Multiple publications demonstrate an association between time to initiation of corticosteroids and outcomes such as mortality and reversal of shock. However, the optimal time to initiate hydrocortisone remains unknown.

To evaluate the impact of early versus late initiation of hydrocortisone in septic shock patients.

A retrospective, multicentered, observational study was conducted. Adults admitted from July 1, 2014, to August 31, 2019, diagnosed with septic shock receiving vasopressors and low-dose hydrocortisone were evaluated. Participants were divided into the "early" group if hydrocortisone was initiated within 12 hours or "late" group if initiated after 12 hours of vasopressor initiation. The primary outcome was time to vasopressor discontinuation. Secondary outcomes included in-hospital mortality, intensive care unit (ICU) and hospital length of stay (LOS), vasopressor utilization, fluids administered, and need for renal replacement therapy.

A total of 198 patients were identified for inclusion in this propensity score-weighted cohort 99 in the early group and 99 in the late group. Early initiation was associated with shorter time to vasopressor discontinuation compared with late initiation (40.7 vs 60.6 hours;
 = 0.0002). There was also a reduction in ICU LOS (3.6 vs 5.1 days;
 = 0.0147) and hospital LOS (8.9 vs 10.9 days;
 = 0.0220) seen in the early group. There was no difference in mortality between groups.

In this propensity-matched cohort, administration of hydrocortisone within 12 hours from the onset of septic shock was associated with improved time to vasopressor discontinuation and reduced ICU and hospital LOS.
In this propensity-matched cohort, administration of hydrocortisone within 12 hours from the onset of septic shock was associated with improved time to vasopressor discontinuation and reduced ICU and hospital LOS.
There are numerous well-described benefits to breastfeeding to both infant and mother. Even in healthy children with an uncomplicated perinatal course, there may be significant struggles maintaining a breastfeeding relationship. Infants with a complicated clinical course have been shown to benefit even more from the provision of breastmilk, however they are seldom encouraged to feed directly at the breast. There are no reports of successful direct breastfeeding in an infant with a tracheostomy.

We present the case of a breastfeeding dyad including a trach-dependent infant with congenital idiopathic bilateral vocal fold immobility who successfully initiated and maintained an inclusive breastfeeding relationship.

This case illustrates that successful direct breastfeeding can be achieved in an infant with a tracheostomy. If a patient is felt to be capable of oral feeding via bottle, there is no reason that there should not be a trial of direct feeding at the breast, for the benefit of both members of the breastfeeding dyad.
This case illustrates that successful direct breastfeeding can be achieved in an infant with a tracheostomy. If a patient is felt to be capable of oral feeding via bottle, there is no reason that there should not be a trial of direct feeding at the breast, for the benefit of both members of the breastfeeding dyad.Given the scope and adverse clinical consequences of child abuse, assessment of salient etiological factors can lend critical insights needed for abuse prevention. Increasingly, dual-processing models have been applied to aggression, which postulate that parallel automatic and conscious processes can evoke aggressive behavior, implicating both affective and cognitive elements in both routes. Using two samples of mothers (n = 110 and n = 195), the current investigation considered evidence of the reliability and convergent, concurrent, and construct validity of the new Automatic Parent Emotion Analog Response task relevant to parent-child aggression, contrasted with a self-reported conscious processing measure. Findings provide evidence that affective reactions of both anger and worry relate to child abuse risk and inclination to respond aggressively, and demonstrate how mothers' automatic reactions relate to both perceived child misbehavior and child dangerous behavior. Current results lend psychometric support for automatic processing in parent-child aggression consistent with other dual-processing theories of aggression.
Alzheimer's disease (AD) and related dementias contribute to one in three senior deaths. Lifestyle factors, including sleep, may contribute to AD risk and mortality; however, current evidence on sleep and AD mortality is mixed.

We used data from the NIH-AARP Diet and Health Study. Sleep duration and napping were self-reported and AD death were ascertained via linkage to the National Death Index.

Long sleep and napping were both associated with increased AD mortality. Specifically, 9+ hr of sleep was associated with 50% increase (hazard ratio = 1.50, 95% CI = [1.17, 1.92]) in AD mortality when compared 7 to 8 hr, while napping for 1+ hr was associated with 29% increase (1.29 [1.08, 1.55]) when compared with no napping. Results appeared to be stronger in men and remained after removing AD deaths within first 5 years after baseline.

Long sleep and napping may predict higher AD mortality in the older population.
Long sleep and napping may predict higher AD mortality in the older population.
Patients frequently use the internet as a source to obtain health information. The purpose of this study was to evaluate the quality and readability of online resources on the diagnosis and treatment of ankle osteochondral lesions (OCLs).

