Disease severity impacts perceived quality of life in congenital diaphragmatic hernia: a prospective observational study

BACKGROUND

While research indicates comparable quality of life (QOL) in congenital diaphragmatic hernia (CDH) and healthy populations, the effect of CDH severity on patients' health perceptions remains unexplored. We aimed to assess QOL perception in CDH, hypothesising a decline correlated with increased disease severity.

METHODS

In this prospective observational study, we analysed patients with CDH aged 5 years and above participating in a longitudinal outpatient programme. We excluded bilateral CDH, genetic/syndromic conditions, prematurity and late diagnosis. Participants self-administered the age-adapted Pediatric Quality of Life Inventory (PedsQL) survey, covering four domains (physical, emotional, social, school). After enrolment, data were collected blind to severity status (larger defects denoting significant/'severe' disease). Repeated measurements were managed using a random mixed-effects model.

RESULTS

Of 34 participants (50% males) who completed the PedsQL, 10 provided measurements at two visits. Eight required a patch (type C), while 26 had primary repairs (type A=8; type B=18). Age at first evaluation was comparable across groups (no patch: median 11 (7-16), patch: 13 (8-15) years, p=0.78). Severe CDH correlated significantly with lower PedsQL scores (adjusted β: -18%, 95% CI -28%; -7%, adjusted for age at visit and sex). Lower scores specifically occurred in walking, exercising, social and academic functioning.

CONCLUSION

Severe CDH significantly lowers QOL. This finding is crucial for resource allocation in long-term CDH health surveillance and advocates for regular inclusion of patient experiences in quality improvement efforts.

Response to Hydrocortisone in an Extremely Preterm Neonate With Late-Onset Sepsis, Meningoencephalitis, and Drug-Resistant Seizures

Corticosteroids are commonly used in children with bacterial meningitis; however, there are very few data regarding possible utility in neonates, particularly those born premature. We describe our experience using hydrocortisone in the treatment of a girl born at 26 weeks, 6 days gestation. She had suffered profound brain injury following late onset group B streptococcus sepsis and meningitis, and developed drug-resistant seizures. Because seizures continued despite treatment with phenobarbital, phenytoin, levetiracetam, lacosamide, and midazolam, intravenous hydrocortisone was added. We observed a marked decrease in focal electrographic seizures within 2 days of initiation of hydrocortisone. This experience suggests that corticosteroids could be a treatment option for drug-resistant seizures and status epilepticus in preterm neonates, particularly those with bacterial meningitis.

qSOFA does not predict bacteremia in patients with severe manifestations of sepsis

BACKGROUND

Bloodstream infections in septic patients may be missed due to preceding antibiotic therapy prior to obtaining blood cultures. We leveraged the FABLED cohort study to determine if the quick Sequential Organ Failure Assessment (qSOFA) score could reliably identify patients at higher risk of bacteremia in patients who may have false negative blood cultures due to previously administered antibiotic therapy.

METHODS

We conducted a multi-centre diagnostic study among adult patients with severe manifestations of sepsis. Patients were enrolled in one of seven participating centres between November 2013 and September 2018. All patients from the FABLED cohort had two sets of blood cultures drawn prior to the administration of antimicrobial therapy, as well as additional blood cultures within 4 hours of treatment initiation. Participants were categorized according to qSOFA score, with a score ≥2 being considered positive.

RESULTS

Among 325 patients with severe manifestations of sepsis, a positive qSOFA score (defined as a score ≥2) on admission was 58% sensitive (95% CI 48% to 67%) and 41% specific (95% CI 34% to 48%) for predicting bacteremia. Among patients with negative post-antimicrobial blood cultures, a positive qSOFA score was 57% sensitive (95% CI 42% to 70%) and 42% specific (95% CI 35% to 49%) to detect patients who were originally bacteremic prior to the initiation of therapy.

CONCLUSIONS

Our results suggest that the qSOFA score cannot be used to identify patients at risk for occult bacteremia due to the administration of antibiotics pre-blood culture.

60 Impact of sequential implementation of a standardized feeding protocol and donor breastmilk on necrotizing enterocolitis among preterm infants born <31 weeks gestation

Primary Subject area

Neonatal-Perinatal Medicine

Background

Necrotizing enterocolitis (NEC) is the leading cause of gastrointestinal morbidity and mortality among preterm infants born <31 weeks. Nutritional interventions such as a standardized feeding protocol (SFP) and donor breastmilk (DBM) are recommended to reduce NEC.

Objectives

Our objective was to assess the impact of implementing a feeding protocol and pasteurized donor breastmilk protocol on NEC among preterm infants born < 31 weeks GA.

Design/Methods

Retrospective cohort study including 682 infants born < 31 weeks, who survived ≥ 14 days and were admitted to two tertiary NICUs from 2009-2018. Data was obtained from the local Canadian Neonatal Network database. Infants were classified into epochs, based on the timing of interventions: Epoch 1, baseline (2009-2012); Epoch 2, SFP (2013-2015); Epoch 3, SFP + DBM (2016-2018). The primary outcome was NEC stage ≥ 2. Multivariable logistic regression models were used to assess associations between epochs and outcomes and were adjusted for confounders.

