bluuebunny/crossref_metadata_2025 huggingface dataset:
Understanding the role of the cytoprotective transcription factor nuclear factor erythroid 2-related factor 2—lessons from evolution, the animal kingdom and rare progeroid syndromes
Authors: Stenvinkel Peter , Meyer Colin J , Block Geoffrey A , Chertow Glenn M , Shiels Paul G
Published: May 2019

The cytoprotective transcriptor factor nuclear factor erythroid 2– related factor 2 (NRF2) is part of a complex regulatory network that responds to environmental cues. To better understand its role in a cluster of inflammatory and pro-oxidative burden of lifestyle diseases that accumulate with age, lessons can be learned from evolution, the animal kingdom and progeroid syndromes. When levels of oxygen increased in the atmosphere, mammals required ways to protect themselves from the metabolic toxicity that arose from the production of reactive oxygen species. The evolutionary origin of the NRF2–Kelch-like ECH-associated protein 1 (KEAP1) signalling pathway from primitive origins has been a prerequisite for a successful life on earth, with checkpoints in antioxidant gene expression, inflammation, detoxification and protein homoeostasis. Examples from the animal kingdom suggest that superior antioxidant defense mechanisms with enhanced NRF2 expression have been developed during evolution to protect animals during extreme environmental conditions, such as deep sea diving, hibernation and habitual hypoxia. The NRF2–KEAP1 signalling pathway is repressed in progeroid (accelerated ageing) syndromes and a cluster of burden of lifestyle disorders that accumulate with age. Compelling links exist between tissue hypoxia, senescence and a repressed NRF2 system. Effects of interventions that activate NRF2, including nutrients, and more potent (semi)synthetic NRF2 agonists on clinical outcomes are of major interest. Given the broad-ranging actions of NRF2, we need to better understand the mechanisms of activation, biological function and regulation of NRF2 and its inhibitor, KEAP1, in different clinical conditions to ensure that modulation of this thiol-based system will not result in major adverse effects. Lessons from evolution, the animal kingdom and conditions of accelerated ageing clarify a major role of a controlled NRF2–KEAP1 system in healthy ageing and well-being.
The Safety and Efficacy of Continuous Tirofiban as a Monoantiplatelet Therapy in the Management of Ruptured Aneurysms Treated Using Stent-Assisted Coiling or Flow Diversion and Requiring Ventricular Drainage
Authors: Limaye Kaustubh , Zanaty Mario , Hudson Joseph , Nakagawa Daichi , Al Kasab Sami , Alvarez Carlos , Dandapat Sudeepta , Kung David K , Ortega-Gutierrez Santiago , Jabbour Pascal , Samaniego Edgar A , Hasan David
Published: May 2019

BACKGROUND

Hemorrhagic complications are a major concern for aneurysmal subarachnoid hemorrhage patients treated with stenting or stent-assisted coiling and undergoing additional procedures such as shunting, ventriculostomy placement, and craniotomies/craniectomies.

OBJECTIVE

To assess the safety and efficacy of using a continuous infusion of tirofiban as a monoantiplatelet therapy in the management of ruptured aneurysms in the setting of either stent-assisted coiling (SAC) or flow diversion devices (FDD) in patients requiring either an external ventricular drain (EVD) or ventriculoperitoneal shunt (VPS).

METHODS

Aneurysmal subarachnoid hemorrhage (aSAH) patients between July 2017 and September 2018 who were treated with SAC or FDD were started on a continuous tirofiban infusion protocol (0.10 μg/kg/min) with no preceding loading dose as a monoantiplatelet therapy. Safety analysis was performed retrospectively to assess the complication rate, hemorrhagic rate, and rate of ischemic events. There were no hemorrhages related to the VPS surgery.

RESULTS

Nineteen subjects were included in the series. The patients received a total of 25 procedures that included 19 EVDs and 6 VPSs. Two patients (8.3%) developed small asymptomatic track hemorrhages after EVD placement. One patient developed a large retroperitoneal hemorrhage due to renal artery branch injury during procedure, and another patient developed an idiosyncratic transient thrombocytopenia which resolved after stopping the medication. One patient (4%) developed a transient ischemic attack, which resolved after a bolus of tirofiban.

CONCLUSION

Our study suggests that long-term use of intravenous tirofiban monotherapy in aSAH subjects for endovascular SAC or FDD is safe in the perioperative setting.
Does Neck Disability Index Correlate With 12-Month Satisfaction After Elective Surgery for Cervical Radiculopathy? Results From a National Spine Registry
Authors: Khan Inamullah , Sivaganesan Ahilan , Archer Kristin R , Bydon Mohamad , McGirt Matthew J , Nian Hui , Harrell Frank E , Foley Kevin T , Mummaneni Praveen V , Bisson Erica F , Shaffrey Christopher , Harbaugh Robert , Asher Anthony L , Devin Clinton J ,   QOD Vanguard Sites, Asher Anthony L , McGirt Matthew J , Devin Clinton J , Foley Kevin T , Sorenson Jeffrey M , Briggs Thomas B , Kremer Adam , Griffitt Wesley E , Bisson Erica F , Shaffrey Mark E , Shaffrey Christopher , Fassett Daniel , Oetting Gregory , Elowitz Eric H , Rumana Christopher
Published: May 2019

BACKGROUND

Modern healthcare reforms focus on identifying and measuring the quality and value of care. Patient satisfaction is particularly important in the management of degenerative cervical radiculopathy (DCR) since it leads to significant neck pain and disability primarily affecting the patients’ quality of life.

