BACKGROUND:Patients with urinary tract infections (UTIs) may have treatment initiated in the emergency department (ED) before discharge with an antibiotic prescription. The effect of a single antibiotic dose administered before discharge on ED length of stay (LOS) is unknown.OBJECTIVES:The purpose of this study was to compare the LOS and the rate of revisits within 30 days among patients diagnosed as having UTIs other than pyelonephritis who received parenteral, oral, or no antibiotic during an ED visit.METHODS:This was a retrospective cohort study of adult patients with a diagnosis of UTI who received an antibiotic prescription at discharge from a single community ED in the United States between 2019 and 2020. Patients were excluded if they were admitted to the hospital, were diagnosed as having pyelonephritis, or had an ED visit in the previous 30 days. ED LOS was compared using 3-factor analysis of variance. ED revisits at 72 hours and 30 days were compared using the chi-square test.RESULTS:A total of 694 patients with an ED visit for UTI and an antibiotic prescription at discharge were included. The mean age of the study population was 58 years. Parenteral antibiotic administration in the ED was associated with a 60-minute increase in ED LOS compared with those who received an oral antibiotic (P < 0.001) and a 30-minute increase in ED LOS compared with no antibiotic (P < 0.001). No differences were observed in revisits to the ED at 72 hours (5%, 5%, 2%; P = 0.17) or 30 days (15%, 16%, 17%: P = 0.98) among patients who received parenteral, oral, or no antibiotic before discharge.CONCLUSIONS:A single dose of parenteral antibiotic before discharge was associated with an increased ED LOS compared with treatment with oral antibiotic or discharge without ED treatment. ED revisit rates were similar regardless of ED treatment.

Introduction Rett syndrome (RTT) is a neurodevelopmental disorder that primarily affects females and can result in cognitive impairment, seizures, spasticity, breathing problems, gastrointestinal issues, motor impairment, and behavioral concerns. Gene therapy may be a potential treatment in the future as clinical trials are underway. Aim This study evaluates the attitudes and opinions of family members and caregivers of patients with RTT towards gene therapy using a mixed-method approach. Methods Sixty-six caregivers of individuals with RTT completed an online survey asking about their previous experience in research and questions about their understanding of gene therapy, their expectations, as well as their hopes and concerns for treating RTT. Ten respondents also participated in online focus groups, which were evaluated using thematic analysis. Results Overall, most participants (95. 5%) had heard about gene therapy. More than half of the respondents (68.2%) reported being somewhat knowledgeable about gene therapy, and 18.2% reported no understanding of gene therapy. When asked the highest level of risk they would accept when enrolling the individual with Rett syndrome in a gene therapy clinical trial, 47.7% stated they would accept a low risk, and 7.7% indicated they would accept a high risk. In the focus groups, individuals discussed barriers to gene therapy, their hopes and concerns regarding gene therapy treatment, and how they would like to receive information about future research and therapies. Participants had concerns about possible side effects of gene therapy, including physical and mental harm, a potential decrease in quality of life, whether individuals with RTT would want to “change who they are,” and the irreversibility of the treatment. Conclusion Although most participants have heard about gene therapy, many caregivers would only accept a low risk when considering gene therapy for the individual with RTT. This could be in part due to concerns about side effects and potential harm to the patient as well as anticipated barriers related to cost and accessibility to appropriate follow-up care. Understanding caregiver opinions is important in setting goals and evaluating the success of current studies, identifying and addressing barriers to trials and treatment, and in the development and implementation of educational resources for gene therapy in RTT.

Background The ligaments implicated in the earliest stages of developing a progressive collapsing foot deformity are poorly understood. Commonly employed cadaveric flatfoot models are created from simultaneous transection of multiple ligaments, making it difficult to assess early changes in pressure distribution from ligaments critical for maintaining load distribution. A serial transection of ligaments may provide insight into changes in pressure distribution under the foot to identify a potential combination of ligaments that may be involved in early deformities. Methods Specimens were loaded using a custom designed axial and tendon loading system. Plantar pressure data for the forefoot and hindfoot were recorded before and after six sequential ligament complex transections. Findings Sectioning the plantar fascia (first) and short/long plantar ligaments (second) failed to generate appreciable differences in load distribution. Dividing the spring ligament (third) led to changes in hindfoot load distribution with a shift towards the lateral column indicative of hindfoot valgus angulation. All subsequent conditions resulted in similar patterns in hindfoot plantar load distribution. An anterior shift in the center of pressure only occurred after transection of all six ligament complexes. Interpretation Loss of the plantar fascia and short/long plantar ligaments are not critical in maintaining plantar load distribution or contact area. However, the additional loss of the spring ligament caused notable changes in hindfoot load distribution, indicating the combination of these three ligament complexes is particularly critical for preventing peritalar subluxation. Minimal changes in load distribution occurred when performing additional transections to reach a complete flatfoot deformity.

