Implementing a Hospital-Based Safe Sleep Program for Newborns and Infants.

BACKGROUND: An unsafe sleep environment remains the leading contributor to unexpected infant death. PURPOSE: To determine the effectiveness of a quality improvement initiative developed to create a hospital-based safe sleep environment for all newborns and infants. METHODS: A multidisciplinary team from the well-baby nursery (WBN) and neonatal intensive care unit (NICU) of a 149-bed academic, quaternary care, regional referral center developed and implemented safe sleep environments within the hospital for all prior to discharge. To monitor compliance, the following were tracked monthly: documentation of parent education, caregiver surveys, and hospital crib check audits. On the inpatient general pediatric units, only hospital crib check audits were tracked. Investigators used Plan-Do-Study-Act (PDSA) cycles to evaluate the impact of the initiative from October 2015 through February 2018. RESULTS: Safe sleep education was documented for all randomly checked records (n = 440). A survey (n = 348) revealed that almost all caregivers (95.4%) reported receiving information on safe infant sleep. Initial compliance with all criteria in WBN (n = 281), NICU (n = 285), and general pediatric inpatient units (n = 121) was 0%, 0%, and 8.3%, respectively. At 29 months, WBN and NICU compliance with all criteria was 90% and 100%, respectively. At 7 months, general pediatric inpatient units' compliance with all criteria was 20%. IMPLICATIONS FOR PRACTICE: WBN, NICU and general pediatric inpatient unit collaboration with content experts led to unit-specific strategies that improved safe sleep practices. IMPLICATIONS FOR RESEARCH: Future studies on the impact of such an initiative at other hospitals are needed.

A Bifunctional Anti-Amyloid Blocks Oxidative Stress and the Accumulation of Intraneuronal Amyloid-Beta.

There is growing recognition regarding the role of intracellular amyloid beta (Aß) in the Alzheimer's disease process, which has been linked with aberrant signaling and the disruption of protein degradation mechanisms. Most notably, intraneuronal Aß likely underlies the oxidative stress and mitochondrial dysfunction that have been identified as key elements of disease progression. In this study, we employed fluorescence imaging to explore the ability of a bifunctional small molecule to reduce aggregates of intracellular Aß and attenuate oxidative stress. Structurally, this small molecule is comprised of a nitroxide spin label linked to an amyloidophilic fluorene and is known as spin-labeled fluorene (SLF). The effect of the SLF on intracellular Aß accumulation and oxidative stress was measured in MC65 cells, a human neuronal cell line with inducible expression of the amyloid precursor protein and in the N2a neuronal cell line treated with exogenous Aß. Super-resolution microscopy imaging showed SLF decreases the accumulation of intracellular Aß. Confocal microscopy imaging of MC65 cells treated with a reactive oxygen species (ROS)-sensitive dye demonstrated SLF significantly reduces the intracellular Aß-induced ROS signal. In order to determine the contributions of the separate SLF moieties to these protective activities, experiments were also carried out on cells with nitroxides lacking the Aß targeting domain or fluorene derivatives lacking the nitroxide functionality. The findings support a synergistic effect of SLF in counteracting both the conformational toxicity of both endogenous and exogenous Aß, its promotion of ROS, and Aß metabolism. Furthermore, these studies demonstrate an intimate link between ROS production and Aß oligomer formation.

Lipotoxic brain microvascular injury is mediated by activating transcription factor 3-dependent inflammatory and oxidative stress pathways.

Dysfunction of the cerebrovasculature plays an important role in vascular cognitive impairment (VCI). Lipotoxic injury of the systemic endothelium in response to hydrolyzed triglyceride-rich lipoproteins (TGRLs; TGRL lipolysis products) or a high-fat Western diet (WD) suggests similar mechanisms may be present in brain microvascular endothelium. We investigated the hypothesis that TGRL lipolysis products cause lipotoxic injury to brain microvascular endothelium by generating increased mitochondrial superoxide radical generation, upregulation of activating transcription factor 3 (ATF3)-dependent inflammatory pathways, and activation of cellular oxidative stress and apoptotic pathways. Human brain microvascular endothelial cells were treated with human TGRL lipolysis products that induced intracellular lipid droplet formation, mitochondrial superoxide generation, ATF3-dependent transcription of proinflammatory, stress response, and oxidative stress genes, as well as activation of proapoptotic cascades. Male apoE knockout mice were fed a high-fat/high-cholesterol WD for 2 months, and brain microvessels were isolated by laser capture microdissection. ATF3 gene transcription was elevated 8-fold in the hippocampus and cerebellar brain region of the WD-fed animals compared with chow-fed control animals. The microvascular injury phenotypes observed in vitro and in vivo were similar. ATF3 plays an important role in mediating brain microvascular responses to acute and chronic lipotoxic injury and may be an important preventative and therapeutic target for endothelial dysfunction in VCI.