Results

Among 682 infants, 46 (7%) had NEC and 74 (11%) had mortality/NEC. Rates of NEC decreased with each epoch: 10% (25/246) Epoch 1 (baseline); 5% (8/163) Epoch 2 (SFP); and 5% (13/273) Epoch 3 (SFP+DBM), (p<0.01) (Table1). SFP alone was associated with significantly lower odds of NEC compared to baseline (Epoch 2 vs 1, AOR 0.42, 95% CI 0.17-0.93) (Table 2). Implementation of DBM was not associated with lower odds of NEC compared to SFP alone (Epoch 3 vs 2, AOR 0.94, 95% CI 0.38-2.42) (Table2). Number of NPO days prior to the initiation of enteric feeds after birth decreased in Epoch 3 (Epoch 1&2: 2 days versus Epoch 3: 1 day; p<0.01). Exclusive human breastmilk feeds during the first 3 weeks increased from 62% in Epoch 2 to 82% in Epoch 3 (p<0.01). A significant decrease in number of total parenteral nutrition and central venous line (CVL) days was observed from Epoch 1 to 3 (25 to 15 days and 26 to 15 days respectively; p<0.01) (Table 1), this was reflected in the decrease in late onset sepsis (Epoch 3 vs 1, AOR 0.55, 95% CI 0.35-0.86).

Conclusion

Implementation of SFP was associated with a significant decrease in NEC among infants born < 31 weeks. Combining the SFP and DBM did not further decrease NEC, but was associated with shorter NPO days, higher exclusive human breastmilk exposure, and significant decrease in number of central venous line (CVL) days.

Neither Blood Culture Positivity nor Time to Positivity Is Associated With Mortality Among Patients Presenting With Severe Manifestations of Sepsis: The FABLED Cohort Study

Background

Sepsis is a leading cause of morbidity, mortality, and health care costs worldwide.

Methods

We conducted a multicenter, prospective cohort study evaluating the yield of blood cultures drawn before and after empiric antimicrobial administration among adults presenting to the emergency department with severe manifestations of sepsis. Enrolled patients who had the requisite blood cultures drawn were followed for 90 days. We explored the independent association between blood culture positivity and its time to positivity in relation to 90-day mortality.

Results

Three hundred twenty-five participants were enrolled; 90-day mortality among the 315 subjects followed up was 25.4% (80/315). Mortality was associated with age (mean age [standard deviation] in those who died was 72.5 [15.8] compared with 62.9 [17.7] years among survivors; P < .0001), greater Charlson Comorbidity Index (2 [interquartile range {IQR}, 1–3] vs 1 [IQR, 0–3]; P = .008), dementia (13/80 [16.2%] vs 18/235 [7.7%]; P = .03), cancer (27/80 [33.8%] vs 47/235 [20.0%]; P = .015), positive quick Sequential Organ Failure Assessment score (57/80 [71.2%] vs 129/235 [54.9%]; P = .009), and normal white blood cell count (25/80 [31.2%] vs 42/235 [17.9%]; P = .02). The presence of bacteremia, persistent bacteremia after antimicrobial infusion, and shorter time to blood culture positivity were not associated with mortality. Neither the source of infection nor pathogen affected mortality.

Conclusions

Although severe sepsis is an inflammatory condition triggered by infection, its 90-day survival is not influenced by blood culture positivity nor its time to positivity.

Clinical Trials Registration

NCT01867905.

Adjunctive Daptomycin in the Treatment of Methicillin-susceptible Staphylococcus aureus Bacteremia: A Randomized, Controlled Trial

BACKGROUND

Bloodstream infections (BSIs) with methicillin-susceptible Staphylococcus aureus (MSSA) are associated with significant morbidity and mortality. Our objective in this study was to determine the efficacy of synergistic treatment with daptomycin when given with either cefazolin or cloxacillin for the treatment of MSSA BSI.

METHODS

A randomized, double-blind, placebo-controlled trial was performed at 2 academic hospitals in Montreal, Canada. Patients aged ≥18 years with MSSA BSI receiving either cefazolin or cloxacillin monotherapy were considered for inclusion. In addition to the standard-of-care treatment, participants received a 5-day course of adjunctive daptomycin or placebo. The primary outcome was the duration of MSSA BSI in days.

RESULTS

Of 318 participants screened, 115 were enrolled and 104 were included in the intention-to-treat analysis (median age, 67 years; 34.5% female). The median duration of bacteremia was 2.04 days among patients who received daptomycin vs 1.65 days in those who received placebo (absolute difference, 0.39 days; P = .40). In a modified intention-to-treat analysis that involved participants who remained bacteremic at the time of enrollment, we found a median duration of bacteremia of 3.06 days among patients who received daptomycin vs 3.0 days in those who received placebo (absolute difference, 0.06 days; P = .77). Ninety-day mortality in the daptomycin arm was 18.9% vs 17.7% in the placebo arm (P = 1.0).

CONCLUSIONS

Among patients with MSSA BSIs, the administration of adjunctive daptomycin therapy to standard-of-care treatment did not shorten the duration of bacteremia and should not be routinely considered.

CLINICAL TRIALS REGISTRATION

NCT02972983.

