Digital location tracking in the parent/caregiver-college student dyad.

INTRODUCTION: As college students navigate new developmental milestones, many families rely on digital technology to stay connected and aid in the transition to adulthood. Digital location tracking apps allow for parental monitoring in new ways that may have implications for youth development. Although recent research has begun to examine prevalence and motivations for digital location tracking in adolescence, we know little about how and why families continue to track into the transition to college, and how this may relate to perceptions of helicopter and autonomy supportive parenting. METHODS: In a cross-sectional study of 706 community college and 4-year university students in the Southeastern United States, we describe prevalence and sociodemographic differences in parent/caregiver digital location tracking of their college student children, and how this may be associated with perceptions of helicopter parenting and parent/caregiver autonomy support. RESULTS: Findings suggest that digital location tracking is a fairly common practice among college students, with nearly half of the sample endorsing currently or previously being digitally location tracked by their parent/caregiver. Younger, White, and higher socioeconomic status students were more likely to be tracked. Those students who were currently being digitally location tracked tended to perceive their primary parent/caregiver as engaging in more helicopter parenting and as less supportive of their autonomy. CONCLUSIONS: This brief report provides preliminary insight into parent/caregiver digital location tracking of their college student children. It is our hope that future research will further examine how digital location tracking may be helping or hindering attainment of developmental milestones in the digital age.

Probabilistic reaction norm reveals family-related variation in the association between size, condition, and sexual maturation onset in Atlantic salmon (Salmo salar).

This study investigated the relationship between the size, condition, year class, family, and sexual maturity of Atlantic salmon (Salmo salar) using data collected in an aquaculture selective breeding programme. Males that were sexually mature at 2 years of age (maiden spawn) have, on average, greater fork length and condition factor (K) at 1 year of age than their immature counterparts. For every 10-mm increase in fork length or 0.1 increase in K at 1 year of age, the odds of sexual maturity at 2 years of age increased by 1.48 or 1.22 times, respectively. Females that were sexually mature at 3 years of age (maiden spawn) have, on average, greater fork length and K at 2 years of age than their immature counterparts. For every 10-mm increase in fork length or 0.1 increase in K at 2 years of age, the odds of sexual maturity at 3 years of age increased by 1.06 or 1.44 times, respectively. The family explained 34.93% of the variation in sexual maturity among 2-year-old males that was not attributable to the average effects of fork length and K at 1 year of age and year class. The proportion of variation in sexual maturity among 3-year-old females explained by the family could not be investigated. These findings suggest that the onset of sexual maturation in Atlantic salmon is conditional on performance (with respect to energy availability) surpassing a threshold, the magnitude of which can vary between families and is determined by a genetic component. This could support the application of genetic selection to promote or inhibit the onset of sexual maturation in farmed stocks.

Plasma cell-free DNA concentration increases during luteolysis in beef cows.

During cell death, DNA is fragmented and reaches the bloodstream in the form of cell-free DNA (cfDNA). Luteal cells must undergo an apoptotic process during structural luteolysis to begin a new oestrous cycle. We hypothesized that cfDNA concentrations would increase when inducing luteolysis by applying prostaglandin F2α (PGF2α) analog to the cycling cow. Multiparous non-pregnant and non-lactating Angus cows (Bos taurus; n = 15) were synchronized using the 7-day CoSynch + CIDR protocol. Ten days after oestrus was detected, two treatments were applied (PGF2α, n = 10; or Con, n = 5). Twice a day, grey mode and colour Doppler ultrasonography were used to calculate area (CL-A) and luteal blood perfusion (LBP%). Additionally, we collected one blood sample for plasma progesterone (P4) and cfDNA concentrations for four consecutive days. Data analysis was performed using the GLM procedure of SAS. The luteolysis induction was demonstrated by a decrease in P4 concentrations (p ≤ .01) and CL-A (p ≤ .01) in the PGF2α group after 12 h of the PGF2α injection. Reduction of LBP% (p ≤ .01) in the PGF2α group after 36 h of the injection. The concentration of cfDNA showed a significant increase (p = .05) after 48 h of the PGF2α application in the PGF2α group. In conclusion, cfDNA showed a significantly increased concentration after luteolysis induction, which can imply that cfDNA could be used as a luteolysis biomarker in plasma.

