Inflammatory Rhabdomyoblastic Tumor of the Posterior Pharyngeal Wall.

This case report describes a healthy man in his 40s who presented with a 1-year history of snoring, sleep apnea, dysphonia, and dysphagia owing to a large mass of the posterior pharynx and was diagnosed with an inflammatory rhabdomyoblastic tumor.

Influenza Antiviral Shortages Reported by State and Territorial Public Health Officials, 2022-2023.

This study provides survey results from state and territorial public health preparedness directors regarding antiviral shortages during the 2022-2023 respiratory viral season.

Cope-Type Hydroamination of Vinylboronates.

Aminoboronic acid derivatives can serve as versatile synthetic intermediates and pharmacophores but remain difficult to synthesize. Herein we report a synthesis of the ß-aminoboronic acid motif via anti-Markovnikov hydroamination of vinylboronates. This reaction benefits from the activating effect of the boronate substituent and forms novel BON-containing heterocycles, oxazaborolidine zwitterions. A computational study is included to help determine the effects of alkene boron substitution. Derivatization reactions also support the synthetic utility of the oxazaborolidine adducts.

Cost-Effectiveness of Routine Type and Screens in Select Endonasal Skull Base Surgeries.

Objective The study aimed to evaluate the cost-effectiveness of obtaining preoperative type and screens (T/S) for common endonasal skull base procedures, and determine patient and hospital factors associated with receiving blood transfusions. Study Design Retrospective database analysis of the 2006 to 2015 National (nationwide) Inpatient Sample and cost-effectiveness analysis. Main Outcome Measures Multivariate regression analysis was used to identify factors associated with transfusions. A cost-effectiveness analysis was then performed to determine the incremental cost-effectiveness ratio (ICER) of obtaining preoperative T/S to prevent an emergency-release transfusion (ERT), with a willingness-to-pay threshold of $1,500. Results A total of 93,105 cases were identified with an overall transfusion rate of 1.89%. On multivariate modeling, statistically significant factors associated with transfusion included nonelective admission (odds ratio [OR]: 2.32; 95% confidence interval [CI]: 1.78-3.02), anemia (OR: 4.42; 95% CI: 3.35-5.83), coagulopathy (OR: 4.72; 95% CI: 2.94-7.57), diabetes (OR: 1.45; 95% CI: 1.14-1.84), liver disease (OR: 2.37; 95% CI: 1.27-4.43), pulmonary circulation disorders (OR: 3.28; 95% CI: 1.71-6.29), and metastatic cancer (OR: 5.85; 95% CI: 2.63-13.0; p < 0.01 for all). The ICER of preoperative T/S was $3,576 per ERT prevented. One-way sensitivity analysis demonstrated that the risk of transfusion should exceed 4.12% to justify preoperative T/S. Conclusion Routine preoperative T/S does not represent a cost-effective practice for these surgeries using nationally representative data. A selective T/S policy for high-risk patients may reduce costs.

A redox-enabled strategy for intramolecular hydroamination.

Metal- or acid-catalyzed intramolecular hydroamination and Cope-type intramolecular hydroamination, a distinct concerted approach using hydroxylamines, typically suffer from significant synthetic limitations. Herein we report a process for intramolecular hydroamination that uses a redox-enabled strategy relying on efficient in situ generation of hydroxylamines by oxidation, followed by Cope-type hydroamination, then reduction of the resulting pyrrolidine N-oxide. The steps are performed sequentially in a single pot, no catalyst is required, the conditions are mild, the process is highly functional group tolerant, and no chromatography is generally required for isolation. A robustness screen and a gram-scale example further support the practicality of this approach.

Ethylmalonic encephalopathy masquerading as meningococcemia.

Ethylmalonic encephalopathy (MIM #602473) is a rare autosomal recessive metabolic condition caused by biallelic variants in ETHE1 (MIM #608451), characterized by global developmental delay, infantile hypotonia, seizures, and microvascular damage. The microvascular changes result in a pattern of relapsing spontaneous diffuse petechiae and purpura, positional acrocyanosis, and pedal edema, hemorrhagic suffusions of mucous membranes, and chronic diarrhea. Here, we describe an instructive case in which ethylmalonic encephalopathy masqueraded as meningococcal septicemia and shock. Ultrarapid whole-genome testing (time to result 60 h) and prompt biochemical analysis facilitated accurate diagnosis and counseling with rapid implementation of precision treatment for the metabolic crisis related to this condition. This case provides a timely reminder to consider rare genetic diagnoses when atypical features of more common conditions are present, with an early referral to ensure prompt biochemical and genomic diagnosis.

