Multisystem Inflammatory Syndrome in Children: Survey of Protocols for Early Hospital Evaluation and Management.

OBJECTIVE: To describe the similarities and differences in the evaluation and treatment of multisystem inflammatory syndrome in children (MIS-C) at hospitals in the US. STUDY DESIGN: We conducted a cross-sectional survey from June 16 to July 16, 2020, of US children's hospitals regarding protocols for management of patients with MIS-C. Elements included characteristics of the hospital, clinical definition of MIS-C, evaluation, treatment, and follow-up. We summarized key findings and compared results from centers in which >5 patients had been treated vs those in which ≤5 patients had been treated. RESULTS: In all, 40 centers of varying size and experience with MIS-C participated in this protocol survey. Overall, 21 of 40 centers required only 1 day of fever for MIS-C to be considered. In the evaluation of patients, there was often a tiered approach. Intravenous immunoglobulin was the most widely recommended medication to treat MIS-C (98% of centers). Corticosteroids were listed in 93% of protocols primarily for moderate or severe cases. Aspirin was commonly recommended for mild cases, whereas heparin or low molecular weight heparin were to be used primarily in severe cases. In severe cases, anakinra and vasopressors frequently were recommended; 39 of 40 centers recommended follow-up with cardiology. There were similar findings between centers in which >5 patients vs ≤5 patients had been managed. Supplemental materials containing hospital protocols are provided. CONCLUSIONS: There are many similarities yet key differences between hospital protocols for MIS-C. These findings can help healthcare providers learn from others regarding options for managing MIS-C.

Kawasaki disease: a comprehensive review of treatment options.

WHAT IS KNOWN AND OBJECTIVE: Kawasaki disease (KD) is an acute self-limiting systemic vasculitis with specific predilection for the coronary arteries that affects previously healthy young infants and children. It is the leading cause of childhood-acquired heart disease in the developed world. Although the stimulus for the cascade of inflammation in KD is unknown, prompt treatment within 10 days of symptom onset has been shown to improve clinical outcomes and reduce the risk of coronary artery complications. Standard initial therapy is intravenous immunoglobulin (IVIG) and aspirin. Non-responders to initial therapy remain a challenge. This present review summarizes the treatment options for initial and refractory KD, including the role of steroids and other immunosuppressive therapies. METHODS: Literature search using PubMed database to identify pharmacologic studies in KD using the terms Kawasaki disease, intravenous immunoglobulin, refractory, corticosteroids, infliximab, cyclosporine, methotrexate, high risk from January 1988-May 2015 was performed. Bibliographies of selected references were also evaluated for relevant articles. Results were limited to those published in English. All articles identified from the PubMed searches were evaluated. RESULTS AND DISCUSSION: Initial IVIG therapy results in rapid resolution of clinical symptoms in 80-90% of patients and has been shown to reduce the risk of coronary disease. Although concomitant aspirin remains the standard of care for the initial management of KD, the evidence to support its efficacy in improving coronary artery outcomes are lacking. Initial therapy with corticosteroids in addition to intravenous immunoglobulin and aspirin improves outcomes in patients in Japan. However, identifying patients at high risk who may benefit from additional corticosteroids in heterogeneous populations has been challenging. Therapeutic options for non-responders to initial therapy are also challenging given the paucity of data. Patients who fail to respond to the first dose of IVIG will most often receive a second dose. Patients who fail to respond to two doses of IVIG present a unique challenge as the appropriate treatment remains uncertain. Although their effectiveness remains unproven, treatment with infliximab, cyclosporine or methotrexate may be considered in those patients who fail multiple doses of IVIG and steroids. WHAT IS NEW AND CONCLUSION: The role of steroids in high-risk non-Japanese patients is unclear, with the biggest challenge being early identification of patients at high risk of developing adverse coronary artery outcomes. Limited data evaluating other immunosuppressive agents are available and should be reserved for patients failing two doses of IVIG. Although recent advances in research have broadened our understanding of the epidemiology, genetic susceptibility and pathogenesis of KD, the aetiology of KD remains unclear. Ongoing research will help determine more precise pathogenesis and may assist in developing a diagnostic test as well as identifying new targets for more precise treatment interventions.

