Association between antibiotic administration before discharge and emergency department length of stay for urinary tract infection: A retrospective analysis.

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.

Brain PUFA Concentrations Are Differentially Affected by Interactions of Diet, Sex, Brain Regions, and Phospholipid Pools in Mice.

BACKGROUND: PUFAs play vital roles in the development, maintenance, and functioning of circuitries that regulate reward and social behaviors. Therefore, modulations in PUFA concentrations of these brain regions may disrupt reward and social circuitries contributing to mood disorders, developmental disabilities, and addictions. Though much is known about regional and phospholipid-pool-specific PUFA concentrations, less is known about the effects of dietary interventions that concurrently lowers n-6 PUFA and supplements n-3 PUFA, on brain PUFA concentrations. There is even less knowledge on the effects of sex on brain PUFA concentrations. OBJECTIVE: This study aimed to comprehensively examine the interaction effects of diet (D), sex (S), brain regions (BR), and phospholipid pools (PL) on brain PUFA concentrations. METHODS: Male and female C57BL/6J mice were fed 1 of 4 custom-designed diets varying in linoleic acid (LNA) (8 en% or 1 en%) and eicosapentaenoic acid/docosahexaenoic acid (EPA/DHA) (0.4 en% or 0 en%) concentrations from in utero to 15 weeks old. At 15 weeks old, the prefrontal cortex, dorsal striatum, and cerebellum were collected. Fatty acids of 5 major PL were quantified by GC-flame ionization detection. Repeated measures ANOVA was used to test for differences among the groups for D, S, BR, and PL. RESULTS: No significant 4-way interactions on PUFA concentrations. DHA, predominant n-3 PUFA, concentrations were dependent on significant D × BR × PL interactions. DHA concentration was not affected by sex. Arachidonic acid (ARA; predominant n-6 PUFA) concentrations were not dependent on 3-way interactions. However, significant 2-way D × PL, BR × PL, and D × Sinteractions affected ARA concentrations. Brain fatty acid concentrations were differentially affected by various combinations of D, S, BR, and PL interactions. CONCLUSION: Though DHA concentrations are not affected by sex, ARA concentrations are affected by interactions of the 4 variables examined. This study provides comprehensive references in the investigation of complex interactions between factors that affect brain PUFA concentrations in mice.

Clinical location of the fourth and fifth intercostal spaces as a percent of the length of the sternum.

OBJECTIVES: To verify accurate placement of the precordial ECG leads by identifying the 4th and 5th intercostal spaces as a function of the length of the sternum. This should decrease the percentage of lead misplacement leading to misdiagnoses. METHODS: The population consisted of patients and healthy volunteers. The proposed method compared palpation of the 4th and 5th intercostal spaces to a percentile of the sternal length. Location of the 4th and 5th intercostal space using a simple device was evaluated to assist in proper placement of the precordial leads to obtain accurate diagnosis. RESULTS: The location of the 4th and 5th intercostal space is related to the length of the sternum. It is 77% of the sternal length that measures 15cm for the 4th intercostal space. The position of the V1 and V2 electrodes decreases to 57% when the sternal length is 26cm. Similar data was obtained to locate the 5th intercostal space with proper position of V4-V6 electrodes. Tables are provided to facilitate this process. An instrument was designed to measure the 4th and 5th intercostal space as a function of the sternal length. CONCLUSIONS: The location of the 4th and 5th intercostal space is identified based on the length of the sternum.

The Tokuhashi score: effectiveness and pitfalls.

PURPOSE: Accurate survival estimation is prerequisite to determine the most appropriate treatment for patients with metastatic spine disease. Several authors have proposed classification systems analyzing clinical and radiological parameters, such as, performance status, metastasis localization, and primary tumor histotype, but the modified Tokuhashi score (mTS) is the most widely used. Although it is regarded as one of the most complete and accurate systems, it does not take the effectiveness of new therapeutic strategies into consideration, contributing to a progressive loss of accuracy. The purpose of this review is to verify the ability of the mTS to accurately estimate metastatic spine patient survival, nearly 10 years after it was introduced. METHODS: A literature review was conducted to evaluate mTS accuracy to predict metastatic spine patient survival. RESULTS: Ten studies were selected, representing 1686 patients. The total predictive accuracy of the mTS was 63.00%; for patients expected to survive less than 6 months (group I), it was 64.10%; 6-12 months (group II), 55.32%; and more than 12 months (group III), 77.21%. A progressive decrease in accuracy over time was statistically significant in groups I and II. CONCLUSIONS: The mTS is suggestive of actual survival for patients with a good prognosis. It is less accurate for patients with an estimated survival of less than 12 months. The decreasing trend in mTS accuracy over time will likely further reduce mTS utility. An important opportunity exists to develop new instruments to assist spine surgeons and oncologists to choose appropriate surgical or non-surgical treatment modalities for patients with metastatic spine disease.

