Impact of Subspecialty Pediatric Palliative Care on Children with Heart Disease; A Systematic Review and Meta-analysis.

While many experts in pediatric cardiology have emphasized the importance of palliative care involvement, very few studies have assessed the influence of specialty pediatric palliative care (SPPC) involvement for children with heart disease. We conducted a systematic review using keywords related to palliative care, quality of life and care-satisfaction, and heart disease. We searched PubMed, EMBASE, CINAHL, CENTRAL and Web of Science in December 2023. Screening, data extraction and methodology followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. Pairs of trained reviewers independently evaluated each article. All full texts excluded from the review were hand-screened for eligible references including systematic reviews in general pediatric populations. Two reviewers independently extracted: (1) study design; (2) methodology; (2) setting; (3) population; (4) intervention/exposure and control definition; (5) outcome measures; and (6) results. Of 4059 studies screened, 9 met inclusion criteria including two with overlapping patient data. Study designs were heterogenous, including only one randomized control and two historical control trials with SPPC as a prospective intervention. Overall, there was moderate to high risk of bias. Seven were single centers studies. In combined estimates, patients who received SPPC were more likely to have advance care planning documented (RR 2.7, [95%CI 1.6, 4.7], p < 0.001) and resuscitation limits (RR 4.0, [2.0, 8.1], p < 0.001), while half as likely to have active resuscitation at end-of-life ([0.3, 0.9], p = 0.032). For parental stress, receipt of SPPC improved scores by almost half a standard deviation (RR 0.48, 95%CI 0.10, 0.86) more than controls. Ultimately, we identified a paucity of high-quality data studying the influence of SPPC; however, findings correlate with literature in other pediatric populations. Findings suggest benefits of SPPC integration for patients with heart disease and their families.

Implementation of point-of-care platforms for rapid detection of porcine circovirus type 2.

BACKGROUND: Porcine circovirus type 2 (PCV2) infection is ubiquitous around the world. Diagnosis of the porcine circovirus-associated disease requires clinic-pathological elements together with the quantification of viral loads. Furthermore, given pig farms in regions lacking access to sufficient laboratory equipment, developing diagnostic devices with high accuracy, accessibility, and affordability is a necessity. OBJECTIVES: This study aims to investigate two newly developed diagnostic tools that may satisfy these criteria. METHODS: We collected 250 specimens, including 170 PCV2-positive and 80 PCV2-negative samples. The standard diagnosis and cycle threshold (Ct) values were determined by quantitative polymerase chain reaction (qPCR). Then, two point-of-care (POC) diagnostic platforms, convective polymerase chain reaction (cPCR, qualitative assay: positive or negative results are shown) and EZtargex (quantitative assay: Ct values are shown), were examined and analyzed. RESULTS: The sensitivity and specificity of cPCR were 88.23% and 100%, respectively; the sensitivity and specificity of EZtargex were 87.65% and 100%, respectively. These assays also showed excellent concordance compared with the qPCR assay (κ = 0.828 for cPCR and κ = 0.820 for EZtargex). The statistical analysis showed a great diagnostic power of the EZtargex assay to discriminate between samples with different levels of positivity. CONCLUSIONS: The two point-of-care diagnostic platforms are accurate, rapid, convenient and require little training for PCV2 diagnosis. These POC platforms can discriminate viral loads to predict the clinical status of the animals. The current study provided evidence that these diagnostics were applicable with high sensitivity and specificity in the diagnosis of PCV2 infection in the field.

Pre-emptive paracetamol reduces intra-operative opioid use in patients undergoing day-case oncologic breast surgery.

Minimization of intra-operative opioid use is an area of ongoing research interest with several potential benefits to the patient. Pre-emptive analgesia, defined as the administration of an analgesic before surgery to prevent establishment of central sensitization of pain, is one avenue that has been explored to achieve this. A retrospective observational study was undertaken to examine the effect of pre-emptive paracetamol on intra-operative opioid requirements. The medical and operative data of 156 patients who underwent day-case wide local excision and sentinel lymph node biopsy with and without regional block surgery at our center between October 2019 and May 2022 was carried out. Data were collected on demographics, total intra-operative and immediate post-operative opioid consumption. 57 patients did not receive pre-emptive paracetamol while 90 did. Baseline characteristics were similar. Our results showed a statistically significant reduction in morphine (p <0.029) and remifentanil (p <0.007) consumption in patients who received a regional block and pre-emptive paracetamol. Those who did not receive a regional block and were given pre-emptive paracetamol had a decrease in OxyNorm (p <0.022) requirements. A combination of general anesthesia (GA), regional block and pre-emptive paracetamol reduced intra-operative consumption of Fentanyl, OxyNorm, diclofenac, dexketoprofen, and clonidine (P <0.001) when compared to just GA alone. Use of pre-emptive paracetamol in reduction of intra-operative opioid requirements showed promising results but larger studies may strengthen the evidence for this association. A multimodal analgesic approach that utilizes pre-emptive paracetamol can be a viable method to decrease intra-operative of analgesic requirements.