There are nearly 65 million people with chronic heart failure (CHF) globally, with no treatment directed at the pathologic cause of the disease, the loss of functioning cardiomyocytes. We have an allogeneic cardiac patch comprised of cardiomyocytes and human fibroblasts on a bioresorbable matrix. This patch increases blood flow to the damaged heart and improves left ventricular (LV) function in an immune competent rat model of ischemic CHF. After 6 months of treatment in an immune competent Yucatan mini swine ischemic CHF model, this patch restores LV contractility without constrictive physiology, partially reversing maladaptive LV and right ventricular remodeling, increases exercise tolerance, without inducing any cardiac arrhythmias or a change in myocardial oxygen consumption. Digital spatial profiling in mice with patch placement 3 weeks after a myocardial infarction shows that the patch induces a CD45pos immune cell response that results in an infiltration of dendritic cells and macrophages with high expression of macrophages polarization to the anti-inflammatory reparative M2 phenotype. Leveraging the host native immune system allows for the potential use of immunomodulatory therapies for treatment of chronic inflammatory diseases not limited to ischemic CHF.

Background The Dichotic Digits Test (DDT) evaluates central auditory nervous system (CANS) dysfunction. The DDT is widely used in audiology clinics worldwide, because it is clinically efficient and has good sensitivity and specificity for CANS lesions. However, the DDT shows a strong ceiling effect, which can mitigate its ability to detect subtle CANS dysfunction. Purpose This study examines the effects of adding monaural and binaural speech-spectrum noise to the DDT in an effort to make the test more taxing to the CANS and thereby reduce the observed ceiling effect. Research Design This was an experimental repeated measures study. Study Sample The participants were 20 adults aged 18 to 50 years with bilaterally symmetric speech-reception thresholds and pure-tone thresholds (250-8000 Hz) of 25 dB HL or better. Data Collection and Analysis Each participant was administered one standard DDT test list (no noise added) and DDT test lists with binaural, monaural right, and monaural left noise added. For each of the noise-added conditions, lists were administered at two different signal-to-noise ratios, for a grand total of seven DDT test lists per participant, presented in randomized order. Monaural and binaural noise effects on DDT scoring indices (Right and Left Ear Percent Correct Scores, Combined Total Percent Correct Scores, and Dichotic Difference Scores), as well as noise effects on the right ear advantage for speech, were examined. Mixed model analyses of variance were used to examine fixed effects and interactions of Noise Condition and Ear. Results Adding noise to the standard DDT systematically reduced Right and Left Ear Percent Correct Scores and Combined Total Percent Correct Scores. Statistically significant differences on all indices were found between monaural and binaural noise-added conditions, suggesting a possible advantage for binaural listening in noise. Conclusions These findings suggest that adding noise to tests of dichotic listening increases the difficulty of the task, and that further investigation of dichotic listening patterns in noise could potentially lead to more sensitive clinical evaluations of CANS integrity and function.

Melanoma in Black patients carries a poor prognosis. Due to its rarity, melanoma in this population has not been well characterized. This study evaluates survival predictors in Black patients with melanoma. This was a retrospective cohort study of Black patients with cutaneous melanoma from the National Cancer Database 2004-2018. Of the 2464 cases, melanoma was more common among females than males (57.1% vs. 42.9%, p < .001). Median Breslow depth was 1.8 mm (interquartile range 0.4-4.4). Lower extremities were the most common location (52.8%), followed by upper extremities (13.1%) along with otherwise specified/overlapping/other (13.1%), then by trunk (11.8%), and lastly head and neck (9.2%). Stage at diagnosis was I (30.7%), II (27.5%), III (24.1%), and IV (17.7%). Ulceration was observed in 41.4% of lesions. Acral lentiginous melanoma (ALM) was the most common specific histologic subtype (20.3%), followed by superficial spreading melanoma (9.4%). After adjusting for confounders, higher stages and primary site on the head and neck were the strongest independent predictors of worse overall survival. Melanoma in Black patients is most likely to appear on the lower extremities. A large portion (41.8%) presented with stage III or IV disease. ALM was the most common specific histologic subtype.

