with CRS with and without nasal polyps in comparison to healthy controls.ResultsThe airway epithelium in nasal polyposis displayed increased tuft cell transcripts and decreased ciliated cell transcripts along with an IL-13 activation signature. In contrast, chronic rhinosinusitis without polyps showed an IL-17 activation signature. IL-13 activation scores were associated with increased tuft cell, goblet cell and mast cell scores and decreased ciliated cell scores. Furthermore, the IL-13 score was strongly associated with a previously reported activated (“polyp”) tuft cell score and a prostaglandin E2 (PGE2) activation signature. The Lund-McKay score, a computed tomographic metric of sinus opacification, correlated positively with activated tuft cell, mast cell, PGE2, and IL-13 and negatively with ciliated cell transcriptional signatures.ConclusionsThese results demonstrate that cell type alterations and PGE2 stimulation are key components of IL-13 induced epithelial remodeling in nasal polyposis, while IL-17 signaling is more prominent in CRS without polyps, and that clinical severity correlates with the degree of IL-13 induced epithelial remodeling.Key MessagesCell type signatures from single cell RNA sequencing, applied to bulk sequenced RNA sinus brushes, suggest increased tuft cells and mast cells and decreased ciliated cells in nasal polyp epithelium.IL-17 signaling rather than IL-13 signaling is observed in epithelium from CRSsNP.IL-13-drives epithelial remodeling and prostaglandin E2 signatures correlated with clinical measures of sinus opacification in CRS.Capsule SummaryMeasures of epithelial remodeling, including both IL-13 and PGE2 induced epithelial activation and cell type specific transcript alterations, correlate with a radiographic metric of disease severity in CRSwNP.

This is the first report specifically describing outcomes of pediatric patients who underwent cardiac catheterization while on uninterrupted anticoagulation. One hundred forty-four cardiac catheterizations were identified that met inclusion criteria at our institution from 11/2014 to 10/2019. The median age and weight of the patients were 6.3 [0.01–20.9] years and 19.3 [2.1–172.5] kg, respectively. Seventy-eight (54%) catheterizations involved inpatients. The most common cardiac diagnoses among the cohort were single ventricle (n = 41), conotruncal defects (n = 37), and structurally normal heart (n = 16). The most common indications for anticoagulation were arterial/venous thrombus (n = 45), Fontan physiology (n = 32), and mechanical valve thrombus prophylaxis (n = 27). The anticoagulation medications used were warfarin (n = 57), heparin (n = 52), enoxaparin (n = 25), fondaparinux (n = 5), rivaroxaban (n = 2), and both heparin and warfarin (n = 3). Interventions were performed in 96 cases (67%). The median length of the procedure was 122.5 [15–760] minutes, and the median time to achieve hemostasis was 18.0 [range: 5–76, IQR: 13–25] minutes. Adverse events were present in 11 cases (7.6%), and of those only 2 cases (1.4%) were bleeding-related complications. Our single-center data suggest that performing cardiac catheterization on pediatric patients while on uninterrupted anticoagulation is safe and does not substantially increase the risk of bleeding complications based on a cohort of patients that varied in age, size, diagnosis, medical complexity, and type of intervention performed. Patients on warfarin therapy for a mechanical valve are most likely to benefit from this practice, as the ability to continue warfarin therapy avoids the need for bridging and other interruption-related complications.

We performed an anonymous patient survey to find out more about patients’ perspectives on the topical treatments they use and recycling their packaging. We provide the results of our pilot study and also summarize key points for future research and development.

OBJECTIVE The middle fossa approach is an effective option for the treatment of small (Koos grade I and II) vestibular schwannomas (VSs) when the goal is hearing preservation. The authors evaluated the rates of hearing preservation and examined the factors associated with improved hearing outcomes after the middle fossa approach for VSs. METHODS In this retrospective, single-center cohort study evaluating the clinical outcomes after resection of small VSs using the middle fossa approach, consecutive adult patients (> 18 years) who underwent surgery between January 2000 and December 2021 were included. Clinical and imaging characteristics were analyzed, including baseline hearing status, duration of surgery, anesthetic parameters, and imaging characteristics of the surgically treated tumors. RESULTS Among the 131 included patients, 102 had valid and discoverable pre- and postoperative audiology assessments. The mean follow-up was 26 months (range 1–180 months). There were 85 patients with serviceable hearing preoperatively, defined as American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) class A or B, of whom 78% retained class A or B hearing at the last follow-up. Binary logistic regression demonstrated that preoperative hearing AAO-HNS class (OR 0.19, 95% CI 0.05–0.77; p = 0.02), overlap between fundus and cochlea (OR 0.32, 95% CI 0.11–0.96; p = 0.04), and duration of anesthesia (OR 0.98, 95% CI 0.97–0.99; p = 0.03) were independent predictors of hearing outcomes. Additionally, 75% of patients with high diffusion-weighted imaging signal in the tumor (p = 0.009) and 67% of patients with the tumor originating at the modiolus of the cochlea (p = 0.004) had poor hearing outcomes. CONCLUSIONS The hearing preservation rates after microsurgical resection of small VSs using the middle fossa approach are high, with 78% of patients maintaining AAO-HNS class A or B hearing. Poor hearing status at baseline, longer duration of anesthesia, and large overlap between the fundus of the internal auditory canal and the cochlea were independently associated with unfavorable hearing outcomes. Imaging characteristics can be used to stratify patients’ risk of hearing loss.

