Evaluation of Facial Profile Esthetics After Maxillomandibular Advancement Surgery for the Treatment of Obstructive Sleep Apnea.

PURPOSE: Maxillomandibuar advancement (MMA) surgery has been shown to be a successful treatment for obstructive sleep apnea (OSA), but concerns still exist regarding esthetic outcomes due to the large advancements involved. The objective of this study was to evaluate facial profile changes in patients who underwent MMA surgery for OSA by utilizing panels of external evaluators. METHODS: Pre- and posttreatment silhouettes of 21 patients (10 females, 11 males; mean age 43.2 [±11.5] years), who underwent MMA surgery for OSA, were generated from profile photographs. Utilizing survey software, the individual silhouettes were shown in random order to surgeons, orthodontists and laypeople, who assessed the esthetics of each via a sliding visual analogue scale (0 to 10). RESULTS: For all evaluators combined, postsurgical esthetic scores were significantly improved in 19 of 21 patients (P < .001). Ninety-five percent of evaluators judged the changes after surgery as positive or neutral. There was a mean increase in postsurgical esthetic scores of 1.9 [±1.9], which was moderately correlated with AHI changes (r = 0.48, P < .05). Mean esthetic score changes were significantly different between evaluator groups for 12 of 21 patients (P < .05), with surgeons and orthodontists reporting more positive change than laypeople. CONCLUSIONS: Overall, MMA surgery for the treatment of OSA does not have a negative impact on facial profile esthetics, with external evaluators judging the changes as favorable in the majority of patients assessed.

Vancomycin Therapeutic Drug Monitoring: A Cross-Sectional Survey of Canadian Hospitals.

Background: Little is known about the current landscape of vancomycin therapeutic drug monitoring (TDM) in Canadian hospitals, which operate within publicly funded health care systems. Objectives: To determine current TDM practices for vancomycin and associated challenges and to gather perceptions about TDM based on area under the concentration-time curve (AUC) in Canadian hospitals. Methods: An electronic survey was distributed to hospital pharmacists in spring 2021 through multiple national and provincial antimicrobial stewardship, public health, and pharmacy organizations. The survey gathered data about hospital characteristics, TDM methods, inclusion criteria for patient selection, pharmacokinetic and pharmacodynamic targets, vancomycin susceptibility testing and reporting, and perceived barriers and challenges. Results: In total, 120 pharmacists from 10 of the 13 provincial and territorial jurisdictions in Canada, representing 12.5% of Canadian acute care hospitals (n = 962), completed at least 90% of survey questions. The predominant TDM method was trough-based (107/119, 89.9%); another 10.1% of respondents (12/119) reported performing AUC-based TDM (with or without trough-based TDM), and 17.9% (19/106) of those not already using AUC-based TDM were considering implementing it within 1 to 2 years. Among hospitals performing trough-based TDM, 60.5% (66/109) targeted trough levels between 15 and 20 mg/L for serious infections with methicillin-resistant Staphylococcus aureus. One-quarter of the respondents using this method (27/109, 24.8%) agreed that trough-based TDM was of uncertain benefit, and about one-third (33/109, 30.3%) were neutral on this question. Multiple challenges were identified for trough-based TDM, including sub- or supra-therapeutic concentrations and collection of specimens at inappropriate times. Overall, 40.5% (47/116) of respondents agreed that AUC-based TDM was likely safer than trough-based TDM, whereas 23.3% (27/116) agreed that AUC-based TDM was likely more effective. Conclusions: This survey represents a first step in developing evidence-based, standardized best practices for vancomycin TDM that are uniquely suited to the Canadian health care system.

