Race and Antibiotic Use for Children Hospitalized With Acute Respiratory Infections

We sought to evaluate whether children hospitalized with acute respiratory infections experienced differences in antibiotic use by race and ethnicity. We found that likelihood of broad-spectrum antibiotic receipt differed across racial and ethnic groups. Future work should confirm this finding, evaluate causes, and ensure equitable antibiotic use.

Literature Review: Mechanism, Indications, and Clinical Efficacy of Peripheral Nerve Stimulators in Lower Extremity Pain

PURPOSE OF REVIEW

Lower extremity pain is deemed by Center for Disease Control and Prevention (CDC) to be a significant source of chronic pain in adults. If not appropriately managed, patients are subjected to risks of prolonged musculoskeletal dysfunction, disruption to quality of life, and elevated healthcare expenditures. Peripheral nerve stimulation (PNS) has shown great potential in recent years demonstrating efficacy in multiple diagnoses ranging from acute post-surgical pain to complex regional pain syndrome (CRPS). This study seeks to delineate efficacy of peripheral neuromodulation in the context of chronic lower extremity pain.

RECENT FINDINGS

Prevailing clinical studies demonstrate evidence levels ranging from II to V (Oxford Centre of Level of Evidence) in lower limb PNS, attaining positive outcomes in pain scores, opioid use, and quality of life measures. Nerves most frequently targeted are the sciatic and femoral nerves with post-amputation pain and CRPS most commonly investigated for efficacy. PNS is a promising therapeutic modality demonstrated to be effective for a variety of nociceptive and neuropathic pain conditions in the lower extremity. PNS offers chronic pain physicians a powerful tool in the multi-modal management of lower limb chronic pain.

Applications of Cryoneurolysis in Chronic Pain Management: a Review of the Current Literature

PURPOSE OF REVIEW

The purpose of this review is to evaluate and summarize the literature investigating cryoneurolysis in the treatment of various chronic pain pathologies.

RECENT FINDINGS

There is an increasing amount of interest in the use of cryoneurolysis in chronic pain, and various studies have investigated its use in lumbar facet joint pain, SI joint pain, post-thoracotomy syndrome, temporomandibular joint pain, chronic knee pain, phantom limb pain, neuropathic pain, and abdominal pain. Numerous retrospective studies and a more limited number of prospective, sham-controlled prospective studies suggest the efficacy of cryoneurolysis in managing these chronic pain pathologies with a low complication rate. However, more blinded, controlled, prospective studies comparing cryoneurolysis to other techniques are needed to clarify its relative risks and advantages.

Resveratrol differentially affects MMP-9 release from neurons and glia; implications for therapeutic efficacy

Resveratrol, a naturally occurring polyphenol that activates sirtuin 1 (SIRT1), has been shown to reduce overall levels of matrix metalloprotease-9 (MMP-9) in cerebrospinal fluid (CSF) samples from patients with Alzheimer's dementia (AD). Depending on the site of release, however, MMP-9 has the potential to improve or impair cognition. In particular, its release from microglia or pericytes proximal to the blood brain barrier can damage the basement membrane, while neuronal activity-dependent release of this protease from glutamatergic neurons can instead promote dendritic spine expansion and long-term potentiation of synaptic plasticity. In the present study, we test the hypothesis that resveratrol reduces overall MMP-9 levels in CSF samples from patients with APOE4, an allele associated with increased glial inflammation. We also examine the possibility that resveratrol reduces inflammation-associated MMP release from cultured glia but spares neuronal activity-dependent release from cultured cortical neurons. We observe that resveratrol decreases overall levels of MMP-2 and MMP-9 in CSF samples from AD patients. Resveratrol also reduces CSF levels of tissue inhibitor of metalloproteinases-1 (TIMP-1), glial-derived protein that restricts long-term potentiation of synaptic transmission, in individuals homozygous for APOE4. Consistent with these results, we observe that resveratrol reduces basal and lipopolysaccharide (LPS)-stimulated MMP and TIMP-1 release from cultured microglia and astrocytes. In contrast, however, resveratrol does not inhibit release of MMP-9 from cortical neurons. Overall, these results are consistent with the possibility that while resveratrol reduces potentially maladaptive MMP and TIMP-1 release from activated glia, neuroplasticity-promoting MMP release from neurons is spared. In contrast, resveratrol reduces release of neurocan and brevican, extracellular matrix components that restrict neuroplasticity, from both neurons and glia. These data underscore the diversity of resveratrol's actions with respect to affected cell types and molecular targets and also suggest that further studies may be warranted to determine if its effects on glial MMP release could make it a useful adjunct for AD- and/or anti-amyloid therapy-related damage to the blood brain barrier.

