Detection of Rotavirus in Respiratory Specimens From Bangladeshi Children Aged <2 Years Hospitalized for Acute Gastroenteritis.

To examine the potential for respiratory transmission of rotavirus, we systematically assessed if rotavirus RNA is detectable by real-time quantitative reverse transcription-polymerase chain reaction from nasal and oropharyngeal swab specimens of Bangladeshi children with acute rotavirus gastroenteritis. Forehead swabs were collected to assess skin contamination. Among 399 children aged <2 years hospitalized for gastroenteritis during peak rotavirus season, rotavirus RNA was detected in stool, oral, nasal and forehead swab specimens of 354 (89%). A subset was genotyped; genotype was concordant within a child's specimen set and several different genotypes were detected across children. These findings support possible respiratory transmission of rotavirus and warrant further investigation.

Impact of the COVID-19 Pandemic on Emergency Department Encounters in a Major Metropolitan Area.

BACKGROUND: The end of 2019 marked the emergence of the COVID-19 pandemic. Public avoidance of health care facilities, including the emergency department (ED), has been noted during prior pandemics. OBJECTIVE: This study described pandemic-related changes in adult and pediatric ED presentations, acuity, and hospitalization rates during the pandemic in a major metropolitan area. METHODS: The study was a cross-sectional analysis of ED visits occurring before and during the pandemic. Sites collected daily ED patient census; monthly ED patient acuity, as the Emergency Severity Index (ESI) score; and disposition. Prepandemic ED visits occurring from January 1, 2019 through December 31, 2019 were compared with ED visits occurring during the pandemic from January 1, 2020 through March 31, 2021. The change in prepandemic and pandemic ED volume was found using 7-day moving average of proportions. RESULTS: The study enrolled 83.8% of the total ED encounters. Pandemic adult and pediatric visit volume decreased to as low as 44.7% (95% CI 43.1-46.3%; p < 0.001) and 22.1% (95% CI 19.3-26.0%; p < 0.001), respectively, of prepandemic volumes. There was also a relative increase in adult and pediatric acuity (ESI level 1-3) and the admission percentage for adult (20.3% vs. 22.9%; p < 0.01) and pediatric (5.1% vs. 5.6%; p < 0.01) populations. CONCLUSIONS: Total adult and pediatric encounters were reduced significantly across a major metropolitan area. Patient acuity and hospitalization rates were relatively increased. The development of strategies for predicting ED avoidance will be important in future pandemics.

A Goat Cadaver as a Cost-effective Resource for Teaching Emergency Medicine Procedures in Kijabe, Kenya.

BACKGROUND: A pediatric emergency medicine and critical care fellowship was recently developed in Kenya through the University of Nairobi/Kenyatta National Hospital and AIC Kijabe Hospital. As part of this training, a week-long trauma and emergency medicine course was developed with emphasis on trauma and emergency medicine procedures. Given limited resources, we developed a course with simulation of procedures centered around utilization of a goat cadaver. OBJECTIVE: The aim of the study was to describe fellow and faculty experiences and perspectives when using a goat cadaver to teach emergency medicine procedures by simulation in Kijabe, Kenya. METHODS: A 5-day course was given to 2 fellows with a variety of didactics and simulations after which fellows completed a questionnaire to rate their satisfaction with the content and teaching effectiveness. RESULTS: The course was rated very highly, with an average content satisfaction score of 4.5 5 and average teaching effectiveness score of 4.4 of 5. Qualitative faculty feedback was positive, with specific learnings allowing ongoing adaptation of this model. CONCLUSIONS: A goat cadaver is a cost-effective resource not often considered that can be adequately used to teach several emergency medicine skills by simulation.

Rotavirus Vaccine Is Effective Against Rotavirus Gastroenteritis Resulting in Outpatient Care: Results From the Medically Attended Acute Gastroenteritis (MAAGE) Study.

