Publications by authors named "Emily Rose"

60 Publications

Pediatric Fever.

Authors:
Emily Rose

Emerg Med Clin North Am 2021 Aug 9;39(3):627-639. Epub 2021 Jun 9.

Department of Emergency Medicine, Los Angeles County + University of Southern California Medical Center, Keck School of Medicine of the University of Southern California, Old General Hospital, Room 1011, 1200 North State Street, Los Angeles, CA 90033, USA. Electronic address:

Pediatric fever is a common complaint in children. The most common cause is self-limited viral infection. However, neonates and young infants are evaluated and treated differently than older, vaccinated, and clinically evaluable children. Neonates should be admitted to the hospital, young infants in the second month of life may be risk stratified, and those deemed low risk on testing may be sent home with close follow-up. Children older than 2 months may be evaluated clinically for signs of bacterial infection that require intervention. Urinary tract infections cause more than 90% of serious bacterial illness in children, and younger children have a higher incidence of infection.
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http://dx.doi.org/10.1016/j.emc.2021.04.011DOI Listing
August 2021

ACR Appropriateness Criteria® Seizures-Child.

J Am Coll Radiol 2021 May;18(5S):S199-S211

Specialty Chair, Riley Hospital for Children Indiana University, Indianapolis, Indiana.

In children, seizures represent an extremely heterogeneous group of medical conditions ranging from benign cases, such as a simple febrile seizure, to life-threatening situations, such as status epilepticus. Underlying causes of seizures also represent a wide range of pathologies from idiopathic cases, usually genetic, to a variety of acute and chronic intracranial or systemic abnormalities. This document discusses appropriate utilization of neuroimaging tests in a child with seizures. The clinical scenarios in this document take into consideration different circumstances at the time of a child's presentation including the patient's age, precipitating event (if any), and clinical and electroencephalogram findings and include neonatal seizures, simple and complex febrile seizures, post-traumatic seizures, focal seizures, primary generalized seizures in a neurologically normal child, and generalized seizures in neurologically abnormal child. This practical approach aims to guide clinicians in clinical decision-making and to help identify efficient and appropriate imaging workup. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2021.02.020DOI Listing
May 2021

Somatic Mutations in UBA1 Define a Distinct Subset of Relapsing Polychondritis Patients with VEXAS Syndrome.

Arthritis Rheumatol 2021 Mar 28. Epub 2021 Mar 28.

Hematology Branch, National Heart, Lung, and Blood Institute, Bethesda, MD, USA.

Objective: Somatic mutations in ubiquitin activating enzyme 1 (UBA1) cause a newly defined syndrome known as VEXAS. More than fifty percent of patients currently identified with VEXAS meet diagnostic criteria for relapsing polychondritis (RP). Clinical features that characterize VEXAS within a cohort of RP have not been defined.

Methods: Exome and targeted sequencing of the UBA1 gene was performed in a prospective observational cohort of patients with RP. Clinical and immunological characteristics of patients with RP were compared based on presence or absence of UBA1 mutations. Random forest was used to derive a clinical algorithm to identify patients with UBA1 mutations.

Results: Seven out of 92 patients with RP (7.6%) had UBA1 mutations (VEXAS-RP). Patients with VEXAS-RP were male, ≥ 45 years at disease onset, and commonly had fever, ear chondritis, skin involvement, deep vein thrombosis, and pulmonary infiltrates. No patient with VEXAS-RP had chondritis of the airways or costochondritis. Mortality was greater in VEXAS-RP than RP (27% vs 2%, p=0.01). Elevated acute phase reactants and hematologic abnormalities (e.g. macrocytic anemia, thrombocytopenia, lymphopenia, multiple myeloma, myelodysplastic syndrome) were prevalent in VEXAS-RP. A decision tree algorithm based on male sex, MCV>100fL, and platelet count<200k/uL classified between VEXAS-RP and RP with 100% sensitivity and 96% specificity.

Conclusion: Mutations in UBA1 are causal for disease in a subset of patients with RP. These patients are defined by disease onset in the fifth decade of life or later, male sex, ear/nose chondritis and hematologic abnormalities. Early identification is important in VEXAS given the associated high mortality rate.
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http://dx.doi.org/10.1002/art.41743DOI Listing
March 2021

A Unique Case of Valacyclovir Toxicity and Pseudobulbar Affect in a Patient On Peritoneal Dialysis.

Cureus 2021 Feb 22;13(2):e13494. Epub 2021 Feb 22.

Internal Medicine/Nephrology, Virginia Commonwealth University, Richmond, USA.

There are a few cases of valacyclovir-associated neurotoxicity (VAN) reported. This case report documents a case of a 55-year-old male presenting with emotional lability or pseudobulbar affect as the predominant or sole manifestation of VAN. A failure to adjust valacyclovir's dose for herpes simplex infection in the setting of dialysis-dependent end-stage renal disease (ESRD) preceded VAN in this patient. The patient presented with involuntary and uncontrollable outbursts of emotion. Computerized tomography (CT) scan identified no underlying cause. A complete neurological examination with cognitive assessment was performed, with no abnormalities. He benefited from the use of aggressive peritoneal dialysis (PD) that was employed to enhance valacyclovir's clearance in this case of intractable VAN. On discharge, the patient was back to baseline mental function. Traumatic brain injury, neoplasm, vascular lesions, metabolic abnormality, neurological disease, herpetic encephalitis, and disorders of mood were ruled out. This led to the hypothesis of encephalopathy due to valacyclovir intoxication. Given that the clinical manifestations were related to ESRD, a dose-adjustment of valacyclovir is imperative in the setting of ESRD to prevent VAN. Our case presents important clinical variations. Firstly, our patient demonstrates that VAN may present with no focal neurological impairment, but pseudobulbar affect. Secondly, aggressive PD was useful in this case for the treatment of VAN as opposed to hemodialysis. We believe that it cleared valacyclovir resulting in the resolution of symptoms.
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http://dx.doi.org/10.7759/cureus.13494DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7990347PMC
February 2021

The population genomics of repeated freshwater colonizations by Gulf pipefish.

