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The evidence supporting the efficacy of antibiotic therapy in the treatment of chronic rhinosinusitis is not compelling. A limited number of studies show that the changes in the nasal microbiome in patients following drug therapy are unpredictable and variable. The evidence for the impact of oral antibiotics on the gut microbiota is stronger, possibly as a result of differences in drug distribution to various sites around the body. There are few studies on sinus mucosal and mucus levels of oral antibiotics used in the treatment of chronic rhinosinusitis. The distribution dependent effects of antibiotics on the sinonasal microbiome is unclear.
This review highlights that relative drug concentrations and their efficacy on microbiota at different sites is an important subject for future studies investigating chronic rhinosinusitis.
Disaster Medicine (DM) education for Emergency Medicine (EM) residents is highly variable due to time constraints, competing priorities, and program expertise. The investigators’ aim was to define and prioritize DM core competencies for EM residency programs through consensus opinion of experts and EM professional organization representatives.
Investigators utilized a modified Delphi methodology to generate a recommended, prioritized core curriculum of 40 DM educational topics for EM residencies.
The DM topics recommended and outlined for inclusion in EM residency training included: patient triage in disasters, surge capacity, introduction to disaster nomenclature, blast injuries, hospital disaster mitigation, preparedness, planning and response, hospital response to chemical mass-casualty incident (MCI), decontamination indications and issues, trauma MCI, disaster exercises and training, biological agents, personal protective equipment, and hospital response to radiation MCI.
This expert-consensus-driven, prioritized ranking of DM topics may serve as the core curriculum for US EM residency programs.
Public awareness of ‘red flag’ symptoms for head and neck cancer is low. There is a lack of evidence regarding patient concerns and expectations in consultations for cancer assessment.
This prospective questionnaire study examined the symptoms, concerns and expectations of 250 consecutive patients attending an ‘urgent suspicion of cancer’ clinic at a tertiary referral centre.
The patients’ most frequent responses regarding their concerns were ‘no concerns’ (n = 72, 29 per cent); ‘all symptoms’ were a cause for concern (n = 65, 26 per cent) and ‘neck lump’ was a symptom causing concern (n = 37, 17 per cent). The expectations of patients attending clinic were that they would find out what was wrong with them, followed by having no expectations at all. Overall patient knowledge of red flag symptoms was lacking and their expectations were low.
Patients with non-cancer symptoms are frequently referred with suspected cancer. Patients with red flag symptoms are not aware of their significance and they have low expectations of healthcare.
Altica is a rare first-farming village site in the Basin of Mexico that has survived to modern times. Thus, it provides a glimpse into life during the Early–Middle Formative period. While valuable archaeological information on the village was recovered in excavation, only four burials comprising four individuals were recovered, a very small sample. Two individuals are older-aged females; the third, a middle-aged male, was accompanied by prestigious nonperishable goods and indicates that there are status differences even at this early date. The final individual was a young male buried in a deviant manner, suggesting possible foul play. While all individuals have indicators of periods of poor health, stable isotopes of carbon and nitrogen paint a more complete picture of the types of foods these individuals consumed over their lifetime. Radiogenic strontium isotopes of tooth enamel identify one individual, the young male buried in a deviant manner, as non-native to the Altica region. Thus, there is mystery in the manner of death, but even in this small sample, the wider connections Altica had that are so evident in the artefactual analysis are found in the skeletons. In addition, accelerator mass spectrometry radiocarbon dating provides a chronology of occupation through the people.
