Complex spinal dysraphism: myelomenigocele associated with dorsal bony spur, split cord malformation type I, syringomyelia, lipoma and tethered cord.

Variations in split cord malformation (SCM) are known. However, association of SCM type I with myelomeningocele along with same level dorsal bony spur has not been described previously. We report a 1-year old male child who presented with these findings with associated syringomyelia, lipoma and tethered cord.

Ultrashort Pulse Excited Tip-Enhanced Raman Spectroscopy in Molecules.

Vibrational fingerprints of molecules and low-dimension materials can be traced with subnanometer resolution by performing Tip-enhanced Raman spectroscopy (TERS) in a scanning tunneling microscope (STM). Strong atomic-scale localization of light in the plasmonic nanocavity of the STM enables high spatial resolution in STM-TERS; however, the temporal resolution is so far limited. Here, we demonstrate stable TERS measurements from subphthalocyanine (SubPc) molecules excited by ∼500 fs long laser pulses in a low-temperature (LT) ultrahigh-vacuum (UHV) STM. The intensity of the TERS signal excited with ultrashort pulses scales linearly with the increasing flux of the laser pulses and exponentially with the decreasing gap-size of the plasmonic nanocavity. Furthermore, we compare the characteristic features of TERS excited with ultrashort pulses and with a continuous-wave (CW) laser. Our work lays the foundation for future experiments of time-resolved femtosecond TERS for the investigation of molecular dynamics with utmost spatial, temporal, and energy resolutions simultaneously.

Emergence of Extended-Spectrum ß-Lactamase Urinary Tract Infections Among Hospitalized Emergency Department Patients in the United States.

STUDY OBJECTIVE: Enterobacteriaceae resistant to ceftriaxone, mediated through extended-spectrum ß-lactamases (ESBLs), commonly cause urinary tract infections worldwide, but have been less prevalent in North America. Current US rates are unknown. We determine Enterobacteriaceae antimicrobial resistance rates among US emergency department (ED) patients hospitalized for urinary tract infection. METHODS: We prospectively enrolled adults hospitalized for urinary tract infection from 11 geographically diverse university-affiliated hospital EDs during 2018 to 2019. Among participants with culture-confirmed infection, we evaluated prevalence of antimicrobial resistance, including that caused by ESBL-producing Enterobacteriaceae, resistance risk factors, and time to in vitro-active antibiotics. RESULTS: Of 527 total participants, 444 (84%) had cultures that grew Enterobacteriaceae; 89 of 435 participants (20.5%; 95% confidence interval 16.9% to 24.5%; 4.6% to 45.4% by site) whose isolates had confirmatory testing had bacteria that were ESBL producing. The overall prevalence of ESBL-producing Enterobacteriaceae infection among all participants with urinary tract infection was 17.2% (95% confidence interval 14.0% to 20.7%). ESBL-producing Enterobacteriaceae infection risk factors were hospital, long-term care, antibiotic exposure within 90 days, and a fluoroquinolone- or ceftriaxone-resistant isolate within 1 year. Enterobacteriaceae resistance rates for other antimicrobials were fluoroquinolone 32.3%, gentamicin 13.7%, amikacin 1.3%, and meropenem 0.3%. Ceftriaxone was the most common empirical antibiotic. In vitro-active antibiotics were not administered within 12 hours of presentation to 48 participants (53.9%) with ESBL-producing Enterobacteriaceae infection, including 17 (58.6%) with sepsis. Compared with other Enterobacteriaceae infections, ESBL infections were associated with longer time to in vitro-active treatment (17.3 versus 3.5 hours). CONCLUSION: Among adults hospitalized for urinary tract infection in many US locations, ESBL-producing Enterobacteriaceae have emerged as a common cause of infection that is often not initially treated with an in vitro-active antibiotic.

Answering the Challenge of COVID-19 Pandemic Through Innovation and Ingenuity.

