Antibiotic Resistance Pattern of Pathogens Isolated from Pediatric Patients during and after the COVID-19 Pandemic.

Background/Objectives: The present study aims to highlight the possible significant changes due to the COVID-19 pandemic in the resistance of pathogens involved in cases of pediatric infections. Methods: This study included children hospitalized in the Pediatric Intensive Care Unit, Surgery and Pediatrics from a tertiary teaching hospital, during and after the COVID-19 period (2020-2023). Results: The research included 845 samples collected during 2020-2023, from 685 pediatric patients. A total of 937 bacterial isolates were obtained, of which 509 isolates (54.32%) were Gram-negative bacteria. Around 30% of all the pathogens were multidrug-resistant (MDR), with a statistically significant increase post-pandemic, in the case of the MDR Escherichia coli strains (p < 0.05). A very high percentage of MDR Acinetobacter spp. isolates was found, with an important, but not statistically significant, increase in the post-pandemic period. The highest percentage of the MDR Gram-positive pathogens was registered in the case of S. aureus strains (31.80%). Over 20% of the Coagulase-negative Staphylococci (CoNS) strains isolated between 2020 and 2023 were MDR, with an important increase in the post-COVID-19 period. The proportion of carbapenem-resistant Gram-negative pathogens significantly decreased in the post-COVID-19 period compared with the COVID-19 period (p < 0.05), especially in the case of the Klebsiella spp. strains. Conclusions: Our findings revealed the increase in the post-COVID-19 period of the prevalence of MDR strains of Acinetobacter spp., CoNS, and Escherichia coli isolated in pediatric patient samples and a significant decline in the trend of the carbapenem-resistant Gram-negative pathogens, which may be due to the testing rate and to the specific pathology of the pediatric patients hospitalized in the two periods.

The Impact of Competitive Sports on Oral Health: Exploring Their Relationship with Salivary Oxidative Stress in Children.

This article explores the correlation between salivary biomarkers, such as glutathione peroxidase (GPX), total antioxidant capacity (TAC), and superoxide dismutase (SOD), and their association with oral health for children in competitive sports. Saliva has emerged as a valuable resource for evaluating physiological and pathological conditions due to its non-invasive collection method and easy storage. This study examines the potential of GPX, TAC, and SOD as salivary biomarkers for assessing the impact of competitive sports on children's oral health. It discusses the potential implications of increased oxidative stress due to intense physical activity and the role of antioxidant defense mechanisms in maintaining oral health. In total, 173 children aged between 6 and 17 were divided into three groups, 58 hockey players, 55 football players, and 60 in the control group, and examined to assess their oral hygiene and dental and periodontal health. Saliva was collected, centrifuged, and the supernatant was analyzed for the relevant biomarkers. The findings seem to suggest that salivary biomarkers, like GPX, TAC, and SOD, might serve as indicators of the physiological response to competitive sports in children, as well as indicators of oral health, especially dental cavities, and periodontal disease. Statistical analysis showed significant differences between the groups, with better values for athletes, regardless of age, sex, or activity type. Understanding the relationship between salivary biomarkers and competitive sports in children can have significant implications for monitoring and optimizing the health and performance of young athletes. Further research is needed to establish the specific associations between these biomarkers and the effects of several types and intensities of sports activities on oral health in children.

Assessment of tumoral and peritumoral inflammatory reaction in cutaneous malignant melanomas.

