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Jurkowicz M, Leibovitz E, Ben-Zeev B, Keller N, Kriger O, Sherman G, Amit S, Barkai G, Mandelboim M, Stein M. A Systematic Review and Clinical Presentation of Central Nervous System Complications of Severe Acute Respiratory Syndrome Coronavirus 2 in Hospitalized Pediatric Patients During the Coronavirus Disease 2019 Pandemic in Israel. Pediatr Neurol 2024; 153:68-76. [PMID: 38335916 DOI: 10.1016/j.pediatrneurol.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 11/11/2023] [Accepted: 01/05/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND Coronavirus disease-associated central nervous system complications (CNS-C) in hospitalized children, especially during the Omicron wave, and in comparison with influenza associated CNS-C, are not well understood. METHODS The study population included 755 children aged <18 years hospitalized with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) at Sheba Medical Center, during March 2020 to July 2022. A comparative cohort consisted of 314 pediatric patients with influenza during the 2018-2019 and 2019-2020 influenza seasons. RESULTS Overall, 5.8% (n = 44) of patients exhibited CNS-C. Seizures at presentation occurred in 33 patients with COVID-19 (4.4%), with 2.6% (n = 20) experiencing nonfebrile seizures, 1.1% (n = 8) febrile seizures, and 0.7% (n = 5) status epilepticus. More patients with CNS-C experienced seizures during the Omicron wave versus the pre-Omicron period (77.8% vs 41.2%, P = 0.03). Fewer patients were admitted to the intensive care unit in the Omicron wave (7.4%) versus prior waves (7.4% vs 41.2%, P = 0.02). Fewer patients with SARS-CoV-2 experienced CNS-C (5.8%) versus patients with influenza (9.9%), P = 0.03. More patients with SARS-CoV-2 experienced nonfebrile seizures (2.6% vs 0.6%, P = 0.06), whereas more patients with influenza experienced febrile seizures (7.3% vs 1.1%, P < 0.01). CONCLUSIONS The Omicron wave was characterized by more seizures and fewer intensive-care-unit admissions than previous waves. Pediatric patients with SARS-CoV-2 experienced fewer CNS-C and more nonfebrile seizures compared with patients with influenza.
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Affiliation(s)
- Menucha Jurkowicz
- Faculty of Medicine, Department of Epidemiology and Preventive Medicine, School of Public Health, Tel Aviv University, Tel Aviv, Israel; Central Virology Laboratory, Ministry of Health, Chaim Sheba Medical Center, Ramat Gan, Israel; Pediatric Infectious Disease Unit, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Eugene Leibovitz
- Pediatric Infectious Disease Unit, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Bruria Ben-Zeev
- Pediatric Neurology Unit, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Ramat Gan, Israel
| | | | - Or Kriger
- Pediatric Infectious Disease Unit, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Gilad Sherman
- Pediatric Infectious Disease Unit, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Sharon Amit
- Clinical Microbiology Laboratory, Sheba Medical Center, Ramat-Gan, Israel
| | - Galia Barkai
- Pediatric Infectious Disease Unit, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Michal Mandelboim
- Faculty of Medicine, Department of Epidemiology and Preventive Medicine, School of Public Health, Tel Aviv University, Tel Aviv, Israel; Central Virology Laboratory, Ministry of Health, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Michal Stein
- Pediatric Infectious Disease Unit, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Ramat Gan, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Tessler I, Shemesh R, Sherman G, Soudry E, Chen SCA, Ziv O, Kordeluk S, Bar-On D, Novikov I, Yakirevitch A. Impact of azole antifungal treatment on outcome in acute invasive fungal rhinosinusitis with orbitocranial involvement: a surgical perspective. Rhinology 2023; 61:561-567. [PMID: 37566791 DOI: 10.4193/rhin23.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2023]
Abstract
PURPOSE To provide real-life data on azole treatment outcomes and the role of surgery in the current management of invasive fungal rhinosinusitis complicated by orbitocranial fungal infection (OCFI). METHODS Data was collected retrospectively from a chart review from four participating centers and a systematic literature review. The study group included patients with OCFI treated with azole antifungals. The control cases were treated with other antifungal agents. The cranial and orbital involvement degree was staged based on the imaging. The extent of the surgical resection was also classified to allow for inter-group comparison. RESULTS There were 125 patients in the azole-treated group and 153 in the control group. Among the patients with OCFI cranial extension, 23% were operated on in the azole-treated group and 18% in the control group. However, meninges and brain resection were performed only in the controls (11% of patients) and never in the azole antifungals group. Orbital involvement required surgery in 26% of azole-treated cases and 39% of controls. Despite a more aggressive cranial involvement, azole-treated patients' mortality was significantly lower than in controls, with an OCFI-specific mortality rate of 21% vs. 52%. A similar, though not statistically significant, trend was found for the extent of the orbital disease and surgery. CONCLUSION Despite less aggressive surgical intervention for cranial involvement, OCFI patients treated with azoles had a higher survival rate. This finding suggests we may improve morbidity with a more conservative surgical approach in conjunction with azole treatment. The same trend is emerging for orbital involvement.
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Affiliation(s)
- I Tessler
- Department of Otolaryngology-Head and Neck Surgery, Sheba Medical Center, Tel Hashomer, Israel and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - R Shemesh
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel and Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel
| | - G Sherman
- Pediatric Infectious Diseases Unit, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Israel
| | - E Soudry
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel and Department of Otolaryngology-Head and Neck Surgery, Rabin Medical Center, Israel
| | - S C A Chen
- Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead Hospital, Westmead, Australia and Sydney Medical School, The University of Sydney, Australia
| | - O Ziv
- Department of Otolaryngology-Head and Neck Surgery, Soroka Medical Center, Israel and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - S Kordeluk
- Department of Otolaryngology-Head and Neck Surgery, Soroka Medical Center, Israel and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - D Bar-On
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel and Department of Otolaryngology-Head and Neck Surgery, Rabin Medical Center, Israel
| | - I Novikov
- Biostatistics and Biomathematics unit, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Israel
| | - A Yakirevitch
- Department of Otolaryngology-Head and Neck Surgery, Sheba Medical Center, Tel Hashomer, Israel and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Demirhan S, Munoz FM, Valencia Deray KG, Bocchini CE, Danziger-Isakov L, Blum S, Sharma TS, Sherman G, Boguniewicz J, Bacon S, Ardura MI, Maron GM, Ferrolino J, Foca M, Herold BC. Body surface area compared to body weight dosing of valganciclovir is associated with increased toxicity in pediatric solid organ transplantation recipients. Am J Transplant 2023; 23:1961-1971. [PMID: 37499799 DOI: 10.1016/j.ajt.2023.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 07/19/2023] [Accepted: 07/20/2023] [Indexed: 07/29/2023]
Abstract
Optimal dosing of valganciclovir (VGCV) for cytomegalovirus (CMV) prevention in pediatric solid organ transplantation recipients (SOTR) is controversial. Dosing calculated based on body surface area (BSA) and creatinine clearance is recommended but simplified body weight (BW) dosing is often prescribed. We conducted a retrospective 6-center study to compare safety and efficacy of these strategies in the first-year posttransplant There were 100 (24.2%) pediatric SOTR treated with BSA and 312 (75.7%) with BW dosing. CMV DNAemia was documented in 31.0% vs 23.4% (P = .1) at any time during the first year and breakthrough DNAemia in 16% vs 12.2% (P = .3) of pediatric SOTR receiving BSA vs BW dosing, respectively. However, neutropenia (50% vs 29.3%, P <.001), lymphopenia (51% vs 15.0%, P <.001), and acute kidney injury causing treatment modification (8.0% vs 1.8%, P <.001) were documented more frequently during prophylaxis in pediatric SOTR receiving BSA vs BW dosing. The adjusted odds ratio of VGCV-attributed toxicities comparing BSA and BW dosing was 2.3 (95% confidence interval [CI], 1.4-3.7] for neutropenia, 7.0 (95% CI, 3.9-12.4) for lymphopenia, and 4.6 (95% CI, 2.2-9.3) for premature discontinuation or dose reduction of VGCV, respectively. Results demonstrate that BW dosing is associated with significantly less toxicity without any increase in CMV DNAemia.
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Affiliation(s)
- Salih Demirhan
- Department of Pediatrics, Division of Infectious Diseases, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Flor M Munoz
- Department of Pediatrics, Division of Infectious Diseases, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Kristen G Valencia Deray
- Department of Pediatrics, Division of Infectious Diseases, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Claire E Bocchini
- Department of Pediatrics, Division of Infectious Diseases, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Lara Danziger-Isakov
- Department of Pediatrics, Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Samantha Blum
- Department of Pediatrics, Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Tanvi S Sharma
- Department of Pediatrics, Division of Infectious Diseases, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gilad Sherman
- Department of Pediatrics, Division of Infectious Diseases, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Juri Boguniewicz
- Department of Pediatrics, Division of Infectious Diseases, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Samantha Bacon
- Department of Pediatrics, Division of Infectious Diseases, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Monica I Ardura
- Department of Pediatrics, Division of Infectious Diseases & Host Defense, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Gabriela M Maron
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jose Ferrolino
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Marc Foca
- Department of Pediatrics, Division of Infectious Diseases, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York, USA.
| | - Betsy C Herold
- Department of Pediatrics, Division of Infectious Diseases, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York, USA.
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Kriger O, Gefen-Halevi S, Belausov N, Sherman G, Adam E, Rubinstein O, Kassif-Lerner R, Barkai G, Stein M, Listman A, Grossman T, Amit S. Respiratory cryptosporidiosis detected by commercial multiplex-PCR in immunosuppressed pediatric patients. Diagn Microbiol Infect Dis 2023; 107:116033. [PMID: 37549634 DOI: 10.1016/j.diagmicrobio.2023.116033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/16/2023] [Accepted: 07/17/2023] [Indexed: 08/09/2023]
Abstract
We report the off-label use of a commercial gastrointestinal protozoa multiplex-PCR panel for bronchoalveolar lavage samples, detecting respiratory cryptosporidiosis in 2 immunocompromised pediatric patients. We suggest that implying this readily available assay in cases in which systemic cryptosporidiosis is suspected, may widen our understanding regarding this rarely reported syndrome.
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Affiliation(s)
- Or Kriger
- Clinical Microbiology, Sheba Medical Center, Ramat-Gan, Israel; Pediatric Infectious Disease Unit, Sheba Medical Center, Ramat-Gan, Israel.
| | | | | | - Gilad Sherman
- Pediatric Infectious Disease Unit, Sheba Medical Center, Ramat-Gan, Israel
| | - Etai Adam
- Department of Pediatric Hemato-Oncology, Sheba Medical Center, Ramat-Gan, Israel
| | - Orit Rubinstein
- Department of Pediatric Hemato-Oncology, Sheba Medical Center, Ramat-Gan, Israel
| | - Reut Kassif-Lerner
- Department of Pediatric Intensive Care, Sheba Medical Center, Ramat-Gan, Israel
| | - Galia Barkai
- Pediatric Infectious Disease Unit, Sheba Medical Center, Ramat-Gan, Israel
| | - Michal Stein
- Pediatric Infectious Disease Unit, Sheba Medical Center, Ramat-Gan, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anna Listman
- Clinical Microbiology, Sheba Medical Center, Ramat-Gan, Israel
| | - Tamar Grossman
- Public Health Laboratories Jerusalem (PHL-J), Public Health Services, Ministry of Health, Jerusalem, Israel
| | - Sharon Amit
- Clinical Microbiology, Sheba Medical Center, Ramat-Gan, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Kahan Y, Tope SG, Ovadia A, Shpring A, Shatzman-Steuerman R, Sherman G, Barkai G, Mandelberg A, Armoni-Domany K, Tasher D. Risk Factors and Characteristics of Candidemia After Cardiac Surgery in Pediatric Patients in Central Israel. Pediatr Infect Dis J 2023; 42:368-373. [PMID: 36854105 DOI: 10.1097/inf.0000000000003847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Candidemia is a serious complication in pediatric patients with congenital heart defects (CHD) after cardiac surgery. Information about the epidemiology, clinical characteristics and risk factors for candidemia in this vulnerable population remains limited. METHODS This retrospective case-control study was conducted in 2 pediatric intensive care units between 2004 and 2019. All patients <18 years old who developed candidemia following cardiac surgery were included. Each case was matched with 2 control patients based on age and date of surgery. Multivariable logistic regression analysis was conducted to determine the risk factors for postoperative candidemia. RESULTS Thirty-five candidemia cases were identified and matched to 70 control cases. The incidence of candidemia was 6.3 episodes per 1000 admissions. The median age for candidemia cases was 4 months. The attributable mortality was 28.5%. The predominant (54%) pathogens isolated were non- albicans Candida species, of which C. parapsilosis isolates demonstrated high resistance to fluconazole (70%). Independent risk factors associated with candidemia included cumulative antibiotic exposure for ≥4 days [OR: -4.3; 95% confidence interval (CI): 1.3-14.6; P = 0.02], the need for total parenteral nutrition or peritoneal dialysis (OR: -6.1; 95% CI: 2-18.8; P = 0.001), male sex (OR: 6.2; 95% CI: 1.9-20.3; P = 0.002) and delayed sternal closure≥2 days (OR: -3.2; 95% CI: 1-11.2; P = 0.05). CONCLUSIONS Postoperative candidemia in children with CHD is an uncommon but severe complication. Our study revealed an unexpectedly high frequency of fluconazole-resistant C. parapsilosis as the main cause of non- albicans candidemia. In addition to confirming previously recognized risk factors, our results reveal new potential risk factors such as delayed sternal closure and male sex.
