Racial and Ethnic Differences in Hospital Admission and Diagnostic Evaluation for Febrile Seizures in the Emergency Department.

OBJECTIVE: To examine differences in hospital admission and diagnostic evaluation for febrile seizure by race and ethnicity. STUDY DESIGN: We conducted a cross-sectional study among children 6 months to 6 years with simple or complex febrile seizure between January 1, 2016, and December 31, 2021, using data from the Pediatric Health Information System. The primary outcome was hospital admission. Secondary outcomes included the proportion of encounters with neuroimaging or lumbar puncture. We used mixed-effects logistic regression model with random intercept for hospital and patient to estimate the association between outcomes and race and ethnicity after adjusting for covariates, including seizure type. RESULTS: In total, 94 884 encounters were included. Most encounters occurred among children of non-Hispanic White (37.0%), Black (23.9%), and Hispanic/Latino (24.6%) race and ethnicity. Black and Hispanic/Latino children had 29% (aOR 0.71; 95% CI 0.66-0.75) and 26% (aOR 0.74; 95% CI 0.69-0.80) lower odds of hospital admission compared with non-Hispanic White children, respectively. Black and Hispanic/Latino children had 21% (aOR 0.79; 95% CI 0.73-0.86) and 22% (aOR 0.78; 95% CI 0.71-0.85) lower adjusted odds of neuroimaging compared with non-Hispanic White children. For complex febrile seizure, the adjusted odds of lumbar puncture was significantly greater among Asian children (aOR 2.12; 95% CI 1.19-3.77) compared with non-Hispanic White children. There were no racial differences in the odds of lumbar puncture for simple febrile seizure. CONCLUSIONS: Compared with non-Hispanic White children, Black and Hispanic/Latino children with febrile seizures are less likely to be hospitalized or receive neuroimaging.

Model selection, hummingbird natural history, and biological hypotheses: a response to Sazatornil et al.

We have previously suggested that a shift from bee to hummingbird pollination, in concert with floral architecture modifications, occurred at the crown of Salvia subgenus Calosphace in North America ca. 20 mya (Kriebel et al. 2020 and references therein). Sazatornil et al. (2022), using a hidden states model, challenged these assertions, arguing that bees were the ancestral pollinator of subg. Calosphace and claiming that hummingbirds could not have been the ancestral pollinator of subg. Calosphace because hummingbirds were not contemporaneous with crown subg. Calosphace in North America. Here, using a variety of models, we demonstrate that most analyses support hummingbirds as ancestral pollinators of subg. Calosphace and show that Sazatornil et al. (2022) erroneously concluded that hummingbirds were absent from North America ca. 20 mya. We contend that "biological realism" - based on timing and placement of hummingbirds in Mexico ca. 20 mya and the correlative evolution of hummingbird associated floral traits - must be considered when comparing models based on fit and complexity, including hidden states models.

Optimal circulatory arrest temperature for aortic hemiarch replacement with antegrade brain perfusion.

OBJECTIVE: This study sought to identify the optimal temperature for moderate hypothermic circulatory arrest in patients undergoing elective hemiarch replacement with antegrade brain perfusion. METHODS: The Society of Thoracic Surgeons adult cardiac surgery database was queried for elective hemiarch replacements using antegrade brain perfusion for aneurysmal disease (2014-2019). Generalized estimating equations and restricted cubic splines were used to determine the risk-adjusted relationships between temperature as a continuous variable and outcomes. RESULTS: Elective hemiarch replacement with antegrade brain perfusion occurred in 3898 patients at 374 centers with a median nadir temperature of 24.9°C (first quartile, third quartile = 22.0°C, 27.5°C) and median circulatory arrest time of 19 minutes (first quartile, third quartile = 14.0 minutes, 27.0 minutes). After adjustment for comorbidities, circulatory arrest time, and individual surgeon, patients cooled between 25 and 28°C had an early survival advantage compared with 24°C, whereas those cooled between 21 and 23°C had higher risks of mortality compared with 24°C. A nadir temperature of 27°C was associated with the lowest risk-adjusted odds of mortality (odds ratio, 0.62; 95% confidence interval, 0.42-0.91). A nadir temperature of 21°C had the highest risk of mortality (odds ratio, 1.4; 95% confidence interval, 1.13-1.73). Risk of experiencing a major morbidity was elevated in patients cooled between 21 and 23°C, with the highest risk occurring in patients cooled to 21°C (odds ratio, 1.12; 95% confidence interval, 1.01-1.24). CONCLUSIONS: For patients with aneurysmal disease undergoing elective hemiarch with antegrade brain perfusion, circulatory arrest with a nadir temperature of 27°C confers the greatest early survival benefit and smallest risk of postoperative morbidity.

