Peripheral Nucleated Red Blood Cells and Mortality in Critically Ill Children.

The present retrospective cohort study examines whether there is an association between circulating nucleated red blood cells (nRBCs) and mortality in critically ill children. nRBCs are erythropoietic progenitor cells not found in peripheral blood of healthy adults and children beyond the neonatal period. The presence of circulating nRBCs is associated with poor prognosis in adults and neonates, though little is known about their significance in children. Admissions to both the general and cardiac pediatric intensive care unit at the Stollery Children's Hospital in Edmonton, Alberta between January 1, 2015 and December 31, 2017 were examined, and logistic regression was performed to ascertain the association between the peak absolute nRBC counts and in-hospital mortality in critically ill children. A total of 2065 admissions were included. The number of admissions with detectable nRBCs was 386 (prevalence: 13.9%), and the number of deaths was 93 (mortality: 4.5%). A statistically significant association was found between the absolute value of nRBC peak and intensive care unit mortality (odds ratio=1.37; 95% confidence interval: 1.13-1.67; P=0.002) as well as hospital mortality (odds ratio=1.38; 95% confidence interval: 1.12-1.70; P=0.003) independent of the Pediatric Index of Mortality 3 score (PIM3). This result warrants more attention to nRBC values and their potential clinical use.

Minimally invasive anterior foraminotomy for cervical radiculopathy: how I do it.

BACKGROUND: The standard treatment for cervical radiculopathy is anterior discectomy and fusion. The authors describe a minimally invasive anterior cervical foraminotomy as a surgical option for direct nerve root decompression in cervical radiculopathy. METHOD: Through a modified Smith-Robinson approach, the prevertebral fascia is mobilized laterally, displacing the sympathetic chain with it. A thumbnail size portion of the longus colli muscle is removed. A tubular retractor is placed, centered over the index uncovertebral joint. The lateral part of the joint is progressively drilled towards the foramen. After exposure of the intervertebral foramen, the perivascular ligamentous tissue is opened. Removal of disc fragments and osteophytes allows direct visualization and direct decompression of the nerve root. CONCLUSION: Anterior cervical foraminotomy is a safe "motion preserving" procedure for direct nerve decompression in selected patients with cervical radiculopathy that does not require cervical fusion.

Delayed presentation of deep penetrating trauma to the subaxial cervical spine.

PURPOSE: To present a rare case of deep penetrating neck trauma in which a retained foreign body in the cervical spine (a broken knife blade) resulted in delayed radicular injury. We describe the surgical management using a retrojugular approach. CASE REPORT: Our patient sustained a stab wound to the supraclavicular triangle from a small pocketknife. He was initially managed in a local hospital by simple primary wound closure without any radiological examinations, and was discharged home. The patient re-consulted in a delayed fashion with mild local persistent neck pain. Subsequent radiological investigations revealed a foreign body (the broken blade of a pocket knife) embedded in the left neural foramen between the C6 and C7 vertebrae penetrating the disc space. The blade was lying between the left C7 nerve root and the ipsilateral vertebral artery (VA) at the transition of V1 and V2 segments. Initial neurological evaluation was normal. Some days later, the patient developed a delayed left C7 radicular deficit. We undertook urgent exploration along the wound corridor through a retrojugular, transforaminal approach with successful removal of the blade. DISCUSSION: To our knowledge, this is a unique case where a retained foreign body penetrated the soft tissues of the neck, embedding deep in the vertebral column without vascular, aerodigestive or significant primary neurological injury, while causing delayed neck pain and delayed onset radicular injury. We describe our surgical management for removal of the retained blade. The retrojugular approach gives excellent access to all of the important anatomical structures of the neck from an anterolateral approach.

Low transient storage and uptake efficiencies in seven agricultural streams: implications for nutrient demand.