The novel coronavirus disease 2019 (COVID-19) pandemic has created a maelstrom of challenges affecting virtually every aspect of global healthcare system. Critical hospital capacity issues, depleted ventilator and personal protective equipment stockpiles, severely strained supply chains, profound economic slowdown, and the tremendous human cost all culminated in what is questionably one of the most profound challenges that humanity faced in decades, if not centuries. Effective global response to the current pandemic will require innovation and ingenuity. This chapter discusses various creative approaches and ideas that arose in response to COVID-19, as well as some of the most impactful future trends that emerged as a result. Among the many topics discussed herein are telemedicine, blockchain technology, artificial intelligence, stereolithography, and distance learning.

Report Highlights Burden Frontline Providers Face in Recognizing, Preventing Sepsis.

Although much of the research on sepsis has focused on early recognition and treatment, the CDC issued a new report highlighting opportunities to prevent the condition from developing. To facilitate improvements in this area, investigators highlighted data showing which infections and healthcare factors are associated most commonly with sepsis so that providers can improve their efforts. Investigators reviewed the medical records of 246 adult patients diagnosed with severe sepsis or septic shock at four New York hospitals, finding that the most common types of infections associated with sepsis were respiratory tract, urinary tract, gastrointestinal, and skin and soft tissue. Among 79 pediatric cases, the most common infections included respiratory tract, gastrointestinal, and bloodstream. Investigators found that sepsis occurred most often in patients with one or more comorbidities and that most developed infections that led to sepsis outside the hospital. Given that many patients at highest risk for sepsis frequently encounter the healthcare system, there is an opportunity for providers to better educate patients about prevention and early warning signs.

A Hanging and Its Complications.

Hanging has become the second most common form of successful suicide in the United States. Along with a high mortality rate, the long-term morbidity is consequential for both the individual patient and society. A thorough knowledge of the clinical approach will assist the emergency physician in providing optimal care and helping to minimize delayed respiratory complications. Using a case-based scenario, the initial management strategies along with rational evidence-based treatments are reviewed.

Viral single stranded RNA induces a trophoblast pro-inflammatory and antiviral response in a TLR8-dependent and -independent manner.

Interest is growing in the role of viral infections and their association with adverse pregnancy outcomes. The trophoblast is permissive to viruses, but little is known about their impact on the placenta. We previously established that viral single stranded RNA (ssRNA), a Toll-like receptor 8 (TLR8) agonist, induces a restricted trophoblast pro-inflammatory cytokine/chemokine response by upregulating the secretion of interleukin (IL)-6 and IL-8. In parallel, the type I interferon, IFNbeta, is produced and acts back on the cell in an autocrine/paracrine manner to trigger caspase-3-dependent apoptosis. In this study, we sought to extend these findings by determining the mechanisms involved, examining whether viral ssRNA could induce a trophoblast antiviral response, and evaluating the influence of viral ssRNA on pregnancy outcome using a mouse model. Viral ssRNA induced human first-trimester trophoblast inflammation, type I interferon production, an antiviral response, and apoptosis in both a TLR8/MyD88-dependent and -independent manner. Furthermore, administration of viral ssRNA to pregnant mice induced placental caspase-3 activation, a pro-inflammatory cytokine/chemokine, type I interferon, and antiviral response as well as immune cell infiltration. Thus, ssRNA viral infections may compromise pregnancy by altering placental trophoblast survival and function through both TLR8 and non-TLR8 signaling pathways, leading to immune changes at the maternal-fetal interface.

Dendritic cells sequester antigenic epitopes for prolonged periods in the absence of antigen-encoding genetic information.