Anteroposterior Knee Stability During Stair Descent.

This study examined the influence of tibio-femoral conformity on anteroposterior (AP) knee stability during stair descent, particularly with a dished cruciate sacrificing (CS) design. A joint simulator simulated stair descent of cadaveric knees. Tibio-femoral displacement was measured. Knees were tested in intact, ACL-deficient, and TKA with cruciate-retaining (CR), CS and posterior-stabilizing (PS) inserts. Loading during stair descent simulation caused femur displacement anteriorly prior to quadriceps contraction. Quadriceps contraction reestablished the initial femoral AP position. During simulated stair descent, AP stability was restored using PS, CR or CS inserts with an intact PCL. The CS design without the PCL did not provide AP stability. Increasing quadriceps force to restore AP stability may explain the clinical findings of pain and fatigue experienced by some patients after TKA.

Successful Cardiac Surgical Management in a Trisomy 21 Child After Long-Term Hospitalization Associated With Bronchopneumonia and Hepatitis C Virus Seropositivity: A Case Report.

A 31-month-old girl with trisomy 21 (Down syndrome) was seen in the emergency department of pediatrics because of oxygen desaturation associated with features of lower respiratory tract infections. She was born at full term and diagnosed with congenital heart disease (CHD) having ventricular septal defect (VSD), and patent ductus arteriosus (PDA); consequently, she underwent corrective surgery after adequate optimization of treatment. Incidentally, she was detected to have the presence of anti-hepatitis C virus (HCV) antibodies. In this case report, we mainly focus on the multi-modal approach to medical and surgical management.

The Relationship between Pain Catastrophizing and Cognitive Function in Chronic Musculoskeletal Pain: A Scoping Review.

Objective: Chronic musculoskeletal pain (CMP) poses a considerable threat to physical, mental, and financial health worldwide. Beyond physical difficulties, CMP has a pronounced impact on pain behaviors and cognitive function. The purpose of this scoping review was to examine the relationship between pain catastrophizing (PC) and cognitive function in CMP, identify gaps in the literature, and provide future directions for research on the topic. Methods: Search strings were entered in the following databases: PubMed, CINAHL, Nursing and Allied Health, Ovid Emcare, PsycInfo, and Scopus. Data from the included articles were extracted thematically based on diagnostic classification and included author(s), year of publication, country, aim, sample, methods, intervention (if applicable), and key findings. Results: 30 articles were included after screening. The studied populations included patients with fibromyalgia, chronic low back pain, and CMP. Two studies were designed to assess the relationship between PC and cognition as the primary aim. The included studies demonstrated variable evidence regarding the relationship between PC and cognition. Only four studies included clinically relevant PC populations (i.e., Pain Catastrophizing Scale score >30), and all found significant correlations. Conclusion: Although evidence exists for the relationship between cognitive function and PC, there is a lack of rigorous research to indicate the strength of this relationship and the specific cognitive functions affected. The literature lacks appropriate populations needed to investigate clinically relevant PC and is limited by heterogeneous neuropsychological test batteries. Future research should include populations demonstrating the behaviors being studied, intentional analysis of outcomes, and appropriate cognitive tests.

Interventions to Manage Pain Catastrophizing Following Total Knee Replacement: A Systematic Review.

Background: Pain catastrophizing is a maladaptive cognitive strategy that is associated with increased emotional responses and poor pain outcomes. Total knee replacement procedures are on the rise and 20% of those who have the procedure go on to have ongoing pain. Pain catastrophizing complicates this pain and management of this is important for recovery from surgery and prevention of chronic pain. This study examines the effect of interventions on PC for patients undergoing total knee replacement (TKR). Methods: Multiple search engines were searched from inception up to March 2021 for relevant studies measuring PC in adults who have undergone TKR. Studies were screened using the Downs and Black Checklist. We included 10 studies (n = 574) which recruited peri surgical TKR participants. Effect sizes were calculated and compared on effect of intervention on PC. Results: Five studies examined the effect of cognitive behavioral therapy-based intervention on PC with low to moderate effects. Two studies examined the effect of a pain neuroscience education on PC with small effects short term. One study examined the effect of hypnotic therapy on PC with small, short-term effect (1 month) but large effect at 6 months. One study compared the effect of an isometric quadricep exercise with auditory and visual feedback on PC to treatment as usual with small, short-term effects. One study compared the effects of an activity and goal setting diary on PC with a moderate effect at 4 weeks. Conclusion: PC is a modifiable characteristic. Several interventions show modest benefit, however more research is needed to aid in clinical decision-making for this population. Interventions are most likely to produce benefits when they are targeted to people with high levels of PC.