OBJECTIVE

To determine the association of baseline and 12-mo Neck Disability Index (NDI) with patient satisfaction after elective surgery for DCR.

METHODS

The Quality Outcomes Database cervical module was queried for patients who underwent elective surgery for DCR. A multivariable proportional odds regression model was fitted with 12-mo satisfaction as the outcome. The covariates for this model included patients’ demographics, surgical characteristics, and baseline and 12-mo patient reported outcomes (PROs). Wald-statistics were calculated to determine the relative importance of each independent variable for 12-mo patient satisfaction.

RESULTS

The analysis included 2206 patients who underwent elective surgery for DCR. In multivariable analysis, after adjusting for baseline and surgery specific variables, the 12-mo NDI score showed the highest association with 12-mo satisfaction (Waldχ2-df = 99.17, 58.1% of total χ2). The level of satisfaction increases with decrease in 12-mo NDI score regardless of the baseline NDI score.

CONCLUSION

Our study identifies 12-mo NDI score as a very influential driver of 12-mo patient satisfaction after surgery for DCR. In addition, there are lesser contributions from other 12-mo PROs, baseline Numeric Rating Scale for arm pain and American Society of Anesthesiologists (ASA) grade. The baseline level of disability was found to be irrelevant to patients. They seemed to only value their current level of disability, compared to baseline, in rating satisfaction with surgical outcome.
Relationship between arginine intake in parenteral nutrition and preterm neonatal population plasma arginine concentrations: a systematic review
Authors: Premakumar Chandini M , Turner Mark A , Morgan Colin
Published: May 2019

Context

Very preterm neonates (VPNs) are unable to digest breast milk and therefore rely on parenteral nutrition (PN) formulations. This systematic review was prepared following PRISMA-P 2015 guidelines. For the purpose of this review, desirable mean plasma arginine concentration is defined as ≥80 micromoles/L.

Objective

The review was performed to answer the following research question: “In VPNs, are high amounts of arginine in PN, compared with low amounts of arginine, associated with appropriate circulating concentrations of arginine?” Therefore, the aims were to 1) quantify the relationship between parenteral arginine intakes and plasma arginine concentrations in PN-dependent VPNs; 2) identify any features of study design that affect this relationship; and 3) estimate the target parenteral arginine dose to achieve desirable preterm plasma arginine concentrations.

Data Sources

The PubMed, Scopus, Web of Science, and Cochrane databases were searched regardless of study design; review articles were not included.

Data Extraction

Only articles that discussed amino acid (AA) intake and measured plasma AA profile post PN in VPNs were included. Data were obtained using a data extraction checklist that was devised for the purpose of this review.

Data Analysis

Twelve articles met the inclusion criteria. The dose–concentration relationship of arginine content (%) and absolute arginine intake (mg/(kg × d)) with plasma arginine concentrations showed a significant positive correlation (P < 0.001).

Conclusion

Future studies using AA solutions with arginine content of 17%–20% and protein intakes of 3.5–4.0 g/kg per day may be needed to achieve higher plasma arginine concentrations.
Speaking for the People in Early Modern England*
Authors: Coast David
Published: May 2019

The voice of the people is assumed to have carried little authority in early modern England. Elites often caricatured the common people as an ignorant multitude and demanded their obedience, deference and silence. Hostility to the popular voice was an important element of contemporary political thought. However, evidence for a very different set of views can be found in numerous polemical tracts written between the Reformation and the English Civil War. These tracts claimed to speak for the people, and sought to represent their alleged grievances to the monarch or parliament. They subverted the rules of petitioning by speaking for ‘the people’ as a whole and appealing to a wide audience, making demands for the redress of grievances that left little room for the royal prerogative. In doing so, they contradicted stereotypes about the multitude, arguing that the people were rational, patriotic and potentially better informed about the threats to the kingdom than the monarch themselves. ‘Public opinion’ was used to confer legitimacy on political and religious demands long before the mass subscription petitioning campaigns of the 1640s.
Factors associated with undiagnosed type II diabetes mellitus, undiagnosed impaired fasting glucose and these patients’ quality of life in Lebanon
Authors: Hallit Souheil , Saade Sylvia , Zeidan Rouba Karen , Iskandar Katia , Kheir Nelly , Youssef Lara , Costantine Rachelle , Hallit Rabih , Salameh Pascale
Published: May 2019

Objective

To assess the association between undiagnosed impaired fasting glucose (UIFG) and diabetes (UD), their risk factors and the patients’ knowledge about diabetes and their quality of life (QOL).

Methods

A cross-sectional study was conducted between May and September 2017 in four laboratories enrolling 495 patients. We used the Diabetes Knowledge and SF-12 questionnaires to assess the patients’ knowledge about diabetes and QOL. This study meets the Wilson and Jungner criteria for disease screening.

Results

A higher knowledge score (ORa = 0.85) was significantly associated with the absence of diabetes compared to UPD, whereas an increased age (ORa = 1.2) and a positive family history of diabetes (ORa = 1.81) were significantly associated with higher odds of UPD. An increased knowledge score (ORa = 0.55) was significantly associated with an absence of diabetes compared to UD, whereas an increased BMI (ORa = 1.40) and an increased age (ORa = 1.07) were associated with increased odds of having UD.

UD (Beta = −5.799) was significantly associated with decreased total physical component QOL score, whereas increased diabetes knowledge score (Beta = 0.415) was significantly associated with increased physical QOL. A higher diabetes knowledge score (Beta = 0.459) were associated with increased mental QOL.

