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Background: The glycemia risk index (GRI) is a composite metric developed and used to estimate quality of glycemia in adults with diabetes who use continuous glucose monitor (CGM) devices. In a cohort of youth with type 1 diabetes (T1D), we examined the utility of the GRI for evaluating quality of glycemia between clinic visits by analyzing correlations between the GRI and longitudinal glycated hemoglobin A1c (HbA1c) measures., Method: Using electronic health records and CGM data, we conducted a retrospective cohort study to analyze the relationship between the GRI and longitudinal HbA1c measures in youth (T1D duration ≥1 year; ≥50% CGM wear time) receiving care from a Midwest pediatric diabetes clinic network (March 2016 to May 2022). Furthermore, we analyzed correlations between HbA1c and the GRI high and low components, which reflect time spent with high/very high and low/very low glucose, respectively., Results: In this cohort of 719 youth (aged = 2.5-18.0 years [median = 13.4; interquartile range [IQR] = 5.2]; 50.5% male; 83.7% non-Hispanic White; 68.0% commercial insurance), baseline GRI scores positively correlated with HbA1c measures at baseline and 3, 6, 9, and 12 months later (r = 0.68, 0.65, 0.60, 0.57, and 0.52, respectively). At all time points, strong positive correlations existed between HbA1c and time spent in hyperglycemia. Substantially weaker, negative correlations existed between HbA1c and time spent in hypoglycemia., Conclusions: In youth with T1D, the GRI may be useful for evaluating quality of glycemia between scheduled clinic visits. Additional CGM-derived metrics are needed to quantify risk for hypoglycemia in this population., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: MAC receives consulting fees as Chief Medical Officer for Glooko, Inc and receives research support from Abbott Diabetes Care and Dexcom. Other authors have no conflicts of interest related to this work.

Background: The Glycemia Risk Index (GRI) was developed in adults with diabetes and is a validated metric of quality of glycemia. Little is known about the relationship between GRI and type 1 diabetes (T1D) self-management habits, a validated assessment of youths' engagement in habits associated with glycemic outcomes., Method: We retrospectively examined the relationship between GRI and T1D self-management habits in youth with T1D who received care from a Midwest pediatric diabetes clinic network. The GRI was calculated using seven days of continuous glucose monitor (CGM) data, and T1D self-management habits were assessed ±seven days from the GRI score. A mixed-effects Poisson regression model was used to evaluate the total number of habits youth engaged in with GRI, glycated hemoglobin A1c (HbA1c), age, race, ethnicity, and insurance type as fixed effects and participant ID as a random effect to account for multiple clinic visits per individual., Results: The cohort included 1182 youth aged 2.5 to 18.0 years (mean = 13.8, SD = 3.5) comprising 50.8% male, 84.6% non-Hispanic White, and 64.8% commercial insurance users across a total of 6029 clinic visits. Glycemia Risk Index scores decreased as total number of habits performed increased, suggesting youth who performed more self-management habits achieved a higher quality of glycemia., Conclusions: In youth using CGMs, GRI may serve as an easily obtainable metric to help identify youth with above target glycemia, and engagement/disengagement in the T1D self-management habits may inform clinicians with suitable interventions for improving glycemic outcomes., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: We compare in-hospital complications in youth with isolated diabetic ketoacidosis (DKA) to youth with hyperosmolarity., Method: We reviewed medical records of youth (1-20 years) admitted over two years with DKA, hyperglycemic hyperosmolar state (HHS), and hyperosmolar DKA. We evaluated outcomes, including hospital length of stay, altered mental status (AMS), and acute kidney injury (AKI)., Results: Of 369 admissions, 334 had isolated DKA, 32 had hyperosmolar DKA, and three had isolated HHS. Hyperosmolar youth had longer length of stay, larger initial fluid boluses, more frequent pediatric intensive care unit admissions, and increased risk of AKI and AMS. The odds of AKI were positively associated with serum osmolality and negatively associated with new-onset diabetes mellitus (DM) compared with established DM., Conclusions: In youth with DM, hyperosmolarity increases acute complications compared with isolated DKA. Larger-scale studies are needed to identify ways to prevent acute complications in youth experiencing hyperglycemic emergencies., Competing Interests: CONFLICTS OF INTEREST None to report., (Copyright © 2023 National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved.)

Pediatric pial arteriovenous shunts in the brain and spine are challenging to understand because of low incidence, variable presentation, and associations with genetic syndromes. What is known about their natural history comes from reviews of small series. To better understand the natural history and role for intervention, two cases are presented followed by a review of the literature. In the first case, an infant with a prior history of intracranial hemorrhage from a ruptured pial fistula returns for elective embolization for a second pial fistula which was found to be spontaneously thrombosed 2 weeks later. In the second case, a 5-year-old with a vertebro-vertebral fistula, identified on work up for a heart murmur and documented with diagnostic angiography, is brought for elective embolization 6 weeks later where spontaneous thrombosis is identified. In reviewing the literature on pediatric single-hole fistulae of the brain and spine, the authors offer some morphologic considerations for identifying which high-flow fistulae may undergo spontaneous thrombosis to decrease the potentially unnecessary risk associated with interventions in small children., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: To meet their glycated hemoglobin (HbA 1c ) goals, youth with type 1 diabetes (T1D) need to engage with their daily T1D treatment. The mealtime insulin Bolus score (BOLUS) is an objective measure of youth's T1D engagement which we have previously shown to be superior to other objective engagement measures in predicting youth's HbA 1c . Here, to further assess the BOLUS score's validity, we compared the strengths of the associations between youth's HbA 1c with their mean insulin BOLUS score and a valid, self-report measure of T1D engagement, the Self-Care Inventory (SCI)., Methods: One-hundred and five youth with T1D self-reported their T1D engagement using the SCI. We also collected two weeks of insulin pump data and a concurrent HbA 1c level. We scored youth's SCI and calculated their mean insulin BOLUS score using standardized methods. For the analyses, we performed simple correlations, partial correlations, and multiple regression models., Results: Youth had a mean age of 15.03 ± 1.97 years, mean time since diagnosis of 8.11 ± 3.26 years, and a mean HbA 1c of 8.78 ± 1.49%. The sample included n = 58 boys (55%) and n = 96 families (91%) self-identified as white. Simple correlations between youth's age, HbA 1c , SCI total score, and BOLUS score were all significant. Partial correlation and regression models revealed that youth's insulin BOLUS score was more strongly associated with HbA 1c than the SCI., Conclusions: Youths' BOLUS score has better concurrent validity with HbA 1c than the SCI. We should consider reporting the BOLUS score as an outcome metric in insulin pump data reports., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr Mark A. Clements is Chief Medical Officer of Glooko, Inc and has received grants or contracts from Dexcom, Abbott Diabetes Care, National Institutes of Health, JDRF, the Emily Rosebud Foundation, Eli Lilly, Tolerion, and Garmin. Dr Susana R. Patton has received grants from the National Institutes of Health.