Association of Cigarette Smoking Patterns Over 30 Years With Audiometric Hearing Impairment and Speech-in-Noise Perception: The Atherosclerosis Risk in Communities Study.

IMPORTANCE: The implications of cigarette smoking and smoking cessation for hearing impairment remain unknown. Many studies on this topic have failed to account for attrition among smokers in their findings. OBJECTIVE: To assess the association of cigarette smoking patterns with audiometric and speech-in-noise hearing measures among participants of the Atherosclerosis Risk in Communities Study. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study included participants of the Atherosclerosis Risk in Communities Study from 4 US communities. The analysis includes data from visit 1 (1987-1989) through visit 6 (2016-2017); data were analyzed from March 16 through June 25, 2021. Audiometric hearing and speech-in-noise testing was offered to all participants at visit 6. Participants with incomplete audiometric data or missing data for educational level, body mass index, drinking status, a diabetes or hypertension diagnosis, or occupational noise were excluded. In addition, individuals were excluded if they self-reported as having other than Black or White race and ethnicity, or if they self-reported as having Black race or ethnicity and lived in 2 predominantly White communities. MAIN OUTCOMES AND MEASURES: Smoking behavior was classified from visit 1 (1987-1989) to visit 6 (2016-2017) using group-based trajectory modeling based on self-reported smoking status at each clinic visit. Hearing was assessed at visit 6. An audiometric 4-frequency (0.5, 1, 2, 4 kHz) pure-tone average (PTA) was calculated for the better-hearing ear and modeled as a continuous variable. Speech-in-noise perception was assessed via the Quick Speech-in-Noise Test (QuickSIN) and modeled continuously. Attrition during the 30 years of follow-up was addressed by inverse probability of attrition weighting. RESULTS: A total of 3414 participants aged 72 to 94 years (median [IQR] age, 78.8 [76.0-82.9] years; 2032 [59.5%] women) when hearing was measured at visit 6 (2016-2017) were included in the cohort; 766 (22.4%) self-identified as Black and 2648 (77.6%) as White individuals. Study participants were classified into 3 smoking groups based on smoking behavior: never or former smoking at baseline (n = 2911 [85.3%]), quit smoking during the study period (n = 368 [10.8%]), and persistent smoking (n = 135 [4.0%]). In fully adjusted models, persistent smoking vs never or former smoking was associated with an average 2.69 (95% CI, 0.56-4.81) dB higher PTA (worse hearing) and 1.42 (95% CI, -2.29 to -0.56) lower QuickSIN score (worse performance). Associations were stronger when accounting for informative attrition during the study period (3.53 [95% CI, 1.14-5.93] dB higher PTA; 1.46 [95% CI, -2.52 to -0.41] lower QuickSIN scores). Smoking cessation during the study (vs never or former smoking) was not associated with changes in hearing. CONCLUSIONS AND RELEVANCE: In this cross-sectional study, persistent smoking was associated with worse audiometric hearing and speech-in-noise perception. Hearing measures among participants who quit smoking during the study period did not differ from those for never or former smokers, indicating that smoking cessation (as opposed to persistent smoking) may have benefits for hearing health.

Longitudinal Blood Pressure Patterns From Mid- to Late Life and Late-Life Hearing Loss in the Atherosclerosis Risk in Communities Study.

BACKGROUND: Hearing loss is prevalent and associated with adverse functional outcomes in older adults. Prevention thus has far-reaching implications, yet few modifiable risk factors have been identified. Hypertension may contribute to age-related hearing loss, but epidemiologic evidence is mixed. We studied a prospective cohort of 3343 individuals from the Atherosclerosis Risk in Communities study, aged 44-65 years at baseline with up to 30 years of follow-up. METHODS: Hearing was assessed in late life (2016-2017) using a better-ear audiometric pure tone average (0.5, 1, 2, 4 kHz) and the Quick Speech-in-Noise (QuickSIN) test. Hypertension was defined as systolic blood pressure ≥140 mmHg, diastolic blood pressure ≥90 mmHg, or antihypertensive medication use. Midlife hypertension was defined by hypertension at 2 consecutive visits between 1987-1989 and 1996-1998. Late-life hypertension was defined in 2016-2017. Late-life low blood pressure was defined as a systolic blood pressure less than 90 mmHg or diastolic blood pressure less than 60 mmHg, irrespective of antihypertensive medication use. Associations between blood pressure patterns from mid- to late life and hearing outcomes were assessed using multivariable-adjusted linear regression. RESULTS: Compared to persistent normotension, persistent hypertension from mid- to late life was associated with worse central auditory processing (difference in QuickSIN score = -0.66 points, 95% CI: -1.14, -0.17) but not with audiometric hearing. CONCLUSIONS: Participants with persistent hypertension had poorer late-life central auditory processing. These findings suggest that hypertension may be more strongly related to hearing-related changes in the brain than in the cochlea.

