bluuebunny/crossref_metadata_2025 huggingface dataset:
Congenital Toxoplasmosis: Missed Opportunities for Diagnosis and Prevention
Authors: Mueller Raquel Aitken Soares , Frota Ana Cristina Cisne , Menna Barreto Daniela Durão , Vivacqua Daniela Pires Ferreira , Loria Gabriela Bueno , Lebreiro Giuliana Pucarelli , Martins Mariana Guerreiro , Potsch Mariana Vigo , Maia Paula Dias , Coutinho Raquel Lara Melo , Abreu Thalita Fernandes , Hofer Cristina Barroso
Published: July 2020

Objectives

Identify missed opportunities for the prevention and early diagnosis of congenital toxoplasmosis (CT) in infants followed up in a reference center for pediatric infectious diseases (PID) in Rio de Janeiro between January 2007 and December 2016.

Methods

Descriptive study including infants with CT, diagnosis established based on Brazil’s Ministry of Health’s criteria. All data regarding the infants and their mother’s prenatal care were collected from the medical records of the Instituto de Puericultura e Pediatria Martagão Gesteira (IPPMG)—a tertiary public pediatric university hospital. The study enrolled infants aged between 0 and 12 months followed up in the PID department of IPPMG and with confirmed infection by Toxoplasma gondii in the period between January 2007 and December 2016. All patients with diagnosis of CT registered in the PID database of the IPPMG and admitted in the above-mentioned period were included in the study. Patients whose records were not available, or who went to just one clinic appointment were excluded.

Results

The obstetric history of all 44 women, whose infants (45) were diagnosed with CT, was analyzed. Their median age was 22 years. None had undergone preconception serological testing for toxoplasmosis. Only 20 (45%) of them started antenatal care during the first trimester of gestation, a total of 24 (55%) had more than six antenatal care visits, and 16% of those did not undergo serological testing for toxoplasmosis. None were adequately informed of preventive measures. The diagnosis of acute toxoplasmosis was made in 50% of these pregnancies but 32% of the women were not treated. Only 10 children of these mothers were adequately screened and treated at birth.

Conclusion

Despite the existence of national recommendations, several opportunities were missed to prevent CT during the antenatal period and to diagnose and treat this condition in the neonatal period.
Neurological Complications of SARS-CoV-2 Infection in Children: A Systematic Review and Meta-Analysis
Authors: Panda Prateek Kumar , Sharawat Indar Kumar , Panda Pragnya , Natarajan Vivekanand , Bhakat Rahul , Dawman Lesa
Published: July 2020

Background

Knowledge about neurological complications of COVID-19 in children is limited due to the paucity of data in the existing literature. Some systematic reviews are available describing overall clinical features of COVID-19 in children and neurological complications of COVID-19 in adults. But to the best of our knowledge, no systematic review has been performed to determine neurological manifestations of COVID-19.

Methods

Six different electronic databases (MEDLINE, EMBASE, Web of Science, CENTRAL, medRxiv and bioRxiv) were searched for articles related to COVID-19 and neurological complications in children. Studies/case series reporting neurological manifestations of COVID-19 in patients aged ≤18 years, as well as case reports, as neurological complications appear to be rare. The pooled estimate of various non-specific and specific neurological manifestations was performed using a random effect meta-analysis.

Results

Twenty-one studies/case series and five case reports (3707 patients) fulfilled the eligibility criteria and were included in this systematic review, from a total of 460 records. Headache, myalgia and fatigue were predominant non-specific neurological manifestations, presenting altogether in 16.7% cases. Total of 42 children (1%) were found to have been reported with definite neurological complications, more in those suffering from a severe illness (encephalopathy—25, seizure—12, meningeal signs—17). Rare neurological complications were intracranial hemorrhage, cranial nerve palsy, Guillain–Barré syndrome and vision problems. All children with acute symptomatic seizures survived suggesting a favorable short-term prognosis.

Conclusion

Neurological complications are rare in children suffering from COVID-19. Still, these children are at risk of developing seizures and encephalopathy, more in those suffering from severe illness.
Complete Genome Sequence of Pantoea stewartii subsp. indologenes ZJ-FGZX1, a Lucky Bamboo Pathogen
Authors: Ren Lei , Zhang Song , Xu Zhiying , Hu Hanqiao
Published: July 2020

The phytopathogen Pantoea stewartii subsp. indologenes causes Stewart’s wilt disease in lucky bamboo. Here, we report the complete genome of P. stewartii subsp. indologenes ZJ-FGZX1, which represents the first whole-genome sequence of an isolate from China. The assembled genome consisted of three contigs, with one circular chromosome of 4,550,072 bp and two circular plasmids of 326,337 and 106,454 bp. The complete genome will provide a valuable resource for further studies on bacterial blight worldwide.
Corroboration That Highly Resistant Impatiens Cultivars Are Not Immune to Downy Mildew Disease: A Report of Crop Losses from Two California Producers
Authors: Daughtrey Margery , Beckerman Janna , Davis William J. , Rane Karen , Crouch Jo Anne
Published: July 2020

