Juvenile Myasthenia Gravis in North Texas: Clinical Features, Treatment Response, and Outcomes.

BACKGROUND: Juvenile myasthenia gravis (JMG) is a rare autoimmune disease that causes fatigable muscle weakness in children aged <18 years. There is currently no curative treatment or internationally accepted standard of care for JMG. The objective is to investigate relationships between clinical presentation, antibody status, severity of disease onset, electrodiagnostic evaluation, and response to therapy in JMG. METHODS: This study was a retrospective chart review. Congenital myasthenic syndromes were excluded. Data on demographics, treatments, and outcomes were collected. Disease severity was evaluated using Myasthenia Gravis Foundation of America (MGFA) clinical classifications. RESULTS: We identified 84 patients with JMG at Children's Medical Center Dallas between January 2014 and February 2022. It was found that 52% of patients presented with ocular JMG (median onset age 4.5 years) and 48% with generalized JMG (median onset age 11.5 years); 81% tested positive for acetylcholine receptor antibodies. Patients were 17% non-Hispanic white, 29% Hispanic, 39% black, and 12% Asian. There was a significant difference in average MGFA scores between ethnicities (P = 0.047) and age groups (P = 0.004), with postpubertal patients having higher average MGFA scores than prepubertal patients. Seventy-one percent of patients who underwent thymectomy experienced a decrease in MGFA scores postprocedure. CONCLUSIONS: Our study showed that there were significant differences in disease severity between ethnicities and age groups and that most patients who underwent thymectomy showed clinical improvement. These outcomes highlight the need for additional therapies in the treatment of JMG and the importance of extending clinical trials to the pediatric population.

Myxovirus resistance protein A (MxA) expression in myositides: Sarcoplasmic expression is common in both dermatomyositis and lupus myositis.

INTRODUCTION/AIMS: Myxovirus resistance protein A (MxA) is a type I interferon (IFN1) pathway activation marker and MxA sarcoplasmic expression is currently recognized as a highly specific marker for dermatomyositis (DM). However, we have frequently observed endothelial tubuloreticular inclusions (TRI), another surrogate IFN1 activation marker, in a variety of overlap myositides. The aim of this study was to examine MxA expression in those myositides. METHODS: We retrospectively performed MxA immunostaining on a wide range of myositides. RESULTS: MxA sarcoplasmic expression was present in DM (94.4%, 17/18), active lupus myositis (LM, 80%,16/20), inactive LM (36%, 4/11), antisynthetase syndrome (ASyS, 20%, 2/10), systemic sclerosis (13%, 2/15), Sjogren's syndrome (7.7%, 1/13), and human immunodeficiency virus (HIV) myositis (5.6%, 1/18) and was absent in immune-mediated necrotizing myopathy (IMNM, 0/16) and hydroxychloroquine myopathy (0/5). The sensitivity and specificity of MxA sarcoplasmic expression for LM and DM combined compared with all other myositides were 84.6% (95% CI: 69.5-94.1) and 92.1 (95% CI: 83.6-97.0), respectively, and superior to TRIs. MxA capillary expression was nonspecific. Histologically, 35% of LM cases demonstrated a unique panfascicular necrotizing myopathy pattern. The remainder of the LM cases had significant morphological overlap with DM/ASyS (20%), IMNM (20%), or polymyositis (15%). DISCUSSION: MxA sarcoplasmic expression is highly prevalent in LM and DM and is a useful marker in differentiating DM and LM from other myositides. LM can manifest in various pathology patterns that need to be differentiated from DM, IMNM, ASyS, and polymyositis.

Dual-Innervated Gracilis Free Functional Muscle Transfers in Facial Palsy Patients: Comparing Long-Term Outcomes between One- versus Two-Stage Procedures.

