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This chapter investigates bacterial meningitis. Meningitis is the inflammation of the meninges, mainly the inner meninges comprised of the arachnoid and pia mater, which surround the brain and spinal cord and through which cerebrospinal fluid (CSF) flows. Meningitis can be caused by viral, bacterial, fungal, or parasitic infections or by noninfectious etiologies such as medications, inflammatory diseases, and malignancies, as well as autoimmune disorders. Bacterial meningitis occurs most commonly by hematogenous spread but can also occur by direct invasion from the sinuses, ear, or post-operatively. Rates of bacterial meningitis in the Unites States have declined significantly in the past decades. This trend is largely due to availability of effective vaccines against the most common pathogens and education of high-risk populations. Despite this decline, the case fatality rate of bacterial meningitis in the US has remained fairly stable but varies depending on pathogen and host factors.

An important tenet of competency-based medical education is that the educational continuum should be seamless. The transition from undergraduate medical education (UME) to graduate medical education (GME) is far from seamless, however. Current practices around this transition drive students to focus on appearing to be competitively prepared for residency. A communication at the completion of UME-an educational handover-would encourage students to focus on actually preparing for the care of patients. In April 2018, the American Medical Association's Accelerating Change in Medical Education consortium meeting included a debate and discussion on providing learner performance measures as part of a responsible educational handover from UME to GME. In this Perspective, the authors describe the resulting 5 recommendations for developing such a handover: (1) The purpose of the educational handover should be to provide medical school performance data to guide continued improvement in learner ability and performance, (2) the process used to create an educational handover should be philosophically and practically aligned with the learner's continuous quality improvement, (3) the educational handover should be learner driven with a focus on individualized learning plans that are coproduced by the learner and a coach or advisor, (4) the transfer of information within an educational handover should be done in a standardized format, and (5) together, medical schools and residency programs must invest in adequate infrastructure to support learner improvement. These recommendations are shared to encourage implementation of the educational handover and to generate a potential research agenda that can inform policy and best practices.

This plain language summary explains nosebleeds, also known as epistaxis (pronounced ep-ih-stak-sis), to patients. The summary applies to any individual aged 3 years and older with a nosebleed or history of nosebleed who needs medical treatment or wants medical advice. It is based on the 2020 "Clinical Practice Guideline: Nosebleed (Epistaxis)." This guideline uses research to advise doctors and other health care providers on the diagnosis, treatment, and prevention of nosebleeds. The guideline includes recommendations that are explained in this summary. Recommendations may not apply to every patient but can be used to help patients ask questions and make decisions in their own care.

Objectives Postoperative hemorrhage is a serious complication of tonsillectomy, with secondary bleeding rates affecting up to 0.8% to 3% of patients. Although these bleeds are anecdotally perceived as occurring more frequently at night, the occurrence of hemorrhage relative to the time of day has not been investigated. We measured the frequency of post-tonsillectomy hemorrhage onset relative to the time of day. Methods We reviewed electronic medical records of all patients who experienced postprocedural hemorrhage (International Classification of Disease, Ninth Edition [ICD-9] 998.11, ICD-10 J95.830 at two hospitals within a tertiary academic health system in a 10-year period). Patient demographics, time of bleed onset, emergency room [ED] arrival time, and management (operating room vs. observation) were abstracted. Patients without a recorded bleeding time were excluded. Time of bleed onset was categorized as morning (6:01 am-12 pm), afternoon (12:01 pm-6 pm), evening (6:01 pm-12 am), or overnight (12:01 am-6 am). Chi-square goodness of fit test was used to assess the distribution of hemorrhage timing (P ≤ 0.05). Results A total of 7,396 patients underwent tonsillectomy May 2008 through May 2018, among whom 121 (2%) post-tonsillectomy hemorrhage patients were identified. Among the 104 patients with ED arrival times, 29 (28%) arrived in the morning; 15 (14%) arrived in the afternoon; 40 (38%) arrived in the evening; and 20 (19%) arrived overnight (P = 0.003). Sixty patients (mean age 17.1 years, standard deviation 16.6) had a recorded timing of bleed onset. Bleed onset occurred most commonly overnight (24, 40%), followed by evening (21, 35%), afternoon (11, 18%), and morning (4, 7%) (P = 0.0007). Conclusion In this cohort, post-tonsillectomy hemorrhage occurred most frequently between midnight and 6 am. Our findings confirm anecdotal experience and provide data in setting caregiver expectations. Level of evidence 4 Laryngoscope, 130:1823-1827, 2020.