Two new series of Impatiens walleriana (impatiens) cultivars, Beacon and Imara XDR, were released to commercial growers in the United States in 2019 to 2020. Field trials show these new cultivar series are highly resistant to impatiens downy mildew (IDM). However, neither of these two impatiens series are completely immune to the disease, and preventive fungicide programs are still recommended for use throughout production to maintain plant health. Here we report two destructive outbreaks of IDM from Imara XDR in two commercial production facilities in California, one in 2019 and one in 2020. The disease outbreaks were caused by a known rDNA genotype of Plasmopara destructor (synonym = P. obducens). Modified Koch’s postulates showed that the pathogen could infect and cause disease in both Beacon and Imara XDR plants. Mefenoxam applied by both growers may have been ineffective due to resistance in P. destructor populations, which has been demonstrated on several previous occasions. Given these findings, fungicide programs intended to supplement genetic resistance should not be overly reliant upon application of mefenoxam and should utilize effective materials from different mode of action groups, in rotation. Fungicides to supplement genetic resistance are particularly appropriate in frost-free areas or in any circumstances that provide a potential inoculum source.
Identifying Entrustable Professional Activities for Shared Decision Making in Postgraduate Medical Education: A National Delphi Study
Authors: Baghus Anouk , Giroldi Esther , Muris Jean , Stiggelbout Anne , van de Pol Marjolein , Timmerman Angelique , van der Weijden Trudy
Published: July 2020

Purpose

Although shared decision making (SDM) is considered the preferred approach in medical decision making, it is currently not routinely used in clinical practice. To bridge the transfer gap between SDM training and application, the authors aimed to reach consensus on entrustable professional activities (EPAs) for SDM and associated behavioral indicators as a framework to support self-directed learning during postgraduate medical education.

Method

Using existing literature on SDM frameworks and competencies; input from an interview study with 17 Dutch experts in SDM, doctor–patient communication, and medical education; and a national SDM expert meeting as a starting point, in 2017, the authors conducted a modified online Delphi study with a multidisciplinary Dutch panel of 32 experts in SDM and medical education.

Results

After 3 Delphi rounds, consensus was reached on 4 EPAs—(1) the resident discusses the desirability of SDM with the patient, (2) the resident discusses the options for management with the patient, (3) the resident explores the patient’s preferences and deliberations, and (4) the resident takes a well-argued decision together with the patient. Consensus was also reached on 18 associated behavioral indicators. Of the 32 experts, 30 (94%) agreed on this list of SDM EPAs and behavioral indicators.

Conclusions

The authors succeeded in developing EPAs and associated behavioral indicators for SDM for postgraduate medical education to improve the quality of SDM training and the application of SDM in clinical practice. These EPAs are characterized as process EPAs for SDM in contrast with content EPAs related to diverse medical complaints. A next step is the implementation of the SDM EPAs in existing competency-based workplace curricula.
An Incentive to Innovate: Improving Health Care Value and Restoring Physician Autonomy Through Physician-Directed Reinvestment
Authors: Vilendrer Stacie M. , Asch Steven M. , Anzai Yoshimi , Maggio Paul
Published: July 2020

Problem

Many health care systems in the United States are shifting from a fee-for-service reimbursement model to a value-based payment model. To remain competitive, health care administrators must engage frontline clinicians in their efforts to reduce costs and improve patient outcomes. Engaging physicians and other clinicians is challenging, however, as many feel overwhelmed with clinical responsibilities and do not view cost reduction as in their purview. Even if they are willing, providing a direct financial incentive to clinicians to control costs poses ethical and legal challenges. An effective incentive in the current system must motivate clinicians to engage in creative problem solving and mitigate ethical and legal risk.

Approach

Evidence suggests the most successful behavior change interventions in physicians are multifaceted and combine intrinsic motivators, such as increased autonomy, with extrinsic motivators, such as access to funding or social recognition. Two academic health centers—the University of Utah Health and Stanford Health Care—have begun experimenting with an alternative value-sharing arrangement. Physician-directed reinvestment is an explicit agreement in which a health care system reinvests a portion of savings attributed to physician-led cost reduction initiatives back into areas of the physician’s choosing, such as capital investment, research, or education.

Outcomes

Both organizations reported similar positive outcomes, including increased engagement from clinicians and administrators, sustained or improved quality of care, reduced costs of care, and benefits from reinvested funds. Many savings opportunities were previously unknown to administrators.

Next Steps

Physician-directed reinvestment appears to effectively engage physicians in ongoing efforts to improve value in health care, although formal evaluation is still needed. This incentive structure may hold promise in other configurations, such as inviting nonphysicians to apply as project leaders (clinician-directed reinvestment) and expanding the program to nonacademic and ambulatory settings.
Mepivacaine versus Bupivacaine Spinal Anesthesia for Early Postoperative Ambulation
Authors: Schwenk Eric S. , Kasper Vincent P. , Smoker Jordan D. , Mendelson Andrew M. , Austin Matthew S. , Brown Scot A. , Hozack William J. , Cohen Alexa J. , Li Jonathan J. , Wahal Christopher S. , Baratta Jaime L. , Torjman Marc C. , Nemeth Alyson C. , Czerwinski Eric E.
Published: July 2020

Background

Early ambulation after total hip arthroplasty predicts early discharge. Spinal anesthesia is preferred by many practices but can delay ambulation, especially with bupivacaine. Mepivacaine, an intermediate-acting local anesthetic, could enable earlier ambulation than bupivacaine. This study was designed to test the hypothesis that patients who received mepivacaine would ambulate earlier than those who received hyperbaric or isobaric bupivacaine for primary total hip arthroplasty.

Methods

This randomized controlled trial included American Society of Anesthesiologists Physical Status I to III patients undergoing primary total hip arthroplasty. The patients were randomized 1:1:1 to 52.5 mg of mepivacaine, 11.25 mg of hyperbaric bupivacaine, or 12.5 mg of isobaric bupivacaine for spinal anesthesia. The primary outcome was ambulation between 3 and 3.5 h. Secondary outcomes included return of motor and sensory function, postoperative pain, opioid consumption, transient neurologic symptoms, urinary retention, intraoperative hypotension, intraoperative muscle tension, same-day discharge, length of stay, and 30-day readmissions.