Skin cancer is one of the most common types of cancer, with an increasing worldwide incidence in recent decades. The main risk factor for increasing the skin cancer incidence is ultraviolet (UV) radiation. Of the two major forms of skin cancer (melanomas and non-melanotic cancers), the cutaneous melanoma (CM) is the most aggressive form, causing about 80% of the deaths resulted from this type of tumor. Malignant melanoma develops through malignant transformation of melanocytes in the skin because of prolonged exposure to solar or artificial UV. The malignant transformation of the melanocytes in the skin is accompanied by the presence of a local inflammatory reaction that, in the initial stages of carcinogenesis, would oppose to tumor development. Chronic exposure to UV or other etiopathogenic factors induces chronic inflammation, which, by producing inflammatory molecules (cytokines, chemokines, prostaglandins), constitutes a tumoral microenvironment that favors carcinogenesis, tumor invasion, metastasis, and the presence of neoplastic "mutant cells" that avoid the protective action of the immune system. Using immunohistochemistry techniques, we assessed the intra- and peritumoral inflammatory infiltrate cells in CM. The chronic inflammatory infiltrate presented more intense in the peritumoral stroma compared to the intratumoral one, heterogenous, more intensely composed of lymphocytes, plasma cells, macrophages, and mast cells (MCs), the most numerous cells in the inflammatory infiltrate being T-lymphocytes, plasma cells and macrophages; B-lymphocytes and MCs were in a small number, especially intratumorally. Inflammatory cells had a direct contact with tumor cells, blood vessels, connective matrix, suggesting that the inflammatory microenvironment plays an important role in carcinogenesis, tumor invasion, local angiogenesis, and tumor metastasis.

Retrospective Study of a Patient with Multiple de Novo Skin Tumor Formations.

In Romania, the incidence of malignant melanocytic tumors is continuously increasing. According to the World Health Organization, the incidence of melanocytic and non-melanocytic skin neoplasms has increased considerably and globally, in the last decade. We present the case of a 49-year-old patient who, over the course of 7 years, came in the Plastic Surgery Clinic of the Emergency County Hospital of Craiova for the excision of a number of 25 skin tumor formations, located on the face, cervical region, trunk and upper limbs. Treatment included complete microsurgical excision and supervision. In the end, the patient's treatment compliance decreased significantly.

Mechanisms of Altered Immune Response in Skin Melanoma.

Melanoma, a deadly form of skin cancer, poses significant challenges to the host immune system, allowing tumor cells to evade immune surveillance and persist. This complex interplay between melanoma and the immune system involves a multitude of mechanisms that impair immune recognition and promote tumor progression. This review summarizes the intricate strategies employed by melanoma cells to evade the immune response, including defective immune recognition, immune checkpoint activation, and the role of regulatory T-cells, myeloid-derived suppressor cells, and exosomes in suppressing anti-tumor immunity. Additionally, we discuss potential therapeutic targets aimed at reversing immune evasion in melanoma, highlighting the importance of understanding these mechanisms for developing more effective immunotherapies. Improved insights into the interactions between melanoma and the immune system will aid in the development of novel treatment strategies to enhance anti-tumor immune responses and improve patient outcomes.

Custom-Made Direct Metal Laser Sintering Titanium Subperiosteal Implants in Oral and Maxillofacial Surgery for Severe Bone-Deficient Patients-A Pilot Study.

BACKGROUND: Nowadays, a combination of classical subperiosteal implant designs with 3D imaging and printing allows one to reduce treatment time and provides support for fixed prostheses in cases where other techniques do not provide satisfactory results. This study aims to present a digital technique for the manufacturing of custom-made subperiosteal implants and what complications might appear after this type of surgery. METHODS: Sixteen patients treated with a custom-made DMLS titanium subperiosteal implant during the period between October 2021 and February 2022 were enrolled in the study. Orthopantomography (OPT) and cone-beam computer tomography (CBCT) were recorded for all patients. The measurements taken into account in this study were the fit and stability of implants, duration of surgery, implant survival, and early and late complications. RESULTS: The fit of the implants was extremely satisfactory, with a mean rating of 4 out of 5. The mean duration of the intervention was 86.18 min. At the end of the study, one implant was lost due to insufficient fit and recurrent, untreatable infections. Eleven implants (69%) were placed on the maxillary and five (31%) implants were placed on the mandible. CONCLUSIONS: Taking this into consideration, custom-made DMLS titanium subperiosteal implants could present satisfactory implant survival and low complication rates.

