Evidence Based Scarce Resource Allocation During the COVID-19 Pandemic: A Case Study of Bamlanivimab Administration in the Emergency Department.

Background: Patients presenting for emergency department (ED) evaluation may be appropriate for treatment with monoclonal antibodies for mild to moderate COVID-19. While many sites have implemented infusion centers for these agents, EDs will continue to evaluate these patients where appropriate identification and efficient infusion of eligible patients is critical. Objectives: Patients receiving bamlanivimab in the EDs of an academic medical center are described. The primary objective was to describe operational metrics and secondary objectives reported clinical outcomes. Methods: Patients receiving bamlanivimab and discharged from the ED were included from November 16, 2020 to January 16, 2021 in the retrospective, observational cohort. Primary outcome was adherence to institutional criteria. Secondary outcomes included ED visit metrics, clinical characteristics, and return visits within 30 days. Risk factors for return visits were assessed with regression. Results: One hundred nineteen patients were included. Most (71%) were diagnosed with COVID-19 during the ED visit and median symptom duration was 3(IQR 2-5) days. Median number of risk factors for progression to severe disease was 2 (IQR 1-2). Thirty percent had a documented abnormal chest x-ray. Institutional criteria adherence was 99.2%. Median time from ED room to bamlanivimab was 4 (IQR 3.1-5.2) hours. Thirty patients had return visit within 30 days; 19 were COVID-19 related. Two multivariable regression models were analyzed for COVID-19 related return visit. Characteristics on ED presentation were considered in Model I: male gender (OR 3.01[0.97-9.31]), age (per 10 years) (OR 1.49[1.05-2.12]), African-American race (OR 3.46[1.09-11.06]), and symptom duration (per day) (OR 1.34[1.05-1.73]). Model II included labs and imaging acquired in ED. In Model II, age (per 10 years) (OR 1.52[1.07-2.16]) and abnormal CXR (OR 5.74[1.95-16.9]) were associated with COVID-19 related return visits. Conclusions: Administration of bamlanivimab to ED patients can be done efficiently, with the potential to reduce COVID-19 related return visits. Age and abnormal imaging were independent predictors of COVID-19 return visits.

Clinical Outcomes With Definitive Treatment of Methicillin-Resistant Staphylococcus aureus Bacteremia With Retained Daptomycin and Ceftaroline Combination Therapy vs De-escalation to Monotherapy With Vancomycin, Daptomycin, or Ceftaroline.

BACKGROUND: Lower mortality has been observed with combination therapy compared to monotherapy for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia; however, there is a lack of evidence for continued combination therapy over de-escalation to monotherapy following bacteremia clearance. METHODS: This was a single-center, retrospective study evaluating patients with MRSA bacteremia hospitalized from November 1, 2011, through July 31, 2019. Patients who received three to ten days of combination therapy followed by de-escalation to monotherapy were directly compared to patients retained on combination therapy. The primary composite outcome included inpatient infection-related mortality, 60-day readmission, and 60-day bacteremia recurrence. RESULTS: A total of 286 patients with MRSA bacteremia were identified, with 146 patients omitted based on exclusion criteria. The study population included 66 in the combination therapy group and 74 in the monotherapy group. Study population was 51% female (n = 71) and 78% white (n = 109) with median age of 46 years (IQR 34.5-61). No significant difference was observed in the primary composite outcome (21% combination therapy group vs 24% monotherapy group; P =.66), with retained observations after controlling for confounders. Within this outcome, there was no significant difference in 60-day readmission (20% combination therapy group vs 18% monotherapy group; P =.75), bacteremia recurrence (3% combination therapy group vs 7% monotherapy group; P =.45), or inpatient infection-related mortality (2% combination therapy group vs 5% monotherapy group; P = 1.00). CONCLUSIONS: No difference was found in the composite outcome of 60-day bacteremia recurrence, readmission, or inpatient infection-related mortality for patients with MRSA bacteremia retained on combination therapy versus those de-escalated to monotherapy.