Northeast Yucatan hurricane activity during the Maya Classic and Postclassic periods.

The collapse of the Maya civilization in the late 1st/early 2nd millennium CE has been attributed to multiple internal and external causes including overpopulation, increased warfare, and environmental deterioration. Yet the role hurricanes may have played in the fracturing of Maya socio-political networks, site abandonment, and cultural reconfiguration remains unexplored. Here we present a 2200 yearlong hurricane record developed from sediment recovered from a flooded cenote on the northeastern Yucatan peninsula. The sediment archive contains fine grain autogenic carbonate interspersed with anomalous deposits of coarse carbonate material that we interpret as evidence of local hurricane activity. This interpretation is supported by the correlation between the multi-decadal distribution of recent coarse beds and the temporal distribution of modern regional landfalling storms. In total, this record allows us to reconstruct the variable hurricane conditions impacting the northern lowland Maya during the Late Preclassic, Classic, and Postclassic Periods. Strikingly, persistent above-average hurricane frequency between ~ 700 and 1450 CE encompasses the Maya Terminal Classic Phase, the declines of Chichén Itza, Cobá, and subsequent rise and fall of the Mayapán Confederacy. This suggests that hurricanes may have posed an additional environmental stressor necessary of consideration when examining the Postclassic transformation of northern Maya polities.

Complications and outcomes of posterior fossa decompression with duraplasty versus without duraplasty for pediatric patients with Chiari malformation type I and syringomyelia: a study from the Park-Reeves Syringomyelia Research Consortium.

OBJECTIVE: The aim of this study was to determine differences in complications and outcomes between posterior fossa decompression with duraplasty (PFDD) and without duraplasty (PFD) for the treatment of pediatric Chiari malformation type I (CM1) and syringomyelia (SM). METHODS: The authors used retrospective and prospective components of the Park-Reeves Syringomyelia Research Consortium database to identify pediatric patients with CM1-SM who received PFD or PFDD and had at least 1 year of follow-up data. Preoperative, treatment, and postoperative characteristics were recorded and compared between groups. RESULTS: A total of 692 patients met the inclusion criteria for this database study. PFD was performed in 117 (16.9%) and PFDD in 575 (83.1%) patients. The mean age at surgery was 9.86 years, and the mean follow-up time was 2.73 years. There were no significant differences in presenting signs or symptoms between groups, although the preoperative syrinx size was smaller in the PFD group. The PFD group had a shorter mean operating room time (p < 0.0001), fewer patients with > 50 mL of blood loss (p = 0.04), and shorter hospital stays (p = 0.0001). There were 4 intraoperative complications, all within the PFDD group (0.7%, p > 0.99). Patients undergoing PFDD had a 6-month complication rate of 24.3%, compared with 13.7% in the PFD group (p = 0.01). There were no differences between groups for postoperative complications beyond 6 months (p = 0.33). PFD patients were more likely to require revision surgery (17.9% vs 8.3%, p = 0.002). PFDD was associated with greater improvements in headaches (89.6% vs 80.8%, p = 0.04) and back pain (86.5% vs 59.1%, p = 0.01). There were no differences between groups for improvement in neurological examination findings. PFDD was associated with greater reduction in anteroposterior syrinx size (43.7% vs 26.9%, p = 0.0001) and syrinx length (18.9% vs 5.6%, p = 0.04) compared with PFD. CONCLUSIONS: PFD was associated with reduced operative time and blood loss, shorter hospital stays, and fewer postoperative complications within 6 months. However, PFDD was associated with better symptom improvement and reduction in syrinx size and lower rates of revision decompression. The two surgeries have low intraoperative complication rates and comparable complication rates beyond 6 months.

