Measuring the density structure of an accretion hot spot.

Magnetospheric accretion models predict that matter from protoplanetary disks accretes onto stars via funnel flows, which follow stellar magnetic field lines and shock on the stellar surfaces1-3, leaving hot spots with density gradients4-6. Previous work has provided observational evidence of varying density in hot spots7, but these observations were not sensitive to the radial density distribution. Attempts have been made to measure this distribution using X-ray observations8-10; however, X-ray emission traces only a fraction of the hot spot11,12 and also coronal emission13,14. Here we report periodic ultraviolet and optical light curves of the accreting star GM Aurigae, which have a time lag of about one day between their peaks. The periodicity arises because the source of the ultraviolet and optical emission moves into and out of view as it rotates along with the star. The time lag indicates a difference in the spatial distribution of ultraviolet and optical brightness over the stellar surface. Within the framework of a magnetospheric accretion model, this finding indicates the presence of a radial density gradient in a hot spot on the stellar surface, because regions of the hot spot with different densities have different temperatures and therefore emit radiation at different wavelengths.

Clinical Laboratory Biosafety Gaps: Lessons Learned from Past Outbreaks Reveal a Path to a Safer Future.

Patient care and public health require timely, reliable laboratory testing. However, clinical laboratory professionals rarely know whether patient specimens contain infectious agents, making ensuring biosafety while performing testing procedures challenging. The importance of biosafety in clinical laboratories was highlighted during the 2014 Ebola outbreak, where concerns about biosafety resulted in delayed diagnoses and contributed to patient deaths. This review is a collaboration between subject matter experts from large and small laboratories and the federal government to evaluate the capability of clinical laboratories to manage biosafety risks and safely test patient specimens. We discuss the complexity of clinical laboratories, including anatomic pathology, and describe how applying current biosafety guidance may be difficult as these guidelines, largely based on practices in research laboratories, do not always correspond to the unique clinical laboratory environments and their specialized equipment and processes. We retrospectively describe the biosafety gaps and opportunities for improvement in the areas of risk assessment and management; automated and manual laboratory disciplines; specimen collection, processing, and storage; test utilization; equipment and instrumentation safety; disinfection practices; personal protective equipment; waste management; laboratory personnel training and competency assessment; accreditation processes; and ethical guidance. Also addressed are the unique biosafety challenges successfully handled by a Texas community hospital clinical laboratory that performed testing for patients with Ebola without a formal biocontainment unit. The gaps in knowledge and practices identified in previous and ongoing outbreaks demonstrate the need for collaborative, comprehensive solutions to improve clinical laboratory biosafety and to better combat future emerging infectious disease outbreaks.

Advancing Diagnostic Stewardship for Healthcare-Associated Infections, Antibiotic Resistance, and Sepsis.

Diagnostic stewardship means ordering the right tests for the right patient at the right time to inform optimal clinical care. Diagnostic stewardship is an integral part of antibiotic stewardship efforts to optimize antibiotic use and improve patient outcomes, including reductions in antibiotic resistance and treatment of sepsis. The Centers for Disease Control and Prevention's Division of Healthcare Quality Promotion hosted a meeting on improving patient safety through diagnostic stewardship with a focus on use of the laboratory. At the meeting, emerging issues in the field of diagnostic stewardship were identified, awareness of these issues among stakeholders was raised, and strategies and interventions to address the issues were discussed-all with an emphasis on improved outcomes and patient safety. Here, we summarize the key takeaways of the meeting including needs for diagnostic stewardship implementation, promising future avenues for diagnostic stewardship implementation, and areas of needed research.

COVID-19 Self-Test Data: Challenges and Opportunities - United States, October 31, 2021-June 11, 2022.