Background: Although prior research has identified multiple risk factors for diabetic ketoacidosis (DKA), clinicians continue to lack clinic-ready models to predict dangerous and costly episodes of DKA. We asked whether we could apply deep learning, specifically the use of a long short-term memory (LSTM) model, to accurately predict the 180-day risk of DKA-related hospitalization for youth with type 1 diabetes (T1D)., Objective: We aimed to describe the development of an LSTM model to predict the 180-day risk of DKA-related hospitalization for youth with T1D., Methods: We used 17 consecutive calendar quarters of clinical data (January 10, 2016, to March 18, 2020) for 1745 youths aged 8 to 18 years with T1D from a pediatric diabetes clinic network in the Midwestern United States. The input data included demographics, discrete clinical observations (laboratory results, vital signs, anthropometric measures, diagnosis, and procedure codes), medications, visit counts by type of encounter, number of historic DKA episodes, number of days since last DKA admission, patient-reported outcomes (answers to clinic intake questions), and data features derived from diabetes- and nondiabetes-related clinical notes via natural language processing. We trained the model using input data from quarters 1 to 7 (n=1377), validated it using input from quarters 3 to 9 in a partial out-of-sample (OOS-P; n=1505) cohort, and further validated it in a full out-of-sample (OOS-F; n=354) cohort with input from quarters 10 to 15., Results: DKA admissions occurred at a rate of 5% per 180-days in both out-of-sample cohorts. In the OOS-P and OOS-F cohorts, the median age was 13.7 (IQR 11.3-15.8) years and 13.1 (IQR 10.7-15.5) years; median glycated hemoglobin levels at enrollment were 8.6% (IQR 7.6%-9.8%) and 8.1% (IQR 6.9%-9.5%); recall was 33% (26/80) and 50% (9/18) for the top-ranked 5% of youth with T1D; and 14.15% (213/1505) and 12.7% (45/354) had prior DKA admissions (after the T1D diagnosis), respectively. For lists rank ordered by the probability of hospitalization, precision increased from 33% to 56% to 100% for positions 1 to 80, 1 to 25, and 1 to 10 in the OOS-P cohort and from 50% to 60% to 80% for positions 1 to 18, 1 to 10, and 1 to 5 in the OOS-F cohort, respectively., Conclusions: The proposed LSTM model for predicting 180-day DKA-related hospitalization was valid in this sample. Future research should evaluate model validity in multiple populations and settings to account for health inequities that may be present in different segments of the population (eg, racially or socioeconomically diverse cohorts). Rank ordering youth by probability of DKA-related hospitalization will allow clinics to identify the most at-risk youth. The clinical implication of this is that clinics may then create and evaluate novel preventive interventions based on available resources., (©David D Williams, Diana Ferro, Colin Mullaney, Lydia Skrabonja, Mitchell S Barnes, Susana R Patton, Brent Lockee, Erin M Tallon, Craig A Vandervelden, Cintya Schweisberger, Sanjeev Mehta, Ryan McDonough, Marcus Lind, Leonard D'Avolio, Mark A Clements. Originally published in JMIR Diabetes (https://diabetes.jmir.org), 18.07.2023.)

Importance: The 2018 Chronic Care Act allowed Medicare Advantage plans to have greater flexibility in offering supplemental benefits, such as meals and services, to address unmet needs of beneficiaries with certain chronic conditions. Based on earlier studies of community-based nutritional support, such programs may result in reduced use., Objective: To evaluate the association of a 4-week posthospitalization home-delivered meals benefit with 30-day all-cause rehospitalization and mortality in patients admitted for heart failure (HF) and other acute medical conditions (non-HF)., Design, Setting, and Participants: In this cohort study, patients who received meals (the meals group) were compared with 2 controls: (1) no meals in the 2019 historical cohort who would have been eligible for the benefit (the no meals-2019 group) and (2) no meals in the 2021 and 2022 concurrent cohort who were referred but did not receive the meals due to unsuccessful contacts and active declines (the no meals-2021/2022 group). This study took place in a large integrated health care system in southern California among Medicare Advantage members with a hospitalization for HF or other acute medical conditions at 15 Kaiser Permanente hospitals discharged to home., Exposure: The exposure was receipt of at least 1 and up to 4 shipments of home-delivered meals (total of 56 to 84 meals) after hospital discharge., Main Outcomes and Measures: The main outcomes were 30-day all-cause composite rehospitalization and death., Results: A total of 4032 adults with admission to the hospital for HF (mean [SD] age, 79 [9] years; 1951 [48%] White; 2001 [50%] female) and 7944 with non-HF admissions (mean [SD] age, 78 [8] years; 3890 [49%] White; 4149 [52%] female) were included in the analyses. Unadjusted rates of 30-day death and rehospitalization for the meals, no meals-2019, and no meals-2021/2022 cohorts were as follows: HF: 23.3%, 30.1%, and 38.5%; non-HF: 16.5%, 22.4%, and 32.9%, respectively. For HF, exposure to meals was significantly associated with lower odds of 30-day death and rehospitalization compared with the no meals-2021/2022 cohort (OR, 0.55; 95% CI, 0.43-0.71; P < .001) but was not significant compared with the no meals-2019 cohort (OR, 0.86; 95% CI, 0.72-1.04; P = .12). For non-HF, exposure to meals was associated with significantly lower odds of 30-day death and rehospitalization when compared with the no meals-2019 (OR, 0.64; 95% CI, 0.52-0.79; P < .001) and the no meals-2021/2022 (OR, 0.48; 95% CI, 0.37-0.62; P < .001) cohorts., Conclusions and Relevance: In this cohort study, exposure to posthospitalization home-delivered meals was associated with lower 30-day rehospitalization and mortality; randomized clinical trials are needed to confirm these findings.

Aim: Since 2011 the Centers for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System (WISQARS) has demonstrated per-injury average and population total medical and non-medical costs of injuries by type (such as unintentional cut/pierce) in the USA. This article describes the impact of data and methods changes in the newest version of WISQARS Cost of Injury., Methods: Data sources and methods were compared for the legacy version of the WISQARS Cost of Injury website (available 2011-2021; most recent prior update was published in 2014 with 2010 injury incidence and costs) and the new version (published 2021; 2015-present injury incidence and costs). Cost data sources were updated for the new website and the basis for medical costs and non-fatal injury work loss costs changed from mathematical modelling (combined estimates from multiple data sources) in the legacy website to statistical modelling of actual injury-related medical and work loss financial transactions in the new website. Monetary valuation of non-medical costs for injury deaths changed from lost employment income and household work in the legacy website to value of statistical life. Quality of life loss costs were added for non-fatal injuries. Per-injury average medical and non-medical costs by injury type (mechanism and intent) and total population injury costs were compared for years 2010 (legacy website data) and 2020 (new website data) to illustrate the impact of data and methods changes on reported costs in the context of changed annual injury incidence., Results: Owing to more comprehensive cost capture yielding higher per-injury average costs for most injury types-including those with high incidence in 2020 such as unintentional poisoning and unintentional falls-reported total US medical and non-medical injury costs were substantially higher in 2020 (US$4.6 trillion) compared with 2010 (US$693 billion) (both 2020 USD)., Conclusions and Relevance: New data and methods increased the injury costs reported in WISQARS Cost of Injury. Researchers and public health professionals can use this information to proficiently communicate the burden of injuries and violence in terms of economic cost., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To evaluate the 2016 Cincinnati International Turner syndrome (TS) consensus guideline adherence within our pediatric tertiary referral center and determine if patients managed in our single-day, coordinated multidisciplinary clinic (MDC) format showed superior adherence rates when compared with those managed outside our MDC format., Methods: We retrospectively reviewed the charts of patients with TS followed at our center from January 1, 2018, to April 30, 2020. The individual and overall adherence rates of 9 age-appropriate screening recommendations were evaluated along with rates of TS comorbidities within our cohort., Results: A total of 111 girls met the study criteria. Sixty-eight were managed in the MDC and 43 were managed outside the MDC. Only 42% of all the girls met all 9 evaluated age-appropriate screening recommendations, of 47 girls, 33 (70%) were managed in MDC compared with 14 (30%) who were managed in the non-MDC. Girls managed in the MDC had higher screening adherence rates versus non-MDC girls for 7 of the 9 evaluated screenings with especially large differences noted for thyroid stimulating hormone (95% vs 78%, P = .034), auditory evaluation (97% vs 65%, P < .001), and HgA1c levels (82% vs 54%, P = .014)., Conclusion: Girls managed in the MDC format showed higher rates of screening guideline adherence, both overall and with multiple specific screening tests, than those managed outside the MDC format. Overall guideline adherence remained low (42%), highlighting the need for continued optimization and improvement in guideline adherence in this unique subset of the population., Competing Interests: Disclosure The authors have no multiplicity of interest to disclose., (Copyright © 2022 AACE. Published by Elsevier Inc. All rights reserved.)