Studies with a number of viral systems have shown, on the basis of the ability of a host to prime naïve T cells, that viral antigens persist in the infected host well beyond complete clearance of the infection and even when viral antigen is undetectable by the most sensitive methods. This has led to a reasonable assumption that the antigen persists through persistence of antigen-encoding genetic information (DNA or RNA) that resides in the host at a subdetectable level. Here, we demonstrate that epitopes, or epitope precursors, of a model antigen (ovalbumin) persist in a host for prolonged periods (weeks), well beyond the time at which the intact antigen has disappeared, and in the complete absence of genetic information encoding it. Dendritic cells are shown to be the site of this epitope sequestration in vivo, as well as in cultures in vitro. For sequestration to occur, the uptaken antigen must be significantly large, that is, the epitope and its 18-mer precursor are not sequestered. Dendritic cells are shown to create an hsp90-dependent intracellular pool of epitopes or epitope precursors that continues to release epitopes for presentation on the major histocompatibility complex I molecules for prolonged periods. Demonstration of such long-term sequestration of antigenic epitopes inside dendritic cells presents new opportunities for stimulation of immune response against cancers and viruses.

Predictors of a Top Performer During Emergency Medicine Residency.

BACKGROUND: Emergency Medicine (EM) residency program directors and faculty spend significant time and effort creating a residency rank list. To date, however, there have been few studies to assist program directors in determining which pre-residency variables best predict performance during EM residency. OBJECTIVE: To evaluate which pre-residency variables best correlated with an applicant's performance during residency. METHODS: This was a retrospective multicenter sample of all residents in the three most recent graduating classes from nine participating EM residency programs. The outcome measure of top residency performance was defined as placement in the top third of a resident's graduating class based on performance on the final semi-annual evaluation. RESULTS: A total of 277 residents from nine institutions were evaluated. Eight of the predictors analyzed had a significant correlation with the outcome of resident performance. Applicants' grade during home and away EM rotations, designation as Alpha Omega Alpha (AOA), U.S. Medical Licensing Examination (USMLE) Step 1 score, interview scores, "global rating" and "competitiveness" on nonprogram leadership standardized letter of recommendation (SLOR), and having five or more publications or presentations showed a significant association with residency performance. CONCLUSION: We identified several predictors of top performers in EM residency: an honors grade for an EM rotation, USMLE Step 1 score, AOA designation, interview score, high SLOR rankings from nonprogram leadership, and completion of five or more presentations and publications. EM program directors may consider utilizing these variables during the match process to choose applicants who have the highest chance of top performance during residency.

Mini incision open pyeloplasty - Improvement in patient outcome.

PURPOSE: To assess the subjective and objective outcomes of mini-incision dismembered Anderson-Hynes pyeloplasty in the treatment of primary ureteropelvic junction obstruction (UPJO). MATERIALS AND METHODS: Between January 2008 to January 2013, Anderson-Hynes pyeloplasty was performed in 71 patients diagnosed with primary UPJO. Small subcostal muscle splitting incision was used in all cases. Sixteen patients with renal calculi underwent concomitant pyelolithotomy. Subjective outcome was assessed using visual pain analogue score (VAS). For objective assessment, the improvement in differential renal function (DRF) and radio-tracer wash out time (T1/2) on Tc-99m DTPA scan and decrease in hydronephrosis (HDN) on renal ultrasound (USG) and urography (IVU) were assessed. RESULTS: Mean incision length was 5.2 cm. The average operating time and postoperative hospital stay was 63 (52-124) minutes and 2.5 (2-6) days respectively. Concomitant renal calculi were successfully removed in all the patients. Overall complication rates were 8.4% and overall success rate was 98.6% at median follow-up of 16 months. There was significant improvement in pain score (p=0.0001) and significant decrease in HDN after the procedure. While preoperative mean T1/2 was 26.7±6.4 minutes, postoperative half-time decreased to 7.8±4.2 minutes at 6 months and to 6.7±3.3 minutes at 1 year. Mean pre-operative DRF was 26.45% and it was 31.38% and 33.19% at 6 months and 1 year respectively. CONCLUSIONS: Mini-incision pyeloplasty is a safe and effective technique with combined advantage of high success rates of standard open pyeloplasty with decreased morbidity of laparoscopic approach. Excellent functional and objective outcomes can be achieved without extra technical difficulty.

