Fournier's Gangrene: A Rare Infectious Entity in an Adolescent with Type II Diabetes.

Fournier's gangrene is a rapidly progressive necrotizing fasciitis of the perineum and external genital organs that is uncommon in the pediatric age group. We present a case report of a 17-year-old obese male with comorbidities of type II diabetes, hypertension, and tobacco use, who presented to the hospital with vague systemic symptoms and pain in the gluteal area. On examination, he was febrile and had erythema and induration of his left scrotum, perineum, and gluteal region. Imaging obtained due to rapid progression of symptoms was consistent with a diagnosis of Fournier's gangrene. He was managed with broad-spectrum antibiotics, aggressive surgical debridement, and a diverting colostomy. This case brings to light to a classically adult diagnosis that should be considered in adolescents, especially given the rising numbers of risk factors in this population, such as diabetes, obesity, and smoking.

Demographic and clinical characteristics of pediatric COVID-19 in Arkansas: March-December 2020.

The COVID-19 pandemic reached the United States in early 2020 and spread rapidly across the country. This retrospective study describes the demographic and clinical characteristics of 308 children presenting to an Arkansas Children's emergency department (ED) or admitted to an Arkansas Children's hospital with COVID-19 in the first 10 months of the COVID-19 pandemic, prior to the emergence of clinically significant variants and available vaccinations. Adolescents aged 13 and older represented the largest proportion of this population. The most common presenting symptoms were fever, gastrointestinal symptoms, and upper respiratory symptoms. Patients with multisystem inflammatory syndrome in children (MIS-C) had a longer length of stay (LOS) than patients with acute COVID-19. Children from urban zip codes had lower odds of admission but were more likely to be readmitted after discharge. Nearly twenty percent of the study population incidentally tested positive for COVID-19. Despite lower mortality in children with COVID than in adults, morbidity and resource utilization are significant. With many Arkansas children living in rural areas and therefore far from pediatric hospitals, community hospitals should be prepared to evaluate children presenting with COVID-19 and to determine which children warrant transport to pediatric-specific facilities.

Present, future, and novel bioclimates of the San Francisco, California region.

Bioclimates are syntheses of climatic variables into biologically relevant categories that facilitate comparative studies of biotic responses to climate conditions. Isobioclimates, unique combinations of bioclimatic indices (continentality, ombrotype, and thermotype), were constructed for northern California coastal ranges based on the Rivas-Martinez worldwide bioclimatic classification system for the end of the 20(th) century climatology (1971-2000) and end of the 21(st) century climatology (2070-2099) using two models, Geophysical Fluid Dynamics Laboratory (GFDL) model and the Parallel Climate Model (PCM), under the medium-high A2 emission scenario. The digitally mapped results were used to 1) assess the relative redistribution of isobioclimates and their magnitude of change, 2) quantify the loss of isobioclimates into the future, 3) identify and locate novel isobioclimates projected to appear, and 4) explore compositional change in vegetation types among analog isobioclimate patches. This study used downscaled climate variables to map the isobioclimates at a fine spatial resolution -270 m grid cells. Common to both models of future climate was a large change in thermotype. Changes in ombrotype differed among the two models. The end of 20(th) century climatology has 83 isobioclimates covering the 63,000 km(2) study area. In both future projections 51 of those isobioclimates disappear over 40,000 km(2). The ordination of vegetation-bioclimate relationships shows very strong correlation of Rivas-Martinez indices with vegetation distribution and composition. Comparisons of vegetation composition among analog patches suggest that vegetation change will be a local rearrangement of species already in place rather than one requiring long distance dispersal. The digitally mapped results facilitate comparison with other Mediterranean regions. Major remaining challenges include predicting vegetation composition of novel isobioclimates and developing metrics to compare differences in climate space.

Too frail for surgery? Initial results of a large multidisciplinary prospective study examining preoperative variables predictive of poor surgical outcomes.

BACKGROUND: The decision as to whether a patient can tolerate surgery is often subjective and can misjudge a patient's true physiologic state. The concept of frailty is an important assessment tool in the geriatric medical population, but has only recently gained attention in surgical patients. Frailty potentially represents a measureable phenotype, which, if quantified with a standardized protocol, could reliably estimate the risk of adverse surgical outcomes. STUDY DESIGN: Frailty was prospectively evaluated in the clinic setting in patients consenting for major general, oncologic, and urologic procedures. Evaluation included an established assessment tool (Hopkins Frailty Score), self-administered questionnaires, clinical assessment of performance status, and biochemical measures. Primary outcome was 30-day postoperative complications. RESULTS: There were 189 patients evaluated: 117 from urology, 52 from surgical oncology, and 20 from general surgery clinics. Mean age was 62 years, 59.8% were male, and 71.4% were Caucasian. Patients who scored intermediately frail or frail on the Hopkins Frailty Score were more likely to experience postoperative complications (odds ratio [OR] 2.07, 95% CI 1.05 to 4.08, p = 0.036). Of all other preoperative assessment tools, only higher hemoglobin (p = 0.033) had a significant association and was protective for 30-day complications. CONCLUSIONS: The aggregate score of patients as "intermediately frail or frail" on the Hopkins Frailty Score was predictive of a patient experiencing a postoperative complication. This preoperative assessment tool may prove beneficial when weighing the risks and benefits of surgery, allowing objective data to guide surgical decision-making and patient counseling.