Comparative Evaluation of Sealing Ability of Different Type of MTA as Root-End Filling Materials Using Dye Penetration Technique - An In Vitro Study.

Introduction: The main goal of the root-end filling material is to create a hermetic seal to protect against microbes and their by-products. Excellent biocompatibility and sealing ability are characteristics of MTA developed by Torabinejad et al. This study aimed to compare the sealing ability of different type MTA as root-end filling material using dye penetration technique. Material and Method: One-twenty (N = 120) extracted human maxillary anterior teeth were decontaminated, cleaned, and decoronated. Endodontic treatment and root-end resection were done. Then root-end cavity was prepared and filled with tested materials (N = 30). A calibrated stereomicroscope was used to evaluate linear measurement. All data were tabulated and statistically analyzed with a level of significance set at P < .05. Result: This order of increasing microleaks was observed: MTA Angelus < MTA Plus < PRO-Root MTA < Control group. There was a statistically significant difference in mean microleakage in MTA Angelus and MTA Plus groups (P = 0.040). MTA Angelus shows the least microleakage among all the bioceramic material groups. Conclusion: Although the sealing ability of MTA Angelus is superior to MTA Plus, PRO-Root MTA. MTA Plus, PRO-Root MTA could be considered an acceptable alternative to MTA Angelus in peri-radicular surgeries.

Physical Function Trajectories and Mortality in Older Adults With Multisensory Impairment.

Importance: Single sensory impairment is associated with reduced functional resilience and increased mortality, though the effects of multiple sensory deficits are not known. Objective: To investigate longitudinal associations of the type, severity, and number of sensory impairments with physical function trajectories and mortality in older adults. Design, Setting, and Participants: This retrospective analysis of a longitudinal cohort study, the Health, Aging, and Body Composition (Health ABC) study, incorporated data from April 1997 to July 2013, featuring a 16-year follow-up with annual examinations and questionnaires. The cohort comprised 3075 men and women, aged 70 to 79 years at baseline, residing in Memphis, Tennessee, and Pittsburgh, Pennsylvania. All participants with complete sensory testing and covariate data at analytical baseline (year 5, 2002) were included. The data were analyzed September 1, 2022. Exposures: Visual, olfactory, auditory, and touch sensory functions were assessed between 2000 and 2002. Main Outcomes: The main outcomes included physical functioning trajectories and mortality risk. Physical function was assessed longitudinally using the Health ABC physical performance battery (HABCPPB). Results: A total of 1825 individuals (mean [SD] age, 77.4 [3.2] years; 957 [52%] female) were included in this study. Multivariable analysis of HABCPPB decline indicated that having 1 sensory impairment (ß estimate, -0.01 [95% CI, -0.02 to -0.001]); 2 sensory impairments (ß estimate, -0.01 [95% CI, -0.02 to -0.01]); 3 sensory impairments (ß estimate, -0.03 [95% CI, -0.04 to -0.02]); or 4 sensory impairments (ß estimate, -0.04 [95% CI, -0.05,-0.03]) was significantly associated with a steeper HABCPPB score decline in a dose-dependent manner. Adjusted Cox proportional hazards models indicated that having 1 sensory impairment (hazard ratio [HR], 1.35 [95% CI, 1.01-1.81]), 2 sensory impairments (HR, 1.58 [95% CI, 1.19-2.11]), 3 sensory impairments (HR, 1.79 [95% CI, 1.33-2.42]), or 4 sensory impairments (HR, 1.97 [95% CI, 1.39-2.79]) was significantly associated with increased mortality risk in a similarly dose-dependent manner. Conclusion: In this retrospective cohort study, the degree and number of multiple sensory impairments were associated with worse physical functioning and increased mortality risk. These findings represent an opportunity for further investigation into the value of screening, prevention, and treatment of sensory impairments to reduce morbidity and mortality in older adults.

Association of Win-Loss Record With Neuropsychiatric Symptoms and Brain Health Among Professional Fighters.