Post-operative vomiting and enhanced recovery after congenital cardiac surgery.

BACKGROUND: Post-operative nausea and vomiting is frequent after congenital cardiac surgery. AIMS: We sought to determine factors associated to severe post-operative vomiting after congenital cardiac surgery and the effect on post-operative outcomes. METHODS: Patients > 30 days of age who underwent elective cardiac surgical repair as part of an enhanced recovery after congenital cardiac surgery programme were retrospectively reviewed. Patient characteristics and perioperative factors were compared by univariate analysis for patients with severe post-operative vomiting, defined as three events or more, and for patients with no-or-mild post-operative vomiting. All variables with a p-value < 0.1 were included in a multivariable model, and major post-operative outcomes were compared using regression analysis. RESULTS: From 1 October, 2018 to 30 September, 2019, 430 consecutive patients were included. The median age was 4.8 years (interquartile range 1.2-12.6). Twenty-one per cent of patients (91/430) experienced severe post-operative vomiting. Total intraoperative opioids > 5.0 mg/kg of oral morphine equivalent (adjusted odds ratio 1.72) and post-operative inotropes infusion(s) (adjusted odds ratio 1.64) were identified as independent predictors of severe post-operative vomiting after surgery. Patients suffering from severe post-operative vomiting had increased pulmonary complications (adjusted odds ratio 5.18) and longer post-operative hospitalisation (adjusted coefficient, 0.89). CONCLUSIONS: Greater cumulative intraoperative opioids are associated with severe post-operative vomiting after congenital cardiac surgery. Multimodal pain strategies targeting the reduction of intraoperative opioids should be considered during congenital cardiac surgery to enhance recovery after surgery.

Anaesthesia for non-cardiac surgery in children and young adults with Fontan physiology.

INTRODUCTION: Patients with Fontan physiology require non-cardiac surgery. Our objectives were to characterise perioperative outcomes of patients with Fontan physiology undergoing non-cardiac surgery and to identify characteristics which predict discharge on the same day. MATERIALS AND METHOD: Children and young adults with Fontan physiology who underwent a non-cardiac surgery or an imaging study under anaesthesia between 2013 and 2019 at a single-centre academic children's hospital were reviewed in a retrospective observational study. Continuous variables were compared using the Wilcoxon rank sum test, and categorical variables were analysed using the Chi-square test or Fisher's exact test. Multivariable logistic regression analysis results are presented by adjusted odds ratios with 95% confidence intervals and p values. RESULTS: 182 patients underwent 344 non-cardiac procedures with anaesthesia. The median age was 11 years (IQR 5.2-18), 56.4% were male. General anaesthesia was administered in 289 (84%). 125 patients (36.3%) were discharged on the same day. On multivariable analysis, independent predictors that reduced the odds of same-day discharge included the chronic condition index (OR 0.91 per additional chronic condition, 95% CI 0.76-0.98, p = 0.022), undergoing a major surgical procedure (OR 0.17, 95% CI 0.05-0.64, p = 0.009), the use of intraoperative inotropes (OR 0.48, 95% CI 0.25-0.94, p = 0.031), and preoperative admission (OR = 0.24, 95% CI: 0.1-0.57, p = 0.001). DISCUSSION: In a contemporary cohort of paediatric and young adults with Fontan physiology, 36.3% were able to be discharged on the same day of their non-cardiac procedure. Well selected patients with Fontan physiology can undergo anaesthesia without complications and be discharged same day.

Infection With the US Neisseria meningitidis Urethritis Clade Does Not Lower Future Risk of Urethral Gonorrhea.

