High Prevalence of Abnormal General Movements in Hospitalized Very Low Birth Weight Infants.

OBJECTIVE: Abnormal general movements (GMs) are predictive of later risk of motor impairments in preterm infants. The goals of this study are to (1) describe the implementation of the GM assessment (GMA) in a neonatal intensive care unit (NICU) and (2) investigate the prevalence and evolution of abnormal GMs in very low birth weight (VLBW) infants. STUDY DESIGN: Observational study of GMs in VLBW infants (gestational age [GA] <32 weeks and/or birth weight [BW] <1,500 g) following GMA implementation in a level-IV NICU. All VLBW infants admitted between November 2017 and April 2019 were eligible for the GMA. Infants were excluded if they required high-frequency ventilation or if they could not be unbundled for video acquisition. GMAs were scored weekly by at least 2 GMA-certified providers. RESULTS: The GMA was performed in 121 VLBW infants with a mean (standard deviation [SD]) GA of 28.3 (2.6) and BW of 1,113 (400 g). Only 28% of infants had normal GMs on initial assessment (32.9 ± 2.7 weeks' GA), while 61 and 11% had poor repertoire and cramped-synchronized GMs, respectively. At NICU discharge (37.6 ± 3.4 weeks corrected GA), 45 and 21% of infants were classified as having poor repertoire and cramped-synchronized GMs, respectively. Most infants with cramped-synchronized GMs on initial assessment had persistent abnormal GMs at discharge. In contrast, only one infant with normal GMs on first assessment developed cramped-synchronized GMs. CONCLUSION: Abnormal GMs are common in VLBW infants, including a high prevalence of the more concerning cramped-synchronized movement pattern. The GMA can be successfully performed in VLBW infants. The GMA may be helpful in identifying infants at increased risk of later motor impairments, as well as assisting clinicians, in the stratification of infants who may benefit from additional brain imaging and/or an intensive hospital-based interventions. KEY POINTS: · Abnormal GMs are common in VLBW infants.. · Poor repertoire in the most prevalent pattern observed.. · Infants at risk for abnormal motor outcomes can be identified in the NICU..

Implementation of a Follow-Up System for Pediatric Sepsis Survivors in a Large Academic Pediatric Intensive Care Unit.

Background: Survivors of pediatric sepsis often develop new morbidities and deterioration in quality of life after sepsis, leading to a need for improved follow-up for children who survive sepsis. Objective: To implement a follow-up system for pediatric sepsis survivors in a pediatric health system. Methods: We performed a retrospective case series of patients treated for sepsis from October 2018 through October 2019 in a pediatric intensive care unit in a quaternary children's hospital, and describe implementation of a follow-up system for sepsis survivors. Program planning started in 2017 with multidisciplinary meetings including physical, occupational, and speech therapists, teachers, neuropsychologists, and coordinators from other survivorship programs (neonatology, stroke, and oncology). In 2018, a workshop was held to consult with local and national experts. The Pediatric Sepsis Survivorship Program launched in October 2018 led by a nurse coordinator who met with families to educate about sepsis and offer post-discharge follow-up. Patients with high pre-existing medical complexity or established subspecialty care were referred for follow-up through existing care coordination or subspecialty services plus guidance to monitor for post-sepsis morbidity. For patients with low-moderate medical complexity, the nurse coordinator administered a telephone-based health-assessment 2-3 months after discharge to screen for new physical or psychosocial morbidity. Patients flagged with concerns were referred to their primary physician and/or to expedited neuropsychological evaluation to utilize existing medical services. Results: Of 80 sepsis patients, 10 died, 20 were referred to care coordination by the program, and 13 had subspecialty follow-up. Five patients were followed in different health systems, four were adults not appropriate for existing follow-up programs, four remained hospitalized, and four were missed due to short stay or unavailable caregivers. The remaining 20 patients were scheduled for follow-up with the Pediatric Sepsis Program. Nine patients completed the telephone assessment. Four patients were receiving new physical or occupational therapy, and one patient was referred for neuropsychology evaluation due to new difficulties with attention, behavior, and completion of school tasks. Conclusions: Implementation of an efficient, low-cost pediatric sepsis survivorship program was successful by utilizing existing systems of care, when available, and filling a follow-up gap in screening for select patients.