BACKGROUND: Rotavirus is a common cause of severe pediatric acute gastroenteritis. Two vaccines are licensed in the United States and have demonstrated high effectiveness against moderate to severe disease. However, fewer data are available on rotavirus vaccine effectiveness (VE) against milder disease. METHODS: We leveraged active surveillance data from Kaiser Permanente Northwest to calculate rotavirus VE against medically attended rotavirus illness among age-eligible children. We utilized a test-negative case-control design and applied 4 distinct case definitions based on reverse transcription-quantitative real-time PCR (qRT-PCR) assay and enzyme immunoassay (EIA) test results. VE was calculated as 100 × (1 - odds ratio), and models were adjusted for age group. RESULTS: The VE analysis population comprised 842 children, 799 (95%) of whom had mild disease requiring at most a clinic visit and 698 (83%) of whom were fully vaccinated against rotavirus. Age-adjusted VE was 70% (95% confidence interval [CI], 37-86%) against disease defined solely by qRT-PCR results, 72% (95% CI, 31-89%) against disease as defined by qRT-PCR with a quantification cycle (C q ) value <27, 73% (95% CI, 32-90%) against disease that was qRT-PCR positive but EIA negative, and 62% (95% CI, -20-88%) against disease defined solely by EIA. Results were similar when restricting to disease resulting in at most an ambulatory clinic or emergency department visit. CONCLUSIONS: These results support the effectiveness of rotavirus vaccination in protecting US children from mild to moderate and severe disease. Our findings are also useful to show the effectiveness of rotavirus vaccination against qRT-PCR-defined illness.

Development of a Real-Time Reverse Transcription-PCR Assay To Detect and Quantify Group A Rotavirus Equine-Like G3 Strains.

Since 2013, group A rotavirus strains characterized as novel DS-1-like intergenogroup reassortant "equine-like G3" strains have emerged and spread across 5 continents among human populations in at least 14 countries. Here, we report a novel one-step TaqMan quantitative real-time reverse transcription-PCR assay developed to genotype and quantify the viral load for samples containing rotavirus equine-like G3 strains. Using a universal G forward primer and a newly designed reverse primer and TaqMan probe, we developed and validated an assay with a linear dynamic range of 227 to 2.3 × 109 copies per reaction and a limit of detection of 227 copies. The percent positive agreement, percent negative agreement, and precision of our assay were 100.00%, 99.63%, and 100.00%, respectively. This assay can simultaneously detect and quantify the viral load for samples containing DS-1-like intergenogroup reassortant equine-like G3 strains with high sensitivity and specificity, faster turnaround time, and decreased cost. It will be valuable for high-throughput screening of stool samples collected to monitor equine-like G3 strain prevalence and circulation among human populations throughout the world.

A SWOT Analysis of Urology Residency.

PURPOSE OF REVIEW: Residency training is a pivotal educational step on the road to becoming a urologist. It combines both clinical and surgical instruction with the goal of producing proficient and compassionate surgeons and clinicians. In this review, we employ a SWOT analysis (Strengths, Weaknesses, Opportunities, and Threats) to investigate the current state of urologic residency training. RECENT FINDINGS: Urology remains an attractive and competitive residency with varied and complex surgical and medical training. Areas for improvement include standardization of evaluation and feedback, improving resident wellness, and expanding the use of surgical simulation. Workforce issues such as the predicted urologist supply deficit and poor readiness to enter the business of medicine can be addressed at the residency level. Failure to attract and retain underrepresented minorities, increasing burden of student debt, and resident burnout are serious threats to our field. Using a SWOT analysis we identify key areas for expansion, underscore valuable strengths, and provide a working roadmap for improvement of these formative years.

The role of perioperative medications in urinary retention following midurethral sling.

AIMS: Postoperative urinary retention (PUR) is a known complication of midurethral sling (MUS) placement. The use of certain perioperative medications may influence the risk of this complication. This study aimed to investigate the association of perioperative medications with urinary retention after MUS. METHODS: This was a retrospective study of women undergoing MUS placement for stress urinary incontinence by a fellowship-trained urologic surgeon between 2015 and 2018, under approval by the Institutional Review Board. Both retropubic and transobturator approaches were included. All patients underwent an active void trial following surgery. Intraoperative medications given by the anesthesia team were retrospectively noted. The Fisher's exact test was used to compare the association of PUR with categorical variables. RESULTS: A total of 82 patients were included, 17 (21%) of whom failed postoperative void trial due to urinary retention. Of 25 patients receiving perioperative scopolamine, 40% failed the postoperative void trial, compared to 12% of patients not receiving scopolamine (p = .048). Groups were then stratified based on scopolamine use due to the observed independent association with PUR. Subgroup analysis revealed a stronger association of postoperative retention with scopolamine in patients undergoing concomitant prolapse surgery. Notably, retention rate and scopolamine use were similar whether patients underwent sling placement alone or in combination with prolapse surgery. Rate of retention was also higher for retropubic versus transobturator slings (36% vs. 9%; p = .005). CONCLUSIONS: Perioperative scopolamine may be associated with an increased risk of postoperative urinary retention following MUS, especially in the setting of a concomitant prolapse surgery.

