An assessment of the predictive value of low risk criteria for children with intermittent asthma.

BACKGROUND: Current asthma guidelines recommend short acting beta agonist medication (SABA) be used in combination with an inhaled corticosteroid to reduce risk for severe asthma exacerbations. This may not be appropriate for patients at low risk for severe exacerbations. METHODS: This study is a cohort study using computerized claims data from Texas Children's Health Plan. Inclusion criteria were members 1 to <18 years with a diagnosis of asthma in a baseline year between 2016 and 2018 and who had ≤2 SABA canisters or equivalent dispensed, no oral corticosteroid or inhaled corticosteroid dispensing, no asthma hospitalizations, and no asthma emergency department visits in the baseline year. Follow up year outcomes of asthma hospitalizations and emergency department visits were determined for the year following the baseline year. FINDINGS: Forty-five thousand two hundred and thiry health plan members 1 to <18 years met inclusion criteria. The rate of follow up year asthma hospitalization was 1.1 per thousand for those with no baseline SABA dispensing and 1.5 per thousand for those with >0 and ≤2 SABA canister dispensings (p = 0.3). Follow up year Emergency Department visits rates were 14 per thousand and 17 per thousand, respectively (p = 0.08). In analyses adjusted for age group, the follow up year asthma hospitalization rate was not different comparing the 0 SABA to the >0 and ≤2 SABA canister dispensings group (odds ratio: 0.99, 95% confidence interval: 0.54-1.81). INTERPRETATION: Asthma patients at low risk for severe exacerbations can be identified. This information can be useful to guide treatment decisions.

A pediatric hospital-wide asthma severity score: Reliability and effectiveness.

BACKGROUND: Asthma is a leading cause of pediatric hospitalization in the United States. Children hospitalized with asthma are often managed in different care settings during hospitalization, posing challenges to accurate communication among care providers about illness severity. Our objective was to study the feasibility, reliability, and safety of a new pediatric hospital-wide asthma severity score (HASS) across different care units within a single tertiary-care pediatric center. METHODS: 150 patients between the ages of 2 and 18 years hospitalized with a principal diagnosis of status asthmaticus were included in this study. Study patients were followed from the time of initial triage in the emergency department until the time of medical readiness for discharge. Rates of medical errors, early transfers to a higher level of care and medically indicated hospital length of stay (LOS) were compared between 75 patients before and 75 patients after widespread implementation of the HASS using retrospective chart review and anonymous staff reporting. Interrater reliability was determined by collecting independent HASS scores from blinded staff members after tandem or simultaneous patient assessment. RESULTS: Interrater reliability among untrained staff members using the HASS was high. Hospital LOS, rates of adverse events, medical errors, and early transfer to a higher level of care were not significantly different before and after widespread HASS implementation. CONCLUSION: The HASS is a reliable asthma severity tool that can be used throughout hospitalization and among multiple clinical providers to trend clinical progress and optimize communication, particularly during times of care handoffs.

Brief report: A randomized controlled trial of a compensatory cognitive training to improve prospective memory performance in people with schizophrenia or depression.

People with schizophrenia or depression have prospective memory (PM) deficits, which affect their daily living. Given the paucity of research into training to correct PM deficits, we subjected a group of participants to a Chinese version of the PM module of the Cognitive Compensatory Training (CCT-C-PM) intervention to study its effect on their PM performance. Specifically, we independently randomized two diagnostic cohorts (schizophrenia and depression) into control groups (occupational therapy only) or experimental groups (CCT-C-PM and occupational therapy). The schizophrenia cohort had 17 participants in its control group and 23 participants in its experimental group. The depression cohort had 10 participants in its control group and 12 participants in its experimental group. The sociodemographic information of the participants was collected. Their symptoms and PM performances were measured at baseline and after treatment (after the completion of the CCT-C-PM intervention in the experimental group and the same timeframe in the control group). The treatment effects were examined by a repeated measure analysis of variance/analysis of covariance and a post hoc Scheffé test. The effect sizes (Cohen's d) of treatments against the controls were also calculated. There was no difference between the experimental and control groups in either cohort in terms of sociodemographic data, symptoms, and PM measures at baseline. The sex combination differed across the groups in the depression cohort. We found that the CCT-C-PM improved PM, especially event-based PM, for which large effect sizes were seen. The effect on time-based PM was unclear and requires future study. Our findings suggest that the CCT-C-PM is a viable training method for improving PM.