BACKGROUND: In facial reanimation, dual-innervated gracilis free functional muscle transfers (FFMTs) may have amalgamated increases in tone, excursion, synchroneity, and potentially spontaneity when compared with single innervation. The ideal staging of dual-innervated gracilis FFMTs has not been investigated. We aim to compare objective long-term outcomes following one- and two-stage dual-innervated gracilis FFMTs. METHODS: Included were adult patients with facial paralysis who underwent either one- (one-stage group) or two-stage (two-stage group) dual-innervated gracilis FFMT with ≥1 year of postoperative follow-up. Facial measurements were obtained from standardized photographs of patients in repose, closed-mouth smile, and open-mouth smile taken preoperatively, 1 year postoperatively, and 3 years postoperatively. Symmetry was calculated from the absolute difference between the paralyzed and healthy hemiface; a lower value indicates greater symmetry. RESULTS: Of 553 facial paralysis patients, 14 were included. Five and nine patients were in the one- and two-stage groups, with mean follow-up time, respectively, being 2.5 and 2.6 years. Within-group analysis of both groups, most paralyzed-side and symmetry measurements significantly improved over time with maintained significance at 3 years postoperatively in closed and open-mouth smile (all p ≤ 0.05). However, only the two-stage group had maintained significance in improvements at 3 years postoperatively in paralyzed-side and symmetry measurements in repose with commissure position (median change [interquartile range, IQR], 7.62 [6.00-10.56] mm), commissure angle (median change [IQR], 8.92 [6.18-13.69] degrees), commissure position symmetry (median change [IQR], -5.18 [-10.48 to -1.80] mm), commissure angle symmetry (median change [IQR], -9.78 [-11.73 to -7.32] degrees), and commissure height deviation (median change [IQR], -5.70 [-7.19 to -1.64] mm; all p ≤ 0.05). In the between-group analysis, all measurements were comparable in repose, closed-mouth smile, and open-mouth smile (all p > 0.05). CONCLUSION: Long-term outcomes demonstrate that both one- and two-stage dual-innervated gracilis FFMTs significantly improve excursion, but only two-stage reconstruction significantly improves resting tone.

A brief intervention decreases student distress.

PURPOSE OF THE ARTICLE: Health professions graduate students have experienced substantial increases in stress and anxiety in recent years. This can result in decreased academic performance, poor retention, and burnout. Interventions to help students cope are therefore a critical need for academic institutions. The current study sought to demonstrate the effectiveness of a brief multimodal intervention in reducing student distress. METHOD: The study was a randomised controlled design that evaluated a brief intervention of cognitive-behavioural therapy, mindfulness, and healthy lifestyle choices. The Depression Anxiety Stress Scale-21 was administered to participants at baseline and two post-intervention time points. Control participants did not participate in any intervention. Participants were recruited from graduate students in first-year classes within the School of Health Professions at UT Southwestern Medical Center. RESULTS: Analysis revealed an overall mild to moderate decline in Depression Anxiety Stress Scale-21 total scores over three assessment periods for both treatment and control groups, with no statistical differences noted between groups; however, the treatment group's scores declined approximately 6 weeks before the control participants' scores declined. CONCLUSION: The pattern of change in the two groups suggests that our intervention facilitated the reduction in student anxiety more quickly than would have occurred normally and with sustained results.

Lateral Tarsal Strip versus Tensor Fascia Lata Sling for Paralytic Ectropion: Comparison and Long-Term Outcomes.

BACKGROUND: Paralytic ectropion increases risk for corneal injury in facial palsy patients. Although a lateral tarsal strip (LTS) provides corneal coverage through superolateral lower eyelid pull, the unopposed lateral force may result in lateral displacement of the lower eyelid punctum and overall worsening asymmetry. A tensor fascia lata (TFL) lower eyelid sling may overcome some of these limitations. This study quantitatively compares scleral show, punctum deviation, lower marginal reflex distance, and periorbital symmetry between the two techniques. METHODS: Retrospective review was performed on facial paralysis patients who underwent LTS or TFL sling surgery with no prior lower lid suspension procedures. Standardized preoperative and postoperative images in primary gaze position were used to measure scleral show and lower punctum deviation using ImageJ, and lower marginal reflex distance using Emotrics. RESULTS: Of 449 facial paralysis patients, 79 met inclusion criteria. Fifty-seven underwent LTS surgery and 22 underwent TFL sling surgery. Compared with preoperatively, lower medial scleral show improved significantly with both LTS (10.9 mm 2 ; P < 0.01) and TFL (14.7 mm 2 ; P < 0.01). The LTS group showed significant worsening of horizontal and vertical lower punctum deviation when compared with the TFL group (both P < 0.01). The LTS group was unable to achieve periorbital symmetry between the healthy and paralytic eye across all parameters measured postoperatively ( P < 0.01); and the TFL group achieved symmetry in medial scleral show, lateral scleral show, and lower punctum deviation. CONCLUSION: In patients with paralytic ectropion, TFL sling provides similar outcomes to LTS, with the added advantages of symmetry without lateralization or caudalization of the lower medial punctum. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Association of outcomes in point-of-care lung ultrasound for bronchiolitis in the pediatric emergency department.

