Preoperative nutritional status and use of total parenteral nutrition in pediatric and adolescent patients undergoing continent urinary tract reconstruction.

INTRODUCTION: A nutritional assessment is a critical but often neglected aspect of a preoperative evaluation. Malnutrition is clearly associated with worse surgical outcomes in adults undergoing major abdominal surgery, whereas a paucity of evidence is available in the pediatric population. OBJECTIVE: The objectives were to describe the preoperative nutritional status of pediatric and adolescent patients undergoing continent urinary tract reconstruction and to determine the association among malnutrition, use of total parenteral nutrition (TPN), and surgical outcomes. STUDY DESIGN: A retrospective cohort study was performed for patients aged up to 20 years who underwent continent urinary tract reconstruction between January 2012 and November 2016. Malnutrition was classified with body mass index and height for age z-scores on admission as well as change in z-scores and weight over the 3-6 months before surgery. Primary outcomes included the duration of intensive care and hospitalization as well as readmissions and complications within 30 days. RESULTS: A total of 123 patients who underwent 130 continent urinary tract reconstructions were identified during the study period. Demographic and perioperative data are provided in the Table. Anthropometric and biochemical measurements as well as the early initiation of TPN (≤2 days) were not associated with any primary outcomes. In a subgroup analysis of patients with a bowel anastomosis, the early initiation of TPN was an independent predictor for duration of hospitalization (P < 0.0001) and 30-day complications (odds ratio 9.51, P = 0.005) after adjusting for other statistically significant and clinically relevant variables. DISCUSSION: The few available studies on surgical nutrition have primarily focused on infants and young children undergoing cardiac surgery and provided no consensus on a preoperative nutritional assessment. The findings on TPN from the present study favorably compare with a growing body of evidence in adult and pediatric critically ill and surgical patients. The limitations of the present study include its retrospective design at a single institution, potential misclassification of nutritional status, and selection bias from the initiation of TPN at the discretion of the primary surgeon. CONCLUSIONS: Malnutrition was identified in greater than 20% of pediatric and adolescent patients undergoing continent urinary tract reconstruction. Anthropometric and biochemical parameters were not associated with surgical outcomes, although the early initiation of TPN did not offer any benefit for nutritional support. In a subset of patients with a bowel anastomosis, TPN was associated with worse surgical outcomes, including a longer duration of hospitalization and development of 30-day complications.

Development and Implementation of Health and Wellness CBT for Individuals with Depression and HIV.

Rates of depression are reported to be between 22-33% in adults with HIV, which is double that of the general population. Depression negatively affects treatment adherence and health outcomes of those with medical illnesses. Further, it has been shown in adults that reducing depression may improve both adherence and health outcomes. To address the issues of depression and non-adherence, Health and Wellness (H&W) Cognitive Behavioral Therapy (CBT) and medication management (MM) treatment strategies have been developed specifically for youth living with both HIV and depression. H&W CBT is based on other studies with uninfected youth and upon research on adults with HIV. H&W CBT uses problem-solving, motivational interviewing, and cognitive-behavioral strategies to decrease adherence obstacles and increase wellness. The intervention is delivered in 14 planned sessions over a 6-month period, with three different stages of CBT. This paper summarizes the feasibility and acceptability data from an open depression trial with 8 participants, 16-24 years of age, diagnosed with HIV and with a Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) diagnosis of depression, conducted at two treatment sites in the Adolescent Trials Network (ATN). Both therapists and subjects completed a Session Evaluation Form (SEF) after each session, and results were strongly favorable. Results from The Quick Inventory of Depressive Symptomatology-Clinician (QIDS-C) also showed noteworthy improvement in depression severity. A clinical case vignette illustrates treatment response. Further research will examine the use of H&W CBT in a larger trial of youth diagnosed with both HIV and depression.

Pediatric organ transplantation and the hispanic population: approaching families and obtaining their consent.