Human arrival and landscape dynamics in the northern Bahamas.

The first Caribbean settlers were Amerindians from South America. Great Abaco and Grand Bahama, the final islands colonized in the northernmost Bahamas, were inhabited by the Lucayans when Europeans arrived. The timing of Lucayan arrival in the northern Bahamas has been uncertain because direct archaeological evidence is limited. We document Lucayan arrival on Great Abaco Island through a detailed record of vegetation, fire, and landscape dynamics based on proxy data from Blackwood Sinkhole. From about 3,000 to 1,000 y ago, forests dominated by hardwoods and palms were resilient to the effects of hurricanes and cooling sea surface temperatures. The arrival of Lucayans by about 830 CE (2σ range: 720 to 920 CE) is demarcated by increased burning and followed by landscape disturbance and a time-transgressive shift from hardwoods and palms to the modern pine forest. Considering that Lucayan settlements in the southern Bahamian archipelago are dated to about 750 CE (2σ range: 600 to 900 CE), these results demonstrate that Lucayans spread rapidly through the archipelago in less than 100 y. Although precontact landscapes would have been influenced by storms and climatic trends, the most pronounced changes follow more directly from landscape burning and ecosystem shifts after Lucayan arrival. The pine forests of Abaco declined substantially between 1500 and 1670 CE, a period of increased regional hurricane activity, coupled with fires on an already human-impacted landscape. Any future intensification of hurricane activity in the tropical North Atlantic Ocean threatens the sustainability of modern pine forests in the northern Bahamas.

Mapping spatial and temporal variation of seafloor organic matter Δ14C and δ13C in the Northern Gulf of Mexico following the Deepwater Horizon Oil Spill.

Following the Deepwater Horizon oil spill of 2010, large amounts of biodegraded oil (petrocarbon) sank to the seafloor. Our objectives were to 1) determine post-spill isotopic values as the sediments approached a new baseline and 2) track the recovery of affected sediments. Sediment organic carbon δ13C and Δ14C reached a post-spill baseline averaging -21.2 ± 0.9‰ (n = 129) and -220 ± 66‰ (n = 95). Spatial variations in seafloor organic carbon baseline isotopic values, 13C and 14C, were influenced by river discharge and hydrocarbon seepage, respectively. Inverse Distance Weighting of surface sediment Δ14C values away from seep sites showed a 50% decrease in the total mass of petrocarbon, from 2010 to 2014. We estimated a rate of loss of -2 × 109 g of petrocarbon-C/year, 2-11% of the degradation rates in surface slicks. Despite the observed recovery in sediments, lingering residual material in the surface sediments was evident seven years following the blowout.

Using Clinical History Factors to Identify Bacterial Infections in Young Febrile Infants.

OBJECTIVE: To develop a novel predictive model using primarily clinical history factors and compare performance to the widely used Rochester Low Risk (RLR) model. STUDY DESIGN: In this cross-sectional study, we identified infants brought to one pediatric emergency department from January 2014 to December 2016. We included infants age 0-90 days, with temperature ≥38°C, and documented gestational age and illness duration. The primary outcome was bacterial infection. We used 10 predictors to develop regression and ensemble machine learning models, which we trained and tested using 10-fold cross-validation. We compared areas under the curve (AUCs), sensitivities, and specificities of the RLR, regression, and ensemble models. RESULTS: Of 877 infants, 67 had a bacterial infection (7.6%). The AUCs of the RLR, regression, and ensemble models were 0.776 (95% CI 0.746, 0.807), 0.945 (0.913, 0.977), and 0.956 (0.935, 0.975), respectively. Using a bacterial infection risk threshold of .01, the sensitivity and specificity of the regression model was 94.6% (87.4%, 100%) and 74.5% (62.4%, 85.4%), compared with 95.5% (87.5%, 99.1%) and 59.6% (56.2%, 63.0%) using the RLR model. CONCLUSIONS: Compared with the RLR model, sensitivities of the novel predictive models were similar whereas AUCs and specificities were significantly greater. If externally validated, these models, by producing an individualized bacterial infection risk estimate, may offer a targeted approach to young febrile infants that is noninvasive and inexpensive.

Predicting Adverse Outcomes for Shiga Toxin-Producing Escherichia coli Infections in Emergency Departments.

