Magnesium supplementation therapy to prevent cisplatin-induced acute nephrotoxicity in pediatric cancer: a randomized phase-2 trial

BACKGROUND

The present study aimed to examine the effect of magnesium (Mg) supplementation on cisplatin-induced nephrotoxicity (CIN) in pediatric cancer patients.

METHODS

The present phase-2, open-label, multicenter, randomized controlled trial enrolled patients aged less than 20 years who were scheduled to receive cisplatin-containing chemotherapy and randomly allocated them at a ratio of 1:1 to a Mg supplementation arm with even-numbered chemotherapy courses (arm AB) or another arm with odd-numbered courses (arm BA). Analysis objects were reconstructed into two groups depending on whether the chemotherapy course had Mg supplementation (group B) or not (group A). The primary outcome was the proportion of chemotherapy courses resulting in elevated serum creatinine per chemotherapy course. The secondary outcomes included efficacies evaluated using other biomarkers and the safety of the Mg supplementation.

RESULTS

Twenty-eight patients were randomly allocated to either group (16 to arm AB and 12 to arm BA). The baseline characteristics of the groups were similar. There was no significant difference in the proportion of courses with increased serum creatinine between the groups (group A: 10% vs. group B: 6%; P = 0.465) nor was any significant difference observed in other biomarkers during any chemotherapy course. The Mg value during chemotherapy was significantly higher in group B than that in group A. No adverse events related to magnesium administration were observed.

CONCLUSIONS

The study design, which treated a single chemotherapy course as a study object, failed to detect a statistically significant benefit of Mg supplementation for preventing CIN in pediatric cancer patients.

TRIAL REGISTRATION

JRCT ( https://jrct.niph.go.jp/ ) Identifier UMIN000029215 jRCTs031180251. UMIN-CTR ( http://www.umin.ac.jp/icdr/index.html ) Identifier UMIN000029215.

Novel Approach for Detecting Respiratory Syncytial Virus in Pediatric Patients Using Machine Learning Models Based on Patient-Reported Symptoms: Model Development and Validation Study

BACKGROUND

Respiratory syncytial virus (RSV) affects children, causing serious infections, particularly in high-risk groups. Given the seasonality of RSV and the importance of rapid isolation of infected individuals, there is an urgent need for more efficient diagnostic methods to expedite this process.

OBJECTIVE

This study aimed to investigate the performance of a machine learning model that leverages the temporal diversity of symptom onset for detecting RSV infections and elucidate its discriminatory ability.

METHODS

The study was conducted in pediatric and emergency outpatient settings in Japan. We developed a detection model that remotely confirms RSV infection based on patient-reported symptom information obtained using a structured electronic template incorporating the differential points of skilled pediatricians. An extreme gradient boosting-based machine learning model was developed using the data of 4174 patients aged ≤24 months who underwent RSV rapid antigen testing. These patients visited either the pediatric or emergency department of Yokohama City Municipal Hospital between January 1, 2009, and December 31, 2015. The primary outcome was the diagnostic accuracy of the machine learning model for RSV infection, as determined by rapid antigen testing, measured using the area under the receiver operating characteristic curve. The clinical efficacy was evaluated by calculating the discriminative performance based on the number of days elapsed since the onset of the first symptom and exclusion rates based on thresholds of reasonable sensitivity and specificity.

RESULTS

Our model demonstrated an area under the receiver operating characteristic curve of 0.811 (95% CI 0.784-0.833) with good calibration and 0.746 (95% CI 0.694-0.794) for patients within 3 days of onset. It accurately captured the temporal evolution of symptoms; based on adjusted thresholds equivalent to those of a rapid antigen test, our model predicted that 6.9% (95% CI 5.4%-8.5%) of patients in the entire cohort would be positive and 68.7% (95% CI 65.4%-71.9%) would be negative. Our model could eliminate the need for additional testing in approximately three-quarters of all patients.

CONCLUSIONS

Our model may facilitate the immediate detection of RSV infection in outpatient settings and, potentially, in home environments. This approach could streamline the diagnostic process, reduce discomfort caused by invasive tests in children, and allow rapid implementation of appropriate treatments and isolation at home. The findings underscore the potential of machine learning in augmenting clinical decision-making in the early detection of RSV infection.

Evaluation of a joint workshop on study design for hospital and community pharmacists: a retrospective cross-sectional survey

BACKGROUND

Although pharmacists often identify numerous clinical questions, they face several barriers, including the lack of mentors for research activities in clinical settings. Therefore, a workshop for the appropriate selection of a study design, which is a fundamental first step, may be necessary. The purpose of this study was to evaluate the effectiveness of a workshop on study design for hospital and community pharmacists. Moreover, the characteristics of pharmacists with little involvement in research activities were extracted using decision-tree analysis to guide the design of future workshops.

METHODS

A workshop was conducted on October 1, 2023. It comprised three parts: lectures, group work, and presentations. Questionnaire-based surveys were conducted with workshop participants regarding their basic information, their background that influenced research activities, their satisfaction, and their knowledge/awareness. For the questions on knowledge/awareness, the same responses were requested before and after the workshop using a five-scale scoring system. Multivariate logistic regression analysis was conducted to identify independent factors influencing research activities. Decision tree analysis was performed to extract low-effort characteristics of the research activities.

RESULTS

Of the 40 workshop attendees, the overall satisfaction score for the workshop was 4.38 of 5, and the score for each question was 4 or higher. Significant increases were observed in the scores of knowledge/awareness after the workshop. Moreover, 95% of the pharmacists answered that it would be highly useful to conduct a joint workshop between hospitals and community pharmacists. Although independent influencing factors were not detected in the multivariate logistic regression analysis, the decision tree analysis revealed that pharmacists who were no member of an academic society (85%, 11/13) or members without any certifications or accreditations related to pharmacy practice (80%, 4/5) were the least active in clinical research. In contrast, those belonging to academic societies and holding certifications or accreditations related to pharmacy practice frequently conducted clinical research.

CONCLUSION

The present study revealed that a joint workshop on study design may have the potential to change pharmacists' knowledge and awareness of research activities. Moreover, future workshops should be conducted with pharmacists who do not belong to academic societies.

Retinoid Therapy for Neuroblastoma: Historical Overview, Regulatory Challenges, and Prospects

Retinoids are vitamin A derivatives and include trans-retinoic acid, isotretinoin, tamibarotene, and bexarotene, all of which are currently available for clinical use. The clinical development of retinoid therapy for neuroblastoma has a history spanning more than four decades. The most promising agent is isotretinoin, which can contribute to improving event-free survival in patients with high-risk neuroblastoma by approximately 10% when administered over six months as maintenance therapy. Although isotretinoin is regarded as an essential component in the standard clinical management of high-risk neuroblastoma, its use for this purpose in the US and EU is off-label. To promote isotretinoin use in Japan as a treatment for neuroblastoma, our clinical research team is planning to launch an investigator-initiated, registration-directed clinical trial. The present review article discusses the basic science behind retinoid therapy, pre-clinical/clinical evidence on neuroblastoma, the concept of the proposed clinical trial, and prospects for this therapy.