We used mass load budgets, transient storage modeling, and nutrient spiraling metrics to characterize nitrate (NO), ammonium (NH), and inorganic phosphorus (SRP) demand in seven agricultural streams across the United States and to identify in-stream services that may control these conditions. Retention of one or all nutrients was observed in all but one stream, but demand for all nutrients was low relative to the mass in transport. Transient storage metrics (/, , , and ) correlated with NO retention but not NH or SRP retention, suggesting in-stream services associated with transient storage and stream water residence time could influence reach-scale NO demand. However, because the fraction of median reach-scale travel time due to transient storage () was ≤1.2% across the sites, only a relatively small demand for NO could be generated by transient storage. In contrast, net uptake of nutrients from the water column calculated from nutrient spiraling metrics were not significant at any site because uptake lengths calculated from background nutrient concentrations were statistically insignificant and therefore much longer than the study reaches. These results suggest that low transient storage coupled with high surface water NO inputs have resulted in uptake efficiencies that are not sufficient to offset groundwater inputs of N. Nutrient retention has been linked to physical and hydrogeologic elements that drive flow through transient storage areas where residence time and biotic contact are maximized; however, our findings indicate that similar mechanisms are unable to generate a significant nutrient demand in these streams relative to the loads.

[Inter-hospital CHUV-HUG medical consensus of back pain management. Its application in care pathways within CHUV of Lausanne]. / Consensus interdisciplinaire CHUV-HUG sur la prise en charge des douleurs du dos. Son application lausannoise dans la filière du dos.

Back pain is a considerable economical burden in industrialised countries. Its management varies widely across countries, including Switzerland. Thus, the University Hospital and University of Lausanne (CHUV) recently improved intern processes of back pain care. In an already existing collaborative context, the two university hospitals in French-speaking Switzerland (CHUV, University Hospital of Geneva), felt the need of a medical consensus, based on a common concept. This inter-hospital consensus produced three decisional algorithms that bear on recent concepts of back pain found in literature. Eventually, a fast track was created at CHUV, to which extern physicians will have an organised and rapid access. This fast track aims to reduce chronic back pain conditions and provides specialised education for general practitioners-in-training.

Vulnerability of streams to legacy nitrate sources.

The influence of hydrogeologic setting on the susceptibility of streams to legacy nitrate was examined at seven study sites having a wide range of base flow index (BFI) values. BFI is the ratio of base flow to total streamflow volume. The portion of annual stream nitrate loads from base flow was strongly correlated with BFI. Furthermore, dissolved oxygen concentrations in streambed pore water were significantly higher in high BFI watersheds than in low BFI watersheds suggesting that geochemical conditions favor nitrate transport through the bed when BFI is high. Results from a groundwater-surface water interaction study at a high BFI watershed indicate that decades old nitrate-laden water is discharging to this stream. These findings indicate that high nitrate levels in this stream may be sustained for decades to come regardless of current practices. It is hypothesized that a first approximation of stream vulnerability to legacy nutrients may be made by geospatial analysis of watersheds with high nitrogen inputs and a strong connection to groundwater (e.g., high BFI).

Two independent LAMP assays for rapid identification of the serpentine leafminer, Liriomyza huidobrensis (Blanchard, 1926) (Diptera: Agromyzidae) in Australia.

Liriomyza huidobrensis is a leafminer fly and significant horticultural pest. It is a quarantine listed species in many countries and is now present as an established pest in Australia. Liriomyza huidobrensis uses a broad range of host plants and has potential for spread into various horticultural systems and regions of Australia. Rapid in-field identification of the pest is critically needed to assist efforts to manage this pest. Morphological identification of the pest is effectively limited to specialist examinations of adult males. Generally, molecular methods such as qPCR and DNA barcoding for identification of Liriomyza species require costly laboratory-based hardware. Herein, we developed two independent and rapid LAMP assays targeted to independently inherited mitochondrial and nuclear genes. Both assays are highly sensitive and specific to L. huidobrensis. Positive signals can be detected within 10 min on laboratory and portable real-time amplification fluorometers. Further, we adapted these assays for use with colorimetric master mixes, to allow fluorometer free in-field diagnostics of L. huidobrensis. Our LAMP assays can be used for stand-alone testing of query specimens and are likely to be essential tools used for rapid identification and monitoring of L. huidobrensis.

Development and first-in-human testing of FLUME urinary catheter with protected tip and relocated drainage holes.