Self-tests* to detect current infection with SARS-CoV-2, the virus that causes COVID-19, are valuable tools that guide individual decision-making and risk reduction† (1-3). Increased self-test use (4) has likely contributed to underascertainment of COVID-19 cases (5-7), because unlike the requirements to report results of laboratory-based and health care provider-administered point-of-care COVID-19 tests,§ public health authorities do not require reporting of self-test results. However, self-test instructions include a recommendation that users report results to their health care provider so that they can receive additional testing and treatment if clinically indicated.¶ In addition, multiple manufacturers of COVID-19 self-tests have developed websites or companion mobile applications for users to voluntarily report self-test result data. Federal agencies use the data reported to manufacturers, in combination with manufacturing supply chain information, to better understand self-test availability and use. This report summarizes data voluntarily reported by users of 10.7 million self-tests from four manufacturers during October 31, 2021-June 11, 2022, and compares these self-test data with data received by CDC for 361.9 million laboratory-based and point-of-care tests performed during the same period. Overall trends in reporting volume and percentage of positive results, as well as completeness of reporting demographic variables, were similar across test types. However, the limited amount and quality of data reported from self-tests currently reduces their capacity to augment existing surveillance. Self-tests provide important risk-reduction information to users, and continued development of infrastructure and methods to collect and analyze data from self-tests could improve their use for surveillance during public health emergencies.

Long-term cancer surveillance: results from the Forteo Patient Registry Surveillance Study.

The Forteo Patient Registry estimated the incidence of osteosarcoma in US patients treated with teriparatide and enrolled in the study between 2009 and 2019. No incident cases of osteosarcoma were identified among patients registered, and the crude incidence rate was 0 (95% confidence interval [CI], 0-10.2) cases per million person-years. PURPOSE: The prospective, voluntary Forteo Patient Registry was established to estimate the incidence of osteosarcoma in patients who have received treatment with teriparatide (Forteo). METHODS: Information on US adults prescribed teriparatide and enrolled in the Forteo Patient Registry 2009-2019 was linked with data from participating state cancer registries annually (2010-2019) to identify incident osteosarcoma cases using a standardized linkage algorithm. Teriparatide exposure was ascertained from self-reported data that included teriparatide initiation and demographics necessary to complete linkage. Osteosarcoma cases diagnosed on or after January 1, 2009, were identified by participating state cancer registries. The crude incidence rate (IR) and standardized incidence ratio (SIR) of observed cases to the expected number of cases adjusted to the background rate (3 per million person-years) and corresponding 95% CIs for the occurrence of osteosarcoma were calculated whereby the cumulative amount of person-time observed was adjusted for mortality. RESULTS: Data for 75,247 enrolled patients (representing 361,763 cumulative person-years) were linked to each of 42 participating state cancer registries (covering 93% of the US population), which included information on 6180 cases of osteosarcoma. No matches with incident cases of osteosarcoma following registry enrollment were found. The crude IR was 0 (95% CI, 0-10.2) cases per million person-years and the SIR was 0 (95% CI, 0-3.0). CONCLUSIONS: The ability to draw conclusions about the incidence of osteosarcoma among patients participating in the registry was limited due to the smaller than expected amount of patient follow-up time and the fact that no cases were identified.

Wooden hoof blocks: are we using the right wood?

AIMS: To investigate the association between the density of wooden hoof blocks and resistance to wear in pasture-based dairy herds, and to assess the density of commercially available wooden hoof blocks. METHODS: Three types of wooden hoof blocks with different densities (low, medium and high) were attached to 36 lactating dairy cows with parity ≤2 and sound locomotion (score ≤2 on a scale of 1-4). The height of wooden blocks was measured in three different regions, front, abaxial and caudal on Days 7, 11, 14, 18, 21, 25 and 28 after application. Due to the loss of low-density wooden blocks, the data for these blocks were analysed for only two measurements on Days 7 and 11. The data for medium and high-density wooden blocks were analysed from Days 7-25. A linear mixed model with repeated measures was used to analyse the repeated observations. Height, density and surface area of commercially available hoof blocks (n = 19) were measured and compared to the blocks used in this study. RESULTS: The magnitude of wear, in the front and the abaxial point of the blocks were greater in blocks made of low-density wood compared to those made of medium and high-density wood (p < 0.001). The amount of wear increased over time for all groups (p < 0.001). Wood density was negatively associated with wear and loss. Measurements of commercial wooden blocks revealed that the 13/19 (63%) had lower density and 12/19 (68%) less surface area than the wooden blocks with medium density used in this study. CONCLUSION: In this study, the density of the wood was significantly associated with the longevity of hoof blocks when applied to hooves of pasture-based dairy cows. CLINICAL RELEVANCE: The longevity of the wooden hoof blocks applied to treat lame cows plays a significant role in the healing of the claw horn lesions. The density of a wooden hoof block affects the rate of wear of the block, and this should be considered by manufacturers and those treating lame cows.