Crises as the Crucible for Change in Physical Therapist Education.

This Perspective issues a challenge to physical therapists to reorient physical therapist education in ways that directly address the crises of COVID-19 and systemic racism. We advocate that professional education obligates us to embrace the role of trusteeship that demands working to meet society's needs by producing graduates who accept their social and moral responsibilities as agents and advocates who act to improve health and health care. To achieve this, we must adopt a curriculum philosophy of social reconstruction and think more deeply about the why and how of learning. Currently, health professions education places strong emphasis on habits of head (cognitive knowledge) and hand (clinical skills) and less focus on habits of heart (professional formation). We believe that habits of heart are the essential foundations of the humanistic practice needed to address health inequities, find the moral courage to change the status quo, and address imbalances of power, privilege, and access. A social reconstruction orientation in physical therapist education not only places habits of heart at the center of curricula, but it also requires intentional planning to create pathways into the profession for individuals from underrepresented groups. Adopting social reconstructionism begins with a faculty paradigm shift emphasizing the learning sciences, facilitating learning, metacognition, and development of a lifelong master adaptive learner. Achieving this vision depends not only on our ability to meet the physical therapy needs of persons with COVID-19 and its sequalae but also on our collective courage to address injustice and systemic racism. It is imperative that the physical therapy community find the moral courage to act quickly and boldly to transform DPT education in ways that enable graduates to address the social determinants of health and their systemic and structural causes that result in health disparities. To succeed in this transformation, we are inspired and strengthened by the example set by Geneva R. Johnson, who has never wavered in recognizing the power of physical therapy to meet the needs of society.

Impact of Job Resources and Job Demands on Burnout among Physical Therapy Providers.

Job burnout is a threat for physical therapists. Little research has been conducted to identify possible protective factors against burnout in this population. Accordingly, we utilized the job demands-resources (JD-R) model and self-determination theory to guide our examination of basic psychological needs as factors to predict burnout in physical therapists. One hundred and two licensed physical therapists completed surveys. Higher levels of autonomy, competence and relatedness predicted burnout, even after accounting for job demands. Job resources, such as the basic psychological needs outlined by the self-determination theory, along with perceived respect, buffer the negative effects of secondary trauma on burnout. The job resource of perceived respect also buffers the negative effects of the physical demands of the job on burnout. These findings suggest that while job demands can be difficult to change, increasing the fulfillment of job resources can help ameliorate burnout in physical therapists. The present findings highlight the need for workplace interventions which cultivate the satisfaction of the basic psychological needs of autonomy, competence, and relatedness to address burnout among physical therapists.

Short-Duration Electronic Health Record Option Buttons to Reduce Prolonged Length of Antibiotic Therapy in Outpatients.

