Efficacy of integrating a semi-immersive virtual device in the HABIT-ILE intervention for children with unilateral cerebral palsy: a non-inferiority randomized controlled trial.

BACKGROUND: The implementation of virtual devices can facilitate the role of therapists (e.g., patient motivation, intensity of practice) to improve the effectiveness of treatment for children with cerebral palsy. Among existing therapeutic devices, none has been specifically designed to promote the application of principles underlying evidence-based motor skill learning interventions. Consequently, evidence is lacking regarding the effectiveness of virtual-based sessions in motor function rehabilitation with respect to promoting the transfer of motor improvements into daily life activities. We tested the effectiveness of implementing a recently developed virtual device (REAtouch®), specifically designed to enable the application of therapeutic motor skill learning principles, during a Hand Arm Bimanual Intensive Therapy Including Lower Extremities (HABIT-ILE) intervention. METHODS: Forty children with unilateral cerebral palsy (5-18 years; MACS I-III; GMFCS I-II) were randomly assigned to a control group or a "REAtouch®" experimental group for a 90-h HABIT-ILE day-camp intervention (two weeks). Children in the REAtouch® group spent nearly half of their one-on-one therapeutic time using the REAtouch®. Participants underwent three testing sessions: the week before (T1), after intervention (T2), and at three months follow-up (T3). The primary outcome was the Assisting Hand Assessment (T3-T1; blinded). Secondary outcomes measured uni-bimanual hand function, stereognosis, gait endurance, daily life abilities, and functional goals. Accelerometers and a manual report of daily activities served to document therapeutic dosage and treatment characteristics. We used one-way RMANOVA to compare the efficacies of the two interventions, and non-inferiority analyses to contrast changes in the "REAtouch®" group versus the "HABIT-ILE" control group. RESULTS: We found significant improvements in both groups for most of the outcome measures (p < 0.05). There was significant non-inferiority of changes in the REAtouch® group for upper extremities motor function, functional goals attainment, and abilities in daily life activities (p < 0.05). CONCLUSIONS: Use of the REAtouch® device during HABIT-ILE showed non-inferior efficacy compared to the conventional evidence-based HABIT-ILE intervention in children with unilateral cerebral palsy. This study demonstrates the feasibility of using this virtual device in a high dosage camp model, and establishes the possibility of applying the therapeutic principles of motor skill learning during specifically designed virtual-based sessions. TRIAL REGISTRATION: Trial registration number: NCT03930836-Registration date on the International Clinical Trials Registry Platform (ICTRP): June 21th, 2018; Registration date on NIH Clinical Trials Registry: April 29th, 2019. First patient enrollment: July 3rd, 2018.

TREX-1-Related Disease Associated with the Presence of Cryofibrinogenemia.

PURPOSE: Cryofibrinogenemia is a rare cryopathy presenting as acrocyanosis following exposure to cold. Familial presentation has been described but the underlying molecular cause remained undetermined. METHODS: Forty (40) members from a large family with an initial diagnosis of familial cryofibrinogenemia were interviewed and examined to determine affected status and collect DNA. Exome sequencing was performed on three affected individuals from distinct branches of the pedigree. RESULTS: Seventeen (17) family members reported a history of acrocyanosis with cold exposure. None reported symptoms were suggestive of lupus. Exome sequencing of three subjects identified the heterozygous mutation D18N in the TREX1 gene which was then confirmed by Sanger sequencing in all affected as well as 2 unaffected family members. The mutation is already being associated with familial chilblain lupus erythematosus (CHLE), and a systematic review of literature was undertaken to compare reports of familial CHLE and cryofibrinogenemia. Both entities were found to share highly similar clinical presentations suggesting they are part of a same syndrome in which cryofibrinogenemia and lupus manifestations have variable penetrance. CONCLUSIONS: Familial cryofibrinogenemia without lupus should be added to the spectrum of TREX1-related disease.

Introduction of peanuts in younger siblings of children with peanut allergy: a prospective, double-blinded assessment of risk, of diagnostic tests, and an analysis of patient preferences.