Coronary computed tomography angiography-based tricuspid annular plane systolic excursion: correlation with 2D echocardiography.

BACKGROUND: Right heart evaluation on coronary computed tomography angiography (CCTA) is underutilized due to nonopacification of the right heart chambers and poor endocardial resolution. We analyzed feasibility and reproducibility of right heart functional analysis by measuring CCTA-based tricuspid annular plane systolic excursion (CT-TAPSE) on ECG-gated CCTA and correlated the results with 2D transthoracic echocardiography (TTE)-derived TAPSE (Echo-TAPSE). METHODS: CT-TAPSE was measured on a total population of 41 patients who had CCTA and TTE performed within 6 months of each other. Two independent CCTA readers performed analysis on reformatted four-chamber view. Intra- and inter-observer variability analysis was performed on 16 randomly selected patients. Correlative (Spearman's R) and Bland-Altman analysis was used to assess the level of agreement between the 2 methods and to compare CT-TAPSE with Echo-TAPSE. RESULTS: CT-TAPSE measured by Readers 1 and 2 on 16 randomly selected patients, demonstrated excellent intra-observer and inter-observer agreement, with very close correlation (R > 0.80 and 2-tailed P-value of <0.001). When tested in the entire study population of 41 patients, CT-TAPSE correlated closely with Echo-TAPSE (R = 0.738, P < 0.001). Bland-Altman analysis indicated that the 2 methods provided similar measures as majority of values lay within the 95% confidence limits. Based on abnormal Echo-TAPSE cutoff value of <16 mm, CT-TAPSE identified impaired right ventricle (RV) function with sensitivity of 82% and specificity of 93%, respectively. CONCLUSION: We demonstrated feasibility and reproducibility of assessing TAPSE on coronary CTA. RV functional analysis utilizing CT-TAPSE is simple and reproducible methodology, and is in close agreement with Echo-TAPSE.

An ex vivo sequential ligament transection model of flatfoot.

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.

Effects of Adding Monaural and Binaural Noise to a Dichotic Listening Task.

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 18-50 years with normal, bilaterally symmetric peripheral hearing sensitivity. 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 (SNRs), 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 (REA) for speech, were examined. Mixed model analyses of variance (ANOVAs) 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.

Evaluation of Intravenous Push Piperacillin-Tazobactam on Time to Antibiotic Administration in Emergency Department Patients with Sepsis.

Purpose: The purpose of this study was to determine if intravenous push (IVP) administration of piperacillin-tazobactam reduced the time to antibiotic administration compared to intravenous piggyback (IVPB) in emergency department (ED) patients who present with sepsis. Methods: This was a retrospective cohort study of patients with sepsis who received piperacillin-tazobactam before and after implementation of an IVPB to IVP conversion protocol. Results: A total of 486 charts were reviewed and the final analysis included 127 patients in each group. The mean time to administration of piperacillin-tazobactam was 67 (± 48) minutes and 58 (± 36) minutes in the IVPB and IVP cohorts, respectively (P = NS). The time to administration of secondary antibiotics was reduced by 38 minutes in patients who received piperacillin-tazobactam by IVP (105 min ±69 vs 67 min ±37; P < .001). Nurse administration time was reduced by 11 min for piperacillin-tazobactam (54 min ±46 vs 43 min ±33; P = .034) and 40 min for secondary antibiotics (90 min ±67 vs 50 min ±32; P = < .001) in the IVP group. There was no difference in hypersensitivity reactions, hospital length of stay, or mortality. Conclusion: Conversion from piperacillin-tazobactam IVPB to IVP was associated with a reduction in time to piperacillin-tazobactam and secondary antibiotic administration in emergency department patients with sepsis. Further prospective research is needed to evaluate clinical outcomes associated with IVP administration.

Primary cutaneous melanoma in Black patients: An analysis of 2464 cases from the National Cancer Database 2004-2018.

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.

Keratoconus: Diagnosis and Staging.

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.