Differences in Perceived Stress During the COVID-19 Pandemic Among Military Dental Postgraduate Residents.

INTRODUCTION: In military training settings, stress can improve focus and motivation fostering effective learning. However, high perceived stress can be debilitating resulting in poor learning and clinical errors. Multiple studies have focused on medical residency stress; but there has been minimal focus on dental residents and even less on the impact of the unique stressors from the COVID-19 pandemic. The objectives of this study were to determine the impact of the COVID-19 pandemic on perceived stress of residents in a military dental residency training program and explore the association among perceived stress and anxiety, depression, sleep quality, and social support. MATERIALS AND METHODS: Dental residents (N = 20) at the Naval Postgraduate Dental School participated in this study. Residents were assessed via self-report measures quarterly from March 2020 through June 2021. The assessment included measures of anxiety (GAD-7), depression (PHQ-9), perceived stress (PSS), fatigue (FSI), and social support (DUKE-SSQ). RESULTS: Before the pandemic shutdown, 60% of participants reported high perceived stress. These residents reported an initial decrease in symptoms of anxiety, depression, and fatigue compared to residents reporting low pre-pandemic perceived stress but returned to baseline levels post-shutdown. Additionally, the high stress participants reported lower social support. CONCLUSIONS: Based on pre-pandemic perceived stress, participants responded differently to the impact of the pandemic shutdown. The low baseline stress participants may have a more robust sense of grit and resilience. These findings suggest that postgraduate dental training programs should integrate coping skills training opportunities, especially for residents reporting high perceived stress before residency.

Periprosthetic Joint Infection in Patients With Arthroplasty Undergoing Perioperative Colonoscopy.

Importance: Periprosthetic joint infection (PJI) is a rare but devastating complication. Most patients undergoing total joint arthroplasty (TJA) also need routine screening colonoscopy, in which transient bacteremia may be a potential source for hematogenous PJI. Patients and surgeons must decide on an optimal time span or sequence for these 2 generally elective procedures, but no such guidelines currently exist. Objective: To evaluate associations of colonoscopy with the risk of post-TJA PJI for the development of clinical practice recommendations for colonoscopy screening in patients undergoing TJA. Design, Setting, and Participants: This retrospective cohort study of Military Health System (MHS) beneficiaries older than 45 years who underwent TJA from January 1, 2010, to December 31, 2016, used propensity score matching and logistic regression to evaluate associations of colonoscopy with PJI risk. Statistical analyses were conducted between January and October 2023. Exposure: Colonoscopy status was defined by Current Procedural Terminology code for diagnostic colonoscopy within 6 months before or 6 months after TJA. Main Outcomes and Measures: Periprosthetic joint infection status was defined by a PJI International Classification of Diseases code within 1 year after TJA and within 1 year from the post-TJA index colonoscopy date. Results: Analyses included 243 671 patients (mean [SD] age, 70.4 [10.0] years; 144 083 [59.1%] female) who underwent TJA in the MHS from 2010 to 2016. In the preoperative colonoscopy cohort, 325 patients (2.8%) had PJI within 1 year postoperatively. In the postoperative colonoscopy cohort, 138 patients (1.8%) had PJI within 1 year from the index colonoscopy date. In separate analyses of colonoscopy status within 6 months before and 6 months after TJA, younger age, male sex, and several chronic health conditions (diabetes, kidney disease, and pulmonary disease) were each associated with higher PJI risk. However, no association was found with PJI risk for perioperative colonoscopy preoperatively (adjusted odds ratio, 1.10; 95% CI, 0.98-1.23) or postoperatively (adjusted odds ratio, 0.90; 95% CI, 0.74-1.08). Conclusions and Relevance: In this large retrospective cohort of patients undergoing TJA, perioperative screening colonoscopy was not associated with PJI and should not be delayed for periprocedural risk. However, health conditions were independently associated with PJI and should be medically optimized.

Particle analysis of surgical lung biopsies from deployed and non-deployed US service members during the Global War on Terrorism.