BACKGROUND: Prolonged antibiotic therapy may be associated with increased adverse events and antibiotic resistance. We deployed an intervention in the electronic health record (EHR) to reduce antibiotic duration for pediatric outpatients. METHODS: A preintervention and postintervention interrupted time series analysis of antibiotic duration for 7 antibiotics was performed for patients discharged from the ED and clinics of a children's hospital network from 2012 to 2018. In February 2015, clickable 5- and 7-day duration option buttons were deployed in the EHR for clindamycin, cephalexin, ciprofloxacin and levofloxacin, trimethoprim-sulfamethoxazole, amoxicillin, and cefdinir, with an additional 10-day option for the latter 2. Prescribers were able to enter a free-text duration. The option buttons were not announced, and were not linked to a specific diagnosis or quality improvement initiative. The primary outcome was proportion of prescriptions per month with duration of 10 days. Balancing secondary outcomes were reorders of the same agent, return to clinic, and inpatient admissions within 30 days. RESULTS: There were 54 315 prescriptions for the 7 antibiotics associated with 39 894 patients, 18 683 clinic visits, and 35 632 ED visits. Overall, a -5.1% (95% confidence interval [CI], -8.3% to -2.0%) change in the proportion of prescriptions with a 10-day duration was attributable to the intervention, with larger effects noted for clindamycin (-20.8% [95% CI, -26.9% to -14.7%]) and cephalexin (-9.9% [95% CI, -14.3% to -5.4%]). There was no increase in the reorders of the same agent, return clinical encounters, or inpatient admissions within 30 days. CONCLUSIONS: A simple intervention in the EHR can safely reduce duration of antibiotic therapy.

Ideal and Actual Impact of Rapid Diagnostic Testing and Antibiotic Stewardship on Antibiotic Prescribing and Clinical Outcomes in Children With Positive Blood Cultures.

BACKGROUND: Implementing matrix-assisted laser desorption ionization-time of flight and multiplex polymerase chain reaction has been associated with decreased mortality and hospital length of stay in adults, but the impact in pediatrics is less understood. METHODS: This pre-post quasi-experimental study compared antibiotic prescribing for positive blood cultures in patients ≤21 years of age collected in 2012 (preintervention) and in 2015 (after matrix-assisted laser desorption ionization-time of flight/multiplex polymerase chain reaction). Time to effective and optimal antimicrobial therapy was evaluated using Cox proportional hazards regression. Time to ideal optimal therapy was estimated as the earliest potential initiation of optimal therapy. Antibiotic use and clinical outcomes were measured. RESULTS: There were 242 and 192 positive monomicrobial blood cultures in 2012 and 2015, respectively. Postintervention, time to optimal therapy (73.8 vs. 48.8 hours; P < 0.001) and organism identification (55.6 vs. 29.5 hours; P < 0.001) were reduced, and patients were more likely to receive optimal therapy by 7 days (hazard ratio, 1.85; P < 0.001). In the ideal scenario in 2015, there was an 8.8-hour delay in initiating optimal therapy based on the time that sufficient microbiologic data were available. Postintervention, time to effective therapy (2.8 vs. 2.7 hours; P = 0.782) and clinical outcomes did not differ. Unnecessary antibiotic duration for probable contaminants (skin flora) (43.1 vs. 29.7 hours; P = 0.027), vancomycin for methicillin-sensitive Staphylococcus aureus (54.0 vs. 41.3 hours; P = 0.008) and nonpenicillin/ampicillin antibiotics for group A Streptococcus, group B Streptococcus and Enterococcus faecalis (87.2 vs. 33.4 hours; P < 0.001) were reduced postintervention. CONCLUSIONS: Rapid diagnostics reduced time to optimal antimicrobial therapy and unnecessary antibiotic use without worse clinical outcomes.

Safety of Palivizumab Stewardship in Conjunction with Infection Prevention and Control Strategies for Healthcare-Associated Respiratory Syncytial Virus Infections.

Transitioning from administration of monthly palivizumab to a single dose at discharge was associated with substantial pharmacy cost savings. With the concurrent adoption of private hospital rooms and visitor restriction policies, hospital-wide and neonatal intensive care unit healthcare-associated respiratory syncytial virus infections decreased following these changes. Infect Control Hosp Epidemiol 2018;39:485-487.

Effectiveness of a Group-Based Culturally Tailored Lifestyle Intervention Program on Changes in Risk Factors for Type 2 Diabetes among Asian Indians in the United States.