Reflection from the strong gravity regime in a lensed quasar at redshift z = 0.658.

The co-evolution of a supermassive black hole with its host galaxy through cosmic time is encoded in its spin. At z > 2, supermassive black holes are thought to grow mostly by merger-driven accretion leading to high spin. It is not known, however, whether below z ≈ 1 these black holes continue to grow by coherent accretion or in a chaotic manner, though clear differences are predicted in their spin evolution. An established method of measuring the spin of black holes is through the study of relativistic reflection features from the inner accretion disk. Owing to their greater distances from Earth, there has hitherto been no significant detection of relativistic reflection features in a moderate-redshift quasar. Here we report an analysis of archival X-ray data together with a deep observation of a gravitationally lensed quasar at z = 0.658. The emission originates within three or fewer gravitational radii from the black hole, implying a spin parameter (a measure of how fast the black hole is rotating) of a = 0.87(+0.08)(-0.15) at the 3σ confidence level and a > 0.66 at the 5σ level. The high spin found here is indicative of growth by coherent accretion for this black hole, and suggests that black-hole growth at 0.5 ≤ z ≤ 1 occurs principally by coherent rather than chaotic accretion episodes.

Skull fractures in forensic putrefied/skeletonised cases: The challenge of estimating the post-traumatic interval.

The objective of our study was to assess the reliability of the estimation of posttraumatic survival time (PTST) in forensic cases based on microCT and histology of putrefied/dry bone samples with comparison of initial macroscopic fracture classification performed during autopsy. Macroscopic morphological patterns of bone fracture are routinely used in forensic pathology and anthropology to distinguish between antemortem, perimortem and postmortem injuries. Based on macroscopic and microscopic analysis of six craniofacial fractures, our study results illustrate the need to complete macroscopical findings and initial fracture classification with microscopic analysis to avoid any inaccuracy. MicroCT has become a powerful technique to identify early bone healing signs but histology remains the gold standard to estimate the PTST and determine vital fracture based on hemorrhage marker. Raman microspectroscopy can identify a blood clot in the fracture line.

Rapid, complete and sustained tumour response to the TRK inhibitor larotrectinib in an infant with recurrent, chemotherapy-refractory infantile fibrosarcoma carrying the characteristic ETV6-NTRK3 gene fusion.

BACKGROUND: The ETV6-NTRK3 gene fusion is present in the majority of cases of infantile fibrosarcoma (IFS) and acts as a potent oncogenic driver. We report the very rapid, complete, and sustained response of an advanced, chemotherapy-refractory, recurrent IFS to targeted treatment with the oral tropomyosin receptor kinase (TRK) inhibitor larotrectinib. PATIENT AND METHODS: A male infant born with a large congenital IFS of the tongue had the tumour surgically resected at age 4 days. Within 2 months, he developed extensive lymph node recurrence that progressed during two cycles of vincristine-doxorubicin-cyclophosphamide chemotherapy. At screening, a large right cervical mass was clinically visible. Magnetic resonance imaging (MRI) revealed bilateral cervical and axillary lymph node involvement as well as infiltration of the floor of the mouth. The largest lesion measured 5.5×4.5×4.4 cm (ca. 55 cm3). The patient started outpatient oral larotrectinib at 20 mg/kg twice daily at age 3.5 months. RESULTS: After 4 days on treatment, the parents noted that the index tumour was visibly smaller and softer. The rapid tumour regression continued over the following weeks. On day 56 of treatment, the first scheduled control MRI showed the target lesion had shrunk to 1.2×1.2×0.8 cm (ca. 0.6 cm3), corresponding to a complete response according to the Response Evaluation Criteria In Solid Tumors version 1.1. This response was maintained over subsequent follow-up visits, and on day 112 at the second control MRI the target lymph node was completely normal. At last follow-up, the disease remained in complete remission after 16 months on larotrectinib, with negligible toxicity and no safety concerns. CONCLUSION(S): Selective TRK inhibition by larotrectinib offers a novel, highly specific and highly effective therapeutic option for IFS carrying the characteristic ETV6-NTRK3 gene fusion. Its use should be considered when surgery is not feasible. (NCT02637687).