Conclusion

Seeing the relatively high percentage of UD and UIFG, we propose that screening should be considered and subject to proper assessment in the light of the findings of this study.
Effectiveness of different combinations of DMARDs and glucocorticoid bridging in early rheumatoid arthritis: two-year results of CareRA
Authors: Stouten Veerle , Westhovens René , Pazmino Sofia , De Cock Diederik , Van der Elst Kristien , Joly Johan , Verschueren Patrick ,   on behalf of the CareRA study group, Maeyaert B , De Brabanter G , Devinck M , Langenaken C , Lenaerts J , Corluy L , Remans J , Vander Cruyssen B , Ravelingien I , Van Essche E , Vandevyvere K , Durnez A , Verbruggen A , Geens E , Raeman F , Joos R , de Vlam K , Taelman V , Vanhoof J , Coppens M , Geusens P , Sileghem A , Volders P , Van Den Bosch F , Verschueren P , Westhovens R
Published: May 2019

Objectives

To investigate whether MTX should be combined with an additional DMARD and bridging glucocorticoids as initial treatment for patients with early RA to induce an effective long-term response.

Methods

The Care in early RA study is a two-year investigator-initiated pragmatic multicentre randomized trial. Early RA patients, naïve to DMARDs and glucocorticoids, were stratified based on prognostic factors. High-risk patients were randomized to COBRA-Classic (n = 98): MTX, sulfasalazine, prednisone step-down from 60 mg; COBRA-Slim (n = 98): MTX, prednisone step-down from 30 mg; or COBRA-Avant-Garde (n = 93): MTX, leflunomide, prednisone step-down from 30 mg. Low-risk patients were randomized to COBRA-Slim (n = 43); or Tight Step Up (TSU) (n = 47): MTX without prednisone. Clinical/radiological outcomes at year 2, sustainability of response, safety and treatment adaptations were assessed.

Results

In the high-risk group 71/98 (72%) patients achieved a DAS28-CRP < 2.6 with COBRA-Slim compared with 64/98 (65%) with COBRA-Classic and 69/93 (74%) with COBRA-Avant-Garde (P = 1.00). Other clinical/radiological outcomes and sustainability of response were similar. COBRA-Slim treatment resulted in less therapy-related adverse events compared with COBRA-Classic (P = 0.02) or COBRA-Avant-Garde (P = 0.005). In the low-risk group, 29/43 (67%) patients on COBRA-Slim and 34/47 (72%) on TSU achieved a DAS28-CRP < 2.6 (P = 1.00). On COBRA-Slim, low-risk patients had lower longitudinal DAS28-CRP scores over 2 years, a lower need for glucocorticoid injections and a comparable safety profile compared with TSU.

Conclusion

All regimens combining DMARDs with glucocorticoids were effective for patients with early RA up to 2 years. The COBRA-Slim regimen, MTX monotherapy with glucocorticoid bridging, provided the best balance between efficacy and safety, irrespective of patients’ prognosis.

Trial registration

ClinicalTrials.gov, http://www.clinicaltrials.gov, NCT01172639.
An Introduction to Skin as an Interface: Implications for Interprofessional Collaboration and Whole-Person Care
Authors: Sherman Deborah Witt , Kamel Geovanna
Published: May 2019

The skin reflects not only a person’s physical state of health, but also the dynamic interplay of emotional and cultural influences. This article will increase health practitioner understanding of the skin and skin assessment by highlighting its multidimensional aspects and significant implications for interprofessional collaboration in whole-person care. Through a multidimensional assessment of the skin, practitioners can better understand the health story of each patient and intervene holistically to improve overall well-being and quality of life.

GENERAL PURPOSE

To increase health care professionals' awareness and perceptions of the skin as one of the largest body organs with multidimensional aspects and significant implications for interprofessional collaboration in whole-person care.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant should be better able to:

1. Apply physiologic and integumentary knowledge to assessing common skin variations and problems.

2. Summarize the results of the authors' literature review of the evidence regarding the emotional, psychosocial, cultural, and spiritual aspects of skin health and disorders.
Understanding the Experiences of Nursing Student Veterans
Authors: Shellenbarger Teresa , Decker Julie L.
Published: May 2019

AIM

The aim of this study was to understand the experiences of veterans enrolled in prelicensure nursing programs.

BACKGROUND

As the number of veterans enrolling in higher education continues to remain high, nurse faculty working with veteran students are faced with the challenge of meeting their unique educational needs and assisting them as they transition to professional nursing roles.

METHOD

A hermeneutic phenomenological study was conducted to understand the experiences of veterans enrolled in prelicensure nursing programs.

RESULTS

Findings from interviews with nine veteran nursing students revealed four themes: maneuvering through the mental mind shift, battling conflicting forces, avoiding landmines, and accepting support.

CONCLUSION

Based upon these findings, recommendations are presented for nursing programs and faculty to use to support students.
Enhancing Access for Student Nurse Athletes: Office Hours on the Road
Authors: Krautscheid Lorretta , Williams Samuel , Kahn Benjamin
Published: May 2019

The purpose of this education innovation was to facilitate office hour (OH) instruction for student nurse athletes due to training schedules and off-campus travel. Effective integration of technology, learning theory, and multimedia resources provide strategies to enhance student athlete access to faculty OH and associated learning opportunities. Explain Everything™ software, a digital interactive whiteboard space, enables students and faculty to collaborate and learn across distance. This innovative approach enriches learning, ensuring OH access among student athletes.
Use of Commercial Virtual Reality Technology to Assess Verticality Perception in Static and Dynamic Visual Backgrounds
Authors: Zaleski-King Ashley , Pinto Robin , Lee General , Brungart Douglas
Published: May 2019

Objectives:

The Subjective Visual Vertical (SVV) test and the closely related Rod and Disk Test (RDT) are measures of perceived verticality measured in static and dynamic visual backgrounds. However, the equipment used for these tests is variable across clinics and is often too expensive or too primitive to be appropriate for widespread use. Commercial virtual reality technology, which is now widely available, may provide a more suitable alternative for collecting these measures in clinical populations. This study was designed to investigate verticality perception in symptomatic patients using a modified RDT paradigm administered through a head-mounted display (HMD).