Nocturnal Enuresis in the Adult.

PURPOSE OF REVIEW: The goal of this paper is to describe the pathophysiology of adult nocturnal enuresis and develop a generalized approach for evaluation and treatment. RECENT FINDINGS: Although nocturnal enuresis (NE) impacts a significant proportion of the adult population, research on this topic remains lacking. In the few existing studies, the management strategy is extrapolated from research on pediatric nocturnal enuresis. Furthermore, treatment approaches highlight the importance of identifying risk factors and contributing pathologies. The modern urologist should understand the complexity of this problem and the variety of techniques to evaluate and treat the adult patient with NE. Adult nocturnal enuresis is multifactorial and may have multiple underlying pathologies. A comprehensive workup requires an understanding of the patient's history and symptomatology and the pathophysiologic processes that can occur. Treatment should first target identifiable etiologies, although a generalized algorithm can then be utilized with behavioral and lifestyle modifications, followed by medical therapy. Future studies will provide a better framework for treating this problem.

Are testers also admitters? Comparing emergency physician resource utilization and admitting practices.

OBJECTIVE: To describe the relationship between emergency department resource utilization and admission rate at the level of the individual physician. METHODS: Retrospective observational study of physician resource utilization and admitting data at two emergency departments. We calculated observed to expected (O/E) ratios for four measures of resource utilization (intravenous medications and fluids, laboratory testing, plain radiographs, and advanced imaging studies) as well as for admission rate. Expected values reflect adjustment for patient- and time-based variables. We compared O/E ratios for each type of resource utilization to the O/E ratio for admission for each provider. We report degree of correlation (slope of the trendline) and strength of correlation (adjusted R2 value) for each association, as well as categorical results after clustering physicians based on the relationship of resource utilization to admission rate. RESULTS: There were statistically significant positive correlations between resource utilization and physician admission rate. Physicians with lower resource utilization rates were more likely to have lower admission rates, and those with higher resource utilization rates were more likely to have higher admission rates. CONCLUSIONS: In a two-facility study, emergency physician resource utilization and admission rate were positively correlated: those who used more ED resources also tended to admit more patients. These results add to a growing understanding of emergency physician variability.

Examining Hemodialysis Reliable Outflow catheter performance and cost in hemodialysis access.

BACKGROUND: The Hemodialysis Reliable Outflow (HeRO) vascular access device is a hybrid polytetrafluoroethylene graft-stent construct designed to address central venous occlusive disease. Although initial experience has demonstrated excellent mid-term patency rates, subsequent studies have led to external validity questions. The purpose of this study was to examine a single center experience with this vascular access device in challenging access cases with associated costs. METHODS: A retrospective study representing the authors' cumulative HeRO vascular access device experience was undertaken. The primary endpoint was graft failure or death, with secondary endpoints including secondary intervention rates and cost. RESULTS: Forty-one patients with 15,579 HeRO days and a mean of 12.7 ± 1.5 mo with the vascular access device were available for analysis. Secondary patency was 81.6% at 6 mo and 53.7% at 12 mo. The reintervention rate was 2.84 procedures per HeRO vascular access device year. Associated HeRO costs related to subsequent procedures were estimated at $34,713.63 per patient/y. CONCLUSIONS: These data on the patency and primary outcome data diverge significantly from initial multicenter studies and represent a real-world application of this technology. It is costly to maintain patency. Use of HeRO vascular access devices should be judicious with outcome expectations reduced.

A novel concept in residency education: case-based remediation.

