Antimicrobial prescribing after rapid influenza PCR implementation in the emergency department

INTRO

Influenza shares common symptoms with bacterial pneumonia, which may result in unnecessary antibiotic prescriptions in the emergency department (ED) when the diagnosis is unknown. Rapid influenza polymerase chain reaction (PCR) tests have reduced turnaround times compared to standard multiplex PCR respiratory panels allowing for earlier diagnosis, which may improve antimicrobial stewardship outcomes in the ED. This study aims to compare antibiotic and antiviral use before and after deployment of the rapid influenza PCR in the ED.

METHODS

This single-center, retrospective, cohort study included pediatric and adult patients discharged from the ED with a positive influenza test using a standard multiplex PCR respiratory panel (January 2017 - July 2019) or rapid PCR (July 2019 - February 2020). The primary endpoint was number of antibiotic prescriptions pre- and post-implementation of the rapid influenza PCR in the ED. Secondary endpoints included number of antiviral prescriptions, duration of antimicrobial therapy, test turnaround time, ED length of stay, 30-day readmission, and adverse events. A multivariable logistic regression evaluated patient factors associated with antimicrobial prescribing.

RESULTS

A total of 620 positive influenza results were identified with 280 patients (standard multiplex PCR = 33; rapid PCR = 247) meeting inclusion criteria. Patients were less likely to be prescribed antibiotics (39.4% vs 8.9%, OR 0.15, 95% CI 0.067-0.34) and more likely to be prescribed antivirals (24.2% vs 61.1%, OR 4.92, 95% CI 2.13-11.34) with the rapid influenza PCR. Rapid influenza PCR significantly reduced ED length of stay (4.9 vs 3.4 h, p < 0.01) and test turnaround time (27 h vs 3.5 h, p < 0.01). Patients at high risk for complications associated with influenza were more likely to be prescribed antiviral therapy (22.7% vs 67.8%, OR 7.16, 95% CI 2.52-20.40). Based on the regression analysis conducted, asthma, (OR 3.5, 95% CI 1.48-8.26), immunosuppression (OR 9.6, 95% CI 1.18-78.2), and age <5 years old (OR 3.1, 95% CI 1.80-5.45) were predictors of antiviral prescribing.

CONCLUSION

Implementation of a rapid influenza PCR in the ED reduced antibiotic use and optimized antiviral therapy for patients with influenza including those at higher risk of complications.

A pan-influenza antibody inhibiting neuraminidase via receptor mimicry

Rapidly evolving influenza A viruses (IAVs) and influenza B viruses (IBVs) are major causes of recurrent lower respiratory tract infections. Current influenza vaccines elicit antibodies predominantly to the highly variable head region of haemagglutinin and their effectiveness is limited by viral drift¹ and suboptimal immune responses². Here we describe a neuraminidase-targeting monoclonal antibody, FNI9, that potently inhibits the enzymatic activity of all group 1 and group 2 IAVs, as well as Victoria/2/87-like, Yamagata/16/88-like and ancestral IBVs. FNI9 broadly neutralizes seasonal IAVs and IBVs, including the immune-evading H3N2 strains bearing an N-glycan at position 245, and shows synergistic activity when combined with anti-haemagglutinin stem-directed antibodies. Structural analysis reveals that D107 in the FNI9 heavy chain complementarity-determinant region 3 mimics the interaction of the sialic acid carboxyl group with the three highly conserved arginine residues (R118, R292 and R371) of the neuraminidase catalytic site. FNI9 demonstrates potent prophylactic activity against lethal IAV and IBV infections in mice. The unprecedented breadth and potency of the FNI9 monoclonal antibody supports its development for the prevention of influenza illness by seasonal and pandemic viruses.

The Queensland Twin Adolescent Brain Project, a longitudinal study of adolescent brain development

We describe the Queensland Twin Adolescent Brain (QTAB) dataset and provide a detailed methodology and technical validation to facilitate data usage. The QTAB dataset comprises multimodal neuroimaging, as well as cognitive and mental health data collected in adolescent twins over two sessions (session 1: N = 422, age 9-14 years; session 2: N = 304, 10-16 years). The MRI protocol consisted of T1-weighted (MP2RAGE), T2-weighted, FLAIR, high-resolution TSE, SWI, resting-state fMRI, DWI, and ASL scans. Two fMRI tasks were added in session 2: an emotional conflict task and a passive movie-watching task. Outside of the scanner, we assessed cognitive function using standardised tests. We also obtained self-reports of symptoms for anxiety and depression, perceived stress, sleepiness, pubertal development measures, and risk and protective factors. We additionally collected several biological samples for genomic and metagenomic analysis. The QTAB project was established to promote health-related research in adolescence.

Interactions between the lipidome and genetic and environmental factors in autism

Autism omics research has historically been reductionist and diagnosis centric, with little attention paid to common co-occurring conditions (for example, sleep and feeding disorders) and the complex interplay between molecular profiles and neurodevelopment, genetics, environmental factors and health. Here we explored the plasma lipidome (783 lipid species) in 765 children (485 diagnosed with autism spectrum disorder (ASD)) within the Australian Autism Biobank. We identified lipids associated with ASD diagnosis (n = 8), sleep disturbances (n = 20) and cognitive function (n = 8) and found that long-chain polyunsaturated fatty acids may causally contribute to sleep disturbances mediated by the FADS gene cluster. We explored the interplay of environmental factors with neurodevelopment and the lipidome, finding that sleep disturbances and unhealthy diet have a convergent lipidome profile (with potential mediation by the microbiome) that is also independently associated with poorer adaptive function. In contrast, ASD lipidome differences were accounted for by dietary differences and sleep disturbances. We identified a large chr19p13.2 copy number variant genetic deletion spanning the LDLR gene and two high-confidence ASD genes (ELAVL3 and SMARCA4) in one child with an ASD diagnosis and widespread low-density lipoprotein-related lipidome derangements. Lipidomics captures the complexity of neurodevelopment, as well as the biological effects of conditions that commonly affect quality of life among autistic people.

Case series of cefiderocol for salvage therapy in carbapenem-resistant Gram-negative infections

Purpose

This case series describes real-world utilization of cefiderocol and associated clinical outcomes in the setting of carbapenem-resistant Gram-negative bacterial infections.

