Performance of a Norfentanyl Immunoassay in Specimens with Low Concentrations of Fentanyl and/or Norfentanyl.

BACKGROUND: Many fentanyl immunoassays are limited in their ability to detect norfentanyl. Urine specimens collected from individuals who have been exposed to fentanyl frequently have detectable concentrations of norfentanyl (≥2 ng/mL) but low concentrations of fentanyl (<2 ng/mL) by LC-MS/MS. The Lin-Zhi Fentanyl II Immunoassay (Lin-Zhi) claims 100% cross-reactivity with norfentanyl and therefore may detect exposure missed by other assays. METHODS: In addition to verifying the manufacturer's analytical sensitivity claims, we selected 92 urine specimens with low-positive Lin-Zhi results (1-99 absorbance units, lowest 10%) for analysis by the Immunalysis Health Equity Impact Assessment and ARK II fentanyl methods. The accuracy of the 3 immunoassays was compared to LC-MS/MS as the reference method. RESULTS: Spiking studies using purified fentanyl and norfentanyl and a set of 100 consecutive specimens confirmed the manufacturer's claims of limit of detection for fentanyl (3.8 ng/mL) and norfentanyl (5.0 ng/mL). However, the 92 low-positive patient specimens demonstrated concentrations of norfentanyl and fentanyl below 2.0 ng/mL by LC-MS/MS, with 47 (51%) having only norfentanyl detected. When comparing Lin-Zhi to the Immunalysis and ARK II immunoassays, only 27 (29%) of the 92 specimens were concordant. Fifty-two (57%) of the specimens were positive by LC-MS/MS and Lin-Zhi but false negative by one or both other immunoassays. Seven specimens (8%) were positive by Lin-Zhi but negative by the other immunoassays and had undetectable concentrations (<2 ng/mL) of fentanyl and norfentanyl by LC-MS/MS. CONCLUSIONS: The clinical sensitivity of the Lin-Zhi exceeds the manufacturer's claims, providing results comparable to LC-MS/MS methods.

Optimizing the Glass Bead Sterilization Protocol Focusing on Removal of Organic and Bacterial Intraoperative Contamination.

Validated glass bead sterilization protocols to effectively sterilize rodent surgical instruments after bacterial exposure (for example, cecal contamination) are lacking. To refine current approaches, we added either a multienzyme detergent, neutral pH detergent, or chlorhexidine scrub step before glass bead sterilization of forceps or needle drivers exposed to cecal contents. We exposed sets of forceps and needle drivers to cecal contents, which were then air dried for 3 min. Immediately after, the instruments were wiped several times with a clean, dry paper towel. The contaminated tips were soaked in either a multienzyme or neutral pH detergent (t = 5 min), chlorhexidine scrub (t = 2 min), or no pretreatment solution. To further increase debris removal, instruments (from all groups) were brushed using a clean toothbrush. The nonpretreatment instruments were briefly soaked in saline before brushing. After being rinsed with sterile water, all instruments were exposed to a glass bead sterilizer for 60 s at 500 °F (260 °C). Sets were then swabbed for bacterial culturing. Swabs were plated onto either sheep blood agar (n = 23) or chocolate agar (n = 20) for aerobic culturing or Brucella agar (n = 20) for anaerobic culturing. A subset of instruments was sampled to determine organic material presence after treatment using an ATP luminometer (n = 21). Multiple agar types and bioluminescence were used to more deeply evaluate tool sterility and to differentiate the relative effectiveness of each protocol. From the saline group, only one pair of forceps yielded growth on Brucella agar, and 2 pairs yielded growth on chocolate agar. No other bacterial growth was observed. The use of a pretreatment agent also lowered overall organic contamination levels in needle drivers compared with using only saline. These results indicate that brushing instruments to mechanically remove debris from instruments is paramount to ensure sterility. However, a best practice would be to also use one of the pretreatment options used in this study.

The environmental health impacts of Russia's war on Ukraine.