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Affiliation(s)
- Yaara Kahan
- Pediatric Infectious Diseases Unit, Edith Wolfson Medical Center, Holon, Israel
- Pediatric Infectious Disease Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel
| | - Samantha G Tope
- Pediatric Infectious Disease Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel
| | - Adi Ovadia
- Pediatric Infectious Disease Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel
- Department of Pediatrics, Edith Wolfson Medical Center, Holon, Israel
| | - Adi Shpring
- Pediatric Infectious Disease Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel
- Department of Pediatrics, Edith Wolfson Medical Center, Holon, Israel
| | - Rachel Shatzman-Steuerman
- Pediatric Infectious Disease Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel
| | - Gilad Sherman
- Pediatric Infectious Disease Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel
| | - Galia Barkai
- Pediatric Infectious Disease Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel
| | - Avigdor Mandelberg
- Pediatric Infectious Disease Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel
- Department of Pediatrics, Edith Wolfson Medical Center, Holon, Israel
| | - Keren Armoni-Domany
- Pediatric Infectious Disease Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel
- Department of Pediatrics, Edith Wolfson Medical Center, Holon, Israel
| | - Diana Tasher
- Pediatric Infectious Diseases Unit, Edith Wolfson Medical Center, Holon, Israel
- Pediatric Infectious Disease Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel
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Sherman G, Lamb GS, Sharma TS, Lloyd EC, Nagel J, Dandam NN, Oliveira CR, Sheikha HS, Anosike BI, Lee P, Vora SB, Patel K, Sue PK, Rubbab B, Yarbrough AM, Ganapathi L, Nakamura MM. Monoclonal Antibody Use for Coronavirus Disease 2019 in Pediatric Patients: A Multicenter Retrospective Study. J Pediatric Infect Dis Soc 2023; 12:152-155. [PMID: 36928172 PMCID: PMC10112679 DOI: 10.1093/jpids/piac124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 11/23/2022] [Indexed: 03/18/2023]
Abstract
Monoclonal antibodies for COVID-19 are authorized in high-risk patients aged ≥12 years, but evidence in pediatric patients is limited. In our cohort of 142 patients treated at seven pediatric hospitals between 12/1/20 and 7/31/21, 9% developed adverse events, 6% were admitted for COVID-19 within 30 days, and none received ventilatory support or died.
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Affiliation(s)
- Gilad Sherman
- Division of Infectious Diseases, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School
| | - Gabriella S Lamb
- Division of Infectious Diseases, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School
| | - Tanvi S Sharma
- Division of Infectious Diseases, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School
| | - Elizabeth C Lloyd
- Department of Pediatrics, University of Michigan and CS Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - Jerod Nagel
- Department of Pharmacy, University of Michigan and CS Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - Nada N Dandam
- Department of Pharmacy, University of Michigan and CS Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - Carlos R Oliveira
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Hassan S Sheikha
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Brenda I Anosike
- Department of Pediatrics, Children's Hospital at Montefiore, New York, New York, USA
| | - Philip Lee
- Department of Pediatrics, Children's Hospital at Montefiore, New York, New York, USA
| | - Surabhi B Vora
- Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington, USA
| | - Karisma Patel
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Paul K Sue
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Beenish Rubbab
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - April M Yarbrough
- Department of Pharmacy, Children's of Alabama, Birmingham, Alabama, USA
| | - Lakshmi Ganapathi
- Division of Infectious Diseases, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School
| | - Mari M Nakamura
- Division of Infectious Diseases, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School
- Antimicrobial Stewardship Program, Boston Children's Hospital, Boston, MA, USA
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Sherman G, Lamb GS, Platt CD, Wessels MR, Chochua S, Nakamura MM. Simultaneous Late, Late-Onset Group B Streptococcal Meningitis in Identical Twins. Clin Pediatr (Phila) 2023; 62:96-99. [PMID: 35883267 DOI: 10.1177/00099228221113630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
To our knowledge, late, late-onset group B streptococcal (GBS) meningitis in identical twins has yet to be reported. We describe a case of 14-week-old twins who developed fever hours apart and presented simultaneously to the emergency department 2 days later with seizures. Blood and cerebrospinal fluid (CSF) cultures from both infants were positive for GBS. Their clinical courses were highly similar, with magnetic resonance imaging (MRI) demonstrating ventriculitis and subdural empyema, complicated by clinical and subclinical seizures requiring quadruple antiepileptic treatment. The CSF was sterile for both on follow-up lumbar puncture 48 hours after the initial positive CSF culture. Both showed marked improvement on antimicrobial and antiepileptic therapy, with fever resolving after 5 days of therapy, control of seizures, and slowly improving MRI findings. Twin A received a 6-week course of penicillin, whereas twin B received 6 weeks plus an additional 10 days due to persistent left cochlear enhancement consistent with labyrinthitis. Evaluation for an underlying primary immunodeficiency was negative. Genomic analysis revealed that the patients' CSF GBS isolates were essentially identical and of capsular polysaccharide serotype Ia.
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Affiliation(s)
- Gilad Sherman
- Department of Pediatrics, Division of Infectious Diseases, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Gabriella S Lamb
- Department of Pediatrics, Division of Infectious Diseases, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Craig D Platt
- Harvard Medical School, Boston, MA, USA.,Department of Pediatrics, Division of Immunology, Boston Children's Hospital, Boston, MA, USA
| | - Michael R Wessels
- Department of Pediatrics, Division of Infectious Diseases, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Sopio Chochua
- Respiratory Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Mari M Nakamura
- Department of Pediatrics, Division of Infectious Diseases, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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Ollech A, Simon AJ, Lev A, Stauber T, Sherman G, Solomon M, Barzilai A, Somech R, Greenberger S. A horse or a zebra? Unusual manifestations of common cutaneous infections in primary immunodeficiency pediatric patients. Front Pediatr 2023; 11:1103726. [PMID: 36950172 PMCID: PMC10026180 DOI: 10.3389/fped.2023.1103726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 01/09/2023] [Indexed: 03/24/2023] Open
Abstract
Background Patients with primary immunodeficiency disorders (PIDs) often suffer from recurrent infections because of their inappropriate immune response to both common and less common pathogens. These patients may present with unique and severe cutaneous infectious manifestations that are not common in healthy individuals and may be more challenging to diagnose and treat. Objective To describe a cohort of patients with PIDs with atypical presentations of skin infections, who posed a diagnostic and/or therapeutic challenge. Methods This is a retrospective study of pediatric patients with PID with atypical presentations of infections, who were treated at the immunodeficiency specialty clinic and the pediatric dermatology clinic at the Sheba Medical Center between September 2012 and August 2022. Epidemiologic data, PID diagnosis, infectious etiology, presentation, course, and treatment were recorded. Results Eight children with a diagnosis of PID were included, five of whom were boys. The average age at PID diagnosis was 1.7 (±SD 3.2) years. The average age of cutaneous infection was 6.9 (±SD 5.9) years. Three patients were born to consanguineous parents. The PIDs included the following: common variable immunodeficiency, severe combined immunodeficiency, DOCK8 deficiency, ataxia telangiectasia, CARD11 deficiency, MALT1 deficiency, chronic granulomatous disease, and a combined cellular and humoral immunodeficiency syndrome of unknown etiology. The infections included the following: ulcerative-hemorrhagic varicella-zoster virus (two cases) atypical fungal and bacterial infections, resistant Norwegian scabies, giant perianal verrucae (two cases), and diffuse molluscum contagiosum. Conclusions In this case series, we present unusual manifestations of infectious skin diseases in pediatric patients with PID. In some of the cases, recognition of the infectious process prompted life-saving treatment. Increasing familiarity with these dermatological manifestations, as well as keeping a high index of suspicion, is important to enabling early diagnosis of cutaneous infections in PIDs and initiation of prompt suitable treatment.
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Affiliation(s)
- Ayelet Ollech
- Department of Dermatology, Pediatric Dermatology Service, Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Correspondence: Ayelet Ollech
| | - Amos J Simon
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Sheba Cancer Research Center and Institute of Hematology, Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel
- Pediatric Department A and the Immunology Service, Jeffrey Modell Foundation Center, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel
| | - Atar Lev
- Sheba Cancer Research Center and Institute of Hematology, Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel
| | - Tali Stauber
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Sheba Cancer Research Center and Institute of Hematology, Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel
| | - Gilad Sherman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Infectious Disease Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel
| | - Michal Solomon
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Dermatology, Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel
| | - Aviv Barzilai
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Dermatology, Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel
| | - Raz Somech
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Sheba Cancer Research Center and Institute of Hematology, Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel
- Pediatric Department A and the Immunology Service, Jeffrey Modell Foundation Center, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel
| | - Shoshana Greenberger
- Department of Dermatology, Pediatric Dermatology Service, Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Kahan Y, Tope SG, Ovadia A, Shpring A, Shatzman-Steuerman R, Sherman G, Barkai G, Mandelberg A, Tasher D. 1341. Risk Factors for Candidemia after Cardiac Surgery in Pediatric Patients with Congenital Heart Defects. Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.1170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
Candidemia is a serious complication in children with congenital heart defects (CHD) after cardiac surgery. Data on risk factors for postoperative candidemia in this high-risk population remains limited. This study aimed to identify the incidence, outcome, and risk factors for candidemia in this population.
Methods
This retrospective case-control study was carried out at two different pediatric intensive care units between 2004-2019. Candidemia cases were matched with control patients without candidemia. Univariate and multivariable logistic regression analyses were conducted to identify risk factors for postoperative candidemia.
Results
Overall, 105 patients were included. Thirty-five candidemia cases were matched to 70 control cases. The overall incidence of candidemia was 6.3/1000 admissions. The median age of candidemia cases was 4 months (range 16 days to 9.4 years). Crude 30-day mortality of candidemia cases was 43%. Risk factors independently associated with candidemia included cumulative antibiotic exposure for ≥4 days (OR 4.3, 95% CI 1.3-14.6; p =0.02), the need for total parenteral nutrition (TPN) or peritoneal dialysis (OR 6.1, 95% CI 2-18.8; p =0.001), male gender (OR 6.2, 95% CI 1.8-21.6, p=0.04) and delayed sternal closure ≥ 2 days (OR 3.2, 95% CI 1-11.2; p =0.05). The areas under the receiver operating characteristic curves for cumulative antibiotic exposure ≥ 4 days, the need for TPN or peritoneal dialysis, delayed sternal closure ≥ 2 days, male gender, and overall, were 0.74 (95% CI, 0.64-0.84), 0.75 (95% CI, 0.65-0.85), 0.65 (95% CI, 0.53-0.77), 0.65 (95% CI, 0.55-0.77) and 0.87 (95% CI, 0.81-0.94) respectively, which is for overall an excellent discrimination.