Ductus Venosus Agenesis and Portal System Anomalies-Association and Outcome.

To evaluate the prenatal diagnosis of agenesis of ductus venosus (ADV) and portal venous system (PVS) anomalies and describe the outcome of these cases, either isolated or associated. We evaluated the intrahepatic vascular system regarding the presence of normal umbilical drainage and PVS characteristics in the second and third trimester of pregnancy. The associated anomalies and umbilical venous drainage were noted. Follow-up was performed at six months follow-up. Ultrasonography was performed in 3517 cases. A total of 19 cases were prenatally diagnosed: 18 ADV cases, seven abnormal PVS cases, and six associations of the two anomalies. We noted an incidence of 5.1‱ and 1.9‱ for ADV and PVS anomalies, respectively. Out of the 18 ADV cases, 27.7% were isolated. Five cases (26.3%) presented genetic anomalies. PVS anomalies were found in 33.3% of the ADV cases. ADV was present in 85.7% of the PVS anomalies. DV and PVS abnormalities were found with a higher than reported frequency. Normal DV is involved in the normal development of the PVS. Additional fetal anomalies are the best predictor for the outcome of ADV cases. Evaluation of PVS represents a powerful predictor for ADV cases and addresses the long-term prognosis.

Retrospective Study Over the Hypospadias Surgery in a Single Tertiary Center.

Hypospadias surgery is a common activity in every department for pediatric surgery, increased incidence of this condition contributing this aspect. For this purpose permanent review of the data of cases is probably necessary, in order to promptly evaluate short and long term results. MATERIAL AND METHODS: The authors are presenting this retrospective clinical and statistical study, enrolling 149 patients, hospitalized and operated in the Department of Pediatric Surgery and Orthopedics, between 2009 and 2018. several parameters were taken into consideration: moment of conception, type of hypospadias, associated malformations, use of meatoplasty, age at meatoplasty, age at urethroplasty, type of urethroplasty, postoperative incidents and complications. RESULTS: Most of the patients included in the study were classified as anterior type of hypospadias, associated malformations were present in 20,13% of the patients, and 80% of the associated malformations belonged to the urogenital system. Over 60% of the cases underwent meatoplasty as a tactical procedure. Mathieu was the most appreciated procedure (74,5%) for urethroplasty and over a half of the patients were operated after the age of 3 years. Early and late postoperative fistula formation was noted in 18,12% of cases. CONCLUSIONS: Better parameters to assess the exact type of hypospadias are needed to be introduced. Also, clear protocols for preoperative work-up in detection of other abnormalities, especially genito-urinary. Meatoplasty as a tactical procedure is having unclear influence for urethroplasty. Decreasing the age at urethroplasty should be the next goal. Some surgeons should really get overspecialized for this type of surgery.

Does Point of Care Ultrasound Improve Resuscitation Markers in Undifferentiated Hypotension? An International Randomized Controlled Trial From The Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED) Series.