Efficacy of Depression Management in an Integrated Psychiatric-Diabetes Education Clinic for Comorbid Depression and Diabetes Mellitus Types 1 and 2.

OBJECTIVES: Patients with type 1 and type 2 diabetes mellitus (DM) are 2 times as predisposed to developing mood disorders, such as major depressive disorder (MDD), compared with patients without diabetes. Management of comorbid MDD and DM remains a challenge because patients often suffer from poor medication compliance, lifestyle factors and refractory depression. Integration of psychiatric care into diabetes education clinics (DECs) has been suggested as an effective method of managing the comorbid conditions. As this strategy is being implemented into clinical care, its effectiveness in practice warrants further research. METHODS: A retrospective chart review of 24 patients (10 men and 14 women) followed by an integrated psychiatry-DEC in Newmarket, Ontario, Canada, between April 2016 and July 2019 was performed. Depressive symptom severity at each appointment was assessed with the Patient Health Questionnaire-9 (PHQ-9) depression rating scale. RESULTS: There was no significant change in PHQ-9 depression rating scale scoring between the first and most recent appointments (paired t test, p=0.356); however, patients who had improved PHQ-9 scoring were more likely to have more clinic visits (analysis of variance, p=0.0271). A significant negative correlation was found between both number of visits (Pearson coefficient, -0.56; p=0.005) and overall time the patients were followed by DEC (Pearson coefficient, -0.42; p=0.040) and PHQ-9 score changes between the first and most recent appointments. PHQ-9 change between individual appointments also displayed a positive correlation with time between appointments (Pearson coefficient, 0.26; p=0.027). CONCLUSIONS: Regular follow up in a psychiatry-DEC service might be beneficial in managing MDD symptom severity for comorbid MDD and DM.

Standardized Protocol Is Associated With a Decrease in Continuous Albuterol Use and Length of Stay in Critical Status Asthmaticus.

OBJECTIVES: The primary aim of this study was to reduce duration of continuous albuterol and hospital length of stay in critically ill children with severe status asthmaticus. DESIGN: Observational prospective study from September 2012 to May 2016. SETTING: Medicine ICU and intermediate care unit. PATIENTS: Children greater than 2 years old with admission diagnosis of status asthmaticus admitted on continuous albuterol and managed via a standardized protocol. INTERVENTIONS: The protocol was an iterative algorithm for escalation and weaning of therapy. The algorithm underwent three revisions. Iteration 1 concentrated on reducing duration on continuous albuterol; iteration 2 concentrated on reducing hospital length of stay; and iteration 3 concentrated on reducing helium-oxygen delivered continuous albuterol. Balancing measures included adverse events and readmissions. MEASUREMENTS AND RESULTS: Three-hundred eighty-five patients were treated as follows: 123, 138, and 124 in iterations 1, 2, and 3, respectively. Baseline data was gathered from an additional 150 patients prior to protocol implementation. There was no difference in median age (6 vs 8 vs 7 vs 7 yr; p = 0.130), asthma severity score (9 vs 9 vs 9 vs 9; p = 0.073), or female gender (42% vs 41% vs 43% vs 48%; p = 0.757). Using statistical process control charts, the mean duration on continuous albuterol decreased from 24.9 to 17.5 hours and the mean hospital length of stay decreased from 76 to 49 hours. There was no difference in adverse events (0% vs 1% vs 4% vs 0%; p = 0.054) nor in readmissions (0% vs 0% vs 1% vs 2%; p = 0.254). CONCLUSIONS: Implementation of a quality improvement protocol in critically ill patients with status asthmaticus was associated with a decrease in continuous albuterol duration and hospital length of stay.

Cross-Cultural Adaptation and Validation of the Hong Kong Version of the Knee Injury and Osteoarthritis Outcome Score (HK-KOOS) for Patients with Knee Osteoarthritis.