Results

Of 154 patients, 50 received mepivacaine, 53 received hyperbaric bupivacaine, and 51 received isobaric bupivacaine. Patient characteristics were similar among groups. For ambulation at 3 to 3.5 h, 35 of 50 (70.0%) of patients met this endpoint in the mepivacaine group, followed by 20 of 53 (37.7%) in the hyperbaric bupivacaine group, and 9 of 51 (17.6%) in the isobaric bupivacaine group (P < 0.001). Return of motor function occurred earlier with mepivacaine. Pain and opioid consumption were higher for mepivacaine patients in the early postoperative period only. For ambulatory status, 23 of 50 (46.0%) of mepivacaine, 13 of 53 (24.5%) of hyperbaric bupivacaine, and 11 of 51 (21.5%) of isobaric bupivacaine patients had same-day discharge (P = 0.014). Length of stay was shortest in mepivacaine patients. There were no differences in transient neurologic symptoms, urinary retention, hypotension, muscle tension, or dizziness.

Conclusions

Mepivacaine patients ambulated earlier and were more likely to be discharged the same day than both hyperbaric bupivacaine and isobaric bupivacaine patients. Mepivacaine could be beneficial for outpatient total hip arthroplasty candidates if spinal is the preferred anesthesia type.

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New
Perceived Knowledge, Attitudes, and Implementation of Evidence-Based Practice Among Jordanian Nurses in Critical Care Units
Authors: Salah Ma'moun A. , Abu-Moghli Fathieh A.
Published: July 2020

Background

Evidence-based practice (EBP) has become of great interest to policymakers, health care practitioners, and researchers.

Objective

This study aimed at assessing knowledge associated with, attitudes toward, and implementation of EBP among Jordanian registered nurses (RNs) in critical care units.

Method

A descriptive, correlational, and cross-sectional study was conducted in 5 hospitals: 3 public and 2 private. A convenience sample of 200 RNs was invited. Data were collected using a paper-based and self-administered questionnaire, in 2 sections; the first section was the demographic and contextual characteristics and the second was the Evidence-Based Practice Questionnaire (J Adv Nurs. 2006;53(4):454-458) to measure RNs' knowledge, attitudes, and EBP.

Results

A total of 187 RNs were included in this study. Findings revealed that Jordanian RNs in critical care units perceived themselves as having a satisfactory level of knowledge and practice of evidence-based interventions. In addition, RNs strongly recognized the value of EBP. There were significant positive associations between EBP and knowledge associated with EBP (r = 0.708, P < .001) and attitude toward EBP (r = 0.490, P < .001).

Conclusion

Knowledge associated with EBP, a positive attitude toward EBP, higher educational qualifications, and training in EBP all increased the implementation of EBP. It is recommended that continuing education programs on EBP for nurses be conducted. Nursing educators in clinical settings have to consider a number of strategies to improve EBP. A qualitative research design and/or including open-ended questions are encouraged to gain more in-depth views about EBP.
How We Manage Patients With Chronic Lymphocytic Leukemia During the SARS‐CoV‐2 Pandemic
Authors: Rossi Davide , Shadman Mazyar , Condoluci Adalgisa , Brown Jennifer R. , Byrd John C. , Gaidano Gianluca , Hallek Michael , Hillmen Peter , Mato Anthony , Montserrat Emili , Ghia Paolo
Published: July 2020

Infections are a major cause of morbidity and mortality in patients with chronic lymphocytic leukemia (CLL). These can be exacerbated by anti‐leukemic treatments. In addition, the typical patients with CLL already have fragilities and background risk factors that apply to the general population for severe COVID‐19. On these bases, patients with CLL may experience COVID‐19 morbidity and mortality. Recurrent seasonal epidemics of SARS‐CoV‐2 are expected, and doctors taking care of patients with CLL must be prepared for the possibility of substantial resurgences of infection and adapt their approach to CLL management accordingly. In this Guideline Article, we aim at providing clinicians with a literature‐informed expert opinion on the management of patients with CLL during SARS‐CoV‐2 epidemic.
Two Episodes of Cutaneous Larva Migrans, Two Months Apart, Despite a Single Exposure Period
Authors: Del Giudice Pascal , Hubiche Thomas
Published: July 2020

We present a case of a 22-month-old girl who had 2 episodes of cutaneous larva migrans 2 months apart after returning from a tropical area, despite a single exposure period.
Initial Evaluation and Classification of Knee Dislocations
Authors: Ockuly Andrew C. , Imada Allicia O. , Richter Dustin L. , Treme Gehron P. , Wascher Daniel C. , Schenck Robert C.
Published: July 2020

The traumatic knee dislocation (KD) is a complex condition resulting in injury to >1 ligament or ligament complexes about the knee, termed multiligament knee injuries. Typically, KDs result in injury to both cruciate ligaments with variable injury to collateral ligament complexes. Very rarely, KD may occur with single cruciate injuries combined with collateral involvement but it is important to understand that not all multiligament knee injuries are KDs. Patients can present in a wide spectrum of severity; from frank dislocation of the tibiofemoral joint to a spontaneously reduced KD, either with or without neurovascular injury. The initial evaluation of these injuries should include a thorough patient history and physical examination, with particularly close attention to vascular status which has the most immediate treatment implications. Multiple classification systems have been developed for KDs, with the anatomic classification having the most practical application.
Knee Ligament Anatomy and Biomechanics
Authors: Hassebrock Jeffrey D. , Gulbrandsen Matthew T. , Asprey Walker L. , Makovicka Justin L. , Chhabra Anikar
Published: July 2020

