Standardizing Prostaglandin Initiation in Prenatally Diagnosed Ductal-Dependent Neonates; A Quality Initiative.

Prostaglandin E1 (PGE) is used in patients with ductal-dependent congenital heart disease (CHD). Side effects of apnea and fever are often dose dependent and occur within 48 h after initiation. We initiated a standardized approach to PGE initiation after our institution recognized a high incidence of side effects and a wide variety of starting doses of PGE. Neonates with prenatally diagnosed ductal-dependent CHD were identified, started on a standardized protocol that started PGE at 0.01 mcg/kg/min, and evaluated for PGE related side effects. Compliance, outcomes and dose adjustments during the first 48 h post-PGE initiation were evaluated. Fifty patients were identified (25 pre-intervention; 25 post-intervention). After intervention, compliance with the protocol was 96%, and apnea or fever occurred in 28% (compared to 63% pre-intervention, p = 0.015). Dose adjustments (either increase or decrease) prior to cardiac surgery were similar in both cohorts (60%, 52%, p = 0.569). There were no mortalities or emergent procedures performed due to ductus arteriosus closure. Standardizing a protocol for initiating PGE in prenatally diagnosed ductal-dependent CHD was successful and reduced the incidence of apnea, fever, and sepsis evaluations. A starting dose of 0.01 mcg/kg/min did not cause increased adverse effects.

Gastrostomy tube placement in congenital cardiac surgery: a multi-institutional database study.

INTRODUCTION: Neonates and infants who undergo congenital cardiac surgery frequently have difficulty with feeding. The factors that predispose these patients to require a gastrostomy tube have not been well defined. We aimed to report the incidence and describe hospital outcomes and characteristics in neonates and infants undergoing congenital cardiac surgery who required gastrostomy tube placement. MATERIALS AND METHOD: A retrospective review was performed on patients undergoing congenital cardiac surgery between October 2015 and December 2020. Patients were identified by International Classification of Diseases 10th Revision codes, utilising the performance improvement database Vizient® Clinical Data Base, and stratified by age at admission: neonates (<1 month) and infants (1-12 months). Outcomes were compared and comparative analysis performed between admissions with and without gastrostomy tube placement. RESULTS: There were 11,793 admissions, 3519 (29.8%) neonates and 8274 (70.2%) infants. We found an increased incidence of gastrostomy tube placement in neonates as compared to infants following congenital cardiac surgery (23.1% versus 6%, p = <0.001). Outcomes in neonates and infants were similar with increased length of stay and cost in those requiring a gastrostomy tube. Gastrostomy tube placement was noted to be more likely in neonates and infants with upper airway anomalies, congenital abnormalities, hospital infections, and genetic abnormalities. DISCUSSION: Age at hospitalisation for congenital cardiac surgery is a definable risk factor for gastrostomy tube requirement. Additional factors contribute to gastrostomy tube placement and should be used when counselling families regarding the potential requirement of a gastrostomy tube.

Invasive Cardiac Procedures in Interstage Single Ventricle Patients in Emergent Hospitalizations.

Single ventricle congenital heart disease (SV CHD) patients are at risk of morbidity and mortality between the first and second palliative surgical procedures (interstage). When these patients present acutely they often require invasive intervention. This study sought to compare the outcomes and costs of elective and emergent invasive cardiac procedures for interstage patients. Retrospective review of discharge data from The Vizient Clinical Data Base/Resource Manager™, a national health care analytics platform. The database was queried for admissions from 10/2014 to 12/2017 for children 1-6 months old with ICD-9 or ICD-10 codes for SV CHD who underwent invasive cardiac procedures. Demographics, length of stay (LOS), complication rate, in-hospital mortality and direct costs were compared between elective and emergent admissions using t test or χ2, as appropriate. The three most frequently performed procedures were also compared. 871 admissions identified, with 141 (16%) emergent. Age of emergent admission was younger than elective (2.9 vs. 4 months p < 0.001). Emergent admissions including cardiac catheterization or superior cavo-pulmonary anastomosis had longer LOS (58.7 vs. 25.8 day, p < 0.001 and 54.8 vs .22.6 days, p < 0.001) and higher costs ($134,774 vs. $84,253, p = 0.013 and $158,679 vs. $81,899, p = 0.017). Emergent admissions for interstage SV CHD patients undergoing cardiac catheterization or superior cavo-pulmonary anastomosis are associated with longer LOS and higher direct costs, but with no differences in complications or mortality. These findings support aggressive interstage monitoring to minimize the need for emergent interventions for this fragile patient population.

