Patients with Altered Mental Status May Benefit from Medical Toxicology Consultation.

BACKGROUND: Presentation of intoxicated patients to hospitals is frequent, varied, and increasing. Medical toxicology expertise could lead to important changes in diagnosis and treatment, especially in patients presenting with altered mental status. OBJECTIVES: To describe and analyze clinical scenarios during a 1-year period after the establishment of a medical toxicology consultation service (MTCS). METHODS: Cases of 10 patients with altered mental status at presentation were evaluated. Medical toxicology consultation suggested major and significant changes in diagnosis and management. RESULTS: Of 973 toxicology consultations performed during the study period, bedside consultation was provided for 413 (42%) patients. Of these 413, 88 (21%) presented with some level of altered mental status. We described 10 patients in whom medical toxicology consultation brought about major and significant changes in diagnosis and management. CONCLUSIONS: Benefits may be derived from medical toxicology consultations, especially in patients with altered mental status. Medical toxicology specialists are well positioned to provide high value and expedited patient care.

Does the delivery mode affect post-birth neonatal serum C-reactive protein levels? A causal effect analysis.

AIM: To determine if the delivery mode has a causal effect on neonatal serum C-reactive protein (CRP) levels. If such a causal effect exists, we aim to quantify its magnitude. METHODS: We investigated the causal effect of the delivery mode on serum CRP levels 6-8 h after delivery, with appropriate statistical tools for retrospective studies, combining classical and machine-learning methods. The statistical inference is followed by sensitivity analysis to quantify the magnitude of unobserved bias required in order to alter the study's conclusion. RESULTS: This retrospective study reviewed laboratory records of neonates after birth who underwent blood tests due to suspected sepsis. A total of 440 newborns were included, 324 of which underwent a vaginal delivery, 59 an urgent caesarean delivery, and 57 an elective caesarean delivery. Our results revealed that serum CRP values following elective caesarean deliveries were 50% less than those following a vaginal delivery (P = 0.030; -0.907; 95% CI [-1.545, -0.268] in log-CRP units). No significant effect was found for urgent caesarean deliveries compared to vaginal deliveries (P = 0.887). Those results were strengthened by (1) a sensitivity magnitude of 1.6 to unobserved bias and (2) non-significant effects when analysis is repeated on blood collected 12-24 h after birth. CONCLUSION: CRP concentrations in neonatal blood during the first 6-8 h of life are higher following vaginal deliveries compared to elective caesarean deliveries. Further studies with the intent of improving EONS detection should include information on the delivery mode.

C-reactive protein and the neonatal early-onset sepsis calculator for the diagnosis of neonatal sepsis.

Our aim was to evaluate the utility of the neonatal early-onset sepsis risk calculator (NEOSC) to the utility of C-reactive protein (CRP) for diagnosing neonatal EOS. This retrospective study reviewed the records of neonates who underwent sepsis workups due to equivocal symptoms and compared their CRP values to the calculator's recommendations and their cultures. A total of 382 newborns who underwent sepsis work-up due to equivocal symptoms were included in our study. The calculator's recommendations would have reduced the number of newborns who underwent sepsis workups by 82.5% and antibiotic treatment by 83.4% (n = 315). Considering that 373 of 382 (97.6%) ultimately had no sepsis, the calculator's specificity was higher than that of CRP (83.9% versus 76.1%). When comparing the maximal CRP value with the risk according to the neonatal sepsis calculator, a significant correlation was found between them (P < 0.01), but the relationship was not strong (Pearson's correlation = 0.27). We found a significant correlation between the risk of sepsis according to the NEOSC and the CRP values, although the correlation was not strong. The calculator's high specificity enables safe avoidance of multiple blood tests and antibiotic treatments for suspected neonates who are not infected. CRP tests can reduce the number of infected newborns the calculator may miss, at the cost of unnecessary blood tests and antibiotic therapy to many newborns.

Risk factors for readmission for phototherapy due to jaundice in healthy newborns: a retrospective, observational study.

BACKGROUND: The guidelines of the American Academy of Pediatrics (AAP) for monitoring neonatal jaundice recommend universal postnatal screening for hyperbilirubinemia within 48 h from discharge. We observed that neonate with low-risk jaundice were more likely to be readmitted to hospital for phototherapy compared to neonate with high-risk jaundice. The aim of this study was to identify additional factors that increase the risk for jaundice-related readmission. METHODS: This observational case-control study was performed on 100 consecutive neonates with jaundice who were readmitted to hospital for phototherapy treatment and were compared to 100 neonates with jaundice during hospitalization who were not readmitted after discharge. The data retrieved from the medical records of all participants included maternal characteristics, delivery type and noteworthy events, gestational age at delivery, birth weight and weight loss, neonate physical findings, Apgar scores, laboratory findings, length of hospital stay, and administration of phototherapy during hospitalization. The length of time since discharge and readmission for jaundice was also recorded. RESULTS: The risk of readmission decreased by 48% [odds ratio (OR) =0.52; 95% confidence interval (CI) 0.341-0.801] with every day added to the original hospitalization stay, and by 71% (OR = 0.29; 95% CI 0.091-0.891) if phototherapy had been administered during postnatal hospitalization. In contrast, the risk increased by 28% (OR = 1.28; 95% CI 1.164-1.398) with every elevation by 1% in hematocrit, and by 2.78 time (95% CI 1.213-6.345; p = 0.0156) when the delta in infant weight was > 5% (the difference between birth weight and weight at discharge during the postnatal hospitalization). CONCLUSIONS: The risk factors for readmission, such as substantial weight loss (> 5% difference between birth and discharge) and elevated hematocrit should be taken into account in the decision to discharge neonate with low-risk jaundice. The AAP guidelines for decreasing readmission rates of neonatal jaundice by postnatal screening for hyperbilirubinemia alone may be more appropriate for neonate with high-risk jaundice.