INTRODUCTION: This study aimed to validate the Hong Kong version of the Knee Injury and Osteoarthritis Outcome Score (HK-KOOS) for patients with knee osteoarthritis. METHODS: Content validity was assessed using the Item and Scale Content Validity Index (I-CVI and S-CVI). Test-retest reliability and internal consistency were assessed by the Intraclass Correlation Coefficient (ICC) and Cronbach's alpha. Dimensionality was assessed by performing exploratory factor analysis (EFA). Convergent and Divergent Validity was performed by examining the correlation between the HK-KOOS and the Chinese version of the Short Form 12 (SF-12) Health Survey, the Chinese Modified Barthel Index (C-MBI), and the Visual Analogue Scale for Pain (VAS-Pain). Ceiling and floor effects were also examined. RESULTS: A total of 125 participants were recruited in this study. In general, all instructions, items, and response options were considered as understandable, indicating a satisfactory cross-cultural adaptation. The I-CVI and S-CVI scores were 0.80-1 and 0.90-1, respectively, indicating excellent content validity in terms of relevance, representativeness, and understandability. The test-retest reliability of all HK-KOOS subscales was satisfactory with ICC exceeding 0.70 for all domains. Cronbach's alpha exceeded 0.80 for all subscales, indicating satisfactory internal consistency. Medium to strong correlations were found between the HK-KOOS and the VAS-Pain, SF-12, and C-MBI. However, factor analysis indicated a seven-factor structure, rather than the original five-factor structure. Items on pain and activities of daily living were loaded in the same factors. A floor effect was present in the sports and recreation subscale. DISCUSSION AND CONCLUSIONS: Future studies should further examine the dimensionality of the KOOS. The HK-KOOS is a culturally adapted, reliable, and valid outcome measure instrument to be used in Hong Kong patients with primary knee osteoarthritis.

A Critical Asthma Standardized Clinical and Management Plan Reduces Duration of Critical Asthma Therapy.

BACKGROUND AND OBJECTIVE: Reduction of critical asthma management time can reduce intensive care utilization. The goal of this study was to determine whether a Critical Asthma Standardized Clinical Assessment and Management Plan (SCAMP) can decrease length of critical asthma management time. METHODS: This retrospective study compared critical asthma management times in children managed before and after implementation of a Critical Asthma SCAMP. The SCAMP used an asthma severity score management scheme to guide stepwise escalation and weaning of therapies. The SCAMP guided therapy until continuous albuterol nebulization (CAN) was weaned to intermittent albuterol every 2 hours (q2h). Because the SCAMP was part of a quality improvement initiative in which all patients received a standardized therapy, informed consent was waived. The study was conducted in Medicine ICU and Intermediate Care Units in a tertiary care freestanding children's hospital. Children ≥2 years of age who had CAN initiated in the emergency department and were admitted to the Division of Medicine Critical Care with status asthmaticus were included. The time to q2h dosing from initiation of CAN was compared between the baseline and SCAMP cohorts. Adverse events were compared. The Mann-Whitney test was used for analysis; P values <.05 were considered statistically significant. RESULTS: There were 150 baseline and 123 SCAMP patients eligible for analysis. There was a decrease in median time to q2h dosing after the SCAMP (baseline, 21.6 hours [interquartile range, 3.2-32.3 hours]; SCAMP, 14.2 hours [interquartile range, 9.0-23.1 hours]; P < .01). There were no differences in adverse events or readmissions. CONCLUSIONS: A Critical Asthma SCAMP was effective in decreasing time on continuous albuterol.

MEF2B mutations in non-Hodgkin lymphoma dysregulate cell migration by decreasing MEF2B target gene activation.

Myocyte enhancer factor 2B (MEF2B) is a transcription factor with mutation hotspots at K4, Y69 and D83 in diffuse large B-cell lymphoma (DLBCL). To provide insight into the regulatory network of MEF2B, in this study, we analyse global gene expression and DNA-binding patterns. We find that candidate MEF2B direct target genes include RHOB, RHOD, CDH13, ITGA5 and CAV1, and that indirect target genes of MEF2B include MYC, TGFB1, CARD11, MEF2C, NDRG1 and FN1. MEF2B overexpression increases HEK293A cell migration and epithelial-mesenchymal transition, and decreases DLBCL cell chemotaxis. K4E, Y69H and D83V MEF2B mutations decrease the capacity of MEF2B to activate transcription and decrease its' effects on cell migration. The K4E and D83V mutations decrease MEF2B DNA binding. In conclusion, our map of the MEF2B regulome connects MEF2B to drivers of oncogenesis.