To develop a clinical consensus statement on the use of balloon dilation of the eustachian tube (BDET).An expert panel of otolaryngologists was assembled with nominated representatives of general otolaryngology and relevant subspecialty societies. The target population was adults 18 years or older who are candidates for BDET because of obstructive eustachian tube dysfunction (OETD) in 1 or both ears for 3 months or longer that significantly affects quality of life or functional health status. A modified Delphi method was used to distill expert opinion into clinical statements that met a standardized definition of consensus.After 3 iterative Delphi method surveys, 28 statements met the predefined criteria for consensus, while 28 statements did not. The clinical statements were grouped into 3 categories for the purposes of presentation and discussion: (1) patient criteria, (2) perioperative considerations, and (3) outcomes.This panel reached consensus on several statements that clarify diagnosis and perioperative management of OETD. Lack of consensus on other statements likely reflects knowledge gaps regarding the role of BDET in managing OETD. Expert panel consensus may provide helpful information for the otolaryngologist considering the use of BDET for the management of patients with OETD.

Rapid response teams have become necessary components of patient care within the hospital community, including for airway management. Pediatric patients with an increased risk of having a difficult airway emergency can often be predicted on the basis of clinical scenarios and medical history. This predictability has led to the creation of airway consultation services designed to develop airway management plans for patients experiencing respiratory distress and who are at risk for having a difficult airway requiring advanced airway management. In addition, evolving technology has facilitated airway management outside of the operating suite. Training and continuing education on the use of these tools for airway management is imperative for clinicians responding to airway emergencies. We describe the comprehensive multidisciplinary, multicomponent Pediatric Difficult Airway Program we created that addresses each component identified above: the Pediatric Difficult Airway Response Team (PDART), the Pediatric Difficult Airway Consult Service, and the pediatric educational airway program. Approximately 41% of our PDART emergency calls occurred in the evening hours, requiring a specialized team ready to respond throughout the day and night. A multitude of devices were used during the calls, obviating the need for formal education and hands-on experience with these devices. Lastly, we observed that the majority of PDART calls occurred in patients who either were previously designated as having a difficult airway and/or had anatomic variations that suggest challenges during airway management. By instituting the Pediatric Difficult Airway Consult Service, we have decreased emergent Difficult Airway Response Team calls with the ultimate goal of first-attempt intubation success.

OBJECTIVES/HYPOTHESIS To quantify otolaryngologic surgery utilization in patients with achondroplasia, and to identify any changes in utilization over the past four decades. STUDY DESIGN Retrospective cohort study. METHODS A retrospective cohort study of 1,374 patients with achondroplasia enrolled in the CLARITY retrospective cohort study at four centers of multi-specialty care for patients with achondroplasia. Otolaryngologic surgeries are presented by birth cohort decade. The main outcomes were number of primary and additional otolaryngologic procedures; age at surgery; likelihood of repeated surgery; temporal trends in surgical utilization. RESULTS In this cohort of 1,374 patients with achondroplasia, 620 (45.1%) had pharyngeal surgery at least once, 150 (10.9%) had pharyngeal surgery on more than one occasion, and patients who had adenoidectomy first were 2.68 times more likely to require a second pharyngeal surgery than those who had adenotonsillectomy. Seven hundred and seventy-nine (56.7%) had tympanostomy tubes placed at least once, and 447 (32.5%) had tympanostomy tubes placed more than one time. Age at first pharyngeal surgery decreased by 1.2 years per birth cohort decade, and age at tympanostomy tube placement decreased by 1.1 years per decade. CONCLUSIONS Patients with achondroplasia often require otolaryngologic surgery, particularly adenoidectomy and/or tonsillectomy as well as tympanostomy tube placement. Such surgery is performed now more frequently and at younger ages than in earlier decades. While otolaryngologic disease associated with achondroplasia is now recognized earlier and treated more frequently, long-term outcome studies are needed. LEVEL OF EVIDENCE 3 Laryngoscope, 2021.

Few validated methods that are grounded in educational theory exist to effectively teach medical knowledge, clinical skills, and diagnostic reasoning to learners at different stages of medical training. The goal of this Perspective was to address potential gaps in clinical education pedagogy by modeling new concepts for teaching in the field of infectious diseases. Our approach involved synthesizing the relevant literature, identifying proven approaches, and enhancing an existing educational microskills model — the one-minute preceptor. Our strategy was to emphasize the essential core elements of the one-minute preceptor using a descriptive acronym — DEFT (Diagnosis, Evidence, Feedback, Teaching), meaning skillful — as a potentially helpful reminder to improve the quality of interactions between learners and preceptors. The need for learners to discuss risk factors, mechanisms of disease, and potential complications, and for preceptors to model analytical and diagnostic skills, was further illustrated using a practical example of a teacher–learner interaction about a child with a respiratory infection. The one-minute preceptor/DEFT approach is experiential, adaptable, case-driven, and skills-focused, and also applicable to clinical training in other specialties.

