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Arthrobacter phage Iter was isolated in North Georgia. Its genome is 43,963 bp with 70 open reading frames (ORFs) and a GC content of 67.4%. It shares 89.11% nucleotide identity with Arthrobacter phage Phives. Actinobacteriophages that share over 50% nucleotide identity are sorted into clusters, with Iter in cluster AZ.

This cohort study of patients at a single integrated health system examines trends in COVID-19–related treatment location and mortality.

Heart failure (HF) is a chronic condition causing nearly 1 million hospital admissions annually in the United States with 25% of patients rehospitalized within 30 days.The purpose of this study was to investigate whether telemanagement of HF patients throughout the post-acute continuum of care would reduce rehospitalization rates and improve patient self-care knowledge and satisfaction.HF patients discharged to a skilled nursing facility (SNF) received telemanagement by HF clinicians with opportunity for continuation at home with assistance of home healthcare (HHC) nurses. Wireless sensors worn at SNF and home captured continuous health information visible to HF clinicians on secure cloud database. Point-of-care devices were available at SNF. Patients had scheduled and as-needed video visits with audio and auscultation capacity with HF clinician. HF education was provided by SNF and HHC nursing. Patients were compared with historical control group receiving standard care at same SNF.Patients receiving telemanagement had 29% lower rehospitalization rates (17% vs. 24%), despite higher predicted rehospitalization risk. Median age was 81. Seven of eight patients who were rehospitalized in the telemanagement group had advanced HF symptoms (New York Heart Association Class IV). Five patients in telemanagement group were receiving continuous inotrope infusions. Patients reported good satisfaction and self-care knowledge.Reduction of rehospitalization rates was clinically significant in population of advanced age and HF symptoms. Technology enhanced communication content and timeliness across the post-acute care continuum.Post-acute telemanagement may reduce rehospitalization rates even in high-risk, older HF populations.

BACKGROUND: Otitis media (OM) susceptibility has significant heritability, however the role of rare variants in OM is mostly unknown. Our goal is to identify novel rare variants that confer OM susceptibility. METHODS: We performed exome and Sanger sequencing of >1,000 DNA samples from 551 multi-ethnic families with OM and unrelated individuals, RNA-sequencing, and microbiome sequencing and analyses of swabs from the outer ear, middle ear, nasopharynx and oral cavity. We also examined protein localization and gene expression in infected and healthy middle ear tissues. RESULTS: A large, intermarried pedigree that includes 81 OM-affected and 53 unaffected individuals co-segregates two known rare A2ML1 variants, a common FUT2 variant and a rare, novel pathogenic variant c.1682A>G (p.Glu561Gly) within SPINK5 (LOD=4.09). Carriage of the SPINK5 missense variant resulted in increased relative abundance of Microbacteriaceae in the middle ear, along with occurrence of Microbacteriaceae in the outer ear and oral cavity but not the nasopharynx. Eight additional novel SPINK5 variants were identified in twelve families and individuals with OM. A role for SPINK5 in OM susceptibility is further supported by lower RNA counts in variant carriers, strong SPINK5 localization in outer ear skin, faint localization to middle ear mucosa and eardrum, and increased SPINK5 expression in human cholesteatoma. CONCLUSION: SPINK5 variants confer susceptibility to non-syndromic OM. These variants potentially contribute to middle ear pathology through breakdown of mucosal and epithelial barriers, immunodeficiency such as poor vaccination response, alteration of head and neck microbiota, and facilitation of entry of opportunistic pathogens into the middle ear.

Supplemental material, Sup_Material_908115_-_Prediction_of_readiness_to_decannulation_from_venovenous_extracorporeal_membrane_oxygenation for Prediction of readiness to decannulation from venovenous extracorporeal membrane oxygenation by Emma L Hartley, Barnaby Sanderson, Francesco Vasques, Kathleen JR Daly, Maria Lozinski, Nicholas A Barrett and Luigi Camporota in Perfusion