An understanding of knee ligament anatomy and biomechanics is foundational for physicians treating knee injuries, especially the more rare and morbid multiligamentous knee injuries. This chapter examines the roles that the cruciate and collateral anatomy and morphology play in their kinematics. Additionally, the biomechanics of the ACL, PCL, MCL, and LCL are discussed as they have surgical and reconstructive implications.
Avoid the “Southern Diet”? What, Really, Do You Mean?
Authors: Kolasa Kathryn M. , Firnhaber Gina C. , Craven Kay
Published: July 2020

As far as eating patterns go, the southern diet is often viewed as synonymous with poor food choices. But is it really? How do we know? When attempting to balance patient beliefs, habits, and cultural norms with best evidence, we must interpret and apply research evidence regarding dietary patterns such as the “Southern Diet.” We address the complexities of interpreting dietary pattern–based research evidence and present the cases of 2 born and bred southern adults with potential to benefit from culturally appropriate nutrition and dietary counseling.
Fermented Foods and the Gut Microbiome
Authors: Heinen Emily , Ahnen Rylee T. , Slavin Joanne
Published: July 2020

The question of what role intestinal bacteria play in human health has grown in popularity recently, because of the rise in “gut-healthy” consumer products and increased research into the ways the gut affects various systems in the body. This term has raised questions about the role that probiotics and prebiotics play in shaping the health of that gut health and how fermented foods-a centuries-old staple now heavily marketed to consumers—might also affect the composition of the microbiota. Various studies on probiotics, fermented foods, and gut health are examined to determine the extent to which the gut really plays a major in human health and whether products marketed for gut health actually alter its makeup. In general, evidence about such products is inconsistent, and conclusions are varied. Many studies show links between the profile of the intestinal microbiota and digestion, disease states, and even mental health. Probiotics, in general, have been determined to positively boost the levels of Lactobacilli, Bifidobacteria, and Streptococci in the gut, which may increase the positive effects of the microbiome. However, other fermented foods such as kombucha, kimchi, and tofu, which are often marketed as containing probiotics, require more human subject studies to draw concrete conclusions about these supposed benefits.
Pediatric Cardiac Intensive Care Distribution, Service Delivery, and Staffing in the United States in 2018*
Authors: Horak Robin V. , Alexander Peta M. , Amirnovin Rambod , Klein Margaret J. , Bronicki Ronald A. , Markovitz Barry P. , McBride Mary E. , Randolph Adrienne G. , Thiagarajan Ravi R.
Published: July 2020

Objectives:

To assess the distribution, service delivery, and staffing of pediatric cardiac intensive care in the United States.

Design:

Based on a 2016 national PICU survey, and verified through online searching and clinician networking, medical centers were identified with a separate cardiac ICU or mixed ICU. These centers were sent a structured web-based survey up to four times, with follow-up by mail and phone for nonresponders.

Setting:

Cardiac ICUs were defined as specialized units, specifically for the treatment of children with life-threatening primary cardiac conditions. Mixed ICUs were defined as separate units, specifically for the treatment of children with life-threatening conditions, including primary cardiac disease.

Participants:

Cardiac ICU or mixed ICU physician medical directors or designees.

Measurements and Main Results:

One-hundred twenty ICUs were identified: 61 (51%) were mixed ICUs and 59 (49%) were cardiac ICUs. Seventy five percent of institutions at least sometimes used a neonatal ICU prior to surgery. The most common temporary cardiac support beyond extracorporeal membrane oxygenation was a centrifugal pump such as Centrimag. Durable cardiac support devices were far more common in separate cardiac ICUs (84% vs 20%; p < 0.0001). Significantly less availability of electrophysiology, heart failure, and cardiac anesthesia consultation was available in mixed ICUs (p = 0.0003, p < 0.0001, p = 0.042 respectively). ICU attending physicians were in-house day and night 98% of the time in mixed ICUs and 87% of the time in cardiac ICUs. Nurse practitioners were consistent front-line providers in the ICUs caring for children with primary cardiac disease staffing 88% of cardiac ICUs and 56% of mixed ICUs. Mixed ICUs were more commonly staffed with pediatric residents, and critical care fellows were found in more cardiac ICUs (83% vs 77%; p < 0.0001).

Conclusions:

Mixed ICUs and cardiac ICUs have statistically different staffing models and available services. More evaluation is needed to understand how this may impact patient outcomes and training programs of physicians and nurses.
Clinical Signs to Categorize Shock and Target Vasoactive Medications in Warm Versus Cold Pediatric Septic Shock*
Authors: Walker Sarah B. , Conlon Thomas W. , Zhang Bingqing , Mensinger Janell L. , Fitzgerald Julie C. , Himebauch Adam S. , Glau Christie , Nishisaki Akira , Ranjit Suchitra , Nadkarni Vinay , Weiss Scott L.
Published: July 2020

Objectives:

Determine level of agreement among clinical signs of shock type, identify which signs clinicians prioritize to determine shock type and select vasoactive medications, and test the association of shock type-vasoactive mismatch with prolonged organ dysfunction or death (complicated course).

Design:

Retrospective observational study.

Setting:

Single large academic PICU.

Patients:

Patients less than 18 years treated on a critical care sepsis pathway between 2012 and 2016.

Interventions:

None.