SummaryBackgroundSchool-based COVID-19 contacts in England are asked to self-isolate at home. However, this has led to large numbers of missed school days. Therefore, we trialled daily testing of contacts as an alternative, to investigate if it would affect transmission in schools.MethodsWe performed an open-label cluster randomised controlled trial in students and staff from secondary schools and further education colleges in England (ISRCTN18100261). Schools were randomised to self-isolation of COVID-19 contacts for 10 days (control) or to voluntary daily lateral flow device (LFD) testing for school contacts with LFD-negative contacts remaining at school (intervention). Household contacts were excluded from participation.Co-primary outcomes in all students and staff were symptomatic COVID-19, adjusted for community case rates, to estimate within-school transmission (non-inferiority margin: FindingsOf 99 control and 102 intervention schools, 76 and 86 actively participated (19-April-2021 to 27-June-2021); additional national data allowed most non-participating schools to be included in the co-primary outcomes. 2432/5763(42.4%) intervention arm contacts participated. There were 657 symptomatic PCR-confirmed infections during 7,782,537 days-at-risk (59.1/100k/week) and 740 during 8,379,749 days-at-risk (61.8/100k/week) in the control and intervention arms respectively (ITT adjusted incidence rate ratio, aIRR=0.96 [95%CI 0.75-1.22;p=0.72]) (CACE-aIRR=0.86 [0.55-1.34]). There were 55,718 COVID-related absences during 3,092,515 person-school-days (1.8%) and 48,609 during 3,305,403 person-school-days(1.5%) in the control and intervention arms (ITT-aIRR=0.80 [95%CI 0.53-1.21;p=0.29]) (CACE-aIRR 0.61 [0.30-1.23]). 14/886(1.6%) control contacts providing an asymptomatic PCR sample tested positive compared to 44/2981(1.5%) intervention contacts (adjusted odds ratio, aOR=0.73 [95%CI 0.33-1.61;p=0.44]). Rates of symptomatic infection in contacts were 44/4665(0.9%) and 79/5955(1.3%), respectively (aOR=1.21 [0.82-1.79;p=0.34]).InterpretationDaily contact testing of school-based contacts was non-inferior to self-isolation for control of COVID-19 transmission. COVID-19 rates in school-based contacts in both intervention and control groups were

Introduction In recent years, several methods have been described for the treatment of deep Miller Class II recessions. Most of these techniques concentrate on single recessions or one deep recession accompanied by just slight neighboring root denudations. A modified technique is presented for treating two or more deep recessions beyond the mucogingival margin combining a subepithelial connective tissue graft (SCTG), enamel matrix derivative, and a multiple pedicle coronally advanced flap. To the best of our knowledge, this is the first report to describe the treatment of multiple deep Miller Class II recessions exceeding beyond the mucogingival junction using a pedicled advanced flap. Case presentation A 29-year-old woman was referred to the periodontal practice of JT for the treatment of progressive deep Miller Class II recessions. The root coverage procedure was performed by a modified multiple pedicle flap combined with a connective tissue graft harvested from the palate and enamel matrix derivative. The case was followed up for 2 years. Conclusions This modified technique of a multiple pedicled flap is a feasible and useful method for treating several deep neighboring recessions. Due to the improved incision techniques, scar tissue formation might be reduced not to interfere with the esthetic result.

Background The goal of this study was to determine if difficult airway risk factors were similar in children cared for by the difficult airway response team (DART) and those cared for by the rapid response team (RRT). Methods In this retrospective database analysis of prospectively collected data, we analyzed patient demographics, comorbidities, history of difficult intubation, and intubation event details, including time and place of the emergency and devices used to successfully secure the airway. Results Within the 110-patient cohort, median age (IQR) was higher among DART patients than among RRT patients [8.5 years (0.9-14.6) versus 0.3 years (0.04-3.6); P < 0.001]. The odds of DART management were higher for children ages 1-2 years (aOR, 43.3; 95% CI: 2.73-684.3) and >5 years (aOR, 13.1; 95% CI: 1.85-93.4) than for those less than one-year-old. DART patients were more likely to have craniofacial abnormalities (aOR, 51.6; 95% CI: 2.50-1065.1), airway swelling (aOR, 240.1; 95% CI: 13.6-4237.2), or trauma (all DART managed). Among patients intubated by the DART, children with a history of difficult airway were more likely to have musculoskeletal (P = 0.04) and craniofacial abnormalities (P < 0.001), whereas children without a known history of difficult airway were more likely to have airway swelling (P = 0.04). Conclusion Specific clinical risk factors predict the need for emergency airway management by the DART in the pediatric hospital setting. The coordinated use of a DART to respond to difficult airway emergencies may limit attempts at endotracheal tube placement and mitigate morbidity.