Deep genome-wide measurement of meiotic gene conversion using tetrad analysis in Arabidopsis thaliana.

Gene conversion, the non-reciprocal exchange of genetic information, is one of the potential products of meiotic recombination. It can shape genome structure by acting on repetitive DNA elements, influence allele frequencies at the population level, and is known to be implicated in human disease. But gene conversion is hard to detect directly except in organisms, like fungi, that group their gametes following meiosis. We have developed a novel visual assay that enables us to detect gene conversion events directly in the gametes of the flowering plant Arabidopsis thaliana. Using this assay we measured gene conversion events across the genome of more than one million meioses and determined that the genome-wide average frequency is 3.5×10(-4) conversions per locus per meiosis. We also detected significant locus-to-locus variation in conversion frequency but no intra-locus variation. Significantly, we found one locus on the short arm of chromosome 4 that experienced 3-fold to 6-fold more gene conversions than the other loci tested. Finally, we demonstrated that we could modulate conversion frequency by varying experimental conditions.

The Russian Thistle (Salsola kali) pollen major allergen, Sal k 1, can be quantified in allergenic extracts and airborne pollen.

BACKGROUND: Russian thistle (Salsola kali) pollen is an important cause of pollinosis in areas where rainfall is not abundant. Our aim was to develop an ELISA for quantification of the major allergen of S. kali extracts, Sal k 1, and to assess the correlation of this allergen content with the allergenic activity of extracts. METHODS: Sal k 1 was purified by ion exchange and gel permeation chromatography and identified by mass spectrometry. Monoclonal antibody 4C11 was used for capture at 5 microg/ml and biotin-labeled specific antiserum at 0.25 microg/ml served for detection. The allergenic activity of the pollen extracts was measured by enzyme allergosorbent test inhibition. RESULTS: Sal k 1 reacted to 85% of sera from 40 S. kali-allergic patients and was able to inhibit 92% of the IgE-binding capacity of patients' serum pool to the whole extract. The ELISA had a lineal range between 1.25 and 20 ng/ml of purified Sal k 1. The intra- and interassay coefficients of variation were lower than 5 and 10%, respectively. The assay was very sensitive since it had a detection limit of 0.08 ng/ml. No reactivity was found outside the Amaranthaceae family where only Kochia and Salicornia sp. gave significant reactivity. A good correlation (Spearman's rho = 0.92) was obtained between Sal k 1 content of different S. kali extracts and their IgE-binding activity. CONCLUSIONS: The results proved the usefulness of the two-site sandwich ELISA for aeroallergen control and for the standardization of S. kali pollen extracts intended for clinical use.

Antifungal and antitumor activities of a monoclonal antibody directed against a stress mannoprotein of Candida albicans.

Immunization of mice with a stress mannoprotein of >200 kDa from the cell wall of Candida albicans led to the production of monoclonal antibody (Mab) C7. The immunogen is a major target of secretory IgA and its expression is regulated by different environmental conditions including temperature, pH, glucose concentration and ammonium sulphate in the culture medium. Mab C7 reacted with a peptide epitope present in the >200 kDa antigen as well as in a number of antigens from the blastoconidium and germ tube cell wall, including enolase. In addition to its reactivity with C. albicans, Mab C7 also reacted with antigens present in C. krusei, C, tropicalis, C. glabrata, C. dubliniensis and C. lusitaniae, as well as in Cryptococcus neoformans, Scedosporium prolificans and Aspergillus fumigatus. Mab C7 exhibited four important biological activities, namely inhibition of adhesion of C. albicans to a variety of surfaces, inhibition of germination of C. albicans, direct candidacidal activity and direct tumoricidal activity. In tumor cells, Mab C7 reacted with nucleoporin Nup88, a reactivity that can be utilized for diagnostic and prognostic purposes.