The association between the strength of the working alliance and sharing concerns by advanced cancer patients: a pilot study.

OBJECTIVES: A strong therapeutic alliance between cancer patients and medical staff is associated with treatment adherence, better health outcomes, and an emotional acceptance of a terminal illness. Given its significant role, the current study investigated the association between the working alliance and sharing concerns by advanced cancer patients. METHODS: Advanced cancer patients completed the Working Alliance Inventory-Short Revised and a checklist of topics in which they rated their degree of concern about the topics and the degree of sharing them with their physician/nurse. RESULTS: Fifty-two patients completed the study. The working alliance was found to be strong with respect to treating physicians and nurses. The four topics that concerned patients the most were family coping with their illness (81%), fear of future suffering (71%), symptom control (67%), and the oncological treatment (65%). Patients with a strong working alliance with their physician shared to a higher extent the personal and main concern regarding their family's coping, and a significant correlation was found between them (r = 0.53, p < .01). In addition, sharing fears of future suffering was also correlated with a strong working alliance with the physician (r = 0.28, p < .05). A strong working alliance with the nurse was correlated with discussing symptoms control (r = 0.30, p < .05). CONCLUSION: These findings provide preliminary support for an association between the strength of the working alliance and the type of concerns that advanced cancer patients choose to discuss with their medical staff and highlight the importance of follow-up studies to further explore this association.

Bacterial vs viral etiology of fever: A prospective study of a host score for supporting etiologic accuracy of emergency department physicians.

BACKGROUND: A host-protein score (BV score) that combines the circulating levels of TNF-related apoptosis-inducing ligand (TRAIL), interferon gamma-induced protein 10 (IP-10) and C-reactive protein (CRP) was developed for distinguishing bacterial from viral infection. This study assessed the potential of the BV score to impact decision making and antibiotic stewardship at the emergency department (ED), by comparing BV score's performance to physician's etiological suspicion at patient presentation. METHODS: Rosetta study participants, aged 3 months to 18 years with febrile respiratory tract infection or fever without source, were prospectively recruited in a tertiary care pediatric ED. 465 patients were recruited, 298 met eligibility criteria and 287 were enrolled. ED physician's etiological suspicion was recorded in a questionnaire. BV score was measured retrospectively with results interpreted as viral, bacterial or equivocal and compared to reference standard etiology, which was adjudicated by three independent experts based on all available data. Experts were blinded to BV scores. RESULTS: Median age was 1.3 years (interquartile range 1.7), 39.7% females. 196 cases were reference standard viral and 18 cases were reference standard bacterial. BV score attained sensitivity of 88.9% (95% confidence interval: 74.4-100), specificity 92.1% (88.1-96.0), positive predictive value 53.3% (35.5-71.2) and negative predictive value 98.8% (97.1-100). Positive likelihood ratio was 11.18 (6.59-18.97) and negative likelihood ratio was 0.12 (0.03-0.45). The rate of BV equivocal scores was 9.4%. Comparing physician's suspicion to BV score and to the reference standard, and assuming full adoption, BV score could potentially correct the physician's diagnosis and reduce error ~2-fold, from 15.9% to 8.2%. CONCLUSIONS: BV score has potential to aid the diagnostic process. Future studies are warranted to assess the impact of real-time BV results on ED practice.

C-reactive protein in early-onset neonatal sepsis - a cutoff point for CRP value as a predictor of early-onset neonatal sepsis in term and late preterm infants early after birth?

OBJECTIVE: To identify whether the first plasma C-reactive protein values taken 6-8 h postpartum are predictive of the clinical early-onset neonatal sepsis (cEONS). STUDY DESIGN: We retrospectively analyzed C-reactive protein (CRP) values of 400 neonates, including 28 with cEONS, who underwent plasma CRP measurements as part of sepsis work-up. To determine whether the first CRP measurement is predictive of cEONS, logistic regression was used with CRP as an independent variable and cEONS (yes/no) as a dependent variable. RESULT: A moderate predictive ability of the first CRP measurement (odds ratio 1.4, CI: [1.13, 1.76], p=.003) was revealed, at a 5.3 mg/L threshold. However, it resulted in poor sensitivity of 50%, and a false positive rate of 30%. Increasing the sensitivity to 75% or 90% lead to increased false-positive rates of 55% and 75%, respectively. CONCLUSIONS: Our findings suggest that the first CRP value taken in neonates is a weak predictor of cEONS.