Design:

A group of adult patients referred by a physician for vestibular testing based on the presence of dizziness symptoms and a group of healthy adults without dizziness symptoms were included. We investigated degree of visual dependence in both groups by measuring SVV as a function of kinematic changes to the visual background.

Results:

When a dynamic background was introduced into the HMD to simulate the RDT, significantly greater shifts in SVV were found for the patient population than for the control population. In patients referred for vestibular testing, the SVV measured with the HMD was significantly correlated with traditional measures of SVV collected in a rotary chair when accounting for head tilt.

Conclusions:

This study provides initial proof of concept evidence that reliable SVV measures in static and dynamic visual backgrounds can be obtained using a low-cost commercial HMD system. This initial evidence also suggests that this tool can distinguish individuals with dizziness symptomatology based on SVV performance in dynamic visual backgrounds.
Switching Streams Across Ears to Evaluate Informational Masking of Speech-on-Speech
Authors: Calcus Axelle , Schoof Tim , Rosen Stuart , Shinn-Cunningham Barbara , Souza Pamela
Published: May 2019

Objectives:

This study aimed to evaluate the informational component of speech-on-speech masking. Speech perception in the presence of a competing talker involves not only informational masking (IM) but also a number of masking processes involving interaction of masker and target energy in the auditory periphery. Such peripherally generated masking can be eliminated by presenting the target and masker in opposite ears (dichotically). However, this also reduces IM by providing listeners with lateralization cues that support spatial release from masking (SRM). In tonal sequences, IM can be isolated by rapidly switching the lateralization of dichotic target and masker streams across the ears, presumably producing ambiguous spatial percepts that interfere with SRM. However, it is not clear whether this technique works with speech materials.

Design:

Speech reception thresholds (SRTs) were measured in 17 young normal-hearing adults for sentences produced by a female talker in the presence of a competing male talker under three different conditions: diotic (target and masker in both ears), dichotic, and dichotic but switching the target and masker streams across the ears. Because switching rate and signal coherence were expected to influence the amount of IM observed, these two factors varied across conditions. When switches occurred, they were either at word boundaries or periodically (every 116 msec) and either with or without a brief gap (84 msec) at every switch point. In addition, SRTs were measured in a quiet condition to rule out audibility as a limiting factor.

Results:

SRTs were poorer for the four switching dichotic conditions than for the nonswitching dichotic condition, but better than for the diotic condition. Periodic switches without gaps resulted in the worst SRTs compared to the other switch conditions, thus maximizing IM.

Conclusions:

These findings suggest that periodically switching the target and masker streams across the ears (without gaps) was the most efficient in disrupting SRM. Thus, this approach can be used in experiments that seek a relatively pure measure of IM, and could be readily extended to translational research.
Update on the treatment and outcome of systemic lupus erythematous in children
Authors: Rodriguez-Smith Jackeline , Brunner Hermine I.
Published: May 2019

Purpose of review

Provide an update of studies published in last 2 years on the outcomes and therapies in childhood-onset systemic lupus erythematous (cSLE).

Recent findings

Additional evidence has been provided about the benefits of universal hydroxychloroquine in SLE patients, although antimalarial maculopathy may be more prevalent than previously thought. Recent studies support lower glucocorticoid doses than used in the past may provide comparable therapeutic benefits, and cSLE patients can mount adequate immunogenic response and sustain long-term seroprotective titers when vaccinated. Long-term studies of adults with cSLE confirmed that damage accrual increases with disease duration. Cardiovascular disease, renal transplants, replacement arthroplasties, and myocardial infarctions occur between 20 and 40 years of age. Higher prednisone doses predicted higher damage trajectory and antimalarial exposure was protective. There were no prospective clinical trials published in pediatric patients with cSLE, but positive results from phase II trials with bariticinib and ustekinumab in adult SLE may raise the expectation that these drugs could be beneficial when used in cSLE.

The dire need for more clinical trials and licensed medications for cSLE persist as well as decreasing damage accrual.
Continuation of Newly Initiated Midodrine Therapy After Intensive Care and Hospital Discharge: A Single-Center Retrospective Study
Authors: Rizvi Mahrukh S. , Nei Andrea M. , Gajic Ognjen , Mara Kristin C. , Barreto Erin F.
Published: May 2019

Objectives:

Midodrine is an α1-agonist approved for orthostatic hypotension. Recently, it has received attention as an oral vasopressor to facilitate ICU discharge. The purpose of this study was to identify the incidence of continuation of newly initiated midodrine upon ICU and hospital discharge and identify risk factors associated with its occurrence.

Design:

Single-center retrospective study.

Setting:

ICU patients from January 2011 to October 2016 at Mayo Clinic, Rochester.

Patients:

Adult patients admitted to any ICU who received new midodrine for hypotension and survived to discharge.

Interventions:

None.