BACKGROUND: Cross-protective immunity between Neisseria meningitidis (Nm) and Neisseria gonorrhoeae (Ng) may inform gonococcal vaccine development. Meningococcal serogroup B (MenB) outer membrane vesicle (OMV) vaccines confer modest protection against gonorrhea. However, whether urethral Nm infection protects against gonorrhea is unknown. We examined gonorrhea risk among men with US Nm urethritis clade (US_NmUC) infections. METHODS: We conducted a retrospective cohort study of men with urethral US_NmUC (n = 128) between January 2015 and April 2018. Using diagnosis date as the baseline visit, we examined Ng status at return visits to compute urethral Ng risk. We compared these data to 3 referent populations: men with urethral Ng (n = 253), urethral chlamydia (Ct) (n = 251), and no urethral Ng or Ct (n = 255). We conducted sensitivity analyses to assess varied approaches to censoring, missing data, and anatomical site of infection. We also compared sequences of protein antigens in the OMV-based MenB-4C vaccine, US_NmUC, and Ng. RESULTS: Participants were primarily Black (65%) and heterosexual (82%). Over follow-up, 91 men acquired urethral Ng. Men with urethral US_NmUC had similar Ng risk to men with prior urethral Ng (adjusted hazard ratio [aHR]: 1.27; 95% CI: .65-2.48). Men with urethral US_NmUC had nonsignificantly increased Ng risk compared with men with urethral Ct (aHR: 1.51; 95% CI: .79-2.88), and significantly increased Ng risk compared with men without urethral Ng or Ct (aHR: 3.55; 95% CI: 1.27-9.91). Most of the protein antigens analyzed shared high sequence similarity. CONCLUSIONS: Urethral US_NmUC infection did not protect against gonorrhea despite substantial sequence similarities in shared protein antigens.

Evaluation of Urethrotropic-Clade Meningococcal Infection by Urine Metagenomic Shotgun Sequencing.

Urethral infections caused by an emerging nongroupable (NG) urethrotropic clade of Neisseria meningitidis were first reported in the United States in 2015 (the "U.S. NmNG urethritis clade"). Here, we evaluate for the presence of other urethral pathogens in men with U.S. NmNG urethritis clade infection. We evaluated 129 urine specimens collected from men at a sexual health clinic, including 33 from patients with culture-confirmed or suspected urethral N. meningitidis infection and 96 specimens in which nucleic acid amplification test detected Neisseria gonorrhoeae, Chlamydia trachomatis, both pathogens, or neither pathogen. N. meningitidis was detected first by real-time PCR, followed by metagenomic shotgun sequencing of 91 specimens to identify coinfections. N. meningitidis genomes were sequenced following selective whole-genome amplification when possible. Metagenomic sequencing detected N. meningitidis in 16 of 17 specimens from culture-confirmed N. meningitidis cases, with no coinfection by other conventional urethral pathogens. Metagenomic sequencing also detected N. meningitidis in three C. trachomatis-positive specimens, one specimen positive for both N. gonorrhoeae and C. trachomatis, and nine specimens with negative N. gonorrhoeae and C. trachomatis results, eight of which had suspected Neisseria infections. N. meningitidis from culture-confirmed N. meningitidis cases belonged to the U.S. NmNG urethritis clade, while N. meningitidis identified in other specimens belonged to multiple clonal complexes. Additional urethral pathogens were predominant in non-N. meningitidis specimens, including N. gonorrhoeae, C. trachomatis, Mycoplasma genitalium, Ureaplasma urealyticum, and herpes simplex virus 2. Coinfection with other conventional urethral pathogens is rare in men with culture-confirmed U.S. NmNG urethritis clade infection and points to the strong association of this clade with disease.

Staphylococcus epidermidis-Skin friend or foe?

Our skin is our first line of defense against environmental and pathogenic challenges. It is densely populated by a flora of bacteria, fungi, and viruses that normally interact with each other and with our immune system to promote skin health and homeostasis. Staphylococcus epidermidis is one of the most abundant bacterial colonizers of healthy human skin. While the field has historically assumed that all S. epidermidis isolates behave similarly, emerging evidence suggests that colonization by specific strains of S. epidermidis can either help or hurt the skin barrier depending on the context. In this short review, we discuss what is currently understood about S. epidermidis strain-level diversity and evaluate costs and benefits of S. epidermidis skin colonization. We challenge the current dogma that "all S. epidermidis strains behave equally" and posit that behavior is in fact highly context and strain dependent. Finally, in light of current proposals to use skin commensals as nonantibiotic treatments for acute or chronic skin diseases, we conclude that more work is urgently needed to fully understand the pathogenic and protective roles of commensals before we use them therapeutically.

Beyond mismatch repair deficiency? Pre-treatment neutrophil-to-lymphocyte ratio is associated with improved overall survival in patients with recurrent endometrial cancer treated with immunotherapy.

