bluuebunny/crossref_metadata_2025 huggingface dataset:
How to diagnose food allergy
Authors: Sato Sakura , Yanagida Noriyuki , Ebisawa Motohiro
Published: March 2018

Purpose of review

To assess the recent studies that focus on specific immunoglobulin E (sIgE) testing and basophil activation test (BAT) for diagnosing IgE-mediated food allergies.

Recent findings

The sIgE to allergen extract or component can predict reactivity to food. The cutoff value based on the positive predictive value (PPV) of sIgE can be considered whenever deciding whether oral food challenge (OFC) is required to diagnose hen's egg, cow's milk, wheat, peanut, and cashew nut allergy. However, PPV varies depending on the patients’ background, OFC methodology, challenge foods, and assay methodology. Component-resolved diagnostics (CRD) has been used for food allergy diagnosis. Ovomucoid and omega-5 gliadin are good diagnostic markers for heated egg and wheat allergy. More recently, CRD of peanut, tree nuts, and seed have been investigated. Ara h 2 showed the best diagnostic accuracy for peanut allergy; other storage proteins, such as Jug r 1 for walnut, Ana o 3 for cashew nut, Ses i 1 for sesame, and Fag e 3 for buckwheat, are also better markers than allergen extracts. Some studies suggested that BAT has superior specificity than skin prick test and sIgE testing.

The sIgE testing and BAT can improve diagnostic accuracy. CRD provides additional information that can help determine whether OFCs should be performed to diagnose food allergy.
Early-phase Innate Immune Suppression in Murine Severe Sepsis Is Restored with Systemic Interferon-β
Authors: Kusakabe Yoshiomi , Uchida Kanji , Yamamura Yoshiro , Hiruma Takahiro , Totsu Tokie , Tamai Yuho , Tsuyuzaki Hitoshi , Hasegawa Kyoko , Chang Kyungho , Yamada Yoshitsugu
Published: March 2018

Background

Sepsis is a leading cause of death in the intensive care unit. Immune modulatory therapy targeting sepsis-associated proinflammatory responses has not shown survival benefit. Here, the authors evaluated innate immunity at the early stage of murine mild or severe peritoneal sepsis induced by cecal ligation and puncture, and the effect of systemic interferon-β, a potent inflammatory mediator, on severe sepsis as well as its mechanism of action.

Methods

Mild and severe sepsis was induced in C57BL/6 mice by cecal ligation and puncture with 22- and 18-gauge needles for puncture, respectively. Interferon-β (700 U/g) was subcutaneously administered either before or 12 h after cecal ligation and puncture for the severe sepsis group.

Results

Severe sepsis resulted in significantly lower 6-day survival rates than mild sepsis (n = 48, 25% vs. n = 11, 81.8%, P = 0.002), significantly less phagocytic capacity of peritoneal exudate cells, and lower CXC chemokine receptor-2 expression on circulating neutrophils at 24 h after cecal ligation and puncture. Interferon-β administration 12 h after cecal ligation and puncture associated with significantly improved survival (n = 34, 52.9%, P = 0.017) increased the number and function of peritoneal exudate cells, peritoneal/systemic inflammatory cytokine/chemokine concentrations, and CXC chemokine receptor-2 on neutrophils, compared with the severe sepsis controls. However, those responses were not observed in the prophylactic interferon-β group (n = 24). Interferon-β increased lipopolysaccharide-induced interleukin-6 messenger RNA/protein expression of lipopolysaccharide-tolerant murine peritoneal macrophages, which was not observed in nontolerant cells.

Conclusions

In severe sepsis, immune suppression occurs within 24 h and is associated with worse mortality. Interferon-β given after the onset of peritonitis restores impaired innate immunity in vivo and in vitro.
Common techniques useful to the practicing or training orthopaedic surgeon on call in a pediatric hospital
Authors: Sheffer Benjamin W.
Published: March 2018

This article highlights surgical procedures with which orthopaedic residents entering a pediatric rotation should be familiar. Closed reduction and percutaneous pinning of supracondylar humeral fractures, in situ pinning of slipped capital femoral epiphysis, and flexible intramedullary nailing of long bone fractures are described. Although these are just a few of many procedures a resident will learn while on a pediatric rotation, they probably are the most utilized while on call at a pediatric hospital.
The Speaker Gender Gap at Critical Care Conferences
Authors: Mehta Sangeeta , Rose Louise , Cook Deborah , Herridge Margaret , Owais Sawayra , Metaxa Victoria
Published: March 2018

Objectives:

To review women’s participation as faculty at five critical care conferences over 7 years.

Design:

Retrospective analysis of five scientific programs to identify the proportion of females and each speaker’s profession based on conference conveners, program documents, or internet research.

Setting:

Three international (European Society of Intensive Care Medicine, International Symposium on Intensive Care and Emergency Medicine, Society of Critical Care Medicine) and two national (Critical Care Canada Forum, U.K. Intensive Care Society State of the Art Meeting) annual critical care conferences held between 2010 and 2016.

Subjects:

Female faculty speakers.

Interventions:

None.