Bronchoscopic procedures and lung biopsies in pediatric lung transplant recipients.

Bronchoscopy remains a pivotal diagnostic and therapeutic intervention in pediatric patients undergoing lung transplantation (LTx). Whether performed as part of a surveillance protocol or if clinically indicated, fibre-optic bronchoscopy allows direct visualization of the transplanted allograft, and in particular, an assessment of the patency of the bronchial anastomosis (or tracheal anastomosis following heart-lung transplantation). Additionally, bronchoscopy facilitates differentiation of infective processes from rejection episodes through collection and subsequent assessment of bronchoalveolar lavage (BAL) and transbronchial biopsy (TBBx) samples. Indeed, the diagnostic criteria for the grading of acute cellular rejection is dependent upon the histopathological assessment of biopsy samples collected at the time of bronchoscopy. Typically, performed in an out-patient setting, bronchoscopy is generally a safe procedure, although complications related to hemorrhage and pneumothorax are occasionally seen. Airway complications, including stenosis, malacia, and dehiscence are diagnosed at bronchoscopy, and subsequent management including balloon dilatation, laser therapy and stent insertion can also be performed bronchoscopically. Finally, bronchoscopy has been and continues to be an important research tool allowing a better understanding of the immuno-biology of the lung allograft through the collection and analysis of collected BAL and TBBx samples. Whilst new investigational tools continue to evolve, the simple visualization and collection of samples within the lung allograft by bronchoscopy remains the gold standard in the evaluation of the lung allograft. This review describes the use and experience of bronchoscopy following lung transplantation in the pediatric setting.

Lafora disease with novel autopsy findings: a case report with endocrine involvement and literature review.

BACKGROUND: Lafora disease is a rare, autosomal recessive, progressive myoclonic epilepsy with onset typically in the second decade of life and uniformly fatal outcome. Most of the current literature focuses on diagnosis, genetic basis, neurological signs, and possible treatment of this currently incurable disease. On literature review of over 50 articles including over 300 patients, there were no comments on or pathologic description of endocrinologic issues in relation to Lafora disease. PATIENT DESCRIPTION: We describe a patient with Lafora disease with severe neurological deterioration. During hospitalization for urosepsis, he exhibited thyrotoxicosis with a free thyroxine (T4) level greater than 7.77 ng/dL. On autopsy, he had lymphocytic thyroiditis and Lafora bodies throughout his organs including the anterior pituitary, hypothalamus, and pancreas. CONCLUSIONS: This is the first report of the pathologic findings of Lafora bodies in endocrine organs. Although this patient's thyrotoxic state was likely not a direct result of his Lafora disease, given the diffuse deposition of Lafora bodies, endocrinologic abnormalities should be considered in patients with Lafora disease. Furthermore, acute decompensation in these individuals may arise not from a declining neurological status but from a coincidental disease process.

Cutaneous squamous cell carcinoma in two pediatric lung transplant patients on prolonged voriconazole treatment.

Oral voriconazole is commonly used for treatment and prophylaxis of invasive fungal disease post-LTx. Development of cutaneous SCC has been described in adult LTx recipients, although it is extremely rare in children. We describe two Caucasian children who developed cutaneous SCC beyond three yr post-LTx. Both developed severe photosensitivity, actinic keratosis and required curative surgical excision of the cutaneous SCC lesions. Neither patient developed metastatic lesions nor had allograft dysfunction as a result of the SCC or the change in medical treatments. The effect of voriconazole on the development of malignant skin lesions is discussed and a recommendation on dermatologic surveillance, preventive measures against phototoxicity and early treatment of SCC are provided.

Cardiac output assessed by non-invasive monitoring is associated with ECG changes in children with critical asthma.