Protective spin-labeled fluorenes maintain amyloid beta peptide in small oligomers and limit transitions in secondary structure.

Alzheimer's disease is characterized by the presence of extracellular plaques comprised of amyloid beta (Aß) peptides. Soluble oligomers of the Aß peptide underlie a cascade of neuronal loss and dysfunction associated with Alzheimer's disease. Single particle analyses of Aß oligomers in solution by fluorescence correlation spectroscopy (FCS) were used to provide real-time descriptions of how spin-labeled fluorenes (SLFs; bi-functional small molecules that block the toxicity of Aß) prevent and disrupt oligomeric assemblies of Aß in solution. Furthermore, the circular dichroism (CD) spectrum of untreated Aß shows a continuous, progressive change over a 24-hour period, while the spectrum of Aß treated with SLF remains relatively constant following initial incubation. These findings suggest the conformation of Aß within the oligomer provides a complementary determinant of Aß toxicity in addition to oligomer growth and size. Although SLF does not produce a dominant state of secondary structure in Aß, it does induce a net reduction in beta secondary content compared to untreated samples of Aß. The FCS results, combined with electron paramagnetic resonance spectroscopy and CD spectroscopy, demonstrate SLFs can inhibit the growth of Aß oligomers and disrupt existing oligomers, while retaining Aß as a population of smaller, yet largely disordered oligomers.

Binding of apolipoprotein E inhibits the oligomer growth of amyloid-ß peptide in solution as determined by fluorescence cross-correlation spectroscopy.

One of the primary neuropathological hallmarks of Alzheimer disease is the presence of extracellular amyloid plaques resulting from the aggregation of amyloid-ß (Aß) peptides. The intrinsic disorder of the Aß peptide drives self-association and progressive reordering of the conformation in solution, and this dynamic distribution of Aß complicates biophysical studies. This property poses a challenge for understanding the interaction of Aß with apolipoprotein E (apoE). ApoE plays a pivotal role in the aggregation and clearance of Aß peptides in the brain, and the ε4 allele of APOE is the most significant known genetic modulator of Alzheimer risk. Understanding the interaction between apoE and Aß will provide insight into the mechanism by which different apoE isoforms determine Alzheimer disease risk. Here we applied alternating laser excitation fluorescence cross-correlation spectroscopy to observe the single molecule interaction of Aß with apoE in the hydrated state. The diffusion time of freely diffusing Aß in the absence of apoE shows significant self-aggregation, whereas in the presence of apoE, binding of the protein results in a more stable complex. These results show that apoE slows down the oligomerization of Aß in solution and provide direct insight into the process by which apoE influences the deposition and clearance of Aß peptides in the brain. Furthermore, by developing an approach to remove signals arising from very large Aß aggregates, we show that real-time single particle observations provide access to information regarding the fraction of apoE bound and the stoichiometry of apoE and Aß in the complex.

Postprandial VLDL lipolysis products increase monocyte adhesion and lipid droplet formation via activation of ERK2 and NFκB.