Pregnancy and COVID-19: pharmacologic considerations

In this review, we summarize evidence regarding the use of routine and investigational pharmacologic interventions for pregnant and lactating patients with coronavirus disease 2019 (COVID-19). Antenatal corticosteroids may be used routinely for fetal lung maturation between 24 and 34 weeks' gestation, but decisions in those with critical illness and those < 24 or > 34 weeks' gestation should be made on a case-by-case basis. Magnesium sulfate may be used for seizure prophylaxis and fetal neuroprotection, albeit cautiously in those with hypoxia and renal compromise. There are no contraindications to using low-dose aspirin to prevent placenta-mediated pregnancy complications when indicated. An algorithm for thromboprophylaxis in pregnant patients with COVID-19 is presented, which considers disease severity, timing of delivery in relation to disease onset, inpatient vs outpatient status, underlying comorbidities and contraindications to the use of anticoagulation. Nitrous oxide may be administered for labor analgesia while using appropriate personal protective equipment. Intravenous remifentanil patient-controlled analgesia should be used with caution in patients with respiratory depression. Liberal use of neuraxial labor analgesia may reduce the need for emergency general anesthesia which results in aerosolization. Short courses of non-steroidal anti-inflammatory drugs can be administered for postpartum analgesia, but opioids should be used with caution due to the risk of respiratory depression. For mechanically ventilated pregnant patients, neuromuscular blockade should be used for the shortest duration possible and reversal agents should be available on hand if delivery is imminent. To date, dexamethasone is the only proven and recommended experimental treatment for pregnant patients with COVID-19 who are mechanically ventilated or who require supplemental oxygen. Although hydroxycholoroquine, lopinavir/ritonavir and remdesivir may be used during pregnancy and lactation within the context of clinical trials, data from non-pregnant populations have not shown benefit. The role of monoclonal antibodies (tocilizumab), immunomodulators (tacrolimus), interferon, inhaled nitric oxide and convalescent plasma in pregnancy and lactation needs further evaluation. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

117. Adjunctive Daptomycin in the Treatment of staphylococcus Aureus Bacteremia

Background

Bloodstream infections (BSI) caused by methicillin-susceptible Staphylococcus aureus (MSSA) are associated with significant morbidity and mortality. The objective of our study was to determine whether daptomycin given in combination with an anti-staphylococcal beta-lactam improved outcomes in MSSA BSI.

Methods

A randomized, double blind, placebo-controlled trial was performed at two academic hospitals in Montreal, Canada. Patients ≥ 18 years of age with MSSA BSI receiving either cefazolin or cloxacillin monotherapy were considered for inclusion. In addition to the standard of care treatment, participants received a 5-day course of adjunctive daptomycin or placebo. The primary outcome was the duration of MSSA BSI in days.

Results

Of 318 participants screened, 115 were enrolled and 104 were included in the intention to treat analysis (median age 67 years; 34.5% female). The median duration of bacteremia was 2.04 days among patients who received daptomycin versus 1.65 days in those who received placebo (absolute difference 0.39 days, p=0.40). A modified intention to treat analysis involving participants who remained bacteremic at the time of enrollment found a median duration of bacteremia of 3.06 days among patients who received daptomycin versus 3.0 days in those who received placebo (absolute difference 0.06 days, p=0.77). Ninety-day mortality in the daptomycin arm was 18.9% vs. 17.7% in the placebo arm (p=1.0). There were no significant differences in the proportion of patients who developed renal failure, hepatotoxicity, or rhabdomyolysis between groups.

Conclusion

Among patients with MSSA BSI, the administration of adjunctive daptomycin therapy to standard of care treatment did not shorten the duration of bacteremia.

Disclosures

All Authors: No reported disclosures

Clinical Trials Increase Off-Study Drug Use: A Segmented Time-Series Analysis

Background

The effect of participation in a clinical trial on concomitant off-study investigational drug use has not been described. We sought to determine if participation in the Daptomycin as Adjunctive Therapy for Staphylococcus aureus bacteremia (DASH) trial increased overall daptomycin prescribing at study sites.

Methods

We retrospectively analyzed daptomycin use for 8 years preceding the trial, off-study daptomycin use during the trial itself (31 months), and daptomycin use for 6 fiscal months after trial completion. We used a segmented linear regression analysis of an interrupted time series to analyze changes in each drug’s defined daily doses (DDD) per 1000 patient-days. As a control, we analyzed use of linezolid over these periods and also accounted for rates of methicillin-resistant S. aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) infections.

Results

For 1.5 years before the DASH trial, daptomycin use was decreasing by –0.30 DDD per 1000 patient-days per fiscal period (95% CI, –0.52 to –0.07). Following the initiation of the study, there was a statistically significant increase in daptomycin use of 0.28 DDD per 1000 patient-days per fiscal period (95% CI, 0.03 to 0.52), despite low, stable rates of MRSA and VRE infections. Following trial completion, daptomycin use decreased back toward prestudy rates. Use of linezolid remained stable throughout.

Conclusions

Despite the DASH trial being a negative study, it impacted the prescribing habits of local clinicians during recruitment. Trialists should be aware of potential off-target study effects, and prescribers should be wary of early uptake of interventions before definitive study results.

Serodiagnostics for Severe Acute Respiratory Syndrome-Related Coronavirus 2 : A Narrative Review

Accurate serologic tests to detect host antibodies to severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2) will be critical for the public health response to the coronavirus disease 2019 pandemic. Many use cases are envisaged, including complementing molecular methods for diagnosis of active disease and estimating immunity for individuals. At the population level, carefully designed seroepidemiologic studies will aid in the characterization of transmission dynamics and refinement of disease burden estimates and will provide insight into the kinetics of humoral immunity. Yet, despite an explosion in the number and availability of serologic assays to test for antibodies against SARS-CoV-2, most have undergone minimal external validation to date. This hinders assay selection and implementation, as well as interpretation of study results. In addition, critical knowledge gaps remain regarding serologic correlates of protection from infection or disease, and the degree to which these assays cross-react with antibodies against related coronaviruses. This article discusses key use cases for SARS-CoV-2 antibody detection tests and their application to serologic studies, reviews currently available assays, highlights key areas of ongoing research, and proposes potential strategies for test implementation.