Mol Ecol 2021 04 6;30(7):1672-1687. Epub 2021 Mar 6.

Department of Biological Sciences, University of Idaho, Moscow, ID, USA.

How organisms adapt to the novel challenges imposed by the colonization of a new habitat has long been a central question in evolutionary biology. When multiple populations of the same species independently adapt to similar environmental challenges, the question becomes whether the populations have arrived at their adaptations through the same genetic mechanisms. In recent years, genetic techniques have been used to tackle these questions by investigating the genome-level changes underlying local adaptation. Here, we present a genomic analysis of colonization of freshwater habitats by a primarily marine fish, the Gulf pipefish (Syngnathus scovelli). We sample pipefish from four geographically distinct freshwater locations and use double-digest restriction site associated DNA sequencing to compare them to 12 previously studied saltwater populations. The two most geographically distant and isolated freshwater populations are the most genetically distinct, although demographic analysis suggests that these populations are experiencing ongoing migration with their saltwater neighbours. Additionally, outlier regions were found genome-wide, showing parallelism across ecotype pairs. We conclude that these multiple freshwater colonizations involve similar genomic regions, despite the large geographical distances and different underlying mechanisms. These similar patterns are probably facilitated by the interacting effects of intrinsic barriers, gene flow among populations and ecological selection in the Gulf pipefish.
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http://dx.doi.org/10.1111/mec.15841DOI Listing
April 2021

Physician Global Assessment as a Disease Activity Measure for Relapsing Polychondritis.

Arthritis Care Res (Hoboken) 2021 Feb 5. Epub 2021 Feb 5.

Systemic Autoimmunity Branch, National Institutes of Health, NIAMS, Bethesda, MD, USA.

Objective: Relapsing polychondritis (RP) is a systemic inflammatory disorder of cartilage that lacks validated disease activity measures. Physician global assessment (PhGA), a measure of disease activity commonly used in rheumatologic diseases, has not been tested in a cohort of patients with RP.

Methods: Adult patients in an observational cohort of RP underwent standardized, comprehensive evaluation at approximately 6-month intervals. PhGA was scored by three physicians from the evaluating institution on a scale of 0 to 10 for each visit. A random subset of twenty visits was scored by three, independent physicians not affiliated with the evaluating institution. Treatment change between consecutive visits was categorized as increased, decreased or unchanged.

Results: 78 patients were evaluated over 164 visits. The interclass correlation coefficient (ICC) (2, 1) for the three raters from the evaluating institution was excellent (0.79, 95% CI: 0.73-0.84) but was poor in the subset of cases scored by the additional raters (ICC (2,1) = 0.27, 95% CI: -0.01-0.53). Median PhGA was 3 (range 0-7). PhGA weakly correlated with CRP (r = 0.30, p< 0.01). In response to increased treatment, median PhGA decreased from 3 (IQR: 2-4) to 2 (IQR: 2-3) (p< 0.01) but rarely went to 0.

Conclusion: Within a single-center, PhGA can be used to quantify disease activity and monitor disease response in RP. Persistent disease activity despite treatment, rather than a relapsing-remitting pattern, is observed for most patients with RP. Reliability of PhGA may not generalize across different institutions. A validated disease-specific activity index is needed in RP.
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http://dx.doi.org/10.1002/acr.24574DOI Listing
February 2021

Optimizing the workforce: a proposal to improve regionalization of care and emergency preparedness by broader integration of pediatric emergency physicians certified by the American Board of Pediatrics.

J Am Coll Emerg Physicians Open 2020 Dec 8;1(6):1520-1526. Epub 2020 Jul 8.

Department of Emergency Medicine University of Oklahoma School of Community Medicine Tulsa Oklahoma USA.

Background: Emergency care in the United States faces notable challenges with regard to children. In some jurisdictions, available resources are not sufficient to meet local needs. Physicians with specialty training in pediatric emergency care are largely concentrated in children's medical centers within larger urban areas. Rural emergency facilities, which are more likely to face ongoing staffing shortages in all specialties, are particularly deficient in pediatric emergency medicine (PEM) physicians. This paper addresses challenges in distribution of pediatric emergency care specialists into suburban and rural health care facilities, and proposes potential local and regional solutions to improve pediatric emergency care capabilities as well as to enhance disaster response in children.

Objectives: The American College of Emergency Physicians (ACEP) committee on PEM generated the objective to study and explore methods and strategies to address current challenges and shortcomings in the distribution of pediatric emergency physicians and to develop recommendations to improve access to emergency pediatric expertise in all care settings. A sub-committee was formed to generate a written report followed by full committee input. The content was reviewed by the ACEP Board of Directors.

Discussion: Pediatric emergency physicians are certified either by the American Board of Emergency Medicine or the American Board of Pediatrics (ABP) depending on whether their training occurred through the emergency medicine or a pediatric residency program. ABP-certified PEM that account for the majority of PEM physicians, remain largely concentrated in urban tertiary pediatric care centers, primarily children's hospitals. By contrast to the resources, the majority of pediatric patients receive emergency care in emergency departments (EDs) outside this setting. The goal of our recommendations is to help regionalize PEM expertise, allowing sharing of such resources with facilities that have traditionally not had access to PEM expertise. Financial or low number of pediatric cases likely contributed to lack of PEM resources in suburban and rural EDs, although a significant factor for lack of access to ABP-certified PEM physicians may be local privilege and practice restrictions. Expanding the scope of practice for ABP-certified PEM physicians beyond traditionally assigned arbitrary age limits to include selective adult patients has the potential to alleviate credentialing barriers and offset the financial and volume concerns while enhancing preparedness efforts, resource utilization, and access to specialized pediatric emergency care.