Postprandial lipemia is characterized by a transient increase in circulating triglyceride-rich lipoproteins such as very low-density lipoprotein (VLDL) and has been shown to activate monocytes in vivo. Lipolysis of VLDL releases remnant particles, phospholipids, monoglycerides, diglycerides, and fatty acids in close proximity to endothelial cells and monocytes. We hypothesized that postprandial VLDL lipolysis products could activate and recruit monocytes by increasing monocyte expression of proinflammatory cytokines and adhesion molecules, and that such activation is related to the development of lipid droplets. Freshly isolated human monocytes were treated with VLDL lipolysis products (2.28 mmol/l triglycerides + 2 U/ml lipoprotein lipase), and monocyte adhesion to a primed endothelial monolayer was observed using a parallel plate flow chamber coupled with a CCD camera. Treated monocytes showed more rolling and adhesion than controls, and an increase in transmigration between endothelial cells. The increased adhesive events were related to elevated expression of key integrin complexes including Mac-1 [α(m)-integrin (CD11b)/ß2-integrin (CD18)], CR4 [α(x)-integrin (CD11c)/CD18] and VLA-4 [α4-integrin (CD49d)/ß1-integrin (CD29)] on treated monocytes. Treatment of peripheral blood mononuclear cells (PBMCs) and THP-1 monocytes with VLDL lipolysis products increased expression of TNFα, IL-1ß, and IL-8 over controls, with concurrent activation of NFkB and AP-1. NFκB and AP-1-induced cytokine and integrin expression was dependent on ERK and Akt phosphorylation. Additionally, fatty acids from VLDL lipolysis products induced ERK2-dependent lipid droplet formation in monocytes, suggesting a link to inflammatory signaling pathways. These results provide novel mechanisms for postprandial monocyte activation by VLDL lipolysis products, suggesting new pathways and biomarkers for chronic, intermittent vascular injury.

Management of apparent life-threatening events in infants: a systematic review.

OBJECTIVE: To determine in patients who are well-appearing and without a clear etiology after an apparent life-threatening event (ALTE): (1) What historical and physical examination features suggest that a child is at risk for a future adverse event and/or serious underlying diagnosis and would, therefore, benefit from testing or hospitalization? and (2) What testing is indicated on presentation and during hospitalization? STUDY DESIGN: Systematic review of clinical studies, excluding case reports, published from 1970 through 2011 identified using key words for ALTE. RESULTS: The final analysis was based on 37 studies; 18 prospective observational, 19 retrospective observational. None of the studies provided sufficient evidence to fully address the clinical questions. Risk factors identified from historical and physical examination features included a history of prematurity, multiple ALTEs, and suspected child maltreatment. Routine screening tests for gastroesophageal reflux, meningitis, bacteremia, and seizures are low yield in infants without historical risk factors or suggestive physical examination findings. CONCLUSION: Some historical and physical examination features can be used to identify risk in infants who are well-appearing and without a clear etiology at presentation, and testing tailored to these risks may be of value. The true risk of a subsequent event or underlying disorder cannot be ascertained. A more precise definition of an ALTE is needed and further research is warranted.

Increasing Utilization of the Preparticipation Physical Evaluation.

OBJECTIVE: The American Heart Association and American Academy of Pediatrics endorse the preparticipation physical evaluation (PPE) to screen student athletes for the risk of sudden cardiac arrest. We sought to identify barriers precluding its use and improve utilization. METHODS: We analyzed documentation of PPE elements during well-care visits of patients aged 12 to 18 years from 5 primary care practices. Employing quality improvement (QI) methodology, we focused on improving PPE utilization in 1 practice by assessing the number of PPE elements addressed per chart. We expanded our QI project to 4 additional practices by using the same interventions but assessing the percentage of charts that had a complete PPE documented. RESULTS: A baseline analysis of 5 targeted practices revealed an average of 3.5 of 14 PPE elements documented. Using plan-do-study-act cycles, PPE elements addressed increased from 2.5 to 14 over an 18-month period in the initial practice. By spreading successful interventions to 4 other practices, complete PPE utilization increased from a median baseline of 10.0% to a median of 70.0% over a 12-month period. Postintervention, 12 of 16 patients (75%) required additional follow-up with pediatric cardiology beyond the initial consultation, as compared with 2 of 14 patients (14%) preintervention. CONCLUSION: The PPE is an underutilized but effective tool in screening student athletes for sudden cardiac arrest. QI methodology was helpful in increasing the use of PPE in the primary care setting.

The vascular contribution to Alzheimer's disease.

