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Callahan KP, Munson D, Feudtner C. A Cure for Prognostic Pessimism Among Neonatologists. JAMA Netw Open 2024; 7:e240525. [PMID: 38393732 DOI: 10.1001/jamanetworkopen.2024.0525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2024] Open
Affiliation(s)
- Katharine P Callahan
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Medical Ethics and Health Policy, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - David Munson
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Chris Feudtner
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Medical Ethics and Health Policy, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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Taylor SN, Munson D. Health Care of People Experiencing Homelessness: Part II. NEJM Evid 2023; 2:EVIDra2300175. [PMID: 38320194 DOI: 10.1056/evidra2300175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Health Care of People Experiencing HomelessnessIn this second part of a two-part review of health care for people experiencing homelessness, Taylor and Munson discuss approaches to care that are tailored to this population.
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Affiliation(s)
| | - David Munson
- Massachusetts General Hospital, Boston
- Boston Health Care for the Homeless Program, Boston
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Abstract
Homelessness and Health CarePeople who experience homelessness have high rates of medical illness. They struggle with conditions associated with living in crowded shelters, trauma, and exposure to extreme weather. Here, Taylor and Munson review the care of this vulnerable population.
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Affiliation(s)
| | - David Munson
- Massachusetts General Hospital, Boston
- Boston Health Care for the Homeless Program, Boston
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Harting MT, Munson D, Linebarger J, Hirshberg E, Gow KW, Malek MM, Robbins AJ, Turnbull J. Ethical Considerations in Critically Ill Neonatal and Pediatric Patients. J Pediatr Surg 2023; 58:1059-1073. [PMID: 36948932 DOI: 10.1016/j.jpedsurg.2023.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/03/2023] [Indexed: 02/19/2023]
Abstract
The care of critically ill neonates and pediatric patients can be particularly emotionally and ethically challenging. Emerging evidence suggests that we can improve the patient, family, and care team experience in the critical care setting through a better understanding and application of ethical frameworks and communication strategies. We conducted a multidisciplinary panel session at the American Academy of Pediatrics National Conference and Exhibition in the fall of 2022 wherein we explored a myriad of ethical and communication considerations in this unique patient population, with congenital diaphragmatic hernia (CDH) as the congenital anomaly/disease framework. In this review, we will cover state of the art topics in ethics, communication, and palliative care including basic terminology, communication strategies such as trauma-informed communication, establishing/evolving goals of care, futility, medically inappropriate treatment, ethical frameworks, parental discretion, establishing milestones, internal/external intentions, and re-direction of care. These topics will be helpful to many specialties who are involved in the care of critically ill neonates and children including maternal fetal medicine, pediatrics, neonatology, pediatric critical care, palliative care, and pediatric surgery, along with the pediatric surgical subspecialties. We use a theoretical CDH case as an example and include the live audience responses from the interactive session. This primer provides overarching educational principles, as well as practical communication concepts, that can cultivate compassionate multidisciplinary teams, equipped to optimize family-centered, evidence-based compassionate communication and care.
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Affiliation(s)
- Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, Houston, TX, USA.
| | - David Munson
- Department of Pediatrics, Division of Neonatology, Perelman School of Medicine at the University of Pennsylvania and the Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jennifer Linebarger
- Department of Pediatrics, University of Missouri - Kansas City and Children's Mercy Hospital, Kansas City, MO, USA
| | - Ellie Hirshberg
- Department of Pediatrics, University of Utah School of Medicine and Intermountain Healthcare, Salt Lake City, UT, USA
| | - Kenneth W Gow
- Department of Surgery, Division of Pediatric Surgery, University of Washington and Seattle Children's Hospital, Seattle, WA, USA
| | - Marcus M Malek
- Department of Surgery, Division of Pediatric Surgery, University of Pittsburgh and UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Alexandria J Robbins
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA; Department of Family Medicine and Community Health, Division of Palliative Care, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Jessica Turnbull
- Department of Pediatrics and the Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN, USA
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Callahan KP, Flibotte J, Skraban C, Wild KT, Joffe S, Munson D, Feudtner C. Influence of Genetic Information on Neonatologists' Decisions: A Psychological Experiment. Pediatrics 2022; 149:184790. [PMID: 35169841 PMCID: PMC8892772 DOI: 10.1542/peds.2021-052130] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/01/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Genetic testing is expanding among ill neonates, yet the influence of genetic results on medical decision-making is not clear. With this study, we sought to determine how different types of genetic information with uncertain implications for prognosis influence clinicians' decisions to recommend intensive versus palliative care. METHODS We conducted a national study of neonatologists using a split sample experimental design. The questionnaire contained 4 clinical vignettes. Participants were randomly assigned to see one of 2 versions that varied only regarding whether they included the following genetic findings: (1) a variant of uncertain significance; (2) a genetic diagnosis that affects neurodevelopment but not acute survival; (3) a genetic versus nongenetic etiology of equally severe pathology; (4) a pending genetic testing result. Physicians answered questions about recommendations they would make for the patient described in each vignette. RESULTS Vignette versions that included a variant of uncertain significance, a diagnosis foreshadowing neurodevelopmental impairment, or a genetic etiology of disease were all associated with an increased likelihood of recommending palliative rather than intensive care. A pending genetic test result did not have a significant effect on care recommendations. CONCLUSIONS Findings from this study of hypothetical cases suggest neonatologists apply uncertain genetic findings or those that herald neurodevelopmental disability in problematic ways. As genetic testing expands, understanding how it is used in decision-making and educating clinicians regarding appropriate use are paramount.