Conclusion: Recognition that the training of ABP-certified PEM physicians allows for these individuals to safely care for selective adult patients with common disease patterns that extend beyond traditionally assigned arbitrary pediatric age limits has the potential to improve resource dissemination and utilization, allowing for greater access to pediatric emergency physicians in currently underserved settings.
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http://dx.doi.org/10.1002/emp2.12114DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7771807PMC
December 2020

Characterizing Ischaemic Tolerance in Rat Pheochromocytoma (PC12) Cells and Primary Rat Neurons.

Neuroscience 2021 01 24;453:17-31. Epub 2020 Nov 24.

School of Pharmacy and Bioengineering, Keele University, Staffordshire ST5 5BG, UK. Electronic address:

Preconditioning tissue with sublethal ischaemia or hypoxia can confer tolerance (protection) against subsequent ischaemic challenge. In vitro ischaemic preconditioning (IPC) is typically achieved through oxygen glucose deprivation (OGD), whereas hypoxic preconditioning (HPC) involves oxygen deprivation (OD) alone. Here, we report the effects of preconditioning of OGD, OD or glucose deprivation (GD) in ischaemic tolerance models with PC12 cells and primary rat neurons. PC12 cells preconditioned (4 h) with GD or OGD, but not OD, prior to reperfusion (24 h) then ischaemic challenge (OGD 6 h), showed greater mitochondrial activity, reduced cytotoxicity and decreased apoptosis, compared to sham preconditioned PC12 cells. Furthermore, 4 h preconditioning with reduced glucose (0.565 g/L, reduced from 4.5 g/L) conferred protective effects, but not for higher concentrations (1.125 or 2.25 g/L). Preconditioning (4 h) with OGD, but not OD or GD, induced stabilization of hypoxia inducible factor 1α (HIF1α) and upregulation of HIF1 downstream genes (Vegf, Glut1, Pfkfb3 and Ldha). In primary rat neurons, only OGD preconditioning (4 h) conferred neuroprotection. OGD preconditioning (4 h) induced stabilization of HIF1α and upregulation of HIF1 downstream genes (Vegf, Phd2 and Bnip3). In conclusion, OGD preconditioning (4 h) followed by 24 h reperfusion induced ischaemic tolerance (against OGD, 6 h) in both PC12 cells and primary rat neurons. The OGD preconditioning protection is associated with HIF1α stabilization and upregulation of HIF1 downstream gene expression. GD preconditioning (4 h) leads to protection in PC12 cells, but not in neurons. This GD preconditioning-induced protection was not associated with HIF1α stabilization.
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http://dx.doi.org/10.1016/j.neuroscience.2020.11.008DOI Listing
January 2021

Local and Topical Anesthetics for Pediatric Patients in the Emergency Department.

Pediatr Emerg Care 2020 Dec;36(12):593-601

Departments of Emergency Medicine and Pediatrics, University of Florida College of Medicine-Jacksonville, Jacksonville, FL.

Painful diagnostic and therapeutic procedures are common in the emergency department. Adequately treating pain, including the pain of procedures is an essential component of the practice of emergency medicine. Pain management is also part of the core competency for emergency medicine residencies and pediatric emergency medicine fellowships. There are many benefits to providing local and/or topical anesthesia before performing a medical procedure, including better patient and family satisfaction and increased procedural success rates. Local and topical anesthetics when used appropriately, generally, have few, if any, systemic side effects, such as hypotension or respiratory depression, which is an advantage over procedural sedation. Use of local and topical anesthetics can do much toward alleviating the pain and anxiety of pediatric patients undergoing procedures in the emergency department.
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http://dx.doi.org/10.1097/PEC.0000000000002285DOI Listing
December 2020

Clinical management of Lupus patients during the COVID-19 pandemic.

Lupus 2020 Nov 15;29(13):1661-1672. Epub 2020 Oct 15.

Rheumatology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK.

Severe acute respiratory syndrome coronavirus (SARS-CoV-2), the virus causing Coronavirus disease 2019 (COVID-19), has had a huge impact on health services with a high mortality associated with complications including pneumonia and acute respiratory distress syndrome. Historical evidence suggests that Lupus patients have a higher incidence of several viral infections. This is likely due to a combination of immune dysfunction, immunosuppressive therapy and excess co-morbidities. In this context there has been concern that Lupus patients may be at a higher risk of developing COVID-19 and suffering a severe disease course. As a result, many Lupus patients have been advised to 'shield' by isolating from social contact in the hope that this will reduce the likelihood of infection. Early clinical data does not appear to show that the incidence of COVID-19 is higher in Lupus patients. Reassuringly, the clinical course of COVID-19 in Lupus does not generally seem to be more severe than in the general population. There has been huge interest in repurposing existing drugs as potential treatments, including several used to treat Lupus. Of these, corticosteroids and hydroxychloroquine are the most well researched so far. The current evidence suggests that the corticosteroid dexamethasone improves outcome for the sickest COVID-19 patients requiring respiratory support. Initial reports suggested that hydroxychloroquine could have a positive impact on the course of COVID-19, however larger prospective studies have not supported this. Janus kinase inhibitors, currently being investigated for efficacy in lupus, have been shown to have anti-viral effects in vitro and inhibiting the JAK-STAT pathway may dampen down the host hyper-inflammatory response. Several trials are ongoing to assess the outcome of the use of JAK inhibitors in COVID-19 positive patients. For most patients continuing with their existing therapies to prevent a lupus flare or adverse events associated with sudden corticosteroid withdrawal is important whilst an Individualised risk assessment remains vital.
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http://dx.doi.org/10.1177/0961203320961848DOI Listing
November 2020

Paramedic Identification of Pediatric Seizures: A Prospective Cohort Study.

