We present a 47-year-old with Ehlers-Danlos syndrome (EDS) type IV (vascular subtype) referred with recurrent episodes of severe biliary colic requiring elective cholecystectomy. Successful surgical management required extensive planning and multidisciplinary teamwork. This report is intended as a guide for clinicians in the perioperative planning of elective EDS typeIV patients.

Background. Median survival age in cystic fibrosis (CF) has increased in developed countries. Scarce literature exists about survival in Latin American, especially in Mexico. The aim of our study was to assess the median age of CF patients’ survival in Mexico over a 20-year period. Methods. We conducted a retrospective study, with all patients registered and followed in the CF Center in Monterrey, Mexico from 2000 to 2020. Median survival age was the primary outcome, assessed with the Kaplan-Meier analysis. Influence of clinical, biological, and demographic factors on survival were analyzed with the Cox regression model. Results. Two-hundred five patients were included. Median survival for the cohort was 21.37 years (95% CI 17.20 – 25.55). In the multivariate Cox regression model, low socioeconomic status (hazard ratio [HR] 4.21, 95% CI 2.43 – 7.27), chronic Pseudomonas aeruginosa (P. aeruginosa) infection at 6 years (HR 10.45, 95% CI 5.66 – 19.28), and pancreatic insufficiency (HR 3.13, 1.38 – 7.13) were independent risk factors for mortality. Conclusion. Median survival in Mexican patients with CF is lower than in high-income countries, and socioeconomic status plays a conspicuous role in the disparity. To increase patient survival for those residing in low-income countries, public health authorities must design policies that fully cover diagnosis and treatment strategies for the CF population.

Background and Objectives: Extubation failure in preterm infants is associated with increased risk of mortality and morbidities. There is limited evidence to suggest if the increased morbidities are due to inherent differences among infants who fail or succeed; or whether these are due to a true respiratory setback among those who fail extubation. The aim of this study was to evaluate the respiratory status of infants who fail extubation and to assess the time taken for these infants to achieve pre-extubation respiratory status. Methods: This was a retrospective study of infants with birth weight ≤1,250 g who were born between January 2009 and December 2016. Infants were eligible if they failed first elective extubation. Extubation failure was defined as need for re-intubation within 5 days of extubation. Ventilator settings, blood gas parameters, respiratory severity score and ventilation index were used to assess respiratory status of infants. Results: Of 384 infants, 76% were successful and 24% failed extubation. Among those who failed extubation 91%, 77% and 56% infants remained intubated at 24 hours, 72 hours and 7 days, respectively. Respiratory status was worse at 24 hours and 72 hours after re-intubation when compared to pre-extubation levels. The median times for respiratory severity score and ventilation index to reach pre-extubation levels were 4 days and 7 days respectively. Conclusion: Among preterm infants, failed elective extubation is associated with a significant setback in the respiratory status. Infants who fail an extubation attempt may not achieve pre-extubation respiratory status for many days after reintubation.

Background and Objectives: Swallowing disorders lead to chronic lung aspiration. Early detection and treatment of aspiration in children with dysphagia is important to prevent lung damage. Diagnosis of aspiration, which may be silent, requires an instrumental study such as fiberoptic endoscopic evaluation of swallowing (FEES). Despite its usefulness, it is rarely practiced by pediatric pulmonologists. This study aimed to evaluate the feasibility and utility of FEES performed in the pediatric respiratory unit of a tertiary hospital, analyze the clinical characteristics, endoscopic findings and proposed treatments, and identify the factors associated with penetration or aspiration. Methods: Medical records of 373 children with suspected aspiration who were referred to the pediatric respiratory unit for FEES were reviewed retrospectively. Clinical characteristics, FEES findings, and the proposed treatments were analyzed. Results: Aspiration was seen in 47.9% of the patients. The most common associated conditions were neurological disease and prematurity. The most frequently observed endoscopic finding was altered laryngeal sensitivity (36.5%). Intervention was recommended in 54.2 % of the patients. Complications were not seen during any of the procedures. Conclusions: The FEES procedure performed by pediatric pulmonologists is a reliable method for diagnosing aspiration in children. It can be safely executed by trained pulmonologists, and significant endoscopic signs other than aspiration can guide in the diagnosis and management recommendations.