Measurements and Main Results:

Male speakers outnumbered female speakers at all five conferences, in all 7 years. Overall, women represented 5–31% of speakers, and female physicians represented 5–26% of speakers. Nursing and allied health professional faculty represented 0–25% of speakers; in general, more than 50% of allied health professionals were women. Over the 7 years, Society of Critical Care Medicine had the highest representation of female (27% overall) and nursing/allied health professional (16–25%) speakers; notably, male physicians substantially outnumbered female physicians in all years (62–70% vs 10–19%, respectively). Women’s representation on conference program committees ranged from 0% to 40%, with Society of Critical Care Medicine having the highest representation of women (26–40%). The female proportions of speakers, physician speakers, and program committee members increased significantly over time at the Society of Critical Care Medicine and U.K. Intensive Care Society State of the Art Meeting conferences (p < 0.05), but there was no temporal change at the other three conferences.

Conclusions:

There is a speaker gender gap at critical care conferences, with male faculty outnumbering female faculty. This gap is more marked among physician speakers than those speakers representing nursing and allied health professionals. Several organizational strategies can address this gender gap.
Factors Associated With Canadian Nurses' Informatics Competency
Authors: Kleib Manal , Nagle Lynn
Published: March 2018

As digital innovations continue to transform health systems in Canada, it is important to examine registered nurses' preparedness in informatics, and factors associated with informatics competency. An exploratory, descriptive, cross-sectional survey was used to determine self-perceived informatics competencies, and factors associated with competency, among practicing nurses in Alberta. Results from 2844 completed surveys showed that nurses' self-perceived informatics competency was slightly above the mark of competent. Perceptions of competency were highest on foundational computer literacy skills and lowest on information and knowledge management competencies. However, overall informatics competency mean scores varied significantly in relation to age, educational qualification, years of experience, and work setting. The quality of informatics training and support offered by employers contributed the most to variance in mean scores of total and subdomains of informatics competency. Other factors, such as age, educational qualification, work setting, previous informatics education, access to the Internet, use of health technology, access to supporting resources, informatics training, an informatics role, and continuing education in informatics, also contributed to mean scores variance in differing degrees. Findings from this study provide a basis for actionable policies to address informatics educational needs and support requirements among nurses practicing now and in the future.
Family Presence During Resuscitation
Authors: Twibell Renee Samples , Siela Debra , Neal Alexis , Riwitis Cheryl , Beane Heather
Published: March 2018

Background

Families often desire proximity to loved ones during life-threatening resuscitations and perceive clear benefits to being present. However, critical care nurses and physicians perceive risks and benefits. Whereas research is accumulating on nurses' perceptions of family presence, physicians' perspectives have not been clearly explicated. Psychometrically sound measures of physicians' perceptions are needed to create new knowledge and enhance collaboration among critical care nurses and physicians during resuscitation events.

Objective

This study tests 2 new instruments that measure physicians' perceived risks, benefits, and self-confidence related to family presence during resuscitation.

Methods

By a correlational design, a convenience sample of physicians (N = 195) from diverse clinical specialties in 1 hospital in the United States completed the Physicians' Family Presence Risk-Benefit Scale and Physicians' Family Presence Self-confidence Scale.

Results

Findings supported the internal consistency reliability and construct validity of both new scales. Mean scale scores indicated that physicians perceived more risk than benefit and were confident in managing resuscitations with families present, although more than two-thirds reported feeling anxious. Higher self-confidence was significantly related to more perceived benefit and less perceived risk (P = .001). Younger physicians, family practice physicians, and physicians who previously had invited family presence expressed more positive perceptions (P = .05-.001).

Discussion

These 2 new scales offer a means to assess key perceptions of physicians related to family presence. Further testing in diverse physician populations may further validate the scales and yield knowledge that can strengthen collaboration among critical care nurses and physicians and improve patient and family outcomes.
Use of Recruitment Maneuvers in Patients With Acute Respiratory Distress Syndrome
Authors: Nguyen Angela
Published: March 2018

Acute respiratory distress syndrome (ARDS) is a deadly complication in critically ill patients that causes significant morbidity and mortality. Patients with ARDS are seen across intensive care unit settings, with treatment being largely supportive involving techniques through mechanical ventilation. Using low–tidal-volume ventilation is a standard of practice for patients with ARDS, as a lung protection strategy; however, alveolar decruitment may occur. Recruitment maneuvers can recruit collapsed alveoli and promote oxygenation. There are several methods of recruitment maneuvers—each with varying levels and durations of positive end-expiratory pressure. It is still uncertain which method is the best. The evidence for the efficacy of recruitment maneuvers has shown a decrease in intensive care unit mortality, but strong evidence is lacking for its routine use, and the decision to use recruitment maneuvers should be based on individual characteristics and responses. This article reviews management of ARDS, recruitment maneuver techniques, and clinical application through a case study.
Psychological Impact of Pregnancy Loss: Best Practice for Obstetric Providers
Authors: RICH DEBORAH
Published: March 2018

Three overlapping areas of study form the foundation of the psychological impact of pregnancy loss: (1) transition to parenthood and the development of attachment, (2) perinatal mental health disorders, and (3) complicated grief. This article integrates findings from prominent lineages of theory to offer the obstetric provider an evidence-based framework for patient care. Current consensus across fields of study is that preexisting depression and anxiety are the strongest predictors of psychological functioning after loss and through the subsequent pregnancy. Compassionate care, informational guidance and timed follow-up positively impact patient outcomes. The article concludes with recommendations for obstetric provider training and self-care.
Erythroferrone: An Erythroid Regulator of Hepcidin and Iron Metabolism
Authors: Coffey Richard , Ganz Tomas
Published: March 2018

