Pediatric Veno-Veno Extracorporeal Membrane Oxygenation Rescue From Carbon Monoxide Poisoning.

BACKGROUND: Carbon monoxide poisoning affects approximately 5000 children per year and can be challenging to diagnose and treat (Pediatr Emerg Med Pract. 2016;13:1-24). It is in the differential diagnosis of a patient presented with altered consciousness. Patients may look quite "pink" and well perfused, but are often in serious distress. We present the first case in the literature of carbon monoxide poisoning treated with the use of veno-veno extracorporeal membrane oxygenation (ECMO). CASE: We report the case of a 10-year-old patient who had carbon monoxide poisoning (carboxyhemoglobin of 18%). She was treated with hydroxocobalamin at 70 mg/kg and was being prepared to transfer to a facility that offered hyperbaric therapy when she suffered a cardiac arrest requiring cardiopulmonary resuscitation. After 11 minutes of resuscitation, she had return of spontaneous circulation and an echocardiogram showed reasonable cardiac function. She was judged too unstable for ambulance transport and the ECMO team was called. Veno-veno ECMO was placed via a single right internal jugular dual-lumen catheter with fluoroscopy in the cardiac catheterization laboratory. There was a rapid improvement in carboxyhemoglobin level, and the ECMO therapy was weaned the next day. The patient eventually made a full recovery. CONCLUSIONS: This is the first time that veno-veno ECMO has been reported for the emergent treatment of carbon monoxide intoxication. If emergency physicians are treating such a patient and cannot administer hyperbaric oxygen therapy, ECMO represents a valuable alternative that is not commonly thought of in this situation before.

Pharmacokinetic interactions between BMS-626529, the active moiety of the HIV-1 attachment inhibitor prodrug BMS-663068, and ritonavir or ritonavir-boosted atazanavir in healthy subjects.

BMS-663068 is a prodrug of BMS-626529, a first-in-class attachment inhibitor that binds directly to HIV-1 gp120, preventing initial viral attachment and entry into host CD4(+) T cells. This open-label, multiple-dose, four-sequence, crossover study addressed potential two-way drug-drug interactions following coadministration of BMS-663068 (BMS-626529 is a CYP3A4 substrate), atazanavir (ATV), and ritonavir (RTV) (ATV and RTV are CYP3A4 inhibitors). Thirty-six healthy subjects were randomized 1:1:1:1 to receive one of four treatment sequences with three consecutive treatments: BMS-663068 at 600 mg twice daily (BID), BMS-663068 at 600 mg BID plus RTV at 100 mg once daily (QD), ATV at 300 mg QD plus RTV at 100 mg QD (RTV-boosted ATV [ATV/r]), or BMS-663068 at 600 mg BID plus ATV at 300 mg QD plus RTV at 100 mg QD. Compared with the results obtained by administration of BMS-663068 alone, coadministration of BMS-663068 with ATV/r increased the BMS-626529 maximum concentration in plasma (Cmax) and the area under the concentration-time curve in one dosing interval (AUCtau) by 68% and 54%, respectively. Similarly, coadministration of BMS-663068 with RTV increased the BMS-626529 Cmax and AUCtau by 53% and 45%, respectively. Compared with the results obtained by administration of ATV/r alone, ATV and RTV systemic exposures remained similar following coadministration of BMS-663068 with ATV/r. BMS-663068 was generally well tolerated, and there were no adverse events (AEs) leading to discontinuation, serious AEs, or deaths. Moderate increases in BMS-626529 systemic exposure were observed following coadministration of BMS-663068 with ATV/r or RTV. However, the addition of ATV to BMS-663068 plus RTV did not further increase BMS-626529 systemic exposure. ATV and RTV exposures remained similar following coadministration of BMS-663068 with either ATV/r or RTV. BMS-663068 was generally well tolerated alone or in combination with either RTV or ATV/r.

Deucravacitinib, a Tyrosine Kinase 2 Inhibitor, in Systemic Lupus Erythematosus: A Phase II, Randomized, Double-Blind, Placebo-Controlled Trial.