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Affiliation(s)
- Katharine Press Callahan
- Children's Hospital of Philadelphia, Philadelphia,
Pennsylvania,Department of Medical Ethics and Health Policy, Perelman
School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania,Address correspondence to Katharine Press Callahan, MD,
Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia,
PA 19104. E-mail:
| | - John Flibotte
- Children's Hospital of Philadelphia, Philadelphia,
Pennsylvania
| | - Cara Skraban
- Children's Hospital of Philadelphia, Philadelphia,
Pennsylvania
| | | | - Steven Joffe
- Children's Hospital of Philadelphia, Philadelphia,
Pennsylvania,Department of Medical Ethics and Health Policy, Perelman
School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Munson
- Children's Hospital of Philadelphia, Philadelphia,
Pennsylvania
| | - Chris Feudtner
- Children's Hospital of Philadelphia, Philadelphia,
Pennsylvania,Department of Medical Ethics and Health Policy, Perelman
School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Callahan KP, Flibotte J, Skraban C, Wild KT, Joffe S, Munson D, Feudtner C. How neonatologists use genetic testing: findings from a national survey. J Perinatol 2022; 42:260-261. [PMID: 34848850 PMCID: PMC8825701 DOI: 10.1038/s41372-021-01283-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 11/08/2021] [Accepted: 11/18/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Katharine Press Callahan
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA. .,Department of Medical Ethics and Health Policy, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - John Flibotte
- The Children’s Hospital of Philadelphia; Philadelphia, Pennsylvania
| | - Cara Skraban
- The Children’s Hospital of Philadelphia; Philadelphia, Pennsylvania
| | | | - Steven Joffe
- The Children’s Hospital of Philadelphia; Philadelphia, Pennsylvania;,Department of Medical Ethics and Health Policy, The Perelman School of Medicine at the University of Pennsylvania; Philadelphia, Pennsylvania
| | - David Munson
- The Children’s Hospital of Philadelphia; Philadelphia, Pennsylvania
| | - Chris Feudtner
- The Children’s Hospital of Philadelphia; Philadelphia, Pennsylvania;,Department of Medical Ethics and Health Policy, The Perelman School of Medicine at the University of Pennsylvania; Philadelphia, Pennsylvania
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Ruiz F, Jehng T, Spindler T, Munson D, Karlen J, Thota V, Wang A, Chuan J, Yedwabnick M, Dubovsky J, Aftab BT. COMPREHENSIVE ACTIVATION PROFILING OF TABELECLEUCEL, AN OFF‐THE‐SHELF, ALLOGENEIC EBV‐SPECIFIC T‐CELL IMMUNOTHERAPY. Hematol Oncol 2021. [DOI: 10.1002/hon.90_2881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- F. Ruiz
- Atara Biotherapeutics Thousand Oaks California USA
| | - T. Jehng
- Atara Biotherapeutics Thousand Oaks California USA
| | - T. Spindler
- Atara Biotherapeutics Thousand Oaks California USA
| | - D. Munson
- Atara Biotherapeutics Thousand Oaks California USA
| | - J. Karlen
- Atara Biotherapeutics Thousand Oaks California USA
| | - V. Thota
- Atara Biotherapeutics Thousand Oaks California USA
| | - A. Wang
- Atara Biotherapeutics Thousand Oaks California USA
| | - J. Chuan
- Atara Biotherapeutics Thousand Oaks California USA
| | | | - J. Dubovsky
- Atara Biotherapeutics Thousand Oaks California USA
| | - B. T. Aftab
- Atara Biotherapeutics Thousand Oaks California USA
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Abstract
Bronchopulmonary dysplasia (BPD) is an acquired, developmental chronic lung disease that is a consequence of premature birth. In the most severe form of the disease, infants may require prolonged periods of positive pressure ventilation. BPD is a heterogeneous disease with lung mechanics that differ from those in respiratory distress syndrome; strategies to manage the respiratory support in infants with severe BPD should take this into consideration. When caring for these infants, practitioners need to shift from the acute care ventilation strategies that use frequent blood gases and support adjustments designed to minimize exposure to positive pressure. Infants with severe BPD benefit from a chronic care model that uses less frequent ventilator adjustments and provides the level of positive support that will achieve the longer-term goal of ongoing lung growth and repair.
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Affiliation(s)
| | | | - Stamatia Alexiou
- Pulmonology, Department of Pediatrics, Children's Hospital of Philadelphia and The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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9
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Foglia EE, Ades A, Hedrick HL, Rintoul N, Munson D, Moldenhauer JS, Gebb J, Serletti B, Chaudhary A, Weinberg DD, Napolitano N, Fraga MV, Ratcliffe SJ. Initiating resuscitation before umbilical cord clamping in infants with congenital diaphragmatic hernia: a pilot feasibility trial. Arch Dis Child Fetal Neonatal Ed 2020; 105:322-326. [PMID: 31462406 PMCID: PMC7047568 DOI: 10.1136/archdischild-2019-317477] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 08/13/2019] [Accepted: 08/13/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Infants with congenital diaphragmatic hernia (CDH) often experience hypoxaemia with acidosis immediately after birth. The traditional approach in the delivery room is immediate cord clamping followed by intubation. Initiating resuscitation prior to umbilical cord clamping (UCC) may support this transition. OBJECTIVES To establish the safety and feasibility of intubation and ventilation prior to UCC for infants with CDH. To compare short-term outcomes between trial participants and matched controls treated with immediate cord clamping before intubation and ventilation. DESIGN Single-arm, single-site trial of infants with CDH and gestational age ≥36 weeks. Infants were placed on a trolley immediately after birth and underwent intubation and ventilation, with UCC performed after qualitative CO2 detection. The primary feasibility endpoint was successful intubation prior to UCC. Prespecified safety and physiological outcomes were compared with historical controls matched for prognostic variables using standard bivariate tests. RESULTS Of 20 enrolled infants, all were placed on the trolley, and 17 (85%) infants were intubated before UCC. The first haemoglobin and mean blood pressure at 1 hour of life were significantly higher in trial participants than controls. There were no significant differences between groups for subsequent blood pressure values, vasoactive medications, inhaled nitric oxide or extracorporeal membrane oxygenation. Blood gas and oxygenation index values did not differ between groups at any point. CONCLUSIONS Intubation and ventilation prior to UCC is safe and feasible among infants with CDH. The impact of this approach on clinically relevant outcomes deserves investigation in a randomised trial.
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Affiliation(s)
| | - Anne Ades
- Children’s Hospital of Philadelphia, Philadelphia PA
| | | | | | - David Munson
- Children’s Hospital of Philadelphia, Philadelphia PA
| | | | - Juliana Gebb
- Children’s Hospital of Philadelphia, Philadelphia PA
| | | | | | | | | | | | - Sarah J. Ratcliffe
- Division of Biostatistics, Department of Public Health Sciences, University of Virginia, Charlottesville VA
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10
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Benjamin JL, Dennis R, White S, Munson D, Anupindi SA, Piskunowicz M, Darge K, Gokli A, Hwang M. Improved Diagnostic Sensitivity of Bowel Disease of Prematurity on Contrast-Enhanced Ultrasound. J Ultrasound Med 2020; 39:1031-1036. [PMID: 31705672 DOI: 10.1002/jum.15168] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 08/30/2019] [Accepted: 10/11/2019] [Indexed: 06/10/2023]
Abstract
Bowel diseases of prematurity, including necrotizing enterocolitis, are dreaded ailments of neonates. Early diagnosis is difficult, with clinical and radiographic findings often inconclusive. We present a novel use of contrast-enhanced ultrasound in detection of pediatric bowel disease. Early identification of compromised blood flow or an at-risk bowel can be quantitatively detected and monitored. This ability has implications for guidance of emerging therapies, allowing targeting of inflammation. These findings represent an advancement in detection of bowel disease in neonates.