COVID-19 and Orthopaedic International Humanitarianism.

As the world continues to adjust to life with COVID-19, one topic that requires further thought and discussion is whether elective international medical volunteerism can continue, and, if so, what challenges will need to be addressed. During a pandemic, the medical community is attentive to controlling the disease outbreak, and most of the literature regarding physician involvement during a pandemic focuses primarily on physicians traveling to areas of need to help treat the disease. As a result, little has been written about medical volunteerism that focuses on medical treatment unrelated to the disease outbreak. In a world-wide pandemic, many factors are to be considered in determining whether, and when, a physician should travel to another region to provide care and training for medical issues not directly related to the pandemic. Leaders of humanitarian committees of orthopaedic surgery subspecialties engaged with one another and host orthopaedic surgeons and a sponsoring organization to provide thoughtful insight and expert opinion on the challenges faced and possible pathways to provide continued orthopaedic support around the globe. Although this discussion focuses on international orthopaedic care, these suggestions may have a much broader application to the international medical community as a whole.

A Maternal-Administered Multimodal Neonatal Bundle in Hospitalized Very Preterm Infants: A Pilot Study.

BACKGROUND: Premature infants are at an increased risk for developing cerebral palsy (CP). Evidence-based strategies designed to promote healthy brain development and facilitate adaptation after brain injury in infants still admitted to the neonatal intensive care unit (NICU) represent a novel approach that may lead to improved long-term outcomes. PURPOSE: To investigate the feasibility of a maternal-administered early intervention bundle in very preterm infants prior to NICU discharge. METHODS: A pilot trial evaluating a maternal-administered NICU-based bundle of interventions in preterm infants (≤32 weeks' gestational age and/or ≤1500 g birth weight). The impact of the bundle on short-term developmental outcomes of infants, as well as maternal stress, anxiety, and depression, is evaluated. RESULTS: The intervention bundle was implemented in 11 mother-infant dyads (including 1 set of twins) for a median of 8 weeks and was overall well received. Vocal soothing, scent exchange, and comforting touch were feasible, performed at or above the predetermined goal of 71% of the time (5/7 days), while kangaroo care and infant massage were not. Maternal stress, anxiety, and depression were decreased during the study time. IMPLICATIONS TO PRACTICE: A neonatal multimodal intervention bundle provided by mothers is feasible. IMPLICATIONS TO RESEARCH: Additional randomized controlled studies are needed to determine whether this type of bundled interventions can (1) improve the neurodevelopmental outcomes of participating infants and (2) improve long-term parental outcomes, including decreased burden of anxiety and depression, as well as improved attachment and optimal patterns of social interaction.

Identification of Pediatric Sepsis for Epidemiologic Surveillance Using Electronic Clinical Data.