Reference values for urinary protein, albumin, beta 2-microglobulin, and the alpha 1-microglobulin-to-creatinine ratio in Japanese children

BACKGROUND

The importance of the ratio of creatinine to urinary protein, albumin, and low-molecular weight protein as a urinary marker in chronic kidney disease patients is widely recognized. However, no reference values have hitherto been established for these markers in Japanese children. The present study aimed to establish the reference values for these urinary markers in Japanese children.

METHODS

The first morning urine was randomly collected from 1712 pupils aged ≥ 3 to < 18 years during school and kindergarten mass urinary screenings. The upper limit of the reference values was set at the 97.5th percentile of the creatinine ratio per marker.

RESULTS

The urinary protein-to-creatinine ratio (PCR), urinary albumin-to-creatinine ratio (ACR), urinary beta 2-microglobulin-to-creatinine ratio (BMCR), and urinary alpha 1-microglobulin-to-creatinine ratio (AMCR) showed an age-related decrease at the 50th percentile reflecting an age-related increase in urinary creatinine. The appropriate reference value for the PCR and ACR was 0.12 g/gCr and 35 mg/gCr, respectively, in the entire cohort. The appropriate reference value for the BMCR was 0.5 μg /mgCr for age ≥ 3 to < 6 years and 0.35 μg/mgCr for age 6 years or older. The appropriate reference value for the AMCR was 5.0 μg/mgCr for age ≥ 3 to < 6 years and 3.5 μg /mgCr for age 6 years or older.

CONCLUSION

The present study was the first to determine appropriate reference values for the PCR, ACR, BMCR, and AMCR based on an analysis of the first morning urine samples of a large number of children.

Proportion of Successful Lumbar Punctures in Infants Younger Than Three Months

It is important to perform lumbar punctures (LPs) without a single traumatic tap in infants younger than three months owing to the risk of serious complications. The proportion of LPs in which clear cerebrospinal fluid (CSF) was obtained has been previously reported, but some of the procedures involved a traumatic tap. The present study aimed to identify the proportion of LPs in which clear CSF was obtained without a single traumatic tap and the factors associated with successful LPs in infants younger than three months. This retrospective, observational study included children younger than three months who underwent an LP in the pediatric emergency department between April 2018 and March 2021. The primary outcome was the proportion of successful LPs, defined as LPs obtaining clear CSF without a single traumatic tap. Multiple logistic regression analysis was used to identify factors related to successful LPs. Of 126 eligible patients, 121 were included. Among these, 83 (69%) were in the successful group. No factors significantly associated with successful LPs were found. Larger studies based on an accurate definition of successful LPs, such as that provided by this study, are needed to investigate related factors to increase the rate of successful LPs in this age group.

Analgesic efficacy of continuous wound infiltration compared with continuous intravenous fentanyl after gynaecological surgery: a non-inferiority, randomised controlled trial

OBJECTIVE

The present trial aimed to prove the non-inferiority of the analgesic efficacy of continuous wound infiltration (CWI) to that of continuous intravenous fentanyl (IV) and to compare the safety of the two methods.

METHODS

This trial was a prospective, single-centre, two-arm, non-inferiority, randomised controlled trial. Patients participating in the trial were randomised to a CWI group or an IV group. The VAS (visual analogue scale), additional analgesic usage and side effects were then compared between the groups.

RESULTS

In total, 61 patients were enrolled; two in CWI were excluded, leaving 59 (30 in the CWI group and 29 in the IV group) for analysis. The difference in the VAS score at 24 h (CWI group - IV group) was -3.2 (95% confidence interval [CI] -14.7 to 8.2), which was less than the non-inferiority margin of 15. The mean amount of total fentanyl use at postoperative hour 48 was 1395 (95% CI 886-1903) µg in the CWI group and 3186 (95% CI 2716-3658) µg in the IV group. The amount of other analgesics and the incidence of adverse effects did not differ significantly between the groups.

CONCLUSION

CWI was non-inferior to IV in terms of its analgesic effect, and has an opioid sparing effect in open gynaecological surgery.

Life expectancy associated with different ages at diagnosis of type 2 diabetes in high-income countries: 23 million person-years of observation

BACKGROUND

The prevalence of type 2 diabetes is increasing rapidly, particularly among younger age groups. Estimates suggest that people with diabetes die, on average, 6 years earlier than people without diabetes. We aimed to provide reliable estimates of the associations between age at diagnosis of diabetes and all-cause mortality, cause-specific mortality, and reductions in life expectancy.

METHODS

For this observational study, we conducted a combined analysis of individual-participant data from 19 high-income countries using two large-scale data sources: the Emerging Risk Factors Collaboration (96 cohorts, median baseline years 1961-2007, median latest follow-up years 1980-2013) and the UK Biobank (median baseline year 2006, median latest follow-up year 2020). We calculated age-adjusted and sex-adjusted hazard ratios (HRs) for all-cause mortality according to age at diagnosis of diabetes using data from 1 515 718 participants, in whom deaths were recorded during 23·1 million person-years of follow-up. We estimated cumulative survival by applying age-specific HRs to age-specific death rates from 2015 for the USA and the EU.

FINDINGS

For participants with diabetes, we observed a linear dose-response association between earlier age at diagnosis and higher risk of all-cause mortality compared with participants without diabetes. HRs were 2·69 (95% CI 2·43-2·97) when diagnosed at 30-39 years, 2·26 (2·08-2·45) at 40-49 years, 1·84 (1·72-1·97) at 50-59 years, 1·57 (1·47-1·67) at 60-69 years, and 1·39 (1·29-1·51) at 70 years and older. HRs per decade of earlier diagnosis were similar for men and women. Using death rates from the USA, a 50-year-old individual with diabetes died on average 14 years earlier when diagnosed aged 30 years, 10 years earlier when diagnosed aged 40 years, or 6 years earlier when diagnosed aged 50 years than an individual without diabetes. Using EU death rates, the corresponding estimates were 13, 9, or 5 years earlier.

INTERPRETATION

Every decade of earlier diagnosis of diabetes was associated with about 3-4 years of lower life expectancy, highlighting the need to develop and implement interventions that prevent or delay the onset of diabetes and to intensify the treatment of risk factors among young adults diagnosed with diabetes.

FUNDING

British Heart Foundation, Medical Research Council, National Institute for Health and Care Research, and Health Data Research UK.