OBJECTIVE: To assess the efficacy and safety of deucravacitinib, an oral, selective, allosteric inhibitor of TYK2, in a phase II trial in adult patients with active systemic lupus erythematosus (SLE). METHODS: Adults with active SLE were enrolled from 162 sites in 17 countries. Patients (n = 363) were randomized 1:1:1:1 to receive deucravacitinib 3 mg twice daily, 6 mg twice daily, 12 mg once daily, or placebo. The primary end point was SLE Responder Index 4 (SRI-4) response at week 32. Secondary outcomes assessed at week 48 included SRI-4, British Isles Lupus Assessment Group-based Composite Lupus Assessment (BICLA) response, Cutaneous Lupus Erythematosus Disease Area and Severity Index 50 (CLASI-50), Lupus Low Disease Activity State (LLDAS), and improvements in active (swollen plus tender), swollen, and tender joint counts. RESULTS: At week 32, the percentage of patients achieving SRI-4 response was 34% with placebo compared to 58% with deucravacitinib 3 mg twice daily (odds ratio [OR] 2.8 [95% confidence interval (95% CI) 1.5, 5.1]; P < 0.001 versus placebo), 50% with 6 mg twice daily (OR 1.9 [95% CI 1.0, 3.4]; P = 0.02 versus placebo), and 45% with 12 mg once daily (OR 1.6 [95% CI 0.8, 2.9]; nominal P = 0.08 versus placebo). Response rates were higher with deucravacitinib treatment for BICLA, CLASI-50, LLDAS, and joint counts compared to placebo. Rates of adverse events were similar across groups, except higher rates of infections and cutaneous events, including rash and acne, with deucravacitinib treatment. Rates of serious adverse events were comparable, with no deaths, opportunistic infections, tuberculosis infections, major adverse cardiovascular events, or thrombotic events reported. CONCLUSION: Deucravacitinib treatment elicited higher response rates for SRI-4 and other end points compared with placebo, with an acceptable safety profile, in adult patients with active SLE.

Multisite Qualification of an Automated Incubator and Colony Counter for Environmental and Bioburden Applications in Pharmaceutical Microbiology.

Traditional microbiological techniques have been used for well over a century as the basis for contamination testing of pharmaceutical products and processes. With more recent focus on faster product release and concerns around the integrity of the test data, new technologies have been implemented to detect and enumerate organisms faster and provide paperless processes to minimize data integrity issues. Manual colony counting technologies, where incubation is performed in a standard incubator, and the plate is manually transferred to the colony counter for a single read at the end of incubation, have been used for many years to reduce the potential for human error; however, they pose validation challenges due to poor counting accuracy. Colony counters that automatically perform both the incubation and enumeration functions (multiple enumeration calculations through the incubation phase) have recently been implemented for quality control (QC) laboratory analytical processes, supporting a cGMP environment. This article summarizes the findings of eight companies demonstrating the qualification of an automated colony counter technology to perform the majority of microbial tests required for QC, environmental monitoring, and bioburden for in-process, bulk drug substance, and water system testing. Comparable analytical performance and time to result data generated during individual studies at all companies allows the system to be qualified and implemented for cGMP processes while reducing data integrity risks.

Electron-Phonon Interaction Contribution to the Total Energy of Group IV Semiconductor Polymorphs: Evaluation and Implications.

In density functional theory (DFT)-based total energy studies, the van der Waals (vdW) and zero-point vibrational energy (ZPVE) correction terms are included to obtain energy differences between polymorphs. We propose and compute a new correction term to the total energy, due to electron-phonon interactions (EPI). We rely on Allen's general formalism, which goes beyond the quasi-harmonic approximation (QHA), to include the free energy contributions due to quasiparticle interactions. We show that, for semiconductors and insulators, the EPI contributions to the free energies of electrons and phonons are the corresponding zero-point energy contributions. Using an approximate version of Allen's formalism in combination with the Allen-Heine theory for EPI corrections, we calculate the zero-point EPI corrections to the total energy for cubic and hexagonal polytypes of carbon, silicon and silicon carbide. The EPI corrections alter the energy differences between polytypes. In SiC polytypes, the EPI correction term is more sensitive to crystal structure than the vdW and ZPVE terms and is thus essential in determining their energy differences. It clearly establishes that the cubic SiC-3C is metastable and hexagonal SiC-4H is the stable polytype. Our results are consistent with the experimental results of Kleykamp. Our study enables the inclusion of EPI corrections as a separate term in the free energy expression. This opens the way to go beyond the QHA by including the contribution of EPI on all thermodynamic properties.

Hepatoprotective activity of punarnavashtak kwath, an Ayurvedic formulation, against CCl4-induced hepatotoxicity in rats and on the HepG2 cell line.