OBJECTIVES: A method to identify pediatric sepsis episodes that is not affected by changing diagnosis and claims-based coding practices does not exist. We derived and validated a surveillance algorithm to identify pediatric sepsis using routine clinical data and applied the algorithm to study longitudinal trends in sepsis epidemiology. DESIGN: Retrospective observational study. SETTING: Single academic children's hospital. PATIENTS: All emergency and hospital encounters from January 2011 to January 2019, excluding neonatal ICU and cardiac center. EXPOSURE: Sepsis episodes identified by a surveillance algorithm using clinical data to identify infection and concurrent organ dysfunction. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A surveillance algorithm was derived and validated in separate cohorts with suspected sepsis after clinician-adjudication of final sepsis diagnosis. We then applied the surveillance algorithm to determine longitudinal trends in incidence and mortality of pediatric sepsis over 8 years. Among 93,987 hospital encounters and 1,065 episodes of suspected sepsis in the derivation period, the surveillance algorithm yielded sensitivity 78% (95% CI, 72-84%), specificity 76% (95% CI, 74-79%), positive predictive value 41% (95% CI, 36-46%), and negative predictive value 94% (95% CI, 92-96%). In the validation period, the surveillance algorithm yielded sensitivity 84% (95% CI, 77-92%), specificity of 65% (95% CI, 59-70%), positive predictive value 43% (95% CI, 35-50%), and negative predictive value 93% (95% CI, 90-97%). Notably, most "false-positives" were deemed clinically relevant sepsis cases after manual review. The hospital-wide incidence of sepsis was 0.69% (95% CI, 0.67-0.71%), and the inpatient incidence was 2.8% (95% CI, 2.7-2.9%). Risk-adjusted sepsis incidence, without bias from changing diagnosis or coding practices, increased over time (adjusted incidence rate ratio per year 1.07; 95% CI, 1.06-1.08; p < 0.001). Mortality was 6.7% and did not change over time (adjusted odds ratio per year 0.98; 95% CI, 0.93-1.03; p = 0.38). CONCLUSIONS: An algorithm using routine clinical data provided an objective, efficient, and reliable method for pediatric sepsis surveillance. An increased sepsis incidence and stable mortality, free from influence of changes in diagnosis or billing practices, were evident.

Child Fatalities Due to Heroin/Fentanyl Exposure: What the Case History Missed.

This case report presents three unrelated children found to have heroin and/or fentanyl in their systems after general unknown systematic toxicological analysis (STA). The first case involves an 11-month-old male found unresponsive at their residence. The scene response suggested a potentially unsafe sleeping condition or a sudden unexplained infant death. The second case is a 14-month-old female found unresponsive after eating soft candies, suggesting that a choking related death may have occurred. The third case is a 12-year-old male found unresponsive in bed and foaming from the mouth. Gum was removed from the child's airway, suggesting another choking related death. The STA included a 14-drug category enzyme linked immunosorbant assay (ELISA) screening in whole blood. Cases 1 and 3 were presumptively positive for fentanyl, while Case 2 was presumptively positive for opiates and fentanyl. Reflex confirmation was performed in blood, urine and gastric contents, by solid-phase extraction (SPE) for 12 opiates including morphine and 6-monoacetylmorphine (6MAM) by gas chromatography-mass spectrometry (GC-MS) and for fentanyl, norfentanyl, and novel analogs, by liquid chromatography tandem mass spectrometry (LC-MS-MS). High concentrations of fentanyl and 6MAM in the gastric contents of Case 1, along with the presence of diacetylmorphine, suggested probable enteral ingestion of heroin and fentanyl, separately or in a combined formulation. Interpretation of the toxicology results could not determine a probable route of exposure to heroin/fentanyl in Case 2, however, the cause of death was clearly related to this drug mixture. In Case 3, the presence of acetylfentanyl suggested an illicit fentanyl exposure. The intention of this case report is to demonstrate the need for a STA approach for all non-trauma postmortem cases regardless of case circumstances, age or suspicion of drug use.

Overcoming mutagenicity and ion channel activity: optimization of selective spleen tyrosine kinase inhibitors.

Development of a series of highly kinome-selective spleen tyrosine kinase (Syk) inhibitors with favorable druglike properties is described. Early leads were discovered through X-ray crystallographic analysis, and a systematic survey of cores within a selected chemical space focused on ligand binding efficiency. Attenuation of hERG ion channel activity inherent within the initial chemotype was guided through modulation of physicochemical properties including log D, PSA, and pKa. PSA proved most effective for prospective compound design. Further profiling of an advanced compound revealed bacterial mutagenicity in the Ames test using TA97a Salmonella strain, and subsequent study demonstrated that this mutagenicity was pervasive throughout the series. Identification of intercalation as a likely mechanism for the mutagenicity-enabled modification of the core scaffold. Implementation of a DNA binding assay as a prescreen and models in DNA allowed resolution of the mutagenicity risk, affording molecules with favorable potency, selectivity, pharmacokinetic, and off-target profiles.