Measurements and Main Results:

Agreement among clinical signs (extremity temperature, capillary refill, pulse strength, pulse pressure, and diastolic blood pressure) was measured using Fleiss and Cohen’s κ. Association of clinical signs with shock type and shock type-vasoactive mismatch (e.g., cold shock treated with vasopressor rather than inotrope) with complicated course was determined using multivariable logistic regression. Of 469 patients, clinicians determined 307 (65%) had warm and 162 (35%) had cold shock. Agreement across all clinical signs was low (κ, 0.25; 95% CI, 0.20–0.30), although agreement between extremity temperature, capillary refill, and pulse strength was better than with pulse pressure and diastolic blood pressure. Only extremity temperature (adjusted odds ratio, 26.6; 95% CI, 15.5–45.8), capillary refill (adjusted odds ratio, 15.7; 95% CI, 7.9–31.3), and pulse strength (adjusted odds ratio, 21.3; 95% CI, 8.6–52.7) were associated with clinician-documented shock type. Of the 86 patients initiated on vasoactive medications during the pathway, shock type was discordant from vasoactive medication (κ, 0.14; 95% CI, –0.03 to 0.31) and shock type-vasoactive mismatch was not associated with complicated course (adjusted odds ratio, 0.3; 95% CI, 0.1–1.02).

Conclusions:

Agreement was low among common clinical signs used to characterize shock type, with clinicians prioritizing extremity temperature, capillary refill, and pulse strength. Although clinician-assigned shock type was often discordant with vasoactive choice, shock type-vasoactive mismatch was not associated with complicated course. Categorizing shock based on clinical signs should be done cautiously.
Dexmedetomidine Sedation in Mechanically Ventilated Critically Ill Children: A Pilot Randomized Controlled Trial
Authors: Erickson Simon J. , Millar Johnny , Anderson Brian J. , Festa Marino S. , Straney Lahn , Shehabi Yahya , Long Debbie A. ,   for the Baby SPICE Investigators and the Australian and New Zealand Intensive Care Society Paediatric Study Group (ANZICS-PSG)
Published: July 2020

Objectives:

To assess the feasibility, safety, and efficacy of a sedation protocol using dexmedetomidine as the primary sedative in mechanically ventilated critically ill children.

Design:

Open-label, pilot, prospective, multicenter, randomized, controlled trial. The primary outcome was the proportion of sedation scores in the target sedation range in the first 48 hours. Safety outcomes included device removal, adverse events, and vasopressor use. Feasibility outcomes included time to randomization and protocol fidelity.

Setting:

Six tertiary PICUs in Australia and New Zealand.

Patients:

Critically ill children, younger than 16 years old, requiring intubation and mechanical ventilation and expected to be mechanically ventilated for at least 24 hours.

Interventions:

Children randomized to dexmedetomidine received a dexmedetomidine-based algorithm targeted to light sedation (State Behavioral Scale –1 to +1). Children randomized to usual care received sedation as determined by the treating clinician (but not dexmedetomidine), also targeted to light sedation.

Measurements and Main Results:

Sedation with dexmedetomidine as the primary sedative resulted in a greater proportion of sedation measurements in the light sedation range (State Behavioral Scale –1 to +1) over the first 48 hours (229/325 [71%] vs 181/331 [58%]; p = 0.04) and the first 24 hours (66/103 [64%] vs 48/116 [41%]; p < 0.001) compared with usual care. Cumulative midazolam dosage was significantly reduced in the dexmedetomidine arm compared with usual care (p = 0.002).There were more episodes of hypotension and bradycardia with dexmedetomidine (including one serious adverse event) but no difference in vasopressor requirements. Median time to randomization after intubation was 6.0 hours (interquartile range, 2.0–9.0 hr) in the dexmedetomidine arm compared with 3.0 hours (interquartile range, 1.0–7.0 hr) in the usual care arm (p = 0.24).

Conclusions:

A sedation protocol using dexmedetomidine as the primary sedative was feasible, appeared safe, achieved early, light sedation, and reduced midazolam requirements. The findings of this pilot study justify further studies of sedative agents in critically ill children.
Current State of Nutrition Education in Pediatric Critical Care Medicine Fellowship Programs in the United States and Canada
Authors: De Souza Bradley J. , Callif Charles , Staffa Steven J. , Mehta Nilesh M. , Wolbrink Traci A.
Published: July 2020

Objectives:

To assess the current state of nutrition education provided during pediatric critical care medicine fellowship.

Design:

Cross-sectional survey.

Setting:

Program directors and fellows from pediatric critical care medicine fellowship programs in America and Canada.

Subjects:

Seventy current pediatric critical care medicine fellows and twenty-five pediatric critical care medicine fellowship program directors were invited to participate.

Interventions:

Participants were asked demographic questions related to their fellowship programs, currently utilized teaching methods, perceptions regarding adequacy and effectiveness of current nutrition education, and levels of fellow independence, comfort, confidence, and expectations in caring for the nutritional needs of patients.

Measurements and Main Results:

Surveys were sent to randomly selected program directors and fellows enrolled in pediatric critical care medicine fellowship programs in America and Canada. Twenty program directors (80%) and 60 fellows (86%) responded. Ninety-five percent of programs (19/20) delivered a formal nutrition curriculum; no curriculum was longer than 5 hours per academic year. Self-reported fellow comfort with nutrition topics did not improve over the course of fellowship (p = 0.03), with the exception of nutritional aspects of special diets. Sixty-five percent of programs did not hold fellows responsible for writing daily parenteral nutrition prescriptions. There was an inverse relationship between total number of fellows in a pediatric critical care medicine program and levels of comfort in ability to provide parenteral nutrition support (p = 0.01). Program directors perceived their nutritional curriculum to be more effective than did their fellows (p ≤ 0.001).