Interinstitutional differences in clinical pediatric exercise laboratory (CPEL) practices may affect patient care and efficacy of multicenter research., Purpose: To describe current practices/procedures in CPELs and explore differences in CPELs employing exercise physiologists to those that do not., Methods: A 40-item survey was distributed to CPELs in North America focusing on (1) staffing; (2) exercise stress testing (EST) volumes, reporting, and interpretation; and (3) EST procedures/protocols., Results: Of the 55 responses, 89% were in the United States, 85% were children's hospitals with university affiliation, and 58% were cardiology specific. Exercise physiologists were employed in 56% of CPELs, and 78% had master's degrees or higher. Certifications were required in most CPELs (92% emergency life-support, 27% professional, and 21% clinical). Median volume was 201 to 400 ESTs per year, 80% used treadmill, and 10% used cycle ergometer as primary modalities. Ninety-three percent of CPELs offered metabolic ESTs, 87% offered pulmonary function testing, 20% used institution-specific EST protocols, and 72% offered additional services such as cardiac/pulmonary rehabilitation. CPELS staffing exercise physiologists performed higher volumes of ESTs (P = .004), were more likely to perform metabolic ESTs (P = .028), participated in more research (P < .001), and provided services in addition to ESTs (P = .001)., Conclusions: Heterogeneity in CPELs staffing and operation indicates need for standardization.

Ladder falls from overreaching are a problem in older adults. Evidence suggests ladder use behavior to be dependent on interfacing user and environmental circumstances (i.e. situational factors). This study investigates the effects of situational factors (remaining debris, ladder position, time into task, hand dominant reach, reaching disposition) on reaching during a gutter clearing task on a ladder in 104 older adults. Reaching was quantified as the maximum lateral center of pressure (COP) displacement from the ladder's center. A reach was classified as an overreach when the COP displaced outside the ladder width, indicative of a ladder tip. Reaching disposition, remaining debris, ladder position, and the interaction of reaching disposition and remaining debris predicted 20% of the reaching variability during the ladder task. Overreaching was observed in 40% of participants accounting for 13% of all extended reaches (beyond ladder). This work can guide interventions on mitigating overreaching and improving ladder safety., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Suicide rates among adolescents in the United States continue to climb and many at-risk youths are undetected. Screening for suicidal thoughts has become the primary approach to identify those at risk, but no studies have assessed reactions to its deployment in pediatric outpatient settings. This mixed-method study assessed parents' and adolescents' thoughts about suicide risk screening in non-psychiatric, pediatric outpatient specialty settings.As part of a multi-site measurement validation study, adolescents ( n  = 269; ages 10-21) and parents ( n  = 246) at pediatric specialty clinics in the Midwest completed a survey regarding thoughts about suicide risk screening. Data were collected on tablet computers and transcribed verbatim. Three study team members independently coded transcripts of open-ended responses to identify major themes, and frequency data were analyzed using StataSE 15.1. Inter-rater agreement was substantial (Fleiss' Kappa ranged 75-86%).Parents (55% 41-50 years of age, 20% male, 80% White) and adolescents (Mean age = 14.3, 50% male, 77% White) agreed medical providers should screen adolescents for suicide risk (93% and 88%, respectively). Majority of parents indicated that the pediatric outpatient setting is appropriate for suicide risk screening. Major themes included the important role of providers in identifying at-risk youth, the potential for screening to prevent suicides, and concerns about iatrogenic risk and misdiagnosis.Most parents and adolescents support screening for suicide risk in pediatric outpatient settings. Nevertheless, some have concerns about the screening process and implications. As suicide risk screening becomes standard practice in adolescent care, it's critical to develop screening processes that maximize comfort and address concerns.

Introduction: We prospectively investigated the associations between diabetes-related family conflict, parent engagement in child type 1 diabetes (T1D) care, and child glycated hemoglobin (HbA1c) in 127 families of school-age children who we recruited within the first year of their T1D diagnosis., Research Design and Methods: Parents completed the Diabetes Family Conflict Scale-Revised (DFCS-R) to assess for diabetes-related family conflict and the Diabetes Self-Management Questionnaire-Brief (DSMQ-Brief) to assess parent engagement in child T1D care at the initial study visit (T1) and at 12 (T2) and 27 (T3) months later. We also collected child HbA1c at these time points. Our analyses included Pearson correlations and repeated measures linear mixed models controlling for child age, sex, and T1D duration at T1., Results: Parents' DFCS-R scores negatively correlated with DSMQ-Brief scores (r=-0.13, p<0.05) and positively correlated with children's HbA1c (r=0.26, p<0.001). In our linear mixed models, parents' DSMQ-Brief scores were unchanged at T2 (β=-0.71, 95% CI -1.59 to 0.16) and higher at T3 (β=8.01, 95% CI 6.89 to 9.13) compared with T1, and there was an association between increasing DFCS-R and decreasing DSMQ-Brief scores (β=-0.14, 95% CI -0.21 to -0.06). Child HbA1c values were significantly higher at T2 (β=0.66, 95% CI 0.38 to 0.94) and T3 (β=0.95, 95% CI 0.63 to 1.27) compared with T1, and there was an association between increasing DFCS-R scores and increasing child HbA1c (β=0.04, 95% CI 0.02 to 0.06)., Conclusions: Increasing diabetes-specific family conflict early in T1D may associate with decreasing parent engagement in child T1D care and increasing child HbA1c, suggesting a need to assess and intervene on diabetes-specific family conflict. Trial registration number NCT03698708., Competing Interests: Competing interests: MAC is the chief medical officer for Glooko and has consulted with Medtronic Diabetes and Eli Lilly on topics unrelated to the submitted work. All other authors have nothing to disclose., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

As part of a population health-focused primary care transformation, in 2019 a health system in Minnesota developed a primary care team to exclusively care for high-cost high-need patients. Through its development and implementation, the team has discovered several key lessons in delivering care to complex patients. These lessons include the benefits of more integrative team-based care, the need and advantages of designated complex care team members, the importance of teamwork both within and outside of the complex care team, the need for frequent communication, and the importance of identifying mental health needs. In addition, there are several areas that require ongoing research and exploration, such as determining when a patient is able to graduate out of the program, how to enhance access to the complex care team, determining appropriate visit characteristics, and model feasibility. While addressing the needs of high cost high need patients is essential to improving quality of care and decreasing health care costs, there are several unique challenges and opportunities that come with caring for this patient population. Although this highly integrated model of care continues to evolve, the initial lessons learned may inform other health systems and care teams undertaking the care of complex patients.