Introduction Point of Care Ultrasound (PoCUS) protocols are commonly used to guide resuscitation for patients with undifferentiated hypotension, yet there is a paucity of evidence for any outcome benefit. We undertook an international multicenter randomized controlled trial (RCT) to assess the impact of a PoCUS protocol on key clinical outcomes. Here we report on resuscitation markers.  Methods Adult patients presenting to six emergency departments (ED) in Canada and South Africa with undifferentiated hypotension (systolic blood pressure (SBP) <100mmHg or a Shock Index >1.0) were randomized to receive a PoCUS protocol or standard care (control). Reported physiological markers include shock index (SI), and modified early warning score (MEWS), with biochemical markers including venous bicarbonate and lactate, at baseline and four hours.  Results A total of 273 patients were enrolled, with data collected for 270. Baseline characteristics were similar for each group. Improvements in mean values for each marker during initial treatment were similar between groups: Shock Index; mean reduction in Control 0.39, 95% CI 0.34 to 0.44 vs. PoCUS 0.33, 0.29 to 0.38; MEWS, mean reduction in Control 2.56, 2.22 to 2.89 vs. PoCUS 2.91, 2.49 to 3.32; Bicarbonate, mean reduction in Control 2.71 mmol/L, 2.12 to 3.30 mmol/L vs. PoCUS 2.30 mmol/L, 1.75 to 2.84 mmol/L, and venous lactate, mean reduction in Control 1.39 mmol/L, 0.93 to 1.85 mmol/L vs. PoCUS 1.31 mmol/L, 0.88 to 1.74 mmol/L. Conclusion We found no meaningful difference in physiological and biochemical resuscitation markers with or without the use of a PoCUS protocol in the resuscitation of undifferentiated hypotensive ED patients. We are unable to exclude improvements in individual patients or in specific shock types.

Changes in nursing students' knowledge, attitudes and interest in caring for older adults: A longitudinal cohort study.

Nursing education programs have a responsibility to prepare future nurses to care for the growing number of older adults who will be accessing health care services. Preparation involves ensuring students have the knowledge, skills and desire to provide quality care to older adults. A longitudinal cohort study was conducted to collect data on students' knowledge of, attitudes towards, and interest in working with older adults during each year of an undergraduate nursing program. Data were collected using the Kogan Attitudes Towards Older People Scale, Palmore's Fact on Aging Quiz and a demographic instrument designed specifically for this study. Results showed slight improvements in students' overall attitudes towards older adults at the completion of their nursing degree. Increases in knowledge were seen in 12 of 24 areas measured. Gerontology as a preferred career choice was highest immediately following a clinical placement focusing on caring for older adults. Integrating gerontological clinical experiences into a beginning fundamental nursing course does not necessarily improve students' learning in the area of caring for older adults. Nursing programs have a responsibility to design, monitor and update curricula to ensure students are being adequately prepared to care for older adults.

Prenatal findings and pregnancy outcome in fetuses with right and double aortic arch. A 10-year experience at a tertiary center.

OBJECTIVE: Our objective was to evaluate the accuracy of the prenatal diagnosis and the relation between the type of right aortic arch (RAA) with other intra- or extracardiac (EC) and chromosomal anomalies. METHODS: A retrospective, observational study was conducted between 2011-2020 in a Romanian tertiary center. All RAA cases, including double aortic arch (DAA), were extracted from the databases and studied thoroughly. RESULTS: We detected 18 RAA cases: five (27.78%) type I (mirror image, "V" type), 11 (61.12%) type II ("U" type), and two (11.10%) DAA cases. Heart anomalies were associated in 38.89% (overall), 60% (type I), 36.37% (type II), and 0% (DAA) cases. Tetralogy of Fallot represented the most prevalent cardiac malformation (in 22.23% of cases). EC anomalies were present in 44.44% of fetuses (20% of type I, 54.55% of type II, and 50% of DAA cases). Genetic abnormalities were found in 41.17% of pregnancies, with 22q11.2 deletion in 23.53%. 55.55% of the cases had a good neonatal evolution and 44.45% of the pregnancies were terminated. An overall good outcome of pregnancy was noted in 40% of type I RAA, 63.64% of type II RAA, and 50% of DAA cases. All RAA cases examined in the first trimester were correctly diagnosed. CONCLUSIONS: RAA can be accurately diagnosed and classified by means of prenatal ultrasound since early pregnancy. A detailed anatomy scan and genetic testing, including 22q11 deletion, should be offered to all pregnancies when RAA is discovered. When isolated, RAA associates a good outcome, indifferently the anatomical type.

Peripheral adenopathies in children - an attempt of clinical morphological profile.