Feasibility and Safety of Super Energy-dense Oral Nutritional Supplementation in Postoperative Gastric Cancer Patients

BACKGROUND/AIM

Ensuring that postoperative gastric cancer patients receive sufficient oral nutritional supplementation (ONS) to prevent body weight loss (BWL) is a serious challenge. The present pilot study evaluated the feasibility and safety of small, frequent sip feeds (SIP) with super energy-dense ONS (SED ONS; 4 kcal/ml) in postoperative gastric cancer patients.

PATIENTS AND METHODS

Patients received 400 kcal/day of SED ONS in four, daily, 25 ml SIP for 12 weeks after gastrectomy. The primary outcome was the percentage of postoperative weight change. The expected mean weight change was 90% (10% standard deviation). A sample population of 14 patients, sufficient for a 95% confidence interval with a 10% margin of error, was enrolled.

RESULTS

The mean weight change for patients receiving SIP with SED ONS was 93.8%. The mean SED ONS intake was 348 kcal/day. Thirteen patients consumed more than 200 kcal/day of SED ONS. One patient with a mean intake of 114 kcal/day had undergone total gastrectomy followed by adjuvant chemotherapy.

CONCLUSION

Small, frequent SIP with SED ONS was found to be feasible and safe in postoperative gastric cancer patients. A multicenter randomized controlled trial is warranted to determine whether SIP with SED ONS is effective in preventing BWL.

Identifying Kawasaki Disease With a Low Coronary Artery Aneurysm Risk

INTRODUCTION

Kawasaki disease (KD) patients with a high risk of coronary artery aneurysm (CAA) development are well characterized and targeted for intensified primary intravenous immunoglobulin (IVIG) treatment. However, the characteristics of KD patients with a low CAA risk are less well-known.

METHODS

The present study was a secondary analysis of Prospective Observational study on STRAtified treatment with Immunoglobulin plus Steroid Efficacy for Kawasaki disease (Post RAISE), a multicenter, prospective cohort study of KD patients in Japan. The target of the analysis was patients with a Kobayashi score <5 who were predicted to respond to IVIG. The incidence of CAA during the acute phase, the primary outcome, was assessed based on all echocardiographic evaluations performed between week 1 (days 5-9) and month 1 (days 20-50) after the start of primary treatment. Multivariable logistic regression was used to identify the independent risk factors of CAA during the acute phase, based on which a decision tree was created to identify a subpopulation of patients with KD with a low CAA risk.

RESULTS

Multivariate analysis found that a baseline maximum Z score >2.5, age <12 months at fever onset, nonresponsiveness to IVIG, low neutrophils, high platelets and high C-reactive protein were independent predictors of CAA during the acute phase. The decision tree created by using these risk factors identified 679 KD patients who had a low incidence of CAA during the acute phase (4.1%) and no medium or large CAA.

CONCLUSIONS

The present study identified a KD subpopulation with a low CAA risk comprising around a quarter of the entire Post RAISE cohort.

Investigation of in-line filter replacement intervals for infusion

BACKGROUND

In-line filters in peripheral and central venous catheters are used to remove bacterial cells mechanically. A recent study indicated an extension of the use of infusion sets to 7 days. There is no evidence regarding replacement intervals for in-line filters.

AIM

To test in-line filters that were used continuously for 7 days in order to investigate their ability to remove bacteria and assess the flow rate.

METHODS

Three different in-line filters were attached to an ELNEOPA-NF No. 2 premixed infusion bag of intravenous hyperalimentation, into which Staphylococcus epidermidis ATCC12228 or Escherichia coli ATCC25922 was inoculated. These experiments were compared with a control infusion. The infusion was dropped at a flow rate of 40 mL/h and replaced at 24-h intervals for 7 days. Samples were collected 24 h after drop initiation.

FINDINGS

S. epidermidis was not detected in droplets between Days 1 and 6, but In-line filters 1 and 2 showed droplets containing 6-10 colony-forming units/mL on Day 7. E. coli was not detected in any of the filters after 7 days of continuous use. Flow rates <40 mL/h were observed on Day 7 for In-line filter 3 in studies of S. epidermidis, and on Days 4 and 3 for In-line filters 2 and 3, respectively, in studies of E. coli.

CONCLUSION

This study revealed differences in bacterial removal and flow rates under high inoculation between the three in-line filters tested. It is suggested that in-line filters can be used continuously for a maximum of 6 days, and reductions in flow rate after 48 h of continuous use should be noted carefully.

The Impact of Cold Ambient Temperature in the Pattern of Influenza Virus Infection

Background

Prior literature suggests that cold temperature strongly influences the immune function of animals and human behaviors, which may allow for the transmission of respiratory viral infections. However, information on the impact of cold stimuli, especially the impact of temporal change in the ambient temperature on influenza virus transmission, is limited.

Methods

A susceptible-infected-recovered-susceptible model was applied to evaluate the effect of temperature change on influenza virus transmission.

Results

The mean temperature of the prior week was positively associated with the number of newly diagnosed cases (0.107 [95% Bayesian credible interval {BCI}, .106-.109]), whereas the mean difference in the temperature of the prior week was negatively associated (-0.835 [95% BCI, -.840 to -.830]). The product of the mean temperature and mean difference in the temperature of the previous week were also negatively associated with the number of newly diagnosed cases (-0.192 [95% BCI, -.197 to -.187]).

Conclusions

The mean temperature and the mean difference in temperature affected the number of newly diagnosed influenza cases differently. Our data suggest that high ambient temperature and a drop in the temperature and their interaction increase the risk of infection. Therefore, the highest risk of infection is attributable to a steep fall in temperature in a relatively warm environment.

Impact of glycaemic control and CYP3A5 polymorphisms on tacrolimus trough concentrations after adult kidney transplantation

AIMS

Diabetes mellitus affects the pharmacokinetics of cytochrome P450 3A4/5 (CYP3A4/5) substrates. We evaluated the relationship between haemoglobin A1c (HbA1c) levels and the pharmacokinetics of controlled-release tacrolimus.

METHODS

This retrospective observational cohort study included kidney transplant recipients (>18 years) receiving controlled-release tacrolimus orally. CYP3A5 genotypes were categorized as expressers (*1/*1 or *1/*3) and non-expressers (*3/*3). Multiple linear regression analysis determined the predictors for trough concentration/dose-normalized by body weight (C/D) ratio of tacrolimus at 7 days, 6 months and 12 months after administration. Correlations between the C/D ratio and HbA1c levels at baseline, 6 and 12 months after tacrolimus initiation were evaluated with Bonferroni correction.

