Predictive values of indirect ultrasound signs for low risk of acute appendicitis in paediatric patients without visualisation of the appendix on ultrasound.

BACKGROUND AND OBJECTIVES: The ability to rule appendicitis in or out using ultrasound is limited by studies where the appendix is not visualised. We determined whether the absence of indirect ultrasound signs can rule out appendicitis in children undergoing a radiology-performed ultrasound in which the appendix is not visualised METHODS: This was a single-centre retrospective observational study of patients aged 3-13 with a clinical suspicion of acute appendicitis evaluated in a Paediatric Emergency Department in Spain from 1 January 2013 to 31 December 2019. For those patients who had formal ultrasound, direct and indirect findings of ultrasound were abstracted from the ultrasound report. The surgical pathology report was established as the gold standard in patients who underwent an appendectomy. In those who did not, appendicitis was considered not to be present if there was no evidence in their charts that they had undergone an appendectomy or conservative therapy for appendicitis during the episode. The main outcome variable was the diagnosis of acute appendicitis. For patients undergoing ultrasound, the independent association of each indirect ultrasound sign with the diagnosis of appendicitis in patients without a visualised appendix was analysed using logistic regression. RESULTS: We included 1756 encounters from 1609 different episodes. Median age at the first visit of each episode was 10.1 years (IQR, 7.7-11.9) and 921 (57.2%) patients were men. There were 730 (41.6%) encounters with an Alvarado score ≤3, 695 (39.6%) with a score 4-6 and 331 (18.9%) with a score ≥7. Appendicitis was diagnosed in 293 (17.8%) episodes. Ultrasonography was performed in 1115 (61.6%) encounters, with a visualised appendix in 592 (53.1%).The ultrasound findings independently associated with appendicitis in patients without a visualised appendix were the presence of free intra-abdominal fluid in a small quantity (OR:5.0 (95% CI 1.7 to 14.6)) or in an abundant quantity (OR:30.9 (95% CI 3.8 to 252.7)) and inflammation of the peri-appendiceal fat (OR:7.2 (95% CI 1.4 to 38.0)). The absence of free fluid and inflammation of the peri-appendiceal fat ruled out acute appendicitis in patients with an Alvarado score <7 with a sensitivity of 84.6% (95% CI 57.8 to 95.7) and a negative predictive value of 99.4% (95% CI 97.8 to 99.8). CONCLUSIONS: Patients with an Alvarado score <7 and without a visualised appendix on ultrasound but who lack free fluid and inflammation of the peri-appendiceal fat are at very low risk of acute appendicitis.

Globe-LFMC 2.0, an enhanced and updated dataset for live fuel moisture content research.

Globe-LFMC 2.0, an updated version of Globe-LFMC, is a comprehensive dataset of over 280,000 Live Fuel Moisture Content (LFMC) measurements. These measurements were gathered through field campaigns conducted in 15 countries spanning 47 years. In contrast to its prior version, Globe-LFMC 2.0 incorporates over 120,000 additional data entries, introduces more than 800 new sampling sites, and comprises LFMC values obtained from samples collected until the calendar year 2023. Each entry within the dataset provides essential information, including date, geographical coordinates, plant species, functional type, and, where available, topographical details. Moreover, the dataset encompasses insights into the sampling and weighing procedures, as well as information about land cover type and meteorological conditions at the time and location of each sampling event. Globe-LFMC 2.0 can facilitate advanced LFMC research, supporting studies on wildfire behaviour, physiological traits, ecological dynamics, and land surface modelling, whether remote sensing-based or otherwise. This dataset represents a valuable resource for researchers exploring the diverse LFMC aspects, contributing to the broader field of environmental and ecological research.

A Novel Risk Score to Guide the Evaluation of Acute Hematogenous Osteomyelitis in Children.