COVID-19 Case Investigation and Contact Tracing Programs and Practice: Snapshots From the Field.

Between Fall 2020 and Spring 2021, the Association of State and Territorial Health Officials conducted 2 rapid queries to collect information from the field regarding the status of COVID-19 case investigation and contact tracing (CI/CT) programs and practice. These short surveys were distributed to senior deputies in state and territorial health agencies, yielding a response rate of 45.8% (November 2020) and 40.7% (April 2021). Findings indicated that CI/CT staff roles and assigned functions varied across jurisdictions, as did staffing levels/capacity, approaches for linking individuals to social supports, and program changes that were planned or underway. Agency-reported staffing levels/capacity and programmatic challenges changed over time, highlighting the dynamic nature of CI/CT program practice and implementation. While findings from the surveys cannot be generalized to the national level, they provide critical insights from the field on CI/CT program implementation, challenges, and changes in response to the evolving COVID-19 epidemic in the United States.

The utility of ICG fluorescence for sentinel lymph node identification in head and neck melanoma.

PURPOSE: Perform an evidence-based review to determine the utility of indocyanine green fluorescence (ICG) to detect sentinel lymph nodes (SLN) in patients with head and neck melanoma compared to blue dye or radiocolloid injection (RI). MATERIALS AND METHODS: A systematic review of the literature was performed to identify patients with head and neck melanoma managed with ICG fluorescence. PubMed, Embase, and Cochrane Library databases were searched. Included studies were assessed for level of evidence. Patient demographics and data on SLN identification were determined. RESULTS: Twenty-two studies encompassing 399 patients (75% male, 25% female, average age 57.1 years) met inclusion criteria. Publications comprised of two case reports, four retrospective case series, twelve cohort studies, and four clinical trials. Most common site of melanoma was scalp/temple/forehead (35%), cheek/midface (22%), and ear (17%) with an average Breslow thickness of 3.32 mm. SLN was identified in 80.7% (n = 201/249) of patients using ICG-RI, 85.2% (n = 75/88) using RI alone, and 63.4% (n = 52/82) using blue dye-RI. CONCLUSIONS: ICG-99mTc-nanocolloid hybrid tracer may be a superior alternative to blue dye + adiocolloid and has theoretical advantages compared to RI alone. Additional prospective randomized controlled trials are needed to further compare these methods and obtain data on false negative rates, operating room time, and cost effectiveness to fully elucidate the utility of ICG-99mTc-nanocolloid over current methods used for SLN identification in this patient population.

Acute epiglottitis: Analysis of U.S. mortality trends from 1979 to 2017.

PURPOSE: Evaluate trends in mortality due to acute epiglottitis before and after adoption of Haemophilus influenza Type b vaccination (Hib) in pediatric and adult populations. MATERIALS AND METHODS: Patients who died from acute epiglottis from 1979 to 2017 identified using National Vital Statistics System. Mortality rates calculated using age-adjusted US census data expressed in rate per 100,000 individuals. Trends analyzed using the National Cancer Institute Joinpoint Regression Program (version 4.7.0; Bethesda, Maryland). RESULTS: 1187 epiglottitis-related deaths were identified over thirty-nine years. Total deaths decreased from 65 in 1979 to 15 in 2017. Adult deaths accounted for 63.5% and decreased from 0.015 per 100,000 individuals (24 deaths) in 1979 to 0.006 per 100,000 individuals (14 deaths) in 2017. Best fitting log-liner regression model showed APC of -3.5% (95% CI, -4.2 to -2.7%) from 1979 to 2017. Pediatric and adolescent deaths accounted for 443 (37.3%) deaths, decreasing from 0.064 per 100,000 individuals (41 deaths) in 1979 to 0.001 per 100,000 individuals (1 death) in 2017. APC was -11.1% (95% CI, -13.8% to -8.3%) in 1979 to 1990; 46.5% (95% CI, -16.6% to 157.3%) in 1990 to 1993; -61.6% (95% CI, -88% to 23%) in 1993 to 1996; and 1.1% (95% CI, -2.4% to 4.7%) in 1996 to 2017. CONCLUSIONS: Mortality from acute epiglottitis decreased after widespread adoption of Hib vaccination in the US. Adults are now more likely than children to die of acute epiglottitis. Further research including multi-institutional cohort studies must be done to elucidate causative factors contributing to remaining cases of mortality.