Prehosp Emerg Care 2020 Nov 11:1-7. Epub 2020 Nov 11.

Objective: Pediatric seizures commonly trigger emergency medical services (EMS) activation and account for approximately 5-15% of all pediatric 911-EMS calls. More than 50% of children with active seizure activity do not receive prehospital antiepileptic drugs, potentially because they are not recognized by EMS. The purpose of this study is to evaluate specificity and sensitivity of paramedic identification of pediatric seizures and to describe the characteristics of unrecognized seizures.

Methods: This is an 18-month prospective cohort study at a single, pediatric emergency department (ED). EMS patients ≤15 years old with a prehospital provider impression of seizure were included. Upon ED arrival, a data collection form, which included the EMS verbal report and patient's clinical status, was completed by the attending emergency physician. The primary outcome was sensitivity and specificity of paramedic identification of active seizure. Secondary outcomes included characteristics of missed seizures, ED interventions, and disposition. Descriptive statistics, sensitivity, and specificity were computed. Patient characteristics and clinical outcomes were compared.

Results: Surveys were completed for 349 patients (Median 3, IQR = 3.4). Fifty-two of the patients (15%) were actively seizing upon arrival at the ED. Sensitivity was 54% and specificity was 96% for paramedic identification of active seizure. Common features of missed cases were abnormal vital signs (75%), gaze deviation (50%) and clenched jaw (33%). Of these, 37% required intubation and 53% were admitted to the intensive care unit.

Conclusion: Paramedics were highly specific, but not sensitive in identifying active seizures on ED arrival. Patients with unrecognized seizures presented most commonly with abnormal vital signs and gaze deviation.
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http://dx.doi.org/10.1080/10903127.2020.1831667DOI Listing
November 2020

Paramedic Identification of Pediatric Seizures: A Prospective Cohort Study.

Prehosp Emerg Care 2020 Nov 11:1-7. Epub 2020 Nov 11.

Objective: Pediatric seizures commonly trigger emergency medical services (EMS) activation and account for approximately 5-15% of all pediatric 911-EMS calls. More than 50% of children with active seizure activity do not receive prehospital antiepileptic drugs, potentially because they are not recognized by EMS. The purpose of this study is to evaluate specificity and sensitivity of paramedic identification of pediatric seizures and to describe the characteristics of unrecognized seizures.

Methods: This is an 18-month prospective cohort study at a single, pediatric emergency department (ED). EMS patients ≤15 years old with a prehospital provider impression of seizure were included. Upon ED arrival, a data collection form, which included the EMS verbal report and patient's clinical status, was completed by the attending emergency physician. The primary outcome was sensitivity and specificity of paramedic identification of active seizure. Secondary outcomes included characteristics of missed seizures, ED interventions, and disposition. Descriptive statistics, sensitivity, and specificity were computed. Patient characteristics and clinical outcomes were compared.

Results: Surveys were completed for 349 patients (Median 3, IQR = 3.4). Fifty-two of the patients (15%) were actively seizing upon arrival at the ED. Sensitivity was 54% and specificity was 96% for paramedic identification of active seizure. Common features of missed cases were abnormal vital signs (75%), gaze deviation (50%) and clenched jaw (33%). Of these, 37% required intubation and 53% were admitted to the intensive care unit.

Conclusion: Paramedics were highly specific, but not sensitive in identifying active seizures on ED arrival. Patients with unrecognized seizures presented most commonly with abnormal vital signs and gaze deviation.
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http://dx.doi.org/10.1080/10903127.2020.1831667DOI Listing
November 2020

The Estrogen-Responsive Transcriptome of Female Secondary Sexual Traits in the Gulf Pipefish.

J Hered 2020 05;111(3):294-306

Department of Biological Sciences, University of Idaho, Moscow, ID.

Sexual dimorphism often results from hormonally regulated trait differences between the sexes. In sex-role-reversed vertebrates, females often have ornaments used in mating competition that are expected to be under hormonal control. Males of the sex-role-reversed Gulf pipefish (Syngnathus scovelli) develop female-typical traits when they are exposed to estrogens. We aimed to identify genes whose expression levels changed during the development and maintenance of female-specific ornaments. We performed RNA-sequencing on skin and muscle tissue in male Gulf pipefish with and without exposure to estrogen to investigate the transcriptome of the sexually dimorphic ornament of vertical iridescent bands found in females and estrogen-exposed males. We further compared differential gene expression patterns between males and females to generate a list of genes putatively involved in the female secondary sex traits of bands and body depth. A detailed analysis of estrogen-receptor binding sites demonstrates that estrogen-regulated genes tend to have nearby cis-regulatory elements. Our results identified a number of genes that differed between the sexes and confirmed that many of these were estrogen-responsive. These estrogen-regulated genes may be involved in the arrangement of chromatophores for color patterning, as well as in the growth of muscles to achieve the greater body depth typical of females in this species. In addition, anaerobic respiration and adipose tissue could be involved in the rigors of female courtship and mating competition. Overall, this study generates a number of interesting hypotheses regarding the genetic basis of a female ornament in a sex-role-reversed pipefish.
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http://dx.doi.org/10.1093/jhered/esaa008DOI Listing
May 2020

The cost of operating room delays in an endourology center.

Can Urol Assoc J 2020 Jul;14(7):E304-E308

Cleveland Clinic Glickman Urological and Kidney Institute, Cleveland, OH, United States.

Introduction: This study sought to characterize delays and estimate resulting costs during nephrolithiasis surgery.

Methods: Independent observers documented delays during ureteroscopy (URS) and percutaneous nephrolithotomy (PCNL) procedures. Fifty index cases over a period of three months was considered sufficient to observe the generalizable trends. Operating room staff, excluding the surgeons, were blinded. Time-related metrics and delays preventing case progression were recorded using a smartphone-accessible data-collection instrument. Delays were categorized as: 1) missing equipment; 2) missing personnel; 3) equipment malfunction; or 4) delay due to case complexity. The first two categories were regarded as preventable and the latter two non-preventable.