BACKGROUND: Russia's invasion of Ukraine in February 2022 ignited the largest armed conflict in Europe since World War II. Ukrainian government agencies, civil society organizations, and international agencies have gathered an unprecedented amount of data about the impact of war on the environment, which is often the silent victim of war. We review these data and highlight the limitations of international governance for protection of the environment during time of war. METHODS: We performed an integrative review of academic, institutional, and media information resources using the search terms "Ukraine", "Russia", "war", "environment", "health", "human rights", "international humanitarian law", "international human rights law", "ecocide", and "war crimes". MAIN TEXT: Nearly 500,000 military personnel have been killed or wounded during the war, and more than 30,000 civilians have been killed or injured. Indirect health effects of the war have likely accounted for an even greater amount of civilian morbidity and mortality. The war has displaced more than 11 million people. Russia's military forces have caused extensive damage to civilian infrastructure. The war has devastated Ukraine's economy and reduced food and energy security in many countries. The war has caused more than $56.4 billion in damage to the environment. There has been widespread chemical contamination of air, water, and soil, and 30% of Ukraine has been contaminated with landmines and unexploded ordnance. Landscape destruction, shelling, wildfires, deforestation, and pollution have adversely affected 30% of Ukraine's protected areas. Russia's seizure of the Zaporizhzhia Nuclear Power Plant and destruction of the Nova Kakhovka Dam have posed risks of long-term environmental catastrophe. Most of these environmental impacts threaten human health. CONCLUSION: In addition to enormous human costs, Russia's war on Ukraine has had devastating impacts on the natural environment and the built environment. International law mandates that methods of warfare must be implemented with due regard to the protection and preservation of the natural environment. A just and lasting peace necessitates, among other requirements, rebuilding and restoration of Ukraine's natural environment and built environment. The environmental consequences of all wars need to be investigated and more effective measures need to be implemented to protect the environment during war.

Beta-blocker and calcium-channel blocker toxicity: current evidence on evaluation and management.

Beta-blocker and calcium-channel blocker overdoses are associated with severe morbidity and mortality; therefore, it is important to recognize and appropriately treat individuals with toxicity. The most common clinical findings in toxicity are bradycardia and hypotension. In addition to supportive care and cardiac monitoring, specific treatment includes administration of calcium salts, vasopressors, and high-dose insulin euglycaemia treatment. Other advanced treatments (e.g. ECMO) may be indicated depending on the severity of toxicity and specific agents involved.

Labor trafficking in marijuana production: a hidden epidemic in the shadows of the cannabis industry.

Labor trafficking in marijuana production remains a concealed epidemic within the expanding cannabis industry. This abstract brings attention to the systemic exploitation of vulnerable individuals engaged in cultivating, harvesting, and processing cannabis. It explores the factors contributing to labor trafficking, including demand for cheap labor, inadequate regulation, and the vulnerability of the workforce. By compiling published cases, both in peer-reviewed literature and the media, this perspective piece investigates the extent of health issues experienced by labor-trafficked victims. These include chronic pain from repetitive tasks, respiratory problems due to exposure to pesticides and other toxic substances, musculoskeletal injuries, malnutrition, and mental health disorders stemming from trauma and extreme stress. Additionally, this perspective article examines the factors contributing to poor health outcomes of labor-trafficked victims, including hazardous working conditions, lack of access to healthcare, and physical and psychological abuse. Addressing the health challenges faced by labor-trafficked victims in the cannabis industry requires multidimensional solutions: awareness among healthcare providers, comprehensive medical services, and mental health support. Furthermore, collaborative efforts among government agencies, healthcare providers, labor organizations, and the cannabis industry are essential in preventing trafficking and addressing the health disparities faced by labor-trafficked victims.

Surveying mental health stressors of emergency management professionals: Factors in recruiting and retaining emergency managers in an era of disasters and pandemics.

