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Estimating flood damage, although crucial for assessing flood risk and for designing mitigation policies, continues to face numerous challenges, notably the assessment of indirect damage. It is widely accepted that damage other than direct damage can account for a significant proportion of total damage. Yet due to scarcer data sources and lack of knowledge on links within and between economic activities, indirect impacts have received less attention than direct impacts. Furthermore, attempts to grasp indirect damage through economic models have not gone below regional levels. Even though local communities can be devastated by flood events without this being reflected in regional accounts, few studies have been conducted from a microeconomic perspective at local level. What is more, the standard practices applied at this level of analysis tackle entities but ignore how they may be linked. This paper addresses these two challenges by building a novel agent-based model of a local agricultural production chain (a French cooperative wine-making system), utilized as a virtual laboratory for the ex ante estimation of flood impacts. We show how overlooking existing interactions between economic entities in production chains can result in either overestimation (double counting) or underestimation (wrong estimation of the consequences for the activity) of flood damage. Our results also reveal that considering interactions requires thorough characterization of their spatial configuration. Based on both the application of our method and the results obtained, we propose balanced recommendations for flood damage estimation at local level.

Objectives: To characterize the voriconazole and posaconazole serum trough ordering practices in patients receiving prophylactic and treatment antifungal therapy., Methods: A retrospective chart review over a 6-year period of pediatric patients who received voriconazole and/or posaconazole for >24 hours., Results: A total of 113 patients were included in this study and of these patients, 105 received voriconazole and 16 received posaconazole during the study period. Additionally, 167 trough levels were assessed in this study. Only 50% and 54% of levels were considered within goal recommendations for voriconazole and posaconazole, respectively. The median dose required to achieve goal trough concentration was dependent on drug, indication, and dosage form. Lastly, the most common adverse drug reactions (ADRs) were hepatoxicity, QTc prolongation, and CNS changes, which were in concordance with ADRs documented in the clinical trials for voriconazole and posaconazole. Approximately 20% of patients receiving either voriconazole or posaconazole died during the study period and the median trough in both groups was subtherapeutic., Conclusions: Increased monitoring of trough concentrations may be warranted to prevent death or breakthrough invasive fungal infections. Further studies are warranted for assessing the relationship between trough concentrations and treatment outcomes as well as relationship between dosing and achieving goal trough concentrations., Competing Interests: Disclosure. The authors declare no conflicts or financial interest in any product or service mentioned in the manuscript, including grants, equipment, medications, employment, gifts, and honoraria. The authors had full access to all data and take responsibility for the integrity and accuracy of the data analysis., (Copyright Pediatric Pharmacy Association. All rights reserved. For permissions, email: mhelms@pediatricpharmacy.org 2021.)

Purpose: Bolus injection of fluid into subcutaneous tissue results in accumulation of fluid at the injection site. The fluid does not form a pool. Rather, the injection pressure forces the interstitial matrix to expand to accommodate the excess fluid in its volume, and the fluid becomes bound similar to that in a hydrogel. We seek to understand the properties and dynamics of externally tumesced (swollen) subcutaneous tissue as a first step in assessing whether tumescent antibiotic injections into wounds may provide a novel method of treatment., Methods: Subcutaneous injections of saline are performed in live and dead pigs and the physical properties (volume, expansion ratio, residence time, apparent diffusion constant) of the resulting fluid deposits are observed with diffusion-weighted magnetic resonance imaging, computed tomography, and 3D scanning., Results: Subcutaneous tissue can expand to a few times its initial volume to accommodate the injected fluid, which is dispersed thoroughly throughout the tumescent volume. The fluid spreads to peripheral unexpanded regions over the course of a few minutes, after which it remains in place for several hours. Eventually the circulation absorbs the excess fluid and the tissue returns to its original state., Conclusions: Given the evidence for dense fluid dispersal and several-hour residence time, a procedure is proposed whereby tumescent antibiotic injections are used to treat drug-resistant skin infections and chronic wounds that extend into the subcutaneous tissue. The procedure has the potential to effectively treat otherwise untreatable wounds by keeping drug concentrations above minimum inhibitory levels for extended lengths of time.