AIM: The authors have proposed to assess peripheral adenopathies in a series of hospitalized children in order to identify and define clinical and morphological profiles of different types of lymph node (LN) diseases. MATERIALS AND METHODS: The studied group consisted of 58 patients less than 18 years of age. The investigation algorithm included: gender, age, site, involvement, side, extension and histopathological (HP) type of LN lesions. Tissue fragments were processed using classical histological techniques (formalin fixation and paraffin embedment) and stained with Hematoxylin-Eosin (HE). In some cases (tuberculous lesions and lymphomas), special stainings (Ziehl-Neelsen) and immunohistochemistry were used. Stratification scales of cases were defined according to each parameter in order to compare the data. All obtained data were assessed individually, compared to each other and with similar data from the literature with the help of a statistical apparatus [χ² (chi-squared) test and analysis of variance (ANOVA) test] in some cases. RESULTS: The young patients were slightly more frequently boys, of all ages but with a mean age of 10 and half years. The affected LNs belonged most often to neck region, either on the left or on the right side but sometimes bilateral or even on the midline; usually, more than one LN was involved in the area. In most of the cases, the lesions were localized in only one LN area. HP picture was dominated by the inflammatory processes, firstly the nonspecific ones, followed by tuberculosis. DISCUSSIONS: Our observations fitted, for each parameter, with the wide ranges found in the literature. Comparisons between parameters' variations revealed differences, sometimes significant that we tried to organize in clinical and morphological profiles. CONCLUSIONS: The assessment of our data allowed us to define some clinical and morphological profiles of different types of adenopathy that, by improvement on studies including larger series, could be of real use in daily pediatric practice.

Does Point-of-care Ultrasonography Change Emergency Department Care Delivered to Hypotensive Patients When Categorized by Shock Type? A Post-Hoc Analysis of an International Randomized Controlled Trial from the SHoC-ED Investigators.

Introduction Our previously reported randomized-controlled-trial of point-of-care ultrasound (PoCUS) for patients with undifferentiated hypotension in the emergency department (ED) showed no survival benefit with PoCUS. Here, we examine the data to see if PoCUS led to changes in the care delivered to patients with cardiogenic and non-cardiogenic shock. Methods A post-hoc analysis was completed on a database of 273 hypotensive ED patients randomized to standard care or PoCUS in six centres in Canada and South Africa. Shock categories recorded one hour after the ED presentation were used to define subcategories of shock. We analyzed initial intravenous fluid volumes, as well as rates of inotrope use and procedures. Results  261 patients could be classified as cardiogenic or non-cardiogenic shock types. Although there were expected differences in the mean fluid volume administered between patients with non-cardiogenic and cardiogenic shock (p-value<0.001), there was no difference between the control and PoCUS groups (mean non-cardiogenic control 1881mL (95% CI 1567-2195mL) vs non-cardiogenic PoCUS 1763mL (1525-2001mL); and cardiogenic control 680mL (28.4-1332mL) vs. cardiogenic PoCUS 744mL (370-1117mL; p= 0.67). Likewise, there were no differences in rates of inotrope administration nor procedures for any of the subcategories of shock between the control group and PoCUS group patients. Conclusion Despite differences in care delivered by subcategory of shock, we did not find any difference in key elements of emergency department care delivered between patients receiving PoCUS and those who did not. This may help explain the previously reported lack of outcome differences between groups.

Do combined ultrasound and electrocardiogram-rhythm findings predict survival in emergency department cardiac arrest patients? The Second Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED2) study.