OBJECTIVE: Punarnavashtak kwath (PNK) is a classical Ayurvedic formulation, mentioned in Ayurvedic literature Bhaishajya Ratnavali, for hepatic disorders and asthma. This study investigated the hepatoprotective activity of PNK to validate the traditional use of this formulation. MATERIALS AND METHODS: PNK was prepared in the laboratory according to the method given in Ayurvedic literature. Phytochemical screening was performed to determine the presence of phytoconstituents. Hepatoprotective activity was evaluated against CCl(4)-induced hepatotoxicity in rats and by its effect on the HepG2 cell line. RESULTS: Preliminary phytochemical screening revealed the presence of alkaloids, tannins, flavonoids, saponins, and a bitter principle in PNK. Administration of PNK produced significant hepatoprotective effect as demonstrated by decreased levels of serum liver marker enzymes such as aspartate transaminase, serum alanine transaminase, serum alkaline phosphatase, and serum bilirubin and an increase in protein level. Thiopentone-induced sleeping time was also decreased in the PNK-treated animals compared with the CCl(4)-treated group. It also showed antioxidant activity by increase in activity of glutathione, superoxide dismutase, and catalase and by a decrease in thiobarbituric acid reactive substance level compared with the CCl(4)-treated group. Results of a histopathological study also support the hepatoprotective activity of PNK. Investigation carried out on the HepG2 cell line depicted significant increase in viability of cells exposed to PNK as compared with CCl(4)-treated cells. DISCUSSION AND CONCLUSION: It can be concluded that PNK protects hepatocytes from CCl(4)-induced liver damages due to its antioxidant effect on hepatocytes. An in vitro study on HepG2 cell lines also supports its protective effect.

Comparative effectiveness of early-targeted use of fidaxomicin versus oral vancomycin among hospitalized veterans' affairs patients with infections due to Clostridioides difficile.

STUDY OBJECTIVES: This study sought to compare real-world effectiveness outcomes between hospitalized patients with Clostridioides difficile infections (CDIs) who received early-targeted fidaxomicin or oral vancomycin at two Veterans Affairs Medical Centers (VAMCs). DESIGN: A retrospective cohort study was performed among hospitalized patients at two VAMCs from January 2008 until July 2017. SETTING: Albany and Syracuse VAMCs. PATIENTS: Patients were included in this analysis if they were age ≥18 years; were hospitalized; had a CDI with a Hines Severity Score Index (SSI) ≥2; received oral vancomycin (January 2008-June 2014 at Albany or Syracuse VAMCs) or fidaxomicin (March 2012-July 2017 at Albany VAMC) within 5 days of positive CDI stool sample for ≥ 48 hours. INTERVENTION: Receipt of an oral vancomycin- or fidaxomicin-containing CDI regimen. MEASUREMENTS: The primary outcome was a composite of 30-day mortality and 60-day recurrence. MAIN RESULTS: The study included 54 oral vancomycin and 38 fidaxomicin recipients. The population was predominantly male (97.8%), and mean ± standard deviation age was 74.6 ± 11.1 years. The composite outcome was significantly different between fidaxomicin and vancomycin recipients (26.3% fidaxomicin vs. 51.9% vancomycin; odds ratio (OR): 0.33, 95% CI: 0.14-0.81, p = 0.01). This finding was maintained in the multivariate analysis after adjustment for confounders (adjusted OR: 0.25, 95% CI: 0.09-0.73, p = 0.01) CONCLUSIONS: This real-world effectiveness study suggests that use of fidaxomicin potentially results in better outcomes relative to oral vancomycin for initial treatment of hospitalized VAMC patients with CDIs.

Cs2TlBiI6: a new lead-free halide double perovskite with direct band gap.

The recent development of halide double perovskites A2B'B"X6 with favorable band gaps have provided a new search direction for stable Pb-free perovskite solar cells. Here, we propose a new lead free double perovskite Cs2TlBiI6 as a potential candidate for perovskite solar cell absorber. We probe the structural, electronic and optical properties of this material through density functional theory calculations. Our calculations on this material show that Cs2TlBiI6 adopt cubic double perovskite structure with space group Fm-3m. Using PBE exchange-correlation functional we obtain direct band gap of about 1.37 eV at the centre of Brillouin zone. The direct band gap and strong optical absorption of this material in the visible energy range of solar spectrum implies that Cs2TlBiI6 can be a potential candidate for perovskite based solar cell. Our fundamental calculations on this material would open up further possibility of experimental studies on TlBi based perovskite.