Iron homeostasis ensures adequate iron for biological processes while preventing excessive iron accumulation, which can lead to tissue injury. In mammalian systems, iron availability is controlled by the interaction of the iron‐regulatory hormone hepcidin with ferroportin, a molecule that functions both as the hepcidin receptor as well as the sole known cellular exporter of iron. By reducing iron export through ferroportin to blood plasma, hepcidin inhibits the mobilization of iron from stores and the absorption of dietary iron. Among the many processes requiring iron, erythropoiesis is the most iron‐intensive, consuming most iron circulating in blood plasma. Under conditions of enhanced erythropoiesis, more iron is required to provide developing erythroblasts with adequate iron for heme and hemoglobin synthesis. Here the hormone erythroferrone, produced by erythroblasts, acts on hepatocytes to suppress hepcidin production, and thereby increase dietary iron absorption and mobilization from stores. This review focuses on the discovery of erythroferrone and recent advances in understanding the role of this hormone in the regulation of iron homeostasis during states of increased erythropoietic demand. Gaps in our understanding of the role of erythroferrone are highlighted for future study.
Missing Voices: Profile, Extent, and 12-Month Outcomes of Nonfatal Traumatic Brain Injury in Aboriginal and Non-Aboriginal Adults in Western Australia Using Linked Administrative Records
Authors: Katzenellenbogen Judith M. , Atkins Emily , Thompson Sandra C. , Hersh Deborah , Coffin Juli , Flicker Leon , Hayward Colleen , Ciccone Natalie , Woods Deborah , Greenland Melanie E. , McAllister Meaghan , Armstrong Elizabeth M.
Published: March 2018

Objective:

To investigate differences in the profile and outcomes between Aboriginal and non-Aboriginal Western Australians (WAs) hospitalized with traumatic brain injury (TBI).

Setting:

WA hospitals.

Participants:

TBI cases aged 15 to 79 years surviving their first admission during 2002-2011.

Design:

Patients identified from diagnostic codes and followed up for 12 months or more using WA-wide person-based linked hospital and mortality data.

Main Measures:

Demographic profile, 5-year comorbidity history, injury mechanism, injury severity, 12-month readmission, and mortality risks. Determinants of 12-month readmission.

Results:

Of 16 601 TBI survivors, 14% were Aboriginal. Aboriginal patients were more likely to be female, live remotely, and have comorbidities. The mechanism of injury was an assault in 57% of Aboriginal patients (vs 20%) and transport in 33% of non-Aboriginal patients (vs 17%), varying by remoteness. One in 10 Aboriginal TBI patients discharged themselves against medical advice. Crude 12-month readmission but not mortality risk was significantly higher in Aboriginal patients (48% vs 36%). The effect of age, sex, and injury mechanism on 12-month readmission was different for Aboriginal and non-Aboriginal patients.

Conclusion:

These findings suggest an urgent need for multisectoral primary prevention of TBI, as well as culturally secure and logistically appropriate medical and rehabilitation service delivery models to optimize outcomes.
Effects of Web-Based Parent Training on Caregiver Functioning Following Pediatric Traumatic Brain Injury: A Randomized Control Trial
Authors: Raj Stacey P. , Shultz Emily L. , Zang Huaiyu , Zhang Nanhua , Kirkwood Michael W. , Taylor H. Gerry , Stancin Terry , Yeates Keith Owen , Wade Shari L.
Published: March 2018

Objective:

To examine the effects of a Web-based parenting intervention (I-InTERACT), and an abbreviated version (Express), on caregiver depression, psychological distress, parenting stress, and parenting efficacy following pediatric traumatic brain injury (TBI).

Setting:

Four children's hospitals and 1 general hospital in the United States.

Participants:

148 caregivers of 113 children aged 3 to 9 years with a moderate to severe TBI.

Design:

Multicenter randomized controlled trial. Participants were randomly assigned to I-InTERACT, Express, or an active control condition. Caregiver data were collected at baseline and postintervention (6 months later).

Intervention:

I-InTERACT (10-14 sessions) and Express (7 sessions) combine live coaching of parenting skills and positive parenting strategies.

Main Measures:

Center for Epidemiologic Studies Depression Scale (CES-D); Global Severity Index of the Symptom Checklist-90-R (GSI), Parenting Stress Index (PSI), and Caregiver Self-Efficacy Scale (CSES).

Results:

Analyses revealed no main effects of treatment on caregiver distress (GSI), parenting stress (PSI), or parenting efficacy (CSES). However, analyses examining baseline severity as a moderator found that caregivers with elevated levels of depression in I-InTERACT experienced significantly greater reductions in CES-D scores compared with caregivers in the active control condition.

Conclusions:

I-InTERACT reduced caregiver depression but no other facets of caregiver psychological functioning. Modifications to the treatment content may be necessary to reduce parenting stress and improve caregiver efficacy.
Family Needs on an Inpatient Brain Injury Rehabilitation Unit: A Quantitative Assessment
Authors: Kreutzer Jeffrey S. , Marwitz Jennifer H. , Klyce Daniel W. , Wilder Schaaf Kathryn P. , Sima Adam P. , Welch Abigail M. , Niemeier Janet P.
Published: March 2018

Objective:

To examine the needs of family members in an inpatient setting and factors predicting extent to which needs are perceived as met.

Setting:

University health system inpatient rehabilitation unit.

Participants:

Adult survivors of traumatic brain injury and family members (n = 85).

Design:

Prospective, cross-sectional.

Main Measure:

Family Needs Questionnaire-Revised (FNQ-R).