We search for cavitation in tumescent subcutaneous tissue of a live pig under application of pulsed, 1-MHz ultrasound at 8 W cm -2 spatial peak and pulse-averaged intensity. We find no evidence of broadband acoustic emission indicative of inertial cavitation. These acoustic parameters are representative of those used in external-ultrasound-assisted lipoplasty and in physical therapy and our null result brings into question the role of cavitation in those applications. A comparison of broadband acoustic emission from a suspension of ultrasound contrast agent in bulk water with a suspension injected subcutaneously indicates that the interstitial matrix suppresses cavitation and provides an additional mechanism behind the apparent lack of in-vivo cavitation to supplement the absence of nuclei explanation offered in the literature. We also find a short-lived cavitation signal in normal, non-tumesced tissue that disappears after the first pulse, consistent with cavitation nuclei depletion in vivo., (Copyright © 2018 World Federation for Ultrasound in Medicine and Biology. Published by Elsevier Inc. All rights reserved.)

Background: Misdiagnosing appendicitis may lead to unnecessary surgery. The study evaluates the risk factors for negative appendectomies, as well as the clinical and socioeconomic consequences of negative appendectomy across three states., Materials and Methods: Data were obtained from the California, New York, and Florida State Inpatient Databases 2005-2011. Patients (<18 years) who underwent nonincidental appendectomies (n = 156,660) were evaluated with hierarchical and multivariate negative binomial regression analyses on outcomes including hospital cost, length of stay (LOS), and associated morbidity., Results: From 2005 to 2011, there was a decrease in the rate of negative appendicitis and perforated appendicitis, whereas the rate of true acute nonperforated appendicitis increased. Whites, females, and privately insured patients were associated with higher negative appendicitis rates, whereas those at an increased risk for perforated appendicitis were African-Americans, males, and those with public or no insurance. Compared to patients with acute nonperforated appendicitis, those with negative appendicitis have significantly higher morbidity (2.5% versus 1.3%), longer LOS (3.4 versus 1.8 d), and greater hospital costs averaged over time ($6926 versus $6492 per patient)., Conclusions: Despite a low incidence, negative appendicitis is associated with greater morbidity, longer LOS, and higher cost than acute nonperforated appendicitis. Certain subpopulations are at higher risk for undergoing surgery for negative appendicitis, whereas others are at greater risk for presenting with perforated appendicitis. Further research is needed to understand what drives such disparities and to inform efforts to improve quality of hospital care across all groups of patients., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Context: Up to 75% of skateboarders and snowboarders admitted to the hospital sustain head injuries. It is unclear why not all children and teenagers wear helmets while snowboarding and skateboarding given the protection they afford., Objectives: To report on the prevalence of, and factors associated with, skateboarding and snowboarding in injured children and to explore factors that influence helmet use, head injury, and hospitalization in this sample., Design: A cross-sectional study of skateboard- and snowboard-associated injuries from 2003 to 2012 among individuals younger than age 18 years using National Electronic Injury Surveillance System (NEISS) data from approximately 100 hospitals., Main Outcome Measures: Helmet use, head injury, and hospitalization., Results: Of 1742 patients in the study, 852 (48.9%) and 890 (51.1%) were skateboarders and snowboarders, respectively. Overall, 907 (52.1%) did not use helmets, and 704 (40.4%) sustained head injuries. Multiple logistic regression analysis showed that age, race/ethnicity, location of boarding, and engaging in skateboarding influenced helmet use. Sex, race/ethnicity, helmet use, and skateboarding predicted head injury. Age, sex, skateboarding, and head injury predicted hospital admission., Conclusion: Statistically significant differences exist in helmet use, head injury, and hospitalization rates between skateboarders and snowboarders. Our findings suggest that injury prevention and outreach programs are needed to increase helmet use and reduce the risk of head injury and hospitalization in skateboarders and other at-risk groups. Further studies are needed to clarify the association between race/ethnicity and helmet use among skateboarders and snowboarders.