Burning postharvest sugarcane residue is a standard practice to remove extraneous leaf material before spring regrowth. Live-fires were simulated from field-collected postharvest sugarcane residue and seeds of divine nightshade and itchgrass were exposed to dry and moistened postharvest residue (PHR) at four densities (6.1, 12.1, 18.2, and 24.2 Mg ha−1) and a nonburned control. The moisture content of residue exposed to simulated rainfall was 14% more in Experiment 2 than Experiment 1; however, burning PHR with 44% moisture when wind speeds were lower allowed the fire to continue and created a smoldering effect that reduced weed emergence by 23% when compared with burning PHR with 30% moisture during breezy conditions. The moistened 6.1 Mg ha−1 PHR treatment resulted in 53% more divine nightshade and itchgrass emergence when compared with dry 6.1 Mg ha−1 PHR after burning, and greater emergence was attributed to more seed survival for divine nightshade than itchgrass. The PHR moisture condition failed to influence the burn duration; however, the burn duration increased 103% and 56% as the amount of PHR increased from 6.1 to 12.1 Mg ha−1 and 12.1 to 18.2 Mg ha−1, respectively. The combination of high wind speeds and moistened PHR did not enhance the maximum burn temperature near the soil surface, but surface-deposited divine nightshade and itchgrass seeds were susceptible to prolonged exposure times at 100 C. Burning PHR from fields with poor stands or older ratoon, especially when PHR is abundantly wet, will not produce temperatures lethal to divine nightshade and itchgrass seeds. The fluid-filled and fleshy content that comprises divine nightshade fruit protected seed from short durations of high temperatures, but may not insulate seeds long enough when exposed to a smoldering fire.
Objective: Multiple concussions sustained in youth sport may be associated with later-life brain changes and worse cognitive outcomes. We examined the association between two or more concussions during high school football and later-life white matter (WM) microstructure (i.e., 22–47 years following football retirement) using diffusion tensor imaging (DTI). Method: Forty former high school football players aged 40–65 who received 2+ concussions during high school football (N = 20), or denied concussive events (N = 20) were recruited. Participants underwent neurocognitive testing and DTI scanning. Results: Groups did not statistically differ on age, education, or estimated pre-morbid intelligence. Tract-based Spatial Statistics (TBSS) correcting for Family-Wise Error (FWE)(p < .05) did not yield differences between groups at the whole-brain level. Region of interest analyses showed higher mean diffusivity (MD) in the anterior limb of the internal capsule (ALIC) in the concussed group compared to the non-concussed former players. More liberal analyses (i.e., p < .001, uncorrected for multiple comparisons, ≥8 voxels) also revealed that former players endorsing 2+ concussions had higher MD in the ALIC. Analyses that covaried for age did not reveal differences at either threshold. Concussive histories were not associated with worse cognitive functioning, nor did it impact the relationship between neuropsychological scores and DTI metrics. Discussion: Results suggest only minimal neuroanatomical brain differences in former athletes many years following original concussive injuries compared to controls.
Changes in glacier length and extent are indicators of contemporary and archives of past climate changes, but this common climate proxy presents a challenge for inferring a climate signal. Modeling studies suggest that length fluctuations can occur due to interannual climate variability within an unchanging mean climate and that changes in interannual climate variability can also drive changes in average length. This paper quantifies the impacts of interannual climate variability on average glacier length and mass balance, using a flowline model coupled to a simplified mass-balance model. Results illustrate that changes in the magnitude of interannual temperature variability can non-linearly affect the mean glacier length through a mass-balance asymmetry between warm and cold years. This asymmetry is present in models where melt only initiates after a temperature threshold is crossed. Glaciers susceptible to this asymmetry can be identified based on the shape of their mass-balance profiles. The presence of mass-balance asymmetries in glaciological databases is evaluated, but current records are too short for high statistical resolving power. While the asymmetry in this study can affect the average length and mass-balance, its impacts are small, and paleoclimate interpretations from glacier-length changes are likely not notably influenced by this process.