Results:

Needs related to the Health Information subscale were most frequently rated as met, whereas needs related to the Instrumental Support and Emotional Support subscales were most frequently rated as unmet. Predictors related to the FNQ-R included family income, gender, and ethnicity. For 4 of 6 subscales, white family members were more likely to rate needs as unmet than minority members. For 3 subscales, females were more likely to rate needs as unmet than males. Greater household income was associated with fewer met needs for 2 subscales.

Conclusions:

The ranking of met and unmet needs in the present study was remarkably similar to previous studies within and outside the United States. Clinicians should not assume that families with relatively higher incomes will experience fewer unmet needs. Through structured assessment, clinicians can reveal perceived needs that might have otherwise been unrecognized and facilitate appropriate supports. Findings provide direction for inpatient program development.
Adjuvant Use of Cyclosporine A in the Treatment of Primary Pterygium: A Systematic Review and Meta-Analysis
Authors: Zhang Qing , Bao Ning , Liang Kun , Tao Liming
Published: March 2018

Purpose:

To evaluate the efficacy and tolerability of cyclosporine A (CsA) as an adjuvant treatment for primary pterygium.

Methods:

A comprehensive literature search from 7 databases (EMBASE, ISI Web of Science, PubMed, and the Cochrane Library for studies published in English and VIP, Wan Fang, and CNKI for studies published in Chinese). For the recurrence rate, pooled odds ratio (OR) and 95% confidence interval (CI) were calculated using a random-effects model. Tolerability estimates were measured by OR for adverse events.

Results:

A total of 7 studies meeting the inclusion criteria were included in this meta-analysis. Compared with the group with adjunctive CsA usage, the control group (no adjuvant use of CsA) showed a significantly increased risk of pterygium recurrence (OR = 2.71; 95% CI, 1.62–4.54). No obvious heterogeneity was detected in the included studies. Subgroup analysis showed that adjuvant use of CsA with pterygium excision alone resulted in a significantly lower frequency of recurrence than was seen in the group without adjuvant use of CsA (OR = 3.16; 95% CI, 1.18–8.84). However, there is no significant difference in pterygium recurrence between the subgroup (CsA + pterygium excision + limbal conjunctival autograft or flap rotation) and the subgroup without adjunctive CsA usage (pterygium excision + limbal conjunctival autograft or flap rotation).

Conclusions:

This meta-analysis suggests that adjuvant use of CsA can significantly reduce the risk of pterygium recurrence compared with pterygium excision alone, whereas adjuvant use of CsA may not reduce the risk of pterygium recurrence in terms of pterygium excision + limbal conjunctival autograft or conjunctival flap rotation.
Antibiotic Overuse in Children with Respiratory Syncytial Virus Lower Respiratory Tract Infection
Authors: van Houten Chantal B. , Naaktgeboren Christiana , Buiteman Brigitte J. M. , van der Lee Maaike , Klein Adi , Srugo Isaac , Chistyakov Irena , de Waal Wouter , Meijssen Clemens B. , Meijers Pieter W. , de Winter-de Groot Karin M. , Wolfs Tom F.W. , Shachor-Meyouhas Yael , Stein Michal , Sanders Elisabeth A. M. , Bont Louis J.
Published: March 2018

Background:

Respiratory syncytial virus (RSV) is the most common cause of lower respiratory tract infections (LRTI) during the first year of life. Antibiotic treatment is recommended in cases suspected of bacterial coinfection. The aim of this prospective study was to estimate the incidence of bacterial coinfections and the amount of antibiotic overuse in children infected with RSV using expert panel diagnosis.

Methods:

Children 1 month of age and over with LRTI or fever without source were prospectively recruited in hospitals in the Netherlands and Israel. Children with confirmed RSV infection by Polymerase Chain Reaction (PCR) on nasal swabs were evaluated by an expert panel as reference standard diagnosis. Three experienced pediatricians distinguished bacterial coinfection from simple viral infection using all available clinical information, including all microbiologic evaluations and a 28-day follow-up evaluation.

Results:

A total of 188 children (24% of all 784 recruited patients) were positive for RSV. From these, 92 (49%) were treated with antibiotics. All 27 children (29%) with bacterial coinfection were treated with antibiotics. Fifty-seven patients (62%) were treated with antibiotics without a diagnosis of bacterial coinfection. In 8 of the 92 (9%), the expert panel could not distinguish simple viral infection from bacterial coinfection.

Conclusion:

This is the first prospective international multicenter RSV study using an expert panel as reference standard to identify children with and without bacterial coinfection. All cases of bacterial coinfections are treated, whereas as many as one-third of all children with RSV LRTI are treated unnecessarily with antibiotics.
Increasing Prevalence of Pediatric Drug-resistant Tuberculosis in Mumbai, India, and Its Outcome
Authors: Shah Miti A. , Shah Ira
Published: March 2018

Background:

The prevalence and type of Drug resistant tuberculosis (DR-TB) was evaluated pre- and post-2013, and outcome was studied.

Methods:

Descriptive retrospective study. Children were defined as having DR-TB on the basis of GeneXpert or line probe assay and/or drug susceptibility testing (DST) of M. tuberculosis grown on culture or from contact’s DST.