Although the use of dermoscopy has markedly improved both the sensitivity and specificity for skin cancer detection, there is still opportunity for improvement. Ancillary techniques provide additional ways to assess a lesion with the aim of improving our diagnostic ability with little extra cost. Usage of these techniques can strengthen diagnosis and help reduce unnecessary biopsies of benign lesions.

To characterize normative adult ranges for cochlear promontory thickness relevant to the development of subendosteal and transpromontory electrodes to rehabilitate various neurotologic disorders.Adults (≥18 years).In vivo radiologic assessment using a 192-slice CT scanner (Force-192; Siemens Healthcare) with ultrahigh-resolution scan mode combined and iterative reconstruction.Cochlear promontory thickness.Among 48 included patients (96 ears), the mean (SD) age was 56 (18) years (range 25-94) and included 25 (52%) women. Of that 12 patients (25%) had osteopenia (Cochlear promontory thickness can vary by almost 1.5 mm across patients and is significantly associated with patient sex, body mass index, and comorbid osteopenia/osteoporosis. Subendosteal and transpromontory electrode placement techniques must account for this degree of variability.IV.

To evaluate the outcomes of cochlear implantation (CI) in adults with preoperatively diagnosed cognitive impairment.Retrospective cohort study.Tertiary-care academic center.Adults undergoing CI with preexisting cognitive impairment.Cochlear implantation.1) Hearing improvement after CI; 2) morbidity and mortality associated with surgery.Eight patients met inclusion criteria with mean age 77.8 years (SD, 9.6 y) at time of implantation; 7 were included in subsequent analysis as one did not have speech recognition scores. Average preoperative MoCA cognitive score of 22.6 (SD, 3.9, ≤25 demonstrates cognitive impairment). Average follow-up was 29.0 months (SD, 33.3 mo). Two patients passed away at an average 58.0 months (SD, 31.1 mo) after surgery. Median preoperative pure tone average was 86.3 dB HL ( interquartile range 31.3 dB HL) compared with 33.8 dB HL (IQR 5.0 dB HL) postoperatively ( p =0.001). Median preoperative speech testing score (AzBio/HINT) was 21% (IQR, 24%) compared with 44% (IQR, 21%) postoperatively ( p =0.001). There were no observed surgical complications during the follow-up period.This study demonstrates that patients with cognitive impairment before CI can experience improved hearing, no increased risk of complications, and good longevity after CI. Further prospective studies are needed to further define the utility of CI in patients with impaired cognition.

Unlike the autosomal dominant inheritance of neurofibromatosis 2, there are no known inherited risk factors for sporadic, unilateral vestibular schwannoma (VS), which comprise most VS cases. The authors tested a hypothesis positing a genetic contribution to predisposition to these lesions by analyzing familial clustering of cases.Familial clustering of individuals with unilateral VS was analyzed in two independent genealogical resources with linked diagnosis data: the Veterans Health Administration Genealogy Resource and the Utah Population Database. Tests for excess relatedness, estimation of relative risks (RRs) in close and distant relatives, and identification of pedigrees with a significant excess of unilateral VS among descendants were performed.The average pairwise relatedness of the Veterans Health Administration Genealogy Resource VS cases significantly exceeded the expected relatedness ( p = 0.016), even when close relationships were ignored ( p = 0.002). RR for third- and fifth-degree relatives developing VS were significantly elevated (RR, 60.83; p = 0.0005; 95% confidence interval [CI], 7.37-219.73) and (RR, 11.88; p = 0.013; 95% CI, 1.44-42.90), respectively. No VS-affected first-, second-, or fourth-degree relatives were observed. In the Utah Population Database population, no first- or second-degree relatives with VS were observed. RR for fifth-degree relatives developing VS was significantly elevated (RR, 2.23; p = 0.009; 95% CI, 1.15-3.90).These results provide strong evidence for an inherited predisposition to sporadic, unilateral VS. This study exhibits the value of genealogical resources with linked medical data for examining hypotheses regarding inherited predisposition. The high-risk unilateral VS pedigrees identified in two independent resources provide a powerful means of pursuing predisposition gene identification.