OBJECTIVES: Point-of-care ultrasound (POCUS) is used increasingly during resuscitation. The aim of this study was to assess whether combining POCUS and electrocardiogram (ECG) rhythm findings better predicts outcomes during cardiopulmonary resuscitation in the emergency department (ED). METHODS: We completed a health records review on ED cardiac arrest patients who underwent POCUS. Primary outcome measurements included return of spontaneous circulation (ROSC), survival to hospital admission, and survival to hospital discharge. RESULTS: POCUS was performed on 180 patients; 45 patients (25.0%; 19.2%-31.8%) demonstrated cardiac activity on initial ECG, and 21 (11.7%; 7.7%-17.2%) had cardiac activity on initial POCUS; 47 patients (26.1%; 20.2%-33.0%) achieved ROSC, 18 (10.0%; 6.3%-15.3%) survived to admission, and 3 (1.7%; 0.3%-5.0%) survived to hospital discharge. As a predictor of failure to achieve ROSC, ECG had a sensitivity of 82.7% (95% CI 75.2%-88.7%) and a specificity of 46.8% (32.1%-61.9%). Overall, POCUS had a higher sensitivity of 96.2% (91.4%-98.8%) but a similar specificity of 34.0% (20.9%-49.3%). In patients with ECG-asystole, POCUS had a sensitivity of 98.18% (93.59%-99.78%) and a specificity of 16.00% (4.54%-36.08%). In patients with pulseless electrical activity, POCUS had a sensitivity of 86.96% (66.41%-97.22%) and a specificity of 54.55% (32.21%-75.61%). Similar patterns were seen for survival to admission and discharge. Only 0.8% (0.0-4.7%) of patients with ECG-asystole and standstill on POCUS survived to hospital discharge. CONCLUSION: The absence of cardiac activity on POCUS, or on both ECG and POCUS together, better predicts negative outcomes in cardiac arrest than ECG alone. No test reliably predicted survival.

OBJECTIF: On a de plus en plus recours à l'échographie au chevet (EC) durant les manœuvres de réanimation. L'étude visait donc à déterminer si l'association de l'EC et de l'électrocardiogramme (ECG) pour analyse du rythme avait une meilleure valeur prévisionnelle que l'ECG seul quant à l'issue durant les manœuvres de réanimation cardiorespiratoire au service des urgences (SU). MÉTHODE: Il s'agit d'un examen de dossiers médicaux de patients en état d'arrêt cardiaque qui ont été soumis à une EC au SU. Les principaux critères d'évaluation étaient le retour à la circulation spontanée (RCS), la survie en cours d'hospitalisation et la survie après le congé de l'hôpital. RÉSULTATS: Une EC a été effectuée chez 180 patients; la présence d'activité électrique a été observée à l'ECG initial chez 45 d'entre eux (25,0%; 19,2­31,8%) et à l'EC initiale chez 21 d'entre eux (11,7%; 7,7­17,2%). Quarante-sept patients (26,1%; 20,2­33,0%) ont connu un RCS, 18 (10,0%; 6,3­15,3%) ont survécu à l'hospitalisation et 3 (1,7%; 0,3­5,0%) ont survécu au congé de l'hôpital. L'ECG a révélé une sensibilité de 82,7% (intervalle de confiance à 95% : 75,2%−88,7%) et une spécificité de 46,8% (32,1­61,9%) à l'égard de la valeur prévisionnelle du non-retour à la circulation spontanée. Dans l'ensemble, l'EC avait une sensibilité supérieure (96,2%; [(91,4­98,8%]) mais une spécificité comparable (34,0%; [(20,9­49,3%]) à celles de l'ECG. Chez les patients présentant une asystole à l'ECG, l'EC avait une sensibilité de 98,18% (93,59­99,78%) et une spécificité de 16,00,% (4,54­36,08%). Quant aux patients ayant une activité électrique sans pouls, l'EC avait une sensibilité de 86,96% (66,41­97,22%) et une spécificité de 54,55% (32,21­75,61%). Des résultats comparables ont été obtenus en ce qui concerne la survie en cours d'hospitalisation ainsi qu'après le congé de l'hôpital. Enfin, seulement 0,8% (0,0­4,7%) des patients présentant une asystole à l'ECG et un arrêt des contractions du cœur à l'EC ont survécu au congé de l'hôpital. CONCLUSION: L'absence d'activité électrique cardiaque à l'EC seule ou à l'association de l'ECG et de l'EC a une meilleure valeur prévisionnelle que l'ECG seul quant à l'issue défavorable des.