Psychotropic Treatment Pattern in Medicaid Pediatric Patients With Concomitant ADHD and ODD/CD.

OBJECTIVE: To describe psychotropic treatment pattern and evaluate the association of socio-demographic factors and psychotropic combination therapy in children with ADHD and oppositional defiant disorder/conduct disorder (ODD/CD). METHOD: This is a cross-sectional drug utilization study based on Medicaid fee-for-service programs in 26 U.S. states (1999-2006). Children aged 4 to 18 with concomitant ADHD and ODD/CD were included. We calculated the prevalence of psychotropic drugs and used logistic regression to evaluate the role of socio-demographic factors in psychotropic combination therapy. RESULTS: We identified 121,740 children with ADHD and ODD/CD (140,777 person-years). The period prevalence of "no psychotropic therapy," psychotropic monotherapy, and psychotropic dual therapy was 38.1%, 44.7%, and 9.0%, respectively. The most common drug class was stimulants. Whites, males, and children in foster care were more likely to use psychotropic combination therapy. State-level variation was observed. CONCLUSION: "No psychotropic therapy" and stimulants dominate treatment choices in children with ADHD and ODD/CD. Socio-demographic characteristics are associated with combination psychotropic therapy.

Plain Language Summary of the PAISLEY study: deucravacitinib as a treatment for people with systemic lupus erythematosus.

What is this summary about?This plain language summary describes the results of the phase 2 study called PAISLEY which tested deucravacitinib, a new medicine under investigation before approval, in people living with lupus. In this trial, researchers wanted to find out if deucravacitinib would be safe and reduce the symptoms and disease activity in people living with lupus. PAISLEY looked at the type of lupus known as systemic lupus erythematosus, shortened to SLE.What happened in the study?The study included 363 people from 17 countries who had SLE and were between 18 and 75 years of age. The participants were divided into 4 groups at random. One group was given placebo (a fake or dummy pill that contains no medicine) and the other 3 groups took deucravacitinib, a pill taken by mouth. Each of the groups taking deucravacitinib took a different dose, either 3 milligrams (mg) twice daily, 6 mg twice daily, or 12 mg once daily. After 32 and 48 weeks, researchers measured the number of people in each group who had improvements in their SLE symptoms and disease activity, as measured by different tests. They also looked at any side effects people experienced, which may or may not have been caused by the medicine.What do the results mean?After 32 weeks of treatment, SLE symptoms and disease activity improved in more people in each of the deucravacitinib dose groups compared with the people taking placebo (the dummy pill). After 48 weeks of treatment, SLE symptoms and disease activity were still improved in more people taking deucravacitinib compared with people taking placebo, and this was measured in several different ways. The best results were seen in people taking deucravacitinib 3 mg twice daily. The number of serious side effects was similar for people taking deucravacitinib and those taking placebo. The most common side effects that were seen in people taking deucravacitinib were infections such as sore throat, cough, or bronchitis (upper respiratory tract), infltion in the nose (nasopharyngitis), headaches, and urinary tract infections. More people taking deucravacitinib than placebo had acne, rash, and cold sores (oral herpes). These were not serious and did not have any long-term effects on patient health or lead to patients stopping treatment.How to say (double click sound icon to play sound)… Systemic lupus erythematosus: SIS-teh-MIC LOO-puhs Eh-RE-the-ma-TOE-susDeucravacitinib: doo-KRAV-a-sih-ti-nibEnzyme: EN-zimeInterferon: in-tur-FER-onPlacebo: pluh-SEE-bohTyrosine kinase: TY-ruh-seen KY-naysTYK2: TIK-tu.

Factors Affecting the Outcome of Stapes Surgery.