BACKGROUND: Resident remediation is required for all residents who do not meet minimum standards in one or more of the Accreditation Council for Graduate Medical Education core competencies. The Council of Residency Directors in Emergency Medicine Remediation Taskforce identified the need for case-based examples of remediation efforts. OBJECTIVES: 1) To describe a complicated resident remediation case and employ consensus panel evaluation of the process. 2) To discuss the available assessment tools (including neuropsychologic/medical testing), due process, documentation, reassessment, and relevant barriers to implementation for this and other resident remediations. DISCUSSION: Details of a remediation case were altered to protect resident confidentiality, and then presented to a multidisciplinary group of program directors. The case details, action plan, and course were submitted and the remediation process, action plan, and course are assessed based on a standardized remediation approach. The resident entered remediation for poor organizational skills and an inability to make or follow through with patient care plans. Opportunities for improvement in the applied remediation process are identified and discussed. Legal concerns and utility of neuropsychological assessment of residents are reviewed. CONCLUSIONS: Remediation requires a complicated and detailed effort. This case demonstrates issues that program directors may face when working with residents and provides suggestions for use of specific remediation tools.

Implications of Opioid Prescriptions for Acute Renal Colic in the Emergency Setting on Return Visits and Long-Term Opioid Dependence.

Introduction: We sought to examine the practice patterns of pain management in the emergency room (ER) for renal colic and the impact of opioid prescriptions on return ER visits and persistent opioid use. Methods: TriNetX is a collaborative research enterprise that collects real-time data from multiple health care organizations within the United States. The Research Network obtains data from electronic medical records and the Diamond Network provides claims data. We queried the Research Network for adults who visited the ER for urolithiasis, stratified by receipt of oral opioid prescriptions, to calculate the risk ratio (RR) of patients returning to the ER within 14 days and persistent opioid use ≥6 months from the initial visit. Propensity score matching was performed to control for confounders. The analysis was repeated in the Diamond Network as a validation cohort. Results: There were 255,447 patients in the research network who visited the ER for urolithiasis, of whom 75,405 (29.5%) were prescribed oral opioids. Black patients were less likely to receive opioid prescriptions than other races (p < 0.001). After propensity score matching, patients who were prescribed opioids had an increased risk of a return ER visit (RR 1.25, confidence interval [95% CI] 1.22-1.29, p < 0.001) and persistent opioid use (RR 1.12, 95% CI 1.11-1.14, p < 0.001) compared with patients who were not prescribed opioids. These findings were confirmed in the validation cohort. Conclusions: A significant proportion of patients presenting to the ER for urolithiasis receive opioid prescriptions, which carries a markedly increased risk of return ER visits and long-term opioid use.

Coding-complete genome sequences of rotavirus A reference strains EDIM, Ph158, and CC425.

This study reports the coding-complete genome sequences of three rotavirus A (RVA) reference strains previously adapted in tissue culture: RVA/Mouse-tc/USA/EDIM/XXXX/G16P[16] with a G16-P[16]-I7-R7-C7-M8-A7-N7-T10-E7-H9 genotype constellation, RVA/Human-tc/USA/Ph158/1998/G9P[6] with a G9-P[6]-I2-R2-C2-M2-A2-N2-T2-E2-H2 genotype constellation, and RVA/Human-tc/USA/CC425/1998/G3P[9] with a G3-P[9]-I2-R2-C2-M2-A3-N2-T1-E2-H3 genotype constellation.

Whole genome analysis of rotavirus strains circulating in Benin before vaccine introduction, 2016-2018.