Key Points • Sepsis is associated with high morbidity and mortality and is a known complication of infections of the head and neck. Screening for sepsis should be conducted on admission in order to identify patients at risk and provide early intervention. • Our audit on an ENT ward in a district general hospital found that sepsis screening is poor, however this can be improved further by education and visual reminders such as poster or a clerking proforma. • The most common head and neck infections admitted to a district general hospital were tonsillitis, peritonsillar cellulitis and peritonsillar abscesses. • The incidence of sepsis as a complication of head and neck infections is very rare if diagnosed according to the updated qSOFA criteria. • Using SIRS criteria may result in falsely high rates of diagnosis of sepsis and may lead to excessive and inappropriate clinical management in patients who could otherwise be managed less aggressively.

In this paper, we consider the Cauchy problem for one nonclassical, third-order, partial differential equation with gradient non-linearity $|\nabla u(x,t)|^q$. The solution to this problem is understood in a weak sense. We show that for $1“3/2$ the existence of the only local-in-time weak solution of Cauchy’s problem.If $3/2”

Coronary artery and cerebrovascular disease represent a major cause of cardiovascular morbidity and mortality worldwide. Despite technological advancements in percutaneous interventions, surgical revascularization remains the preferred strategy in patients with left main or multivessel disease and in those with complex lesions with high SYNTAX score. As a result, an increasing number of older patients with diffuse atherosclerotic extracoronary disease are referred for coronary artery bypass grafting (CABG). Cerebrovascular complications after isolated coronary surgery occurs in 1-5% of patients; the magnitude of injury ranges from overt neurologic lesions with varying degree of permanent disability to “asymptomatic” cerebral events detected by dedicated neuro-imaging, nevertheless associated with significant long term cognitive and functional decline. Thromboembolic events due to manipulation of an atherosclerotic aorta are universally recognized as the leading etiology of early postoperative stroke following CABG. Coronary bypass surgery performed on an arrested heart relies on considerable aortic instrumentation associated with significant atheroembolic risk especially in older patients presenting with diffuse aortic calcifications. Surgical techniques to deal with a calcified ascending aorta during isolated coronary surgery have evolved over the last forty years. Moving away from aggressive aortic debridement or replacement, surgeons have developed strategies aimed to minimize aortic manipulation: from pump-assisted beating heart surgery with the use of composite grafts to complete avoidance of aortic manipulation with “anaortic” off-pump coronary artery bypass grafting, a safe and effective approach in significantly reducing the risk of intraoperative stroke.

Interactions of organisms with their environment are complex and environmental regulation at different levels of biological organization is often non-linear. Therefore, the genotype to phenotype continuum requires study at multiple levels of organization. While studies of transcriptome regulation are now common for many species, quantitative studies of environmental effects on proteomes are needed. Here we report the generation of a data-independent acquisition (DIA) assay library that enables simultaneous targeted proteomics of thousands of Oreochromis niloticus kidney proteins using a label- and gel-free workflow that is well suited for ecologically relevant field samples. We demonstrate the usefulness of this DIA assay library by discerning environmental effects on the kidney proteome of O. niloticus. Moreover, we demonstrate that the DIA assay library approach generates data that are complimentary rather than redundant to transcriptomics data. Transcript and protein abundance differences in kidneys of tilapia acclimated to freshwater and brackish water (25 g/kg) were correlated for 2114 unique genes. A high degree of non-linearity in salinity-dependent regulation of transcriptomes and proteomes was revealed suggesting that the regulation of O. niloticus renal function by environmental salinity relies heavily on post-transcriptional mechanisms. The application of functional enrichment analyses using STRING and KEGG to DIA assay datasets is demonstrated by identifying myo-inositol metabolism, antioxidant and xenobiotic functions, and signaling mechanisms as key elements controlled by salinity in tilapia kidneys. The DIA assay library resource presented here can be adopted for other tissues and other organisms to study proteome dynamics during changing ecological contexts.

The Ardières catchment, (150 km²), in Beaujolais (France), belongs to the first European catchments where surface water contamination by pesticides has been highlighted in the late 1980s. Research on this site mainly aims at better understanding organic pesticides and trace elements hydrological pathways to watercourses, and at evaluating subsequent contamination and impact on aquatic ecosystems. Landscape as well as instream processes are studied in order to highlight catchment vulnerability to contaminants and possible mitigation actions. A consistent hydrological and chemical monitoring of the Ardières River and one of its tributaries, the Morcille River, has been taking place since 2002. It was supplemented by biological measurements on aquatic micro-organisms and macroinvertebrates, more particularly after 2005. The results show the importance of long-term study to account for the kinetics of contaminant transfer in hydro-biogeochemical systems. Physico-chemical, ecological and ecotoxicological measurements all showed spatial and temporal variability in water quality and a gradient of impact on community structures and ecological functions as a function of the pressure of human activity. Results allowed to develop indicators of toxic impacts and resilience of communities and provided avenues for action to improve water quality.