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Affiliation(s)
- Jamaal L Benjamin
- Department of Radiology, Hospital of the University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Rebecca Dennis
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Stacy White
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - David Munson
- Department of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sudha A Anupindi
- Department of Radiology, Hospital of the University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Maciej Piskunowicz
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Radiology, Medical University of Gdansk, Gdansk, Poland
| | - Kassa Darge
- Department of Radiology, Hospital of the University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ami Gokli
- Department of Radiology, Hospital of the University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Misun Hwang
- Department of Radiology, Hospital of the University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Tomasulo CE, Gillespie MJ, Munson D, Demkin T, O'Byrne ML, Dori Y, Smith CL, Rome JJ, Glatz AC. Incidence and fate of device-related left pulmonary artery stenosis and aortic coarctation in small infants undergoing transcatheter patent ductus arteriosus closure. Catheter Cardiovasc Interv 2020; 96:889-897. [PMID: 32339400 DOI: 10.1002/ccd.28942] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 03/28/2020] [Accepted: 04/14/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To evaluate short- and middle-term outcomes after transcatheter patent ductus arteriosus (TC-PDA) closure in small infants, specifically device-related left pulmonary artery (LPA) stenosis and aortic coarctation, risk factors, and changes over time. BACKGROUND Recent studies have demonstrated successful transcatheter PDA (TC-PDA) closure in small infants. LPA stenosis and aortic coarctation have been seen after TC-PDA, but it is not clear whether device-related LPA/aortic obstruction persists. METHODS A single-center retrospective study of infants ≤4 kg who underwent TC-PDA closure from February 1, 2007 to September 1, 2018 was performed, evaluating the incidence and risk factors for LPA stenosis and coarctation. RESULTS Forty-four patients underwent successful TC-PDA with Amplatzer Vascular Plug II (AVPII; n = 30), Amplatzer Duct Occluder II-Additional Sizes (n = 10), Amplatzer Duct Occluder I (n = 3), and coil-filled AVPI (n = 1) devices, all via an antegrade approach. Median birthweight and procedural weight were 890 g (range: 490-3,250) and 2.8 kg (range: 1.2-4.0), respectively. Median follow-up was 0.7 years (range: 2 days-7 years). Thirty-eight patients had post-procedure echocardiograms assessing LPA/aortic obstruction. Of those, 17 had LPA flow acceleration/stenosis (≥1.5 m/s), which improved or resolved in all patients with available follow-up; 3 developed mild coarctation (>2 m/s), which improved in the two with more than short-term follow-up; 4 developed mild flow acceleration (1.5-2 m/s) in the descending aorta, which resolved in three and increased in one (2.4 m/s). Flow acceleration in the LPA was associated with younger procedural age, larger PDA minimal diameter, and placement of a device other than the AVPII. There was no device-related mortality or need for reintervention. CONCLUSION TC-PDA in small infants is effective, without significant complications. Device-related LPA/aortic obstruction can improve with time/growth.
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Affiliation(s)
- Catherine E Tomasulo
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Matthew J Gillespie
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - David Munson
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Taylor Demkin
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Michael L O'Byrne
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Yoav Dori
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Christopher L Smith
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jonathan J Rome
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Andrew C Glatz
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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12
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Aftab B, Munson D, Rasor K, Foubert P, Tsai D, Kai Weng W, Ghobadi A, van Besien K, Sun Y, Hiremath M, Navarrow W, Prockop S. CORRELATION OF CIRCULATING EPSTEIN-BARR VIRUS-TARGETED CYTOTOXIC T LYMPHOCYTE PRECURSORS (EBV-CTLp) AND CLINICAL RESPONSE FOLLOWING TABELECLEUCEL (TAB-CEL) INFUSION IN PATIENTS WITH EBV-DRIVEN DISEASE. Hematol Oncol 2019. [DOI: 10.1002/hon.186_2631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- B. Aftab
- Preclinical and Translational Science; Atara Biotherapeutics; Thousand Oaks United States
| | - D. Munson
- Preclinical and Translational Science; Atara Biotherapeutics; Thousand Oaks United States
| | - K. Rasor
- Preclinical and Translational Science; Atara Biotherapeutics; Thousand Oaks United States
| | - P. Foubert
- Preclinical and Translational Science; Atara Biotherapeutics; Thousand Oaks United States
| | - D. Tsai
- Clinical; Loxo Oncology; Stamford United States
| | - W. Kai Weng
- Internal Medicine; Stanford; Palo Alto United States
| | - A. Ghobadi
- Internal Medicine; Saint Louis Children's Hospital; Saint Louis United States
| | | | - Y. Sun
- Biostatistics; Atara Biotherapeutics; Thousand Oaks United States
| | - M. Hiremath
- Clinical Development; Atara Biotherapuetics; San Francisco United States
| | - W. Navarrow
- Clinical Development; Atara Biotherapuetics; San Francisco United States
| | - S. Prockop
- Pediatric Hematology-Oncology; MSK; New York United States
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Drago MJ, Guillén U, Schiaratura M, Batza J, Zygmunt A, Mowes A, Munson D, Lorenz JM, Farkouh-Karoleski C, Kirpalani H. Constructing a Culturally Informed Spanish Decision-Aid to Counsel Latino Parents Facing Imminent Extreme Premature Delivery. Matern Child Health J 2019. [PMID: 29520727 DOI: 10.1007/s10995-018-2471-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Objective How Latino parents perceive and understand antenatal counseling for extreme prematurity, < 26 weeks of gestational age (GA), is not clear. We aim to characterize Latino parental perceptions of antenatal counseling in order to construct and validate a Spanish decision-aid (SDA) to improve parental knowledge of prematurity after antenatal consults. Methods This is a three-phased, prospective, multicenter study. First, interviews of 22 Latino parents with a history of birth < 26 weeks GA were conducted. Thematic analysis identified themes valued during antenatal counseling for decisions regarding neonatal resuscitation. Next, we incorporated these themes into the SDA. Finally, improvement in knowledge of prematurity in two Spanish-speaking groups, 'experienced' parents with a history of extremely premature birth and 'naïve' adult Latino volunteers, was measured using a multiple choice test before and after simulated counseling with the SDA. Result Twenty-two interviews generated seven unique themes. An SDA was constructed that preserved six themes paralleled by those found in a previously studied English population, and addressed a novel theme of "intercultural linguistic barriers" unique to our population. Knowledge scores rose in "naive" volunteers, 41 ± 12% to 71 ± 15% (P < 0.001), after simulated counseling with the SDA. 'Experienced' parents had a ceiling effect in knowledge scores, 62 ± 9% to 65 ± 11% (P = 0.22). The SDA was well received by participants. Conclusions for Practice Interviews of Latino parents with a history of premature birth generated similar themes to English-speaking parents, with intercultural linguistic barriers as a novel theme. An SDA for Latino parents facing extremely premature birth may improve comprehension of antenatal counseling.
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Affiliation(s)
- Matthew J Drago
- Columbia University, New York, NY, USA. .,Yale University School of Medicine, 333 Cedar Street, Neonatal-Perinatal Medicine, New Haven, CT, 06520, USA.