RESULTS

Out of 42 patients (CYP3A5 expressers, n = 17, and non-expressers, n = 25), the multiple linear regression analysis showed that the C/D ratio on Day 7 was marginally higher in CYP3A5 non-expressers than in CYP3A5 expressers (r = .43, P = .028). Factors affecting the elevation of tacrolimus C/D ratio after 6 and 12 months of treatment were male sex and CYP3A5 non-expressers (r = .59, P < .001) and increased HbA1c levels and CYP3A5 non-expressers (r = .62, P < .001), respectively. The C/D ratio and HbA1c levels after 12 months was positively correlated in CYP3A5 non-expressers (y = 54.6x - 194.6, r = .63, P = .004, Bonferroni correction). Furthermore, intra-individual changes in the C/D ratio and HbA1c levels from 6 to 12 months were nearly correlated (y = 54.5x + 20.2, r = .41, P = .036, Bonferroni correction).

CONCLUSION

HbA1c and CYP3A5 genotypes might be considered to understand the inter- and intra-individual variability in blood tacrolimus concentrations after 6 months post-kidney transplantation.

Clinical implications of gallbladder enlargement in Kawasaki disease

BACKGROUND

Kawasaki disease (KD) presents with gallbladder enlargement (GBE) or hydrops in the acute phase. Although GBE is highly specific to KD, epidemiological data on GBE have not been updated. In this study we evaluated the occurrence rate of GBE in KD and characterized the clinical features of patients who developed GBE.

METHODS

The present study was a prospective, observational study. The maximum longitudinal area of the gallbladder and the common bile duct diameter in KD patients were measured by ultrasonography at the start of initial intravenous immunoglobulin (IVIG) therapy (day 0) and on days 7, 30, and 60 of therapy. The primary outcome was the complication rate of GBE (z- score ≥2.0) on day 0. The secondary outcome was the association of GBE with cholestasis, unresponsiveness to IVIG, and coronary artery lesions (CAL).

RESULTS

Gallbladder enlargement occurred in 35% (35/101) of patients on day 0. Cholestasis and severe patients (Kobayashi score [KS] ≥5) were more common in the GBE group (20.6% vs. 1.6%, p = 0.002, and 54.3% vs. 15.2%, p < 0.001, respectively). In patients with a KS of ≤4, the non-responder rate was higher in the GBE group (44% vs. 20%, p = 0.0495) but did not differ in those with a KS of ≥5 (21% vs. 20%, p = 0.95). The rate of CAL occurrence did not differ significantly between the groups (8.6% vs. 6.1%, p = 0.64).

CONCLUSIONS

Gallbladder enlargement occurred in 35% of KD patients and was associated with cholestasis. Gallbladder enlargement may not only be a diagnostic finding, but also a severity marker in KD patients.

A prospective cohort study of sensorineural hearing loss associated with Kawasaki disease

AIM

About 60 cases of sensorineural hearing loss (HL) have been reported in patients with Kawasaki disease (KD), but the current estimate of its prevalence is uncertain. The present study aimed to determine the prevalence and risk factors of sensorineural HL associated with KD.

METHODS

The present, prospective cohort study, conducted from May 2019 to May 2020, evaluated patients with a diagnosis of KD who received the initial therapy and underwent two auditory brainstem response (ABR) tests. HL was defined as a threshold of 40 dB or more, and borderline hearing was defined as a threshold of 30 dB.

RESULTS

In total, 107 patients were enrolled, and 75 underwent two ABR tests. Thirty-one patients (30.0%) received prednisolone with their initial intravenous immune globulin and acetylsalicylic acid therapy. HL was present in only one patient who had congenital conductive HL. Five patients had borderline hearing but had normal hearing behavior. There was no significant difference between the patients with normal hearing and those with borderline hearing in terms of the clinical variables.

CONCLUSIONS

In Japan, the prevalence of sensorineural HL after KD is not high. It may therefore be unnecessary to perform routine hearing tests for all patients with KD.

NAME OF TRIAL REGISTER

Association between Kawasaki Disease and Sensorineural Hearing Loss.

CLINICAL TRIAL REGISTRATION NUMBER

UMIN000037019 (the date of registration: June 11, 2019).

Exercise Stress Electrocardiography Using the Two-Minute Jump Test in Children

Although the treadmill and cycle ergometer are commonly used for exercise stress electrocardiography (ECG) testing, they are often difficult to perform with children. We herein evaluated the utility and safety of the 2-minute jump test (2MJT) as a simple, alternative exercise test. One hundred patients, including 60 male patients, with an average age at study commencement of 10.7±3.5 years (mean±standard deviation) and with no exercise restriction who underwent a cardiac check-up between November 2020 and March 2022 at the study center were included. After recording their resting ECG, they jumped for 2 minutes during ECG recording, and the change in heart rate (HR), ECG findings, and occurrence of adverse events were investigated. As a result, patients jumped 185±60 times in two minutes, and their HR increased from 76±13 beats/min at rest to 172±18 beats/min at peak during the test. Ninety (90%) patients attained the ideal target HR of > 150 beats/minute. During the recovery period after loading, five patients had abnormal ECG findings (ventricular extrasystoles, second-degree atrioventricular block, and atrial extrasystoles in two, two, and one patient, respectively) but completely resolved spontaneously within three minutes. Our findings suggested that the 2MJT is a useful and safe exercise test capable of inducing sufficient increase in HR in a short time in children.

Impact of super energy-dense oral nutritional supplementation (SED ONS) on glycemic variability and food intake postoperatively in gastric cancer patients

PURPOSE

Adherence to oral nutritional supplements (ONS) to prevent weight loss after gastrectomy is problematic. The present study evaluated the impact of super energy-dense ONS (SED ONS; 4 kcal/mL) on glycemic change and energy intake after gastrectomy.

METHODS

Gastrectomy patients were placed on continuous glucose monitoring for a 3-day observation period after food intake had been stabilized postoperatively. In addition, they were given 0, 200, and 400 kcal/day of SED ONS on Days 1, 2, and 3, respectively. The primary outcome was the area under the curve < glucose 70 mg/dL (AUC < 70). The secondary outcomes were other indices of glucose fluctuation and the amount of food and SED ONS intake.

RESULTS

Seventeen patients were enrolled. The AUC < 70 did not differ significantly with or without SED ONS over the observation period. SED ONS did not cause postprandial hypoglycemia and prevented nocturnal hypoglycemia. The mean dietary intake did not change significantly during the observation period, and the total energy intake increased significantly according to the amount of SED ONS provided.

CONCLUSION

SED ONS after gastrectomy increased the total energy intake without dietary reduction and it did not result in hypoglycemia.