Methods

Adult hospitalized patients administered at least 5 days of cefiderocol as definitive treatment from October 1, 2020 to September 16, 2021 were included in this retrospective cohort analysis. The primary outcome was clinical success defined as a composite of 30 day survival, resolution of infection, and absence of 30 day recurrence of the same organism.

Results

Among 24 patients, pneumonia (19, 79%) was the most common source of infection with Acinetobacter baumannii (14, 58%) and P. aeruginosa (10, 42%) as the predominant organisms isolated. Cefiderocol monotherapy was used as definitive treatment in 16 (67%) patients. Eleven patients (46%) met clinical success. Thirty-day mortality occurred in ten (42%) patients while seven (29%) patients had recurrence of infection. Thirteen out of 21 total isolates (62%) tested for susceptibility were deemed susceptible. Of the 16 patients with available susceptibility, 9 (56%) had an infection where all isolated organisms were susceptible to cefiderocol.

Conclusions

Our results provide additional insight into the in vivo activity of cefiderocol. Cefiderocol remains a salvage option for carbapenem-resistant Gram-negative organisms.

Patients experiences of using a publicly avaliable mobile health application for self-care of heart failure in a real-world setting

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): University of Kentucky disseration award

Background

Publicly available patient-focused mobile health applications (mHealth apps) are being increasingly integrated into routine heart failure (HF)-related self-care. However, there is a dearth of research on patients’ experiences using mHealth apps for self-care in real-world settings. The purpose of this study was to explore patients’ experiences using a publicly available mHealth app, OnTrack to Health, for HF self-care in a real-world setting.

Method

Patient satisfaction, measured with a 5-point Likert scale and an open-ended survey were used to gather data from 23 patients with HF who were provided the OnTrack to Health app as a part of routine HF management. A content analysis of patients’ responses was conducted with qualitative software, Atlas. ti version 8.

Results

Patients (median age = 64.0 [57.0, 70.5] years, 73.9% (n = 17) male) used OnTrack to Health for a median duration of 164.0 [ 51.2, 639.9] days before the survey. All patients reported excellent experiences related to app use and would recommend the app to other patients with HF. Four themes emerged from the responses to the open-ended questions: (1) perceived benefits (simplified self-care tasks, improved adherence to medications, enhanced communication and connection with healthcare providers, facilitated HF symptoms monitoring, improved HF knowledge, decreased hospitalization, and provided assurance of safety); (2) barriers (challenges of abandoning previous self-care strategies); (3) facilitators (perceived ease of use, availability of technical support); (4) suggested improvements (streamlining data entry, integration of apps with an electronic medical record, and personalization of app features).

Conclusion

Patients were satisfied with using mHealth apps for self-care. They perceived apps as a valuable tool for improving self-care ability and decreasing hospitalization rates. Personalization of app features and integration of mHealth apps with electronic health records are essential to sustain high-quality patient experiences related to app use for self-care.

Does perceived stress mediate the relationship between financial status, depression, and anxiety in caregivers at risk for cardiovascular disease (CVD)?

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): National Institutes of Health National Institute of Nursing Research

Background/Introduction

Caregivers are at high risk of anxiety and depression, and caregiver mental health is linked to higher CVD risk in caregivers over their non-caregiving peers. Most research focuses on caregiver burden as a primary cause for caregiver’s emotional distress, such as anxiety and depression. Other stressors like financial burden are less emphasized, despite widespread documentation of financial burden as a key social determinant of health. We hypothesize financial status predicts anxiety and depression through perceived stress.

Purpose

To identify the relationship between financial status and caregiver anxiety and depression and determine if it is mediated by perceived stress.

Methods

We analyzed cross-sectional data from the Rural Intervention for Caregiver’s Heart Health study. Anxiety was assessed using the Brief Symptom Inventory – Anxiety subscale (range 0 -3.5) and depression was assessed by the Patient Health Questionnaire –9 (range 0 - 27). Financial status was measured with one item that asked participants to rank their financial situation by level of comfort (not enough to make ends meet, enough to make ends meet, and comfortable), and perceived stress measured with Cohen’s Perceived Stress Scale – 4. Analysis was performed separately for the two mental health outcomes using OLS regression and, to test mediation, the PROCESS macro for SPSS and the bootstrapping procedure with 5,000 samples. We included age, gender, marital status, number of people in the household, body mass index, smoking status, and caregiver burden as covariates.

Results

Of the 287 participants, average age was 54 ± 13; 76% were female, 95.8% were Caucasian, and 70.4% were married. Controlling for covariates, caregivers with not enough to make ends meet reported substantially greater depressive symptoms (b=2.22, 95% CI = 0.48 – 3.96) and marginally greater anxiety (b=0.23, 95% CI = -0.02 – 0.47) compared to caregivers who were financially comfortable. These associations were not mediated by perceived stress as hypothesized.

Conclusions

Among caregivers who are at risk for CVD, financial status was important in reporting both depression and to a lesser extent, anxiety however perceived stress does not mediate this relationship. This is interesting as perceived stress is often a target for interventions that focus on reducing depression and anxiety in this population however our analysis emphasizes the importance of financial status alone. When designing interventions to reduce the CVD risk factors of anxiety and depression, more attention should be paid to relieving financial burden.

Autism-related dietary preferences mediate autism-gut microbiome associations

There is increasing interest in the potential contribution of the gut microbiome to autism spectrum disorder (ASD). However, previous studies have been underpowered and have not been designed to address potential confounding factors in a comprehensive way. We performed a large autism stool metagenomics study (n = 247) based on participants from the Australian Autism Biobank and the Queensland Twin Adolescent Brain project. We found negligible direct associations between ASD diagnosis and the gut microbiome. Instead, our data support a model whereby ASD-related restricted interests are associated with less-diverse diet, and in turn reduced microbial taxonomic diversity and looser stool consistency. In contrast to ASD diagnosis, our dataset was well powered to detect microbiome associations with traits such as age, dietary intake, and stool consistency. Overall, microbiome differences in ASD may reflect dietary preferences that relate to diagnostic features, and we caution against claims that the microbiome has a driving role in ASD.

Linking salt preference to enjoyment of low sodium diet in patients with heart failure

Background

Preference for salty foods is linked to dietary sodium intake. Increased salt preference is a barrier to low sodium diet (LSD) adherence due to perceived poor taste. Although patients with heart failure (HF) are advised to follow a LSD, the adherence remains poor. Understanding the relationship among attitudes, subjective norms (individuals' beliefs about how much they follow the advice of respected others), and perceived control for following a LSD, salt preference, and LSD enjoyment will help in designing interventions to increase adherence in patients with HF.