Volunteering Internationally: Why, Where and How.

Oral health volunteers have an important role in addressing oral health care shortages around the world, but to be effective they need to understand and prepare for the challenges of working overseas.

A fatal intoxication of 2,5-dimethoxy-4-chloroamphetamine: a case report.

Designer drugs appear to be increasing in popularity because of the ease of obtaining these constituents, the lack of ability to identify the substance(s) in routine drug screening, the appeal of the drug(s) being 'safe' due to them being marketed as a 'legal high' and possibly due to stronger restrictions that are being placed on prescription drugs. As components of designer drugs are identified and regulated by the DEA, new constituents, or analogs, of these designer drugs are being manufactured to circumvent legislation. 2,5-Dimethoxy-4-chloroamphetamine (DOC) is a substituted alpha-methylated phenethylamine and acts as a selective serotonin receptor partial agonist. There is limited literature on this particular compound and no literature that attributes death to use of this drug alone. We present a case of a 37-year-old male found at home lying face down next to a book titled 'Psychedelic Chemistry' by Michael Valentine Smith and in the early stages of decomposition. The decedent was a known methamphetamine abuser. A peripheral blood sample collected at autopsy was sent to toxicology for routine analysis. Results yielded negative for the drugs of abuse classes on the enzyme-linked immunosorbent assay screen but was positive for DOC during routine GC-MS analysis. A urine sample collected at autopsy was subjected to a routine urine liquid/liquid analysis via GC-MS, and the specimen was positive for DOC. Quantification analyses showed DOC concentration levels to be 377 ng/mL in iliac blood; 3,193 ng/mL in urine; 3,143 ng/g in liver and 683 ng/g in brain. DOC was not detected in the gastric contents. Caffeine was the only other compound detected in blood and urine. Due to the lack of literature, we believe that this is the first case where death can be attributed to DOC alone.

Brief report #3: building a rural community caregiver network: student learning in small town America.

The Rural Caregiver Network Project in Eastern Maine is a prime example of indigenous coalition-building in a region struggling to ensure that vulnerable older adults can age-in-place and manage with scarce resources. Through this innovative initiative, a range of elder caregiver interventions were mobilized, coordinated, and sustained in a rural two-county region in Maine, including navigator services, adult day care, information and referral, caregiver support groups, a caregiver resource center, and caregiver skills-building workshops. The endorsement of participatory research, evaluation, and programming principles enabled undergraduate and graduate social work students to assume major roles in all aspects of project planning, implementation, and assessment while remaining grounded in the realities of rural life. Competence in such a generalist gerontological social work practice perspective is critical in small towns and nonmetropolitan communities.

The role of trauma team leaders in missed injuries: does specialty matter?

BACKGROUND: Previous studies have identified missed injuries as a common and potentially preventable occurrence in trauma care. Several patient- and injury-related variables have been identified, which predict for missed injuries; however, differences in rate and severity of missed injuries between surgeon and nonsurgeon trauma team leaders (TTLs) have not previously been reported. METHODS: A retrospective review was conducted on a random sample of 10% of all trauma patients (Injury Severity Score [ISS] > 12) from 1999 to 2009 at a Canadian Level I trauma center. Missed injuries were defined as those identified greater than 24 hours after presentation and were independently adjudicated by two reviewers. TTLs were identified as either surgeons or nonsurgeons. RESULTS: Of our total trauma population of 2,956 patients, 300 charts were randomly pulled for detailed review. Missed injuries occurred in 46 patients (15%). Most common missed injuries were fractures (n = 32, 70%) and thoracic injuries (n = 23, 50%). The majority of missed injuries resulted in minor morbidity with only 5 (11%) requiring operative intervention. On univariate analysis, higher ISS (p < 0.01), higher maximum Abbreviated Injury Scale (MAIS) score of the thorax (p < 0.01), and nonsurgeon TTL status were predictive of missed injuries (p = 0.02). Multivariable logistic regression revealed that, after adjustment for age, ISS, and severe head injuries, the presence of a nonsurgeon TTL was associated with an increased odds of missed injury (odds ratio, 2.15; 95% confidence interval, 1.10-4.20). CONCLUSION: Missed injuries occurred in 15% of patients. A unique finding was the increased odds of missed injury with nonsurgeon TTLs. Further research should be undertaken to explore this relationship, elucidate potential causes, and propose interventions to narrow this discrepancy between TTL provider types. LEVEL OF EVIDENCE: Therapeutic study, level IV. Prognostic and epidemiologic study, level III.