Measurements and Main Results:

During the study period, 1,010 patients were newly started on midodrine and survived to ICU discharge. Midodrine was continued in 67% (672/1,010) of patients at ICU discharge. Admission to cardiovascular surgery ICU and mixed medical/surgical ICU was a risk factor for midodrine continuation at ICU discharge (odds ratio, 3.94 [2.50–6.21] and 2.03 [1.29–3.20], respectively). At hospital discharge, 34% (311/909) of patients were continued on midodrine therapy. History of congestive heart failure predicted midodrine continuation at hospital discharge (odds ratio, 1.49 [1.05–2.12]). Hypertension and use of mechanical ventilation were associated with a decreased odds of midodrine prescription at both ICU and hospital discharge. Of those discharged from the ICU or hospital on midodrine, 50% were concomitantly prescribed antihypertensives. Discharge from the ICU on midodrine was associated with a significantly shorter ICU length of stay (7.5 ± 8.9 vs 10.6 ± 13.4 d) and reduced risk of in-hospital mortality (hazard ratio, 0.47 [95% CI, 0.32–0.70]; p < 0.001), despite no difference in baseline severity of illness scores. In contrast, patients discharged from the hospital on midodrine had a higher risk of 1-year mortality (hazard ratio, 1.60 [95% CI, 1.26–2.04]; p < 0.001).

Conclusions:

This study established a high prevalence of midodrine continuation in transitions of care. The risks and benefits of this practice remain unclear. Future studies should explore the impact of this practice on patient outcomes and resource utilization. These insights could be used to model interventions for proper tapering, discontinuation, or follow-up of new start midodrine.
Early Intervention Referral and Enrollment Among Infants with Neonatal Abstinence Syndrome
Authors: Peacock-Chambers Elizabeth , Leyenaar JoAnna K. , Foss Sheila , Feinberg Emily , Wilson Donna , Friedmann Peter D. , Visintainer Paul , Singh Rachana
Published: May 2019

Objective:

To identify factors associated with referral and enrollment in early intervention (EI) for infants with neonatal abstinence syndrome (NAS).

Methods:

We conducted a retrospective cohort study of 256 infants born with NAS (2006–2013) at a tertiary care hospital in (Springfield), Massachusetts, linking maternal-infant birth hospitalization records with Department of Public Health EI records. We calculated the percent of infants retained at each step in the EI enrollment process over the first 3 years of life. We conducted separate multivariable logistic regression analyses to identify factors associated with EI referral and enrollment.

Results:

Among mothers, 82% received medication-assisted treatment at delivery, 36% endorsed illicit drug use during pregnancy, and 76% retained custody of their child at discharge. Among infants, 77% were referred to EI and 48% were enrolled in services. Of infants discharged to biological parents, 81% were referred to EI versus 66% of infants discharged to foster care (p ≤ 0.05); this difference persisted in multivariable analysis [adjusted odds ratio, 2.30; 95% confidence interval (CI), 1.09–4.86]. Infants in the highest tertile for length of stay had 2.70 times the odds of EI enrollment (95% CI, 1.37–5.31).

Conclusion:

Fewer than half of the eligible infants with NAS were enrolled in EI services. Discharge to a biological parent and longer hospital stay had the strongest associations with EI referral and enrollment, respectively. Efforts to improve EI referral rates during the birth hospitalization, particularly among infants discharged into foster care, and close follow-up for infants with shorter hospital stays would enhance the developmental supports for this vulnerable population.
Caring for the Transgender Adolescent: It Takes a Village
Authors: Agana Marisha , Apple Roger , Alavi Zakia , Gibb Tyler , Soares Neelkamal , Augustyn Marilyn
Published: May 2019

CASE:

Christa is a 15-year-old male-to-female (MTF) transgender patient who comes to your Developmental-Behavioral Pediatrics office for consultation on attention deficit/hyperactivity disorder (ADHD) management and concerns about worsening anxiety. Review of medical history included mild persistent asthma managed with steroid inhaler and leukotriene antagonist. She was diagnosed with ADHD at 12 years and has been placed on methylphenidate and clonidine over the years with little improvement. She struggles in school, with barely passing grades, and feels that she cannot focus on her assignments.

She was diagnosed with MTF transition gender dysphoria, social anxiety disorder, and depressive disorder at 13 years by a psychiatrist and was treated with sertraline with some mood improvement. More recently, she reports having thoughts of wanting to hurt people and “wanting to watch them wither away.” She expressed being terrified by these thoughts, which lasted for a couple of days but have since resolved. She denied any suicidal thoughts recently and gives credit to her “best girlfriend” for her overall improved mood, improved sleep pattern, and increased energy level. She expressed having deepening feelings for this girlfriend but admitted to not having acted on these feelings as she is afraid of the consequences. She currently uses the pronouns she/her/hers.

Family history is pertinent for paternal bipolar disorder. There is considerable psychosocial stress as Christa is estranged from her father, who is not supportive of her transition, although mother is. Unfortunately, she is dependent on her father for medical insurance coverage, and he is refusing to give authorization to proceed with the evaluations and diagnostic workup for the transformation. Christa has been repeatedly encouraged to seek counseling but has declined because of previous poor experiences with counselors. Her primary care clinician in Family Medicine has been administering hormonal replacement therapy because she cannot access the regional center of excellence because of above-mentioned insurance issues. She presents to you now with her mother for management suggestions and diagnostic clarification. What is your next step?
Behavioral Health Service Utilization and Unmet Need After Traumatic Brain Injury in Childhood
Authors: Narad Megan E. , Moscato Emily , Yeates Keith Owen , Taylor H. Gerry , Stancin Terry , Wade Shari L.
Published: May 2019

Objective:

The need for behavioral health services, service utilization, and predictors of utilization was examined in children with moderate-to-severe traumatic brain injury (TBI) relative to a comparison group of children with orthopedic injury (OI) 6.8 years after injury.