Purpose

The purpose of this study was to examine whether attitudes toward following a LSD, subjective norms about LSD, and perceived behavioral control for following a LSD mediated the association between salt preference and enjoyment of a LSD in patients with HF.

Methods

In this cross-sectional study, outpatients with HF completed the Dietary Sodium Restriction Questionnaire (DSRQ) based on the Theory of Planned Behavior, and rated salt preference and enjoyment of a LSD on a scale from 0 to 10 with 10 indicating the highest salt preference and enjoyment of LSD. Parallel mediation analyses were conducted using the PROCESS macro program in SPSS with 5,000 bootstrap samples controlling for age and gender. Three subscales of the DSRQ (i.e., attitude, subjective norms, and perceived behavioral control) were used as mediators.

Results

A sample of 117 patients with HF (65% male, mean age = 61.2±14.3, range 27 to 94, 82% white) completed the study. The mean salt preference rating was 5.26 (SD=2.7), and the LSD enjoyment rating was 4.56 (SD=2.5). Salt preference was not directly associated with LSD enjoyment (direct effect = −0.0506, 95% CI: [−0.2394, 0.1381]). There was a significant indirect effect of salt preference on the enjoyment of LSD through perceived behavioral control (indirect effect = −0.1178, 95% CI: [−0.0321, 0.0446]) (Figure 1). Patients with a high salt preference were more likely to have low levels of LSD enjoyment through the mediator of having low levels of perceived behavioral control over following a LSD. Subjective norms and attitudes toward LSD were not significant mediators of the association between salt preference and LSD enjoyment.

Conclusion

High preference for salty food decreased perceived behavioral control of LSD, which reduced enjoyment of LSD in patients with HF. Salt preference and perceived behavioral control in LSD are behavioral barriers in hedonic shift in LSD enjoyment. The findings suggest that intervention to promote LSD adherence should include strategies to increase perceived behavioral control in eating LSD and decreasing salt preference.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Institutes of Health in the USA

Association of age and dietary sodium intake in patients with heart failure: testing mediating effects of preference for salt and enjoyment of sodium-restricted diet

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): National Institutes of Health (NIH)

Background

The poor taste foods in a low sodium diet and patients’ preferences for salty foods are known barriers to sodium restricted diet (SRD) adherence. Older adults may experience less enjoyment of SRD due to decreased sense of taste. However, little is known about how age is associated with sodium intake, preference for salt, and enjoyment of SRD in patients with heart failure (HF).

Purpose

The purpose of this study was to examine effect of age on dietary sodium intake through their preference for salt and enjoyment of SRD in patients with HF.

Methods

 In this cross-sectional study, we used baseline data from participants in a randomized controlled trial of a SRD intervention for patients with HF and their caregivers. Patients were asked to collect 24-hour urine to measure dietary sodium intake. Preference for salty food and enjoyment of SRD were assessed using a question on an 11-point numeric scale (range 0 to 10). Parallel mediation analyses were conducted using the PROCESS macro program in SPSS with 5,000 bootstrap samples.

Results

A total of 136 patients with HF (64% male, mean age = 60.3 ± 14.4, range 27 to 90, 80.1% white) had a mean 24-hr urine sodium of 4320mg (SD = 2053, range: 1553 mg – 11495 mg) with most (71%) having a 24-hr urine sodium &gt; 3000mg. The mean preference for salty food was 5.3 (SD = 2.8) on a scale from 0 to 10 with 10 indicating greater preference and enjoyment of SRD was 4.4 (SD = 2.5) on the same scale. Age was significantly associated with sodium intake in that older patients were more likely to eat less sodium (effect= -40.3236, 95% CI= [-63.7151, -16.9321]). The indirect effects of age on sodium intake through preference of salty food (effect= .7033, 95% CI = [-2.3361, 4.5357]) and enjoyment of SRD (effect = -.0271, 95% CI = [ -3.2736, 2.2213]) were not significant, indicating that these factors did not mediate the relationship between age and dietary sodium consumption. When we controlled gender, education, and ethnicity, age was also associated with sodium intake, but the two indirect effects were not significant.

Conclusion

Although most patients consumed foods high in sodium, older patients were more likely to consume foods lower in salt. However, contrary to what we expected, preference for salty foods and enjoyment of SRD did not play mediator roles in the association of age with salt consumption. The findings suggest that older adults may need different types of intervention to promote adherence than younger patients. Further research is needed to explore other factors related to SRD (e.g., efficacy of SRD or perceived control of diet behaviors) that affect sodium intake in patients with HF.

Clinical Outcomes of Patients Treated for Candida auris Infections in a Multisite Health System, Illinois, USA

Candida auris is an emerging fungal pathogen that is typically resistant to fluconazole and is known to cause healthcare-associated outbreaks. We retrospectively reviewed 28 patients who had >1 positive culture for C. auris within a multisite health system in Illinois, USA, during May 2018–April 2019. Twelve of these patients were treated as inpatients for C. auris infections; 10 (83%) met criteria for clinical success, defined as absence of all-cause mortality, C. auris recurrence, and infection-related readmission at 30 days from the first positive culture. The other 2 patients (17%) died within 30 days. Most patients (92%) were empirically treated with micafungin. Four (14%) of 28 total isolates were resistant to fluconazole, 1 (3.6%) was resistant to amphotericin B, and 1 (3.6%) was resistant to echinocandins. Our findings describe low rates of antifungal resistance and favorable clinical outcomes for most C. auris patients.

Impact of Mandatory Infectious Diseases Consultation and Real-time Antimicrobial Stewardship Pharmacist Intervention on Staphylococcus aureus Bacteremia Bundle Adherence

Background

The purpose of this study was to evaluate the impact of infectious diseases consultation (IDC) and a real-time antimicrobial stewardship (AMS) review on the management of Staphylococcus aureus bacteremia (SAB).

Methods

This retrospective study included adult inpatients with SAB from January 2016 to December 2018 at 7 hospitals. Outcomes were compared between 3 time periods: before mandatory IDC and AMS review (period 1), after mandatory IDC and before AMS review (period 2), and after mandatory IDC and AMS review (period 3). The primary outcome was bundle adherence, defined as appropriate intravenous antimicrobial therapy, appropriate duration of therapy, appropriate surveillance cultures, echocardiography, and removal of indwelling intravenous catheters, if applicable. Secondary end points included individual bundle components, source control, length of stay (LOS), 30-day bacteremia-related readmission, and in-hospital all-cause mortality.