BACKGROUND: Acute bronchiolitis (AB) is the most common lower respiratory tract infection in infants. Objective scoring tools and plain film radiography have limited application, thus diagnosis is clinical. The role of point-of-care lung ultrasound (LUS) is not well established. OBJECTIVE: We sought to characterize LUS findings in infants presenting to the pediatric ED diagnosed with AB, and to identify associations between LUS and respiratory support (RS) at 12 and 24 h, maximum RS during hospitalization, disposition, and hospital length of stay (LOS). METHODS: Infants ≤12 months presenting to the ED and diagnosed with AB were enrolled. LUS was performed at the bedside by a physician. Lungs were divided into 12 segments and scanned, then scored and summated (min. 0, max. 36) in real time accordingly: 0 - A lines with <3 B lines per lung segment. 1 - ≥3 B lines per lung segment, but not consolidated. 2 - consolidated B lines, but no subpleural consolidation. 3 - subpleural consolidation with any findings scoring 1 or 2. Chart review was performed for all patients after discharge. RS was categorized accordingly: RS (room air), low RS (wall O2 or heated high flow nasal cannula <1 L/kg), and high RS (heated high flow nasal cannula ≥1 L/kg or positive pressure). RESULTS: 82 subjects were enrolled. Regarding disposition, the mean (SD) LUS scores were: discharged 1.18 (1.33); admitted to the floor 4.34 (3.62); and admitted to the ICU was 10.84 (6.54). For RS, the mean (SD) LUS scores at 12 h were: no RS 1.56 (1.93), low RS 4.34 (3.51), and high RS 11.94 (6.17). At 24 h: no RS 2.11 (2.35), low RS 4.91 (3.86), and high RS 12.64 (6.48). Maximum RS: no RS 1.22 (1.31), low RS 4.11 (3.61), and high RS 10.45 (6.16). Mean differences for all dispositions and RS time points were statistically significant (p < 0.05, CI >95%). The mean (SD) hospital LOS was 84.5 h (SD 62.9). The Pearson correlation coefficient (r) comparing LOS and LUS was 0.489 (p < 0.0001). CONCLUSION: Higher LUS scores for AB were associated with increased respiratory support, longer LOS, and more acute disposition. The use of bedside LUS in the ED may assist the clinician in the management and disposition of patient's diagnosed with AB.

High school science fair: School location trends in student participation and experience.

The findings reported in this paper are based on surveys of U.S. high school students who registered and managed their science and engineering fair (SEF) projects through the online Scienteer website over the three years 2019/20, 2020/21, and 2021/22. Almost 2500 students completed surveys after finishing all their SEF competitions. We added a new question in 2019/20 to our on-going surveys asking the students whether their high school location was urban, suburban, or rural. We learned that overall, 74% of students participating in SEFs indicated that they were from suburban schools. Unexpectedly, very few SEF participants, less than 4%, indicated that they were from rural schools, even though national data show that more than 20% of high school students attend rural schools. Consistent with previous findings, Asian and Hispanic students indicated more successful SEF outcomes than Black and White students. However, whereas Asian students had the highest percentage of SEF participants from suburban vs. urban schools- 81% vs. 18%, Hispanic students had the most balanced representation of participants from suburban vs. urban schools- 55% vs. 39%. Differences in students' SEF experiences based on gender and ethnicity showed the same patterns regardless of school location. In the few items where we observed statistically significant (probability < .05) differences based on school location, students from suburban schools were marginally favored by only a few percentage points compared to students from urban schools. In conclusion, based on our surveys results most students participating in SEFs come from suburban schools, but students participating in SEFs and coming from urban schools have equivalent SEF experiences, and very few students participating in SEFs come from rural schools.