OBJECTIVES: To identify independent predictors of and derive a risk score for acute hematogenous osteomyelitis (AHO) in children. METHODS: We conducted a retrospective matched case-control study of children >90 days to <18 years of age undergoing evaluation for a suspected musculoskeletal (MSK) infection from 2017 to 2019 at 23 pediatric emergency departments (EDs) affiliated with the Pediatric Emergency Medicine Collaborative Research Committee. Cases were identified by diagnosis codes and confirmed by chart review to meet accepted diagnostic criteria for AHO. Controls included patients who underwent laboratory and imaging tests to evaluate for a suspected MSK infection and received an alternate final diagnosis. RESULTS: We identified 1135 cases of AHO matched to 2270 controls. Multivariable logistic regression identified 10 clinical and laboratory factors independently associated with AHO. We derived a 4-point risk score for AHO using (1) duration of illness >3 days, (2) history of fever or highest ED temperature ≥38°C, (3) C-reactive protein >2.0 mg/dL, and (4) erythrocyte sedimentation rate >25 mm per hour (area under the curve: 0.892, 95% confidence interval [CI]: 0.881 to 0.901). Choosing to pursue definitive diagnostics for AHO when 3 or more factors are present maximizes diagnostic accuracy at 84% (95% CI: 82% to 85%), whereas children with 0 factors present are highly unlikely to have AHO (sensitivity: 0.99, 95% CI: 0.98 to 1.00). CONCLUSIONS: We identified 10 predictors for AHO in children undergoing evaluation for a suspected MSK infection in the pediatric ED and derived a novel 4-point risk score to guide clinical decision-making.

Prevalence of invasive bacterial infection in febrile infants ≤90 days with a COVID-19 positive test: a systematic review and meta-analysis.

BACKGROUND: Febrile infants with an infection by influenza or enterovirus are at low risk of invasive bacterial infection (IBI). OBJECTIVE: To determine the prevalence of IBI among febrile infants ≤90 days old with a positive COVID-19 test. METHODS: MEDLINE, Embase, Cochrane Central Register databases, Web of Science, ClinicalTrials.gov and grey literature were searched for articles published from February 2020 to May 2023. INCLUSION CRITERIA: researches reporting on infants ≤90 days of age with fever and a positive test for SARS-CoV-2 (antigen test/PCR). Case reports with <3 patients, articles written in a language other than English, French or Spanish, editorials and other narrative studies were excluded. Preferred Reposting Items for Systematic Reviews and Meta-analysis guidelines were followed, and the National Institutes of Health Quality Assessment Tool was used to assess study quality. The main outcome was the prevalence of IBI (a pathogen bacterium identified in blood and/or cerebrospinal fluid (CSF)). Forest plots of prevalence estimates were constructed for each study. Heterogeneity was assessed and data were pooled by meta-analysis using a random effects model. A fixed continuity correction of 0.01 was added when a study had zero events. RESULTS: From the 1023 studies and 3 databases provided by the literature search, 33 were included in the meta-analysis, reporting 3943 febrile infants with a COVID-19 positive test and blood or CSF culture obtained. The pooled prevalence of IBI was 0.14% (95% CI, 0.02% to 0.27%). By age, the prevalence of IBI was 0.56% (95% CI, 0.0% to 1.27%) in those 0-21 days old, 0.53% (95% CI, 0.0% to 1.22%) in those 22-28 days old and 0.11% (95% CI, 0.0% to 0.24%) in those 29-60 days old. CONCLUSION: COVID-19-positive febrile infants ≤90 days old are at low risk of IBI, especially infants >28 days old, suggesting this subgroup of patients can be managed without blood tests. PROSPERO REGISTRATION NUMBER: CRD42022356507.

Comparison of severity scales for acute bronchiolitis in real clinical practice.

