The safety of respiratory positive pressure support immediately following pediatric tonsillectomy.

INTRODUCTION: Adenotonsillectomy is the first-line treatment for pediatric obstructive sleep apnea (OSA). The postoperative course may be complicated by hypoxia, requiring intervention. Positive pressure respiratory support (PPS) could be used to bridge the postoperative period and avoid invasive mechanical ventilation; however, the safety of PPS following tonsillectomy has not been established. Objective To review the incidence of complications and risk factors associated with PPS use immediately after tonsillectomy. METHODS: A retrospective cohort study between 2015 and 2020 of patients who underwent tonsillectomy and were admitted to the pediatric intensive care unit at a single healthcare system. RESULTS: Seven hundred eighty patients met inclusion criteria, including 101 patients treated with PPS immediately following surgery. A similar number of patients were diagnosed with severe OSA in each group prior to surgery. One patient in the PPS cohort developed pneumomediastinum and pneumothorax. Eleven patients (12%) in the PPS group and 18 patients (2%) in the non-PPS group developed life-threatening complications, defined as pneumothorax/pneumomediastinum, re-intubation, post-tonsillectomy bleeding that required surgical intervention, pulmonary edema and death, and all occurred in patients who had not used PPS at baseline. Regression analysis identified body mass index, surgical technique, and PPS use to be associated with increased odds of life-threatening complications. CONCLUSION: Our study suggests that PPS is generally safe to use. New-onset PPS is associated with increased odds of life-threatening complications, likely reflecting a severe post-surgical clinical course.

Incidence and Risk Factors Associated with Respiratory Compromise in Planned PICU Admissions Following Tonsillectomy.

OBJECTIVES: Review the incidence and factors associated with respiratory compromise requiring intensive care unit level interventions in children with planned admission to the pediatric intensive care unit (PICU) following tonsillectomy or adenotonsillectomy (T/AT). STUDY DESIGN: Retrospective cohort study. METHODS: Review of all patients with PICU admissions following T/AT from 2015 to 2020 at a tertiary care pediatric hospital. Patient demographics, underlying comorbidities, operative data, and respiratory complications during PICU admission were extracted. RESULTS: Seven hundred and seventy-two patients were admitted to the PICU following T/AT, age 6.1 ± 4.6 years. All children were diagnosed with obstructive sleep apnea or sleep-disordered breathing (mean pre-operative apnea-hypopnea index 29 ± 26.5 and O2 nadir 77.1% ± 11.1). Neuromuscular disease, enteral feed dependence, and obesity were common findings (N = 240 (31%), N = 106 (14%), and N = 209 (27%) respectively). Overall, 29 patients (3.7%) developed respiratory compromise requiring PICU-level support, defined as new-onset continuous or bilevel positive airway pressure support (n = 25) or reintubation (n = 9). Three patients were diagnosed with pulmonary edema. Multivariable regression analysis demonstrated pre-operative oxygen nadir and enteral feed dependence were associated with respiratory compromise (OR = 0.97, 95% CI 0.94-0.99, P = .04; OR = 6.3, 95% CI 2.36-52.6, P = .001 respectively). CONCLUSIONS: Our study found respiratory compromise in 3.7% of patients with planned PICU admissions following T/AT. Oxygen nadir and enteral feeds were associated with higher respiratory compromise rates. Attention should be given to these factors in planning for post-operative disposition.

Does improved oleic acid content due to marker-assisted introgression of ahFAD2 mutant alleles in peanuts alter its mineral and vitamin composition?

Peanuts (Arachis hypogaea L.) with high oleic acid content have extended shelf life and several health benefits. Oleic, linoleic, and palmitic acid contents in peanuts are regulated by ahFAD2A and ahFAD2B mutant alleles. In the present study, ahFAD2A and ahFAD2B mutant alleles from SunOleic 95R were introgressed into two popular peanut cultivars, GG-7 and TKG19A, followed by markers-assisted selection (MAS) and backcrossing (MABC). A total of 22 MAS and three MABC derived lines were developed with increased oleic acid (78-80%) compared to those of GG 7 (40%) and TKG 19A (50%). Peanut kernel mineral and vitamin composition remained unchanged, while potassium content was altered in high oleic ingression lines. Two introgression lines, HOMS Nos. 37 and 113 had over 10% higher pooled pod yield than respective best check varieties. More than 70% recurrent parent genome recovery was observed in HOMS-37 and HOMS-113 through recombination breeding. However, the absence of recombination in the vicinity of the target locus resulted in its precise introgression along with ample background genome recovery. Selected introgression lines could be released for commercial cultivation based on potential pod yield and oleic acid content.