BACKGROUND: While the number of children on waiting lists for organ donation continues to increase, little data exists concerning Hispanic children and organ donation. For physicians who care for Hispanic children, it is important to understand the factors that may influence organ donation in this population. METHODS: This retrospective chart review included 88 cases of brain death that occurred between 1990 and 1999 in 3 pediatric intensive care units. The data set included brain death determination, age, ethnicity, whether the family was approached for organ donation, and rate of consent. RESULTS: Compared with non-Hispanic/Caucasian (NH/C) families, fewer Hispanic/Caucasian (H/C) families consented to organ donation (P < or = .03). H/C families were approached less often for organ donation than NH/C families, although the difference was not significant (P < or = .08). Even once approached, H/C families were probably less likely to consent to organ donation (P < or = .087). CONCLUSION: H/C families of children with brain death show a lower organ donation consent rate than do NH/C families. However, H/C families are less likely to be approached for organ donation and this may possibly explain the reason that fewer H/C families consent to organ donation.

Sleep polysomnography as a predictor of recurrence in children and adolescents with major depressive disorder.

Adults with major depressive disorder (MDD) demonstrate certain sleep polysomnographic abnormalities, including sleep continuity disturbances, reduced slow-wave sleep, shortened rapid eye movement (REM) latency, and increased REM density. Findings of sleep EEG studies in depressed children and adolescents have yielded conflicting results, possibly because of methodological variations across the studies. Generally, however, studies have demonstrated that depressed children and adolescents exhibit less sleep continuity and non-REM sleep differences in comparison with control subjects than do adults. Thus, results from adult sleep polysomnography studies cannot necessarily be generalized to children and adolescents. Depressed adults who have reduced REM latency during the symptomatic episode appear more likely to have a relapse once treatment is discontinued than those with normal REM latency. No studies of the relationship between sleep polysomnographic variables and clinical course have been reported in depressed children and adolescents. Data for baseline clinical variables and 3 nights of sleep polysomnography were examined in 113 depressed children (< or = 12 yr; n = 51) and adolescents (> or = 13 yr; n = 62) (56 in-patients and 57 outpatients) where data was available on at least 1 yr of naturalistic follow-up. Subjects came from 2 studies of sleep polysomnography in children and adolescents with MDD. Clinical course was assessed using the Kiddie-Longitudinal Interval Follow-Up Evaluation (K-LIFE). This interview was used to define recovery from the index episode of MDD and recurrence, a new episode of meeting full criteria for MDD. Clinically, within 1 yr of initial evaluation 102/113 subjects had recovered from their index episode of depression (minimal or no symptoms for 60 d). Of the 102 subjects who recovered, 36 (35.3%) had a recurrence of MDD. The majority of subjects (55%) who had a recurrence were not on medication at the time of recurrence. Subjects who had a recurrence were more likely to report suicidal thoughts or attempts at baseline compared to those without a recurrence (67 vs. 37%; F = 8.77; p = 0.004). On baseline sleep polysomnography, subjects with a later recurrence had decreased sleep efficiency and delayed sleep onset (sleep latency > 10 min). Probability of recurrence at 12 months was 0.39 compared to 0.15 in subjects with non-delayed sleep onset (p = 0.005). Baseline suicidal ideation and sleep dysregulation on sleep polysomnography predicted recurrence in a large sample of depressed children and adolescents. Depression in children and adolescents is frequently a chronic, recurrent illness. Factors that can predict clinical course are important in increasing our understanding of depression in this age group.

Mood disorders in children and adolescents: psychopharmacological treatment.

Mood disorders are the leading causes of morbidity and mortality in children and adolescence. As a result, many adolescents are treated with psychopharmacologic agents such as antidepressants and mood stabilizers. To date, research into the safety and efficacy of these medications has lagged behind clinical practice. Several controlled trials of antidepressants in this population have recently been completed or are ongoing, yet few controlled trials of mood stabilizers have been conducted. Although acute efficacy of antidepressants is being addressed, many questions remain about pharmacological treatment of early-onset mood disorders. This article will focus on unmet research needs for the psychopharmacologic treatment of child and adolescent mood disorders.