Urethro-ejaculatory duct reflux, a complication of peno-bulbar urethral stricture: case report with review of the literature.

Urethro-ejaculatory duct reflux (UEDR) is an uncommonly discussed entity that may result in devastating complications. We discuss the case of a young married male with obstructive voiding symptoms along with intermittent left scrotal pain for last the 2 years. On voiding cystourethrography, he had intravasation of contrast into the prostatic ducts, vas deferens and epididymal ducts suggestive of UEDR which might be the cause of his scrotal pain due to recurrent episodes of epididymitis. Complete resolution of voiding symptoms and recurrent scrotal pain occurred after management of urethral stricture. The possibility of UEDR should be kept in mind while dealing with men suffering from recurrent prostatitis, seminal vesiculitis, epididymitis or, less commonly, infertility.

Real-time tracking of coherent oscillations of electrons in a nanodevice by photo-assisted tunnelling.

Coherent collective oscillations of electrons excited in metallic nanostructures (localized surface plasmons) can confine incident light to atomic scales and enable strong light-matter interactions, which depend nonlinearly on the local field. Direct sampling of such collective electron oscillations in real-time is crucial to performing petahertz scale optical modulation, control, and readout in a quantum nanodevice. Here, we demonstrate real-time tracking of collective electron oscillations in an Au bowtie nanoantenna, by recording photo-assisted tunnelling currents generated by such oscillations in this quantum nanodevice. The collective electron oscillations show a noninstantaneous response to the driving laser fields with a T2 decay time of nearly 8 femtoseconds. The contributions of linear and nonlinear electron oscillations in the generated tunnelling currents were precisely determined. A phase control of electron oscillations in the nanodevice is illustrated. Functioning in ambient conditions, the excitation, phase control, and read-out of coherent electron oscillations pave the way toward on-chip light-wave electronics in quantum nanodevices.

Hyperkalemic paralysis: an elective abortion gone wrong.

BACKGROUND: Commonly used abortion agents carry potentially serious side effects for the mother. It is important for emergency physicians to be aware of the medications used in elective abortions from the late first trimester to term. If digoxin is used as an abortifacient, it is injected intrafetally or intraplacentally. With this method there is a chance of extraplacental injection, resulting in maternal systemic digoxin toxicity and serious morbidity or death. OBJECTIVES: This report presents a case report, discusses the risks of digoxin-induced abortion, and teaches the reader about the abortifacient agents currently in use, along with their associated complications. CASE REPORT: This is a case of a 28-year-old pregnant woman of approximately 20 weeks gestation, who presented with severe muscular weakness and respiratory failure requiring intubation. She was subsequently found to have hyperkalemic paralysis from digoxin toxicity after an extraplacental injection during the first step of a two-part elective abortion. CONCLUSIONS: It is important for emergency physicians to be aware of the various late first-trimester to term abortifacient agents and procedures being used in obstetrical/gynecological practice, and the potential risks of these interventions. Digoxin toxicity or hyperkalemia should be suspected when a patient presents with severe weakness and respiratory distress after an attempted abortion.

An interesting cause of wide complex tachycardia: Ashman's phenomenon in atrial fibrillation.

BACKGROUND: Ashman's phenomenon is an aberrant intraventricular conduction abnormality that occurs in response to a change in QRS cycle length. In atrial fibrillation, Ashman's phenomenon will present as a long RR cycle followed by a short RR cycle, with the subsequent QRS complex manifesting a right bundle branch block morphology. This morphologic variation can create difficulty with electrocardiographic interpretation, and can alter management in patients with this dysrhythmia. OBJECTIVES: This report presents a case, describes the Ashman's phenomenon in atrial fibrillation, and discusses interpretation of this electrocardiographic finding. CASE REPORT: This is a 27-year-old woman who presented with palpitations and chest pain. The patient was symptomatic with a heart rate >200 beats/min and a wide complex tachycardia on electrocardiogram. CONCLUSIONS: Ashman's phenomenon should be suspected in atrial fibrillation when there is a long cycle followed by a short cycle, with the subsequent QRS complex manifesting a right bundle branch block pattern. Emergency physician awareness of this phenomenon may improve diagnostic certainty and have an impact on dysrhythmia management.

