Systematic Review and Expert Consensus on the Use of Orthoses (Splints and Casts) with Adults and Children after Burn Injury to Determine Practice Guidelines

The objective of this review was to systematically evaluate the available literature addressing the use of orthoses (splints and casts) with adult and pediatric burn survivors and determine whether practice guidelines could be proposed. This review provides evidence-based recommendations specifically for rehabilitation professionals who are responsible for burn survivor rehabilitation. A summary recommendation was made after the literature was retrieved using a systematic review and critical appraisal by multiple authors. The level of evidence of the literature was determined in accordance with the Oxford Centre for Evidence-based Medicine criteria. Due to the low level of evidence in the available literature, only one practice guideline could be recommended: orthotic use should be considered as a treatment choice for improving range of motion or reducing contracture in adults who have sustained a burn injury. To address the rehabilitation-specific gaps found in the literature regarding orthotic use in burn rehabilitation and provide guidance to clinicians, a formal expert consensus exercise was conducted as a final step to the project. The resultant manuscript provides a summary of the literature regarding orthotic use with burn patients, one practice guideline, proposed orthotic terminology and additional practice recommendations based on expert opinion. The limitations in the current literature are also discussed, and suggestions are made for future studies in the area of orthotic use after burn injury.

Pulmonary Histopathology Findings in Patients With STAT3 Gain of Function Syndrome

INTRODUCTION AND AIM

Multiorgan autoimmunity and interstitial lung disease (ILD) are reported in patients with STAT3 GOF syndrome.

RESULTS

We present lung histopathology findings in 3 such children, two of whom underwent wedge biopsies with adequate diagnostic material. Wedge biopsies showed interstitial cellular expansion with linear and nodular aggregates of CD8 positive T lymphocytes, plasma cells, and histiocytes; consistent with lymphocytic interstitial pneumonia pattern (LIP). CD4+ T cells and CD20+ B cells were present but infrequent in the interstitium. FOXP3 cells ranged from 0-5%. Focal interstitial and intraalveolar histiocytes were also seen. Neutrophils and eosinophils were rare/absent. Non-occlusive peribronchial lymphoid aggregates showed equal T and B cells; likely reactive in nature. Pulmonary vessels appeared normal without vasculitis or hypertensive change. There was no interstitial or subepithelial fibrosis or organizing pneumonia. Interlobular septa and visceral pleura were unremarkable.

CONCLUSION

Children with multi-system autoimmune disorders with ILD should be investigated for STAT3 GOF syndrome. Lung wedge biopsies are more informative than transbronchial biopsies, if a tissue sampling is indicated. CD8 dominant T cell inflammation seems to be a key driver of ILD. Although interstitial fibrosis was not seen in our small sample, longer follow up is needed to understand the natural history.

Listening to First Nations women' expressions of heart health: mite achimowin digital storytelling study

Historically, heart health was approached holistically by First Nations (FN) peoples, which was integrated into daily living. Caring for the physical, emotional and spiritual needs of individuals, community, family, and the living environment was integral. The Truth and Reconciliation Commission of Canada demonstrates the decimation of health practices through governmental policy to destroy the cultural foundations of FN peoples. Relational systems and ways of living were outlawed, and the health of FN people suffered. A digital storytelling study collaborated with Manitoba FN women with lived experience of caring for a biomedical-diagnosed heart condition. The objective was to identify concepts, language, and experiences of heart health among FN women. Six women created five digital stories; four are available publically online. Themes addressed by the storytellers include: changes to diet and lifestyle, related health conditions, experiences with healthcare system, residential schools, and relationships with children and grandchildren. The intersection of Western and FN knowledges heard in the women's stories suggests heart health knowledge and care is embedded within historical and social contexts. Insights into the non-dichotomous relationship between FN and biomedical knowledge of heart health, along with their conceptualisations of heart, suggests historical and social roots underlying heart health issues First Nations women face.