Results:

The prevalence of DR-TB was 110 of 1145 cases (9.6%), which showed an increase, compared with 5.6% pre-2010 and 7% in 2010–2013 (P = 0.014408). Twenty-two children (20%) had pulmonary-TB and 88 (80%) had extra-pulmonary-TB with disseminated-TB being the most common presentation in 31 children (28.18%). Ninety-six children (87.3%) were bacteriologically confirmed TB cases, and 14 (12.7%) were clinically diagnosed-TB and treated as per contact DST. Eight cases (7.2%) were monoresistant, 7 (6.3%) polyresistant, MDR-TB seen in 28 patients (25.45%), 32 (29.09%) had pre-XDR-TB, 9 (8.18%) had XDR-TB and 12 (10.9%) were rifampicin resistant. Ethionamide resistance increased from 26.1% pre-2013 to 60.8% post-2013 (P = 0.014408) and ofloxacin resistance rose from 30.4% pre-2010, to 47.6% in 2010–2013 and 56.9% post-2013 (P = 0.080863). Moxifloxacin resistance showed an acute rise from 8.7% pre-2010, to 46% in 2010–2013 and 57% post-2013 (P = 0.000275). Thirty-three patients (30%) had completed their treatment, 21 (19.09%) were lost to follow-up and 56 (50.09%) patients are still on treatment.

Conclusions:

DR-TB is increasing in Mumbai, India. Based on the DST results, individualised therapy would be recommended.
Dietary Supplementation With Medium-Chain Triglycerides Reduces Candida Gastrointestinal Colonization in Preterm Infants
Authors: Arsenault Amanda B. , Gunsalus Kearney T. W. , Laforce-Nesbitt Sonia S. , Przystac Lynn , DeAngelis Erik J. , Hurley Michaela E. , Vorel Ethan S. , Tucker Richard , Matthan Nirupa R. , Lichtenstein Alice H. , Kumamoto Carol A. , Bliss Joseph M.
Published: March 2018

Background:

Candida is an important cause of infections in premature infants. Gastrointestinal colonization with Candida is a common site of entry for disseminated disease. The objective of this study was to determine whether a dietary supplement of medium-chain triglycerides (MCTs) reduces Candida colonization in preterm infants.

Methods:

Preterm infants with Candida colonization (n = 12) receiving enteral feedings of either infant formula (n = 5) or breast milk (n = 7) were randomized to MCT supplementation (n = 8) or no supplementation (n = 4). Daily stool samples were collected to determine fungal burden during a 3-week study period. Infants in the MCT group received supplementation during 1 week of the study period. The primary outcome was fungal burden during the supplementation period as compared with the periods before and after supplementation.

Results:

Supplementation of MCT led to a marked increase in MCT intake relative to unsupplemented breast milk or formula as measured by capric acid content. In the treatment group, there was a significant reduction in fungal burden during the supplementation period as compared with the period before supplementation (rate ratio, 0.15; P = 0.02), with a significant increase after supplementation was stopped (rate ratio, 61; P < 0.001). Fungal burden in the control group did not show similar changes.

Conclusions:

Dietary supplementation with MCT may be an effective method to reduce Candida colonization in preterm infants.
Itraconazole Dosing and Drug Monitoring at a Tertiary Children’s Hospital
Authors: Leong Ying Hua , Boast Alison , Cranswick Noel , Curtis Nigel , Gwee Amanda
Published: March 2018

Background:

Itraconazole is a broad-spectrum antifungal agent used for prophylaxis and treatment of fungal infections in immunocompromised children. Achieving the recommended target serum itraconazole trough concentration of ≥0.5 mg/L is challenging in children because of variation in itraconazole pharmacokinetics with age. We studied itraconazole use and treatment outcomes in a tertiary children’s hospital.

Methods:

We did a 10-year retrospective review of medical records of children at the Royal Children’s Hospital Melbourne who received oral itraconazole and had therapeutic drug monitoring (TDM).

Results:

Overall, 81 children received 92 courses of oral itraconazole and had TDM. Of 222 TDM samples, 183 (82.4%) were taken at the appropriate time (trough level at steady state). Patients ≤12 and >12 years of age required median doses of 6.2 and 3.9 mg/kg/d, respectively, to attain target trough levels (P < 0.001). Of children ≤12 years of age, 71.4% required doses above the recommended dose of 5 mg/kg/d to achieve therapeutic levels, compared with 17.4% of those >12 years of age. At least 1 subtherapeutic trough concentration was reported in 63 (76.8%) courses; in only 18 (28.6%) of these was the dose adjusted. Gastrointestinal symptoms [14/92 (15.2%) courses] and hepatotoxicity [6/92 (6.5%)] were the most frequent adverse events. Neither was associated with elevated trough levels.

Conclusions:

The poor attainment of target levels with current recommended dosing in children <12 years of age suggests that higher empiric doses are needed in this age group. The poor compliance with TDM guidelines highlights the need for better education about appropriate timing of sampling and dose adjustment.
Analysis of Treatment Outcomes for Recurrent Clostridium difficile Infections and Fecal Microbiota Transplantation in a Pediatric Hospital
Authors: Aldrich Aileen M. , Argo Taylor , Koehler Tracy J. , Olivero Rosemary
Published: March 2018

Background:

Clostridium difficile infection (CDI) is one of the most common nosocomial infections in the United States, with an increasing incidence in children. Approximately 20% of pediatric patients develop recurrent infections. It’s imperative to further analyze the incidence of recurrent CDI in the pediatric population and determine the most effective treatments. The primary goal of this study is to characterize children with recurrent CDI at our institution, including both hospital-acquired CDI (HA-CDI) and community-acquired CDI (CA-CDI) cases, summarize the various treatments utilized, including fecal microbiota transplant (FMT) and compare their success rates.