Food elimination diet is a viable alternative therapy for eosinophilic esophagitis responsive to proton pump inhibitors

BACKGROUND

First-line treatment of eosinophilic esophagitis (EoE) includes monotherapy with proton-pump inhibitors (PPIs), food elimination diet (FED), or topical corticosteroids. Current guidelines suggest patients with EoE should continue any responsive first-line monotherapies. However, the efficacy of FED monotherapy in patients with EoE responsive to PPI monotherapy has not been well studied. Our study aimed to investigate how attempting FED monotherapy after experiencing remission of EoE after PPI monotherapy influenced long-term EoE management.

METHODS

We retrospectively identified patients with EoE responsive to PPI monotherapy who trialed FED monotherapy. We then employed a mixed method approach to a prospective cohort. Selected patients were observed long term for quantitative outcomes, while qualitative results were obtained from patient surveys regarding their perspectives on the trial of FED monotherapy.

RESULTS

We identified 22 patients who trialed FED monotherapy after experiencing remission of EoE following PPI monotherapy. Of these 22 patients, 13 had remission of EoE with FED monotherapy, while 9 had re-activation of EoE. Out of 22 patients, 15 were enrolled in a cohort for observation. No exacerbations of EoE occurred while on maintenance treatment. Most patients stated that they would recommend this process to others with EoE (93.33%) and that trial of FED monotherapy helped them identify a treatment plan that aligned with their lifestyle (80%).

CONCLUSION

Our work shows that FED monotherapy can be an effective alternative for patients with EoE responsive to PPI monotherapy that may improve patient quality of life, suggesting alternative treatment options should be considered for monotherapy-responsive EoE.

Behcet disease: an undifferentiating and complex vasculitis

Behçet Disease is a relapsing and remitting variable vessel vasculitis characterized by recurrent mucocutaneous ulcers that can involve almost every organ system in the body. Indeed, the presence of recurrent oral or genital ulcers with other auto-inflammatory symptoms should raise suspicion for this elusive disease. It is unique among the vasculitides in that it can affect vessels of small, medium, and large size and tends to involve venous rather than arterial circulation, and its effects on the pulmonary venous circulation are particularly notable for their role in disease mortality. Classically seen in Mediterranean, Middle-Eastern, and eastern Asian countries, and relatively rare in the United States, prevalence has been increasing, prompting an increased need for internists to be aware of Behcet's clinical presentation and treatment. As early recognition and diagnosis of the disease is key to successful treatment and better prognosis, this review provides a brief summary of the current etiological theories, important clinical manifestations, and treatments including newer biologic alternatives.

Flushing an Offensive Term for Vancomycin Infusion Reaction From the Electronic Medical Record

BACKGROUND

The medical establishment continues to be complicit in the degradation of native peoples of the United States through the use of the racist phrase "red man syndrome" (RMS) to describe the histamine-release syndrome that accompanies vancomycin infusion.

METHODS

Five months after the transition from 1 electronic health record to another at our freestanding children's hospital, our antimicrobial stewardship team reviewed all active allergy records to identify and then replace use of RMS terminology with preferred alternative "vancomycin flushing syndrome." In partnership with institutional stakeholders, we also launched an educational campaign and instituted in the electronic health record an autocorrect functionality to prevent new RMS entries.

RESULTS

We identified allergy records for 21 034 individual patients. Vancomycin was an allergen for 445 (2.1%) patients, and RMS-related terminology appeared in 274 (61.6%) of these records; we replaced all RMS instances with the vancomycin flushing syndrome term. During the 3-month period after the intervention, we identified allergy records for 8648 additional patients, with vancomycin as allergen in 65 (0.7%) and with RMS terminology identified and replaced in 29 (44.6%). In addition to the lower rate of RMS among allergy records after the intervention, we detected 3 instances of alternative terminology use.

CONCLUSIONS

Implementing an institutional-level change in terminology, even for racist language, requires education, reinforcement, and continued surveillance. To effectively replace this term, we need the support of national stakeholders to remove this language from our medical education systems, our textbooks, and our clinical lexicon.

Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS): A Quality Improvement Collaborative

BACKGROUND

Although many children's hospitals have established antimicrobial stewardship programs (ASPs), data-driven benchmarks for optimizing antimicrobial use across centers are lacking. We developed a multicenter quality improvement collaborative focused on sharing data reports and benchmarking antimicrobial use to improve antimicrobial prescribing among hospitalized children.

