Prenatal and Peripartum Exposure to Antibiotics and Cesarean Section Delivery Are Associated with Differences in Diversity and Composition of the Infant Meconium Microbiome

The meconium microbiome may provide insight into intrauterine and peripartum exposures and the very earliest intestinal pioneering microbes. Prenatal antibiotics have been associated with later obesity in children, which is thought to be driven by microbiome dependent mechanisms. However, there is little data regarding associations of prenatal or peripartum antibiotic exposure, with or without cesarean section (CS), with the features of the meconium microbiome. In this study, 16S ribosomal RNA gene sequencing was performed on bacterial DNA of meconium samples from 105 infants in a birth cohort study. After multivariable adjustment, delivery mode (p = 0.044), prenatal antibiotic use (p = 0.005) and peripartum antibiotic use (p < 0.001) were associated with beta diversity of the infant meconium microbiome. CS (vs. vaginal delivery) and peripartum antibiotics were also associated with greater alpha diversity of the meconium microbiome (Shannon and Simpson, p < 0.05). Meconium from infants born by CS (vs. vaginal delivery) had lower relative abundance of the genus Escherichia (p < 0.001). Prenatal antibiotic use and peripartum antibiotic use (both in the overall analytic sample and when restricting to vaginally delivered infants) were associated with differential abundance of several bacterial taxa in the meconium. Bacterial taxa in the meconium microbiome were also differentially associated with infant excess weight at 12 months of age, however, sample size was limited for this comparison. In conclusion, prenatal and peripartum antibiotic use along with CS delivery were associated with differences in the diversity and composition of the meconium microbiome. Whether or not these differences in the meconium microbiome portend risk for long-term health outcomes warrants further exploration.

P4775Efficacy and safety of vernakalant for cardioversion of recent-onset atrial fibrillation in real-world clinical practice: the SPECTRUM post-approval safety study

Background

Vernakalant is an antiarrhythmic agent designed for pharmacological conversion of recent onset of atrial fibrillation (AF) with combined action on cardiac potassium and sodium currents mainly concentrated in the atria.

Purpose

SPECTRUM was a post-authorisation safety study of vernakalant, conducted to collect information about real-life conditions of use and appropriate dosing, and to quantify possible medically significant risks associated with the use of vernakalant in real-world clinical practice.

Methods

This prospective and retrospective registry was conducted from Sep 2011 to Apr 2018 in 53 hospitals in EU countries including Austria, Denmark, Finland, Germany, Spain and Sweden. A total of 1,778 patients with 2,009 episodes of recent-onset AF received vernakalant and were followed up for 24 hours after the last infusion or until hospital discharge/end of medical encounter to obtain information on medically significant health outcomes of interest (HOIs, defined as significant hypotension, significant ventricular arrhythmia, significant atrial flutter, significant bradycardia), and serious adverse events (SAEs).

Results

In more than 99% of treatments, vernakalant was used in accordance to the labelled indication for conversion of AF for non-surgery (94.7%) or post-cardiac surgery patients (5.2%). Vernakalant was administered in the emergency department in 64.2% of cases, with a median stay of 7.5 hours and successfully converted 70.2% (95% CI: 68.1–72.2) of patients in the effectiveness analysis population with a median time to conversion of 11 minutes (95% CI: 8.0–27.0). A total of 19 HOIs were reported in 17 patients (0.8%, 95% CI: 0.5– .4%) with individual HOIs ranging from <0.1% to 0.7% suggesting these HOIs are uncommon. Significant bradycardia was the most common HOI observed in 15 patients (0.8%, 95% CI: 0.4–1.2%), with all events occurring within the first two hours (0.8%, 95% CI: 0.4–1.2%). The incidence of significant hypotension was 0.1% (2/2,009), significant atrial flutter (with 1:1 conduction) was 0.1% (2/2,009), and significant ventricular arrhythmia (sustained ventricular tachycardia) was <0.1% (1/2,009). A total of 28 SAEs, including all HOIs, were observed (1.3%, 95% CI: 0.8–1.9%); all patients fully recovered, except one who recovered with sequelae after an SAE of pericardial effusion definitely not related to vernakalant. There were no cases of torsades de pointes, ventricular fibrillation, or deaths reported in the SPECTRUM study.

Conclusion(s)

SPECTRUM is, to our knowledge, the largest drug registry conducted on the cardioversion of recent onset AF. The cumulative data from 2,009 vernakalant treatment episodes demonstrate an incidence of HOIs and SAEs similar or lower to what has been reported in earlier vernakalant IV clinical trials. The observed conversion rate was higher than reported in pivotal trials supporting vernakalant's efficacy and allowing early discharge.