Methods:

A retrospective cohort study of pediatric patients 1–21 years of age treated for CDI at a single institution from January 2010 to December 2014 was performed.

Results:

There were 175 subjects with 215 separate episodes of CDI. Oral metronidazole was the most common initial treatment (145/207, 70%) followed by oral vancomycin (30/207, 15%), with recurrence rates of 30% (42/145) and 37% (11/30), respectively. Twenty-nine percent (63/215) of all initial CDI cases had at least 1 documented recurrence. Using multivariate analysis, subjects with HA-CDI were 2.6 times less likely to recur than those with CA-CDI (odds ratio: 0.39; 95% confidence interval: 0.18–0.85; P = 0.018). The overall success rate for FMT at our institution was 10/12 (83%).

Conclusions:

Our data show that cases of HA-CDI were less likely to recur compared with CA-CDI. Although currently reserved for multiply-recurrent cases, FMT was highly successful in our small cohort. More studies on FMT should be conducted to further evaluate its usefulness in the treatment of recurrent CDI in children.
Successful Treatment of a South African Pediatric Case of Acute Liver Failure Caused by Perinatal Transmission of Hepatitis B
Authors: Chotun Nafiisah , Strobele Silvia , Maponga Tongai Gibson , Andersson Monique Ingrid , Nel Etienne De La Rey
Published: March 2018

We report on the successful treatment of a South African infant with hepatitis B virus (HBV)–induced acute liver failure using lamivudine with no evidence of clinical resistance. Perinatal HBV transmission occurred despite timely HBV vaccination at 6, 10 and 14 weeks, as per South African vaccination schedule, highlighting the need to introduce the birth-dose HBV vaccine in South Africa.
Spinal manipulation and exercise for low back pain in adolescents: a randomized trial
Authors: Evans Roni , Haas Mitchell , Schulz Craig , Leininger Brent , Hanson Linda , Bronfort Gert
Published: March 2018

Low back pain (LBP) is common in adolescence, but there is a paucity of high-quality research to inform care. We conducted a multicenter randomized trial comparing 12 weeks of spinal manipulative therapy (SMT) combined with exercise therapy (ET) to ET alone. Participants were 185 adolescents aged 12 to 18 years with chronic LBP. The primary outcome was LBP severity at 12, 26, and 52 weeks. Secondary outcomes included disability, quality of life, medication use, patient- and caregiver-rated improvement, and satisfaction. Outcomes were analyzed using longitudinal linear mixed effect models. An omnibus test assessing differences in individual outcomes over the entire year controlled for multiplicity. Of the 185 enrolled patients, 179 (97%) provided data at 12 weeks and 174 (94%) at 26 and 52 weeks. Adding SMT to ET resulted in a larger reduction in LBP severity over the course of 1 year (P = 0.007). The group difference in LBP severity (0-10 scale) was small at the end of treatment (mean difference = 0.5; P = 0.08) but was larger at weeks 26 (mean difference = 1.1; P = 0.001) and 52 (mean difference = 0.8; P = 0.009). At 26 weeks, SMT with ET performed better than ET alone for disability (P = 0.04) and improvement (P = 0.02). The SMT with ET group reported significantly greater satisfaction with care at all time points (P ≤ 0.02). There were no serious treatment-related adverse events. For adolescents with chronic LBP, spinal manipulation combined with exercise was more effective than exercise alone over a 1-year period, with the largest differences occurring at 6 months. These findings warrant replication and evaluation of cost effectiveness.
Machine-learned analysis of the association of next-generation sequencing–based human TRPV1 and TRPA1 genotypes with the sensitivity to heat stimuli and topically applied capsaicin
Authors: Kringel Dario , Geisslinger Gerd , Resch Eduard , Oertel Bruno G. , Thrun Michael C. , Heinemann Sarah , Lötsch Jörn
Published: March 2018

Heat pain and its modulation by capsaicin varies among subjects in experimental and clinical settings. A plausible cause is a genetic component, of which TRPV1 ion channels, by their response to both heat and capsaicin, are primary candidates. However, TRPA1 channels can heterodimerize with TRPV1 channels and carry genetic variants reported to modulate heat pain sensitivity. To address the role of these candidate genes in capsaicin-induced hypersensitization to heat, pain thresholds acquired before and after topical application of capsaicin and TRPA1/TRPV1 exomic sequences derived by next-generation sequencing were assessed in n = 75 healthy volunteers and the genetic information comprised 278 loci. Gaussian mixture modeling indicated 2 phenotype groups with high or low capsaicin-induced hypersensitization to heat. Unsupervised machine learning implemented as swarm-based clustering hinted at differences in the genetic pattern between these phenotype groups. Several methods of supervised machine learning implemented as random forests, adaptive boosting, k-nearest neighbors, naive Bayes, support vector machines, and for comparison, binary logistic regression predicted the phenotype group association consistently better when based on the observed genotypes than when using a random permutation of the exomic sequences. Of note, TRPA1 variants were more important for correct phenotype group association than TRPV1 variants. This indicates a role of the TRPA1 and TRPV1 next-generation sequencing–based genetic pattern in the modulation of the individual response to heat-related pain phenotypes. When considering earlier evidence that topical capsaicin can induce neuropathy-like quantitative sensory testing patterns in healthy subjects, implications for future analgesic treatments with transient receptor potential inhibitors arise.
Illness Uncertainty and Posttraumatic Stress in Young Adults With Congenital Heart Disease
Authors: Moreland Patricia , Santacroce Sheila Judge
Published: March 2018

Background:

Young adults with congenital heart disease (CHD) are at risk for chronic illness uncertainty in 4 domains: ambiguity about the state of their illness; lack of information about the disease, its treatment, and comorbidities; complexity of the healthcare system and relationship with healthcare providers; and unpredictability of the illness course and outcome. Chronic uncertainty has been associated with posttraumatic stress symptoms (PTSS) and posttraumatic stress disorder (PTSD).

