Pediatric growth faltering: Evaluation and management in primary care.

ABSTRACT: Pediatric growth faltering (GF), previously known as failure to thrive and now also called pediatric malnutrition and weight faltering, is a common clinical finding in primary care. Most pediatric GF cases are caused by inadequate caloric intake, not organic disease states. Evaluation requires clinicians to obtain detailed nutritional, medical, psychosocial, and family histories; take accurate anthropometric measurements; and perform a careful physical examination. Evaluation findings should be analyzed to determine whether targeted diagnostic workup, specialty referral, or a trial of nutritional counseling is indicated. Management includes caregiver education about childhood nutrition and frequent monitoring of growth parameters. A multidisciplinary approach that includes nutritionist, developmental therapist, and other specialty team member involvement is desirable.

Multidisciplinary Care of Alcohol-related Liver Disease and Alcohol Use Disorder: A Narrative Review for Hepatology and Addiction Clinicians.

PURPOSE: Models of integrated, multidisciplinary care are optimal in the setting of complex, chronic diseases and in the overlap of medical and mental health disease, both of which apply to alcohol-related liver disease (ALD). Alcohol use disorder (AUD) drives nearly all cases of ALD, and coexisting mental health disease is common. ALD is a complex condition with severe clinical manifestations and high mortality that can occasionally lead to liver transplantation. As a result, integrated care for ALD is an attractive proposition. The aim of this narrative review was to: (1) review the overlapping and concerning trends in the epidemiology of AUD and ALD; (2) use a theoretical framework for integrated care known as the "five-component model" as a basis to highlight the need for integrated care and the overlapping clinical manifestations and management of the 2 conditions; and (3) review the existing applications of integrated care in this area. METHODS: We performed a narrative review of epidemiology, clinical manifestations, and management strategies in AUD and ALD, with a particular focus on areas of overlap that are pertinent to clinicians who manage each disease. Previously published models were reviewed for integrating care in AUD and ALD, both in the general ALD population and in the setting of liver transplantation. FINDINGS: The incidences of AUD and ALD are rising, with a pronounced acceleration driven by the Coronavirus Disease 2019 pandemic. Hepatologists are underprepared to diagnose and treat AUD despite its high prevalence in patients with liver disease. A patient who presents with overlapping clinical manifestations of both AUD and ALD may not fit neatly into typical treatment paradigms for each individual disease but rather will require new management strategies that are appropriately adapted. As a result, the dimensions of integrated care, including collective ownership of shared goals, interdependence among providers, flexibility of roles, and newly created professional activities, are highly pertinent to the holistic management of both diseases. IMPLICATIONS: Integrated care models have proliferated as recognition grows of the dual pathology of AUD and ALD. Ongoing coordination across disciplines and research in the fields of hepatology and addiction medicine are needed to further elucidate optimal mechanisms for collaboration and improved quality of care.

Direct and indirect healthcare and carbon savings with ACTIVE Particle ControlTM air-purification.

Controlling airborne transmitted disease remains a challenge to clinicians, healthcare administrators, and engineers. Engineering measures are critical to any infection control program but can require extensive installation procedures, may be expensive to maintain, and may not always demonstrate clinical or financial benefit. We determined the financial and carbon benefits of an engineering solution to combat air pollutants and to control airborne transmitted disease. We determined the costs of healthcare associated infections (HAIs), and the costs of installation, maintenance, energy demands, and carbon impacts of an ACTIVE Particle ControlTM (APC) air-purification system. In a 20 month study with over 65,000 patient days the significant reductions in HAIs resulted in significant financial, energy, maintenance, and carbon savings from this engineering solution. Positive clinical and financial outcomes are possible with novel air-purification solutions such as APC.

Enhanced gut barrier integrity sensitizes colon cancer to immune therapy.

