The authors performed telephone interviews of parents of adolescents (n = 430) and their older adolescents (n = 208) in Monroe County, New York to measure parent and adolescent acceptance of human papillomavirus (HPV) vaccine, its association with ratings of provider communication, and vaccine-related topics discussed with the adolescent's provider. More than half of adolescent girls had already received an HPV vaccination, with fewer than one quarter refusing. Parent and teen ratings of provider communication was high, and not related to HPV vaccine refusal. Parents were more likely to refuse if they were Hispanic (odds ratio [OR] = 5.88, P = .05) or did not consider vaccines "very safe" (OR = 2.76, P = .04). Most parents of boys (85%) believed males should be given HPV vaccine if recommended. Few parents and teens recalled discussing that vaccination does not preclude future Pap smear testing. Providers should address cultural and vaccine safety concerns in discussions about HPV vaccine.

Purkerson JM, Heintz EV, Nakamori A, Schwartz GJ. Insights into acidosis-induced regulation of SLC26A4 (pendrin) and SLC4A9 (AE4) transporters using three-dimensional morphometric analysis of ␤-intercalated cells. Am J Physiol Renal Physiol 307: F601-F611, 2014. First published July 2, 2014; doi:10.1152/ajprenal.00404.2013.-The purpose of this study was to examine the three-dimensional (3-D) expression and distribution of anion transporters pendrin (SLC26A4) and anion exchanger (AE)4 (SLC4A9) in ␤-intercalated cells (␤-ICs) of the rabbit cortical collecting duct (CCD) to better characterize the adaptation to acid-base disturbances. Confocal analysis and 3-D reconstruction of ␤-ICs, using identifiers of the nucleus and zona occludens, permitted the specific orientation of cells from normal, acidotic, and recovering rabbits, so that adaptive changes could be quantified and compared. The pendrin cap likely mediates apical Cl Ϫ /HCO 3 Ϫ exchange, but it was also found beneath the zona occludens and in early endosomes, some of which may recycle back to the apical membrane via Rab11a ϩ vesicles. Acidosis reduced the size of the pendrin cap, observed as a large decrease in cap volume above and below the zona occludens, and the volume of the Rab11a ϩ apical recycling compartment. Correction of the acidosis over 12-18 h reversed these changes. Consistent with its proposed function in the basolateral exit of Na ϩ via Na ϩ -HCO 3 Ϫ cotransport, AE4 was expressed as a barrel-like structure in the lateral membrane of ␤-ICs. Acidosis reduced AE4 expression in ␤-ICs, but this was rapidly reversed during the recovery from acidosis. The coordinate regulation of pendrin and AE4 during acidosis and recovery is likely to affect the magnitude of acid-base and possibly Na ϩ transport across the CCD. In conclusion, acidosis induces a downregulation of AE expression in ␤-ICs and a diminished presence of pendrin in apical recycling endosomes. acidosis; alkalosis; anion exchangers; anion exchanger 4; confocal microscopy; rabbit FINAL REGULATION of acid-base transport occurs in the distal nephron of the kidney, particularly in the cortical collecting duct (CCD). We have previously shown in rabbits that acidosis results in increased proton secretion and decreased HCO 3 Ϫ secretion, respectively, by ␣-and ␤-intercalated cells (ICs) from isolated perfused CCDs (23,25,26,29). Some of these adaptive changes occur via a downregulation of the apical Cl Ϫ /HCO 3 Ϫ exchanger, which mediates HCO 3 Ϫ secretion (17,26). This exchanger in ␤-ICs was subsequently shown to be pendrin (SLC26A4) (22); it appears as an apical cap and clearly plays a role in acid-base regulation. However, other studies have shown that pendrin expression is also dependent on urinary Cl Ϫ excretion (11, 34) and, if unregulated, could cause hypertension (34). A study (21) of pendrin expression during acid-base disturbances revealed that the expression, mRNA, protein abundance, and number of pendrin-positive cells in rabbit kidneys were decreased after 3 days of acidosis. Simila...