The role that inhaled particulate matter plays in the development of post-deployment lung disease among US service members deployed to Southwest Asia during the Global War on Terrorism has been difficult to define. There is a persistent gap in data addressing the relationship between relatively short-term (months to a few years) exposures to high levels of particulate matter during deployment and the subsequent development of adverse pulmonary outcomes. Surgical lung biopsies from deployed service members and veterans (DSMs) and non-deployed service members and veterans (NDSMs) who develop lung diseases can be analyzed to potentially identify residual deployment-specific particles and develop associations with pulmonary pathological diagnoses. We examined 52 surgical lung biopsies from 25 DSMs and 27 NDSMs using field emission scanning electron microscopy (FE-SEM) with energy dispersive x-ray spectroscopy (EDS) to identify any between-group differences in the number and composition of retained inorganic particles, then compared the particle analysis results with the original histopathologic diagnoses. We recorded a higher number of total particles in biopsies from DSMs than from NDSMs, and this difference was mainly accounted for by geologic clays (illite, kaolinite), feldspars, quartz/silica, and titanium-rich silicate mixtures. Biopsies from DSMs deployed to other Southwest Asia regions (SWA-Other) had higher particle counts than those from DSMs primarily deployed to Iraq or Afghanistan, due mainly to illite. Distinct deployment-specific particles were not identified. Particles did not qualitatively associate with country of deployment. The individual diagnoses of the DSMs and NDSMs were not associated with elevated levels of total particles, metals, cerium oxide, or titanium dioxide particles. These results support the examination of particle-related lung disease in DSMs in the context of comparison groups, such as NDSMs, to assist in determining the strength of associations between specific pulmonary pathology diagnoses and deployment-specific inorganic particulate matter exposure.

Assessing Knowledge, Counseling, and Referral Patterns Regarding Fertility Preservation Before Gonadotoxic Treatments Among Physicians in the Military Health System.

Purpose: We sought to evaluate physicians' baseline knowledge of fertility preservation services available to patients with a cancer diagnosis within the military health system (MHS). Methods: Data on current cancer prevalence of over 31,000 unique cancer diagnoses were obtained from a comprehensive nationwide MHS dataset. Additionally, a 22-item survey was distributed to physicians practicing within the MHS assessing knowledge of reproductive health benefits, oncofertility counseling practices, and subspecialist referral patterns. Results: From 2020 to 2022, there were 31,103 individuals of reproductive age with cancer receiving care at a military treatment facility. One hundred fourteen physicians completed our survey, 76 obstetrician gynecologists (OB/GYNs), 18 oncologists, and 20 primary care physicians (PCPs). Ninety-three percent of respondents felt conversations about fertility preservation for reproductive-aged patients with cancer were very important. A total of 66.7% of oncologists, 35.5% of OB/GYNs, and 0% of PCPs felt comfortable counseling patients on coverage. A total of 33.3% of oncologists, 29.3% of OB/GYNs, and 0% of PCPs were familiar with oncofertility Defense Health Agency guidelines. Conclusion: Primary care, OB/GYN, and oncology practitioners are well situated to provide fertility preservation counseling to all individuals with a cancer diagnosis, but differences in counseling and referral patterns and a lack of knowledge of current agency policies may impair a patient's timely access to these resources. We propose implementation of an electronic patient navigator to address gaps in oncofertility care and standardize patient counseling in the MHS. This patient-focused guide would serve as a valuable model in all types of health care settings.

PHQ-9 and GAD-7 Score Response After Parathyroidectomy for Primary Hyperparathyroidism: a Systematic Review and Meta-analysis.