Tracheal Resection in the Management of Thyroid Cancer: An Evidence-Based Approach.

OBJECTIVE: Determine the effect of patient demographics and surgical approach on patient outcomes after tracheal resection in the management of thyroid cancer. STUDY DESIGN: Systematic review and meta-analysis. METHODS: Systematic review of literature was performed using PubMed, Embase, and Cochrane Library to identify patients with thyroid carcinoma who underwent tracheal resection. Pooled estimates for patient demographics, presenting findings, complications, and outcomes are determined using random-effects meta-analyses. RESULTS: Ninety-six relevant studies encompassing 1,179 patients met inclusion criteria. Meta-analysis pooled rates of complications: 1.7% (confidence interval [CI] 0.8-2.5; P < .001; I2 = 1.85%) airway complications, 2.8% (CI 1.6-3.9; P < .001; I2 = 13.34%) bilateral recurrent laryngeal nerve paralysis, 2.2% (CI 1.2-3.1; P < .001; I2 = 6.72%) anastomotic dehiscence. Circumferential resection pooled estimates major complications, locoregional recurrence, distal recurrence, overall survival: 14.1% (CI 8.3-19.9; P < .001; I2 = 35.26%), 15% (CI 9.6-20.3; P < .001; I2 = 38.2%), 19.7% (CI 13.7-25.8; P < .001; I2 = 28.83%), 74.5% (CI 64.4-84.6; P < .001; I2 = 85.07%). Window resection estimates: 19.8% (CI 6.9-32.8; P < .001; I2 = 18.83%) major complications, 25.6% (CI 5.1-46.1; P < .014; I2 = 84.68%) locoregional recurrence, 15.6% (CI 9.7-21.5; P < .001; I2 = 0%) distal recurrence, 77.1% (CI 58-96.2; P < .001; I2 = 78.77%) overall survival. CONCLUSION: Management of invasive thyroid carcinoma may require tracheal resection to achieve locoregional control. Nevertheless, postoperative complications are not insignificant, and therefore this risk cannot be overlooked when counseling patients perioperatively. Laryngoscope, 131:932-946, 2021.

Nasal Analysis of Classic Animated Movie Villains versus Hero Counterparts.

Opposing facial features between animated villains and heroes have historically been used to demonstrate contrasting morality between characters, and this could have an impact on how humans view someone as good or evil in everyday life. Studies have been done investigating classic dermatologic features of villainous characters. This principle can be applied to nasal features as well. A search for "top animated characters" was performed. Characters were chosen from American Film Institute's "The Top Tens," Rolling Stone's "25 Best Pixar Movie Characters," and Screenrant's "The 30 Best Animated Movie Characters of All Time." Twenty villains and twenty hero counterparts from respective films were chosen. Classic nasal features were analyzed. Twenty villains (14 male, 6 female) and 20 heroes (12 male, 8 female) were analyzed. Sixteen villains (80%) had greater than normal nasal frontal angle versus 18 heroes (90%). Thirteen villains (65%) had an acute nasolabial angle versus two heroes (10%). Two villains (10%) had excess columellar show versus seven heroes (35%). Seven villains (35%) and one hero (5%) had a dorsal hump. Twelve villains (60%) had an overprojected chin versus three heroes (15%). Villains in pre-2000s films more frequently had a dorsal hump, overprojected chin, ptotic tip, pollybeak deformity, and bulbous tip. Heroes in pre-2000s films more frequently had an overrotated tip. Villains and heroes commonly have a greater than normal nasofrontal angle. Villains more commonly have an acute nasolabial angle, underrotated tip, overprojected chin, dorsal hump, and pollybeak deformity. Heroes more commonly have a large nasolabial angle and overrotated tip. Further research in conjunction with psychologists is required to obtain concrete data on how this affects whether an individual in real life is seen as good or evil, and the impact this has on interactions in society, including in the medical field.