| | | | | | | | | | - Anja Mowes
- Drexel University, Philadelphia, PA, USA
| | - David Munson
- University of Pennsylvania, Philadelphia, PA, USA
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14
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Sammons JS, Graf EH, Townsend S, Hoegg CL, Smathers SA, Coffin SE, Williams K, Mitchell SL, Nawab U, Munson D, Quinn G, Binenbaum G. Outbreak of Adenovirus in a Neonatal Intensive Care Unit: Critical Importance of Equipment Cleaning During Inpatient Ophthalmologic Examinations. Ophthalmology 2018; 126:137-143. [PMID: 30180976 DOI: 10.1016/j.ophtha.2018.07.008] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 06/29/2018] [Accepted: 07/12/2018] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Outbreaks of adenovirus in neonatal intensive care units (NICUs) can lead to widespread transmission and serious adverse outcomes. We describe the investigation, response, and successful containment of an adenovirus outbreak in a NICU associated with contaminated handheld ophthalmologic equipment used during retinopathy of prematurity (ROP) screening. DESIGN Epidemiologic outbreak investigation. PARTICIPANTS A total of 23 hospitalized neonates, as well as NICU staff and parents of affected infants. MAIN OUTCOME MEASURES Routine surveillance identified an adenovirus outbreak in a level IV NICU in August 2016. Epidemiologic investigation followed, including chart review, staff interviews, and observations. Cases were defined as hospital-acquired adenovirus identified from any clinical specimen (NICU patient or employee) or compatible illness in a family member. Real-time polymerase chain reaction (PCR) and partial- and whole-genome sequencing assays were used for testing of clinical and environmental specimens. RESULTS We identified 23 primary neonatal cases and 9 secondary cases (6 employees and 3 parents). All neonatal case-patients had respiratory symptoms. Of these, 5 developed pneumonia and 12 required increased respiratory support. Less than half (48%) had ocular symptoms. All neonatal case-patients (100%) had undergone a recent ophthalmologic examination, and 54% of neonates undergoing examinations developed adenovirus infection. All affected employees and parents had direct contact with infected neonates. Observations revealed inconsistent disinfection of bedside ophthalmologic equipment and limited glove use. Sampling of 2 handheld lenses and 2 indirect ophthalmoscopes revealed adenovirus serotype 3 DNA on each device. Sequence analysis of 16 neonatal cases, 2 employees, and 2 lenses showed that cases and equipment shared 100% identity across the entire adenovirus genome. Infection control interventions included strict hand hygiene, including glove use; isolation precautions; enhanced cleaning of lenses and ophthalmoscopes between all examinations; and staff furlough. We identified no cases of secondary transmission among neonates. CONCLUSIONS Adenovirus outbreaks can result from use of contaminated ophthalmologic equipment. Even equipment that does not directly contact patients can facilitate indirect transmission. Patient-to-patient transmission can be prevented with strict infection control measures and equipment cleaning. Ophthalmologists performing inpatient examinations should take measures to avoid adenoviral spread from contaminated handheld equipment.
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Affiliation(s)
- Julia S Sammons
- Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Infection Prevention and Control, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Erin H Graf
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Infectious Diseases Diagnostics Laboratory, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sara Townsend
- Department of Infection Prevention and Control, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Cindy L Hoegg
- Department of Infection Prevention and Control, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sarah A Smathers
- Department of Infection Prevention and Control, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Susan E Coffin
- Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Infection Prevention and Control, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Philadelphia Department of Public Health, Philadelphia, Pennsylvania
| | - Katie Williams
- Department of Infection Prevention and Control, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Stephanie L Mitchell
- Clinical Microbiology Laboratory, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ursula Nawab
- Division of Neonatology, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - David Munson
- Division of Neonatology, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Graham Quinn
- Division of Ophthalmology, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Gil Binenbaum
- Division of Ophthalmology, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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15
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Abstract
ECMO has proven to be a life-saving intervention for a variety of disease entities with a high rate of survival in the neonatal population. However, ECMO requires clinical teams to engage in many ethical considerations. Even with ongoing improvements in technology and expertise, some patients will not survive a course of ECMO. An unsuccessful course of ECMO can be difficult to accept and cause a great deal of angst. These questions can result in real conflict both within the care team, and between the care team and the family. Herein we explore a range of ethical considerations that may be encountered when caring for a patient on ECMO, with a particular focus on those courses where it appears likely that the patient will not survive. We then consider how a palliative care approach may provide a tool set to help engage the team and family in confronting the difficult decision to discontinue ECMO.
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Affiliation(s)
- Roxanne Kirsch
- Department of Critical Care, The Hospital for Sick Children, Toronto, Canada; Department of Bioethics, The Hospital for Sick Children, Toronto, Canada; Department of Pediatrics, University of Toronto, Toronto, Canada.
| | - David Munson
- Department of Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA
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16
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James J, Munson D, DeMauro SB, Langer JC, Dworetz AR, Natarajan G, Bidegain M, Fortney CA, Seabrook R, Vohr BR, Tyson JE, Bell EF, Poindexter BB, Shankaran S, Higgins RD, Das A, Stoll BJ, Kirpalani H. Outcomes of Preterm Infants following Discussions about Withdrawal or Withholding of Life Support. J Pediatr 2017; 190. [PMID: 28647272 PMCID: PMC5690862 DOI: 10.1016/j.jpeds.2017.05.056] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES To describe the frequency of postnatal discussions about withdrawal or withholding of life-sustaining therapy (WWLST), ensuing WWLST, and outcomes of infants surviving such discussions. We hypothesized that such survivors have poor outcomes. STUDY DESIGN This retrospective review included registry data from 18 centers of the National Institute of Child Health and Human Development Neonatal Research Network. Infants born at 22-28 weeks of gestation who survived >12 hours during 2011-2013 were included. Regression analysis identified maternal and infant factors associated with WWLST discussions and factors predicting ensuing WWLST. In-hospital and 18- to 26-month outcomes were evaluated. RESULTS WWLST discussions occurred in 529 (15.4%) of 3434 infants. These were more frequent at 22-24 weeks (27.0%) compared with 27-28 weeks of gestation (5.6%). Factors associated with WWLST discussion were male sex, gestational age (GA) of ≤24 weeks, birth weight small for GA, congenital malformations or syndromes, early onset sepsis, severe brain injury, and necrotizing enterocolitis. Rates of WWLST discussion varied by center (6.4%-29.9%) as did WWLST (5.2%-20.7%). Ensuing WWLST occurred in 406 patients; of these, 5 survived to discharge. Of the 123 infants for whom intensive care was continued, 58 (47%) survived to discharge. Survival after WWLST discussion was associated with higher rates of neonatal morbidities and neurodevelopmental impairment compared with babies for whom WWLST discussions did not occur. Significant predictors of ensuing WWLST were maternal age >25 years, necrotizing enterocolitis, and days on a ventilator. CONCLUSIONS Wide center variations in WWLST discussions occur, especially at ≤24 weeks GA. Outcomes of infants surviving after WWLST discussions are poor. TRIAL REGISTRATION ClinicalTrials.gov: NCT00063063.
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Affiliation(s)
- Jennifer James
- Department of Pediatrics, The Children's Hospital of Philadelphia and The University of Pennsylvania, Philadelphia, PA.