OBJECTIVE: Currently, the relationship between parathyroidectomy and objective neuropsychiatric outcomes are not clearly defined. The purpose of this study is to perform the first ever Meta-analysis of preoperative and postoperative PHQ-9 and GAD-7 scores in patients with primary hyperparathyroidism undergoing parathyroidectomy with the goal of identifying a specific psychometric score that could be used as an indication for surgical intervention. DATA SOURCES: A comprehensive search of the literature was performed using PubMed, Embase, PsycINFO, Web of Science, and Ovid All EBM Reviews. REVIEW METHODS: Studies met inclusion criteria if they evaluated preoperative and postoperative PHQ-9 and/or GAD-7 scores in patients with primary hyperparathyroidism undergoing parathyroidectomy. Random effects Meta-analyses were used to analyze the compiled data. RESULTS: The literature search returned 1433 articles for initial review of which 6 (1105 participants) met criteria for inclusion and Meta-analysis. Meta-analysis revealed that primary hyperparathyroidism patients had significantly higher presurgical PHQ-9 scores when compared to control groups. Additionally, patients experienced a statistically significant and sustained decrease in PHQ-9 scores following parathyroidectomy. Notably, there was a dramatic decrease in the percentage of patients with PHQ-9 scores ≥10 (considered clinically significant for depression) following parathyroidectomy. CONCLUSION: Patients with primary hyperparathyroidism experience a statistically significant and sustained improvement in PHQ-9 scores following parathyroidectomy. Additionally, symptoms of anxiety and suicidal ideation appear to decrease after parathyroidectomy. We propose that a PHQ-9 score ≥10 could potentially be used as an indication for parathyroidectomy in patients with asymptomatic primary hyperparathyroidism.

Simulated Fewer-Angle SPECT/CT Imaging Protocol for Parathyroid Adenoma.

A new SPECT/CT protocol for parathyroid imaging detailing fewer image-angle acquisitions (fewer-angle SPECT/CT [FASpecT/CT]) was evaluated for identification of parathyroid adenoma. The motivation for validating this protocol was to be able to use it in the future to decrease patient imaging time in our clinic. Methods: This was a retrospective review of existing data performed as a simulated case control study evaluating 50 parathyroid SPECT/CT scans acquired using the standard 60-stop protocol and the tested 15-stop FASpecT protocol acquired using angular sampling software. Agreement on the final interpretations between imaging methods was evaluated using the McNemar test and the Cohen κ. Interrater reliability among the 3 readers was described for each method using the Fleiss κ interpreted as in the strength-of-agreement guidelines by Landis and Koch. Results: Of the 50 evaluated images, 45 (90%) had concordant final image interpretations between imaging methods. The sensitivity of FASpecT/CT relative to SPECT/CT was 17 of 19 (89.5%; 95% CI, 66.9%-98.7%), and the specificity was 28 of 31 (90.3%; 95% CI, 74.2%-98.0%). Additionally, there was statistically significant substantial agreement between protocols and among readers for each protocol. Conclusion: Adequate diagnostic-quality SPECT/CT images can be acquired using significantly fewer imaging stops given advances in camera quality and processing algorithms such as iterative reconstruction.

Hymenoptera venom skin testing: Adopting an accelerated test protocol.

BACKGROUND: The standard method of Hymenoptera venom intradermal skin test is performed at a starting concentration of 0.001 to 0.01 µg/mL and increased by 10-fold concentrations until positive or a maximum concentration of 1 µg/mL. Accelerated methods that start at higher concentrations have been reported as safe; however, many institutions have not adopted this approach. OBJECTIVE: To compare the outcome and safety of standard and accelerated venom skin test protocols. METHODS: This was a retrospective chart review of patients with suspected venom allergy who underwent skin testing at 4 allergy clinics within a single health care system from 2012 to 2022. Demographic data, test protocol (standard vs accelerated), test results, and adverse reactions were reviewed. RESULTS: Of 134 patients who underwent standard venom skin test, 2 (1.5%) experienced an adverse reaction, whereas none of the 77 patients who underwent accelerated venom skin test experienced an adverse reaction. One patient, with a history of chronic urticaria, experienced urticaria. The other experienced anaphylaxis requiring an epinephrine although had tested negative to all venom concentrations. Within the standard testing protocol, more than 75% of the positive results occurred at concentrations of 0.1 or 1 µg/mL. Within the accelerated testing protocol, more than 60% of the positive results occurred at 1 µg/mL. CONCLUSION: The study underscores the overall safety of venom intradermal skin test. Most of the positive results occurred at 0.1 or 1 µg/mL. Adopting an accelerated approach would reduce time and cost associated with testing.