Emergency managers are responsible for managing crises and disasters, and while their work is essential, it can be stressful and impact their mental health, particularly during the COVID-19 pandemic. This study aimed to examine the mental health of professional emergency managers and factors associated with their intent to leave the field before and during the COVID-19 pandemic. A total of 903 respondents completed an online survey assessing their secondary traumatic stress, emergency reaction strategies, organizational culture, age, length of time in primary position, the highest level of education as well as other metrics. The Secondary Traumatic Stress Scale (STSS) was used to determine scores of secondary traumatic stress symptoms, and the Emergency Reaction Questionnaire (ERQ) index was used to evaluate levels of predominant personality types and its tendency towards "fight or flight" reactions in emergency situations. Results revealed significant differences among respondents who reported considering leaving the field before or during the COVID-19 pandemic in terms of secondary traumatic stress scores, ERQ levels, perceived organizational culture (OC), age category, length of time in primary position, and the highest level of education (p < 0.05). Logistic regression analysis indicated that respondents with higher secondary traumatic stress scores, poorer organizational culture, younger age, less experience, and a bachelor's degree had nearly three times the odds of reporting considering leaving the field (p < 0.05). Additionally, respondents with a graduate degree had nearly four times the odds of reporting leaving the field (p < 0.05), while those who had directly managed between three and five disasters had nearly two times the odds of reporting and considering leaving the field (p < 0.05). These findings underscore the importance of addressing secondary traumatic stress, promoting positive organizational culture, and providing support for emergency managers now and in the future. By addressing the factors identified in this study, such as secondary traumatic stress symptoms, promoting positive organizational culture, and providing adequate support, emergency management organizations can improve the mental health and well-being of their personnel, reduce attrition rates, and ensure that they are better equipped to respond to future crises.

Review of Toxocariasis at a Children's Hospital Prompting Need for Public Health Interventions.

BACKGROUND: Toxocariasis, caused the by dog and cat roundworm, is one of the most common zoonotic helminth infections in the United States and can lead to severe lifelong morbidity in children. Although historical seroprevalence studies have identified a high frequency of toxocariasis regionally in the United States, there are few studies linking epidemiology and clinical disease in children. The study objective was to examine the contemporary epidemiology of pediatric toxocariasis within an endemic US region. METHODS: We conducted an epidemiologic study analyzing children diagnosed with toxocariasis presenting to a tertiary pediatric hospital in Texas from 2010 to 2021. We examined risk factors and performed a geospatial analysis, including a comparative analysis of human cases and locations of surrendered infected stray animals in the same region. RESULTS: Children diagnosed with toxocariasis were most commonly of Hispanic/Latino ethnicity (30/46; 65%), white race (41/45; 91%) and receiving Medicaid (34/44, 77%). Many infected children had contact with dogs or cats. Ocular toxocariasis was associated with a lack of peripheral eosinophilia ( P < 0.001). No other Toxocara syndromes were associated with defined absolute eosinophil count levels. Post-treatment resolution of eosinophilia was variable, ranging from 1 to 172 weeks. A Toxocara hotspot was identified in northeast Houston, comprising one of the lowest median household incomes in the region. CONCLUSIONS: Toxocariasis is a devastating zoonotic infection in children living in the US. As it is not a reportable disease, the true burden remains unknown. It is critical to increase awareness of toxocariasis to direct public health interventions and ultimately reduce Toxocara -induced morbidity in US children.

Fulminant Anti-Myelin Oligodendrocyte Glycoprotein-Associated Cerebral Cortical Encephalitis: Case Series of a Severe Pediatric Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease Phenotype.

BACKGROUND: We describe a cohort of children with severe myelin oligodendrocyte glycoprotein (MOG)-IgG-associated cerebral cortical encephalitis (CCE), manifesting with bilateral cortical cytotoxic edema and critical neurological illness. METHODS: We retrospectively reviewed our pediatric MOG antibody-associated disease (MOGAD) database and identified patients with specific radiographic pattern of bilateral, multifocal cortical cytotoxic lesions. We collected demographic, clinical, and outcomes data from these patients and compared select variables with radiographically distinct cerebral MOGAD syndromes (case-control analysis). We assessed the correlation of quantitative clinical variables with severity/outcomes measures using simple linear regression. RESULTS: Sixty-five of 88 total MOGAD cases had cerebral disease, and six of 88 met inclusion criteria for fulminant CCE (f-CCE). Age range was 2 to 7 years; five of six were male. Six of six were critically ill with severe encephalopathy and seizures, two of six required barbiturate coma, and two of six required invasive intracranial pressure monitoring. Six of six required treatment escalation beyond steroids. Four of six had favorable outcome; two of six had moderate-severe disability. Compared with other cerebral MOGAD cases (n = 59), children with f-CCE were more likely to have critical illness and poor neurological outcomes scores. Neurofilament light chain and treatment latency positively correlated with intensive care unit length of stay and outcomes scores; cerebrospinal fluid (CSF) white blood cell count and neutrophil-to-lymphocyte ratio did not. CONCLUSIONS: Pediatric CCE with bilateral cytotoxicity is associated with more fulminant disease and worse outcomes than other cerebral MOGAD syndromes.