Retrospective Comparison of the Effectiveness and Safety of Ceftriaxone 1 g Twice Daily versus 2 g Once Daily for Treatment of Aspiration Pneumonia

Although a 2 g once daily administration of ceftriaxone remains the standard dosing regimen for the treatment of aspiration pneumonia, there are no studies to investigate the optimal dosing method. Hence, we retrospectively evaluated the effectiveness and safety of 1 g twice daily versus 2 g once daily administration of ceftriaxone in adult patients with aspiration pneumonia. Patients who received ceftriaxone for the treatment of aspiration pneumonia between 2015 and 2021 were included in this study. Clinical responses, inflammatory markers, and incidence of adverse events after completion of ceftriaxone therapy were investigated. In total, 33 patients received 1 g twice daily (group 1) and 28 received 2 g once daily (group 2) ceftriaxone for the treatment of mild-to-moderate aspiration pneumonia. Compared with that of group 1, group 2 demonstrated significantly improved clinical responses (group 1 vs. group 2, 84.8% vs. 100%, p = 0.0316). Although the safety profile was not significantly different between the two groups, the incidence of choleliths during ceftriaxone therapy in group 1 was higher than that in group 2 (31.3% vs. 9.1%, p = 0.174). Therefore, a 2 g once daily administration of ceftriaxone appeared to be a simple regimen adequate for the treatment of inpatients with mild-to-moderate aspiration pneumonia, which might not be heavily involved by anaerobes.

Effects of ultra-pure soft water on the hands of nurses in a neonatal intensive care unit: A randomized crossover study

BACKGROUND

Healthcare workers (HCWs) wash their hands with tap water (TW) and soap. However, hard TW causes dermatitis.

OBJECTIVES

The present study aimed to compare the effects of ultra-pure soft water (UPSW) with those of TW on the hands of HWCs.

METHODS

The present study was a prospective randomized trial with a crossover design. All the nurses in the neonatal intensive care unit (NICU) at the study centre were divided into Sequence 1 (UPSW to TW) or 2 (TW to UPSW) and washed their hands with TW or UPSW in alternating 4-week periods with a 4-week washout period. Trans-epidermal water loss (TEWL) and stratum corneum hydration (SCH) were evaluated. Skin condition was self-assessed.

RESULTS

Twenty-one and 22 nurses were assigned to Sequence 1 and Sequence 2, respectively. USPW increased SCH to a significantly greater degree than TW (mean: 26.3 μS ± 12.3 SD; 95% confidence interval: 1.12-51.54; p = 0.041) although it did not affect TEWL. UPSW use significantly improved the subjects' skin condition, as reflected in an overall increase in the assessment scores.

CONCLUSIONS

UPSW improved SCH and the condition of hand skin. Prolonged USPW use may increase nurses' comfort during work and hand hygiene compliance.

Follow-Up Duration of Echocardiography in Patients with Kawasaki Disease with No Initial Coronary Aneurysms

OBJECTIVE

To evaluate the optimal duration of echocardiographic follow-up in patients with Kawasaki disease without an initial coronary aneurysm.

STUDY DESIGN

In this single-center, retrospective, observational study, we reviewed the results of follow-up echocardiography in children with Kawasaki disease enrolled in the Prospective Observational Study on Stratified Treatment with Immunoglobulin Plus Steroid Efficacy for Kawasaki Disease from a children's hospital. The main enrollment criterion was the absence of coronary aneurysms, defined as a maximum z-score (Zmax) ≥2.5, in the proximal right coronary artery and the proximal left anterior descending artery within 9 days from treatment initiation. The primary outcome was Zmax on follow-up echocardiography at up to 5 years.

RESULTS

Among 386 patients, 106 (27.5%) received prednisolone with intravenous immunoglobulin for first-line therapy, and 57 (14.8%) showed a poor response. Echocardiography at 1 month detected 9 patients with a Zmax ≥2, including 3 (0.8%) with coronary aneurysms requiring additional antithrombotic treatment and observation. Of 7 patients (1.8%) with normal echocardiographic findings at 1 month but a Zmax ≥2 later, 2 were lost to follow-up and 5 experienced spontaneous resolution, but none of the 7 patients required any change in management.

CONCLUSIONS

The optimal duration of echocardiographic follow-up may be 1 month in patients with no initial coronary aneurysms and a Zmax <2 at 1 month. Coronary artery abnormalities observed after 1 month are rare and mostly benign in this category of patients.

Efficacy, safety, and economic impact of diazepam suppositories with as-needed acetaminophen for prevention of seizure recurrence during the same fever episode in children with suspected simple febrile seizures

OBJECTIVE

To evaluate the efficacy, safety, and economic impact of diazepam suppositories with as-needed acetaminophen in comparison with as-needed acetaminophen alone for prevention of seizure recurrence during the same fever episode in suspected pediatric simple febrile seizures (SFS).

METHODS

This single-center, prospective, observational study was conducted from July 29, 2019 to February 15, 2021 at a children's hospital. Children aged 6 months to 60 months presenting to the emergency department with suspected SFS were included. Participants receiving both diazepam suppositories and as-needed acetaminophen were compared with those receiving as-needed acetaminophen alone. The primary outcome was seizure recurrence during the same fever episode. The secondary outcomes included the incidence of central nervous system (CNS) pathologies, adverse events, and medical costs.

RESULTS

Of the 316 participants, 228 (72.2%) had their first febrile seizure. Diazepam (0.3-0.5 mg/kg for up to two doses) was administered to 88/316 patients (27.8%). The outcomes were available for 306 patients. The recurrence rate was 3.5% (3/85) in the patients receiving diazepam with as-needed acetaminophen and 12.2% (27/221) in the patients receiving as-needed acetaminophen alone (relative risk: 0.29 [95% CI: 0.09-0.93]; P=0.03). The adjusted odds ratio of diazepam administration against recurrence was 0.23 (95% CI: 0.07-0.78; P=0.02). None of the patients had a CNS pathology. No severe adverse events occurred although mild ataxia was observed significantly more often in the patients receiving diazepam and as-needed acetaminophen (29.4% vs 18.7%, P=0.04). The median medical cost was US Dollars 199 (IQR: 86-244) for the group receiving both medications and US Dollars 202 (IQR: 114-242) for the group receiving as-needed acetaminophen alone.

SIGNIFICANCE

Compared with as-needed acetaminophen alone, diazepam with as-needed acetaminophen may reduce seizure recurrence more during the same fever episode without severe adverse events or additional costs in children with suspected SFS.

Oxygen saturation targets in pediatric respiratory disease

BACKGROUND

The present study aimed to assess the appropriate oxygen saturation target in patients with pediatric respiratory diseases by lowering the oxygen saturation target from SpO₂ 94% to 90%. No previous study has explored appropriate oxygen saturation targets in respiratory diseases other than bronchiolitis.

METHODS

The present, prospective, single-arm intervention trial enrolled pediatric inpatients with bronchiolitis, bronchitis, pneumonia, and asthma. The oxygen saturation target was lowered from SpO₂ 94% to 90% after the patients' general condition improved. The patients continued to be observed for 12 h after achieving SpO₂ 94%. The duration from the first cut-off point (SpO₂ 90% for 12 h without oxygen) to the second cut-off point (SpO₂ 94% for 12 h) was then evaluated.