OBJECTIVE: Repetitive head impacts in professional fighting commonly lead to head injuries. Increased exposure to repetitive head trauma, measured by the number of professional fights and years of fighting, has been associated with slower processing speed and smaller brain volumes. The impact of win-loss outcomes has been investigated in other sports, with several studies suggesting that individuals on losing teams experience more head injuries. Here, the authors hypothesized that fighters with a worse fight record would exhibit poorer brain health outcomes. METHODS: The Professional Fighters Brain Health Study examined changes in neuropsychiatric symptoms, regional brain volume, and cognition among professional boxers and mixed martial arts fighters. These data were used to evaluate the relationship between win-loss ratios and brain health outcomes among professional fighters (N=212) by using validated neuropsychiatric symptom and cognitive measures and MRI data. RESULTS: Retired fighters with a better record demonstrated more impulsiveness (B=0.21, df=48) and slower processing speed (B=-0.42, df=31). More successful fighters did not perform better than fighters with worse records on any neuropsychiatric or cognitive test. Retired fighters with better fight records had smaller brain volumes in the subcortical gray matter, anterior corpus callosum, left and right hippocampi, left and right amygdala, and left thalamus. More successful active fighters had a smaller left amygdala volume. CONCLUSIONS: These findings suggest that among retired fighters, a better fight record was associated with greater impulsiveness, slower processing speed, and smaller brain volume in certain regions. This study shows that even successful fighters experience adverse effects on brain health.

Reduction in olfactory dysfunction prevalence among patients with diabetes taking metformin.

KEY POINTS: Metformin treatment is associated with reduced olfactory dysfunction (OD) in diabetic patients Metformin may possess potential protective effects on olfaction beyond glycemic control.

Cochlear Implant Electrode Array Design and Speech Understanding.

OBJECTIVE: Cochlear implant electrode arrays are categorized based on their design as lateral wall (LW) and perimodiolar (PM) electrode arrays. The objective of this study was to investigate the effect of LW versus PM designs on postoperative speech perception across multiple manufacturers and over long follow-up durations. DESIGN: Retrospective cohort study. SETTING: Single academic medical center. PARTICIPANTS: A total of 478 adult cochlear implant recipients, implanted between the years 1992 and 2017. INTERVENTIONSS: PM versus LW cochlear implants. MAIN OUTCOMES AND MEASURES: Postoperative Consonant-Nucleus-Consonant Word (CNC-w) and Hearing in Noise Test (HINT) scores between 6 months and 5 years. RESULTS: Across 478 patients, approximately one-third received LW (n = 176, 36.8%), whereas 302 patients received a PM array (63.2%). The PM group had higher CNC-w scores from 6 months to 2 years (52 [interquartile range, 38-68] versus 48 [31-62], p = 0.036) and from 2 to 5 years (58 [43-72] versus 48 [33-66], p < 0.001). Multivariable analysis of patient-averaged scores indicated that the PM group had greater improvement from preoperative scores at all time points after the initial 6 months for both CNC-w ( ß = 4.4 [95% confidence interval, 0.6-8.3], p = 0.023) and HINT testing ( ß = 4.5 [95% confidence interval, 0.3-8.7], p = 0.038). CONCLUSIONS: This study indicates that PM electrode arrays are associated with small increases in postoperative speech perception scores, relative to LW arrays, when assessed across manufacturers, over long time durations, and using multiple outcome instruments. These findings may help guide surgeon selection and patient counseling of cochlear implant arrays.

Qualitative and quantitative characteristics of xylazine-associated deaths detected using a post-mortem toxicology testing program.