Lipid-based nutrient supplements (LNS) may be beneficial for malnourished HIV-infected patients starting antiretroviral therapy (ART). We assessed the effect of adding vitamins and minerals to LNS on body composition and handgrip strength during ART initiation. ART-eligible HIV-infected patients with BMI <18·5 kg/m2 were randomised to LNS or LNS with added high-dose vitamins and minerals (LNS-VM) from referral for ART to 6 weeks post-ART and followed up until 12 weeks. Body composition by bioelectrical impedance analysis (BIA), deuterium (2H) diluted water (D2O) and air displacement plethysmography (ADP), and handgrip strength were determined at baseline and at 6 and 12 weeks post-ART, and effects of LNS-VM v. LNS at 6 and 12 weeks investigated. BIA data were available for 1461, D2O data for 479, ADP data for 498 and handgrip strength data for 1752 patients. Fat mass tended to be lower, and fat-free mass correspondingly higher, by BIA than by ADP or D2O. At 6 weeks post-ART, LNS-VM led to a higher regain of BIA-assessed fat mass (0·4 (95 % CI 0·05, 0·8) kg), but not fat-free mass, and a borderline significant increase in handgrip strength (0·72 (95 % CI −0·03, 1·5) kg). These effects were not sustained at 12 weeks. Similar effects as for BIA were seen using ADP or D2O but no differences reached statistical significance. In conclusion, LNS-VM led to a higher regain of fat mass at 6 weeks and to a borderline significant beneficial effect on handgrip strength. Further research is needed to determine appropriate timing and supplement composition to optimise nutritional interventions in malnourished HIV patients.
Epistaxis is the most common ENT emergency. This study aimed to assess one-year mortality rates in patients admitted to a large teaching hospital.
This study was a retrospective case note analysis of all patients admitted to the Queen Elizabeth University Hospital in Glasgow with epistaxis over a 12-month period.
The one-year overall mortality for a patient admitted with epistaxis was 9.8 per cent. The patients who died were older (mean age 77.2 vs 68.8 years; p = 0.002), had a higher Cumulative Illness Rating Scale-Geriatric score (9.9 vs 6.7; p < 0.001) and had a higher performance status score (2 or higher vs less than 2; p < 0.001). Other risk factors were a low admission haemoglobin level (less than 128 g/dl vs 128 g/dl or higher; p = 0.025), abnormal coagulation (p = 0.004), low albumin (less than 36 g/l vs more than 36 g/l; p < 0.001) and longer length of stay (p = 0.046).
There are a number of risk factors associated with increased mortality after admission with epistaxis. This information could help with risk stratification of patients at admission and enable the appropriate patient support to be arranged.
Determining infectious cross-transmission events in healthcare settings involves manual surveillance of case clusters by infection control personnel, followed by strain typing of clinical/environmental isolates suspected in said clusters. Recent advances in genomic sequencing and cloud computing now allow for the rapid molecular typing of infecting isolates.
To facilitate rapid recognition of transmission clusters, we aimed to assess infection control surveillance using whole-genome sequencing (WGS) of microbial pathogens to identify cross-transmission events for epidemiologic review.
Clinical isolates of Staphylococcus aureus, Enterococcus faecium, Pseudomonas aeruginosa, and Klebsiella pneumoniae were obtained prospectively at an academic medical center, from September 1, 2016, to September 30, 2017. Isolate genomes were sequenced, followed by single-nucleotide variant analysis; a cloud-computing platform was used for whole-genome sequence analysis and cluster identification.
Most strains of the 4 studied pathogens were unrelated, and 34 potential transmission clusters were present. The characteristics of the potential clusters were complex and likely not identifiable by traditional surveillance alone. Notably, only 1 cluster had been suspected by routine manual surveillance.
Our work supports the assertion that integration of genomic and clinical epidemiologic data can augment infection control surveillance for both the identification of cross-transmission events and the inclusion of missed and exclusion of misidentified outbreaks (ie, false alarms). The integration of clinical data is essential to prioritize suspect clusters for investigation, and for existing infections, a timely review of both the clinical and WGS results can hold promise to reduce HAIs. A richer understanding of cross-transmission events within healthcare settings will require the expansion of current surveillance approaches.