Objective: Management of febrile infants 60 days and younger for suspected serious infection varies widely. Clinical practice guidelines (CPGs) are intended to improve clinician adherence to evidence-based practices. In 2011, a CPG for managing febrile infants was implemented in an urban children's hospital with simultaneous release of an electronic order set and algorithm to guide clinician decisions for managing infants for suspected serious bacterial infection. The objective of the present study was to determine the association of CPG implementation with order set use, clinical practices, and clinical outcomes., Methods: Records of febrile infants 60 days and younger from February 1, 2009, to January 31, 2013, were retrospectively reviewed. Clinical documentation, order set use, clinical management practices, and outcomes were compared pre-CPG and post-CPG release., Results: In total, 1037 infants pre-CPG and 930 infants post-CPG implementation were identified. After CPG release, more infants 29 to 60 days old underwent lumbar puncture (56% vs 62%, P = 0.02). Overall antibiotic use and duration of antibiotic use decreased for infants 29 to 60 days (57% vs 51%, P = 0.02). Blood culture and urine culture obtainment remained unchanged for older infants. Diagnosed infections, hospital readmissions, and length of stay were unchanged. Electronic order sets were used in 80% of patient encounters., Conclusions: Antibiotic use and lumbar puncture performance modestly changed in accordance with CPG recommendations provided in the electronic order set and algorithm, suggesting that the presence of embedded prompts may affect clinician decision-making. Our results highlight the potential usefulness of these decision aids to improve adherence to CPG recommendations., Competing Interests: Disclosure: J.G.N. has grant support from Pfizer. R.J.M. receives support from National Institute for Child Health and Human Development grant number UG1 HD090849, a component of the National Institutes of Health, and from the Gerber Foundation. The other authors declare no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Aims: Chondroblastomas (CB) are rare bone tumours that typically arise in the epiphysis/apophysis of long bones in skeletally immature patients. We explore the clinicopathological features of CB presenting in adults., Methods and Results: CB in patients ≥20 years of age were retrieved from our institutional archives. Thirty-nine CB were identified (29 male/10 female; aged 20-54 years). Twenty (51%) cases occurred in long tubular bones, 10 (26%) in small bones of the feet, five (13%) in flat bones and four (10%) in the patella. All cases showed classic cytological features of CB, and chondroid matrix was universally present. Calcification was identified in 10 cases (26%), including various combinations of serpiginous (n = 7), punctate (n = 6), classic chicken-wire (n = 4) and psammomatous (n = 2) patterns. Haemosiderin (n = 19), woven bone (n = 13), secondary aneurysmal bone cyst formation (n = 8), foamy macrophages (n = 4), hyalinised vascular spaces (n = 2) and cholesterol clefts (n = 2) were noted. Follow-up information (n = 32, 1-452 months) revealed local recurrence in three patients, all >40 years of age with flat bone origin, one of which developed pulmonary metastases 132 months after initial diagnosis., Conclusions: CB in patients >20 years of age more frequently involves the short bones of the hands/feet and flat bones compared to those arising in their younger counterparts. A subset may harbour extensive serpiginous or psammomatous calcification rather than the classic chicken-wire pattern. Although the overall local recurrence rate in adulthood is approximately 10%, all three patients with recurrent disease had tumours involving flat bones, suggesting that tumours arising in these sites may behave more aggressively., (© 2019 John Wiley & Sons Ltd.)

Management of soft-tissue and bone neoplasms depends on a definitive histologic diagnosis. Percutaneous image-guided biopsy of bone and soft-tissue tumors is a cost-effective and accurate method to obtain a histopathologic diagnosis. Biopsy requests must be approached thoughtfully to avoid numerous potential pitfalls. Hasty biopsy planning places the patient at increased risk for misdiagnosis, delayed therapy, repeated invasive procedures, and substantial morbidity. Biopsy planning begins with a thorough review of the relevant clinical history and pertinent imaging. The biopsy route must be planned in concert with the referring orthopedic oncologist to preserve limb-sparing options. Carefully selecting the most appropriate imaging modality to guide the biopsy increases the chances of reaching a definitive diagnosis. It is also critical to identify and target with expertise the part of the lesion that is most likely to yield an accurate diagnosis. Percutaneous biopsy is a safe procedure, and familiarity with preprocedural laboratory testing parameters, anticoagulation guidelines, and commonly used sedation medications minimizes the risk of complications while ensuring patient comfort. Nondiagnostic biopsy results are not infrequent and may still have value in guiding patient treatment. Awareness of the imaging manifestations of tumor recurrence is also important. The aim of this article is to provide a comprehensive review of pertinent preprocedural, periprocedural, and postprocedural considerations for bone and soft-tissue musculoskeletal biopsies. The online slide presentation from the RSNA Annual Meeting is available for this article. © RSNA, 2020.

Smoking rates are high among low-income populations who seek care in safety-net clinics. While most safety-net clinics screen for cigarette smoking, there are substantial disparities in the delivery of smoking cessation counseling in these systems. We conducted a mixed method study between July 2016 and April 2017 to examine receipt of smoking cessation counseling and estimate recent cessation attempts among primary care patients in four safety-net clinics in San Francisco. We used the electronic health record (EHR) to examine receipt of cessation services and estimate cessation attempts, defined as transition from current to former smoking status during the 9-month study period. We conducted interviews with 10 staff and 16 patients to assess barriers to and facilitators of providing cessation services. Of the 3301 smokers identified via EHR, the majority (95.6%) received some type of cessation counseling during at least one clinical encounter, and 17.6% made a recent cessation attempt. Recent smoking cessation attempts and receipt of smoking cessation services differed significantly by clinic after adjusting for demographic factors. We identified patient and staff-level pre-disposing, reinforcing and enabling factors to increase delivery of cessation care, including increasing access to cessation medications and higher intensity counseling using a team-based approach. The EHR presents a useful tool to monitor patients' recent cessation attempts and access to cessation care. Combining EHR data with qualitative methods can help guide and streamline interventions to improve quality of cessation care and promote quit attempts among patients in safety-net settings.

Background: This study examined the impact of a tobacco-free grounds (TFG) policy and the California $2.00/pack tobacco tax increase on tobacco use among individuals in residential substance use disorder (SUD) treatment., Methods: We conducted three cross-sectional surveys of clients enrolled in three residential SUD treatment programs. Wave 1 (Pre-TFG) included 190 clients, wave 2 (post-TFG and pre-tax increase) included 200 clients, and wave 3 (post-tax increase) included 201 clients. Demographic and tobacco-use characteristics were first compared between waves using bivariate comparisons. Regression models were used to compare each outcome with survey wave as the predictor, while adjusting for demographic characteristics and nesting of participants within programs., Results: Odds of clients being current smokers was lower (AOR = 0.43, 95%CI = 0.30,0.60) after implementation of TFG compared to baseline. Adjusted mean ratio (AMR) for cigarettes per day was lower post-TFG compared to baseline (AMR = 0.70, CI = 0.59, 0.83). There were no differences, across waves, in tobacco-related knowledge, attitudes, or services received by program clients, or use of nicotine replacement therapy. Increased cigarette taxation was not associated with reductions in client smoking., Conclusion: Implementation of a TFG policy was associated with a lower prevalence of client smoking among individuals in residential SUD treatment. Increased state cigarette excise taxes were not associated with a further reduction in client smoking in the presence of TFG policies, though this may have been confounded by relaxing of the TFG policy. SUD treatment programs should promote TFG policies and increase tobacco cessation services for clients., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Purpose: The purpose of this study was to develop a measure of type 1 diabetes mellitus (T1DM) knowledge that is aimed at youth and is based on contemporary management standards. Methods: An 88-item test was derived from the American Association of Diabetes Educators 7 Self-Care Behaviors. Results: A multidisciplinary team selected the best 49 items which were piloted in a sample of 119 youths (59 males, aged 12-18, having a mean ± standard deviation glycated haemoglobin (A1C) of 9.9%±1.80 (84.7±19.7 mmol/mol). A minimum absolute point-biserial correlation coefficient of 0.250 was used to choose 49 items from the original 88 questions. Categorical principal component analysis was then used to identify the best factor analytical model that consisted of five factors composed of 19 items. These five factors explained 57% of item variances. Factors were associated with the latent variables: advanced problem-solving, hypoglycaemia prevention and management, taking insulin/medication administration, daily management and healthy active living. Conclusion: A new T1D knowledge test for youth was refined from 88 to 49 questions based on expert opinion and empirical test construction. The instrument was then refined to 19 items based on exploratory factor analysis. Future goals are to validate this factor model with another cohort and confirm concurrent validity based on youth's glycated haemoglobin and adherence behaviours. Our new T1DM knowledge measure initially appears valid and promising as a new clinical and research tool., Competing Interests: Disclosure: Melinda Storm works for Insulet, however, she did not work for this company during the development of this project or writing of the manuscript. Sarah Tsai, Susana Patton, Stephen DeLurgio, David D Williams, Kavitha Dileepan, Alexander Karmazin and Mark Clements have no conflicts of interest to disclose.