Rapid, complete and sustained tumour response to the TRK inhibitor larotrectinib in an infant with recurrent, chemotherapy-refractory infantile fibrosarcoma carrying the characteristic ETV6-NTRK3 gene fusion.

BACKGROUND: The ETV6-NTRK3 gene fusion is present in the majority of cases of infantile fibrosarcoma (IFS) and acts as a potent oncogenic driver. We report the very rapid, complete, and sustained response of an advanced, chemotherapy-refractory, recurrent IFS to targeted treatment with the oral tropomyosin receptor kinase (TRK) inhibitor larotrectinib. PATIENT AND METHODS: A male infant born with a large congenital IFS of the tongue had the tumour surgically resected at age 4 days. Within 2 months, he developed extensive lymph node recurrence that progressed during two cycles of vincristine-doxorubicin-cyclophosphamide chemotherapy. At screening, a large right cervical mass was clinically visible. Magnetic resonance imaging (MRI) revealed bilateral cervical and axillary lymph node involvement as well as infiltration of the floor of the mouth. The largest lesion measured 5.5×4.5×4.4 cm (ca. 55 cm3). The patient started outpatient oral larotrectinib at 20 mg/kg twice daily at age 3.5 months. RESULTS: After 4 days on treatment, the parents noted that the index tumour was visibly smaller and softer. The rapid tumour regression continued over the following weeks. On day 56 of treatment, the first scheduled control MRI showed the target lesion had shrunk to 1.2×1.2×0.8 cm (ca. 0.6 cm3), corresponding to a complete response according to the Response Evaluation Criteria In Solid Tumors version 1.1. This response was maintained over subsequent follow-up visits, and on day 112 at the second control MRI the target lymph node was completely normal. At last follow-up, the disease remained in complete remission after 16 months on larotrectinib, with negligible toxicity and no safety concerns. CONCLUSION(S): Selective TRK inhibition by larotrectinib offers a novel, highly specific and highly effective therapeutic option for IFS carrying the characteristic ETV6-NTRK3 gene fusion. Its use should be considered when surgery is not feasible. (NCT02637687).

Occurrence and characterization of Escherichia coli ST410 co-harbouring blaNDM-5, blaCMY-42 and blaTEM-190 in a dog from the UK.

BACKGROUND/OBJECTIVES: Carbapenemase-producing Enterobacteriaceae (CPE) are a public health threat, and have been found in humans, animals and the environment. Carbapenems are not authorized for use in EU or UK companion animals, and the prevalence of carbapenem-resistant Gram-negative bacilli (CRGNB) in this population is unknown. METHODS: We investigated CRGNB isolated from animal specimens received by one diagnostic laboratory from 34 UK veterinary practices (September 2015-December 2016). Any Gram-negative isolates from clinical specimens showing reduced susceptibility to fluoroquinolones and/or aminoglycosides and/or cephalosporins were investigated phenotypically and genotypically for carbapenemases. A complete genome assembly (Illumina/Nanopore) was generated for the single isolate identified to investigate the genetic context for carbapenem resistance. RESULTS: One ST410 Escherichia coli isolate [(CARB35); 1/191, 0.5%], cultured from a wound in a springer spaniel, harboured a known carbapenem resistance gene (blaNDM-5). The gene was located in the chromosome on an integrated 100 kb IncF plasmid, also harbouring other drug resistance genes (mrx, sul1, ant1 and dfrA). The isolate also contained blaCMY-42 and blaTEM-190 on two separate plasmids (IncI1 and IncFII, respectively) that showed homology with other publicly available plasmid sequences from Italy and Myanmar. CONCLUSIONS: Even though the use of carbapenems in companion animals is restricted, the concurrent presence of blaCMY-42 and other antimicrobial resistance genes could lead to co-selection of carbapenemase genes in this population. Further studies investigating the selection and flow of plasmids carrying important resistance genes amongst humans and companion animals are needed.