Methods:

A total of 130 children hospitalized for moderate-to-severe TBI (16 severe and 42 moderate) or OI (72) between the ages of 3 and 7 years, who were enrolled at the time of injury at 3 tertiary care children's hospital and one general hospital in Ohio, and completed a long-term follow-up 6.8 years after injury were included in analyses.

Results:

Adolescents with TBI (moderate [38%] and severe [69%]) had significantly greater rates of need than those with OI (17%). Behavioral health services were utilized by 10% of the sample with no injury group differences (OI: 6%; moderate: 17%; severe: 13%). Early treatment and white race were associated with less service utilization; 77% had an unmet need, with no injury group differences (OI: 75%; moderate: 75%; severe: 82%). Rate of unmet need was greater among white than non-white children.

Conclusion:

Children who sustain a TBI in early childhood experience persistent and clinically significant impairments even years after injury. Rates of unmet need were high for all injury groups. Findings underscore the importance of long-term monitoring to identify developing needs and prevent significant complications/deficits.
The Relationship Among Screen Use, Sleep, and Emotional/Behavioral Difficulties in Preschool Children with Neurodevelopmental Disorders
Authors: Lin Jiayong , Magiati Iliana , Chiong Shi Hui Rachel , Singhal Swati , Riard Natasha , Ng Isabel Hui-Xuan , Muller-Riemenschneider Falk , Wong Chui Mae
Published: May 2019

Objective:

Despite evidence that excessive screen use may contribute to negative health, developmental, emotional, and behavioral outcomes, more children are engaging in increasing amounts of screen-related activities. For children with neurodevelopmental conditions, increased screen use could exacerbate emotional/behavioral difficulties (EBDs) by interfering with sleep quantity and quality.

Aims:

This study examined the possible mediating role of sleep in the relationship between screen use and EBDs in preschool children with neurodevelopmental disorders (NDDs) clinically referred to a child development center in Singapore.

Methods:

A screen use questionnaire developed for the purposes of the present study, the Children's Sleep Habits Questionnaire, and the Strengths and Difficulties Questionnaire were completed by 367 caregivers of 2- to 5-year-old children with NDDs (39.5% autism spectrum disorder; 36.8% speech-language disorders; 23.7% others).

Results:

Average daily screen use duration was 3.98 hours, with 93.9% exceeding 1 hour of screen time daily. 57.7% of children had screen devices in their bedrooms, while 52% commenced screen use at the age of 18 months or earlier. Sleep problems fully mediated the relationship between the number of bedroom screen devices and children's EBDs, as well as between the age of first screen use and EBDs, but not between hours of screen use and EBDs. Controlling for age, developmental level, and family income, children who started using screens earlier than 18 months and who had screen devices in their bedrooms had significantly more sleep problems and EBDs than those without.

Conclusion:

Children with neurodevelopmental conditions may have more difficulties disengaging from screen devices in their bedrooms, and an earlier age of screen exposure may contribute to more chronic disruption of sleep.
Value-Driven Care in Developmental-Behavioral Pediatrics, Part 2: Measuring Quality and Meeting the Challenge
Authors: Sandler Adrian D.
Published: May 2019

The drive to improve quality and reduce cost of health care is leading to a value-driven transformation of the US health care landscape. This is the second of a 2-part series on value-driven care and its implications for developmental-behavioral pediatrics (DBP). Part 1 addressed costs of care and enhancing value of care, with a particular focus on the value proposition of the field of DBP. This study begins with a discussion of the Donabedian's model of quality, including structure, process, patient satisfaction, and outcomes. The challenges of measuring process and outcomes in DBP are discussed, with a focus on (1) children 0 to 3 years of age identified as having global developmental delay, (2) recent diagnosis of complex attention-deficit hyperactivity disorder (ADHD) (ADHD plus comorbid conditions), and (3) children with autism spectrum disorder (ASD) and disruptive behavior. The study concludes with some of the important next steps for DBP providers, researchers, health care systems, professional societies, and families. With a discussion of national trends and a local example of a DBP program's response to these trends, the series is intended to provoke discussion and action in the field, contribute to the demonstration of value of a DBP approach to care, and help to chart a course toward growth and sustainability of DBP in an era of value-based care.
Transepithelial Phototherapeutic Keratectomy Followed by Corneal Collagen Crosslinking for the Treatment of Pellucid Marginal Degeneration: Long-term Results
Authors: Cagil Nurullah , Sarac Ozge , Yesilirmak Nilufer , Caglayan Mehtap , Uysal Betul S. , Tanriverdi Burak
Published: May 2019

Purpose:

To evaluate visual, refractive, topographic, and aberrometric outcomes of transepithelial phototherapeutic keratectomy (PTK) + corneal collagen crosslinking in the treatment of pellucid marginal degeneration.

Methods:

This retrospective study includes 20 eyes of 15 patients with pellucid marginal degeneration treated with transepithelial PTK + accelerated corneal collagen crosslinking. Visual acuity, refraction, topographic keratometry, pachymetry, and aberrations were recorded pretreatment and 6, 12, 24, and 36 months after treatment.