Contexte: On connaît peu de choses sur le paysage actuel du suivi thérapeutique pharmacologique (STP) de la vancomycine dans les hôpitaux canadiens, dont les activités s'inscrivent dans le cadre des systèmes de soins de santé financés par les deniers publics. Objectifs: Déterminer les pratiques actuelles de STP de la vancomycine et les défis associés et recueillir les perceptions concernant le STP sur la base de l'aire sous la courbe de la concentration en fonction du temps (ASC) dans les hôpitaux canadiens. Méthodes: Un sondage a été distribué électroniquement aux pharmaciens d'hôpitaux au printemps 2021 par plusieurs organismes nationaux et provinciaux de gestion de l'utilisation des antimicrobiens, de santé publique et de pharmacie. Le sondage a permis de rassembler des données concernant les caractéristiques des hôpitaux, les méthodes de STP, les critères d'inclusion pour la sélection des patients, les objectifs pharmacocinétiques et pharmacodynamiques, les tests de sensibilité à la vancomycine et les rapports des résultats, ainsi que les obstacles et les défis perçus. Résultats: Au total, 120 pharmaciens de 10 des 13 provinces et territoires du Canada, représentant 12,5 % des hôpitaux canadiens de soins actifs (n = 962), ont répondu à au moins 90 % des questions du sondage. La méthode de STP prédominante utilisée était celle de la concentration minimale (107/119, 89,9 %); un autre 10,1 % des répondants (12/119) ont déclaré effectuer un STP basé sur l'ASC (avec ou sans STP basé sur la concentration minimale), et 17,9 % (19/106) de ceux qui n'effectuaient pas déjà le STP basé sur l'ASC envisageaient de le mettre en œuvre d'ici 1 à 2 ans. Parmi les hôpitaux pratiquant le STP basé sur la concentration minimale, 60,5 % (66/109) ciblaient des concentrations minimales entre 15 et 20 mg/L pour les infections graves à Staphylococcus aureus résistant à la méthicilline. Un quart des répondants qui utilisaient cette méthode (27/109, 24,8 %) convenaient que les avantages du STP basé sur la concentration minimale étaient incertains, et environ un tiers (33/109, 30,3 %) étaient neutres. De multiples défis ont été identifiés pour le STP basé sur la concentration minimale, notamment des concentrations sous-ou supra-thérapeutiques et la collecte d'échantillons à des moments inappropriés. Dans l'ensemble, 40,5 % (47/116) des répondants convenaient que le STP basé sur l'ASC était probablement plus sûr que le STP basé sur la concentration minimale, tandis que 23,3 % (27/116) convenaient que le STP basé sur l'ASC était probablement plus efficace. Conclusions: Ce sondage représente une première étape dans l'élaboration de pratiques exemplaires normalisées et fondées sur des données probantes pour le STP de la vancomycine qui sont particulièrement adaptées au système de santé canadien.

Antibiotic treatment durations for pyogenic liver abscesses: A systematic review.

Background: We sought to systematically review the existing research on pyogenic liver abscesses to determine what data exist on antibiotic treatment durations. Methods: We conducted a systematic review and meta-analysis of contemporary medical literature from 2000 to 2020, searching for studies of pyogenic liver abscesses. The primary outcome of interest was mean antibiotic treatment duration, which we pooled by random-effects meta-analysis. Meta-regression was performed to examine characteristics influencing antibiotic durations. Results: Sixteen studies (of 3,933 patients) provided sufficient data on antibiotic durations for pooling in meta-analysis. Mean antibiotic durations were highly variable across studies, from 8.4 (SD 5.3) to 68.9 (SD 30.3) days. The pooled mean treatment duration was 32.7 days (95% CI 24.9 to 40.6), but heterogeneity was very high (I2 = 100%). In meta-regression, there was a non-significant trend towards decreased mean antibiotic treatment durations over later study years (-1.14 days/study year [95% CI -2.74 to 0.45], p = 0.16). Mean treatment duration was not associated with mean age of participants, percentage of infections caused by Klebsiella spp, percentage of patients with abscesses over 5 cm in diameter, percentage of patients with multiple abscesses, and percentage of patients receiving medical management. No randomized trials have compared treatment durations for pyogenic liver abscess, and no observational studies have reported outcomes according to treatment duration. Conclusions: Among studies reporting on antibiotic durations for pyogenic liver abscess, treatment practices are highly variable. This variability does not seem to be explained by differences in patient, pathogen, abscess, or management characteristics. Future RCTs are needed to guide optimal treatment duration for patients with this complex infection.