New Zealand White Rabbits Effectively Clear Borrelia burgdorferi B31 despite the Bacterium's Functional vlsE Antigenic Variation System.

Borrelia burgdorferi is a tick-borne bacterium responsible for approximately 300,000 annual cases of Lyme disease (LD) in the United States, with increasing incidences in other parts of the world. The debilitating nature of LD is mainly attributed to the ability of B. burgdorferi to persist in patients for many years despite strong anti-Borrelia antibody responses. Antimicrobial treatment of persistent infection is challenging. Similar to infection of humans, B. burgdorferi establishes long-term infection in various experimental animal models except for New Zealand White (NZW) rabbits, which clear the spirochete within 4 to 12 weeks. LD spirochetes have a highly evolved antigenic variation vls system, on the lp28-1 plasmid, where gene conversion results in surface expression of the antigenically variable VlsE protein. VlsE is required for B. burgdorferi to establish persistent infection by continually evading otherwise potent antibodies. Since the clearance of B. burgdorferi is mediated by humoral immunity in NZW rabbits, the previously reported results that LD spirochetes lose lp28-1 during rabbit infection could potentially explain the failure of B. burgdorferi to persist. However, the present study unequivocally disproves that previous finding by demonstrating that LD spirochetes retain the vls system. However, despite the vls system being fully functional, the spirochete fails to evade anti-Borrelia antibodies of NZW rabbits. In addition to being protective against homologous and heterologous challenges, the rabbit antibodies significantly ameliorate LD-induced arthritis in persistently infected mice. Overall, the current data indicate that NZW rabbits develop a protective antibody repertoire, whose specificities, once defined, will identify potential candidates for a much-anticipated LD vaccine.

Validation of the short form of the International Crowding Measure in Emergency Departments: an international study.

OBJECTIVE: There is little consensus on the best way to measure emergency department (ED) crowding. We have previously developed a consensus-based measure, the International Crowding Measure in Emergency Departments. We aimed to externally validate a short form of the International Crowding Measure in Emergency Department (sICMED) against emergency physician's perceptions of crowding and danger. METHODS: We performed an observational validation study in seven EDs in five different countries. We recorded sICMED observations and the most senior available emergency physician's perceptions of crowding and danger at the same time. We performed a times series regression model. RESULTS: A total of 397 measurements were analysed. The sICMED showed moderate positive correlations with emergency physician's perceptions of crowding, r = 0.4110, P < 0.05) and safety (r = 0.4566, P < 0.05). There was considerable variation in the performance of the sICMED between different EDs. The sICMED was only slightly better than measuring occupancy or ED boarding time. CONCLUSION: The sICMED has moderate face validity at predicting clinician's concerns about crowding and safety, but the strength of this validity varies between different EDs and different countries.

Pathological fractures of humerus in children. Therapeutic and pathological considerations.

INTRODUCTION: A pathological fracture appears after a low-energy trauma or minor trauma on bones with a modified histological structure; sometimes, the patient reports shoulder pain antedating the fracture. The most common benign bone tumors that cause pathological fractures in children are simple bone cysts, aneurysmal bone cysts, non-ossifying fibromas and fibrous dysplasia. This type of bone tumors is usually asymptomatic until they reach a large size and cause a pathological fracture after minor trauma. The optimal treatment remains controversial. Our objective was to describe our modern treatment strategies of the large benign osseous tumors of the humerus complicated by pathological humerus fractures and histological aspects in these cases. PATIENTS, MATERIALS AND METHODS: The study was prospective and included patients who were diagnosed with pathological humeral fractures, which required surgically orthopedic treatment. We selected three cases of pathological fractures of humerus in children each with its particularities, treated in the Department of Pediatric Surgery and Orthopedics, Emergency County Hospital, Arad, Romania. Treatment included curettage of the cyst, sampling for histopathological (HP) examination, bone substitution and titanium elastic nails (TEN) osteosynthesis. RESULTS: No complications and no recurrence were seen in the early postoperative period. CONCLUSIONS: Osteosynthesis with TEN and bone substitution is a viable option for treatment of pathological fracture of humerus, secondary to the osseous benign tumors, which required surgically treatment, despite the different HP aspects. By using a combined treatment in these cases, we eliminate the disadvantages of isolated use of the described techniques in the literature.

