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Objective Data-informed decision making is valued among school districts, but challenges remain for local health departments to provide data, especially during a pandemic. We describe the rapid planning and deployment of a school-based COVID-19 surveillance system in a metropolitan US county. Methods In 2020, we used several data sources to construct disease- and school-based indicators for COVID-19 surveillance in Franklin County, an urban county in central Ohio. We collected, processed, analyzed, and visualized data in the COVID-19 Analytics and Targeted Surveillance System for Schools (CATS). CATS included web-based applications (public and secure versions), automated alerts, and weekly reports for the general public and decision makers, including school administrators, school boards, and local health departments. Results We deployed a pilot version of CATS in less than 2 months (August–September 2020) and added 21 school districts in central Ohio (15 in Franklin County and 6 outside the county) into CATS during the subsequent months. Public-facing web-based applications provided parents and students with local information for data-informed decision making. We created an algorithm to enable local health departments to precisely identify school districts and school buildings at high risk of an outbreak and active SARS-CoV-2 transmission in school settings. Practice Implications Piloting a surveillance system with diverse school districts helps scale up to other districts. Leveraging past relationships and identifying emerging partner needs were critical to rapid and sustainable collaboration. Valuing diverse skill sets is key to rapid deployment of proactive and innovative public health practices during a global pandemic.

Background: Basilar invagination (BI) is a complex condition characterized by prolapse of the odontoid into the brain stem/upper cervical cord. This lesion is often associated with Chiari malformations, and rheumatoid arthritis (RA). Treatment options for BI typically include cervical traction, an isolated anterior transoral odontoidectomy, anterior endonasal odontoidectomy, an isolated posterior fusion, or combined anterior/ posterior surgical approach. Case Description: A 45-year-old female with a Chiari I malformation and RA underwent a combined posterior C0-C5 posterior decompression/fusion, followed by an anterior odontoidectomy (i.e. endoscopic/endonasal under neuronavigation). Postoperatively, the patient’s symptoms and neurological signs resolved. Conclusion: BI in was successfully managed with a combined posterior C0-C5 decompression/fusion followed by an anterior endoscopic/endonasal odontoidectomy performed under neuronavigation.

Objective To determine whether theta burst repetitive transcranial magnetic stimulation is an effective treatment for chronic tinnitus compared with a control stimulus. Study design A two-arm, single-blind, randomized controlled trial comparing an active treatment group to a placebo control group. Setting Neurotology department of a tertiary referral center. Patients Forty new and existing patients with chronic unilateral or bilateral tinnitus were recruited from specialist hearing and balance clinics. Interventions The subjects were randomized into two groups representing the treatment and sham subcategories. Two 40 second trains, 15 minutes apart of transcranial stimulation was provided using a super rapid stimulator (2.2. Tesla, Magstim Inc., Wales, UK) using a circular delivery coil. Treatment was provided over 5 consecutive days. Main outcome measure Tinnitus functional index (TFI) scores were recorded before treatment, immediately after treatment, 2 weeks, and at 4 weeks following treatment and compared. Results TFI scores were analyzed using the Shapiro-Wilk test and found to be normally distributed. A paired Student t test was then performed. Both the active treatment group and control group had a significant improvement in their TFI scores following treatment; however, there was no significant difference between active treatment and sham treatment groups. Conclusion This study demonstrated a significant placebo effect following treatment with sham therapy and may suggest that repetitive transcranial magnetic stimulation does not have a therapeutic use in treating chronic tinnitus.