Shigella in Africa: New Insights From the Vaccine Impact on Diarrhea in Africa (VIDA) Study.

BACKGROUND: We evaluated the burden of Shigella spp from children aged 0-59 months with medically attended moderate-to-severe diarrhea and matched controls at sites in Mali, The Gambia, and Kenya participating in the Vaccine Impact on Diarrhea in Africa (VIDA) study from 2015 to 2018. METHODS: Shigella spp were identified using coprocultures and serotyping in addition to quantitative polymerase chain reaction (qPCR). Episode-specific attributable fractions (AFe) for Shigella were calculated using Shigella DNA quantity; cases with AFe ≥0.5 were considered to have shigellosis. RESULTS: The prevalence of Shigella was determined to be 359 of 4840 (7.4%) cases and 83 of 6213 (1.3%) controls by culture, and 1641 of 4836 (33.9%) cases and 1084 of 4846 (22.4%) controls by qPCR (cycle threshold <35); shigellosis was higher in The Gambia (30.8%) than in Mali (9.3%) and Kenya (18.7%). Bloody diarrhea attributed to Shigella was more common in 24- to 59-month-old children (50.1%) than 0- to 11-month-old infants (39.5%). The Shigella flexneri serogroup predominated among cases (67.6% of isolates), followed by Shigella sonnei (18.2%), Shigella boydii (11.8%), and Shigella dysenteriae (2.3%). The most frequent S. flexneri serotypes were 2a (40.6%), 1b (18.8%), 6 (17.5%), 3a (9.0%), and 4a (5.1%). Drug-specific resistance among 353 (98.3%) Shigella cases with AMR data was as follows: trimethoprim-sulfamethoxazole (94.9%), ampicillin (48.4%), nalidixic acid (1.7%), ceftriaxone (0.3%), azithromycin (0.3%), and ciprofloxacin (0.0%). CONCLUSIONS: A high prevalence of shigellosis continues in sub-Saharan Africa. Strains are highly resistant to commonly used antibiotics while remaining susceptible to ciprofloxacin, ceftriaxone, and azithromycin.

Rates and Predictors of Surgery for Lumbar Disc Herniation Between the Military and Civilian Health Care Systems.

STUDY DESIGN: Retrospective review (level of evidence III). OBJECTIVE: Surgical care patterns for lumbar disc herniation (LDH), a common musculoskeletal condition of high relevance to the Military Health System (MHS), have not been described or compared across the direct care and purchased care MHS components. This study aimed to describe surgery rates in MHS beneficiaries who were diagnosed with LDH in direct care versus purchased care and to evaluate characteristics associated with the location of surgery. Differences in care patterns for LDH may suggest unexpected variation within the centrally managed MHS. METHODS: We described 1-year rates of surgery among beneficiaries who were diagnosed with LDH in direct care versus purchased care. Among beneficiaries who were diagnosed in direct care and had surgery, multivariable logistic regression models were used to identify characteristics associated with surgery location. RESULTS: We identified 726,638 MHS beneficiaries who were diagnosed with LDH in direct care or purchased care during the 9-year study period. One-year surgery rates were 10.1% in beneficiaries who were diagnosed in direct care versus 11.3% in beneficiaries who were diagnosed in purchased care. Among the 7467 patients who were diagnosed in direct care and had surgery within 1 year, characteristics associated with lower probability of surgery in purchased care versus direct care included diagnosing facility type (hospital with a neurosurgery or spine specialty versus clinic (odds ratio [OR], 0.12 (95% CI, 0.10-0.15)), Navy versus Army (OR, 0.24 (95% CI, 0.21-0.28)), and diagnosing facility specialty (Medical Expense and Performance Reporting System) (surgical care (OR, 0.33 (95% CI, 0.27-0.40)) and orthopedic care (OR, 0.39 (95% CI, 0.33-0.46)) versus primary care. The presence of comorbidities was associated with higher probability of surgery in purchased care versus direct care (OR, 1.20 (95% CI, 1.06-1.36)). CONCLUSIONS: The 1-year rate of surgery for LDH was modestly higher in beneficiaries who were diagnosed in purchased care versus direct care. Among patients who were diagnosed in direct care, several patient-level and facility-level characteristics were associated with receiving surgery in purchased care, suggesting potentially unexpected variation in care utilization across components of the MHS.