Oral IL-10 suppressed tumor growth in the APCmin/+ mouse/Bacteroides fragilis colon cancer model while a similar formulation of IL-12 exacerbated disease. In contrast, combined treatment with IL-10 and IL-12 resulted in near-complete tumor eradication and a significant extension of survival. The cytokines mediated distinct immunological effects in the gut, i.e. IL-10 diminished Th17 cell prevalence whereas IL-12 induced IFNγ and enhanced CD8 + T-cell activity. Loss-of-function studies demonstrated that IL-12-driven CD8 + T-cell expansion was only partially responsible for the synergy, and that both the detrimental and the beneficial activities of IL-12 required IFNγ. Examination of colon physiology in mice receiving single vs dual treatment revealed that exacerbation of disease by IL-12 monotherapy was associated with compromised gut barrier integrity whereas combined treatment reversed this effect, uncovering additional activity by the cytokines on the stroma. Further analysis showed that the stromal effects of IL-12 included a 6-fold increase in IL-10RA expression in the colon epithelium, linking the epithelial activity of the cytokines. Finally, dual but not monotherapy induced a 3-fold increase in tight junction protein levels in the colon, identifying the mechanism by which IL-10 blocked the detrimental effect of the IL-12-IFNγ axis on barrier function without interfering with its beneficial immunological activity. These findings establish that the synergy between IL-12 and IL-10 was mediated by pleiotropic effects on the immune and the non-immune compartments and that the latter activity was critical to therapeutic outcome.

Intravaginal Administration of Interleukin 12 during Genital Gonococcal Infection in Mice Induces Immunity to Heterologous Strains of Neisseria gonorrhoeae.

It has previously been shown that genital tract infection with Neisseria gonorrhoeae in mice does not induce a state of protective immunity against reinfection but instead suppresses the development of adaptive immune responses against N. gonorrhoeae dependent on transforming growth factor beta (TGF-ß) and interleukin 10 (IL-10). Intravaginal administration during gonococcal infection of IL-12 encapsulated in biodegradable microspheres (IL-12/ms) reverses the immunosuppression and promotes the production of gamma interferon (IFN-γ) and of specific antibodies in serum and genital secretions and accelerates clearance of the infection. In this study, microspheres were shown to remain largely within the genital tract lumen and to release IL-12 over the course of 4 days. Antigonococcal IgA and IgG antibodies induced by IL-12/ms treatment reacted with antigenically different strains of N. gonorrhoeae and led to resistance to reinfection with heterologous and homologous strains. Immune resistance to reinfection persisted for at least 6 months after clearance of the primary infection. Experiments performed with immunodeficient strains of mice lacking either IFN-γ or B cells demonstrated that both IFN-γ and B cells were necessary for the IL-12-induced generation of immune responses to N. gonorrhoeae and the resulting accelerated clearance of the infection. It is therefore concluded that intravaginally administered IL-12/ms achieves its effect by the sustained release of IL-12 that promotes Th1-driven adaptive immune responses, including the production of specific antigonococcal antibodies that cross-react with multiple strains of N. gonorrhoeae. IL-12-enhanced immunity to N. gonorrhoeae can be recalled against reinfection after prolonged intervals and is dependent upon both IFN-γ and antibody production by B cells. IMPORTANCE Genital infection with Neisseria gonorrhoeae (gonorrhea) is a significant cause of reproductive tract morbidity in women, leading to pelvic inflammatory disease, tubal factor infertility, and increased risk for ectopic pregnancy. WHO estimates that 78 million new infections occur annually worldwide. In the United States, >350,000 cases are reported annually, but the true incidence is probably >800,000 cases/year. Increasing resistance to currently available antibiotics raises concern that gonorrhea might become untreatable. Infection does not induce a state of immune protection against reinfection. Previous studies have shown that N. gonorrhoeae suppresses the development of adaptive immune responses by mechanisms dependent on the regulatory cytokines TGF-ß and IL-10. This study shows that intravaginal treatment of gonococcal infection in female mice with microencapsulated IL-12 induces persisting anamnestic immunity against reinfection with N. gonorrhoeae, even of antigenically diverse strains, dependent on T-cell production of IFN-γ and B-cell production of antibodies.