| | - David Munson
- Department of Pediatrics, The Children’s Hospital of Philadelphia and The University of Pennsylvania, Philadelphia, PA
| | - Sara B. DeMauro
- Department of Pediatrics, The Children’s Hospital of Philadelphia and The University of Pennsylvania, Philadelphia, PA
| | - John C. Langer
- Social, Statistical, and Environmental Sciences Unit, RTI International, Research Triangle Park, NC
| | - April R. Dworetz
- Emory University School of Medicine, Department of Pediatrics, Children’s Healthcare of Atlanta, Atlanta, GA
| | | | - Margarita Bidegain
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | | | - Ruth Seabrook
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH
| | - Betty R. Vohr
- Department of Pediatrics, Women and Infants Hospital, Brown University, Providence, RI
| | - Jon E. Tyson
- Department of Pediatrics, University of Texas Medical School at Houston, Houston, TX
| | - Edward F. Bell
- Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Brenda B. Poindexter
- Perinatal Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | | | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda
| | - Abhik Das
- Social, Statistical, and Environmental Sciences Unit, RTI International, Rockville, MD
| | - Barbara J. Stoll
- Emory University School of Medicine, Department of Pediatrics, Children’s Healthcare of Atlanta, Atlanta, GA
| | - Haresh Kirpalani
- Department of Pediatrics, The Children’s Hospital of Philadelphia and The University of Pennsylvania, Philadelphia, PA
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17
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Sammons JS, Townsend S, Hoegg CL, Smathers SA, Graf EH, Coffin S, Williams KL, Farnon E, Nawab U, Munson D, Dysart K, Binenbaum G. Outbreak of Adenovirus in a Neonatal Intensive Care Unit: Rapid Detection and Successful Prevention of Secondary Transmission. Am J Infect Control 2017. [DOI: 10.1016/j.ajic.2017.04.253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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18
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Abstract
Over the last few decades, the fields of fetal surgery and maternal-fetal medicine have developed interventions aimed at modifying severe diseases in utero. Innovations in fetal approaches to congenital diaphragmatic hernia and myelomeningocele have shown considerable promise in modifying the clinical course with fetal intervention. Patients who present to fetal centers to be evaluated for these interventions face challenging decisions that directly relate to questions of mortality and quality of life. This article explores how clinicians might apply the tools and principles of fetal palliative care to supporting a woman and her family who are considering fetal surgery.
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Affiliation(s)
- David Munson
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; The Children׳s Hospital of Philadelphia, 3401 Civic Center Blvd, 2nd Floor, Main, Philadelphia, PA 19104.
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19
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Coughlin K, Mackley A, Kwadu R, Shanks V, Sturtz W, Munson D, Guillen U. Characterization of Spirituality in Maternal-Child Caregivers. J Palliat Med 2017; 20:994-997. [PMID: 28060549 DOI: 10.1089/jpm.2016.0361] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To characterize spiritual beliefs and support provided by maternal-child staff at three academic hospitals. BACKGROUND Parents in neonatal intensive care units (NICUs) believe that addressing spirituality is important. The spiritual beliefs and the support provided by NICU staff are currently unknown. METHODS This prospective study surveyed all maternal-child staff (NICU and Obstetrics): physicians, neonatal nurse practitioners, physician assistants, nurses, respiratory therapists, and social workers. Two validated tools were used: Spiritual Involvement and Beliefs Scale (SIBS) and Spiritual Care Inventory (SCI); SIBS assesses spiritual beliefs and practices, SCI assesses the perception of spiritual care that one provides. Demographic information, including self-identified religious affiliation, was collected. RESULTS Respondents of 406 completed surveys were mostly nurses, female, white, and Christian. SIBS scores ranged between 21 and 136. Higher SIBS score was associated with Christian religion (p = 0.001) and African American (p = 0.003) and Asian (p = 0.017) race, when controlling for site, age, gender, education, role in the NICU, and years in practice. A high SCI score was also associated with Christian religion (p = 0.01). There was a trend toward an association between SCI and older age (p = 0.051). There was an association between a high SIBS score and higher ratings on both SCI subscales used. DISCUSSION There is a wide range in spirituality and perceived spiritual support among maternal-child staff. This may coincide with the spiritual needs of families in the NICU.
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Affiliation(s)
| | - Amy Mackley
- 2 Christiana Care Health System , Newark, Delaware
| | - Rachel Kwadu
- 2 Christiana Care Health System , Newark, Delaware
| | | | - Wendy Sturtz
- 2 Christiana Care Health System , Newark, Delaware
| | - David Munson
- 1 Children's Hospital of Philadelphia , Philadelphia, Pennsylvania
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20
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Huang C, Jiang D, Francisco D, Berman R, Wu Q, Ledford JG, Moore CM, Ito Y, Stevenson C, Munson D, Li L, Kraft M, Chu HW. Tollip SNP rs5743899 modulates human airway epithelial responses to rhinovirus infection. Clin Exp Allergy 2016; 46:1549-1563. [PMID: 27513438 DOI: 10.1111/cea.12793] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 07/15/2016] [Accepted: 07/19/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND Rhinovirus (RV) infection in asthma induces varying degrees of airway inflammation (e.g. neutrophils), but the underlying mechanisms remain unclear. OBJECTIVE The major goal was to determine the role of genetic variation [e.g. single nucleotide polymorphisms (SNPs)] of Toll-interacting protein (Tollip) in airway epithelial responses to RV in a type 2 cytokine milieu. METHODS DNA from blood of asthmatic and normal subjects was genotyped for Tollip SNP rs5743899 AA, AG and GG genotypes. Human tracheobronchial epithelial (HTBE) cells from donors without lung disease were cultured to determine pro-inflammatory and antiviral responses to IL-13 and RV16. Tollip knockout and wild-type mice were challenged with house dust mite (HDM) and infected with RV1B to determine lung inflammation and antiviral response. RESULTS Asthmatic subjects carrying the AG or GG genotype (AG/GG) compared with the AA genotype demonstrated greater airflow limitation. HTBE cells with AG/GG expressed less Tollip. Upon IL-13 and RV16 treatment, cells with AG/GG (vs. AA) produced more IL-8 and expressed less antiviral genes, which was coupled with increased NF-κB activity and decreased expression of LC3, a hallmark of the autophagic pathway. Tollip co-localized and interacted with LC3. Inhibition of autophagy decreased antiviral genes in IL-13- and RV16-treated cells. Upon HDM and RV1B, Tollip knockout (vs. wild-type) mice demonstrated higher levels of lung neutrophilic inflammation and viral load, but lower levels of antiviral gene expression. CONCLUSIONS AND CLINICAL RELEVANCE Our data suggest that Tollip SNP rs5743899 may predict varying airway response to RV infection in asthma.
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Affiliation(s)
- C Huang
- Department of Medicine, National Jewish Health, Denver, CO, USA
| | - D Jiang
- Department of Medicine, National Jewish Health, Denver, CO, USA
| | - D Francisco
- Department of Medicine, University of Arizona College of Medicine, Tucson, AZ, USA
| | - R Berman
- Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Q Wu
- Department of Medicine, National Jewish Health, Denver, CO, USA
| | - J G Ledford
- Department of Medicine, University of Arizona College of Medicine, Tucson, AZ, USA
| | - C M Moore
- Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Y Ito
- Department of Medicine, National Jewish Health, Denver, CO, USA
| | - C Stevenson
- Department of Medicine, National Jewish Health, Denver, CO, USA
| | - D Munson
- Department of Medicine, National Jewish Health, Denver, CO, USA
| | - L Li
- Department of Biological Sciences, Virginia Polytechnic Institute and State University, Blacksburg, VA, USA
| | - M Kraft
- Department of Medicine, University of Arizona College of Medicine, Tucson, AZ, USA
| | - H W Chu
- Department of Medicine, National Jewish Health, Denver, CO, USA
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21
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Reuter S, Baack M, Munson D. 31-Week Premature Male with Congenital Syphilis. S D Med 2015; 68:487-492. [PMID: 26689031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
The incidence of syphilis is on the rise in many parts of the U.S., including South Dakota. We present a case of congenital syphilis and review the evaluation, clinical course, and treatment of this devastating disease process.
