Utility of Decision Rules for Transcutaneous Bilirubin Measurements

BACKGROUND

Transcutaneous bilirubin (TcB) meters are widely used for screening newborns for jaundice, with a total serum bilirubin (TSB) measurement indicated when the TcB value is classified as "positive" by using a decision rule. The goal of our study was to assess the clinical utility of 3 recommended TcB screening decision rules.

METHODS

Paired TcB/TSB measurements were collected at 34 newborn nursery sites. At 27 sites (sample 1), newborns were routinely screened with a TcB measurement. For sample 2, sites that typically screen with TSB levels also obtained a TcB measurement for the study. Three decision rules to define a positive TcB measurement were evaluated: ≥75th percentile on the Bhutani nomogram, 70% of the phototherapy level, and within 3 mg/dL of the phototherapy threshold. The primary outcome was a TSB level at/above the phototherapy threshold. The rate of false-negative TcB screens and percentage of blood draws avoided were calculated for each decision rule.

RESULTS

For sample 1, data were analyzed on 911 paired TcB-TSB measurements from a total of 8316 TcB measurements. False-negative rates were <10% with all decision rules; none identified all 31 newborns with a TSB level at/above the phototherapy threshold. The percentage of blood draws avoided ranged from 79.4% to 90.7%. In sample 2, each rule correctly identified all 8 newborns with TSB levels at/above the phototherapy threshold.

CONCLUSIONS

Although all of the decision rules can be used effectively to screen newborns for jaundice, each will "miss" some infants with a TSB level at/above the phototherapy threshold.

Phototherapy for the Treatment of Neonatal Jaundice and Breastfeeding Duration and Exclusivity

INTRODUCTION

Because neonatal jaundice remains one of the most commonly treated conditions of the newborn infant, it is important to assess the unintended consequences of treatment with phototherapy. The objective of this study was to evaluate whether treatment with phototherapy affects breastfeeding duration in newborns >35 weeks gestation.

MATERIALS AND METHODS

We analyzed data from the Infant Feeding Practices Study II. The exposure of interest was treatment of neonatal jaundice with phototherapy. The outcomes of interest were any breastfeeding through 12 months and exclusive breastfeeding through 4 months. Logistic regression models were developed to evaluate the association between the exposure and outcomes of interest. All models were adjusted for maternal age, race, education, household income, and gestational age, as well as for several potential markers of suboptimal breastfeeding.

RESULTS

Our study included 4,441 infants, of which 220 (5%) received phototherapy. We found no difference in the likelihood of any breastfeeding through 9 months of age, however, by 12 months, infants exposed to phototherapy were less likely to still be breastfed than those who were not exposed (adjusted odds ratio [aOR] 0.58, 95% confidence interval [95% CI] 0.37-0.92). Infants exposed to phototherapy were less likely to be exclusively breastfed throughout the first 4 months of life.

CONCLUSION

Although phototherapy use did not substantially impact rates of any breastfeeding during the first year, it was associated with decreased rates of exclusive breastfeeding in the first 4 months of life. This suggests that we need to tailor messaging to mothers of infants receiving phototherapy to promote exclusive breastfeeding.

Senior Smiles: preliminary results for a new model of oral health care utilizing the dental hygienist in residential aged care facilities

OBJECTIVES

The aim of this study was to determine whether a qualified dental hygienist could improve oral health outcomes for residents living in residential aged care facilities on the Central Coast of New South Wales, Australia.

METHODS

A qualified dental hygienist undertook a 24-week oral hygiene intervention in five residential aged care facilities to test the Senior Smiles, oral health model of care. The facilities were invited to take part in the research, which was funded by a grant from NSW Medicare Local, Erina. Residents were asked to consent to having oral health risk assessments, oral healthcare plans and to receiving referrals for treatment where needed. Pre- and post-intervention plaque scores were recorded for residents and P values calculated using a paired t-test. In addition, the number of residents examined, treated and referred for more complex dental care was recorded.