OBJECTIVE: To determine the association of pre-treatment neutrophil-to-lymphocyte ratio (NLR) with progression-free survival (PFS) and overall survival (OS) for patients with recurrent endometrial cancer (EC) treated with immunotherapy. METHODS: Recurrent EC patients treated with immunotherapy alone or in combination from 2016 to 2021 were included. Demographics, pre-treatment laboratory results, pathologic data, response at first radiographic assessment, and cancer outcomes were obtained from the medical record. Kaplan-Meier curves were generated to compare PFS and OS stratified by NLR. RESULTS: The 106 patients included in the study were stratified by NLR <6 (n = 77, 72.6%) or NLR ≥6 (n = 29, 27.3%). Most had endometrioid pathology (59%), widely metastatic disease, and 36.8% had received ≥2 treatment lines before initiating immunotherapy. Mismatch repair deficiency (dMMR) was noted in 52 (49.1%) tumors. Most dMMR patients (94.3%) were treated with single-agent pembrolizumab, and most MMR proficient patients (78.7%) were treated with lenvatinb plus pembrolizumab. In the overall cohort, 40.2% (partial response (PR) 29.9%, complete response (CR) 10.4%) of patients with a NLR <6 responded at first radiographic assessment, compared to 31% (PR 27.5%, CR 3.4%) of patients with NLR ≥6 (p 0.691). Kaplan-Meier curves stratified by NLR <6 vs. ≥6 showed no difference in PFS. However, NLR <6 was associated with improved OS (p < 0.05). In the NLR < 6 group, the probability of survival at one year was 69% (95% CI: 58%, 82%), compared to 41% (95% CI: 26%, 67%) for the NLR > 6 group. CONCLUSIONS: Pre-treatment NLR <6 was associated with improved OS for recurrent EC patients treated with immunotherapy. NLR holds promise as a predictive biomarker for survival after immunotherapy treatment for patients with recurrent EC.

Motivation to test, treat, and report malaria cases: a quantitative assessment among private sector providers in the Greater Mekong Subregion.

BACKGROUND: Accurately testing, treating, and tracking all malaria cases is critical to achieving elimination. Ensuring health providers are able and motivated to test, treat, and report cases is a necessary component of elimination programmes, and particularly challenging in low endemic settings where providers may not encounter a large volume of cases. This study aimed to understand provider motivations to test, treat, and report malaria cases to better optimize programme design, adjust incentive schemes, and ultimately improve reporting rates while growing the evidence base around private providers in the Greater Mekong Subregion (GMS). METHODS: With funding from the Bill & Melinda Gates Foundation, this study aimed to identify and validate distinctive subtypes of motivation among private sector providers enrolled in the Greater Mekong Subregion Elimination of Malaria through Surveillance (GEMS) programme, implemented by Population Services International. Quantitative questionnaires were administered electronically in person by trained enumerators to various provider groups in Myanmar, Lao PDR, and Vietnam. A three-stage confirmatory factor analysis was then conducted in STATA. RESULTS: Following this analysis, a two-factor solution that describes motivation in this population of providers was identified, and providers were scored on the two dimensions of motivation. The correlation between the two rotated factors was 0.3889, and the Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy was 0.93, indicating an excellent level of suitability. These providers, who are often assumed to only be financially motivated, engaged in malaria elimination activities because of both internal and external motivational factors that are independent of remuneration or financial gain. For all three countries' data, significant covariances between the two latent variables for internal and external motivation were found. The models were found to be of adequate to good fit for the data across all three countries. It was determined that private sector providers, who were previously believed to be primarily financially motivated, were also motivated by personal factors. Motivation was also associated with key outcomes of importance to malaria elimination, such as reporting and stocking of tests and treatments. CONCLUSION: Maintaining or increasing provider motivation to test and treat is essential in the fight to eliminate malaria from the GMS, as it helps to ensure that providers continue to pursue this goal, even in a low incidence environment where cases may be rare and in which providers face financial pressure to focus on areas of health service provision. Establishing mechanisms to better motivate providers through intrinsic factors is likely to have a substantive impact on the sustainability of malaria case management activities.

End-user research in support of long-acting systemic antiretroviral delivery systems: insights from qualitative research with providers and target users in South Africa.

