Real-world utility of overnight oximetry for the screening of obstructive sleep apnea in children.

BACKGROUND: Obstructive sleep apnea (OSA) is a common problem in children and can result in developmental and cognitive complications if untreated. The gold-standard tool for diagnosis is polysomnography (PSG); however, it is an expensive and time-consuming test to undertake. Overnight oximetry has been suggested as a faster and cheaper initial test in comparison to PSG as it can be performed at home using limited, reusable equipment. AIM: This retrospective case control study aims to evaluate the effectiveness of a home oximetry service (implemented in response to extended waiting times for routine PSG) in reducing the time between patient referral and treatment. METHODS: Patients undergoing diagnostic sleep evaluation for suspected OSA who utilized the Queensland Children's Hospital screening home oximetry service in the first year since its inception in 2021 (n = 163) were compared to a historical group of patients who underwent PSG in 2018 (n = 311). Parameters compared between the two groups included time from sleep physician review to sleep test, ENT review, and definitive treatment in the form of adenotonsillectomy surgery (or CPAP initiation for those who had already undergone surgery). RESULTS: The time from sleep physician review and request of the sleep-related study to ENT surgical treatment was significantly reduced (187 days for the HITH oximetry group vs 359 days for the comparable PSG group; p-value <0.05), and time from sleep study request to the report of results was significantly lower for patients in the oximetry group compared to those in the PSG group (11 days vs 105 days; p-value <0.05). CONCLUSION: These results suggest that for children referred to a tertiary sleep center for possible obstructive sleep disordered breathing, a home oximetry service can be effective in assisting sleep evaluation and reducing the time to OSA treatment.

Whole blood-based measurement of SARS-CoV-2-specific T cells reveals asymptomatic infection and vaccine immunogenicity in healthy subjects and patients with solid-organ cancers.

Accurate assessment of SARS-CoV-2 immunity is critical in evaluating vaccine efficacy and devising public health policies. Whilst the exact nature of effective immunity remains incompletely defined, SARS-CoV-2-specific T-cell responses are a critical feature that will likely form a key correlate of protection against COVID-19. Here, we developed and optimized a high-throughput whole blood-based assay to determine the T-cell response associated with prior SARS-CoV-2 infection and/or vaccination amongst 231 healthy donors and 68 cancer patients. Following overnight in vitro stimulation with SARS-CoV-2-specific peptides, blood plasma samples were analysed for TH 1-type cytokines. Highly significant differential IFN-γ+ /IL-2+ SARS-CoV-2-specific T-cell responses were seen amongst previously infected COVID-19-positive healthy donors in comparison with unknown / naïve individuals (p < 0·0001). IFN-γ production was more effective at identifying asymptomatic donors, demonstrating higher sensitivity (96·0% vs. 83·3%) but lower specificity (84·4% vs. 92·5%) than measurement of IL-2. A single COVID-19 vaccine dose induced IFN-γ and/or IL-2 SARS-CoV-2-specific T-cell responses in 116 of 128 (90·6%) healthy donors, reducing significantly to 27 of 56 (48·2%) when measured in cancer patients (p < 0·0001). A second dose was sufficient to boost T-cell responses in the majority (90·6%) of cancer patients, albeit IFN-γ+ responses were still significantly lower overall than those induced in healthy donors (p = 0·034). Three-month post-vaccination T-cell responses also declined at a faster rate in cancer patients. Overall, this cost-effective standardizable test ensures accurate and comparable assessments of SARS-CoV-2-specific T-cell responses amenable to widespread population immunity testing, and identifies individuals at greater need of booster vaccinations.

Biological basis of child health 10: function and formation of blood and common blood disorders in children.