Introduction: The purpose of this retrospective study is to identify medical conditions impacting neurodevelopmental outcomes of extremely low birth weight and very low birth weight preterm infants at three years of age.Methods: Infants born in Banner Diamond Children's University Medical Center, receiving services in the Newborn Intensive Care Unit, and attending Neonatal Developmental Follow-Up Clinic were identified.Participants received developmental assessment and follow-up from August 2012 through December 2018.Relevant clinical conditions during initial hospital stay and up to three years of age were obtained by reviewing medical and developmental records.Bayley Scales of Infant Toddler Development (Bayley III) was used to evaluate skill development at 6, 9, 12, 18, 24, 30, 36 months.Results: Data analysis did not reveal significant p-values; it did demonstrate that some predictor variables impact neurodevelopmental outcomes in cognitive, language and motor skill development.Conclusion: This retrospective study reports significant association between birth weight and low cognitive scores.Correlations were also found between gestational age and Total Language, and the longer an infant stayed in the NICU, the poorer the Total Language Scaled Scores at 8 to 12 months, 15 to 18 months, and 24 to 36 months.Birth weight was found to be the greatest predictor of poor motor scores.

Medical induction of labor (mIOL) is generally associated with high risk of Cesarean Delivery (CD) and performed under non ideal circumstances. We sought to compare the rate of primary CD in women requiring mIOL to women undergoing elective induction of labor (eIOL) at term in viable pregnancies. We performed a retrospective review of singleton pregnancies undergoing either mIOL or eIOL from Jan 2018 to Jul 2020. Women with viable singleton gestations, no prior CD, at 35 – 42 weeks gestation were included for analysis. Labor management was based on the Consortium on Safe Labor guidelines for prevention of primary CD. The main outcome was the primary CD rate. Maternal characteristics, induction methods, maternal and neonatal complications were assessed. Median time for admission to delivery and membrane rupture were calculated and the % of women who achieved delivery within 24 hours. Data were analyzed in SPSS v.28. Of the 632 women in the cohort, 398 (63.0%) underwent mIOL and 234 (37.0%) underwent eIOL (Table 1). Primary CD rate was similar between mIOL vs eIOL (14.8% vs 15.0%, p=0.964) (Table 2). The rate of morbid obesity (BMI >35) was higher in women undergoing mIOL (30.2 vs 15.4%, p< .001). The mIOL group had lower gestational age and modified Bishop score on admission. Cervical ripening methods and oxytocin use were similar. Maternal and neonatal outcomes were favorable in both groups. Time to delivery was longer for patients undergoing mIOL with 64.3% achieving delivery in < 24 hours compared to 73.5% in the eIOL group. Despite multiple high-risk factors for CD including medical and obstetrical complications, morbid obesity, earlier gestational age, lower Bishop scores, our mIOL group achieved a low rate of primary Cesarean (14.8%) that was comparable to our eIOL group (15.0%). We attribute our low CD rate in both groups to adoption of the Consortium of Safe Labor guidelines for labor management and allowing longer labors to achieve vaginal delivery with no apparent increase in maternal or neonatal morbidity.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

ABSTRACT The advent of refractive surgery and corneal cross-linking for ectatic disease has further highlighted the need to recognize early or subclinical ectatic disease. Historical systems depend on anterior corneal changes that occur late in the disease course and are commonly associated with visual loss. Tomographic imaging allows for the acquisition of posterior corneal surface data and corneal thickness distribution. This led to the development of modalities to diagnose early or subclinical keratoconus and to screen patients for refractive surgery.This article reviews the modern methods for assessing changes in posterior corneal surface and pachymetric distribution, now accepted by the major cornea societies to be the hallmarks of ectatic disease. Screening tools utilized by the commonly used tomographic imaging devices are discussed, and the difference between screening for ectasia and diagnosing keratoconus is highlighted. The Belin ABCD staging and classification system and the ABCD Progression Display are reviewed as a new grading and monitoring system that can be used for earlier intervention and prevention of visual loss in keratoconus.

Validation and improvement of a previously published induction of labor (IOL) success calculator in a cohort of patients from a single university hospital. We performed a retrospective review of 707 singleton pregnancies undergoing either elective or medically indicated IOL at our institution from January 2018 to July 2020 at gestational age 32 – 42 6/7 weeks. We assessed the accuracy of 7 variables reported in a previously published IOL calculator (prior vaginal birth, prior cesarean birth, maternal race, and maternal weight, maternal height, maternal age, and gestational age at birth) for predicting vaginal delivery. We also added 2 new variables: modified Bishop score and IOL indication (elective or medically) not included in the previous calculator. After comparing predictors to vaginal delivery in univariate analyses, we used multivariable logistic regression (LR) to construct a receiver operator characteristic (ROC) curve using the 7 above-mentioned covariates. We then added the 2 new predictor variables individually and collectively to the LR model to construct 3 additional ROC curves and compared their Area under the curve (AUC) to the AUC from the original 7-variable model. The AUC's were compared using chi-square, alpha=0.05. In univariate analyses, prior vaginal delivery, prior cesarean delivery, maternal height, and modified Bishop score were significantly associated with vaginal delivery (Table 1). The 7-variable IOL calculator had an AUC = 0.7379 (95% C.I. 0.6879-0.7878) (Figure 1). The increase in AUC with the addition of the modified Bishop score (AUC=0.7555 C.I. 0.7057-0.8043, p=NS), the indication for IOL (AUC=0.7392 C.I. 0.6892-0.7893 p=NS) or both (AUC=0.7566 C.I. 0.7072-0.8060, p=NS) did show a statistically significant improvement in predictive accuracy (Figure 1). The published IOL calculator had fair accuracy for predicting the success of IOL in our population. The addition of modified Bishop score and IOL indication made a minimal, non-significant improvement in the AUC. Larger studies are needed to improve existing IOL success calculators.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