RESULTS

The statistical analysis program, SPSS, was used to conduct a paired t-test to compare pre- and post-intervention plaque scores on residents from the 5 RACFs. A statistically significant result of P < 0.0001 showed the intervention of the dental hygienist was effective in reducing plaque scores in residents across the 5 RACFs.

CONCLUSION

The Senior Smiles model of care provided residents with preventive oral hygiene care, referral pathways for complex dental treatment needs and established a formal management programme for ongoing oral health care within the RACFs. The Senior Smiles model of care is successful and transportable.

The Influence of Provider Communication Behaviors on Parental Vaccine Acceptance and Visit Experience

OBJECTIVES

We investigated how provider vaccine communication behaviors influence parental vaccination acceptance and visit experience.

METHODS

In a cross-sectional observational study, we videotaped provider-parent vaccine discussions (n = 111). We coded visits for the format providers used for initiating the vaccine discussion (participatory vs presumptive), parental verbal resistance to vaccines after provider initiation (yes vs no), and provider pursuit of recommendations in the face of parental resistance (pursuit vs mitigated or no pursuit). Main outcomes were parental verbal acceptance of recommended vaccines at visit's end (all vs ≥ 1 refusal) and parental visit experience (highly vs lower rated).

RESULTS

In multivariable models, participatory (vs presumptive) initiation formats were associated with decreased odds of accepting all vaccines at visit's end (adjusted odds ratio [AOR] = 0.04; 95% confidence interval [CI] = 0.01, 0.15) and increased odds of a highly rated visit experience (AOR = 17.3; 95% CI = 1.5, 200.3).

CONCLUSIONS

In the context of 2 general communication formats used by providers to initiate vaccine discussions, there appears to be an inverse relationship between parental acceptance of vaccines and visit experience. Further exploration of this inverse relationship in longitudinal studies is needed.

The Diagnostic Value of Capillary Refill Time for Detecting Serious Illness in Children: A Systematic Review and Meta-Analysis

Importance

Capillary refill time (CRT) is widely recommended as part of the routine assessment of unwell children.

Objective

To determine the diagnostic value of capillary refill time for a range of serious outcomes in children.

Methods

We searched Medline, Embase and CINAHL from inception to June 2014. We included studies that measured both capillary refill time and a relevant clinical outcome such as mortality, dehydration, meningitis, or other serious illnesses in children aged up to 18 years of age. We screened 1,265 references, of which 24 papers were included in this review. Where sufficient studies were available, we conducted meta-analysis and constructed hierarchical summary ROC curves.

Results

Meta-analysis on the relationship between capillary refill time and mortality resulted in sensitivity of 34.6% (95% CI 23.9 to 47.1%), specificity 92.3% (88.6 to 94.8%), positive likelihood ratio 4.49 (3.06 to 6.57), and negative likelihood ratio 0.71 (0.60 to 0.84). Studies of children attending Emergency Departments with vomiting and diarrhea showed that capillary refill time had specificity of 89 to 94% for identifying 5% dehydration, but sensitivity ranged from 0 to 94%. This level of heterogeneity precluded formal meta-analysis of this outcome. Meta-analysis was not possible for other outcomes due to insufficient data, but we found consistently high specificity for a range of outcomes including meningitis, sepsis, admission to hospital, hypoxia, severity of illness and dengue.

Conclusions

Our results show that capillary refill time is a specific sign, indicating that it can be used as a “red-flag”: children with prolonged capillary refill time have a four-fold risk of dying compared to children with normal capillary refill time. The low sensitivity means that a normal capillary refill time should not reassure clinicians.

