Notes

Left over skin lesions about chest-Xray after SARS-CoV-2 pneumonia: Recognition of risk factors.
Microanatomical organization of innate immune cells within lymph nodes (LNs) is critical for the generation of adaptive responses. In particular, steady-state LN-resident dendritic cells (Res cDCs) are strategically localized to intercept lymph-draining antigens. Whether myeloid cell organization changes during inflammation and how that might affect the generation of immune responses are unknown. Here, we report that during type I, but not type II, inflammation after adjuvant immunization or viral infection, antigen-presenting Res cDCs undergo CCR7-dependent intranodal repositioning from the LN periphery into the T cell zone (TZ) to elicit T cell priming. Concurrently, inflammatory monocytes infiltrate the LNs via local blood vessels, enter the TZ, and cooperate with Res cDCs by providing polarizing cytokines to optimize T cell effector differentiation. Monocyte infiltration is nonuniform across LNs, generating distinct microenvironments with varied local innate cell composition. These spatial microdomains are associated with divergent early T cell effector programming, indicating that innate microenvironments within LNs play a critical role in regulating the quality and heterogeneity of T cell responses. Together, our findings reveal that dynamic modulation of innate cell microenvironments during type I inflammation leads to optimized generation of adaptive immune responses to vaccines and infections.
To assess the characteristics of children hospitalized with complicated pneumonia at US children's hospitals and compare these characteristics with those of children hospitalized with community-acquired pneumonia (CAP).

We identified children hospitalized with complicated pneumonia (parapneumonic effusion, empyema, necrotizing pneumonia, or lung abscess) or CAP across 34 hospitals between 2011 and 2019. We evaluated differences in patient characteristics, antibiotic selection, and outcomes between children with complicated pneumonia and CAP. We, also, assessed seasonal variability in the frequency of these 2 conditions and evaluated the prevalence of complicated pneumonia over the 9-year study period.

Compared with children hospitalized with CAP (
= 75 702), children hospitalized with complicated pneumonia (
= 6402) were older (a median age of 6.1 vs 3.4 years;
< .001), with 59.4% and 35.2% of patients ≥5 years of age, respectively. Patients with complicated pneumonia had higher rates of antibiotic therapy targeted against methicillin-resistant
(46.3% vs 12.2%;
< .001) and
(8.6% vs 6.7%;
< .001), whereas differences in rates of coverage against mycoplasma were not clinically significant. Children with complicated pneumonia had a longer median hospital length of stay and higher rates of ICU admissions, mechanical ventilation, 30-day readmissions, and costs. Seasonal variation existed in both complicated pneumonia and CAP, with 42.7% and 46.0% of hospitalizations occurring during influenza season. The proportion of pneumonia hospitalizations due to complicated pneumonia increased over the study period (odds ratio 1.04, 95% confidence interval 1.02-1.06).

Complicated pneumonia more frequently occurs in older children and accounts for higher rates of resource use, compared to CAP.
Complicated pneumonia more frequently occurs in older children and accounts for higher rates of resource use, compared to CAP.
To determine if serum procalcitonin, an indicator of bacterial etiology in pneumonia in all ages and a predictor of severe pneumonia in adults, is associated with disease severity in children with community-acquired pneumonia.

We prospectively enrolled children 2 months to <18 years with clinical and radiographic pneumonia at 2 children's hospitals (2014-2019). Procalcitonin samples were obtained at presentation. An ordinal outcome scale of pneumonia severity was defined very severe (intubation, shock, or death), severe (intensive care admission without very severe features and/or high-flow nasal cannula), moderate (hospitalization without severe or very severe features), and mild (discharge). Hospital length of stay (LOS) was also examined. Ordinal logistic regression was used to model associations between procalcitonin and outcomes. We estimated adjusted odds ratios (aORs) for a variety of cut points of procalcitonin ranging from 0.25 to 3.5 ng/mL.

The study included 488 children with pneumonia; 30 (6%) were classified as very severe, 106 (22%) as severe, 327 (67%) as moderate, and 25 (5%) as mild. Median procalcitonin in the very severe group was 5.06 (interquartile range [IQR] 0.90-16.83), 0.38 (IQR 0.11-2.11) in the severe group, 0.29 (IQR 0.09-1.90) in the moderate group, and 0.21 (IQR 0.12-1.2) in the mild group. Increasing procalcitonin was associated with increasing severity (range of aORs 1.03-1.25) and increased LOS (range of aORs 1.04-1.36). All comparisons were statistically significant.