METHODS

A national antimicrobial stewardship collaborative among children's hospitals, Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS), was established in 2013. Characteristics of the hospitals and their ASPs were obtained through a standardized survey. Antimicrobial-use data reports were developed on the basis of input from the participating hospitals. Collaborative learning opportunities were provided through monthly webinars and annual meetings.

RESULTS

Since 2013, 36 US hospitals have participated in the SHARPS collaborative. The median full-time equivalent (pharmacist and physician) dedicated to 30 of these ASPs was 0.75 (interquartile range, 0.45-1.4). To date, the collaborative has developed 26 data reports that include benchmarking reports according to specific antimicrobial agents, indications, and clinical service lines. The collaborative has conducted 27 webinars and 3 in-person meetings to highlight the stewardship work being conducted in the hospitals. The data reports and learning opportunities have resulted in approximately 36 distinct stewardship interventions.

CONCLUSION

A pediatric antimicrobial stewardship collaborative has been successful in promoting the development of and innovation among pediatric ASPs. Additional research is needed to determine the impact of these efforts.

Neuroligin 1 regulates spines and synaptic plasticity via LIMK1/cofilin-mediated actin reorganization

The C-terminal domain of NLG1 is sufficient to enhance spine and synapse number and to modulate synaptic plasticity, and it exerts these effects via its interaction with SPAR and the subsequent activation of LIMK1/cofilin-mediated actin reorganization.

Neuroligin (NLG) 1 is important for synapse development and function, but the underlying mechanisms remain unclear. It is known that at least some aspects of NLG1 function are independent of the presynaptic neurexin, suggesting that the C-terminal domain (CTD) of NLG1 may be sufficient for synaptic regulation. In addition, NLG1 is subjected to activity-dependent proteolytic cleavage, generating a cytosolic CTD fragment, but the significance of this process remains unknown. In this study, we show that the CTD of NLG1 is sufficient to (a) enhance spine and synapse number, (b) modulate synaptic plasticity, and (c) exert these effects via its interaction with spine-associated Rap guanosine triphosphatase–activating protein and subsequent activation of LIM-domain protein kinase 1/cofilin–mediated actin reorganization. Our results provide a novel postsynaptic mechanism by which NLG1 regulates synapse development and function.

Effectiveness of proprioceptive exercises for ankle ligament injury in adults: a systematic literature and meta-analysis

The purpose of this study was to assess the effectiveness of such proprioceptive exercise following ankle ligament injury. A systematic review of the databases MEDLINE, EMBASE, CINHAL, AMED, the Cochrane library database and the PEDro database, in addition to unpublished literature databases was conducted to July 2011. When appropriate, meta-analysis was conducted to pool results from homogeneous studies. The methodological quality of the literature was reviewed using the Critical Appraisal Skills Programme tool. The results indicated that there is no statistically significant difference in recurrent injury between the addition of proprioceptive exercises during the rehabilitation of patients following ankle ligament injury (p = 0.68). The addition of proprioceptive training demonstrated a significant reduction in subjective instability and functional outcomes (p < 0.05). There was no consensus on the advantages of including proprioceptive training in the rehabilitation of this population for swelling, postural sway, joint position sense, ankle range of motion or return to sport outcomes. Further study is warranted to develop the rigour of the evidence-base and to determine the optimal proprioceptive training programme following ankle ligament injury with different populations.

Lhermitte sign after chemo-IMRT of head-and-neck cancer: incidence, doses, and potential mechanisms

PURPOSE

We have observed a higher rate of Lhermitte sign (LS) after chemo-intensity-modulated radiotherapy (IMRT) of head-and-neck cancer than the published rates after conventional radiotherapy. We hypothesized that the inhomogeneous spinal cord dose distributions produced by IMRT caused a "bath-and-shower" effect, characterized by low doses in the vicinity of high doses, reducing spinal cord tolerance.

METHODS AND MATERIALS

Seventy-three patients with squamous cell carcinoma of the oropharynx participated in a prospective study of IMRT concurrent with weekly carboplatin and paclitaxel. Of these, 15 (21%) reported LS during at least 2 consecutive follow-up visits. Mean dose, maximum dose, and partial volume and absolute volume (in milliliters) of spinal cord receiving specified doses (≥10 Gy, ≥20 Gy, ≥30 Gy, and ≥40 Gy), as well as the pattern of dose distributions at the "anatomic" spinal cord (from the base of the skull to the aortic arch) and "plan-related" spinal cord (from the top through the bottom of the planning target volumes), were compared between LS patients and 34 non-LS patients.

