Epidemiology and assessment of Hepatitis B positive children in Western Australia.

AIM: To describe the characteristics of patients with chronic hepatitis B (CHB) presenting to a tertiary paediatric hospital in Perth, Western Australia. Review of implementation of previous follow-up recommendations for the cohort was also undertaken. METHOD: A retrospective data analysis of all individuals aged between 0 and 17 years presenting to the tertiary children's hospital who were hepatitis B surface antigen (HBsAg) positive over 8 years (2013-2020). Demographic features, clinical progress and follow up are described, including proportion transferred to adult services. RESULTS: Seventy-four patients were identified to have CHB; mean age at diagnosis 11 years; standard deviation 4 years; 41 (55%) male. Cultural and ethnolinguistic diversity was high; 74% (n = 55) were from refugee-like backgrounds. Many did not demonstrate English proficiency (23/40; 75%) and 7 (10%) Australian born including 4 patients who were Aboriginal. Most patients (58%) with CHB were in the hepatitis B e antigen-positive chronic infection phase with no intervention provided. Seventeen children had undergone liver ultrasonography and one underwent liver biopsy; none received antiviral treatment. Follow up was concerning; 28 (38%) had at least one clinic non-attendance, 24 (32%) lost to follow-up and interpreter utilisation was poorly documented. Thirty-nine (53%) were transferred to adult services with only 56% attending follow-up. CONCLUSION: CHB burden is higher in those from culturally and ethnolinguistically diverse backgrounds. There is a significant loss to follow-up and suboptimal transfer to adult services. Improved recall, education and referral processes are necessary to overcome language, socioeconomic and cultural barriers. Although childhood complications are infrequent, longitudinal monitoring is crucial to prevent long-term complications and adult morbidity.

Osteochondral Allograft Transplant for Degenerative Joint Disease of the First Metatarsophalangeal Joint: A Case Report.

The first metatarsophalangeal joint is the most common location for arthritis in the foot. Pain and limited mobility associated with arthritis of the first metatarsophalangeal joint are the hallmarks of this disease. Treatments include shoe modification, orthotic devices, nonsteroidal anti-inflammatory drugs, injections, physical therapy, and surgery. Surgery has been the most perplexing, with surgical treatments ranging from simple ostectomies to fusion of the first metatarsophalangeal joint. Implant arthroplasty, with its various designs and techniques, has yet to be proven as the definitive solution for first metatarsophalangeal joint arthritis or hallux limitus (unlike the knee and hip). Interpositional arthroplasty and tissue-engineered cartilage grafts also have limitations when dealing with osteoarthritis and hallux limitus of the first metatarsophalangeal joint. In this case report, we present a 45-year-old woman with arthritis of the left first metatarsophalangeal joint who underwent surgical intervention by means of a frozen osteochondral allograft transplant to the first metatarsal head.

Predictors of Overweight and Obesity in Early Care and Education Teachers during COVID-19.

The purpose of this cross-sectional study was to determine individual, sociocultural, policy, and economic predictors of overweight/obesity in early care and education (ECE) teachers to identify modifiable opportunities to enhance the health of this critical workforce. ECE teachers (n = 1434) in the U.S. completed an online survey in late spring to mid-summer 2020. Teachers self-reported height and weight; body mass index (BMI) and weight status were calculated. Teachers reported micro-environment variables including age, race, gender, obesogenic lifestyle behaviors, well-being, food security, personal health, stress, job stress, type of ECE, COVID-19 teaching modality, and age of children in the classroom. Logistic regression predicting overweight/obesity and linear regression predicting BMI were conducted. Teachers with more years of teaching experience (OR: 1.022: 95% CI 1.005, 1.039) and higher consumption of fast food (2.038: 1.310, 3.169) had higher odds of overweight/obesity. Teachers with higher levels of education (0.58: 0.407, 0.828) and higher physical health (0.836: 0.775, 0.902) had lower odds of overweight/obesity. Other variables were not associated with overweight/obesity. Variables significant in logistic regression were also associated with higher BMI. Additionally, Native American race (ß = 2.467 SE = 1.206) and sedentary hours/day (ß = 0.152 SE = 0.075) were associated with higher BMI. Implications for enhancing workplace health for these ECE teachers are emerging.

Heart Failure as the Initial Presentation of Anomalous Left Coronary Artery From the Pulmonary Artery.