Purpose: Evaluation of a catheter design which protects its tip with the retaining balloon when inflated, and has eyeholes at the base of the balloon to improve drainage. Materials and methods: Preclinical tests included assessment of retaining balloon performance, and microbiological blockage. Clinical testing evaluated short-term use and safety in hospital (stage 1) or the patient's usual residence (stage 2). Results: The retaining balloon supported static loads of 0.7kg, with reduced trauma when modelling forced evulsion. In vitro time to blockage with P. Mirabilis was significantly slower for FLUME compared with latex Foley catheters, but not the silicone Foley. Stage 1 testing (10 patients) confirmed balloon inflation, drainage, retention and removal, with no serious adverse events caused by catheterisation; one balloon failed to inflate, one patient could not be catheterised. Of five patients at stage 2, one had the catheter for 28 days without complication, one experienced spontaneous balloon deflation (14th day) and three needed early removal (blood clot, bypassing, difficulty connecting the drainage bag). Bacterial profiles of two FLUME catheters retained at least 2 weeks matched the Foley catheters. Acquired catheter colouration (two FLUME, one Foley) was not associated with biochemical change in the material. Conclusion: FLUME catheter performed well in preclinical blockage and balloon tests. Tests in 15 patients confirmed basic function and additional training was not needed for staff familiar with Foley catheterisation. Clinical issues commonly seen with catheters included failed catheterisation, clot blockage and bypassing. In addition, an unintended balloon deflation and a failure of bag connection occurred. Plain language summary: This article describes a new catheter design which aims to improve patient comfort and safety, and maximise bladder drainage, by protecting the bladder from the exposed catheter tip and by locating the drainage holes better. Various tests were done to check the catheter retaining balloon was safe and how well the catheter did when exposed to bacteria that could block it. The catheter was also used in people for the first time, to check it could be put in safely and functioned as intended. The results showed the FLUME catheter did well in the balloon and blockage tests. Tests in 15 patients confirmed basic function and showed placement was easy for staff familiar with conventional catheters. There were some clinical issues typical of urinary catheters and some possible improvements were identified.

[Trends in the treatment of spinal osteoporic fractures: vertebroplasty and kyphoplasty]. / Nouveautés dans la prise en charge des fractures vertébrales ostéoporotiques: place de la vertébroplastie et de la kyphoplastie.

Vertebral osteoporotic fracture (VOF) is a major problem of public health. Surgical treatments such as vertebroplasty and kyphoplasty are interesting adjuvant treatments for the management of osteoporosis. A consensus proposed by the principal contributors of this management is important. Regarding the actual data, we propose a vertebroplasty or a kyphoplasty for all patients suffering of an acute VOF. If a previous kyphosis or an important local kyphosis exists, secondary to the acute VOF or others, we propose a kyphoplasty. If the VOF is older and the conservative treatment is inefficient, we propose a vertebroplasty. In all cases, a specific management and treatment of osteoporosis is proposed.

Transtubular image-guided surgery for spinal intradural lesions: techniques, results, and complications in a consecutive series of 60 patients.

OBJECTIVE: The authors previously described the image merge tailored access resection (IMTAR) technique for resection of spinal intradural lesions (SIDLs). The authors reported their updated experience with the IMTAR technique and compared surgical results between patients who underwent operations with 2D or 3D fluoroscopic guidance. METHODS: The authors reviewed 60 patients who underwent SIDL resection with transtubular techniques over a 14-year period. The earlier patients in the series underwent operations with 2D fluoroscopic image guidance. The latter patients underwent operations with the IMTAR technique based on 3D image guidance. The results of both techniques were analyzed. RESULTS: Sixty patients were included: 27 females (45%) and 33 males (55%). The median (range) age was 50.5 (19-92) years. Gross-total resection (GTR) was achieved in 52 patients (86.7%). Subtotal resection was accomplished in 5 patients (8.3%). Neurological complications occurred in 3 patients (5%), and tumor recurrence occurred in 1 patient (1.7%). The non-IMTAR and IMTAR cohorts showed similar postoperative Nurick scale scores and rates of neurological complications and GTR. The median (interquartile range) bone resection surface area at the index level was 89.5 (51-147) mm2 in the non-IMTAR cohort and 35.5 (11-71) mm2 in the IMTAR cohort, with a statistically significant difference (p = 0.0112). CONCLUSIONS: Surgery for SIDLs may be challenging, and meticulous surgical planning is crucial to optimize tumor access, maximize resection, and minimize risk of complications. Image-guided transtubular resection is an additional surgical technique for SIDLs and facilitates microsurgical tumor removal of ventrally located lesions with a posterolateral approach, without requiring potentially destabilizing bone resection.