Species A rotaviruses (RVA) still play a major role in causing acute diarrhea in children under five years old worldwide. Currently, an 11-gene classification system is used to designate the full genotypic constellations of circulating strains. Viral proteins and non-structural proteins in the order VP7-VP4-VP6-VP1-VP2-VP3-NSP1-NSP2-NSP3-NSP4-NSP5/6 are represented by the genotypes Gx-P[x]-Ix-Rx-Cx-Mx-Ax-Nx-Tx-Ex-Hx, respectively. In Benin, ROTAVAC® vaccine was introduced into the Expanded Programme on Immunization in December 2019. To monitor circulating RVA strains for changes that may affect vaccine performance, in-depth analysis of strains prior to vaccine introduction are needed. Here we report, the whole-gene characterization (11 ORFs) for 72 randomly selected RVA strains of common and unusual genotypes collected in Benin from the 2016 to 2018 seasons. The sequenced strains were 15 G1P[8], 20 G2P[4], 5 G9P[8], 14 G12P[8], 9 G3P[6], 2 G1P[6], 3 G2P[6], 2 G9P[4], 1 G12P[6], and 1 G1G9P[8]/P[4]. The study strains exhibited two genetic constellations designed as Wa-like G1/G9/G12-P[6]/P[8]-I1-R1-C1-M1-A1-N1-T1-E1-H1 and DS-1-like G2/G3/G12-P[4]/P[6]-I2-R2-C2-M2-A2-N2-T2-E2-H2. Genotype G9P[4] strains possessed a DS-1-like genetic constellation with an E6 NSP4 gene, G9-P[4]-I2-R2-C2-M2-A2-N2-T2-E6-H2. The mixed genotype showed both Wa-like and DS-1-like profiles with a T6 NSP3 gene G1/G9P[8]/[4]-I1/I2-R1/R2-C1/C2-M1/M2-A1/A2-N1/N2-T1/T6-E1/E6-H1/H2. At the allelic level, the analysis of the Benin strains, reference strains (with known alleles), vaccine strains (with known alleles) identified 2-13 and 1-17 alleles for DS-1-like and Wa-like strains, respectively. Most of the study strains clustered into previously defined alleles, but we defined 3 new alleles for the VP7 (G3 = 1 new allele and G12 = 2 new alleles) and VP4 (P[4] = 1 new allele and P[6] = 2 new alleles) genes which formed the basis of the VP7 and VP4 gene clusters, respectively. For the remaining 9 genes, 0-6 new alleles were identified for both Wa-like and DS-1-like strains. This analysis of whole genome sequences of RVA strains circulating in Benin described genetic point mutations and reassortment events as well as novel alleles. Further detailed studies on these new alleles are needed and these data can also provide a baseline for studies on RVA in the post-vaccination period.

The Nazi engineers: reflections on technological ethics in hell.

Engineers, architects, and other technological professionals designed the genocidal death machines of the Third Reich. The death camp operations were highly efficient, so these technological professionals knew what they were doing: they were, so to speak, good engineers. As an educator at a technological university, I need to explain to my students-future engineers and architects-the motivations and ethical reasoning of the technological professionals of the Third Reich. I need to educate my students in the ethical practices of this hellish regime so that they can avoid the kind of ethical justifications used by the Nazi engineers. In their own professional lives, my former students should not only be good engineers in a technical sense, but good engineers in a moral sense. In this essay, I examine several arguments about the ethical judgments of professionals in Nazi Germany, and attempt a synthesis that can provide a lesson for contemporary engineers and other technological professionals. How does an engineer avoid the error of the Nazi engineers in their embrace of an evil ideology underlying their technological creations? How does an engineer know that the values he embodies through his technological products are good values that will lead to a better world? This last question, I believe, is the fundamental issue for the understanding of engineering ethics.

Whole gene analysis of a genotype G29P[6] human rotavirus strain identified in Central African Republic.

OBJECTIVE: Rotavirus A (RVA) remains the main causative agent of gastroenteritis in young children and the young of many mammalian and avian species. In this study we describe a RVA strain detected from a 6-month-old child from Central African Republic (CAR). RESULTS: We report the 11 open reading frame sequences of a G29-P[6]-I2-R2-C2-M2-A2-N2-T2-E2-H2 rotavirus strain, RVA/Human-wt/CAR/CAR91/2014/G29P[6]. Nine genes (VP1-VP3, VP6, NSP1-NSP5) shared 90-100% sequence similarities with genogroup 2 rotaviruses. Phylogenetically, backbone genes, except for VP3 and NSP4 genes, were linked with cognate gene sequences of human DS-1-like genogroup 2, hence their genetic origin. The VP3 and NSP4 genes, clustered genetically with both human and animal strains, an indication genetic reassortment human and animal RVA strains has taken place. The VP7 gene shared nucleotide (93-94%) and amino acid (95.5-96.7%) identities with Kenyan and Belgian human G29 strains, as well as to buffalo G29 strain from South Africa, while the VP4 gene most closely resembled P[6]-lineage I strains from Africa and Bangladesh (97%).