CARE USA

Managing posterior teeth presenting with pulpal involvement and proximal caries is of great challenge. It requires a treatment approach which can restore biologic function of the tooth to a great extent. This case report presents the endodontic treatment and direct Class II Composite restoration of tooth #24 in a 29-year-old patient who presented with deep carious involvement and sensitivity to thermal stimuli. On radiographic examination, it was revealed that the tooth presented with irreversible pulpitis with periapical involvement. This condition of tooth concluded that a root canal treatment is mandatory to ensure tooth integrity. For better treatment outcome, a stepwise clinical protocol was mandatory. This involved access preparation, biomechanical cleaning and shaping, and obturation with gutta-percha was performed under rubber dam isolation. Following successful endodontic therapy, the proximal defect was restored using a direct Class II Composite resin technique. This was done to achieve both functional integrity and anatomical contour of the tooth. An optimal obturation and coronal sealing was confirmed on postoperative radiographs. A follow-up of 6 months was advised to the patient. This follow up would demonstrate resolution of symptoms, radiographic periapical healing and satisfactory functional outcomes.

Adolescents in sub-Saharan Africa continue to face a high burden of HIV, with adolescent girls and young women disproportionately affected. Yet despite major investments in HIV education, testing, condoms, and biomedical prevention such as PrEP, reductions in new infections remain slow in countries like Kenya and Nigeria. This viewpoint argues that current prevention strategies overlook the social realities that shape adolescent decision-making. Drawing on Bicchieri’s Social Norms Theory and field experience, we highlight how visible sanctions tied to pregnancy, reputation, and respectability guide protection choices more than biomedical logic. For many adolescents, discreet hormonal contraception allows girls to avoid public shame, while boys often avoid condoms because being seen purchasing them signals sexual activity and attracts moral judgment. These gendered pressures reduce dual protection even when knowledge and access exist, and fragmented HIV and reproductive health services reinforce the divide. Health systems often deepen this pattern when adolescents feel judged or questioned by providers. Effective HIV prevention requires confronting these normative pressures and integrating youth-friendly reproductive and HIV services. Prevention becomes stronger when it aligns with how adolescents interpret risk, dignity, and responsibility within their social environments rather than focusing on biomedical solutions alone.

Young people in the U.S. Southeast navigate a constellation of legal, systemic and social barriers for abortion care. We identified and described barriers to abortion access experienced by young Southerners who sought abortion funding and the context they navigate to do so. We conducted a secondary qualitative data analysis of case notes from people ages 21 and under who resided in six Southeastern states and contacted ARC-Southeast for support between January 2017 and May 2021 (n = 2,278). Nine-hundred and fifty information rich case notes were selected for thematic analysis. The findings revealed young Southerners encounter a multitude of barriers addressed by abortion funds within four primary categories: structural barriers, financial barriers, personal barriers, and the COVID-19 pandemic. Case notes also described the context that youth seeking abortion care navigate, which are scarcely documented in abortion access literature, such as pre-existing conditions, intimate partner violence, and immigration status. We conceptualized these findings into a framework synthesizing the challenges, impacts, and opportunities for abortion provision in the U.S. Southeast. Each category of barrier contributed to constrained bodily autonomy and delayed abortion care. Abortion funds are uniquely situated among other key actors (e.g., health care providers, legal experts, other advocates, policymakers) and equipped to mitigate barriers that could otherwise deter and delay youth from obtaining abortion care and facilitate young people’s dignity and respect. This research highlights areas where such community-led and youth-centered efforts could be bolstered to address inequities in abortion access and other intersecting health and social systems.

To clarify the impact of systematic nursing on preventing lower limb deep venous thrombosis after obstetrics and gynaecology surgery. The study was conducted at the Nanjing Women and Children's Healthcare Hospital, Nanjing, China, from November 2020 to November 2022, and comprised women inpatients who had undergone caesarean section. The subjects were randomised into control group CG and observation group OG. CG subjects underwent conventional nursing, while OG subjects received systematic nursing intervention, including preoperative, intraoperative and postoperative nursing. Negative emotions, nursing satisfaction, complication incidence and lower limb status were compared between the groups. Data was analysed using SPSS 27. Of the 100 subjects, 50(50%) women were in CG group with mean age 29.41±1.34 years, while 50(50%) were in OG group with mean age 29.55±1.35 years. Post-intervention, negative emotion scores were lower, nursing satisfaction scores were higher, the incidences of lower limb deep venous thrombosis and pulmonary embolism were fewer, and the scores of lower limb status were lower in OG group compared to CG (p<0.05). The application of systematic nursing intervention in obstetrics and gynaecology patients undergoing surgery could effectively prevent lower limb deep venous thrombosis, reduce the incidence of pulmonary embolism, improve patients' lower limb status and negative emotions, and increase satisfaction level with nursing.