Mineralocorticoid receptor antagonists attenuate pulmonary inflammation and bleomycin-evoked fibrosis in rodent models.

Accumulating evidence indicates protective actions of mineralocorticoid antagonists (MR antagonists) on cardiovascular pathology, which includes blunting vascular inflammation and myocardial fibrosis. We examined the anti-inflammatory and anti-fibrotic potential of MR antagonists in rodent respiratory models. In an ovalbumin allergic and challenged Brown Norway rat model, the total cell count in nasal lavage was 29,348 ± 5451, which was blocked by spironolactone (0.3-60 mg/kg, p.o.) and eplerenone (0.3-30 mg/kg, p.o.). We also found that MR antagonists attenuated pulmonary inflammation in the Brown Norway rat. A series of experiments were conducted to determine the actions of MR blockade in acute/chronic lung injury models. (1) Ex vivo lung slice rat experiments found that eplerenone (0.01 and 10 µM) and spironolactone (10 µM) diminished lung hydroxyproline concentrations by 55 ± 5, 122 ± 9, and 83 ± 8%. (2) In in vivo studies, MR antagonists attenuated the increases in bronchioalveolar lavage (BAL) neutrophils and macrophages caused by lung bleomycin exposure. In separate studies, bleomycin (4.0 U/kg, i.t.) increased lung levels of hydroxyproline by approximately 155%, which was blocked by spironolactone (10-60 mg/kg, p.o.). In a rat Lipopolysaccharide (LPS) model, spironolactone inhibited acute increases in BAL cytokines with moderate effects on neutrophils. Finally, we found that chronic LPS exposure significantly increased end expiratory lung and decreased lung elastance in the mouse. These functional effects of chronic LPS were improved by MR antagonists. Our results demonstrate that MR antagonists have significant pharmacological actions in the respiratory system.

Inhibition of spleen tyrosine kinase attenuates allergen-mediated airway constriction.

Spleen tyrosine kinase (SYK) is a key activator of signaling pathways downstream of multiple surface receptors implicated in asthma. SYK function has been extensively studied in mast cells downstream of the high-affinity IgE receptor, FcεR1. Preclinical studies have demonstrated a role for SYK in models of allergic inflammation, but a role in airway constriction has not been demonstrated. Here, we have used a potent and selective pharmacological inhibitor of SYK to determine the role of SYK in allergen-mediated inflammation and airway constriction in preclinical models. Attenuation of allergic airway responses was evaluated in a rat passive anaphylaxis model and rat and sheep inhaled allergen challenge models, as well as an ex vivo model of allergen-mediated airway constriction in rats and cynomolgus monkeys. Pharmacological inhibition of SYK dose-dependently blocked IgE-mediated tracheal plasma extravasation in rats. In a rat ovalbumin-sensitized airway challenge model, oral dosing with an SYK inhibitor led to a dose-dependent reduction in lung inflammatory cells. Ex vivo analysis of allergen-induced airway constriction in ovalbumin-sensitized brown Norway rats showed a complete attenuation with treatment of a SYK inhibitor, as well as a complete block of allergen-induced serotonin release. Similarly, allergen-mediated airway constriction was attenuated in ex vivo studies from nonhuman primate lungs. Intravenous administration of an SYK inhibitor attenuated both early- and late-phase allergen-induced increases in airway resistance in an Ascaris-sensitive sheep allergen challenge model. These data support a key role for SYK signaling in mediating allergic airway responses.