INTRODUCTION: The United States drug overdose crisis continues to evolve. Xylazine has been increasingly identified as an adulterant in illicit opioid supplies. The incorporation of novel adulterants, like xylazine, into the illicit drug supply adds complexity to post-mortem toxicology testing, public health messaging, substance use mitigation, and the treatment of people who use drugs. METHODS: We assessed trends, decedent characteristics, drug co-detection, and blood concentrations of xylazine-positive post-mortem cases in Michigan. We utilized a toxicology testing program capable of detecting several opioids and non-opioids in post-mortem blood samples within 72 hours. RESULTS: A total of 279 deaths were xylazine-positive between October 2019 and June 2023, with 100 percent positive for fentanyl. Only 30 percent of xylazine-involved samples were positive for naloxone, while 21.2 percent of xylazine-negative and opioid-positive samples were positive for naloxone. The percentage of xylazine-positive deaths increased from 3.2 percent in 2021 to 4.7 percent in January-June 2023. A median of five total drug groups were present among xylazine-positive deaths. Post-mortem xylazine concentrations for 55 decedent blood samples ranged from 5.2 to 200 µg/L. DISCUSSION: Our study demonstrated increases in xylazine detection among post-mortem cases. Our findings are consistent with national trends of increasing xylazine presence among drug-involved deaths. Our range of detected post-mortem xylazine blood concentrations was consistent with what has been reported in previous literature. Fentanyl was detected in 100 percent of xylazine-positive overdose deaths. Naloxone detection was relatively low, highlighting the continued importance of increasing naloxone access and distribution. Deaths associated with xylazine often involved multiple other drugs. Limited human clinical xylazine research precludes accurate interpretation and attribution of causality from these data. CONCLUSIONS: Overdose-related deaths with xylazine detection are increasing in Michigan and across the United States. Further clinical and toxicological research can help contextualize the clinical significance of xylazine in opioid overdose, clarify epidemiologic and clinical research, and inform appropriate public health messaging.

Outcome prediction of methadone poisoning in the United States: implications of machine learning in the National Poison Data System (NPDS).

Methadone is an opioid receptor agonist with a high potential for abuse. The current study aimed to compare different machine learning models to predict the outcomes following methadone poisoning. This six-year retrospective longitudinal study utilizes National Poison Data System (NPDS) data. The severity of outcomes was derived from the NPDS Coding Manual. Our database was divided into training (70%) and test (30%) sets. We used a light gradient boosting machine (LGBM), extreme gradient boosting (XGBoost), random forest (RF), and logistic regression (LR) to predict the outcomes of methadone poisoning. A total of 3847 patients with methadone exposures were included. Our results demonstrated that machine learning models conferred high accuracy and reliability in determining the outcomes of methadone poisoning cases. The performance evaluation showed all models had high accuracy, precision, specificity, recall, and F1-score values. All models could reach high specificity (more than 96%) and high precision (80% or more) for predicting major outcomes. The models could also achieve a high sensitivity to predict minor outcomes. Finally, the accuracy of all models was about 75%. However, XGBoost and LGBM models achieved the best performance among all models. This study showcased the accuracy and reliability of machine learning models in the outcome prediction of methadone poisoning.

Potential Role for Diet in Mediating the Association of Olfactory Dysfunction and Cognitive Decline: A Nationally Representative Study.

In the context of a growing body of evidence associating olfactory dysfunction (OD) with cognitive decline, this cross-sectional study used data from the 2013-2014 National Health and Nutrition Examination Survey (NHANES) sample in order to explore the role of dietary intake in this association. Leveraging a nationally representative sample of U.S. adults aged 60 years and older, this study analyzed dietary patterns using exploratory factor analysis. OD was categorized based on the NHANES Pocket Smell Test, and cognitive function was measured with a battery of tests. Survey-weighted multivariable regressions and causal mediation analysis were used to examine the relationship between dietary patterns, OD, and cognitive function. Results indicated that a poor adherence to a diet rich in monounsaturated fats (MUFAs) and polyunsaturated fats (PUFAs) was independently associated with both cognitive and olfactory dysfunctions, after adjusting for sociodemographic and health factors. Moreover, the relationship between OD and cognitive decline was found to be partly mediated by adherence to such a diet. This study proposes a potential link between diet, olfactory function, and cognitive decline, highlighting the role of nutritional interventions in mitigating cognitive decline, particularly in individuals with olfactory impairment.

Treatment of pediatric antimuscarinic delirium with oral rivastigmine.