Coronary arteries arising from the pulmonary artery have an incidence of 0.002% in the general population. We present a 29-year-old woman who presented to our hospital with acute decompensated heart failure and atrial fibrillation with a rapid ventricular rate. She underwent a cardiac catheterization to rule out ischemic disease, which revealed retrograde contrast flow through the left coronary artery from the right coronary artery. A coronary computed tomography (CT) angiogram was pursued which showed the presence of an anomalous left coronary artery arising from the pulmonary artery (ALCAPA). For the management of her atrial fibrillation, she was electrically cardioverted. She was discharged on guideline-directed medical therapy for her heart failure, with a cardiac surgery referral for the surgical fixation of her ALCAPA.

Feasibility and Safety of Tethered Capsule Endomicroscopy in Patients With Barrett's Esophagus in a Multi-Center Study.

BACKGROUND & AIMS: Tethered capsule endomicroscopy (TCE) involves swallowing a small tethered pill that implements optical coherence tomography (OCT) imaging, procuring high resolution images of the whole esophagus. Here, we demonstrate and evaluate the feasibility and safety of TCE and a portable OCT imaging system in patients with Barrett's esophagus (BE) in a multi-center (5-site) clinical study. METHODS: Untreated patients with BE as per endoscopic biopsy diagnosis were eligible to participate in the study. TCE procedures were performed in unsedated patients by either doctors or nurses. After the capsule was swallowed, the device continuously obtained 10-µm-resolution cross-sectional images as it traversed the esophagus. Following imaging, the device was withdrawn through mouth, and disinfected for subsequent reuse. BE lengths were compared to endoscopy findings when available. OCT-TCE images were compared to volumetric laser endomicroscopy (VLE) images from a patient who had undergone VLE on the same day as TCE. RESULTS: 147 patients with BE were enrolled across all sites. 116 swallowed the capsule (79%), 95/114 (83.3%) men and 21/33 (63.6%) women (P = .01). High-quality OCT images were obtained in 104/111 swallowers (93.7%) who completed the procedure. The average imaging duration was 5.55 ± 1.92 minutes. The mean length of esophagus imaged per patient was 21.69 ± 5.90 cm. A blinded comparison of maximum extent of BE measured by OCT-TCE and EGD showed a strong correlation (r = 0.77-0.79). OCT-TCE images were of similar quality to those obtained by OCT-VLE. CONCLUSIONS: The capabilities of TCE to be used across multiple sites, be administered to unsedated patients by either physicians or nurses who are not expert in OCT-TCE, and to rapidly and safely evaluate the microscopic structure of the esophagus make it an emerging tool for screening and surveillance of BE patients. Clinical trial registry website and trial number: NCT02994693 and NCT03459339.

American College of Foot and Ankle Surgeons Clinical Consensus Statement: Appropriate Clinical Management of Adult-Acquired Flatfoot Deformity.

This clinical consensus statement of the American College of Foot and Ankle Surgeons focuses on the highly debated subject of the management of adult flatfoot (AAFD). In developing this statement, the AAFD consensus statement panel attempted to address the most relevant issues facing the foot and ankle surgeon today, using the best evidence-based literature available. The panel created and researched 16 statements and generated opinions on the appropriateness of the statements. The results of the research on this topic and the opinions of the panel are presented here.

Intranasal micro-optical coherence tomography imaging for cystic fibrosis studies.

Cystic fibrosis (CF) is a genetic disease caused by mutations in the CF transmembrane conductance regulator (CFTR) gene. Although impairment of mucociliary clearance contributes to severe morbidity and mortality in people with CF, a clear understanding of the pathophysiology is lacking. This is, in part, due to the absence of clinical imaging techniques capable of capturing CFTR-dependent functional metrics at the cellular level. Here, we report the clinical translation of a 1-µm resolution micro-optical coherence tomography (µOCT) technology to quantitatively characterize the functional microanatomy of human upper airways. Using a minimally invasive intranasal imaging approach, we performed a clinical study on age- and sex-matched CF and control groups. We observed delayed mucociliary transport rate at the cellular level, depletion of periciliary liquid layer, and prevalent loss of ciliation in subjects with CF. Distinctive morphological differences in mucus and various forms of epithelial injury were also revealed by µOCT imaging and had prominent effects on the mucociliary transport apparatus. Elevated mucus reflectance intensity in CF, a proxy for viscosity in situ, had a dominant effect. These results demonstrate the utility of µOCT to determine epithelial function and monitor disease status of CF airways on a per-patient basis, with applicability for other diseases of mucus clearance.

Global Forum: Spine Research and Training in Underserved, Low and Middle-Income, Culturally Unique Communities: The World Spine Care Charity Research Program's Challenges and Facilitators.