BACKGROUND: While oral pre-exposure prophylaxis (PrEP) has been shown to reduce the risk of HIV, challenges such as adhering to a daily-dosing regimen and persistence have emerged as barriers for at-risks populations in South Africa. This qualitative research sought to investigate perceptions of and preferences for a long-acting, biodegradable implantable PrEP product designed to address these barriers. METHODS: To identify and understand motivators, barriers, and preferences for the PrEP implant, we conducted qualitative in-depth interviews (IDIs) among health care providers (HCPs) and target end-users (young women, adolescent girls, and female sex workers) in urban and rural/peri-urban regions of Gauteng Province, South Africa. The IDIs focused on defining values, beliefs, habits, lifestyles, influencers, and information channels for potential PrEP implant end-users. RESULTS: We conducted 36 IDIs across health care providers and target end-user respondent segments. Respondents had generally positive reactions to the PrEP implant. Most end-users felt that some undesirable aspects of the implant (e.g., side effects, pain during insertion, potential scarring, and inability to remove implant) would be offset by having a highly effective, and long-lasting HIV prevention product. Although some HCPs believed the implantable PrEP would lead to increases in promiscuity and risky sexual behavior, most HCPs saw value in the PrEP implant's long duration of protection, its biodegradability, and the likelihood of higher adherence relative to oral PrEP. CONCLUSIONS: This study is a first step toward further research needed to demonstrate the demand for a biodegradable, long-acting implantable PrEP and suggests such a product would be accepted by end-users and HCPs in South Africa. This study indicates the need to develop more convenient, discreet, long-acting, and highly effective biomedical HIV prevention options for at-risk populations.

The Practice of Pediatric Cardiac Anesthesiology in the United States.

BACKGROUND: With advances in surgical and catheter-based interventions and technologies in patients with congenital heart disease (CHD), the practice of pediatric cardiac anesthesiology has evolved in parallel with pediatric cardiac surgery and pediatric cardiology as a distinct subspecialty over the past 80 years. To date, there has not been an analysis of the distribution of pediatric cardiac anesthesiologists relative to cardiac and noncardiac procedures in the pediatric population. The primary aim is to report the results of a survey and its subsequent analysis to describe the distribution of pediatric cardiac anesthesiologists relative to pediatric cardiac procedures that include surgical interventions, cardiac catheterization procedures, imaging studies (echocardiography, magnetic resonance, computed tomography, positron emission tomography), and noncardiac procedures. METHODS: A survey developed in Research Electronic Data Capture (REDcap) was sent to the identifiable division chiefs/cardiac directors of 113 pediatric cardiac anesthesia programs in the United States. Data regarding cardiac surgical patients and procedures were collected from the Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHD). RESULTS: This analysis reveals that only 38% (117 of 307) of pediatric cardiac anesthesiologists caring for patients with CHD pursued additional training in pediatric cardiac anesthesiology, while 44% (136 of 307) have gained experience during their clinical practice. Other providers have pursued different training pathways such as adult cardiac anesthesiology or pediatric critical care. Based on this survey, pediatric cardiac anesthesiologists devote 35% (interquartile range [IQR], 20%-50%) of clinical time to the care of patients in the cardiac operating room, 25% (20%-35%) of time to the care of patients in the cardiac catheterization laboratory, 10% (5%-10%) to patient care in imaging locations, and 15% covering general pediatric, adult, or cardiac patients undergoing noncardiac procedures. Attempts to actively recruit pediatric cardiac anesthesiologists were reported by 49.2% (29 of 59) of the institutions surveyed. Impending retirement of staff was anticipated in 17% (10 of 59) of the institutions, while loss of staff to relocation was anticipated in 3.4% (2 of 59) of institutions. Thirty-seven percent of institutions reported that they anticipated no immediate changes in current staffing levels. CONCLUSIONS: The majority of currently practicing pediatric cardiac anesthesiologists have not completed a fellowship training in the subspecialty. There is, and will continue to be, a need for subspecialty training to meet increasing demand for services especially with increase survival of this patient population and to replace retiring members of the workforce.

Dosing of Opioid Medications During and After Pediatric Cardiac Surgery for Children With Down Syndrome.