This study used an experimental, pretest-posttest control group repeated measures design to evaluate the effectiveness of a community-based culturally appropriate lifestyle intervention program to reduce the risk for type 2 diabetes (T2DM) among Gujarati Asian Indians (AIs) in an urban community in the US. Participants included 70 adult AIs in the greater Houston metropolitan area. The primary outcomes were reduction in weight and hemoglobin A1c (HbA1c) and improvement in physical activity. Participants were screened for risk factors and randomly assigned to a 12-week group-based lifestyle intervention program (n = 34) or a control group (n = 36) that received standard print material on diabetes prevention. Participants also completed clinical measures and self-reported questionnaires about physical activity, social, and lifestyle habits at 0, 3, and 6 months. No significant baseline differences were noted between groups. While a significant decline in weight and increase in physical activity was observed in all participants, the intervention group lowered their HbA1c (p < 0.0005) and waist circumference (p = 0.04) significantly as compared to the control group. Findings demonstrated that participation in a culturally tailored, lifestyle intervention program in a community setting can effectively reduce weight, waist circumference, and HbA1c among Gujarati AIs living in the US.

Effect of Probiotic Dietary Intervention on Calcium and Haematological Parameters in Geriatrics.

INTRODUCTION: Probiotics are live microorganisms which when administered in adequate amounts confer a health benefit on the host. Sufficient calcium intake has been reported to support bone growth and prevent bone loss during the ageing process. AIM: To determine the effect of Lactobacillus helveticus MTCC 5463 probiotic dietary intervention on serum calcium & haematological parameters in geriatric population. MATERIALS AND METHODS: Healthy volunteers with age ranging from 64-74 years were recruited from the nearby residential areas in and around Anand, Gujarat. Study duration was from 2012 to 2015. Of the 112 subjects initially enrolled in the trial, 36 withdrew before the intervention because of not matching with criterias. Of the 76 participants, 5 subjects (4%) under test group and 12 subjects (11%) under placebo left the study. We had 59 subjects who successfully completed a double blind cross over trial. Probiotic fermented milk products (in form of "Lassi") was prepared by supplementing toned milk with honey and fermenting with probiotic Lactobacillus helveticus MTCC 5463 and Streptococcus thermophilus MTCC 5460. The final product had at least 10(8) CFU/ml of viable Lactobacillus helveticus MTCC 5463 at the time of feeding. During feeding period, 200 ml of fermented product containing the test strain to one group and a similar product but without the test strain as placebo were fed regularly at the time of breakfast in morning for 4 weeks. Subjects of each group were given a washout period of 4 weeks before they were crossed over and included to the other group. The study was approved by institutional ethics committee. RESULTS: The socio-demographic and clinical profiles were similar at baseline. The mean (SD) calcium level improved significantly in test {9.36 (0.45) vs 8.45 (0.61), p<0.001}. No significant effect was observed with respect to haemoglobin & haematological parameters. CONCLUSION: The well-documented probiotic Lactobacillus helveticus MTCC 5463 confirmed increase in serum calcium level but no effect on haematological parameters when administered to geriatrics.

Geriatric Respondents and Non-Respondents to Probiotic Intervention Can be Differentiated by Inherent Gut Microbiome Composition.

SCOPE: Probiotic interventions are known to have been shown to influence the composition of the intestinal microbiota in geriatrics. The growing concern is the apparent variation in response to identical strain dosage among human volunteers. One factor that governs this variation is the host gut microbiome. In this study, we attempted to define a core gut metagenome, which could act as a predisposition signature marker of inherent bacterial community that can help predict the success of a probiotic intervention. METHODS AND RESULTS: To characterize the geriatric gut microbiome, we designed primers targeting the 16S rRNA hypervariable region V2-V3 followed by semiconductor sequencing using Ion Torrent PGM. Among respondents and non-respondents, the chief genera of phylum Firmicutes that showed significant differences are Lactobacillus, Clostridium, Eubacterium, and Blautia (q < 0.002), while in the genera of phylum Proteobacteria included Shigella, Escherichia, Burkholderia and Camphylobacter (q < 0.002). CONCLUSION: We have identified potential microbial biomarkers and taxonomic patterns that correlate with a positive response to probiotic intervention in geriatric volunteers. Future work with larger cohorts of geriatrics with diverse dietary influences could reveal the potential of the signature patterns of microbiota for personalized nutrition.