RNA isolation from Peyer's patch lymphocytes and mononuclear phagocytes to determine gene expression profiles using NanoString technology.

Sampling and immune surveillance within gut-associated lymphoid tissues such as the intestinal Peyer's patch (PP) occurs by an elegantly orchestrated effort that involves the epithelial barrier, B and T lymphocytes, and an extensive network of mononuclear phagocytes. Although we now understand more about the dynamics of antigen and microbial sampling within PPs, the gene expression changes that occur in individual cell subsets during sampling are not well characterized. This protocol describes the isolation of high-quality RNA from sorted PP, B and T-lymphocytes, and CD11c+ phagocytes for use with nCounter-NanoString technology. This method allows investigators to study gene expression changes within PPs in response to antigens, microbes, and oral vaccine delivery vehicles of interest that are sampled.

Oral IL-10 suppresses colon carcinogenesis via elimination of pathogenicCD4+ T-cells and induction of antitumor CD8+ T-cell activity.

An oral sustained-release formulation of Interleukin-10 suppressed tumor growth and enhanced survival in the APCmin/+/Bacteroides fragilis spontaneous colon cancer model. Therapeutic benefit was associated with a 5-fold reduction in CD4+RORγt+Foxp3-IL-17+ T-helper cell, CD4+RORγt+Foxp3+IL-17+ pathogenic T-regulatory cell and CD4+RORγt-Foxp3+IL-17- conventional T-regulatory cell numbers and a concurrent 2-fold enhancement in CD8+ T-cell activity in the colon. Selective subset depletion and functional blockade studies demonstrated that at steady-state CD4+RORγt+IL-17+ T-cell subsets and CD4+Foxp3+ cTreg supported tumorigenesis, whereas CD8+ cytotoxic T-lymphocytes impeded tumor progression following IL-10 therapy. Suppression of tumor growth by CD8+ T-cells was associated with enhanced tumor infiltration and cytotoxic granule exocytosis. These findings establish the utility of oral IL-10 as a potential new therapeutic in the management of colon cancer and shed light on the cellular mechanisms that underlie its antitumor activity.

Effects of an interdisciplinary volunteer experience on students' knowledge of and attitudes toward the health care team.

PURPOSE: To assess the effect of an interdisciplinary, volunteer clinical experience completed by physician assistant (PA), pharmacy, and nursing students and whether the experience will change students' knowledge of, or attitudes toward, a team approach to health care. METHODS: Surveys were conducted before and after the project using a 5-point Likert scale that measured the impact of the project on a nonrandom sample of PA, pharmacy, and nursing students who completed a minimum of four hours of service at Head Start preschool sites in southern New Hampshire. Students were recruited through email announcements and a lunchtime information session describing the program. Presurveys were completed using Blackboard before the student's scheduled participation day. Postsurveys were completed onsite at the end of the volunteer time. Surveys were blinded using a number and letter code. Students' knowledge (survey questions 1-4) and attitudes (survey questions 5-7) toward the health care team were evaluated in several areas including the importance of working in a team, knowledge level of other team members, awareness of community agencies as part of the team, and the importance of communication within the health care team. Paired t-tests were used to determine whether significant changes occurred in attitudes or knowledge as a result of the interdisciplinary volunteer experience. Approval of the study protocol was granted by the college's institutional review board. RESULTS: Statistically significant increases were noted in awareness of community resources, understanding of the strengths and skills of other members of the health care team, and experiences in working with other disciplines. Student attitudes toward a team approach to health care did not significantly change as a result of this experience. CONCLUSION: Enabling students to interact with other disciplines and to provide care to patients significantly increased students' awareness of community resources as well as their understanding of the strengths and skills of other members of the health care team. Students also gained experience working in a health care team. This demonstrates that a volunteer experience involving interdisciplinary collaboration can be used to enhance students' knowledge of the health care team.