Redefining bacterial origins of replication as centralized information processors

In this review we stress the differences between eukaryotes and bacteria with respect to their different cell cycles, replication mechanisms and genome organizations. One of the most basic and underappreciated differences is that a bacterial chromosome uses only one ori while eukaryotic chromosome uses multiple oris. Consequently, eukaryotic oris work redundantly in a cell cycle divided into separate phases: First inactive replication proteins assemble on eukaryotic oris, and then they await conditions (in the separate “S-phase”) that activate only the ori-bound and pre-assembled replication proteins. S-phase activation (without re-assembly) ensures that a eukaryotic ori “fires” (starts replication) only once and that each chromosome consistently duplicates only once per cell cycle. This precise chromosome duplication does not require precise multiple ori firing in S-phase. A eukaryotic ori can fire early, late or not at all. The single bacterial ori has no such margin for error and a comparable imprecision is lethal. Single ori usage is not more primitive; it is a totally different strategy that distinguishes bacteria. We further argue that strong evolutionary pressures created more sophisticated single ori systems because bacteria experience extreme and rapidly changing conditions. A bacterial ori must rapidly receive and process much information in “real-time” and not just in “cell cycle time.” This redefinition of bacterial oris as centralized information processors makes at least two important predictions: First that bacterial oris use many and yet to be discovered control mechanisms and second that evolutionarily distinct bacteria will use many very distinct control mechanisms. We review recent literature that supports both predictions. We will highlight three key examples and describe how negative-feedback, phospho-relay, and chromosome-partitioning systems act to regulate chromosome replication. We also suggest future studies and discuss using replication proteins as novel antibiotic targets.

Communication practices and antibiotic use for acute respiratory tract infections in children

PURPOSE

This study examined relationships between provider communication practices, antibiotic prescribing, and parent care ratings during pediatric visits for acute respiratory tract infection (ARTI).

METHODS

A cross-sectional study was conducted of 1,285 pediatric visits motivated by ARTI symptoms. Children were seen by 1 of 28 pediatric providers representing 10 practices in Seattle, Washington, between December 2007 and April 2009. Providers completed post-visit surveys reporting on children's presenting symptoms, physical examination findings, assigned diagnoses, and treatments prescribed. Parents completed post-visit surveys reporting on provider communication practices and care ratings for the visit. Multivariate analyses identified key predictors of prescribing antibiotics for ARTI and of parent visit ratings.

RESULTS

Suggesting actions parents could take to reduce their child's symptoms (providing positive treatment recommendations) was associated with decreased risk of antibiotic prescribing whether done alone or in combination with negative treatment recommendations (ruling out the need for antibiotics) [adjusted risk ratio (aRR) 0.48; 95% CI, 0.24-0.95; and aRR 0.15; 95% CI, 0.06-0.40, respectively]. Parents receiving combined positive and negative treatment recommendations were more likely to give the highest possible visit rating (aRR 1.16; 95% CI, 1.01-1.34).

CONCLUSION

Combined use of positive and negative treatment recommendations may reduce the risk of antibiotic prescribing for children with viral ARTIs and at the same time improve visit ratings. With the growing threat of antibiotic resistance at the community and individual level, these communication techniques may assist frontline providers in helping to address this pervasive public health problem.

Job strain and cognitive decline: a prospective study of the framingham offspring cohort

BACKGROUND

Workplace stress is known to be related with many behavioral and disease outcomes. However, little is known about its prospective relationship with measures of cognitive decline.

OBJECTIVE

To investigate the association of job strain, psychological demands and job control on cognitive decline.

METHODS

Participants from Framingham Offspring cohort (n=1429), were assessed on job strain, and received neuropsychological assessment approximately 15 years and 21 years afterwards.

RESULTS

High job strain and low control were associated with decline in verbal learning and memory. Job strain was associated with decline in word recognition skills. Active job and passive job predicted decline in verbal learning and memory relative to low strain jobs in the younger subgroup. Active job and demands were positively associated with abstract reasoning skills.

CONCLUSIONS

Job strain and job control may influence decline in cognitive performance.