BACKGROUND: The prevalence of peanut allergy in younger siblings of children with peanut allergy has been reported between 7% and 8.5%, but the anaphylactic risk at the time of introduction is currently unknown, which limits our ability to best counsel parents on this issue. OBJECTIVE: To determine the risk of anaphylaxis and working parameters of allergy testing in this context. METHODS: One hundred and fifty-four peanut-naïve younger siblings of peanut-allergic children underwent double-blinded skin testing, followed by parent-led peanut introduction. Questionnaires were dispensed to parents to investigate preferences with regard to peanut introduction in this subgroup. RESULTS: Eight participants (5.2%) presented unequivocal IgE-mediated reactions to peanut upon introduction, including five anaphylaxes. These participants were significantly older compared to the rest of the cohort (median 4.0 vs 1.9 years, P = 0.04). The negative predictive value of skin prick test with peanut extract and peanut butter and of specific IgE was 99%, 100%, and 100%, respectively. Six peanut-tolerant participants had positive peanut allergy tests. The option of introducing at home without prior skin testing was associated with high levels of anxiety (median 8.4 on 10-point Likert scale) when compared to supervised introduction (median 3.8, P < 0.0001) or home introduction after negative skin test (median 4.3, P < 0.0001). CONCLUSIONS: There is an increased risk of anaphylaxis upon peanut introduction in siblings of children with peanut allergy, and parents are reluctant to introduce at home without testing. Allergy testing prior to introduction is negative in over 90% of cases and carries a high negative predictive value.

Analysis of active surveillance uptake for localized prostate cancer in Quebec in 2016: A Canadian bicentric study and comparison with 2010 data.

INTRODUCTION: Active surveillance (AS) has emerged as a primary management strategy for low-risk prostate cancer (PC) patients. We aimed to assess AS uptake over a 1-year snapshot throughout Quebec and to compare it to 2010 multicentric Canadian data. METHODS: A retrospective chart review and data collection was performed in 1 academic and 2 non-academic community centres from Quebec, among men identified in 2016 with localized T1c-T2c PC on biopsy, fulfilling NCCN criteria of low-risk (LR)-PC, including very-low-risk (VLR) and non-VLR-PC, and favourable-intermediate risk (FIR)-PC. AS adherence was defined when chosen as initial strategy, without any radical treatment within 6 months. RESULTS: Overall, 259 patients fulfilled the inclusion criteria with 50.2% of VLR-PC patients. At 6 months, 81% patients in the LR group and 65% in the FIR group were considered as adherent to AS, in both centres, but with an increased use of AS in the community centres compared to 2010 data. The rates of AS maintenance decreased at 12 months to respectively 69% and 58%. Among the VLR group, the rate of initiation was 98% and decreased to 85% at 12 months. CONCLUSION: Our data suggest that the majority of low-risk PC patients indeed initiated an AS in 2016, with even a greater proportion of VLR-PC patients compared to 2010. This ideal strategy should be encouraged and improved at 12 months, and assessed with recent data and longer follow-up.

The prevalence of human papillomavirus in paediatric tonsils in Southwestern Ontario.

OBJECTIVE: To determine the prevalence of human papillomavirus in paediatric tonsils in Southwestern Ontario, Canada. MATERIALS AND METHODS: Patients aged 0-18 years undergoing tonsillectomy were recruited. Two specimens (left and right tonsils) were collected from each participant. Tonsillar DNA was analysed using quantitative polymerase chain reaction to determine the presence of human papillomavirus subtypes 6, 11, 16 or 18. RESULTS: A total of 102 patients, aged 1-18 years (mean age of 5.7 years), were recruited. Ninety-nine surveys were returned. There were 44 females (44.4 per cent) and 55 males (55.6 per cent). Forty patients (40.4 per cent) were firstborn children and 73 (73.7 per cent) were delivered vaginally. Six mothers (6.1 per cent) and one father (1.0 per cent) had prior known human papillomavirus infection, and one mother (1.0 per cent) had a history of cervical cancer. All tonsil specimens were negative for human papillomavirus subtypes 6, 11, 16 and 18. CONCLUSION: No human papillomavirus subtypes 6, 11, 16 or 18 were found in paediatric tonsil specimens from Southwestern Ontario.

Peanut allergy: is maternal transmission of antigens during pregnancy and breastfeeding a risk factor?