Results:

Stabilization in visual acuity was observed throughout the 36 months of follow-up (P > 0.05). The cylindrical value was significantly lower (P < 0.05) during the follow-up compared with the baseline (4.97 ± 2.00, 3.86 ± 2.01, 3.92 ± 2.27, 2.87 ± 1.70, and 3.28 ± 3.12 D at the baseline and postoperative 6th, 12th, 24th, and 36th month, respectively). Spherical equivalent was significantly lower at the 24th (P = 0.02) and 36th month (P = 0.01) follow-up intervals. A significant decrease (P < 0.05) in average keratometry readings was observed in all follow-up points (47.12 ± 4.66, 46.65 ± 4.38, 46.57 ± 4.57, 46.46 ± 4.81, and 46.27 ± 4.46 D, respectively). The maximum keratometry value remained stable (P > 0.05) in all visits (64.30 ± 10.70, 63.49 ± 10.05, 62.97 ± 9.50, 63.33 ± 10.06, and 62.27 ± 10.36 D, respectively). The Baiocchi Calossi Versaci index was significantly lower (P < 0.05) at all follow-up points compared with the baseline (3.21 ± 1.93, 2.99 ± 1.96, 2.96 ± 1.93, 2.82 ± 1.95, and 2.86 ± 1.99 μm, respectively). Central and minimum corneal thicknesses were significantly lower (P ≤ 0.01) compared with the baseline throughout the follow-up. Higher order aberration, trefoil, coma, and spherical aberration values remained stable during the follow-up compared with the baseline (P > 0.05).

Conclusions:

The combination of transepithelial PTK with accelerated corneal collagen crosslinking seems to be an effective treatment in patients with pellucid marginal degeneration in the long-term.
Invasive Haemophilus influenzae Disease at Texas Children’s Hospital, 2011 to 2018
Authors: Vallejo Jesus G. , McNeil J. Chase , Hultén Kristina G. , Sommer Lauren M. , Dunn James J. , Kaplan Sheldon L.
Published: May 2019

Background:

Universal vaccination with Haemophilus influenzae type b conjugate vaccines has significantly changed the epidemiology of invasive H. influenzae disease in the United States. We reviewed the epidemiology, clinical features, and outcomes in 61 patients with invasive H. influenzae disease evaluated at Texas Children’s Hospital (TCH).

Methods:

Cases of invasive H. influenzae disease, defined as isolation of the organism from cerebrospinal fluid, blood, synovial fluid or pleural fluid, during 2011 to 2018 among children cared for at TCH in Houston, TX, were included.

Results:

We identified 61 cases of invasive H. influenzae disease in children ≤18 years of age. The overall hospitalization rate due to invasive H. influenzae disease increased between 2011 and 2018 (0 vs. 0.64/1000 hospitalizations; P = 0.019). The majority (80%) of infections occurred in children <5 years of age. Of the 61 H. influenzae infections, 24 (39.3%) infections were caused by nontypeable H. influenzae strains, 18 (29.5%) infections were caused by H. influenzae type a, 12 (19.7%) infections were caused by H. influenzae type f, 3 (4.9%) infections were caused by H. influenzae type e and 4 (6.6%) isolates were not typed. A total of 78.7% of the isolates were β-lactamase negative. The most common clinical presentations were bacteremia without a source, pneumonia and meningitis.

Conclusions:

The hospitalization rate for H. influenzae invasive disease increased over an 8-year period at TCH. The overall trend was mainly driven by an increasing number of invasive infections caused by nontypeable H. influenzae and H. influenzae type a. Morbidity was substantial, especially in meningitis cases.
Pharmacological interventions for chronic pain in children: an overview of systematic reviews
Authors: Eccleston Christopher , Fisher Emma , Cooper Tess E. , Grégoire Marie-Claude , Heathcote Lauren C. , Krane Elliot , Lord Susan M. , Sethna Navil F. , Anderson Anna-Karenia , Anderson Brian , Clinch Jacqueline , Gray Andrew L. , Gold Jeffrey I. , Howard Richard F. , Ljungman Gustaf , Moore R. Andrew , Schechter Neil , Wiffen Philip J. , Wilkinson Nick M.R. , Williams David G. , Wood Chantal , van Tilburg Miranda A.L. , Zernikow Boris
Published: May 2019

We know little about the safety or efficacy of pharmacological medicines for children and adolescents with chronic pain, despite their common use. Our aim was to conduct an overview review of systematic reviews of pharmacological interventions that purport to reduce pain in children with chronic noncancer pain (CNCP) or chronic cancer-related pain (CCRP). We searched the Cochrane Database of Systematic Reviews, Medline, EMBASE, and DARE for systematic reviews from inception to March 2018. We conducted reference and citation searches of included reviews. We included children (0-18 years of age) with CNCP or CCRP. We extracted the review characteristics and primary outcomes of ≥30% participant-reported pain relief and patient global impression of change. We sifted 704 abstracts and included 23 systematic reviews investigating children with CNCP or CCRP. Seven of those 23 reviews included 6 trials that involved children with CNCP. There were no randomised controlled trials in reviews relating to reducing pain in CCRP. We were unable to combine data in a meta-analysis. Overall, the quality of evidence was very low, and we have very little confidence in the effect estimates. The state of evidence of randomized controlled trials in this field is poor; we have no evidence from randomised controlled trials for pharmacological interventions in children with cancer-related pain, yet cannot deny individual children access to potential pain relief. Prospero ID: CRD42018086900.
Stasis Dermatitis
Authors: Sung Calvin T. , Taguines Pamela R. , Jacob Sharon E.
Published: May 2019