Real-world Time to Positivity of 2 Widely Used Commercial Blood Culture Systems in Patients With Severe Manifestations of Sepsis: An Analysis of the FABLED Study

Background

Of all microbiological tests performed, blood cultures have the most impact on patient care. Timely results are essential, especially in the management of sepsis. While there are multiple available blood culture systems on the market, they have never been compared in a prospective study in a critically ill population.

Methods

We performed an analysis of the FABLED study cohort to compare culture results and time to positivity (TTP) of 2 widely used blood culture systems: BacT/Alert and BACTEC. In this multisite prospective study, patients with severe manifestations of sepsis had cultures drawn before antibiotics using systematic enrollment criteria and blood drawing methodology allowing for minimization of pre-analytical biases.

Results

We enrolled 315 patients; 144 had blood cultures (47 positive) with BacT/Alert and 171 with BACTEC (53 positive). Patients whose blood cultures were processed using the BacT/Alert system were younger (median, 64 vs 70 years; P = .003), had a higher proportion of HIV (9.03% vs 1.75%; P = .008) and a lower qSOFA (P = .003). There were no statistically significant differences in the most commonly identified bacterial species. TTP was shorter for BACTEC (median [interquartile range {IQR}], 12.5 [10-14] hours) compared with BacT/Alert (median [IQR], 17 [14-21] hours; P < .0001).

Conclusions

In this large prospective multi-centre study comparing the two blood culture systems among patients with severe manifestations of sepsis, and using a rigorous pre-analytical methodology, the BACTEC system yielded positive culture results 4.5 hours earlier than BacT/Alert. These results apply to commonly isolated bacteria. However, our study design did not allow direct comparison of TTP for unusual pathogens nor of clinical sensitivity between systems. More research is needed to determine the clinical implications of this finding.

Increased Incidence but Lack of Association Between Cardiovascular Risk Factors in Adults Born Preterm

Preterm birth incurs an increased risk of early cardiovascular events and death. In the general population, cardiovascular risk factors cluster in the context of inflammation and oxidative stress. Whether this also occurs in young adults born preterm is unknown. We analyzed 101 healthy young adults (ages 18–29) born preterm (≤29 weeks of gestation) and 105 full-term controls, predominantly (90%) white. They underwent a comprehensive clinical and biological evaluation, including measurement of blood pressure, lung function (spirometry), glucose metabolism (fasting glucose, glycated hemoglobin, and oral glucose tolerance test), as well as biomarkers of inflammation and oxidative stress. Individuals born preterm were at higher risk than those born full-term of stage ≥1 hypertension (adjusted odds ratio, 2.91 [95% CI, 1.51–5.75]), glucose intolerance (adjusted odds ratio, 2.22 [95% CI, 1.13–4.48]), and airflow limitation (adjusted odds ratio, 3.47 [95% CI, 1.76–7.12]). Hypertension was strongly associated with adiposity and with glucose intolerance in participants born full-term but not in those born preterm. We did not find any group difference in levels of biomarkers of inflammation and oxidative stress. In individuals born preterm, inflammation, and oxidative stress were not related to hypertension or glucose intolerance but were associated with adiposity. In those born preterm, cardiovascular risk factors were not related to each other suggesting different pathophysiological pathways leading to the development of cardiovascular risk following preterm birth. Clinicians should consider screening for these abnormalities irrespectively of other risk factors in this at-risk population.

Clinical Trial Registration

URL: http://www.clinicaltrials.gov . Unique identifier: NCT03261609.

847. The Effect of Antimicrobial Administration on Blood Culture Positivity in Patients with Severe Manifestations of Sepsis

Background

Current guidelines recommend obtaining blood cultures prior to antimicrobial therapy in patients with sepsis. Administering antimicrobials immediately without waiting for blood cultures could potentially decrease time to treatment and improve outcomes, but it is unclear the degree to which this strategy impacts diagnostic yield.

Methods

We performed a patient-level, single-arm, diagnostic trial. Seven urban emergency departments affiliated with academic medical centers across Canada and the United States participated in the study. Adults ≥18 years of age presenting to the emergency department with evidence of severe manifestations of sepsis, including a systolic blood pressure <90 mmHg and/or a serum lactate ≥4 mmol/L were included. Study participants had 2 sets of blood cultures drawn prior to and immediately following antimicrobial administration. The primary outcome was the difference in blood culture pathogen recovery rates before and after administration of antimicrobial therapy.

Results

Of the 3,164 participants screened, 325 were included in the study (mean age, 65.6 years; 63.0% men) and had repeat blood cultures drawn after the initiation of antimicrobial therapy (median time of 70 minutes, IQR 50 to 110 minutes). Pre-antimicrobial blood cultures were positive for one or more microbial pathogens in 102/325 (31.4%) patients. Fifty-four participants (52.9%) had matching blood culture results after initiation of antimicrobial treatment. The absolute difference in pathogen recovery rates was 14.5% ([95% CI 8.0 to 21.0%]; P < 0.0001) between pre- and post-antimicrobial blood cultures. Results were consistent in an analysis of the per-protocol population (absolute difference, 13.3% [95% CI 6.1 to 20.4%]; P < 0.0001). Including the results of other microbiological cultures done as part of routine care, microbial pathogens were recovered in 69 of 102 (67.7%) participants (absolute difference, 10.2% [95% CI 3.4 to 16.8%]; P < 0.0001).

Conclusion

Among patients with severe manifestations of sepsis, the administration of empiric antimicrobial therapy significantly reduces the yield of pathogen recovery when blood cultures are drawn shortly after treatment initiation.

Disclosures

All Authors: No reported Disclosures.