Higher procalcitonin was associated with increased severity and LOS. Procalcitonin may be useful in helping clinicians evaluate pneumonia severity.
Higher procalcitonin was associated with increased severity and LOS. Procalcitonin may be useful in helping clinicians evaluate pneumonia severity.When the ability to cough is impaired, secretion clearance may be assisted and augmented with mechanical insufflation-exsufflation (MI-E). In some individuals, the efficacy of MI-E may be hampered by counterproductive upper airway reactions, where the airways close in response to positive pressures. To fully utilize the therapeutic potential inherent in the MI-E technology, we need a better understanding of the pathophysiology behind these untoward reactions. There is increasing interest in monitoring and measuring upper airway responses to MI-E and how such information can be used to optimize MI-E settings. The purpose of this narrative review is to increase the theoretical understanding of the larynx as a respiratory organ, summarize the current literature in the area, and provide insight into how this knowledge can affect current clinical practice.Effective communication between members of the multidisciplinary team is imperative for patient safety. Within the Medicine for the Elderly wards at Royal Victoria Hospital (RVH) in Dundee, we identified an inefficient process of information-sharing between the orthopaedics outpatient department (OPD) at the main teaching hospital and our hospital's rehabilitation teams, and sought to improve this by introducing several changes to the work system. Our aim was for all patients who attended the OPD clinic to have a plan communicated to the RVH team within 24 hours.Before our intervention, clinic letters containing important instructions for ongoing rehabilitation were dictated by the OPD team, transcribed and uploaded to an electronic system before the RVH team could access them. We analysed clinic attendances over a 4-week period and found that it took 15 days on average for letters to be shared with the RVH teams. We worked with both teams to develop a clinical communication tool and new processes, aiming to expedite the sharing of key information. Patients attended the OPD with this form, the clinician completed it at the time of their appointment and the form returned with the patient to RVH on the same day.We completed multiple Plan-Do-Study-Act cycles; before our project was curtailed by the COVID-19 pandemic. During our study period, seven patients attended the OPD with a form, with all seven returning to RVH with a completed treatment plan documented by the OPD clinician. This allowed rehabilitation teams to have access to clinic instructions generated by orthopaedic surgeons almost immediately after a patient attended the clinic, essentially eliminating the delay in information-sharing.The introduction of a simple communication tool and processes to ensure reliable transfer of information can expedite information-sharing between secondary care teams and can potentially reduce delays in rehabilitation.
Electronic health record (EHR) clinical decision support (CDS) tools can provide evidence-based feedback at the point of care to reduce low-value imaging. Success of these tools has been limited partly due to lack of engagement by busy clinicians.

Measure the impact of a time-saving quality improvement intervention to increase engagement with a CDS tool for low back pain imaging ordering.

We conducted a quasi-experimental difference-in-differences analysis at (BLINDED), examining back pain imaging orders from 29 May 2015 to 07 January 2016. selleckchem The intervention site was (BLINDED) Emergency Medicine/Urgent Care Center (n=5736) and control sites included all other (BLINDED) hospitals and clinics (n=1621). In May 2015, the Department of Health Services installed a CDS tool that triggered a survey when clinicians ordered an imaging test, generating an 'appropriateness score' based on the American College of Radiology guidelines. Clinicians often bypassed the tool, resulting in 'unscored' tests.

To increase cllow time-saving interventions may increase physician engagement with CDS tools and have potential to improve practice patterns.Paediatric voice disorders in the normal paediatric population ranges from 6% to 20%. We outline the important features in the initial evaluation of a persistent altered cry or voice in children and highlight the subsequent management currently used by ear, nose and throat (ENT) surgeons and speech and language therapists (SLTs). It is important to appreciate that there are stark differences between a child and adult larynx due to anatomical and physiological changes during development. The voice history elicited from both child and parent includes birth and developmental history, hearing, early feeding and respiratory function. Red flag symptoms or signs presenting with dysphonia include stridor, dysphagia, failure to thrive and recurrent chest infections. The most likely cause for dysphonia in children presenting to general paediatric practice and primary care will be secondary to laryngitis, hyperfunction and vocal cord nodules, and laryngopharyngeal reflux. Regarding treatment, in most cases a non-surgical option is preferred with voice therapy preferably delivered by a specialist paediatric voice SLT. The maximum effectiveness of behavioural or direct therapy is to children over 7 years, for in excess of 8 weeks with additional rigorous home rehearsal.Rumination syndrome is a functional bowel disorder where stomach contents effortlessly regurgitate into the mouth. It is an entirely separate entity to gastro-oesophageal reflux disease and requires behavioural rather than pharmaceutical management. Symptoms usually respond well to treatment, though in extreme cases, patients may experience significant weight loss and require inpatient admission.Conservative care, a comprehensive treatment path for advanced kidney disease most suitable for individuals unlikely to benefit from dialysis, is underutilized in the United States. One reason is an absence of robust education about this approach and how to discuss it with potential candidates. To address this need, we developed a multimodal conservative care curriculum for nephrology fellows. This curriculum consists of four online modules that address essential concepts and communication skills related to conservative care. It is followed by an in-person, interactive, "flipped classroom" session facilitated by designated nephrology educators at participating Accreditation Council for Graduate Medical Education nephrology training programs. Curriculum effect was assessed using surveys completed by participating fellows immediately before and following the curriculum and for participating nephrology educators following flipped classroom teaching; 148 nephrology trainees from 19 programs participated, with 108 completing both pre- and postcurriculum surveys.
Website: https://www.selleckchem.com/