Dual Versus Single Innervation of Gracilis Free Functional Muscle Transfer in Facial Paralysis - Long-Term Resting and Dynamic Outcomes.

BACKGROUND: Comparing long-term tone and excursion between single- versus dual-innervated free functional muscle transfer (FFMT) in patients with longstanding facial paralysis. METHODS: Longstanding facial palsy patients treated with a FFMT innervated either by a nerve-to-masseter (single-innervation group) or by nerve-to-masseter and cross-facial-nerve graft (dual-innervation group) were included. One year minimal follow up was required. Outcome measures, based on standardized photos, included excursion, smile angle, teeth exposure, commissure height deviation, and upper lip height deviation in repose and in closed and open teeth smile preoperatively, and at 3-months, 1-year, and 3-years postoperatively. Emotrics software (Massachusetts Eye and Ear Infirmary, Boston, MA) and ImageJ (Rasband, W.S., ImageJ, U.S, National Institutes of Health, Bethesda, MD) were used for measurements. Between group and within group longitudinal comparisons were analyzed. RESULTS: At three years (single=24, dual=13), significance was found between groups in commissure position (single=26.42mm, dual=31.51mm, p<0.0001) and excursion with open mouth smile (single=31.32mm, dual=26.59mm, p<0.001). Single-innervation FFMT within group analysis lacked significant improvement in commissure height deviation and upper lip height deviation at 3 years in repose, while dual-innervation group revealed significant improvements (3.67mm and p<0.001, 3.17mm and p<0.001 respectively). Teeth exposure revealed an increase in the dual-innervation group (single=35.753 mm 2, dual=64.177 mm 2), albeit significance was not observed. CONCLUSIONS: Dually innervated FFMT revealed improvements in resting tone and teeth exposure with minimal decrease in smile excursion compared with single innervated FFMT.

Implementation and evaluation of a store-and-forward teledermatology workflow in a United States safety-net hospital urgent care emergency center: A retrospective cohort study.

Background: Teledermatology (TD) is an important method for increasing access to care in outpatient settings. However, less is known regarding its use in emergency/urgent care centers. Objective: To evaluate the effect of TD on urgent care emergency center (UCEC) dwell time and postencounter utilization. Study type and methods: This retrospective cohort study evaluated patients in a safety-net hospital (Parkland Health, Dallas, Texas, USA) UCEC, who (1) received a TD consult in 2018, (2) were referred to dermatology clinic in 2017, or (3) were referred to dermatology clinic in 2018 without a TD consult. Results: We evaluated 2024 patients from 2017 to 2018. Of the 973 referred to dermatology clinic in 2018, 332 (34%) received TD consultations. Mean dwell time for patients receiving TD was longer versus the 2017 cohort (303 vs 204 minutes, respectively). Patients receiving TD consultation with inflammatory skin conditions had lower odds of dermatology clinic visits compared with those that did not (odds ratio, 0.5; 95% CI, 0.3-0.8). Teledermatology was not associated with differences in repeat UCEC utilization. Limitations: Single institution study and inability to account for differences in patient complexity. Conclusion: TD increases dwell time in a safety-net hospital's UCEC but can reduce dermatology clinic utilization for patients with inflammatory skin conditions.

Thoracic Interfascial Plane Blocks and Outcomes After Minithoracotomy for Valve Surgery.