Antimuscarinic drug toxicity is a common pediatric emergency, which produces central and peripheral symptoms. Treatment of agitation and hyperactive antimuscarinic delirium, with first-line agents like cholinesterase inhibitors or benzodiazepines, is imperative to prevent severe toxicity. Intravenous physostigmine salicylate is a cholinesterase inhibitor that is commonly used to treat central antimuscarinic delirium. Its chemical structure facilitates crossing of the blood-brain barrier. Overlapping nationwide physostigmine and benzodiazepine shortages have prompted consideration of therapeutic alternatives. Rivastigmine is a long-acting cholinesterase inhibitor with a similar chemical structure to physostigmine. It represents a potential therapeutic option for antimuscarinic delirium. Rivastigmine offers potential benefits over physostigmine including a longer duration of action, slower rate of central nervous system penetration, more favorable side effect profile, and availability in multiple formulations. A paucity of literature exists describing the use of rivastigmine for central antimuscarinic delirium. We describe the effective use of oral rivastigmine in a child with central antimuscarinic delirium.

Exploring Olfactory Dysfunction as a Marker of Frailty and Postoperative Outcomes in Head and Neck Cancer.

Importance: Olfactory dysfunction (OD) is increasingly recognized as a robust marker of frailty and mortality. Despite broad recognition of frailty as a critical component of head and neck cancer (HNC) care, there is no standardized frailty assessment. Objective: To assess the prevalence of OD and its association with frailty and postoperative outcomes in HNC. Design, Setting, and Participants: In this prospective cohort study with enrollment between February 17, 2021, to September 29, 2021, at a tertiary academic medical center, 85 eligible adult patients with primary, treatment-naive HNC of mucosal or cutaneous origin were included. Patients with a history of COVID-19, neurocognitive, or primary smell/taste disorders were excluded. Exposures: Prospective olfactory assessments (self-reported, visual analog scale [VAS] and psychophysical, University of Pennsylvania Smell Identification Test [UPSIT]) with concurrent frailty assessment (Risk Analysis Index [RAI]) were used. Olfactory-specific quality of life (QOL) was examined with brief Questionnaire of Olfactory Disorders-Negative Statements (QOD-NS). Main Outcome(s) and Measure(s): The primary outcome was the prevalence of OD as assessed by VAS (0-10, no to normal smell) and UPSIT (0-40, higher scores reflect better olfaction) and its association with frailty (RAI, 0-81, higher scores indicate greater frailty). For surgical patients, secondary outcomes were associations between OD and postoperative length of stay (LOS), 30-day postoperative outcomes, and QOD-NS (0-21, higher scores indicate worse QOL). Results: Among 51 patients with HNC (mean [SD] age, 63 [10] years; 39 [77%] male participants; 41 [80%] White participants), 24 (47%) were frail, and 4 (8%) were very frail. Despite median (IQR) self-reported olfaction by VAS of 9 (8-10), 30 (59%) patients demonstrated measured OD with psychophysical testing. No meaningful association was found between self-reported and psychophysical testing (Hodges-Lehmann, <0.001; 95% CI, -2 to 1); a total of 46 (90%) patients did not report decreased olfaction-specific QOL. Median UPSIT scores were lower in frail patients (Hodges-Lehmann, 6; 95% CI, 2-12). Multivariate modeling demonstrated severe microsmia/anosmia was associated with 1.75 (95% CI, 1.09-2.80) times odds of being frail/very frail and approximately 3 days increased LOS (ß, 2.96; 95% CI, 0.29-5.62). Conclusions and Relevance: Although patients with HNC are unaware of olfactory changes, OD is common and may serve as a bellwether of frailty. In this prospective cohort study, a dose-dependent association was demonstrated between increasing degrees of OD and frailty, and the potential utility of olfaction was highlighted as a touchstone in the assessment of HNC frailty.

Pediatric hand sanitizer exposures reported to United States poison centers, 2017-2021.