Enoxaparina como alternativa antitrombótica para la cirugía en pacientes de alto riesgo tromboembólico crónicamente anticoagulados con dicumarínicos / Enoxaparinas an alternative to antocoagulant therapy in hight risk patients under chronic treatment with vitamin K antagonists

En la actualidad no existe un criterio uniforme para el manejo anticoagulante perioperatorio de los pacientes con alto riesgo tromboembólico y crónicamente anticoagulados con dicumarínicos. Se ha propuesto el uso de las HBPM en reemplazo de la heparina no fraccionada pero la experiencia publicada es escasa y no hay un consenso sobre la dosis y el momento adecuado para reiniciar la anticoagulación en el período post quirúrgico, especialmente en cirugía mayor. Nuestro objetivo fue evaluar la efectividad y seguridad de la enoxaparina 1 mg/kg SC cada 12 horas en el manejo perioperatorio de pacientes con alto riesgo tromboembólico. Resultados: 48 pacientes (edad promedio: 70 años, 32 hombres) anticoagulados por RVM 64,5 porciento y FA con antecedente de embolia o trombo auricular en 35,5 porciento. El 45 porciento requirió suspender los AO por una cirugía programada, 33 porciento por cirugía odontológica, 16 porciento cateterismo cardíaco y 6 porciento por una biopsia. Los pacientes suspendían la AO 3 a 5 días previos al procedimiento y lo reemplazaban por enoxaparina. la dosis promedio de enoxaparina fue de 80 mg cada 12 horas. El 92 porciento de los pacientes reinició AO en las primeras 24 horas de la cirugía. No se detectaron eventos trombóticos hasta 1 mes de la cirugía. Cuatro pacientes presentaron hemorragias, 3 sangrados menores y 1 sangrado mayor que requirió múltiples transfusiones. Conclusión: La enoxaparina puede ser una alternativa antitrombótica eficaz en pacientes con alto riesgo tromboembólico y permitirá mediante 1 o 2 dosis diarias (ajustadas al peso) el manejo ambulatorio con un bajo índice de sangrado

Enoxaparina como alternativa antitrombótica para la cirugía en pacientes de alto riesgo tromboembólico crónicamente anticoagulados con dicumarínicos / Enoxaparinas an alternative to antocoagulant therapy in hight risk patients under chronic treatment with vitamin K antagonists

En la actualidad no existe un criterio uniforme para el manejo anticoagulante perioperatorio de los pacientes con alto riesgo tromboembólico y crónicamente anticoagulados con dicumarínicos. Se ha propuesto el uso de las HBPM en reemplazo de la heparina no fraccionada pero la experiencia publicada es escasa y no hay un consenso sobre la dosis y el momento adecuado para reiniciar la anticoagulación en el período post quirúrgico, especialmente en cirugía mayor. Nuestro objetivo fue evaluar la efectividad y seguridad de la enoxaparina 1 mg/kg SC cada 12 horas en el manejo perioperatorio de pacientes con alto riesgo tromboembólico. Resultados: 48 pacientes (edad promedio: 70 años, 32 hombres) anticoagulados por RVM 64,5 porciento y FA con antecedente de embolia o trombo auricular en 35,5 porciento. El 45 porciento requirió suspender los AO por una cirugía programada, 33 porciento por cirugía odontológica, 16 porciento cateterismo cardíaco y 6 porciento por una biopsia. Los pacientes suspendían la AO 3 a 5 días previos al procedimiento y lo reemplazaban por enoxaparina. la dosis promedio de enoxaparina fue de 80 mg cada 12 horas. El 92 porciento de los pacientes reinició AO en las primeras 24 horas de la cirugía. No se detectaron eventos trombóticos hasta 1 mes de la cirugía. Cuatro pacientes presentaron hemorragias, 3 sangrados menores y 1 sangrado mayor que requirió múltiples transfusiones. Conclusión: La enoxaparina puede ser una alternativa antitrombótica eficaz en pacientes con alto riesgo tromboembólico y permitirá mediante 1 o 2 dosis diarias (ajustadas al peso) el manejo ambulatorio con un bajo índice de sangrado (AU)

Chronic low back pain patients around the world: cross-cultural similarities and differences.