Results

A total of 579 patients met inclusion criteria for analysis. Complete bundle adherence was 65% in period 1 (n = 241/371), 54% in period 2 (n = 47/87), and 76% in period 3 (n = 92/121). Relative to period 3, bundle adherence was significantly lower in period 1 (odds ratio [OR], 0.58; 95% confidence interval [CI], 0.37–0.93; P = .02) and period 2 (OR, 0.37; 95% CI, 0.20–0.67; P = .0009). No difference in bundle adherence was noted between periods 1 and 2. Significant differences were seen in obtaining echocardiography (91% vs 83% vs 100%; P < .001), source control (34% vs 45% vs 45%; P = .04), and hospital LOS (10.5 vs 8.9 vs 12.0 days; P = .01). No differences were noted for readmission or mortality.

Conclusions

The addition of AMS pharmacist review to mandatory IDC was associated with significantly improved quality care bundle adherence.

Low-Dose Anti-Thymocyte Globulin Preserves C-Peptide, Reduces HbA1c, and Increases Regulatory to Conventional T-Cell Ratios in New-Onset Type 1 Diabetes: Two-Year Clinical Trial Data

A three-arm, randomized, double-masked, placebo-controlled phase 2b trial performed by the Type 1 Diabetes TrialNet Study Group previously demonstrated that low-dose anti-thymocyte globulin (ATG) (2.5 mg/kg) preserved β-cell function and reduced HbA_1c for 1 year in new-onset type 1 diabetes. Subjects (N = 89) were randomized to 1) ATG and pegylated granulocyte colony-stimulating factor (GCSF), 2) ATG alone, or 3) placebo. Herein, we report 2-year area under the curve (AUC) C-peptide and HbA_1c, prespecified secondary end points, and potential immunologic correlates. The 2-year mean mixed-meal tolerance test-stimulated AUC C-peptide, analyzed by ANCOVA adjusting for baseline C-peptide, age, and sex (n = 82) with significance defined as one-sided P < 0.025, was significantly higher in subjects treated with ATG versus placebo (P = 0.00005) but not ATG/GCSF versus placebo (P = 0.032). HbA_1c was significantly reduced at 2 years in subjects treated with ATG (P = 0.011) and ATG/GCSF (P = 0.022) versus placebo. Flow cytometry analyses demonstrated reduced circulating CD4:CD8 ratio, increased regulatory T-cell:conventional CD4 T-cell ratios, and increased PD-1⁺CD4⁺ T cells following low-dose ATG and ATG/GCSF. Low-dose ATG partially preserved β-cell function and reduced HbA_1c 2 years after therapy in new-onset type 1 diabetes. Future studies should determine whether low-dose ATG might prevent or delay the onset of type 1 diabetes.

Pediatric Quality of Life Inventory (PedsQL) 3.2 Diabetes Module for youth with Type 2 diabetes: reliability and validity

AIM

To test the measurement properties of the revised and updated Pediatric Quality of Life Inventory (PedsQL) 3.2 Diabetes Module originally developed in Type 1 diabetes in youth with Type 2 diabetes.

METHODS

The PedsQL 3.2 Diabetes Module and PedsQL Generic Core Scales were administered in a field test study to 100 young people aged 9-25 years with Type 2 diabetes. Factor analysis was conducted to determine the factor structure of the items.

RESULTS

The 15-item Diabetes Symptoms Summary Score and 12-item Type 2-specific Diabetes Management Summary Score were empirically derived through factor analysis. The Diabetes Symptoms and Type 2-specific Diabetes Management Summary Scores showed acceptable to excellent reliability across the age groups tested (α = 0.85-0.94). The Diabetes Symptoms and Type 2-specific Diabetes Management Summary Scores evidenced construct validity through large effect size correlations with the Generic Core Scales Total Scale Score (r = 0.67 and 0.57, respectively). HbA_1c was correlated with the Diabetes Symptoms and Type 2-specific Diabetes Management Summary Scores (r = -0.13 and -0.22). Minimal clinically important difference (MCID) scores were 5.91 and 7.39 for the Diabetes Symptoms and Type 2-specific Diabetes Management Summary Scores.

CONCLUSIONS

The PedsQL 3.2 Diabetes Module Diabetes Symptoms Summary Score and Type 2-specific Diabetes Management Summary Score exhibited satisfactory measurement properties for use as youth self-reported diabetes symptoms and diabetes management outcomes for clinical research and clinical practice for young people with Type 2 diabetes.

Maternal blood-pressure trends throughout pregnancy and development of pre-eclampsia in women receiving first-trimester aspirin prophylaxis

OBJECTIVES

To study women who initiated aspirin in the first trimester for high risk of pre-eclampsia, and compare blood-pressure trends throughout pregnancy between those with normal outcome and those who subsequently developed pre-eclampsia.

METHODS

Women were enrolled into a prospective observational study at 9-14 weeks' gestation. This was a secondary analysis of those who started daily doses of 81 mg of aspirin before 16 weeks for increased risk of pre-eclampsia based on maternal history and bilateral uterine artery notching. Enrollment characteristics and blood-pressure measurements throughout gestation were compared between women who did and those who did not develop pre-eclampsia.

RESULTS

Of the 237 women who initiated first-trimester aspirin prophylaxis, 29 (12.2%) developed pre-eclampsia. A total of 2881 serial blood-pressure measurements obtained between 4 and 41 weeks' gestation (747 in the first trimester, 1008 in the second and 1126 in the third) showed that women with pre-eclampsia started pregnancy with higher blood pressure and maintained this trend despite taking aspirin (mean arterial blood pressure in women with pre-eclampsia = (0.13 × gestational age (weeks)) + 93.63, vs (0.11 × gestational age (weeks)) + 82.61 in those without; P < 0.005). First-trimester diastolic and second-trimester systolic blood pressure were independent risk factors for pre-eclampsia (β = 1.087 and 1.050, respectively; r²  = 0.24, P < 0.0001). When average first-trimester diastolic blood pressure was >74 mmHg, the odds ratio for pre-eclampsia was 6.5 (95% CI, 2.8-15.1; P < 0.001) and that for pre-eclampsia before 34 weeks was 14.6 (95% CI, 1.72-123.5; P = 0.004). If, in addition, average second-trimester systolic blood pressure was >125 mmHg, the odds ratio for pre-eclampsia was 9.4 (95% CI, 4.1-22.4; P < 0.001) and that for early-onset disease was 34.6 (95% CI, 4.1-296.4; P = 0.004).