Receiver Operating characteristic (ROC) curves for cumulative antibiotic exposure ≥ 4 days, the need for TPN or peritoneal dialysis, delayed sternal closure ≥ 2 days, male gender and overall
Conclusion
We found that postoperative candidemia in patients with CHD is an uncommon complication, occurring mostly in young infants. In our population, cumulative antibiotic exposure ≥ 4 days and the need for TPN or peritoneal dialysis were the strongest independent discriminative risk factors. However, adding previously unreported risks such as gender and delayed sternal closure strengthen the discrimination. Our results may help to define which patients with CHD should be given prophylactic or presumptive antifungal therapy.
Disclosures
All Authors: No reported disclosures.
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Affiliation(s)
- Yaara Kahan
- Pediatric Infectious Diseases Unit, Edith Wolfson Medical Center , Holon /Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Holon, HaMerkaz , Israel
| | - Samantha G Tope
- Sackler School of Medicine, Tel-Aviv University , Tel-Aviv, Tel-Aviv, HaMerkaz , Israel
| | - Adi Ovadia
- Department of Pediatrics, Edith Wolfson Medical Center, Holon /Sackler School of Medicine, Tel-Aviv University , Tel-Aviv, Holon, HaMerkaz , Israel
| | - Adi Shpring
- Department of Pediatrics, Edith Wolfson Medical Center, Holon /Sackler School of Medicine, Tel-Aviv University , Tel-Aviv, Holon, HaMerkaz , Israel
| | - Rachel Shatzman-Steuerman
- Pediatric Infectious Diseases Unit, Sheba Medical Center, Ramat-Gan/ Sackler School of Medicine, Tel-Aviv University , Tel-Aviv, Ramat-Gan, HaMerkaz , Israel
| | - Gilad Sherman
- Pediatric Infectious Diseases Unit, Sheba Medical Center, Ramat-Gan/ Sackler School of Medicine, Tel-Aviv University , Tel-Aviv, Ramat-Gan, HaMerkaz , Israel
| | - Galia Barkai
- Pediatric Infectious Diseases Unit, Sheba Medical Center, Ramat-Gan/ Sackler School of Medicine, Tel-Aviv University , Tel-Aviv, Ramat-Gan, HaMerkaz , Israel
| | - Avigdor Mandelberg
- Department of Pediatrics, Edith Wolfson Medical Center, Holon /Sackler School of Medicine, Tel-Aviv University , Tel-Aviv, Holon, HaMerkaz , Israel
| | - Diana Tasher
- Pediatric Infectious Diseases Unit, Edith Wolfson Medical Center , Holon /Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Holon, HaMerkaz , Israel
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Wittmann Dayagi T, Sherman G, Bielorai B, Adam E, Besser MJ, Shimoni A, Nagler A, Toren A, Jacoby E, Avigdor A. Characteristics and risk factors of infections following CD28-based CD19 CAR-T cells. Leuk Lymphoma 2021; 62:1692-1701. [PMID: 33563059 DOI: 10.1080/10428194.2021.1881506] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
CAR T-cells are approved for the treatment of relapsed and refractory leukemia and lymphoma. Here, we studied the infectious complications in 88 patients treated with CD28-based CD19 CAR T-cells. Overall, 36 infections were documented in 24 patients within the first month after CAR T-cell infusion: Six events of bacteremia, sixteen focal bacterial infections, and fourteen systemic or localized viral infections. Seven patients had nine infectious episodes beyond the first 30 days of follow-up, including three events of bacteremia, three focal bacterial, two viral and one fungal infection. The presence of neutropenia, neutropenic fever and lack of response to treatment were associated with a higher rate of infections. Children had less severe infections than adults. In a multivariate analysis lack of response to treatment was the only significant risk factor. Overall, the incidence of bacterial infections following CAR T-cells is modest especially in children and in patients responding to therapy.
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Affiliation(s)
- Talya Wittmann Dayagi
- Department of Pediatrics, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gilad Sherman
- Department of Pediatrics, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Bella Bielorai
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Division of Pediatric Hematology and Oncology, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat Gan, Israel
| | - Etai Adam
- Division of Pediatric Hematology and Oncology, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat Gan, Israel
| | - Michal J Besser
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Ella Institute of Immuno-Oncology, Sheba Medical Center, Ramat Gan, Israel
| | - Avichai Shimoni
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Division of Hematology and Bone Marrow Transplantation, Sheba Medical Center, Ramat Gan, Israel
| | - Arnon Nagler
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Division of Hematology and Bone Marrow Transplantation, Sheba Medical Center, Ramat Gan, Israel
| | - Amos Toren
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Division of Pediatric Hematology and Oncology, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat Gan, Israel
| | - Elad Jacoby
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Division of Pediatric Hematology and Oncology, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat Gan, Israel
| | - Abraham Avigdor
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Division of Hematology and Bone Marrow Transplantation, Sheba Medical Center, Ramat Gan, Israel
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Pleniceanu O, Twig G, Tzur D, Sherman G, Afek A, Erlich T, Keinan-Boker L, Skorecki K, Vivante A, Calderon-Margalit R. Acute pyelonephritis in children and the risk of end-stage kidney disease. J Nephrol 2020; 34:1757-1765. [PMID: 32875542 DOI: 10.1007/s40620-020-00841-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 08/12/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pyelonephritis is the most common serious bacterial infection during childhood. The long-term importance of kidney scarring is unclear. OBJECTIVE To assess the risk of end-stage kidney disease (ESKD) in adolescents and young adults with history of pyelonephritis. STUDY DESIGN A nationwide, population-based, historical cohort study, including 1,509,902 persons (62% male) examined for military service between 1967 and 1997. Participants with a history of pyelonephritis were sub-grouped according to presence of kidney scarring and baseline kidney function. Data were linked to the Israeli ESKD registry to identify incident ESKD cases. Cox proportional hazards models were used to estimate the hazard ratio (HR) of treated ESKD (dialysis or kidney transplant). RESULTS Pyelonephritis was diagnosed in 6979 participants (0.46%). 6479 had normal kidney function and no evidence of kidney scarring, 400 had normal kidney function with evidence of scarring, and 100 demonstrated reduced baseline kidney function. Treated ESKD developed in 2352 individuals (0.2%) without history of pyelonephritis, 58 individuals (0.9%) with normal kidney function, history of pyelonephritis and no kidney scarring, 14 individuals (3.5%) with normal kidney function, history of pyelonephritis and kidney scarring, and 23 individuals (23.0%) with history of pyelonephritis and reduced baseline kidney function, yielding HR of 3.3, 34.8 and 43.2, respectively, controlling for age, gender, paternal origin, enrollment year, body mass index, and blood pressure, and accounting for death as a competing risk. CONCLUSION History of pyelonephritis was associated with significantly increased risk of treated ESKD, particularly when associated with kidney scarring or reduced baseline kidney function.
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Affiliation(s)
- Oren Pleniceanu
- Israel Defense Forces, Medical Corps, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Gilad Twig
- Israel Defense Forces, Medical Corps, Ramat Gan, Israel
- Talpiot Medical Leadership Program, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
- Department of Military Medicine, Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem, Israel
| | - Dorit Tzur
- Israel Defense Forces, Medical Corps, Ramat Gan, Israel
| | - Gilad Sherman
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
- Department of Pediatrics B and Pediatric Infectious diseases Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Arnon Afek
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
- Central Management, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Tomer Erlich
- Israel Defense Forces, Medical Corps, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
- Urology Department, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Lital Keinan-Boker
- Israel Center for Disease Control, Ministry of Health, Ramat Gan, Israel
- School of Public Health, University of Haifa, Haifa, Israel
| | - Karl Skorecki
- Department of Nephrology, Rambam Health Care Campus and the Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Azrieli Faculty of Medicine, Bar-Ilan University, Ramat Gan, Israel
| | - Asaf Vivante
- Talpiot Medical Leadership Program, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel.
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel.
- Department of Pediatrics B and Pediatric Nephrology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Ramat Gan, 5265601, Israel.
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12
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Raibin K, Levy I, Atiya Nasagi Y, Ashkenazi‐Hoffnung L, Sherman G, Avneri L, Landau D, Scheuerman O. Atypical presentation of human ehrlichiosis and anaplasmosis in children in Israel. Acta Paediatr 2019; 108:1727-1728. [PMID: 31140643 DOI: 10.1111/apa.14882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Karine Raibin
- Department of Pediatrics B Schneider Children's Medical Center of Israel Petach Tikva Israel
| | - Itzhak Levy
- Pediatric Infectious Diseases Unit Schneider Children's Medical Center of Israel Petach Tikva Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | | | - Liat Ashkenazi‐Hoffnung
- Department of Pediatrics B Schneider Children's Medical Center of Israel Petach Tikva Israel
- Pediatric Infectious Diseases Unit Schneider Children's Medical Center of Israel Petach Tikva Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - Gilad Sherman
- Pediatric Infectious Diseases Unit Schneider Children's Medical Center of Israel Petach Tikva Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - Liad Avneri
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
- Department of Pediatrics C Schneider Children's Medical Center of Israel Petach Tikva Israel
| | - Daniel Landau
- Department of Pediatrics B Schneider Children's Medical Center of Israel Petach Tikva Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - Oded Scheuerman
- Department of Pediatrics B Schneider Children's Medical Center of Israel Petach Tikva Israel
- Pediatric Infectious Diseases Unit Schneider Children's Medical Center of Israel Petach Tikva Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
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13
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Sherman G, Nemet D, Moshe V, Consolaro A, Ravelli A, Ruperto N, Uziel Y. Disease activity, overweight, physical activity and screen time in a cohort of patients with juvenile idiopathic arthritis. Clin Exp Rheumatol 2018; 36:1110-1116. [PMID: 29600947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 02/01/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Physical activity is an important part of children's health and social development. Juvenile idiopathic arthritis (JIA) can lead to decreased physical activity and quality of life. This study characterised clinical aspects, physical activity rates, obesity, and screen time in a group of JIA patients. METHODS Ninety-seven JIA patients in the Paediatric Rheumatology Clinic at Meir Medical Center were evaluated over a 6-month period and compared by statistical methods to 98 age-matched healthy controls. Information on disease activity, type and amount of physical activity (using the Modified Godin Leisure-Time Exercise Questionnaire), and daily screen time hours were collected. RESULTS Among the JIA patients, 56% had oligoarthritis, 22% polyarthritis and 17% systemic disease. Disease activity among all JIA sub-groups was low (average of 1.7/10), two-thirds of patients had disease activity lower than 3, only 4% over 5, and 56% were in clinical remission. Obesity rates in the patient and control groups were 21.5% and 19.4%, respectively. Physical activity levels were similar in both groups. Age at onset of disease and physical activity rate were negatively correlated (r=-0.288, p=0.004). Total weekly leisure activity of the control group was higher (46.9 vs. 38.4 hours, respectively), while daily screen time was similar (3.2 vs. 2.9 hours, respectively). CONCLUSIONS Physical activity, obesity rates and screen time hours were similar between JIA patients and controls. This lack of difference could be attributed to clinical remission following early, aggressive, treat-to-target therapy.
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Affiliation(s)
- Gilad Sherman
- Paediatric Rheumatology Unit, Department of Paediatrics, Meir Medical Center, Kfar Saba; and Sackler School of Medicine, Tel Aviv University, Israel
| | - Dan Nemet
- Sackler School of Medicine, Tel Aviv University; and Department of Paediatrics, Paediatric Child Health Sport Center, Meir Medical Center, Kfar Saba, Israel
| | - Veronica Moshe
- Paediatric Rheumatology Unit, Department of Paediatrics, Meir Medical Center, Kfar Saba; and Sackler School of Medicine, Tel Aviv University, Israel
| | | | - Angelo Ravelli
- Istituto G. Gaslini, Pediatria II-Reumatologia, Genova, Italy
| | | | - Yosef Uziel
- Paediatric Rheumatology Unit, Department of Paediatrics, Meir Medical Center, Kfar Saba; and Sackler School of Medicine, Tel Aviv University, Israel.