Cardiac resynchronization therapy (CRT) using biventricular pacing has limited efficacy in patients with heart failure (HF) and right bundle branch block (RBBB). Left bundle branch area pacing (LBBAP) is a novel physiologic pacing option. OBJECTIVE The aim of the study was to assess the feasibility and outcomes of LBBAP in HF patients with RBBB and reduced left ventricular systolic function, and indication for CRT or ventricular pacing. METHODS LBBAP was attempted in patients with left ventricular ejection fraction (LVEF) = 5% increase in ejection fraction) to LBBAP were assessed. RESULTS LBBAP was attempted in 121 patients and successful in 107 (88%). Patient characteristics included age 74 +/- 12 years, female 25%, ischemic cardiomyopathy 49%, and ejection fraction 35% +/- 9%. QRS axis at baseline was normal in 24%, left axis 63%, right axis 13%. LBBAP threshold and R-wave amplitudes were 0.8 +/- 0.3 V@ 0.5 ms and 10 +/- 9 mV at implant and remained stable during mean follow-up of 13 +/- 8 months. LBBAP resulted in narrowing of QRS duration (156 +/- 20 ms to 150 +/- 24 ms (P = .01) with R-wave peak times in V-6 of 85 +/- 16 ms. LVEF improved from 35% +/- 9% to 43% +/- 12% (P,.01). Clinical and echocardiographic response was observed in 60% and 61% of patients, respectively. Female sex and reduction in QRS duration with LBBAP were predictive of echocardiographic response and super-response. CONCLUSION LBBAP is a feasible alternative to deliver CRT or physiologic ventricular pacing in patients with RBBB, HF, and LV dysfunction.

Two derivatives of the numeric rating scale (NRS) and visual analog scale (VAS), namely patient-reported percentage pain reduction (PRPPR) and calculated percentage pain reduction (CPPR), are commonly used when evaluating pain reduction. A small number of studies have attempted to assess the agreement between PRPPR and CPPR. However, they have been limited in their scope by a focus on specific types of pain, or by their focus on specific treatment modalities. As far as the authors of this article are aware, this is the first study to assess the agreement between PRPPR and CPPR in chronic pain patients, as well as the first to assess how the duration of treatment affects the correlations between PRPPR and CPPR. The aim of this retrospective analysis was to determine whether the duration of treatment affects CPPR and PRPPR, and the discrepancy and agreement between the two. Additionally, the study assessed whether individual treatment modalities, or the lack there of, impacted the discrepancy and correlation between PRPPR and CPPR. The mean PRPPR and CPPR for the entire patient population were 59.98 and 40.71, respectively. The mean discrepancy between the two parameters was 19.27. The agreement between PRPPR and CPPR, as measured by the concordance correlation coefficient, was 0.984 (95% C.I., 0.982–0.986).

We performed a retrospective case analysis to identify opportunities to introduce a patient-initiated follow-up (PIFU) pathway for patients with psoriasis completing narrowband ultraviolet B phototherapy at our centre. In total, 42 patients completed phototherapy between January 2016 and August 2018 and outcomes were observed for 36 months after phototherapy cessation. Had a PIFU pathway been in place, 24 routine follow-up appointments could have been saved and 8 nonattendances could have been avoided. Seven patients who were discharged or did not attend follow-up after phototherapy flared within 12 months and could have benefited from PIFU to re-access dermatology care. In total 21 patients (50.0%) experienced a relapse within 36 months of completion of phototherapy, and 18 of these (85.7%) relapsed at 0–12 months. The median time to relapse was 6 months. We conclude a post-phototherapy PIFU pathway could help eliminate unnecessary appointments for patients in remission and improve access for patients who relapse. A 12-month PIFU duration prior to discharge would be sufficient to capture the majority of relapses.

We highlight the growing challenge of undertaking skin cancer surgery in adult patients lacking capacity, given the nature of the ageing population, increasing prevalence of dementia and rise in skin cancer diagnoses. In such cases a decision must be made in the patient’s best interests, taking into account the patient’s own views, the existence of a lasting power of attorney, and the views of close family and friends. On occasion it may be reasonable not to aim to cure a skin cancer in a patient approaching the end of life.

Glycosaminoglycans (GAGs) are long, linear polysaccharides that are ubiquitously expressed on the cell surface and in the extracellular matrix of all animal cells. These complex carbohydrates play important roles in many cellular processes and have been implicated in many disease states, including cancer, inflammation, and genetic disorders. GAGs are among the most complex molecules in biology with enormous information content and extensive structural and functional heterogeneity. GAG biosynthesis is a nontemplate-driven process facilitated by a large group of biosynthetic enzymes that have been extensively characterized over the past few decades. Interestingly, the expression of the enzymes and the consequent structure and function of the polysaccharide chains can vary temporally and spatially during development and under certain pathophysiological conditions, suggesting their assembly is tightly regulated in cells. Due to their many key roles in cell homeostasis and disease, there is much interest in targeting the assembly and function of GAGs as a therapeutic approach. Recent advances in genomics and GAG analytical techniques have pushed the field and generated new perspectives on the regulation of mammalian glycosylation. This review highlights the spatiotemporal diversity of GAGs and the mechanisms guiding their assembly and function in human biology and disease.

Objectives This study aims to assess the safety and feasibility of achieving His-Purkinje conduction system pacing (HPCSP) in consecutive patients with atrioventricular block (AVB) and to describe the site of conduction block in patients with infranodal AVB. Background HPCSP has evolved as the preferred form of physiologic pacing. Left bundle branch area pacing (LBBAP) has emerged as an effective alternative to His bundle pacing (HBP). Methods Consecutive patients with AVB referred for pacemaker implantation were included in the study. HBP or LBBAP was attempted in all patients. Site of conduction block was identified as nodal or infranodal (intra-Hisian or infra-Hisian) AVB. Results HPCSP was attempted in 333 consecutive patients with AVB and was successful in 322 (97%) patients. HBP was achieved in 140 patients, LBBAP in 179 patients, and both in 3 patients. Site of conduction block was nodal in 55% and infranodal in 45% (intra-Hisian 89%; infra-Hisian 4%; indeterminate 7%). QRS duration at baseline was 111±27 versus 129±31 (P Conclusions HPCSP pacing was successfully performed in 97% of unselected patients with AVB irrespective of the site of conduction block. True infra-Hisian block (distal His-Purkinje conduction disease) is rare. HBP and LBBAP were complementary in achieving stable and low capture thresholds.