What Affects an Orthopaedic Surgeon's Online Rating? A Large-Scale, Retrospective Analysis.

INTRODUCTION: In the past decade, online physician review websites have become an important source of information for patients, with the largest and most popular being Healthgrades.com. Our study aims to investigate demographic and volume-based trends for online reviews of every Healthgrades-listed orthopaedic surgeon through a nationwide, retrospective analysis. METHODS: All available demographic and rating information for orthopaedic surgeons (n = 28,713; Healthgrades.com) was analyzed using one-way Analysis of Variance, Tukey Studentized Range (Honestly Significant Difference), linear regression, and Pearson correlation coefficient. RESULTS: The mean rating for all surgeons was 3.99 (SD 0.92), and the mean number of ratings was 13.43 (SD 20.4). Men had a greater mean rating at 4.02 compared with women at 3.91 (P < 0.0001), and DO surgeons had greater mean rating at 4.11 compared with MD surgeons at 3.90 (P < 0.0001). The correlation between rating and age had a significant negative correlation (P < 0.0001). The correlation between average online rating and number of reviews had a significant positive correlation (P < 0.0001). DISCUSSION: Our analysis suggests that greater online ratings are associated with the male sex and DO degrees. In addition, our study discovered that the number of ratings was positively correlated with greater mean online ratings, whereas older age was negatively correlated with greater mean online ratings.

Steady expression of high oleic acid in peanut bred by marker-assisted backcrossing for fatty acid desaturase mutant alleles and its effect on seed germination along with other seedling traits.

Peanut (Arachis hypogaea L.) is an important nutrient-rich food legume and valued for its good quality cooking oil. The fatty acid content is the major determinant of the quality of the edible oil. The oils containing higher monounsaturated fatty acid are preferred for improved shelf life and potential health benefits. Therefore, a high oleic/linoleic fatty acid ratio is the target trait in an advanced breeding program. The two mutant alleles, ahFAD2A (on linkage group a09) and ahFAD2B (on linkage group b09) control fatty acid composition for higher oleic/linoleic ratio in peanut. In the present study, marker-assisted backcrossing was employed for the introgression of two FAD2 mutant alleles from SunOleic95R into the chromosome of ICGV06100, a high oil content peanut breeding line. In the marker-assisted backcrossing-introgression lines, a 97% increase in oleic acid, and a 92% reduction in linoleic acid content was observed in comparison to the recurrent parent. Besides, the oleic/linoleic ratio was increased to 25 with respect to the recurrent parent, which was only 1.2. The most significant outcome was the stable expression of oil-content, oleic acid, linoleic acid, and palmitic acid in the marker-assisted backcrossing-introgression lines over the locations. No significant difference was observed between high oleic and normal oleic in peanuts for seedling traits except germination percentage. In addition, marker-assisted backcrossing-introgression lines exhibited higher yield and resistance to foliar fungal diseases, i.e., late leaf spot and rust.

The ill, jaundiced patient: a triple whammy and the importance of waiting for all results.

There are many causes of raised liver function tests in HIV infection. This lesson discusses a case where autoimmune hepatitis, acute hepatitis B and acute toxoplasmosis were diagnosed in a lady presenting with abdominal pain and jaundice. Oral steroids for autoimmune hepatitis may have worsened the clinical picture as her hepatitis serology was not available at the time. This lesson highlights the importance of waiting for all serology results to return in an ill jaundiced patient before deciding on active management and treatment

A delayed diagnosis: conflicting investigation results should be challenged.

We present a case where a diagnosis of advanced HIV led to many other diagnoses but more importantly life-threatening multivariant Castleman's disease which is rare and was successfully treated. This case highlights the importance of questioning and challenging investigations when it does not fit with the clinical picture. Multidisciplinary teams are crucial and always seek expert advice if unsure. The much-quoted adage of "many symptoms and signs will fit one diagnosis" also bodes well in this case.

Kikuchi-Fujimoto syndrome presenting to a sexual health clinic.