Historique: Les chercheurs ont procédé à l'analyse systématique des recherches sur les abcès hépatiques pyogènes afin de découvrir les données sur la durée de l'antibiothérapie. Méthodologie: Les chercheurs ont réalisé une analyse systématique et une méta-analyse des publications médicales parues entre 2000 et 2020 pour en extraire les études sur les abcès hépatiques pyogènes. Le résultat primaire était la durée moyenne de l'antibiothérapie, qu'ils ont regroupée par méta-analyse à effets aléatoires. Ils ont procédé à une méta-régression pour examiner les caractéristiques qui influent sur la durée de l'antibiothérapie. Résultats: Seize études (auprès de 3 933 patients) contenaient assez de données sur la durée de l'antibiothérapie pour être regroupées dans la méta-analyse. La durée moyenne de l'antibiothérapie était très variable d'une étude à l'autre, de 8,4±5,3 à 68,9±30,3 jours. La durée moyenne du traitement regroupé était de 32,7 jours (IC à 95 %, 24,9 à 40,6 jours), mais l'hétérogénéité était très élevée (I2 = 100 %). La méta-régression a révélé une tendance non significative vers une durée moins longue de l'antibiothérapie moyenne pendant les dernières années de l'étude (−1,14 jour par année d'étude, IC à 95 %, −2,74+0,45, p = 0,16). La durée moyenne du traitement n'était pas associée à l'âge moyen des participants, au pourcentage d'infections causées par les espèces de Klebsiella, au pourcentage de patients ayant un abcès de plus de cinq centimètres de diamètre, au pourcentage de patients ayant de multiples abcès et au pourcentage de patients recevant une prise en charge médicale. Aucune étude randomisée n'avait comparé la durée du traitement de l'abcès hépatique pyogène, et aucune étude observationnelle n'avait rendu compte des résultats cliniques en fonction de la durée du traitement. Conclusions: Dans les études sur la durée de l'antibiothérapie des abcès hépatiques pyogènes, les pratiques thérapeutiques sont très variables. Cette variabilité ne semble pas s'expliquer par les différences entre les patients, les agents pathogènes, les abcès ou les caractéristiques de prise en charge. Des études randomisées et contrôlées devront être réalisées pour obtenir des indications quant à la durée optimale du traitement chez les patients atteints de cette infection complexe.

Estimating daily antibiotic harms: an umbrella review with individual study meta-analysis.

BACKGROUND: There is growing evidence supporting the efficacy of shorter courses of antibiotic therapy for common infections. However, the risks of prolonged antibiotic duration are underappreciated. OBJECTIVES: To estimate the incremental daily risk of antibiotic-associated harms. METHODS: We searched three major databases to retrieve systematic reviews from 2000 to 30 July 2020 in any language. ELIGIBILITY: Systematic reviews were required to evaluate shorter versus longer antibiotic therapy with fixed durations between 3 and 14 days. Randomized controlled trials included for meta-analysis were identified from the systematic reviews. PARTICIPANTS: Adult and paediatric patients from any setting. INTERVENTIONS: Primary outcomes were the proportion of patients experiencing adverse drug events, superinfections and antimicrobial resistance. RISK OF BIAS ASSESSMENT: Each randomized controlled trial was evaluated for quality by extracting the assessment reported by each systematic review. DATA SYNTHESIS: The daily odds ratio (OR) of antibiotic harm was estimated and pooled using random effects meta-analysis. RESULTS: Thirty-five systematic reviews encompassing 71 eligible randomized controlled trials were included. Studies most commonly evaluated duration of therapy for respiratory tract (n = 36, 51%) and urinary tract (n = 29, 41%) infections. Overall, 23 174 patients were evaluated for antibiotic-associated harms. Adverse events (n = 20 345), superinfections (n = 5776) and antimicrobial resistance (n = 2330) were identified in 19.9% (n = 4039), 4.8% (n = 280) and 10.6% (n = 246) of patients, respectively. Each day of antibiotic therapy was associated with 4% increased odds of experiencing an adverse event (OR 1.04, 95% CI 1.02-1.07). Daily odds of severe adverse effects also increased (OR 1.09, 95% CI 1.00-1.19). The daily incremental odds of superinfection and antimicrobial resistance were OR 0.98 (0.92-1.06) and OR 1.03 (0.98-1.07), respectively. CONCLUSION: Each additional day of antibiotic therapy is associated with measurable antibiotic harm, particularly adverse events. These data may provide additional context for clinicians when weighing benefits versus risks of prolonged antibiotic therapy.