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22
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Guillén Ú, Weiss EM, Munson D, Maton P, Jefferies A, Norman M, Naulaers G, Mendes J, Justo da Silva L, Zoban P, Hansen TWR, Hallman M, Delivoria-Papadopoulos M, Hosono S, Albersheim SG, Williams C, Boyle E, Lui K, Darlow B, Kirpalani H. Guidelines for the Management of Extremely Premature Deliveries: A Systematic Review. Pediatrics 2015; 136:343-50. [PMID: 26169424 DOI: 10.1542/peds.2015-0542] [Citation(s) in RCA: 138] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Available data on survival rates and outcomes of extremely low gestational age (GA) infants (22-25 weeks' gestation) display wide variation by country. Whether similar variation is found in statements by national professional bodies is unknown. The objectives were to perform a systematic review of management from scientific and professional organizations for delivery room care of extremely low GA infants. METHODS We searched Embase, PubMed, and Google Scholar for management guidelines on perinatal care. Countries were included if rated by the United Nations Development Programme's Human Development Index as "very highly developed." The primary outcome was rating of recommendations from "comfort care" to "active care." Secondary outcomes were specifying country-specific survival and considering potential for 3 biases: limitations of GA assessment; bias from different definitions of stillbirths and live births; and bias from the use of different denominators to calculate survival. RESULTS Of 47 highly developed countries, 34 guidelines from 23 countries and 4 international groups were identified. Of these, 3 did not state management recommendations. Of the remaining 31 guidelines, 21 (68%) supported comfort care at 22 weeks' gestation, and 20 (65%) supported active care at 25 weeks' gestation. Between 23 and 24 weeks' gestation, much greater variation was seen. Seventeen guidelines cited national survival rates. Few guidelines discussed potential biases: limitations in GA (n = 17); definition bias (n = 3); and denominator bias (n = 7). CONCLUSIONS Although there is a wide variation in recommendations (especially between 23 and 24 weeks' GA), there is general agreement for comfort care at 22 weeks' GA and active care at 25 weeks' GA.
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Affiliation(s)
- Úrsula Guillén
- Division of Neonatology, Christiana Care Health System, Newark, Delaware;
| | - Elliott M Weiss
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - David Munson
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Ann Jefferies
- Department of Paediatrics, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mikael Norman
- Department of Neonatal Medicine, Karolinska Hospital, Stockholm, Sweden
| | - Gunnar Naulaers
- Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
| | | | | | - Petr Zoban
- Department of Neonatology, Charles University, Prague, Czech Republic
| | - Thor W R Hansen
- Women & Children's Division, Oslo University Hospital, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Mikko Hallman
- Department of Pediatrics, Oulu University Hospital and University of Oulu, Oulu, Finland
| | | | - Shigeharu Hosono
- Department of Pediatrics, Nihon University School of Medicine, Tokyo, Japan
| | - Susan G Albersheim
- Division of Neonatology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Constance Williams
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Elaine Boyle
- Department of Pediatrics, University of Leicester, Leicester, United Kingdom
| | - Kei Lui
- Department of Newborn Care, University of New South Wales, Sydney, Australia; and
| | - Brian Darlow
- Department of Pediatrics, University of Otago, Christchurch, New Zealand
| | - Haresh Kirpalani
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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23
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VenOsdel N, Hogden L, Munson D. Primary Care Follow-up of the NICU Graduate. S D Med 2015; 68:310-314. [PMID: 26267932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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24
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Ragsdale L, Zhong W, Morrison W, Munson D, Kang TI, Dai D, Feudtner C. Pediatric exposure to opioid and sedation medications during terminal hospitalizations in the United States, 2007-2011. J Pediatr 2015; 166:587-93.e1. [PMID: 25454928 DOI: 10.1016/j.jpeds.2014.10.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 09/03/2014] [Accepted: 10/03/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To describe the use of opioids and sedatives to pediatric patients dying in the hospital in the 2 weeks preceding death. STUDY DESIGN We conducted a retrospective study on opioid and sedation medication exposure among children who die in hospitals in the US by using large administrative data sources. We described patterns of exposure to these medications for deceased inpatients (<21 years of age) between 2007 and 2011 (n = 37,459) and factors associated with the exposure. Multivariable logistic regression models were used to estimate the ORs. RESULTS Overall, 74% patients were exposed to opioids or sedatives in the 14 days before death. Among patients with 6 or more hospital days before death, the daily exposure rate ranged from 73% (the sixth day before death) to 89% (the day of death). The most commonly used medications were fentanyl (52%), midazolam (44%), and morphine (40%). Older age (ORs 1.6-3.7), black race (ORs 0.8), longer hospital stay (ORs 6.6-9.3), receiving medical interventions (including mechanical ventilation, surgery, and stay in the intensive care unit, ORs 1.7-2.6), having comorbidities (ORs 1.7-2.4), and being hospitalized in children's hospitals (ORs 4.0-4.5) were associated with exposure of opioid and sedation medication on adjusted analysis. CONCLUSION Although most pediatric patients terminally hospitalized are exposed to opioid and sedation medication, some patients do not receive such medications before death. Given that patient and hospital characteristics were associated with opioid/sedative exposure, these findings suggest areas of potential quality improvement and further research.
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Affiliation(s)
| | - Wenjun Zhong
- The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Wynne Morrison
- The Children's Hospital of Philadelphia, Philadelphia, PA
| | - David Munson
- The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Tammy I Kang
- The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Dingwei Dai
- The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Chris Feudtner
- The Children's Hospital of Philadelphia, Philadelphia, PA.
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25
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Feudtner C, Walter JK, Faerber JA, Hill DL, Carroll KW, Mollen CJ, Miller VA, Morrison WE, Munson D, Kang TI, Hinds PS. Good-parent beliefs of parents of seriously ill children. JAMA Pediatr 2015; 169:39-47. [PMID: 25419676 PMCID: PMC4946564 DOI: 10.1001/jamapediatrics.2014.2341] [Citation(s) in RCA: 149] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Parents' beliefs about what they need to do to be a good parent when their children are seriously ill influence their medical decisions, and better understanding of these beliefs may improve decision support. OBJECTIVE To assess parents' perceptions regarding the relative importance of 12 good-parent attributes. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional, discrete-choice experiment was conducted at a children's hospital. Participants included 200 parents of children with serious illness. MAIN OUTCOMES AND MEASURES Ratings of 12 good-parent attributes, with subsequent use of latent class analysis to identify groups of parents with similar ratings of attributes, and ascertainment of whether membership in a particular group was associated with demographic or clinical characteristics. RESULTS The highest-ranked good-parent attribute was making sure that my child feels loved, followed by focusing on my child's health, making informed medical care decisions, and advocating for my child with medical staff. We identified 4 groups of parents with similar patterns of good-parent-attribute ratings, which we labeled as: child feels loved (n=68), child's health (n=56), advocacy and informed (n=55), and spiritual well-being (n=21). Compared with the other groups, the child's health group reported more financial difficulties, was less educated, and had a higher proportion of children with new complex, chronic conditions. CONCLUSIONS AND RELEVANCE Parents endorse a broad range of beliefs that represent what they perceive they should do to be a good parent for their seriously ill child. Common patterns of how parents prioritize these attributes exist, suggesting future research to better understand the origins and development of good-parent beliefs among these parents. More important, engaging parents individually regarding what they perceive to be the core duties they must fulfill to be a good parent may enable more customized and effective decision support.
