A National Survey of Neonatologists' Perspectives on Probiotics Use in Neonatal Intensive Care Units in the U.S.A

Introduction: Most recent clinical reports from the American Academy of Pediatrics (AAP) concluded current evidence does not support routine universal administration of probiotics to preterm infants, particularly those with birth weight <1000 grams. Despite this, the use of probiotics is increasing in US neonatal intensive care units (NICU).Objectives: Collaborating with the Perinatal Neonatal Medicine of AAP, we conducted a national survey to obtain neonatologist opinion on probiotics use.Methods: Survey questionnaires were sent to 3000 neonatologists via email.Results: Of 3000 potential respondents, 249 (8.3 %) completed the survey. Seventy-five (30%) neonatologists working in 23 different NICUs reported using probiotics in their practice, while 168 (70%) neonatologists working in 54 different NICUs reported not using probiotics. Of those not currently use probiotics, 49% indicated they would consider using probiotics in the future vs. 12% indicating they would not use probiotics. The most common indication for probiotics use was average gestational age < 32 weeks and mean birth weight < 1500 grams. Probiotics were discontinued at mean gestational age of 35 weeks. Respondents who prescribe probiotics were more likely to work in a setting without fellowship or residency training (48% vs 20%). Probiotics users were more often from the West (29 % vs 7%) and less often from Northeast (5% vs 34%) compared to non-users. The proportion of those using probiotics did not significantly differ by NICU size, NICU level, or years working in a NICU. Similac Tri-Blend, Evivo, and Culturelle were the top three probiotics used in the respondent's NICU.Conclusion: Though a majority of respondents are not currently using probiotics in their NICU, a large number of nonusers are interested in using probiotics in the future. Differences continue to exist in the brand of probiotics used in US NICUs.

Novel predictors of permanent pacemaker implantation following transcatheter aortic valve replacement

BACKGROUND

Conduction and rhythm abnormalities requiring permanent pacemakers (PPM) are short-term complications following transcatheter aortic valve replacement (TAVR), and their clinical outcomes remain conflicting. Potential novel predictors of post-TAVR PPM, like QRS duration, QTc prolongation, and supraventricular arrhythmias, have been poorly studied.

AIM

To evaluate the effects of baseline nonspecific interventricular conduction delay and supraventricular arrhythmia on post-TAVR PPM requirement and determine the impact of PPM implantation on clinical outcomes.

METHODS

A retrospective cohort study that identified patients with TAVR between January 1, 2012 to December 31, 2019. The group was dichotomized into those with post-TAVR PPM and those without PPM. Both groups were followed for one year.

RESULTS

Out of the 357 patients that met inclusion criteria, the mean age was 80 years, 188 (52.7%) were male, and 57 (16%) had a PPM implantation. Baseline demographics, valve type, and cardiovascular risk factors were similar except for type II diabetes mellitus (DM), which was more prevalent in the PPM cohort (59.6% vs 40.7%; P = 0.009). The PPM cohort had a significantly higher rate of pre-procedure right bundle branch block, prolonged QRS > 120 ms, prolonged QTc > 470 ms, and supraventricular arrhythmias. There was a consistently significant increase in the odds ratio (OR) of PPM implantation for every 20 ms increase in the QRS duration above 100 ms: QRS 101-120 [OR: 2.44; confidence intervals (CI): 1.14-5.25; P = 0.022], QRS 121-140 (OR: 3.25; CI: 1.32-7.98; P = 0.010), QRS 141-160 (OR: 6.98; CI: 3.10-15.61; P < 0.001). After model adjustment for baseline risk factors, the OR remained significant for type II DM (aOR: 2.16; CI: 1.18-3.94; P = 0.012), QRS > 120 (aOR: 2.18; CI: 1.02-4.66; P = 0.045) and marginally significant for supraventricular arrhythmias (aOR: 1.82; CI: 0.97-3.42; P = 0.062). The PPM cohort had a higher adjusted OR of heart failure (HF) hospitalization (aOR: 2.2; CI: 1.1-4.3; P = 0.022) and nonfatal myocardial infarction (MI) (aOR: 3.9; CI: 1.1-14; P = 0.031) without any difference in mortality (aOR: 1.1; CI: 0.5-2.7; P = 0.796) at one year.

CONCLUSION

Pre-TAVR type II DM and QRS duration > 120, regardless of the presence of bundle branch blocks, are predictors of post-TAVR PPM. At 1-year post-TAVR, patients with PPM have higher odds of HF hospitalization and MI.