AD (Alzheimer's disease) is a progressive neurodegenerative disease of unknown origin. Despite questions as to the underlying cause(s) of this disease, shared risk factors for both AD and atherosclerotic cardiovascular disease indicate that vascular mechanisms may critically contribute to the development and progression of both AD and atherosclerosis. An increased risk of developing AD is linked to the presence of the apoE4 (apolipoprotein E4) allele, which is also strongly associated with increased risk of developing atherosclerotic cardiovascular disease. Recent studies also indicate that cardiovascular risk factors, including elevated blood cholesterol and triacylglycerol (triglyceride), increase the likelihood of AD and vascular dementia. Lipids and lipoproteins in the circulation interact intimately with the cerebrovasculature, and may have important effects on its constituent brain microvascular endothelial cells and the adjoining astrocytes, which are components of the neurovascular unit. The present review will examine the potential mechanisms for understanding the contributions of vascular factors, including lipids, lipoproteins and cerebrovascular Abeta (amyloid beta), to AD, and suggest therapeutic strategies for the attenuation of this devastating disease process. Specifically, we will focus on the actions of apoE, TGRLs (triacylglycerol-rich lipoproteins) and TGRL lipolysis products on injury of the neurovascular unit and increases in blood-brain barrier permeability.

Trends in Pediatric Malpractice Claims 1987-2015: Results From the Periodic Survey of Fellows.

BACKGROUND: Pediatricians are less frequently sued than other physicians. When suits are successful, however, the average payout is higher. Little is known about changes in the risk of litigation over time. We sought to characterize malpractice lawsuit trends for pediatricians over time. METHODS: The Periodic Survey is a national random sample survey of American Academy of Pediatrics members. Seven surveys between 1987 and 2015 asked questions regarding malpractice (n = 5731). Bivariate and multivariable analyses examined trends and factors associated with risk and outcome of malpractice claims and lawsuits. Descriptive analyses examined potential change in indemnity amount over time. RESULTS: In 2015, 21% of pediatricians reported ever having been the subject of any claim or lawsuit, down from a peak of 33% in 1990. Report of successful outcomes in the most-recent suit trended upward between 1987 and 2015, greatest in 2015 at 58%. Median indemnity was unchanged, averaging $128 000 in 2018 dollars. In multivariate analysis, male sex, hospital-based subspecialty (neonatology, pediatric critical care, pediatric emergency medicine, and hospital medicine), longer career, and more work hours were associated with a greater risk of malpractice claim. CONCLUSIONS: From 1987 to 2015, the proportion of pediatricians sued has decreased and median indemnity has remained unchanged. Male pediatricians and hospital-based subspecialists were more likely to have been sued. Greater knowledge of the epidemiology of malpractice claims against pediatricians is valuable because it can impact practice arrangements, advise risk-management decisions, influence quality and safety projects, and provide data to guide advocacy for appropriate tort reform and future research.

Interpreting Osteogenesis Imperfecta Variants of Uncertain Significance in the Context of Physical Abuse: A Case Series.

Unexplained childhood fracture(s) warrant consideration of physical abuse and osteogenesis imperfecta (OI). Genetic OI testing may identify "variants of unknown significance (VUS)." Interpretation of VUS in context of potential abuse may have protective, criminal, and medical impacts. This case series explores practices regarding clinicians' interpretation of VUS during child abuse evaluations. Variability was noted regarding factors considered for interpreting clinical significance. Based on these cases, recommendations for careful and thorough evaluation are detailed, including proposed use of a limited follow-up skeletal survey in 3 months, as a consideration to assess healing of prior fractures and to look for any additional injuries.

Understanding Liability Risks and Protections for Pediatric Providers During Disasters.

Although most health care providers will go through their careers without experiencing a major disaster in their local communities, if one does occur, it can be life and career altering. The American Academy of Pediatrics has been in the forefront of providing education and advocacy on the critical importance of disaster preparedness. From experiences over the past decade, new evidence and analysis have broadened our understanding that the concept of preparedness is also applicable to addressing the unique professional liability risks that can occur when caring for patients and families during a disaster. Concepts explored in this technical report will help to inform pediatric health care providers, advocates, and policy makers about the complexities of how providers are currently protected, with a focus on areas of unappreciated liability. The timeliness of this technical report is emphasized by the fact that during the time of its development (ie, late summer and early fall of 2017), the United States went through an extraordinary period of multiple, successive, and overlapping disasters within a concentrated period of time of both natural and man-made causes. In a companion policy statement (www.pediatrics.org/cgi/doi/10.1542/peds.2018-3892), recommendations are offered on how individuals, institutions, and governments can work together to strengthen the system of liability protections during disasters so that appropriate and timely care can be delivered with minimal fear of legal reprisal or confusion.