Root caries in geriatric patients is a growing problem as more people are maintaining their natural teeth into advanced age. We determined the levels of various bacterial species previously implicated in root caries disease or health using quantitative real-time PCR in a pilot study of 7 patients with 1 to 4 root caries lesions per person. Levels of 12 different species on diseased roots compared to healthy (contralateral control) roots were measured. Four species were found at significantly higher levels on diseased roots (Streptococcus mutans, Veillonella parvula/dispar, Actinomyces naeslundii/viscosus, and Capnocytophaga granulosa) compared across all plaque samples. The level of colonization by these species varied dramatically (up to 1,000-fold) between patients, indicating different patients have different bacteria contributing to root caries disease. Neither of the two species previously reported to correlate with healthy roots (C. granulosa and Delftia acidovorans) showed statistically significant protective roles in our population, although D. acidovorans showed a trend toward higher levels on healthy teeth (P = 0.08). There was a significant positive correlation between higher levels of S. mutans and V. parvula/dispar on the same diseased teeth. In vitro mixed biofilm studies demonstrated that co-culturing S. mutans and V. parvula leads to a 50 to 150% increase in sucrose-dependent biofilm mass compared to S. mutans alone, depending on the growth conditions, while V. parvula alone did not form in vitro biofilms. The presence of V. parvula also decreased the acidification of S. mutans biofilms when grown in artificial saliva and enhanced the health of mixed biofilms.

Flare frequency distributions represent a key approach to addressing one of the largest problems in solar and stellar physics: determining the mechanism that counter-intuitively heats coronae to temperatures that are orders of magnitude hotter than the corresponding photospheres. It is widely accepted that the magnetic field is responsible for the heating, but there are two competing mechanisms that could explain it: nanoflares or Alfv\'en waves. To date, neither can be directly observed. Nanoflares are, by definition, extremely small, but their aggregate energy release could represent a substantial heating mechanism, presuming they are sufficiently abundant. One way to test this presumption is via the flare frequency distribution, which describes how often flares of various energies occur. If the slope of the power law fitting the flare frequency distribution is above a critical threshold, $\alpha=2$ as established in prior literature, then there should be a sufficient abundance of nanoflares to explain coronal heating. We performed $>$600 case studies of solar flares, made possible by an unprecedented number of data analysts via three semesters of an undergraduate physics laboratory course. This allowed us to include two crucial, but nontrivial, analysis methods: pre-flare baseline subtraction and computation of the flare energy, which requires determining flare start and stop times. We aggregated the results of these analyses into a statistical study to determine that $\alpha = 1.63 \pm 0.03$. This is below the critical threshold, suggesting that Alfv\'en waves are an important driver of coronal heating., Comment: 1,002 authors, 14 pages, 4 figures, 3 tables, published by The Astrophysical Journal on 2023-05-09, volume 948, page 71

This review examines the relationship between cochlear implantation and cognition and quality of life in older adults, as well as how frailty affects outcomes for older patients with cochlear implants. A growing body of evidence suggests that there is a strong association between hearing loss and cognitive impairment. Preliminary studies suggest that cochlear implantation in older adults may be protective against cognitive decline. While studies have observed a positive impact of cochlear implantation on quality of life, currently it is unclear what factors contribute the most to improved quality of life. Frailty, as a measurement of general health, likely plays a role in complication rates and quality-of-life outcomes after cochlear implantation, though larger prospective studies are required to further elucidate this relationship.

Root caries in geriatric patients is a growing problem as more people are maintaining their natural teeth into advanced age. We determined the levels of various bacterial species previously implicated in root caries disease or health using quantitative real-time PCR in a pilot study of 7 patients with 1 to 4 root caries lesions per person.

Introduction Changing the physical zip code location of an academic trauma center may affect the distribution and surgical volume of its trauma patients. General surgical residency case log requirements may also be affected. This study describes the impact of moving a level I trauma center to a different zip code location, on the hospital and resident trauma case volumes. Methods This retrospective analysis included all patients within the local trauma registry across two fiscal years representing the pre- and post-move timeframes. Variables collected included patient basic sociodemographic and injury information, trauma activation level and transfer status, management (operative management [OPM] versus non-operative management [NOPM]), and resident case logs. Results During fiscal years 2016-2017 and 2017-2018, 3,025 patients were included. Pre-move and post-move trauma volumes were 1,208 and 1,817 respectively. Post-move changes demonstrated differences in basic sociodemographics, with differences in age (six years older), a shift toward white and away from black (12.89%), and males being seen more frequently (11.87%). Injury severity score distribution shifted (7.72%) towards less severe trauma scores (15), the percentage of patients with blunt trauma (4.19%) and falls increased (ground level and greater than 1 meter, 9.78%) while the number of patients considered full activations were decreased (15.67%). Proportions of OPM and NOPM trauma cases remained unchanged with the exception of a reduction in emergent operative trauma (3.1%). Resident case logs requirements were met both pre- and post-move. Conclusion Relocating the trauma center to a different zip code location did not negatively impact our resident case volumes. Total trauma volumes were increased, with a shift in the demographics and severity distribution of injuries.