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Affiliation(s)
- Chris Feudtner
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jennifer K. Walter
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jennifer A. Faerber
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Douglas L. Hill
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Karen W. Carroll
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Cynthia J. Mollen
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Victoria A. Miller
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Wynne E. Morrison
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - David Munson
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Tammy I. Kang
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Pamela S. Hinds
- Department of Nursing Research and Quality Outcomes, Children’s National Health System, Washington, DC4Department of Pediatrics, School of Medicine and Health Sciences, George Washington University, Washington, DC
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26
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Affiliation(s)
- Tammy I Kang
- The Children's Hospital of Philadelphia, Philadelphia, PA
| | - David Munson
- The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jennifer Hwang
- The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Chris Feudtner
- The Children's Hospital of Philadelphia, Philadelphia, PA
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27
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Abu Hazeem AA, Gillespie MJ, Thun H, Munson D, Schwartz MC, Dori Y, Rome JJ, Glatz AC. Percutaneous closure of patent ductus arteriosus in small infants with significant lung disease may offer faster recovery of respiratory function when compared to surgical ligation. Catheter Cardiovasc Interv 2013; 82:526-33. [PMID: 23723091 DOI: 10.1002/ccd.25032] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Accepted: 05/19/2013] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To describe our experience with percutaneous closure of patent ductus arteriosus (PDA) in small infants and compare outcomes to matched surgical patients. BACKGROUND Ligation via thoracotomy has been used to close PDAs in small infants, but has been associated with respiratory and hemodynamic compromise. We hypothesized that percutaneous closure would offer faster recovery of respiratory function. METHODS Patients <4 kg requiring positive pressure ventilation who underwent percutaneous PDA closure between January 2000 and April 2012 were reviewed and matched to contemporary surgical patients on gestational age (GA), birth weight (BW), procedure weight (WT), and ventilation mode. Patients returned to baseline respiratory status when the product of mean airway pressure and FiO2 returned to pre-procedural levels. RESULTS Eight matched pairs were included. Median BW, GA, and WT were 1.43 kg (0.52-2.97), 29.8 weeks (24-39), and 2.8 kg (2.2-3.9) for catheter patients and 1.55 kg (0.48-3.04), 29 weeks (23-37), and 2.75 kg (2.3-4.2) for surgical patients. Complete PDA closure occurred in all. The median time to return to baseline respiratory status was significantly shorter in the percutaneous group (17 hr (range 0-113) vs. 53 hr (range 13-219), P < 0.05). In the percutaneous group, two patients developed mild aortic coarctation, one mild left pulmonary artery stenosis, and four femoral vascular thromboses which all resolved with medical therapy. Surgical complications included significant respiratory and cardiac compromise, rib fractures and urinary retention. CONCLUSIONS Percutaneous closure of PDA in small infants on respiratory support is equivalent in safety and efficacy and may offer shorter recovery time than surgical ligation.
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Affiliation(s)
- Anas A Abu Hazeem
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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28
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Affiliation(s)
- Chris Feudtner
- Director of the Department of Medical Ethics, director of research, and an attending physician for PACT (Palliative Care Team) and integrated care service (ICS), all at the Children's Hospital of Philadelphia
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29
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Abstract
Withdrawing life-sustaining technologies requires all of the resources and concepts that the field of palliative care has to offer. By learning some fundamental principles of medical management at the time of withdrawal and by mastering a few communication techniques, pediatricians, neonatologists, and pediatric intensivists can dramatically improve the care provided to their patients at the end of life. Although we may argue in pediatrics if there is ever such a thing as a good death, we should all strive to ensure one that is free of suffering, and one that supports the family in moving down a path of healthy grief and recovery.
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Affiliation(s)
- David Munson
- Division of Neonatology, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.
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30
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Abstract
Prenatal diagnosis of a lethal anomaly is a monumental moment in a family's life. It requires extensive team counseling and planning about complex neonatal and obstetric medical management. The construct of palliative care with its focus on emotional, spiritual, social, and symptom support can provide a model for caring for these families.
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Affiliation(s)
- David Munson
- Division of Neonatology, The Children's Hospital of Philadelphia, The University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.
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31
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Abstract
The oxidative environment within the lung generated upon administration of oxygen may be a critical regulator for the efficacy of inhaled nitric oxide therapy, possibly as a consequence of changes in nitrosative and nitrative chemistry. Changes in S-nitrosocysteine and 3-nitrotyrosine adducts were therefore evaluated after exposure of rats to 80% or >95% oxygen for 24 or 48 h with and without 20 ppm inhaled nitric oxide. Exposure to 80% oxygen led to increased formation of S-nitrosocysteine and 3-nitrotyrosine adducts in lung tissue that were also associated with increased expression of iNOS. The addition of inhaled nitric oxide in 80% oxygen exposure did not alter any of these adducts in the lung or in the bronchoalveolar lavage (BAL). Exposure to >95% oxygen led to a significant decrease in S-nitrosocysteine and an increase in 3-nitrotyrosine adducts in the lung. Co-administration of inhaled nitric oxide with >95% oxygen prevented the decrease in S-nitrosocysteine levels. The levels of S-nitrosocysteine and 3-nitrotyrosine returned to baseline in a time-dependent fashion after termination of exposure to >95% oxygen and inhaled nitric oxide. These data suggest the formation of S-nitrosating and tyrosine-nitrating species is regulated by oxygen tensions and co-administration of inhaled nitric oxide restores the nitrosative chemistry without a significant impact upon the nitrative pathway.
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Affiliation(s)
- Scott A Lorch
- The Joseph Stokes Jr. Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
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Abstract
Accumulating evidence shows that S-nitrosothiols, formed by the addition of nitric oxide (NO) to a cysteine thiol, S-nitrosylation, are involved in basal cellular regulation. It has been proposed that SNO formation/removal may be disrupted in a variety of pathophysiological conditions. Two types of methodology are presently available to identify specific S-nitrosylated proteins: (1) derivatization and (2) post-purification chemical detection. Neither of these techniques allows for in situ visualization of SNOs. Recently, we demonstrated that an antibody generated to the SNO moiety could be used to detect SNO formation from each of three isoforms of NOS by immunohistochemistry. This chapter details the immunohistochemical methodology used to detect SNOs in situ, offering a potentially powerful alternative for detection of SNO within tissue sections.
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Affiliation(s)
- Andrew J Gow
- Division of Neonatology, Joseph Stokes Junior Research Institute, Children's Hospital of Philadelphia, PA, USA
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Venditti CP, Harris MC, Huff D, Peterside I, Munson D, Weber HS, Rome J, Kaye EM, Shanske S, Sacconi S, Tay S, DiMauro S, Berry GT. Congenital cardiomyopathy and pulmonary hypertension: another fatal variant of cytochrome-c oxidase deficiency. J Inherit Metab Dis 2004; 27:735-9. [PMID: 15505378 DOI: 10.1023/b:boli.0000045711.89888.5e] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Biventricular hypertrophy was noted at 24 weeks' gestation in a fetus with isolated cytochrome-c oxidase (COX) deficiency. Shock, caused by hypertrophic cardiomyopathy and severe pulmonary hypertension, led to the patient's death on day 6. His phenotype defines a new lethal variant of COX deficiency characterized by prenatal-onset cardiopulmonary pathophysiology.