This article, the tenth in a series on the biological basis of child health, focuses on blood. Blood has a crucial role in the transport of substances such as respiratory gases, nutrients and antibodies, as well as in acid-base balance, fluid balance, blood clotting and the immune system. This article describes the composition, formation and function of blood, outlines normal blood count values and explains the effects of low blood cell counts in children. It also provides an overview of the blood disorders that are commonly seen in children, including anaemia, sickle cell disease, clotting disorders and blood cancers. It is essential for children's nurses to have knowledge and an understanding of blood, including its physiology and pathophysiology, to provide optimal care and support to children and young people and their families.

Biological basis of child health 6: development of the skeletal system and orthopaedic conditions.

This article is the sixth in a series on the biological basis of child health. It provides an overview of the development of the skeletal system before and after birth, and outlines the potential congenital anomalies that may occur. The article explains the structure and function of the bones before describing the role of the joints, tendons and ligaments. It also outlines the presentation and management of some of the common orthopaedic conditions seen in infants and children, including fractures, osteogenesis imperfecta, scoliosis, juvenile idiopathic arthritis, developmental dysplasia of the hip and achondroplasia.

Biological basis of child health 5: development of the respiratory system and elements of respiratory assessment.

This article is the fifth in a series on the biological basis of child health. It describes the development of the respiratory system, which starts relatively late in the embryo and continues after birth until the age of seven to eight years. It explains what the developing anatomy of the respiratory system in infants and children means in terms of the conditions that may occur and the precautions required when assessing them. The article provides an overview of the elements of respiratory assessment in infants and children and describes some respiratory conditions seen in these patient groups. It also discusses some of the changes in the care of children with respiratory conditions, which has increasingly moved from hospital into the community and become nurse-led, multidisciplinary and holistic.

Digital PCR analysis of circulating tumor DNA: a biomarker for chondrosarcoma diagnosis, prognostication, and residual disease detection.

Conventional chondrosarcoma is the most common primary bone tumor in adults. Prognosis corresponds with tumor grade but remains variable, especially for individuals with grade (G) II disease. There are currently no biomarkers available for monitoring or prognostication of chondrosarcoma. Circulating tumor DNA (ctDNA) has recently emerged as a promising biomarker for a broad range of tumor types. To date, little has been done to study the presence of ctDNA and its potential utility in the management of sarcomas, including chondrosarcoma. In this study, we have assessed ctDNA levels in a cohort of 71 patients, 32 with sarcoma, including 29 individuals with central chondrosarcoma (CS) and 39 with locally aggressive and benign bone and soft tissue tumors, using digital PCR. In patients with CS, ctDNA was detected in pretreatment samples in 14/29 patients, which showed clear correlation with tumor grade as demonstrated by the detection of ctDNA in all patients with GIII and dedifferentiated disease (n = 6) and in 8/17 patients with GII disease, but never associated with GI CS. Notably detection of ctDNA preoperatively in GII disease was associated with a poor outcome. A total of 14 patients with CS had ctDNA levels assessed at multiple time points and in most patients there was a clear reduction following surgical removal. This research lays the foundation for larger studies to assess the utility of ctDNA for chondrosarcoma diagnosis, prognostication, early detection of residual disease and monitoring disease progression.

Society for Endocrinology Competency Framework for Adult Endocrine Nursing: 2nd edition.

This competency framework was developed by a working group of endocrine specialist nurses with the support of the Society for Endocrinology to enhance the clinical care that adults with an endocrine disorder receive. Nurses should be able to demonstrate that they are functioning at an optimal level in order for patients to receive appropriate care. By formulating a competency framework from which an adult endocrine nurse specialist can work, it is envisaged that their development as professional practitioners can be enhanced. This is the second edition of the Competency Framework for Adult Endocrine Nursing. It introduces four new competencies on benign adrenal tumours, hypo- and hyperparathyroidism, osteoporosis and polycystic ovary syndrome. The authors and the Society for Endocrinology welcome constructive feedback on the document, both nationally and internationally, in anticipation that further developments and ideas can be incorporated into future versions.

Pressure alopecia.

