Analysis of the Infectious Diseases Fellowship Program Directors Postmatch 2023 Survey.

The 2023 United States infectious diseases (ID) fellowship match resulted in a large percentage of programs with unfilled positions. A survey was sent to ID program directors nationwide to better understand their perceptions on the match. Program directors perceived geography, a small applicant pool, and low specialty pay as contributing factors to the match results. Developing specialized fellowship tracks, increasing funding for the ID trainee pipeline, and national advocacy for higher compensation were identified as areas to focus on to increase the applicant pool. Areas of controversy, such as decreasing the number or size of fellowship programs, require further discussion.

The utility of blow fly (Diptera: Calliphoridae) evidence from burned human remains.

Burning of human remains is a common method to conceal or destroy evidence associated with homicides and illegal activities. However, data regarding blow fly colonization of burned remains are scarce, with all previously published empirical studies focusing only on non-human animals. It is critically important to obtain basic data on blow fly colonization patterns of burned human remains as such evidence may represent the only feasible method for PMI estimation in cases of burning. In this study, we thermally altered six human donors to a Crow-Glassman Scale Level 3 (CGS-3) and placed them at the Anthropology Research Facility at the University of Tennessee in Summer 2021, Spring 2022, and Summer 2022. Six unburned human donors were used as controls. Observations for insect activity began within 24 h of placement and continued twice weekly through decomposition. Age estimations were performed with immature blow flies to estimate the time of colonization (TOC), and accuracy was assessed against the time of placement for each donor. All burned donors examined in this study were colonized by blow flies. No significant difference in species composition was determined between treatments, though TOC estimations from burned donors were slightly (but significantly) less accurate than TOC estimations from unburned donors (80% vs. 83% accuracy; χ2 = 0.041, df = 1, P = 0.840). These results indicate that blow flies can successfully colonize human remains burned to CGS-3 and that accurate TOC estimations can still be generated from larval specimens. Though several limitations to this study exist (e.g., inconsistent donor BMI, lack of donor temperature data), our results underscore the utility of entomological evidence in cases of burned human remains.

Treatments for COVID-19.

The treatment for COVID-19 has evolved rapidly since the start of the pandemic and now consists mainly of antiviral and immunomodulatory agents. Antivirals, such as remdesivir and nirmatrelvir-ritonavir, have proved to be most useful earlier in illness (e.g., as outpatient therapy) and for less severe disease. Immunomodulatory therapies, such as dexamethasone and interleukin-6 or Janus kinase inhibitors, are most useful in severe disease or critical illness. The role of anti-SARS-CoV-2 monoclonal antibodies has diminished because of the emergence of viral variants that are not anticipated to be susceptible to these treatments, and there still is not a consensus on the use of convalescent plasma. COVID-19 has been associated with increased rates of venous thromboembolism, but the role of antithrombotic therapy is limited. Multiple investigational agents continue to be studied, which will alter current treatment paradigms as new data are released.

Management of Gout in the Hand and Wrist.

Gout, or monosodium urate deposition disease, is the most common form of inflammatory arthritis that affects almost 4% of adults in the United States.Medical management involves lifestyle modifications and urate-lowering therapy to reduce the frequency of gout flares, decrease the tophi size, and improve upper extremity function. Goals for surgical management of gout include functional optimization, symptomatic treatment, and cosmetic restoration.This article focuses on the medical and surgical treatment of the common manifestations of gout in the upper extremity including tophi, tenosynovitis, joint contractures, neural compression, and arthropathy.

Application of Tendon With Z-Lengthening Technique.