Objective:

The aims of this study were to explore how young adults with CHD experience uncertainty and to describe the relationship between PTSS and the appraisal and management process.

Methods:

An exploratory, mixed methods design was used. Data were collected in person and via Skype from 25 participants (19–35 years old), who were diagnosed with CHD during childhood and able to read and write English. In-depth interviews and the University of California at Los Angeles Posttraumatic Stress Disorder Reaction Index were used to collect data. Qualitative data were analyzed using the constant comparative method.

Results:

The 4 domains of uncertainty were evident in the narratives. The PTSD mean (SD) score was 31.3 (7.7). Six participants met criteria for PTSD. Narrative analysis revealed a relationship between severity of PTSS and the appraisal and management of uncertainty. Participants with PTSD used management strategies that included avoidance, reexperiencing, and hyperarousal.

Conclusions:

Young adults with CHD may be at risk for the development of long-term psychological stress and PTSD in the setting of chronic uncertainty. Regular monitoring to identify PTSS/PTSD may be a means to promote treatment adherence and participation in healthcare.
A Survey on Sexual Counseling for Patients With Cardiac Disease Among Nurses in Jordan
Authors: Abu Ali Raeda M. , Abed Mona A. , Khalil Amani A. , Al-Kloub Manal I. , Ashour Ala F. , Alnsour Intesar A.
Published: March 2018

Background:

Recovery among patients with cardiac disease also requires attention to their sexual health. However, cultural, religious, and social factors may make Arab Muslim patients reluctant to disclose their sexual concerns and nurses hesitant to discuss patients’ sexuality matters.

Objective:

The aim of this study was to explore sexual counseling (SC) among nurses in Jordan in terms of responsibility, confidence, and practice.

Method:

This was a descriptive, correlational study. Staff nurses were recruited from 10 hospitals in Jordan. Nurses completed the cardiac version of the Survey of Sexuality-Related Nursing Practice and reported their demographics.

Results:

The sample consisted of 379 nurses (female, 59%; mean age, 28.1 years). A significant proportion of nurses viewed assessment/discussion of patients’ sexuality matters as not within their responsibilities (39%), did not feel confident to address sexuality matters (50%), and rated themselves as not at all/not very knowledgeable about sexuality (60%). Few nurses were routinely integrating SC in clinical practice (9%). Sexual counseling was associated with nurses’ gender (male, higher confidence and practice) and previous training on sexuality in nursing practice.

Conclusions:

Nurses in Jordan, especially female nurses, are neither prepared nor competent to provide SC. Nurses need focused education on sexuality to optimize patients’ sexual health.
Decreased Quality of Life Due to Driving Restrictions After Cardioverter Defibrillator Implantation
Authors: Timmermans Ivy , Jongejan Niels , Meine Mathias , Doevendans Pieter , Tuinenburg Anton , Versteeg Henneke
Published: March 2018

Background:

Driving restrictions for patients with an implantable cardioverter defibrillator (ICD) may require significant lifestyle adjustment and affect patients’ psychological well-being. This study explored the prevalence of, and factors associated with, patient-reported decrease in quality of life due to driving restrictions in the first 2 months postimplantation.

Methods:

Dutch ICD patients (N = 334; median age, 64 [interquartile range, 55–70) years; 81% male) completed questionnaires at the time of implantation and 4 months postimplantation, assessing their sociodemographic, psychological, and driving-related characteristics. Clinical baseline data were retrieved from patients’ medical records.

Results:

Nearly half of the patients (49%) reported decreased quality of life due to driving restrictions. Patient-reported reasons included dependency on others/public transport, (social) isolation, and inability to work. Patients reporting decreased quality of life were more likely to be younger (P = .01), to feel that the restriction lasts too long (P = .004), to have considered ICD refusal because of the restrictions (P = .03), and to have Type D personality (P = .02), anxiety (P = .05), depression (P = .003), and ICD-related concerns (P = .02). Multivariable analysis showed that being younger than 60 years (odds ratio [OR], 2.30; 95% confidence interval [CI], 1.09–4.88; P = .03), feeling the driving restriction lasts too long (OR, 1.77; 95% CI, 1.23–2.55; P = .002), and depression (OR, 3.21; 95% CI, 1.09–9.47; P = .035) were independently associated with decreased quality of life due to driving restrictions.

Conclusions:

This study indicated that a significant group of ICD patients may experience decreased quality of life because of the driving restrictions postimplantation. The restrictions seem to particularly affect patients who are younger and distressed and patients who feel that the restriction lasts too long.
Predicting adverse hemodynamic events in critically ill patients
Authors: Yoon Joo H. , Pinsky Michael R.
Published: March 2018

Purpose of review

The art of predicting future hemodynamic instability in the critically ill has rapidly become a science with the advent of advanced analytical processed based on computer-driven machine learning techniques. How these methods have progressed beyond severity scoring systems to interface with decision-support is summarized.