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14
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Uziel Y, Sherman G, Rabinowicz N, Harel L, Consolaro A, Bovis F, Ruperto N. The Hebrew version of the Juvenile Arthritis Multidimensional Assessment Report (JAMAR). Rheumatol Int 2018; 38:227-233. [PMID: 29637355 PMCID: PMC5893751 DOI: 10.1007/s00296-018-3956-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 01/11/2018] [Indexed: 11/30/2022]
Abstract
The Juvenile Arthritis Multidimensional Assessment Report (JAMAR) is a new parent/patient reported outcome measure that enables a thorough assessment of the disease status in children with juvenile idiopathic arthritis (JIA). We report the results of the cross-cultural adaptation and validation of the parent and patient versions of the JAMAR in the Hebrew language. The reading comprehension of the questionnaire was tested in ten JIA parents and patients. Each participating centre was asked to collect demographic, clinical data, and the JAMAR in 100 consecutive JIA patients or all consecutive patients seen in a 6-month period and to administer the JAMAR to 100 healthy children and their parents. The statistical validation phase explored descriptive statistics and the psychometric issues of the JAMAR: the three Likert assumptions, floor/ceiling effects, internal consistency, Cronbach’s alpha, interscale correlations, and construct validity (convergent and discriminant validity). A total of 116 JIA patients (17.2% systemic, 56% oligoarticular, 20.7% RF negative poly-arthritis, and 6.1% other categories) and 98 healthy children were enrolled in two centres. The JAMAR components discriminated well healthy subjects from JIA patients. All JAMAR components revealed good psychometric performances. In conclusion, the Hebrew version of the JAMAR is a valid tool for the assessment of children with JIA and is suitable for use both in routine clinical practice and in clinical research.
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Affiliation(s)
- Yosef Uziel
- Department of Pediatrics, Pediatric Rheumatology Unit, Meir Medical Centre, Kfar Saba and Sackler School of Medicine, Tel Aviv University, 59 Tshernichovski Street, 44281, Kfar Saba, Israel.
| | - Gilad Sherman
- Department of Pediatrics, Pediatric Rheumatology Unit, Meir Medical Centre, Kfar Saba and Sackler School of Medicine, Tel Aviv University, 59 Tshernichovski Street, 44281, Kfar Saba, Israel
| | - Noa Rabinowicz
- Department of Pediatrics, Pediatric Rheumatology Unit, Meir Medical Centre, Kfar Saba and Sackler School of Medicine, Tel Aviv University, 59 Tshernichovski Street, 44281, Kfar Saba, Israel
| | - Liora Harel
- Pediatric Rheumatology Unit, Schneider Childrens Medical Center, Petach-Tikvah, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alessandro Consolaro
- Clinica Pediatrica e Reumatologia, Paediatric Rheumatology International Trials Organisation (PRINTO), Istituto Giannina Gaslini, Via Gaslini 5, 16147, Genoa, Italy.,Dipartimento di Pediatria, Università di Genova, Genoa, Italy
| | - Francesca Bovis
- Clinica Pediatrica e Reumatologia, Paediatric Rheumatology International Trials Organisation (PRINTO), Istituto Giannina Gaslini, Via Gaslini 5, 16147, Genoa, Italy
| | - Nicolino Ruperto
- Clinica Pediatrica e Reumatologia, Paediatric Rheumatology International Trials Organisation (PRINTO), Istituto Giannina Gaslini, Via Gaslini 5, 16147, Genoa, Italy.
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15
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Sherman G, Moshe V, Haviv R, Reis Y, Consolaro A, Ruperto N, Uziel Y. FRI0534 Physical Activity, Overweight, and Leisure Time Activity in a Cohort of Juvenile Idiopathic Arthritis Patients. Ann Rheum Dis 2015. [DOI: 10.1136/annrheumdis-2015-eular.2833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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16
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Paximadis M, Schramm DB, Gray GE, Sherman G, Coovadia A, Kuhn L, Tiemessen CT. Influence of intragenic CCL3 haplotypes and CCL3L copy number in HIV-1 infection in a sub-Saharan African population. Genes Immun 2012; 14:42-51. [PMID: 23151487 PMCID: PMC3554858 DOI: 10.1038/gene.2012.51] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Two CCL3 haplotypes (HapA1 and Hap-A3) and two polymorphic positions shared by the haplotypes (Hap-2SNP) were investigated together with CCL3L copy number (CN), for their role in HIV-1 disease. Hap-A1 was associated with protection from in utero HIV-1 infection: exposed-uninfected infants had higher representation of WT/Hap-A1 than infected infants (excluding intrapartum-infected infants), which maintained significance post maternal Nevirapine (mNVP) and viral load (MVL) correction (P=0.04; OR=0.33). Mother-infant pair analyses showed the protective effect of Hap-A1 is dependent on its presence in the infant. Hap-A3 was associated with increased intrapartum transmission: WT/Hap-A3 was increased in intrapartum vs. non-transmitting mothers, and remained significant post mNVP and MVL correction (P=0.02; OR=3.50). This deleterious effect of Hap-A3 seemed dependent on its presence in the mother. Hap-2SNP was associated with lower CD4 count in the non-transmitting mothers (P=0.03). CCL3 Hap-A1 was associated with high CCL3L CN in total (P=0.001) and exposed-uninfected infants (P=0.006); the effect was not additive, however having either Hap-A1 or high CCL3L CN was more significantly (P=0.0008) associated with protection from in utero infection than Hap-A1 (P=0.028) or high CCL3L CN (P=0.002) alone. Linkage disequilibrium between Hap-A1 and high CCL3L CN appears unlikely given that a Nigerian population showed an opposite relationship.
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Affiliation(s)
- M Paximadis
- Centre for HIV and STIs: Cell Biology, National Institute for Communicable Diseases, National Health Laboratory Services, Johannesburg, South Africa.
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Sherman G, Zeller L, Avriel A, Friger M, Harari M, Sukenik S. Intermittent balneotherapy at the Dead Sea area for patients with knee osteoarthritis. Isr Med Assoc J 2009; 11:88-93. [PMID: 19432036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
BACKGROUND Balneotherapy, traditionally administered during a continuous stay at the Dead Sea area, has been shown to be effective for patients suffering from knee osteoarthritis. OBJECTIVES To evaluate the effectiveness of an intermittent regimen of balneotherapy at the Dead Sea for patients with knee osteoarthritis. METHODS Forty-four patients with knee osteoarthritis were included in a prospective randomized single-blind controlled study. The patients were divided into two groups: a treatment group (n=24), which were treated twice weekly for 6 consecutive weeks in a sulfur pool heated to 35-36 degrees C, and a control group (n=20) treated in a Jacuzzi filled with tap water heated to 35-36 degrees C. Participants were assessed by the Lequesne index of osteoarthritis severity, the WOMAC index, the SF-36 quality of health questionnaire, VAS scales for pain (completed by patients and physicians), and physical examination. RESULTS A statistically significant improvement, lasting up to 6 months, was observed in the treatment group for most of the clinical parameters. In the control group the only improvements were in the SF-36 bodily pain scale at 6 months, the Lequesne index at 1 month and the WOMAC pain score at the end of the treatment period. Although the patients in the control group had milder disease, the difference between the two groups was not statistically significant. CONCLUSIONS Intermittent balneotherapy appears to be effective for patients with knee osteoarthritis.
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Affiliation(s)
- Gilad Sherman
- Department of Medicine D, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
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Stevens W, Sherman G, Downing R, Parsons LM, Ou CY, Crowley S, Gershy-Damet GM, Fransen K, Bulterys M, Lu L, Homsy J, Finkbeiner T, Nkengasong JN. Role of the laboratory in ensuring global access to ARV treatment for HIV-infected children: consensus statement on the performance of laboratory assays for early infant diagnosis. Open AIDS J 2008; 2:17-25. [PMID: 18923696 PMCID: PMC2556199 DOI: 10.2174/1874613600802010017] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2007] [Revised: 02/06/2008] [Accepted: 02/14/2008] [Indexed: 02/07/2023] Open
Abstract
A two day meeting hosted by the World Health Organization (WHO) and the U.S. Centers for Disease Control and Prevention (CDC) was held in May 2006 in Entebbe, Uganda to review the laboratory performance of virologic molecular methods, particularly the Roche Amplicor DNA PCR version 1.5 assay, in the diagnosis of HIV-1 infection in infants. The meeting was attended by approximately 60 participants from 17 countries. Data on the performance and limitations of the HIV-1 DNA PCR assay from 9 African countries with high-burdens of HIV/AIDS were shared with respect to different settings and HIV- subtypes. A consensus statement on the use of the assay for early infant diagnosis was developed and areas of needed operational research were identified. In addition, consensus was reached on the usefulness of dried blood spot (DBS) specimens in childhood as a means for ensuring greater accessibility to serologic and virologic HIV testing for the paediatric population.
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Affiliation(s)
- W Stevens
- University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa, Global AIDS Program
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19
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Sydnor M, Sherman G, Wood A, Komorowski D, Leung D, Tisnado J. Abstract No. 319 EE: Unique Applications of Bone Augmentation for Painful Metastatic Foci to the Axial Skeleton. J Vasc Interv Radiol 2008. [DOI: 10.1016/j.jvir.2007.12.367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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20
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Stevens W, Sherman G, Cotton M, Gerntholtz L, Webber L. Revised guidelines for diagnosis of perinatal HIV-1 infection in South Africa. South Afr J HIV Med 2006. [DOI: 10.4102/sajhivmed.v7i1.611] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
No abstract available.
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21
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Choi BCK, Frank J, Mindell JS, Orlova A, Lin V, Vaillancourt ADMG, Puska P, Pang T, Skinner H, Marsh M, Mokdad AH, Yu SZ, Lindner MC, Sherman G, Barreto SM, Green LW, Svenson LW, Sainsbury P, Yan Y, Zhang ZF, Zevallos JC, Ho SC, de Salazar LM. 260: Vision for a Global Registry of Anticipated Public Health Studies (GRAPHS). Am J Epidemiol 2005. [DOI: 10.1093/aje/161.supplement_1.s65c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- B C K Choi
- Public Health Agency of Canada, Ottawa, Ontario, K1A 1B4
| | - J Frank
- Public Health Agency of Canada, Ottawa, Ontario, K1A 1B4
| | - J S Mindell
- Public Health Agency of Canada, Ottawa, Ontario, K1A 1B4
| | - A Orlova
- Public Health Agency of Canada, Ottawa, Ontario, K1A 1B4
| | - V Lin
- Public Health Agency of Canada, Ottawa, Ontario, K1A 1B4
| | | | - P Puska
- Public Health Agency of Canada, Ottawa, Ontario, K1A 1B4
| | - T Pang
- Public Health Agency of Canada, Ottawa, Ontario, K1A 1B4
| | - H Skinner
- Public Health Agency of Canada, Ottawa, Ontario, K1A 1B4
| | - M Marsh
- Public Health Agency of Canada, Ottawa, Ontario, K1A 1B4
| | - A H Mokdad
- Public Health Agency of Canada, Ottawa, Ontario, K1A 1B4
| | - S-Z Yu
- Public Health Agency of Canada, Ottawa, Ontario, K1A 1B4
| | - M C Lindner
- Public Health Agency of Canada, Ottawa, Ontario, K1A 1B4
| | - G Sherman
- Public Health Agency of Canada, Ottawa, Ontario, K1A 1B4
| | - S M Barreto
- Public Health Agency of Canada, Ottawa, Ontario, K1A 1B4
| | - L W Green
- Public Health Agency of Canada, Ottawa, Ontario, K1A 1B4
| | - L W Svenson
- Public Health Agency of Canada, Ottawa, Ontario, K1A 1B4
| | - P Sainsbury
- Public Health Agency of Canada, Ottawa, Ontario, K1A 1B4
| | - Y Yan
- Public Health Agency of Canada, Ottawa, Ontario, K1A 1B4
| | - Z-F Zhang
- Public Health Agency of Canada, Ottawa, Ontario, K1A 1B4
| | - J C Zevallos
- Public Health Agency of Canada, Ottawa, Ontario, K1A 1B4
| | - S C Ho
- Public Health Agency of Canada, Ottawa, Ontario, K1A 1B4
| | - L M de Salazar
- Public Health Agency of Canada, Ottawa, Ontario, K1A 1B4
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Avent M, Cory BJ, Galpin J, Ballot DE, Cooper PA, Sherman G, Davies VA. A comparison of high versus low dose recombinant human erythropoietin versus blood transfusion in the management of anaemia of prematurity in a developing country. J Trop Pediatr 2002; 48:227-33. [PMID: 12200985 DOI: 10.1093/tropej/48.4.227] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The purpose of this study was to evaluate the effectiveness of early treatment with erythropoietin (EPO) in two different treatment regimes (high vs. low dose) in comparison to the conventional treatment of packed red blood cell (PRBC) transfusions in the management of anaemia of prematurity in a country with limited resources. An open controlled trial was conducted on 93 preterm infants (7 days postnatal age, 900-1500 g birthweight). Patients were randomly assigned either to a low dose (250 IU/kg), a high dose (400 IU/kg), or a control group. EPO was administered subcutaneously three times a week and all infants received 6 mg/kg iron orally from study entry to endpoint of therapy. Haematological parameters were measured and compared. The success was defined as an absence of transfusions and a haematocrit that did not fall below 30 per cent during the time period that the infants were in the study. The three groups were statistically comparable at study entry with respect to gestational age, birthweight, Apgar scores, and haematological values. Over the period that the infants were in the study, 75 per cent of the low dose group and 71 per cent of the high dose group met the criteria for success compared with 40 per cent in the control group (p < 0.001). However, there was no significant difference in the number of transfusions when the low and high EPO dose groups (9.5 per cent) were combined and compared with the control group (26.7 per cent) p = 0.0587. It was concluded that in stable infants, 900-1500 g, where phlebotomy losses are minimized and stringent transfusion guidelines are adhered to, EPO does not significantly decrease the number of transfusions. A conservative approach in the management of anaemia of prematurity, is a viable alternative in areas with limited resources.