Describe a series of cases of idiopathic chronic auricular chondritis refractory to antibiotics and steroids treated successfully with surgery.Case series.Two tertiary academic medical centers.We analyzed four patients diagnosed with chronic auricular deformity, pain, and drainage for a period of 1 to 5 years who had failed prolonged treatment consisting of antibiotics, corticosteroids, and incision and drainage. All four patients were smokers, three were diabetic, and two had a history of bariatric surgery.Operative subcutaneous partial auriculectomy (removal of diseased cartilage and excess skin) was performed.Resolution of pain and drainage, need for additional procedures, and reduction in narcotics required for pain control were analyzed.Two of the four patients were given an immediate postoperative course of doxycycline and ciprofloxacin. With a minimum of 6 weeks' follow-up, all four patients had complete resolution of pain and recurrent drainage postoperatively. One patient requiring daily narcotic medication for pain and benzodiazepine for sleep preoperatively no longer required prescription medication. All specimens revealed chronic dermal and cartilage inflammation. Three of four cases had polymicrobial infection. One case had only skin contaminant growth on culture following multiple oral and parental antibiotic regimens.Surgical excision of diseased cartilage as a result of idiopathic chronic chondritis is an effective treatment in those cases refractory to antibiotics and incision and drainage, and should be considered in the treatment algorithm for similar patients, potentially offering definitive cure.

Oral isotretinoin is a highly effective drug for severe acne but with ongoing serious safety concerns and we are cautiously reminded by the Medicines and Healthcare products Regulatory Authority to prescribe this drug within licence. We review the National Institute for Health and Care Excellence recommendations for considering referral of acne to specialist care and propose some improvements. This may help manage patient expectations of treatment, ensure only appropriate patients are seen in secondary care and help prescribers remain within the isotretinoin product licence.

Thrombocytopenia is a common entity seen in ICU patients and is associated with increased morbidity such as bleeding and transfusions, and mortality in ICU patients. Various mechanisms such as decreased platelet production, sequestration, destruction, consumption, and sometimes a combination of these factors contribute to thrombocytopenia. An understanding of the mechanism is essential to diagnose the cause of thrombocytopenia and to help provide appropriate management. The management strategies are aimed at treating the underlying disorder, such as platelet transfusion to treat complications like bleeding. Several studies have aimed to provide the threshold for platelet transfusions in various clinical settings and recommend a conservative approach in the appropriate scenario. In this review, we discuss various pathophysiological mechanisms of thrombocytopenia and the diverse scenarios of thrombocytopenia encountered in the ICU setting to shed light on the varied thresholds for platelet transfusion, alternative agents to platelet transfusion, and future directions for the implementation of thromboelastography (TEG) in multiple clinical scenarios to assist in the administration of appropriate blood products to correct coagulopathy.

Physical stressors are common predisposing factors for takotsubo cardiomyopathy (TTC). However, the role of traumatic injuries in TTC has not been well defined. This study describes the characteristics of TTC in the broad spectrum of traumatic injuries using the information available in the National Trauma Data Bank (NTDB).This retrospective study analyzed trauma patients ≥ 18 years old in the NTDB, from 2007 to 2018, with a diagnosis of TTC.A total of 95 TTC diagnoses were found. The median age was 68 years old (interquartile range: 55-80). Patients were predominantly female (67.4%), white (88.4%), and sustained blunt mechanisms of injury (90.5%). Penetrating trauma was most common in males (16%). Most diagnoses were related to extremity trauma (53.7%), followed by head injury (26.3%). The most common severity scores were Glasgow Coma Scale (GCS)13 or8, and Injury Severity Score (ISS)15 or25. Males more commonly presented with GCS8 (68%), ISS25 (33%), high intensive care unit (ICU) admission rate (77.4%), and mechanical ventilation (51.6%). The median duration of the mechanical ventilation was eight days for both sexes. The ICU length of stay (LOS) was six days with a hospital LOS of nine days and a trend toward a longer LOS in males. The in-hospital mortality rate was 11.7% for both sexes.TTC in traumatic injuries is common at both ends of the severity spectrum and has different sex distribution. TTC patients are predominantly females and have more commonly extremity trauma than head injury. Males are more severely injured and under mechanical ventilation.