RESULTS

LS patients had significantly higher spinal cord mean doses, V(30), V(40), and absolute volumes receiving 30 Gy or more and 40 Gy or more compared with the non-LS patients (p < 0.05). The strongest predictors of LS were higher V(40) and higher cord volumes receiving 40 Gy or more (p ≤ 0.007). There was no evidence of larger spinal cord volumes receiving low doses in the vicinity of higher doses (bath-and-shower effect) in LS compared with non-LS patients.

CONCLUSIONS

Greater mean dose, V(30), V(40), and cord volumes receiving 30 Gy or more and 40 Gy or more characterized LS compared with non-LS patients. Bath-and-shower effects could not be validated in this study as a potential contributor to LS. The higher-than-expected rates of LS may be because of the specific concurrent chemotherapy agents or more accurate identification of LS in the setting of a prospective study.

Multidrug-resistant Enterococcus faecium meningitis in a toddler: characterization of the organism and successful treatment with intraventricular daptomycin and intravenous tigecycline

A case of enterococcal meningitis in a toddler is presented. The organism was highly resistant to all drugs previously used for pediatric Gram-positive meningitis. She was successfully treated with intraventricular and intravenous daptomycin and intravenous tigecycline. The organism was characterized as a member of CC17, a notorious emerging nosocomial clone of Enterococcus faecium.

Rap2-JNK removes synaptic AMPA receptors during depotentiation

The related small GTPases Ras and Rap1 are important for signaling synaptic AMPA receptor (-R) trafficking during long-term potentiation (LTP) and long-term depression (LTD), respectively. Rap2, which shares 60% identity to Rap1, is present at excitatory synapses, but its functional role is unknown. Here, we report that Rap2 activity, stimulated by NR2A-containing NMDA-R activation, depresses AMPA-R-mediated synaptic transmission via activation of JNK rather than Erk1/2 or p38 MAPK. Moreover, Rap2 controls synaptic removal of AMPA-Rs with long cytoplasmic termini during depotentiation. Thus, Rap2-JNK pathway, which opposes the action of the NR2A-containing NMDA-R-stimulated Ras-ERK1/2 signaling and complements the NR2B-containing NMDA-R-stimulated Rap1-p38 MAPK signaling, channels the specific signaling for depotentiating central synapses.

Polo-like kinases in the nervous system

Polo like kinases (Plks) are key regulators of the cell cycle, but little is known about their functions in postmitotic cells such as neurons. Recent findings indicate that Plk2 and Plk3 are dynamically regulated in neurons by synaptic activity at the mRNA and protein levels. In COS cells, Plk2 and Plk3 interact with spine-associated Rap guanosine triphosphatase-activating protein (SPAR), a regulator of actin dynamics and dendritic spine morphology, leading to its degradation through the ubiquitin-proteasome system. Induction of Plk2 in hippocampal neurons eliminates SPAR protein, depletes a core postsynaptic scaffolding molecule (PSD-95), and causes loss of mature dendritic spines and synapses. These findings implicate neuronal Plks as mediators of activity-dependent change in molecular composition and morphology of synapses. Induction of Plks might provide a homeostatic mechanism for global dampening of synaptic strength following heightened neuronal activity ('synaptic scaling'). Synapse-specific actions of induced Plks are also possible, particularly in light of the discovery of phosphoserine/threonine peptide motifs as binding targets of the polo box domain, which could allow for 'priming' phosphorylation by upstream kinases that could 'tag' Plk substrates only in specific synapses.

Use of natural zeolite to enhance nitrification in biofilter

To enhance nitrification, natural zeolite and activated carbon were tested as a media in a biofilter to treat wastewater containing relatively high concentrations of TKN. Using those media, the adsorption isotherms for ammonium ion were compared; the K values for natural zeolite and activated carbon were found to be 0.5117 and 0.0006, respectively. In comparison of the performance of the two media, two identical, lab-scale biofilters were then operated for 4 months. The effect of NH3-N loading rates on the performance was investigated. The results showed that higher NH3-N removal efficiency and faster nitrification were achieved in the biofilter with natural zeolite throughout the experimental period. Nitrosomonas and Nitrobacter, two principal nitrifiers, in biofilm grown on two different media were counted and compared. Nitrobacter which is the more fragile of the two principal nitrifiers was outgrown in the biofilm on natural zeolite media. The reason for this may be due to the ammonium ion exchanging capacity of natural zeolite which provided the favorable environment for Nitrobacter.

