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BACKGROUND: Per- and polyfluoroalkyl substances (PFAS), endocrine disrupting chemicals with worldwide exposure, cause changes in mammary gland development in rodents. A few human studies report delay in pubertal events with increasing perfluorooctanoic acid (PFOA) exposure, but to our knowledge none have examined reproductive hormone levels at thelarche. METHODS: In a cohort of Greater Cincinnati (GC) and San Francisco Bay Area (SFBA) girls recruited at 6–8 years of age, clinical examinations were conducted annually or semiannually with sequential Tanner staging. PFAS concentrations were measured in the first serum sample of 704 girls. In 304 GC girls, estradiol (E2), estrone (E1), testosterone (T), and dihydroepiandrosterone sulfate (DHEAS) were measured in serum at four time points around puberty. Relationships between PFAS and age at thelarche, pubarche, and menarche were analyzed using survival and structural equation models. The association between PFAS and reproductive hormones was assessed using linear regression models. RESULTS: Median PFOA serum concentrations in GC (푁 = 353, 7.3 ng/mL) and the SFBA (푁 =351, 5.8 ng/mL) were higher than in the U.S. population. In multivariable Cox proportional hazard models [adjusted for race, body mass index (BMI)], increasing serum log-transformed PFOA was associated with a delay in pubarche [hazard ratio (HR)=0.83; 95% CI: 0.70, 0.99] and menarche (HR=0.04; 95% CI: 0.01, 0.25). Structural equation models indicated a triangular relationship between PFOA, BMI percentile, and the age at the pubertal milestone. Increased PFOA had a statistically significant direct effect of delay on all three milestones, as did BMI. Perfluorononanoic acid (PFNA), perfluorodecanoic acid (PFDeA), and 2-(N-methyl-perfluorooctane sulfonamido) acetic acid (Me-PFOSA-AcOH) also were associated with later thelarche, and Me-PFOSA-AcOH also with later pubarche. PFOA was inversely associated with DHEAS (푝<0.01), E1 (푝=0.04), and T (푝=0.03) concentrations at 6 months prior to puberty. CONCLUSIONS: PFAS may delay pubertal onset through the intervening effects on BMI and reproductive hormones. The decreases in DHEAS and E1 associated with PFOA represent biological biomarkers of effect consistent with the delay in onset of puberty. [ABSTRACT FROM AUTHOR]

Background: Validated perioperative pressure injury (PI) risk assessment measures are few and often cumbersome to complete, leading to missed opportunities to identify and target prevention interventions to those patients at increased risk for developing a postsurgical PI. Objectives: Previous validation of a six-item perioperative risk assessment measure for skin (PRAMS) was conducted in our community hospital with positive findings. The purpose of this study was to increase generalizability by revalidating the PRAMS in a larger sample. Methods: This was a retrospective chart review of all surgical patients aged ≥18 years positioned in the supine or lateral position in a Midwest quaternary care, multispecialty, 1,500-bed hospital during a 6-month period (n = 1,526). The intent of the study was to revalidate the PRAMS. The main outcome of interest was the development of PI after surgery. Risk indicators of interest included diabetes, age, surgical time, Braden score, previous surgery, and preexisting PI. The diagnostic ability of any of the risk indicators on the development of a postsurgical PI was evaluated using sensitivity, specificity, and predictive values. Results: Postsurgical PIs occurred in 121 patients. Comparing current to previous study results, the PRAMS was effective in identifying surgical patients at risk for PI (sensitivity =.98). Those patients with a postsurgical PI had a lower mean Braden score, were more likely to have a preexisting PI, and were more likely to have a previous surgery during the same admission (p <.001 for all risk indicators), comparing favorably to the original study. Patients without risk indicators were unlikely to develop a postsurgical PI (negative predictive value =.98). Discussion: Results of this validation study demonstrate that the PRAMS is effective in identifying patients who developed a postsurgical PI using information readily available to the perioperative staff. [ABSTRACT FROM AUTHOR]

Prediction Rule to Identify Patients at High Risk for Early Demise Following CRT Background In patients with advanced heart failure, the decision of whether to pursue cardiac resynchronization therapy (CRT) or to proceed directly to advanced heart failure therapies can be challenging. We sought to create a prediction rule to identify patients with advanced systolic heart failure at heightened risk of rapid deterioration despite receiving CRT. Methods Clinical data were collected on consecutive patients with advanced heart failure presenting for a new CRT device at the Cleveland Clinic between February 12, 2002 and July 8, 2008. Early demise was defined as death, left ventricular assist device, or heart transplant within 6 months following CRT implant. Using a multivariate model, variables associated with early demise were identified and a prediction rule created. Results A total of 879 patients were included of whom 47 met criteria for early demise. Using forward stepwise regression followed by a bootstrapping analysis, the final model included: left ventricular end-diastolic diameter ≥6.5 cm (OR 3.23 [1.72-6.06 g], P < 0.001), the presence of a non-left bundle branch block (non-LBBB) morphology (OR 2.18 [1.18-4.04, P = 0.013]), creatinine ≥1.5 mg/dL (OR 2.98 [1.52-5.49], P < 0.001), and lack of or intolerance to β-blocker use (OR 2.80 [1.46-5.39], P = 0.002). The specificity for ≥2 and ≥3 risk factors was 72.6% and 94.6%, respectively. Conclusions Left ventricular dilatation, the presence of a non-LBBB morphology, renal dysfunction, and lack of or intolerance to β-blockers are associated with early demise following CRT. In patients with at least 3 of these factors, bypassing CRT with early adoption of advanced heart failure therapies may be considered given the high specificity for rapid decline. [ABSTRACT FROM AUTHOR]