Several clinical scales have been developed to assess the severity of bronchiolitis as well as the probability of needing in-hospital care. A recent systematic review of 32 validated clinical scores for bronchiolitis concluded that 6 of them (Wood-Downes, M-WCAS, Respiratory Severity Score, Respiratory Clinical Score, Respiratory Score and Bronchiolitis risk of admission score) were the best ones regarding reliability, sensitivity, validity, and usability. However, to the best of our knowledge, no study has compared all of them in a clinical scenario. Also, after this review, three more scales were published: BROSJOD, Tal modified, and one score developed by PERN. Our main aim was to compare the ability of different clinical scales for bronchiolitis to predict any relevant outcome. A prospective observational study was conducted that included patients of up to 12 months old attended to, due to bronchiolitis, in the paediatric Emergency Department of a secondary university hospital from October 2019 to January 2022. For each patient, the attending clinician filled in a form with the items of the scales, decomposed, in order to prevent the clinician from knowing the score of each scale. Then, the patient was managed according to the protocol of our Emergency Department. A phone call was made to each patient in order to check whether the patient ended up being admitted in the next 48 h. In the case of those that were impossible to contact by phone, the clinical history was reviewed. For the purpose of the study, any of the following were considered to be a relevant outcome: admission to ward and need for supplementary oxygen, non-invasive ventilation (NIV) or intravenous fluids, and admission to the paediatric intensive care unit (PICU) within the next 48 h or death. For the aim of the study, the area under the curve (AUC) and the odds ratio (OR) for a relevant outcome were calculated in each scale. Also, the best cut-off point was estimated according to the Youden index, and its sensitivity (Sn) and specificity (Sp) for a relevant outcome were calculated. We included 265 patients (52.1% male) with a median age of 5.3 months (P25-P75 2.6-7.4). Among them, 46 (17.4%) had some kind of relevant outcome. AUC for prediction of a relevant outcome ranged from 0.705 (Respiratory Score) to 0.786 (BRAS), although no scale performed significantly better than others. A score ≤ 2 in the PERN scale showed a sensitivity of 91.3% (CI95% 79.7-96.6) for a relevant outcome, with only 4 misdiagnosed patients (only 2 of them needed NIV).   Conclusions: There were no differences in the performance of the nine scales to predict relevant outcomes in patients with bronchiolitis. However, the PERN scale might be more useful to select patients at low risk of a severe outcome. What is Known: • Several clinical scales are used to assess the severity of bronchiolitis. Nevertheless, none of them seems to be better than others. What is New: • This is the first study comparing different bronchiolitis scales in a real clinical scenario. None of the nine scales compared performed better than the other. However, the PERN scale might be more useful to select patients at low risk of relevant outcomes.

Termite sensitivity to temperature affects global wood decay rates.

Deadwood is a large global carbon store with its store size partially determined by biotic decay. Microbial wood decay rates are known to respond to changing temperature and precipitation. Termites are also important decomposers in the tropics but are less well studied. An understanding of their climate sensitivities is needed to estimate climate change effects on wood carbon pools. Using data from 133 sites spanning six continents, we found that termite wood discovery and consumption were highly sensitive to temperature (with decay increasing >6.8 times per 10°C increase in temperature)-even more so than microbes. Termite decay effects were greatest in tropical seasonal forests, tropical savannas, and subtropical deserts. With tropicalization (i.e., warming shifts to tropical climates), termite wood decay will likely increase as termites access more of Earth's surface.

Differences in temperature sensitivity and drought recovery between natural stands and plantations of conifers are species-specific.

Forests are being impacted by climate and land-use changes which have altered their productivity and growth. Understanding how tree growth responds to climate in natural and planted stands may provide valuable information to prepare management in sight of climate change. Plantations are expected to show higher sensitivity to climate and lower post-drought resilience than natural stands, due to their lower compositional and structural diversity. We reconstructed and compared the radial growth of six conifers with contrasting ecological and climatic niches (Abies pinsapo, Cedrus atlantica, Pinus sylvestris, Pinus nigra, Pinus pinea, Pinus pinaster) in natural and planted stands subjected to seasonal drought in 40 sites. We quantified the relationships between individual growth variability and climate variables (temperature, precipitation and the SPEI drought index), as well as post-drought resilience. Elevated precipitation during the previous autumn-winter and current spring to early summer enhanced growth in both natural and planted stands of all species. Temperature effects on growth were less consistent: only plantations of A. pinsapo, C. atlantica, P. nigra, P. pinea, P. sylvetris and a natural stand of P. nigra showed negative impacts of summer temperature on growth. Drought reduced growth of all species in both plantations and natural stands, with variations in the temporal scale of the response. Drought constrained growth more severely in natural stands than in plantations of C. atlantica, P. pinaster and P. nigra, whereas the inverse pattern was found for A. pinsapo. Resilience to drought varied between species: natural stands of A. pinsapo, C. atlantica and P. pinaster recovered faster than plantations, while P. pinea plantations recovered faster than natural stands. Overall, plantations did not consistently show a higher sensitivity to climate and a lower capacity to recover after drought. Therefore, plantations are potential tools for mitigating climate warming.