RESULTS

In total, 248 patients completed the study. Patients with bronchiolitis, bronchitis, pneumonia, and asthma had an interval between the two cut-off points of 23.9, 15.5, 19.1, and 13.8 h, respectively, (mean 17.2 h; 95% confidence interval 15.0-19.5).

CONCLUSIONS

In generally healthy children, setting the oxygen saturation target at SpO₂ 90% after confirming improvement in their general condition was safe. The time required for increasing SpO₂ from 90% to 94% was longest in the patients with bronchiolitis.

Risk Factors of Coronary Artery Aneurysms in Kawasaki Disease with a Low Risk of Intravenous Immunoglobulin Resistance: An Analysis of Post RAISE

OBJECTIVE

To detect risk factors of coronary artery aneurysm (CAA) development in patients with Kawasaki disease determined to have a low risk for resistance to primary intravenous immunoglobulin (IVIG) treatment based on the Kobayashi score.

STUDY DESIGN

This study included 1757 predicted IVIG responders from Prospective Observational study on STRAtified treatment with Immunoglobulin plus Steroid Efficacy for Kawasaki disease (Post RAISE), a large-scale, multicenter, prospective cohort study of Kawasaki disease in Japan. Predicted IVIG responders were defined as patients with Kawasaki disease with a Kobayashi score of <5, a predictive scoring system for IVIG resistance created in Japan. The primary outcome was CAA development at 1 month after disease onset. CAA was defined as a Z score of ≥2.5. Multivariable logistic regression was used to identify the independent risk factors of CAA. The variables for inclusion were identified based on univariate analysis results and previously reported risk factors of CAA.

RESULTS

Among 1632 patients who had complete coronary outcome data, CAA developed in 90 patients (5.5%) at 1 month after disease onset. Multivariable analysis found that a baseline maximum Z score of >2.5, age of <12 months at fever onset, and nonresponsiveness to IVIG were significant, independent risk factors of CAA development at 1 month after disease onset. Among the risk factors, a baseline maximum Z score of >2.5 was most strongly associated with CAA development (OR, 7.1; 95% CI, 4.1-12.2; P ≤ .001).

CONCLUSIONS

Predicted IVIG responders with CAA risk factors identified in this study may be candidates for future clinical trials of intensified primary IVIG treatment with prednisolone, cyclosporine or infliximab.

Pediatric emergency healthcare utilization during the coronavirus disease 2019 pandemic in Tokyo

BACKGROUND

Various public health interventions have been implemented against the coronavirus disease 2019 pandemic. We investigated changes in pediatric emergency healthcare utilization during the current pandemic.

METHODS

Based on data on outpatient healthcare visits to one pediatric emergency department in Tokyo, Japan, the descriptive, cross-sectional study compared the number of emergency department visits in 2020 to the number in the previous 3 years. Data were extracted from the electronic triage reporting system. The primary outcome was the number of emergency department visits. The characteristics of patients by age group were also investigated.

RESULTS

A 40.6% reduction in pediatric emergency healthcare utilization was observed during the study period, with the greatest decrease occurring in the number of visits for fever. However, while the number of patients with a complaint with an exogenous cause decreased, the proportion of these patients increased. Although social activities in the greater community have now almost normalized, and only a slight increase in the number of patients with fever has been reported, the number of emergency department visits remains lower than in previous years as of this writing.

CONCLUSIONS

Public health interventions led to a reduction in emergency department visits, thereby allowing time to redistribute health-care resources.

PEDT-9 A study of NovoTTF-100A to expand the regulatory indication for childhood glioblastoma through a pediatric clinical trial based on the Advanced Medical Care system

Background: Tumor-treating fields (TTF) are alternating electric fields applied continuously to the brain by attaching 2-pair arrays on the scalp. Although TTF therapy has demonstrated efficacy against supratentorial glioblastoma (GBM) in adults, its safety and efficacy in children have not been confirmed. In Japan, off-label use of medical devices is almost impossible because the national health insurance system does not cover the cost of off-label use of drugs and medical devices. Therefore, TTF therapy cannot be applied to the treatment of pediatric GBM.

[Objectives] The investigator-initiated clinical trial aims to expand regulatory approval of TTF therapy for pediatric GBM treatment based on safety and exploratory efficacy data.

Methods: Patients aging between 5 and 17 years with histopathological diagnosis of GBM (either newly diagnosed or first-recurrence), which located in the supratentorial region would be included. All the patients will receive TTF therapy for 28 days per course for up to 26 courses until the end-of-therapy criteria are met. The primary endpoint is the adverse event rate with causality. The secondary endpoints include various time-to-event measures and QoL. In total ten patients will be enrolled.

Current Status: Discussions with the Pharmaceuticals and Medical Devices Agency (PMDA) led to a tentative consensus that the accumulated data on the efficacy of NovoTTF-100A for adult GBM may be extrapolatable to pediatric GBM if the trial is able to demonstrate efficacy equivalent to that found in previous, adult studies. On the other hand, the combination of the pediatric safety data gathered in this trial and the findings of international studies, including clinical trials and post-marketing surveillance studies, may expedite approval of the device for pediatric GBM treatment. The trial started patient enrollment in April, 2021 with the supervision of the Advanced Medical Care administration system and is currently awaiting the first eligible patient.

Predictor of Early Administration of Antibiotics and a Volume Resuscitation for Young Infants with Septic Shock

(1) Background: It is critical to administer antibiotics and fluid bolus within 1 h of recognizing sepsis in pediatric patients. This study aimed to identify the predictor of the successful completion of a 1-h sepsis bundle for infants with suspected sepsis. (2) Methods: This is an observational study using a prospective registry including febrile young infants (aged < 90 days) who visited a pediatric emergency department with a core body temperature of 38.0 °C or higher and 36.0 °C or lower. Univariate and logistic regression analyses were conducted to determine the predictor (s) of successful sepsis bundle completion. (3) Results: Of the 323 registered patients, 118 patients with suspected sepsis were analyzed, and 38 patients (32.2%) received a bundle-compliant treatment. Among potential variables, such as age, sex, and vital sign parameters, the logistic regression analysis showed that heart rate (odds ratio: OR 1.02; 95% confidence interval: 1.00-1.04) is a significant predictor of the completion of a 1-h sepsis bundle. (4) Conclusions: We found that tachycardia facilitated the sepsis recognition and promoted the successful completion of a 1-h sepsis bundle for young infants with suspected septic shock and a possible indicator for improving the quality of the team-based sepsis management.

Evaluation of a Kawasaki Disease Risk Model for Predicting Coronary Artery Aneurysms in a Japanese Population: An Analysis of Post RAISE

OBJECTIVES

To test the performance of the Son risk score, which was created to predict coronary artery abnormalities from baseline variables in North American patients with Kawasaki disease.