Conclusions:

Nutrition education was reported as highly underrepresented in pediatric critical care medicine fellowship curricula. The majority of programs rely on allied health care professionals to prescribe parenteral nutrition, which may influence trainee independence in the provision of nutritional therapies. Improving the format of current nutrition curriculums, by relying on more active teaching methods, may improve the delivery and efficacy of nutrition education. The impact of novel training interventions on improving the competency and safety of enteral and parenteral nutrition delivery in the PICU must be further examined.
Nurse-Implemented Goal-Directed Strategy to Improve Pain and Sedation Management in a Pediatric Cardiac ICU
Authors: Lincoln Patricia A. , Whelan Katherine , Hartwell Lauren P. , Gauvreau Kimberlee , Dodsen Brenda L. , LaRovere Joan M. , Thiagarajan Ravi R. , Hickey Patricia A. , Curley Martha A. Q.
Published: July 2020

Objectives:

To assess the impact of a nurse-implemented goal-directed sedation strategy on patient care and nursing practice in a pediatric cardiac ICU.

Design:

Quality improvement project with a pre-post interval measurement plan.

Setting:

Thirty-one bed pediatric cardiac ICU in a freestanding tertiary care children’s hospital.

Patients:

Postoperative pediatric cardiac surgery patients.

Interventions:

The implementation of cardiac-Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE), a nurse-implemented goal directed strategy to improve pain and sedation management in a pediatric cardiac ICU which included daily team discussion of the patient’s trajectory of illness (acute, titration, or weaning phase), prescription of a sedation target score based on the patient’s trajectory of illness, arousal assessments, and opioid and/or sedative titration. Withdrawal Assessment Scores were used to assess and manage iatrogenic withdrawal symptoms.

Measurements and Main Results:

Data related to opioid and sedation use, pain and sedation scores, and the occurrence and management of iatrogenic withdrawal symptoms were reviewed on 1,243 patients during four separate time periods: one pre-implementation and three discontinuous post-implementation time intervals. Patient age and complexity were consistent across the data collection periods. Post-implementation opioids and benzodiazepines use was reduced about 50% without a concomitant increase in the use of other sedative classes. Few post-intervention patients were discharged from the pediatric cardiac ICU or to home on methadone (pediatric cardiac ICU: pre 19% to post 3%; hospital: pre 12% to post 1.3%). Documentation of pain, sedation, and withdrawal scores became more consistent and nurses reported satisfaction with their patient’s comfort management.

Conclusions:

The implementation of a nurse-driven goal-directed plan such as cardiac-RESTORE to manage pediatric cardiac ICU patient pain and sedation is possible, sustainable, and associated with reduced sedative and methadone use.
Perspective of the Surviving Sepsis Campaign on the Management of Pediatric Sepsis in the Era of Coronavirus Disease 2019*
Authors: Weiss Scott L. , Peters Mark J. , Agus Michael S. D. , Alhazzani Waleed , Choong Karen , Flori Heidi R. , Inwald David P. , Nadel Simon , Nunnally Mark E. , Schlapbach Luregn J. , Tasker Robert C. , Tissieres Pierre , Kissoon Niranjan
Published: July 2020

Severe acute respiratory syndrome coronavirus 2 is a novel cause of organ dysfunction in children, presenting as either coronavirus disease 2019 with sepsis and/or respiratory failure or a hyperinflammatory shock syndrome. Clinicians must now consider these diagnoses when evaluating children for septic shock and sepsis-associated organ dysfunction. The Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-associated Organ Dysfunction in Children provide an appropriate framework for the early recognition and initial resuscitation of children with sepsis or septic shock caused by all pathogens, including severe acute respiratory syndrome coronavirus 2. However, the potential benefits of select adjunctive therapies may differ from non-coronavirus disease 2019 sepsis.
Nitrincola iocasae sp. nov., a bacterium isolated from sediment collected at a cold seep field in the South China Sea
Authors: Zhang Huan , Wang Hao , Chen Hao , Sun Qinglei , Zhong Zhaoshan , Wang Minxiao , Cao Lei , Lian Chao , Zhou Li , Li Chaolun
Published: July 2020

A novel bacterium, designated strain KXZD1103T, was isolated from sediment collected at a cold seep field of the Formosa Ridge in the South China Sea. Cells were Gram-stain-negative, facultatively anaerobic, motile, oxidase- and catalase-positive, and grew optimally at 28 °C, pH 6.0–pH 7.0 and in the presence of 1–3 % (w/v) NaCl. The major cellular fatty acids were summed feature 8 (C18 : 1
 ω7c/C18 : 1
 ω6c), summed feature 3 (C16 : 1
 ω7c/C16 : 1
 ω6c) and C16 : 0. The major respiratory ubiquinone was Q-8. The predominant polar lipids were diphosphatidylglycerol, phosphatidylethanolamine and phosphatidylglycerol. Analysis of 16S rRNA gene sequences revealed that strain KXZD1103T grouped with members of the genus

Nitrincola

, with

Nitrincola lacisaponensis

4CAT (98.1 % sequence similarity) and

Nitrincola schmidtii

R4-8T (97.7 %) as its closest neighbours. Genome sequencing revealed a genome size of 4.17 Mb and a DNA G+C content of 50.1 %. Genomic average nucleotide identity values for strain KXZD1103T with the type strains within the genus