BACKGROUND The last decade has seen an increase in the number of centres able to provide venovenous extracorporeal membrane oxygenation (VV-ECMO) internationally across different health care systems. To support this growth, a variety of staffing arrangements have been adopted depending on local need and availability of resources, both in terms of manpower and finances to safely meet the complex needs of the patient and circuit management. AIM The aim of the survey was to describe current staffing arrangements of care provision for adult patients on VV-ECMO, with a focus on understanding the professional roles and responsibilities of staff managing the circuit in order to inform further discussion around different approaches to staffing. METHODS We conducted a cross-sectional international survey using an electronic questionnaire emailed to 177 worldwide ECMO centres treating adult patients with acute respiratory failure. The survey questions were generated through an internal and external iterative process and assessed for clarity, content and face validity. RESULTS The response rate was 82%. Respondents managed extracorporeal oxygenation for adult respiratory alone (75%) or in combination with adult cardiac (67%), paediatric respiratory (62%) and paediatric cardiac (58%). The specialist nurse to patient ratio was 1:1 in 59% of centres, with 24-h/day presence in 74%. Overall, the specialist nurse provided the 24-h/day management of the circuit, including interventions. Perfusionists were responsible for the technical aspects of circuit management. CONCLUSIONS A specialist nurse with perfusion backup is the staffing arrangement implemented by most centres and likely reflects the most efficient use of the professional competences available. RELEVANCE TO CLINICAL PRACTICE Staffing for adult respiratory extracorporeal support has important implications for the planning of workforce, training and education, quality of service and the number of ECMO beds available.

Community integration is recognized as a crucial component of recovery from serious mental illness. Although the construct of community integration can be measured with structured instruments, little is known about the subjective and experiential meaning of community and community involvement for persons with serious mental illness.In 2010, 30 individuals with serious mental illness treated in two public mental health clinics completed semistructured interviews that elicited the places and people that they associate with the experience of community and the larger meaning of community in their lives.Participants described four experiences as integral to their concepts of community: receiving help, minimizing risk, avoiding stigma, and giving back. Participants looked for communities that provide reliable support, and they described the need to manage community contact in order to protect themselves and others from their symptoms and from discrimination. Most participants experienced communities centered on mental health treatment or mentally ill peers as providing opportunities for positive engagement.The experience of having a serious mental illness shapes preferences for and perceptions of community in pervasive ways. Participants described community involvement not as a means to move away from illness experiences and identities but as a process that is substantially influenced by them. Mental health communities may help individuals with serious mental illness to both manage their illness and recognize and enjoy a sense of community. The findings indicate the need for further research on the relationship between community integration and outcome in serious mental illness.

The prone position has been used successfully for many years to improve oxygenation in patients who require mechanical ventilatory support for management of acute respiratory distress syndrome (ARDS). Proning improves oxygenation by optimizing lung recruitment and ventilation–perfusion matching. The following improved outcomes have been shown: when the prone position is used for moderate to severe ARDS; when used in combination with protective lung ventilation; and when the duration of the proning session is >16 h. 1 However, proning is not without contraindications and complications. 2 There are only two absolute contraindications to proning, which are suspected raised intracranial pressure and spinal instability. Some high-risk relative contraindications that may preclude proning include: recent sternotomy, facial surgery, and severe haemodynamic instability. Other relative contraindications include an open abdomen, pregnancy, and multiple traumas with unstable fractures. Respiratory ECMO is not a contr...

Extracorporeal membrane oxygenation (ECMO) is a highly complex, resource-intensive intervention. The use of veno-venous ECMO for the management of patients with acute, reversible lung failure has increased significantly over the past 10 years. 1 Advances in ECMO technology have resulted in the development of simpler, safer circuits, which are associated with fewer complications. Concomitantly with the clinical and technological changes in ECMO, the role of the ECMO specialist has evolved to manage patient–circuit interaction and the clinical needs of the patient, and to ensure safety of the ECMO circuit through continuous surveillance, assessment and troubleshooting, as well as preventing and managing circuit emergencies. The Extracorporeal Life Support Organization (ELSO) defines the specialist as “the technical specialist trained to manage the ECMO system and clinical needs of the patient on ECMO under direction and supervision of an ECMO trained physician”. 2 Internationally, specialists come from a ra...