Background: High levels of humeral torsion allow baseball pitchers to achieve maximum external rotation in the late cockingphase of pitching with lower twisting and shear forces on the long head of the biceps tendon and rotator cuff tendons.Hypothesis: Humeral torsion is inversely related to the incidence and severity of shoulder injuries and other upper extremityinjuries in professional baseball pitchers.Study Design: Case-control study; Level of evidence, 3.Methods: A total of 25 professional pitchers from a single Major League Baseball organization were prospectively recruited intothis study. Computed tomography (CT) was performed on dominant and nondominant humeri, and image data were processedwith a 3-dimensional volume-rendering postprocessing program. The software program was then modified to model a simplifiedthrowing motion and to measure potential internal impingement distances in a small subset of players. Players were followed for 2years after CT, and the number of days missed from pitching activities was recorded as a measure of injury severity andincidence.Results: The mean dominant humeral torsion was 38.5° ± 8.9°; the mean nondominant humeral torsion was 27.6° ± 8.0°. Thedifference between dominant and nondominant torsions was significant (P<.0001). Among the 11 pitchers (44%) injured duringfollow-up, 5 players had shoulder injuries, 7 had elbow injuries, and 2 had finger injuries. Dominant humeral torsion was a statisticallysignificant predictor of severe injuries (≥30 days; P = .048) but not of milder injuries. Among injured players, higher numbersof days missed because of injury were strongly correlated with lower degrees of dominant humeral torsion (r = 20.78; P = .005)and smaller differences between dominant and nondominant humeral torsions (r = 20.59; P = .055). There was no significantassociation between the incidence of shoulder injury and minimum glenoid-tuberosity distance in the dominant or nondominantshoulder or degree of dominant glenoid version.Conclusion: A strong relationship was found between lower degrees of dominant humeral torsion and more severe upperextremity injuries as well as a trend relating lower side-to-side differences in torsion with more severe dominant upper extremityinjuries. In addition, there was a higher incidence of severe injuries in players with lower degrees of dominant torsion. If futurestudies confirm these results, humeral torsion measurements could play a role in risk assessment in pitchers. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To characterize the health care burden of influenza from 2004 through 2009, years when influenza vaccine recommendations were expanded to all children aged ≥6 months. METHODS: Population-based surveillance for laboratory-confirmed influenza was performed among children aged <5 years presenting with fever and/or acute respiratory illness to inpatient and outpatient settings during 5 influenza seasons in 3 US counties. Enrolled children had nasal/throat swabs tested for influenza by reverse transcriptase-polymerase chain reaction and their medical records reviewed. Rates of influenza hospitalizations per 1000 population and proportions of outpatients (emergency department and clinic) with influenza were computed. RESULTS: The study population comprised 2970, 2698, and 2920 children from inpatient, emergency department, and clinic settings, respectively. The single-season influenza hospitalization rates were 0.4 to 1.0 per 1000 children aged <5 years and highest for infants <6 months. The proportion of outpatient children with influenza ranged from 10% to 25% annually. Among children hospitalized with influenza, 58% had physician-ordered influenza testing, 35% had discharge diagnoses of influenza, and 2% received antiviral medication. Among outpatients with influenza, 7% were tested for influenza, 7% were diagnosed with influenza, and <1% had antiviral treatment. Throughout the 5 study seasons, <45% of influenza-negative children ≥6 months were fully vaccinated against influenza. CONCLUSIONS: Despite expanded vaccination recommendations, many children are insufficiently vaccinated, and substantial influenza burden remains. Antiviral use was low. Future studies need to evaluate trends in use of vaccine and antiviral agents and their impact on disease burden and identify strategies to prevent influenza in young infants. [ABSTRACT FROM AUTHOR]

Objective: To determine epidemiology and clinical characteristics of infants with methicillin-susceptible (MSSA) and -resistant Staphylococcus aureus (MRSA) in a level III neonatal intensive care unit (NICU). Study Design: All NICU admissions (2001 to 2008) with any positive S. aureus culture were included as cases. Cases were further characterized as either colonized or infected with invasive disease. Results: Four thousand three hundred four infants were admitted; 273 (6.3%) had at least one culture positive for S. aureus, including 198 with MSSA and 75 with MRSA. Invasive disease occurred in 23.2% of MSSA cases versus 29.3% MRSA (p = 0.298). Between the study periods 2001 to 2005 versus 2006 to 2008, the incidence of all MSSA cultures (colonization and invasive disease) decreased from 53.6 to 38.9/1000 admissions (p = 0.044), and that of MRSA increased from 13.7 to 24.77/1000 admissions (p = 0.010). The incidence of invasive MSSA (p = 0.49) and MRSA (p = 0.38) disease between the two periods remained similar. Infants with invasive MRSA versus MSSA had a longer duration of positive cultures (55 versus 19 days, p = 0.009). None of five available isolates collected prior to 2006 was characterized as USA300, but 11/21 isolates collected subsequently were USA300 (p = 0.053). Conclusion: The incidence of MRSA (colonization and infection) nearly doubled during the study period coinciding with emergence of community-acquired MRSA USA300. [ABSTRACT FROM AUTHOR]