Nitrincola

ranged from 71.0 to 75.7 %, while the in silico DNA–DNA hybridization values for strain KXZD1103T with these strains ranged from 16.1 to 21.6 %. On the basis of the results of phylogenetic, phenotypic and chemotaxonomic analyses, strain KXZD1103T is considered to represent a novel species of the genus

Nitrincola

, for which the name Nitrincola iocasae sp. nov. is proposed. The type strain is KXZD1103T (=KCTC 72678T=MCCC 1K04283T).
Genomic variant-identification methods may alter Mycobacterium tuberculosis transmission inferences
Authors: Walter Katharine S. , Colijn Caroline , Cohen Ted , Mathema Barun , Liu Qingyun , Bowers Jolene , Engelthaler David M. , Narechania Apurva , Lemmer Darrin , Croda Julio , Andrews Jason R.
Published: July 2020

Pathogen genomic data are increasingly used to characterize global and local transmission patterns of important human pathogens and to inform public health interventions. Yet, there is no current consensus on how to measure genomic variation. To test the effect of the variant-identification approach on transmission inferences for Mycobacterium tuberculosis, we conducted an experiment in which five genomic epidemiology groups applied variant-identification pipelines to the same outbreak sequence data. We compared the variants identified by each group in addition to transmission and phylogenetic inferences made with each variant set. To measure the performance of commonly used variant-identification tools, we simulated an outbreak. We compared the performance of three mapping algorithms, five variant callers and two variant filters in recovering true outbreak variants. Finally, we investigated the effect of applying increasingly stringent filters on transmission inferences and phylogenies. We found that variant-calling approaches used by different groups do not recover consistent sets of variants, which can lead to conflicting transmission inferences. Further, performance in recovering true variation varied widely across approaches. While no single variant-identification approach outperforms others in both recovering true genome-wide and outbreak-level variation, variant-identification algorithms calibrated upon real sequence data or that incorporate local reassembly outperform others in recovering true pairwise differences between isolates. The choice of variant filters contributed to extensive differences across pipelines, and applying increasingly stringent filters rapidly eroded the accuracy of transmission inferences and quality of phylogenies reconstructed from outbreak variation. Commonly used approaches to identify

M. tuberculosis

genomic variation have variable performance, particularly when predicting potential transmission links from pairwise genetic distances. Phylogenetic reconstruction may be improved by less stringent variant filtering. Approaches that improve variant identification in repetitive, hypervariable regions, such as long-read assemblies, may improve transmission inference.
Association between Alzheimer’s disease and COVID-19: A bidirectional Mendelian randomization
Authors: Liu Di , Zhang Xiaoyu , Cao Weijie , Zhang Jie , Song Manshu , Xing Weijia , Wang Wei , Meng Qun , Wang Youxin
Published: July 2020

Background

In observational studies, Alzheimer’s disease (AD) has been associated with an increased risk of Coronavirus disease 2019 (COVID-19), and the prognosis of COVID-19 can affect nervous systems. However, the causality between these conditions remains to be determined.

Methods

This study sought to investigate the bidirectional causal relations of AD with COVID-19 using two-sample Mendelian randomization (MR) analysis.

Results

We found that genetically predicted AD was significantly associated with higher risk of severe COVID-19 (odds ratio [OR], 3.329; 95% confidence interval [CI], 1.139-9.725; P=0.028). It’s interesting that genetically predicted severe COVID-19 was also significantly associated with higher risk of AD (OR, 1.004; 95% CI, 1.001-1.007; P=0.018). In addition, the two strong genetic variants associated with severe COVID-19 was associated with higher AD risk (OR, 1.018; 95% CI, 1.003-1.034; P=0.018). There is no evidence to support that genetically predicted AD was significantly associated with COVID-19 susceptibility, and vice versa. No obvious pleiotropy bias and heterogeneity were observed.

Conclusion

Overall, AD may causally affect severe COVID-19, and vice versa, performing bidirectional regulation through independent biological pathways.
METFORMIN USE IS ASSOCIATED WITH REDUCED MORTALITY IN A DIVERSE POPULATION WITH COVID-19 AND DIABETES
Authors: Crouse Andrew B. , Grimes Tiffany , Li Peng , Might Matthew , Ovalle Fernando , Shalev Anath
Published: July 2020

BACKGROUND

Coronavirus disease-2019 (COVID-19) is a growing pandemic with an increasing death toll that has been linked to various comorbidities as well as racial disparity. However, the specific characteristics of these at-risk populations are still not known and approaches to lower mortality are lacking.

METHODS

We conducted a retrospective electronic health record data analysis of 25,326 subjects tested for COVID-19 between 2/25/20 and 6/22/20 at the University of Alabama at Birmingham Hospital, a tertiary health care center in the racially diverse Southern U.S. The primary outcome was mortality in COVID-19-positive subjects and the association with subject characteristics and comorbidities was analyzed using simple and multiple linear logistic regression.

RESULTS

The odds ratio of contracting COVID-19 was disproportionately high in Blacks/African- Americans (OR 2.6; 95%CI 2.19-3.10; p<0.0001) and in subjects with obesity (OR 1.93; 95%CI 1.64-2.28; p<0.0001), hypertension (OR 2.46; 95%CI 2.07-2.93; p<0.0001), and diabetes (OR 2.11; 95%CI 1.78-2.48; p<0.0001). Diabetes was also associated with a dramatic increase in mortality (OR 3.62; 95%CI 2.11-6.2; p<0.0001) and emerged as an independent risk factor in this diverse population even after correcting for age, race, sex, obesity and hypertension. Interestingly, we found that metformin treatment was independently associated with a significant reduction in mortality in subjects with diabetes and COVID-19 (OR 0.33; 95%CI 0.13-0.84; p=0.0210).