Dynamic and broad expression of adamts9 in developing and adult zebrafish.

BACKGROUND: Previous studies showed that Adamts9 is involved in multiple functions including ovulation, spine formation, primordial germ cell migration, and development of primary ovarian follicles in animals. However, systemic examination and high-resolution analyses of adamts9 expression are missing due to lack of a sensitive reporter assay. RESULTS: In the present study, we created a new transgenic zebrafish reporter line Tg(adamts9:EGFP) and assayed its expression in various tissues and cells during development and in adults at high-resolution using confocal imaging. Reporter expression was validated with real-time quantitative PCR, whole mount in situ hybridization, and immunohistochemistry for endogenous adamts9. Strong expression of the adamts9:EGFP transgene was found in a wide range of adult and embryonic zebrafish tissues/cells including ovaries, testes, brains, eyes, pectoral fins, intestine, skin, gill, muscle, and heart; while lower expression was observed in the liver and growing ovarian follicles (stages II and III). CONCLUSIONS: Our results of a broad and dynamic expression pattern for this evolutionary conserved metalloprotease suggest involvement of adamts9 in the development and physiological functions of various tissues in animals.

A sensation for inflation: initial swim bladder inflation in larval zebrafish is mediated by the mechanosensory lateral line.

Larval zebrafish achieve neutral buoyancy by swimming up to the surface and taking in air through their mouths to inflate their swim bladders. We define this behavior as 'surfacing'. Little is known about the sensory basis for this underappreciated behavior of larval fish. A strong candidate is the mechanosensory lateral line, a hair cell-based sensory system that detects hydrodynamic information from sources such as water currents, predators, prey and surface waves. However, a role for the lateral line in mediating initial inflation of the swim bladder has not been reported. To explore the connection between the lateral line and surfacing, we used a genetic mutant (lhfpl5b-/-) that renders the zebrafish lateral line insensitive to mechanical stimuli. We observed that approximately half of these lateral line mutants over-inflate their swim bladders during initial inflation and become positively buoyant. Thus, we hypothesized that larval zebrafish use their lateral line to moderate interactions with the air-water interface during surfacing to regulate swim bladder inflation. To test the hypothesis that lateral line defects are responsible for swim bladder over-inflation, we showed that exogenous air is required for the hyperinflation phenotype and transgenic rescue of hair cell function restores normal inflation. We also found that chemical ablation of anterior lateral line hair cells in wild-type larvae causes hyperinflation. Furthermore, we show that manipulation of lateral line sensory information results in abnormal inflation. Finally, we report spatial and temporal differences in the surfacing behavior between wild-type and lateral line mutant larvae. In summary, we propose a novel sensory basis for achieving neutral buoyancy where larval zebrafish use their lateral line to sense the air-water interface and regulate initial swim bladder inflation.

Regionalized Protein Localization Domains in the Zebrafish Hair Cell Kinocilium.