To study the outcome of stapes surgery based on the Clinical, Audiometry, and Surgical pre- and postoperative factors. This study is a prospective study of factors affecting the outcome of stapes surgery in otosclerosis patients. From February 2010 to June 2011, 57 patients of confirmed clinical otosclerosis were analysed. Out of them, 31 patients were included in our study as were available for follow-up. Clinical, audiometry and surgery-related parameters were included to assess the surgery outcome. Results were reported as suggested by AAO-HNS (American Association of Otolaryngology and Head and Neck Surgery) guidelines for stapes surgery, 1995. The paired t-test and analysis of variables test (ANOVA) were used to evaluate the results. A p value of <0.05 was considered significant. There was statistically significant improvement in ABG (air bone gap) closure at 3 months of surgery (p value <0.001). Among all cases, PTA BC (pure tone average bone conduction) at 3 months of surgery was found in the range of 7.5 dB to 43.75 dB. ABG closure was achieved in the range of 0 dB to 27.5 dB among all cases. Variables like gender, degree of hearing loss, type of footplate, sealing material, and piston diameter were definitely predicting the outcome of stapes surgery. Pure tone audiometry plays an important role to diagnose the otosclerosis, to evaluate degree and type of hearing loss and to assess hearing outcome after surgery. Our results may improve knowledge of predictive factors, providing the surgeon with useful information to plan surgery with a better case selection as well as to counsel the patient on the likelihood of success of the procedure.

Retinal de novo lipogenesis coordinates neurotrophic signaling to maintain vision.

Membrane lipid composition is central to the highly specialized functions of neurological tissues. In the retina, abnormal lipid metabolism causes severe forms of blindness, often through poorly understood neuronal cell death. Here, we demonstrate that deleting the de novo lipogenic enzyme fatty acid synthase (FAS) from the neural retina, but not the vascular retina, results in progressive neurodegeneration and blindness with a temporal pattern resembling rodent models of retinitis pigmentosa. Blindness was not rescued by protection from light-evoked activity; by eating a diet enriched in palmitate, the product of the FAS reaction; or by treatment with the PPARα agonist fenofibrate. Vision loss was due to aberrant synaptic structure, blunted responsiveness to glial-derived neurotrophic factor and ciliary neurotrophic factor, and eventual apoptotic cell loss. This progressive neurodegeneration was associated with decreased membrane cholesterol content, as well as loss of discrete n-3 polyunsaturated fatty acid- and saturated fatty acid-containing phospholipid species within specialized membrane microdomains. Neurotrophic signaling was restored by exogenous cholesterol delivery. These findings implicate de novo lipogenesis in neurotrophin-dependent cell survival by maintaining retinal membrane configuration and lipid composition, and they suggest that ongoing lipogenesis may be required to prevent cell death in many forms of retinopathy.

GoPro HERO 4 Black recording of scleral buckle placement during retinal detachment repair.

OBJECTIVE: GoPro and Google Glass technology have previously been used to record procedures in ophthalmology and other medical fields. In this manuscript, GoPro's latest HERO 4 Black edition camera (GoPro Inc, San Mateo, Calif.) will be used to record the placement of a scleral buckle during retinal detachment surgery. METHODS: GoPro HERO 4 Black edition camera, which records 4K-quality video with a resolution of 3840 (pixels) x 2160 (lines), was mounted on a head strap to record placement of a scleral buckle for a retinal detachment. RESULTS: Excellent video quality was achieved with the 4K SuperView setting. Bluetooth connection with an Apple iPad (Apple Inc, Cupertino, Calif.) provided live streaming and use of the GoPro App. Zoom, horizontal/vertical alignment, exposure, and contrast adjustments were made with postproduction editing on GoPro Studio software. CONCLUSIONS: Video recording with the GoPro HERO 4 Black edition camera is an excellent way to document extraocular procedures to improve medical education, self-training, or medicolegal documentation.

Management of Degenerative Retinoschisis-Associated Retinal Detachment.