Tendon deficiency limits repair and reconstructive options after tendon and nerve injuries of the upper extremity. Current treatment options include intercalary tendon autograft, tendon transfers, and two-stage tenodesis, with sacrifice of the flexor digitorum superficialis. These reconstructive techniques are associated with donor site morbidity and limited in the setting of multiple tendon deficiencies. The tendon with z-lengthening (TWZL) technique is presented here as an alternative treatment method for tendon injuries and tendon transfer reconstruction after nerve injuries. The TWZL technique involves splitting a tendon longitudinally, reflecting the freed tendon limb distally, and suture augmentation at the bridge site located at the distal end of the native tendon. The TWZL technique has applications throughout the upper extremity-flexor and extensor tendons injuries, biceps and triceps tendon injuries, and tendon transfers for restoration of hand function after nerve injuries. An illustrative case example is also provided. The experienced hand surgeon should consider the TWZL technique as a potential treatment option when faced with difficult clinical conditions of the hand and upper extremities.

C3a-C3aR signaling is a novel modulator of skeletal homeostasis.

Osteoimmune studies have identified complement signaling as an important regulator of the skeleton. Specifically, complement anaphylatoxin receptors (i.e., C3aR, C5aR) are expressed on osteoblasts and osteoclasts, implying that C3a and/or C5a may be candidate mediators of skeletal homeostasis. The study aimed to determine how complement signaling influences bone modeling/remodeling in the young skeleton. Female C57BL/6J C3aR-/-C5aR-/- vs. wildtype and C3aR-/- vs. wildtype mice were examined at age 10 weeks. Trabecular and cortical bone parameters were analyzed by micro-CT. In situ osteoblast and osteoclast outcomes were determined by histomorphometry. Osteoblast and osteoclast precursors were assessed in vitro. C3aR-/-C5aR-/- mice displayed an increased trabecular bone phenotype at age 10 weeks. In vitro studies revealed C3aR-/-C5aR-/- vs. wildtype cultures had less bone-resorbing osteoclasts and increased bone-forming osteoblasts, which were validated in vivo. To determine whether C3aR alone was critical for the enhanced skeletal outcomes, wildtype vs. C3aR-/- mice were evaluated for osseous tissue outcomes. Paralleling skeletal findings in C3aR-/-C5aR-/- mice, C3aR-/- vs. wildtype mice had an enhanced trabecular bone volume fraction, which was attributed to increased trabecular number. There was elevated osteoblast activity and suppressed osteoclastic cells in C3aR-/- vs. wildtype mice. Furthermore, primary osteoblasts derived from wildtype mice were stimulated with exogenous C3a, which more profoundly upregulated C3ar1 and the pro-osteoclastic chemokine Cxcl1. This study introduces the C3a/C3aR signaling axis as a novel regulator of the young skeleton.

Not by the Book: Observations of Delayed Oviposition and Re-Colonization of Human Remains by Blow Flies.

Postmortem interval estimations can be complicated by the inter-individual variation present in human decomposition. Forensic entomologists may especially face challenges interpreting arthropod evidence in scenarios that are not "by the book", or that vary in unexpected ways. Therefore, it is important to report instances where blow fly colonization does not align with expected soft tissue decomposition as blow fly larvae are often used to produce a time of colonization (TOC) estimation to infer a minimum PMI. We followed the decomposition and blow fly activity of three human donors at the Anthropology Research Facility (University of Tennessee). Delayed oviposition occurred on one donor 115 d post-placement, whereas two donors experienced blow fly re-colonization after cessation of the consumption phase, one 22 d and one more than 200 d after blow fly larvae were last observed. A null hypothesis model tested whether the entomological TOC and anthropological total body score (TBS) estimations encompassed the time of placement (TOP) for each donor. While the null hypothesis was rejected for all TOC estimations, it could not be rejected for the TBS estimations. We discuss how the non-linear nature of human decomposition can pose challenges to interpreting blow fly evidence and suggest that forensic entomology practitioners should recognize these limitations in both research endeavors and applied casework.

Body Mass Index (BMI) Impacts Soil Chemical and Microbial Response to Human Decomposition.