INTRODUCTION: The COVID-19 pandemic increased demand for alcohol-based hand sanitizers. We aimed to describe the epidemiological trends in pediatric alcohol-based hand sanitizer cases reported to United States poison centers. We characterized clinically significant pediatric reports involving alcohol-based hand sanitizer products before and during the pandemic and methanol-containing hand sanitizers during the pandemic. METHODS: We included all single-substance cases involving alcohol-based hand sanitizers reported to the National Poison Data System among children ≤ 19 years from 1 January 2017 to 31 December 2021, and methanol-containing hand sanitizers from 23 June 2020 to 31 December 2021. Multiple product exposures and non-human exposures were excluded. Clinically significant outcomes included moderate or major effects or death. RESULTS: There were 95,718 alcohol-based hand sanitizer pediatric cases during the study period. Most (n = 89,521; 94%) were unintentional, occurred by ingestion (n = 89,879; 93.9%), occurred at home, and were managed at the exposure site (n = 89,774; 93.8%). Common symptoms were vomiting (n = 2,969; 3.1%), coughing (n = 1,102; 1.2%), ocular irritation (n = 1,244; 1.3%), and drowsiness (n = 981; 1.0%). Most children (n = 3,937; 66.2%) managed at a health care facility were treated and released; a minority were admitted (n = 527; 9.0%). Few children (n = 81; 1.4%) were admitted to the intensive care unit. The prevalence of clinically significant cases increased in 2020 and 2021, compared to 2017. Population-adjusted rates, by state, of alcohol-based hand sanitizer cases ranged from 280 to 2,700 per million children. Of the 540 reported cases involving methanol-containing hand sanitizers, the majority (n = 255) occurred in July 2020. Thirteen cases (2.4%) had clinically significant outcomes. The prevalence of clinically significant cases remained similar in 2020 and 2021 and exhibited lower prevalence compared to alcohol-based products. Population-adjusted rates, by state, ranged from fewer than 0.9 to 40 per million children. CONCLUSIONS: Clinically significant pediatric cases involving alcohol-based hand sanitizers increased during the pandemic and remained elevated in 2021. Cases involving methanol-containing products were less frequent. Our findings may inform heightened product quality control and regulatory oversight.

The Association of Multiple Sensory Impairment and Telomere Length: The Health ABC Study.

OBJECTIVES: The objective of this study was to characterize the associations of sensory impairments, including olfaction (OI), vision (VI), hearing (HI), and touch (TI), with telomere length (TL) in a group of community-dwelling older adults who participated in the Health ABC study. METHODS: Across 1603 participants, OI was classified with the Brief Smell Identification Test (<11), HI with pure-tone averages (<25 dB), VI with visual acuity (20/50 or worse), and TI with monofilament testing (inability to detect three of four touches). Shorter TL was defined as the lowest quartile of sample TLs. Adjusted multivariable regressions were used to examine the cross-sectional association between the modality, severity, and number of sensory impairments with TL. RESULTS: Participants had an average age of 77.4 ± 2.84 years, and 89.7% (n = 1438) had at least one or more sensory impairments. Severe OI (odds ratio [OR] = 1.73, 95% confidence interval [CI] = [1.19, 2.6]) was independently associated with increased odds of shorter TL. Additionally, having one (OR = 2.79, 95% CI = [1.69, 4.70]), two (OR = 2.5, 95% CI = [1.51, 4.26]), three (OR = 3.04, 95% CI = [1.79, 5.36]), or four impairments (OR = 3.72, 95% CI = [1.52, 7.33]) was associated with increased odds of shorter TL in a dose-dependent manner. CONCLUSION: Severe OI and TI appear to be particularly robust markers of shortened TL. Additionally, multiple sensory impairment is strongly associated with shortened TL, suggesting that sensory dysfunction may represent a unique biomarker of unhealthy aging. LEVEL OF EVIDENCE: Level II Laryngoscope, 133:3132-3138, 2023.

Olfactory Dysfunction and Balance Dysfunction are Associated with Increased Falls in Older Adults.