Acknowledgement/Funding

Study funded by Correvio International Sarl, Geneva, Switzerland

Folliculin regulates mTORC1/2 and WNT pathways in early human pluripotency

To reveal how cells exit human pluripotency, we designed a CRISPR-Cas9 screen exploiting the metabolic and epigenetic differences between naïve and primed pluripotent cells. We identify the tumor suppressor, Folliculin(FLCN) as a critical gene required for the exit from human pluripotency. Here we show that FLCN Knock-out (KO) hESCs maintain the naïve pluripotent state but cannot exit the state since the critical transcription factor TFE3 remains active in the nucleus. TFE3 targets up-regulated in FLCN KO exit assay are members of Wnt pathway and ESRRB. Treatment of FLCN KO hESC with a Wnt inhibitor, but not ESRRB/FLCN double mutant, rescues the cells, allowing the exit from the naïve state. Using co-immunoprecipitation and mass spectrometry analysis we identify unique FLCN binding partners. The interactions of FLCN with components of the mTOR pathway (mTORC1 and mTORC2) reveal a mechanism of FLCN function during exit from naïve pluripotency.

The pathways involved in exit from pluripotency in human embryonic stem cells are poorly understood. Here, the authors performed a CRISPR-based screen to identify genes that promote exit from naïve pluripotency and find a role for folliculin (FLCN) by regulating the mTOR and Wnt pathways.

A Study of Coagulation Factor Levels in Women during Labour and in Their Newborn Infants

1. Coagulation factors levels were measured in 10 normal mothers and in their infants within 15 min of birth and at 48-96 hrs of age.

2. In the mothers the levels of fibrinogen (532 mg/%), factors VIII (196%), IX (130%) and X (122%) were elevated; the levels of prothrombin (107%) and factor V (108%) were normal ; and the level of factor XI (69%) was reduced.

3. The infants blood examined within 15 min of birth had a slightly elevated factor VIII level (138%), slightly reduced fibrinogen (195 mg/%) and factor V levels (79%), low levels of prothrombin (55%) and factors IX (27%), X (35%) and XI (32%).

4. Blood from the infants at 48-96 hrs of age showed little change from the birth levels of factors V (89%), and VIII (116%) and a slight increase in factor XI level (39%). Four of the infants had received vitamin K1 and had higher levels of prothrombin and factors IX and X than the 7 who had not received vitamin K1.

5. These results are compared with those of previous studies and the possible mechanisms underlying the changes is discussed.

Comparison of Infant Gut and Skin Microbiota, Resistome and Virulome Between Neonatal Intensive Care Unit (NICU) Environments

Background: There is a growing move to provide care for premature infants in a single family, private room neonatal intensive care unit (NICU) in place of the traditional shared space, open bay NICU. The resultant effect on the developing neonatal microbiota is unknown.

Study Design: Stool and groin skin swabs were collected from infants in a shared-space NICU (old NICU) and a single-family room NICU (new NICU) on the same hospital campus. Metagenomic sequencing was performed and data analyzed by CosmosID bioinformatics software package.

Results: There were no significant differences between the cohorts in gestational age, length of stay, and delivery mode; infants in the old NICU received significantly more antibiotics (p = 0.03). Differentially abundant antimicrobial resistance genes and virulence associated genes were found between the cohorts in stool and skin, with more differentially abundant antimicrobial resistance genes in the new NICU. The entire bacterial microbiota analyzed to the genus level significantly differed between cohorts in skin (p = 0.0001) but not in stool samples. There was no difference in alpha diversity between the two cohorts. DNA viruses and fungi were detected but did not differ between cohorts.

Conclusion: Differences were seen in the resistome and virulome between the two cohorts with more differentially abundant antimicrobial resistance genes in the new NICU. This highlights the influence that different NICU environments can have on the neonatal microbiota. Whether the differences were due to the new NICU being a single-family NICU or located in a newly constructed building warrants exploration. Long term health outcomes from the differences observed must be followed longitudinally.