CONCLUSION

In women treated with prophylactic aspirin from the first trimester, those who develop pre-eclampsia have significantly and sustained higher blood pressure from the onset of pregnancy compared with those who do not develop pre-eclampsia. This raises the possibility that mildly elevated blood pressure predisposes women to abnormal placentation, which then acts synergistically with elevated blood pressure to predispose such women to pre-eclampsia to a degree that is incompletely mitigated by aspirin. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Primal world beliefs

Beck's insight-that beliefs about one's self, future, and environment shape behavior-transformed depression treatment. Yet environment beliefs remain relatively understudied. We introduce a set of environment beliefs-primal world beliefs or primals-that concern the world's overall character (e.g., the world is interesting, the world is dangerous). To create a measure, we systematically identified candidate primals (e.g., analyzing tweets, historical texts, etc.); conducted exploratory factor analysis (N = 930) and two confirmatory factor analyses (N = 524; N = 529); examined sequence effects (N = 219) and concurrent validity (N = 122); and conducted test-retests over 2 weeks (n = 122), 9 months (n = 134), and 19 months (n = 398). The resulting 99-item Primals Inventory (PI-99) measures 26 primals with three overarching beliefs-Safe, Enticing, and Alive (mean α = .93)-that typically explain ∼55% of the common variance. These beliefs were normally distributed; stable (2 weeks, 9 months, and 19 month test-retest results averaged .88, .75, and .77, respectively); strongly correlated with many personality and wellbeing variables (e.g., Safe and optimism, r = .61; Enticing and depression, r = -.52; Alive and meaning, r = .54); and explained more variance in life satisfaction, transcendent experience, trust, and gratitude than the BIG 5 (3%, 3%, 6%, and 12% more variance, respectively). In sum, the PI-99 showed strong psychometric characteristics, primals plausibly shape many personality and wellbeing variables, and a broad research effort examining these relationships is warranted. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Low-Dose Anti-Thymocyte Globulin (ATG) Preserves β-Cell Function and Improves HbA1c in New-Onset Type 1 Diabetes

OBJECTIVE

A pilot study suggested that combination therapy with low-dose anti-thymocyte globulin (ATG) and pegylated granulocyte colony-stimulating factor (GCSF) preserves C-peptide in established type 1 diabetes (T1D) (duration 4 months to 2 years). We hypothesized that 1) low-dose ATG/GCSF or 2) low-dose ATG alone would slow the decline of β-cell function in patients with new-onset T1D (duration <100 days).

RESEARCH DESIGN AND METHODS

A three-arm, randomized, double-masked, placebo-controlled trial was performed by the Type 1 Diabetes TrialNet Study Group in 89 subjects: 29 subjects randomized to ATG (2.5 mg/kg intravenously) followed by pegylated GCSF (6 mg subcutaneously every 2 weeks for 6 doses), 29 to ATG alone (2.5 mg/kg), and 31 to placebo. The primary end point was mean area under the curve (AUC) C-peptide during a 2-h mixed-meal tolerance test 1 year after initiation of therapy. Significance was defined as one-sided P value < 0.025.

RESULTS

The 1-year mean AUC C-peptide was significantly higher in subjects treated with ATG (0.646 nmol/L) versus placebo (0.406 nmol/L) (P = 0.0003) but not in those treated with ATG/GCSF (0.528 nmol/L) versus placebo (P = 0.031). HbA_1c was significantly reduced at 1 year in subjects treated with ATG and ATG/GCSF, P = 0.002 and 0.011, respectively.

CONCLUSIONS

Low-dose ATG slowed decline of C-peptide and reduced HbA_1c in new-onset T1D. Addition of GCSF did not enhance C-peptide preservation afforded by low-dose ATG. Future studies should be considered to determine whether low-dose ATG alone or in combination with other agents may prevent or delay the onset of the disease.

Fetal blood-gas values during fetoscopic myelomeningocele repair performed under carbon dioxide insufflation

Fetoscopic myelomeningocele (MMC) repair is performed using intrauterine carbon dioxide (CO₂ ) insufflation. Sheep experiments have shown that CO₂ insufflation is associated with significant fetal acidemia; however, corresponding data for human pregnancy are not available. We performed umbilical venous cord blood sampling in three patients during fetoscopic MMC repair at 25 + 1, 25 + 3 and 24 + 0 weeks' gestation, respectively. Fetal venous pH at the beginning of CO₂ insufflation was 7.36, 7.46 and 7.37, respectively in the three fetuses, and repeat values were 7.28, 7.35 and 7.36 after 181, 159 and 149 min, respectively. The partial pressure of oxygen and CO₂ was maintained in the normal range during these times, and pH decrease was less in Patient 3 who received humidified CO₂ insufflation. Our observations suggest that, in contrast to sheep experiments, CO₂ insufflation during fetoscopic myelomeningocele repair does not cause acidemia in human fetuses. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

MDM2 inhibition rescues neurogenic and cognitive deficits in a mouse model of fragile X syndrome

Fragile X syndrome, the most common form of inherited intellectual disability, is caused by loss of the fragile X mental retardation protein (FMRP). However, the mechanism remains unclear, and effective treatment is lacking. We show that loss of FMRP leads to activation of adult mouse neural stem cells (NSCs) and a subsequent reduction in the production of neurons. We identified the ubiquitin ligase mouse double minute 2 homolog (MDM2) as a target of FMRP. FMRP regulates Mdm2 mRNA stability, and loss of FMRP resulted in elevated MDM2 mRNA and protein. Further, we found that increased MDM2 expression led to reduced P53 expression in adult mouse NSCs, leading to alterations in NSC proliferation and differentiation. Treatment with Nutlin-3, a small molecule undergoing clinical trials for treating cancer, specifically inhibited the interaction of MDM2 with P53, and rescued neurogenic and cognitive deficits in FMRP-deficient mice. Our data reveal a potential regulatory role for FMRP in the balance between adult NSC activation and quiescence, and identify a potential new treatment for fragile X syndrome.