The World Spine Care (WSC), established by volunteers from 5 continents, is dedicated to providing sustainable, evidence-based spine care to individuals and communities in low and middle-income countries consistent with available health-care resources and integrated within the local culture. The research committee approves and oversees the WSC's collaborative research and training projects worldwide and serves to create a sustainable research community for underserved populations focused on preventing disability from spinal disorders. The purpose of this article is to describe 4 projects overseen by the WSC research committee and to discuss several challenges and specific facilitators that allowed successful completion of initiatives. These novel projects, which involved establishing spine surgery expertise and data collection in the WSC clinics and surrounding communities, all met their aims. This was achieved by overcoming language and resource challenges, adapting to local customs, and taking time to build mutual respect and to nurture relationships with local investigators and stakeholders.

Development of the CASH assessment tool to address existential concerns in patients with serious illness.

INTRODUCTION: Existential suffering in patients with serious illness significantly impacts quality of life, yet it remains a challenge to define, assess, and manage adequately. Improving upon understanding and practice in the existential domain is a topic of interest for palliative care providers. METHODS: As a quality improvement project, our palliative care team created an existential assessment tool utilizing a dialogue-oriented approach with four questions designed to identify sources of existential distress as well as strengths and challenges in coping with this distress. The tool utilized the mnemonic CASH, with each letter representing the core objective of the question. Providers who requested the palliative care consult were asked to evaluate the CASH assessment. On completion of the project, palliative care consultants evaluated the appropriateness of the CASH assessment tool. RESULTS: Patient responses to the CASH questions were insightful and reflected their beliefs, priorities, and concerns. Eight of nine providers found that the assessment enabled understanding of their patient. Seven noted a positive impact on their practice, and five reported an improvement in patient care after the assessment. The palliative care consultants who used the tool enjoyed using it, and half of them suggested changes to patient care based on their assessment. The most common reasons for not using the CASH assessment were inappropriateness to the consult, lack of perceived patient/caregiver receptiveness, or consultation service too busy. CONCLUSION: Our quality improvement project demonstrated that the CASH assessment tool is useful in ascertaining existential concerns of patients with serious illness. It enhances patient care by the primary team as well as the palliative care team. As a brief set of questions with an easy-to-remember mnemonic, the CASH assessment tool is feasible for a busy palliative consult service. Furthermore, the positive results of this project merit more rigorous evaluation of the CASH assessment tool in the future.

Detection and source tracking of Escherichia coli, harboring intimin and Shiga toxin genes, isolated from the Little Bighorn River, Montana.

The Little Bighorn River flows through the Crow Indian Reservation in Montana. In 2008, Escherichia coli concentrations as high as 7179 MPN/100 ml were detected in the river at the Crow Agency Water Treatment Plant intake site. During 2008, 2009, and 2012, 10 different serotypes of E. coli, including O157:H7, harboring both intimin and Shiga toxin genes were isolated from a popular swim site of the Little Bighorn River in Crow Agency. As part of a microbial source tracking study, E. coli strains were isolated from river samples as well as from manure collected from a large cattle feeding operation in the upper Little Bighorn River watershed; 23% of 167 isolates of E. coli obtained from the manure tested positive for the intimin gene. Among these manure isolates, 19 were identified as O156:H8, matching the serotype of an isolate collected from a river sampling site close to the cattle feeding area.

Bile salts affect expression of Escherichia coli O157:H7 genes for virulence and iron acquisition, and promote growth under iron limiting conditions.

Bile salts exhibit potent antibacterial properties, acting as detergents to disrupt cell membranes and as DNA-damaging agents. Although bacteria inhabiting the intestinal tract are able to resist bile's antimicrobial effects, relatively little is known about how bile influences virulence of enteric pathogens. Escherichia coli O157:H7 is an important pathogen of humans, capable of causing severe diarrhea and more serious sequelae. In this study, the transcriptome response of E. coli O157:H7 to bile was determined. Bile exposure induced significant changes in mRNA levels of genes related to virulence potential, including a reduction of mRNA for the 41 genes making up the locus of enterocyte effacement (LEE) pathogenicity island. Bile treatment had an unusual effect on mRNA levels for the entire flagella-chemotaxis regulon, resulting in two- to four-fold increases in mRNA levels for genes associated with the flagella hook-basal body structure, but a two-fold decrease for "late" flagella genes associated with the flagella filament, stator motor, and chemotaxis. Bile salts also caused increased mRNA levels for seventeen genes associated with iron scavenging and metabolism, and counteracted the inhibitory effect of the iron chelating agent 2,2'-dipyridyl on growth of E. coli O157:H7. These findings suggest that E. coli O157:H7 may use bile as an environmental signal to adapt to changing conditions associated with the small intestine, including adaptation to an iron-scarce environment.