Blood Culture Results Before and After Antimicrobial Administration in Patients With Severe Manifestations of Sepsis: A Diagnostic Study

BACKGROUND

Administering antimicrobial agents before obtaining blood cultures could potentially decrease time to treatment and improve outcomes, but it is unclear how this strategy affects diagnostic sensitivity.

OBJECTIVE

To determine the sensitivity of blood cultures obtained shortly after initiation of antimicrobial therapy in patients with severe manifestations of sepsis.

DESIGN

Patient-level, single-group, diagnostic study. (ClinicalTrials.gov: NCT01867905).

SETTING

7 emergency departments in North America.

PARTICIPANTS

Adults with severe manifestations of sepsis, including systolic blood pressure less than 90 mm Hg or a serum lactate level of 4 mmol/L or more.

INTERVENTION

Blood cultures were obtained before and within 120 minutes after initiation of antimicrobial treatment.

MEASUREMENTS

Sensitivity of blood cultures obtained after initiation of antimicrobial therapy.

RESULTS

Of 3164 participants screened, 325 were included in the study (mean age, 65.6 years; 62.8% men) and had repeated blood cultures drawn after initiation of antimicrobial therapy (median time, 70 minutes [interquartile range, 50 to 110 minutes]). Preantimicrobial blood cultures were positive for 1 or more microbial pathogens in 102 of 325 (31.4%) patients. Postantimicrobial blood cultures were positive for 1 or more microbial pathogens in 63 of 325 (19.4%) patients. The absolute difference in the proportion of positive blood cultures between pre- and postantimicrobial testing was 12.0% (95% CI, 5.4% to 18.6%; P < 0.001). Sensitivity of postantimicrobial culture was 52.9% (CI, 42.8% to 62.9%). When the results of other microbiological cultures were included, microbial pathogens were found in 69 of 102 (67.6% [CI, 57.7% to 76.6%]) patients.

LIMITATION

Only a proportion of screened patients were recruited.

CONCLUSION

Among patients with severe manifestations of sepsis, initiation of empirical antimicrobial therapy significantly reduces the sensitivity of blood cultures drawn shortly after treatment initiation.

PRIMARY FUNDING SOURCE

Vancouver Coastal Health, St. Paul's Hospital Foundation Emergency Department Support Fund, the Fonds de recherche Santé-Québec, and the Maricopa Medical Foundation.

Kidney Size, Renal Function, Ang (Angiotensin) Peptides, and Blood Pressure in Young Adults Born Preterm

Preterm birth incurs a higher risk for adult cardiovascular diseases, including hypertension. Because preterm birth may impact nephrogenesis, study objectives were to assess renal size and function of adults born preterm versus full term and to examine their relationship with blood pressure (BP; 24-hour ambulatory BP monitoring) and circulating renin-Ang (angiotensin) system peptides. The study included 92 young adults born (1987-1997) preterm (≤29 weeks of gestation) and term (n=92) matched for age, sex, and race. Young adults born preterm had smaller kidneys (80±17 versus 90±18 cm³/m²; P<0.001), higher urine albumin-to-creatinine ratio (0.70; interquartile range, 0.47-1.14 versus 0.58, interquartile range 0.42 to 0.78 mg/mmol, P=0.007), higher 24-hour systolic (121±9 versus 116±8 mm Hg; P=0.001) and diastolic (69±5 versus 66±6 mm Hg; P=0.004) BP, but similar estimated glomerular filtration rate. BP was inversely correlated with kidney size in preterm participants. Plasma Ang I was higher in preterm versus term participants (36.3; interquartile range, 13.2-62.3 versus 19.4; interquartile range, 9.9-28.1 pg/mL; P<0.001). There was no group difference in renin, Ang II, Ang (1-7), and alamandine. In the preterm, but not in the term group, higher BP was significantly associated with higher renin and alamandine and lower birth weight and gestational age with smaller adult kidney size. Young adults born preterm have smaller kidneys, higher urine albumin-to-creatinine ratio, higher BP, and higher circulating Ang I levels compared with term controls. Preterm young adults with smaller kidneys have higher BP. Clinical Trial Registration- URL: http://www.clinicaltrials.gov . Unique identifier: NCT03261609.

Cancer risk in children and young adults born preterm: A systematic review and meta-analysis

Introduction

Risk of developing a malignancy when born premature is unknown. We hypothesised that risk of certain cancers might be increased in youth born preterm versus term. We therefore performed a systematic review and meta-analysis to evaluate the incidence of malignancy in the context of preterm birth, according to various cancer types.

Methods

The study was designed per MOOSE and PRISMA guidelines. Articles were identified through November 2015. Observational studies exploring the association between childhood malignancy and birth characteristics were included. Of the 1658 records identified, 109 full text articles were evaluated for eligibility. Random effects meta-analyses were conducted on 10/26 studies retained; 95% confidence intervals were computed and adjusted following sensitivity analysis. Publication bias was evaluated using funnel plots, Begg’s and Egger’s tests.

Results

No differences in risk of primary central nervous system tumor [OR 1.05; 95% CI 0.93–1.17, 5 studies, 580 cases] and neuroblastoma [OR 1.09; 95% CI 0.90–1.32, 5 studies, 211 cases] were observed in individuals born <37 versus ≥37 weeks’ gestation. Preterm birth was consistently associated with hepatoblastoma [ORs 3.12 (95% CI 2.32–4.20), 1.52 (95% CI 1.1–2.1), 1.82 (95% CI 1.01–3.26), and 2.65 (95% CI 1.98–3.55)], but not leukemia, astrocytoma, ependymoma, medulloblastoma, lymphoma, nephroblastoma, rhabdomyosarcoma, retinoblastoma or thyroid cancer.