Evaluation of different antimicrobial stewardship models at a rehabilitation hospital: An interrupted time series (ITS) study.

Objective: To evaluate different prospective audit-and-feedback models on antimicrobial prescribing at a rehabilitation hospital. Design: Retrospective interrupted time series (ITS) and qualitative methods. Setting: A 178-bed rehabilitation hospital within an academic health sciences center. Methods: ITS analysis was used to analyze monthly days of therapy (DOT) per 1,000 patient days (PD) and monthly urine cultures ordered per 1,000 PD. We compared 2 sequential intervention periods to the baseline: (1) a period when a dedicated antimicrobial stewardship (AMS) pharmacist performed prospective audit and feedback and provided urine culture education followed by (2) a period when ward pharmacists performing audit and feedback. We conducted an electronic survey with physicians and semistructured interviews with pharmacists, respectively. Results: Audit and feedback conducted by an AMS pharmacist resulted in a 24.3% relative reduction in total DOT per 1,000 PD (incidence rate ratio [IRR], 0.76; 95% confidence interval [CI], 0.58-0.99; P = .04), whereas we detected no difference between ward pharmacist audit and feedback and the baseline (IRR, 1.20; 95% CI, 0.53-2.70; P = .65). We detected no statistically significant change in monthly urine-culture orders between the AMS pharmacist period and the baseline (level coefficient, 0.81; 95% CI, 0.65-1.01; P = .07). Compared to baseline, the ward pharmacist period showed a statistically significant increase in urine-culture ordering over time (slope coefficient, 1.04; 95% CI, 1.01-1.08; P = .02). The barrier most identified by pharmacists was insufficient time. Conclusions: Audit and feedback conducted by an AMS pharmacist in a rehabilitation hospital was associated with decreased antimicrobial use.

Use of Novel Strategies to Develop Guidelines for Management of Pyogenic Osteomyelitis in Adults: A WikiGuidelines Group Consensus Statement.

Importance: Traditional approaches to practice guidelines frequently result in dissociation between strength of recommendation and quality of evidence. Objective: To construct a clinical guideline for pyogenic osteomyelitis management, with a new standard of evidence to resolve the gap between strength of recommendation and quality of evidence, through the use of a novel open access approach utilizing social media tools. Evidence Review: This consensus statement and systematic review study used a novel approach from the WikiGuidelines Group, an open access collaborative research project, to construct clinical guidelines for pyogenic osteomyelitis. In June 2021 and February 2022, authors recruited via social media conducted multiple PubMed literature searches, including all years and languages, regarding osteomyelitis management; criteria for article quality and inclusion were specified in the group's charter. The GRADE system for evaluating evidence was not used based on previously published concerns regarding the potential dissociation between strength of recommendation and quality of evidence. Instead, the charter required that clear recommendations be made only when reproducible, prospective, controlled studies provided hypothesis-confirming evidence. In the absence of such data, clinical reviews were drafted to discuss pros and cons of care choices. Both clear recommendations and clinical reviews were planned with the intention to be regularly updated as new data become available. Findings: Sixty-three participants with diverse expertise from 8 countries developed the group's charter and its first guideline on pyogenic osteomyelitis. These participants included both nonacademic and academic physicians and pharmacists specializing in general internal medicine or hospital medicine, infectious diseases, orthopedic surgery, pharmacology, and medical microbiology. Of the 7 questions addressed in the guideline, 2 clear recommendations were offered for the use of oral antibiotic therapy and the duration of therapy. In addition, 5 clinical reviews were authored addressing diagnosis, approaches to osteomyelitis underlying a pressure ulcer, timing for the administration of empirical therapy, specific antimicrobial options (including empirical regimens, use of antimicrobials targeting resistant pathogens, the role of bone penetration, and the use of rifampin as adjunctive therapy), and the role of biomarkers and imaging to assess responses to therapy. Conclusions and Relevance: The WikiGuidelines approach offers a novel methodology for clinical guideline development that precludes recommendations based on low-quality data or opinion. The primary limitation is the need for more rigorous clinical investigations, enabling additional clear recommendations for clinical questions currently unresolved by high-quality data.