COVID-19 Case Investigation and Contact Tracing: Early Lessons Learned and Future Opportunities.

CONTEXT: Case investigation and contact tracing are fundamental public health strategies for controlling and preventing the spread of infectious diseases. Although the principles behind these strategies are not new, the capacity and operational requirements needed to support disease investigation during the SARS-CoV-2 (COVID-19) pandemic are unprecedented. This article analyzes the implementation of case investigation and contact tracing in controlling COVID-19 transmission during the early stages of the US pandemic response (January 20 through August 31, 2020). PROGRAM IMPLEMENTATION: Governmental public health agencies mobilized to expand case investigation and contact tracing programs in the early months of the pandemic. In doing so, they encountered a range of challenges that included rapidly scaling up the workforce; developing and subsequently revising guidance and protocols specific to COVID-19 as more was learned about the virus over time; defining job functions; encouraging public acceptance of and participation in case investigation and contact tracing; and assessing the utility of these activities during both the containment and mitigation phases of outbreak response. COVID-19 case investigation and contact tracing programs presented an array of opportunities for health departments to innovate, especially around technology to support public health efforts, as well as opportunities to address health equity and advance community resilience. CONCLUSION: Lessons learned from disease intervention specialists, guidance and resources from federal agencies and national partners, and peer-to-peer exchange of promising practices can support jurisdictions encountering early implementation challenges. Further research is needed to assess COVID-19 case investigation and contact tracing program models and innovations, as well as strategies for implementing these activities during containment and mitigation phases.

Diagnosis and management of congenital floor of mouth masses: A systematic review.

OBJECTIVES: Determine the utility of preoperative imaging and the optimal course of management for congenital floor of mouth (FOM) cysts in infants. METHODS: A systematic review of the literature was performed conforming to PRISMA guidelines. Pubmed, Embase and Cochrane Library databases were queried to identify cases of infants with congenital floor of mouth masses. Patient demographics, presenting findings, imaging, management, complications, and outcomes were determined. RESULTS: 85 patients were evaluated. 98% of patients presented at 16 months of age or younger. The most common presenting symptom was submental mass or swelling, 31.3%. Among the patients that underwent imaging, the suspected diagnosis obtained from imaging findings was consistent with the final pathologic diagnosis 59% of the time reported and inaccurate 34% of the time. There were multiple definitive treatment modalities described in the literature review including surgical excision, 82.3%, marsupialization, 12.9%, chemical injection 2.3%, sclerotherapy 1.2%,% and radiation, 1.2%. Recurrence rate after initial definitive treatment was as follows, surgical excision, 8.8%, marsupialization, 80%, sclerotherapy, 100%, chemical injection, 50%, and radiation, 100%. CONCLUSION: Preoperative imaging studies should not be relied upon alone to determine suspected pathology and subsequent management in pediatric patients with FOM masses. It may be beneficial for these patients to undergo primary surgical excision regardless of imaging studies or suspected pathology. Needle aspiration offers limited addition to pathologic diagnosis and should only be performed in the setting of acute symptomatic management. Surgical excision should be considered as definitive treatment modality in all patients with FOM masses, regardless of the suspected diagnosis of ranula. Further multi-institutional cohort studies could be invaluable to elucidate definitive treatment guidelines in this patient population.

Orbital Roof Fractures: An Evidence-Based Approach.