Conclusions

Children born premature may be at increased risk for hepatoblastoma but there is no strong evidence of an increased risk of primary central nervous system tumours or neuroblastoma. There is insufficient evidence to conclude whether prematurity modulates the risk of other childhood cancers.

Endothelial Colony-Forming Cells in Young Adults Born Preterm: A Novel Link Between Neonatal Complications and Adult Risks for Cardiovascular Disease

BACKGROUND

Preterm birth is linked to cardiovascular risks and diseases. Endothelial progenitor cells play a critical role in vascular development and repair. Cord blood endothelial progenitor cells of preterm-born infants, especially endothelial colony-forming cells (ECFC), show enhanced susceptibility to prematurity-related pro-oxidant stress. Whether ECFC dysfunction is present in adulthood following preterm birth is unknown.

METHODS AND RESULTS

This cross-sectional observational study includes 55 preterm-born (≤29 gestational weeks) young adults (18-29 years old, 38% male) and 55 sex- and age-matched full-term controls. ECFC were isolated from peripheral blood; cell proliferative and vascular cord formation capacities were assessed in vitro. Daytime systolic blood pressure was higher, whereas glucose tolerance and body mass index were lower in preterm-born subjects. ECFC colonies grew in culture for 62% of full-term- and 58% of preterm-born participants. Preterm-born participants have formed ECFC colonies later in culture and have reduced proliferation compared with controls. Only in preterm-born individuals, we observed that the later the ECFC colony grows in culture, the worse was overall ECFC function. In addition, in preterms, elevated systolic blood pressure significantly correlated with reduced ECFC proliferation (r_S=-0.463; P=0.030) and numbers of branches formed on matrigel (r_S=-0.443; P=0.039). In preterm-born subjects, bronchopulmonary dysplasia was associated with impaired ECFC function, whereas exposure to antenatal steroids related to better ECFC function.

CONCLUSIONS

This study is the first to examine ECFC in preterm-born adults and to demonstrate ECFC dysfunction compared with full-term controls. In the preterm-born group, ECFC dysfunction was associated with bronchopulmonary dysplasia, the major prematurity-related neonatal morbidity, and with increased systolic blood pressure into adulthood.

Daptomycin versus placebo as an adjunct to beta-lactam therapy in the treatment of Staphylococcus aureus bacteremia: study protocol for a randomized controlled trial

BACKGROUND

Staphylococcus aureus bacteremia is associated with significant morbidity and mortality. To treat this infection, the current standard of care includes intravenous anti-staphylococcal beta-lactam antibiotics and obtaining adequate source control. Combination therapy with an aminoglycoside or rifampin, despite early promise, can no longer be routinely recommended due to an absence of proven benefit and risk of harm. Daptomycin is a rapidly acting bactericidal antibiotic that is approved for the treatment of Staphylococcus aureus bacteremia as monotherapy but has not been shown to be superior to the current standard of care. As demonstrated in vitro, the addition of daptomycin to beta-lactam therapy may result in enhanced anti-staphylococcal activity. Our objective is to assess the efficacy and safety of prescribing the combination of daptomycin with cefazolin or cloxacillin for the treatment of methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia in adults. We hypothesize that adjunctive therapy with daptomycin will reduce the duration of bacteremia in this population.

METHODS

The DASH-RCT trial is a randomized, double blind, placebo-controlled trial designed per the Standard Protocol Items: Recommendation for Interventional Trials (SPIRIT) and Consolidated Standards of Reporting Trials (CONSORT) guidelines. We recruit adults with confirmed MSSA bacteremia, at the McGill University Health Center. Patients are eligible if they are 18 years or older, can receive cefazolin or cloxacillin monotherapy, and are enrolled within 72 h of the first blood culture being drawn. Exclusion criteria include anaphylaxis to study drugs, having polymicrobial bacteremia, anticipated hospital admission for < 5 days, and healthcare team refusal. While receiving standard of care, study patients are randomized to a 5-day course of adjunctive daptomycin or placebo. The trial began in December 2016 and is expected to end in December 2018, after recruiting an estimated 102 patients.

DISCUSSION

The DASH-RCT will compare the use of daptomycin as an adjunct to an anti-staphylococcal beta-lactam versus placebo in the treatment of MSSA bacteremia. We believe that a short course of dual therapy will result in earlier eradication of bacteremia and that subsequent research could evaluate effects on metastatic infection, relapse, and/or mortality. Ongoing issues in the trial include a delay between presentation of infection, enrollment in the trial, and the potential for unrecognized deep foci of infection at diagnosis.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02972983 . Registered on 25 November 2016. Trial protocol: http://individual.utoronto.ca/leet/dash/dashprotocol.pdf.

Abstract P138: Alterations in Cardiac Structure and Function in Young Adults Born Extremely Preterm: Impact of Neonatal Bronchopulmonary Dysplasia

Objective: Studies support a causal association between preterm birth and increased risk of cardiovascular diseases. Increased left and right ventricular mass and impaired systolic and diastolic function has been reported in young adults born preterm. However, the impact of extreme preterm birth and prematurity-specific complications on adult cardiac structure and function has not been evaluated. We assessed cardiac structure and function in young adults born extremely preterm (EPT) versus term, and correlated long term cardiac remodeling with neonatal bronchopulmonary dysplasia (BPD).