Recent findings

Data mining of large multidimensional clinical time-series databases using a variety of machine learning tools has led to our ability to identify alert artifact and filter it from bedside alarms, display real-time risk stratification at the bedside to aid in clinical decision-making and predict the subsequent development of cardiorespiratory insufficiency hours before these events occur. This fast evolving filed is primarily limited by linkage of high-quality granular to physiologic rationale across heterogeneous clinical care domains.

Using advanced analytic tools to glean knowledge from clinical data streams is rapidly becoming a reality whose clinical impact potential is great.
Reduction in postpercutaneous coronary intervention angina in addition to gastrointestinal events in patients on combined proton pump inhibitors and dual antiplatelet therapy: a systematic review and meta-analysis
Authors: Khan Muhammad Y. , Siddiqui Waqas J. , Alvarez Chikezie , Aggarwal Sandeep , Hasni Syed F. , Ahmad Asyia , Eisen Howard
Published: March 2018

Background

Primary percutaneous coronary intervention (PCI) is a standard treatment in patients with acute coronary syndrome. Studies have shown that proton pump inhibitors (PPIs) can potentially attenuate the antiplatelet effects of P2Y12 inhibitors with associated adverse cardiovascular outcomes.

Materials and methods

Medline was searched using Pubmed from inception to 8 November 2017 for randomized control trials studying the effect of PPIs on coronary artery disease with concomitant use of dual antiplatelet therapy (DAPT). Overall, 692 studies were identified of which five randomized control trials were included. Statistical analysis was done using RevMan, version 5.3.

Results

Five studies with 6239 patients (3113 on PPI with DAPT and 3126 with only DAPT) were included. Our analysis showed that PPI significantly reduced the incidence of gastrointestinal (GI) bleed [22 vs. 66, odds ratio (OR)=0.37, confidence interval (CI)=0.23–0.61, P≤0.0001, I
2=0%], GI ulcers and GI erosions (7 vs. 18, OR=0.39, CI=0.16–0.94, P=0.04, I
2=0%), and the incidence of post-PCI unstable angina in patients treated with PPI and P2Y12 agents (46 vs. 67, OR=0.67, CI=0.45–0.99, P=0.05, I
2=0%). There was an insignificant difference in myocardial infarction, stroke, and cardiovascular cause of mortality. A trend toward decreased all-cause mortality with PPIs was noted. Heterogeneity was calculated using I
2.

Conclusion

Concomitantly administered PPIs with P2Y12 inhibitors have a protective effect on the GI events. It also decreases the post-PCI angina without increased adverse cardiovascular outcomes.
Myeloid cells regulate plasma LDL-cholesterol levels
Authors: Bazioti Venetia , La Rose Anouk M. , Westerterp Marit
Published: March 2018

Purpose of review

Leukocytosis, elevated blood leukocyte levels, is associated with enhanced cardiovascular risk in humans. Hematopoietic stem and progenitor cells (HSPCs) drive leukocyte production in a process called hematopoiesis, which mainly occurs in the bone marrow, and under certain conditions also in other organs such as the spleen. Cholesterol accumulation in HSPCs enhances hematopoiesis, increasing levels of blood monocytes that infiltrate into atherosclerotic plaques. Although HSPC proliferation and monocytosis enhance atherogenesis in several studies, concomitant decreases in LDL-cholesterol levels have also been reported, associated with anti-atherogenic effects. This review focuses on the link between HSPC proliferation, leukocytosis, plasma LDL-cholesterol levels, and atherogenesis.

Recent findings

Recent studies have shown that an acute infection enhances cholesterol accumulation in HSPCs, driving HSPC proliferation, and leading to the expansion of myeloid cells (monocytes, neutrophils, and macrophages). Enhanced hematopoiesis is associated with low plasma LDL-cholesterol levels in animal models and humans, probably because of the increased number of myeloid cells that take up LDL-cholesterol. Despite low-plasma LDL-cholesterol levels, specific patient populations with enhanced hematopoiesis show increased cardiovascular risk.

Enhanced hematopoiesis and monocytosis may accelerate atherogenesis. Studies on these processes may lead to the identification of new therapeutic targets for cardiovascular diseases.
Evolving understanding of neonatal necrotizing enterocolitis
Authors: Isani Mubina A. , Delaplain Patrick T. , Grishin Anatoly , Ford Henri R.
Published: March 2018

Purpose of review

Necrotizing enterocolitis (NEC) is a devastating disease that predominately affects premature neonates. The pathogenesis of NEC is multifactorial and poorly understood. Risk factors include low birth weight, formula-feeding, hypoxic/ischemic insults, and microbial dysbiosis. This review focuses on our current understanding of the diagnosis, management, and pathogenesis of NEC.

Recent findings

Recent findings identify specific mucosal cell types as potential therapeutic targets in NEC. Despite a broadly accepted view that bacterial colonization plays a key role in NEC, characteristics of bacterial populations associated with this disease remain elusive. The use of probiotics such as lactobacilli and bifidobacteria has been studied in numerous trials, but there is a lack of consensus regarding specific strains and dosing. Although growth factors found in breast milk such as epidermal growth factor and heparin-binding epidermal growth factor may be useful in disease prevention, developing new therapeutic interventions in NEC critically depends on better understanding of its pathogenesis.

NEC is a leading cause of morbidity and mortality in premature neonates. Recent data confirm that growth factors and certain bacteria may offer protection against NEC. Further studies are needed to better understand the complex pathogenesis of NEC.