STUDY DESIGN

The dataset from Post RAISE, the largest prospective cohort study of Japanese patients with Kawasaki disease to date, was used for the present study. With high risk defined as ≥3 points, sensitivity, specificity, positive predictive value, and negative predictive value for coronary artery abnormality development were calculated. To evaluate the effect of each risk factor in the Son score, the OR and 95% CIs were calculated using logistic regression analysis with the presence of coronary artery abnormality at 1 month after disease onset.

RESULTS

Post RAISE enrolled 2628 consecutive patients with Kawasaki disease, and 304 patients had a high-risk score, of whom 15.1% showed coronary artery abnormality. At the cutoff ≥3 points, the sensitivity was 37.7%, and the specificity was 87.2%. The maximum z score at baseline ≥2.0 (OR 3.5, 95% CI 2.3-5.2) and age <6 months at disease onset (OR 3.2, 95% CI 1.9-5.4), were significantly associated with coronary artery abnormality development. However, a high concentration of C-reactive protein was not associated with coronary artery abnormality. The area under the receiver operating characteristic curve for the Son score was 0.65 (95% CI 0.59-0.71).

CONCLUSIONS

The Son score had insufficient sensitivity and good specificity in a Japanese cohort of patients with Kawasaki disease. Among the variables comprising the Son score, a large baseline z score and young age at disease onset were significant, independent predictors of coronary artery abnormality development.

Live attenuated vaccine efficacy six months after intravenous immunoglobulin therapy for Kawasaki disease

BACKGROUND

Due to the presence of maternal passive antibodies, the measles vaccine is ineffective if administered before age 12-15 months. The optimal timing for administering a live attenuated vaccine (LAV) after intravenous immunoglobulin therapy (IVIG) for Kawasaki disease (KD) has not been fully investigated. The recommended interval between vaccination and IVIG therapy for KD differs by country. The present study aimed to evaluate efficacy of LAV six months after IVIG therapy for KD in Japan.

METHODS

The present, single-arm, prospective, interventional study included patients aged 6 months or older with no medical history of measles, rubella, varicella or mumps or vaccinations against these diseases. The subjects received these vaccinations for the first time at six months after IVIG therapy. Virus-specific IgG levels for each virus measured by EIA was examined at nine months after IVIG therapy. If the results were negative, the subjects received a booster vaccination at 12 months after IVIG therapy. The primary outcome was the prevalence of positivity for antibodies after the initial and booster vaccinations.

RESULTS

The present study enrolled 32 subjects, 31% of whom were female, with an average age of 10.8 (standard deviation 2.8) months at IVIG therapy. At six months after IVIG therapy, 9% and 6% of the subjects were seropositive for measles and varicella titers, respectively, but were seronegative for the mumps and rubella titers. The seroconversion rate for measles, mumps, rubella, and varicella after the initial vaccination was 88%, 6%, 78%, and 16%, respectively. The seroconversion rate after a booster vaccination was 100% for measles and rubella, 97% for mumps, and 77% for varicella.

CONCLUSIONS

The seroconversion rate was low for LAV at six months after a single dose of IVIG for KD, but seroconversion was achievable with a booster vaccination at 12 months.

CLINICAL TRIAL REGISTRATION

UMIN-CTR, UMIN000007174, https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000008452.

Accuracy of shorter respiratory rate measurement times in the pediatric population

BACKGROUND

As one of the vital signs, the respiratory rate is an important index of general health in an initial examination. The duration of respiratory rate measurements is known to influence the results in adults. We examined the difference in respiratory rate measurements between two measurement durations in a pediatric population.

METHODS

The prospective, cross-sectional study was conducted from November 2017 through March 2018 at Tokyo Metropolitan Children's Medical Center and analyzed differences in the respiratory rate in a 1 min group and 30 s group using the Bland-Altman plot.

RESULTS

Ninety-five patients were enrolled. The median age was 0.99 years, and 50 patients were male. The correlation between the results of the 30 s and 1 min measurement durations was good (r²  = 0.970, P < 0.001; Spearman's rank correlation). The mean difference between the 30 s and 1 min measurement results was 0.86 (95% confidence interval: 0.27-1.45).

CONCLUSIONS

The shorter measurement duration may result in overestimation of the respiratory rate, especially in young children or children with tachypnea. Nonetheless, the shorter measurement times correlated well with the 1 min measurement, and the difference was less than one per minute compared with the 1 min measurement. Thus, this method may be able to detect life-threatening conditions earlier than longer measurement times.

Tumor-Treating Fields Therapy for Pediatric Brain Tumors

Tumor-treating fields (TTFields) are alternating electric fields applied continuously to the brain by attaching two-pair arrays on the scalp. Although TTFields therapy has demonstrated efficacy against supratentorial glioblastoma (GBM) in adults, its safety and efficacy in children have not been confirmed. Despite differences in the genetic etiology of the adult and pediatric forms of GBM, both have certain clinical behaviors in common, allowing us to test TTFields therapy in pediatric GBM. Recently, several, pediatric case-series using TTFields therapy have been published, and a few, prospective, pediatric studies are ongoing. Because GBMs are extremely rare in pediatric patients, where they comprise a wide variety of genetic subtypes, these pediatric studies are feasibility studies targeting various types of malignant brain tumor. Although they are important for confirming the safety and feasibility of TTFields therapy in the pediatric population, confirming its efficacy against each type of pediatric brain tumor, including the GBM, is difficult. Our clinical research team, therefore, planned an investigator-initiated clinical trial targeting pediatric supratentorial GBMs (as in adults) with the aim of expanding regulatory approval of TTFields therapy for pediatric GBM treatment based on safety and exploratory efficacy data in combination with the accumulated evidence on adult GBMs.

Prognosis of ultrasonographic low-grade pediatric appendicitis treated with supportive care

BACKGROUND

A previous report proposed ultrasonography-based classification as a promising means of predicting pediatric spontaneously resolving appendicitis. The present study investigated the long-term prognosis of supportive care for low-grade appendicitis identified by ultrasonography, defined as an appendix with a smooth submucosal layer irrespective of blood flow or an appendix with an irregular layer and increased blood flow.

METHODS

The present, retrospective cohort study enrolled patients under 16 years of age with acute appendicitis at a children's hospital between October 2010 and September 2016. The inclusion criteria were ultrasonography findings showing an appendix with (1) full visualization, (2) a diameter ≥6 mm, (3) a smooth submucosal layer or an irregular layer with increased blood flow, and (4) no appendiceal mass, abscess, or perforation. The exclusion criteria were: (1) a history of acute appendicitis, (2) antibiotic administration within 72 hours before diagnosis, and (3) antibiotic administration or surgery before supportive care. The primary outcome was the event-free duration, defined as a period of supportive care alone with no additional intervention or recurrence of appendicitis.