Role of the fish Astyanax aeneus (Characidae) as a keystone nutrient recycler in low-nutrient neotropical streams.

Nutrient recycling by animals is a potentially important biogeochemical process in both terrestrial and aquatic ecosystems. Stoichiometric traits of individual species may result in some taxa playing disproportionately important roles in the recycling of nutrients relative to their biomass, acting as keystone nutrient recyclers. We examined factors controlling the relative contribution of 12 Neotropical fish species to nutrient recycling in four streams spanning a range of phosphorus (P) levels. In high-P conditions (135 microg/L soluble reactive phosphorus, SRP), most species fed on P-enriched diets and P excretion rates were high across species. In low-P conditions (3 microg/L SRP), aquatic food resources were depleted in P, and species with higher body P content showed low rates of P recycling. However, fishes that were subsidized by terrestrial inputs were decoupled from aquatic P availability and therefore excreted P at disproportionately high rates. One of these species, Astyanax aeneus (Characidae), represented 12% of the total population and 18% of the total biomass of the fish assemblage in our focal low-P study stream but had P excretion rates > 10-fold higher than other abundant fishes. As a result, we estimated that P excretion by A. aeneus accounted for 90% of the P recycled by this fish assemblage and also supplied approximately 90% of the stream P demand in this P-limited ecosystem. Nitrogen excretion rates showed little variation among species, and the contribution of a given species to ecosystem N recycling was largely dependent upon the total biomass of that species. Because of the high variability in P excretion rates among fish species, ecosystem-level P recycling could be particularly sensitive to changes in fish community structure in P-limited systems.

Transtubular Anterior Cervical Foraminotomy for the Treatment of Compressive Cervical Radiculopathy: Surgical Results and Complications in a Consecutive Series of Cases.

STUDY DESIGN: This was a retrospective review of patients with compressive cervical radiculopathy treated with a minimally invasive anterior cervical foraminotomy (ACF). PURPOSE: This study aimed to evaluate the results and complication rates of ACF in a consecutive series of patients and to report our clinical results of ACF as a minimally invasive technique in a series of 45 consecutive patients treated for compressive cervical radiculopathy. OVERVIEW OF LITERATURE: ACF is a motion-sparing procedure and an alternative to anterior cervical discectomy and fusion (ACDF) and posterior cervical foraminotomy for direct nerve root decompression in patients with compressive cervical radiculopathy. METHODS: The chart review recorded clinical and radiological features preoperatively and postoperatively and at follow-up (FU). The effect of prognostic factors was analyzed in relation to the clinical outcome. RESULTS: Between January 2004 and October 2019, 45 patients (15 females and 30 males) with a mean age of 55.9 years (range, 28-78 years) underwent ACF for unilateral cervical radiculopathy. The global clinical outcome according to the MacNab scale was evaluated as excellent in 64.5% of patients (n=29), good in 28.9% (n=13), fair in 4.4% (n=2), and poor in 2.2% (n=1). The radiological FU was available for 73.3% (n=33). The statistical analysis revealed no influence of age, sex, operated level, and side on the clinical outcome. Only one patient (2.2%) exhibited spontaneous bone fusion at the operated level on FU after a right-sided C6-7 ACF with no clinical consequences. No patient presented with signs of delayed segmental instability. The overall reoperation rate of this series was 4.4%. CONCLUSIONS: ACF is a feasible and low-cost alternative to ACDF in selected patients with cervical radiculopathy. The use of tubular retractors in ACF may confer an added advantage that creates a safe corridor for direct cervical root decompression yet minimizing surrounding soft tissue retraction and avoiding unnecessary bone removal.

Using Smartphones for Clinical Assessment in Cervical Spondylotic Myelopathy a Feasibility Study.