Effects of widespread non-native trees on regulating ecosystem services.

Tree taxa are often planted beyond their native range to increase the provision of some ecosystem services. Yet, they can disrupt ecosystem processes in their new ranges, causing changes in the provision of other services. Here we review the effects of five widespread tree taxa (Acacia, Ailanthus, Eucalyptus, Pinus and Robinia) on six regulating ecosystem services in areas where they are non-native. We conducted a literature search for pair-wise comparisons between sites dominated by any of the selected taxa and sites with native vegetation. An array of variables were used as indicators for each ecosystem service. Data were analysed using multi-level meta-analyses to compare effects of taxa on each ecosystem service, and effects of the same taxa across contexts. We compiled 857 case studies from 107 source papers. Several taxa tended to increase climate regulation, mostly Eucalyptus. Acacia decreased fire risk prevention. Robinia, Acacia and Ailanthus increased soil fertility, while Eucalyptus and Pinus, tended to decrease it. Soil formation was enhanced by Robinia and Ailanthus. Acacia promoted the increase of water in land pools, while Eucalyptus tended to decrease them. All effects show a large heterogeneity across case studies. Part of this heterogeneity could be attributed to gross climatic differences (i.e. biome), to species differences within each genus, to the structure of the recipient ecosystem, and/or to human management. Managers and policy-makers should consider the context-dependency and the potential effects of non-native trees on a wide range of services to ground their decisions. Our analyses also revealed important gaps of knowledge (e.g. on fire risk prevention, erosion control or water cycle regulation) and some potential publication bias. The methodology used here easily allows for future updates as new information will become available.

Radiation and Drought Impact Residual Leaf Conductance in Two Oak Species With Implications for Water Use Models.

Stomatal closure is one of the earliest responses to water stress but residual water losses may continue through the cuticle and incomplete stomatal closure. Residual conductance (g res ) plays a large role in determining time to mortality but we currently do not understand how do drought and shade interact to alter g res because the underlying drivers are largely unknown. Furthermore, g res may play an important role in models of water use, but the exact form in which g res should be incorporated into modeling schemes is currently being discussed. Here we report the results of a study where two different oak species were experimentally subjected to highly contrasting levels of drought (resulting in 0, 50 and 80% losses of hydraulic conductivity) and radiation (photosynthetic photon flux density at 1,500 µmol m-2 s-1 or 35-45 µmol m-2 s-1). We observed that the effects of radiation and drought were interactive and species-specific and g res correlated positively with concentrations of leaf non-structural carbohydrates and negatively with leaf nitrogen. We observed that different forms of measuring g res , based on either nocturnal conductance under high atmospheric water demand or on the water mass loss of detached leaves, exerted only a small influence on a model of stomatal conductance and also on a coupled leaf gas exchange model. Our results indicate that, while understanding the drivers of g res and the effects of different stressors may be important to better understand mortality, small differences in g res across treatments and measurements exert only a minor impact on stomatal models in two closely related species.

Prevalence of Urinary Tract Infection in Febrile Infants With Upper Respiratory Tract Symptomatology.

Among 439 infants presenting with symptoms of upper respiratory tract infection and temperature ≥39°C, 19 (4.3% [95% confidence interval, 2.8-6.7]) received a diagnosis of urinary tract infection (abnormal urine dipstick from a sterile urine sample and positive urine culture). Regardless of respiratory presentation, all infants presenting with a temperature of 39°C should be screened for urinary tract infection.

Customized Massive Parallel Sequencing Panel for Diagnosis of Pulmonary Arterial Hypertension.