Methods: Eighty five EPT (gest. age = 27.1±1.4 weeks) were recruited along with term-born controls matched for age, sex and socioeconomic status. Birth and neonatal data (gestational age, birth weight, BPD indicated by O 2 requirements at 36 weeks postmenstrual age) was collected. Ambulatory blood pressure (Spacelabs) and echocardiographic measurements (Phillips) were taken. Comparisons were performed using ANOVA or T-test.

Results: EPT presented with increased systolic (119±9 vs 116±8 mmHg, P<0.05) and diastolic (68±5 vs 66±6 mmHg, P<0.05) blood pressures. EPT exhibited reduced septal thickness (IVS, 6.8±0.8 vs 7.1±1.1 mm, P<0.05), left ventricular internal dimension (LVID, 46±4 vs 48±5 mm, P<0.05), LV end-diastolic (98±20 vs 106±24 ml, P<0.05) and end-systolic (36±9 vs 40±11 ml, P<0.01) volumes, right ventricular internal dimension (RVID, 22±3 vs 24±4 mm, P<0.05), and LV mass (104±27 vs 115±30 g, P<0.05), but similar LV mass and volume indexes. EPT exhibited increased LV myocardial performance index (0.41±0.04 vs 0.39±0.04, P<0.01), reduced mitral lateral e’ (17.6±2.8 vs 19.1±2.6 cm/s, P<0.01), mitral s’ (10.7±2.3 vs 11.6±2.3 cm/s, P<0.01), tricuspid E’ (15.8±2.7 vs 16.8±2.1 cm/s, P<0.05), and tricuspid S’ (13.1±2.0 vs 14.0±2.0 cm/s, P<0.01) waves, and a trend in reduced mitral E wave (81±14 vs 85±15 cm/s, P=0.09). EPT with neonatal BPD exhibited greater reduction in IVS (6.5±0.8 mm, P<0.05 vs terms), LVID (45±4 mm, P<0.05), LV Mass (98±22 g, P<0.05), and RVID (20±3 mm, P<0.01).

Conclusions: EPT exhibit cardiac structural and functional alterations compared to term-born individuals. Neonatal BPD in EPT is a key contributor to long term cardiac remodeling.

Adult Consequences of Extremely Preterm Birth: Cardiovascular and Metabolic Diseases Risk Factors, Mechanisms, and Prevention Avenues

Extremely preterm babies are exposed to various sources of injury during critical stages of development. The extremely preterm infant faces premature transition to ex utero physiology and undergoes adaptive mechanisms that may be deleterious in the long term because of permanent alterations in organ structure and function. Perinatal events can also directly cause structural injury. These disturbances induce morphologic and functional changes in their organ systems that might heighten their risks for later adult chronic diseases. This review examines the pathophysiology of programming of long-term health and diseases after preterm birth and associated perinatal risk factors.

Abstract 134: Association Between Kidney Size, Function and Blood Pressure in Young Adults Born Extremely Preterm

Background: Children born extremely preterm (EPT; ≤29 weeks) have higher blood pressure (BP), lower nephron mass, and increased risk in later life of renal and cardiovascular dysfunction. Whether nephron mass and renal function impact BP in EPT subjects is unknown. We correlated BP with renal size and function in young adults born EPT vs term (T).

Methods: Anthropometric measurements, serum and urine chemistry, renal ultrasound, and 24 hour ambulatory BP were obtained in 40 EPT and 40 T born young adults matched for age, sex, race, and socioeconomic status. Comparisons were made using paired T and Wilcoxon signed ranked tests and correlations using Pearson correlation.

Results: Study population characteristics are in Table 1. Young adults born EPT had higher systolic BP (SBP) and diastolic BP (DBP), and smaller kidneys (Table 2). Awake SBP and DBP loads in the hypertensive range inversely correlated with kidney size only in EPT participants.

Conclusion: Young adults born EPT have higher BP and smaller kidneys vs T controls. EPT young adults with smaller kidneys have a greater BP load in the hypertensive range.

Abstract 045: Endothelial Colony Forming Cells Dysfunction Relates to Cardiovascular Alterations in Preterm Born Adults

Endothelial colony-forming cell (ECFC), a subtype of endothelial progenitor cells with high clonogenic and proliferative capacity, is present in cord and peripheral blood, participating in neovessel formation and regeneration. Cord blood ECFCs have impaired bioactivity in pregnancy complications and preterm (PT) birth. Dysfunction of cord blood ECFC is also related to complications of prematurity such as bronchopulmonary dysplasia. Although cardiovascular alterations, such as high blood pressure (BP) and left ventricular (LV) dysfunction, occur in PT subjects during adulthood, whether ECFC dysfunction beyond the neonatal period relates to such alterations is not known. OBJECTIVE: We aim in this study to assess if ECFC function relates to cardiovascular alterations in PT born adults. METHODS: Peripheral blood mononuclear cells from 30 young adults (21-28 years old) born very PT (<29 weeks gestation) and 30 at term (T, ≥37 weeks gestation) were separated by density gradient and cultured to ECFC colony formation. ECFC proliferative and angiogenic function were assessed in vitro by modified thymidine analogue (EdU) incorporation and tube formation in Matrigel. BP was measured by 24h monitor and LV mass index (g/cm 2 ) by ultrasound imaging. All analyses were performed blind; correlations were significant when p<0.05. RESULTS: The proportion of early (<15 days) and late (≥15 days) time for ECFC colony formation was different between PT and T, with a higher frequency for late growth or no colony in the PT born group. Time to colony formation inversely correlated with ECFC proliferation rate (r=-0.57, r 2 =0.32) and tube formation (r=-0.57, r 2 =0.33) in PT, which shows ECFC dysfunction in those PT subjects with late colony formation, with no significant correlations in T. Additionally, time to colony formation has positively related to systolic BP (r=0.54, r 2 =0.29) and LV mass index (r=0.49, r 2 =0.24) in PT born subjects. CONCLUSION: Our findings demonstrate, for the first time, an association between dysfunctional circulating ECFCs and cardiovascular alterations in adults born PT. We also show that ECFC dysfunction, in PT adults, significantly relates to important cardiovascular risk factors such as high BP and increased LV mass.