Purpose: Bedside newborn hearing screening is highly successful in identifying deaf or hard-of-hearing infants. However, newborn hearing screening protocols have high loss to follow-up rates. We propose that bloodspot-based genetic testing for GJB2 alleles can provide a means for rapid confirmation in a subset of infants who fail bedside newborn hearing screening. Methods: We performed a case-control study comparing the prevalence of common GJB2 mutations from deidentified bloodspots designated as “refer” by newborn hearing screening and contemporaneously selected randomly chosen controls designated as “pass.” Between March 2006 and December 2007, 2354 spots were analyzed for common alleles, c.35delG, c.167delT, c.235delC, and p.V37I in GJB2 with a subset reanalyzed by conventional Sanger sequencing to search for additional alleles. Results: The prevalence of biallelic GJB2 mutations in bloodspots from infants who referred by newborn hearing screening is approximately 1 in 50 (23/1177). In contrast, one bloodspot from an infant who passed newborn hearing screening was identified to harbor biallelic GJB2 mutations. Conclusions: These findings show that when a newborn refers by newborn hearing screening, there is a significant chance that GJB2-related hearing loss is present. Bloodspot-based genetic testing for common GJB2 alleles should be considered as second tier testing for bedside newborn hearing screening.

The 2007 Recent Advances in Otitis Media Research Conference Panel Report provides an update on otitis media (OM) research published from 2003 to 2007. This report summarizes important trends in disease incidence and prevalence, describes established and newly identified risk factors for acute and chronic OM and OM with effusion, and conveys information on newly discovered genetic factors. In this report, researchers have described declining rates of OM diagnosis, antibiotic prescriptions, offices visits for OM, and middle ear surgery since the licensure and routine use of pneumococcal conjugate vaccine in infants. The panel report also recommends short and long term goals for current and future OM research.

Summary Otitis media with effusion (OME) is a condition that has significant impact on the quality of life of children. Although the etiology is multi-factorial, certain risk factors such as an allergic predisposition, daycare, and cigarette smoke exposure contribute to its pathogenesis. Objective (1) To determine whether there is a tendency for children with chronic or recurrent OME (cases) to have higher serum levels of the T-helper 2 cell (Th-2) allergenic-type cytokines, interleukin-4 (IL-4), and IL-5, or the T-helper 1(Th-1) infectious-type cytokines, interferon-γ (IFN-γ), and tumor necrosis factor-α (TNF-α), compared to children without a history of recurrent OME (controls) and (2) to determine any possible correlations between the cytokine levels and risk factors associated with OME. Methods We analyzed serum levels of these four cytokines by enzyme-linked immunosorbent assays of 19 cases and 17 controls. Results Cases, independent of age, had increased levels of serum IL-5 compared to controls ( p = 0.014). While a significant difference in serum IL-4 levels did not exist between cases and controls, children exposed to cigarette smoke had significantly higher levels of serum IL-4 ( p = 0.003). While serum levels of IFN-γ were statistically significantly higher in cases than controls with univariate analysis ( p = 0.011), when controlling for age and smoke exposure with multivariate analyses, the difference did not reach significance ( p = 0.086). Conclusion These results suggest that patients with chronic or recurrent OME and those exposed to cigarette smoke mount a Th-2 allergic-like response, as demonstrated by their serum cytokines.

Summary American Indian children have three times the rate of otitis media compared to the general population, yet prospective cohort studies of OME and hearing loss have not been previously reported in American Indian infants. Between 1997 and 2003, a cohort of 421 infants was enrolled at birth from Minnesota American Indian reservations and an urban clinic and followed to age 2 years. This study reports OAE hearing screening results related to OME diagnoses, as well as risk for recurrent hearing screening failure and OME in American Indian infants and children. Methods Infants were prospectively assessed at regular intervals with pneumatic otoscopy, distortion product otoacoustic emissions, and tympanometry by nurses who were trained in all procedures and validated on pneumatic otoscopy. Results In the newborn period, 23.5% of infants failed hearing screening in at least one ear. Hearing screening failures increased to 29.9% from 2 to 5 months of age. Technical fail results due to excessive noise occurred frequently in infants 6–24 months of age, making interpretation of true pass and fail rates questionable in older infants. OAE test result was associated with OM diagnosis, and this relationship strengthened with age, with the strongest association above 6 months of age. Conclusions A high rate of hearing screening failures occurred among American Indian infants in the first 5 months of age, and was significantly associated with a correspondingly high rate of otitis media. Only one infant out of 366 was identified with sensorineural hearing loss, thus essentially all of the hearing screening failures reflected either a middle ear origin or other temporary problems. OAE screening provided a valuable hearing screening measure in this population at high risk for recurrent otitis media, but due to excessive noise in infants 6 months and older, practical use of OAE screening is limited. Use of behavioral assessment is needed after 6 months of age, when high rates of OME persist in this population. Increased efforts to develop public and medical education, as well as screening, diagnosis and treatment programs are needed to detect and decrease recurrent OME in American Indian infants and children.