Understanding Liability Risks and Protections for Pediatric Providers During Disasters.

Although most health care providers will go through their careers without experiencing a major disaster in their local communities, if one does occur, it can be life and career altering. The American Academy of Pediatrics has been at the forefront of providing education and advocacy on the critical importance of disaster preparedness. From experiences over the past decade, new evidence and analysis have broadened our understanding that the concept of preparedness is also applicable to addressing the unique professional liability risks that can occur when caring for patients and families during a disaster. In our recommendations in this policy statement, we target pediatric health care providers, advocates, and policy makers and address how individuals, institutions, and government can work together to strengthen the system of liability protections during disasters so that appropriate and timely care can be delivered with minimal fear of legal reprisal or confusion.

Inhibition of vascular inflammation by dehydroepiandrosterone sulfate in human aortic endothelial cells: roles of PPARalpha and NF-kappaB.

Dehydroepiandrosterone sulfate (DHEAS) is a hormone produced by the adrenal gland and is a precursor for both androgens and estrogens. Atherosclerosis is a well characterized inflammatory disease, but little is known about the role of DHEAS in vascular inflammation. We hypothesize that DHEAS can reduce inflammation in vascular endothelial cells and the mechanism involves the peroxisome proliferator-activated receptor alpha (PPARalpha), thereby inhibiting transcription factors involved in endothelial cell inflammation. To test our hypothesis, aortic endothelial cells were pretreated for 48 h with DHEAS, then with TNF-alpha. TNF-alpha-induced upregulation of the expression of inflammatory genes interleukin (IL)-8 and intracellular adhesion molecule (ICAM)-1 was attenuated by incubation with DHEAS. DHEAS inhibited the TNF-alpha-induced surface expression of vascular cell adhesion molecule (VCAM)-1. This effect was abolished by the addition of MK866, a PPARalpha inhibitor, indicating that PPARalpha is involved in the mechanism of this inhibition. The addition of the aromatase inhibitor letrozole had no effect on the inhibition of TNF-alpha-induced VCAM-1 expression by DHEAS. Treatment of endothelial cells with DHEAS dramatically inhibited the TNF-alpha-induced activation of NF-kappaB, an inflammatory transcription factor, and increased protein levels of the NF-kappaB inhibitor, IkappaB-alpha. These results signify the ability of DHEAS to directly inhibit the inflammatory process and show a potential direct effect of DHEAS on vascular inflammation that has implications for the development of atherosclerotic cardiovascular disease.

Infections and apparent life-threatening events.

The need for routine sepsis evaluation in patients who have experienced an apparent life-threatening event but lack signs of infection remains controversial. To assess their risk of a serious occult bacterial infection, records were reviewed of 95 infants in whom infections were discovered during their inpatient evaluation after an apparent life-threatening event. Noted for each patient was the presence of any suggestive findings that would have prompted a physician to consider the given type of infection in the differential diagnosis. Thirty patients had bacterial infections; all but 5 had suggestive findings. The exceptions included 1 patient with pneumonia and 4 with urinary tract infections. None of the remaining 25 patients had occult bacterial infections. In patients with an apparent life-threatening event who appear well and lack signs suggestive of a serious bacterial infection, it may be possible to forego routine sepsis evaluation beyond a chest radiograph and urine culture without risking a serious missed diagnosis.

Is fluorescence under an alternate light source sufficient to accurately diagnose subclinical bruising?

This single-blinded, randomized validation study was conducted to evaluate whether fluorescence under alternate light sources (ALS) is sufficient to diagnose subclinical bruising (bruising not visible under white light). Standardized trauma was induced on randomly selected ventral forearms. On days 1, 7, and 14 investigators independently examined case forearms under white light for perceived bruising and under ALS for fluorescence and compared body maps. 56 case and 62 control forearms (n = 118) were examined. Sensitivity of ALS on days 1, 7, and 14 was 76.8%, 69.6%, and 60.7%, respectively, compared to 69.6%, 60.0%, and 32.1% for white light. The specificity of ALS on days 1, 7, and 14 was 51.6%, 59.7%, and 53.2%, respectively, compared to 71.0%, 81.4%, and 86.9% for white light. ALS has increased sensitivity yet low specificity compared to white light in accurately detecting bruises. Fluorescence under ALS is not sufficient to accurately or responsibly diagnose subclinical bruising.