OBJECTIVE: To assess the performance of a hemolytic uremic syndrome (HUS) severity score among children with Shiga toxin-producing Escherichia coli (STEC) infections and HUS by stratifying them according to their risk of adverse events. The score has not been previously evaluated in a North American acute care setting. STUDY DESIGN: We reviewed medical records of children <18 years old infected with STEC and treated in 1 of 38 participating emergency departments in North America between 2011 and 2015. The HUS severity score (hemoglobin [g/dL] plus 2-times serum creatinine [mg/dL]) was calculated using first available laboratory results. Children with scores >13 were designated as high-risk. We assessed score performance to predict severe adverse events (ie, dialysis, neurologic complication, respiratory failure, and death) using discrimination and net benefit (ie, threshold probability), with subgroup analyses by age and day-of-illness. RESULTS: A total of 167 children had HUS, of whom 92.8% (155/167) had relevant data to calculate the score; 60.6% (94/155) experienced a severe adverse event. Discrimination was acceptable overall (area under the curve 0.71, 95% CI 0.63-0.79) and better among children <5 years old (area under the curve 0.77, 95% CI 0.68-0.87). For children <5 years, greatest net benefit was achieved for a threshold probability >26%. CONCLUSIONS: The HUS severity score was able to discriminate between high- and low-risk children <5 years old with STEC-associated HUS at a statistically acceptable level; however, it did not appear to provide clinical benefit at a meaningful risk threshold.

Median Arcuate Ligament Syndrome with Orthostatic Intolerance: Intermediate-Term Outcomes following Surgical Intervention.

OBJECTIVES: To report the intermediate-term outcome following surgical intervention for median arcuate ligament syndrome (MALS) in adolescents and young adults with orthostatic intolerance (OI) to assess clinical improvement in the gastrointestinal and 5 other functional domains and if relief of arterial obstruction is associated with resolution of clinical symptoms. STUDY DESIGN: Thirty-one patients were given 2 dysautonomia-designed questionnaires to assess changes in symptoms following operative intervention in 6 functional domains and underwent postoperative repeat abdominal ultrasound examinations. RESULTS: Average follow-up after surgery was 22.4 ± 14.8 months. Self-assessed quality of health on a Likert scale (1-10 with 10 being normal) improved from 4.5 ± 2.1 preoperatively to 5.3 ± 2.4 postoperatively (P = not significant). Gastrointestinal symptoms of abdominal pain, nausea, and vomiting improved in 63% (P = .007), 53% (P = .040), and 62% (P = .014) of patients, respectively. Cardiovascular symptoms of dizziness, syncope, chest pain, and palpitations improved in 45% (P = not significant), 50% (P = not significant), 54% (P = .043), and 54% (P = .037) of patients, respectively. Transabdominal ultrasound peak supine expiratory velocity decreased from 348 ± 105 cm/s preoperatively to 251 ± 109 cm/s at 6 months or more after a ligament release procedure. Decrease of the postoperative celiac artery Doppler velocity was not associated with an improvement in gastrointestinal symptoms (P = .075). CONCLUSIONS: Adolescent and young adult patients with median arcuate ligament syndrome and OI have a good response to surgical intervention. About two-thirds of patients report significant improvement in symptoms of abdominal pain, nausea, and vomiting. Despite these encouraging data, many patients with MALS and OI continue to have an impaired quality of health.

Historically unprecedented Northern Gulf of Mexico hurricane activity from 650 to 1250 CE.

Hurricane Michael (2018) was the first Category 5 storm on record to make landfall on the Florida panhandle since at least 1851 CE (Common Era), and it resulted in the loss of 59 lives and $25 billion in damages across the southeastern U.S. This event placed a spotlight on recent intense (exceeding Category 4 or 5 on the Saffir-Simpson Hurricane Wind Scale) hurricane landfalls, prompting questions about the natural range in variability of hurricane activity that the instrumental record is too short to address. Of particular interest is determining whether the frequency of recent intense hurricane landfalls in the northern Gulf of Mexico (GOM) is within or outside the natural range of intense hurricane activity prior to 1851 CE. In this study, we identify intense hurricane landfalls in northwest Florida during the past 2000 years based on coarse anomaly event detection from two coastal lacustrine sediment archives. We identified a historically unprecedented period of heightened storm activity common to four Florida panhandle localities from 650 to 1250 CE and a shift to a relatively quiescent storm climate in the GOM spanning the past six centuries. Our study provides long-term context for events like Hurricane Michael and suggests that the observational period 1851 CE to present may underrepresent the natural range in landfalling hurricane activity.