Are follow-up throat cultures necessary when rapid antigen detection tests are negative for group A streptococci?

The frequency of obtaining false-negative Group A Streptococcal (GAS) rapid antigen detection (RAD) tests utilizing currently available kits in a private practice setting and the cost effectiveness of requiring follow-up throat cultures were studied. Laboratory records of the Elmwood Pediatric Group (EPG), Rochester, NY, were retrospectively reviewed to identify all patients with pharyngeal RAD tests for GAS performed from January 1996 through May 1999. From January 1996 through October 1997 (study period 1), EPG physicians used either a RAD test or a throat culture to identify GAS; from November 1997 through May 1999 (study period 2), RAD tests were used as the primary test on all patients. Rapid antigen detection test negative results were confirmed with culture. During the 3-year study 11,427 RAD tests were performed. 8,385 (73.4%) were negative and 3,042 (26.6%) were positive. In study period 1, 3,547 (73.2%) were negative and 1,299 (26.8%) were positive; in study period 2 4,837 (73.5%) were negative and 1,743 (26.5%) were positive. Of the 8,385 negative tests, 8,234 (98.2%) were followed up with throat cultures. Of these, 200 (2.4%) were identified to have been negative RAD tests that were throat culture positive (132 [3.8%] of 3,474 in study period 1 and 68 [1.4%] of 4,764 in study period 2). A cost analysis was performed for study period 2, which showed that abandoning throat culture confirmation would generate a cost saving of $13,521 per year to the practice. Throat culture confirmation of RAD test negative results in pharyngitis patients may not be medically necessary for most patients with currently available RAD tests and is costly.

Nutrition intervention in pediatric patients with thermal injuries who require laparotomy.

Increased intra-abdominal pressure is a complication of thermal injuries that is most commonly noted during burn shock or sepsis. Severely elevated intra-abdominal pressure requires surgical treatment by laparotomy to avert cardiac, respiratory, and renal compromise. The purpose of this retrospective study was to examine the manipulation of the nutrition program and outcomes in response to such a procedure. Open laparotomy for increased intra-abdominal pressure was necessary for 6 patients admitted to a pediatric burn facility from March 1993 to April 1999. One patient was excluded from the review because he died 2 days after the burn injury (1 day after the laparotomy) and nutrition intervention was not initiated. Four of the five remaining patients received parenteral nutrition within 48 hours of surgery. One patient did not receive parenteral nutrition because the enteral regimen was at the goal by 5 days after the laparotomy. Trophic enteral feedings were initiated in all 5 patients within 48 hours of the operations. Tube feedings were gradually increased and the parenteral nutrition rate was decreased in accordance with gastrointestinal tolerance (abdominal girth, bowel motility). Enteral nutrition was started before abdomen closure in all of the patients. No mechanical, infectious, or mortality-related complications related to the initiation of enteral nutrition after open laparotomies were noted. Surgical intervention by open laparotomy interrupts the postburn nutrition regimen but does not preclude the safe postoperative delivery and advancement of enteral feedings.

Penicillin failure in streptococcal tonsillopharyngitis: causes and remedies.