Guidelines for day-case surgery 2019: Guidelines from the Association of Anaesthetists and the British Association of Day Surgery

Guidelines are presented for the organisational and clinical management of anaesthesia for day-case surgery in adults and children. The advice presented is based on previously published recommendations, clinical studies and expert opinion.

Outcomes after Allogeneic Transplant in Patients with Wiskott-Aldrich Syndrome

/kg (range, .3 to 7.9). The median times to neutrophil and platelet engraftment were 19 days (range, 13 to 27) and 18.5 days (range, 12 to 31), respectively. The rate of overall survival was 92% with median follow-up of 67 months (range, 3 to 146). Two patients developed grade IV acute graft-versus-host disease, and 1 died on day +99. Five of 12 patient's (42%) had mixed donor chimerism (range, 12% to 85%) at day +180. None of the pretransplant patient parameters was predictive of mixed chimerism. Nonetheless, of these 5 patients, 2 had normalization of the platelet count despite the mixed chimerism, 2 had full donor chimerism after receiving a second transplant with the same donor, and 1 remains transfusion dependent awaiting a second transplant. Hence, even with a significant rate of mixed chimerism, HSCT provides substantial benefit to WAS patients, with excellent overall survival.

Copa Syndrome: a Novel Autosomal Dominant Immune Dysregulatory Disease

Inherently defective immunity typically results in either ineffective host defense, immune regulation, or both. As a category of primary immunodeficiency diseases, those that impair immune regulation can lead to autoimmunity and/or autoinflammation. In this review we focus on one of the most recently discovered primary immunodeficiencies that leads to immune dysregulation: "Copa syndrome". Copa syndrome is named for the gene mutated in the disease, which encodes the alpha subunit of the coatomer complex-I that, in aggregate, is devoted to transiting molecular cargo from the Golgi complex to the endoplasmic reticulum (ER). Copa syndrome is autosomal dominant with variable expressivity and results from mutations affecting a narrow amino acid stretch in the COPA gene-encoding COPα protein. Patients with these mutations typically develop arthritis and interstitial lung disease with pulmonary hemorrhage representing a striking feature. Immunologically Copa syndrome is associated with autoantibody development, increased Th17 cells and pro-inflammatory cytokine expression including IL-1β and IL-6. Insights have also been gained into the underlying mechanism of Copa syndrome, which include excessive ER stress owing to the impaired return of proteins from the Golgi, and presumably resulting aberrant cellular autophagy. As such it represents a novel cellular disorder of intracellular trafficking associated with a specific clinical presentation and phenotype.

High resolution phenotyping identifies NK cell subsets that distinguish healthy children and adults

Natural killer (NK) cells possess an array of germline-encoded activating, inhibitory and adhesion receptors, the balance of which in concert with their developmental stage, determine their cytotoxic and cytokine-producing potential. Although NK cells develop in the bone marrow and secondary lymphoid tissues, substantive differentiation is apparent in the peripheral blood including known age-related variation. In order to gain greater insight into phenotypic and functional variation within peripheral blood NK cells across age groups, we used multi-parameter, polyfunctional flow cytometry to interrogate the NK cell variability in 20 healthy adults and 15 5–10, 11–15 and 16–20 year-old children. We found that the normative ranges in both adults and children displayed great inter-individual variation for most subsets. Children possessed >76% unstimulated NK subsets coexpressing perforin and granzyme B as opposed to >65% in adults. Children also had >28% NK subsets expressing all adhesion receptors in our panel compared to half of that in adults. As examples, terminally differentiated CD16+CD57+CD11b+ NK cells were reduced after 16 years of age as well as NKp46, 2B4, CD107a and newly-synthesized perforin in adults. Although CD107a intensity and new perforin synthesis was lower in adults, induced levels of IFNγ (by intensity) was higher. Despite most receptors not differing in their overall expression levels, major phenotypic differences were revealed in the combinatorial expression of NK receptors between adults and children. Our findings identify previously unappreciated NK cell subsets potentially distinguishing children from adults and suggest functional correlates that may have relevance in age-specific host defense.