Ethnicity has been previously described as a risk factor for middle ear disease. Little data exist on the presence of middle ear disease based on tympanometry screening comparing Asian children and children of other races.Two hundred and seventy children aged 3-5 were screened with tympanometry at six Head Start sites in St. Paul, Minnesota during the months of September and October of 2004. Gender, age, and race/ethnicity was recorded and entered into a database, along with values for canal volume, static admittance, peak pressure, and tympanometric width.Criteria for abnormal tympanometry were based on American Speech-Language Hearing Association (ASHA) recommendations for a failed tympanogram for 1-5 year olds (admittance0.3 mmho or width200 daPa). There were no statistically significant differences in failure rates between males and females. There were, however, more failures for Asian (predominantly Hmong) children compared to children of other races/ethnicities after adjusting for age and gender differences (OR=6.39, CI 3.65-11.2, p0.001) and for children4-years-old compared to children 4-5-years-old after adjusting for race and gender differences (OR=1.99, CI 1.03-3.84, p0.05).Asian children were more than six times as likely to fail tympanometry as children of other races/ethnicities. The explanation for this difference is likely to be multifactorial, and further research is needed to characterize this difference.

Maternal pneumococcal immunization may be a strategy for the prevention of pneumococcal disease during the first months of life before infant-administered pneumococcal conjugate vaccine (PCV) becomes protective. Preparatory to a Phase III efficacy trial to investigate this strategy for preventing early infant otitis media (OM), we are conducting a Phase I–II randomized, double-masked trial to determine if maternal 9-valent PCV immunization alters active antibody production in infants who are immunized with PCV-7 and to compare local and systemic adverse events among women immunized with PCV-9 or placebo. A pilot study was conducted in 1997 in a Minneapolis–St. Paul health maintenance organization, HealthPartners (HP), to estimate enrollment rate for the proposed Phase III trial. A total of 154 pregnant women were selected of whom 122 appeared to be eligible from ICD codes in the HP claims database; 76 responded, and 46 of these were eligible for participation. Four of the 46 reported that they would be very likely and 21 somewhat likely to participate; an estimated 20% (25/122) participation rate. The records of 4289 women in their second trimester have been reviewed to date for the Phase I/II trial; 2589 (60%) were found not to be eligible; and an additional 1015 (24%) could not be contacted. Of the 685 remaining, 558 (81%) were not interested in participating when interviewed, and 127 (19%) have consented. Most (46%) of those who declined participation have cited concern about the safety of vaccination during pregnancy. While the overall participation rate of second trimester women is only 3% (127/4289), maternal attrition (2.8%) and infant attrition from the study before age 7 months (3.9%) are lower than projected (25%). Differences in study design could explain the difference in participation rates estimated in the pilot study and experienced in the Phase I/II study. Reports of safety from large-scale studies of maternal PCV immunization in industrialized countries are needed before women are receptive to maternal immunization to protect their infants against pneumococcal disease.

Objectives/Hypothesis Microwave radiation exposure from cellular telephone use has been implicated in the development of intracranial tumors. The intratemporal facial nerve (IFN) is exposed to higher levels of cellular telephone radiation than intracranial tissues. The purpose of the study was to determine whether cellular telephone use is associated with an increased risk of IFN tumors. Study Design Case-control using a structured telephone survey at an academic, tertiary-care referral center. Methods Patients with IFN tumors (n = 18) were case-matched with patients treated for acoustic neuroma (n = 51), rhinosinusitis (n = 72), and dysphonia or gastroesophageal reflux disease (n = 69). Risk of facial nerve tumorigenesis was compared by extent of cellular telephone use and other risk factors. Results The odds ratio of developing an IFN tumor was 0.6 (95% CI, 0.2–1.9) with any handheld cellular telephone use and 0.4 (95% CI, 0.1–2.1) with regular cellular telephone use. No factors were associated with an increased risk for IFN tumor development. Conclusions Regular cellular telephone use does not appear to be associated with a higher risk of IFN tumor development. The short duration of widespread cellular telephone use precludes definite exclusion as a risk for IFN tumor development.