Uncovering the hillslope scale flow and transport dynamics in an experimental hydrologic systemMinseok Kim1, Till H. M. Volkmann1,2, Aaron Bugaj1, Yadi Wang3, Antônio A. Meira Neto4, Katarena Matos4, Ciaran J. Harman5,6, Peter A. Troch1,41Biosphere 2, University of Arizona, Tucson, AZ, USA,2Applied Intelligence, Accenture, Kronberg im Taunus, Germany, 3Department of Environmental Science, University of Arizona, Tucson, AZ, USA, 4Department of Hydrology and Atmospheric Sciences, University of Arizona, Tucson, AZ, USA, 5Department of Environmental Health and Engineering, Johns Hopkins University, Baltimore, MD, USA,6Department of Earth and Planetary Sciences, Johns Hopkins University, Baltimore, MD, USAHillslope scale water flow and transport dynamics have been extensively studied (Burt & McDonnell, 2015; Hewlett & Hibbert, 1963), but observing those internal dynamics in high spatial and temporal resolutions remains challenging. In this study, we uncover internal water flow and transport dynamics in an artificial hillslope in the Landscape Evolution Observatory (LEO), Biosphere 2, University of Arizona, Tucson, USA, using the experimental dataset collected in December 2016. Complete information about the hillslope and experiment can be found elsewhere (Pangle et al., 2015; Till H. M. Volkmann et al., 2018); Here, we only summarize some relevant information.The first part of the animation describes the experimental system and setup (time 00:12 – 04:14 in Animation S1). The LEO hillslope is 330 m3 (30 m long, 11 m wide, and 1 m deep) sloping soil lysimeter. The hillslope is primarily made up of loamy-sand textured basaltic tephra, and the most downslope 5.5 m3 is filled with gravel-textured basaltic tephra. A custom irrigation system supplies reverse osmosis filtered water onto the LEO surface. The downslope boundary is exposed to atmospheric pressure, creating the seepage face boundary condition. The sensor networks (including pressure transducers and volumetric water content sensors) and the water isotope sampling locations and intervals (7 hrs to 101 hrs) are illustrated in Animation S1 (time 02:09 – 03:01). The isotope composition of subsurface water is obtained from laser-based online measurements of vapor that is extracted via custom gas probes through equilibrium calculation (T. H.M. Volkmann & Weiler, 2014). The irrigation sequence of this experiment was designed to generate a periodic steady state, which allows the application of the PERidoic Tracer Hierarchy method (Harman & Kim, 2014) for the observation of the time-variable transit time distributions and the StorAge Selection functions. Deuterium-labeled water was irrigated during the first two irrigation events.The second part of the animation shows the dynamics of the perched water table and soil water content (time 04:15 – 06:53). The extent of the saturated zone was estimated using the pressure transducer data and Delaunay triangulation (Delaunay, 1934). The experimental data show the saturation from below mechanisms—wetting up from the bedrock surface into the soil profile (McDonnell, 1997)—and the saturation from downslope to upslope. The water table profile forms a wedge-like shape, which is a characteristic of hillslope with a high hillslope (Peclet) number (Berne et al., 2005; Brutsaert, 1994). The hillslope Peclet number of the LEO hillslope during the experiment is high (> 10) (Kim et al., 2020). Significant time delays in the water table dynamics are observed at some upslope locations (e.g., at 13 m upslope), which is mostly due to the delayed water supply from the convergent upslope area. The water content data indicates that the convergent upslope water content began to decrease around the timing of the water table peak at 13 m upslope.The third part of the animation shows the tracer dynamics (from time 06:43). The animated experimental data reveal two notable water transport dynamics. First, the vertical tracer movement is faster at the upslope. This faster movement at the upslope is, in a sense, counter-intuitive because the upslope region is drier than the downslope. This is due to the lateral flow in the saturated zone and the tension saturated zone, that are thicker at the downslope. While water velocity is higher at the downslope, the direction of velocity is not vertical but rotated towards the downslope in those zones.Second, the animated data illustrate that old water is present only at the downslope. This observation is a characteristic of hillslope with a high hillslope number, in which old water is preferentially discharged (Kim et al., 2020). Indeed, the observed SAS function in this hillslope is concave (Kim et al., 2020), indicating that the hillslope preferentially discharges old water that is stored at the downslope.