Impact of Establishing Dental Access for Preventable Infectious Dental Diseases (PIDD) in Medical Settings: Case Study from Rural Wisconsin

OBJECTIVE

The frequency of Preventable Infectious Dental Disease (PIDD) visits in medical centers was examined pre and post establishment of expanded dental access and adoption of an integrated medical-dental care delivery model.

METHODS

A retrospective observational study of patient attributes and frequency of unscheduled PIDD visits between January 1, 1990 and February 29, 2020. Chi-squared tests compared (a) the number of PIDD visits (pre/post dental center establishment), (b) age at first diagnosis, (c) gender, (d) race, (e) primary insurance at the time of PIDD visits and (f) healthcare setting where visit occurred.

RESULTS

System-wide, 21,957 unique patients were documented with a total of 34,892 PIDD visits as the primary diagnosis. Patients between 18-30 years and patients with Medicaid had the highest frequency of PIDD visits in medical settings. Following the establishment of dental centers, reduced relative risk of PIDD visits was observed for patients with no health insurance or self-pay/other coverage. PIDD visits in primary care settings was 0.87 times as likely as PIDD visits at ED/UCs after dental centers opened.

CONCLUSIONS

The number of PIDD visits to medical centers increased before the dental infrastructure was established, followed by a decline afterwards, inclusive of disparity populations. Some residual persistence of PIDD visits to primary care settings was identified. This study reinforced importance of dental healthcare access for achieving appropriate PIDD management while reducing PIDD visits to medical settings.

LBSAT367 Association Of Thyroid Functioning With Depression: A Population-based Historical Cohort Study

Background

Despite the abundance of literature, the relationship between hypothyroidism and depression is not clearly defined. We conducted this study to investigate the association of thyroid functioning [measured by serum Thyroid Stimulating Hormone (TSH) level] with depression [measured by Patient Health Questionnaire-9 (PHQ-9)] in a population-based study. Method: This is a cross-sectional and longitudinal study, which included all adult patient who received care at the Marshfield Clinical Health System from 2015 through 2020 and had one or more TSH and PHQ-9 measurement pair within 6 months. Logistic regression was used to estimate the effect of TSH level on depression in patients without or with thyroid diseases (untreated thyroid disease- not on any thyroid medications and treated thyroid disease - on thyroid medications). Candidate models included depression regressed on (1) TSH, (2) log-transformed TSH, (3) TSH level: normal (0.5-4.9), elevated (5. 0-9.9), very elevated (≥10), and model fit statistics were used to select the TSH-level model. Patient characteristics that were significantly associated with TSH level were included as covariates including Charlson Score.

Results

127,587 unique patients with 236,799 pairs of PHQ-9 and TSH were identified from Electronic Medical Record (EMR) data base. The average age was 53.6 (19.1) years, 90.4% were Caucasians, and 66.2% were females. 87.8% had no depression, 4.4% had minimal depression, and 3.6% had moderate depression, while rest had severe depression. 5.4% had low TSH, 85.8% had normal TSH, 6.8% had elevated and 2. 0% had very elevated TSH. 38.6% had thyroid disease, off which 32.6% were treated In adjusted model, patients without thyroid disorder did not have an increased risk of depression with elevated and very elevated TSH. However, patients with untreated thyroid disorder had increased risk of depression with very elevated TSH (OR=2. 08, 95% CI: 1.39-3.12), while patients with treated thyroid disorder had increased risk of depression with elevated (OR=1.15, 95% CI: 1. 03-1.27) and very elevated TSH (OR=1.26, 95% CI: 1.11-1.42) Conclusions: This large cohort study suggests that there is no association between TSH and depression in patients without any thyroid disorders. However patients with thyroid disorders do have higher risk of depression with elevated TSH level.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Changes in Pediatric Intensive Care Admissions in Wisconsin During the 2020 COVID-19 Pandemic

BACKGROUND

We perceived changes in the frequency of and reasons for admissions to Wisconsin pediatric intensive care units (PICU) during the advent of the COVID-19 pandemic, and we hypothesized that the rates of total, scheduled, and respiratory viral admissions were lower during the first calendar year of the pandemic than would have been predicted by historical admission data. Such findings would reflect important changes in PICU utilization paradigms during the pandemic. There are no descriptions of PICU admission changes in a single American state during the pandemic.

METHODS

We compared all Wisconsin PICU admissions during the COVID-19 pandemic in 2020 (the study epoch) to admissions in seasonally matched, growth-adjusted "no-COVID-19" projections generated by time series analysis of all Wisconsin PICU admissions in the previous 5 years (the control epoch).