Objective: Specialty addiction programs treat people who are addicted to alcohol, opioids, stimulants, and other drugs. This study identified the proportion of addiction program clients who received tobacco-related services and factors associated with receipt of such services., Methods: In 2015 and 2016, clients (N=2,119) in 24 programs were surveyed for receipt of services aligning with three of the five As of tobacco cessation: ask, advise, assist. Multivariate analyses examined factors associated with receipt of each service., Results: Most clients (76%) were asked about smoking. Among smokers (N=1,630), 53% were advised to quit, 41% received counseling, 26% received cessation medication, and 17% received counseling and medication. Clients were more likely to receive tobacco-related services if they wanted help quitting smoking or were enrolled in programs with tobacco-free grounds., Conclusions: These correlational findings suggest that increasing client motivation to quit and implementing tobacco-free policies on the grounds of treatment centers may increase tobacco-related services in addiction treatment.

Introduction: Patients with suspected adrenal insufficiency undergo screening with a serum morning cortisol level and confirmatory testing with an adrenocorticotropic hormone (ACTH) stimulation test. However, much of the data collected to determine appropriate values for morning cortisol levels are derived from adult populations and may not accurately represent pediatric physiology. The purpose of this study was to evaluate the mean morning cortisol level in the pediatric population based on pubertal status and sex in order to better understand such influences on laboratory evaluation of adrenal insufficiency., Methods: A retrospective chart review was conducted using electronic medical records of patients seen at Children's Mercy Kansas City from 11/01/2007 to 11/01/2017. Patients between 2 and 18 years of age who had pubertal staging assessed by a pediatric endocrinologist and confirmed adrenal sufficiency by high-dose ACTH stimulation testing were included. Two-sample Wilcoxon rank sum (Mann-Whitney) tests or t tests were used to compare morning cortisol levels between females and males - both independent of Tanner stage and by Tanner stage. Multivariable regression models were used to evaluate associations among covariates on two outcomes: morning cortisol levels and peak cortisol values with ACTH stimulation., Results: Morning cortisol levels were greater in females than males independent of Tanner staging (p = 0.0054) and also in Tanner stage 1 (p = 0.0042). No differences in mean morning cortisol levels between Tanner stage 2-5 females and males were found (p = 0.4652). Morning cortisol levels were not significantly different between Tanner 1 patients and Tanner 2-5 patients independent of sex (p = 0.0575). Sex was predictive of serum morning cortisol levels (p = 0.015), and morning cortisol levels were predictive of peak cortisol levels during ACTH stimulation testing (p < 0.001)., Conclusions: These data suggest that different normative cortisol values may need to be established for pediatric females and males, and by pubertal status. Larger prospective studies are needed to evaluate the role of sex and pubertal status in identifying adrenal insufficiency in the -pediatric population., (© 2019 S. Karger AG, Basel.)

Liver cirrhosis is an independent risk factor for hepatocellular carcinoma (HCC). The mechanisms that contribute to HCC development in the cirrhotic microenvironment are unknown. We found that HCC grown in the highly stressed cirrhotic microenvironment undergoes autophagy switching from a protective state characterized by high macroautophagy with low chaperone-mediated autophagy (CMA) to an HCC-promoting state characterized by low macroautophagy with high CMA. This study examined how the stress response executes oncogenic cell programming through autophagy switching using hepatitis C virus cell culture. Protein kinase R-like endoplasmic reticulum kinase expression increased to high levels in hepatitis C virus culture. Protein kinase R-like endoplasmic reticulum kinase-dependent activation of nuclear factor erythroid 2-related factor (Nrf2) led to increased transcription of the cytoprotective genes: heat shock cognate 70 kDa protein and lysosome-associated membrane protein 2A (LAMP2A) and precipitated the induction of CMA. CMA selectively targeted beclin1 degradation, leading to accumulation of the autophagy flux protein p62 due to impaired autophagosome-endosome fusion. This impaired autophagosome-endosome fusion due to beclin1 degradation inhibited endocytosis and degradation of epidermal growth factor receptor. Silencing Nrf2 and LAMP2A reduced cell viability, suggesting that the stress response activates CMA as a compensatory mechanism of cell survival. We report a novel mechanism through which stress response triggers oncogenic Nrf2 signaling that promotes autophagy switching to favor cell survival., (Copyright © 2018 American Society for Investigative Pathology. Published by Elsevier Inc. All rights reserved.)

Meniscal surgery is commonplace. Patients who have had prior surgery may return for additional imaging for continued or new pain, limited range of motion, or interval injury. Accurate interpretation of postoperative imaging requires a clear understanding of the normal meniscal anatomy and biomechanics. Surgical goals and current surgical techniques impact the imaging appearance. These techniques are reviewed in the context of the various meniscal tear patterns. Multiple imaging modalities may be used in patient assessment with magnetic resonance (MR) imaging providing key information regarding the integrity of the meniscal repair. Imagers need to be aware of the key findings for a normal versus pathologic appearance to the postoperative meniscus as well as other potential MR findings that may account for patient presentation., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

There are higher rates of menthol cigarette smoking within certain population subgroups. Limited research has examined menthol use among individuals in treatment for substance use disorders (SUD), a population with a high prevalence of cigarette smoking, poor smoking cessation outcomes, and high tobacco disease burden. Survey data were collected from 863 smokers sampled from 24 SUD treatment programs affiliated with the NIDA Clinical Trials Network (CTN) in the United States. Prevalence of menthol cigarette smoking was examined for the sample. Bivariate and multivariate analyses were used to examine demographic and tobacco use characteristics associated with menthol cigarette smoking. Overall, the prevalence of menthol smoking among individuals in SUD treatment was 53.3%. Smoking menthol versus non-menthol cigarettes was associated with being female (AOR=1.61, p=0.003), African American (AOR=7.89, p<0.001), Hispanic/Latino (AOR=3.39, p<0.001), and lower odds of having a college degree (AOR=0.49, p=0.015). Controlling for demographic factors, menthol smokers were more likely to report marijuana (AOR=3.33, p<0.007) as their primary drug compared to alcohol. Lastly, menthol smokers were more likely to report interest in getting help for quitting smoking (AOR=1.53, p=0.01), although they were not more likely to report making a past year quit attempt. In conclusion, use of menthol cigarettes was higher among smokers in SUD treatment than in general population smokers. Regulatory policies targeting the manufacture, marketing, or sale of menthol cigarettes may benefit vulnerable populations, including smokers in SUD treatment., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Injuries and violence among young people have a substantial emotional, physical, and economic toll on society. Understanding the epidemiology of this public health problem can guide prevention efforts, help identify and reduce risk factors, and promote protective factors. We examined fatal and nonfatal unintentional injuries, injuries intentionally inflicted by other (i.e., assaults and homicides) among children ages 0-19, and intentionally self-inflicted injuries (i.e., self-harm and suicides) among children ages 10-19. We accessed deaths (1999-2015) and visits to emergency departments (2001-2015) for these age groups through the Centers for Disease Control and Prevention's (CDC) Web-based Injury Statistics Query and Reporting System (WISQARS), and examined trends and differences by age, sex, race/ethnicity, rural/urban status, and injury mechanism. Almost 13,000 children and adolescents age 0-19 years died in 2015 from injury and violence compared to over 17,000 in 1999. While the overall number of deaths has decreased over time, there were increases in death rates among certain age groups for some categories of unintentional injury and for suicides. The leading causes of injury varied by age group. Our results indicate that efforts to reduce injuries to children and adolescents should consider cause, intent, age, sex, race, and regional factors to assure that prevention resources are directed at those at greatest risk., Competing Interests: The authors declare no conflict of interest.