OBJECTIVE: To determine whether children with Down syndrome (DS) receive higher doses of opioid medications compared with children without DS for repair of complete atrioventricular canal (CAVC). DESIGN: A retrospective chart review of children with and without DS who underwent primary repair of CAVC. The exclusion criteria included unbalanced CAVC and patients undergoing biventricular staging procedures. The primary outcome was oral morphine equivalents (OME) received in the first 24 hours after surgery. The secondary outcomes included intraoperative OME, OME at 48 and 72 hours, nonopioid analgesic and sedative medications received, pain scores, time to extubation, and length of stay. SETTING: A pediatric academic medical center in the United States. PARTICIPANTS: One hundred thirty-one patients with DS and 24 without, all

Race and Outcomes in Patients with Congenital Cardiac Disease in an Enhanced Recovery Program.

OBJECTIVES: Disparities in perioperative outcomes exist. In addition to patient and socioeconomic factors, racial disparities in outcome measures may be related to issues at the provider and institutional levels. Recognizing a potential role of standardized care in mitigating provider bias, this study aims to compare the perioperative sedation and pain management and consequent outcomes in Enhanced Recovery After Surgery (ERAS) cardiac patients of different races undergoing congenital heart surgery at a single quaternary children's hospital. DESIGN: A retrospective study. SETTING: A single quaternary pediatric hospital. PARTICIPANTS: Patients, infants to adults, undergoing elective congenital cardiac surgery and enrolled in the ERAS protocol from October 2018 to December 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the patients, 872 were reviewed and 606 with race information were analyzed. There was no significant difference in intraoperative and postoperative oral morphine equivalent, perioperative sedatives, and regional blockade in Asian or African American patients when compared to White patients. Postoperative pain scores and outcomes among African American and Asian races were also not statistically different when compared to White patients. CONCLUSIONS: Racial disparity in perioperative management and outcomes in patients with standardized ERAS protocols does not exist at the authors' institution. Future comparative studies of ERAS noncardiac patients may provide additional information on the role of standardization in reducing implicit bias.

Anesthesia in Children With Pulmonary Hypertension: Clinically Significant Serious Adverse Events Associated With Cardiac Catheterization and Noncardiac Procedures.

OBJECTIVES: To determine the incidence of clinically significant serious adverse events in a contemporary population of pediatric patients with pulmonary hypertension who require anesthesia and identify factors associated with adverse outcomes. DESIGN: A retrospective, cross-sectional study. SETTING: A single-center quaternary-care freestanding children's hospital in the northeastern United States. PARTICIPANTS: Pediatric patients with pulmonary hypertension based on hemodynamic criteria on cardiac catheterization during a 3-year period from 2015 to 2018. INTERVENTIONS: Anesthesia care for cardiac catheterization, noncardiac surgery, and diagnostic imaging. MEASUREMENTS AND MAIN RESULTS: Two hundred forty-nine children underwent 862 procedures, 592 for cardiac catheterization and 278 for noncardiac surgery and diagnostic imaging. The median age was 1.6 years, and the weight was 9.5 lbs. On index catheterization, median pulmonary artery pressure was 36 mmHg, and the pulmonary vascular resistance was 5.1 indexed Wood units. Ten percent of anesthetics were performed with a natural airway, and 80% used volatile anesthetics. Serious adverse events occurred in 26% of procedures (confidence interval [CI], 22%-30%). The rate of periprocedural cardiac arrest was 8 per 1,000 anesthetic administrations. In multivariate analysis, younger age (adjusted odds ratio [aOR], 1.4 per year; CI, 1.1-1.9; p = 0.01), location in the catheterization laboratory (aOR, 5.1; CI, 1.7-16; p = 0.004), and longer procedure duration (aOR, 1.3 per 30 minutes; CI, 1.1-1.4; p = 0.001) were associated with serious adverse events. Patients with a tracheostomy in place were less likely to experience an adverse event (aOR, 0.1; CI, 0.04-0.5; p = 0.001). The primary anesthetic technique was not associated with adverse events. Interventional cardiac catheterization was associated with an increased incidence of adverse events compared with diagnostic catheterization (42% v 21%; OR, 2.23; CI, 1.5-3.3; p < 0.001). CONCLUSIONS: Serious adverse events were common in this cohort. Careful planning to minimize anesthesia time in young children with pulmonary hypertension should be undertaken, and these factors considered in designing risk mitigation strategies.

Two-dimensional pattern recognition methods for rapidly recording and interpreting high resolution coherent three-dimensional spectra.

