Guidance for Structuring a Pediatric Intermediate Care Unit

The purpose of this policy statement is to update the 2004 American Academy of Pediatrics clinical report and provide enhanced guidance for institutions, administrators, and providers in the development and operation of a pediatric intermediate care unit (IMCU). Since 2004, there have been significant advances in pediatric medical, surgical, and critical care that have resulted in an evolution in the acuity and complexity of children potentially requiring IMCU admission. A group of 9 clinical experts in pediatric critical care, hospital medicine, intermediate care, and surgery developed a consensus on priority topics requiring updates, reviewed the relevant evidence, and, through a series of virtual meetings, developed the document. The intended audience of this policy statement is broad and includes pediatric critical care professionals, pediatric hospitalists, pediatric surgeons, other pediatric medical and surgical subspecialists, general pediatricians, nurses, social workers, care coordinators, hospital administrators, health care funders, and policymakers, primarily in resource-rich settings. Key priority topics were delineation of core principles for an IMCU, clarification of target populations, staffing recommendations, and payment.

The effect of referral for genetic counseling on genetic testing and surgical prevention in women at high risk for ovarian cancer: Results from a randomized controlled trial

BACKGROUND

Guidelines recommend genetic counseling and testing for women who have a pedigree suggestive of an inherited susceptibility for ovarian cancer. The authors evaluated the effect of referral to genetic counseling on genetic testing and prophylactic oophorectomy in a randomized controlled trial.

METHODS

Data from an electronic mammography reporting system identified 12,919 women with a pedigree that included breast cancer, of whom 625 were identified who had a high risk for inherited susceptibility to ovarian cancer using a risk-assessment questionnaire. Of these, 458 women provided informed consent and were randomized 1:1 to intervention consisting of a genetic counseling referral (n = 228) or standard clinical care (n = 230).

RESULTS

Participants were predominantly aged 45 to 65 years, and 30% and 20% reported a personal history of breast cancer or a family history of ovarian cancer, respectively. Eighty-five percent of women in the intervention group participated in a genetic counseling session. Genetic testing was reported by 74 (33%) and 20 (9%) women in the intervention and control arms (P < .005), respectively. Five women in the intervention arm and 2 in the control arm were identified as germline mutation carriers. Ten women in the intervention arm and 3 in the control arm underwent prophylactic bilateral salpingo-oophorectomy (P < .05).

CONCLUSIONS

Routine referral of women at high risk for ovarian cancer to genetic counseling promotes genetic testing and prophylactic surgery. The findings from the current randomized controlled trial demonstrate the value of implementing strategies that target women at high risk for ovarian cancer to ensure they are offered access to recommended care. CA Cancer J Clin 2016. © 2016 American Cancer Society, Inc. Cancer 2016;122:3509-3518. © 2016 American Cancer Society.

Cancer Risk Awareness and Concern among Women with a Family History of Breast or Ovarian Cancer

Women with a documented deleterious mutation in BRCA1 or BRCA2 are at substantially elevated risk for ovarian cancer. To understand what percentage of women with high-risk family histories know their risk is elevated we surveyed 1,885 women with a high- or moderate-risk family history and no personal history of breast or ovarian cancer, and asked about their perceived risk of breast and ovarian cancer. Among high-risk women, fewer than 20% reported use of genetic counseling, and knowledge of elevated risk of ovarian cancer was low. Prior genetic counseling was associated with greater perceived risk for ovarian cancer. Results suggest that most high-risk women (>75%) do not know their risk for ovarian cancer. Identification of potentially high-risk women for referral to genetic counseling may improve informed ovarian cancer risk management.

Abstract POSTER-CTRL-1214: Systematic identification of high risk women for genetic counseling and surgical prevention of ovarian cancer

Objectives: Information technology provides an opportunity for systematic identification of high-risk patients for appropriate referral. We conducted a randomized controlled trial to test whether routine identification of women at high risk for epithelial ovarian cancer using an electronic database and subsequent referral to genetic counseling would promote genetic testing and prophylactic surgery.

Methods: Electronic data in a mammography reporting system from a large community hospital in Seattle was used to identify women at increased risk for ovarian cancer based on personal and family cancer history. Following secondary confirmation of eligibility and consent, women were randomly assigned to an intervention consisting of a genetic counseling referral, or to standard clinical care.

Results: A total of 458 women were enrolled. Compared to standard clinical care systemic identification and referral of high risk women to genetic counseling increased the number of women who elect to undergo genetic testing (75 vs 20, p&lt;0.005) and prophylactic surgery (OR: 3.5, p=0.05).