Results: Forty URS and 18 PCNL cases were included. There was a total of 56 delays in 35 (65%) cases. Twelve (67%) PCNLs and 23 (58%) URSs had delays (p=0.57). The mean cumulative delay per case was 3.5±3.2 minutes. Pre-start delays (n=17) were 4.5±3.5 minutes on average while intraoperative delays (n=39) were 3.1±2.9 minutes (p=0.167). Delays were evenly spread among the four categories. Thirty-one (55%) delays were preventable (mean 3.7±3.2 minutes) while 25 (45%) were non-preventable (mean 3.2±3.2 minutes) (p=0.58). This translates to $137 per case in preventable costs.

Conclusions: Preventable operative delays are encountered frequently in nephrolithiasis surgery, translating to significant additional charges and costs. We demonstrate a rationale for the development of improved communication and workflow protocols to increase efficiency in endourological surgeries. Key limitations are the observational nature of the study and sample size.
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http://dx.doi.org/10.5489/cuaj.6099DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7337710PMC
July 2020

Pediatric stroke: diagnosis and management in the emergency department.

Pediatr Emerg Med Pract 2019 Nov 2;16(11):1-20. Epub 2019 Nov 2.

Director for Pre-Health Undergraduate Studies, Director of the Minor in Health Care Studies, Keck School of Medicine of the University of Southern California; Associate Professor of Clinical Emergency Medicine (Educational Scholar), Department of Emergency Medicine, Los Angeles County + USC Medical Center, Los Angeles, CA.

Although pediatric stroke is rare, it is a leading cause of morbidity and mortality in children. The diagnosis of stroke is often delayed in children, which can contribute to death and disability. Management of pediatric stroke is challenging because there are few data to support the efficacy of interventions, and management is based on society guidelines and expert opinion, as well as extrapolation from adult stroke management. This issue reviews the most common causes of pediatric stroke, provides guidance for distinguishing stroke from stroke mimics, discusses the indications for laboratory studies and imaging modalities, and offers evidence-based recommendations for treatment.
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November 2019

Active Seizures in Children Are Often Subtle and Unrecognized by Prehospital Providers.

Pediatr Emerg Care 2019 Oct;35(10):e177-e180

From the Keck School of Medicine of the University of Southern California and, Department of Emergency Medicine, Los Angeles County + University of Southern California Medical Center, Los Angeles, CA.

Early recognition and treatment of seizures is essential for optimal patient outcomes. Seizure activity, particularly in young children, can be subtle and often go unrecognized by providers. This case series retrospectively identified 7 cases of pediatric patients (14 years and younger) who presented to the emergency department with active seizure activity that was unrecognized by the prehospital care providers. The presentation of these patients, their clinical signs of seizure, and emergency department disposition are highlighted in this series.
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http://dx.doi.org/10.1097/PEC.0000000000001941DOI Listing
October 2019

When more is not merrier: Using wild population dynamics to understand the effect of density on ex situ seahorse mating behaviors.

PLoS One 2019 2;14(7):e0218069. Epub 2019 Jul 2.

Biology Department, University of Tampa, Tampa, FL, United States of America.

Seahorses are considered one of the most iconic examples of a monogamous species in the animal kingdom. This study investigates the relationship between stocking density and mating and competitive behavior from the context of the field biology of the dwarf seahorse, Hippocampus zosterae (Jordan & Gilbert). Animals were housed in 38 liter tanks at a range of densities and sex ratios (from 2-8 animals per tank), and their reproductive and other social behaviors were monitored from tank introduction through copulation. At low tank densities and even sex ratios but comparatively high field densities, frequency of both mating and competitive behaviors was low in trials. A higher level of males in tanks across all densities increased competition, activity levels, and aggression leading to egg transfer errors and brood expulsion, resulting in lower reproductive success. Across seahorse species, mean and maximum wild densities were consistently lower than those used in ex situ breeding, with adult sex ratios that were significantly female biased. However, significant variation exists in wild seahorse densities across species, with higher densities detected in focal/mark recapture studies and on artificial habitat structures than reported with belt transect sampling techniques. Interchange of knowledge gained in both aquarium and wild contexts will allow us to better understand the biology of this genus, and improve reproduction in captivity. Interpreting ex situ reproductive behaviors of seahorses within various densities reported from natural populations will help us predict the impact of conservation efforts and increase the likelihood of long-term persistence of populations for this threatened genus.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0218069PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6605648PMC
February 2020

Endocrine regulation of MFS2 by branchless controls phosphate excretion and stone formation in Drosophila renal tubules.

Sci Rep 2019 06 19;9(1):8798. Epub 2019 Jun 19.

Section Endocrinology, Yale School of Medicine, New Haven, CT, USA.

How inorganic phosphate (Pi) homeostasis is regulated in Drosophila is currently unknown. We here identify MFS2 as a key Pi transporter in fly renal (Malpighian) tubules. Consistent with its role in Pi excretion, we found that dietary Pi induces MFS2 expression. This results in the formation of Malpighian calcium-Pi stones, while RNAi-mediated knockdown of MFS2 increases blood (hemolymph) Pi and decreases formation of Malpighian tubule stones in flies cultured on high Pi medium. Conversely, microinjection of adults with the phosphaturic human hormone fibroblast growth factor 23 (FGF23) induces tubule expression of MFS2 and decreases blood Pi. This action of FGF23 is blocked by genetic ablation of MFS2. Furthermore, genetic overexpression of the fly FGF branchless (bnl) in the tubules induces expression of MFS2 and increases Malpighian tubule stones suggesting that bnl is the endogenous phosphaturic hormone in adult flies. Finally, genetic ablation of MFS2 increased fly life span, suggesting that Malpighian tubule stones are a key element whereby high Pi diet reduces fly longevity previously reported by us. In conclusion, MFS2 mediates excretion of Pi in Drosophila, which is as in higher species under the hormonal control of FGF-signaling.
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http://dx.doi.org/10.1038/s41598-019-45269-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6584732PMC
June 2019

Financial Conflicts of Interest Among Emergency Medicine Contributors on Free Open Access Medical Education (FOAMed).