OBJECTIVE: This study aims to characterize the association between impairments in olfaction and balance, both of which are mediated in part by the cerebellum, and how this relates to prospective incidence of falls in a cohort of aging adults. METHODS: The Health ABC study was queried to identify 296 participants with data on both olfaction (measured using the 12-item Brief Smell Identification Test) and balance-related function (measured using the Romberg test). The relationship between olfaction and balance was investigated using multivariable logistic regression. Predictors of performance on a standing balance assessment and predictors of falls were studied. RESULTS: Of 296 participants, 52.7% had isolated olfactory dysfunction, 7.4% had isolated balance dysfunction, and 5.7% had dual dysfunction. Severe olfactory dysfunction was associated with increased odds of balance dysfunction when compared to those without olfactory dysfunction, even when adjusting for age, gender, race, education, BMI, smoking, diabetes, depression, and dementia (OR = 4.1, 95% CI [1.5, 13.7], p = 0.011). Dual sensory dysfunction was associated with worse performance on a standing balance assessment (ß = -22.8, 95% CI [-35.6, -10.1], p = 0.0005) and increased falls (ß = 1.5, 95% CI [1.0, 2.3], p = 0.037). CONCLUSION: This study highlights a unique relationship between olfaction and balance, and how dual dysfunction is associated with increased falls. With substantial implications of falls on morbidity and mortality in older adults, this novel relationship between olfaction and balance emphasizes a potentially shared mechanism between olfactory dysfunction and increased fall risk in older adults; however, further study is required to explore the novel relationship of olfaction with balance and future falls. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:1964-1969, 2023.

Factors related to wellness and burnout in academic otolaryngology: A pre- and Post-COVID-19 analysis.

Objectives: Describe demographic and professional factors predictive of burnout in academic otolaryngology before and during the COVID-19 pandemic. Methods: In 2018 and 2020, cross-sectional surveys on physician wellness and burnout were distributed to faculty members of a single academic institution's otolaryngology department. Faculty were dichotomized into low and high burnout groups for 2018 (n = 8 high burnout, 19%) and 2020 (n = 11 high burnout, 37%). To identify protective factors against burnout, three semi-structured interviews were conducted with faculty that reported no burnout. Results: Forty-two participants (59%) in 2018 and 30 out of 49 participants (62%) in 2020 completed the survey. In multivariate analysis of 2018 survey data, full and associate professors had significantly lower odds of high burnout (OR 0.06, 95% CI 0.00-0.53; p = .03). Female gender was associated with increased in odds of high burnout (OR 15.55, 95% CI 1.86-231.74; p = .02). However, academic rank and gender did not remain independent predictors of high burnout in the 2020 survey. We identified significant differences in drivers of burnout brought on by the pandemic, including a shift from a myriad of work-related stressors in 2018 to a focus on patientcare and family obligations in 2020. Interview analysis identified three themes in faculty who reported no burnout: (1) focus on helping others, (2) happiness over compensation as currency, and (3) gratitude for the ability to have an impact. Conclusion: Approximately 20% of faculty reported high burnout before the pandemic, and this proportion nearly doubled during the pandemic. The risk factors and themes identified in this study may help academic otolaryngologists prevent burnout. Lay Summary: Factors driving burnout among academic otolaryngologists during the COVID-19 pandemic transitioned away from research, conferences, and work outside business hours toward family and patient responsibilities. Females report higher burnout and full professors report lower burnout. Level of evidence: III.

The role of decision tree and machine learning models for outcome prediction of bupropion exposure: A nationwide analysis of more than 14 000 patients in the United States.

Bupropion is widely used for the treatment of major depressive disorder and for smoking cessation assistance. Unfortunately, there are no practical systems to assist clinicians or poison centres in predicting outcomes based on clinical features. Hence, the purpose of this study was to use a decision tree approach to inform early diagnosis of outcomes secondary to bupropion overdose. This study utilized a dataset from the National Poison Data System, a 6-year retrospective cohort study on toxic exposures and patient outcomes. A machine learning algorithm (decision tree) was applied to the dataset using the sci-kit-learn library in Python. Shapley Additive exPlanations (SHAP) were used as an explainable method. Comparative analysis was performed using random forest (RF), Gradient Boosting classification, eXtreme Gradient Boosting, Light Gradient Boosting (LGM) and voting ensembling. ROC curve and precision-recall curve were used to analyse the performance of each model. LGM and RF demonstrated the highest performance to predict outcome of bupropion exposure. Multiple seizures, conduction disturbance, intentional exposure, and confusion were the most influential factors to predict the outcome of bupropion exposure. Coma and seizure, including single, multiple and status, were the most important factors to predict major outcomes.