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Affiliation(s)
- M Avent
- Department of Pharmacy, University of the Witwatersrand, South Africa.
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23
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Abstract
OBJECTIVE To evaluate a clinical guideline for the treatment of ventilator-associated pneumonia. DESIGN Prospective before-and-after study design. SETTING A medical intensive care unit from a university-affiliated, urban teaching hospital. PATIENTS Between April 1999 and January 2000, 102 patients were prospectively evaluated. INTERVENTIONS Prospective patient surveillance, data collection, and implementation of an antimicrobial guideline for the treatment of ventilator-associated pneumonia. MEASUREMENTS AND MAIN RESULTS The main outcome evaluated was the initial administration of adequate antimicrobial treatment as determined by respiratory tract cultures. Secondary outcomes evaluated included the duration of antimicrobial treatment for ventilator-associated pneumonia, hospital mortality, intensive care unit and hospital lengths of stay, and the occurrence of a second episode of ventilator-associated pneumonia. Fifty consecutive patients with ventilator-associated pneumonia were evaluated in the before period and 52 consecutive patients with ventilator-associated pneumonia were evaluated in the after period. Severity of illness using Acute Physiology and Chronic Health Evaluation II (25.8 +/- 5.7 vs. 25.4 +/- 8.1, p =.798) and the clinical pulmonary infection scores (6.6 +/- 1.0 vs. 6.9 +/- 1.2, p =.105) were similar for patients during the two treatment periods. The initial administration of adequate antimicrobial treatment was statistically greater during the after period compared with the before period (94.2% vs. 48.0%, p <.001). The duration of antimicrobial treatment was statistically shorter during the after period compared with the before period (8.6 +/- 5.1 days vs. 14.8 +/- 8.1 days, p <.001). A second episode of ventilator-associated pneumonia occurred statistically less often among patients in the after period (7.7% vs. 24.0%, p =.030). CONCLUSIONS The application of a clinical guideline for the treatment of ventilator-associated pneumonia can increase the initial administration of adequate antimicrobial treatment and decrease the overall duration of antibiotic treatment. These findings suggest that similar types of guidelines employing local microbiological data can be used to improve overall antibiotic utilization for the treatment of ventilator-associated pneumonia.
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Affiliation(s)
- E H Ibrahim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
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24
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Meddows-Taylor S, Kuhn L, Meyers TM, Sherman G, Tiemessen CT. Defective neutrophil degranulation induced by interleukin-8 and complement 5a and down-regulation of associated receptors in children vertically infected with human immunodeficiency virus type 1. Clin Diagn Lab Immunol 2001; 8:21-30. [PMID: 11139191 PMCID: PMC96006 DOI: 10.1128/cdli.8.1.21-30.2001] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2000] [Accepted: 09/26/2000] [Indexed: 11/20/2022]
Abstract
The polymorphonuclear neutrophils (PMNs) of patients infected with human immunodeficiency virus type 1 (HIV-1) show impaired microbicidal responses. The present study assessed the functional integrity of PMN degranulation responses and the expression of specific receptors that mediate these responses in a group of children vertically infected with HIV-1. PMN degranulation in response to interleukin-8 (IL-8) and complement 5a (C5a) was measured in a group of HIV-1-infected children with mild and severe clinical disease and in an uninfected control group. In addition, the expression of CXCR1, CXCR2, and CD88 on whole-blood PMNs was quantified by flow cytometry. Although CXCR1 expression was found to be largely unaltered in the HIV-1-infected children relative to that in the control children, the intensity of CXCR2 expression was significantly reduced in those with severe disease. Furthermore, there was a significant reduction in the percentage of cells expressing CD88 and in the intensity of CD88 fluorescence in the HIV-1-infected children compared to that in control children, with CD88 fluorescence intensity more significantly reduced in the presence of severe disease. PMNs from a large proportion of the HIV-1-infected children either showed reciprocal degranulation responses or were unresponsive to IL-8 and C5a, whereas the PMNs from the uninfected children showed positive responses. Inefficient agonist-induced degranulation may contribute to the increased susceptibility of HIV-1-infected children to secondary microbial infections. Furthermore, reduced expression of CXCR2 and CD88 may be suggestive of defects in other functions of PMNs from HIV-1-infected children.
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Affiliation(s)
- S Meddows-Taylor
- AIDS Virus Research Unit, National Institute for Virology, Johannesburg, South Africa
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Kollef MH, Ward S, Sherman G, Prentice D, Schaiff R, Huey W, Fraser VJ. Inadequate treatment of nosocomial infections is associated with certain empiric antibiotic choices. Crit Care Med 2000; 28:3456-64. [PMID: 11057801 DOI: 10.1097/00003246-200010000-00014] [Citation(s) in RCA: 125] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the impact of scheduled changes of antibiotic classes, used for the empirical treatment of suspected or documented Gram-negative bacterial infections, on the occurrence of inadequate antimicrobial treatment of nosocomial infections. DESIGN Prospective observational study. SETTING Medical (19-bed) and surgical (18-bed) intensive care units in an urban teaching hospital. PATIENTS A total of 3,668 patients requiring intensive care unit admission were prospectively evaluated during three consecutive time periods. INTERVENTIONS During each time period, one antibiotic class was selected for the empirical treatment of Gram-negative bacterial infections as follows: time period 1 (baseline period) (1,323 patients), ceftazidime; time period 2 (1,243 patients), ciprofloxacin; and time period 3 (1,102 patients), cefepime. MEASUREMENTS AND MAIN RESULTS The overall administration of inadequate antimicrobial treatment for nosocomial infections decreased during the course of the study (6.1%, 4.7%, and 4.5%; p = .15). This was primarily because of a statistically significant decrease in the administration of inadequate antibiotic treatment for Gram-negative bacterial infections (4.4%, 2.1%, and 1.6%; p < .001). There were no statistically significant differences in the overall hospital mortality rate among the three time periods (15.6%, 16.4%, and 16.2%; p = .828) despite a significant increase in severity of illness as measured with Acute Physiology and Chronic Health Evaluation (APACHE) II scores (15.3 +/- 7.6, 15.7 +/- 8.0, and 20.7 +/- 8.6; p < .001). The hospital mortality rate decreased significantly during time period 3 (20.6%) compared with time period 1 (28.4%; p < .001) and time period 2 (29.5%; p < .001) for patients with an APACHE II score > or = 15. CONCLUSIONS These data suggest that scheduled changes of antibiotic classes for the empirical treatment of Gram-negative bacterial infections can reduce the occurrence of inadequate antibiotic treatment for nosocomial infections. Reducing inadequate antibiotic administration may improve the outcomes of critically ill patients with APACHE II scores > or = 15.
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Affiliation(s)
- M H Kollef
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
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26
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Abstract
OBJECTIVES: To compare the clinical outcomes of early versus late tracheostomy in patients who require prolonged mechanical ventilation. METHODS: A prospective observational study was done. The sample was a cohort of 90 patients who had tracheostomy in the medical intensive care unit of a university-affiliated teaching hospital. Primary outcome measures were duration of mechanical ventilation and total cost of hospitalization. Tracheostomy was defined as early if performed by day 10 of mechanical ventilation and late if performed thereafter. RESULTS: Fifty-three patients had early tracheostomy (mean +/- SD = day 5.9 +/- 7.2 of ventilation), and 37 patients had late tracheostomy (mean +/- SD = day 16.7 +/- 2.9) (P < .001). The mean (+/- SD) duration of mechanical ventilation was 28.3 +/- 28.2 days in the early-tracheostomy group versus 34.4 +/- 17.8 days in the late-tracheostomy group (P = .005). Total cost of hospitalization was significantly lower in the early-tracheostomy group (mean +/- SD = $86,189 +/- $53,570) than in the late-tracheostomy group (mean +/- SD = $124,649 +/- $54,282) (P = .001). Male sex (adjusted odds ratio = 3.84; 95% CI = 2.32-6.34; P = .007) and higher ratios of PaO2 to fraction of inspired oxygen (adjusted odds ratio = 1.01; 95% CI = 1.00-1.01; P = .03) were associated with early tracheostomy. The timing of tracheostomy was not associated with hospital mortality. CONCLUSION: Early tracheostomy is associated with shorter lengths of stay and lower hospital costs than is late tracheostomy among patients in the medical intensive care unit. Prospective clinical trials are necessary to determine the optimal timing of tracheostomy in that setting.
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27
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Brook AD, Sherman G, Malen J, Kollef MH. Early versus late tracheostomy in patients who require prolonged mechanical ventilation. Am J Crit Care 2000; 9:352-9. [PMID: 10976359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
OBJECTIVES To compare the clinical outcomes of early versus late tracheostomy in patients who require prolonged mechanical ventilation. METHODS A prospective observational study was done. The sample was a cohort of 90 patients who had tracheostomy in the medical intensive care unit of a university-affiliated teaching hospital. Primary outcome measures were duration of mechanical ventilation and total cost of hospitalization. Tracheostomy was defined as early if performed by day 10 of mechanical ventilation and late if performed thereafter. RESULTS Fifty-three patients had early tracheostomy (mean +/- SD = day 5.9 +/- 7.2 of ventilation), and 37 patients had late tracheostomy (mean +/- SD = day 16.7 +/- 2.9) (P < .001). The mean (+/- SD) duration of mechanical ventilation was 28.3 +/- 28.2 days in the early-tracheostomy group versus 34.4 +/- 17.8 days in the late-tracheostomy group (P = .005). Total cost of hospitalization was significantly lower in the early-tracheostomy group (mean +/- SD = $86,189 +/- $53,570) than in the late-tracheostomy group (mean +/- SD = $124,649 +/- $54,282) (P = .001). Male sex (adjusted odds ratio = 3.84; 95% CI = 2.32-6.34; P = .007) and higher ratios of PaO2 to fraction of inspired oxygen (adjusted odds ratio = 1.01; 95% CI = 1.00-1.01; P = .03) were associated with early tracheostomy. The timing of tracheostomy was not associated with hospital mortality. CONCLUSION Early tracheostomy is associated with shorter lengths of stay and lower hospital costs than is late tracheostomy among patients in the medical intensive care unit. Prospective clinical trials are necessary to determine the optimal timing of tracheostomy in that setting.