Objectives To determine the rate of otitis media (OM)-associated transient evoked otoacoustic emissions (TEOAE) screening failure in a sample of preschool children, to evaluate concordance between TEOAE and tympanometry, to investigate risk factors for TEOAE failure, and to determine agreement between TEOAE failure and physician findings at referral. Study Design Cross-sectional. Methods Children from birth to 5 years underwent screening by TEOAE and tympanometry, and those with one or more abnormal test result(s) were referred to their physician for further evaluation. Univariate associations between risk factors and TEOAE failure were determined using chi-square analysis. Multiple logistic regression analysis was done to examine the relationship between specific risk factors and TEOAE failure. Results A total of 664 children aged 2 weeks to 71 months were screened between September 1997 and May 1999. TEOAE and tympanometry failure was found in 25% and 35% of all subjects, respectively. The overall prevalence of OM-associated hearing loss was 20%. Agreement between tympanometry and TEOAE was better for the youngest (

Three boys from two families were identified as having a syndrome of X-linked mental retardation (XLMR) with microcephaly and short stature, clinically resembling Renpenning syndrome but with normal size of testicles in affected men. When the effort to map the gene for the above condition was initiated, it was realized that the two families were actually related to each other. Over 50 polymorphic markers of known locations along the X chromosome were scored in this family in a study to map the disease gene. Nine affected and four unaffected males were genotyped to produce a maximum LOD score of 4.42 at zero recombination with markers in proximal Xq. The results indicate that the gene responsible for this disorder is located in the cytogenetic Xq12 to Xq21.31 interval of the X chromosome within a section of chromosome of about 17 cM between the AR and DXS1217 loci over some 25 mb. Since the gene for the X-linked mental retardation from the original Saskatchewan family described by Renpenning [Renpenning et al., 1962: Can Med Assoc J 87:954-956; Fox and Gerrard, 1980: Am J Med Genet 7:491-495] was recently mapped to a different nonoverlapping region [Stevenson et al., 1998: Am J Hum Genet 62:1092-1101] this would appear to be a separate disorder.

Chronic OME, which arises from a complex series of inflammatory events in the middle ear, affects approximately 5% to 30% of children. The mean duration of MEE is 16 to 20 weeks during the first 2 years of life. This condition is diagnosed best with pneumatic otoscopy and tympanometry. The risk of chronic OME is increased by environmental factors and characteristics of the child, including disease history. Approximately 70% of MEE are culture-positive, with approximately 50% of these yielding S pneumoniae, H influenzae, or M catarrhalis. However, antibiotic treatment of acute otitis media and OME has only a minimal effect on the long-term resolution of MEE. Research has shown that 70% of children who have chronic OME suffer mild-to-moderate hearing loss, so a child who has bilateral MEE for 3 months should undergo hearing evaluation. If the child has hearing impairment, referral to an otolaryngologist for myringotomy and tympanostomy tube insertion is a treatment option that the AHCPR recommends after 4 months of effusion with hearing loss. Sequelae of chronic OME include deficient expressive language and poorer attention skills due to the temporary hearing loss associated with OME, high-frequency sensorineural hearing loss, tympanic membrane atrophy, perforation, retraction, atelectasis, and cholesteatoma.