Google Internet searches on residency applicants do not facilitate the ranking process.

BACKGROUND: Information used by program directors (PDs) to evaluate and rank residency applicants is largely limited to the Electronic Residency Application Service and the interview day. The Internet represents a potential source of additional data on applicants. Recent surveys reveal that up to 90% of United States (US) companies are already using the Internet to post jobs and to screen candidates. However, its use in residency applicant evaluation is not well studied. OBJECTIVE: We hypothesize that the Internet, through the use of a Google search, will provide useful information to PDs in ranking applicants. METHODS: This prospective observational study was completed by six Accreditation Council for Graduate Medical Education-accredited Emergency Medicine residency programs. After the interview process, programs formed their rank order list in their usual fashion. Then participating programs performed a Google search on applicants from their list. A standardized search was used and information reviewed was limited to the first two Google pages. The main outcome measure was change in an applicant's status on the rank order list. Change in status was based on the judgment of the individual program's PD. RESULTS: A total of 547 applicants were reviewed. The time for review of information was 4,386 min total and a mean of 7.2 min per resident. Position on the rank order list was changed for three applicants; two moved up on the list and one moved down. Four programs made no changes. No applicants were removed. CONCLUSIONS: The Internet, through the use of a Google search, did not appear to provide useful information in a time-effective manner to PDs in ranking applicants.

Phagocytosis: history's lessons.

The assimilation of lessons from the past is an essential component of education for scientists of tomorrow. These lessons are not easy to find. History books on science are few and usually highly dramatized and biographies of scientists tend to exaggerate the pomp of scientific discovery. Both underplay the hard and laborious work that is integral to any scientific pursuit. Here we illustrate one such example. A century ago, the Nobel Prize in Medicine was awarded to two scientists: Ilya Metchnikoff, a Russian zoologist, for the discovery ofphagocytosis-a cell-mediated ingestion ofmicrobes; and Paul Ehrlich, a distinguished physician-scientist, for discovering a highly antigen-specific serum-derived antibody-based immune defense. These two diametrically opposing views of the host-pathogen interaction set the stage for a strife that led to seminal advancements in immunology. Mirrored in this journey are important lessons for scientists today--ubiquitously as applicable to modern scientific life as they were a century ago. This commentaryhighlights these lessons--a fitting centenary to a well-deserved recognition.

Imaging and controlling coherent phonon wave packets in single graphene nanoribbons.

The motion of atoms is at the heart of any chemical or structural transformation in molecules and materials. Upon activation of this motion by an external source, several (usually many) vibrational modes can be coherently coupled, thus facilitating the chemical or structural phase transformation. These coherent dynamics occur on the ultrafast timescale, as revealed, e.g., by nonlocal ultrafast vibrational spectroscopic measurements in bulk molecular ensembles and solids. Tracking and controlling vibrational coherences locally at the atomic and molecular scales is, however, much more challenging and in fact has remained elusive so far. Here, we demonstrate that the vibrational coherences induced by broadband laser pulses on a single graphene nanoribbon (GNR) can be probed by femtosecond coherent anti-Stokes Raman spectroscopy (CARS) when performed in a scanning tunnelling microscope (STM). In addition to determining dephasing (~440 fs) and population decay times (~1.8 ps) of the generated phonon wave packets, we are able to track and control the corresponding quantum coherences, which we show to evolve on time scales as short as ~70 fs. We demonstrate that a two-dimensional frequency correlation spectrum unequivocally reveals the quantum couplings between different phonon modes in the GNR.