Revising evidence of hurricane strikes on Abaco Island (The Bahamas) over the last 700 years.

The northern Bahamas have experienced more frequent intense-hurricane impacts than almost anywhere else in the Atlantic since 1850 CE. In 2019, category 5 (Saffir-Simpson scale) Hurricane Dorian demonstrated the destructive potential of these natural hazards. Problematically, determining whether high hurricane activity levels remained constant through time is difficult given the short observational record (< 170 years). We present a 700-year long, near-annually resolved stratigraphic record of hurricane passage near Thatchpoint Blue Hole (TPBH) on Abaco Island, The Bahamas. Using longer sediment cores (888 cm) and more reliable age-control, this study revises and temporally expands a previous study from TPBH that underestimated the sedimentation rate. TPBH records at least 13 ≥ category 2 hurricanes per century between 1500 to 1670 CE, which exceeds the 9 ≥ category 2 hurricanes per century within 50 km of TPBH since 1850 CE. The eastern United States also experienced frequent hurricanes from 1500 to 1670 CE, but frequency was depressed elsewhere in the Atlantic Ocean. This suggests that spatial heterogeneity in Atlantic hurricane activity since 1850 CE could have persisted throughout the last millennium. This heterogeneity is impacted by climatic and stochastic forcing, but additional high-resolution paleo-hurricane reconstructions are required to assess the mechanisms that impact regional variability.

Radiological Society of North America Expert Consensus Statement on Reporting Chest CT Findings Related to COVID-19. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA - Secondary Publication.

Routine screening CT for the identification of COVID-19 pneumonia is currently not recommended by most radiology societies. However, the number of CTs performed in persons under investigation (PUI) for COVID-19 has increased. We also anticipate that some patients will have incidentally detected findings that could be attributable to COVID-19 pneumonia, requiring radiologists to decide whether or not to mention COVID-19 specifically as a differential diagnostic possibility. We aim to provide guidance to radiologists in reporting CT findings potentially attributable to COVID-19 pneumonia, including standardized language to reduce reporting variability when addressing the possibility of COVID-19. When typical or indeterminate features of COVID-19 pneumonia are present in endemic areas as an incidental finding, we recommend contacting the referring providers to discuss the likelihood of viral infection. These incidental findings do not necessarily need to be reported as COVID-19 pneumonia. In this setting, using the term "viral pneumonia" can be a reasonable and inclusive alternative. However, if one opts to use the term "COVID-19" in the incidental setting, consider the provided standardized reporting language. In addition, practice patterns may vary, and this document is meant to serve as a guide. Consultation with clinical colleagues at each institution is suggested to establish a consensus reporting approach. The goal of this expert consensus is to help radiologists recognize findings of COVID-19 pneumonia and aid their communication with other healthcare providers, assisting management of patients during this pandemic.

The southern Gulf of Mexico: A baseline radiocarbon isoscape of surface sediments and isotopic excursions at depth.

The southern Gulf of Mexico (sGoM) is home to an extensive oil recovery and development infrastructure. In addition, the basin harbors sites of submarine hydrocarbon seepage and receives terrestrial inputs from bordering rivers. We used stable carbon, nitrogen, and radiocarbon analyses of bulk sediment organic matter to define the current baseline isoscapes of surface sediments in the sGoM and determined which factors might influence them. These baseline surface isoscapes will be useful for accessing future environmental impacts. We also examined the region for influence of hydrocarbon deposition in the sedimentary record that might be associated with hydrocarbon recovery, spillage and seepage, as was found in the northern Gulf of Mexico (nGoM) following the Deepwater Horizon (DWH) oil spill in 2010. In 1979, the sGoM experienced a major oil spill, Ixtoc 1. Surface sediment δ13C values ranged from -22.4‰ to -19.9‰, while Δ14C values ranged from -337.1‰ to -69.2‰. Sediment δ15N values ranged from 2.8‰ to 7.2‰, while the %C on a carbonate-free basis ranged in value of 0.65% to 3.89% and %N ranged in value of 0.09% to 0.49%. Spatial trends for δ13C and Δ14C were driven by water depth and distance from the coastline, while spatial trends for δ15N were driven by location (latitude and longitude). Location and distance from the coastline were significantly correlated with %C and %N. At depth in two of twenty (10%) core profiles, we found negative δ13C and Δ14C excursions from baseline values in bulk sedimentary organic material, consistent with either oil-residue deposition or terrestrial inputs, but likely the latter. We then used 210Pb dating on those two profiles to determine the time in which the excursion-containing horizons were deposited. Despite the large spill in 1979, no evidence of hydrocarbon residue remained in the sediments from this specific time period.