Background: To examine the current trends in trauma call coverage of pediatric orthopaedic surgeons in North America and to identify predictors of surgeon on-call satisfaction., Methods: In 2015, ∼1200 active members of the Pediatric Orthopaedic Society of North America (POSNA) were surveyed regarding emergency room on-call practices. In total, 410 members completed the survey with a response rate of 35%. Information collected included call frequency, practice setting and satisfaction with call. This information was analyzed and compared with the 2006 and 2010 trauma call surveys of Pediatric Orthopaedic Society of North America membership using 2 sample difference in proportion, χ tests for trend and the Fisher exact tests. Logistic regression analyses were used to identify predictors of call satisfaction among pediatric orthopaedic surgeons., Results: In total, 47% of pediatric orthopaedic surgeons had access to a designated trauma operating room in 2015, up from 39% in 2010 and 24% in 2006. In total, 43% of pediatric orthopaedic surgeons currently receive a stipend for taking call, up from 35% in 2010 and 28% in 2006. Although 83% of pediatric orthopaedic surgeons believe that trauma call is an integral part of their practice, only 53% are satisfied with their call experience. Controlling for covariates, believing that call is integral to one's practice doubles odds of call satisfaction. Having resident or fellow support and being financially compensated for orthopaedic trauma call also increases one's odds of satisfaction. The odds of being satisfied with call decrease by 7% for each year of increase in age of the surgeon., Conclusions: Access to a designated trauma operating room and financial compensation for call coverage have steadily increased over the past decade. A sizable majority of respondents continue to believe that trauma care is an integral part of being a pediatric orthopedist. Despite this, 47% of respondents remain dissatisfied with their trauma call arrangements. The age and attitude of the individual surgeon and extent of hospital support predict satisfaction of surgeons providing trauma coverage., Level of Evidence: Level V-economic and decision analysis.

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Objectives: To evaluate clinical practice patterns and patient outcomes among febrile low-risk infants with respiratory syncytial virus (RSV) infection or enterovirus (EV) meningitis after implementing a clinical practice guideline (CPG) that provides recommendations for managing febrile infants with RSV infection and EV meningitis., Methods: Our institution implemented a CPG for febrile infants, which gives explicit recommendations for managing both RSV-positive and EV-positive infants in 2011. We retrospectively analyzed medical records of febrile infants ≤60 days old from June 2008 to January 2013. Among 134 low-risk RSV-positive infants, we compared the proportion of infants who underwent lumbar puncture (LP), the proportion of infants who received antibiotics, antibiotic hours of therapy (HOT), and length of stay (LOS) pre- and post-CPG implementation. Among 274 low-risk infants with EV meningitis, we compared HOT and LOS pre- and post-CPG implementation., Results: Among low-risk RSV-positive patients, the proportion of infants undergoing LP, the proportion of infants receiving antibiotics, HOT, and LOS were unchanged post-CPG. Among low-risk infants with EV meningitis, HOT (79 hours pre-CPG implementation versus 46 hours post-CPG implementation, P < .001) and LOS (47 hours pre-CPG implementation versus 43 hours post-CPG implementation, P = .01) both decreased post-CPG., Conclusions: CPG implementation is associated with decreased antibiotic exposure and hospital LOS among low-risk infants with EV meningitis; however, there were no associated changes in the proportion of infants undergoing LP, antibiotic exposure, or LOS among low-risk infants with RSV. Further studies are needed to determine specific barriers and facilitators to effectively incorporate diagnostic viral testing into medical decision-making for these infants., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2017 by the American Academy of Pediatrics.)

Of the 30 extant orders of true insect, 12 are considered to be aquatic, or semiaquatic, in either some or all of their life stages. Out of these, six orders contain species engaged in entomophagy, but very few are being harvested effectively, leading to over-exploitation and local extinction. Examples of existing practices are given, ranging from the extremes of including insects (e.g., dipterans) in the dietary cores of many indigenous peoples to consumption of selected insects, by a wealthy few, as novelty food (e.g., caddisflies). The comparative nutritional worth of aquatic insects to the human diet and to domestic animal feed is examined. Questions are raised as to whether natural populations of aquatic insects can yield sufficient biomass to be of practicable and sustained use, whether some species can be brought into high-yield cultivation, and what are the requirements and limitations involved in achieving this?, Competing Interests: The authors declare no conflict of interest.

In retired professional association football (soccer) players with a past history of repetitive head impacts, chronic traumatic encephalopathy (CTE) is a potential neurodegenerative cause of dementia and motor impairments. From 1980 to 2010, 14 retired footballers with dementia were followed up regularly until death. Their clinical data, playing career, and concussion history were prospectively collected. Next-of-kin provided consent for six to have post-mortem brain examination. Of the 14 male participants, 13 were professional and 1 was a committed amateur. All were skilled headers of the ball and had played football for an average of 26 years. Concussion rate was limited in six cases to one episode each during their careers. All cases developed progressive cognitive impairment with an average age at onset of 63.6 years and disease duration of 10 years. Neuropathological examination revealed septal abnormalities in all six post-mortem cases, supportive of a history of chronic repetitive head impacts. Four cases had pathologically confirmed CTE; concomitant pathologies included Alzheimer's disease (N = 6), TDP-43 (N = 6), cerebral amyloid angiopathy (N = 5), hippocampal sclerosis (N = 2), corticobasal degeneration (N = 1), dementia with Lewy bodies (N = 1), and vascular pathology (N = 1); and all would have contributed synergistically to the clinical manifestations. The pathological diagnosis of CTE was established in four individuals according to the latest consensus diagnostic criteria. This finding is probably related to their past prolonged exposure to repetitive head impacts from head-to-player collisions and heading the ball thousands of time throughout their careers. Alzheimer's disease and TDP-43 pathologies are common concomitant findings in CTE, both of which are increasingly considered as part of the CTE pathological entity in older individuals. Association football is the most popular sport in the world and the potential link between repetitive head impacts from playing football and CTE as indicated from our findings is of considerable public health interest. Clearly, a definitive link cannot be established in this clinico-pathological series, but our findings support the need for further systematic investigation, including large-scale case-control studies to identify at risk groups of footballers which will justify for the implementation of protective strategies.