Metastatic bone cancer of the foot: a case report.

Metastasis to the foot is rarely presented in the literature. We describe a 56-year-old woman with nonspecific pain in the left foot, ankle, and knee for 3 months. The patient was diagnosed as having urothelial carcinoma with metastasis to the left lower extremity, including the foot. This diagnosis was reached through the combined efforts of radiologic techniques and biopsies. This case discusses the importance of paying close attention to the details of the history and physical examination, performing appropriate tests, and obtaining suitable referrals.

El síndrome cardiorenal en insuficiencia cardíaca: un paradigma en evolución / The cardiorenal syndrome in heart failure: an envolving paradigm

Background: Heart failure constitutes a significant source of morbidity and mortality in the United States and its incidence and prevalence continue to grow, increasing its burden on the health care system. Renal dysfunction in patients with heart failure is common and has been associated with adverse clinical outcomes. This interaction, termed the cardiorenal syndrome, is a complex phenomenon characterized by a pathophysiological disequilibrium between the heart and the kidney, in which malfunction of one organ subsequently promotes the impairment of the other. Multiple neuro-humoral mechanisms are involved in this cardiorenal interaction, including the deficiency of and/or resistance to compensatory natriuretic peptides, leading to sodium retention, volume overload and organ remodeling. Management of patients with the cardiorenal syndrome can be challenging and should be individualized. Emerging therapies must address the function of both organs in order to secure better clinical outcomes. To this end, a multidisciplinary approach is recommended to achieve optimal results.

The cardiorenal syndrome in heart failure: an evolving paradigm.

Heart failure constitutes a significant source of morbidity and mortality in the United States, and its incidence and prevalence continue to grow, increasing its burden on the healthcare system. Renal dysfunction in patients with heart failure is common and has been associated with adverse clinical outcomes. This interaction, termed the cardiorenal syndrome, is a complex phenomenon characterized by a pathophysiologic disequilibrium between the heart and the kidney, in which malfunction of 1 organ consequently promotes the impairment of the other. Multiple neurohumoral mechanisms are involved in this cardiorenal interaction, including the deficiency of and/or resistance to compensatory natriuretic peptides, leading to sodium retention, volume overload and organ remodeling. Management of patients with the cardiorenal syndrome can be challenging and should be individualized. Emerging therapies must address the function of both organs to secure better clinical outcomes. To this end, a multidisciplinary approach is recommended to achieve optimal results.

Minimizing decomposition of vaporized hydrogen peroxide for biological decontamination of galvanized steel ducting.

The behavior of vaporous hydrogen peroxide (VHP) was examined in clean, room-scale galvanized steel (GS) and polyvinylchloride-coated steel air ducts, to understand how it might be used to decontaminate larger ventilation systems. VHP injected into the GS duct decreased in concentration along the length of the duct, whereas VHP concentrations in the polyvinylchloride coated duct remained essentially constant, suggesting that VHP decomposed at the GS surface. However, decomposition was reduced at lower temperatures (approximately 22 degrees C) and higher flow rates (approximately 80 actual cubic meter per hour). A computational fluid dynamics model incorporating reactive transport was used to estimate surface VHP concentrations where bioaerosol contamination is likelyto reside, and also showed that VHP decomposition was enhanced at bends within the duct, compared to straight sections. Use of G. stearothermophilus indicators, in conjunction with model estimates, indicated that a concentration-contact time of approximately 100 mg/L H2O2(g) x min was required to achieve a 6 log reduction of indicator spores in clean GS duct, at 30 degrees C. When VHP is selected for building decontamination, this work suggests the most efficacious strategy may be to decontaminate GS ducting separately from the rest of the building, as opposed to a single decontamination event in which the ventilation system is used to distribute VHP throughout the entire building.

Nitinol compression staples for bone fixation in foot surgery.

We reviewed the use of compression staples made of the memory metal alloy nitinol for fixation in foot surgery. A retrospective study was performed of 31 feet in 27 patients who underwent arthrodesis or an osteotomy fixated using compression staples. OSStaples (BME, San Antonio, Texas) were used in 18 feet, and Memodyn staples (Telos Medical, Fallston, Maryland) were used in 13 feet. A total of 48 compression staples were implanted. The following procedures were performed and fixated using compression staples: 15 Akin osteotomies, 2 first metatarsal base epiphysiodeses, 3 first metatarsal-cuneiform fusions, 2 naviculocuneiform fusions, 3 calcaneocuboid fusions, 4 talonavicular fusions, 3 subtalar joint fusions, and 2 Evans osteotomies. In our clinical experience, compression staples provide an adequate source of internal fixation in foot surgery. Good bone apposition and stabilization and compression of the bone surfaces before staple fixation are important when using staple fixation to promote an optimal environment for bone healing.

