Management of nutritional iron deficiency anemia for young children in the emergency department

BACKGROUND

Guidelines for young children with nutritional iron deficiency anemia (IDA) presenting to the emergency department (ED) are lacking, leading to variability in care. We aimed to standardize management of these patients through the development and implementation of an evidence-based algorithm using quality improvement methodology.

PROCEDURE

Baseline data of the target population (n = 42; 60% male; median age 22.5 months, median hemoglobin 5.3 g/dl) identified variability across four key measures of clinical management: laboratory evaluation, therapy choice, therapy administration, and patient disposition. Literature review and consensus from pediatric hematology providers informed a draft algorithm that was refined in an iterative multidisciplinary process. From September 2020 to June 2021, we aimed to increase IDA management per the algorithm by ≥20% relative to baseline for the four key outcome measures using sequential Plan-Do-Study-Act (PDSA) cycles. Process measures focusing on provider communication/documentation and balancing measures involving efficiency and therapy-related adverse events were assessed concurrently.

RESULTS

Thirty-five patients were evaluated among four PDSA cycles and shared similar characteristics as the baseline population. Improvements of ≥20% above baseline adherence levels or 100% adherence were achieved for all outcome measure across four PDSA cycles. Adherence to recommended laboratory evaluation improved from 43 (baseline) to 71%, therapy choice from 78 to 100%, therapy administration from 50 to 83%, and disposition from 85 to 100%. ED length of stay remained stable.

CONCLUSIONS

Implementation of a standardized algorithm for young children with nutritional IDA in the ED increased adherence to evidence-based patient care.

Romiplostim for the Treatment of Immune Thrombocytopenia: Spotlight on Patient Acceptability and Ease of Use

Immune thrombocytopenia (ITP) is an immune-mediated disorder resulting in platelet destruction and subsequent thrombocytopenia. Bleeding symptoms range from mild cutaneous bleeding to life-threatening hemorrhage. Romiplostim, a peptide-antibody fusion product, is a thrombopoietin receptor agonist (TPO-RA) indicated for use in patients with ITP. Romiplostim is US Food and Drug Administration (FDA) approved in children ≥1 year of age with ITP of >6 months' duration who have had an inadequate response to first-line therapies or splenectomy. FDA approval in adults with chronic ITP was expanded in October 2019 to include adults with newly diagnosed (<3 months' duration) and persistent (3-12 months' duration) ITP who demonstrated an inadequate response to first-line therapies, including corticosteroids and immunoglobulins, or splenectomy. The newly published 2019 American Society of Hematology ITP Guidelines place TPO-RAs, including romiplostim, as second-line therapies in both children and adults. Here, we review the use of romiplostim as second-line therapy with a spotlight on health-related quality of life, ease of use, and patient preference.

Identification and differential subcellular localization of the neuronal class C and class D L-type calcium channel alpha 1 subunits

To identify and localize the protein products of genes encoding distinct L-type calcium channels in central neurons, anti-peptide antibodies specific for the class C and class D alpha 1 subunits were produced. Anti-CNC1 directed against class C immunoprecipitated 75% of the L-type channels solubilized from rat cerebral cortex and hippocampus. Anti-CND1 directed against class D immunoprecipitated only 20% of the L-type calcium channels. Immunoblotting revealed two size forms of the class C L-type alpha 1 subunit, LC1 and LC2, and two size forms of the class D L-type alpha 1 subunit, LD1 and LD2. The larger isoforms had apparent molecular masses of approximately 200-210 kD while the smaller isoforms were 180-190 kD, as estimated from electrophoresis in gels polymerized from 5% acrylamide. Immunocytochemical studies using CNC1 and CND1 antibodies revealed that the alpha 1 subunits of both L-type calcium channel subtypes are localized mainly in neuronal cell bodies and proximal dendrites. Relatively dense labeling was observed at the base of major dendrites in many neurons. Staining in more distal dendritic regions was faint or undetectable with CND1, while a more significant level of staining of distal dendrites was observed with CNC1, particularly in the dentate gyrus and the CA2 and CA3 areas of the hippocampus. Class C calcium channels were concentrated in clusters, while class D calcium channels were generally distributed in the cell surface membrane of cell bodies and proximal dendrites. Our results demonstrate multiple size forms and differential localization of two subtypes of L-type calcium channels in the cell bodies and proximal dendrites of central neurons. The differential localization and multiple size forms may allow these two channel subtypes to participate in distinct aspects of electrical signal integration and intracellular calcium signaling in neuronal cell bodies. The preferential localization of these calcium channels in cell bodies and proximal dendrites implies their involvement in regulation of calcium-dependent functions occurring in those cellular compartments such as protein phosphorylation, enzyme activity, and gene expression.