Massive warfarin overdose management in an adolescent patient.

INTRODUCTION: Warfarin is a widely used oral anticoagulant with established reversal guidelines in the setting of a supratherapeutic international normalized ratio (INR). Limited literature exists on managing acute warfarin overdoses in patients who are not chronically anticoagulated. CASE: A 15-year-old male, with no indication for anticoagulation, presented to a pediatric emergency department after an acute 1,000 mg warfarin ingestion. He had no significant complaints upon presentation aside from a mild intermittent headache. His past medical history was significant for anxiety, depression, Tourette syndrome, attention deficit hyperactivity disorder, and polysubstance misuse. Computed tomography of his head was unremarkable and serum acetaminophen, salicylate, and ethanol concentrations were negative. Approximately 16 h post-ingestion, his INR was 1.9 with an increase to 3.3 by 26 h. The regional poison center was consulted and recommended, consistent with the CHEST guidelines, holding treatment with vitamin K until INR was >10 or if signs or symptoms of bleeding occurred. The patient was admitted for monitoring and by hospital day (HD) #4, his INR had risen to >11.8 at which point oral vitamin K 10 mg was administered. On HD #7, the patient was deemed stable for transfer to inpatient psychiatry after repeat INRs of 2.9 and 3.4. DISCUSSION: Case reports have demonstrated early administration of vitamin K can temporarily lower INR and prevent detection of rebound. The CHEST warfarin reversal guidelines describe the risks and benefits with respect to bleeding and thrombosis in the non-intentional overdose patient. Application and extrapolation of these guidelines to acute overdose in patients who lack an indication for anticoagulation may or may not be warranted. CONCLUSION: While established clinical guidance exists on reversing a supratherapeutic INR in patients chronically anticoagulated with warfarin, the risks and benefits of extrapolating this approach are unclear in those who lack an indication for anticoagulation.

Are Speech Perception Scores in Cochlear Implant Recipients Consistent Across Different Tests?

OBJECTIVE: Cochlear implant (CI) candidacy and postoperative outcomes are assessed using sets of speech perception tests that vary from center to center, limiting comparisons across institutions and time periods. The objective of this study was to determine if scores on one speech perception test could be reliably predicted from scores on another test. STUDY DESIGN: Arizona Biomedical (AzBio) Sentence Test, Consonant-Nucleus-Consonant word (CNCw), and Hearing in Noise Test (HINT) scores in quiet for the implanted ear were collected for individuals who received a CI between 1985 and 2019. Scores collected during the same testing session were analyzed using Bland-Altman plots to assess agreement between testing methods. Simple linear regression with logit transformation was used to generate predictive functions and 95% confidence intervals for expected mean and individual scores. SETTING: Single academic medical center. PATIENTS: A total of 1,437 individuals with a median age of 59.9 years (range, 18-95 yr) and 46% (654 of 1,437) male. INTERVENTIONS: N.A. MAIN OUTCOME MEASURES: Agreement as a function of test score, mean, variance, and correlation coefficients. RESULTS: A total of 2,052 AzBio/CNCw, 525 AzBio/HINT, and 7,187 CNCw/HINT same-session score pairings were identified. Pairwise test comparisons demonstrated limited agreement between different tests performed in the same session, and a score correlation between different speech tests revealed large variances. CONCLUSION: Transformation functions between test batteries were predictive of mean scores but performed poorly for prediction of individual scores. Point-wise comparisons of scores across CI test batteries should be used with caution in clinical and research settings.

Pediatric Melatonin Ingestions - United States, 2012-2021.