Perhaps now more than any time in history, anonymous threatening communications (ATCs) are easily delivered, highly disruptive, and frequently used by offenders who seek to frighten, harass, and intimidate their victims. The ability to quickly and defensibly triage and evaluate ATCs has become a necessary skill for threat assessment professionals who serve on corporate security, education, or community-based teams. In this chapter, the authors (both former members of the FBI’s Behavioral Analysis Unit) provide a step-by-step operational guide for the analysis of ATCs. The methods and strategies shared by the authors can be easily adopted and used by threat assessors to confidently address this growing challenge.

ObjectiveOpioid use disorder (OUD), which includes the morbidity of dependence and mortality of overdose, has reached epidemic proportions in the United States. Overprescription of opioids can lead...

Objectives/hypothesis Adenotonsillectomy is first-line treatment for pediatric obstructive sleep apnea syndrome (OSAS) when not otherwise contraindicated. There is concern severe OSAS increases risk of comorbid cardiopulmonary abnormalities, such as ventricular hypertrophy or pulmonary hypertension, which preoperative testing could detect. Our objective is to determine if there is a severity of pediatric OSAS where previously undetected cardiopulmonary comorbidities are likely. Study design Retrospective chart review. Methods We performed a retrospective review of 358 patients ≤21 years with severe OSAS who underwent adenotonsillectomy at a tertiary hospital June 1, 2016 to June 1, 2018. We extracted demographics, comorbidities, polysomnography, and preoperative tests. Wilcoxon rank-sum and logistic regression estimated associations of OSAS severity (based on obstructive apnea-hypopnea index [OAHI], hypoxia, hypercarbia) with preoperative echocardiograms and chest X-rays (CXRs). Results Mean age was 5.9 (±3.6) years and 52% were male. Mean OAHI and oxygen saturation nadir were 30.3 (±23.8) and 80.7% (±9.2), respectively. OAHI ≥60 was associated with having a preoperative echocardiogram (OR, 3.8; 95% CI, 1.7-8.5) or CXR (OR, 3.0; 95% CI, 1.4-6.8) compared to OAHI 10-59. There were no significant associations between OSAS severity and test abnormalities. The presence of previously diagnosed cardiopulmonary comorbidities was associated with abnormalities on echocardiogram (OR, 36; 95% CI, 4.1-320.1) and CXR (OR, 4.1; 95% CI, 1.2-14.4). Conclusions Although pediatric patients with very severe OSAS (OAHI ≥60) underwent more pre-adenotonsillectomy cardiopulmonary tests, OSAS severity did not predict abnormal findings. Known cardiopulmonary comorbidities may be a better indication for cardiopulmonary testing than polysomnographic parameters, which could streamline pre-adenotonsillectomy evaluation and reduce cost. Level of evidence 4 Laryngoscope, 131:2361-2368, 2021.

Supplemental material, sj-pdf-1-pss-10.1177_0956797621993104 for Parents Fine-Tune Their Speech to Children’s Vocabulary Knowledge by Ashley Leung, Alexandra Tunkel and Daniel Yurovsky in Psychological Science

Every transaction has the potential to go wrong and international commercial contracts are not spared this plight. It is when an international commercial contract fails – irrespective of the reasons, that the impact of different legal and cultural backgrounds of the parties come to light. The obvious venue for commercial disputes to be decided is generally understood to be in court (litigation) or before an arbitral tribunal (arbitration). However, there are numerous other alternative dispute mechanisms4 available to parties that are less well known and also deserve consideration; not least because they offer parties methods of resolving the dispute between them in a more time and cost-efficient manner, and with a stronger focus on the commercial interest of the parties. Mediation is one of these mechanisms. This chapter provides an overview of the basic concepts of mediation; how it distinguishes itself from but can also be employed together with other dispute resolution mechanisms such as, in particular, arbitration; the legal framework; and practical guidelines when drafting a mediation agreement in the context of international commercial contracts.

Context: Performance metrics are a core component of the evaluation of any machine learning model and used to compare models and estimate their usefulness. Recent work started to question the validity of many performance metrics for this purpose in the context of software defect prediction. Objective: Within this study, we explore the relationship between performance metrics and the cost saving potential of defect prediction models. We study whether performance metrics are suitable proxies to evaluate the cost saving capabilities and derive a theory for the relationship between performance metrics and cost saving potential. Methods: We measure performance metrics and cost saving potential in defect prediction experiments. We use a multinomial logit model, decision, and random forest to model the relationship between the metrics and the cost savings. Results: We could not find a stable relationship between cost savings and performance metrics. We attribute the lack of the relationship to the inability of performance metrics to account for the property that a small proportion of very large software artifacts are the main driver of the costs. Conclusion: Any defect prediction study interested in finding the best prediction model, must consider cost savings directly, because no reasonable claims regarding the economic benefits of defect prediction can be made otherwise., Comment: Under review