Pediatric Patient-Centered Transitions From Hospital to Home: Improving the Discharge Medication Process

OBJECTIVES

Medications prescribed at hospital discharge can lead to patient harm if there are access barriers or misunderstanding of instructions. Filling prescriptions before discharge can decrease these risks. We aimed to increase the percentage of patients leaving the hospital with new discharge medications in hand to 70% by 18 months.

METHODS

We used sequential plan-do-study-act cycles from January 2015 to September 2016. We used statistical process control charts to track process measures, new medications filled before discharge, and rates of bedside delivery with pharmacist teaching to the inpatient pediatric unit. Outcome measures included national patient survey data, collected and displayed quarterly, as well as caregiver understanding, comparing inaccuracy of medication teach-back with and without medications in hand before discharge.

RESULTS

Rates of patients leaving the hospital with medications in hand increased from a baseline of 2% to 85% over the study period. Bedside delivery reached 71%. Inaccuracy of caregiver report during a postdischarge phone call decreased from 3.3% to 0.7% (P < .05) when medications were in hand before discharge. Patient satisfaction with education of new medication side effects increased from 50% to 88%.

CONCLUSIONS

By using an engaged interprofessional team, we optimized use of our on-site outpatient pharmacy and increased the percentage of pediatric patients leaving the hospital with new discharge medications in hand to >80%. This, accompanied by increased rates of bedside medication delivery and pharmacist teaching, was associated with improvements in caregiver discharge-medication related experience and understanding.

Characterization of the type I IFN response to liver stage infection with genetically attenuated malaria parasite vaccines

Malaria, a disease caused by Plasmodium parasites, kills nearly 600,000 people annually. Inoculated by an infectious mosquito bite, Plasmodium sporozoites travel to the liver and infect hepatocytes. Here, they develop into merozoites that are released into the blood to cause malaria associated mortality and morbidity. No fully protective malaria vaccine exists, but immunizations with genetically attenuated parasites (GAPs) that arrest in the liver confer sterile protection from challenge in mice. Moreover, using a novel super-infection assay, we observed that GAP immunization induces a potent type I IFN response to control liver stage infection. However, the factors required for the induction and propagation of the IFN response, and the influence of this response on adaptive immunity had not been elucidated. To identify the upstream inducers of IFN signaling, we immunized mice with either mosquito debris or GAPs and measured gene expression in hepatocytes by RNA-Seq. 800 genes were significantly upregulated upon GAP immunization, including transcripts for cytosolic RNA and DNA sensors. To examine the influence of the IFN response on adaptive immunity, WT, IRF3−/− and IFNAR−/− mice were immunized with a suboptimal dose of GAP, and challenged 4 weeks later with WT parasite. The immunization regimen elicited sterile protection in 20% of the WT mice, while 100% protection was achieved in IRF3−/− or IFNAR−/− mice. Taken together, the data suggest that hepatocytes utilize RNA and DNA sensors to induce a type I IFN response that is necessary for early control of liver stage infection, yet detrimental to adaptive immunity. Current studies are examining the mechanisms behind the IFN-mediated suppression of adaptive immunity.

Increasing Incidence of Thyroid Nodules and Thyroid Cancer: Does Increased Detection of a Subclinical Reservoir Justify the Associated Anxiety and Treatment?

The incidence of thyroid cancer has been increasing over the last few decades, and it is subject to debate regarding whether the incidence is reflective of better diagnostic techniques and therefore better detection or if it is a reflection of a true increase in incidence. This increase in incidence has been most clearly manifested by an exponential increase in the diagnosis of micropapillary thyroid carcinomas. This article reviews the diagnosis of thyroid cancers, the dilemmas facing clinicians in the management of these micropapillary thyroid carcinomas, and the advances in molecular diagnostics that are being used to assist in the decision-making process. We consider the possibility of overtreatment of a relatively indolent disease and propose a less aggressive management plan in the appropriate clinical scenario.

Colocalization of a CD1d-Binding Glycolipid with a Radiation-Attenuated Sporozoite Vaccine in Lymph Node-Resident Dendritic Cells for a Robust Adjuvant Effect

A CD1d-binding glycolipid, α-Galactosylceramide (αGalCer), activates invariant NK T cells and acts as an adjuvant. We previously identified a fluorinated phenyl ring-modified αGalCer analog, 7DW8-5, displaying nearly 100-fold stronger CD1d binding affinity. In the current study, 7DW8-5 was found to exert a more potent adjuvant effect than αGalCer for a vaccine based on radiation-attenuated sporozoites of a rodent malaria parasite, Plasmodium yoelii, also referred to as irradiated P. yoelii sporozoites (IrPySpz). 7DW8-5 had a superb adjuvant effect only when the glycolipid and IrPySpz were conjointly administered i.m. Therefore, we evaluated the effect of distinctly different biodistribution patterns of αGalCer and 7DW8-5 on their respective adjuvant activities. Although both glycolipids induce a similar cytokine response in sera of mice injected i.v., after i.m. injection, αGalCer induces a systemic cytokine response, whereas 7DW8-5 is locally trapped by CD1d expressed by dendritic cells (DCs) in draining lymph nodes (dLNs). Moreover, the i.m. coadministration of 7DW8-5 with IrPySpz results in the recruitment of DCs to dLNs and the activation and maturation of DCs. These events cause the potent adjuvant effect of 7DW8-5, resulting in the enhancement of the CD8(+) T cell response induced by IrPySpz and, ultimately, improved protection against malaria. Our study is the first to show that the colocalization of a CD1d-binding invariant NK T cell-stimulatory glycolipid and a vaccine, like radiation-attenuated sporozoites, in dLN-resident DCs upon i.m. conjoint administration governs the potency of the adjuvant effect of the glycolipid.

Mechanisms of stage-transcending protection following immunization of mice with late liver stage-arresting genetically attenuated malaria parasites

Malaria, caused by Plasmodium parasite infection, continues to be one of the leading causes of worldwide morbidity and mortality. Development of an effective vaccine has been encumbered by the complex life cycle of the parasite that has distinct pre-erythrocytic and erythrocytic stages of infection in the mammalian host. Historically, malaria vaccine development efforts have targeted each stage in isolation. An ideal vaccine, however, would target multiple life cycle stages with multiple arms of the immune system and be capable of eliminating initial infection in the liver, the subsequent blood stage infection, and would prevent further parasite transmission. We have previously shown that immunization of mice with Plasmodium yoelii genetically attenuated parasites (GAP) that arrest late in liver stage development elicits stage-transcending protection against both a sporozoite challenge and a direct blood stage challenge. Here, we show that this immunization strategy engenders both T- and B-cell responses that are essential for stage-transcending protection, but the relative importance of each is determined by the host genetic background. Furthermore, potent anti-blood stage antibodies elicited after GAP immunization rely heavily on FC-mediated functions including complement fixation and FC receptor binding. These protective antibodies recognize the merozoite surface but do not appear to recognize the immunodominant merozoite surface protein-1. The antigen(s) targeted by stage-transcending immunity are present in both the late liver stages and blood stage parasites. The data clearly show that GAP-engendered protective immune responses can target shared antigens of pre-erythrocytic and erythrocytic parasite life cycle stages. As such, this model constitutes a powerful tool to identify novel, protective and stage-transcending T and B cell targets for incorporation into a multi-stage subunit vaccine.

