Race, Ethnicity, Language, and the Treatment of Low-Risk Febrile Infants.

Importance: Febrile infants at low risk of invasive bacterial infections are unlikely to benefit from lumbar puncture, antibiotics, or hospitalization, yet these are commonly performed. It is not known if there are differences in management by race, ethnicity, or language. Objective: To investigate associations between race, ethnicity, and language and additional interventions (lumbar puncture, empirical antibiotics, and hospitalization) in well-appearing febrile infants at low risk of invasive bacterial infection. Design, Setting, and Participants: This was a multicenter retrospective cross-sectional analysis of infants receiving emergency department care between January 1, 2018, and December 31, 2019. Data were analyzed from December 2022 to July 2023. Pediatric emergency departments were determined through the Pediatric Emergency Medicine Collaborative Research Committee. Well-appearing febrile infants aged 29 to 60 days at low risk of invasive bacterial infection based on blood and urine testing were included. Data were available for 9847 infants, and 4042 were included following exclusions for ill appearance, medical history, and diagnosis of a focal infectious source. Exposures: Infant race and ethnicity (non-Hispanic Black, Hispanic, non-Hispanic White, and other race or ethnicity) and language used for medical care (English and language other than English). Main Outcomes and Measures: The primary outcome was receipt of at least 1 of lumbar puncture, empirical antibiotics, or hospitalization. We performed bivariate and multivariable logistic regression with sum contrasts for comparisons. Individual components were assessed as secondary outcomes. Results: Across 34 sites, 4042 infants (median [IQR] age, 45 [38-53] days; 1561 [44.4% of the 3516 without missing sex] female; 612 [15.1%] non-Hispanic Black, 1054 [26.1%] Hispanic, 1741 [43.1%] non-Hispanic White, and 352 [9.1%] other race or ethnicity; 3555 [88.0%] English and 463 [12.0%] language other than English) met inclusion criteria. The primary outcome occurred in 969 infants (24%). Race and ethnicity were not associated with the primary composite outcome. Compared to the grand mean, infants of families that use a language other than English had higher odds of the primary outcome (adjusted odds ratio [aOR]; 1.16; 95% CI, 1.01-1.33). In secondary analyses, Hispanic infants, compared to the grand mean, had lower odds of hospital admission (aOR, 0.76; 95% CI, 0.63-0.93). Compared to the grand mean, infants of families that use a language other than English had higher odds of hospital admission (aOR, 1.08; 95% CI, 1.08-1.46). Conclusions and Relevance: Among low-risk febrile infants, language used for medical care was associated with the use of at least 1 nonindicated intervention, but race and ethnicity were not. Secondary analyses highlight the complex intersectionality of race, ethnicity, language, and health inequity. As inequitable care may be influenced by communication barriers, new guidelines that emphasize patient-centered communication may create disparities if not implemented with specific attention to equity.

Evolution of clinical event debriefs in a quaternary pediatric emergency department after implementation of a debriefing tool.

BACKGROUND: Debriefing clinical events in the emergency department (ED) can enhance team performance and provide mutual support. However, ED debriefing remains infrequent and nonstandardized. A clinical tool (DISCERN-Debriefing In Situ Conversation after Emergent Resuscitation Now) was developed to facilitate ED debriefing. To date, there are no studies providing qualitative analysis of clinical event debriefs done using such a tool. Our goal was to explore common themes elicited by debriefing following implementation of DISCERN. METHODS: This was a retrospective mixed-methods study analyzing DISCERN data from 2012 through 2017 in a pediatric ED. Quantitative data were analyzed using descriptive statistics. With constant comparison analysis, themes were categorized when applicable within the context of crisis resource management (CRM) principles, previously used as a framework for description of nontechnical skills. Member checking was performed to ensure trustworthiness. RESULTS: We reviewed 400 DISCERN forms. Overall, 170 (41.6%) of target clinical events were debriefed during the study period. The number of clinical events debriefed per year decreased significantly over the study period, from 118 debriefed events in 2013 to 20 debriefed events in 2017 (p < 0.001). Events were more likely to be debriefed if cardiopulmonary resuscitation was needed (odds ratio [OR] = 11.8, 95% confidence interval [CI] = 4.1-33.8]) or if the patient expired (OR = 8.9, 95% CI = 2.7-29.1]). CRM principles accounted for 81% of debriefing statements, focusing on teamwork, communication, and preparation, and these themes remained consistent throughout the study period. CONCLUSIONS: Use of the DISCERN tool declined over the study period. The DISCERN tool was utilized more commonly after the highest-acuity events. Clinical event debriefs aligned with CRM principles, with medical knowledge discussed less frequently, and the content of debriefs remained stable over time.

