A circular waste bioeconomy development model in the Ecuadorian fishery industry: the impact of government strategy on supply chain integration and smart operations.

This study develops a set of measures to address the interrelationship among circular waste-based bioeconomy (CWBE) attributes, including those of government strategy, digital collaboration, supply chain integration, smart operations, and a green supply chain, to build a circular bioeconomy that feeds fish waste back into the economy. CWBE development is a potential solution to the problem of waste reuse in the fish supply chain; however, this potential remains untapped, and prior studies have failed to provide the criteria to guide its practices. Such an analytical framework requires qualitative assessment, which is subject to uncertainty due to the linguistic preferences of decision makers. Hence, this study adopts the fuzzy Delphi method to obtain a valid set of attributes. A fuzzy decision-making trial and evaluation was applied to address the attribute relationships and determine the driving criteria of CWBE development. The results showed that government strategies play a causal role in CWBE development and drive digital collaboration, smart operations, and supply chain integration. The findings also indicated that smart manufacturing technology, organizational policies, market enhancement, supply chain analytics, and operational innovation are drivers of waste integration from fisheries into the circular economy through waste-based bioeconomy processes.

Pediatric osteomyelitis due to rare tropical multi-drug resistance (MDR) organisms: a treatment quandary.

Osteomyelits due to concurrent multi-drug resistance organisms is difficult to treat for any surgeon and infectious disease physician. An eleven-year-old boy presenting with an open fracture of the left radius and ulna after a fall in a stagnant wet field. Despite prophylactic antibiotics and surgical intervention, the open wound was infected, and Chromobacterium violaceum as well as Klebsiella pneumoniae were isolated. He was treated with six weeks of parenteral cefepime and amikacin and was discharged upon clinical improvement. Unfortunately, chronic osteomyelitis set in with persistent sinus drainage. He then underwent a second procedure for debridement of the wound and Burkholderia pseudomallei was isolated. Parenteral antibiotic therapy was initiated progressing with a marked improvement. However, the long course of antibiotics had exhausted the patient and his family, leading to a premature interruption of the parenteral antibiotic. Despite the suboptimal antibiotic course, there were no signs of relapsed osteomyelitis during subsequent review. The timely surgical intervention with appropriate sampling for subsequent microorganism isolation guided the suitability of the treatment line.

Pediatric Ischemic Stroke: An Infrequent Complication of SARS-CoV-2.

OBJECTIVE: Severe complications of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) include arterial ischemic stroke (AIS) in adults and multisystem inflammatory syndrome in children. Whether stroke is a frequent complication of pediatric SARS-CoV-2 is unknown. This study aimed to determine the proportion of pediatric SARS-CoV-2 cases with ischemic stroke and the proportion of incident pediatric strokes with SARS-CoV-2 in the first 3 months of the pandemic in an international cohort. METHODS: We surveyed 61 international sites with pediatric stroke expertise. Survey questions included: numbers of hospitalized pediatric (≤ 18 years) patients with SARS-CoV-2; numbers of incident neonatal and childhood ischemic strokes; frequency of SARS-CoV-2 testing for pediatric patients with stroke; and numbers of stroke cases positive for SARS-CoV-2 from March 1 to May 31, 2020. RESULTS: Of 42 centers with SARS-CoV-2 hospitalization numbers, 8 of 971 (0.82%) pediatric patients with SARS-CoV-2 had ischemic strokes. Proportions of stroke cases positive for SARS-CoV-2 from March to May 2020 were: 1 of 108 with neonatal AIS (0.9%), 0 of 33 with neonatal cerebral sinovenous thrombosis (CSVT; 0%), 6 of 166 with childhood AIS (3.6%), and 1 of 54 with childhood CSVT (1.9%). However, only 30.5% of neonates and 60% of children with strokes were tested for SARS-CoV-2. Therefore, these proportions represent 2.9, 0, 6.1, and 3.0% of stroke cases tested for SARS-CoV-2. Seven of 8 patients with SARS-CoV-2 had additional established stroke risk factors. INTERPRETATION: As in adults, pediatric stroke is an infrequent complication of SARS-CoV-2, and SARS-CoV-2 was detected in only 4.6% of pediatric patients with ischemic stroke tested for the virus. However, < 50% of strokes were tested. To understand the role of SARS-CoV-2 in pediatric stroke better, SARS-CoV-2 testing should be considered in pediatric patients with stroke as the pandemic continues. ANN NEUROL 2021;89:657-665.

Acute Disseminated Encephalomyelitis: Current Perspectives.

Acute disseminated encephalomyelitis (ADEM) is an immune-mediated central nervous system (CNS) disorder, characterized by polyfocal symptoms, encephalopathy and typical magnetic resonance imaging (MRI) findings, that especially affects young children. Advances in understanding CNS neuroimmune disorders as well as the association of myelin oligodendrocyte glycoprotein antibody (MOG-Ab) with both monophasic and recurrent forms of ADEM have led to new insights into its definition, management and outcome. In this review, we aim to provide an update based on current epidemiologic, clinical, radiological and immunopathological aspects and clinical outcome of ADEM.

Treatment and outcome of aquaporin-4 antibody-positive NMOSD: A multinational pediatric study.

OBJECTIVE: To describe the clinical phenotypes, treatment response, and outcome of children with antibodies against aquaporin-4 (AQP4-Ab) neuromyelitis optica spectrum disorder (NMOSD). METHODS: Retrospective, multicenter, and multinational study of patients with AQP4-Ab NMOSD aged <18 years at disease onset from a center in Brazil and 13 European centers. Data on demographics, clinical findings, and laboratory results were analyzed; calculation of annualized relapse rates (ARRs) pre- and on-treatment with disease-modifying therapies (DMTs) and of ORs for predictors of poor outcome was performed. RESULTS: A total of 67 children were identified. At last follow-up (median 4 years, interquartile range 2-10 years), 37/67(57.8%) were found to have permanent disability. A more severe disease course was seen in the non-White ethnicity with both a shorter time to first relapse (p = 0.049) and a worse Expanded Disability Status Scale score at last follow-up (p = 0.008). The median ARR on treatment was 0.18 on azathioprine (n = 39, range 0-4), 0 on mycophenolate mofetil (n = 18, range 0-3), and 0 on rituximab (n = 29, range 0-2). No patient treated with rituximab as first-line therapy relapsed. Optic neuritis at onset was associated with a poor visual outcome below 20/200 (OR 8.669, 95% CI 1.764-42.616, p = 0.008), and a younger age at onset was associated with cognitive impairment (OR 0.786, 95% CI 0.644-0.959, p = 0.018). CONCLUSIONS: AQP4-Ab NMOSD in children is an aggressive disease with permanent disabilities observed in over half the cohort. All DMTs were associated with a reduction of ARR. First-line rituximab prevented further clinical relapses. International consensus on treatment protocols for children is required to reduce heterogeneity of treatment regimens used worldwide. CLASSIFICATION OF EVIDENCE: This study provides Class IV evidence that for children with AQP4-Ab NMOSD, all DMTs, particularly first-line rituximab, reduced the ARR and prevented further clinical relapses.