The primary aim of this study was to determine changes in CI and SI, if any, in children hospitalized with status asthmatics during the course of treatment as measured by non-invasive EC monitoring. The secondary aim was to determine if there is an association between Abnormal CI (defined as <5 or >95 % tile adjusted for age) and Abnormal ECG (defined as ST waves changes) Non-invasive cardiac output (CO) recordings were obtained daily from admission (Initial) to discharge (Final). Changes in CI and SI measurements were compared using paired t tests or 1-way ANOVA. The association between Abnormal CI on Initial CO recording and Abnormal ECG was analyzed by Fischer's exact test. Data are presented as mean ± SEM with mean differences reported with 95 % confidence interval; p < 0.05 was considered significant. Thirty-five children with critical asthma were analyzed. CI decreased from 6.2 ± 0.2 to 4.5 ± 0.1 [-1.6 (-0.04 to -0.37)] L/min/m(2) during hospitalization. There was no change in SI. There was a significant association between Abnormal Initial CI and Abnormal ECG (p = 0.02). In 11 children requiring prolonged hospitalization CI significantly decreased from 7.2 ± 0.5 to 4.0 ± 0.2 [-3.2 (-4.0 to -2.3)] L/min/m(2) and SI decreased from 51.2 ± 3.8 to 40.3 ± 2.0 [-11.0 (-17.6 to -4.4)] ml/beat/m(2) There was a significant decrease in CI in all children treated for critical asthma. In children that required a prolonged course of treatment, there was also a significant decrease in SI. Abnormal CI at Initial CO recording was associated with ST waves changes on ECG during hospitalization. Future studies are required to determine whether non-invasive CO monitoring can predict which patients are at risk for developing abnormal ECG.

Cardiac parameters in children recovered from acute illness as measured by electrical cardiometry and comparisons to the literature.

Electrical cardiometry (EC) is a non-invasive cardiac output method that can assess cardiac index (CI) and stroke index (SI) but there are no reference values for children per se. The primary aim of this study was to develop reference values for clinical application. The secondary aim was to compare the EC measurements to published values. We performed a prospective observational study in patients (<21 years of age) without structural heart disease who had recovered from an acute illness. EC recordings in children that had normal heart rate and mean arterial blood pressure at discharge were eligible for analysis. The relationship of CI or SI and age in children was performed by regression analysis. Similar analysis was performed comparing measurements by EC to cardiac parameters values compiled from reference sources to assess bias in EC. Eighty-three children (2 weeks-21 years of age) were studied. There was a significant curvilinear relationship between CI or SI and age by EC (F-test, p < 0.05). Regression curves of cardiac parameters reported in the literature using 6 Fick's method, thermodilution, echocardiography and cardiac MRI were the same or higher than (0-19.6 %) values obtained with EC, with higher values being statistically significant (p < 0.05 all). There is a curvilinear relationship of CI or SI and age by EC in normal children. Cardiac parameters reported in the literature using alternative methods are different from those obtained with EC but are within acceptable ranges, with EC biased to underestimate CI. Adjustment of target value is required for EC goal-directed therapies.

RSV prevention and treatment in pediatric lung transplant patients: a survey of current practices among the International Pediatric Lung Transplant Collaborative.

RSV infection can be severe after pediatric lung transplantation. Strategies to prevent and treat RSV in this population are underreported. To assess the current practices, we surveyed the members of the IPLTC regarding RSV prevention and treatment strategies. Twenty-eight programs were surveyed; 18 (64.3%) responded at least partially. A median of 53 transplants (range, 8-355) occurred since inception. RSV testing occurs in asymptomatic (6/17) and symptomatic (17/17) patients. Diagnostic method is polymerase chain reaction at 13 sites and DFA at 8. Transplant candidates were received prophylaxis at 10 sites, with nine following national (5) or local (4) guidelines. All use palivizumab IM and/or IV. Recipients were received prophylaxis with palivizumab at eight centers (eight IM, one IV). Fourteen were treated for RSV (seven all patients; seven age-related). Medications include inhaled (6), oral (4), or IV (4) ribavirin, plus IVIG (9), steroids (8), and IV (2) or IM (3) palivizumab. Prevention and treatment barriers include insurance/hospital concerns, such as institutional reluctance to use inhaled ribavirin. RSV prevention and treatment strategies are diverse at pediatric lung transplant programs. Many centers offer prophylaxis (9/17) and treatments (14/17), but strategies are not uniform.

Changes in cardiac output and stroke volume as measured by non-invasive CO monitoring in infants with RSV bronchiolitis.