We report on a 37-year-old woman who presented with a six-week history of bilateral, tender lymph nodes in her groin. An initial biopsy was done with the histology 'suggestive of lymphogranuloma venereum (LGV)'. She had not had sexual intercourse for over two years and had no symptoms or signs of note to report. Examination revealed large, smooth tender lymph nodes above the inguinal ligament bilaterally with no other areas of lymphadenopathy. Due to a possible diagnosis of LGV, three weeks of doxycycline was given. A further review of the histology slides revealed 'subacute necrotizing lymphadenitis' highly suggestive of Kikuchi-Fujimoto syndrome of unknown cause, which is usually self-limiting. Subsequent follow-up of the patient revealed a reduction in the lymph nodes size with little tenderness.

Are women from high-risk ethnic minority groups more likely to decline antenatal HIV screening?

Eight new cases of human immunodeficiency virus (HIV) were diagnosed in the antenatal population of Milton Keynes within the first two years of our 'opt-out' antenatal testing scheme; the majority (6/8) occurred in women of black African origin. Since it is suggested that individuals from high-risk groups are more likely to decline HIV testing, we were concerned that women from this high-risk ethnic group might not be accepting testing. Such a situation would increase the risk of undiagnosed HIV-positive women delivering at Milton Keynes and undermine the potential benefits of the screening programme. Retrospective review of pregnant women delivering in our area over six months was performed. Hospital obstetric and microbiology databases were analysed for results of HIV screening and ethnic origin of patients. A total of 1586 women delivered during the study period. Among the black African women 13/158 (8.2%) declined screening, compared with 120/1214 (9.8%) and 15/153 (9.8%) of white and Asian women, respectively. The high uptake of testing across all groups suggests that the policy of offering and recommending HIV screening to all women is being appropriately implemented. Black African women were more likely to have undergone screening than white or Asian women, although the differences were not statistically significant.

Use of collagen injections for vesicoureteral reflux in transplanted kidneys.

Reports in the literature suggest the incidence of vesicoureteral reflux (VUR) in transplanted kidneys to range from 2-79%. Collagen injections have been used with reported success rates of up to 65% to prevent VUR into native orifices in children, but have not been studied in transplant neo-orifices. We evaluated the use of collagen injections in seven patients with transplant kidney neo-orifices who displayed grades II-IV VUR and seemed to be related to symptomatic urinary tract infections (UTIs). Postoperative VCUGs obtained at 2 months showed improvement in the grade of reflux in four of seven (57.1%) patients; one (14.3%), no change; and two (28.6%), worse reflux. All patients also redeveloped symptomatic UTIs after collagen injection. We conclude that the use of collagen injections in kidney transplant neo-orifices did not prevent VUR. Although prevention of VUR may have been achieved short term, VCUG examinations 2 months after initial injection revealed persistent reflux. Etiologies for failure to prevent VUR may be the readily absorbable nature of collagen, technical aspects of the procedure, the degree of reflux, and anatomic differences between native orifices (which lie on a well-supported trigone) and transplant neo-orifices (which lie on the posterior wall with less support).

Immunotherapy with nondepleting anti-CD4 monoclonal antibodies but not CD28 antagonists protects islet graft in spontaneously diabetic nod mice from autoimmune destruction and allogeneic and xenogeneic graft rejection.

BACKGROUND: T-cell activation and the subsequent induction of effector functions require not only the recognition of antigen peptides bound to MHC molecules by T-cell receptor (TCR) for antigen but also a costimulatory signal provided by antigen presenting cells. CD4 T-cell activation and function require the CD4 molecule as a coreceptor of TCR. The CD28/B7 pathway is a major costimulatory signal for T-cell activation and differentiation. METHODS: The effect of targeting CD4 by nondepleting anti-CD4 monoclonal antibodies (mAbs) versus blocking CD28/B7 by CTLA4Ig, anti-CD80 mAbs, and anti-CD86 mAbs on the prevention of recurrence of autoimmune diabetes after MHC-matched nonobese diabetes-resistant (NOR) islet transplantation in nonobese diabetic (NOD) mice were compared. Whether nondepleting anti-CD4 mAbs prolong allogeneic islet graft survival and xenogeneic pig islet graft survival in diabetic NOD mice were studied. Furthermore, the effect of nondepleting anti-CD4 mAbs combined with CTLA4Ig on allogeneic islet graft survival in NOD mice was investigated. RESULTS: Recurrence of autoimmune diabetes can be prevented by nondepleting anti-CD4 mAbs. Blocking the CD28/B7 costimulatory pathway by CTLA4Ig or by anti-CD80 mAbs and anti-CD86 mAbs cannot prevent recurrence of autoimmune diabetes after islet transplantation. Short-term treatment with nondepleting anti-CD4 mAbs significantly prolongs allogeneic islet graft survival and xenogeneic pig islet graft survival in diabetic NOD mice. But nondepleting anti-CD4 mAbs combined with CTLA4Ig decreased allogeneic islet graft survival. CONCLUSIONS: Nondepleting anti-CD4 mAbs but not CD28 antagonists protect islet grafts in diabetic NOD mice from autoimmune destruction and allogeneic and xenogeneic graft rejection. The efficacy of nondepleting anti-CD4 mAbs is compromised when it combines with CTLA4Ig.