Cardiac dysfunction is a key determinant of outcome in congenital diaphragmatic hernia (CDH). Pro-b-type natriuretic peptide (proBNP) is used as a prognosticator in heart failure and cardiomyopathy. We hypothesized that proBNP levels would be associated with ventricular dysfunction and high-risk disease in CDH.Patients in the CDH Study Group (CDHSG) from 2015-2019 with at least one proBNP value were included. Ventricular function was determined using echocardiograms from the first 48 h of life.A total of 2,337 patients were identified, and 212 (9%) had at least one proBNP value. Of those, 3 (1.5%) patients had CDHSG stage A defects, 58 (29.6%) B, 111 (56.6%) C, and 24 (12.2%) D. Patients with high-risk defects (Stage C/D) had higher proBNP compared with low-risk defects (Stage A/B) (14,281 vs. 5,025, p = 0.007). ProBNP was significantly elevated in patients who died (median 14,100, IQR 4,377-22,900 vs 4,911, IQR 1,883-9,810) (p0.001). Ventricular dysfunction was associated with higher proBNP than normal ventricular function (8,379 vs. 4,778, p = 0.005). No proBNP value was both sensitive and specific for ventricular dysfunction (AUC=0.61).Among CDH patients, elevated proBNP was associated with high-risk defects, ventricular dysfunction, and mortality. ProBNP shows promise as a biomarker in CDH-associated cardiac dysfunction.

Our institution established a Fontan surveillance plan, which included ambulatory rhythm monitoring (ARM) at 6, 10, 13, 16 and 19 years old, for early detection of Fontan-associated complications. We conducted a retrospective chart review of Fontan patients followed at our institution 2014–2018 to determine the utility of surveillance ARMs. 139 ARMs from 83 patients were included. ARMs with supraventricular tachycardia, sinus node dysfunction, accelerated junctional rhythm, > 1st degree atrioventricular block, and complex ventricular ectopy were classified as positive for arrhythmia. Arrhythmias were occult if detected on surveillance ARM. The ARM indication was surveillance in 78 (56%) and clinically indicated in 61 (44%). 52 (37%) ARMs in 27 (33%) patients had an arrhythmia. There was no difference in the age of patients with and without arrhythmias [median 10.9 (6.5, 17.1 years) vs. 8.8 (7, 13.6 years), p = 0.5]. Clinically indicated ARMs more frequently demonstrated arrhythmias than surveillance ARMs (52% vs. 26%, p

To examine the relationship among frailty index, hearing measures, and hearing-related quality of life (QOL) in older recipients of cochlear implants.Cross-sectional survey.Academic medical center.Adults aged ≥65 years at the time of receiving cochlear implants between July 13, 2000, and April 3, 2019, were asked to complete a questionnaire on hearing-related QOL. Chart review was performed to identify patients' characteristics. Correlations were calculated between frailty index and audiologic outcome measures as well as between speech recognition scores and QOL scores. Linear regression models were developed to examine the impact of clinical characteristics, frailty index, and hearing measures on hearing-related QOL.Data for 143 respondents were included. The mean age was 80.7 years (SD, 7.1), with a mean 27.8 years of hearing loss (SD, 17.4) before implantation. The mean frailty index was 11.1 (SD, 10.6), indicating that patients had 1 or 2 of the measured comorbidities on average. No correlation was found between lower frailty index (better health) and hearing scores, including pure tone averages (PTAs) and speech recognition scores. Lower frailty index and larger improvement in PTA after cochlear implantation predicted better QOL scores on univariate analysis (respectively,Frailty index does not correlate with hearing scores after cochlear implantation in older adults. Lower frailty index and more improvement in PTA predict better QOL scores after cochlear implantation in older adults.

Background Birthdays provide an opportunity to celebrate; however, they can also be associated with various adverse medical events. This is the first study to examine the association between birthdays and in-hospital trauma team evaluation. Methods This retrospective study analyzed trauma registry patients 19-89 years of age, who were evaluated by in-hospital trauma services from 1/1/2011 to 12/31/2021. Results 14,796 patients were analyzed and an association between trauma evaluation and birthdays was found. The strongest incidence rate ratios (IRRs) were on the day of birth (IRR: 1.78; P < .001) followed by ±3 days of the birthday (IRR: 1.21; P = .003). When incidence was analyzed by age groups, 19-36 years of age had the strongest IRR (2.30; P < .001) on their birthday, followed by the >65 groups (IRR: 1.34; P = .008) within ±3 days. Non-significant associations were seen in the 37-55 (IRR: 1.41; P = .209) and 56-65 groups (IRR: 1.60; P = .172) on their birthday. Patient-level characteristics were only significant for the presence of ethanol at trauma evaluation (risk ratio: 1.83; P = .017). Discussion Birthdays and trauma evaluations were found to have a group-dependent association, with the greatest incidence for the youngest age group being on their birthday, and the oldest age group within ±3 days. The presence of alcohol was found to be the best patient-level predictor of trauma evaluation.