The impact of a hospital-based educational video on maternal perceptions and planned practices of infant safe sleep.

PURPOSE: To evaluate whether an educational video would impact infant sleep practices among new mothers. DESIGN AND METHODS: Survey responses of new mothers who did (n = 43) versus did not (n = 49) watch the educational video were compared to identify differences in observed and planned infant sleep practices. RESULTS: Mothers who watched the video were more likely to observe safe sleep practices while in the hospital (67.4% vs. 46.9%, p < .05). They were also less likely to plan for (unsafe) side positioning (23.9% vs. 7.1%, p < .05). PRACTICE IMPLICATIONS: Given the potentially fatal consequence of unsafe sleep, a brief video provided by nursing staff can be a prudent component of new parent education.

Congenital tuberculosis with facial nerve palsy.

Congenital tuberculosis is unusual, and central nervous system involvement is even more rare. We report a case of congenital tuberculosis presenting with facial palsy and purulent otorrhea.

Abusive head injury as a cause of apparent life-threatening events in infancy.

BACKGROUND: An apparent life-threatening event (ALTE) refers to the sudden occurrence of a breathing abnormality, color change, or alteration in muscle tone or mental status in an infant. Several patients with ALTEs admitted to our institution were found to have sustained abusive head injuries. OBJECTIVE: To systematically examine the possible causes of ALTEs and their relative frequencies. STUDY DESIGN: Prospective consecutive case series of 243 infants younger than 12 months admitted to a tertiary care academic medical center for evaluation of an ALTE during a 32-month interval. RESULTS: Thirty-five different causes of ALTEs were identified. Six subjects (2.5%) were diagnosed as having abusive head injuries, or 1 admission every 5 months. Three patients died in the hospital, 2 of whom were diagnosed as having abusive head injuries. CONCLUSIONS: A wide spectrum of diseases and disorders can precipitate an ALTE. Among them, abusive head injury, a recently recognized cause, occurs frequently enough to obligate its inclusion in the differential diagnosis. An ophthalmologic evaluation with dilated fundus examination and cranial imaging should therefore be considered early in the investigation unless another cause becomes apparent soon after admission.

Community-based cardiovascular disease prevention to reduce cardiometabolic risk in Latina women: a pilot program.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death in women, yet significant health disparities exist for high-risk groups, including Latinas, and comprehensive, culturally relevant, and effective prevention intervention models are lacking. We used a systems approach to develop, assess, and pilot a community-based education program for improving outcomes for knowledge/awareness of CVD, cardiometabolic risk, and health behaviors in Latinas. METHODS: Latinas (n=35, mean age 50) participated in a 4-month community-based bilingual preventive cardiovascular education program. Pre/post analyses were for knowledge/awareness of CVD risk factors, symptoms, calling 911; personal risk factors (smoking, physical inactivity, family history of CVD); clinical parameters (weight, body mass index [BMI], waist, blood pressure, fasting lipids, and glucose); diagnosis of metabolic syndrome (MetS); and serum inflammatory markers (tumor necrosis factor [TNF]-α, high-sensitivity C reactive protein [hsCRP], and interleukin [IL]-12). RESULTS: Baseline knowledge/awareness was relatively low, risk factors and MetS prevalent, and serum inflammatory markers elevated. Postintervention, participants demonstrated significant (p<0.05) improvements in knowledge of symptoms, risk factors for CVD, calling 911, and knowledge/adoption of heart-healthy behaviors. Clinical health status also improved, especially for serum triglycerides (p<0.05; 21% decline), prevalence of MetS (from 43% to 37% of participants), and serum levels of the proinflammatory TNF-α (from 16.9 ± 1.11 pg/mL to 13.5 ± 0.8 pg/mL, p<0.05). CONCLUSION: A bilingual culturally appropriate community-based CVD-prevention program based on health education, medical screenings, and empowerment is a successful, effective, adaptable, and replicable model to significantly improve cardiometabolic risk in Latinas.