Clinico-imaging and morphological aspects of the benign serous ovarian epithelial tumors in children and adolescents.

Benign serous ovarian epithelial tumors represent a major area of interest in pediatric pathology through the incidence and the hormonal and reproductive implications that they induce. In this study, we analyzed 24 tumors diagnosed and surgically operated in children and adolescents, in relation to clinical, histological and immunohistochemical parameters, which can provide information on the potential for growth of lesions. The average age of diagnosis was 13.2 years, the majority of tumors being present in patients over 10 years (75%), with accompanying symptoms (83.3%), unilateral (91.7%) and dimensions of maximum 10 cm (66.7%). The histopathological aspect indicated a cystic growth pattern, sometimes papillary, and in three cases, the presence of atypical focal areas of the tumor epithelium. The Ki67 proliferation index values were higher in the case of tumors larger than 10 cm, those with papillary pattern, and in those with atypical areas, while p53 reactions were present only in cases with atypical proliferation areas. The parameters investigated in this study are useful both for assessing the risk of tumor growth and progression, as well as for stratifying patients for active clinical surveillance.

Does Point-of-Care Ultrasonography Improve Clinical Outcomes in Emergency Department Patients With Undifferentiated Hypotension? An International Randomized Controlled Trial From the SHoC-ED Investigators.

STUDY OBJECTIVE: Point-of-care ultrasonography protocols are commonly used in the initial management of patients with undifferentiated hypotension in the emergency department (ED). There is little published evidence for any mortality benefit. We compare the effect of a point-of-care ultrasonography protocol versus standard care without point-of-care ultrasonography for survival and clinical outcomes. METHODS: This international, multicenter, randomized controlled trial recruited from 6 centers in North America and South Africa and included selected hypotensive patients (systolic blood pressure <100 mm Hg or shock index >1) randomized to early point-of-care ultrasonography plus standard care versus standard care without point-of-care ultrasonography. Diagnoses were recorded at 0 and 60 minutes. The primary outcome measure was survival to 30 days or hospital discharge. Secondary outcome measures included initial treatment and investigations, admissions, and length of stay. RESULTS: Follow-up was completed for 270 of 273 patients. The most common diagnosis in more than half the patients was occult sepsis. We found no important differences between groups for the primary outcome of survival (point-of-care ultrasonography group 104 of 136 patients versus standard care 102 of 134 patients; difference 0.35%; 95% binomial confidence interval [CI] -10.2% to 11.0%), survival in North America (point-of-care ultrasonography group 76 of 89 patients versus standard care 72 of 88 patients; difference 3.6%; CI -8.1% to 15.3%), and survival in South Africa (point-of-care ultrasonography group 28 of 47 patients versus standard care 30 of 46 patients; difference 5.6%; CI -15.2% to 26.0%). There were no important differences in rates of computed tomography (CT) scanning, inotrope or intravenous fluid use, and ICU or total length of stay. CONCLUSION: To our knowledge, this is the first randomized controlled trial to compare point-of-care ultrasonography to standard care without point-of-care ultrasonography in undifferentiated hypotensive ED patients. We did not find any benefits for survival, length of stay, rates of CT scanning, inotrope use, or fluid administration. The addition of a point-of-care ultrasonography protocol to standard care may not translate into a survival benefit in this group.