Point-of-care program in HIV, tuberculosis, and associated conditions: A virtual global technical assistance platform to strengthen HIV and tuberculosis workforce capacity.

A global multi-disciplinary faculty was established to work collaboratively and provide virtual technical assistance, using a point-of-care continuing education model, to clinicians across the world engaged in the care of patients with either HIV infection or tuberculosis. Ancillary offerings included live or virtual lectures, case-based conferences, and courses. In spite of the considerable disruption of the program due to the COVID-19 pandemic, we engaged and assisted a substantial number of clinicians across the world and provided meaningful contributions to their continuous professional development and patient care. In light of the ongoing pandemic, virtual technical assistance models such as this should be scaled to continue essential high-quality HIV/TB services.

The Co-occurrence of Pediatric Obesity and ADHD: an Understanding of Shared Pathophysiology and Implications for Collaborative Management.

PURPOSE OF REVIEW: To describe what is known about the association between obesity and attention-deficit hyperactivity disorder (ADHD) in children along with the co-occurring conditions of sleep dysfunction, loss of control/binge eating disorder (LOC-ED/BED), and anxiety. RECENT FINDINGS: Obesity and ADHD share common brain pathways (hypothalamic, executive, and reward centers) with pathophysiology in these areas manifesting in partial or complete expression of these diseases. Sleep dysfunction, LOC-ED/BED, and anxiety share similar pathways and are associated with this disease dyad. The association of obesity and ADHD with sleep dysfunction, LOC-ED/BED, and anxiety is discussed. An algorithm outlining decision pathways for patients with obesity and with and without ADHD is presented. Future research exploring the complex pathophysiology of both obesity and ADHD as well as co-occurring conditions is needed to develop clinical guidelines and ultimately assist in providing the best evidence-based care.

The biological activity of ubiquitinated BoNT/B light chain in vitro and in human SHSY-5Y neuronal cells.

BoNT/B light chain is a zinc-dependent endopeptidase. After entering its target, the neuronal cell, BoNT/B is responsible for synaptobrevin-2 (VAMP-2) cleavage. This results in reduced neurotransmitter (acetylcholine) release from synaptic vesicles, yielding muscular paralysis. Since the toxin persists in neuronal cells for an extended period, regeneration of VAMP-2 is prevented. We evaluated therapeutic targets to overcome botulinum persistence because early removal would rescue the neuronal cell. The ubiquitination/proteasome cellular pathway is responsible for removing "old" or undesirable proteins. Therefore, we assessed ubiquitination of BoNT/B light chain in vitro, and characterized the effects of ubiquitination modulating drugs, PMA (phorbol 12-myristate 13-acetate) and expoxomicin, on ubiquitination of BoNT/B light chain in neuronal cells. Both drugs altered BoNT/B light chain ubiquitination. Ubiquitination in vitro and in cells decreased the biological activity of BoNT/B light chain. These results further elucidate BoNT protein degradation pathways in intoxicated neuronal cells and mechanisms to enhance toxin removal.

Necuparanib, A Multitargeting Heparan Sulfate Mimetic, Targets Tumor and Stromal Compartments in Pancreatic Cancer.

Pancreatic cancer has an abysmal 5-year survival rate of 8%, making it a deadly disease with a need for novel therapies. Here we describe a multitargeting heparin-based mimetic, necuparanib, and its antitumor activity in both in vitro and in vivo models of pancreatic cancer. Necuparanib reduced tumor cell proliferation and invasion in a three-dimensional (3D) culture model; in vivo, it extended survival and reduced metastasis. Furthermore, proteomic analysis demonstrated that necuparanib altered the expression levels of multiple proteins involved in cancer-driving pathways including organ development, angiogenesis, proliferation, genomic stability, cellular energetics, and invasion and metastasis. One protein family known to be involved in invasion and metastasis and altered by necuparanib treatment was the matrix metalloprotease (MMP) family. Necuparanib reduced metalloproteinase 1 (MMP1) and increased tissue inhibitor of metalloproteinase 3 (TIMP3) protein levels and was found to increase RNA expression of TIMP3. MMP enzymatic activity was also found to be reduced in the 3D model. Finally, we confirmed necuparanib's in vivo activity by analyzing plasma samples of patients enrolled in a phase I/II study in patients with metastatic pancreatic cancer; treatment with necuparanib plus standard of care significantly increased TIMP3 plasma protein levels. Together, these results demonstrate necuparanib acts as a broad multitargeting therapeutic with in vitro and in vivo anti-invasive and antimetastatic activity.