Conclusions: Our results demonstrated that systematic identification of high-risk women for referral to genetic counseling is feasible and increases utilization of risk-appropriate prevention strategies.

Citation Format: Robert Resta, MS CGC; Charles W. Drescher, MD; David Beatty, MD; M Robyn Andersen, PhD; Kate Watabayashi, BA; Jason Thorpe, MSc; Hannah Purkey, BS; Jessica Chubak, PhD; Nancy Hanson, MS CGC; Diana S.M. Buist, MPH PhD; Nicole Urban, ScD. Systematic identification of high risk women for genetic counseling and surgical prevention of ovarian cancer [abstract]. In: Proceedings of the 10th Biennial Ovarian Cancer Research Symposium; Sep 8-9, 2014; Seattle, WA. Philadelphia (PA): AACR; Clin Cancer Res 2015;21(16 Suppl):Abstract nr POSTER-CTRL-1214.

Assessing Community-Based Injury Prevention Services in U.S. Children's Hospitals

Objective

Not-for-profit hospitals are required to meet federal reporting requirements detailing their community benefit activities, which support their tax-exempt status. Children's hospitals have long provided community injury prevention (IP) programming and thus can inform public health outreach work in other areas. This work describes IP programming as a community service offered by children's hospitals in the U.S.

Methods

The IP specialist at 232 US-based member institutions of the Children's Hospital Association were invited to complete an assessment of their hospital's IP outreach programming.

Results

47.7 percent of hospitals request financial data from IP programming for tax reporting purposes. Almost all offer injury prevention (IP) services; the majority are in the community (60.3%) and 34.5% are hospital-based. Most IP units are independent (60.3%) and 71.8% are responsible for their own budgets.

Conclusions

By integrating dissemination and implementation sciences and community health needs assessments, these findings can help advance community services provided by hospitals to impact public health.

Cancer-testis antigen expression and immunogenicity in AL amyloidosis

Light-chain amyloidosis (AL) is a plasma cell dyscrasia closely related to multiple myeloma. In multiple myeloma, the cancer-testis antigens (CTAs) CT7 (MAGE-C1), CT10 (MAGE-C2) and MAGE-A CTAs are expressed in up to 80% of cases. In this study, we investigated the expression and immunogenicity of several CTAs in patients with AL amyloidosis in a total of 38 bone marrow specimens by employing standard immunohistochemistry techniques on paraffin-embedded archival tissues. Plasma samples from 35 patients (27 with matched bone marrow samples) were also analyzed by ELISA for sero reactivity to a group of full-length CTA proteins. CT7 was present in 25/38 (66%) while CT10 was demonstrated in 3/38 and GAGE in 1/38 AL amyloid cases. The expression pattern was mostly focal. There were no significant differences with regard to organ involvement, response to treatment, or prognosis in CTA positive compared to negative cases. None of the specimens showed spontaneous humoral immunity to CT7, but sero reactivity was observed in individual patients to other CTAs. This study identifies CT7 as the prevalent CTA in plasma cells of patients with AL amyloidosis. Further analyses determining the biology of CTAs in AL amyloidosis and their value as potential targets for immunotherapy are warranted.

Prophylactic oophorectomy rates in relation to a guideline update on referral to genetic counseling

OBJECTIVE

We sought to determine whether prophylactic oophorectomy rates changed after the introduction of a 2007 health plan clinical guideline recommending systematic referral to a genetic counselor for women with a personal or family history suggestive of an inherited susceptibility to breast/ovarian cancer.

METHODS

We conducted a retrospective cohort study of female members of Group Health, an integrated delivery system in Washington State. Subjects were women aged ≥ 35 years during 2004-2009 who reported a personal or family history consistent with an inherited susceptibility to breast/ovarian cancer. Personal and family history information was collected on a questionnaire completed when the women had a mammogram. We ascertained oophorectomies from automated claims data and determined whether surgeries were prophylactic by medical chart review. Rates were age-adjusted and age-adjusted incidence rate ratios (IRR) and 95% confidence intervals (CI) were computed using Poisson regression.

RESULTS

Prophylactic oophorectomy rates were relatively unchanged after compared to before the guideline change, 1.0 versus 0.8/1000 person-years, (IRR=1.2; 95% CI: 0.7-2.0), whereas bilateral oophorectomy rates for other indications decreased. Genetic counseling receipt rates doubled after the guideline change (95% CI: 1.7-2.4) from 5.1 to 10.2/1000 person-years. During the study, bilateral oophorectomy rates were appreciably greater in women who saw a genetic counselor compared to those who did not regardless of whether they received genetic testing as part of their counseling.