High resolution coherent multidimensional spectroscopy has the ability to reduce congestion and automatically sort peaks by species and quantum numbers, even for simple mixtures and molecules that are extensively perturbed. The two-dimensional version is relatively simple to carry out, and the results are easy to interpret, but its ability to deal with severe spectral congestion is limited. Three-dimensional spectroscopy is considerably more complicated and time-consuming than two-dimensional spectroscopy, but it provides the spectral resolution needed for more challenging systems. This paper describes how to design high resolution coherent 3D spectroscopy experiments so that a small number of strategically positioned 2D scans may be used instead of recording all the data required for a 3D plot. This faster and simpler approach uses new pattern recognition methods to interpret the results. Key factors that affect the resulting patterns include the scanning strategy and the four wave mixing process. Optimum four wave mixing (FWM) processes and scanning strategies have been identified, and methods for identifying the FWM process from the observed patterns have been developed. Experiments based on nonparametric FWM processes provide significant pattern recognition and efficiency advantages over those based on parametric processes. Alternative scanning strategies that use synchronous scanning and asynchronous scanning to create new kinds of patterns have also been identified. Rotating the resulting patterns in 3D space leads to an insight into similarities in the patterns produced by different FWM processes.

The Use of Regional Catheters in Children Undergoing Repair of Aortic Coarctation.

OBJECTIVE: The objective was to assess the effectiveness and safety of peripheral regional anesthesia in congenital cardiac surgical patients undergoing thoracotomy for aortic coarctation. DESIGN: A retrospective chart review of pediatric patients (<18 years) who underwent surgical repair of congenital heart diseases via thoracotomy between September 2013 and July 2018 was done. Among patients who underwent coarctation repair, a propensity score was used to match patients who received a regional catheter (C) versus traditional medical treatment only (M). SETTING: A single center children's hospital. PARTICIPANTS: The median age was 172 days (IQR 64-1315) in group C and 176 days (IQR 71-1146) in group M (SMD = 0.07). The median weight was 6.8 kg (IQR 4.8-13.6) in group C and 7.7 kg (4.6-17.4) in group M (SMD = 0.003). MEASUREMENTS AND MAIN RESULT: Outcomes assessed were postoperative hospital length of stay, median pain scores in the first 24 and 48 hours, and total morphine equivalent use in the first 24 and 48 hours. Complications related to the catheters were reviewed. The median oral morphine equivalent dose administered in the first 24 hours was lower in group C than group M (0.8 mg/kg, IQR 0.5-1.1 vs. 1.4 mg/kg, IQR 0.9-1.7, p = 0.019). There were no major complications related to the catheters, including hematoma. CONCLUSIONS: Peripheral regional catheters may be used to reduce opioid requirements in patients after CoA repair. Due to the low risk of these catheters, they should be considered as part of a pain management strategy for pediatric patients undergoing thoracotomy and should be incorporated into strategies to improve outcomes.

Predictors of Increased Lactate in Neonatal Cardiac Surgery: The Impact of Cardiopulmonary Bypass.

OBJECTIVE: Hyperlactatemia develops intraoperatively during cardiac surgery and is associated with postoperative mortality. This study aimed to determine the factors that lead to an increase in lactate during cardiopulmonary bypass (CPB) in neonates undergoing cardiac surgery. DESIGN: Retrospective study from July 2015 to December 2018. SETTING: Academic tertiary children's hospital. PARTICIPANTS: The study comprised 376 neonates. INTERVENTIONS: No interventions were performed. MEASUREMENTS AND MAIN RESULTS: Lactate measurements at prebypass, upon initiation of CPB and before coming off CPB, last in the operating room, and first in the cardiac intensive care unit were collected. The changes in lactate levels were compared using the nonparametric Wilcoxon signed rank test for paired data. Univariate and multivariate median regression models of the change during CPB were determined. The cohort characteristics were male (60%), median age 5 days (range 1-30), and weight 3.2 kg (range 1.5-4.7). Most patients had a STAT score of 4 (45%) or 5 (23%). Significant increases in lactate were observed from pre-CPB to start of CPB (p < 0.001) and from start to end of CPB (p < 0.001). In the multivariate regression analysis, duration of circulatory arrest (coefficient = 1.216; 95% confidence interval [CI] 0.754-1.678; p < 0.001), duration of mean arterial pressure < 25 mmHg (coefficient = 0.423; 95% CI 0.196-to- 0.651; p < 0.001), and duration of mean arterial pressure between 35 and 39 mmHg (coefficient = -0.246; 95% CI -0.397 to -0.095; p = 0.001) were identified as significant independent predictors of the lactate change per 30- minutes duration. CONCLUSION: These results emphasized the importance of blood pressure management during CPB and the importance of the duration of circulatory arrest.