Postoperative or pressure alopecia (PA) is an infrequently reported group of scarring and non-scarring alopecias. It has been reported after immobilization of the head during surgery and following prolonged stays on intensive care units, and may be analogous to a healed pressure ulcer. This review presents a summary of cases published in pediatrics and after cardiac, gynecological, abdominal and facial surgeries. PA may manifest as swelling, tenderness, and ulceration of the scalp in the first few postoperative days; in other cases, the alopecia may be the presenting feature with a history of scalp immobilization in the previous four weeks. The condition may cause considerable psychological distress in the long term. Regular head turning schedules and vigilance for the condition should be used as prophylaxis to prevent permanent alopecia. A multi-center study in high-risk patients would be beneficial to shed further light on the etiology of the condition.

Correlations between ultrasonographic characteristics of corpora lutea and systemic concentrations of progesterone during the discrete stages of corpora lutea lifespan and secretory activity in cyclic ewes.

Associations between physical characteristics and functionality of corpora lutea (CL) have previously been reported in monovulatory species, albeit several studies in cattle and humans have refuted the existence of temporal relationships between CL size, echotexture and serum progesterone (P(4)) concentrations. The main objective of the present study was to examine whether or not there were correlations between ultrasonographic image attributes of CL and systemic concentrations of P(4) during the discrete stages of the luteal phase in two breeds of sheep differing in ovulation rates (non-prolific Western White Face [WWF] ewes and prolific Finn [F] sheep). Transrectal ovarian ultrasonography utilized a 7.5-MHz linear-array transducer connected to a portable scanner (Aloka SSD-500) and the images were analyzed using commercially available image analytical software (Image ProPlus(®)) validated for the present application in sheep. The correlations were assessed using the Pearson's Product Moment (PPM) analysis and also, to increase the accuracy of statistical tests, the analysis of covariance (ANCOVA), with the number of CL as a co-factor. In WWF ewes, serum concentrations of P(4) correlated significantly with the total luteal area (TLA) during the CL growth phase (days 3-6; day 0 = ovulation) and functional luteolysis (days 12-15), and with numerical pixel values (NPVs--pixel intensity) during luteolysis; the results obtained by using two different statistical methods were generally similar. In prolific F ewes, serum P(4) concentrations were directly correlated with TLA during CL growth (days 3-6; ANCOVA), functional luteolysis (days 13-14; PPM), and structural CL regression (days 11-14; PPM and ANCOVA), and with NPVs during functional luteolysis (PPM and ANCOVA). We concluded that systemic P(4) concentrations could only be accurately predicted from the changes in luteal area during CL growth and regression, and from NPVs during luteolysis, in both prolific and non-prolific ewes, but the changes in size and echotexture of the luteal glands at mid-cycle were not indicative of serum P(4) concentrations in sheep.

Pulsatile LH secretion and ovarian follicular wave emergence and growth in anestrous ewes.

The objective of this study was to determine if pulsatile LH secretion was needed for ovarian follicular wave emergence and growth in the anestrous ewe. In Experiment 1, ewes were either large or small (10 x 0.47 or 5 x 0.47 cm, respectively; n = 5/group) sc implants releasing estradiol-17 beta for 10 d (Day 0 = day of implant insertion), to suppress pulsed LH secretion, but not FSH secretion. Five sham-operated control ewes received no implants. In Experiment 2, 12 ewes received large estradiol-releasing implants for 12 d (Day 0 = day of implant insertion); six were given GnRH (200 ng IV) every 4 h for the last 6 d that the implants were in place (to reinitiate pulsed LH secretion) whereas six Control ewes were given saline. Ovarian ultrasonography and blood sampling were done daily; blood samples were also taken every 12 min for 6 h on Days 5 and 9, and on Days 6 and 12 of the treatment period in Experiments 1 and 2, respectively. Treatment with estradiol blocked pulsatile LH secretion (P < 0.001). In Experiment 1, implant treatment halted follicular wave emergence between Days 2 and 10. In Experiment 2, follicular waves were suppressed during treatment with estradiol, but resumed following GnRH treatment. In both experiments, the range of peaks in serum FSH concentrations that preceded and triggered follicular wave emergence was almost the same as control ewes and those given estradiol implants alone or with GnRH; mean concentrations did not differ (P < 0.05). We concluded that some level of pulsatile LH secretion was required for the emergence of follicular waves that were triggered by peaks in serum FSH concentrations in the anestrous ewe.