Technical note: An evaluation of technology-recorded rumination and feeding behaviors in dairy heifers.

Precision dairy monitoring technologies have become increasingly popular for recording rumination and feeding behaviors in dairy cattle. The objective of this study was to validate the rumination and feeding time functions of the CowManager SensOor (Agis, Harmelen, the Netherlands) against visual observation in dairy heifers. The study took place over a 44-d period beginning June 1, 2016. Holstein heifers equipped with CowManager SensOor tags attached according to manufacturer specifications (n = 49) were split into 2 groups based on age, diet, and housing type. Group 1 heifers (n = 24) were calves (mean ± SD) 2.0 ± 2.7 mo in age, fed hay and calf starter, and housed on a straw-bedded pack. Group 2 heifers (n = 25) were 17.0 ± 1.3 mo in age, fed a TMR, confirmed pregnant, and housed in freestalls. Visual observation shifts occurred at 1500, 1700, 1900, and 2100 h. Each heifer was observed for 2 hour-long periods, with both observation periods occurring on the same day. Visual observations were collected using a synchronized watch, and "start" and "stop" times were recorded for each rumination and feeding event. For correlations, data from CowManager SensOor tags and observations were averaged, so a single 1-h observation was provided per animal, reducing the potential for confounding repeated measures being collected for each animal. Concordance correlations (CCC; epiR package; R Foundation for Statistical Computing, Vienna, Austria) and Pearson correlations (r; CORR procedure; SAS Institute Inc., Cary, NC) were used to calculate association between visual observations and technology-recorded behaviors. Visually observed rumination time was correlated with the CowManager SensOor (r = 0.63, CCC = 0.55). Visually observed feeding time was also correlated with the CowManager SensOor (r = 0.88, CCC = 0.72). The difference between technology-recorded data and visual observation was treated as the dependent variable in a mixed linear model (MIXED procedure of SAS). Time of day, age in months, and group were treated as fixed effects. Individual heifers were treated as random and repeated effects. The effects of time of day, age, and group on rumination and feeding times were not significant. The CowManager SensOor was more effective at recording feeding behavior than rumination behavior in dairy heifers. The CowManager SensOor can be used to provide relatively accurate measures of feeding time in heifers, but its rumination time function should be used with caution.

Use of indirect calorimetry to evaluate utilization of energy in lactating Jersey dairy cattle consuming common coproducts.

The use of coproducts as an alternative feed source is a common practice when formulating dairy rations. A study using 12 multiparous (79 ± 16 d in milk; mean ± standard deviation) lactating Jersey cows was conducted over 5 mo to evaluate the effects of dried distillers grains with solubles (DDGS) or canola meal on milk and gas production. A replicated 4 × 4 Latin square design was used to compare 4 dietary treatments. Treatments comprised a control (CON) containing no coproducts, a treatment diet containing 10% (dry matter basis) low-fat DDGS (LFDG), a treatment diet containing 10% high-fat DDGS (HFDG), and a 10% canola meal (CM) treatment. The crude fat content of the LFDG, HFDG, and CM treatments was 6.05 ± 0.379, 10.0 ± 0.134, and 3.46 ± 0.085%, respectively. Coproducts were included in partial replacement for corn and soybean meal. Indirect headbox-style calorimeters were used to estimate heat production. Dry matter intake and milk yield were similar between all treatments, averaging 17.4 ± 0.56 kg/d and 24.0 ± 0.80 kg, respectively. Milk urea N was affected by treatment and was highest in CON (20.6 mg/dL; 18.0, 19.9, and 18.1 ± 0.62 mg/dL in LFDG, CM, and HFDG, respectively). Heat production per unit of metabolic body weight tended to be affected by treatment and was lowest for CON, and diets containing coproducts were not different (192, 200, 215, and 204 ± 5.91 kcal/kg of metabolic body weight for CON, LFDG, CM, and HFDG, respectively). The concentration of metabolizable energy was affected by dietary treatment; specifically, HFDG did not differ from CON but was greater than LFDG and CM (2.58, 2.46, 2.29, and 2.27 ± 0.09 Mcal/kg for HFDG, CON, LFDG, and CM, respectively). The concentration of net energy balance (milk plus tissue) tended to be affected by dietary treatment; HFDG did not differ from either CON or LFDG, but it was higher than CM (1.38, 1.36, 1.14, and 1.06 ± 0.11 Mcal/kg for HFDG, CON, LFDG, and CM, respectively). Results of this study indicate that milk production and dry matter intake were not affected by feeding common coproducts and that differences may result in whole-animal energy use; fat content of DDGS is a major factor affecting this.