OBJECTIVE: The current study sought to determine whether there were any significant cross-cultural differences in medical-physical findings, or in psychosocial, behavioral, vocational, and avocational functioning, for chronic low back pain patients. DESIGN: Partially double-blind controlled comparison of six different culture groups. SETTING: Subjects were selected from primarily ambulatory care facilities specializing in treating chronic pain patients. PATIENTS-SUBJECTS: Subjects consisted of 63 chronic low back pain patients and 63 healthy controls. Low back pain patients were randomly selected from six different culture groups (American, Japanese, Mexican, Colombian, Italian, and New Zealander). Ten to 11 were gathered per culture from a pool of patients treated at various pain treatment programs. Likewise, 10 or 11 control group subjects were obtained from each culture from a pool of healthy support staff. MAIN OUTCOME MEASURES: The Sickness Impact Profile and the Medical Examination and Diagnostic Information Coding System were used as primary outcome measures. RESULTS: Findings showed that (a) low back pain subjects across all cultures had significantly more medical-physical findings and more impairment on psychosocial, behavioral, vocational, and avocational measures than controls did; (b) Mexican and New Zealander low back pain subjects had significantly fewer physical findings than other low back pain groups did; (c) the American, New Zealander, and Italian low back pain patients reported significantly more impairment in psychosocial, recreational, and/or work areas, with the Americans the most dysfunctional; and (d) findings were not a function of working class, age, sex, pain intensity, pain duration, previous surgeries, or differences in medical-physical findings. CONCLUSIONS: It was concluded that there were important cross-cultural differences in chronic low back pain patients' self-perceived level of dysfunction, with the American patients clearly the most dysfunctional. Possible explanations included cross-cultural differences in social expectation; attention; legal-administrative requirements; financial gains; attitudes-expectations about usage, type, and availability of health care; and self-perceived ability and willingness to cope.

Patterns of conscious failure to provide accurate self-report data in patients with low back pain.

Assessment and treatment responses were compared in 17 subjects with chronic low back pain assessed as showing at least one clear consciously produced inconsistency in statements and/or behaviors during their participation in an interdisciplinary treatment program and 143 subjects assessed as showing no such inconsistency. Numerous statistically significant differences emerged: Inconsistent subjects were more likely to have pending litigation and to be assessed by staff as showing a higher degree of focus on pain and more dramatized complaints, lower levels of medical findings and attention and interest in treatment, and poor compliance with treatment and assessment procedures. In addition, these subjects reported lower levels of physical activity and generally more inconsistent or negative responses to lumbar sympathetic injections with fewer expected changes in physical sensations. Though not definitive, these results suggested a syndrome of characteristics among such subjects which are similar to those proposed as likely characterizing malingerers. The need for a particularly careful validation of self-report data in patients showing many of these characteristics was emphasized.

American and Japanese chronic low back pain patients: cross-cultural similarities and differences.

The study compared and contrasted medical, psychological, social and general behavioral functioning of American and Japanese low back pain patients and normal controls. The Sickness Impact Profile and a standardized Medical Examination Protocol for Pain instrument were used to assess all subjects. Findings showed that the American and Japanese low back pain patients had similar and significantly higher medical-physical findings than their respective controls. Likewise, the American and Japanese low back pain patients showed significantly greater psychological, social, and general behavioral dysfunction compared to control subjects. Finally, despite similar medical and physical findings, the Japanese low back pain patients were significantly less impaired in psychological, social, vocational, and avocational functioning than the American low back pain patients. It was concluded that there were significant cross-cultural differences between the American and Japanese low back pain patients, primarily in the psychosocial and behavioral areas. However, given the small sample size, any conclusion should be considered with caution; replication is needed before more definite conclusions are possible.

Nerve blocks and chronic pain states--an update. 1. Basic considerations.

Appreciation of the extremely complex nature of pain has resulted, regrettably, in diminished use of nerve blocking to manage chronic pain states. Nevertheless, clinical use of these time-honored techniques remains popular in clinical anesthesia for surgery, in obstetrics, and in the control of pathogenic pain resulting from injury or disease. Patients with chronic pain are best assessed by cross-matched analysis of medical, emotional, and social factors.

Nerve blocks and chronic pain states--an update. 2. Clinical indications.

With the unfortunate exception of the differential spinal block, diagnostic nerve blocking has become somewhat obsolete with the development of newer, more sophisticated diagnostic technology. Therapeutic nerve blocks remain useful in treating patients with various terminal cancers, some forms of back pain, tic douloreux, causalgia, reflex sympathetic dystrophy, and many trigger point syndromes. For dysfunctional and pain-disabled patients (rated as class 1 or 3 on Emory Pain Estimate Model), block therapy must be structured in comprehensive pain rehabilitation programs.