Ovarian follicular dominance and the induction of daily follicular waves in the ewe.

Large antral follicles grow in waves in the ewe, and each wave is triggered by a peak in serum concentrations of FSH. The existence of follicular dominance in the ewe is unclear. The objective of experiment 1 was to determine if an endogenously driven follicular wave could emerge during the growth phase of a wave induced by injection of ovine FSH (oFSH). Cyclic ewes (n = 7) were given oFSH (two injections of 0.5 microg/kg; s.c.; 8 h apart) on 2 separate days equally spaced in the interval between the first two endogenously driven follicular waves of an estrous cycle. Injection of oFSH induced two follicular waves in the interval between the first two endogenously driven waves of the cycle. The second endogenously driven wave of the estrous cycle emerged in the midgrowth phase of a follicular wave induced by injection of oFSH and its day of emergence, and growth pattern did not differ from that of the equivalent wave in control ewes (emerging 5.4 +/- 0.2 and 4.8 +/- 0.5 days after ovulation, respectively; P > 0.05). Experiment 2 was designed to determine if emergence of follicular waves could be induced on a daily basis. Six anestrus ewes were given oFSH (two injections of 0.35 microg/kg; s.c.; 8 h apart) on each of 4 days, starting 24 h after the expected time of an endogenously driven FSH peak. Each injection of oFSH resulted in a discrete peak in serum FSH concentrations and the emergence of a new follicular wave. The present findings provide evidence for the lack of follicular dominance in the ewe.

Differential effects of various estradiol-17beta treatments on follicle-stimulating hormone peaks, luteinizing hormone pulses, basal gonadotropin concentrations, and antral follicle and luteal development in cyclic ewes.

In a previous study, 10-day estradiol implant treatment truncated the FSH peaks that precede follicular waves in sheep, but subsequent ovine FSH (oFSH) injection reinitiated wave emergence. The present study's objectives were to examine the effects of a 20-day estradiol and progesterone treatment on FSH peaks, follicle waves, and responsiveness to oFSH injection. Also, different estradiol doses were given to see whether a model that differentially suppressed FSH peaks, LH pulses, or basal gonadotropin secretion could be produced in order to study effects of these changes on follicular dynamics. Mean estradiol concentrations were 11.8 +/- 0.4 pg/ml, FSH peaks were truncated, wave emergence was halted, and the number of small follicles (2-3 mm in diameter) was reduced (P < 0.05) in cyclic ewes given estradiol and progesterone implants (experiment 1). On Day 15 of treatment, oFSH injection failed to induce wave emergence. With three different estradiol implant sizes (experiment 2), estradiol concentrations were 5.2, 19.0, 27.5, and 34.8 (+/-4.6) pg/ml in control and treated ewes, respectively. All estradiol treatments truncated FSH peaks, except those that created the highest estradiol concentrations. Experiment 2-treated ewes had significantly reduced mean and basal FSH concentrations and LH pulse amplitude and frequency. We concluded that 20-day estradiol treatment truncated FSH peaks, blocking wave emergence, and reduced the small-follicle pool, rendering the ovary unresponsive to oFSH injection in terms of wave emergence. Varying the steroid treatment created differential FSH peak regulation compared with other gonadotropin secretory parameters. This provides a useful model for future studies of the endocrine regulation of ovine antral follicular dynamics.