Novel case of resolution of hypsarrhythmia following tuber resection in a patient with infantile spasms and tuberous sclerosis.

This article describes a case involving the resolution of hypsarrhythmia, a generalized abnormal EEG pattern, following focal resection of a cortical tuber in a patient with tuberous sclerosis.

Photosynthetic light reactions increase total lipid accumulation in carbon-supplemented batch cultures of Chlorella vulgaris.

Microalgae are an attractive biofuel feedstock because of their high lipid to biomass ratios, lipid compositions that are suitable for biodiesel production, and the ability to grow on varied carbon sources. While algae can grow autotrophically, supplying an exogenous carbon source can increase growth rates and allow heterotrophic growth in the absence of light. Time course analyses of dextrose-supplemented Chlorella vulgaris batch cultures demonstrate that light availability directly influences growth rate, chlorophyll production, and total lipid accumulation. Parallel photomixotrophic and heterotrophic cultures grown to stationary phase reached the same amount of biomass, but total lipid content was higher for algae grown in the presence of light (an average of 1.90 mg/mL vs. 0.77 mg/mL over 5 days of stationary phase growth).

Genetic isolation of a now extinct population of bottlenose dolphins (Tursiops truncatus).

A number of dolphin species, though highly mobile, show genetic structure among parapatric and sometimes sympatric populations. However, little is known about the temporal patterns of population structure for these species. Here, we apply Bayesian inference and data from ancient DNA to assess the structure and dynamics of bottlenose dolphin (Tursiops truncatus) populations in the coastal waters of the UK. We show that regional population structure in UK waters is consistent with earlier studies suggesting local habitat dependence for this species in the Mediterranean Sea and North Atlantic. One genetically differentiated UK population went extinct at least 100 years ago and has not been replaced. The data indicate that this was a local extinction, and not a case of historical range shift or contraction. One possible interpretation is a declining metapopulation and conservation need for this species in the UK.

Micellar partitioning and its effects on Henry's law constants of chlorinated solvents in anionic and nonionic surfactant solutions.

Micellar partitioning of volatile chlorinated hydrocarbons in surfactant solutions and its effects on vapor-liquid equilibrium is fundamental to the overall design and implementation of surfactant-enhanced aquifer remediation. Surfactant micelles greatly enhance contaminant recovery from the subsurface; however, the reduced volatility of organic compounds compromises the aboveground treatment of surfactant-laden wastewaters using air-stripping process. Batch equilibrium tests were performed to acquire micellar partition coefficients (Km) and apparent Henry's law constants (H*) of three prominent groundwater contaminants (tetrachloroethylene, trichloroethylene, cis-dichlorethylene) in the presence of two anionic surfactants (sodium dodecyl sulfate, SDS; sodium dodecylbenzene sulfonate, SDBS) and two nonionic surfactants (Triton X-100 and Tween 80). The H* values were significantly reduced in the presence of all four surfactants over their critical micelle concentrations (cmc's). On a cmc basis, the anionic surfactant SDS had the greatest effect on H*, followed by SDBS, Triton X-100, and Tween 80. Anionic surfactants decreased H* to an order of magnitude lower than nonionic surfactants, although nonionic surfactants decreased the H* at concentrations significantly lower than the anionic surfactants due to their lower cmc's. Nonionic surfactants present higher Km and molar solubilization ratio than anionic surfactants. Tetrachloroethylene has the highest Km values among three chlorinated solvents, which agrees well with the hydrophobicity (Kow) of these chemicals. An empirical correlation between log Km and log Kow is developed on the basis of data from this study and the Km values reported for a number of chlorinated and nonchlorinated hydrocarbons. Equilibrium data were also tested against three sets of models that describe the partitioning of volatile compounds in vapor-water-micelle phases. Applications of these models in experimentally determining Km from batch vapor-water equilibrium data are discussed.

New periurethral bulking agent for stress urinary incontinence: modified technique and early results.