Case Report: Acute Supraglottitis.

This report illustrates a case of acute supraglottitis, a rare condition that can be easily diagnosed, but can quickly be deadly if missed. The patient presented with a sore throat and unilateral neck swelling that progressed to voice changes and difficulty handling secretions. Initially, radiographs were obtained followed by computed tomography. Imaging raised concern for supraglottitis; therefore otolaryngology consult was obtained and flexible laryngoscopy confirmed the diagnosis. The patient received a prophylactic awake fiberoptic intubation at the bedside and was started on intravenous antibiotics and steroids. She quickly improved and is expected to make a full recovery. Trainees and current practicing physicians in today's post-Haemophilus influenza type b vaccination period rarely encounter epiglottitis or supraglottitis. This case reminds us to keep this uncommon but quickly progressive and dangerous condition in mind to avoid a missed diagnosis which can lead to significant morbidity and mortality. Topics: Supraglottitis, acute supraglottitis, adult, intubation, antibiotic, microbiology.

Autophagy Mediates Astrogenesis in Adult Hippocampal Neural Stem Cells.

Neural stem cells (NSCs) have the ability to self-renew and differentiate into neurons, oligodendrocytes, and astrocytes. Highly dynamic nature of NSC differentiation requires the intimate involvement of catabolic processes such as autophagy. Autophagy is a major intracellular degradation pathway necessary for cellular homeostasis and remodeling. Autophagy is important for mammalian development and its role in neurogenesis has recently drawn much attention. However, little is known about how autophagy is associated with differentiation of NSCs into other neural lineages. Here, we report that autophagy plays a critical role in differentiation of adult rat hippocampal neural stem (HCN) cells into astrocytes. During differentiation, autophagy flux peaked at early time points, and remained high. Pharmacological or genetic suppression of autophagy by stable knockdown of Atg7, LC3 or CRISPR-Cas9-mediated knockout (KO) of p62 impaired astrogenesis, while reintroduction of p62 recovered astrogenesis in p62 KO HCN cells. Taken together, our findings suggest that autophagy plays a key role in astrogenesis in adult NSCs.

Association of membranoproliferative glomerulonephritis with mantle cell lymphoma.

Mantle cell lymphoma (MCL) is a rare and aggressive lymphoid neoplasm. It can involve the kidney, either by direct lymphomatous infiltration or by a paraneoplastic glomerulonephritis. We present here the case of a man with rectal bleeding and rapidly progressive renal failure, who had MCL in the gastrointestinal tract and paraneoplastic membranoproliferative glomerulonephritis, and whose renal dysfunction normalised after chemotherapy.

Sexual behaviour and borderline personality disorder among female psychiatric inpatients.

OBJECTIVE: The objective of the present study was to explore various facets of sexual behaviour in those with borderline personality disorder (BPD). METHOD: Using a cross-sectional approach and a sample of convenience, we surveyed 126 female psychiatric inpatients regarding their sexual histories as well as BPD symptoms on two self-report measures. RESULTS: Compared to participants who were not positive on both measures of BPD (the nonBPD group; n = 52), those who were positive on both measures (the BPD group; n = 70) reported a greater number of sexual partners, and were more likely to report having been raped by a stranger and having been coerced to have sex. There were no between-group differences with regard to age at menarche, age of first intercourse, total number of times treated for a sexually transmitted disease, having experienced date rape or rape by a partner, or having had homosexual experiences. CONCLUSIONS: The psychological themes associated with the positive findings in this study appear to reflect both impulsivity and victimization - psychological themes that are evident in other behaviours in those with BPD.

Body image and borderline personality disorder among psychiatric inpatients.