BACKGROUND: Peanut allergy is an important public health problem in western countries. However, the risk factors associated with this allergy remain uncertain. OBJECTIVE: To determine whether the consumption of peanuts during pregnancy and breastfeeding is a risk factor for peanut allergy in infants. METHODS: We enrolled 403 infants in a case-control study. The cases were infants aged 18 months or less with a diagnosis of peanut allergy based on a history of clinical reaction after exposure to peanuts and the presence of peanut-specific immunoglobulin E. Controls were age-matched infants with no known clinical history or signs of atopic disease. The mothers of the children filled out a detailed questionnaire about maternal diet during pregnancy and breastfeeding, the infant's diet, the presence of peanut products in the infant's environment, and family history of atopy. RESULTS: The mean (SD) age of cases was 1.23 (0.03) years. The groups were comparable in terms of the rate and duration of breastfeeding. However, the reported consumption of peanuts during pregnancy and breastfeeding was higher in the case group and associated with an increased risk of peanut allergy in offspring (odds ratio [OR], 4.22 [95% confidence interval [CI], 1.57-11.30 and OR, 2.28 [95% CI, 1.31-3.97] for pregnancy and breastfeeding, respectively). Overall, the infants with peanut allergy did not seem to be more exposed to peanut products in their environment than the controls. CONCLUSION: Early exposure to peanut allergens, whether in utero or through human breast milk, seems to increase the risk of developing peanut allergy.

Antiplatelet therapy following drug-eluting stent implantation: new clinical data and recommendations.

Technological developments in percutaneous coronary interventions (PCI) allow the possibility for less invasive revascularization in an increasing number of patients with atherosclerotic coronary artery disease. Bare-metal stents (BMS) have considerably improved the efficacy of PCI in addition to greatly reducing restenosis. However, even with standard stents, restenosis has remained a significant limitation of this revascularization technique. The advent of drug-eluting stents (DES) has dramatically reduced in-stent restenosis and, as a result, the need for repeat revascularization. However, their potential thrombogenicity has raised concerns about their clinical utility and long-term safety. Indeed, there is a possible higher rate of late stent thrombosis (LST) with DES compared with BMS. Antiplatelet therapy has been shown to be efficient in preventing DES thrombosis. Nevertheless, in the future, significant improvement will occur to improve the safety and efficacy of this therapy. This article will summarize the pathophysiology and the epidemiology of stent thrombosis (ST). Definitions of definite, probable and possible ST will be described. Furthermore, clinical risk factors for ST will be clearly enumerated. Then, the various antiplatelet therapeutic strategies used to prevent ST will be taken in consideration. Finally, a summary of the major recommendations about antiplatelet therapy made by some of the most prestigious learned societies will be presented.

Publication trends in obstructive sleep apnea: Evidence of need for more evidence.

OBJECTIVE: Published research in obstructive sleep apnea (OSA) appears limited despite OSA being a highly prevalent adult and pediatric disease leading to many adverse outcomes if left untreated. We aimed to quantify the deficit in OSA scientific literature in order to provide a novel way of identifying gaps in knowledge and a need for further research inquiry. METHODS: This was a Bibliometric analysis study. Using Ovid Medline database we analyzed and compared research output (medical and surgical) between adult OSA and similarly prevalent chronic conditions (Type II diabetes (T2DM), coronary artery disease (CAD) and osteoarthritis (OA)) from December 2016 up to fifty years prior. Linear graphs were utilized to trend collected data. Utilizing same strategy, we compared publication trends for pediatric OSA to asthma and gastroesophageal reflux (GER). RESULTS: Adult OSA publications (n = 9314) were significantly underrepresented when compared to T2DM (n = 66,023), CAD (n = 31,526) and OA (n = 34,123). Linear plots demonstrated that despite increasing number of publications this disparity persisted annually. Surgical literature composed 10.4% (n = 972) of adult OSA publications and reached a plateau in the last ten years. Pediatric OSA (n = 2994) had less research output when compared to asthma (n = 47,442) and GER (n = 6705). However, over past five years pediatric OSA surpassed GER in annual number of publications. Surgical literature represented 23.1% (n = 693) of pediatric OSA publications and continued increasing over past ten years. Study methodologies for both adult and pediatric OSA showed a lack of randomized controlled trials and meta-analyses in comparison to other diseases. CONCLUSION: Our review shows substantial deficit in total, annual and surgical adult OSA published research compared to similarly prevalent diseases. This trend is not entirely observed in pediatric OSA literature.