Sensory hair cells are the receptors for auditory, vestibular, and lateral line sensory organs in vertebrates. These cells are distinguished by "hair"-like projections from their apical surface collectively known as the hair bundle. Along with the staircase arrangement of the actin-filled stereocilia, the hair bundle features a single, non-motile, true cilium called the kinocilium. The kinocilium plays an important role in bundle development and the mechanics of sensory detection. To understand more about kinocilial development and structure, we performed a transcriptomic analysis of zebrafish hair cells to identify cilia-associated genes that have yet to be characterized in hair cells. In this study, we focused on three such genes-ankef1a, odf3l2a, and saxo2-because human or mouse orthologs are either associated with sensorineural hearing loss or are located near uncharacterized deafness loci. We made transgenic fish that express fluorescently tagged versions of their proteins, demonstrating their localization to the kinocilia of zebrafish hair cells. Furthermore, we found that Ankef1a, Odf3l2a, and Saxo2 exhibit distinct localization patterns along the length of the kinocilium and within the cell body. Lastly, we have reported a novel overexpression phenotype of Saxo2. Overall, these results suggest that the hair cell kinocilium in zebrafish is regionalized along its proximal-distal axis and set the groundwork to understand more about the roles of these kinocilial proteins in hair cells.

Infectious profiles in pediatric anti-N-methyl-d-aspartate receptor encephalitis.

Anti-N-methyl-d-aspartate receptor autoimmune encephalitis (NMDAR AE) is an antibody-mediated neurological disorder that may be caused by post-herpes simplex virus-1 meningoencephalitis (HSV ME) and ovarian teratomas, although most pediatric cases are idiopathic. We sought to evaluate if other infections precede NMDAR AE by conducting a single-center, retrospective, case-control study of 86 pediatric cases presenting to Texas Children's Hospital between 2006 and 2022. HSV ME (HSV-1 and HSV-2) was a significantly more common preceding infection in the experimental group compared to control patients with idiopathic intracranial hypertension, while there was no difference in remote HSV infection between the two groups. Recent Epstein-Barr virus infection was evident in 8/42 (19%) tested experimental patients in comparison to 1/25 (4%) tested control patients which provided evidence for a genuine measure of effect but was not statistically significant due to small sample size (p = 0.07). The other 25 infectious etiologies were not different among the two groups and not all variables were clinically indicated or obtained in every subject, highlighting the need for future standardized, multi-institutional studies on underlying infectious precursors of autoimmune encephalitis.

Evaluation of Chemical, Biological, Radiological, Nuclear, Explosives (CBRNE) Knowledge Change and Skills Confidence Among Frontline-Line Providers During the Russia-Ukraine War.

OBJECTIVE: The aim of this study was to evaluate the change in knowledge and skill confidence after implementation of a chemical, biological, radiological, nuclear, and explosive (CBRNE) training course during the Russia-Ukraine War. METHODS: Pre/post-test study in the Ukrainian cities of Kyiv, Dnipro, Zaporizhzhia, and Odesa. Fifteen CBRNE courses were conducted over a 3-mo period, August to October 2022. Change in knowledge and skills confidence were evaluated with pre/post-course written exams and practical skill assessments that were observed during the training exercises. Changes were analyzed based on nonparametric Wilcoxon matched-pairs signed-rank testing. Pre/post self-efficacy surveys were analyzed with McNemar's test for paired data. Course evaluations were conducted with standardized questions which assessed instruction quality, teaching relevance, knowledge gained, and post-course skills confidence. RESULTS: A total of 523 participants registered and completed 1 of the 15 courses. Overall mean pre-course test score: 57.8% (SD 20.7%); mean post-course test score: 81.4% (SD 11.3%); participants with increasing test scores: 90.7%; mean difference in score (95% confidence interval) 23.6% (21.2%-25.9%), P < 0.0001. Pre/post self-efficacy surveys (4-point Likert scale) noted participants recognized signs and symptoms of a CBRNE incident, and necessary skills to manage CBRNE exposures, P < 0.0001. CONCLUSIONS: The implementation of this CBRNE course for front-line providers in Ukraine was successful. To our knowledge, it was the first implementation of a field course during the current Russian-Ukraine war. Future research should evaluate knowledge retention and impact of our innovative Train-the-Trainer model. Further iterations should emphasize expanding the quantity of training equipment and practical skill sessions.

Cannabis positivity rates in 17 emergency departments across the United States with varying degrees of marijuana legalization.