Recurrent acute otitis media (RAOM) and chronic otitis media with effusion (COME) exhibit familial aggregation, but environmental risk factors (day care attendance, cigarette smoke exposure, and bottle feeding) are also important in their development. The Family Study of OM was designed to ascertain the RAOM/ COME status of families whose children participated in Otitis Media Research Center studies between 1978 and 1984. Probands were treated with tympanostomy tubes, and had their RAOM/COME status ascertained as criteria for entry into these studies. For the Family Study of OM parents were interviewed about their otitis media and risk factor history; mothers were interviewed about their children's history, and pertinent medical records were obtained. Members of 173 families were examined with otomicroscopy and multifrequency tympanometry; 19% of parents and 32% of siblings were classified as affected, which is substantially higher than RAOM/COME rates from previous reports. Risk factor profiles differed significantly (P < .001) between parents and their children. Younger generation (adjusted odds ratio [OR] = 4.18, 95% confidence interval [CI], 2.74, 6.36) day care attendance (OR = 1.96, 95% CI, 1.32, 2.91) and male gender (OR = 1.42, 95% CI, 1.03, 1.97) were significantly related to RAOM/ COME using logistic regression. Analyses confirm 1) higher disease rates in families with an affected member compared to existing studies of the general population, 2) increased risk of RAOM/COME associated with known risk factors, and 3) increased risk for parents irrespective of risk factors. Additional analyses will explore competing models of disease susceptibility using genetic models and known risk factors.

Using quantitative electroencephalographic coherence (a measure of synchronized electrical activity between brain regions) the authors examined heterogeneity in clinical presentation and outcome inpatients with dementia. Patients (N = 114) with mild-to-moderate dementia of the Alzheimer's type (DAT) or multi-infarct dementia (MID) were examined for coherence from the left hemisphere. More than 70% diagnostic accuracy in distinguishing between DAT and MID subjects was achieved using coherence measures alone. Also, decreased coherence measured across the Rolandic fissure in the left hemisphere was significantly associated with poorer functional status of subjects at 2-year follow-up, despite similar levels of cognitive impairment at baseline. These findings suggest that coherence is a useful measure for assessment and for prediction of the course of illness inpatients with dementia.

Objective: To determine the prevalence of electroencephalogram (EEG) abnormalities at different levels of cognitive impairment and to assess the possible diagnostic usefulness of the test. Design: Combined prospective assessment of subjects receiving EEGs and retrospective chart review of symptoms and medications. Setting: Academic geriatric psychiatry service. Patients: 350 adults age 50 and above; 312 were patients being evaluated for possible organic mental syndrome and 38 were normal controls. Measurements: All subjects had EEGs and Mini-Mental State Examinations (MMSE) performed at the time of the EEG. EEGs were rated for the presence and type of abnormality, and subjects were stratified according to the severity of impairment. Charts were reviewed by a person blinded to EEG results to determine clinical diagnosis and medications received. Main Results: Abnormal EEGs were significantly more common among all patients (67%) in the study than among controls (11%), and the prevalence of abnormality increased with increasing impairment. Many demented patients with equivocal impairment (42%), and most with mild-to-moderate impairment (65%) had abnormal EEGs. An abnormal EEG was not indicative of dementia even when clear cognitive impairment was present, since patients with depression frequently also had abnormal EEG results. Conclusions: These findings suggest that the EEG is a moderately sensitive but non-specific indicator of brain dysfunction in the elderly. The significance of abnormalities among patients with equivocal impairment should be more fully assessed by longitudinal follow-up to determine if greater cognitive impairment develops.

Introduction Otitis media (OM) is a significant disease that affects nearly all children early in life. Recently, childhood overweight has become an epidemic. Past research has demonstrated that a history of OM is related to food preferences and overweight through proposed physiological mechanisms. The purpose of this study was to explore the relationship between recurrent OM (ROM)/tympanostomy tube treatment and overweight status. Methods Data were analyzed from a prospective cohort of mothers and children recruited from 1991–1996 from a local health maintenance organization. ROM and tympanostomy tube status were obtained through a combination of physical exam and medical record abstraction. ROM and tympanostomy tube status were analyzed as categorical variables with weight-for-length (WFL) data from well child checks. Chi-square and logistic regression for univariate and multivariate analyses were performed. Results 11.4% of children had a WFL measure at two years of age ≥ 95th percentile. Those children with a history of tympanostomy tube treatment had a significantly increased risk of having a WFL ≥ 95th percentile after controlling for birth weight, maternal prenatal smoking, maternal education, and family income (OR 3.32, 95% CI 1.43–7.72). The alternative hypothesis that children with larger WFL at two month of age would have a greater number of OM episodes by two years of age was not significant. Conclusion The findings of this study are consistent with the hypothesis and prior research that OM treated with tympanostomy tubes is associated with overweight status.