Objective: To test the hypothesis that HbA1c variability, as measured by standard deviation (SD), is associated with increased risk for incident microalbuminuria and persistent microalbuminuria in pediatric type 1 diabetes (T1D)., Methods: A retrospective analysis using data from electronic health records was performed on 1195 patients from a pediatric diabetes clinic network in the Midwest USA from 1993 to 2009 with ≥1 yr of T1D, ≥4 total HbA1c values, ≥2 HbA1c values/yr, ≥1 urine microalbumin. Microalbuminuria, the main outcome was defined as albumin excretion rate ≥20 mcg/min or 2 of 3 consecutive urine microalbumin/creatinine ≥30 mg/gm. Patients who had persistently high microalbumin or who were treated with an angiotensin-converting-enzyme inhibitor within 1 yr were considered to have persistent microalbuminuria. Sex, race, age, diagnosis age, and duration were covariates., Results: Median numbers of per-patient HbA1c and microalbumin results were 14 and 3, respectively. Median intrapersonal mean HbA1c and SD were 8.62% (70.72 mol/mol) and 1.47% (16.07 mmol/mol), respectively. The median interquartile range (IQR) of diagnosis age was 9.4 yr (6.26-12.02) and diabetes duration was 4.97 yr (2.93-7.64). A total of 172 patients (14.4%) developed microalbuminuria; 55 (4.6%) had persistent microalbuminuria. Patients with higher SD of HbA1c had shorter time to microalbuminuria. In time-dependent Cox Proportional Hazard models, updated SD of HbA1c was significantly associated with microalbuminuria [univariate hazard ratio (HR) 1.48 (1.25-1.76); multivariable HR 1.28 (1.04-1.58)], whereas updated mean HbA1c was not [univariate HR 1.08 (0.97-1.22); multivariable HR 1.05 (0.92-1.2)]. Patients with persistent microalbuminuria had similar HRs., Conclusions: HbA1c variability is independently associated with development of microalbuminuria in children with T1D, highlighting the importance of maintaining stable glycemic control in pediatric patients., (© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

We utilized tunable superomniphobic surfaces with flower-like TiO2 nanostructures to fabricate a simple device with precisely tailored surface energy domains that, for the first time, can sort droplets by surface tension. We envision that our methodology for droplet sorting will enable inexpensive and energy-efficient analytical devices for personalized point-of-care diagnostic platforms, lab-on-a-chip systems, biochemical assays and biosensors.

Objectives: To update the imaging literature regarding spleen appearances in young patients with sickle cell disease (SCD)., Methods: We conducted a retrospective study and included 112 patients age 0 to 21 years with SCD who had at least 1 abdominal sonogram at our institution between 1999 and 2011. Radiologic findings were compared between risk groups by χ(2) analysis. Findings were correlated with other imaging modalities when available., Results: In our cohort, 35.7% of patients had autosplenectomy, and 8.0% had undergone surgical splenectomy. Only 5.0% of individuals age 0 to 5 years had autosplenectomy. In those who had not undergone surgical splenectomy or autosplenectomy, 76.2% had echogenic spleens, heterogeneous-appearing spleens, or both, and patients with the homozygous sickle cell anemia (HbSS) genotype were more likely to have an abnormal spleen echo texture. Patients treated with transfusions had echogenic spleens and had a higher frequency of splenic regeneration nodules. Most patients (80%) with splenomegaly did not require surgical splenectomy after 5.7 years of follow-up., Conclusions: Twenty years ago, children with HbSS SCD were expected to have autosplenectomy by age 5 years. There have been changes in the radiologic appearance of the spleen in patients with SDC, likely due to improved supportive care and the use of acute and chronic transfusion therapy. We found that autosplenectomy is rare by age 5 years, and during childhood and adolescence, the spleen typically appears echogenic, heterogeneous, or both, depending on disease severity.

Context: Diets of subsistence-based Amazonian populations have been linked to local resources, but are changing with market penetration., Objective: To review the available data on traditional Amazonian foods and diets and evaluate their implications for human biology as a step toward understanding nutrition transitions in the region., Methods: This study used the Human Relations Area Files for information on the diets of Amerindian groups in the Amazon Basin from 1950 to the present, and used other published sources and the authors' own data., Results: Data on food use was identified for only nine groups and dietary intake data for individuals in only three of the groups. A diet based on starchy staples (manioc and plantains) and fish, supplemented with a limited variety of other plant and animal foods, was found. Bitter manioc-based foods were associated with the consumption of cyanogens and fish with the consumption of mercury. Diets of adults appear to be adequate in energy and protein and low in fats. Children's diets were not well documented., Conclusion: Based on the limited available data, Amazonian diets are restricted in variety, but appear to be adequate in energy and protein for adults, but likely insufficiently nutrient-dense for children.

Background: Frequency of mealtime insulin bolusing (BOLUS) is a promising new objective assessment of adherence in youths with type 1 diabetes (T1D). As further confirmation of the validity of BOLUS, we compare the associations of glycated hemoglobin (HbA1c) values of T1D youths with the original scoring of BOLUS and two alternative scoring procedures: mean mealtime boluses within a 2-h meal window (2h-BOLUS) and total daily frequency of boluses (TOTAL-BOLUS). In addition, we assess HbA1c associations of these three procedures, including interaction terms for mealtime boluses plus correction boluses., Subjects and Methods: Blood glucose meter data, insulin pump records, and HbA1c levels were collected from a combined clinical and research database for a random sample of 100 youths (mean age, 12.7 ± 4.6 years). Youths' pump records were scored using the published methodology and alternative procedures for evaluating insulin use., Results: Youths' BOLUS, TOTAL-BOLUS, and mealtime boluses within a 2-h meal window (2h-BOLUS) scores are independently associated with youths' HbA1c level; all measures demonstrated stronger associations with youths' HbA1c than did frequency of glucose monitoring. The strongest association was between youths' BOLUS score and their HbA1c level. In multiple regression analyses, youths' BOLUS score better explains the variations in HbA1c levels than either youths' 2h-BOLUS or TOTAL-BOLUS scores. When combined with BOLUS in the same relationships, 2h-BOLUS and TOTAL-BOLUS were not found to have statistically significant coefficients. None of the bivariate relationships of HbA1c and interaction terms of mealtime and correction boluses was significant., Conclusions: The original method for calculating BOLUS appears superior to alternative scoring methods in its association with youths' HbA1c levels.

Background: Previous studies have stratified pediatric asthma patients for risk of future exacerbation and/or health care use, but most incorporate multiple clinical parameters., Objective: To determine whether historical acute care visits (ACVs) alone could predict risk of future health care use., Methods: Children seen for asthma in an outpatient visit during a 3-year period were identified. The number of ACVs in the 12 months before and after the outpatient visit was determined. Logistic regression models were used to determine the odds of a future ACV. Models were adjusted for age, sex, race, and insurance status., Results: Of 28,047 outpatient visits, 21,099 (75.2%) had no historical ACVs. The probability of a future ACV increased from 30% with one historical ACV to 87% with 5 or more historical ACVs. Outpatient visits with one historical ACV had significantly higher odds of a future ACV compared with those with no historical ACVs (adjusted odds ratio [OR], 3.60; 95% confidence interval [CI], 3.14-4.12; P < .001). The OR increased with each additional historical ACV to an adjusted OR of 58.71 (95% CI, 24.34-141.61; P < .001) with 5 or more historical ACVs. Outpatient visits with 5 or more historical ACVs represented only 1.1% of the study sample but accounted for a higher mean number of future ACVs., Conclusion: The historical count of ACVs was predictive of future ACVs. A significant increase in the probability of future ACVs was observed with each additional historical visit, effectively stratifying risk by the historical visit count. Notably, a small group of patients accounted for a disproportionate number of future ACVs., (Copyright © 2016 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Microbially produced methane, a versatile, cleaner-burning alternative energy resource to fossil fuels, is sourced from a variety of natural and engineered ecosystems, including marine sediments, anaerobic digesters, shales, and coalbeds. There is a prevailing interest in developing environmental biotechnologies to enhance methane production. Here, we use small-subunit rRNA gene sequencing and metagenomics to better describe the interplay between coalbed methane (CBM) well conditions and microbial communities in the Alberta Basin. Our results show that CBM microbial community structures display patterns of endemism and habitat selection across the Alberta Basin, consistent with observations from other geographical locations. While some phylum-level taxonomic patterns were observed, relative abundances of specific taxonomic groups were localized to discrete wells, likely shaped by local environmental conditions, such as coal rank and depth-dependent physicochemical conditions. To better resolve functional potential within the CBM milieu, a metagenome from a deep volatile-bituminous coal sample was generated. This sample was dominated by Rhodobacteraceae genotypes, resolving a near-complete population genome bin related to Celeribacter sp. that encoded metabolic pathways for the degradation of a wide range of aromatic compounds and the production of methanogenic substrates via acidogenic fermentation. Genomic comparisons between the Celeribacter sp. population genome and related organisms isolated from different environments reflected habitat-specific selection pressures that included nitrogen availability and the ability to utilize diverse carbon substrates. Taken together, our observations reveal that both endemism and metabolic specialization should be considered in the development of biostimulation strategies for nonproductive wells or for those with declining productivity., (Copyright © 2015, American Society for Microbiology. All Rights Reserved.)