Origins of the Mesoamerican ballgame: Earliest ballcourt from the highlands found at Etlatongo, Oaxaca, Mexico.

The ballgame represents one of the most enduring and iconic features of ancient Mesoamerican civilization, yet its origins and evolution remain poorly understood, primarily associated with the Gulf Coast and southern Pacific coastal lowlands. While one early ballcourt dates to 1650 BCE from the Chiapas lowlands, ballcourts have remained undocumented in the Mesoamerican highlands until a millennium later, suggesting less involvement by highland civilizations in the ballgame's evolution. We provide new data from the southern highlands of Mexico, from the Early Formative period (1500-1000 BCE), that necessitate revising previous paradigms. Along with ballplayer imagery, we recently excavated the earliest highland Mesoamerican ballcourt, dating to 1374 BCE, at the site of Etlatongo, in the Mixtec region of Oaxaca. We conclude that Early Formative highland villagers played an important role in the origins of the formal Mesoamerican ballgame, which later evolved into a crucial component of subsequent states.

Life history of northern Gulf of Mexico Warsaw grouper Hyporthodus nigritus inferred from otolith radiocarbon analysis.

Warsaw grouper, Hyporthodus nigritus, is a western Atlantic Ocean species typically found at depths between 55 and 525 m. It is listed as a species of concern by the U.S. National Marine Fisheries Service and as near threatened by the International Union for the Conservation of Nature. However, little information exists on the species' life history in the northern Gulf of Mexico (nGOM) and its stock status in that region is currently unknown. Age of nGOM Warsaw grouper was investigated via opaque zone counts in otolith thin sections (max age = 61 y), and then the bomb 14C chronometer was employed to validate the accuracy of age estimates. Otolith cores (n = 14) were analyzed with accelerator mass spectrometry and resulting Δ14C values overlain on a loess regression computed for a regional coral and known-age red snapper Δ14C time series. Residual analysis between predicted Δ14C values from the loess regression versus Warsaw grouper otolith core Δ14C values indicated no significant difference in the two data series. Therefore, the accuracy of otolith-based aging was validated, which enabled growth and longevity estimates to be made for nGOM Warsaw grouper. Dissolved inorganic carbon (DIC) Δ14C values collected from the nGOM support the inference that juvenile Warsaw grouper occur in shelf waters (<200 m) since DIC Δ14C values in this depth range are enriched in 14C and similar to the Δ14C values from otolith cores. A Bayesian model was fit to fishery-dependent age composition data and produced von Bertalanffy growth function parameters of L∞ = 1,533 mm, k = 0.14 y-1, and t0 = 1.82 y. Fishing mortality also was estimated in the model, which resulted in a ratio of fishing to natural mortality of 5.1:1. Overall, study results indicate Warsaw grouper is a long-lived species that is estimated to have experienced significant overfishing in the nGOM, with the age of most landed fish being <10 y.

Scurvy Masquerading as Juvenile Idiopathic Arthritis or Vasculitis with Elevated Inflammatory Markers: A Case Series.

Ten patients with scurvy were evaluated by rheumatology; we review their clinical, laboratory, and dietary presentations. Eight patients had developmental delay or autism. All had elevated inflammatory markers. These clinical and laboratory features with imaging findings can mimic rheumatic conditions such as arthritis, vasculitis, and chronic nonbacterial osteomyelitis (CNO).