Recurrent abdominal pain.

The purpose of this article is to provide an empirically informed but clinically oriented overview of behavioral treatment of recurrent abdominal pain. The epidemiology and scope of recurrent abdominal pain are presented. Referral process and procedures are discussed, and standardized approaches to assessment are summarized. Treatment protocols developed by Sanders and colleagues and by Finney and colleagues are described, followed by a review of treatment efficacy. The article concludes with practice recommendations that emphasize the importance of reassurance and education, appropriate and realistic treatment goals, the child's daily functional status, and treatment plans tailored to match the child and family's presentation.

Contrasting effects of self-schema priming on lexical decisions and interpersonal stroop task performance: evidence for a cognitive/interactionist model of interpersonal dependency.

Four experiments tested a key tenet of Bornstein's (1992, 1993) cognitive/interactionist (C/I) model of interpersonal dependency: that priming the helpless self-schema (HSS) alters processing of dependency-related information in dependent--but not nondependent--individuals. Experiments 1 and 2 assessed the effects of subliminal lexical priming and an emotional priming manipulation on lexical decision (LD) judgments for dependency-related words and control words. Experiments 3 and 4 assessed the effects of these same priming procedures on Interpersonal Stroop Task (IST) performance. As predicted, priming the HSS produced contrasting effects on different outcome measures, decreasing LD latencies, but increasing IST response times. Results are discussed in the context of the C/I model, and suggestions for future studies are offered.

A brief group cognitive-behavioral intervention for social phobia in childhood.

Twenty-three preadolescent children (ages 8-11) meeting criteria for social phobia were randomly assigned to either a 3-week cognitive-behavioral group intervention or a wait-list control group. The intervention consisted of psychoeducation, cognitive strategies, and behavioral exposure. Outcome measures included diagnostic interview as well as parent and child report measures of anxiety and depression. Improvements were observed at posttest, with results stronger for parent report and interviewer ratings than for child self-report. At 3-week follow-up, children receiving the intervention demonstrated significant improvements on the majority of child, parent, and interviewer reports of social anxiety and related symptoms relative to wait-list participants. Preliminary support is provided for the utility of a brief intervention for preadolescent children with social phobia. Limitations and implications for future research are discussed.

Construct validity of the relationship profile test: impact of gender, gender role, and gender role stereotype.

Research supports the construct validity of the Relationship Profile Test (RPT; Bornstein & Languirand, 2003), a 30-item, self-report measure of destructive overdependence (DO), dysfunctional detachment (DD), and healthy dependency. In this investigation, we assessed the relationships of gender, gender role, and gender role stereotype ratings to RPT subscale scores. In Study 1, we replicated earlier patterns of gender differences in RPT scores, assessed cross-sample consistency in gender difference effect sizes, and provided preliminary nonclinical norms for the RPT subscales. Study 2 showed that--as expected--DO items are perceived as stereotypically feminine, whereas DD items are perceived as stereotypically masculine. In Study 3, we examined the relationships of RPT subscale scores to masculinity, femininity, and androgyny scores. We discuss the theoretical, empirical, and clinical implications of these findings.

Construct validity of the relationship profile test: a self-report measure of dependency-detachment.

This study evaluated the construct validity of the Relationship Profile Test (RPT; Bornstein & Languirand, 2003), a 30-item self-report measure of dependency-detachment that yields three subscale scores: (a) destructive overdependence, (b) dysfunctional detachment, and (c) healthy dependency. Scores on the RPT subscales generally showed the expected patterns of intercorrelations and gender differences, and comparison of RPT scores with scores on other tests supported the convergent and discriminant validity of each RPT subscale. Results of internal and retest reliability analyses were generally supportive as well, and suggested that the three RPT subscales assess aspects of the traits they purport to measure