Background Standardization of trauma centers improves quality of care, yet that comes with financial challenges. The decision to designate a trauma center typically focuses on access, quality of care, and the needs of the local community, but less often considers the financial viability of the trauma center. A level-1 trauma center was relocated in 2017 and this presented an opportunity to compare financial data at two separate locations in the same city. Methods A retrospective review was performed on the local trauma registry and billing database in all patients aged ≥19 years on the trauma service before and after the move. Results 3041 patients were included (pre-move: 1151; post-move: 1890). After the move, patients were older (9.5 years), and more were females (14.9%) and white (16.5%). Increases in blunt injuries (7.6%), falls (14.8%), and motor vehicle accidents (1.7%) were observed after the move. After the move, patients were less likely to be discharged home (6.5%) and more likely to go to a skilled nursing facility (3%) or inpatient rehabilitation (5.5%). Post-move more patients had Medicare (12.6%) or commercial (8.5%) insurance and charges per patient decreased by $2,833, while charges collected per patient increased by $2425. Patients were seen from a broader distribution of zip codes post-move. Discussion Relocating a trauma center did improve financial viability for this institution. Future studies should consider the impact on the surrounding community and other trauma centers. Level of evidence Level IV.

Novel methoxy, methyl, halogen, and oxy ring-disubstituted octyl phenylcyanoacrylates, RPhCH=C(CN)CO2CH2(CH2)6CH3 (where R is 4-methoxy-2-methyl, 4-methoxy-3-methyl, 3-ethoxy-4-methoxy, 4-ethoxy-3-methoxy, 3-benzyloxy-4-methoxy, 4-benzyloxy-3-methoxy, 2,3-(methylenedioxy), 3-bromo-4-methoxy, 5-bromo-2-methoxy, 2-chloro-3-methoxy, 2-chloro-6-methyl, 3-chloro-4-methyl) were prepared and copolymerized with styrene. The acrylates were synthesized by the piperidine catalyzed Knoevenagel condensation of ring-disubstituted benzaldehydes and octyl cyanoacetate, and characterized by CHN analysis, IR, 1H and 13C NMR. All the acrylates were copolymerized with styrene in solution with radical initiation (ABCN) at 70C. The compositions of the copolymers were calculated from nitrogen analysis.

OBJECTIVE To evaluate adverse events and feasibility of performing 1.5-T MRI in patients with cochlear implants (CI) and auditory brainstem implants (ABI). SETTING Single tertiary academic referral center. PATIENTS CI and ABI recipients undergoing 1.5-T MRI without internal magnet removal. INTERVENTION(S) MRI after tight headwrap application. MAIN OUTCOME MEASURES Adverse events, patient tolerance. RESULTS A total of 131 MR studies in 79 patients were performed, with a total of 157 study ears. Sixty-one patients (77%) had unilateral devices. Four patients (5%) underwent MRI with ABI magnets in place. Sixteen patients (20%) had MRI-compatible devices that did not require a head wrap. There were no instances of device stimulation, device malfunction, or excessive heating of the receiver-stimulator package. Magnet tilt requiring manual repositioning occurred during seven studies (4.5%) and magnet displacement requiring operative intervention occurred during seven studies (4.5%). Significant pain where imaging had to be discontinued occurred during three episodes (2%). No adverse events were noted among patients who underwent MRI with an MRI-compatible magnet. CONCLUSIONS MRI with CI or ABI magnets in place is associated with a low prevalence of adverse events when performed in a controlled setting. Many partial magnet displacements can be corrected with firm manual pressure. Devices with magnets that align with the field within their housing were not associated with any adverse events and do not require immobilization of the magnet during the scan. These may be valuable in patients with known or anticipated need for MRI.

Electrode impedances play a critical role in cochlear implant programming. It has been previously shown that impedances rise during periods of non-use, such as the post-operative recovery period. Then when the device is activated and use is initiated, impedances fall and are typically stable. In this study, we report a new pattern where electrode impedances increase with device use and decrease with device rest.Electrode impedances were measured three to four times every day over a span of 1-3 months for two cochlear implant patients.Two patients with a Nucleus cochlear implant participated in this study.Both subjects in this study show wide fluctuations in electrode impedances. By taking serial electrode impedance measurements throughout a day of use, we observe that electrode impedances consistently increase with device use and decrease with device rest.In this study, we report two cases of electrode impedances increasing as a function of device use. Numerous management strategies were employed to reduce this effect but none prevailed; a clear pathophysiologic mechanism remains elusive. Further study into the cause of this electrode impedance pattern is warranted to establish a management strategy for these cochlear implant users.

Precision cancer medicine aims to classify tumors by site, histology, and molecular testing to determine an individualized profile of cancer alterations. Viruses are a major contributor to oncogenesis, causing 12% to 20% of all human cancers. Several viruses are causal of specific types of cancer, promoting dysregulation of signaling pathways and resulting in carcinogenesis. In addition, integration of viral DNA into the host (human) genome is a hallmark of some viral species. Tests for the presence of viral infection used in the clinical setting most often use quantitative PCR or immunohistochemical staining. Both approaches have limitations and need to be interpreted/scored appropriately. In some cases, results are not binary (virus present/absent), and it is unclear what to do with a weakly or partially positive result. In addition, viral testing of cancers is performed separately from tests to detect human genomic alterations and can thus be time-consuming and use limited valuable specimen. We present a hybrid-capture and massively parallel sequencing approach to detect viral infection that is integrated with targeted genomic analysis to provide a more complete tumor profile from a single sample.