CONCLUSION

A doubling in genetic counseling receipt rates lends support to the idea that the guideline issuance contributed to sustained rates of prophylactic oophorectomies in more recent years.

The AmpC inhibitor, Syn2190, can be used to reveal extended-spectrum beta-lactamases in Escherichia coli

AmpC beta-lactamases are not inhibited by clavulanic acid and could potentially mask detection of extended-spectrum beta-lactamases (ESBLs) using the Clinical and Laboratory Standards Institute confirmatory test. Syn2190 (1,5-dihydroxy-4-pyridone monobactam) selectively inhibits AmpC, but not ESBLs. Fifty-four MicroScan ESBL screen-positive strains of Escherichia coli and an unrelated group of 20 cefoxitin-nonsusceptible E. coli strains were tested with the confirmatory ceftazidime-cefotaxime-clavulanate disk method with or without 4 microg/mL of Syn2190 in the agar. Without Syn2190, 8 (14.8%) of 54 E. coli isolates and 0 of 20 cefoxitin-nonsusceptible E. coli isolates were confirmed. With Syn2190, an additional 9 (16.6%) of 54 of the MicroScan screen-positive E. coli isolates and 6 (30%) of 20 of the cefoxitin-nonsusceptible E. coli isolates were found. Multiplex polymerase chain reaction and sequence analysis confirmed the presence of the plasmid-associated beta-lactamase gene bla(CMY-2) in the 2 available MicroScan-screened E. coli isolates and in 5 of 6 of the cefoxitin-resistant group. These data suggest that in the presence of AmpC, ESBLs in E. coli may not be detected by the currently recommended confirmatory test.

Relation of C-reactive protein and other cardiovascular risk factors to penile vascular disease in men with erectile dysfunction

Erectile dysfunction (ED) may be an early sign or symptom of cardiovascular disease (CVD). We examined the relation of traditional and emerging risk factors for CVD to the severity of penile vascular disease in men with ED and without clinical coronary artery disease (CAD). In total, 137 men with ED were evaluated for penile vascular disease severity by penile Doppler ultrasound. These men were divided into the following groups based on ultrasound results: normal, cavernous venous occlusive disease, mild arterial insufficiency, and severe arterial insufficiency. Traditional (fasting lipid panel, fasting glucose, age, BMI, smoking, Framingham coronary artery disease risk score) and emerging (C-reactive protein, Lp(a), homocysteine) risk factors for CVD were correlated to severity of penile vascular disease in men with ED and without clinical CAD. Using univariate analysis, penile Doppler groups showed significant positive correlation to CRP (r=0.21; < or = 0.05) and age (r=0.30; < or = 0.01). For CRP, this correlation remained significant even when adjusted for age (< or = 0.05). Men displaying evidence of penile arterial disease (mild and severe arterial insufficiency) were characterized by elevated CRP levels (0.17 mg/dl) compared to men with no evidence of arterial abnormalities in the penis (0.04 mg/dl). CRP levels correlate significantly with increasing severity of penile vascular disease as measured by penile Doppler.

Nitric oxide, prostanoids, cyclooxygenase, and angiogenesis in colon and breast cancer

PURPOSE

Several studies have shown an overexpression of cyclooxygenase-2 (COX-2) and elevated levels of prostacyclin (PGI(2)) and thromboxane (TXA(2)) in colon cancer. In this report, we determined the distribution of inducible form of nitric oxide synthase (iNOS), PGI(2), and TXA(2) in cancerous and adjoining areas of specimens from human colon and breast cancer obtained during surgery. Additionally, we investigated differences in expression and histological localization of COX-2 in colon and breast cancer.

EXPERIMENTAL DESIGN

Specimens were obtained during surgery, one centrally located, the second from an adjacent, cancer-free area. Activity of iNOS was determined, using the conversion of L-[(14)C]arginine to L-[(14)C]citrulline. PGI(2) and TXA(2) were measured as their stable metabolites, using enzyme immunoassay. A standard immunoperoxidase method was used for immunohistochemical expression of COX-2.

RESULTS

Significant differences in iNOS, PGI(2), and TXA(2) expressions between colon and breast cancer were noted, with an enhanced expression of COX-2 in colon cancer, including the cancerous, adjoining, and stromatous fields.

CONCLUSIONS

Increased expression of iNOS and production of prostanoids in colon cancer parallels the increase in COX-2, confirming the importance of this enzyme in colon cancer. The overexpression of COX-2, prostanoids, and nitric oxide in areas adjoining the tumor indicates increased metastatic potential for neoplastic cells in this area. Inflammatory changes in the tissue adjoining the cancer may play a role. COX-2 may result in the formation of new blood vessels and the spread of cancer.