RESULTS

We identified 27,425 PICU admissions with 294,577 associated diagnoses in the study and control epochs. Total admissions were 60 ± 9 week-1 in the study epoch versus 103 ± 4 projected (RR 0.63; 95% CI, 0.59-0.68; P  < 0.001). Scheduled admissions were 17 ± 6 week-1 in the study epoch versus 28 ± 3 projected (RR 0.61; 95% CI, 0.55-0.67; P < 0.001). Respiratory viral admissions were 8 ± 5 week-1 in the study epoch versus 19 ± 9 projected (RR 0.40; 95% CI, 0.33-0.48; P < 0.001). Some admission categories experienced dramatic declines (c, respiratory/ear, nose, throat), while others experienced less decline (eg, injury/poisoning/adverse effects) or no significant change (eg, diabetic ketoacidosis). Except cases of COVID-19, no category had significantly increased weekly admissions. There were 104 admissions associated with COVID-19 diagnoses in 2020, 4.3% of the study epoch admissions.

CONCLUSIONS

We describe PICU admission changes in the first calendar year of COVID-19, informing health care staffing and service planning, as well as decisions regarding strategies to combat the evolving pandemic.

Dental manifestations in adult hypophosphatasia and their correlation with biomarkers

Hypophosphatasia (HPP) is a genetic condition with broad clinical manifestations caused by alkaline phosphatase (ALP) deficiency. Adults with HPP exhibit a wide spectrum of signs and symptoms. Dental manifestations including premature tooth loss are common. Much of the published literature reporting dental manifestations consists of case reports and series of symptomatic patients, likely biased towards more severe dental manifestations. The objective of this study was to systematically explore the dental manifestations among adults with HPP by conducting a comprehensive dental evaluation. To minimize bias, the study explored dental manifestations in an unselected cohort of adults with HPP. Participants were identified searching electronic health record (EHR) data from a rural health system to discover adults with persistent ALP deficiency. Heterozygotes with pathogenic (P), likely pathogenic (LP), or uncertain variants (VUS) in ALPL and at least one elevated ALP substrate were defined as adults with HPP and underwent genetic, dental, oral radiographic, and biomarker evaluation. Twenty‐seven participants completed the study. Premature tooth loss was present in 63% (17/27); 19% (5/27) were missing eight or more teeth. Statistically significant associations were found between premature permanent tooth loss and HPP biomarkers ALP (p = 0.049) and bone‐specific ALP (p = 0.006). Serum ALP (ρ = −0.43, p = 0.037) and bone‐specific ALP (ρ = −0.57, p = 0.004) were negatively correlated with number of teeth lost prematurely. As noted with tooth loss, periodontal breakdown was associated with bone‐specific ALP. An inverse association between periodontal breakdown and bone‐specific ALP was observed (p = 0.014). These findings suggest a role for ALP in maintenance of dentition.

Pancreaticoduodenectomy is safe in appropriately resourced rural hospitals

BACKGROUND

Research shows improved safety and treatment outcomes for patients undergoing pancreaticoduodenectomy at high-volume centers. Regionalization of pancreaticoduodenectomy to high-volume urban centers can result in unintended negative consequences for rural patients and communities. This report examines outcomes after pancreaticoduodenectomy performed at a rural hospital and compares them with national standards.

METHODS

A prospectively maintained database of pancreatic operations performed at a rural tertiary hospital was queried. Demographic and clinical information for patients undergoing pancreaticoduodenectomy (2007-2019) was analyzed. Primary outcomes were the rates of patient mortality and morbidity. Secondary outcomes were readmission rates, indications, and associations with clinical variables.

RESULTS

We included 118 patients in our study. There were 41 postoperative complications (34.7%), including 1 death (0.9%). The 90-day readmission rate was 24.6%. The most common indication for readmission was deep space infection (n = 7, 24.1%). Patients requiring an intraoperative transfusion were more likely to need hospital readmission (41.4% vs 9.0% of patients without transfusion, P = .016). Patients with postoperative complications required readmission more frequently (51.7% vs 29.2%, P = .093). These findings are similar to data from urban hospitals.

CONCLUSION

Patient safety and surgical outcomes after pancreaticoduodenectomy performed in appropriately resourced rural hospitals can be comparable with national standards. Safely treating rural patients near their home benefits patients and their communities.