Newborn screening for severe combined immunodeficiency in 11 screening programs in the United States

IMPORTANCE

Newborn screening for severe combined immunodeficiency (SCID) using assays to detect T-cell receptor excision circles (TRECs) began in Wisconsin in 2008, and SCID was added to the national recommended uniform panel for newborn screened disorders in 2010. Currently 23 states, the District of Columbia, and the Navajo Nation conduct population-wide newborn screening for SCID. The incidence of SCID is estimated at 1 in 100,000 births.

OBJECTIVES

To present data from a spectrum of SCID newborn screening programs, establish population-based incidence for SCID and other conditions with T-cell lymphopenia, and document early institution of effective treatments.

DESIGN

Epidemiological and retrospective observational study.

SETTING

Representatives in states conducting SCID newborn screening were invited to submit their SCID screening algorithms, test performance data, and deidentified clinical and laboratory information regarding infants screened and cases with nonnormal results. Infants born from the start of each participating program from January 2008 through the most recent evaluable date prior to July 2013 were included. Representatives from 10 states plus the Navajo Area Indian Health Service contributed data from 3,030,083 newborns screened with a TREC test.

MAIN OUTCOMES AND MEASURES

Infants with SCID and other diagnoses of T-cell lymphopenia were classified. Incidence and, where possible, etiologies were determined. Interventions and survival were tracked.

RESULTS

Screening detected 52 cases of typical SCID, leaky SCID, and Omenn syndrome, affecting 1 in 58,000 infants (95% CI, 1/46,000-1/80,000). Survival of SCID-affected infants through their diagnosis and immune reconstitution was 87% (45/52), 92% (45/49) for infants who received transplantation, enzyme replacement, and/or gene therapy. Additional interventions for SCID and non-SCID T-cell lymphopenia included immunoglobulin infusions, preventive antibiotics, and avoidance of live vaccines. Variations in definitions and follow-up practices influenced the rates of detection of non-SCID T-cell lymphopenia.

CONCLUSIONS AND RELEVANCE

Newborn screening in 11 programs in the United States identified SCID in 1 in 58,000 infants, with high survival. The usefulness of detection of non-SCID T-cell lymphopenias by the same screening remains to be determined.

Dyskeratosis congenita: a combined immunodeficiency with broad clinical spectrum--a single-center pediatric experience

BACKGROUND

Dyskeratosis Congenita (DKC) is a syndrome characterized by immunodeficiency, bone marrow failure, somatic abnormalities, and cancer predisposition resulting from defective telomere maintenance. The immunologic features of DKC remain under diagnosed and under treated despite the fact that immunodeficiency is a major cause of premature mortality in DKC.

METHODS

This study undertook a retrospective review of 7 DKC patients diagnosed at the Children's Hospital of Philadelphia. In parallel, we reviewed previously reported immunologic findings in DKC patients.

RESULTS

Immunologic abnormalities (lymphopenia, low B-cell numbers, hypogammaglobulinemia, and decreased T-cell function) were the most frequent laboratory findings at initial presentation, preceding the development of significant anemia or thrombocytopenia. Recurrent sinopulmonary or opportunistic infections were present in 6/7 patients. Infant-onset patients had more severe immunologic and somatic features (particularly severe enteropathy).

CONCLUSION

In DKC, development of immunologic abnormalities can precede bone marrow failure, highlighting the importance of proper immunodeficiency management to minimize morbidity and premature mortality in this disease.