Purpose Lung transplantation has been increasingly used as a treatment modality for patients with pulmonary lymphangioleiomyomatosis (LAM). In this study, we evaluated the outcome of patients with LAM who underwent lung transplantation with the aim of making some recommendations regarding patient management. Methods We conducted a retrospective review of 79 patients who underwent primary lung transplantation for end-stage pulmonary LAM at 31 US transplant centers between January 1987 and December 2002 and were reported to the United Network for Organ Sharing (UNOS). Results All patients were women with a mean age of 41.1 years (range, 24–65 years). Thirty-four patients (43%) received single-lung transplants. Bilateral lung transplantation was performed in 45 patients (57%). The mean cold ischemia time was 4.7 hours. There were 2 intra-operative deaths. The 30-day mortality was 5% (4 patients). The causes of early death were primary graft failure in 2 patients, hyperacute rejection in 1 patient, and a cardiac event in 1 patient. Twenty late deaths (>30 days post-transplant) occurred. Of those, 5 were from multisystem organ failure, 5 from pulmonary complications, and 2 from fungal infection. Rejection and bronchiolitis obliterans accounted for 2 deaths each. The cause of death was a cardiac event in 1 patient and was not recorded in the remaining 3. Four patients were re-transplanted. Fifty-five patients (70%) were alive at a mean follow-up of 37 months (range 0–128 months). The actuarial Kaplan-Meier survival was 85.75% at 1 year, 76.35% at 3 years, and 64.91% at 5-years. Log-rank analysis showed a statistically significant difference in the survival rate of LAM patients compared with a historical group of patients who had transplantation for all lung conditions during the same period (45.12%, p = 0.0012). Transplant era, type of transplant, donor gender, ischemia time of more than 4 hours, age more than 40 years, and donor/recipient cytomegalovirus did not impact survival. Conclusions Lung transplantation is a valuable therapeutic option for patients with end-stage pulmonary LAM. Transplantation offers survival rates that are equivalent to or better than those of patients who received a lung transplant for other indications.

A localized thrombus involving the ascending aorta and arch rarely occurs in the absence of an underlying etiology such as chest trauma, atherosclerosis, a hypercoagulable state or instrumentation. A review of the literature between 1966 - 2003 yielded 38 reported cases of localized aortic arch thrombi, 21 of which were treated by surgical excision of the thrombus using different approaches. In this communication, we describe this clinical entity, with its diagnosis and management. The technical details that are important to ensure the safe conduct of the procedure are discussed.

Multiple randomized trials support the treatment of patients with multivessel coronary artery disease (CAD) and relatively normal left ventricular (LV) ejection fraction (EF) by either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). However, there has been a paucity of trials in the recent literature that have compared the outcomes of patients with multivessel CAD and low EF who undergo PCI or CABG. This review examines some of the clinical trials and series in this subgroup of patients and also compares the outcome of patients undergoing either procedure in the absence and presence of LV dysfunction. These trials and series support the notion that PCI can be successfully performed in patients with low EF with relatively low mortality, but that CABG is associated with greater freedom from repeat revascularization and from angina or congestive heart failure symptoms. In addition, most of the data published thus far indicate a long-term survival advantage among patients with ventricular dysfunction who have undergone CABG. Further studies, including randomized trials incorporating the evolving techniques of CABG and the recent advances in PCI, will be needed to assess the proper role and outcome of these two interventions.

Primary neuroendocrine tumors of the thymus are highly aggressive tumors that rarely occur. A little more than 200 cases have been reported, many of which were single case reports. Only a few articles contained modest series from single centers for analysis. A review of 157 cases collected from the major series reported to-date show a clinical pattern with male preponderance (male:female ratio, 3:1) and a mean age of 54 years. Most patients presented with symptoms and signs of local compression. Almost 50% of these tumors were functionally active and were associated with endocrinopathies. Several histologic variants have been described, all with similar ultrastructural features. The biologic behavior of these tumors shows a direct relation to the degree of differentiation. Whenever possible, surgical resection is the treatment of choice as adjuvant therapy is controversial and has been used with variable success. Potential therapies exploit the presence of somatostatin receptors on a variety of these tumors. Use of radiolabeled Octreotide for radionuclide therapy has yielded tumor inhibition in animal models and may have clinical application. Fifty-one percent of the patients survived 3 years, 27% survived 5 years, and less than 10% survived beyond 10 years. Histologic grade, tumor extension, and early detection are the most important factors affecting survival. Other prognostic factors that impact outcome include presence of endocrinopathy, incomplete resectability, nodal status, and presence of distant metastasis.

Coronary artery bypass grafting has been utilized as a beneficial treatment for myocardial ischemic disease for over three decades. Failure of coronary artery venous grafts occurs at a substantial rate and has a large impact on two main endpoints, survival and quality of life. An exhaustive amount of basic research has been generated to delineate possible mechanisms responsible for graft failure and modalities to prevent its occurrence. Although pharmacotherapy exists, insufficient translation has emerged from the bench to the operating room. In this article, we review the literature regarding the current mechanisms and mediators including growth factors, nitric oxide and genetics leading to saphenous vein graft occlusion. The review addresses the current state of affairs and modes for prevention of vein graft failure perioperatively and newer technologies that may help ameliorate this problem in the future.