OBJECTIVE To assess cardiac function in infants with bronchiolitis and the association with disease severity and outcomes. WORKING HYPOTHESIS Cardiac function may be impaired in bronchiolitis and represent an early predictor of disease severity. STUDY DESIGN A prospective cohort study. PATIENT SELECTION Infants with suspected bronchiolitis were included. METHODOLOGY All cases received antigen detection and viral genome detection from nasal lavage or swabs and echocardiography within 24 hours from admission. Systolic and diastolic function in left ventricle (LV) and right ventricle (RV) were assessed using longitudinal strain (LS), a measure of myocardial deformation. Pulmonary artery pressures were estimated using tricuspid regurgitation jet (TR), when present, and end-systolic eccentricity index (EI ES). Main outcomes (duration of respiratory support, length of stay [LOS], and type of respiratory support) were collected. Data were compared to normative existing data, and a group of healthy infants, matched in age. RESULTS Twenty-eight infants with bronchiolitis and 10 healthy comparators were included. Cases with bronchiolitis showed significantly lower values of RV LS and LV LS compared to healthy comparators (LV: p0.04 and RV: P

This cadaveric study assessed factors that could lead to nonunions in subtalar joint arthrodesis. The purpose of this study was to assist surgeons in achieving sufficient joint preparation in hopes to achieve more frequent arthrodesis of the subtalar joint. We evaluated the influence of experience in regard to cartilage preparation of the joint. We also assessed which quadrants of the subtalar joint were more likely to have unprepared cartilage. The subtalar joints in 17 cadaveric limbs were prepared by 17 participants with differing levels of experience. After the cartilage was denuded, the percentage of unprepared cartilage in each subtalar joint was calculated. The medial quadrants were more likely to have unprepared surfaces. There was also a learning curve present with subtalar joint preparation, as seen by the significantly larger percentage of unprepared cartilage in cadavers prepared by first year residents.

BACKGROUND Patients undergoing endoscopic resection of neoplasms with both sinonasal and skull base involvement can develop chronic rhinosinusitis (CRS) after treatment and may occasionally benefit from additional endoscopic sinus surgery (ESS). We investigate risk factors and outcomes associated with revision ESS (rESS) after endoscopic skull-base surgery (SBS) for neoplasms with combined sinonasal and skull base involvement. METHODS A retrospective review of patients with neoplasms with both sinonasal and skull base involvement who underwent endoscopic resection at a single tertiary care academic institution from 2004 through 2017 was performed. Eighty-three patients were included. Main outcome measures included incidence and timing of revision surgery, Lund-Mackay (LM) scores, and 22-item Sino-Nasal Outcome Test (SNOT-22) scores. RESULTS rESS was performed in 21 (25%) cases, 15 (18%) of which were due to CRS. Time between initial resection and rESS was an average of 42 months (range, 6 to 142 months). Pre-SBS and post-SBS LM scores were not significantly different (5.0 vs 4.7, p = 0.640), although pre-SBS and post-SBS SNOT-22 scores showed significant improvement (32.6 vs 24.5, p = 0.030). Malignant pathology correlated with need for rESS (odds ratio [OR] 5.07, p = 0.04), as well as treatment including chemotherapy (OR 5.10, p = 0.003) and radiation (OR 4.15, p = 0.013). CONCLUSION A significant proportion of patients develop clinically significant sinusitis after endoscopic SBS for neoplasms with combined sinonasal and skull base involvement and may benefit from rESS. Intervention occurred, on average, 3.5 years after initial tumor resection. Malignant pathology, radiation therapy, and chemotherapy correlate with need for rESS.

Objective Intraoperative far-field auditory brainstem response (ABR) and direct cochlear nerve action potential monitoring using neural response imaging (NRI) are techniques for monitoring the cochlear nerve during vestibular schwannoma (VS) surgery. A new paradigm has developed where the cochlear nerve is anatomically preserved during tumor removal to facilitate cochlear implantation in select circumstances. This report describes the use of an unmodified commercial cochlear implant (CI) to elicit electrically-evoked direct cochlear nerve and far-field ABR monitoring to evaluate the status of the cochlear nerve during tumor resection in real time. Patients Adult female with unilateral, sporadic VS. Intervention(s) Cochlear implantation followed by translabyrinthine resection of VS in single operation. Main outcome measures During tumor resection intra-cochlear electrodes were used to deliver electrical stimulation and measure NRI or the cochlear nerve action potential. Electrically-evoked ABR (eABR) was measured using surface electrodes and wave V was monitored (far-field ABR) during surgery. Results A 61-year-old female was evaluated for a unilateral, enlarging intracanalicular VS with asymmetric SNHL. The patient opted for microsurgery and due to her bilateral hearing loss was a candidate for CI. Cochlear implantation with an unmodified, commercially available lateral wall electrode was performed. The remainder of the approach and tumor resection was performed under continuous eABR and NRI monitoring. Gross total resection was achieved with intact eABR and NRI at the conclusion of the case. Changes in ABR and NRI consistently recovered after modifying dissection strategy. The patient reported auditory percepts with her cochlear implant postoperatively. Conclusions This report demonstrates the feasibility of using real-time NRI and eABR with a CI to facilitate preservation of the cochlear nerve during VS microsurgery. Using this method to mitigate cochlear nerve trauma during microsurgery may preserve the option of CI for hearing rehabilitation.