Effect of ultrasonic vibration on the presence of voids in core build-up materials.

The core build-up procedure is utilized to restore teeth with limited remaining coronal tooth structure. However, voids have been observed radiographically within composite resin- and glass ionomer-based core build-ups, potentially compromising the mechanical strength of a fully restored tooth and requiring build-up replacement before a final restoration can be delivered. The purpose of this in vitro study was to determine whether applying ultrasonic vibration during core build-up placement reduces the presence of radiographically detectable voids. A total of 120 acrylic resin mandibular premolar analogs were fabricated using a 3-dimensional printer and randomly allocated into 4 groups (n = 30). Dual-cured composite resin or glass ionomer core build-ups were placed with or without vibration. The final build-ups were assessed radiographically and rated by 3 independent calibrated clinicians based on a 4-category scale for the severity of voids. In an ordinal logistic regression model with the void severity rating as the outcome, a significant interaction was found for glass ionomer, composite resin, and the use of ultrasonic vibration (P = 0.03). Vibration was associated with worse void severity ratings in glass ionomer specimens (P < 0.01). No effect of vibration was found in the composite resin specimens. The Fleiss kappa score (κ = 0.36) indicated fair agreement in all severity ratings among the 3 raters. These results suggest that the application of ultrasonic vibration during core build-up placement may not be clinically advantageous for improving restorative outcomes.

Ergonomics in Otolaryngology: A Systematic Review and Meta-analysis.

OBJECTIVES: To determine the proportion of otolaryngologists with work-related musculoskeletal discomfort (WRMD) and to review objective ergonomic data that contribute to WRMD. STUDY DESIGN: Systematic review and meta-analysis. METHODS: A comprehensive search of the literature identified 1121 articles for initial review of which 19 (3563 participants) met criteria for qualitative discussion and eight (2192 participants) met criteria for meta-analysis. Random effects meta-analyses were used to estimate the proportion of otolaryngologists reporting WRMD. RESULTS: The overall proportion (95% confidence intervals [CI]) of general otolaryngologists reporting WRMD was 0.79 (0.66, 0.88) for any symptoms; 0.54 (0.40, 0.67) for neck symptoms; 0.33 (0.20, 0.49) for shoulder symptoms; and 0.49 (0.40, 0.59) for back symptoms. Surgeons performing primarily subspecialty cases had a lower estimated overall prevalence of WRMD versus those performing general ENT cases, however the odds ratio (OR) was not statistically significant (OR [95% confidence interval] 0.53 [0.22, 1.25]). 23%-84% of otolaryngologists underwent medical treatment for WRMD. 5%-23% took time off work and 1%-6% stopped operating completely as a result of WRMD. 23%-62.5% of otolaryngologists believed WRMD negatively impacted their quality of life. Objective measures of ergonomic posture indicate moderate to severe risk of injury during the routine clinic and surgical procedures with none found to be low risk. CONCLUSIONS: Ergonomic stressors among otolaryngologists contribute to a high rate of WRMD across all subspecialties with notable impact on productivity, longevity, and quality of life. Laryngoscope, 133:467-475, 2023.

Pre-neuromusculoskeletal injury Risk factor Evaluation and Post-neuromusculoskeletal injury Assessment for Return-to-duty/activity Enhancement (PREPARE) in military service members: a prospective, observational study protocol.