An improved genetic system for detection and analysis of protein nuclear import signals.

BACKGROUND: Nuclear import of proteins is typically mediated by their physical interaction with soluble cytosolic receptor proteins via a nuclear localization signal (NLS). A simple genetic assay to detect active NLSs based on their function in the yeast Saccharomyces cerevisiae has been previously described. In that system, a chimera consisting of a modified bacterial LexA DNA binding domain and the transcriptional activation domain of the yeast Gal4 protein is fused to a candidate NLS. A functional NLS will redirect the chimeric fusion to the yeast cell nucleus and activate transcription of a reporter gene. RESULTS: We have reengineered this nuclear import system to expand its utility and tested it using known NLS sequences from adenovirus E1A. Firstly, the vector has been reconstructed to reduce the level of chimera expression. Secondly, an irrelevant "stuffer" sequence from the E. coli maltose binding protein was used to increase the size of the chimera above the passive diffusion limit of the nuclear pore complex. The improved vector also contains an expanded multiple cloning site and a hemagglutinin epitope tag to allow confirmation of expression. CONCLUSION: The alterations in expression level and composition of the fusions used in this nuclear import system greatly reduce background activity in beta-galactosidase assays, improving sensitivity and allowing more quantitative analysis of NLS bearing sequences.

Children's ideas for the design of AAC assistive technologies for young children with complex communication needs.

This study examined children's preferences and priorities for the design of assistive technologies to enhance communication for children with complex communication needs. Six children without disabilities were provided with drawing and craft materials and were asked to develop low-tech prototypes of inventions to support the communication of a young child who had significant speech and motor impairments. The design process and the inventions were analyzed using qualitative methods. Results showed that the children's inventions differed significantly from the designs of current AAC technologies. Their inventions were not simply speech prostheses; rather, they integrated multiple functions (e.g., communication, social interaction, companionship, play, artistic expression, telecommunications) and provided dynamic contexts to support social interactions with others, especially peers. The children characterized the systems as companions and utilized innovative names, bright colors, lights, transformable shapes, popular themes, humor, and amazing accomplishments to capture interest, enhance appeal, build self-esteem, and establish a positive social image. The systems were easily personalized to reflect the user's age, personality, attitude, interests, and preferences. Re-designing AAC technologies to incorporate these types of functions and features may increase their appeal and make them easier for young children to learn and use. Results are discussed with reference to implications for future research and development.

Psychological contributors to noncompletion of an adolescent preoperative bariatric surgery program.

BACKGROUND: Noncompletion of preoperative bariatric programs is a significant problem among adolescents. Adult studies suggest that psychological factors contribute to noncompletion of preoperative bariatric programs. OBJECTIVE: The aim of this study was to determine the association between adolescent psychological functioning and completion of the preoperative phase of a bariatric program. SETTING: The study was conducted at a tertiary care children's hospital affiliated with a university medical center. METHODS: Seventy-four adolescents and their parents completed an assessment measure of psychological functioning with the Behavior Assessment System for Children, Second Edition. We compared these scores between adolescents who completed the preoperative phase of the bariatric program and proceeded to surgery (completers) to those who did not (noncompleters) using multivariate analysis of covariance and logistic regression analyses, adjusting for demographic characteristics and baseline body mass index. RESULTS: The mean age was 16.0 (1.1) years, most were female (79.8%), and the group was diverse (48.6%, Caucasian; 33.8%, black; 17.6%, other, including Hispanic, Asian, and biracial). Average body mass index was 50.5 (7.6) kg/m2. Forty-two percent of participants were noncompleters. Noncompleters were reported by parents to have more clinically significant externalizing and internalizing behaviors and fewer adaptive behaviors. Noncompleters self-reported more clinically significant internalizing symptoms, emotional problems, and poor personal adjustment. CONCLUSION: Adolescents who did not complete the preoperative phase of a bariatric surgery program had more clinically significant psychological symptoms across multiple domains compared with those who successfully proceeded to bariatric surgery. Early identification and treatment of psychological symptoms may be important in helping adolescents successfully proceed to surgery.