NuGen Fx bioabsorbable screws: a preliminary report of their use in foot surgery.

A single prospective group study in adults was performed using a new bioabsorbable screw, the NuGen Fx screw (Linvatec Biomaterials Ltd, Tampere, Finland). This multisite study included five sites and 50 patients (10 patients per site). The goal of this study was to evaluate the efficiency and safety of the NuGen Fx screw system in the fixation of osteotomies, arthrodeses, and fractures in the foot and ankle. We discuss our own results from 12 patients treated at the Kentucky Podiatric Residency Program at Norton Audubon Hospital, Louisville. The number of patients in the study, screw sizes, instrumentation, radiologic evaluation findings, and our overview of this implant are presented.

Urolithiasis associated with experimental lymphocytic choriomeningitis virus inoculation in Lewis rats.

A high frequency of struvite urolithiasis, hydronephrosis, and other urinary tract lesions developed in a group of Lewis rats inoculated intracranially with lymphocytic choriomeningitis virus (LCMV). Initially, clinically ill rats were referred to necropsy: 30 rats over 3 years. These rats had high frequency of urolithiasis (8/30, 27%), hydronephrosis (12/30, 40%), cystitis (9/30, 30%), transitional cell carcinoma (4/30, 13%), and pyelonephritis (19/30, 63%). Lesions were more common in LCMV-inoculated rats. After this trend was noted, all rats on this protocol were necropsied as part of a cohort study (n = 144). Although the apparent frequency of disease was lower due to increased sampling, there still was a high number of urolithiasis (9/144, 6%) and hydronephrosis (40/144, 28%) cases. All cases of urolithiasis developed in rats inoculated with LCMV (9/44, 20%), as did most cases of hydronephrosis (31/44, 70%). Although sham-injected and uninoculated control rats also had high frequency of hydronephrosis (6/57 [11%] and 3/43 [7%], respectively), LCMV-inoculated rats had a significantly higher frequency of disease than did sham inoculated (P < 0.0001) and uninoculated (P < 0.0001) controls. These results suggest that Lewis rats may be predisposed to developing lesions of the urinary tract, and that intracranial inoculation of rats with LCMV augments this tendency, leading to formation of struvite calculi and associated urinary tract disease.

Contamination of water supplies with Cryptosporidium parvum and Giardia lamblia and diarrheal illness in selected Russian cities.

Cryptosporidium parvum and Giardia lamblia are important agents of waterborne diarrheal illness worldwide. While giardiasis is routinely diagnosed in Russia with a chemical staining technique, data on the prevalence of cryptosporidiosis are scarce. Monitoring of the respective parasites in water supplies in Russia is very limited. A health survey conducted in the city of Cherepovets and three other cities in the European part of Russia using enzyme-linked immunosorbent assays (ELISA) demonstrated that 6.9% of diarrheal patients tested had C. parvum antigens in their fecal samples; 9.4% had G. lamblia antigens. A survey of occurrence of these parasites in water supplies in Cherepovets and seven other cities demonstrated that source and finished water samples from several of these cities were contaminated with either C. parvum oocysts or G. lamblia cysts. The surveys were not designed to assess associations between presence or concentrations of C. parvum and G. lamblia in water and related gastrointestinal diseases in exposed populations. Rather, the goals were to demonstrate the presence of disinfection-resistant protozoan parasites in untreated and treated waters, and the importance of these pathogens as causative agents of diarrheal illnesses in a number of Russian cities.

Cortical bone pin fixation: a preliminary report on fixation of digital arthrodeses and distal chevron first metatarsal osteotomies.

From 1998 to 1999, the senior author utilized Allofix cortical bone pins for primary fixation of 40 first metatarsal distal chevron osteotomies and 30 digital arthrodeses in 42 patients. Radiographs of each patient were evaluated for the presence of graft incorporation, union of the osteotomy or fusion site, and postoperative migration of the osseous segments. In 70 procedures, the average time for graft incorporation as evaluated by the absence of graft visualization on radiographs was 4 months. Complications included one case of graft displacement. The results indicate that Allofix cortical bone pins are a reliable, safe, and effective method for the fixation of first metatarsal distal chevron osteotomies and phalangeal arthrodeses of the foot.