BACKGROUND: Non-battle related musculoskeletal injuries (MSKI) are one of the primary medical issues diminishing Service member medical readiness. The MSKI problem is challenging because it is difficult to assess all of the factors that increase MSKI risk and influence post-MSKI outcomes. Currently, there are no high-throughput, clinically-feasible, and comprehensive assessments to generate patient-centric data for informing pre- and post-MSKI risk assessment and mitigation strategies. The objective of the "Pre-neuromusculoskeletal injury Risk factor Evaluation and Post-neuromusculoskeletal injury Assessment for Return-to-duty/activity Enhancement (PREPARE)" study is to develop a comprehensive suite of clinical assessments to identify the patient-specific factors contributing to MSKI risks and undesired post-MSKI outcomes. METHODS: This is a phased approach, multi-center prospective, observational study (ClinicalTrials.gov number: NCT05111925) to identify physical and psychosocial factors contributing to greater MSKI risk and undesired post-MSKI outcomes, and to identify and validate a minimal set of assessments to personalize risk mitigation and rehabilitation strategies. In Phase I, one cohort (n = 560) will identify the physical and psychosocial factors contributing to greater MSKI risks (single assessment), while a second cohort (n = 780) will identify the post-MSKI physical and psychosocial factors contributing to undesired post-MSKI outcomes (serial assessments at enrollment, 4 weeks post-enrollment, 12 weeks post-enrollment). All participants will complete comprehensive movement assessments captured via a semi-automated markerless motion capture system and instrumented walkway, joint range of motion assessments, psychosocial measures, and self-reported physical fitness performance and MSKI history. We will follow participants for 6 months. We will identify the minimum set of clinical assessments that provide requisite data to personalize MSKI risk mitigation and rehabilitation strategies, and in Phase II validate our optimized assessments in new cohorts. DISCUSSION: The results of this investigation will provide clinically relevant data to efficiently inform MSKI risk mitigation and rehabilitation programs, thereby helping to advance medical care and retain Service members on active duty status. TRIAL REGISTRATION: PREPARE was prospectively registered on ClinicalTrials.gov (NCT05111925) on 5 NOV 2021, prior to study commencement.

Image-Guided Cochlear Implant Programming: A Systematic Review and Meta-analysis.

OBJECTIVE: To review studies evaluating clinically implemented image-guided cochlear implant programing (IGCIP) and to determine its effect on cochlear implant (CI) performance. DATA SOURCES: PubMed, EMBASE, and Google Scholar were searched for English language publications from inception to August 1, 2021. STUDY SELECTION: Included studies prospectively compared intraindividual CI performance between an image-guided experimental map and a patient's preferred traditional map. Non-English studies, cadaveric studies, and studies where imaging did not directly inform programming were excluded. DATA EXTRACTION: Seven studies were identified for review, and five reported comparable components of audiological testing and follow-up times appropriate for meta-analysis. Demographic, speech, spectral modulation, pitch accuracy, and quality-of-life survey data were collected. Aggregate data were used when individual data were unavailable. DATA SYNTHESIS: Audiological test outcomes were evaluated as standardized mean change (95% confidence interval) using random-effects meta-analysis with raw score standardization. Improvements in speech and quality-of-life measures using the IGCIP map demonstrated nominal effect sizes: consonant-nucleus-consonant words, 0.15 (-0.12 to 0.42); AzBio quiet, 0.09 (-0.05 to 0.22); AzBio +10 dB signal-noise ratio, 0.14 (-0.01 to 0.30); Bamford-Kowel-Bench sentence in noise, -0.11 (-0.35 to 0.12); Abbreviated Profile of Hearing Aid Benefit, -0.14 (-0.28 to 0.00); and Speech Spatial and Qualities of Hearing Scale, 0.13 (-0.02 to 0.28). Nevertheless, 79% of patients allowed to keep their IGCIP map opted for continued use after the investigational period. CONCLUSION: IGCIP has potential to precisely guide CI programming. Nominal effect sizes for objective outcome measures fail to reflect subjective benefits fully given discordance with the percentage of patients who prefer to maintain their IGCIP map.