Ataxia telangiectasia AT), an autosomal recessive disorder due to mutations in the ATM gene, results in progressive cerebellar ataxia, oculocutaneous telangiectasia, immunodeficiency, pulmonary compromise, sensitivity to ionizing radiation, and increased risk of hematologic malignancies. Orthopedic manifestations such as scoliosis, hip displacement, gait abnormalities, and extremity contractures are common, but reports are scarce. This study aimed to evaluate and summarize the orthopedic manifestations associated with AT. A retrospective review was conducted of patients with AT. Reported outcomes included demographics, orthopedic manifestations and operative/nonoperative treatments, radiographic exposure, development of malignancy, and ambulatory status (using the Functional Mobility Scale at 50 m, FMS50). Twenty-four children were included [11 (45.8%) female] with a mean age at diagnosis of 5.5 (SD = 3.5) years. The most common reason for orthopedic consultation was ataxia; 12 (50%) were walkers (FMS50 = 4,5) and 12 nonwalkers (FMS50 = 1,2). Foot deformities were present in 10 (42%) including pes planovalgus (N = 6, 25%), Achilles tendon contracture (N = 1, 4%), hallux valgus (N = 1, 4%; underwent Akin osteotomy), equinovarus (N = 1.4%), and gastrocnemius contracture (N = 1, 4%). Six children (25%) developed scoliosis, and three underwent fusion. Other manifestations included hip flexion contracture (N = 2, 8%), hamstring contracture (N = 2, 8%), torticollis (N = 1, 4%), and osteomyelitis of the ischium (N = 1, 4). This report describes orthopedic manifestations associated with AT, most commonly foot deformities, followed by scoliosis. Since radiographic surveillance was not performed due to radiosensitivity, the frequency of hip displacement in AT could not be ascertained. Orthopedic surgical interventions, where required, were generally successful. Level of evidence: 3.

<title>Abstract</title> <bold>Background</bold> : Previous work in adult heart transplant (HTx) has shown donor-derived cell free DNA (dd-cfDNA) levels are elevated in the presence of endomyocardial biopsy (EMB) proven rejection as well as in the presence of donor specific antibodies (DSA). Less is known about impact of DSAs on dd-cfDNA levels in pediatric HTx patients. This study evaluates the relationship of dd-cfDNA with EMB results and DSAs at our center. <bold>Methods</bold> : Primary outcome of this retrospective analysis was a composite endpoint for allograft injury or risk for allograft injury (composite group), defined as the presence of either biopsy-proven acute cellular rejection (ACR) and/or DSAs. Secondary outcomes were the individual components of the composite outcome, including: 1) presence of ACR and 2) DSAs individually, as defined above. <bold>Results</bold> : Analysis consisted of 154 dd-cfDNA samples. Sixty dd-cfDNA levels were collected in the composite group, defined as the presence of ACR and/or DSAs. Of the samples in the composite group, 49 were paired with a positive DSA result, 6 had biopsy-proven ACR without positive DSAs and 5 had both biopsy-proven rejection and DSAs. dd-cfDNA was significantly higher in the composite group when compared to samples without evidence of graft injury (0.43% vs 0.09; p&lt;0.001). Median dd-cfDNA levels were significantly higher in the positive EMB group when compared to the no rejection samples (1.10% vs 0.17%, p=0.003). Dd-cfDNA levels were significantly higher in the DSA positive group when compared to the DSA negative group (0.36% vs 0.08%, p &lt;0.001). <bold>Conclusions</bold> : We demonstrate that in our cohort of pediatric HTx patients, dd-cfDNA levels are elevated in EMB proven ACR and in individuals with positive DSAs.

Abstract Loss of GABAergic and glycinergic inhibitory efficacy in the spinal dorsal horn is associated with neuropathic pain and opioid-induced hyperalgesia in rodent models. Downregulation of the KCC2 chloride extrusion transporter is a key mechanism underlying this decreased inhibitory efficacy, but to-date there is no evidence supporting or opposing this hypothesis in humans. Here we demonstrate that KCC2 expression is decreased in superficial dorsal horn neurons of organ donors who died with a documented history of pain, or of long-term opioid use. We show profoundly decreased KCC2 dorsal horn membrane expression in a primary cohort associated with either chronic pain or opioid use, and in a replication cohort of mixed chronic pain and opioid use history. These results show that decreased dorsal horn inhibitory efficacy likely promotes chronic pain in humans and support the development of therapeutics augmenting KCC2 function as a treatment for chronic pain and opioid use disorders.