Suppression of follicle wave emergence in cyclic ewes by supraphysiologic concentrations of estradiol-17beta and induction with a physiologic dose of exogenous ovine follicle-stimulating hormone.

Follicle waves are preceded by follicle-stimulating hormone (FSH) peaks in ewes. The purpose of the present study was to see whether estradiol implant treatment would block FSH peaks to create a model in which the effect of the timing and mode of FSH peaks could be studied by ovine FSH (oFSH) injection. In Experiment 1, 10 ewes received estradiol-17beta implants on Day 4 after ovulation (Day 0, day of ovulation); five ewes received large implants, and five ewes received small implants. Five control ewes received empty implants. In Experiment 2, 12 ewes received large implants on Day 4. On Day 9, six ewes received oFSH twice, 8 h apart (0.5 microg/kg; s.c.). Implants were left in place for 10 days in both experiments. In both studies, ovarian ultrasonography and blood sampling was done daily. In Experiment 1, estradiol concentrations were significantly higher in ewes with large implants (10.4 +/- 0.7 pg/ml) compared with controls (3.9 +/- 0.7 pg/ml) and ewes with small implants (5.4 +/- 0.7 pg/ml; P < 0.001). A significant reduction was found in mean FSH peak concentration (31%; P < 0.05) and FSH peak amplitude (45%; P < 0.05) in ewes with large implants compared with controls. Mean and basal FSH concentrations were unaffected by the large implants. The large implants halted follicle-wave emergence between Day 0 and 8 after implant insertion. The small follicle pool (2-3 mm in diameter) was unaffected by the large implants. When oFSH was injected into ewes with large implants, a follicle wave emerged 1.5 +/- 0.5 days after injection; however, in ewes given saline alone, a follicle wave emerged 4.8 +/- 0.8 days after injection (P < 0.01). We concluded that truncation of FSH peaks by estradiol implants prevented follicle-wave emergence, but injection of physiologic concentrations of oFSH reinitiated follicle-wave emergence.

Factors influencing cure by transsphenoidal selective adenomectomy in paediatric Cushing's disease.

OBJECTIVE: Early diagnosis and effective treatment of paediatric Cushing's disease (CD) is necessary to minimise associated morbidity. Accepted first-line treatment is selective transsphenoidal microadenomectomy (TSS), which can be technically difficult, and cure rates vary considerably between centres. In our paediatric CD patient group we have assessed the possible factors which may influence cure by TSS. SUBJECTS AND METHODS: From 1983-2004, 27 paediatric patients (16 males, 11 females; mean age+/-s.d., 13.1+/-3.2 yr; range, 6.4-17.8 yr) with CD were managed in our centre and underwent TSS. Sixteen patients (59%), seven males and nine females (mean age+/-s.d., 14.2+/-2.5 yr; range, 8.2-17.8 yr), were cured (post-operative serum cortisol < 50 nM). Eleven patients, nine males and two females (mean age+/-s.d., 11.5+/-3.6 yr; range, 6.4-17.8 yr) had post-operative cortisol levels above 50 nM (2-20 days), with mean serum cortisol levels at 09:00 h of 537 nM (range 269-900 nM) indicating a lack of cure. These 11 patients received external beam pituitary radiotherapy (RT). One patient with a pituitary macroadenoma had a post-operative cortisol level of < 50 nM but 0.8 yr later showed an elevated cortisol and residual disease. RESULTS: The patients cured by TSS alone were significantly older than those not cured (P = 0.038; Student's t test). All patients had CT/MRI pituitary imaging: 14 were reported to have microadenomas and one macroadenoma, while 12 were reported as normal. Bilateral simultaneous inferior petrosal sinus sampling (BSIPSS) with i.v. corticotropin-releasing hormone (CRH) administration was introduced as a pre-operative investigation in 1986 and was performed in 21 patients (78%), on BSIPSS, 16 (76%) had evidence suggesting pituitary adrenocorticotropic hormone (ACTH) secretion (central to peripheral (IPS:P) ACTH ratio after CRH of > or = 3.0) and 16 (76%) showed lateralisation of ACTH secretion (IPSG of > or = 1.4). There was concordance between the BSIPSS finding and the position of the microadenoma at surgery in 17/21 (81%) patients. Of the 16 patients showing lateralisation of ACTH secretion, 12 (75%) were cured by TSS. Of the four without lateralisation of ACTH, suggesting a midline lesion, 3 (75%) were cured by TSS. Post-operative pituitary hormone deficiencies in the patients cured by TSS were: pan-hypopituitarism 1/16, isolated growth hormone deficiency (GHD) (peak GH on glucagon/ITT < 1-17.9 mU/l) 9/16 and diabetes insipidus 3/16. CONCLUSION: Over a 21-year period selective adenomectomy by TSS cured 59% of all paediatric CD patients, with higher age favouring cure. Introduction of BSIPSS resulted in the demonstration of a high rate of lateralisation of ACTH secretion consistent with the surgical identification of the adenoma, and therefore appears likely to have contributed to the higher surgical cure rate.