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Affiliation(s)
- C P Venditti
- Division of Human Genetics and Molecular Biology, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
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Fetterman M, Tan E, Ying L, Stack R, Marks D, Feller S, Cull E, Sullivan J, Munson D, Thoroddsen S, Brady D. Tomographic imaging of foam. Opt Express 2000; 7:186-197. [PMID: 19407864 DOI: 10.1364/oe.7.000186] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The morphology of three-dimensional foams is of interest to physicists, engineers, and mathematicians. It is desired to image the 3-dimensional structure of the foam. Many different techniques have been used to image the foam, including magnetic resonance imaging, and short-focal length lenses. We use a camera and apply tomographic algorithms to accurately image a set of bubbles. We correct for the distortion of a curved plexiglas container using ray-tracing.
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Abstract
A 65-kDa protein (called S1) from Spirochaeta bajacaliforniensis was identified as 'tubulin-like' because it cross-reacted with at least four different antisera raised against tubulin and was isolated, with a co-polymerizing 45-kDa protein, by warm-cold cycling procedures used to purify tubulin from mammalian brain. Furthermore, at least three genera of non-cultivable symbiotic spirochetes (Pillotina, Diplocalyx, and Hollandina) that contain conspicuous 24-nm cytoplasmic tubules displayed a strong fluorescence in situ when treated with polyclonal antisera raised against tubulin. Here we summarize results that lead to the conclusion that this 65-kDa protein has no homology to tubulin. S1 is an hsp65 stress protein homologue. Hsp65 is a highly immunogenic family of hsp60 proteins which includes the 65-kDa antigens of Mycobacterium tuberculosis (an active component of Freund's complete adjuvant), Borrelia, Treponema, Chlamydia, Legionella, and Salmonella. The hsp60s, also known as chaperonins, include E. coli GroEL, mitochondrial and chloroplast chaperonins, the pea aphid 'symbionin' and many other proteins involved in protein folding and the stress response.
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Affiliation(s)
- D Munson
- Molecular and Cellular Biology Program, University of Massachusetts, Amherst 01003
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Schechter GP, Sausville EA, Fischmann AB, Soehnlen F, Eddy J, Matthews M, Gazdar A, Guccion J, Munson D, Makuch R. Evaluation of circulating malignant cells provides prognostic information in cutaneous T cell lymphoma. Blood 1987; 69:841-9. [PMID: 3493044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Peripheral blood lymphocyte morphology was evaluated prospectively by light microscopy of blood smears and E rosette preparations in 160 patients with cutaneous T cell lymphoma (CTCL). Blood involvement was related to the type of cutaneous T-stage, being present in 90% of patients with erythroderma (T4), 27% of those with cutaneous tumors (T3), 9% of those with generalized (T2), and 0% of those with limited skin plaques (T1). Untreated patients with blood involvement (38 of 105) had a higher frequency of CTCL in lymph nodes and viscera and survival inferior to that of patients with normal or nondiagnostic lymphocyte morphology (P less than .001). Multivariate analysis showed skin stage and age to be the most important pretreatment risk factors for survival. Although blood involvement was not an independent risk factor for the entire group, it appeared to have some adverse influence in the T2/T3 subsets (P = .051). Both lymphocytosis and size distribution of the circulating CTCL cells at initial diagnosis influenced survival. Patients with "mixed cell" cytology (greater than 20% large [greater than 11 microns] CTCL cells), had a worse survival than those with predominantly small circulating CTCL cells (P = .009). The former were more likely to have aggressive features, including lymph node effacement by tumor (P less than .001) and visceral disease (P = .074), than were "small cell" patients. Our data indicate that detailed review of the blood lymphocyte morphology in patients with diagnosed or suspected CTCL is helpful in predicting extent of disease and prognosis.
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Abstract
The distribution of peripheral blood T cells bearing Fc receptors for IgG (T gamma) and IgM (T mu) was determined in 18 patients with cutaneous T-cell lymphoma (Sézary syndrome, mycosis fungoides) and 15 normal controls. The mean percent of T mu and T gamma cells in the patients with morphologically normal lymphocytes was similar to that of the control subjects. In 13 patients with circulating malignant cells representing 30-100% of their peripheral blood lymphocytes, the mean percentages of T mu and T gamma were low. In 9 patients the majority of the malignant T cells did not exhibit Fc receptors for IgG or IgM. In some patients, however, high blood lymphocyte counts resulted in normal or high concentrations of all the T-cell subsets. Further, in 4 patients, lymphocytes with the characteristic nuclear abnormalities of "Sézary/mycosis" cells were found in both the T mu and T gamma, as well as the Tnon gamma non mu, subpopulations. The heterogeneity of the Fc receptors on cutaneous T-cell lymphoma lymphocytes suggests that these receptors are not useful as clonal markers in these disorders.
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Schechter GP, Bunn PA, Fischmann AB, Matthews MJ, Guccion J, Soehnlen F, Munson D, Minna JD. Blood and lymph node T lymphocytes in cutaneous T cell lymphoma: evaluation by light microscopy. Cancer Treat Rep 1979; 63:571-4. [PMID: 312694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Cytology of peripheral blood and lymph node lymphocytes from a group of unselected patients with cutaneous T cell lymphoma (CTCL) was studied by light microscopy. Twenty of 45 patients had circulating lymphocytes with convoluted nuclei recognized in routine Wright-Giemsa-stained peripheral blood smears. Cytocentrifuge preparations of E-rosetted lymphocytes showed that greater than 10% of the T cells had convoluted nuclei in each of 16 patients with positive blood smears and in six of 17 whose blood smears were negative or inconclusive. Peripheral blood involvement with greater than 10% convoluted T cells was most frequent in patients with erythroderma (100%) including those with normal of decreased lymphocyte counts, and was not uncommon in patients with mycosis fungoides in the plaque or tumor phase (42%). The light-microscopic morphology of the abnormal cells found in the patients with the plaque or tumor phase of mycosis fungoides was not distinguishable from that of the erythrodermic patients. Increased percentages (less than 15%) of T cells having convoluted nuclei were also found in the lymph node cell suspensions from CTCL patients with adenopathy (18 of 25 patients). These results suggest that a high frequency of extracutaneous involvement occurs in patient with CTCL, the clinical significance of which remains to be determined.
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Melvin GR, Aceto T, Barlow J, Munson D, Wierda D. Iatrogenic congenital goiter and hypothyroidism with respiratory distress in a newborn. S D J Med 1978; 31:15-9. [PMID: 279993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Munson D, Franco D, Arbeter A, Velez H, Vitale JJ. Serum levels of immunoglobulins, cell-mediated immunity, and phagocytosis in protein-calorie malnutrition. Am J Clin Nutr 1974; 27:625-8. [PMID: 4208450 DOI: 10.1093/ajcn/27.6.625] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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