Effects of raloxifene and estradiol on hippocampal acetylcholine release and spatial learning in the rat

The effects of raloxifene on acquisition of a delayed matching to position (DMP) T-maze task and on hippocampal acetylcholine release were evaluated and compared with estradiol, to determine whether raloxifene has estrogenic effects on cognitive performance and hippocampal cholinergic activity. Ovariectomized rats received continuous treatment with raloxifene (one of two doses), estradiol, or vehicle for 30 days, followed by behavioral training, and then in vivo microdialysis assessment of basal and potassium-stimulated acetylcholine release. The data show that estradiol significantly enhanced DMP acquisition, whereas raloxifene did not. In contrast, both estradiol and the higher dose of raloxifene significantly increased potassium-stimulated acetylcholine release in the hippocampus. These data suggest that, despite increasing evidence for estrogenic effects of raloxifene in brain, raloxifene does not mimic the effects of estrogen on cognitive performance as assessed by acquisition of a simple spatial memory task in ovariectomized rats.

Estrogen and cognition: applying preclinical findings to clinical perspectives

The effects of hormone replacement therapy on brain aging and cognition are an important public health issue, which, despite much research and debate, has not yet been resolved. In this Mini-Review, we describe how much of the clinical literature takes on new meaning when interpreted in light of recent preclinical data. We predict, based on these data, that hormone replacement therapy will in fact provide substantial benefit with respect to age-related cognitive decline, provided that therapy is administered in an appropriate regimen and is initiated within a window of time following the loss of ovarian function. The application of these data to recent clinical findings is discussed.

Estrogen enhances potassium-stimulated acetylcholine release in the rat hippocampus

Short-term estrogen replacement has been shown to enhance basal forebrain cholinergic function. Whether or not long-term estrogen replacement can enhance basal forebrain cholinergic function has been questioned in light of recent studies showing that several cholinergic measures which are increased following short-term treatment are not increased following longer-term (>30 days) treatment. In the present study, in vivo microdialysis was used to assess the effects of continuous estradiol replacement on basal forebrain cholinergic function. Our data show that 6-7 weeks of continuous estradiol replacement significantly enhanced potassium-stimulated acetylcholine release in the hippocampus of ovariectomized rats, and that this effect was reversed following discontinuation of the estrogen treatment. These data are consistent with the hypothesis that estrogen-mediated effects on cholinergic neurons can contribute to the effects of long-term estrogen replacement on cognitive performance recently described.

Central regulation of adrenal tyrosine hydroxylase: interaction between dopamine and GABA systems

It has been previously demonstrated that nigrostriatal dopaminergic fibres participate in the neural regulation of the activity of adrenal tyrosine hydroxylase, specifically in its induction. To determine whether activation or inhibition of these fibres is responsible for this induction, the role of presynaptic dopamine receptors was investigated. Apomorphine (0.2 mg/kg), (+)3-PPP (10 mg/kg) and BHT 920 (1-3 mg/kg), drugs that are reported to bind to presynaptic dopamine receptors and thereby inhibit the release of that neurotransmitter, caused significant increases in the activity of the enzyme. As a central GABA (gamma-aminobutyric acid) system is believed to exert inhibitory control over the release of dopamine, GABA agonists were also tested for their effects. Muscimol (3 mg/kg), gamma-hydroxybutyrate (500 mg/kg) and HA-966 (150 mg/kg) produced significant induction of the adrenal enzyme; this induction was not blocked by dopamine postsynaptic receptor antagonists. After intraventricular administration (5 micrograms/rat) in normal animals, HA-966 produced significant induction of tyrosine hydroxylase. Its systemic administration did not induce the enzyme in animals with the adrenal denervated. When administered together at submaximal doses, HA-966 and BHT 920 produced an additive effect in the induction of adrenal tyrosine hydroxylase.

Reduced amounts of S-adenosylmethionine decarboxylase in the adrenal glands of rats following administration of piribedil or 2-deoxyglucose

The activity of S-adenosylmethionine decarboxylase (SAM-DC) is decreased in the adrenal gland of the rat following physical stress, metabolic stress or administration of dopamine agonists [M. Ekker and T. L. Sourkes, Endocrinology 120, 1299 (1987)]. Immunotitration studies with a serum directed against purified rat liver SAM-DC show that the reduction in activity of the enzyme following administration of 2-deoxyglucose or piribedil was paralleled by a decrease in the amount of immuno-reactive protein. There was no difference in the half-life of SAM-DC activity between piribedil-treated rats and controls. The properties of an extensively purified preparation of the adrenal enzyme resembled those of SAM-DC obtained from rat liver. It is suggested that the reduction in adrenal SAM-DC activity and protein content caused by stress is due to a reduction in the rate of synthesis of the enzyme.