Although otitis media (OM) incidence and prevalence estimates from around the world vary widely, it is clear that OM is a very common childhood disease. It is especially prevalent in children younger than 2 years of age. Furthermore, the earlier the first episode of OM, the greater the risk of subsequent recurrent OM and chronic otitis media with effusion. In addition, a number of other host, agent, and environmental factors have been associated with increased risk of otitis media. Environmental factors that favor the transmission of upper respiratory pathogens increase the risk of OM, recurrent OM, and chronic OME with effusion. Several factors suggest a genetic role in OM susceptibility, which needs further exploration.

Objectives. We examined relationships between otitis media risk factors, sociodemographic characteristics, and maternal knowledge and attitudes and early onset of otitis media. Methods. Pregnant women from Minnesota American Indian reservations and an urban clinic were enrolled in our study between 1998 and 2001. Follow-up was performed on enrollees’ infants until the children were 2 years old. Research nurses collected data by ear examination, from interviews and questionnaires given to enrolled mothers, and otitis media episodes that were abstracted from medical records. Results. Sixty-three percent of infants had experienced an otitis media episode by 6 months of age. Logistic regression analyses showed that maternal otitis media history, infant history of upper respiratory infection, and compliance with study visits were significantly related to early otitis media onset. Although high percentages of infants were exposed to cigarette smoke and other children and were formula fed, these factors were not related to otitis media. Mothers’ prenatal awareness of otitis media risks associated with environmental tobacco smoke exposure and formula feeding did not predict their postpartum behaviors. Conclusions. We found that infant history of upper respiratory infection and maternal otitis media history are risk factors for early otitis media in American Indian infants. Mothers’ prepartum knowledge and attitudes regarding otitis media did not predict their postpartum avoidance of risk behaviors.

Physiological track and trigger warning systems (TTs) are used to identify patients outside critical care areas at risk of deterioration and to alert a senior clinician, Critical Care Outreach Service, or equivalent. The aims of this work were: to describe published TTs and the extent to which each has been developed according to established procedures; to review the published evidence and available data on the reliability, validity and utility of existing systems; and to identify the best TT for timely recognition of critically ill patients. Systematic review of studies identified from electronic, citation and hand searching, and expert informants. Cohort study of data from 31 acute hospitals in England and Wales. Thirty-six papers were identified describing 25 distinct TTs. Thirty-one papers described the use of a TT, and five were studies examining the development or testing of TTs. None of the studies met all methodological quality standards. For the cohort study, outcome was measured by a composite of death, admission to critical care, ‘do not attempt resuscitation’ or cardiopulmonary resuscitation. Fifteen datasets met pre-defined quality criteria. Sensitivities and positive predictive values were low, with median (quartiles) of 43.3 (25.4–69.2) and 36.7 (29.3–43.8), respectively. A wide variety of TTs were in use, with little evidence of reliability, validity and utility. Sensitivity was poor, which might be due in part to the nature of the physiology monitored or to the choice of trigger threshold. Available data were insufficient to identify the best TT.

Although the therapeutic strategy of serial 6-hour intravenous infusions of nesiritide for advanced chronic heart failure (HF) is currently under investigation, frequent hospital or clinic visits may present logistical challenges for many patients with HF. Therefore, a pilot study was conducted to evaluate the safety and tolerability of serial nesiritide infusions administered at home in this patient population. Twenty patients with advanced HF were enrolled into a protocol for the administration of 12 weekly intravenous infusions of nesiritide (2 microg/kg bolus, 0.01 microg/kg/min for 6 hours) at home. Blood samples and weights were obtained weekly, and clinical assessments were made at 4 and 12 weeks. During the 12-week study period, there were 3 deaths unrelated to nesiritide therapy. Six patients requiredor=1 hospitalization for HF. Two of 204 infusions resulted in symptomatic hypotension, and there were no adverse renal events. Mean body weight decreased at week 4 but returned to baseline by week 12. Antibodies to nesiritide were not detected in any patient. In conclusion, serial home infusions of nesiritide in patients with advanced HF appear to be safe and well tolerated, but the efficacy of this therapeutic strategy requires definition in a larger, randomized trial.