Oral hygiene, prevalence of gingivitis, and associated risk factors among pregnant women in Sarlahi District, Nepal.

BACKGROUND: The oral health status of pregnant women in low-resource communities such as Nepal has not been well characterized. This sub-population is also of specific interest given associations between poor oral health and adverse pregnancy outcomes previously documented in other settings. We explored relationships between gingivitis and risk factors among pregnant women in rural Nepal. METHODS: The design was a community-based, cross-sectional study in a sub-area of Sarlahi District, Nepal. Pregnant women < 26 weeks gestation underwent clinical periodontal exams conducted by community-based oral health workers. Exams included a full mouth assessment measuring bleeding on probing (BOP), probing depth (PD) (six sites per tooth), and gingival recession, the distance from the cemento-enamel junction to the free gingival margin (two direct sites per tooth). Data on participant risk factors were collected through household surveys, including demographic characteristics, oral health behaviors, care seeking, and health attitudes. Multivariable logistic regression modeling was used to assess relationships between gingivitis and risk factors. RESULTS: We enrolled 1452 participants, of which 40% (n = 582) had signs of clinical gingivitis and 60% (n = 870) clinical health. Average participant age was 23. Most participants (88%) had never received oral health care. Participants averaged 10% of sites with BOP with most (79%) having ≥1 site with BOP. Nine percent of participants had ≥1 site with PD ≥4 mm, although very few participants (0.7%) had sites with PD ≥5 mm. Few participants (13%) had any recession (≥1 mm). In the final adjusted model, odds of gingivitis increased by 3% for each year of age (aOR 1.03, 95% CI 1.00, 1.06) and were higher for women of short maternal stature (< 150 cm) (aOR 1.43, 95% CI: 1.14, 1.79) and among women reporting cost to be a barrier to seeking dental care (aOR 2.13, 95% CI: 1.09, 4.15). CONCLUSIONS: Gingivitis was common and associated with age, maternal stature, self-reported high cost of dental care, and other risk factors among pregnant women in rural Nepal. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01177111 (Nepal Oil Massage Study) and NCT02788786 (Pilot Trial).

Angioedema in chronic spontaneous urticaria is underdiagnosed and has a substantial impact: Analyses from ASSURE-CSU.

BACKGROUND: ASSURE-CSU revealed differences in physician and patient reporting of angioedema. This post hoc analysis was conducted to evaluate the actual rate of angioedema in the study population and explore differences between patients with and without angioedema. METHODS: This international observational study assessed 673 patients with inadequately controlled chronic spontaneous urticaria (CSU). Physicians abstracted angioedema data from medical records, which were compared with patient-reported data. Patients in the Yes-angioedema category had angioedema reported in the medical record and a patient-reported source. For those in the No-angioedema category, angioedema was reported in neither the medical record nor a patient-reported source. Those in the Misaligned category had angioedema reported in only one source. Statistical comparisons between Yes-angioedema and No-angioedema categories were conducted for measures of CSU activity, health-related quality of life (HRQoL), productivity and healthcare resource utilization (HCRU). Regression analyses explored the relationship between Dermatology Life Quality Index (DLQI) score and angioedema, adjusting for important covariates. RESULTS: Among evaluable patients, 259 (40.3%), 173 (26.9%) and 211 (32.8%) were in the Yes-angioedema, No-angioedema and Misaligned category, respectively. CSU activity and impact on HRQoL, productivity, and HCRU was greater for Yes-angioedema patients than No-angioedema patients. After covariate adjustment, mean DLQI score was significantly higher (indicating worse HRQoL) for patients with angioedema versus no angioedema (9.88 vs 7.27, P < .001). The Misaligned category had similar results with Yes-angioedema on all outcomes. CONCLUSIONS: Angioedema in CSU seems to be under-reported but has significant negative impacts on HRQoL, daily activities, HCRU and work compared with no angioedema.