Abstract Two vaccines (JYNNEOS; ACAM2000) were available in the United States to prevent mpox during the 2022 clade II mpox outbreak with the majority of people receiving JYNNEOS. As part of the Biologics Effectiveness and Safety (BEST) Initiative, FDA monitored the safety of JYNNEOS using three commercial health plan claims databases supplemented with local and state Immunization Information System data. We assessed vaccine uptake, described the vaccinated population, monitored rates of 11 potential adverse events (AEs) following vaccination, and compared the observed AE rates to expected background rates. There were 152,001 JYNNEOS doses administered. Of the 92,340 people receiving at least one JYNNEOS dose, most were males (93.1%), aged 25–44 years (63.3%), lived in urban areas (98.7%), and 64.2% received a second dose. AE rates following JYNNEOS doses were similar to expected background rates. Additional safety studies of larger vaccinated populations may be needed to evaluate rare AEs including myocarditis/pericarditis.

Background: Respiratory complications are one of the leading causes of death following spinal cord injury (SCI). Still, there is a lack of clear evidence on how to properly treat SCI patients with deficits related to a trauma injury. Therefore, the goal of the survey is to gain a better understanding of the respiratory care provided to SCI patients. Methods: The Institutional Review Board (IRB) of the University of Baltimore approved the distribution of a survey to respiratory therapists. The survey was disseminated through various channels, including social media platforms like LinkedIn and Facebook and professional networks such as the American Association for Respiratory Care (AARC) Connect. Results: We collected responses from 90 respiratory therapists in 33 states, most working in level 1 trauma centers. According to the survey results, most respondents (75%) are not ventilating with a tidal volume greater than 8 mL/kg/PBW, as discussed in the literature as a ventilating strategy for spinal cord injury (SCI) patients. 48% reported using VC-AC as the initial mode, and over 20% mentioned using dual-targeted modes. 66% set the initial PEEP was set at 5-6 cm H2O but varied from 0 to 10 cm H2O.67% of the respondents stated that they have a secretion clearance protocol, and 53% used it proactively versus as symptoms developed. One respondent stated that they are not using any secretion modalities. The modalities used vary, but the most used devices included cough assist, intrapulmonary percussive ventilation (IPV), CPT, and flutter valves. The use of bronchodilators was reported by 35% as a standard of care, while 64% of the respondents based their use on indications. Conclusions: We see variability in the respiratory care provided to SCI patients in acute care. The results highlight the need for further research to identify best practices and develop standardized clinical practice guidelines for respiratory therapists to follow for optimization of care. Future randomized control studies could focus on the effectiveness of different ventilation modes, the impact of proactive versus reactive use of secretion clearance protocols, and the role of individualized treatment approaches in improving patient outcomes. These efforts, led by respiratory therapists, could bridge the gap between recommended and actual clinical practices, ultimately improving the quality of care for SCI patients.

Most emergency departments (EDs) across the US use the Emergency Severity Index (ESI) to predict acuity and resource needs. A comprehensive assessment of ESI accuracy among pediatric patients is lacking. To assess the frequency of mistriage using ESI (version 4) among pediatric ED visits using automated measures of mistriage and identify characteristics associated with mistriage. This cohort study used operational measures for each ESI level to classify encounters as undertriaged, overtriaged, or correctly triaged to assess the accuracy of the ESI and identify characteristics of mistriage. Participants were pediatric patients at 21 EDs within Kaiser Permanente Northern California from January 1, 2016, to December 31, 2020. During that time, version 4 of the ESI was in use by these EDs. Visits with missing ESI, incomplete ED time variables, patients transferred from another ED, and those who left against medical advice or without being seen were excluded. Data were analyzed between January 2022 and June 2023. Assigned ESI level. Rates of undertriage and overtriage by assigned ESI level based on mistriage algorithm, patient and visit characteristics associated with undertriage and overtriage. This study included 1 016 816 pediatric ED visits; the mean (SD) age of patients was 7.3 (5.6) years, 479 610 (47.2%) were female, and 537 206 (52.8%) were male. Correct triage occurred in 346 918 visits (34.1%; 95% CI, 34.0%-34.2%), while overtriage and undertriage occurred in 594 485 visits (58.5%; 95% CI, 58.4%-58.6%) and 75 413 visits (7.4%; 95% CI, 7.4%-7.5%), respectively. In adjusted analyses, undertriage was more common among children at least 6 years old compared with those younger 6 years; male patients compared with female patients; patients with Asian, Black, or Hispanic or other races or ethnicities compared with White patients; patients with comorbid illnesses compared with those without; and patients who arrived by ambulance compared with nonambulance patients. This multicenter retrospective study found that mistriage with ESI version 4 was common in pediatric ED visits. There is an opportunity to improve pediatric ED triage, both in early identification of critically ill patients (limit undertriage) and in more accurate identification of low-acuity patients with low resource needs (limit overtriage). Future research should include assessments based on version 5 of the ESI, which was released after this study was completed.