The aim of the study is to investigate whether close surgical margins impact oncologic outcomes compared to clear or involved surgical margins. We hypothesize that close surgical margins portend worse outcomes compared with clear margins, but improved outcomes compared with involved margins.

Introduction: Non-invasive fibrosis scores are readily available testing modalities to classify fibrosis, particularly when imaging, transient elastography, or liver biopsy are not accessible. The goal of our study was to determine whether the Fibrosis-4 (FIB-4) score requires modifications to account for race, ethnicity, age, gender, and body mass index (BMI) to accurately identify early-stage fibrosis in patients with biopsy proven non-alcoholic fatty liver disease (NAFLD). Methods: A retrospective study was conducted of patients who had biopsy proven hepatic steatosis from 2015 to 2020 at two major tertiary care centers. Participants were 18-75 years of age. Patients that had hepatic steatosis from Wilson’s disease, viral hepatitis, alcohol use, or autoimmune hepatitis were excluded. Patients with consumption of more than two alcoholic beverages per week were excluded from the study. NAS (NAFLD activity score) steatosis and fibrosis stages were confirmed by two independent pathologists. FIB-4 was calculated from serological markers that were available within six months prior to the patient’s liver biopsy. Early-stage fibrosis via FIB-4 was defined as < 3.25. The ability of FIB-4 to appropriately stratify fibrosis was assessed via nominal logistic regression across various patient characteristics. Results: The study included 265 patients; 40% were male, 73% Caucasian and 36% Hispanic, with a mean body mass index (BMI) of 32.0 and a median age of 54 years. Fifty-seven percent of patients had a NAS steatosis of at least two. Only seventy-one percent of female patients and seventy-three percent of patients with Class I obesity were properly classified as having early-stage fibrosis via the FIB-4 score (χ2= 24.7, p< 0.001, χ2= 12.0, p< 0.01). Additional associations between demographics and fibrosis scoring can be found in Figure 1. Conclusion: Our study demonstrates that the FIB-4 score often misclassifies patients with early-stage liver fibrosis, and therefore modifications must be made to account for these factors. Adaptation of fibrosis scores to represent a diverse and evolving population of patients with NAFLD will be paramount in allowing for appropriate counseling and medical interventions in primary and hepatology care settings, and may ultimately lead to decreased incidence of NASH associated cirrhosis. Modeling to improve logistic regression of FIB-4 and development of a multi-center analysis to provide external validation of this study’s results is currently in progress.Figure 1.: Nominal Logistic Regression Evaluating the Association Among Patient Demographics and Stratification of Hepatic Fibrosis via FIB-4.

Purpose: The aim of this study was to determine whether there are significant clinical variations in the Belin/Ambrosio Enhanced Ectasia Display (BAD display) parameters between Chinese and North American eyes and whether any variations are related to differences in corneal diameter. Design: Retrospective observational study. Methods: Files were generated from patients seeking refractive surgical correction. Patients with previous surgery, evidence of corneal ectasia, or scans representing a non-normal cornea were excluded. Unpaired t tests were performed for all variables. Regression analyses were performed for all variables with respect to corneal diameter, and compared to evaluate the influence of corneal diameter between populations. Data were graphed as standard scores (z scores) to compare different parameters. Results: 127 North American and 49 Chinese patients met study criteria. Statistically significant differences existed for corneal diameter (P< 0.01), anterior elevation at the thinnest point (P< 0.01), and Df (P< 0.01). In both populations, statistically significant correlations existed between corneal diameter and most indices, and most profoundly on pachymetric progression and final D. Regression slopes revealed a statistically significant difference for the influence of corneal diameter on ARTmax (P = 0.04) and was nearly significant for final D (P = 0.06). Conclusions: Corneal diameter had the greatest influence on pachymetric progression and final D, and more profoundly in the Chinese. This suggests that incorporating corneal diameter as an additional variable may make the BAD display more universally applicable. Also, the differences in anterior elevation parameters suggest that specific ethnic/geographic normative values may be beneficial for the BAD display.

Refractory cardiogenic shock requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO) has high mortality. The underlying cardiovascular diagnosis may influence outcomes and have implications for patient selection and management on ECMO. This study evaluated outcomes of patients with