Microorganisms are key decomposers of vertebrate mortalities, breaking down body tissues and impacting decomposition progress. During human decomposition, both extrinsic environmental factors and intrinsic cadaver-related factors have the potential to impact microbial decomposers either directly or indirectly via altered physical or chemical conditions. While extrinsic factors (e.g., temperature, humidity) explain some variation in microbial response during human decomposition in terrestrial settings, recent work has noted that even under the same environmental conditions, individuals can have different decomposition patterns, highlighting the potential for intrinsic factors to impact microbial decomposers. The goal of this study was to investigate the effects of several intrinsic factors (age, sex, diseases at time of death, and body mass index [BMI]) on chemical and microbial changes in decomposition-impacted soils. In a field study conducted at the University of Tennessee Anthropology Research Facility, soils were collected from the decomposition-impacted area surrounding 19 deceased human individuals through the end of active decomposition. Soil physicochemical parameters were measured, and microbial (bacterial and fungal) communities were assessed via amplicon sequencing. BMI was shown to explain some variation in soil pH and microbial response to human decomposition. Hierarchical linear mixed (HLM) effects models revealed that BMI category significantly explained variation in pH response within decomposition-impacted soils over time (HLM F = 9.647; P < 0.001). Additionally, the relative abundance of soil Saccharomycetes in decomposition soils under underweight donors displayed little to no changes (mean maximum change in relative abundance, +6.6%), while all other BMI categories displayed an increased relative abundance of these organisms over time (normal, +50.6%; overweight, +64.4%; and obese, +64.6%) (HLM F = 3.441; P = 0.11). Together, these results reveal intrinsic factors influencing decomposition patterns, especially within the soil environment, and suggest BMI is an important factor for controlling decomposition processes. IMPORTANCE This work begins to address questions about interindividual variation in vertebrate decomposition attributed to intrinsic factors, that is, properties of the carcass or cadaver itself. Most research on factors affecting decomposition has focused on the extrinsic environment, such as temperature or humidity. While these extrinsic factors do explain some variation in decomposition patterns, interindividual variability is still observed. Understanding how intrinsic factors influence microbial decomposers will help reveal the ecological impacts of decomposition. This work also has forensic applications, as soil chemical and biological changes have been suggested as indicators of postmortem interval. We reveal factors that explain variation in the decomposition environment that should be considered in these estimates. This is particularly important as we consider the implications of variations in human populations due to diet, age, BMI, disease, toxicological loading, etc. on forensic investigations dealing with decomposing remains.

Mental State Classification Using Multi-Graph Features.

We consider the problem of extracting features from passive, multi-channel electroencephalogram (EEG) devices for downstream inference tasks related to high-level mental states such as stress and cognitive load. Our proposed feature extraction method uses recently developed spectral-based multi-graph tools and applies them to the time series of graphs implied by the statistical dependence structure (e.g., correlation) amongst the multiple sensors. We study the features in the context of two datasets each consisting of at least 30 participants and recorded using multi-channel EEG systems. We compare the classification performance of a classifier trained on the proposed features to a classifier trained on the traditional band power-based features in three settings and find that the two feature sets offer complementary predictive information. We conclude by showing that the importance of particular channels and pairs of channels for classification when using the proposed features is neuroscientifically valid.

Weight-Bearing Computed Tomography of the Foot and Ankle in the Pediatric Population.