BACKGROUND: Many states in the United States have progressed towards legalization of marijuana including decriminalization, medicinal and/or recreational use. We studied the impact of legalization on cannabis-related emergency department visits in states with varying degrees of legalization. METHODS: Seventeen healthcare institutions in fifteen states (California, Colorado, Connecticut, Florida, Iowa, Kentucky, Maryland, Massachusetts, Missouri, New Hampshire, Oregon, South Carolina, Tennessee, Texas, Washington) participated. Cannabinoid immunoassay results and cannabis-related International Classification of Diseases (ninth and tenth versions) codes were obtained for emergency department visits over a 3- to 8-year period during various stages of legalization: no state laws, decriminalized, medical approval before dispensaries, medical dispensaries available, recreational approval before dispensaries and recreational dispensaries available. Trends and monthly rates of cannabinoid immunoassay and cannabis-related International Classification of Diseases code positivity were determined during these legalization periods. RESULTS: For most states, there was a significant increase in both cannabinoid immunoassay and International Classification of Diseases code positivity as legalization progressed; however, positivity rates differed. The availability of dispensaries may impact positivity in states with medical and/or recreational approval. In most states with no laws, there was a significant but smaller increase in cannabinoid immunoassay positivity rates. CONCLUSIONS: States may experience an increase in cannabis-related emergency department visits with progression toward marijuana legalization. The differences between states, including those in which no impact was seen, are likely multifactorial and include cultural norms, attitudes of local law enforcement, differing patient populations, legalization in surrounding states, availability of dispensaries, various ordering protocols in the emergency department, and the prevalence of non-regulated cannabis products.

A sensation for inflation: initial swim bladder inflation in larval zebrafish is mediated by the mechanosensory lateral line.

Larval zebrafish achieve neutral buoyancy by swimming up to the surface and taking in air through their mouths to inflate their swim bladders. We define this behavior as 'surfacing'. Little is known about the sensory basis for this underappreciated behavior of larval fish. A strong candidate is the mechanosensory lateral line, a hair cell-based sensory system that detects hydrodynamic information from sources like water currents, predators, prey, and surface waves. However, a role for the lateral line in mediating initial inflation of the swim bladder has not been reported. To explore the connection between the lateral line and surfacing, we utilized a genetic mutant ( lhfpl5b -/- ) that renders the zebrafish lateral line insensitive to mechanical stimuli. We observe that approximately half of these lateral line mutants over-inflate their swim bladders during initial inflation and become positively buoyant. Thus, we hypothesize that larval zebrafish use their lateral line to moderate interactions with the air-water interface during surfacing to regulate swim bladder inflation. To test the hypothesis that lateral line defects are responsible for swim bladder over-inflation, we show exogenous air is required for the hyperinflation phenotype and transgenic rescue of hair cell function restores normal inflation. We also find that chemical ablation of anterior lateral line hair cells in wild type larvae causes hyperinflation. Furthermore, we show that manipulation of lateral line sensory information results in abnormal inflation. Finally, we report spatial and temporal differences in the surfacing behavior between wild type and lateral line mutant larvae. In summary, we propose a novel sensory basis for achieving neutral buoyancy where larval zebrafish use their lateral line to sense the air-water interface and regulate initial swim bladder inflation.

Emergency Medicine Provider Impressions of Novel SMS-Based Toxicology Module.

The diagnosis and treatment of common toxicologic disorders is an area of core content that emergency medicine (EM) resident physicians and physician assistants (PA) are required to demonstrate competence in order to become proficient practicing clinicians. Even when EM programs have a required toxicology elective, learners do not encounter all core toxicologic presentations. To supplement these knowledge gaps, many toxicology curriculums rely on internet learning modules which have variable uptake in practice. With remote learning and education becoming more common, we aim to perform a need-based assessment of EM resident and PA toxicology education and use the results to develop and deploy a text message-based, interactive toxicology supplemental program for EM residents and PAs and measure its acceptability and preliminary effectiveness to teach core toxicology principles.

The morphological and functional diversity of apical microvilli.