Efficient gene transfer and expression in islets by an adenoviral vector that lacks all viral genes.

Although adenoviral vector-mediated gene transfer has significant potential for gene therapy, host immune responses to virally expressed proteins and small insert capacity may limit its clinical application. In order to overcome these disadvantages, a new adenoviral vector that lacks all viral genes has been developed. Using the green fluorescent (GFP) gene as a reporter gene, we investigated the efficiency of gene transfer by this all-viral-genes-deleted and minimal cis-element remaining adenoviral vector (miniAd-GFP) in islets in vitro and ex vivo, and compared it with the E1-deleted adenoviral vector (E1-GFP). One day after in vitro infection, GFP was expressed in both miniAd-GFP- and E1-GFP-infected islets. The percentage of GFP-positive single cells was not significantly different between miniAd-GFP-infected islets and E1-GFP-infected islets. When these islets were transplanted into syngeneic diabetic mice, both miniAd-GFP- and E1-GFP-infected islet grafts reversed diabetes, and normal blood glucose levels were maintained for over 20 weeks posttransplantation. Mild lymphocyte infiltration was found in all E1-GFP-infected islet grafts at all time points. However, this was not seen in most miniAd-GFP-infected islet grafts. Our results indicate that gene transfer by an adenoviral vector that lacks all viral genes is as efficient as E1-deleted adenoviral vector-mediated gene transfer in islets. Furthermore, this adenoviral vector might be less immunogeneic than the E1-deleted adenoviral vector.

Hopfield network with constraint parameter adaptation for overlapped shape recognition.

In this paper, we propose an energy formulation for homomorphic graph matching by the Hopfield network and a Lyapunov indirect method-based learning approach to adaptively learn the constraint parameter in the energy function. The adaptation scheme eliminates the need to specify the constraint parameter empirically and generates valid and better quality mappings than the analog Hopfield network with a fixed constraint parameter. The proposed Hopfield network with constraint parameter adaptation is applied to match silhouette images of keys and results are presented.

Histological characterization and pharmacological control of chronic rejection in xenogeneic and allogeneic heart transplantation.

BACKGROUND: Chronic allograft rejection remains a major barrier to successful long-term allograft transplantation in humans. Chronic allograft rejection is characterized by the appearance of arterial lesions with concentric intimal thickening. This study investigates the development and control of chronic rejection in hamster cardiac xenografts transplanted into Lewis rats. METHODS: Chronic rejection in the xenograft model involves transplantation of hamster hearts into Lewis rats treated with leflunomide (Lef) continuously at 15 mg/kg/day. The allograft model involves transplantation of Lewis hearts into Fisher-334 rats treated with cyclosporine (CsA) at 2.5 mg/kg for 5 days. RESULTS: The average scores of arterial intimal thickening on day 45 after transplantation were 1.89+/-0.43 in the xenograft and 2.50+/-0.72 in the allograft. The basic pathology of both xenografts and allografts undergoing chronic rejection was arterial intimal thickening comprising smooth muscle cell proliferation, mononuclear cell infiltration, and fibrosis. The majority of cells infiltrating the arterial intima and myocardium were T cells and macrophages. Compared with the allograft, intimal edema, matrix deposition and fibrinoid necrosis were specifically presented in the xenografts and generally involved the larger arteries. The predominant isotype of antibody deposited was IgM in xenografts and IgG in allografts. When combined Lef and CsA therapy was initiated on day 45 after transplantation, the changes of chronic rejection were reversed in both xenografts and allografts by day 90. The scores of intimal thickening were significantly reduced to 0.97+/-0.45 and 1.48+/-0.56, respectively. CONCLUSIONS: We conclude that chronic rejection can be induced in xenografts under conditions of inadequate immunosuppression. Chronic rejection in xenografts involves arterial lesions that bear some histological similarities to, as well as differences from, those observed in chronically rejected allografts. Finally, combination therapy with CsA and Lef reduced the incidence and severity of the intimal lesions in both chronically rejecting xenografts and allografts.