Pediatric nerve agent poisoning: medical and operational considerations for emergency medical services in a large American city.

Most published recommendations for treatment of pediatric nerve agent poisoning are based on standard resuscitation doses for these agents. However, certain medical and operational concerns suggest that an alternative approach may be warranted for treatment of children by emergency medical personnel after mass chemical events. (1) There is evidence both that suprapharmacological doses may be warranted and that side effects from antidote overdosage can be tolerated. (2) There is concern that many emergency medical personnel will have difficulty determining both the age of the child and the severity of the symptoms. Therefore, the Regional Emergency Medical Advisory Committee of New York City and the Fire Department, City of New York, Bureau of Emergency Medical Services, in collaboration with the Center for Pediatric Emergency Medicine of the New York University School of Medicine and the Bellevue Hospital Center, have developed a pediatric nerve agent antidote dosing schedule that addresses these considerations. These doses are comparable to those being administered to adults with severe symptoms and within limits deemed tolerable after inadvertent nerve agent overdose in children. We conclude that the above approach is likely a safe and effective alternative to weight-based dosing of children, which will be nearly impossible to attain under field conditions.

Disparities in parent confidence managing child weight-related behaviors.

OBJECTIVE: To describe ethnic disparities in parental confidence managing child weight-related behaviors. METHODS: This was a cross-sectional survey of 59 parents of children with obesity between 4 and 7 years of age presenting to a tertiary care pediatric weight management clinic. Parents completed a validated measure assessing their confidence managing their child's weight-related behaviors (parent confidence score). Student's t-tests and linear regression analyses were used to determine parent and child characteristics associated with parent confidence score. RESULTS: Families were ethnically diverse with half being of Hispanic ethnicity. Mean parent confidence score was 159 (SD 66) with 71% of parents with parent confidence scores below the clinical cut-off for the measure. Parent confidence score was lower among Hispanic (mean 133, SD 67) compared to non-Hispanic parents (mean 184, SD 55, p < 0.01). Parent confidence score was most strongly associated with parental ethnicity (ß = -0.39, p = 0.002, adjusted R(2) = 0.14). CONCLUSION: Parental confidence managing weight-related behaviors was low among parents of young obese children, especially those of Hispanic ethnicity. PRACTICE IMPLICATIONS: This study highlights the need to assess parental confidence in managing weight-related behaviors as part of pediatric obesity care and to provide counseling to improve parental management of weight-related behaviors in a culturally-appropriate manner.

Evaluation of intelligence in an adolescent bariatric population.

BACKGROUND: The use of bariatric surgery as treatment for morbid obesity in adolescents has nearly tripled in recent years. Intelligence is an important component to a patient's assent of surgery and maintenance of a healthy lifestyle. The objective of this study was to describe the intelligence testing performance of a cohort of adolescents seeking laparoscopic adjustable gastric banding (LAGB). Twenty-nine patients (93% female, 62% white) with a mean age of 16 years and mean body mass index (BMI) of 49 kg/m(2) were enrolled in an adolescent bariatric program in the United States. METHODS: We conducted a cross-sectional analysis, evaluating patient intelligence at a single preoperative time point using the Weschler Intelligence Scale for Children-IV or Weschler Adult Intelligence Scale-IV. Intelligence quotient (IQ) scores were analyzed descriptively and in relationship to patient anthropometric measurements and characteristics. RESULTS: Mean IQ was average for age (95, SD 16), although 21% of patients had an IQ<80 and no patients had an IQ>120. There was no significant association between IQ and BMI, weight, or waist circumference. Mean IQ was lower in patients who had failed a grade compared with those who had not failed a grade (P<.01) and in patients whose parents had not graduated college compared with those whose parents had (P< .05). CONCLUSION: In our cohort of adolescents seeking LAGB, mean IQ was average for age, suggesting capability to understand the procedure and healthy lifestyle concepts. Patients who exhibit deficits in intellect prior to surgery may benefit from educational resources and clinician support tailored to their reasoning abilities.