Three search terms ("ankle cartilage defect," "cartilage injury," "ankle cartilage damage") were entered into 3 search engines (Google, Yahoo, and Bing). The first 20 websites from each search was collected excluding websites intended for health care providers. The quality of the websites were evaluated using the DISCERN instrument, JAMA benchmark, and a Quality rating criteria specific to ankle OCL. The readability was assessed using Flesch Reading Ease (FRE) and Flesch-Kincaid Grade Level (FKGL). Statistical analysis was performed using one-way analysis of variance.

A total of 41 websites were reviewed. The mean quality ratings were poor across the assessment tools DISCERN = 38.5 ± 9.0 (range, 23.7-56.7) out of 80; JAMA = 1.0 ± 1.1 (range, 0-3.3) out of 4; and Quality rating criteria = 11.3 ± 4.6 (range, 4-20.7) out of 24. The mean FRE and FKGL were 40.7 ± 32.0 (range, -152.3 to 60.2) and 13.5 ± 10.8 (range, 8.4-80.7), respectively; higher than the recommended reading level for patients (fifth grade).

The quality and readability of credible sources for ankle OCL were poor, which could lead to misinformation. FDI-6 order This study should guide the improvement of online information on ankle OCL.
The quality and readability of credible sources for ankle OCL were poor, which could lead to misinformation. This study should guide the improvement of online information on ankle OCL.To promote radiation protection and health promotion among returning residents (returnees) in coastal areas of Fukushima, eHealth principles were used to develop a new application tool (app) that can record radiation exposure and health status while providing comprehensive support to returnees. Intended users are returnees and health and welfare workers. After assessing their needs, a flowchart and prototype for operational logic were created using commercially available software tools. Professional developers will focus on improving the user interface and ensuring data security. The finished app will be compatible with mobile telephones and tablets. Utility and ease of use are paramount to serve returnees of all ages effectively.
Neuromuscular choristoma (NC) is a rare tumor composed of striated muscle fibers admixed with nerve fibers that often affects large peripheral nerve trunks in children. To the best of our knowledge, this is the first reported case in the literature of a NC of the ophthalmic nerve in an adult.

A 27-year-old woman presented with a 20-day history of left periorbital headache radiating to the frontotemporal region, with associated tearing, nausea, and vomiting. The examination was normal, except for hypoesthesia in the distribution of the first trigeminal nerve branch (V1). Cranial computerized tomography showed a lesion in the left orbit and cavernous sinus with widening of the superior orbital fissure. On magnetic resonance imaging, the lesion was well-defined with fusiform morphology and showed a central cystic component and peripheral enhancement. An extradural approach was performed with subtotal tumor resection. Biopsy showed proliferation of striated muscle cells admixed with nerve fascicles and Schwann cells. A pathological diagnosis of NC of V1 was determined. Six months after surgery, left hypotropia with limitation of supraduction was observed, as well as hypoesthesia and paralysis of the left forehead with ipsilateral eyebrow ptosis. The rest of the examination remained within normal limits.

NC should be considered in the differential diagnosis of a young patient with periorbital headache and hypoesthesia in the V1 region.
NC should be considered in the differential diagnosis of a young patient with periorbital headache and hypoesthesia in the V1 region.
Microtia reconstruction is technically challenging due to the intricate contours of the ear. It is common practice to use a two-dimensional tracing of the patient's normal ear as a template for the reconstruction of the affected side. Recent advances in three-dimensional (3D) surface scanning and printing have expanded the ability to create surgical models preoperatively. This study aims to describe a simple and affordable process to fabricate patient-specific 3D ear models for use in the operating room.

Applied basic research on a novel 3D optical scanning and fabrication pathway for microtia reconstruction.

Tertiary care university hospital.

Optical surface scanning of the patient's normal ear was completed using a smartphone with facial recognition capability. The Heges application used the phone's camera to capture the 3D image. The 3D model was digitally isolated and mirrored using the Meshmixer software and printed with a 3D printer (Monoprice
 Select Mini V2) using polylactic acid filaments.

The 3D model of the ear served as a helpful intraoperative reference and an adjunct to the traditional 2D template. Collectively, time for imaging acquisition, editing, and fabrication was approximately 3.5 hours. The upfront cost was around $210, and the recurring cost was approximately $0.35 per ear model.

A novel, low-cost approach to fabricate customized 3D models of the ear is introduced. It is feasible to create individualized 3D models using currently available consumer technology. The low barrier to entry raises the possibility for clinicians to incorporate 3D printing into various clinical applications.
A novel, low-cost approach to fabricate customized 3D models of the ear is introduced. It is feasible to create individualized 3D models using currently available consumer technology. The low barrier to entry raises the possibility for clinicians to incorporate 3D printing into various clinical applications.