Consultation with registered dietitian to prevent accidental reactions to food: insight from an egg allergy influenza vaccination cohort.

Egg is an ubiquitous allergen found in many food products. Current food allergy guidelines recognize the importance of consultation with a registered dietitian to ensure nutritional adequacy. However, there is a lack of evidence on its impact on the implementation of allergen avoidance strategies. Taking advantage of a well-characterized cohort of influenza vaccination in egg-allergic children (n=397), we tested the hypothesis that real-life professional dietary advice was associated with a decrease in accidental reactions to egg in allergic children with retrospective questionnaires. Lack of consultation with a dietitian was associated with a 1.89-fold increase in the risk of accidental reactions to egg (confidence interval: 1.47-2.42). The only other independent variable that predicted reactions was having had a history of acute reaction to egg prior diagnosis (relative risk=2.02; confidence interval: 1.64-3.00). These findings support the usefulness of referral to a food allergy-specialized dietitian at time of diagnosis in order to prevent future accidental reactions to egg.

Bipolar membrane electroacidification of demineralized skim milk.

The aim of this study was to evaluate the effect of decreasing the mineral content of skim milk by electrodialysis (ED) prior to electroacidification with bipolar membrane (BMEA) on the performance of the process, the chemical composition, and the physicochemical and functional properties of the isolates produced. ED used to demineralize the skim milk solution was very efficient. However, the electroacidification parameters were influenced by the demineralization level of the skim milk solution: the energy efficiency was decreased with an increase in demineralization, but it was still possible to perform BMEA at a very low conductivity level. Moreover, the isolates produced by BMEA after electrodialysis demineralization at different rates showed similar chemical composition, except on potassium and lactose contents for 75% demineralized isolate. These isolates, except on protein load for 75% demineralization rate, showed similar physicochemical and functional properties, whatever the demineralization rate.

Tense and temporality: a comparison between children learning a second language and children with SLI.

This study compares the morphosyntax of children with SLI to the morphosyntax of children acquiring a second language (L2) to determine whether the optional infinitive phenomenon (M. Rice, K. Wexler, & P. Cleave, 1995; K. Wexler, 1994) is evident in both learner groups and to what extent cross-learner similarities exist. We analyzed spontaneous production data from French-speaking children with SLI, English-speaking L2 learners of French, and French-speaking controls, all approximately 7 years old. We examined the children's use of tense morphology, temporal adverbials, agreement morphology, and distributional contingencies associated with finiteness. Our findings indicate that the use of morphosyntax by children with SLI and by L2 children has significant similarities, although certain specific differences exist. Both the children with SLI and the L2 children demonstrate optional infinitive effects in their language use. These results have theoretical and clinical relevance. First, they suggest that the characterization of the optional infinitive phenomenon in normal development as a consequence of very early neurological change may be too restrictive. Our data appear to indicate that the mechanism underlying the optional infinitive phenomenon extends to normal (second) language learning after the primary acquisition years. Second, they indicate that tense-marking difficulty may not be an adequate clinical marker of SLI when comparing children with impairment to both monolingual and bilingual peers. A more specific clinical marker would be more effective in diagnosing disordered populations in a multilingual context.

A Fellowship in Quality Management.

The U.S. Healthcare Fellowship in Quality Management at Hahnemann University was developed by a managed health care organization and health science university in order to train physicians in the theory and practice of quality management and clinical outcomes measurement. This article describes in detail the program content and the characteristics of applicants.

Evolution of definitions and understanding of vascular complications related to transcatheter aortic valve replacement.