Validity and reliability of measurement of capillary refill time in children: a systematic review

BACKGROUND

Most guidelines recommend the use of capillary refill time (CRT) as part of the routine assessment of unwell children, but there is little consensus on the optimum method of measurement and cut-off time.

METHODS

We searched Medline (from 1948), Embase (from 1980) and CINAHL (from 1991) to June 2014 to identify studies with information on the normal range of CRT in healthy children, the validity of CRT compared with reference standard measures of haemodynamic status, reliability and factors influencing measurement of CRT, such as body site, pressing time and temperature.

FINDINGS

We included 21 studies on 1915 children. Four studies provided information on the relationship between CRT and measures of cardiovascular status, 13 provided data on the normal range of CRT, 7 provided data on reliability and 10 assessed the effect of various confounding factors. In children over 7 days of age, the upper limit of normal CRT is approximately 2 s when measured on a finger, and 4 s when measured on the chest or foot, irrespective of whether the child is feverish or not. Longer pressing times and ambient temperature outside 20°C-25°C are associated with longer CRT. Evidence suggests that the use of stopwatches reduces variability between observers.

INTERPRETATION

We recommend use of the following standardised CRT method of measurement: press on the finger for 5 s using moderate pressure at an ambient temperature of 20°C-25°C. A capillary refill time of 3 s or more should be considered abnormal.

Introducing loupes to clinical practice: dental hygienists experiences and opinions

OBJECTIVES

Recent literature has identified a number of potential advantages in wearing loupes for dental hygienists, including improved quality of care and ergonomics. The aim of the study was to determine dental hygienists' opinions about wearing loupes.

METHODS

A short online survey was distributed to all dental hygienists who had recently participated in a study investigating the efficacy of loupes on musculoskeletal disorders; all had only worn loupes for a 6-month period, and prior to the study had not worn loupes. All of those invited completed the survey (n = 12), achieving a 100% response rate.

RESULTS

The majority of respondents noted that the loupes were adaptable to wear; however, only one-quarter of hygienists surveyed were wearing them often following the study. Respondents identified that the biggest advantage to loupes was calculus removal (91.7%), and most indicated that they felt the quality of their work increased when wearing loupes (75%). The biggest disadvantage to wearing loupes was the adjustment period (50%), with limited depth of vision, headache, vertigo and infection control noted by at least one-third of respondents.

CONCLUSIONS

This study revealed that hygienists identify both benefits and limitations to wearing loupes, and therefore, ongoing support may be required for hygienists adopting their use in clinical practice.

Discrepancies between transcutaneous and serum bilirubin measurements

OBJECTIVE

To characterize discrepancies between transcutaneous bilirubin (TcB) measurements and total serum bilirubin (TSB) levels among newborns receiving care at multiple nursery sites across the United States.

METHODS

Medical records were reviewed to obtain data on all TcB measurements collected during two 2-week periods on neonates admitted to participating newborn nurseries. Data on TSB levels obtained within 2 hours of a TcB measurement were also abstracted. TcB--TSB differences and correlations between the values were determined. Data on demographic information for individual newborns and TcB screening practices for each nursery were also collected. Multivariate regression analysis was used to identify characteristics independently associated with the TcB--TSB difference.

RESULTS

Data on 8319 TcB measurements were collected at 27 nursery sites; 925 TSB levels were matched to a TcB value. The mean TcB--TSB difference was 0.84 ± 1.78 mg/dL, and the correlation between paired measurements was 0.78. In the multivariate analysis, TcB--TSB differences were 0.67 mg/dL higher in African-American newborns than in neonates of other races (P < .001). The TcB--TSB difference also varied significantly based on brand of TcB meter used and hour of age of the infant. For 2.2% of paired measurements, the TcB measurement underestimated the TSB level by ≥ 3 mg/dL.

CONCLUSIONS

During routine clinical care, TcB measurement provided a reasonable estimate of TSB levels in healthy newborns. Discrepancies between TcB and TSB levels were increased in African-American newborns and varied based on brand of meter used.