CONCLUSION

Thus, these results suggest that while diabetes is an independent risk factor for COVID-19- related mortality, this risk is dramatically reduced in subjects taking metformin, raising the possibility that metformin may provide a protective approach in this high risk population.
Mitochondrial state determines functionally divergent stem cell population in planaria
Authors: Haroon Mohamed Mohamed , Lakshmanan Vairavan , Sarkar Souradeep R. , Lei Kai , Vemula Praveen Kumar , Palakodeti Dasaradhi
Published: July 2020

Mitochondrial state changes were shown to be critical for stem cell function. However, variation in the mitochondrial content in stem cells and the implication, if any, on differentiation is poorly understood. Here, using cellular and molecular studies, we show that the planarian pluripotent stem cells (PSCs) have low mitochondrial mass compared to its progenitors. Further, the mitochondrial mass correlated with OxPhos and inhibiting the transition to OxPhos dependent metabolism in cultured cells resulted in higher PIWI-1Highneoblasts. Transplantation experiments provided functional validation that neoblasts with low mitochondrial mass are the true PSCs. In summary, we show that low mitochondrial mass is a hallmark of PSCs in planaria and provide a mechanism to isolate live, functionally active, PSCs from different cell cycle stages (G0/G1 and S, G2/M). Our study demonstrates that the change in mitochondrial metabolism, a feature of PSCs is conserved in planaria and highlights its role in organismal regeneration.
Gene expression evolution in pattern-triggered immunity withinArabidopsis thalianaand across Brassicaceae species
Authors: Winkelmüller Thomas M. , Entila Frederickson , Anver Shajahan , Piasecka Anna , Song Baoxing , Dahms Eik , Sakakibara Hitoshi , Gan Xiangchao , Kułak Karolina , Sawikowska Aneta , Krajewski Paweł , Tsiantis Miltos , Garrido-Oter Ruben , Fukushima Kenji , Schulze-Lefert Paul , Laurent Stefan , Bednarek Paweł , Tsuda Kenichi
Published: July 2020

Plants recognize surrounding microbes by sensing microbe-associated molecular patterns (MAMPs) to activate pattern-triggered immunity (PTI). Despite their significance for microbial control, the evolution of PTI responses remains largely uncharacterized. Employing comparative transcriptomics of sixArabidopsis thalianaaccessions and three additional Brassicaceae species for PTI responses to the MAMP flg22, we identified a set of genes with expression changes under purifying selection in the Brassicaceae species and genes exhibiting species-specific expression signatures. Variation in flg22-triggered transcriptome and metabolome responses across Brassicaceae species was incongruent with their phylogeny while expression changes were strongly conserved withinA. thaliana, suggesting directional selection for some species-specific gene expression. We found the enrichment of WRKY transcription factor binding sites in 5’-regulatory regions in conserved and species-specific responsive genes, linking the emergence of WRKY-binding sites with the evolution of gene responses in PTI. Our findings advance our understanding of transcriptome evolution during biotic stress.
Ultrasound to identify lupus patients with inflammatory joint symptoms with a better response to therapy: The USEFUL longitudinal multicentre study
Authors: Mahmoud Khaled , Zayat Ahmed S , Md Yusof Md Yuzaiful , Dutton Katherine , Teh Lee Suan , Yee Chee-Seng , D’Cruz David , Ng Nora , Isenberg David , Ciurtin Coziana , Conaghan Philip G , Emery Paul , Edwards Christopher J , Hensor Elizabeth MA , Vital Edward M
Published: July 2020

Objective

To determine whether SLE patients with inflammatory joint symptoms and ultrasound-synovitis achieve better clinical responses to glucocorticoid compared to patients with normal scans. Secondary objectives included identification of clinical features predicting ultrasound-synovitis.

Methods

A longitudinal muticentre study of SLE patients with physician-diagnosed inflammatory joint pain was undertaken. Clinical assessments, patient-reported outcomes, and bilateral hands and wrist ultrasound were collected at 0-, 2- and 6-weeks after intramuscular methylprednisolone 120mg. The primary outcome (determined via internal pilot analysis) was EMS-VAS at 2-weeks, adjusted for the baseline value, comparing patients with positive (GS≥2 and/or PD≥1) and negative ultrasound. Post-hoc analyses adjusting for fibromyalgia were performed.

Results

Of 133 patients recruited, 78/133 had positive ultrasound, but only 68% of these had ≥1 swollen joint. Of 66/133 patients with ≥1 swollen joint, 20% had negative ultrasound. Positive ultrasound was associated with joint swelling, symmetrical small joint distribution and serology. In full analysis set (n=133) there was no difference in baseline-adjusted EMS-VAS at week 2 (−7.7mm 95% CI − 19.0mm, 3.5mm, p=0.178). After excluding 32 fibromyalgia patients, response was significantly better in patients with positive ultrasound at baseline (baseline-adjusted EMS-VAS at 2-weeks - 12.1 mm, 95% CI −22.2mm, −0.1mm, p=0.049). This difference was greater when adjusted for treatment (−12.8mm (95% CI −22mm, −3mm), p=0.007). BILAG and SLEDAI responses were higher in ultrasound-positive patients.

Conclusions

In SLE patients without fibromyalgia, those with positive ultrasound had a better clinical response to therapy. Imaging-detected synovitis should be used to select SLE patients for therapy and enrich clinical trials.