Safety issues in isotretinoin therapy

Isotretinoin (Accutane, Roche Laboratories Inc, Nutley, NJ) is an important drug, not only for the treatment of severe acne, but also for other diagnoses and in chemoprevention settings. Because the use of isotretinoin is increasing, it is important for physicians to be aware of the adverse events, toxicities, and management issues related to its use. The most important issue is that of congenital defects, which has resulted in new pregnancy prevention policies and programs implemented by the manufacturer. A relatively new concern is that of depression associated with isotretinoin use, also resulting in new policies placed by the manufacturer and the FDA. The most common adverse effects observed during treatment are mucocutaneous and ocular in nature, but laboratory abnormalities and effects in the nervous, musculoskeletal, gastrointestinal, pulmonary, hematologic, and other systems are also described. Additionally, potential drug interactions, follow-up, and toxicity prevention measures are discussed.

Soybean genomic survey: BAC-end sequences near RFLP and SSR markers

We are building a framework physical infrastructure across the soybean genome by using SSR (simple sequence repeat) and RFLP (restriction fragment length polymorphism) markers to identify BACs (bacterial artificial chromosomes) from two soybean BAC libraries. The libraries were prepared from two genotypes, each digested with a different restriction enzyme. The BACs identified by each marker were grouped into contigs. We have obtained BAC- end sequence from BACs within each contig. The sequences were analyzed by the University of Minnesota Center for Computational Genomics and Bioinformatics using BLAST algorithms to search nucleotide and protein databases. The SSR-identified BACs had a higher percentage of significant BLAST hits than did the RFLP-identified BACs. This difference was due to a higher percentage of hits to repetitive-type sequences for the SSR-identified BACs that was offset in part, however, by a somewhat larger proportion of RFLP-identified significant hits with similarity to experimentally defined genes and soybean ESTs (expressed sequence tags). These genes represented a wide range of metabolic functions. In these analyses, only repetitive sequences from SSR-identified contigs appeared to be clustered. The BAC-end sequences also allowed us to identify microsynteny between soybean and the model plants Arabidopsis thaliana and Medicago truncatula. This map-based approach to genome sampling provides a means of assaying soybean genome structure and organization.

Soybean genomic survey: BAC-end sequences near RFLP and SSR markers

We are building a framework physical infrastructure across the soybean genome by using SSR (simple sequence repeat) and RFLP (restriction fragment length polymorphism) markers to identify BACs (bacterial artificial chromosomes) from two soybean BAC libraries. The libraries were prepared from two genotypes, each digested with a different restriction enzyme. The BACs identified by each marker were grouped into contigs. We have obtained BAC- end sequence from BACs within each contig. The sequences were analyzed by the University of Minnesota Center for Computational Genomics and Bioinformatics using BLAST algorithms to search nucleotide and protein databases. The SSR-identified BACs had a higher percentage of significant BLAST hits than did the RFLP-identified BACs. This difference was due to a higher percentage of hits to repetitive-type sequences for the SSR-identified BACs that was offset in part, however, by a somewhat larger proportion of RFLP-identified significant hits with similarity to experimentally defined genes and soybean ESTs (expressed sequence tags). These genes represented a wide range of metabolic functions. In these analyses, only repetitive sequences from SSR-identified contigs appeared to be clustered. The BAC-end sequences also allowed us to identify microsynteny between soybean and the model plants Arabidopsis thaliana and Medicago truncatula. This map-based approach to genome sampling provides a means of assaying soybean genome structure and organization.

Helicobacter pylori in dental plaque and gastric mucosa

OBJECTIVE

The aim of this study was to investigate the presence of Helicobacter pylori in both dental plaque and gastric mucus.

STUDY DESIGN

Dental scaling hand instruments were used to collect supragingival and subgingival dental plaque from 81 dentate participants. Denture plaque was obtained from the fitting surfaces of dentures from 41 edentulous patients. Gastric mucus from gastric mucosa of antrum and body of stomach were collected from all 122 participants (92% white) with soft gastroscopic brush. These samples were dispersed in modified urea broth and normal saline solution before being inoculated onto selective Skirrow's agar and incubated in a microaerophilic atmosphere for culturing H. pylori.

RESULTS

Dental plaque from all dentate participants was negative for H. pylori culture. Only one 80-year-old edentulous patient had positive H. pylori culture in both gastric mucus and denture plaque.