Specific and non-specific interactions of ParB with DNA: implications for chromosome segregation

The segregation of many bacterial chromosomes is dependent on the interactions of ParB proteins with centromere-like DNA sequences called parS that are located close to the origin of replication. In this work, we have investigated the binding of Bacillus subtilis ParB to DNA in vitro using a variety of biochemical and biophysical techniques. We observe tight and specific binding of a ParB homodimer to the parS sequence. Binding of ParB to non-specific DNA is more complex and displays apparent positive co-operativity that is associated with the formation of larger, poorly defined, nucleoprotein complexes. Experiments with magnetic tweezers demonstrate that non-specific binding leads to DNA condensation that is reversible by protein unbinding or force. The condensed DNA structure is not well ordered and we infer that it is formed by many looping interactions between neighbouring DNA segments. Consistent with this view, ParB is also able to stabilize writhe in single supercoiled DNA molecules and to bridge segments from two different DNA molecules in trans. The experiments provide no evidence for the promotion of non-specific DNA binding and/or condensation events by the presence of parS sequences. The implications of these observations for chromosome segregation are discussed.

Homeopathic Ear Drops as an Adjunct in Reducing Antibiotic Usage in Children With Acute Otitis Media

Objective. To determine if use of a homeopathic ear drop preparation reduces antibiotic use in children diagnosed with acute otitis media (AOM). Methods. Children 6 months to 11 years old, diagnosed with AOM and managed with a delayed antibiotic approach, were randomized to standard therapy alone or standard therapy plus a homeopathic ear drop preparation. The primary outcome was whether or not the antibiotic prescription given at the index visit was filled during a 12- to 15-day follow-up period. Results. Among 210 enrolled children, follow-up antibiotic data were collected on 206. During the 12- to 15-day follow-up period, fewer parents of children randomized to the homeopathic ear drops group filled the antibiotic prescription compared with those of children receiving standard therapy alone (26.9% and 41.2%, respectively, P = .032). Conclusion. Homeopathic ear drops may be effective in reducing the use of antibiotics in children with AOM managed with a delayed antibiotic approach.

DNA G-segment bending is not the sole determinant of topology simplification by type II DNA topoisomerases

DNA topoisomerases control the topology of DNA. Type II topoisomerases exhibit topology simplification, whereby products of their reactions are simplified beyond that expected based on thermodynamic equilibrium. The molecular basis for this process is unknown, although DNA bending has been implicated. To investigate the role of bending in topology simplification, the DNA bend angles of four enzymes of different types (IIA and IIB) were measured using atomic force microscopy (AFM). The enzymes tested were Escherichia coli topo IV and yeast topo II (type IIA enzymes that exhibit topology simplification), and Methanosarcina mazei topo VI and Sulfolobus shibatae topo VI (type IIB enzymes, which do not). Bend angles were measured using the manual tangent method from topographical AFM images taken with a novel amplitude-modulated imaging mode: small amplitude small set-point (SASS), which optimises resolution for a given AFM tip size and minimises tip convolution with the sample. This gave improved accuracy and reliability and revealed that all 4 topoisomerases bend DNA by a similar amount: ~120° between the DNA entering and exiting the enzyme complex. These data indicate that DNA bending alone is insufficient to explain topology simplification and that the ‘exit gate' may be an important determinant of this process.

The provision of dietary advice by dental practitioners: a review of the literature

PURPOSE

The aim of this literature review was to examine the dietary advice practices of dentists and dental hygienists and to identify factors influencing whether practitioners provide dietary advice to patients.

METHODS

A systematic search was carried out of the electronic databases CINHAL Plus, Medline via OVID and the Cochrane Library, using the search terms 'Diet', 'Nutrition', 'Dental hygienists' and 'Dentists'. Articles included in the review were all empirical studies and existing literature reviews examining the provision of dietary advice practices of dentists, dental hygienists and dental students. Only articles published after 1993 were included in the review to better reflect the current practices of dental practitioners.