Some methods of temporal statistics are presented and proposed for investigating the date of birth as a disease predictor. A subject's birthday is proposed to be used as a continuous variable with a circular distribution, a special type of interval scale without a true zero point. Three types of endpoints are then considered: a dichotomous endpoint; a continuous endpoint; and time-to-event. A study of otitis media is used for illustration. We found, for example, that children born in late winter to early spring tend to have higher cord blood pneumococcal antibody concentration and lower risk of disease as compared to those born in summer to early fall perhaps due largely to exposure to indoor pollution by pregnant mothers.

Objectives: To explore relationships between age and sequelae in two groups of children treated with tympanostomy tubes for chronic otitis media with effusion (OME). Study Design: Cross-sectional study of sequelae among children, adolescents, and adults at 4 years and 9 to 23 years after tympanostomy tube treatment. Methods: Group I was examined with otomicroscopy, tympanometry, and audiometry two to four times a year as part of a prospective study, and they were evaluated 4 years after initial tube treatment for this study. Group II received tubes while participating in a chronic OME study, but participants were not followed prospectively after treatment. Nine to 23 years after tube treatment, they were examined with otomicroscopy, tympanometry, and hearing screening. Results: Among the 5- to 28- year-old subjects, cholesteatoma (≤1%) and perforation (≤2%) were rare. In Group I, tympanosclerosis increased with age (P

The authors examined quantitative electroencephalographc (QEEG) coherence in 37 depressed elderly patients and performed 2-year follow-up evaluations. All subjects had equivocal cognitive impairment, but none had delirium or dementia. More than 40% (16/37) recovered from depression, and 38% (14/37) remained well for 2 years. Twenty-four percent (n = 9) had died within 2 years, most from cardiac causes. Low trans-Rolandic coherence from the left hemisphere was strongly associated with mortality: 44% (7/16) of those with low coherence died, and 78% (7/9) of those who died had low coherence. Among survivors (n = 28) at follow-up, low coherence was significantly associated with lower functional status. These findings suggest that the coherence variable measures actual neurophysiology differences between groups of depressed patients and these differences are associated with the heterogeneous outcomes of depression in elderly patients.

Introduction Critical care outreach services (CCOS) have been widely introduced in England with little rigorous evaluation. We undertook a multicentre interrupted time-series analysis of the impact of CCOS, as characterised by the case mix, outcome and activity of admissions to adult, general critical care units in England. Methods Data from the Case Mix Programme Database (CMPD) were linked with the results of a survey on the evolution of CCOS in England. Over 350,000 admissions to 172 units between 1996 and 2004 were extracted from the CMPD. The start date of CCOS, activities performed, coverage and staffing were identified from survey data and other sources. Individual patient-level data in the CMPD were collapsed into a monthly time series for each unit (panel data). Population-averaged panel-data models were fitted using a generalised estimating equation approach. Various potential outcomes reflecting possible objectives of the CCOS were investigated in three subgroups of admissions: all admissions to the unit, admissions from the ward, and unit survivors discharged to the ward. The primary comparison was between periods when a formal CCOS was and was not present. Secondary analyses considered specific CCOS activities, coverage and staffing. Results In all, 108 units were included in the analysis, of which 79 had formal CCOS starting between 1996 and 2004. For admissions from the ward, CCOS were associated with significant decreases in the proportion of admissions receiving cardiopulmonary resuscitation before admission (odds ratio 0.84, 95% confidence interval 0.73 to 0.96), admission out of hours (odds ratio 0.91, 0.84 to 0.97) and mean Intensive Care National Audit & Research Centre physiology score (decrease in mean 1.22, 0.31 to 2.12). There was no significant change in unit mortality (odds ratio 0.97, 0.87 to 1.08) and no significant, sustained effects on outcomes for unit survivors discharged alive to the ward. Conclusion The observational nature of the study limits its ability to infer causality. Although associations were observed with characteristics of patients admitted to critical care units, there was no clear evidence that CCOS have a big impact on the outcomes of these patients, or for characteristics of what should form the optimal CCOS.