Survival of North American genotypes of Trichinella in frozen pork

North American genotypes of Trichinella spiralis (T-1), Trichinella nativa (T-2), Trichinella pseudospiralis (T-4), Trichinella murrelli (T-5), and Trichinella T-6 were examined for susceptibility to freezing in pork using time-temperature combinations that have been proven to inactivate T. spiralis. Infections were established in 3-month-old pigs of mixed sex and breed by oral inoculation of 10,000 muscle larvae (ML) (all genotypes, rodent-derived ML), 20,000 ML (T-1, T-4, and T-5; cat-derived ML), or 30,000 ML (T-2 and T-6; cat-derived ML). Pigs were euthanized 60 days postinoculation. Muscles from the tongue, masseter muscles, diaphragm, triceps, hams, neck, rump, and loins were ground, pooled, and mixed to ensure even distribution of larvae. Samples (20 g) containing each Trichinella species, genotype, and source combination were placed in heat-sealable pouches, transferred to a constant temperature refrigerant bath, and maintained according to defined time and temperature combinations. Larvae recovered from cold-treated pork samples were inoculated into mice to determine infectivity. Results indicated that the time-temperature combinations known to render pork safe for T. spiralis are sufficient to inactivate T. nativa and T-6 (the freeze-resistant isolates), T. murrelli (the most common sylvatic species in the United States excluding Alaska), and T. pseudospiralis (a species that lacks a muscle nurse cell). These data close a gap in knowledge about the effectiveness of freezing for inactivating these parasites in pork and should alleviate concern about the safety of frozen pork products from the United States.

Larval viability and serological response in horses with long-term Trichinella spiralis infection

The horse is considered an aberrant host for the nematode parasite Trichinella spiralis, and many aspects of the biology and epidemiology of Trichinella infection in the horse are poorly understood. It has been reported that experimentally-infected horses produce a transient serological response to infection and that muscle larvae are cleared more rapidly than in parasite-adapted hosts such as the pig and humans. However, limited numbers of animals have been studied, and both the longevity of larvae in horse musculature and the immune response to Trichinella larvae remain unclear. In this study, we infected 35 horses with 1000, 5000, or 10,000 T. spiralis muscle larvae and followed the course of infection for 1 year, assessing larval burdens in selected muscles, the condition and infectivity of recovered larvae, and the serological response of infected horses. The results demonstrated that T. spiralis establishes infection in horses in a dose dependent manner. Anti-Trichinella IgG antibodies peaked between weeks 6-10 post-inoculation. Viable, infective larvae persisted in horse musculature for the duration of the study (12 months), and exhibited no apparent reduction in muscle burdens over this period. Encapsulated larvae showed no obvious signs of degeneration in histological sections. Larval capsules were surrounded by infiltrates consisting of mature plasma cells and eosinophils. Macrophages were notably absent. Given the lack of a detectable serological response by 26 weeks p.i. and the persistence of infective muscle larvae for at least 1 year, parasite recovery methods are currently the only suitable detection assays for both meat inspection and epidemiological studies of Trichinella infection in the horse.

Viability and infectivity of Trichinella spiralis muscle larvae in frozen horse tissue

Many aspects of the biology and epidemiology of Trichinella infection in the horse are poorly understood, including survival of Trichinella spp in horse muscle. In this study, we have assessed the freeze tolerance of T. spiralis in horse meat stored at 5, -5, and -18 degrees C for 1 day to 24 weeks. Results demonstrate a steady reduction in the number of live ML recovered from the cold stored meat samples. On Day 1, recovery of live larvae had been reduced by 18.6%, 50.1%, and 37.2%, and by 4 weeks, recovery of larvae had been reduced by 65.4%, 66.5%, and 96.2% in samples stored at 5, -5, and -18 degrees C, respectively. Infectivity results (measured as reproductive capacity index (RCI)) from mice inoculated with larvae recovered from non-frozen meat samples at day 0 was 23.5. Following storage at -18 degrees C for one and two days, the RCIs were 2.09 and 0.99, respectively. Small numbers of infective larvae were still present in meat samples stored at -18 degrees C for 4 weeks. The RCI of ML recovered from meat samples stored at -5 degrees C was 14.99 and 6.36 at 2 weeks and 4 weeks respectively; the RCI of samples stored at 5 degrees C was 23.1 at 8 weeks, and fell rapidly thereafter (12 week RCI 1.33; 0 at 24 weeks). These data demonstrate that infective T. spiralis, a non-freeze tolerant species, can survive for at least 4 weeks in horse tissue frozen at -5 or -18 degrees C, and that the numbers of infective larvae decrease substantially by day 2 at -18 degrees C and by week 4 at -5 degrees C.