Endogenous interferon-alpha production by differentiating human monocytes regulates expression and function of the IL-2/IL-4 receptor gamma chain.

In vitro monocyte-derived macrophages (MDMac) and synovial fluid macrophages from inflamed joints differ from monocytes in their responses to interleukin 4 (IL-4). While IL-4 can suppress LPS-induced interleukin beta (IL-beta) and tumour necrosis factor alpha (TNF-alpha) production by monocytes, IL-4 can suppress LPS-induced IL-1 beta, but not TNFalpha production by the more differentiated cells. Recently we reported a correlation between the ability of IL-4 to regulate TNFalpha production by monocytes and the expression of the IL-4 receptor gamma chain or gamma common (gamma c chain). Like MDMac, interferon alpha (IFNalpha)-treated monocytes expressed less IL-4 receptor gamma c chain, reduced levels of IL-4-activated STAT6 and IL-4 could not suppress LPS-induced TNFalpha production. In addition, like monocytes and MDMac, IFNalpha-treated monocytes expressed normal levels of the IL-4 receptor alpha chain and IL-4 significantly suppressed LPS-induced IL-1 beta production. With addition of IFNalpha-neutralizing antibodies, the ability of IL-4 to suppress LPS-induced TNFalpha production with prolonged monocyte culture was restored. Detection of IFNalpha in synovial fluids from inflamed joints further implicates IFNalpha in the inability of IL-4 to suppress TNFalpha production by synovial fluid macrophages. This study identifies a mechanism for the differential expression of gamma c and varied responses to IL-4 by human monocytes compared with MDMac.

IFN-gamma downregulates interleukin-4 functional activity on monocytes by multiple mechanisms.

Interleukin-4 (IL-4) has potent anti-inflammatory properties on monocytes and suppresses lipopolysaccharide (LPS)-induced tumor necrosis factor-alpha (TNF-alpha) and IL-1beta production. Culture with interferon (IFN-gamma) alters human monocyte responses to IL-4 by multiple mechanisms. As previously published, IFN-gamma reduced IL-4-activated signal transducer and activator of transcription-6 (STAT-6). This correlated with an inability of IL-4 to suppress LPS-induced TNF-alpha but not IL-1beta production. A second mechanism, apparent some 48 h after exposure to IFN-gamma, involved a significant suppression of IL-4 receptor (IL-4R) expression at the cell surface, and this correlated with the loss of additional functional responses to IL-4, including IL-4-induced suppression of LPS-induced IL-1beta production. This study identified a further role of IFN-gamma on IL-4 responses, including reduced IL-4R surface expression by human monocytes. Increased release of soluble gammac from IFN-gamma-treated monocytes provides an additional mechanism by which IFN-gamma may control the functional activity of IL-4. This study characterizes further the opposing effects of the type 1 and type 2 cytokine regulatory systems.