UNLABELLED: Penicillin administered for 10 days has been the treatment of choice for group A beta-hemolytic streptococcal tonsillopharyngitis since the 1950s. The bacteriologic failure rate of 10 days of penicillin therapy ranged from approximately 2 to 10% until the early 1970s. Beginning in the late 1970s bacteriologic and clinical failure rates with penicillin therapy began to increase steadily over time and are now reported to be approximately 30%. The primary cause of penicillin treatment failure in streptococcal tonsillopharyngitis may be lack of compliance with the 10-day therapeutic regimen. Other causes of penicillin treatment failure include reexposure to Streptococcus-infected family members or peers; copathogenicity, in which bacteria susceptible to a class of drugs are protected by other, colocalized bacterial strains that lack the same susceptibility; antibiotic-associated eradication of normal protective pharyngeal flora; and penicillin tolerance, whereby streptococcal bacteria repeatedly or continuously exposed to sublethal concentrations of antibiotic become increasingly resistant to eradication. Although 10 days of penicillin therapy is effective in the management of tonsillopharyngitis for many patients, multiple factors may, singly or together, cause treatment failure. A number of antibiotics, particularly the cephalosporins, have been demonstrated to be superior to penicillin at eradicating group A beta-hemolytic Streptococcus, and several are effective when administered for 4 to 5 days. CONCLUSIONS: Ten days of penicillin therapy may not be the best therapeutic choice for all pediatric patients. Other antibiotics, shortened courses of the cephalosporins in particular, may be preferable in some cases.

Structured interview and uniform assessment improves diagnostic reliability.

OBJECTIVE: To compare a Childhood Uniform Assessment Package (CUAP), including a computerized structured diagnosis, with routine assessment and treatment in public mental health settings. DATA SOURCES/STUDY SETTINGS: Data was collected prospectively on 250 children and adolescents in both public mental health inpatient and outpatient settings in a large metropolitan area and a rural area. STUDY DESIGN: Subjects were randomized to either routine assessment and treatment as usual (ATU) or ATU plus an additional "gold standard" assessment battery Childhood Uniform Assessment Package (CUAP). Outcome measures were taken at admission (baseline), discharge, and again 6 months later. METHODS: The study was conducted at a State Hospital (CUAP, n = 75; ATU, n = 75) and a Community Mental Health center (CUAP, n = 50; ATU, n = 50). The "gold standard" diagnostic process was established at the Children's Medical Center-Dallas. Research focused on a comparison of the CUAP diagnostic process to the existing diagnostic process (ATU) and the service delivery system of an inpatient and outpatient public sector clinical treatment setting. PRINCIPAL FINDINGS: A bachelor's level individual can be trained to administer a highly reliable diagnostic battery to meet a "gold standard," suggesting a possible cost-effective way to assist in diagnostic evaluations. Higher reliability was found between this standardized assessment package (CUAP) and inpatient physicians than for outpatient physicians. The highest interrater reliabilities were found for attention deficit and substance abuse disorders, less so for the other behavior disorders. The use of CUAP results in more reliable diagnoses in public settings than those provided by typical clinical staff by identifying mood and anxiety disorders (disorders with the lowest reliability) with better reliability. The addition of "gold standard" diagnostic assessments (CUAP) did not appear to affect length of stay, number of medication changes, use of seclusion or restraints, and other behavioral interventions in the inpatient setting. Outpatient follow-up services did not differ for CUAP versus ATU either. CONCLUSIONS: A standard uniform assessment package that includes a structured diagnostic instrument can improve overall diagnostic reliability but may not have a significant overall impact in clinical treatment strategies or outcomes without additional intervention to assure proper use of the information. A well-trained bachelor's level assistant can administer such a battery.

A SPECT HMPAO study of regional cerebral blood flow in depressed adolescents and normal controls.

1. The objective of this study was to compare the relative regional cerebral blood flow (rCBF) patterns of a group of adolescents with major depressive disorder (MDD) to a group of normal controls. 2. Seven adolescent patients with symptomatic MDD and 7 age- and gender-matched normal controls, underwent SPECT imaging with 99mTc-HMPAO while unmedicated and in a resting state. These subject's data were normalized to whole brain counts, oriented in Talairach space, and analyzed using a voxel-based, t-image approach. 3. The authors found relative rCBF increases in the depressed group as compared to normals in the right mesial temporal cortex, the right superior-anterior temporal lobe, and the left infero-lateral temporal lobe. We found rCBF decreases in the depressed group as compared to normals in the left parietal lobe, the anterior thalamus and the right caudate. 4. Adolescents with MDD show rCBF abnormalities similar to those found in adult MDD rCBF studies. Further controlled studies with larger numbers of MDD subjects and normal age- and gender-matched controls are necessary before any definitive conclusions can be made from these findings.