Skeletal remains from Tlajinga 33 (33:S3W1) have been the focus of research in the southern sector of Teotihuacan since excavations took place in the 1980s. Recent excavations in Tlajinga Compounds 17 and 18 (17:S3E1 and 18:S3E1, respectively), located along the southern Street of the Dead, recovered nine additional skeletons. This article is a description of the burials from Compounds 17 and 18 and a comparative analysis of health, diet, and chronology across all three compounds (Compounds 17, 18, and 33). Here, we test the hypothesis that individuals between residential compounds at Tlajinga lived similar lives and that health and biogeochemical markers of individuals will reflect these similarities. Although the sample size is small, the paleopathological analysis of individuals at Compounds 17 and 18 indicates morbidity patterns similar to Tlajinga 33, but also that these residents were perhaps less susceptible to stressors during periods of juvenile growth. Stable carbon and nitrogen isotopes suggest that, overall, diets were analogous across compounds, but Compounds 17 and 18 were able to supplement their diet with a greater variety of plant resources. There were no clear dietary differences between higher and lower status individuals, however. Finally, accelerated mass spectrometry radiocarbon (AMS 14C) dates indicate that residential living may have occurred later at Compound 18 than at Compound 17 and Tlajinga 33.
Teotihuacan's Tlajinga district is a cluster of neighborhoods on the southern periphery of the city best known for earlier investigations at Compound 33:S3W1. New research includes excavations at two other apartment compounds and along the southern extension of the Street of the Dead. Excavation contexts, major finds, chronology, and preliminary interpretations are the subject of this article. We highlight evidence attesting to a major obsidian-blade workshop at Compound 17:S3E1, offerings, and other features at that compound and Compound 18:S3E1, and the tempo and processes of urbanization viewed through well-recorded stratigraphic sequences of the compounds and the Street of the Dead. We conclude that significant occupation began in the Miccaotli phase, but it was not until some point in the Early Tlamimilolpa phase that the dominant housing type became apartment compounds; the continuation of the axis of Street of the Dead in the district was accomplished by excavating in the volcanic tuft substrate (tepetate) and could have been undertaken by the inhabitants of the district themselves; and the presence of items such as a sculpted stone face, marine shell, and polychrome pottery demonstrates that commoners at Teotihuacan enjoyed some access to finer items within the interregional economy.
There is little consensus on how best to manage head and neck cancer with palliative intent. Predicting outcome is difficult and reported survival varies. The present study sought to delineate local practice and outcomes in patients treated with palliative intent.
The clinical records of all head and neck cancer patients treated with palliative intent presenting between 2015 and 2016 to our multidisciplinary team were reviewed.
Eighty-four patients (21.5 per cent) were treated with palliative intent. All had squamous cell carcinoma. Mean survival time was 151 days (standard deviation = 121.1; range, 8–536 days). Of the patients, 83.3 per cent had a palliative care referral; 74.1 per cent had a hospice referral. Patients received a variety of interventions, and there was an associated complication in 8.2 per cent. The mean number of days spent in hospital for interventions was 11.9 days (standard deviation = 12.5; range, 0–41 days).
Different interventions are used to manage head and neck cancer patients with palliative intent, and these may be associated with significant morbidity. Survival time is variable, often several months; thus, any treatment must take into account morbidity in conjunction with the patient's wishes.
We present a highly detailed study of calving dynamics at Tunabreen, a tidewater glacier in Svalbard. A time-lapse camera was trained on the terminus and programmed to capture images every 3 seconds over a 28-hour period in August 2015, producing a highly detailed record of 34 117 images from which 358 individual calving events were distinguished. Calving activity is characterised by frequent events (12.8 events h−1) that are small relative to the spectrum of calving events observed, demonstrating the prevalence of small-scale calving mechanisms. Five calving styles were observed, with a high proportion of calving events (82%) originating at, or above, the waterline. The tidal cycle plays a key role in the timing of calving events, with 68% occurring on the falling limb of the tide. Calving activity is concentrated where meltwater plumes surface at the glacier front, and a ~ 5 m undercut at the base of the glacier suggests that meltwater plumes encourage melt-under-cutting. We conclude that frontal ablation at Tunabreen may be paced by submarine melt rates, as suggested from similar observations at glaciers in Svalbard and Alaska. Using submarine melt rate to calculate frontal ablation would greatly simplify estimations of tidewater glacier losses in prognostic models.