The purpose of this study is to describe gallbladder imaging findings in patients with sickle cell disease, and to determine how they correspond with occurrence of complications, need for cholecystectomy, and surgical pathology. This study is IRB approved and HIPAA compliant. Informed consent requirements were waived. We reviewed records of 77 children with sickle cell disease ages 0-18 years at the time of their first gallbladder imaging study. Demographics, hospital courses, and radiologic and pathologic reports were collected. Two pediatric radiologists independently and retrospectively reviewed the imaging studies. Statistical analysis was performed using kappa statistic, chi-squared test, and ANOVA F-test. Continuous variables were described with mean, median, variance, and range. Patients who underwent cholecystectomy (N = 25) were more likely than the patients who did not undergo cholecystectomy (N = 52) to have gallstones or sludge (100 versus 36.5 %, p = <0.0001) or other gallbladder or biliary abnormality (70.8 versus 1.9 %, p = <0.0001). Patients who did not undergo cholecystectomy more frequently had normal-appearing gallbladders and biliary tracts (63.5 versus 0 %, p = <0.0001). Ninety-two percent of patients with cholecystectomy had chronic cholecystitis on pathology, and 96 % had a complication, including chronic cholecystitis and sequelae of biliary obstruction. Young patients with sickle cell disease, cholelithiasis, and any other biliary imaging abnormality will almost certainly require cholecystectomy, and many will experience complications. The most common surgical pathologic diagnosis in this group is chronic cholecystitis, which has a variable radiologic appearance. Our findings support recommendations to perform elective cholecystectomy for children and young adults with sickle cell disease and cholelithiasis or gallbladder sludge.

Microbial communities are responsible for the bulk of biogeochemical processing in temporary headwater streams, yet there is still relatively little known about how community structure and function respond to periodic drying. Moreover, the ability to sample temporary habitats can be a logistical challenge due to the limited capability to measure and predict the timing, intensity and frequency of wet-dry events. Unsurprisingly, published datasets on microbial community structure and function are limited in scope and temporal resolution and vary widely in the molecular methods applied. We compared environmental and microbial community datasets for permanent and temporary tributaries of two different North American headwater stream systems: Speed River (Ontario, Canada) and Parkers Creek (Maryland, USA). We explored whether taxonomic diversity and community composition were altered as a result of flow permanence and compared community composition amongst streams using different 16S microbial community methods (i.e., T-RFLP and Illumina MiSeq). Contrary to our hypotheses, and irrespective of method, community composition did not respond strongly to drying. In both systems, community composition was related to site rather than drying condition. Additional network analysis on the Parkers Creek dataset indicated a shift in the central microbial relationships between temporary and permanent streams. In the permanent stream at Parkers Creek, associations of methanotrophic taxa were most dominant, whereas associations with taxa from the order Nitrospirales were more dominant in the temporary stream, particularly during dry conditions. We compared these results with existing published studies from around the world and found a wide range in community responses to drying. We conclude by proposing three hypotheses that may address contradictory results and, when tested across systems, may expand understanding of the responses of microbial communities in temporary streams to natural and human-induced fluctuations in flow-status and permanence.

Background: Studies found that treatment symptoms of concern to oncology/hematology patients were greatly under-identified in medical records. On average, 11.0 symptoms were reported of concern to patients compared to 1.5 symptoms identified in their medical records. A solution to this problem is use of an electronic symptom checklist that can be easily accessed by patients prior to clinical consultations., Purpose: Describe the oncology Therapy-Related Symptom Checklists for Adults (TRSC) and Children (TRSC-C), which are validated bases for e-Health symptom documentation and management. The TRSC has 25 items/symptoms; the TRSC-C has 30 items/symptoms. These items capture up to 80% of the variance of patient symptoms. Measurement properties and applications with outpatients are presented. E-Health applications are indicated., Methods: The TRSC was developed for adults (N = 282) then modified for children (N = 385). Statistical analyses have been done using correlational, epidemiologic, and qualitative methods. Extensive validation of measurement properties has been reported., Results: Research has found high levels of patient/clinician satisfaction, no increase in clinic costs, and strong correlations of TRSC/TRSC-C with medical outcomes. A recently published sequential cohort trial with adult outpatients at a Mayo Clinic community cancer center found TRSC use produced a 7.2% higher patient quality of life, 116% more symptoms identified/managed, and higher functional status., Discussion, Implications, and Follow-Up: An electronic system has been built to collect TRSC symptoms, reassure patients, and enhance patient-clinician communications. This report discusses system design and efforts made to provide an electronic system comfortable to patients. Methods used by clinicians to promote comfort and patient engagement were examined and incorporated into system design. These methods included (a) conversational data collection as opposed to survey style or standardized questionnaires, (b) short response phrases indicating understanding of the reported symptom, (c) use of open-ended questions to reduce long lists of symptoms, (d) directed questions that ask for confirmation of expected symptoms, (e) review of symptoms at designated stages, and (d) alerting patients when the computer has informed clinicians about patient-reported symptoms., Conclusions: An e-Health symptom checklist (TRSC/TRSC-C) can facilitate identification, monitoring, and management of symptoms; enhance patient-clinician communications; and contribute to improved patient outcomes.

Slight changes in climate, such as the rise of temperature or alterations of precipitation and evaporation, will dramatically influence nearly all freshwater and climate-related hydrological behavior on a global scale. The hyporheic zone (HZ), where groundwater (GW) and surface waters (SW) interact, is characterized by permeable sediments, low flow velocities, and gradients of physical, chemical, and biological characteristics along the exchange flows. Hyporheic metabolism, that is biogeochemical reactions within the HZ as well as various processes that exchange substances and energy with adjoining systems, is correlated with hyporheic organisms, habitats, and the organic matter (OM) supplied from GW and SW, which will inevitably be influenced by climate-related variations. The characteristics of the HZ in acting as a transition zone and in filtering and purifying exchanged water will be lost, resulting in a weakening of the self-purification capacity of natural water bodies. Thus, as human disturbances intensify in the future, GW and SW pollution will become a greater challenge for mankind than ever before. Biogeochemical processes in the HZ may favor the release of carbon dioxide (CO2), nitrous oxide (N2O), and methane (CH4) under climate change scenarios. Future water resource management should consider the integrity of aquatic systems as a whole, including the HZ, rather than independently focusing on SW and GW.