PURPOSE: To review a population of degenerative retinoschisis (RS) patients, with attention to those with schisis cavity breaks and with retinal detachment complicating retinoschisis (RDRS), to identify management considerations and incidence for this rare clinical entity. DESIGN: Retrospective chart review of patients with RS and schisis cavity breaks over a 15-year period in a tertiary, multiple-physician vitreoretinal practice. SUBJECTS: A total of 587 cases of RS were confirmed on chart review, with 59 meeting inclusion criteria. METHODS: Included charts required documented RS with schisis cavity breaks, a minimum of 3 months of follow-up, detailed fundus drawings and notes, and filed operative report if surgical interventions were performed. Charts were excluded if the patient had undergone any previous history of laser, cryotherapy, or intraocular surgery (except for cataract surgery). MAIN OUTCOME MEASURES: Incidence of RS with schisis cavity breaks and RDRS, time to development of symptomatic RDRS, clinical characteristics predisposing development of progressive RDRS. RESULTS: Sixty-seven cases (11.4%) presented with schisis cavity breaks, but only 59 met inclusion. Initially, 35 of the 59 included cases (59%) were observed with stability in 54.3% at a mean follow-up of 40.2 months. Only 10 of the initially observed 35 eyes (28.6%) exhibited new-onset symptoms of retinal detachment, with a mean time to progression of 20.6 months. Posterior progression involving the major arcades or macula occurred in 86.7% of symptomatic eyes, as compared with 11.4% of asymptomatic eyes (P < 0.0001). Of the 15 eyes with symptomatic RDRS, 14 eyes underwent vitreoretinal surgery for RDRS, with a single-procedure success rate of 86%. CONCLUSIONS: RDRS requiring vitreoretinal surgical repair is a rare, symptomatic, and progressive condition occurring in 2.4% of 587 cases of RS over a 15-year period in a large, tertiary referral, vitreoretinal-only practice. In cases with RS and outer wall breaks, 54.3% were nonprogressive at 3 years of follow-up, but 28.6% progressed to symptomatic RDRS at a mean of 20.6 months. Surgery is not recommended in asymptomatic individuals except in rare situations based on clinical judgement regarding the observed behavior of the RS. The presence of symptoms should warrant treatment.

Accuracy of Point-of-care Lung Ultrasonography for Diagnosis of Acute Chest Syndrome in Pediatric Patients with Sickle Cell Disease and Fever.

OBJECTIVES: The objective was to determine the test performance characteristics for point-of-care lung ultrasonography (LUS) performed by pediatric emergency medicine (PEM) physicians compared with radiographic diagnosis of acute chest syndrome (ACS) in patients with sickle cell disease (SCD) and fever. METHODS: This was a prospective study of patients up to 21 years with SCD and fever requiring chest X-ray (CXR) evaluation for ACS. Before obtaining CXR, a blinded PEM physician performed LUS using a standardized scanning protocol. Positive LUS for ACS was defined as lung consolidation. All patients received CXR and follow-up. The criterion standard for ACS was consolidation on CXR as determined by a blinded radiologist. LUS clips were reviewed by a blinded expert PEM sonologist. RESULTS: A total of 116 febrile events from 91 patients with a median age of 5.7 years were enrolled by 15 PEM sonologists. CXR was positive for ACS in 15 (13%) patients, and LUS was positive for ACS in 19 (16%) patients. Positive LUS had a sensitivity of 87% (95% confidence interval [CI] = 62% to 96%), specificity of 94% (95% CI = 88% to 97%), positive likelihood ratio of 14.6 (95% CI = 6.5 to 32.5), and negative likelihood ratio of 0.14 (95% CI = 0.04 to 0.52) for ACS. The interobserver agreement (kappa) was 0.77. There were two missed cases of ACS on LUS. CONCLUSIONS: LUS may be sensitive and specific for diagnosis of ACS in pediatric patients with SCD and fever. LUS may reduce the need for routine CXR and associated ionizing radiation exposure in this population.

Pediatric emergency medicine point-of-care ultrasound: summary of the evidence.

The utility of point-of-care ultrasound is well supported by the medical literature. Consequently, pediatric emergency medicine providers have embraced this technology in everyday practice. Recently, the American Academy of Pediatrics published a policy statement endorsing the use of point-of-care ultrasound by pediatric emergency medicine providers.  To date, there is no standard guideline for the practice of point-of-care ultrasound for this specialty. This document serves as an initial step in the detailed "how to" and description of individual point-of-care ultrasound examinations.  Pediatric emergency medicine providers should refer to this paper as reference for published research, objectives for learners, and standardized reporting guidelines.

Magnetic properties of 2D nickel nanostrips: structure dependent magnetism and Stoner criterion.