Degenerative cervical myelopathy (DCM) is characterized by a progressive deterioration in spinal cord function. Its evaluation requires subjective clinical examination with wide interobserver variability. Objective quantification of spinal cord function remains imprecise, even though validated myelopathy-grading scales have emerged and are now widely used. We created a Smartphone Application, the N-Outcome App, with the aim of quantifying accurately and reliably spinal cord dysfunction using a 5-minute Test. A patient suffering from DCM was clinically evaluated before surgery, at 3 and 6 months follow-up after surgical decompression of the cervical spinal cord. Standard scores (Nurick grade, modified Japanese Orthopedic Association (mJOA) score) were documented at these time points. A 5-minute motor and proprioceptive performance test aided by a smartphone with the N-outcome App was also performed. Motor performance in rapid alternating movements and finger tapping improved in correlation with improvements in standard grading scale scores. Clinical improvements were seen in maximum reflex acceleration and in Romberg testing which showed less closed/open eyes variation, suggesting pyramidal and proprioceptive function recovery. We demonstrate that using the N-Outcome App as an adjunct to clinical evaluation of compressive myelopathy is feasible and potentially useful. The results correlate with the results of clinical assessment obtained by standard validated myelopathy scores.

Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine.

BACKGROUND: The Institute of Medicine calls for the use of clinical guidelines and practice parameters to promote "best practices" and to improve patient outcomes. OBJECTIVE: 2007 update of the 2002 American College of Critical Care Medicine Clinical Guidelines for Hemodynamic Support of Neonates and Children with Septic Shock. PARTICIPANTS: Society of Critical Care Medicine members with special interest in neonatal and pediatric septic shock were identified from general solicitation at the Society of Critical Care Medicine Educational and Scientific Symposia (2001-2006). METHODS: The Pubmed/MEDLINE literature database (1966-2006) was searched using the keywords and phrases: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, extracorporeal membrane oxygenation (ECMO), and American College of Critical Care Medicine guidelines. Best practice centers that reported best outcomes were identified and their practices examined as models of care. Using a modified Delphi method, 30 experts graded new literature. Over 30 additional experts then reviewed the updated recommendations. The document was subsequently modified until there was greater than 90% expert consensus. RESULTS: The 2002 guidelines were widely disseminated, translated into Spanish and Portuguese, and incorporated into Society of Critical Care Medicine and AHA sanctioned recommendations. Centers that implemented the 2002 guidelines reported best practice outcomes (hospital mortality 1%-3% in previously healthy, and 7%-10% in chronically ill children). Early use of 2002 guidelines was associated with improved outcome in the community hospital emergency department (number needed to treat = 3.3) and tertiary pediatric intensive care setting (number needed to treat = 3.6); every hour that went by without guideline adherence was associated with a 1.4-fold increased mortality risk. The updated 2007 guidelines continue to recognize an increased likelihood that children with septic shock, compared with adults, require 1) proportionally larger quantities of fluid, 2) inotrope and vasodilator therapies, 3) hydrocortisone for absolute adrenal insufficiency, and 4) ECMO for refractory shock. The major new recommendation in the 2007 update is earlier use of inotrope support through peripheral access until central access is attained. CONCLUSION: The 2007 update continues to emphasize early use of age-specific therapies to attain time-sensitive goals, specifically recommending 1) first hour fluid resuscitation and inotrope therapy directed to goals of threshold heart rates, normal blood pressure, and capillary refill 70% and cardiac index 3.3-6.0 L/min/m.

Identifying pathways and processes affecting nitrate and orthophosphate inputs to streams in agricultural watersheds.

Understanding nutrient pathways to streams will improve nutrient management strategies and estimates of the time lag between when changes in land use practices occur and when water quality effects that result from these changes are observed. Nitrate and orthophosphate (OP) concentrations in several environmental compartments were examined in watersheds having a range of base flow index (BFI) values across the continental United States to determine the dominant pathways for water and nutrient inputs to streams. Estimates of the proportion of stream nitrate that was derived from groundwater increased as BFI increased. Nitrate concentration gradients between groundwater and surface water further supported the groundwater source of nitrate in these high BFI streams. However, nitrate concentrations in stream-bed pore water in all settings were typically lower than stream or upland groundwater concentrations, suggesting that nitrate discharge to streams was not uniform through the bed. Rather, preferential pathways (e.g., springs, seeps) may allow high nitrate groundwater to bypass sites of high biogeochemical transformation. Rapid pathway compartments (e.g., overland flow, tile drains) had OP concentrations that were typically higher than in streams and were important OP conveyers in most of these watersheds. In contrast to nitrate, the proportion of stream OP that is derived from ground water did not systematically increase as BFI increased. While typically not the dominant source of OP, groundwater discharge was an important pathway of OP transport to streams when BFI values were very high and when geochemical conditions favored OP mobility in groundwater.