Sensory neurons use specialized apical processes to perceive external stimuli and monitor internal body conditions. The apical apparatus can include cilia, microvilli, or both, and is adapted for the functions of the particular cell type. Photoreceptors detect light through a large, modified cilium (outer segment), that is supported by a surrounding ring of microvilli-like calyceal processes (CPs). Although first reported 150 years ago, CPs remain poorly understood. As a basis for future study, we therefore conducted a review of existing literature about sensory cell microvilli, which can act either as the primary sensory detector or as support for a cilia-based detector. While all microvilli are finger-like cellular protrusions with an actin core, the processes vary across cell types in size, number, arrangement, dynamics, and function. We summarize the current state of knowledge about CPs and the characteristics of the microvilli found on inner ear hair cells (stereocilia) and cerebral spinal fluid-contacting neurons, with comparisons to the brush border of the intestinal and renal epithelia. The structure, stability, and dynamics of the actin core are regulated by a complement of actin-binding proteins, which includes both common components and unique features when compared across cell types. Further, microvilli are often supported by lateral links, a glycocalyx, and a defined extracellular matrix, each adapted to the function and environment of the cell. Our comparison of microvillar features will inform further research into how CPs support photoreceptor function, and also provide a general basis for investigations into the structure and functions of apical microvilli found on sensory neurons.

Pediatric Eosinophilia: A Review and Multiyear Investigation into Etiologies.

OBJECTIVES: To identify the etiology of peripheral eosinophilia in a large pediatric population and to develop a diagnostic algorithm to help guide diagnosis and management of peripheral eosinophilia in the outpatient pediatric population. STUDY DESIGN: We performed a retrospective chart review of children presenting to Texas Children's Hospital in Houston with peripheral eosinophilia between January 1, 2011 and December 31, 2019. Eosinophilia was classified as mild (absolute eosinophil count [AEC] >500 and <1500 cells/µL), moderate (AEC >1500 and <4500 cells/µL), or severe (AEC >4500 cells/µL). Demographic information and diagnostic workup data were collected. RESULTS: A total of 771 patients aged <18 years were evaluated. The most common cause of eosinophilia was allergy (n = 357; 46%), with atopy (n = 296) and drug reaction (n = 54) the most common subcauses. This was followed by unknown etiology (n = 274; 36%), infectious causes (n = 72; 9%), and eosinophilic disorders (n = 47; 6%). Many patients with an unknown cause (n = 202; 74%) had limited or no follow-up testing. CONCLUSIONS: More information on the etiology of pediatric eosinophilia and workup data could help identify the causes. This study provides important information on the evaluation of eosinophilia in the US pediatric population, including a diagnostic algorithm to guide primary care pediatricians.

Health and Safety Threats to Ukraine From Nonconventional Weapons: A Clear and Present Danger.

This Viewpoint discusses the potential for use of nonconventional warfare threats (chemical, biological, radiological, nuclear, and explosives) in the conflict in Ukraine and how health care professionals need to recognize and respond to these threats.

Incorporating COVID-19 into Acute Febrile Illness Surveillance Systems, Belize, Kenya, Ethiopia, Peru, and Liberia, 2020-2021.

Existing acute febrile illness (AFI) surveillance systems can be leveraged to identify and characterize emerging pathogens, such as SARS-CoV-2, which causes COVID-19. The US Centers for Disease Control and Prevention collaborated with ministries of health and implementing partners in Belize, Ethiopia, Kenya, Liberia, and Peru to adapt AFI surveillance systems to generate COVID-19 response information. Staff at sentinel sites collected epidemiologic data from persons meeting AFI criteria and specimens for SARS-CoV-2 testing. A total of 5,501 patients with AFI were enrolled during March 2020-October 2021; >69% underwent SARS-CoV-2 testing. Percentage positivity for SARS-CoV-2 ranged from 4% (87/2,151, Kenya) to 19% (22/115, Ethiopia). We show SARS-CoV-2 testing was successfully integrated into AFI surveillance in 5 low- to middle-income countries to detect COVID-19 within AFI care-seeking populations. AFI surveillance systems can be used to build capacity to detect and respond to both emerging and endemic infectious disease threats.