Background Most patients who report a penicillin allergy can tolerate cefazolin, the preferred prophylaxis in a total joint arthroplasty (TJA). Regardless, patients with a reported penicillin allergy are less likely to receive first-line perioperative antibiotics as a result of inaccurate penicillin allergy documentation and misconceptions regarding cross-reactivity between penicillin and cephalosporins. The over-reporting of penicillin allergies and the safety of cephalosporins in patients with reported penicillin allergies have been well established throughout the evidence [13]. Questions/purposes The study sought to answer two questions: (1) Do antibiotic stewardship interventions improve adherence to appropriate prophylactic antibiotic usage in patients with a documented penicillin allergy undergoing primary TJA? (2) What is the risk of allergic or adverse reactions secondary to cefazolin use in patients with a documented penicillin allergy? Methods This was a single-center, retrospective study of orthopaedic patients older than 18 years who underwent a primary elective TJA at a 261-bed community hospital. The study had two periods: the preintervention period ran from March 1, 2017 to August 30, 2017 and the postintervention period was from March 1, 2019 to August 30, 2019. A total of 396 patients with a history of a documented penicillin allergy underwent a THA or TKA during the study periods. After reviewing every fourth patient with a history of a documented penicillin allergy who met study inclusion criteria and excluding those patients who had a codocumented cephalosporin allergy, a total of 180 patients with a documented penicillin allergy were evaluated (90 patients in the preintervention group and 90 patients in the postintervention group). To answer our first study question, regarding whether antibiotic stewardship interventions improve adherence to appropriate prophylactic antibiotic usage in patients with a documented penicillin allergy undergoing primary TJA, we evaluated appropriate antibiotic usage pre- and postintervention. To answer our second study question, concerning the risk of allergic or adverse reactions secondary to cefazolin use in patients with a documented penicillin allergy, we reviewed signs of allergic reactions in patients who received cefazolin for a primary TJA and had a documented penicillin allergy. Results Postintervention antibiotic use was more appropriate (91% [82 of 90] versus 54% [49 of 90], risk ratio 1.67 [95% confidence interval 1.37 to 2.04]; p < 0.01), particularly in patients with nonsevere allergy (preintervention: 47% [36 of 76] versus postintervention: 96% [76 of 79]; p < 0.01). No patients had signs of an allergic reaction related to cefazolin, including eight patients with severe penicillin allergy. Conclusion A multifaceted antibiotic stewardship intervention increased the appropriateness of antibiotic prophylaxis in elective primary TJA. Patients with nonsevere penicillin allergies, even those reporting hives or local swelling, tolerated cefazolin. Antibiotic stewardship interventions can be implemented across institutions to expand cephalosporin use in patients with a reported penicillin allergy within orthopaedic TJA patients. Level of Evidence Level III, therapeutic study.

Introduction. Standard culture methods may fail to detect the causative agents of bacterial infection for various reasons including specimen collection after antibiotic administration, or when standard techniques or environmental conditions are not appropriate for growth of the microorganisms. Conventional 16S rRNA gene sequencing is sometimes a useful alternative technique for identification of bacteria, but is confounded by polymicrobial infection. We present a case of a patient who developed a serious neurological infection for which causative oral flora organisms were observed by microscopy, failed to culture but were identified by next-generation DNA sequencing. Case presentation. A male in his forties developed sinus pain and congestion, followed by facial and eye pain, and several weeks later acute-onset confusion and neck stiffness. Cerebrospinal fluid examination revealed pleocytosis and several bacterial morphologies, which were subsequently identified by next-generation sequencing as oral flora constituents Porphyromonas endodontalis , Fusobacterium nucleatum , Streptococcus constellatus , Prevotella species and Parvimonas micra . Conclusion. Oral flora can cause meningoencephalitis and brain abscess formation if translocation occurs by injury or surgical procedures. Next-generation sequencing is often not available at healthcare facilities, or when available may not have been validated for a wide spectrum of specimen sources, but is available at reference laboratories and should be considered when routine methods fail to provide a diagnosis for serious infections.