LUNCH-Lung Ultrasound for early detection of silent and apparent aspiratioN in infants and young CHildren with cerebral palsy and other developmental disabilities: study protocol of a randomized controlled trial

Background

Children with neurological impairment may have dysphagia and/or gastro-esophageal reflux disease (GERD), which predispose to complications affecting the airways, increasing risk for aspiration-induced acute and chronic lung disease, or secondarily malnutrition, further neurodevelopmental disturbances, stressful interactions with their caregivers and chronic pain. Only multidisciplinary clinical feeding evaluation and empirical trials are applied to provide support to the management of feeding difficulties related to dysphagia or GERD, but no standardized feeding or behavioral measure exists at any age to assess aspiration risk and support the indication to perform a videofluoroscopic swallowing study (VFSS) or a fibre-optic endoscopic examination of swallowing (FEES), in particular in newborns and infants with neurological impairments. Lung ultrasound (LUS) has been proposed as a non-invasive, radiation-free tool for the diagnosis of pulmonary conditions in infants, with high sensitivity and specificity.

Methods

A RCT will be conducted in infants aged between 0 and 6 years having, or being at risk for, cerebral palsy, or other neurodevelopmental disease that determines abnormal muscular tone or motor developmental delay assessed by a quantitative scale for infants or if there is the suspicion of GERD or dysphagia based on clinical symptoms. Infants will be allocated in one of 2 groups: 1) LUS-monitored management (LUS-m); 2) Standard care management (SC-m) and after baseline assessment (T0), both groups will undergo an experimental 6-months follow-up. In the first 3 months, infants will be evaluated a minimum of 1 time per month, in-hospital, for a total of 3 LUS-monitored meal evaluations. Primary and secondary endpoint measures will be collected at 3 and 6 months.

Discussion

This paper describes the study protocol consisting of a RCT with two main objectives: (1) to evaluate the benefits of the use of LUS for monitoring silent and apparent aspiration in the management of dysphagia and its impact on pulmonary illness and growth and (2) to investigate the impact of the LUS management on blood sample and bone metabolism, pain and interaction with caregivers.

Trial registration

Trial registration date 02/05/2020; ClinicalTrials.gov Identifier: NCT04253951.

SU-E-T-180: The Radiological Physics Center's Anthropomorphic Quality Assurance Phantom Program

PURPOSE

To describe the phantoms, program logistics and current results for the Radiological Physics Center's (RPC) anthropomorphic QA phantom program for credentialing institutions for participation in NCI-sponsored advanced technology clinical trials.

METHODS

The RPC has developed an extensive phantom credentialing program consisting of four different phantoms designs: H&N, pelvis, lung and spine. These QA phantoms are water-filled plastic shells with imageable targets, avoidance structures, and heterogeneities that contain TLD and radiochromic film dosimeters. Institutions wishing to be credentialed request a phantom and are prioritized for delivery. At the institution, the phantom is imaged, a treatment plan is developed, the phantom is positioned on the treatment couch and the treatment is delivered. The phantom is returned and the measured dose distributions are compared to the institution's electronically submitted treatment plan dosimetry data.

RESULTS

The RPC currently has an inventory of 31 H&N, 10 pelvis, 9 lung, and 8 spine phantoms that are mailed to institutions nationally and internationally. In 2011, 444 of these phantoms were mailed out for credentialing. Once the phantom is sent, it takes the institution an average of 26 days to return it to the RPC. On average the dosimeters are analyzed within 17 days and the report is sent 21 days after receipt of the phantom data. In 2011 the percent of phantoms meeting the acceptance criteria increased by 12, 13 and 6 percentage points for the H&N, spine and lung phantoms, respectively. It fell by 5 percentage points for the pelvis phantom.

CONCLUSIONS

The RPC's QA phantom program has been an effective and responsive QA tool for assessing the use of advanced technologies in NCI sponsored clinical trials. The RPC has been efficient in its mailing of phantoms, and analyzing and reporting results. Work supported by PHS grant CA10953 and CA081647 (NCI, DHHS).

The purge of genetic load through restricted panmixia in a Drosophila experiment

Using Drosophila melanogaster, we explore the consequences of restricted panmixia (RP) on the genetic load caused by segregating deleterious recessive alleles in a population where females mate a full sib with probability about (1/2) and mate randomly otherwise. We find that this breeding structure purges roughly half the load concealed in heterozygous condition. Furthermore, fitness did not increase after panmixia was restored, implying that, during RP, the excess of expressed load induced by inbreeding had also been efficiently purged. We find evidences for adaptation to laboratory conditions and to specific selective pressures imposed by the RP protocol. We discuss some of the consequences of these results, both for the evolution of population breeding structures and for the design of conservation programmes.

Leishmaniasis as an opportunistic infection in HIV-infected patients: determinants of relapse and mortality in a collaborative study of 228 episodes in a Mediterreanean region