PURPOSE: Durasphere (Carbon Medical Technologies, St. Paul, Minnesota) is a newly approved injectable agent for stress urinary incontinence. Proven and potential advantages include nonimmunogenicity, tissue nonreactivity, efficacy at low injectable volume and durability. A concern regarding use is difficulty involved with application. A modified technique for easier implantation of this agent is described and early results are reported. MATERIALS AND METHODS: The surgical technique follows the standard technique for transurethral implantation of bulking agents. Steps modified to allow easier implantation of Durasphere beads include a single needle stick at the 4 o'clock position, hydrodissection with 1.5 ml 1% lidocaine into the submucosa, gradual withdrawal/advancement or rotation of the needle tip after resistance is noted and holding the needle in position for an additional 10 seconds after proper coaptation is achieved to prevent the beads from leaking out of the needle puncture site. Patient charts were retrospectively reviewed. Patient perception of treatment outcomes, a 24-hour pad test and a voiding diary were obtained and analyzed. The strict criteria of the Groutz-Blaivas score were applied as an additional measure of outcome. RESULTS: Of 70 patients 46 (65.7%) for whom full contact information was available responded. Patient age was 46 to 83 years (mean 69.4). A history of a failed prior anti-incontinence procedure was recorded in 15 patients (32.6%) and coexisting symptoms of urge incontinence or urodynamically proven detrusor instability was evident in 29 (63%) and 5 (10.8%), respectively. Bulking agent was delivered at 1 to 3 sessions (mean 1.52) 1 to 3 months apart with 2 to 6 ml (3.2 ml) injected per session. Excellent or good coaptation was achieved in 92% of injections. At a followup of up to 18 months (mean 9.4) 6 (13%), 24 (52.2%) and 16 (34.7%) patients considered themselves cured or improved, or treatment to have failed, respectively. Of the 36 patients who completed a 24-hour pad test 18 (50%), 2 (5.5%) and 16 (44.4%) had a urine loss of 8 or less, 9 to 20 and greater than 20 gm, respectively. Results of the voiding diary and the Groutz-Blaivas score are provided. CONCLUSIONS: The modified technique of Durasphere injection allows easy implantation with good coaptation in the majority of patients. Early results are encouraging. Further research may reveal whether the improved delivery techniques translate into improved outcomes with more durable results compared with other approved bulking agents.

Urethral reconstruction in spinal cord injury patients.

PURPOSE: Bladder management programs for patients with spinal cord injury and neurological disease (SCIND) include intermittent catheterization and sphincterotomy with external catheter drainage. These programs depend on maintaining a patent urethra. Once urethral stricture, erosion, diverticulum or urethrocutaneous fistula occurs, the only treatments available are urethral reconstruction and urinary diversion. We evaluate the role of urethral reconstruction in this subset of patients. MATERIALS AND METHODS: The charts of 18 patients with SCIND (spinal cord injury 16, cerebral palsy 1, meningomyelocele 1) were retrospectively analyzed. Different surgical procedures had been performed according to the presenting pathology and tissue availability. RESULTS: Urethral reconstruction was performed in 17 patients with a mean age of 42.2 years (range 27 to 60). Of the patients 13 are paraplegic and 4 are quadriplegic. Urethral defects included urethral stricture in 6 cases, urethral erosion in 4, urethrocutaneous fistula in 3, urethral diverticula in 1 and combined defects in 3. Mean followup is 3.7 years (range 1 to 13) and the mean number of reoperations was 1.4 (range 0 to 4). Of the 17 patients 11 (64.7%) who underwent urethral reconstruction eventually required urinary diversion for end stage urethral pathology (incontinent ileovesicostomy 5, right colon pouches 2, other procedures 4). The mean time from first urethral reconstruction to eventual urinary diversion was 3.3 years (range 0.7 to 7). Four patients maintain a patent urethra while 1 patient was lost to followup. CONCLUSIONS: Patients with SCIND in whom urethral reconstruction is considered should be advised that urethral surgery carries a high risk of reoperation and eventual need for urinary diversion. Clearly, many patients with neurological disease and severe urethral pathology are best treated with urinary diversion.