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Affiliation(s)
- A D Brook
- Department of Internal Medicine, Washington University School of Medicine, St Louis, Mo., USA
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28
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Ibrahim EH, Sherman G, Ward S, Fraser VJ, Kollef MH. The influence of inadequate antimicrobial treatment of bloodstream infections on patient outcomes in the ICU setting. Chest 2000; 118:146-55. [PMID: 10893372 DOI: 10.1378/chest.118.1.146] [Citation(s) in RCA: 1277] [Impact Index Per Article: 53.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVE To evaluate the relationship between the adequacy of antimicrobial treatment for bloodstream infections and clinical outcomes among patients requiring ICU admission. DESIGN Prospective cohort study. SETTING A medical ICU (19 beds) and a surgical ICU (18 beds) from a university-affiliated urban teaching hospital. PATIENTS Between July 1997 and July 1999, 492 patients were prospectively evaluated. INTERVENTION Prospective patient surveillance and data collection. RESULTS One hundred forty-seven patients (29.9%) received inadequate antimicrobial treatment for their bloodstream infections. The hospital mortality rate of patients with a bloodstream infection receiving inadequate antimicrobial treatment (61.9%) was statistically greater than the hospital mortality rate of patients with a bloodstream infection who received adequate antimicrobial treatment (28.4%; relative risk, 2. 18; 95% confidence interval [CI], 1.77 to 2.69; p < 0.001). Multiple logistic regression analysis identified the administration of inadequate antimicrobial treatment as an independent determinant of hospital mortality (adjusted odds ratio [AOR], 6.86; 95% CI, 5.09 to 9.24; p < 0.001). The most commonly identified bloodstream pathogens and their associated rates of inadequate antimicrobial treatment included vancomycin-resistant enterococci (n = 17; 100%), Candida species (n = 41; 95.1%), oxacillin-resistant Staphylococcus aureus (n = 46; 32.6%), coagulase-negative staphylococci (n = 96; 21.9%), and Pseudomonas aeruginosa (n = 22; 10.0%). A statistically significant relationship was found between the rates of inadequate antimicrobial treatment for individual microorganisms and their associated rates of hospital mortality (Spearman correlation coefficient = 0.8287; p = 0.006). Multiple logistic regression analysis also demonstrated that a bloodstream infection attributed to Candida species (AOR, 51.86; 95% CI, 24.57 to 109.49; p < 0.001), prior administration of antibiotics during the same hospitalization (AOR, 2.08; 95% CI, 1.58 to 2.74; p = 0.008), decreasing serum albumin concentrations (1-g/dL decrements) (AOR, 1.37; 95% CI, 1.21 to 1.56; p = 0.014), and increasing central catheter duration (1-day increments) (AOR, 1.03; 95% CI, 1.02 to 1.04; p = 0.008) were independently associated with the administration of inadequate antimicrobial treatment. CONCLUSIONS The administration of inadequate antimicrobial treatment to critically ill patients with bloodstream infections is associated with a greater hospital mortality compared with adequate antimicrobial treatment of bloodstream infections. These data suggest that clinical efforts should be aimed at reducing the administration of inadequate antimicrobial treatment to hospitalized patients with bloodstream infections, especially individuals infected with antibiotic-resistant bacteria and Candida species.
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Affiliation(s)
- E H Ibrahim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Washington University School of Medicine, Seattle, WA, USA
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Abstract
STUDY OBJECTIVE To compare the clinical outcomes of critically ill patients developing early-onset nosocomial pneumonia (NP; ie, within 96 h of ICU admission) and late-onset NP (ie, occurring after 96 h of ICU admission). DESIGN Prospective cohort study. SETTING A medical ICU and a surgical ICU from a university-affiliated urban teaching hospital. PATIENTS Between July 1997 and November 1998, 3, 668 patients were prospectively evaluated. INTERVENTION Prospective patient surveillance and data collection. RESULTS Four hundred twenty patients (11.5%) developed NP. Early-onset NP was observed in 235 patients (56.0%), whereas 185 patients (44.0%) developed late-onset NP. Among patients with early onset NP, 114 patients (48. 5%) spent at least 24 h in the hospital prior to ICU admission, compared to 57 patients (30.8%) with late-onset NP (p = 0.001). One hundred eighty-three patients (77.9%) with early-onset NP received antibiotics prior to the development of NP, as compared to 162 patients (87.6%) with late-onset NP (p = 0.010). The most common pathogens associated with early-onset NP were Pseudomonas aeruginosa (25.1%), oxacillin-sensitive Staphylococcus aureus (OSSA; 17.9%), oxacillin-resistant S aureus (ORSA; 17.9%), and Enterobacter species (10.2%). P aeruginosa (38.4%), ORSA (21.1%), Stenotrophomonas maltophilia (11.4%), OSSA (10.8%), and Enterobacter species (10.3%) were the most common pathogens associated with late-onset NP. The ICU length of stay was significantly longer for patients with early-onset NP (10.3 +/- 8.3 days; p < 0.001) and late-onset NP (21. 0 +/- 13.7 days; p < 0.001), as compared to patients without NP (3.5 +/- 3.2 days). Hospital mortality was significantly greater for patients with early-onset NP (37.9%; p = 0.001) and late-onset NP (41.1%; p = 0.001) compared to patients without NP (13.1%). CONCLUSIONS Both early-onset and late-onset NP are associated with increased hospital mortality rates and prolonged lengths of stay. The pathogens associated with NP were similar for both groups. This may be due, in part, to the prior hospitalization and use of antibiotics in many patients developing early-onset NP. These data suggest that P aeruginosa and ORSA can be important pathogens associated with early-onset NP in the ICU setting. Additionally, clinicians should be aware of the common microorganisms associated with both early-onset NP and late-onset NP in their hospitals in order to avoid the administration of inadequate antimicrobial treatment.
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Affiliation(s)
- E H Ibrahim
- Pulmonary and Critical Care Medicine Division, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
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Brook AD, Ahrens TS, Schaiff R, Prentice D, Sherman G, Shannon W, Kollef MH. Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Crit Care Med 1999; 27:2609-15. [PMID: 10628598 DOI: 10.1097/00003246-199912000-00001] [Citation(s) in RCA: 764] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare a practice of protocol-directed sedation during mechanical ventilation implemented by nurses with traditional non-protocol-directed sedation administration. DESIGN Randomized, controlled clinical trial. SETTING Medical intensive care unit (19 beds) in an urban teaching hospital. PATIENTS Patients requiring mechanical ventilation (n = 321). INTERVENTIONS Patients were randomly assigned to receive either protocol-directed sedation (n = 162) or non-protocol-directed sedation (n = 159). MEASUREMENTS AND MAIN RESULTS The median duration of mechanical ventilation was 55.9 hrs (95% confidence interval, 41.0-90.0 hrs) for patients managed with protocol-directed sedation and 117.0 hrs (95% confidence interval, 96.0-155.6 hrs) for patients receiving non-protocol-directed sedation. Kaplan-Meier analysis demonstrated that patients in the protocol-directed sedation group had statistically shorter durations of mechanical ventilation than patients in the non-protocol-directed sedation group (chi-square = 7.00, p = .008, log rank test; chi-square = 8.54, p = .004, Wilcoxon's test; chi-square = 9.18, p = .003, -2 log test). Lengths of stay in the intensive care unit (5.7+/-5.9 days vs. 7.5+/-6.5 days; p = .013) and hospital (14.0+/-17.3 days vs. 19.9+/-24.2 days; p < .001) were also significantly shorter among patients in the protocol-directed sedation group. Among the 132 patients (41.1%) receiving continuous intravenous sedation, those in the protocol-directed sedation group (n = 66) had a significantly shorter duration of continuous intravenous sedation than those in the non-protocol-directed sedation group (n = 66) (3.5+/-4.0 days vs. 5.6+/-6.4 days; p = .003). Patients in the protocol-directed sedation group also had a significantly lower tracheostomy rate compared with patients in the non-protocol-directed sedation group (10 of 162 patients [6.2%] vs. 21 of 159 patients [13.2%], p = .038). CONCLUSIONS The use of protocol-directed sedation can reduce the duration of mechanical ventilation, the intensive care unit and hospital lengths of stay, and the need for tracheostomy among critically ill patients with acute respiratory failure.
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Affiliation(s)
- A D Brook
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, USA
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Madhi SA, Gray GE, Huebner RE, Sherman G, McKinnon D, Pettifor JM. Correlation between CD4+ lymphocyte counts, concurrent antigen skin test and tuberculin skin test reactivity in human immunodeficiency virus type 1-infected and -uninfected children with tuberculosis. Pediatr Infect Dis J 1999; 18:800-5. [PMID: 10493341 DOI: 10.1097/00006454-199909000-00011] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND HIV-infected children are at high risk of developing tuberculosis after infection by Mycobacterium tuberculosis. Emphasis is placed on tuberculin skin testing (TST) for diagnosing tuberculosis in children; however, its value in HIV-infected children is controversial. OBJECTIVES To determine whether concurrent antigen testing and/or CD4+ lymphocyte counts help in the interpretation of the TST in children with tuberculosis. METHODS Children eligible for the study were diagnosed as having tuberculosis on clinical criteria. CD4+ lymphocyte counts and delayed-type hypersensitivity (DTH) test, using the CMI Multitest were performed when tuberculosis was diagnosed. RESULTS One hundred thirty children were enrolled. Tuberculin reactivity was lower in HIV-infected children at all cutoff levels than in HIV-uninfected children (P < 0.0001). The positive predictive value of normal CD4+ lymphocyte counts in predicting tuberculin reactions of > or =5 mm (in HIV-1-infected) and > or =10 mm (in HIV-uninfected patients) were 50 and 80.3%, respectively (P < 0.0001). An intact DTH reaction to the CMI Multitest in predicting reactions of > or =5 mm and > or =10 mm to tuberculin in HIV-infected and -uninfected children were 55 and 76%, respectively (P < 0.001). Kwashiorkor was responsible for 53.3% of false-negative TST in HIV-uninfected children with normal CD4+ lymphocyte counts. CONCLUSION TST is of limited value as an adjunct in diagnosing tuberculosis in HIV-infected children. CD4+ lymphocyte counts and concurrent DTH testing are not useful for predicting tuberculin reactivity in HIV-infected patients with tuberculosis.
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Affiliation(s)
- S A Madhi
- Department of Paediatrics, University of the Witwatersrand, Johannesburg, South Africa
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Abstract
BACKGROUND: Acquired organ system derangements are common among patients who require intensive care, but the relative importance of different derangements as determinants of patients' outcomes is unclear. OBJECTIVES: To determine organ system derangements that occur in patients who require intensive care and the relative importance of different derangements to hospital mortality. METHODS: A prospective cohort study design was used to evaluate the occurrence of organ system derangements and hospital mortality in 617 adults admitted to the medical and surgical intensive care units of a university-affiliated teaching hospital. RESULTS: Eighty-three patients (13.5%) died while hospitalized. Patients who died had significantly more derangements than did patients who survived (3.3 +/- 1.2 vs 0.9 +/- 0.9; P < .001). The crude hospital mortality rate varied with the specific organ system involved (pulmonary, 23.6%; gastrointestinal, 25.0%; hepatic, 42.4%; hematological, 47.9%; cardiac, 54.0%; renal, 54.8%; neurological, 65.9%). Derangements of neurological function (adjusted odds ratio, 3.20; 95% CI, 2.0-5.3; P = .019) and cardiac function (adjusted odds ratio, 3.96; 95% CI, 2.63-5.99; P < .001) were independently associated with hospital mortality. Additionally, derangements occurred later during the stay in the intensive care unit in patients who died in the hospital than in patients who survived, especially for derangements of pulmonary, neurological, and renal function. CONCLUSION: Among critically ill patients, neurological and cardiac dysfunction are the acquired organ system derangements most closely associated with hospital mortality. These data suggest that hospital mortality depends on both the specific types of derangements that occur and the total number of such derangements. Interventions to prevent cardiac and neurological dysfunction have the greatest potential for improving outcomes for patients in the intensive care unit.