Pulmonary arterial hypertension is a very infrequent disease, with a variable etiology and clinical expressivity, making sometimes the clinical diagnosis a challenge. Current classification based on clinical features does not reflect the underlying molecular profiling of these groups. The advance in massive parallel sequencing in PAH has allowed for the describing of several new causative and susceptibility genes related to PAH, improving overall patient diagnosis. In order to address the molecular diagnosis of patients with PAH we designed, validated, and routinely applied a custom panel including 21 genes. Three hundred patients from the National Spanish PAH Registry (REHAP) were included in the analysis. A custom script was developed to annotate and filter the variants. Variant classification was performed according to the ACMG guidelines. Pathogenic and likely pathogenic variants have been found in 15% of the patients with 12% of variants of unknown significance (VUS). We have found variants in patients with connective tissue disease (CTD) and congenital heart disease (CHD). In addition, in a small proportion of patients (1.75%), we observed a possible digenic mode of inheritance. These results stand out the importance of the genetic testing of patients with associated forms of PAH (i.e., CHD and CTD) additionally to the classical IPAH and HPAH forms. Molecular confirmation of the clinical presumptive diagnosis is required in cases with a high clinical overlapping to carry out proper management and follow up of the individuals with the disease.

Day length regulates seasonal patterns of stomatal conductance in Quercus species.

Vapour pressure deficit is a major driver of seasonal changes in transpiration, but photoperiod also modulates leaf responses. Climate warming might enhance transpiration by increasing atmospheric water demand and the length of the growing season, but photoperiod-sensitive species could show dampened responses. Here, we document that day length is a significant driver of the seasonal variation in stomatal conductance. We performed weekly gas exchange measurements across a common garden experiment with 12 oak species from contrasting geographical origins, and we observed that the influence of day length was of similar strength to that of vapour pressure deficit in driving the seasonal pattern. We then examined the generality of our findings by incorporating day-length regulation into well-known stomatal models. For both angiosperm and gymnosperm species, the models improved significantly when adding day-length dependences. Photoperiod control over stomatal conductance could play a large yet underexplored role on the plant and ecosystem water balances.

Assessing the potential functions of nocturnal stomatal conductance in C3 and C4 plants.

Nocturnal stomatal conductance contributes to water loss at night without carbon gain in C3 or C4 plants because photosynthesis does not occur in the dark. The functional relevance of nocturnal conductance thus remains an unresolved conundrum. Here, we review and re-analyse previously published datasets on nocturnal conductance (gn ) globally (176 species) to synthesize our current understanding on its potential biological function and to identify remaining research gaps. We found that gn was positively correlated with relative growth rate, which is compatible with the postulate that circadian-driven nocturnal conductance enhances predawn stomatal conductance, thereby priming stomata for photosynthesis in early daylight. The variation in gn across plant species and functional types was not consistent with the hypotheses that the main function of gn is to: remove excess CO2, which might limit growth; enhance oxygen delivery to the functional sapwood; enhance nutrient supply; or that gn is due to stomatal leakiness. We suggest further study regarding the potential of gn to be an important functional and ecological trait influencing competitive outcomes and we outline a research programme to achieve that objective.

Evidence of a seasonal trade-off between growth and starch storage in declining beeches: assessment through stem radial increment, non-structural carbohydrates and intra-ring δ13C.