Antibodies in haystacks: how selection strategy influences the outcome of selection from molecular diversity libraries

Antibodies against most antigens can be isolated from high quality phage antibody libraries. However, not all antibodies binding a particular antigen are necessarily found when standard selections are performed. Here we investigate the effect of two different selection strategies on the isolation of antibodies against a number of different antigens, and find that these different strategies tend to select different antibodies, with little overlap between them. This indicates that the full diversity of these libraries is not tapped by a single selection strategy and that each selection strategy imposes different selective criteria in addition to that of antigen binding. To fully exploit such libraries, therefore, many different selection strategies should probably be employed for each antigen. The use of alternative strategies should be considered when selection apparently fails, or when the number of different antibodies recognizing an antigen needs to be maximised. Furthermore, the microtitre selection strategy developed is likely to prove useful in the application of phage antibody libraries to the human genome project, allowing the high throughput selection of antibodies against multiple antigens simultaneously.

Design parameters for an electrochemical cell with porous electrode to treat metal-ion solution

An electrochemical reactor was designed and operated to treat the solution containing copper ions. Design parameters for the electrochemical reactor using the porous cathode and RuO2/IrO2/Ti anode were investigated. The porous cathode was prepared by the electroless nickel deposition on polyurethane. The apparent current, the gap between cathode and anode, and hydraulic retention time (HRT) were selected as design parameters. The copper removal rate increased with an increase in apparent current. It was not affected by the gap between the cathode and the anode. A reduction in hydraulic retention time stimulated the mass transfer toward the electrode and increased the cathodic current efficiency. Dimensional analysis was conducted to obtain the design equation for scale-up of the electrochemical reactor. The dependence of Sh on Re, Sc, and characteristic lengths, DC/A/L and DW/C/L, was described in the form of a power series. The coefficients were obtained from experimental data.

Motion artifact seen on slot-scanning direct digital mammography

OBJECTIVE

Our goal was to determine the appearance of motion artifact when imaging an anthropomorphic breast phantom using a digital slot-scanning system compared with a screen-film system.

MATERIALS AND METHODS

Digital and screen-film images were obtained during both brief and continuous manually induced motion of an anthropomorphic phantom in four directions. Continuous motion was further characterized using a syringe pump to induce motion artifact.

RESULTS

On screen-film images, brief motion caused degradation of the entire image, simulating a double exposure. Conversely, on digital images using a slot-scanning system, brief motion caused degradation of only a small portion of the image. Continuous motion resulted in smearing of phantom details with both systems, although the smearing was more strongly influenced by the direction of motion when the slot-scanning system was used. With the slot-scanning system, motion in the direction of the detector sweep resulted in elongated distortion, whereas motion in the opposite direction resulted in foreshortening; diagonal smearing was seen with perpendicular phantom motion. The magnitude of distortion for continuous motion at a set velocity was substantially less with the slot-scanning system.

CONCLUSION

Motion artifact with a slot-scanning direct digital mammography unit differs significantly from that seen with a conventional screen-film unit and, despite a relatively long overall exposure, may prove to be less of a problem than with conventional units because any given part of an object is exposed only briefly.

The E1 replication protein of bovine papillomavirus type 1 contains an extended nuclear localization signal that includes a p34cdc2 phosphorylation site

Bovine papillomavirus (BPV) DNA replication occurs in the nucleus of infected cells. Most enzymatic activities are carried out by host cell proteins, with the viral E1 and E2 proteins required for the assembly of an initiation complex at the replication origin. In latently infected cells, viral DNA replication occurs in synchrony with the host cell chromosomes, maintaining a constant average copy number of BPV genomes per infected cell. By analyzing a series of mutants of the amino-terminal region of the E1 protein, we have identified the signal for transport of this protein to the cell nucleus. The E1 nuclear transport motif is highly conserved in the animal and human papillomaviruses and is encoded in a similar region in the related E1 genes. The signal is extended relative to the simple nuclear localization signals and contains two short amino acid sequences which contribute to nuclear transport, located between amino acids 85 and 108 of the BPV-1 E1 protein. Mutations in either basic region reduce nuclear transport of E1 protein and interfere with viral DNA replication. Mutations in both sequences simultaneously prevent any observable accumulation of the protein and reduce replication in transient assays to barely detectable levels. Surprisingly, these mutations had no effect on the ability of viral genomes to morphologically transform cells, although the plasmid DNA in the transformed cells was maintained at a very low copy number. Between these two basic amino acid blocks in the nuclear transport signal, at threonine 102, is a putative site for phosphorylation by the cell cycle regulated kinase p34cdc2. Utilizing an E1 protein purified from either a baculovirus vector system or Escherichia coli, we have shown that the E1 protein is a substrate for this kinase. An E1 gene mutant at threonine 102 encodes for a protein which is no longer a substrate for the p34cdc2 kinase. Mutation of this threonine to isoleucine had no observable effect on either nuclear localization of E1 or DNA replication of the intact viral genome.