Vascular complications have emerged as a major clinical challenge during transcatheter aortic valve replacement (TAVR). Recent reports demonstrate that major vascular complications not only predict major bleeding, transfusions, and renal failure, but are also associated with increased mortality. During the early development of TAVR, heterogeneous definitions of vascular complications were used in the literature. However, the Valve Academic Research Consortium has made significant progress in standardizing outcomes definitions in the study of this emerging technology. This has resulted in a rapidly expanding body of high-quality clinical research exploring important outcomes of TAVR, including vascular complications. This review seeks to summarize the literature and to explore the current state of knowledge with respect to the incidence, predictors, clinical impact, and management of vascular complications associated with TAVR.

The forensic float nurse: a new concept in the effective management of service delivery in a forensic program.

A major challenge faced by Forensic Program management teams is to balance their budgets due to the unpredictability of the forensic patient population, particularly in the context of managing staffing costs where the hospital is not the "gatekeeper" and does not have control over who is admitted and when. In forensic mental health, the justice system, either via the courts, or review boards, determines who is ordered for admission to hospital for assessment or treatment and rehabilitation. Hospitals have little, if any, recourse but to admit these mentally disordered offenders. This typically results in increased levels of staffing with concomitant overtime costs. The literature suggests that clustered float pool nurses develop enhanced relationships with staff and patients, thereby enabling them to attain specialized clinical expertise to treat specific patient populations, promoting safer, high quality care, and overall are more cost effective. Forensic nursing is recognized as a mental health subspecialty. The "Forensic Float Nurse" concept was piloted to provide readily available, highly adaptable, skilled forensic nurses to assist in times of unpredictably heavy workloads and/or unplanned staffing shortages. A significant reduction approaching 50% in overtime was achieved. Heuristic implications of this finding are presented.

Language differentiation in early bilingual development.

It has been claimed that children simultaneously acquiring two languages go through an initial stage when they are unable to differentiate between their two languages. Such claims have been based on the observation that at times virtually all bilingual children mix elements (e.g. lexical, morphological) from their two languages in the same utterance. That most, if not all, children acquiring two languages simultaneously mix linguistic elements in this way is widely documented. Although such code-mixing is not well understood or explained, there are a number of explanations unrelated to lack of language differentiation that may explain it. Moreover, while language differentiation is widely attested among bilingual children once functional categories emerge, usually during the third year, there is still some question as to how early in development differentiation is present. In this study, we examined language differentiation in five bilingual children prior to the emergence of functional categories (they ranged in age from 1;10 to 2;2 and in MLU from 1.23 to 2.08). They were observed with each parent separately and both together, on separate occasions. Our results indicate that while these children did code mix, they were clearly able to differentiate between their two languages. We also examine the possibility that the children's mixing is due to (a) their language dominance, and (b) their parents' rate of mixing. We could find no evidence that their mixing was due to parental input, but there was some evidence that language dominance played a role.

Value of direct catheter staining in the diagnosis of intravascular-catheter-related infection.

Ninety-nine intravascular catheters were evaluated by a semiquantitative culture and Gram and acridine orange direct stains. A diagnosis of catheter-related infection was determined by a retrospective review of clinical records. Compared with the culture method, direct examination of catheters lacked sensitivity. Surprisingly, for some patients, a positive stain for yeasts not recovered by culture was considered significant. The culture correlated with bacteremia but failed to predict infection in 42% of patients.

Farmer's lung and variables related to the decision to quit farming.

An exploratory strategy was used to investigate why 55% of patients with farmer's lung (FL) disease quit farming. Three groups were recruited: 47 patients with FL disease who quit farming because of the disease (FLq), 76 patients with FL disease who continued farming (FLc), and 123 control farmers without a history of FL disease. The severity of FL disease at diagnosis was similar in both groups of patients. For example, single-breath carbon monoxide diffusion capacity predicted for FLq and FLc was 64.4 +/- 28.2 and 63.9 +/- 22.0, respectively. Relying on a cognitive-behavior theory, numerous physiological, behavioral, cognitive, affective, and social variables were assessed. Results showed that the decision to quit farming was based on cognitive and behavioral motives rather than physiological factors. Subjects in the FLq group showed more negative beliefs toward FL and had more fears of FL disease. FLq subjects also reported that family members, friends, and family doctors were more inclined to consider that FL disease could stop them from farming. However, self-efficacy to continue farming despite having FL disease and perceived hindrance caused by FL disease played the most important roles in the decision to quit farming.