The clinical presentation of visceral leishmaniasis shares similarities with other geographically specific infectious diseases associated with AIDS in terms of relapsing course and atypical presentation. However, visceral leishmaniasis has not, until now, been included in the AIDS case definition. The aim of this study was to describe the clinical features and determinants for relapse and case-fatality of visceral leishmaniasis in HIV-infected patients from a Spanish Mediterranean area. A chart review was conducted in 16 hospitals in the autonomous communities of Valencia and Murcia (Spain). From 1988 to 2001, a total of 228 episodes of visceral leishmaniasis were diagnosed in 155 HIV-infected patients by the detection of amastigotes in bone marrow aspirates or in other tissue samples. Most patients had advanced HIV disease, with a median CD4(+) lymphocyte cell count of 55 cells x 10(9) l, and 56% of them had a previous AIDS-indicator disease. The median duration of follow-up was 8.4 months. HIV-infected patients with visceral leishmaniasis presented with fever (76%), hepatomegaly (77%), splenomegaly (78%), and varying degrees of cytopenias. Leishmania was detected in atypical sites in 22 (14%) patients. A total of 37 (24%) patients had a relapse of visceral leishmaniasis. Female gender was a risk factor for relapse, whereas administration of secondary prophylaxis for visceral leishmaniasis and a completed therapy for visceral leishmaniasis were protective factors against relapse. A total of 86 (54%) patients died. Independent determinants for survival were CD4(+) lymphocyte cell count, completed therapy for leishmania, and secondary prophylaxis for visceral leishmaniasis. The findings show that, in HIV-infected patients, visceral leishmaniasis occurs in late stages of HIV disease and often has a relapsing course. Secondary prophylaxis reduces the risk of relapse. Visceral leishmaniasis in the HIV-infected population should be included in the CDC clinical category C for the definition of AIDS in the same way that other geographically specific opportunistic infections are included.

Adolescence and poverty

Adolescents living in America suffer the triple burden of a disproportionate representation among the poor, a major conflict of developmental challenges and poverty-related challenges, and, frequently, additional challenges accompanying a minority heritage. At the same time, these individuals and the communities in which they live enjoy many strengths. This chapter reviews these and related issues.

[Risk factors related to infections during the first year of highly active antiretroviral therapy]

BACKGROUND

To evaluate the immunological, virological and clinical response of HIV-infected patients who start combined therapy with protease inhibitors (PI) in a community hospital. To identify risk factors related with infections.

PATIENTS AND METHOD

Clinical review of patients with combined therapy, assessing CD4+ cell counts, viral load (Amplicor) and development of infections during the first year on PI (group A) and comparative study with the same patients during the previous year with PI (group B).

RESULTS

134 patients were included in group A and 84 in Group B. Nadir of CD4+ was 169 X 10(6)/l. After 6 months of PI therapy, the mean CD4 increased from 217 to 355 X 10(6)/l and the median viral load decreased from 88,000 copies/ml (14,000-485,000) to less than 400 copies /ml (< 400-9,000), 60% of patients had less than 400 copies/ml. The incidence of non-opportunistic infections was similar in both groups (36 vs 43%; p = NS). However, the rate of opportunistic infections decreased from 30 to 15% (RR: 0.41 [CI 0.21-0.81]; p = 0.007) in the group with PI, particularly Pneumocystis carinii pneumonia and toxoplasmosis. Multivariated analysis including CD4+ cell count, nadir of CD4+, viral load and risk behavior only nadir of CD4 < 100 X 10(6)/l was associated with a lower risk of developing opportunistic infections (RR: 0.2 [CI: 0.1-0.7]; p = 0.001).

CONCLUSIONS

Combined therapy with PI improved immunological and virological markers and decreased the rate of opportunistic infections. A CD4+ cell count nadir higher than 100 X 10(6)/l was a marker of good prognosis during the first year with PI irrespective of response to therapy.

Risk factors for acquisition of urinary tract infections caused by ciprofloxacin resistant Escherichia coli

From January 1990 to December 1992, ciprofloxacin resistant Escherichia coli was isolated in 125 of 1,946 urine cultures (6.4%) with more than 10(5) colony-forming units per ml. To determine the risk factors for acquisition of urinary tract infections caused by ciprofloxacin resistant E. coli a retrospective chart review was done. Data from 54 patients with urinary tract infections caused by ciprofloxacin resistant E. coli were compared with 51 controls matched by temporal occurrence and randomly selected among 540 patients with urinary tract infections caused by ciprofloxacin susceptible E. coli. Patients had greater proportions of asymptomatic bacteriuria or lower urinary tract symptoms (85% versus 61%, p = 0.01) and of relapse (22% versus 0%, p = 0.001) than controls. Urinary tract abnormalities (odds ratio 7.98, 95% confidence interval 2.7 to 3.1, p < 0.001), patient age 65 years or older (odds ratio 6.48, 95% confidence interval 2.2 to 19.1, p < 0.001), previous treatment with quinolones (odds ratio 19.09, 95% confidence interval 2.2 to 166.5, p = 0.008) and urinary catheterization (odds ratio 2.92, 95% confidence interval 1.1 to 8.5, p = 0.048) were independently associated with infections caused by ciprofloxacin resistant strains. Our results suggest that patients with urological abnormalities previously treated with quinolones are especially prone to urinary tract infection caused by ciprofloxacin resistant strains.

Once-a-month administration of intravenous pentamidine to patients infected with human immunodeficiency virus as prophylaxis for Pneumocystis carinii pneumonia

We reviewed the charts of 52 patients infected with human immunodeficiency virus (HIV) who received at least three consecutive doses of intravenous pentamidine as prophylaxis for Pneumocystis carinii infections. Pentamidine isethionate was administered intravenously over 60-90 minutes once a month, at a dosage of 4 mg/kg, in 250 mL of 5% dextrose in water. During 387 months of administration of primary prophylaxis to 37 patients, no cases of P. carinii pneumonia were observed. During 200 months of administration of secondary prophylaxis to 15 patients, only one case of P. carinii pneumonia was diagnosed (6.0 cases per 100 patient-years). Side effects associated with the intravenous pentamidine were mild and did not necessitate withdrawal of the drug. Once-a-month administration of intravenous pentamidine is a valid alternative as prophylaxis for P. carinii pneumonia for patients who are intolerant of sulfonamides.