Post-vaccination myositis and myocarditis in a previously healthy male

Background

The immunological literature has been redefining clinical phenomena as hypotheses emerge regarding causal links between triggers, immunologic manifestations, and their specific inflammatory cascades. Of late, autoimmune manifestations that appear to be caused by an external adjuvant have been grouped into a complex syndrome referred to as autoimmune/inflammatory syndrome induced by adjuvants (ASIA). This syndrome may present with diverse clinical problems, which may include neurocognitive impairment, inflammatory musculoskeletal changes, and constitutional symptoms. There is evidence in the literature linking vaccines to different auto-immune manifestations. Vaccines have not traditionally been reported to trigger ASIA, although reports are emerging linking the human papilloma virus and hepatitis B vaccines to it.

Case presentation

We report the first suspected case of ASIA in a previously healthy patient who received the Fluad seasonal influenza vaccine, which contains the MF59 adjuvant. He presented to hospital with profound weakness and was diagnosed with severe rhabdomyolysis. He also had elevated troponin-I and extensive cardiac investigations enabled the diagnosis of myocarditis. His infectious and rheumatologic work-ups were negative. He responded well to conservative management and did not require immune suppressive therapy.

Conclusion

Given the benefits of the influenza vaccine, and the low incidence of clinically significant complications, we encourage ongoing seasonal influenza immunization. However, ongoing surveillance is required to evaluate the occurrence of rare adverse events, including ASIA.

Chest radiography for active tuberculosis case finding in the homeless: a systematic review and meta-analysis

SETTING

In low-incidence regions, tuberculosis (TB) often affects vulnerable populations. Guidelines recommend active case finding (ACF) in homeless populations, but there is no consensus on a preferred screening method.

OBJECTIVE

We performed a systematic review and meta-analysis to evaluate the use of chest X-ray (CXR) screening in ACF for TB in homeless populations.

DESIGN

Articles were identified through EMBASE, Medline and the Cochrane Library. Studies using symptom screens, CXRs, sputum sweeps, tuberculin skin tests and/or interferon-gamma release assays to detect active TB in homeless populations were sought. Data were extracted using a standardised method by two reviewers and validated with an objective tool.

RESULTS

Sixteen studies addressing CXR screening of homeless populations for active TB in low-incidence regions were analysed. The pooled prevalence of active TB in the 16 study cohorts was 931 per 100 000 population screened (95%CI 565-1534) and 782/100 000 CXR performed (95%CI 566-1079). Six of seven longitudinal screening programs reported a reduction in regional TB incidence after implementation of the CXR-based ACF programme.

CONCLUSION

Our data suggest that CXR screening is a good tool for ACF in homeless populations in low-incidence regions.

Voriconazole inhibition of vitamin A metabolism: are adverse events increased in cystic fibrosis patients?

BACKGROUND

As Voriconazole is being used more frequently in cystic fibrosis (CF) patients, we aimed to describe the adverse events associated with voriconazole treatment in this population.

METHODS

We performed a retrospective cohort study of all children with CF who received voriconazole between September 2006 and August 2008.

RESULTS

Five of six CF patients receiving treatment developed photosensitivity, whereas all six patients reported visual disturbances. We report two clinical cases of particular interest: a 7-year-old boy developed striking erythema in the face and upper thorax; a 16-year-old girl who reported unexpected visual disturbances, including scotomas and tunneling vision.

CONCLUSION

Significant adverse effects of voriconazole were noted in all treated CF patients. We speculate that this may be due to suppression of activity of hepatic enzymes involved in all transretinonic acid metabolism coupled with vitamin A supplementation in CF. Consideration should be given to reducing vitamin A supplementation during voriconazole treatment.

Effectiveness of polypropylene film as a barrier to migration from recycled paperboard packaging to fatty and high-moisture food

The capability of a polypropylene (PP) film barrier to prevent migration of residual contaminants from recycled paperboard into food simulants was studied. Anthracene, benzophenone, methyl stearate and pentachlorophenol were chosen as chemical surrogates to represent classes of contaminants likely to be found in recycled paper/paperboard. Each surrogate was spiked into a test specimen made of seven thin virgin paper layers at concentrations of 1-50 mg kg(-1). Test specimen were dried, stacked and sandwiched with PP films, laminated with PP film and then subjected to migration experiments using a compression cell maintained at 100 degrees C for 2 h. The concentration of the surrogates in the test specimen and in 95% ethanol, isopropanol and 10% ethanol food-simulating solvents was determined by gas chromatography with flame ionization and electron capture detection. The results show that although the concentrations of the surrogates in the food simulants decreased with an increase in PP film thickness, they were still high and generally resulted in dietary concentrations >0.5 microg kg(-1), the level that US Food and Drug Administration would equate with negligible risk for a contaminant migrating from food packaging. Only at the lowest spiking level (1 mg kg(-1) benzophenone) did migration from the paperboard through a 0.127-mm PP film result in a dietary concentration of </=0.5 microg kg(-1). Therefore, it can be concluded that for an extended time at 100 degrees C, PP would not be an acceptable barrier to migration of contaminants that are expected to be in post-consumer paper/paperboard.