Glaucoma as a cause of poor vision in severe retinopathy of prematurity

Despite surgical reattachment of the retina in infants with severe retinopathy of prematurity (ROP), visual acuity may decline. We performed gonioscopy and applanation tonometry on 26 eyes of 17 infants with severe ROP who were randomly selected and followed prospectively for 2 years. Of these 26 eyes, one eye of one patient had only peripheral retinocryopexy for threshold stage III disease and had an attached retina before enrollment into the study. Sixteen infants subsequently underwent vitrectomy, scleral buckle, or both. Retinal reattachment of the posterior pole was present in at least one eye each of 10 of the 17 infants. Glaucoma was diagnosed in 5 of the 10 patients; all 5 showed a decrease in visual acuity of greater than 1 octave. Of the 5 infants without glaucoma, 3 showed visual improvement, and 2 remained the same. Although we studied a small number of cases, our results suggest that glaucoma may be a cause of visual decline in infants with severe ROP. A decline in visual acuity in infants with severe ROP and surgical retinal reattachment may warn us of glaucoma, as this diagnosis is difficult to make in these small infants.

Efficient assimilation of lactose carbon in premature infants

Previous studies have shown that there is minimal fecal excretion of carbohydrate energy in premature infants with high breath H2 concentrations, implying that the colon plays an important role in salvaging lactose energy. The present study extends this work by using a stable isotope method for serial assessment of lactose carbon excretion. Thus, in nine premature infants (30-32 weeks of gestation and 11-36 days of age), we conducted 23 longitudinal studies of breath hydrogen concentration and the cumulative fecal excretion of 13C derived from a single dose of [D-1-13C]lactose. The ranges of values (mean +/- SD) for breath hydrogen concentration and lactose absorption were respectively 4-440 ppm/5% CO2 (92 +/- 100) and 82-100% tracer dose (98.4 +/- 3.9). In 21 studies, lactose carbon excretion was less than 2% of the dose. There was a significant correlation between postnatal age and breath hydrogen concentration (R = 0.48; p = 0.02). These studies suggest that colonic fermentation activity is adequate for efficient colonic salvage of lactose even during the second week of life.

Intraocular pressure determination in infants with severe retinopathy of prematurity

We determined intraocular pressure (IOP) in 55 premature infants (122 determinations) with stage V retinopathy of prematurity (ROP) by applanation and indentation tonometry corrected for scleral rigidity and found a modest correlation of r = 0.52 between readings. Chronologic age and the scleral rigidity coefficient were the most significant factors affecting the closeness in readings. Our findings suggest that the applanation method of obtaining IOP values is preferable in infants with ROP because this method is less affected by technical error and the variable nature of premature infant sclera. Frequent examination may be necessary to detect an early IOP increase, especially in infants who have had successful retinal reattachment through vitreoretinal techniques.

[Surgical treatment of fungal bolus in acute lymphoid leukemia]

Case report of a 24 year old female patient with ALL that developed pulmonary invasive aspergillosis during aplastic phase of induction chemotherapy. She was treated with antibiotics and amphotericin B. After recovering from neutropenia, she developed a mycetoma in the inferior lobe of the right lung, which required lobectomy. Nine months after surgery the patient is well, in complete remission of ALL and with no evidence of infection. One month after lobectomy, chemotherapy had been reintroduced. Attention should be called to this form of therapy of Aspergillosis, as a successful way to eradicate this fungal infection that responds poorly to antifungal drugs currently used.

Distinct calcium channels are generated by alternative splicing and are differentially expressed in the mammalian CNS

A number of pharmacologically and electrophysiologically distinct voltage-dependent Ca2+ channels have been identified in mammalian neurons. Two rat brain Ca2+ channel alpha 1 subunits (rbC-I and rbC-II) have been isolated by molecular cloning and shown to be highly related (95%) to the cardiac dihydropyridine-sensitive Ca2+ channel. The rbC-II protein is distinct from rbC-I in that it contains a 3 amino acid insert in the putative cytoplasmic loop between domains II and III and a 28 amino acid substitution corresponding to the third transmembrane segment (S3) of the fourth domain. We show that rbC-I and rbC-II transcripts are generated by alternative splicing and that they are differentially expressed in the rat CNS.