Forest decline is reported in recent decades all over the world. However, developing a clear vision of the associated tree dysfunctioning is still a challenge for plant physiologists. In this study, our aim was to examine the seasonal carbon adjustments of beech trees in the case of a long-term drought-induced decline. We compared healthy and declining trees in terms of stem radial growth, phloem sugar content and δ13C, together with xylem carbohydrates and intra-ring δ13C patterns. The radial growth of declining trees was clearly reduced by lower growth rates and shorter growing season length (44 days compared with healthy trees). The soluble sugar content was higher in the xylem of declining trees compared with the healthy ones, but similar in the phloem except at the end of their growth. Declining trees increased their levels of xylem starch content from budburst until the date of maximal growth rate. These reserve dynamics revealed an early trade-off between radial growth and starch storage that might be the result of an active or passive process. For declining trees, the slight decrease of intra-ring cellulose δ13C pattern during the early growing season was attributed to the synthesis of 13C enriched starch. For healthy trees, δ13C patterns were characterized by a progressive 13C increase along the ring, attributed to increased water-use efficiency (WUE) in response to decreased water availability. Individual variations of the crown area were negatively correlated to the intra-ring δ13C amplitude, which was ascribed to variations in canopy WUE and resource competition for healthy trees and partly to variations in the amount of reserves accumulated during spring for declining ones. Our study highlights the carbon physiological adjustment of declining trees towards reducing spring growth while storing starch, which can be reflected in the individual intra-ring cellulose δ13C patterns.

Diverging shrub and tree growth from the Polar to the Mediterranean biomes across the European continent.

Climate warming is expected to enhance productivity and growth of woody plants, particularly in temperature-limited environments at the northernmost or uppermost limits of their distribution. However, this warming is spatially uneven and temporally variable, and the rise in temperatures differently affects biomes and growth forms. Here, applying a dendroecological approach with generalized additive mixed models, we analysed how the growth of shrubby junipers and coexisting trees (larch and pine species) responds to rising temperatures along a 5000-km latitudinal range including sites from the Polar, Alpine to the Mediterranean biomes. We hypothesize that, being more coupled to ground microclimate, junipers will be less influenced by atmospheric conditions and will less respond to the post-1950 climate warming than coexisting standing trees. Unexpectedly, shrub and tree growth forms revealed divergent growth trends in all the three biomes, with juniper performing better than trees at Mediterranean than at Polar and Alpine sites. The post-1980s decline of tree growth in Mediterranean sites might be induced by drought stress amplified by climate warming and did not affect junipers. We conclude that different but coexisting long-living growth forms can respond differently to the same climate factor and that, even in temperature-limited area, other drivers like the duration of snow cover might locally play a fundamental role on woody plants growth across Europe.

Wood phenology, not carbon input, controls the interannual variability of wood growth in a temperate oak forest.

Although the analysis of flux data has increased our understanding of the interannual variability of carbon inputs into forest ecosystems, we still know little about the determinants of wood growth. Here, we aimed to identify which drivers control the interannual variability of wood growth in a mesic temperate deciduous forest. We analysed a 9-yr time series of carbon fluxes and aboveground wood growth (AWG), reconstructed at a weekly time-scale through the combination of dendrometer and wood density data. Carbon inputs and AWG anomalies appeared to be uncorrelated from the seasonal to interannual scales. More than 90% of the interannual variability of AWG was explained by a combination of the growth intensity during a first 'critical period' of the wood growing season, occurring close to the seasonal maximum, and the timing of the first summer growth halt. Both atmospheric and soil water stress exerted a strong control on the interannual variability of AWG at the study site, despite its mesic conditions, whilst not affecting carbon inputs. Carbon sink activity, not carbon inputs, determined the interannual variations in wood growth at the study site. Our results provide a functional understanding of the dependence of radial growth on precipitation observed in dendrological studies.

Species coexistence in a changing world.

The consequences of global change for the maintenance of species diversity will depend on the sum of each species responses to the environment and on the interactions among them. A wide ecological literature supports that these species-specific responses can arise from factors related to life strategies, evolutionary history and intraspecific variation, and also from environmental variation in space and time. In the light of recent advances from coexistence theory combined with mechanistic explanations of diversity maintenance, we discuss how global change drivers can influence species coexistence. We revise the importance of both competition and facilitation for understanding coexistence in different ecosystems, address the influence of phylogenetic relatedness, functional traits, phenotypic plasticity and intraspecific variability, and discuss lessons learnt from invasion ecology. While most previous studies have focused their efforts on disentangling the mechanisms that maintain the biological diversity in species-rich ecosystems such as tropical forests, grasslands and coral reefs, we argue that much can be learnt from pauci-specific communities where functional variability within each species, together with demographic and stochastic processes becomes key to understand species interactions and eventually community responses to global change.