BACKGROUND: Newer cone-beam computed tomography (CT) technology has grown in popularity for evaluation of foot and ankle pathology in the weight-bearing (WB) position. Many studies have demonstrated its benefits within the adult population, but there is a paucity of its use within the pediatric literature. The purpose of this study was to describe the indications and clinical findings of WBCT within a pediatric population. METHODS: A retrospective cohort of 68 patients (86 extremities) who underwent WBCT for a variety of conditions were compared with 48 patients (59 extremities) who underwent traditional supine nonweight-bearing (NWB) CTs. Clinical indications, demographic data, radiation doses, and cost were obtained from the medical record. WBCTs were obtained in a private outpatient orthopaedic clinic, and the conventional NWBCTs were obtained within a hospital-based system. RESULTS: The most common indications for obtaining a WBCT and NWBCT in our study were fracture, tarsal coalition, and Lisfranc injury. The average WBCT radiation dose was 0.63 mGy for patients <100 lbs and 1.1 mGy for patients >100 lbs undergoing WBCT. For NWBCTs, the average radiation dose was 7.92 mGy for patients <100 lbs and 10.37 mGy for patients greater than 100 lbs. There was a significant reduction in radiation dose for all patients who underwent WBCT (P<0.0001 vs. 0.002). The average reimbursement for NWBCTs was $505 for unilateral studies and $1451 for bilateral studies. The average reimbursement for the WBCTs was $345 for unilateral studies and $635 for bilateral studies. CONCLUSIONS: WBCT offers a new modality for studying complex foot and ankle pathoanatomy in the pediatric population at a reduced radiation exposure and reduced cost. LEVEL OF EVIDENCE: Level III-a retrospective comparative study.

Acute Carpal Tunnel Syndrome and Median Nerve Neurapraxia: A Review.

Prompt diagnosis and treatment of acute injury to the median nerve after wrist trauma are paramount to a successful outcome. Neuropathy can occur primarily at the time of injury, secondary to unreduced fracture fragments or callus, or from prolonged immobilization in palmar flexion. Acute carpal tunnel syndrome is a surgical emergency that requires decompression. Progressively worsening pain and sensory disturbances in the median nerve distribution are findings that will distinguish an acute carpal tunnel syndrome from the less severe median nerve neurapraxia. This article describes the key differences between neurapraxia and acute compartment syndrome and their respective treatment.

Charge density waves and Fermi surface reconstruction in the clean overdoped cuprate superconductor Tl2Ba2CuO6+δ.

Hall effect and quantum oscillation measurements on high temperature cuprate superconductors show that underdoped compositions have small Fermi surface pockets whereas when heavily overdoped, a single much larger pocket is found. The origin of this change in electronic structure has been unclear, but may be related to the high temperature superconductivity. Here we show that the clean overdoped single-layer cuprate Tl2Ba2CuO6+δ (Tl2201) displays CDW order with a remarkably long correlation length ξ ≈ 200 Å which disappears above a hole doping of pCDW ≈ 0.265. We show that the evolution of the electronic properties of Tl2201 as the doping is lowered may be explained by a Fermi surface reconstruction which accompanies the emergence of the CDW below pCDW. Our results demonstrate importance of CDW correlations in understanding the electronic properties of overdoped cuprates.

Magnetic-field-controlled spin fluctuations and quantum critically in Sr3Ru2O7.

When the transition temperature of a continuous phase transition is tuned to absolute zero, new ordered phases and physical behaviour emerge in the vicinity of the resulting quantum critical point. Sr3Ru2O7 can be tuned through quantum criticality with magnetic field at low temperature. Near its critical field Bc it displays the hallmark T-linear resistivity and a [Formula: see text] electronic heat capacity behaviour of strange metals. However, these behaviours have not been related to any critical fluctuations. Here we use inelastic neutron scattering to reveal the presence of collective spin fluctuations whose relaxation time and strength show a nearly singular variation with magnetic field as Bc is approached. The large increase in the electronic heat capacity and entropy near Bc can be understood quantitatively in terms of the scattering of conduction electrons by these spin-fluctuations. On entering the spin-density-wave ordered phase present near Bc, the fluctuations become stronger suggesting that the order is stabilised through an "order-by-disorder" mechanism.

Common Complications of Distal Radial Fractures.

Distal radial fractures are associated with good outcomes; however, although they occur at low rates, complications can significantly impair treatment success. Therefore, the treating surgeon should be aware of potential complications associated with each treatment type and how to best prevent them. Although certain patient-specific and fracture-specific factors may increase the risk of adverse outcomes, most are nonmodifiable risk factors at the time of presentation, so it is imperative that every effort is made to mitigate these risk factors to prevent long-term morbidity. Patients should be well-informed about these complications and potential symptoms so that they can be addressed expeditiously.