Rat brain expresses a heterogeneous family of calcium channels

We describe the isolation and characterization of several rat brain cDNAs that are homologous to the alpha 1 subunit of heart and skeletal muscle dihydropyridine-sensitive Ca channels. Northern blot analysis of 32 cDNAs shows that they can be grouped into four distinct classes (A, B, C, and D), each corresponding to a distinct hybridization pattern of brain mRNAs. Southern blot and DNA sequencing suggest that each class of cDNA represents a distinct gene or gene family. In the regions sequenced, the rat brain class C and D gene products share approximately 75% amino acid identity with the rabbit skeletal muscle Ca channel. In addition, the class C polypeptide is almost identical to the rabbit cardiac Ca channel (97% identity). In contrast, the rat brain class A and B cDNAs are more distantly related to dihydropyridine-sensitive Ca channels (47-64% amino acid identity) and to the brain class C and D genes (51-55% amino acid identity). To examine the functional significance of the isolated brain cDNAs, hybrid depletion experiments were performed in Xenopus oocytes. Antisense oligonucleotides against class A and B cDNAs each partially inhibited, and a class C oligonucleotide almost fully inhibited, the expression of Ba current in rat brain mRNA injected oocytes; but none of the oligonucleotides affected the expression of voltage-gated Na or K conductances. The clone characterization and sequencing results demonstrate that a number of distinct, yet related, voltage-gated Ca-channel genes are expressed in the brain. The antisense oligonucleotide experiments specifically show that one or several of the Ca-channel classes are related to the Ca channels observed in rat brain mRNA injected oocytes.

Anterior segment evaluation of infants with retinopathy of prematurity

To understand the mechanisms of glaucoma in retinopathy of prematurity (ROP), anterior segment evaluation is essential. The authors prospectively examined the anterior segment of 27 eyes of 17 premature infants with stages IV and V ROP. Twenty-six eyes received no previous surgery or treatment. Schiøtz and applanation tonometry were performed. Structural evaluation of each anterior segment was conducted by biomicroscopy and Koeppe gonioscopy. In the 26 eyes, angle closure of greater than 180 degrees was noted in 3 (12%). The authors noted prominent Schwalbe's line in 4 eyes (15%), high iris convexity in 15 (58%), hypopigmentation of the iris root in 19 (73%), translucent matrix in the angles ("Barkan's-type" membrane) in 18 (69%), posterior synechiae in 16 (62%), visible iris or angle vessels in 12 (46%), and pigment clumping in the angle recess in 12 (46%). This study identified structural abnormalities in the anterior segment of ROP infants, including pathologic changes and anatomic features that could have a developmental origin.

Protective effect of vitamin E on genotoxicity of methylmercury

The cytogenetic effects of methylmercury (MeHg) producing chromosomal breakages, C-mitosis, and sister chromatid exchange are well documented. The present investigation was to determine whether vitamin E, which has been shown to exert a certain protective measure on the nervous system of animals exposed to methylmercury, also will diminish the genotoxicity of MeHg. Adult hamsters were given a daily injection (ip) of methylmercury chloride at a dosage of 2.0 mg/kg body weight (kg b.w.) and/or with 2.0 mg/kg b.w. vitamin E for 3 wk. All animals were sacrificed 5 d after the last day of MeHg exposure. Fibroblast cultures were established with cells obtained from skins of these animals. Chromosome preparations were made from these cultures and evaluated, using a double-blind system, for incidences of chromosomal breakage. It was found that all the fibroblast cultures grew well except from those animals treated with MeHg. Furthermore, while the saline control and vitamin E alone cultures showed no significant number of chromosomal breakages, cells from animals treated with only MeHg showed a high incidence of chromosomal damage (50% with 1 break and 15% with 2 or more breaks). Such chromosomal damage, however, was totally eliminated by vitamin E treatment (no chromosomal breakage was observed in cultures from MeHg/vitamin E animals). Our present study represents the first report on in vitro chromosomal damages as a result of in vivo MeHg exposure. Furthermore, our investigation also demonstrated the protective potential of vitamin E against genotoxicity of methylmercury.

Ultraviolet-visible reflectance and fluorescence spectra of the Shroud of Turin

The Shroud of Turin is a partially scorched linen cloth containing an apparently bloodstained sepia image of a man lying in a state of repose. It is believed by some to be the burial cloth of Jesus of Nazareth. A team of scientists, under the auspices of The Shroud of Turin Research Project, Inc., performed nondestructive measurements on the Shroud with electromagnetic energy from x ray to the IR to develop data leading to the analysis of the substances making up the body image stains and bloodstains. Presented here are UV-visible reflectance and fluoroescence spectra of the sepia body image area and scorched and bloodstained areas on the shroud.

Double-blind oral analgesic study of butorphanol in musculoskeletal pain: a comparison with codeine and placebo

Butorphanol tartrate (4 mg and 8 mg) was compared to codeine phosphate (60 mg) and placebo for oral analgesic activity and side-effects employing a double-blind design in ninety-three out-patients suffering from moderate to very severe musculoskeletal pain. The study duration was 72 hours with medication administered every 4 to 6 hours (four times daily) for a total of twelve doses per patient. The results demonstrate that both the 4 mg and 8 mg doses of butorphanol were significantly better (p less than 0.u5) than placebo. While codeine 60 mg also proved active, it appears to be less efficacious than the high dose of butorphanol. The peak effect appeared to be evident in 1 to 2 hours. Butorphanol may be at least seven times more potent than codeine on a milligram basis. Although no serious side-effects were observed, butorphanol appeared to present a greater incidence of side-effects than codeine and placebo in this study.