Teledermatology is a term to describe the provision of dermatologic medical services through telecommunication technology. This is a case of itchy hyperpigmented skin with pitting edema.
Subcutaneous Immunoglobulin Therapy for Chronic Inflammatory Demyelinating Polyneuropathy: A Nursing Perspective
Authors: Watkins Jennifer M. , Dimachkie Mazen M. , Riley Patty , Murphy Elyse
Published: May 2019

Chronic inflammatory demyelinating polyneuropathy (CIDP), an immune-mediated peripheral neuropathy, is frequently treated with long-term maintenance intravenous immunoglobulin (IVIG). However, disadvantages of IVIG are the systemic adverse reactions, lengthy infusions, and need for vascular access. Subcutaneous immunoglobulin (SCIG) addresses many of the issues encountered by those unable, or unwilling, to tolerate the treatment burden of long-term IVIG. Subcutaneous immunoglobulin, a 20% solution stabilized with L-proline, is US Food and Drug Administration–approved for CIDP maintenance therapy in patients after being stabilized with IVIG. Approval was based on a randomized, double-blind, placebo-controlled trial where SCIG demonstrated superiority over placebo and was safe and efficacious in maintaining function. In addition to reviewing the primary efficacy results from the clinical trial, this article aims to update the neurology nursing community on a new option for long-term management of CIDP, including the practicalities of initiating and maintaining patients on SCIG therapy.
Safety of vitamin C in sepsis: a neglected topic
Authors: Khoshnam-Rad Niloofar , Khalili Hossein
Published: May 2019

Purpose of review

Although vitamin C is essentially a nontoxic vitamin; however, it is important to be aware regarding the safety of high doses before the wide clinical use.

Recent findings

Minor side effects of vitamin C have been reported, many being reported in earlier studies. High doses of vitamin C (up to 1.5 g/kg three times a week as intravenously) were safe in cancer patients with normal renal function and perfect glucose-6-phosphate dehydrogenase activity. As the dose and duration of administration of vitamin C in sepsis are lower and shorter than those used in cancer patients, it seems that it is relatively safe for this population. In ongoing trials, safety of high doses of vitamin C is considered.

Data regarding the safety of high doses of vitamin C are scant. Until more data become available, caution should be applied in the use of high doses of vitamin C in patients with hemochromatosis, glucose-6-phosphate dehydrogenase deficiency, renal dysfunction, kidney stone, oxaluria, and pediatrics.
A Randomized Study of Values Affirmation to Promote Interest in Diabetes Prevention Among Women With a History of Gestational Diabetes
Authors: Brown Susan D. , Fotuhi Omid , Grijalva Christina S. , Tsai Ai-Lin , Quesenberry Charles P. , Ritchie Jenna L. , Cohen Geoffrey L. , Ferrara Assiamira
Published: May 2019

Objective:

The objective of this study was to test whether 2 interventions promote interest in diabetes prevention among women with a history of gestational diabetes mellitus, who face high lifetime risk for diabetes.

Research Design and Methods:

We designed an email outreach message promoting an existing preventive lifestyle program. The message incorporated values affirmation, a theory-based intervention that can improve openness to health information but typically relies on a writing exercise less practical in health care settings. In a 3-arm randomized study, 237 women with elevated body mass index and a history of gestational diabetes mellitus were randomized to read an outreach message containing either no affirmation (control) or 1 of 2 affirmations, streamlined to remove the typical writing exercise: either a values affirmation prompting reflection on any personal value, or a parenting affirmation prompting reflection on caregiving-related values. Outcomes included demonstrating interest in the lifestyle program (seeking information about it or intending to join) and seeking publicly-available health information about diabetes prevention.

Results:

Compared with control, participants randomized to the values affirmation more frequently demonstrated interest in the lifestyle program (59.0% vs. 74.4%; adjusted relative risk: 1.31; 95% confidence interval: 1.04–1.66) and sought information about diabetes prevention (59.0% vs. 73.4%; adjusted relative risk: 1.22; 95% confidence interval: 0.97–1.54). The parenting affirmation yielded no significant differences in either outcome.

Conclusions:

A streamlined values affirmation, designed for feasibility in a health care setting, can promote interest in diabetes prevention among women at high risk. Research is needed to evaluate its effects on diabetes prevention program enrollment and clinical outcomes.
Conversion to Gastrojejunostomy Tubes in Developmentally Disabled Children Intolerant to Gastrostomy Tube Feeding
Authors: DeRaddo Joseph S. , Skummer Philip , Rivera Marcus , Kobayashi Katsuhiro
Published: May 2019

This study retrospectively evaluated the safety, impact on growth, and clinical outcomes of gastrojejunostomy tubes (GJTs) converted from surgically placed gastrostomy tubes (GTs) in 44 developmentally disabled children (median age: 28 months). The total duration of GJT follow‐up was 31,378 device‐days (median: 643 device‐days). Three major complications (aspiration pneumonia) were identified in 3 patients (6.8%), 63 minor complications in 31 patients (70.5%), and 202 tube maintenance issues (TMIs) in 41 patients (93.2%). A significantly increased average change in weight‐for‐age z‐scores was observed at each 6‐month interval that continued past 25 months. Patients above the median rate of TMIs had marginally significant lower z‐scores across the study period (P = 0.06), compared with those below the median rate. GJTs were removed in 6 patients (13.6%) because of adequate oral intake at last follow‐up. Conversion from GTs to GJTs was a viable option to achieve sustained growth in developmentally disabled children. Frequency of TMIs may negatively impact their growth.