Acad Emerg Med 2019 07 17;26(7):814-817. Epub 2019 Jun 17.

Department of Emergency Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH.

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http://dx.doi.org/10.1111/acem.13676DOI Listing
July 2019

Simulation-Based Mock-Up Evaluation of a Universal Operating Room.

HERD 2020 01 16;13(1):68-80. Epub 2019 Jun 16.

Vancouver Coastal Health, Vancouver, British Columbia, Canada.

Designing or renovating a physical environment for healthcare is a complex process and is critical for both the staff and the patients who rely on the environment to support and facilitate patient care. Conducting a simulation-based mock-up evaluation as part of the design process can enhance patient safety, staff efficiency, as well as user experience, and can yield financial returns. A large urban tertiary care center located in Vancouver, Canada followed a framework to evaluate the proposed design template for 28 universal operating rooms (ORs) included within the OR Renewal Project scope. Simulation scenarios were enacted by nursing staff, surgeons, anesthesiologists, residents, radiology techs, and anesthesia assistants. Video and debriefing data were used to conduct link analyses, as well as analyses of observed behaviors including congestions and bumps to generate recommendations for evidence-based design changes that were presented to the project team. Recommendations incorporated into the design included relocating doors, booms, equipment, and supplies, as well as reconfigurations to workstations. These recommendations were also incorporated into the mock-up and retested to iteratively develop and evaluate the design. Findings suggest that incorporating the recommended design changes resulted in better room utilization, decreased congestion, and enhanced access to equipment.
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http://dx.doi.org/10.1177/1937586719855777DOI Listing
January 2020

Total hip arthroplasty in the setting of tuberculosis infection of the hip: a systematic analysis of the current evidence.

Expert Rev Med Devices 2019 05 22;16(5):363-371. Epub 2019 Apr 22.

a Department of Orthopaedic Surgery , Cleveland Clinic , Cleveland , OH , USA.

Introduction: Total hip arthroplasty (THA) is a viable option to restore mobility and relieve pain in patients with severe post-tuberculous arthritis, but has been controversial due to concerns of disease reactivation. Over the past several decades, a number of authors have reported outcomes of THA for tuberculosis (TB) infections. However, there is marked heterogeneity in regard to disease activity, surgical approaches, and the use of chemoprophylaxis in these studies.

Areas Covered: The purpose of this review was to critically assess: 1) patient characteristics; 2) perioperative planning; 3) clinical outcomes; 4) radiographic outcomes; and 5) complications of THA in the setting of tuberculosis of the hip.

Expert Opinion: THA is an effective treatment for post-TB hip arthritis. There has been controversy regarding its safety during the past several decades, as it has been thought to increase the risk of disease reactivation. While studies thus far have shown generally favorable results, they have been limited by small sample sizes and their design as retrospective case series. Comparison of these studies reveals marked heterogeneity in the clinical management of this complex disease. However, synthesis of their findings demonstrates favorable outcomes and low rates of complication, including disease reactivation particularly when perioperative anti-tuberculosis therapy is instituted.
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http://dx.doi.org/10.1080/17434440.2019.1606710DOI Listing
May 2019

Seasonal and spatial variation in the reproductive biology of the dwarf seahorse Hippocampus zosterae.

J Fish Biol 2019 Aug 30;95(2):357-366. Epub 2019 Apr 30.

Biology Department, The University of Tampa, Tampa, Florida, USA.

Factors associated with the reproductive ecology of the dwarf seahorse Hippocampus zosterae were investigated. Fish from a Tampa Bay (FL, USA) seagrass ecosystem were collected, photographed and returned to the wild, with photos analysed to determine patterns of body size, density, sex ratio and reproductive state across site and season to understand the population dynamics of H. zosterae over time. Animal density did not vary significantly with site and season, indicating there is little evidence of seasonal migration in this species. Densities reported in this study were higher than the mean density for all seahorse species Hippocampus spp. There was no sexual dimorphism in body length and both sexes reached sexual maturity at the same size. The ratio of gravid to non-gravid males was found to shift by season but not by site, with breeding detected year-round in this population compared with populations further north in their range. Peak breeding (70% gravid males) was observed in the late summer-autumn (August-October) in the site furthest from shore. The largest fish for both sexes were recorded during the summer and autumn months in the mid-shore, deepest site. Sex ratio shifted by site with even sex ratios near the shore but significantly female-biased sex ratios detected at sites near open water. Lastly, an increase in marking dates with decreased time intervals between collections did not yield a higher recapture rate, compared with sampling in 2010. However, the Tampa Bay population of dwarf seahorses demonstrated stable densities across 3 years with year-round breeding, indicating that it is a robust population worthy of long-term monitoring for conservation efforts.
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http://dx.doi.org/10.1111/jfb.13975DOI Listing
August 2019

Defining Dysbiosis in Patients with Urolithiasis.

Sci Rep 2019 04 1;9(1):5425. Epub 2019 Apr 1.

Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.