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Kollef MH, Sherman G. Acquired organ system derangements and hospital mortality: are all organ systems created equally? Am J Crit Care 1999; 8:180-8. [PMID: 10228659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
BACKGROUND Acquired organ system derangements are common among patients who require intensive care, but the relative importance of different derangements as determinants of patients' outcomes is unclear. OBJECTIVES To determine organ system derangements that occur in patients who require intensive care and the relative importance of different derangements to hospital mortality. METHODS A prospective cohort study design was used to evaluate the occurrence of organ system derangements and hospital mortality in 617 adults admitted to the medical and surgical intensive care units of a university-affiliated teaching hospital. RESULTS Eighty-three patients (13.5%) died while hospitalized. Patients who died had significantly more derangements than did patients who survived (3.3 +/- 1.2 vs 0.9 +/- 0.9; P < .001). The crude hospital mortality rate varied with the specific organ system involved (pulmonary, 23.6%; gastrointestinal, 25.0%; hepatic, 42.4%; hematological, 47.9%; cardiac, 54.0%; renal, 54.8%; neurological, 65.9%). Derangements of neurological function (adjusted odds ratio, 3.20; 95% CI, 2.0-5.3; P = .019) and cardiac function (adjusted odds ratio, 3.96; 95% CI, 2.63-5.99; P < .001) were independently associated with hospital mortality. Additionally, derangements occurred later during the stay in the intensive care unit in patients who died in the hospital than in patients who survived, especially for derangements of pulmonary, neurological, and renal function. CONCLUSION Among critically ill patients, neurological and cardiac dysfunction are the acquired organ system derangements most closely associated with hospital mortality. These data suggest that hospital mortality depends on both the specific types of derangements that occur and the total number of such derangements. Interventions to prevent cardiac and neurological dysfunction have the greatest potential for improving outcomes for patients in the intensive care unit.
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Affiliation(s)
- M H Kollef
- Department of Internal Medicine, Washington University School of Medicine, St Louis, Mo., USA
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Kollef MH, Sherman G, Ward S, Fraser VJ. Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients. Chest 1999; 115:462-74. [PMID: 10027448 DOI: 10.1378/chest.115.2.462] [Citation(s) in RCA: 1240] [Impact Index Per Article: 49.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
STUDY OBJECTIVE To evaluate the relationship between inadequate antimicrobial treatment of infections (both community-acquired and nosocomial infections) and hospital mortality for patients requiring ICU admission. DESIGN Prospective cohort study. SETTING Barnes-Jewish Hospital, a university-affiliated urban teaching hospital. PATIENTS Two thousand consecutive patients requiring admission to the medical or surgical ICU. INTERVENTIONS Prospective patient surveillance and data collection. MEASUREMENTS AND RESULTS One hundred sixty-nine (8.5%) infected patients received inadequate antimicrobial treatment of their infections. This represented 25.8% of the 655 patients assessed to have either community-acquired or nosocomial infections. The occurrence of inadequate antimicrobial treatment of infection was most common among patients with nosocomial infections, which developed after treatment of a community-acquired infection (45.2%), followed by patients with nosocomial infections alone (34.3%) and patients with community-acquired infections alone (17.1%) (p < 0.001). Multiple logistic regression analysis, using only the cohort of infected patients (n = 655), demonstrated that the prior administration of antibiotics (adjusted odds ratio [OR], 3.39; 95% confidence interval [CI], 2.88 to 4.23; p < 0.001), presence of a bloodstream infection (adjusted OR, 1.88; 95% CI, 1.52 to 2.32; p = 0.003), increasing acute physiology and chronic health evaluation (APACHE) II scores (adjusted OR, 1.04; 95% CI, 1.03 to 1.05; p = 0.002), and decreasing patient age (adjusted OR, 1.01; 95% CI, 1.01 to 1.02; p = 0.012) were independently associated with the administration of inadequate antimicrobial treatment. The hospital mortality rate of infected patients receiving inadequate antimicrobial treatment (52.1%) was statistically greater than the hospital mortality rate of the remaining patients in the cohort (n = 1,831) without this risk factor (12.2%) (relative risk [RR], 4.26; 95% CI, 3.52 to 5.15; p < 0.001). Similarly, the infection-related mortality rate for infected patients receiving inadequate antimicrobial treatment (42.0%) was significantly greater than the infection-related mortality rate of infected patients receiving adequate antimicrobial treatment (17.7%) (RR, 2.37; 95% CI, 1.83 to 3.08; p < 0.001). Using a logistic regression model, inadequate antimicrobial treatment of infection was found to be the most important independent determinant of hospital mortality for the entire patient cohort (adjusted OR, 4.27; 95% CI, 3.35 to 5.44; p < 0.001). The other identified independent determinants of hospital mortality included the number of acquired organ system derangements, use of vasopressor agents, the presence of an underlying malignancy, increasing APACHE II scores, increasing age, and having a nonsurgical diagnosis at the time of ICU admission. CONCLUSIONS Inadequate treatment of infections among patients requiring ICU admission appears to be an important determinant of hospital mortality. These data suggest that clinical efforts aimed at reducing the occurrence of inadequate antimicrobial treatment could improve the outcomes of critically ill patients. Additionally, prior antimicrobial therapy should be recognized as an important risk factor for the administration of inadequate antimicrobial treatment among ICU patients with clinically suspected infections.
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Affiliation(s)
- M H Kollef
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA.
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Kollef MH, Levy NT, Ahrens TS, Schaiff R, Prentice D, Sherman G. The use of continuous i.v. sedation is associated with prolongation of mechanical ventilation. Chest 1998; 114:541-8. [PMID: 9726743 DOI: 10.1378/chest.114.2.541] [Citation(s) in RCA: 660] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
STUDY OBJECTIVE To determine whether the use of continuous i.v. sedation is associated with prolongation of the duration of mechanical ventilation. DESIGN Prospective observational cohort study. SETTING The medical ICU of Barnes-Jewish Hospital, a university-affiliated urban teaching hospital. PATIENTS Two hundred forty-two consecutive ICU patients requiring mechanical ventilation. INTERVENTIONS Patient surveillance and data collection. MEASUREMENTS AND RESULTS The primary outcome measure was the duration of mechanical ventilation. Secondary outcome measures included ICU and hospital lengths of stay, hospital mortality, and acquired organ system derangements. A total of 93 (38.4%) mechanically ventilated patients received continuous i.v. sedation while 149 (61.6%) patients received either bolus administration of i.v. sedation (n=64) or no i.v. sedation (n=85) following intubation. The duration of mechanical ventilation was significantly longer for patients receiving continuous i.v. sedation compared with patients not receiving continuous i.v. sedation (185+/-190 h vs 55.6+/-75.6 h; p<0.001). Similarly, the lengths of intensive care (13.5+/-33.7 days vs 4.8+/-4.1 days; p<0.001) and hospitalization (21.0+/-25.1 days vs 12.8+/-14.1 days; p<0.001) were statistically longer among patients receiving continuous i.v. sedation. Multiple linear regression analysis, adjusting for age, gender, severity of illness, mortality, indication for mechanical ventilation, use of chemical paralysis, presence of a tracheostomy, and the number of acquired organ system derangements, found the adjusted duration of mechanical ventilation to be significantly longer for patients receiving continuous i.v. sedation compared with patients who did not receive continuous i.v. sedation (148 h [95% confidence interval: 121, 175 h] vs 78.7 h [95% confidence interval: 68.9, 88.6 h]; p<0.001). CONCLUSION We conclude from these preliminary observational data that the use of continuous i.v. sedation may be associated with the prolongation of mechanical ventilation. This study suggests that strategies targeted at reducing the use of continuous i.v. sedation could shorten the duration of mechanical ventilation for some patients. Prospective randomized clinical trials, using well-designed sedation guidelines and protocols, are required to determine whether patient-specific outcomes (eg, duration of mechanical ventilation, patient comfort) can be improved compared with conventional sedation practices.
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Affiliation(s)
- M H Kollef
- Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
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Abstract
OBJECTIVE To determine if a single, over-the-counter dose of the H1 antagonist chlorpheniramine maleate (CM) alters total peripheral resistance (TPR) and oxygen uptake (VO2) during submaximal exercise. DESIGN The study was a prospective, longitudinal, double-blind, random crossover analysis of the cardiovascular and respiratory responses to a single bout of moderately intense exercise. SETTING Exercise tests were conducted in an exercise laboratory equipped with expired gas analysis and bioelectrical impedance cardiographic monitoring capabilities. PARTICIPANTS Subjects were 18 (9 men, 9 women) volunteers (age=29.5+/-3.6yrs; weight=70.7+/-1.1kg), free from exercise-limiting pathology and rhinitis. INTERVENTION Each subject completed a maximal exercise tolerance test on the cycle ergometer followed by two randomly ordered submaximal exercise tests at a power output of 50% of the peak power attained on the maximal test: the first, 2 hours after ingesting 4mg of CM, the second, 2 hours after ingesting a placebo. The submaximal exercise tests lasted 20min and data were recorded at 5, 10, 15, and 20min of exercise during both the CM and placebo tests. Tests were completed approximately 48 hours apart. RESULTS Average VO2 was 1,488+/-367mL/min for the CM test and 1,477+/-351mL/min for the placebo test. TPR was 12.3+/-7.4PRU for the CM and 11.3+/-4.5PRU for the placebo tests. Analysis of variance revealed that these scores were statistically similar. CONCLUSION A single over-the-counter dose of CM does not alter TPR or VO2 during submaximal exercise.
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Affiliation(s)
- M F Peterlin
- Department of Health Promotion and Human Performance, School of Pharmacy, University of Toledo, OH, USA
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Denenberg VH, Sherman G, Schrott LM, Waters NS, Boehm GW, Galaburda AM, Mobraaten LE. Effects of embryo transfer and cortical ectopias upon the behavior of BXSB-Yaa and BXSB-Yaa + mice. Brain Res Dev Brain Res 1996; 93:100-8. [PMID: 8804696 DOI: 10.1016/0165-3806(96)00010-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The BXSB-Yaa and BXSB-Yaa + inbred strains of mice differ primarily with respect to the Y chromosome, although there is evidence that they differ on several autosomal genes as well. Each strain has ectopic collections of neurons in neocortical layer I (ectopias), with a higher occurrence in males (58%) than females (42%). Conventionally reared mice from these strains were compared to mice that were transferred, as 8-cell embryos, into the uteri of non-autoimmune recipients, who gave birth to and reared the offspring. The transfer procedure did not change the incidence of ectopias in either sex. There were, however, major differences in behavior. Compared to conventionally reared controls, embryo transfer mice had greater behavioral asymmetry, poorer performance in a black-white discrimination, poorer Morris maze learning, better Lashley maze learning, and better performance in a two-way shuttlebox. Within the transfer groups, females differed as much as males, confirming our prior findings and supporting our thesis that the two strains differ on several autosomal genes in addition to the Y chromosome. These findings show that the intra-uterine environment can powerfully and selectively affect later behavior. When ectopic and non-ectopic mice were compared, BXSB-Yaa mice with neocortical ectopias were better able to learn the Morris spatial maze than non-ectopic controls; this was true whether the mice were conventionally reared or embryo transferred. In contrast, BXSB-Yaa + ectopic mice did not differ from their controls if conventionally reared, but were much worse than controls if embryo transferred.