Introduction. Thoracic interfascial plane blocks are increasingly used for pain management after minimally invasive thoracotomy for valve repair and replacement procedures. We hypothesized that the addition of these blocks to the intercostal nerve block injected by the surgeon would further reduce pain scores and opioid utilization. Methods. In this retrospective cohort study, 400 consecutive patients who underwent minimally invasive thoracotomy for mitral or aortic valve replacement and were extubated within 2 hours of surgery were enrolled. The maximum pain score and opioid utilization on the day of surgery and other outcome variables were compared between patients who received interfascial plane blocks and those who did not. Results.193 (48%) received at least one interfascial plane block while 207 (52%) received no interfascial plane block. Patients who received a thoracic interfascial plane block had a maximum VAS score on the day of surgery (mean 7.4 ± 2.5) after the block was administered which was significantly lower than patients in the control group who did not receive the block (mean 7.9 ± 2.2) (P = .02). Opioid consumption in the interfascial plane block group on the day of surgery was not significantly different from the control group. Conclusion. Compared to intercostal blocks alone, the addition of thoracic interfascial plane blocks was associated with a modest reduction in maximum VAS score on the day of surgery. However, no difference in opioid consumption was noted. Patients who received interfascial plane blocks also had decreased blood transfusion requirements and a shorter hospital length of stay.

Implementing a Nurse-Driven Protocol for Pneumococcal Vaccination in an Academic Rheumatology Clinic.

OBJECTIVE: Rheumatology patients are at high risk for complications from pneumococcal infections. The goal of this study was to assess the feasibility of implementing a nurse-driven pneumococcal vaccination protocol based on the 2012 Advisory Committee on Immunization Practices (ACIP) guidelines within an academic rheumatology clinic. Our aims were to increase (1) pneumococcal conjugate vaccine (PCV13) and pneumococcal polysaccharide vaccine (PPSV23) monthly vaccination rates in immunosuppressed patients aged 19 to 64 years, and (2) the overall proportion of immunosuppressed patients aged 19 to 64 years who have received both PCV13 and PPSV23 vaccinations by ≥ 10% over a 2-year period. METHODS: We identified eligible adults in the electronic medical record using a search protocol based on preset medication group. We obtained baseline pneumococcal vaccination rates in 2019, calculating the proportion of patients who were unvaccinated, partially vaccinated (received either PCV13 or PPSV23), or fully vaccinated. We created a pneumococcal vaccination protocol based on 2012 ACIP guidelines and converted it into a standing medical order to be implemented by the nursing staff. Postintervention vaccination rates were calculated monthly and at the end of the study period. Multiple comparison testing was performed to assess for significant postintervention changes. RESULTS: The average rate of monthly vaccination with either PCV13 or PPSV23 increased from 4.3% in 2019 to 12.6% in 2021. The proportion of patients who were fully vaccinated increased from 14.6% in 2019 to 26.2% in 2021. Both changes were statistically significant. CONCLUSION: It is feasible to employ a nurse-driven protocol for improving pneumococcal vaccination rates in immunosuppressed patients, despite difficulties posed by coronavirus disease 2019 (COVID-19) pandemic disruptions.

Development and Internal Validation of the Postoperative Analgesic Intake Needs Score: A Predictive Model for Post-Operative Narcotic Requirement after Spine Surgery.

STUDY DESIGN: Retrospective Cohort. OBJECTIVE: The aim of this study was to develop a clinical tool to pre-operatively risk-stratify patients undergoing spine surgery based on their likelihood to have high postoperative analgesic requirements. METHODS: A total of 1199 consecutive patients undergoing elective spine surgery over a 2-year period at a single center were included. Patients not requiring inpatient admission, those who received epidural analgesia, those who had two surgeries at separate sites under one anesthesia event, and those with a length of stay greater than 10 days were excluded. The remaining 860 patients were divided into a derivation and validation cohort. Pre-operative factors were collected by review of the electronic medical record. Total postoperative inpatient opioid intake requirements were converted into morphine milligram equivalents to standardize postoperative analgesic requirements. RESULTS: The postoperative analgesic intake needs (PAIN) score was developed after the following predictor variables were identified: age, race, history of depression/anxiety, smoking status, active pre-operative benzodiazepine use and pre-operative opioid use, and surgical type. Patients were risk-stratified based on their score with the high-risk group being more likely to have high opioid consumption postoperatively compared to the moderate and low-risk groups in both the derivation and validation cohorts. CONCLUSION: The PAIN Score is a pre-operative clinical tool for patients undergoing spine surgery to risk stratify them based on their likelihood for high analgesic requirements. The information can be used to individualize a multi-modal analgesic regimen rather than utilizing a "one-size fits all" approach.

Comparison of Postoperative Outcomes of Laparoscopic vs Open Inguinal Hernia Repair.