Assessing the quality, reliability and readability of online health information regarding systemic lupus erythematosus.

Introduction Systemic lupus erythematosus (SLE) has complex pathophysiology and treatments, and patients often use the internet to better understand their condition. This report systematically assesses the quality, reliability and readability of online information. Methods The search term 'systemic lupus erythematosus' was used with Google™, Bing™ and Yahoo™ search engines sequentially. The first 25 websites returned ('hits') for each search engine (total 75 websites) were compiled. The search terms 'SLE' and 'lupus' were used in separate Google searches to assess for commonality. After removal of excluded hits, websites were assessed using the DISCERN instrument, Journal of the American Medical Association benchmarks and Gunning Fog Index for quality, reliability and readability and presence of 'Health on the Net Code' (HoN) standardisation recorded. Results There was a large degree of commonality among hits from the three different search engines using the search term 'systemic lupus erythematosus', as well as hits returned for the three different search terms using Google. The mean DISCERN score was 47.7 (SD 13.2) for 'systemic lupus erythematosus', 46.4 (SD 14.2) for 'SLE' and 45.2 (SD 10.1) for 'lupus', with no statistically significant difference. The mean number of JAMA benchmarks (maximum four) present for the 'systemic lupus erythematosus', 'SLE' and 'lupus' searches was 1.3 (SD 1.2), 1.4 (SD 1.3) and 1.2 (SD 1.0), respectively, with no statistically significance difference. The average readability of hits for the three different search terms was 9.3 (SD 3.4), 10.0 (SD 3.1) and 11.1 (SD 2.7), with no statistically significant difference. Conclusion There was a large degree of commonality of hits among the different search engines and the utilised search terms but they are not synonymous. Regardless of search term, the overall quality of websites was fair, whilst reliability was poor. Websites appearing higher in searches did not score better. Presence of the HoN did not represent better quality. Readability was higher than recommended for near-universal understanding. There was no difference in quality, reliability or readability of websites using the search terms 'systemic lupus erythematosus', 'SLE' or 'lupus', with some high-scoring websites appearing in only one search term result. This study reminds clinicians to direct patients to high-quality websites rather than rely on search engines.

Initial Public Health Laboratory Response After Hurricane Maria - Puerto Rico, 2017.

Hurricane Maria made landfall in Puerto Rico on September 20, 2017, causing major damage to infrastructure and severely limiting access to potable water, electric power, transportation, and communications. Public services that were affected included operations of the Puerto Rico Department of Health (PRDOH), which provides critical laboratory testing and surveillance for diseases and other health hazards. PRDOH requested assistance from CDC for the restoration of laboratory infrastructure, surveillance capacity, and diagnostic testing for selected priority diseases, including influenza, rabies, leptospirosis, salmonellosis, and tuberculosis. PRDOH, CDC, and the Association of Public Health Laboratories (APHL) collaborated to conduct rapid needs assessments and, with assistance from the CDC Foundation, implement a temporary transport system for shipping samples from Puerto Rico to the continental United States for surveillance and diagnostic and confirmatory testing. This report describes the initial laboratory emergency response and engagement efforts among federal, state, and nongovernmental partners to reestablish public health laboratory services severely affected by Hurricane Maria. The implementation of a sample transport system allowed Puerto Rico to reinitiate priority infectious disease surveillance and laboratory testing for patient and public health interventions, while awaiting the rebuilding and reinstatement of PRDOH laboratory services.

Acute kidney injury after implantation of a left ventricular assist device: a comparison of axial-flow (HeartMate II) and centrifugal-flow (HeartWare HVAD) devices.