A review of the published world experience with heart transplantation for iron overload cardiomyopathy (IOC) between 1967 and 2003 as well as review of unpublished cases from the database of the United Network for Organ Sharing since 1992, identified a total of 16 patients (14 men and 2 women). Mean age was 31 years (range, 14-63 years). IOC etiology was hemochromatosis in 11 patients (69%), thalassemia major in 4 (25%), and Diamond-Blackfan anemia in 1 (6%). The 30-day mortality was 12%. Three patients (19%) died within 1 year of the transplant, all of infectious complications. An additional patient died at 7.14 years (unknown cause). The actuarial Kaplan-Meier 1-, 3-, and 5-year survival rates were 81% for all 3 time intervals. The actuarial 10-year survival was 41%.

Upper thoracic (T2-T3 or T2-T4) sympathectomy with preservation of the stellate ganglion is routinely used for treatment of palmar and axillary hyperhydrosis and also for relief of advanced cutaneous vasoconstriction of the fingers and hand in patients with Raynaud disease. Thoracic sympathectomy has also been advocated and used as a last resort for patients with refractory angina pectoris and those with sustained ventricular tachyarrhythmias that are not responsive to more standard medical and surgical therapy. To our surprise, an extensive MEDLINE search of the world literature from 1966 to date showed no published data on the use of extended thoracic sympathectomy for treatment of hyperhydrosis of the torso, particularly for patients with spinal cord injuries. In this communication we describe the surgical outcome of bilateral extended thoracic (T2-T6) sympathectomy in a man with paraplegia and hyperhydrosis of the torso.

Shingles secondary to reactivation of a previous varicella-zoster virus infection has been reported to develop within surgical wounds and after trauma. We report the case of a 17-year-old girl with history of chicken pox in childhood who had acute postoperative shingles develop along the T3-T4 dermatomes after thoracic sympathectomy for hyperhidrosis. The possible causes and precipitating factors are discussed.

Purpose: Ischemic injury of the saphenous vein graft (SVG) during temporary storage prior to implantation in coronary bypass grafting (CABG) is believed to contribute to SVG thrombosis and stenosis. We aimed to show that; cellular apoptosis in endothelial and smooth muscle cells of the SVG is amplified by the short-term preservation, and that pyruvate-based preservation reduces the degree of cellular apoptosis as compared to other media. Methods: 5-cm SVG segments were taken from 14 patients undergoing CABG. Each 5-cm segment was then subdivided into five 1-cm units (totalling 70 units). For each patient, the first of the five subunits became the control and was immediately examined for apoptosis. These units did not undergo storage. The other four segments were stored at 20°C for 1-hour in one of the following solutions: Normal saline, Euro-Collins (EC), University of Wisconsin solution (UWS) or a 10mM pyruvate solution. Apoptotic cells were detected by terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL assay) and the Student’s t-test was used for comparison. To minimize variability, each patient served as his/her own control. Results: Mean (SEM) number of TUNEL positive cells was similar in segments preserved with pyruvate when compared to Controls (4.00 ± 0.47% versus 4.03 ± 0.40%). When these compared by Student’s t-test, there was no significant difference in the number of apoptotic cells among 10/14 patients (71%). Pyruvate preserved segments had significantly less apoptosis (p < 0.05) in 10/14 patients (71%) when compared to normal saline, in 7/14 patients (50%) when compared to EC, and in 3/14 patients when compared to UWS. Conclusions: Procurement of SVGs is associated with a measurable degree of cellular apoptosis and cellular apoptosis is amplified by the short-term preservation. However, pyruvate preserved SVGs had less cell damage when compared to those preserved in other media and where similar to controls.

An unusual case of a penetrating intracardiac injury is described in a 16-year-old boy who presented with a retained 14-cm segment of an ice pick that went unnoticed by the patient for 4 days. The ice pick had lacerated the anterior papillary muscle of the left ventricle causing avulsion of its tip and prolapse of the anterior leaflet of the mitral valve resulting in severe mitral regurgitation. The urgency for surgical correction of the traumatic mitral valve injury at the time of extraction of the intracardiac foreign body through a single-stage approach versus a two-stage approach is discussed.