Repetitive Transcranial Magnetic Stimulation Promotes Rapid Psychiatric Stabilization in Acutely Suicidal Military Service Members.

OBJECTIVE: This study presents data for using accelerated transcranial magnetic stimulation (TMS) as an intervention for suicidal crisis (SC). METHODS: This prospective, single-site, randomized, double-blind trial enrolled active-duty military participants with SC to receive either active TMS (n = 59) or sham TMS (n = 61) 3 times per day for 3 consecutive days. Our primary outcome, the Beck Scale for Suicidal Ideation-current (SSI-C), was measured before each session of TMS. Secondary outcomes measured both the SSI-C and the Beck Scale for Suicidal Ideation-total daily for the 3 intervention days and at 1, 3, and 6 months of follow-up. RESULTS: In the modified intention to treat (mITT) analysis of SSI-C changes over treatment sessions, the TMS active group had accelerated decline in suicidal ideation as compared with sham: ß for interaction was 0.12 points greater SSI-C decline per session (standard error [SE], 0.06) in TMS versus sham (P = 0.04). In both the mITT and per-protocol active TMS groups, the mean final SSI-C scores were below 3. These scores remained below 3 for the entire 6-month follow-up period. CONCLUSIONS: In this military trial of suicidal patients, we found that both active and sham accelerated TMS rapidly reduces SC. Moreover, in the mITT analysis, there was a statistically significant antisuicidal benefit of active TMS versus sham TMS in the primary outcome. Both the mITT and per-protocol groups moved from higher to approximately 7 times lower suicide risk strata and remained there for the duration of the study. Further studies are warranted to understand accelerated TMS' full potential as a treatment for SC.

Digitally recorded and remotely classified lung auscultation compared with conventional stethoscope classifications among children aged 1-59 months enrolled in the Pneumonia Etiology Research for Child Health (PERCH) case-control study.

BACKGROUND: Diagnosis of pneumonia remains challenging. Digitally recorded and remote human classified lung sounds may offer benefits beyond conventional auscultation, but it is unclear whether classifications differ between the two approaches. We evaluated concordance between digital and conventional auscultation. METHODS: We collected digitally recorded lung sounds, conventional auscultation classifications and clinical measures and samples from children with pneumonia (cases) in low-income and middle-income countries. Physicians remotely classified recordings as crackles, wheeze or uninterpretable. Conventional and digital auscultation concordance was evaluated among 383 pneumonia cases with concurrently (within 2 hours) collected conventional and digital auscultation classifications using prevalence-adjusted bias-adjusted kappa (PABAK). Using an expanded set of 737 cases that also incorporated the non-concurrently collected assessments, we evaluated whether associations between auscultation classifications and clinical or aetiological findings differed between conventional or digital auscultation using χ2 tests and logistic regression adjusted for age, sex and site. RESULTS: Conventional and digital auscultation concordance was moderate for classifying crackles and/or wheeze versus neither crackles nor wheeze (PABAK=0.50), and fair for crackles-only versus not crackles-only (PABAK=0.30) and any wheeze versus no wheeze (PABAK=0.27). Crackles were more common on conventional auscultation, whereas wheeze was more frequent on digital auscultation. Compared with neither crackles nor wheeze, crackles-only on both conventional and digital auscultation was associated with abnormal chest radiographs (adjusted OR (aOR)=1.53, 95% CI 0.99 to 2.36; aOR=2.09, 95% CI 1.19 to 3.68, respectively); any wheeze was inversely associated with C-reactive protein >40 mg/L using conventional auscultation (aOR=0.50, 95% CI 0.27 to 0.92) and with very severe pneumonia using digital auscultation (aOR=0.67, 95% CI 0.46 to 0.97). Crackles-only on digital auscultation was associated with mortality compared with any wheeze (aOR=2.70, 95% CI 1.12 to 6.25). CONCLUSIONS: Conventional auscultation and remotely-classified digital auscultation displayed moderate concordance for presence/absence of wheeze and crackles among cases. Conventional and digital auscultation may provide different classification patterns, but wheeze was associated with decreased clinical severity on both.