Asthma risk after a pediatric intensive care unit admission for respiratory syncytial virus bronchiolitis.

BACKGROUND: Admission to a pediatric intensive care unit (PICU) has been associated with respiratory consequences in children with asthma and carries major implications for management control. Whereas respiratory syncytial virus (RSV) bronchiolitis has been associated with increasing intensity of wheezing, the relationship between RSV-bronchiolitis PICU admission and future asthma is unclear. This retrospective case-control study evaluated whether hospitalization in the PICU due to RSV bronchiolitis is more likely to be associated with future asthma in early life compared with hospitalization in a general pediatric ward. METHODS: Children hospitalized due to RSV bronchiolitis between 2007 and 2019 in the PICU (study group) were compared to those hospitalized in a general pediatric ward (controls). Asthma prevalence was assessed by a follow-up questionnaire based on The International Study of Asthma and Allergies in Childhood questionnaire. RESULTS: Sixty-three PICU patients and 66 controls were included. The PICU patients presented with more severe disease during RSV hospitalization. At follow-up, significantly more PICU patients aged 3-6 years had physician-diagnosed asthma, respiratory symptoms during the previous 12 months, and underwent respiratory treatment since hospital discharge compared to controls (14 [60.9%] vs. 4 [18.2%] patients; 15 [65.2%] vs. 6 [27.3%]; and 16 [69.6%] vs. 8 [36.4%]; respectively). These differences were no longer observed after 6 years of age. CONCLUSIONS: Children admitted to the PICU for RSV bronchiolitis are at higher risk for asthma in subsequent pre-school years and will require close respiratory follow-up than those admitted to general pediatric wards. Admission venue should be queried when asthma is suspected.

Effect of Freezing and Thawing on Human Milk Macronutrients and Energy Composition: A Systematic Review and Meta-Analysis.

Objective: To conduct a systematic review of the effect of freezing and thawing on the macronutrients and energy composition of human milk (HM). Design: Systematic review conducted in May 2019, including all studies reporting macronutrients and energy composition of HM, according to a search of MEDLINE, EMBASE, and Google Scholar using the keywords: HM, breast milk, macronutrients, fat, lipid, protein, carbohydrates, energy, calories, freezing, thawing, and of the references in studies identified as potentially relevant. Meta-analyses were conducted in all the studies that reported one or more of the following: total energy, true protein, fat, and carbohydrates. They were reported according to following groups of freezing duration: 1-7 days, 8-30 days, 31 days-3 months, and >3 months. They were calculated and expressed as weighted averages with pooled standard deviations. Results: Eight studies remained in the final analysis. Regression analyses did not find any significant increase or decrease over time of protein content, lactose content, fat content, or energy content of milk. Conclusions: No dramatic changes in macronutrients and energy contents of milk are expected to occur within the first few months of freezing.

Assessment of Risk Indicators for Targeted Cytomegalovirus Screening in Neonates.

BACKGROUND: In the absence of universal screening for congenital cytomegalovirus (cCMV) infection, the aim of this study was to assess the outcomes of a targeted screening protocol based on maternal and neonatal risk indicators. METHODS: The medical records of 2,623 neonates born in our maternal hospital between June 2016 and December 2018 and screened for cCMV infection were reviewed. Among those of the included neonates, the records of 380 CMV-negative and 19 CMV-positive neonates were randomly assigned to obtain additional comparative data. RESULTS: During the study period, a total of 63 neonates were identified as positive for cCMV, comprising 0.2% of the total birth cohort (63/28,982) and 2.4% of all neonates screened for cCMV (63/2,623). The comparative data analysis showed that suspected or confirmed CMV infection during pregnancy, maternal age, and maternal diabetes mellitus were found to be significantly associated with a positive cCMV diagnosis. Although symmetric small for gestational age and hearing screening failure contributed to the detection of some of the CMV-positive infants, these factors were not specific to this group. The results of the logistic regression model showed that the only factor that was significantly associated with an increased risk for a cCMV diagnosis was maternal serology suspected of CMV infection during pregnancy, with a regression coefficient estimate of 2.657 (adjusted p < 0.001). CONCLUSIONS: A targeted neonatal screening protocol based on multiple maternal and neonatal risk indicators is feasible but provides limited information. Our study emphasizes the importance of universal neonatal screening for the detection of neonates with cCMV.

Preterm Human Milk Macronutrient and Energy Composition: A Systematic Review and Meta-Analysis.

This study is a systematic review of the macronutrient and energy composition of preterm human milk to enable the practicing neonatologist to make informed nutritional decisions in preterm infants. Meta-analyses were conducted in all the studies that reported total energy, true protein, fat, and lactose. Protein content decreased massively (by one-half) and significantly from day 1 to 3 at week 10 to 12. There was a significant linear increase in fat, lactose, and energy content during the same timeframe. Theoretic calculations on energy and macronutrient intake of preterm infants must be made according to a lactation time-specific manner.