OBJECTIVE: With the exclusion of studies in individuals with eating disorders, few investigators have examined body image issues in patients with borderline personality disorder (BPD). In this study, we examined among psychiatric inpatients relationships between body image and BPD. METHOD: In a cross-sectional sample of convenience, we surveyed 126 women in an inpatient psychiatric unit using 5 measures for body image and 2 measures for BPD. RESULTS: Using standardized cutoffs for BPD diagnosis, participants with BPD demonstrated a number of differentiating features with regard to body image issues. Explicitly, BPD did not seem to be related to being self-conscious about one's appearance, although BPD was related to being more self-conscious, in general. Individuals with BPD were not more invested in their appearance as a source of self-definition but evaluated their own appearance more negatively and were more likely to believe that attractiveness is an important factor for happiness and acceptance. Although BPD was not related to perceptions about the strength and competence of one's own body, those with BPD indicated less comfort and trust in their own bodies. In general, it appeared that body image measures that were more perceptually grounded were more likely to be similar to non-BPD participants, whereas body image measures that were more cognitively grounded were more likely to be statistically significantly different in comparison with non-BPD participants. CONCLUSIONS: Psychiatric inpatients with BPD demonstrate a number of disturbances in body image.

Borderline personality and weight divergence in adulthood.

Borderline personality disorder (BPD) is an Axis II dysfunction characterized by extremist thinking (i.e., black/white thinking and thinking in absolutes). In keeping with this cognitive style, and based upon our clinical observations, we wondered whether a possible behavioral marker of extremism, weight divergence (i.e., a large difference between lowest and highest weights in adulthood), might be associated with BPD. Among 95 women psychiatric inpatients, we explored lowest adult weight, current weight, and highest adult weight as well as BPD using two self-report measures for the disorder, the borderline personality disorder scale of the Personality Diagnostic Questionnaire-4 (PDQ-4) and the Self-Harm Inventory (SHI). Results indicated statistically significantly correlations between increasing weight divergence and both BPD measures. Further analyses indicated that this relationship was not explained by overall body size or history of binge eating behavior. Findings suggest that, among psychiatric inpatients, weight divergence in adulthood may be a potential indicator of BPD.

Suicide attempts and domestic violence among women psychiatric inpatients.

Objective. Previous clinical observations, as well as empirical studies in fairly unique samples, suggest that there may be a relationship between domestic-violence victimization and suicide attempts. We wished to examine this relationship among psychiatric women inpatients. Methods. In this study among psychiatric inpatients, we compared women with versus without suicide attempts with regard to scores on a measure of domestic violence. Results. Compared to women without attempts, women with acknowledged histories of suicide attempts had significantly higher scores on the measure of domestic violence. Conclusion. These data support a relationship between domestic-violence victimization and a history of suicide attempts. From the perspective of assessment, inpatient clinicians need to carefully screen every patient with a history of suicide attempts for a history of domestic violence.

Anterior capsulolabral reconstruction for traumatic recurrent anterior shoulder dislocation.

The anterior capsulolabral reconstruction (ACLR) has been shown to yield satisfactory results predominantly in overhead athletes with atraumatic anterior shoulder instability. The purpose of this study was to assess the clinical results of patients who underwent ACLR for recurrent traumatic anterior shoulder dislocation. A retrospective review of 41 patients, mean age 29 (range: 16 to 55 years) who underwent ACLR for traumatic recurrent anterior shoulder dislocation was performed. All patients reported a traumatic anterior shoulder dislocation with subsequent recurrent instability. Seven patients had undergone previous shoulder stabilization surgery which had failed. The mean number of previous dislocations was 4.5 (range: 1 to 15). There were 31 males and 10 females, and the dominant arm was involved in 24 patients. In all cases, the capsulolabral complex was detached from the glenoid rim. The mean follow-up was 3.6 years (range: 15 to 80 months). All patients were evaluated by physical examination. The mean modified Rowe score was 93.6 (range: 65 to 100). There were 32 excellent, 5 good, 1 fair, and 2 poor results. Instability was eliminated in 38 patients (93%). Of 25 patients who engaged in recreational sports, all were able to return to their previous level of participation. One patient sustained a traumatic redislocation and underwent revision surgery. Two patients reported atraumatic recurrent subluxation with one requiring revision surgery due to persistent symptoms of instability. There was no loss of range of motion in comparison to preoperative values. Of the seven shoulders that had undergone previous surgery, all remain stable. These results indicate that a glenoid-sided capsulolabral reconstruction can restore shoulder stability in patients with recurrent traumatic anterior shoulder dislocation. Success rates comparable to those of other open anterior shoulder repair procedures can be achieved.