Starch storage capacity of sapwood is related to dehydration avoidance during drought.

PREMISE: The xylem tissue of plants performs three principal functions: transport of water, support of the plant body, and nutrient storage. Tradeoffs may arise because different structural requirements are associated with different functions or because suites of traits are under selection that relate to resource acquisition, use, and turnover. The structural and functional basis of xylem storage is not well established. We hypothesized that greater starch storage would be associated with greater sapwood parenchyma and reduced fibers, which would compromise resistance to xylem tensions during dehydration. METHODS: We measured cavitation resistance, minimum water potential, starch content, and sapwood parenchyma and fiber area in 30 species of southern California chaparral shrubs (evergreen and deciduous). RESULTS: We found that species storing greater starch within their xylem tended to avoid dehydration and were less cavitation resistant, and this was supported by phylogenetic independent contrasts. Greater sapwood starch was associated with greater parenchyma area and reduced fiber area. For species without living fibers, the associations with parenchyma were stronger, suggesting that living fibers may expand starch storage capacity while also contributing to the support function of the vascular tissue. Drought-deciduous species were associated with greater dehydration avoidance than evergreens. CONCLUSIONS: Evolutionary forces have led to an association between starch storage and dehydration resistance as part of an adaptive suite of traits. We found evidence for a tradeoff between tissue mechanical traits and starch storage; moreover, the evolution of novel strategies, such as starch-storing living fibers, may mitigate the strength of this tradeoff.

Reduction of the Spin Susceptibility in the Superconducting State of Sr_{2}RuO_{4} Observed by Polarized Neutron Scattering.

Recent observations [A. Pustogow et al., Nature (London) 574, 72 (2019).NATUAS0028-083610.1038/s41586-019-1596-2] of a drop of the ^{17}O nuclear magnetic resonance (NMR) Knight shift in the superconducting state of Sr_{2}RuO_{4} challenged the popular picture of a chiral odd-parity paired state in this compound. Here we use polarized neutron scattering (PNS) to show that there is a 34±6% drop in the magnetic susceptibility at the Ru site below the superconducting transition temperature. We measure at lower fields H∼1/3H_{c2} than a previous PNS study allowing the suppression to be observed. The PNS measurements show a smaller susceptibility suppression than NMR measurements performed at similar field and temperature. Our results rule out the chiral odd-parity d=z[over ^](k_{x}±ik_{y}) state and are consistent with several recent proposals for the order parameter including even-parity B_{1g} and odd-parity helical states.

Spatially inhomogeneous competition between superconductivity and the charge density wave in YBa2Cu3O6.67.

The charge density wave in the high-temperature superconductor YBa2Cu3O7-x (YBCO) has two different ordering tendencies differentiated by their c-axis correlations. These correspond to ferro- (F-CDW) and antiferro- (AF-CDW) couplings between CDWs in neighbouring CuO2 bilayers. This discovery has prompted several fundamental questions: how does superconductivity adjust to two competing orders and are either of these orders responsible for the electronic reconstruction? Here we use x-ray diffraction to study YBa2Cu3O6.67 as a function of magnetic field and temperature. We show that regions with F-CDW correlations suppress superconductivity more strongly than those with AF-CDW correlations. This implies that an inhomogeneous superconducting state exists, in which some regions show a fragile form of superconductivity. By comparison of F-CDW and AF-CDW correlation lengths, it is concluded that F-CDW ordering is sufficiently long-range to modify the electronic structure. Our study thus suggests that F-CDW correlations impact both the superconducting and normal state properties of YBCO.

Sensitivity and Specificity of prior Methicillin-Resistant Staphylococcus aureus Nasal Swab Results for Predicting Methicillin-Resistant Staphylococcus aureus Infections in Intensive Care Unit Admissions Over a 1-Year Period: A Pilot Study.