Fluoxetine in child and adolescent depression: acute and maintenance treatment.

The objective was to present naturalistic 1-year follow-up information of 96 child and adolescent outpatients with major depressive disorder who had been randomized in an 8-week double-blind, placebo-controlled trial of fluoxetine. Subjects were children and adolescents, ages 8-18 years, who were entered in a randomized clinical trial of fluoxetine. Following the acute treatment trial, treatment was not controlled. At 6 months and 1 year, the subjects and parents were interviewed using the Kiddie Longitudinal Interval Follow-up Evaluation (K-LIFE) for course of depression. Eighty-seven of the 96 subjects were followed for 1 year. Of these, 74 (85%) recovered from the depressive episode during that time (47 on fluoxetine, 22 on no medication, and 5 on other antidepressants or lithium). Twenty-nine of the subjects (39%) who recovered had a recurrence of depression during the 1-year follow-up, with 55% of these occurring within 6 months. Results of this study are similar to adult studies, with respect to response and recovery of depressive episodes. Most patients (85%) recover from the episode within 1 year, but approximately 40% have a recurrence within 12 months, which is a higher recurrence rate than in adults. Recovery was associated with younger age, lower severity of depressive symptoms, higher family functioning, and fewer comorbid diagnoses. Recurrence, which occurs both on and off medication, was difficult to predict, as there was little clinical data associated with recurrence in this population.

Clinical nutrition protocols for continuous quality improvements in the outcomes of patients with burns.

Multiple guidelines for nutrition services in the postburn period exist. Given that nutrition intervention after burn injury affects outcome, it is appropriate to routinely consider methods for improving current practices. Effective nutrition therapies for the thermally injured individual are outlined in this article. Support for benchmarking these protocols is presented, and the completion of outcomes research in nutrition services for patients with burn injuries is encouraged.

Lack of effect of sleep on energy expenditure and physiologic measures in critically ill burn patients.

OBJECTIVE: Energy expenditure measurements, performed while patients are in standardized resting conditions, are often used as an indicator of care by which to evaluate the adequacy of nutrition support regimens. Little attention has been directed toward examining potential errors incurred by deriving daily energy needs based on a single 15- to 20-minute measurement. This study was designed to differentiate energy expenditure during periods of sleep (defined as time spent in any of the standard sleep stages) and wakefulness in pediatric burn patients. DESIGN: Twenty-four-hour indirect calorimetry, polysomnography, and physiologic assessments (mean arterial pressure, heart rate, body temperature, oxygen saturation, and respiratory rate) were conducted simultaneously in 14 patients, who were thermally injured and tracheally intubated, for a total of 45 24-hour intervals. SUBJECTS: Mean age of the patients was 10.8+/-1.2 years. Mean total body surface area of the injury was 55.7+/-4.7%, and mean full-thickness burn was 48.8+/-6.0%. STATISTICAL ANALYSES PERFORMED: A nested general linear analysis of variance model was used to evaluate the association between sleep, wakefulness, and energy needs; adjustments were made for postburn day and multiple test runs per patient. RESULTS: On average, subjects slept 699+/-46 minutes/day. They experienced a large number of awakenings from sleep (mean=53+/-6.3 awakenings per 24 hours). Patients had mean energy expenditure of 2,529+/-396 kcal/day while awake and 2,360+/-291 kcal/day while asleep, and these mean values did not differ significantly. No differences in physiologic measurements during the awake and sleep states were found. APPLICATIONS: There appears to be little difference in the metabolism of seriously injured burn patients while asleep and while awake. The study deemphasizes the importance of performing indirect calorimetry at rest in critically ill pediatric burn patients, and it supports the extrapolation of daily energy expenditure from a 15- to 20-minute steady-state measurement obtained during either sleep or wakefulness.