RESULTS

The literature revealed that dietary advice is rarely provided by dental practitioners, and that when dietary advice is provided it is often limited. The literature also established that provision of dietary advice is influenced by a number of factors, including financial considerations, time constraints and the dietary education of dental practitioners.

CONCLUSIONS

Further research is required to strengthen the findings from the review and to investigate dietary advice specific to the prevention of dental erosion. Additional research is also required to examine dental curricula and assess the dietary advice practices of dental students.

The architecture of provider-parent vaccine discussions at health supervision visits

OBJECTIVE

To characterize provider-parent vaccine communication and determine the influence of specific provider communication practices on parent resistance to vaccine recommendations.

METHODS

We conducted a cross-sectional observational study in which we videotaped provider-parent vaccine discussions during health supervision visits. Parents of children aged 1 to 19 months old were screened by using the Parent Attitudes about Childhood Vaccines survey. We oversampled vaccine-hesitant parents (VHPs), defined as a score ≥50. We developed a coding scheme of 15 communication practices and applied it to all visits. We used multivariate logistic regression to explore the association between provider communication practices and parent resistance to vaccines, controlling for parental hesitancy status and demographic and visit characteristics.

RESULTS

We analyzed 111 vaccine discussions involving 16 providers from 9 practices; 50% included VHPs. Most providers (74%) initiated vaccine recommendations with presumptive (e.g., "Well, we have to do some shots") rather than participatory (e.g., "What do you want to do about shots?") formats. Among parents who voiced resistance to provider initiation (41%), significantly more were VHPs than non-VHPs. Parents had significantly higher odds of resisting vaccine recommendations if the provider used a participatory rather than a presumptive initiation format (adjusted odds ratio: 17.5; 95% confidence interval: 1.2-253.5). When parents resisted, 50% of providers pursued their original recommendations (e.g., "He really needs these shots"), and 47% of initially resistant parents subsequently accepted recommendations when they did.

CONCLUSIONS

How providers initiate and pursue vaccine recommendations is associated with parental vaccine acceptance.

The relationship between parent attitudes about childhood vaccines survey scores and future child immunization status: a validation study

IMPORTANCE

Acceptance of childhood vaccinations is waning, amplifying interest in developing and testing interventions that address parental barriers to immunization acceptance.

OBJECTIVE

To determine the predictive validity and test-retest reliability of the Parent Attitudes About Childhood Vaccines survey (PACV), a recently developed measure of vaccine hesitancy.

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort of English-speaking parents of children aged 2 months and born from July 10 through December 10, 2010, who belonged to an integrated health care delivery system based in Seattle and who returned a completed baseline PACV. Parents who completed a follow-up survey 8 weeks later were included in the reliability analysis. Parents who remained continuous members in the delivery system until their child was 19 months old were included in the validity analysis.

EXPOSURE

The PACV, scored on a scale of 0 to 100 (100 indicates high vaccine hesitancy).

MAIN OUTCOMES AND MEASURES

Child's immunization status as measured by the percentage of days underimmunized from birth to 19 months of age.

RESULTS

Four hundred thirty-seven parents completed the baseline PACV (response rate, 50.5%), and 220 (66.5%) completed the follow-up survey. Of the 437 parents who completed a baseline survey, 310 (70.9%) maintained continuous enrollment. Compared with parents who scored less than 50, parents who scored 50 to 69 on the survey had children who were underimmunized for 8.3% (95% CI, 3.6%-12.8%) more days from birth to 19 months of age; those who scored 70 to 100, 46.8% (40.3%-53.3%) more days. Baseline and 8-week follow-up PACV scores were highly concordant (ρ = 0.844).

CONCLUSIONS AND RELEVANCE

Scores on the PACV predict childhood immunization status and have high reliability. Our results should be validated in different geographic and demographic samples of parents.