Angiofibroma in a cockatiel (Nymphicus hollandicus)

Human angiofibromas are rare and arise typically in the nasopharynx. In veterinary medicine they have only been described in the dog. Microscopically, angiofibromas consist of irregular groups of blood vessels within a stroma of connective tissue, with oedema and secondary inflammation often present. A cockatiel (Nymphicus hollandicus) was presented with an oral mass that consisted of aggregates of blood vessels surrounded by a connective tissue stroma, with the presence of oedema and secondary inflammation. Tumours of the oral cavity are uncommon in birds and to the authors' knowledge this is the first case of avian angiofibroma.

CD40 is required for protective immunity against liver stage Plasmodium infection

The costimulatory molecule CD40 enhances immunity through several distinct roles in T cell activation and T cell interaction with other immune cells. In a mouse model of immunity to liver stage Plasmodium infection, CD40 was critical for the full maturation of liver dendritic cells, accumulation of CD8(+) T cells in the liver, and protective immunity induced by immunization with the Plasmodium yoelii fabb/f(-) genetically attenuated parasite. Using mixed adoptive transfers of polyclonal wild-type and CD40-deficient CD8(+) T cells into wild-type and CD40-deficient hosts, we evaluated the contributions to CD8(+) T cell immunity of CD40 expressed on host tissues including APC, compared with CD40 expressed on the CD8(+) T cells themselves. Most of the effects of CD40 could be accounted for by expression in the T cells' environment, including the accumulation of large numbers of CD8(+) T cells in the livers of immunized mice. Thus, protective immunity generated during immunization with fabb/f(-) was largely dependent on effective APC licensing via CD40 signaling.

Measurement of Antibody-Mediated Reduction of Plasmodium yoelii Liver Burden by Bioluminescent Imaging

Antibodies against the infectious sporozoite stage of malaria have been shown to be effective in preventing infection of the liver and in mitigating the ensuing blood stage. However, only a handful of antibody targets have been vetted and shown to be successful in mediating in vivo protection. Even more limited are the means with which to measure how effectively antibodies can reduce the number of parasites establishing infection in the liver. Traditionally, only qPCR of infected mouse livers could accurately measure liver parasite burden. However, this procedure requires sacrifice of the animal and precludes monitoring of the ensuing blood stage infection. Herein we describe a method of accurately assessing antibody-mediated reduction of parasite liver burden by combining passive or active immunization of mice and mosquito bite challenge with luciferase-expressing transgenic P. yoelii parasites. This method is rapid, reliable and allows for observation of blood stage disease in the same animal. This model will prove integral in screening the efficacy of novel antibody targets as the search for a more effective malaria vaccine continues.

N-acetyl-L-aspartyl-L-glutamate peptidase-like 2 is overexpressed in cancer and promotes a pro-migratory and pro-metastatic phenotype

N-acetyl-L-aspartyl-L-glutamate peptidase-like 2 (NAALADL2) is a member of the glutamate carboxypeptidase II family, best characterized by prostate-specific membrane antigen (PSMA/NAALAD1). Using immunohistochemistry (IHC), we have shown overexpression of NAALADL2 in colon and prostate tumours when compared with benign tissue. In prostate cancer, NAALADL2 expression was associated with stage and Grade, as well as circulating mRNA levels of the NAALADL2 gene. Overexpression of NAALADL2 was shown to predict poor survival following radical prostatectomy. In contrast to PSMA/NAALAD1, NAALADL2 was localized at the basal cell surface where it promotes adhesion to extracellular matrix proteins. Using stable knockdown and overexpression cell lines, we have demonstrated NAALADL2-dependent changes in cell migration, invasion and colony-forming potential. Expression arrays of the knockdown and overexpression cell lines have identified nine genes that co-expressed with NAALADL2, which included membrane proteins and genes known to be androgen regulated, including the prostate cancer biomarkers AGR2 and SPON2. Androgen regulation was confirmed in a number of these genes, although NAALADL2 itself was not found to be androgen regulated. NAALADL2 was also found to regulate levels of Ser133 phosphorylated C-AMP-binding protein (CREB), a master regulator of a number of cellular processes involved in cancer development and progression. In combination, these data suggest that changes in expression of NAALADL2 can impact upon a number of pro-oncogenic pathways and processes, making it a useful biomarker for both diagnosis and prognosis.

Strain-specific antiviral activity of iminosugars against human influenza A viruses

Objectives

Drugs that target host cell processes can be employed to complement drugs that specifically target viruses, and iminosugar compounds that inhibit host α-glucosidases have been reported to show antiviral activity against multiple viruses. Here the effect and mechanism of two iminosugar α-glucosidase inhibitors, N-butyl-deoxynojirimycin (NB-DNJ) and N-nonyl-deoxynojirimycin (NN-DNJ), on human influenza A viruses was examined.

Methods

The viruses examined were a recently circulating seasonal influenza A(H3N2) virus strain A/Brisbane/10/2007, an older H3N2 strain A/Udorn/307/72, and A/Lviv/N6/2009, a strain representative of the currently circulating pandemic influenza A(H1N1)pdm09 virus.

Results

The inhibitors had the strongest effect on Brisbane/10 and NN-DNJ was more potent than NB-DNJ. Both compounds showed antiviral activity in cell culture against three human influenza A viruses in a strain-specific manner. Consistent with its action as an α-glucosidase inhibitor, NN-DNJ treatment resulted in an altered glycan processing of influenza haemagglutinin (HA) and neuraminidase (NA), confirmed by MS. NN-DNJ treatment was found to reduce the cell surface expression of the H3 subtype HA. The level of sialidase activity of NA was reduced in infected cells, but the addition of exogenous sialidase to the cells did not complement the NN-DNJ-mediated inhibition of virus replication. Using reassortant viruses, the drug susceptibility profile was determined to correlate with the origin of the HA.