How to use low-molecular-weight heparin to treat neonatal thrombosis in clinical practice.

Among children, neonates have the highest incidence of thrombosis due to risk factors such as catheter instrumentation, an evolving coagulation system and congenital heart disease. Low-molecular-weight heparins (LMWHs) are the most commonly used anticoagulants in neonates. Published guidelines delineate dosing and monitoring protocols for LMWH therapy in newborns. However, challenging clinical situations frequently present that warrant healthcare providers to think critically beyond the range of guidelines, and judiciously resolve specific problems. This review describes the use of LMWH in the neonatal population, including practical aspects such as route and site of administration, preparation from concentrated formulations and methods to minimize pain of subcutaneous injection. It is followed by a discussion on dosing, monitoring and outcomes of LMWH therapy in neonates. The risk of recurrence of thrombosis in neonates after LMWH therapy is approximately 3% based on a pooled analysis of studies reporting this outcome over the last 24 years. The article concludes with an overview of the side-effects of LMWH, including the risk of bleeding which is around 4% based on pooled analyses of more than 30 studies.

Developing an eye-tracking algorithm as a potential tool for early diagnosis of autism spectrum disorder in children.

BACKGROUND: Autism spectrum disorder (ASD) currently affects nearly 1 in 160 children worldwide. In over two-thirds of evaluations, no validated diagnostics are used and gold standard diagnostic tools are used in less than 5% of evaluations. Currently, the diagnosis of ASD requires lengthy and expensive tests, in addition to clinical confirmation. Therefore, fast, cheap, portable, and easy-to-administer screening instruments for ASD are required. Several studies have shown that children with ASD have a lower preference for social scenes compared with children without ASD. Based on this, eye-tracking and measurement of gaze preference for social scenes has been used as a screening tool for ASD. Currently available eye-tracking software requires intensive calibration, training, or holding of the head to prevent interference with gaze recognition limiting its use in children with ASD. METHODS: In this study, we designed a simple eye-tracking algorithm that does not require calibration or head holding, as a platform for future validation of a cost-effective ASD potential screening instrument. This system operates on a portable and inexpensive tablet to measure gaze preference of children for social compared to abstract scenes. A child watches a one-minute stimulus video composed of a social scene projected on the left side and an abstract scene projected on the right side of the tablet's screen. We designed five stimulus videos by changing the social/abstract scenes. Every child observed all the five videos in random order. We developed an eye-tracking algorithm that calculates the child's gaze preference for the social and abstract scenes, estimated as the percentage of the accumulated time that the child observes the left or right side of the screen, respectively. Twenty-three children without a prior history of ASD and 8 children with a clinical diagnosis of ASD were evaluated. The recorded video of the child´s eye movement was analyzed both manually by an observer and automatically by our algorithm. RESULTS: This study demonstrates that the algorithm correctly differentiates visual preference for either the left or right side of the screen (social or abstract scenes), identifies distractions, and maintains high accuracy compared to the manual classification. The error of the algorithm was 1.52%, when compared to the gold standard of manual observation. DISCUSSION: This tablet-based gaze preference/eye-tracking algorithm can estimate gaze preference in both children with ASD and without ASD to a high degree of accuracy, without the need for calibration, training, or restraint of the children. This system can be utilized in low-resource settings as a portable and cost-effective potential screening tool for ASD.

Medical management of the athlete: evaluation and treatment of important issues in sports medicine.

Providing care to athletes involves much more than simply treating musculoskeletal injuries. Many of the illnesses and disease processes that affect the general population are also seen in competitive athletes. Medical management of these conditions, however, can be challenging. Treatment plans need to be tailored to the individual athlete and take into consideration the rigors and demands of his or her particular sport. Important conditions that all physicians who provide care for athletes should be familiar with are sudden cardiac death, hypertension, concussion, methicillin-resistant Staphylococcus aureus infections, the female athlete triad, diabetes mellitus, and asthma.