Improving Care for Children with Bloody Diarrhea at Risk for Hemolytic Uremic Syndrome.

INTRODUCTION: Children with infectious bloody diarrhea are at an increased risk for developing hemolytic uremic syndrome (HUS). Early intervention may improve outcomes. This study evaluated the impact of a clinical pathway designed to identify those at risk for HUS, guide initial management, and provide decision support regarding patient disposition. METHODS: We performed a retrospective cohort study of children 4 months to 19 years of age who presented with the acute onset of bloody diarrhea or other HUS risk factors to the pediatric emergency department (ED) from September 2015 through July 2020. A rapid stool polymerase chain reaction (PCR) test became available in May 2017. The clinical pathway was implemented in January 2018. We used Fisher's exact tests and statistical process control charts to analyze patient- and system-level changes following pathway implementation. RESULTS: Three hundred five patients were included. Postimplementation, stool PCR use increased (78%-91%), hospitalization decreased (49%-30%), and mean total charges decreased ($7715-$6797). There were increases in length of stay (226-288 minutes) and charges ($2651-$3524) for patients discharged from the ED. All changes met rules for special cause variation. There was no change in early IV fluid administration, inpatient length of stay, ED return visits, hospital readmissions, or patients with Shiga toxin-producing Escherichia coli (STEC), acute kidney injury (AKI) or HUS. CONCLUSIONS: For children presenting to the ED with bloody diarrhea, introduction of a rapid stool PCR test and clinical pathway correlated with decreased hospitalizations and overall costs without adverse clinical outcomes.

Pembrolizumab and tavokinogene telseplasmid electroporation in metastatic melanoma.

INTRODUCTION: Tavokinogene Telseplasmid Electroporation Therapy (TAVO) and Pembrolizumab therapy is being studied in subjects with immune checkpoint inhibitor (ICI) resistant melanoma. TAVO is a novel office-based local therapy shown to be effective in patients with advanced melanoma. The technique involves the direct injection of a plasmid encoding IL-12 into an accessible tumor driven by electroporation. The tumor cells have then been shown to express high levels of IL-12 resulting in a local inflammatory response within the tumor microenvironment. PRESENTATION OF CASE: The patient with stage IIB, pT3b melanoma was treated with primary tumor resection and found to have a negative sentinel node biopsy. She subsequently developed regional recurrence and was treated with inguinal lymphadenectomy and adjuvant Nivolumab. Despite therapy, she had progression of disease with skin and subcutaneous metastases (in-transit lesions), brain and liver lesions, hilar and iliac nodal disease. She was transitioned to nivolumab + ipilimumab, and Talimogene Laherparepvec (T-VEC) therapy for the in-transit lesions, without success. Stereotactic radiosurgery was used for the brain metastasis. Groin subcutaneous and in-transit lesions were treated with TAVO and intravenous pembrolizumab. Serial physical exams and CT scans were used to assess response. DISCUSSION: All lesions treated with TAVO resolved. An abscopal response was also noted: hilar and mediastinal lymphadenopathy resolved. The liver mass and pelvic lymphadenopathy decreased in size, and her brain metastasis remained stable after radiation. CONCLUSION: This case suggests that combination TAVO and Pembrolizumab is a safe and effective local treatment for ICI resistant metastatic melanoma in the setting of rheumatoid arthritis. An abscopal effect was also noted through control of systemic disease.

Social capital and disaster preparedness in Oromia, Ethiopia: An evaluation of the "Women Empowered" approach.

Ethiopia is faced with challenges posed by natural disasters, especially drought. Integrated approaches to disaster risk reduction are necessary to improve the lives and livelihoods of those most vulnerable to disaster. The Women Empowered (WE) approach provides economic and social opportunities for women to build resilience to respond to disasters. This study examines the association between WE group membership and disaster preparedness and whether this relationship is mediated by social capital. We used a multi-stage random cluster sampling strategy to select and interview 589 female respondents from Lage Hidha district (298 from the intervention area and 291 in the comparison area). Using Stata 14.0, we employed Poisson regression analysis to study the mechanisms through which WE groups are associated with disaster preparedness. After controlling for clustering and confounding factors, we found that different components of social capital mediate the relationship between WE group membership and disaster preparedness. Specifically, taking action to prepare for a disaster is primarily mediated by emotional support from the group and perceived preparedness for a disaster is mediated by social network support, emotional support from the group, collective action, and trust. This study suggests that the association between WE groups and disaster preparedness operates through social capital in drought-prone areas of Ethiopia. Future research is needed to determine which forms of social capital have the greatest potential to help families prepare for and respond to a variety of humanitarian crises.

First Trimester Prenatal Care Initiation Among Hispanic Women Along the U.S.-Mexico Border.

Background First trimester prenatal care (FTPNC) is associated with improved birth outcomes. U.S.-Mexico border Hispanic women have lower FTPNC than non-border or non-Hispanic women. This study aimed to identify (1) what demographic, knowledge and care-seeking factors influence FTPNC among Hispanic women in border counties served by five Healthy Start sites, and (2) what FTPNC barriers may be unique to this target population. Healthy Starts work to eliminate disparities in perinatal health in areas with high poverty and poor birth outcomes. Methods 403 Hispanic women of reproductive age in border communities of California, Arizona, New Mexico and Texas were surveyed on knowledge and behaviors related to prenatal care (PNC) and basic demographic information. Chi square analyses and logistic regressions were used to identify important relationships. Results Chi square analyses revealed that primiparous women were significantly less likely to start FTPNC than multiparous women (χ2 = 6.8372, p = 0.0089). Women with accurate knowledge about FTPNC were more likely to obtain FTPNC (χ2 = 29.280, p < .001) and more likely to have seen a doctor within the past year (χ2 = 5.550, p = .018). Logistic regression confirmed that multiparity was associated with FTPNC and also that living in Texas was negatively associated with FTPNC (R2 = 0.066, F(9,340) = 2.662, p = .005). Among 27 women with non-FTPNC, barriers included late pregnancy recognition (n = 19) and no medical insurance (n = 5). Conclusions This study supports research that first time pregnancies have lower FTPNC, and demonstrated a strong association between delayed PNC and late pregnancy recognition. Strengthened investments in preconception planning could improve FTPNC in this population.

Diagnosing and treating chronic lymphocytic leukemia in 2009.

Over the past decade, major breakthroughs have been made in both the molecular understanding and the treatment of chronic lymphocytic leukemia (CLL). In this article, old and new concepts of CLL biology are explored and insights into the relevance of the newer prognostic factors are discussed. The therapeutic landscape has changed dramatically with the advent of purine analogs, monoclonal antibodies, and combination therapy. As opposed to older agents, these new therapies commonly yield complete remissions. This improvement has spurred a debate as to new goals in treating CLL patients.