Enteral nutrition for the burn patient.

In summary, thermal injury elicits numerous pathophysiological aberrations that affect nutritional status. The current recommendation for macronutrient provision postburn supports a high-calorie, protein and carbohydrate regimen and a reduction of the fat provision because of its apparent immunosuppressive properties. Early and continuous enteral feeding in the burn patient promotes optimal conditions for wound healing and immunocompetence. Because of its direct effect on morbidity and mortality, the introduction of early, continuous enteral feedings is recommended as standard therapy after burn injury. Finally, monitors for enteral placement and tolerance should be incorporated into routine care as well as the multidisciplinary Quality Management Program.

An adaptation of hydrophobic interaction chromatography for estimation of protein solubility optima.

This study describes an adaptation of hydrophobic interaction chromatography (HIC) that can be used to estimate protein solubility optima. The method does not support determination of absolute, e.g. quantitative solubility, however it does provide a basis for identifying the salt concentration, pH, or additive concentrations that support the highest relative solubility. The magnitude of a given salt's effects are consistent with its ranking in the Hofmeister series. IgG in solutions of strong 'precipitating' salts exhibits a classical salting-in/salting-out curve, described by a solubility minimum at low ionic strength, increasing to a well-defined maximum, and then losing solubility with further elevation of salt concentration. The direct effect of pH on protein solubility, as well as its indirect effect via modification of the ionic equilibria of dissolved salts, can also be tracked. Cooperative effects of solubility modifiers such as amino acids can likewise be assessed. The technique can be a useful tool in the development of liquid formulations for protein pharmaceuticals.

Evaluation of predicted and measured energy requirements in burned children.

OBJECTIVE: The energy predictions of nine calculations for pediatric patients were compared with measured resting energy expenditure (MREE) by means of indirect calorimetry to determine the optimal means of energy projection in the burn population younger than 3 years of age. METHODOLOGY: Nutritional sufficiency and maintenance of preburn weight were factors in the confirmation of energy needs. Demographic factors were also studied: preburn weight, percent burn, percent third-degree burn, and age. Group 1 consisted of 24 patients younger than 3 years of age (range = 7 months to 2.6 years) with a percent burn of 30.6 +/- 2.0 and percent third-degree burn of 21.9 +/- 2.6. Group 2, consisting of 24 patients 5 to 10 years old matched by percent burn and percent third-degree burn, was included to determine whether differences between actual and projected needs were evident in older, prepubescent patients. STATISTICAL ANALYSIS: Analysis of variance was used to ascertain the most reliable multiplier for MREE needed to maintain at least 95% of preburn weight at discharge while ensuring adequate nutrition. Multiple regression analysis was used to determine the relationship between energy requirement and body weight, percent burn, and age. RESULTS: An additional 30% of MREE provided a consistent ratio of actual energy intake to required intake. MREE x 1.3 was used as a guide to study the existing calculations. For both groups, the four equations that predicted energy in healthy children most often underestimated MREE x 1.3, whereas the five formulas for children with burns tended to overpredict energy. Regression analysis yielded two new sets of equations using age, preburn weight, and percent burn (< 3 years = Mayes 1 [r2 = .71], 5 to 10 years = Mayes 3 [r2 = 70] or percent third-degree burn (< 3 years = Mayes 2 [r2 = .68], 5 to 10 years = Mayes 4 [r2 = .67]). CONCLUSIONS: The application of a 30% factor to MREE is supported in burn patients younger than 10 years of age. Standard energy projections do not provide an accurate assessment of energy needs in the pediatric burn population; thus, two sets of equations that more closely predict energy needs are proposed.