Coronary flow reserve is the capacity of the coronary circulation to augment the blood flow in response an increase in myocardial metabolic demands and has a powerful prognostic significance in different clinical situations. It might assess with invasive and non-invasive technique. Transthoracic echocardiography Doppler is an emerging diagnostic technique, noninvasive, highly feasible, safe for patient and physician, without radiation, able to detect macrovascular and microvascular anomalies in the coronary circulation. This review aims to describe the benefit and limits of noninvasive assessment of coronary flow reserve, in particular his evaluation with echocardiography.

Background: Phthalates can cause respiratory and immunological disorders. However, little is known about the role of serum periostin and YKL-40 levels in mediating the effects of phthalates. We investigated the mediating role of these biomarkers in the relationship between phthalates and airway dysfunction. Methods: A total of 487 children (aged 10 to 12 years-old) were examined. Four high-molecular-weight phthalate (HMWP) [Σ4HMWP] metabolites and 3 low-molecular-weight phthalate (LMWP) [Σ3LMWP] metabolites in urine samples were measured. Serum periostin and YKL-40 levels were measured. Airway function was measured using impulse oscillometry. A mediation model was used to quantify the mediating effects of periostin and YKL-40 on airway dysfunction. Results: After adjustment for height, gender, BMI z-score, aeroallergen sensitization, secondary smoking, and vitamin D level, the level of urinary Σ3LMWP metabolites was significantly associated with respiratory system resistance at 5 Hz (Rrs5; adjusted β: 0.020, 95% CI: 0.005 to 0.034; P = .010). The levels of urinary Σ4HMWP and Σ3LMWP metabolites were significantly associated with periostin level, but not with YKL-40 level. In addition, the periostin level was associated with Rrs5 (adjusted β: 0.048, 95% CI: 0.015 to 0.081; P = .005) and Rrs20-5 (adjusted β: 0.040, 95% CI: 0.011 to 0.069; P =.007). Serum periostin level had a significant effect in mediating the relationship between Σ3LMWP and Rrs5 (13.9%, 95% CI: 10.7 to 77.0; P < .001). Conclusion: Exposure to LMWPs was significantly associated with airway dysfunction, and this effect was partially attributable to increased serum periostin level.

EP Rounds

A document by Marisol Perez-Toledo. Click on the document to view its contents.

Background A diagnosis of childhood cancer results in new parent-child communication challenges. Little is known about how communication changes over time after diagnosis or relapse. The objective of this study was to determine the effect of time since diagnosis and relapse on quality of parent-child communication. We hypothesized that there would be a positive correlation between time and quality of parent-child communication. Methods Cross-sectional study in children (7 to 17 years) with relapsed/refractory cancer and their caregivers, who spoke English, were not cognitively impaired, and had internet access. Parents were recruited through Facebook ads. Parents and children completed the Parent-Adolescent Communication Scale (PACS), a 20-item measure of communication quality, with openness and problem subscales. Spearman’s Rho coefficients assessed correlations between PACS scores and time since diagnosis/relapse. Results There was a statistically significant negative correlation between parent PACS scores and time since child’s cancer diagnosis (Spearman’s Rho = - 0.21, p = 0.02), indicating a tendency for overall worsening communication as time since diagnosis increased. There was a positive correlation between the parent PACS problem scores and time since diagnosis (Spearman’s Rho = + 0.22, p = 0.01), indicating more problematic communication as time since diagnosis increased. Correlations of time since relapse and PACS scores were small and not statistically significant. Conclusion Parent-child communication worsens over time following a child’s cancer diagnosis with more communication problems, contrary to our hypothesis. Future studies are needed to evaluate intervention timing to best support parent-child communication beyond the new diagnosis period.

This case highlights an atypical presentation of a patient with no history of mental illness who has been diagnosed with a bipolar disorder associated with severe COVID-19 symptoms. Neuroimaging was only positive for subtle white matter changes; he was treated with antipsychotics and mood-stabilizing agents until he reached partial remission.

A 44-year-old man presented to our hospital with lower gastrointestinal bleeding. We performed balloon-assisted enteroscopy, which revealed diverticulum and stricture at the ileum . The patient underwent segmental small bowel resection and diagnosed with Meckel's diverticulum. We should keep in mind the possibility of intestinal stricture due to Meckel's diverticulum.

Myonecrosis and compartment syndrome are rarely seen in sickle cell disease (SCD). Myonecrosis and compartment syndrome have not been previously reported in HbSC. This case report presents the first case of an HbSC patient presenting to emergency department (ED) with bilateral leg pain and swelling.