[Not Available]

Chemical burns raise diagnostic and treatment issues because they have specific appearances and evolution. Our objective was to study the characteristics of chemical burns and to assess the quality of our treatment. This retrospective observational study examined the records of all patients admitted for chemical burns to the burn treatment center of Saint Louis Hospital in Paris from January 1, 1990, through December 31, 2015. During this period, 162 patients came to our center for chemical burn treatment. Most of them were men (67%). The majority of the burns were caused by alkalis (27%) and resulted from workplace accidents (29%). The average time before consultation was 5.36 days. The areas mainly damaged were the hands (36%) and the burn areas averaged 1.2% of the total body surface area (TBSA). Forty-eight patients had at least one deep patch. In total, 59 patients (36.4%) were hospitalized for an average duration of 4.18 days. Thirty-eight of them underwent surgery. Lastly, 92% of the operations had been anticipated from the first consultation. In our center, the population affected, the circumstances and the topography of our patients' burns were similar to the data from the literature. It appears that the principal specificity of our series is a very low body surface burned. This can be attributed to the prevention measures we have in France and underlines their importance. Only 8% of the patients who had surgery were underestimated or their burns became deeper secondarily. This number is lower than the data from other series.

Treatment motivation among caregivers and adolescents with substance use disorders

Substance use disorders (SUDs) in adolescence have negative long-term health effects, which can be mitigated through successful treatment. Caregivers play a central role in adolescent treatment involvement; however, studies have not examined treatment motivation and pressures to enter treatment in caregiver/adolescent dyads. Research suggests that internally motivated treatment (in contrast to coerced treatment) tends to lead to better outcomes. We used Self-determination theory (SDT) to examine intersecting motivational narratives among caregivers and adolescents in SUD treatment. Relationships between motivation, interpretation of caregiver pressures, adolescent autonomy, and relatedness were also explored. Adolescents in SUD treatment and their caregivers (N_Dyads=15) were interviewed about treatment experiences. Interviews were coded for treatment motivation, including extrinsic (e.g., motivated by punishment), introjected (e.g., motivated by guilt), and identified/integrated motivation (e.g., seeing a behavior as integral to the self). Internalization of treatment motivation, autonomy support/competence (e.g., caregiver support for adolescent decisions), and relatedness (e.g., acceptance and support) were also coded. Four dyadic categories were identified: agreement that treatment was motivated by the adolescent (intrinsic); agreement that treatment was motivated by the caregiver (extrinsic); agreement that treatment was motivated by both, or a shift towards adolescent control (mixed/transitional); and disagreement (adolescents and caregivers each claimed they motivated treatment; conflicting). Autonomy support and relatedness were most prominent in intrinsic dyads, and least prominent in extrinsic dyads. The mixed/transitional group was also high in autonomy support and relatedness. The extrinsic group characterized caregiver rules as an unwelcome mechanism for behavioral control; caregivers in the other groups saw rules as a way to build adolescent competence and repair relationships, and adolescents saw rules as indicating care rather than control. Adolescents with intrinsic motivations were the most engaged in treatment. Results suggest the importance of intrinsically motivated treatment, and highlight autonomy support and relatedness as mechanisms that might facilitate treatment engagement.

[Pseudotumor cerebri due to taking minocycline]

The cerebral pseudotumor (PTC) is defined by the increase in cerebrospinal fluid (CSF) pressure, a normal composition of the latter in the absence of identified intracranial structural abnormalities, in particular by neuroimaging. The pathophysiology of PTC is poorly understood although its diagnostic criteria are well established. Drugs such as minocycline, tetracycline and doxycycline have been repeatedly implicated as a causative factor in PTC. The prognosis of PTC related to minocycline, reported in the literature is quite variable. Some authors suggest a benign condition with spontaneous healing by stopping the antibiotic, while others report permanent loss of vision. A 12-year-old girl is admitted to the emergency room for progressively progressive pulsatile temporal headaches associated with diplopia. The patient reported the use of minocycline 50 mg / d for five months, prescribed by her attending physician as part of an acne treatment. PTC will be demonstrated by severe papillary edema and cerebral NMR will demonstrate an enlargement of the subarachnoid space around the optic nerves. After three lumbar punctures, the condition of the patient stabilized and there was a marked improvement in headache despite the persistence of bilateral papillary edema. This work describes a clinical case of PTC induced by the use of minocycline and reviews the physiopathology, the diagnosis and the management of this one.

The technology prescription: linking telecare and informatics by using a need-led paradigm

This paper summarizes a current study examining the availability, appropriateness and acceptability of a technologically dependable healthcare provision to both service users and staff. An interface between the Electronic Patient Record (EPR) and future home care technology (Telecare) is suggested in the form of a ‘technology prescription’. It is argued that appropriately prescribed technology will enable people to benefit from a modern, evidence-based service, which promotes a proactive means of addressing and preventing future health and care needs. The paper argues that technological innovations in care must not be perceived as a threat to the partnerships necessary in achieving maximum health gains, but rather be an aid to a patient centred clinical encounter.