Bilateral Erector Spinae Blocks Decrease Perioperative Opioid Use After Pediatric Cardiac Surgery.

OBJECTIVE: The present study examined the feasibility and efficacy of continuous bilateral erector spinae blocks for post-sternotomy pain in pediatric cardiac surgery. DESIGN: Prospective cohort study; patients were retrospectively matched 1:2 to control patients. Conditional logistic regression was used to compare dichotomous outcomes, and generalized linear models were used for continuous measures, both accounting for clusters. SETTING: Quaternary children's hospital, university setting. PARTICIPANTS: The study comprised 10 children ages five-to-17 years undergoing elective cardiac surgery requiring cardiopulmonary bypass. INTERVENTIONS: Ultrasound-guided bilateral erector spinae blocks at the conclusion of the cardiac surgical procedure, with postoperative infusion of ropivacaine until chest tube removal. Postoperative management otherwise followed standardized guidelines. MEASUREMENTS AND MAIN RESULTS: Patient characteristics were similar in the two groups. The median time to completion of the bilateral blocks was 16.0 minutes (interquartile range [IQR] 14.8-19.3), and no major adverse events were identified. Pain scores were low in both groups. Postoperative opioid use at 48 hours, rendered as oral morphine equivalents, was significantly reduced in the patients receiving the blocks. Cluster-adjusted squared-root-transformed means ± standard error were 0.89 ± 0.06 mg/kg for patients receiving the blocks versus 1.05 ± 0.06 mg/kg for control patients (p = 0.04; raw medians 0.81 [IQR 0.41-1.04] v 1.10 [IQR 0.78-1.35] mg/kg, respectively). There were no differences in recovery metrics, length of stay, or complications. CONCLUSIONS: Bilateral erector spinae blocks were associated with a reduction in opioid use in the first 48 hours after pediatric cardiac surgery compared with a matched cohort from the enhanced recovery program. Larger studies are needed to determine whether this can result in an improvement in recovery and patient satisfaction.

Novel Peptide from Commensal Staphylococcus simulans Blocks Methicillin-Resistant Staphylococcus aureus Quorum Sensing and Protects Host Skin from Damage.

Recent studies highlight the abundance of commensal coagulase-negative staphylococci (CoNS) on healthy skin. Evidence suggests that CoNS actively shape the skin immunological and microbial milieu to resist colonization or infection by opportunistic pathogens, including methicillin-resistant Staphylococcus aureus (MRSA), in a variety of mechanisms collectively termed colonization resistance. One potential colonization resistance mechanism is the application of quorum sensing, also called the accessory gene regulator (agr) system, which is ubiquitous among staphylococci. Common and rare CoNS make autoinducing peptides (AIPs) that function as MRSA agr inhibitors, protecting the host from invasive infection. In a screen of CoNS spent media, we found that Staphylococcus simulans, a rare human skin colonizer and frequent livestock colonizer, released potent inhibitors of all classes of MRSA agr signaling. We identified three S. simulans agr classes and have shown intraspecies cross talk between noncognate S. simulans agr types for the first time. The S. simulans AIP-I structure was confirmed, and the novel AIP-II and AIP-III structures were solved via mass spectrometry. Synthetic S. simulans AIPs inhibited MRSA agr signaling with nanomolar potency. S. simulans in competition with MRSA reduced dermonecrotic and epicutaneous skin injury in murine models. The addition of synthetic AIP-I also effectively reduced MRSA dermonecrosis and epicutaneous skin injury in murine models. These results demonstrate potent anti-MRSA quorum sensing inhibition by a rare human skin commensal and suggest that cross talk between CoNS and MRSA may be important in maintaining healthy skin homeostasis and preventing MRSA skin damage during colonization or acute infection.