Health status of migrant farmworkers in the Shenandoah Valley.

The purpose of this study is to describe the characteristics and health status of a sample of migrant farmworkers in the Shenandoah Valley. The methodology for this study is a retrospective record review and analysis of data on 390 male migrant farmworkers. The group included men from Mexico (57. 2%), Jamaica (26. 9%), and Haiti (13. 0%) with a mean age of 38.5 years. The most common health problems reported were work-related and included musculoskeletal pain, irritated eyes, and respiratory symptoms. This study identifies areas for community and public health nurses to target interventions to address health promotion/disease prevention efforts.

Feasibility of delivering influenza vaccine to household contacts of pediatric patients in a residents' continuity clinic.

BACKGROUND: Since 2004, influenza vaccine has been recommended for household contacts (HCs) of healthy infants and young children, who are at high risk for complications from influenza disease. We examined the feasibility of providing influenza vaccine to HCs of pediatric patients during the children's outpatient clinic visits. METHODS: During influenza season 2006-07, influenza vaccine was offered at no cost to HCs of all patients aged <60 months who received primary care at a pediatric residents' continuity clinic at Children's Medical Center Dallas. The percentage of individuals receiving their first dose of influenza vaccine was calculated for all vaccinated adult HCs and also for a subset of vaccinated adult HCs for whom vaccine was recommended in a previous year, based on the pediatric patient's age. RESULTS: Influenza vaccine was administered to 1,042 HCs of 611 pediatric patients. Fifty percent of all vaccinated adult HCs had no previous history of influenza vaccination. Eighty-five of the 218 (39%) vaccinated adult HCs for whom influenza vaccine was also recommended in a previous year received their first dose through our program. CONCLUSIONS: Delivery of influenza vaccine to HCs of pediatric patients can be integrated into the children's clinic visits and may increase vaccine uptake.

Use of a transitional minimum data set (TMDS) to improve communication between nursing home and emergency department providers.

OBJECTIVE: To study the adoption of a transitional minimum data set (TMDS) and its effectiveness in conveying essential clinical data elements between skilled nursing facility (SNF) and emergency department (ED) staff. DESIGN: Retrospective medical record review of patients transferred from one SNF to one ED over a 14-month period before and after the implementation of the TMDS, to determine whether it improved data transfer compared with prior practice. SETTINGS: One urban 140-bed SNF, averaging 17 ED transfers per month, and their affiliated ED at a major tertiary care hospital in Boston, MA. PARTICIPANTS: The medical records of 74 residents transferred from the SNF to the ED comprised the study data. INTERVENTION: A Transition of Care Minimum Data Set necessary for ED care was developed based on a literature review and expert panel consensus. From this, a TMDS tool was derived. The nursing facility staff was trained on the use of the TMDS tool (Resident Transfer Form and transfer packet), which was sent with each patient at the time of transfer from the SNF to the ED. MEASUREMENTS: Effectiveness of data transfer was determined by the proportion of TMDS items received by the ED following implementation of the TMDS in comparison with prior care. Adoption rate of the TMDS tool was determined by the proportion of hospital medical records that contained a paper copy of the resident transfer form. RESULTS: Following the implementation of the TMDS there was statistically significant improvement in data transfer of 15 of 30 TMDS items. Among these items were the following: patient's family notified of transfer, contact information for the MD/NP at the SNF, contact information for obtaining more patient information from the SNF, resuscitation status, baseline cognitive and functional status, isolation precautions and risk alerts, and whether the SNF could accept the patient back after treatment in the ED. The Resident Transfer Form was found in the hospital medical record of 73% of patients. There were anecdotal reports of hospital provider satisfaction with the TMDS and RTF. CONCLUSION: The TMDS was associated with marked improvement in the transfer of essential clinical information. Educational efforts are warranted to increase consistency of usage.