The prevalence of urinary stone disease (USD) is rapidly rising. However, the factors driving this increase are unknown. Recent microbiome studies suggest that dysbiosis may in part contribute to the increasing prevalence. The objective of the current study was to determine the nature and location of dysbiosis associated with USD. We conducted microbiome analysis from the gastrointestinal and urinary tracts, along with a metabolomic analysis of the urinary metabolome, from subjects with an active episode of USD or no history of the disease. Higher rates of antibiotic use among USD patients along with integrated microbiome and metabolomic results support the hypothesis that USD is associated with an antibiotic-driven shift in the microbiome from one that protects against USD to one that promotes the disease. Specifically, our study implicates urinary tract Lactobacillus and Enterobacteriaceae in protective and pathogenic roles for USD, respectively, which conventional, culture-based methods of bacterial analysis from urine and kidney stones would not necessarily detect. Results suggest that antibiotics produce a long-term shift in the microbiome that may increase the risk for USD, with the urinary tract microbiome holding more relevance for USD than the gut microbiome.
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http://dx.doi.org/10.1038/s41598-019-41977-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6443657PMC
April 2019

Endoscopic guided PCNL in the prone split-leg position versus supine PCNL: a comparative analysis stratified by Guy's stone score.

Can J Urol 2019 02;26(1):9664-9674

Section of Endourology, Division of Urology, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil.

Introduction: The optimal patient positioning for percutaneous nephrolithotomy (PCNL) based on the complexity of stone burden is not yet defined. Thus, we aimed to evaluate the intraoperative parameters, effectiveness and complications of patients undergoing PCNL between the endoscopic-guided prone split-leg PCNL (ePSL) and the supine PCNL by stratifying patients according to Guy's stone score (GSS).

Materials And Methods: A retrospective chart review was conducted of patients undergoing PCNL at two high-volume tertiary referral centers. At one center, patients underwent PCNL using the ePSL technique, while at the second center, patients underwent PCNL in supine. Patient demographics and stone characteristics, operative details, complications and effectiveness were compared between groups. The impact of obesity was also investigated.

Results: Of 830 subjects, a total of 449 (54%) underwent PCNL in ePSL and 381 (46%) in supine. The ePSL group had a greater mean age and body mass index. No statistical differences were found in gender, serum chemistry and Charlson comorbidity index. After stratifying patients by GSS, the differences in baseline stone burden between PSL and supine lost significance and both groups could be compared. Complications were not statistically different between both groups. Univariate analysis demonstrated that multiple tracts and lower pole access were more prevalent in supine. In addition, for GSS1-3, ePSL was correlated with reduced operative time, radiation exposure, length of hospital stay and need for secondary procedure. Multivariate analysis correlated ePSL with lower radiation exposure and need for secondary procedures (p = 0.01). In comparison to the whole trial population, the same tendencies were appreciated for obese cohort.

Conclusions: This is the first report focusing on the performance differences between ePSL and supine PCNL stratified by GSS. Both techniques are safe, with a low rate of complications. For GSS1-3, ePSL reduces radiation exposure and requires less need for both multiple access and secondary procedure.
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February 2019

Carotid Dissection and Cerebral Infarction From Posterior Oropharyngeal Trauma: The Diagnostic and Therapeutic Challenges.

Pediatr Emerg Care 2019 Jan;35(1):e17-e21

Loma Linda University Medical Center, Loma Linda, CA.

Posterior oropharyngeal trauma commonly occurs in children and frequently presents to the emergency department (ED). Rarely, serious infectious and neurologic sequelae result. Emergency providers are tasked with the challenge of diagnosing the minority with life-threatening complications while maintaining thoughtful stewardship regarding radiation exposure. A previously healthy 2-year-old girl sustained trauma to her posterior oropharynx with a toothbrush that resulted in a left carotid dissection. This dissection was diagnosed in the ED via computed tomography angiogram, Otolaryngology and neurosurgery were consulted in the ED, and anticoagulation therapy was initiated with aspirin. The child did initially well and was without neurologic deficit and no brain ischemia on magnetic resonance imaging. She was discharged home on aspirin therapy. Four days after initial injury, the child returned to the ED after a seizure. Computed tomography scan of the head demonstrated infarction at the junction of the left parietal and temporal areas. Although neurologic complications are rare, posterior oropharyngeal trauma in children is not. There are many diagnostic and therapeutic challenges in its management. This case is, to the authors' awareness, the first case report in the English literature of a known and treated carotid dissection in a child after posterior oropharyngeal trauma that resulted in stroke despite diagnosis and initiation of treatment. The diagnostic and therapeutic challenges of posterior oropharyngeal trauma in children are discussed in this article.
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http://dx.doi.org/10.1097/PEC.0000000000001708DOI Listing
January 2019

Total knee arthroplasty in the face of a previous tuberculosis infection of the knee: what do we know in 2018?

Expert Rev Med Devices 2018 10 28;15(10):717-724. Epub 2018 Sep 28.

a Department of Orthopaedic Surgery , Cleveland Clinic , Cleveland , OH , USA.

Introduction: TB of the knee is often associated with marked morbidity because of its late and non-specific presentation. The use of TKA (total knee arthroplasty) in the face of a previous tuberculous knee infection has been criticized with multiple controversies. Therefore, the purpose of this review is to assess: (1) clinical outcomes, (2) radiographic outcomes, and (3) complications of TKA in the face of a previous healed TB infection. Our analysis has demonstrated that previous TB infection of the knee joint does not preclude TKA if indicated and suggests placing patients who have ESR or CRP results out of normal range on pre-operative anti-TB prophylactic antibiotic for a minimum of 2 weeks. In case of local recurrence following TKA, antibiotic therapy alone can be an effective treatment option.

Areas Covered: We examined reported outcomes of performing TKA in patients with previous TB infection of the knee. Different strategies recommended by different authors to maximize the success of TKA in this situation are also discussed.

Expert Commentary: TKA has been proven to be effective in patients who are status post tuberculous arthritis when thoughtful patient selection and peri-operative planning is conducted. Tuberculosis continues to have a rising incidence and increasing spread of multi-drug resistant strains.
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http://dx.doi.org/10.1080/17434440.2018.1520633DOI Listing
October 2018

Evaluation and Management of Dehydration in Children.