Importance: Advocates of laparoscopic surgery argue that all inguinal hernias, including initial and unilateral ones, should be repaired laparoscopically. Prior work suggests outcomes of open repair are improved by using local rather than general anesthesia, but no prior studies have compared laparoscopic surgery with open repair under local anesthesia. Objective: To evaluate postoperative outcomes of open inguinal hernia repair under general or local anesthesia compared with laparoscopic repair. Design, Setting, and Participants: This retrospective cohort study identified 107 073 patients in the Veterans Affairs Surgical Quality Improvement Program database who underwent unilateral initial inguinal hernia repair from 1998 to 2019. Data were analyzed from October 2021 to March 2022. Exposures: Patients were divided into 3 groups for comparison: (1) open repair with local anesthesia (n = 22 333), (2) open repair with general anesthesia (n = 75 104), and (3) laparoscopic repair with general anesthesia (n = 9636). Main Outcomes and Measures: Operative time and postoperative morbidity were compared using quantile regression and inverse probability propensity weighting. A 2-stage least-squares regression and probabilistic sensitivity analysis was used to quantify and address bias from unmeasured confounding in this observational study. Results: Of 107 073 included patients, 106 529 (99.5%) were men, and the median (IQR) age was 63 (55-71) years. Compared with open repair with general anesthesia, laparoscopic repair was associated with a nonsignificant 0.15% (95% CI, -0.39 to 0.09; P = .22) reduction in postoperative complications. There was no significant difference in complications between laparoscopic surgery and open repair with local anesthesia (-0.05%; 95% CI, -0.34 to 0.28; P = .70). Operative time was similar for the laparoscopic and open general anesthesia groups (4.31 minutes; 95% CI, 0.45-8.57; P = .048), but operative times were significantly longer for laparoscopic compared with open repair under local anesthesia (10.42 minutes; 95% CI, 5.80-15.05; P < .001). Sensitivity analysis and 2-stage least-squares regression demonstrated that these findings were robust to bias from unmeasured confounding. Conclusions and Relevance: In this study, laparoscopic and open repair with local anesthesia were reasonable options for patients with initial unilateral inguinal hernias, and the decision should be made considering both patient and surgeon factors.

Evaluating awareness of skin cancer in skin of color organ transplant recipients.

Organ transplant recipients are at high risk for skin cancer. Currently, more than half of the transplant waiting list is composed of skin of color patients. Skin cancer in skin of color is associated with higher morbidity and mortality and has a different clinical presentation and risk factors. Yet, skin cancer prevention resources and efforts are primarily focused on non-skin of color patients. A cross-sectional pilot survey was administered to assess and compare skin cancer attitudes, behaviors, and knowledge especially risk factors and features specific to skin of color between skin of color and non-skin of color organ transplant recipients. Patients from a patient list obtained from the University of Texas Southwestern Medical Center organ transplant center were randomized on Excel and contacted by phone with the choice to participate by phone or online. 219 of 403 patients completed the survey. Skin of color organ transplant recipients was significantly more likely to never practice recommended skin cancer preventative behaviors (p = 0.002, 0.006, 0.02), to hold a lower perceived self-risk (p = 0.02), to worry less about getting skin cancer (p = 0.003), and to have false perceptions about risk factors (p = 0.001, 0.005) in either univariable or multivariable analysis. However, they were more likely (38%, p = 0.02) to recognize human papillomavirus as a risk factor. The knowledge gaps identified can guide the development of skin cancer educational resources that are more comprehensive and relevant to skin of color recipients. This can lead to better outcomes and reduce racial health disparities.

Perioperative Outcomes in Patients With Failing Single-Ventricle Physiology Undergoing Ventricular Assist Device Placement: A Single Institutional Experience.