Melatonin is an endogenous neurohormone that regulates the sleep-wake cycle (1). It is used therapeutically for insomnia in adults and for primary sleep disorders in children (2). Melatonin is regulated by the Food and Drug Administration (FDA) as a dietary supplement. Various synthetic melatonin preparations are widely available over the counter (OTC) in the United States with sales increasing from $285 million in 2016 to $821 million in 2020 (3). Children are at increased risk for melatonin exposure because of the supplement's widespread use and growing popularity as a sleep aid. In 2020, melatonin became the most frequently ingested substance among children reported to national poison control centers (4); however, more research is needed to describe the toxicity and outcomes associated with melatonin ingestions in children. This study assessed isolated melatonin ingestions among the pediatric population (defined here as children, adolescents, and young adults aged ≤19 years) during January 1, 2012-December 31, 2021, using the American Association of Poison Control Centers' National Poison Data System (NPDS). During the 10-year study period, 260,435 pediatric melatonin ingestions were reported to NPDS, and the annual number of ingestions increased 530%. In addition, pediatric melatonin ingestions accounted for 4.9% of all pediatric ingestions reported to poison control centers in 2021 compared with 0.6% in 2012. Pediatric hospitalizations and more serious outcomes due to melatonin ingestions increased during the study period, primarily related to an increase in unintentional ingestions among children aged ≤5 years. Five children required mechanical ventilation, and two died. Consumers and health care professionals should be encouraged to report any melatonin product-related adverse events to MedWatch, the FDA's medical product safety reporting program. Public health initiatives should focus on raising awareness of increasing numbers of melatonin ingestions among children and on the development of preventive measures to eliminate this risk.

Environmental air pollution and chronic rhinosinusitis: A systematic review.

Objective: Chronic rhinosinusitis (CRS) is a highly prevalent and burdensome disease. The pathophysiology is not fully elucidated, but environmental pollutants have been suggested to impact the inflammatory component of the disease process. This review aims to summarize the role of environmental pollution in CRS onset and disease severity. Methods: A systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, EMBASE, Cochrane Library, Web of Science, and Scopus databases were queried in August 2021. Original articles reporting on air pollution exposure in CRS were included. Other forms of sinonasal disease were excluded. Results: Literature search produced 11,983 articles, of which 10 met inclusion criteria. Outcomes evaluated included incidence/prevalence, disease severity, quality of life, and histopathologic/microbial changes. Air pollutant exposure was associated with higher odds of CRS, particularly with particulate matter (PM) exposure. Increasing air pollution exposure was also associated with worsened disease severity and detectable histopathologic changes. Impact on quality of life was less clear. Conclusion: Air pollution (particularly PM) is correlated with CRS incidence/prevalence and disease severity, with evidence of histopathologic changes in CRS tissue samples. Further research is warranted to better understand the mechanisms by which air pollution components may cause CRS and type 2 inflammation. Level of Evidence: 3a.

Association of Frailty Status and Dietary Patterns in a Nationally Representative Sample of United States Adults with Olfactory Dysfunction.

BACKGROUND: Olfactory dysfunction (OD) is a strong, independent predictor of frailty and mortality risk. This study evaluated the association of dietary patterns and frailty status in older adults with OD. METHODS: This cross-sectional study utilized the 2013-2014 National Health and Nutrition Examination Survey. Dietary patterns (DPs) characteristic of OD were derived using exploratory factor analysis (EFA). Multiple logistic regressions adjusted for demographics and frailty risk factors assessed the association of DPs with two frailty metrics: the frailty index (FI) and physical frailty (PF). RESULTS: EFA yielded six distinct DPs in persons with OD. The protein/selenium (OR 0.82 [95% CI 0.74-0.92], p = 0.041) and ß-carotene/vitamin A DPs (OR 0.76 [95% CI 0.66-0.88], p = 0.028) were independently associated with frailty by FI. Only the protein/selenium DP (OR 0.82 [95% CI 0.74-0.92], p = 0.036) was associated with frailty by PF. No DPs were associated with either frailty measure in normosmic persons. CONCLUSIONS: Dietary patterns high in protein/selenium and ß-carotene/vitamin A are associated with lower frailty prevalence in adults with OD. While the relationship between OD and frailty is likely multifaceted, these findings suggest that dietary patterns are uniquely associated with frailty in older adults with OD.