Emerg Med Clin North Am 2018 May 10;36(2):259-273. Epub 2018 Feb 10.

Department of Emergency Medicine, Keck School of Medicine, University of Southern California, 1200 North State Street, GH Room 1011, Los Angeles, CA 90033, USA. Electronic address:

The article discusses the evaluation of dehydration in children and reviews the literature on physical findings of dehydration. Pediatric dehydration is a common problem in emergency departments and wide practice variation in treatment exists. Dehydration can be treated with oral, nasogastric, subcutaneous, or intravenous fluids. Although oral rehydration is underutilized in the United States, most children with dehydration can be successfully rehydrated via the oral route. Selection of oral rehydration solution and techniques for successful oral rehydration are presented. Appropriate selection and rate of administration of intravenous fluids are also discussed for isonatremic, hyponatremic, and hypernatremic dehydration.
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http://dx.doi.org/10.1016/j.emc.2017.12.004DOI Listing
May 2018

Flipping the Classroom in Medical Student Education: Does Priming Work?

West J Emerg Med 2018 Jan 5;19(1):93-100. Epub 2017 Dec 5.

Los Angeles County-University of Southern California Medical Center, Department of Emergency Medicine, Los Angeles, California.

Introduction: The emergency medicine (EM) clerkship curriculum at Los Angeles County + University of Southern California Medical Center includes monthly lectures on pediatric fever and shortness of breath (SOB). This educational innovation evaluated if learning could be enhanced by "priming" the students with educational online videos prior to an in-class session. Factors that impacted completion rates were also evaluated (planned specialty and time given for video viewing).

Methods: Twenty-minute videos were to be viewed prior to the didactic session. Students were assigned to either the fever or SOB group and received links to those respective videos. All participating students took a pre-test prior to viewing the online lectures. For analysis, test scores were placed into concordant groups (test results on fever questions in the group assigned the fever video and test results on SOB questions in the group assigned the SOB video) and discordant groups (crossover between video assigned and topic tested). Each subject contributed one set of concordant results and one set of discordant results. Descriptive statistics were performed with the Mann-Whitney U test. Lecture links were distributed to students two weeks prior to the in-class session for seven months and three days prior to the in-class session for eight months (in which both groups included both EM-bound and non-EM bound students).

Results: In the fifteen-month study period, 64% of students rotating through the EM elective prepared for the in class session by watching the videos. During ten months where exclusively EM-bound students were rotating (n=144), 71.5% of students viewed the lectures. In four months where students were not EM-bound (n=54), 55.6% of students viewed the lectures (p=0.033). Participation was 60.2% when lecture links were given three days in advance and 68.7% when links were given two weeks in advance (p=0.197). In the analysis of concordant scores, the pre-test averaged 56.7% correct, the immediate post-test averaged 78.1% correct, and the delayed post-test was 67.2%. In the discordant groups, the pretest averaged 51.9%, the immediate posttest was 67.1% and the delayed by 68.8%. In the concordant groups, the immediate post-test scores improved by 21.4%, compared with 15.2% in the discordant groups (p = 0.655). In the delayed post-test the concordant scores improved by 10.5% and discordant scores by 16.9 percent (p=0.609). Sixty-two percent of students surveyed preferred the format of online videos with in-class case discussion to a traditional lecture format.

Conclusion: Immediate post-tests and delayed post-tests improved but priming was not demonstrated to be a statistically superior educational method in this study. Medical student completion of the preparatory materials for the EM rotation session increased when the students were EM-bound. Participation rates were not significantly different when given at two weeks versus three days.
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http://dx.doi.org/10.5811/westjem.2017.8.35162DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5785208PMC
January 2018

Reply to Dr. Lameijer.

J Emerg Med 2017 12;53(6):917

Los Angeles, California.

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http://dx.doi.org/10.1016/j.jemermed.2017.08.025DOI Listing
December 2017

Academic Primer Series: Key Papers About Peer Review.

West J Emerg Med 2017 Jun 19;18(4):721-728. Epub 2017 Apr 19.

University of Washington School of Medicine, Department of Medicine, Division of Emergency Medicine, Seattle, Washington.

Introduction: Peer review, a cornerstone of academia, promotes rigor and relevance in scientific publishing. As educators are encouraged to adopt a more scholarly approach to medical education, peer review is becoming increasingly important. Junior educators both receive the reviews of their peers, and are also asked to participate as reviewers themselves. As such, it is imperative for junior clinician educators to be well-versed in the art of peer reviewing their colleagues' work. In this article, our goal was to identify and summarize key papers that may be helpful for faculty members interested in learning more about the peer-review process and how to improve their reviewing skills.

Methods: The online discussions of the 2016-17 Academic Life in Emergency Medicine (ALiEM) Faculty Incubator program included a robust discussion about peer review, which highlighted a number of papers on that topic. We sought to augment this list with further suggestions by guest experts and by an open call on Twitter for other important papers. Via this process, we created a list of 24 total papers on the topic of peer review. After gathering these papers, our authorship group engaged in a consensus-building process incorporating Delphi methods to identify the papers that best described peer review, and also highlighted important tips for new reviewers.

Results: We found and reviewed 24 papers. In our results section, we present our authorship group's top five most highly rated papers on the topic of peer review. We also summarize these papers with respect to their relevance to junior faculty members and to faculty developers.

Conclusion: We present five key papers on peer review that can be used for faculty development for novice writers and reviewers. These papers represent a mix of foundational and explanatory papers that may provide some basis from which junior faculty members might build upon as they both undergo the peer-review process and act as reviewers in turn.
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http://dx.doi.org/10.5811/westjem.2017.2.33430DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5468079PMC
June 2017
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