Importance: There is controversy surrounding the management of orbital roof fractures. Guidelines with regard to when to operate and type of reconstruction are lacking. Categorizing these data will help clinicians make informed decisions about the management of orbital roof fractures and avoid preventable complications. Objective: To perform a systematic review evaluating underlying causes, associated complications, and management of orbital roof fractures including reconstructive options in the general population of children and adults. Evidence Review: A systematic review using the PubMed, EmBase, Cochrane, and MEDLINE databases identified relevant studies for inclusion. Studies were included from 1987 to 2017. Demographics, symptoms, management, reconstruction, and outcomes were reported following preferred reporting items for systematic reviews and meta-analyses guidelines. Inclusion criteria included articles discussing management of traumatic orbital roof fractures across all ages. Included studies were assessed for level of evidence. Findings: Forty-seven studies encompassing 526 patients met inclusion criteria. There were 28 case reports, 15 retrospective case series and 4 retrospective cohort studies. The most common etiologies were motor vehicle accidents (39.5%), falls (30.3%), and assault (11.8%). Periorbital ecchymosis, exophthalmos, and dystopia were the most common initial symptoms. In total, 60.0% of patients underwent surgical repair and 40% of patients were managed conservatively. The most common surgical approach was bicoronal (94.8%), followed by a superolateral orbital rim approach and transpalpebral (5.1%). A variety of grafting materials were utilized, including titanium miniplates (46.2%), bone graft (37.7%), porous polyethylene (2.8%), and silastic implants (2.8%). Overall patients undergoing surgery were adults with clinical symptoms including exophthalmos, diplopia, and gaze restriction as well as patients with dura exposure. Most patients undergoing surgery were those with concomitant fractures. The most common fractures among the surgical patients were frontal bone (32.2%), ethmoid (25.2%), and zygomaticomaxillary complex/zygoma (12.2%). Conclusions and Relevance: Management of orbital roof fractures varies based on individual clinical features including the presence of exophthalmos, gaze restriction, and concomitant injuries such as dural tears. Surgically, bicoronal approaches were performed most commonly along with reconstruction utilizing titanium miniplates. Conservative management was more common among the pediatric population. This systematic review demonstrates both conservative and surgical measures can lead to positive outcomes in appropriately selected patients.

O-Isocyanates as Uncharged 1,3-Dipole Equivalents in [3+2] Cycloadditions.

1,3-Dipoles are commonly used in [3+2] cycloadditions, whereas isoelectronic uncharged dipole variants remain underdeveloped. In contrast to conventional 1,3-dipoles, uncharged dipole equivalents form zwitterionic cycloadducts, which can be exploited to build further molecular complexity. In this work, the first cycloadditions of oxygen-substituted isocyanates (O-isocyanates) were studied experimentally and by DFT calculations. This unique cycloaddition strategy provides access to a novel class of heterocycle aza-oxonium ylides through intramolecular and intermolecular cycloadditions with alkenes. This allowed a systematic study of the reactivity of the transient aza-oxonium ylide intermediate, which can undergo N-O bond cleavage followed by nitrene C-H insertion, and the formation of ß-lactams or isoxazolidinones upon varying the structure of the alkene or O-isocyanate reagents.

Annulation of Oxime-Ether Tethered Donor-Acceptor Cyclopropanes.

Novel oxime-ether tethered cyclopropanes, when exposed to Yb(OTf)3 and heat, annulate to generate hydropyrrolo-oxazines products that can be taken to their respective pyrrolidines via hydrogenative N-O bond cleavage. The hydropyrrolo-oxazines are generated in a diastereoselective manner isolating the cis or trans product based on the temperature of the reaction. 20 examples of selective cis and trans hydropyrrolo-oxazines were generated in high yields by temperature control.

Toddlers prefer to help familiar people.

Young children's willingness to spontaneously help others is the subject of a large body of research investigating the ontogeny of moral behavior and thought. A developing debate centers around the extent to which social factors influence the desire to help. Familiarity with the person needing help is one such factor that varies across many studies but has not been systematically investigated. In Experiment 1, we show that toddlers were significantly more likely to assist a person on an out-of-reach clothespin task when they had previously become familiar with that person. Moreover, and in contrast to previous work, we found that becoming familiar with a person increases helpfulness only toward that person and does not transfer to an unknown person. We further demonstrate, in Experiment 2A, that children were equally likely to approach and take a sticker from an experimenter with whom they were familiar or unfamiliar-thereby ruling out wariness of strangers as the key driver for familiarity effects in Experiment 1. Moreover, in Experiment 2B, we show that children were more likely to help the previously unfamiliar partner (from Experiment 2A) after the partner gave the child the sticker. We conclude that familiarity is an ecologically important social influencer of toddler helping behavior.