OBJECTIVES: The primary aim of the study was to determine the changes, if any, in cardiac output (CO) and stroke volume (SV) in normal infants with RSV bronchiolitis. The secondary aim was to determine whether changes in CO (ΔCO) and SV (ΔSV) are associated with changes in respiratory rate (ΔRR). METHODS: Non-invasive CO recordings were obtained within 24 h of admission and discharge. Changes in CO, SV, and HR measurements were compared using paired t-tests. The effect of fluid boluses during the first 24 h (<60 or ≥60 cc/kg) on CO was assessed by 2 way ANOVA with time and group as main effect. The relationship between ΔRR and ΔCO or ΔSV was assessed by linear regression. Data is presented as Mean ± SEM and mean differences with 95 % confidence interval (p < 0.05 considered significant). RESULTS: 15 infants with RSV bronchiolitis were studied. CO (1.31 ± 0.13 to 1.11 ± 0.11 l/min (0.21 [0.04-0.37]) and SV (9.42 ± 1.10 to 7.75 ± 0.83 ml/beat (1.67 [0.21-3.12]) decreased significantly while HR (142.1 ± 4.0 to 145.2 ± 3.1 beats/min 3.0 [-5.3 to 11.3]) was unchanged. SV (p = 0.02) and CO (p = 0.04) significantly decreased only in the 7 infants that received ≥60 cc/kg. ΔRR correlated significantly with ΔCO (r (2) = 0.28, p = 0.04); but not with ΔSV (r (2) = 0.20, p = 0.09). CONCLUSIONS: ∆CO was related to ΔSV and not Δ HR. The ∆CO and ΔSV were affected by fluid boluses. ΔRR correlated with ΔCO. Non-invasive CO monitoring can trend CO and SV in infants with bronchiolitis during hospitalization.

Cardiovascular effects of dexmedetomidine sedation in children.

BACKGROUND: Dexmedetomidine (DEX) affects heart rate (HR), mean arterial blood pressure, cardiac index (CI), stroke index (SI), and systemic vascular resistance index (SVRI) in adults. In this study we sought to determine whether similar effects occur in children undergoing DEX sedation. METHODS: Hemodynamic changes in children were followed during IV DEX sedation for radiological procedures. One group of 8 patients (DEX-brief) received a bolus (2 mcg/kg bolus over 10 minutes) and completed the procedure within 10 minutes. The second group of 9 patients (DEX-prolong) received the bolus plus additional DEX as needed to maintain sedation for procedures lasting longer than 10 minutes (additional 1 mcg/kg/hr infusion with second bolus if needed). CI, SI, and SVRI were measured using a continuous noninvasive cardiac output monitor. Changes in hemodynamic variables at minutes 10, 20, and discharge (time at which patient achieved Aldrete Score ≥9) were compared to baseline by repeated measures ANOVA with effect sizes reported as mean [95% confidence interval]. RESULTS: Data were obtained during 8 DEX-brief and 9 DEX-prolong procedures. In DEX-brief, HR and CI decreased (18.9 [2.3 to 35.5] bpm and 0.74 [0.15 to 1.33] L/min/m(2); respectively) at T1. There was no change in any other hemodynamic variables and all hemodynamic variables returned to baseline at recovery. In DEX-prolong, both HR and CI remained decreased (24.0 [8.3 to 39.6] bpm, 1.51 [0.95 to 2.06] L/min/m(2); respectively) at recovery. In addition, SI was decreased (8.01 [1.71 to 14.31] mL/m(2)) and SVRI was increased (776.0 [271.9 to 1280.4] dynes-sec/cm(5)/m(2)) at recovery in the DEX-prolong group. There were no significant changes in mean arterial blood pressure in either group. CONCLUSION: DEX decreases CI in children and has a cumulative effect. For patients undergoing prolonged procedures HR and CI remained decreased at the time of discharge together with a decrease in SI and an increase in SVRI.

Non-invasive cardiac output and oxygen delivery measurement in an infant with critical anemia.