We have investigated different geometries of two-dimensional (2D) infinite length Ni nanowires of increasing width using spin density functional theory calculations. Our simulations demonstrate that the parallelogram motif is the most stable and structures that incorporate the parallelogram motif are more stable as compared to rectangular structures. The wires are conducting and the conductance channels increase with increasing width. The wires have a non-linear behavior in the ballistic anisotropic magnetoresistance ratios (BAMR) with respect to the magnetization directions. All 2D nanowires as well as Ni (1 1 1) and Ni (1 0 0) monolayer investigated are ferromagnetic under the Stoner criterion and exhibit enhanced magnetic moments as compared to bulk Ni and the respective Ni monolayers. The easy axis for all nickel nanowires under investigation is observed to be along the wire axis. The double rectangular nanowire exhibits a magnetic anomaly with a smaller magnetic moment when compared to Ni (1 0 0) monolayer and is the only structure with an easy axis perpendicular to the wire axis. The Stoner parameter which has been known to be structure independent in bulk and surfaces is found to vary with the structure and the width of the nanowires. The less stable rectangular and rhombus shaped nanowires have a higher ferromagnetic strength than parallelogram shaped nanowires.

Prospective evaluation of point-of-care ultrasonography for the diagnosis of pneumonia in children and young adults.

OBJECTIVE: To determine the accuracy of point-of-care ultrasonography for the diagnosis of pneumonia in children and young adults by a group of clinicians. DESIGN: Prospective observational cohort study. SETTING: Two urban emergency departments. PARTICIPANTS: Patients from birth to age 21 years undergoing chest radiography for suspected community-acquired pneumonia. INTERVENTION: After documenting clinical examination findings, clinicians with 1 hour of focused training used ultrasonography to diagnose pneumonia in children and young adults. MAIN OUTCOMES MEASURES: Test performance characteristics for the ability of ultrasonography to diagnose pneumonia were determined using chest radiography as a reference standard. Subgroup analysis was performed in patients having lung consolidation exceeding 1 cm with sonographic air bronchograms detected on ultrasonography; specificity and positive likelihood ratio (LR) were calculated to account for lung consolidation of 1 cm or less with sonographic air bronchograms undetectable by chest radiography. RESULTS: Two hundred patients were studied (median age, 3 years; interquartile range, 1-8 years); 56.0% were male, and the prevalence of pneumonia by chest radiography was 18.0%. Ultrasonography had an overall sensitivity of 86% (95% CI, 71%-94%), specificity of 89% (95% CI, 83%-93%), positive LR of 7.8 (95% CI, 5.0-12.4), and negative LR of 0.2 (95% CI, 0.1-0.4) for diagnosing pneumonia by visualizing lung consolidation with sonographic air bronchograms. In subgroup analysis of 187 patients having lung consolidation exceeding 1 cm, ultrasonography had a sensitivity of 86% (95% CI, 71%-94%), specificity of 97% (95% CI, 93%-99%), positive LR of 28.2 (95% CI, 11.8-67.6) and negative LR of 0.1 (95% CI, 0.1-0.3) for diagnosing pneumonia. CONCLUSION: Clinicians are able to diagnose pneumonia in children and young adults using point-of-care ultrasonography, with high specificity.

Prospective application of clinician-performed lung ultrasonography during the 2009 H1N1 influenza A pandemic: distinguishing viral from bacterial pneumonia.

BACKGROUND: Emergency department visits quadrupled with the initial onset and surge during the 2009 H1N1 influenza pandemic in New York City from April to June 2009. This time period was unique in that >90% of the circulating virus was surveyed to be the novel 2009 H1N1 influenza A according to the New York City Department of Health. We describe our experience using lung ultrasound in a case series of patients with respiratory symptoms requiring chest X-ray during the initial onset and surge of the 2009 H1N1 influenza pandemic. METHODS: We describe a case series of patients from a prospective observational cohort study of lung ultrasound, enrolling patients requiring chest X-ray for suspected pneumonia that coincided with the onset and surge of the 2009 H1N1 influenza pandemic. RESULTS: Twenty pandemic 2009 H1N1 influenza patients requiring chest X-ray were enrolled during this time period. Median age was 6.7 years. Lung ultrasound via modified Bedside Lung Ultrasound in Emergency protocol assisted in the identification of viral pneumonia (n = 15; 75%), viral pneumonia with superimposed bacterial pneumonia (n = 7; 35%), isolated bacterial pneumonia only (n = 1; 5%), and no findings of viral or bacterial pneumonia (n = 4; 20%) in this cohort of patients. Based on 54 observations, interobserver agreement for distinguishing viral from bacterial pneumonia using lung ultrasound was ĸ = 0.82 (0.63 to 0.99). CONCLUSIONS: Lung ultrasound may be used to distinguish viral from bacterial pneumonia. Lung ultrasound may be useful during epidemics or pandemics of acute respiratory illnesses for rapid point-of-care triage and management of patients.