The use of dried blood spot cards to assess serologic responses of individuals vaccinated against measles, hepatitis A, tetanus, influenza and varicella zoster.

Traditional blood sampling by venipuncture is cumbersome and relatively expensive. Dried blood spot (DBS) sampling is desirable because of its ease of sample collection, transportation and storage. It has been used in clinical diagnosis but not been thoroughly studied for the potential use to assess the immune status of individuals following natural infection or preventive vaccination. The goal of this study was to compare DBS to traditional blood samplings in detection of antibodies in individuals vaccinated against measles, hepatitis A, tetanus, influenza and varicella zoster. Enzyme linked immunosorbent assay (ELISA) was used to test DBS eluates and serum samples for antibodies against measles, varicella, tetanus and hepatitis A. Sensitivities, specificities, and correlation coefficients were evaluated to compare optical density (OD) values of paired serum and DBS samples. The long-term stability of DBS samples at different temperatures was assessed using simulated immune measles blood. DBS OD was highly correlated with serum OD for antibodies to measles (r = 0.93), varicella (r = 0.82), and tetanus (r = 0.91). Sensitivities of DBS OD ranged from 86-99% and specificities ranged from 96-100% using cut-offs established by each assay. By contrast, the hepatitis A data showed a low sensitivity (31%) and weak correlation (r = 0.14) between DBS and serum samples. Antibody titers in serum samples for anti-influenza A (H1N1 and H3N1) failed to correlate in DBS eluates in HAI and MN assays. DBS samples were stable for 4 weeks when stored at room temperature and for 6 months at 4°C. DBS sampling was sensitive, specific, and highly correlated with traditional venipuncture sampling in detection of antibodies against measles, tetanus and varicella zoster, but not hepatitis A and influenza. Thus, the success of using DBS sampling to assess the antibody levels in immunized individuals may be dependent on the pathogens and the development of the assay used.

Multisite evaluation of fire ant venom immunotherapy safety and efficacy.

Background: Imported fire ant (IFA) venom immunotherapy (VIT) is the only disease-modifying treatment reported to be effective at decreasing the risk of systemic reactions (SRs) to IFA stings. Objective: Our aims were to determine the baseline rates of IFA sensitization in subjects, describe IFA VIT prescribing patterns across the military health system (MHS), and retrospectively evaluate the safety and efficacy of IFA VIT. Methods: We prospectively compared IFA sensitization in participants with and without an SR to flying Hymenoptera venom. Separately, IFA VIT prescription records were extracted from a centralized repository, and rates were described across the MHS. Additionally, we retrospectively reviewed the clinical course of patients being treated with IFA VIT at 11 military treatment facilities. Results: The in vitro IFA sensitization rates in our prospective cohort ranged from 19.1% to 24.1%. Sensitization rates did not differ statistically between the subjects with or without an SR to flying Hymenoptera venom. We found that 60.9% of all MHS IFA VIT prescriptions (491 of 806) were from the 11 facilities in this study. We retrospectively identified 137 subjects actively undergoing IFA VIT. Among the subjects actively undergoing IFA VIT, 28 reported an SR to IFA venom and repeat stings by IFAs after reaching VIT maintenance, and 85.7% (24 of 28) of the subjects noted symptoms no worse than a large swelling reaction after a repeat IFA sting. Notably, only 2.9% of the subjects (4 of 137) had an SR due to VIT. Conclusion: This study's results align with those of prior IFA sensitization reports. A substantial proportion of patients undergoing IFA VIT experienced protection against anaphylaxis with reexposure, with relatively few adverse events.