Conclusions

NN-DNJ inhibits influenza A virus replication in a strain-specific manner that is dependent on the HA.

Visceral smooth muscle α-actin deficiency associated with chronic intestinal pseudo-obstruction in a Bengal cat (Felis catus x Prionailurus bengalensis)

An adult Bengal cat (Felis catus × Prionailurus bengalensis) with a prolonged history of partial anorexia, regurgitation, and weight loss and a clinical, radiographic, and ultrasonographic diagnosis of persistent megaesophagus and gastrointestinal ileus was submitted for necropsy. The intestinal tract was diffusely distended by gas and fluid with appreciable loss of muscle tone and an absence of luminal obstruction, consistent with the clinical history of chronic intestinal pseudo-obstruction. Histologically, the autonomic nervous system was intact, but the smooth muscle within the gastrointestinal wall exhibited a marked basophilia that was most pronounced in the jejunum. Immunohistochemistry for neurofilament, synaptophysin, CD117, and desmin demonstrated that the number of myenteric ganglia, number of interstitial cells, and leiomyocyte desmin content were similar when compared with the unaffected age- and species-matched control. Immunohistochemistry for smooth muscle α-actin demonstrated a striking loss of immunoreactivity, predominantly in the circular layer of the jejunum, that corresponded with the tinctorial change in leiomyocytes. Transmission electron microscopy revealed loss of myofibrils, loss of organelle polarity, and significantly larger central mitochondria (megamitochondria) in affected leiomyocytes, as well as nonspecific degenerative changes. Although the presence of a primary leiomyopathy and a causal relationship could not be confirmed in this case, leiomyopathies are considered a cause of chronic intestinal pseudo-obstruction in human medicine, and loss of smooth muscle α-actin immunoreactivity is one recognized marker for intestinal dysmotility.

Plasmodium yoelii inhibitor of cysteine proteases is exported to exomembrane structures and interacts with yoelipain-2 during asexual blood-stage development

Plasmodium falciparum (Pf) blood stages express falstatin, an inhibitor of cysteine proteases (ICP), which is implicated in regulating proteolysis during red blood cell infection. Recent data using the Plasmodium berghei rodent malaria model suggested an additional role for ICP in the infection of hepatocytes by sporozoites and during liver-stage development. Here we further characterize the role of ICP in vivo during infection with Plasmodium yoelii (Py) and Pf. We found that Py-ICP was refractory to targeted gene deletion indicating an essential function during asexual blood-stage replication, but significant downregulation of ICP using a regulated system did not impact blood-stage growth. Py-ICP localized to vesicles within the asexual blood-stage parasite cytoplasm, as well as the parasitophorous vacuole, and was exported to dynamic exomembrane structures in the infected RBC. In sporozoites, expression was observed in rhoptries, in addition to intracellular vesicles distinct from TRAP containing micronemes. During liver-stage development, Py-ICP was confined to the parasite compartment until the final phase of liver-stage development when, after parasitophorous vacuolemembrane breakdown, it was released into the infected hepatocyte. Finally, we identified the cysteine protease yoelipain-2 as a binding partner of Py-ICP during blood-stage infection. These data show that ICP may be important in regulating proteolytic processes during blood-stage development, and is likely playing a role in liver stage-hepatocyte interactions at the time of exoerythrocytic merozoite release.

Individual and Combined Effects of Peroxisome Proliferator-Activated Receptor α and γ Agonists, Fenofibrate and Rosiglitazone, on Biomarkers of Lipid and Glucose Metabolism in Healthy Nondiabetic Volunteers

This open-label, randomized, placebo-controlled, incomplete-block, 3-period crossover pilot study investigated the effects of peroxisome proliferator-activated receptor alpha- and gamma-agonists on biomarkers of lipid and glucose metabolism in 12 nondiabetic subjects. Plasma samples were collected before and after each 14-day treatment with placebo, fenofibrate (201 mg/d), rosiglitazone (4 mg twice daily), and combined fenofibrate (201 mg/d) plus rosiglitazone (4 mg twice daily). Except for triglycerides (P < .042) and free fatty acids (P < .074), no significant interaction was demonstrated between fenofibrate and rosiglitazone; thus, the effect due to each drug alone was evaluated (presence/absence of drug). Fenofibrate significantly (P < .050) increased lipoprotein lipase activity (35%) and decreased apolipoproteins B (13%) and C-III (20%). Rosiglitazone significantly (P < .050) decreased fasting glucose (7.3%) and increased apolipoprotein C-III (19%) and adiponectin (137%). Fenofibrate and rosiglitazone also produced effects on triglycerides and free fatty acids, but it was not possible to determine if these effects were synergistic in nature.

A reduced-energy intake, well-balanced diet improves weight control in children with Prader-Willi syndrome

BACKGROUND

Children with Prader-Willi syndrome (PWS) have a predictable pattern of weight gain, with obesity beginning in early childhood and worsening as they get older and hyperphagia increases. Data on the most effective dietary modifications are scant and primarily anecdotal. As part of a longitudinal study investigating the natural history of PWS, we evaluated the effect of a well-balanced, energy-restricted diet on body composition and weight in young children with PWS.

METHODS

Sixty-three children, aged 2-10 years, with genetically proven PWS participated in the present study. These children had measurements of body composition by dual-energy X-ray absorptiometry and resting energy expenditure (REE), as well as a 3-day diet history analysis both before and after intervention. Energy calculations were based on the individual's REE, with the recommendation that the macronutrients of the diet consist of 30% fat, 45% carbohydrates and 25% protein, with at least 20 g of fibre per day.

RESULTS

Thirty-three families adhered to our dietary recommendations for both energy intake and macronutrient distribution. Those 33 children had lower body fat (19.8% versus 41.9%; P < 0.001) and weight management (body mass index SD score 0.3 versus 2.23; P < 0.001) than those whose parents followed the energy intake recommendations but did not alter the macronutrient composition of the diet. Those who followed our recommendations also had a lower respiratory quotient (0.84 versus 0.95; P = 0.002).

CONCLUSIONS

Our recommendation for an energy-restricted diet with a well-balanced macronutrient composition and fibre intake improves both weight and body composition in children with PWS compared to a simple energy-restricted diet.