OBJECTIVE: Methicillin-resistant Staphylococcus aureus (MRSA) continues to be a pathogen worldwide. Empiric anti-MRSA therapy is often prescribed in hospital inpatients with potential infection. Recent studies have suggested, particularly for respiratory infections, that MRSA colonization as determined by nasal swab has a high negative predictive value (NPV) for MRSA infections during the index hospitalization. We examined the predictive value of a prior intensive care unit (ICU) MRSA nasal swab on the results from a subsequent ICU admission in the same patient and the results of the latter admission MRSA nasal swab. METHODS: A retrospective chart review of patients 18 years or older admitted to a large tertiary care hospital in the Midwest of the United States in 2016 who had a MRSA nasal swab performed and had an ICU admission stay of over 24 h was conducted. This group of patients was matched to a patient list of subjects who were admitted as an inpatient to the same ICU at least once during the following year. Data were collected on demographic and clinical information, as well as the results of MRSA swabs and the presence of a MRSA infection during both hospitalizations. Predictive values were calculated using 2 × 2 tables including sensitivity and specificity of a first MRSA swab result with a MRSA infection during the subsequent ICU stay. FINDINGS: Seventy-seven patients were matched who had MRSA swabs performed on two separate ICU admissions. The negative predictive value of the first MRSA swab result on a MRSA infection during the second ICU stay was 96%. CONCLUSION: In this pilot study, a previous negative MRSA nasal swab may predict a lack of a MRSA infection in a subsequent infection during a 1-year period.

Detection of Acoustic Plasmons in Hole-Doped Lanthanum and Bismuth Cuprate Superconductors Using Resonant Inelastic X-Ray Scattering.

High T_{c} superconductors show a rich variety of phases associated with their charge degrees of freedom. Valence charges can give rise to charge ordering or acoustic plasmons in these layered cuprate superconductors. While charge ordering has been observed for both hole- and electron-doped cuprates, acoustic plasmons have only been found in electron-doped materials. Here, we use resonant inelastic x-ray scattering to observe the presence of acoustic plasmons in two families of hole-doped cuprate superconductors (La_{1.84}Sr_{0.16}CuO_{4} and Bi_{2}Sr_{1.6}La_{0.4}CuO_{6+δ}), crucially completing the picture. Interestingly, in contrast to the quasistatic charge ordering which manifests at both Cu and O sites, the observed acoustic plasmons are predominantly associated with the O sites, revealing a unique dichotomy in the behavior of valence charges in hole-doped cuprates.

Factors Influencing Family Burden in Pediatric Hematology/Oncology Encounters.

PURPOSE: Caring for a child with cancer or hematologic disease places unique stress on a family unit. Families' subjective experience of this care-related burden mediates the relationship between cost and health-related outcomes. While financial costs are well described for families of pediatric hematology/oncology patients, it is unclear how cost and other factors each contribute to families' overall experience of care-related burden. This study identifies and groups the challenges that families report and describes their association with overall reported burden. METHODS: This mixed-methods analysis of a cross-sectional single-center study was conducted via structured, self-administered questionnaire provided to inpatient and outpatient caregivers of pediatric hematology/oncology patients. Respondents rated their perception of burden associated with that day's medical encounter on a 5-point Likert scale. The questionnaire included an open-ended prompt for caregivers about areas they deemed most burdensome. Primary themes were extracted and categorized. RESULTS: A total of 278 outpatient and 42 inpatient caregivers participated. Six thematic categories emerged: logistics, life disruption, care delivery system, parking, financial burden, and emotional burden. Outpatient caregivers reported more burden than inpatient caregivers for the first three categories, while inpatient caregivers reported more burden for the last three. Salient subthemes associated with higher and lower overall burden were identified in each theme category. CONCLUSIONS: These data establish theme categories for future study of caregiver-perceived burden in pediatric hematologic/oncologic encounters, demonstrate that certain components of cost contribute disproportionately to caregivers' overall sense of care-related burden, and identify areas within each of the 6 burden categories that can be best targeted to alleviate caregiver burden.