OBJECTIVE: To address the current lack of specified data existing regarding the perioperative characteristics and outcomes in a novel patient population, which may bridge the current understanding of how patient characteristics and perioperative management may influence the postoperative hospital course before cardiac transplantation. DESIGN: A retrospective electronic chart review included all patients with failing single- ventricle (SV) physiology receiving ventricular assist device (VAD) support at a high-volume pediatric VAD center between April 5, 2010, and December 1, 2020, using institution-based electronic medical records for retrospective analysis. SETTING: At a single pediatric hospital. PARTICIPANTS: Fourteen pediatric patients with failing SV physiology receiving ventricular assist device therapy (SVAD). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Preoperative, intraoperative, and postoperative patient demographic and medical data were obtained from prior inpatient progress notes, laboratory values, anesthetic records, cardiac catheterization reports, echocardiography reports, and postoperative surgical notes entered during inpatient encounters at the time of SVAD placement. Between April 5, 2010, and December 1, 2020, 16 VAD device implants supported 14 pediatric patients with failing SV physiology. Most patients presented with a preoperative diagnosis of hypoplastic left heart syndrome (N = 9, 64.3%). A total of 6 patients expired on VAD therapy (43%), 7 (50%) survived to receive a cardiac transplant, and 1 patient currently remains on device therapy. CONCLUSION: Although our institutional approach represents a single perspective, we anticipate that our experience institutional experience may prove helpful to others caring for peditric patients with single ventricle physiology undergoing ventricular assist device placement and promote collaborative efforts to improve their care.

The Keloid Area and Severity Index (KASI): an objective tool for the evaluation of keloids.

To aid in the standardization of evaluating patients with multiple keloids, a Keloid Area and Severity Index (KASI) was developed using patient feedback, previous literature, and clinical expertise. The system was validated using intrarater and interrater reliability assessments. Here, we present a verified, reliable method of assessing keloid area and severity in clinical and research settings.

Derivation and Validation of a Clinical Prediction Score to Identify the Isolation of Pseudomonas in Pneumonia.

Given the focus of existing clinical prediction scores on identifying drug-resistant pathogens as a whole, the application to individual pathogens and other institutions may yield weaker performance. This study aimed to develop a locally derived clinical prediction model for Pseudomonas-mediated pneumonia. This retrospective study included patients ≥18 years of age who were admitted to an academic medical center between 1 July 2010 and 31 July 2020 with a CDC National Healthcare Safety Network confirmed pneumonia diagnosis and were receiving antimicrobials during the index encounter, with a positive respiratory culture. Cystic fibrosis patients were excluded. Logistic regression analysis identified risk factors associated with the isolation of Pseudomonas aeruginosa from respiratory cultures within the derivation cohort (n = 186), which were weighted to generate a prediction score that was applied to the derivation and internal validation (n = 95) cohorts. A total of 281 patients met the inclusion criteria. Five predictor variables were identified, namely, tracheostomy status (4 points), chronic obstructive pulmonary disease (5 points), enteral nutrition (9 points), chronic steroid use (11 points), and Pseudomonas aeruginosa isolation from any culture in the prior 6 months (14 points). At a score of >11, the prediction score demonstrated a sensitivity of 52.4% (95% confidence interval [CI], 36.4 to 68.0%) and a specificity of 84.9% (95% CI, 72.4 to 93.35%) in the validation cohort. Score accuracy was 70.5% (95% CI, 60.3 to 79.4%), and the area under the receiver operating characteristic curve (AUROC) was 0.77 (95% CI, 0.68 to 0.87) in the validation cohort. A prediction score for identifying Pseudomonas aeruginosa in pneumonia was derived, which may have the potential to decrease the use of broad-spectrum antibiotics. Validation with larger and external cohorts is necessary. IMPORTANCE In this study, we aimed to develop a locally derived clinical prediction model for Pseudomonas-mediated pneumonia. Utilizing a locally validated prediction score may help direct therapeutic management and be generalizable to other clinical settings and similar populations for the selection of appropriate antimicrobial coverage when data are lacking. Our study highlights a unique patient population, including immunocompromised, structural lung disease, and transplant patients. Five predictor variables were identified, namely, tracheostomy status, chronic obstructive pulmonary disease, enteral nutrition, chronic steroid use, and Pseudomonas aeruginosa isolation from any culture in the prior 6 months. A prediction score for identifying Pseudomonas aeruginosa in pneumonia was derived, which may have the potential to decrease the use of broad-spectrum antibiotics, although validation with larger and external cohorts is necessary.