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Affiliation(s)
- V H Denenberg
- Biobehavioral Sciences Graduate Degree Program, University of Connecticut, Storrs 06269-4154, USA
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Newbold JE, Xin H, Tencza M, Sherman G, Dean J, Bowden S, Locarnini S. The covalently closed duplex form of the hepadnavirus genome exists in situ as a heterogeneous population of viral minichromosomes. J Virol 1995; 69:3350-7. [PMID: 7745682 PMCID: PMC189047 DOI: 10.1128/jvi.69.6.3350-3357.1995] [Citation(s) in RCA: 246] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Replication of hepadnaviruses requires a persistent population of covalently closed circular (CCC) DNA molecules in the nucleus of the infected cell. It is widely accepted that the vital role of this molecule is to be the sole DNA template for the synthesis by RNA polymerase II of all viral transcripts throughout the infection process. Since the transcriptional activity of eukaryotic nuclear DNA is considered to be determined in part by its specific organization as chromatin, the nucleoprotein disposition of the hepadnavirus CCC DNA was investigated. These studies were undertaken on the duck hepatitis B virus (DHBV) CCC DNA present in the liver cell nuclei of DHBV-infected ducks. The organization and protein associations of the DHBV CCC DNA in situ were inferred from sedimentation, micrococcal nuclease digestion, and DNA superhelicity analyses. These three lines of investigation demonstrate that the DHBV CCC DNA is stably associated with proteins in the nuclei of infected liver cells. Moreover, they provide compelling evidence that the viral nucleoprotein complex is indeed a minichromosome composed of classical nucleosomes but in arrays that are atypical for chromatin. When the DHBV chromatin is digested with micrococcal nuclease, a ladder of viral DNA fragments that exhibits a 150-bp repeat is produced. This profile for the viral chromatin is obtained from the same nuclei in which the duck chromatin shows the standard 200-bp ladder. The superhelicity of the DHBV CCC DNA ranges from 0 to 20 negative supertwists per molecule, with all possible 21 topoisomers present in each DNA preparation. The 21 topoisomers of DHBV CCC DNA are inferred to derive from an identically diverse array of viral minichromosomes. In the DHBV minichromosomes composed of 20 nucleosomes, 96.7% of the viral DNA is calculated to be compacted into these chromatin subunits spaced on average by 5 bp of linker DNA; other minichromosomes contain fewer nucleosomes and proportionately more linker DNA. Two major subpopulations of DHBV minichromosomes are detected with comparable prevalence. The two groups correspond to minichromosomes which contain essentially a full or half complement of nucleosomes. The functional significance of this minichromosome diversity is unknown but is suggestive of transcriptional regulation of the viral DNA template.
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Affiliation(s)
- J E Newbold
- Department of Microbiology and Immunology, UNC School of Medicine, University of North Carolina, Chapel Hill 27599-7290, USA
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Abstract
OBJECTIVES To determine whether the offspring of cancer survivors are at an increased risk of congenital anomalies and whether cancer therapy before conception is associated with such an increase. DESIGN Case-control study using computerised record linkage. SETTING Ontario, Canada. SUBJECTS Parents of children born during April 1979 to December 1986 who had a congenital anomaly diagnosed within the first year of life (45,200 mothers and 41,158 fathers) and a matched sample of parents whose children did not have a congenital anomaly (45,200 mothers and 41,158 fathers). MAIN OUTCOME MEASURES Cancer diagnosed in either parent before conception and radiotherapy to the pelvis or abdomen or chemotherapy with an alkylating agent. RESULTS Among the mothers, 54 cases and 52 controls were identified as having had cancer diagnosed in Ontario (relative risk = 1.04, 95% confidence interval 0.7 to 1.5) and among the fathers, 61 cases and 65 controls were identified (0.9, 0.7 to 1.4). No significant associations were found between congenital anomalies in the offspring and any type of cancer treatment in either the mothers or the fathers. CONCLUSIONS The risk of congenital anomalies among liveborn offspring whose parents have had cancer or been treated for cancer is not higher than that in the general population.
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Affiliation(s)
- L Dodds
- University of Toronto, Department of Preventive Medicine and Biostatistics, Ontario, Canada
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Keyser RE, Mott M, Andres FF, Moberg CH, Sherman G. 375 EXERCISE AND CHLOROPHENIRAMINE MALEATE M.F. Peterlin. Med Sci Sports Exerc 1993. [DOI: 10.1249/00005768-199305001-00377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
The herpes simplex virus (HSV) type 1 helicase-primase is a three-protein complex, consisting of a 1:1:1 association of UL5, UL8, and UL52 gene products (J.J. Crute, T. Tsurumi, L. Zhu, S. K. Weller, P. D. Olivo, M. D. Challberg, E. S. Mocarski, and I. R. Lehman, Proc. Natl. Acad. Sci. USA 86:2186-2189, 1989). We have purified this complex, as well as a subcomplex consisting of UL5 and UL52 proteins, from insect cells infected with baculovirus recombinants expressing the appropriate gene products. In confirmation of previous reports, we find that whereas UL5 alone has greatly reduced DNA-dependent ATPase activity, the UL5/UL52 subcomplex retains the activities characteristic of the heterotrimer: DNA-dependent ATPase activity, DNA helicase activity, and the ability to prime DNA synthesis on a poly(dT) template. We also found that the primers made by the subcomplex are equal in length to those synthesized by the UL5/UL8/UL52 complex. In an effort to uncover a role for UL8 in HSV DNA replication, we have developed a model system for lagging-strand synthesis in which the primase activity of the helicase-primase complex is coupled to the activity of the HSV DNA polymerase on ICP8-coated single-stranded M13 DNA. Using this assay, we found that the UL8 subunit of the helicase-primase is critical for the efficient utilization of primers; in the absence of UL8, we detected essentially no elongation of primers despite the fact that the rate of primer synthesis on the same template is undiminished. Reconstitution of lagging-strand synthesis in the presence of UL5/UL52 was achieved by the addition of partially purified UL8. Essentially identical results were obtained when Escherichia coli DNA polymerase I was substituted for the HSV polymerase/UL42 complex. On the basis of these findings, we propose that UL8 acts to increase the efficiency of primer utilization by stabilizing the association between nascent oligoribonucleotide primers and template DNA.
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Affiliation(s)
- G Sherman
- Laboratory of Viral Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland 20892
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Abboud TK, Zhu J, Reyes A, Miller H, Steffens Z, Afrasiabi K, Afrasiabi A, Sherman G, Emershad B. Effect of subarachnoid morphine on the incidence of spinal headache. Reg Anesth 1992; 17:34-6. [PMID: 1599892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND OBJECTIVES The addition of fentanyl to hyperbaric local anesthetics has been shown to reduce the incidence of post dural puncture headache in the obstetric patient. This study was undertaken to evaluate the effects of subarachnoid morphine on the incidence of headache. METHODS Eighty-two healthy patients undergoing cesarean delivery with spinal anesthesia were studied. All patients were hydrated with 1500 ml lactated Ringer's solution. Patients were randomly assigned to receive, in a double-blind fashion, 0.2 mg of either morphine (Group 1, n = 40) or saline (Group 2, n = 42) in 0.2 ml volume mixed with 0.75% bupivacaine in 8.25% dextrose plus 0.2 ml 1:1000 epinephrine. Spinal anesthesia was induced using a 25-gauge spinal needle at L3-4 interspace with the bevel, in most cases, parallel to the dural fibers. Patients were followed for three days to evaluate the incidence and severity of headache using a four-category rank scale (none, mild, moderate, severe). Data were analyzed for statistical significance using Student's t-test or chi-square test as appropriate. A p value less than 0.05 was considered significant. Results. The incidence of post dural puncture headache did not differ significantly between groups. Eight patients in Group 1 versus nine patients in Group 2 developed headache (p greater than 0.05). Similarly, the use of blood patch or intravenous caffeine sodium benzoate to treat the headache did not differ significantly between groups. CONCLUSION It is concluded from our study that subarachnoid morphine did not decrease the incidence of post dural puncture headache in the obstetric patient.
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Affiliation(s)
- T K Abboud
- Department of Anesthesiology, Los Angeles County-University of Southern California Medical Center 90033
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Sherman G. Taking the long-term view. Bus Health 1991; 9:53-4. [PMID: 10114354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
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Sherman G. Running limb varus. J Am Podiatr Med Assoc 1991; 81:567. [PMID: 1774646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Abboud TK, Zhu J, Afrasiabi A, Reyes A, Sherman G, Khan R, Vera Cruz R, Steffens Z. Epidural butorphanol augments lidocaine sensory anesthesia during labor. Reg Anesth 1991; 16:265-7. [PMID: 1958603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
To determine the efficacy and safety of epidural butorphanol combined with lidocaine, 50 healthy parturients were studied during labor and delivery. All patients received a test dose of 3 ml 1.5% lidocaine with 1:200,000 epinephrine. Patients were then randomly assigned to receive 7 ml of one of two epidural regimens in a double-blind fashion: Group 1 patients received 1.5% lidocaine plus 1 mg butorphanol plus 1:300,000 epinephrine; Group 2 patients received 1.5% lidocaine plus 1:300,000 epinephrine. Each group consisted of 25 patients. The study ended at the time of redosing. All subsequent epidural injections were made with one bolus of plain 0.25% bupivacaine followed by continuous infusion of 0.125% bupivacaine. Duration of anesthesia was significantly longer for Group 1 compared to Group 2 (p less than 0.01), 124 +/- 8 minutes versus 99 +/- 6 minutes (mean +/- SEM). There were no difference between groups in duration of first and second stages of labor, method of delivery or neonatal outcome. Umbilical cord acid-base status and neurologic adaptive capacity scores did not differ significantly between the two groups. The authors conclude that adding small doses of butorphanol to epidural lidocaine during labor is effective and safe.
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Affiliation(s)
- T K Abboud
- Department of Anesthesiology, Los Angeles County, University of Southern California Medical Center 90033
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Abstract
This study investigated the association between the disposition of body awareness and medical care utilization among older adult members of a health maintenance organization (HMO). Results indicated that higher levels of body awareness are associated significantly with longitudinal increases in the volume of patient-initiated illness visits to the HMO, and with a greater likelihood of patient-initiated contact with the hospital emergency room, controlling for prior utilization, self-reported health status, and other factors. In contrast, body awareness was not associated significantly with longitudinal changes in physician-initiated follow-up visits, internal referrals, external referrals, or hospital inpatient days. Other findings indicated that higher levels of patient-initiated utilization were associated with greater physician-initiated utilization, controlling for prior utilization. These results illustrate how patient-initiated utilization may influence subsequent physician-initiated utilization.
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Affiliation(s)
- S Hansell
- Institute for Health, Health Care Policy, and Aging Research, Rutgers University
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Abstract
We report what is to our knowledge the first cw, dc-excited, fast-axial-flow CO(2) laser using a variable-reflectivity output coupler. A super-Gaussian reflectivity profile of order 8 with 96% central reflectivity has been achieved by depositing a low-absorption coating onto a ZnSe substrate. The unstable resonator oscillated in the lowest-order mode to produce a diffraction-limited beam of 300 W of power and 0.35-mrad divergence angle (FWHM). The measured near field and far field are in good agreement with the mathematical model. The technique lends itself to extrapolation to the kilowatt level.
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Affiliation(s)
- P Sona
- Euro Laser Technology, Westerring 19, B-9700 Oudenaarde, Belgium
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Abstract
We have characterized capsids made by seven temperature-sensitive (ts) mutants of HSV-1 previously shown to be defective in viral DNA processing and packaging at the nonpermissive temperature (NPT). The empty capsids isolated from mutant-infected cells at the NPT were devoid of DNA, cosedimented in sucrose with wt B capsids, and contained the same structural proteins found in wt B capsids (W. Gibson and B. Roizman (1972). J. Virol. 10, 1044-1052). The presence of VP22a in empty capsids suggests that the processing of this protein from higher-molecular-weight precursors and its association with capsids is required, but not sufficient, for DNA encapsidation. Mutants made no detectable A capsids at the NPT, but did so at the permissive temperature (PT), suggesting that A particles are generated during or subsequent to, rather than prior to, encapsidation. In temperature-shift experiments, it was demonstrated that capsids of one of the mutants, F18, made at the NPT did not participate in DNA encapsidation when cells were subsequently shifted to the PT. Only those capsids made after temperature shift to the PT acquired viral DNA, implying that the ts mutation in F18 may lie in a gene coding for a structural protein, or in a protein involved in the processing of viral DNA.
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Affiliation(s)
- G Sherman
- Department of Microbiology and Immunology, School of Medicine, University of North Carolina, Chapel Hill 27599
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