OBJECTIVE: To assess the combination of a non-invasive blood oxygen content (CaO(2)) monitor and a non-invasive cardiac output (CO) monitor to continuously measure oxygen delivery (DO(2); DO(2) = CaO(2) × CO). METHODS: DO(2) was assessed during blood transfusions in an infant with acute hemolytic anemia following admission (~48 h). CaO(2) was measured by Pulse Co-Oximetry, which also provides estimates of hemoglobin (Hgb) concentration and percent oxygen saturation. CO was measured by Electrical Velocimetry, which also provides an estimate of stroke volume (SV). Lactate levels, an indirect measure of adequate DO(2), were assessed during the initial 8 h following admission. RESULTS: Incremental blood transfusions during the first 36 h increased Hgb from 2.7 to 9.5 g/dL during which time heart rate (HR) normalized from 156 to 115 beats/min. Lactate levels decreased from 20 to 0.8 mmol/L in the first 7 h. Non-invasive Hgb and CaO(2) measurements were well correlated with invasive Hgb and CaO(2) measures (r (2) = 0.88; P = 0.019; r (2) = 0.86; P = 0.0074, respectively). CO decreased from 2.47 ± 0.06 to 1.28 ± 0.02 L/min and SV decreased from 15.9 ± 0.4 to 11.1 ± 0.2 mL/beat. Mean arterial blood pressure was stable throughout the admission with systemic vascular resistance increasing from 407.6 ± 15.2 to 887.7 ± 30.1 dynes-s/cm(5). DO(2) was estimated to increase from 120.2 ± 18.9 to 182.4 ± 5.6 mL O(2)/min. CONCLUSIONS: Non-invasive continuous CO and CaO(2) monitors are shown in this single case to provide continuous DO(2) measurement. The ability to assess DO(2) may improve hemodynamic monitoring during goal directed therapies.

Exercise testing in pediatric lung transplant candidates with cystic fibrosis.

Exercise testing is considered an important prognostic tool for the selection of pediatric lung transplant candidates with end-stage CF lung disease. To better understand the current practice as it pertains to exercise testing, a self-administered questionnaire was distributed to 25 pediatric lung transplant centers within the IPLTC across Australia, Europe, and North America. All centers perform standardized exercise tests. Fifteen centers perform one single-field test (6MWT/12MWT), while seven perform a six-min walk plus an additional test: SWT (N = 1), 3MST (N = 1), and CPET (N = 5). Frequency of testing is markedly different among centers. Two centers conduct exercise testing once, all others at multiple time points. Equipment availability and cost were no limitations, but lack of time (20%) and personnel (16%), and paucity of prognostic evidence (16%) and reference values (12%) were stated. Exercise testing is considered important and extensively used in the evaluation of pediatric lung transplant candidates with CF; methods of exercise test and the frequency of testing vary widely. We propose a prospective multicenter study to evaluate the efficacy of exercise testing and its prognostic value using a standardized protocol.

Positive treatment effects of ustekinumab in psoriasis: analysis of lesional and systemic parameters.

Ustekinumab, a human anti-interleukin (IL)-12/IL-23p40 monoclonal antibody has demonstrated significant efficacy in patients with moderate-to-severe psoriasis. Skin lesion biopsies, cell surface markers on peripheral blood lymphocytes, and ex vivo T-helper (Th)1/Th2 cytokine responses from peripheral blood mononuclear cells (PBMC) from patients receiving ustekinumab 45 or 90 mg, or placebo were evaluated at baseline and week 12. Inflammatory serum protein levels were measured at baseline, week 2 and week 12. At week 12, median epidermal thickness decreased from 312.1 to 132.7 microm, and median levels of cellular proliferation (Ki67) and T-cell infiltration (CD3) decreased by 84.3% and 70.7%, respectively, in the combined ustekinumab group (all P < or = 0.002). Serum levels of tumor necrosis factor (TNF)-alpha, C-C motif ligand 27 (CCL27) and other inflammatory cytokines remained unchanged. Minimal variation in the percentage of T cells expressing cutaneous lymphocyte antigen (CLA) was observed following ustekinumab treatment, with no significant variation in the percentage of cells expressing CD45RA, CD45RO, CD25, human leukocyte antigen-DR (HLA-DR), and C-X-C motif receptor 3 (CXCR3). No apparent effect on the magnitude of Th1/Th2 responses to external stimuli in PBMC was observed following placebo or ustekinumab treatment. Ustekinumab improves histological psoriasis measures, with minimal impact on the systemic immune system.