Spatial patterns of macrobenthic communities in shallow-water tidal embayments and their association with environmental factors.

This study examines the distribution, composition, and structure of benthic communities in nine shallow-water semienclosed embayments on Cape Cod, southeastern Massachusetts. The spatial patterns were used to associate benthic characteristics with local environmental factors. Field data from multiple years were collected to measure macrofaunal abundance, community composition, and environmental characteristics. Multivariate statistics were used to analyze the spatial variations of species composition and the abundance of benthic macrofauna. Canonical ordination, specifically redundancy analysis, was used to determine the relative importance of the environmental factors (nutrients and habitat factors) being studied. The analyses demonstrate that the benthic communities in the shallow tidal embayments are clearly clustered in association with the local environments. Species composition and community structure of the benthic macrofauna are significantly correlated with water column parameters, especially with phytoplankton biomass, total nitrogen, and dissolved oxygen.

Multilevel Pedicular Osteotomies for En Bloc Resection of a Primary Ewing Sarcoma of the Subaxial Cervical Spine with Pedicle Screw Reconstruction.

BACKGROUND: Primary Ewing sarcoma of the mobile spine is a rare disease. Its management requires careful surgical planning, because radical, margin-free excision is directly correlated with prognosis. Extensive bone removal in the cervical spine can lead to instability and cause postoperative iatrogenic cervical deformity. Thus, spinal instrumentation plays an important role in restoring postresection spinal stability and improving quality of life. METHODS: We present a novel technique that allows successful removal of a large Ewing sarcoma of the subaxial cervical spine, infiltrating and traversing the posterior bone elements, and extending into the paraspinal muscles. This technique involves radical en bloc resection of posteriorly located cervical tumors via multilevel pediculotomy, with terminal vertebrae pedicle screw reconstruction. RESULTS: Terminal vertebrae cervical pedicle screw reconstruction allowed wide surgical excision with satisfactory oncologic and mechanical results. CONCLUSIONS: This technique enables 1-stage total tumor resection and stabilization and may be a viable alternative to radical en bloc resection of posteriorly located epidural malignant lesions of the cervical spine in selected cases.

Background on Grain Sorghum Usage.

Sorghum acreage increased significantly as a result of hybridization of the crop in the 1950s. This increase brought the cattle feeding industry to the High Plains; however, demand for the crop in this industry waned, and acres fell significantly due to unfavorable shifts in federal policy. The rise of the modern ethanol industry led to a resurgence in demand for sorghum and a subsequent increase in acres, and the interest generated by these occurrences led to greater interest in other end-uses such as food manufacturing. Sustainability is important to both these industries, so sorghum offers both significant benefits through its low water requirements and small carbon footprint.

Bone cylinder plug and coil technique for accurate pedicle localization in thoracic spine surgery: A technical note.

BACKGROUND: Intraoperative identification of the correct level during thoracic spine surgery is essential to avoid wrong-level procedures. Despite technological progress, intraoperative imaging modalities for identifying the correct thoracic spine level remain unreliable and often lead to wrong-level surgery. To counter potential wrong-level operations, here, we have proposed a novel pedicle/bone cylinder marking technique for use in the thoracic spine utilizing biplanar fluoroscopy and confirmed with computed tomography (CT). METHODS: First, under fluoroscopic guidance, a bone cylinder is removed from the correct thoracic pedicle. Next, endovascular coils are packed into the cancellous bone defect followed by reinsertion of the bony plug. The patient then undergoes a CT scan of the entire thoracolumbosacral spine to precisely identify the marked level before surgery. RESULTS: We utilized this bone cylinder plug/coil technique to identify the T9-T10 level in a 56-year-old female with a soft thoracic disc herniation. The index thoracic pedicle was successfully localized before performing the unilateral minimally invasive laminectomy followed by the transpedicular thoracic disc excision. CONCLUSION: The bone cylinder plug/coil technique is a safe and effective method for marking the correct level in thoracic spine surgery, while also reducing the operative time.