CONCLUSIONS

Although dental plaque has a mixed flora that may act as a reservoir for gastric reinfection, dental plaque could not be implicated as the major reservoir of H. pylori for gastric reinfection.

Bilateral mandibular nerve damage following root canal therapy

A case of bilateral inferior dental nerve paraesthesia following accidental introduction of root canal filling material into the canal is described. The significance of early recognition of the complication and prompt surgical intervention is highlighted.

The herpes simplex virus type 2 gene which encodes the large subunit of ribonucleotide reductase has unusual regulatory properties

Expression of herpes simplex virus type 2 (HSV-2) encoded ribonucleotide reductase (RR) is required for growth of the virus in non-dividing cells. The functional enzyme is composed of a large (RRA) and small (RRB) subunit and the enzyme is expressed as a delayed early activity. The promoter of RRA contains a cis-acting motif (TAATGARAT) which resembles those found in immediate early (IE) genes suggesting RRA is an IE gene. When primate cells were infected with HSV-2, low levels of RRA transcripts were expressed in the presence of cycloheximide indicating RRA is not a true IE gene. Conditions which allow for efficient RRA RNA expression in the presence of cycloheximide were identified in human cells. A phorbol ester, 12-O-tetradecanoyl phorbol-13- acetate (TPA), and hydroxyurea increased the level of RRA RNA expression in the presence of cycloheximide. Hydroxyurea and TPA also stimulated RRA promoter activity in transient assays suggesting these agents induced factors which transactivated the RRA promoter. Expression of an intact c-myc gene transactivated the RRA promoter more than 30-fold in transient assays. Although expression of an intact retinoblastoma gene (Rb) had a slight stimulatory effect on the RRA promoter, mutant Rb proteins also stimulated the RRA promoter. These studies demonstrated that inducible factors in permissive cells increase the steady state levels of RRA RNA in the presence of cycloheximide.

Duplication of 5q11.2----q13.1 from a familial (5;20) balanced insertion

A 2-year-old boy with gross motor delay and few minor anomalies has a pure duplication of a small segment of chromosome 5q11.2----q13.1. A balanced insertion of this 5q segment into chromosome 20q proximal to the centromere has been found in his father, uncle, and paternal grandmother.

Transcutaneous oxygen tension of newborn infants in different behavioral states

Transcutaneous oxygen tension (tcPO2) was continuously monitored, and behavioral state was evaluated in a group of 10 normal preterm infants and 10 normal term infants. In the preterm infant group, birth weight was 1505 +/- 154 g, gestational age was 32.3 +/- 2.3 wk, and postnatal age was 8.4 +/- 5.1 days (mean +/- S.D.). In the term infant group, birth weight was 3245 +/- 247 g, gestational age was 39.9 +/- 0.3 wk, and postnatal age was 6.3 +/- 3.4 days (mean +/- S.D.). A mean tcPO2 level for each behavioral state in each infant was calculated, and a paired comparison between all states was made. In the preterm and term infant groups, mean tcPO2 levels were higher in state 1 ("quiet sleep"), state 4 ("active awake state"), and state 5 ("crying") than during state 2 ("active sleep"). The difference (delta tcPO2) was significant (P < 0.05). In the preterm infant group, mean tcPO2 level in state 2 was 62.9 +/- 17.1 mm Hg (mean +/- S.D.). Mean delta tcPO2 in state 1 was +5.4 mm Hg (range, -0.9 to +9.2 mm Hg), mean delta tcPO2 in state 4 was +6.8 mm Hg (range, +0.6 to +20.2 mm Hg), and in state 5 was +9.9 mm Hg (range, +5.1 to +17.5 mm Hg). In the term infant group, mean tcPO2 level in state 2 was 64.5 +/- 9.6 mm Hg (mean +/- S.D.). Mean delta tcPO2 in state 1 was +5.8 mm Hg (range, -1.2 to +11.0 mm Hg), mean delta tcPO2 in state 4 was +8.1 mm Hg (range, +2.2 to +32.3 mm Hg), and mean delta tcPO2 in state 5 was +7.3 mm Hg (range, -1.6 to +26.5 mm Hg). There was insufficient data to evaluate tcPO2 levels during state 3 ("quiet awake state"). In the term infant group, the effect of bottle feeding on tcPO2 was also assessed. Gross alterations in tcPO2 during bottle feeding were not observed, and mean tcPO2 levels during bottle feeding (76.1 +/- 8.5 mm Hg; mean +/- S.D.) were not significantly different from mean tcPO2 levels found during states 1, 4, and 5.