Continuous-flow left ventricular assist devices (CF-LVADs) are increasingly being used to treat advanced, refractory chronic heart failure. Herein, we sought to determine the incidence of postoperative acute kidney injury (AKI) in axial-flow (HeartMate II; HM-II) and centrifugal-flow (HVAD) CF-LVAD recipients, as well as the effect of AKI on mortality. The study cohort comprised 520 patients who received a HM-II (n = 398) or HVAD (n = 122) at our center between November 2003 and March 2016. Their records were reviewed to determine the incidence of RIFLE-defined AKI after LVAD implantation. We compared the perioperative characteristics, postoperative complications, and survival rates of the patients with and without AKI and differentiated the outcomes based on device type (HM-II or HVAD). Seventy-five patients (14.4%) developed AKI postoperatively. Patients with AKI after LVAD implantation had significantly reduced survival compared to patients without AKI (p = 0.01). Cox proportional hazards models showed that AKI was a significant independent predictor of mortality (HR = 1.54, p = 0.03). Preoperative mechanical circulatory support and prolonged cardiopulmonary bypass time were independent predictors of AKI. The incidence of AKI was similar for HM-II and HVAD recipients (p = 0.25). There was no significant difference in AKI rates for the HM-II and HVAD recipients. Developing AKI adversely affected survival.

Oral health knowledge, behavior, and care seeking among pregnant and recently-delivered women in rural Nepal: a qualitative study.

BACKGROUND: Oral health behavior and attitudes of pregnant women in low-income countries are rarely examined, yet should be considered when designing preventative or therapeutic studies to reduce burden of oral diseases. We aimed to understand dental care-seeking behavior, as well as oral health knowledge and attitudes of oral health among pregnant women in rural Nepal. METHODS: Semi-structured in-depth interviews (n = 16) and focus group discussions (3 groups, n = 23) were conducted among pregnant and recently-delivered women in Sarlahi, Nepal. Transcripts were translated from the local language to English then analyzed using a hybrid approach to thematic coding with Atlas.ti version 7. RESULTS: Women felt confident describing the signs and symptoms of tooth decay and gum disease, but were not knowledgeable about where to receive care for tooth and/or gum pain and relied heavily on the knowledge of their community. Some women used a toothbrush and toothpaste at least once a day to clean their teeth, but many reported the traditional use of a branch of a local shrub or tree as their teeth cleaning instrument. Women suggested a willingness to consider using an oral rinse throughout pregnancy, perceiving that it might have a positive impact on infant health. CONCLUSIONS: Future studies should focus on providing adequate and sustainable resources for pregnant women in Nepal and other low income settings to engage in good oral health behaviors (possibly supported through community-based workers), to maintain dental hygiene, and to access qualified dentists as a means of improving their oral health. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01177111 (Nepal Oil Massage Study) and NCT02788786 (Pilot Trial).

Novel Two-Step Hierarchical Screening of Mutant Pools Reveals Mutants under Selection in Chicks.

Contaminated chicken/egg products are major sources of human salmonellosis, yet the strategies used by Salmonella to colonize chickens are poorly understood. We applied a novel two-step hierarchical procedure to identify new genes important for colonization and persistence of Salmonella enterica serotype Typhimurium in chickens. A library of 182 S. Typhimurium mutants each containing a targeted deletion of a group of contiguous genes (for a total of 2,069 genes deleted) was used to identify regions under selection at 1, 3, and 9 days postinfection in chicks. Mutants in 11 regions were under selection at all assayed times (colonization mutants), and mutants in 15 regions were under selection only at day 9 (persistence mutants). We assembled a pool of 92 mutants, each deleted for a single gene, representing nearly all genes in nine regions under selection. Twelve single gene deletion mutants were under selection in this assay, and we confirmed 6 of 9 of these candidate mutants via competitive infections and complementation analysis in chicks. STM0580, STM1295, STM1297, STM3612, STM3615, and STM3734 are needed for Salmonella to colonize and persist in chicks and were not previously associated with this ability. One of these key genes, STM1297 (selD), is required for anaerobic growth and supports the ability to utilize formate under these conditions, suggesting that metabolism of formate is important during infection. We report a hierarchical screening strategy to interrogate large portions of the genome during infection of animals using pools of mutants of low complexity. Using this strategy, we identified six genes not previously known to be needed during infection in chicks, and one of these (STM1297) suggests an important role for formate metabolism during infection.