RESULTS

One hundred and eighty-two patients were enrolled. The median Alvarado score was 7 (interquartile range, 6-8), and the median follow-up duration in event-free cases was 1,922 days (interquartile range, 1,347-2,614 days). The event-free rate was 75.0%, 67.0%, and 62.5%, at 1, 2, and 5 years, respectively.

CONCLUSION

The long-term, event-free rate exceeded 60% in patients with low-grade appendicitis defined by ultrasonography who received neither surgery nor antibiotic treatment. Most recurrences occurred within 2 years of the initial diagnosis.

Risk factors of bacteremia in children hospitalized with community-acquired pneumonia: A nested case-control study

OBJECTIVE

To assess the risk factors of bacteremia in children hospitalized with community-acquired pneumonia (CAP).

STUDY DESIGN

The present, nested, case-control study enrolled a cohort of patients with CAP aged < 18 years who were hospitalized at Tokyo Metropolitan Children's Medical Center or Tama-Hokubu Medical Center between March 2010 and February 2018. Among the cohort with blood cultures (BCs), patients with bacteremia were identified and matched with five control patients based on their treatment facility, underlying disease, and age. Conditional logistic regression was used to calculate the odds ratios (ORs) of bacteremia for risk factor candidates.

RESULTS

BCs were obtained for 2,383 (84%) of the 2,853 patients in the CAP cohort. Of those with BCs, 34 (1.4%) had bacteremia. S. pneumoniae and H. influenzae accounted for 26 (76%) and four (12%) instances of the bacteremia pathogens, respectively. Bacteremia occurred more frequently among patients hospitalized in the spring than during other seasons (P = 0.022). On multivariate analysis, the severity of pneumonia was not associated with bacteremia incidence (OR: 0.92 [0.30-2.85]) while a white blood cell count > 16,000/μL (OR: 5.90 [2.14-16.3]) was shown to be a significant risk factor. The OR of the need for a ventilator on admission day was significantly high (28.4 [3.02-1374]) on univariate analysis, but the subject pool was too small to determine its significance on multivariate analysis.

CONCLUSIONS

The results of the present study supported BC collection in patients with leukocytosis and in those requiring ventilator use on admission.

Risk Factors of Coronary Artery Abnormalities and Resistance to Intravenous Immunoglobulin Plus Corticosteroid Therapy in Severe Kawasaki Disease: An Analysis of Post RAISE

BACKGROUND

Coronary artery abnormalities (CAAs) still occur in patients with Kawasaki disease receiving intensified treatment with corticosteroids. We aimed to determine the risk factors of CAA development and resistance to intensified treatment in Post RAISE (Prospective Observational Study on Stratified Treatment With Immunoglobulin Plus Steroid Efficacy for Kawasaki Disease)-the largest prospective cohort of Kawasaki disease patients to date.

METHODS

In Post RAISE, 2648 consecutive patients with Kawasaki disease were enrolled. The present study analyzed 724 patients predicted to be intravenous immunoglobulin (IVIG) nonresponders (Kobayashi score ≥5) who received intensified treatment consisting of IVIG plus prednisolone. The association between the baseline characteristics and CAA at 1 month after disease onset was examined. The association between the baseline characteristics and treatment resistance was also investigated.

RESULTS

Maximum Z score at baseline ≥2.5 (odds ratio, 3.4 [95% CI, 1.5-7.8]), age at fever onset <1 year (odds ratio, 3.4 [95% CI, 1.6-7.4]), and nonresponsiveness to IVIG plus prednisolone treatment (odds ratio, 6.8 [95% CI, 3.3-14.0]) were independent predictors of CAA development. Nonresponsiveness to IVIG plus prednisolone was significantly associated with 8 baseline variables. Baseline total bilirubin (odds ratio, 1.4 [95% CI, 1.2-1.7]) was the only significant independent predictor other than the variables included in the Kobayashi score, enabling treatment resistance to be identified at diagnosis. The area under the ROC curve was 0.74 (95% CI, 0.69-0.79). At a cutoff point of 1.0, the sensitivity and specificity for predicting treatment resistance were 71% and 65%, respectively.

CONCLUSIONS

In Post RAISE, younger age at fever onset, a larger maximum Z score at baseline, and nonresponsiveness to IVIG plus prednisolone were risk factors significantly associated with CAA development. Nonresponders were able to be identified at diagnosis based on the total bilirubin value. To prevent CAA, more intensified or adjunctive therapies using other agents, such as pulsed methylprednisolone, ciclosporin, infliximab, and Anakinra, should be considered for patients with these risk factors. Registration: URL: https://www.umin.ac.jp/ctr/; Unique identifier: UMIN000007133.

Decreased hemoglobin after initial treatment is associated with treatment resistance in Kawasaki disease in Kobayashi risk stratification

BACKGROUND

Although Kawasaki disease (KD) is known to cause anemia, the relationship between its prognosis and hemoglobin level is less well known.

METHODS

We herein performed a secondary analysis of data from a previous study (Post-RAISE). Children aged 6 months to 2 years at the time of KD diagnosis were enrolled. Decreased hemoglobin was defined as a decrease > 10% on post-treatment day 2 compared with the level prior to the initial therapy.

RESULTS

Of 1253 KD cases, treatment resistance was observed in 209 (17%) and was significantly more frequent in the decreased hemoglobin group (37/167 vs. 172/1086, P = 0.041). Multivariable logistic regression analysis revealed that decreased hemoglobin was associated with resistance to the initial treatment (odds ratio 1.53; 95% confidence interval 1.00-2.33; P = 0.048).

CONCLUSIONS

Decreased hemoglobin was significantly associated with resistance to initial treatment in patients with KD.

Metered-dose inhaler ipratropium bromide for children with acute asthma exacerbation: A prospective, non-randomized, observational study

BACKGROUND

Ipratropium bromide (IB), when administered with β2-agonists, is effective in reducing hospital admissions of children presenting to the emergency department (ED) with severe asthma. While IB is commonly delivered in its nebulized form, using a metered-dose inhaler (MDI), can, reportedly, shorten patients' length of stay in the ED. However, the effectiveness and safety of IB administration using an MDI with a spacer have not been established. This study aimed to investigate the effectiveness and safety of MDI-delivered IB in pediatric patients with acute asthma exacerbation.

METHODS

This prospective, non-randomized, observational study included patients aged ≥4 years with a history of severe asthma exacerbation. Patients received IB via MDI with a spacer three times at 20-min intervals. IB use was determined by the physicians' treatment policy. Propensity score matching was used to adjust the confounding factors related to IB administration.

RESULTS

Of the 158 patients, 88 were treated with IB and 70 were treated without IB. A propensity score-matching analysis extracted 54 patients from each group. We found no statistical difference in the admission rate of the two groups (IB group: 25.9% vs non-IB group: 31.5%; P = 0.67). The post-treatment modified pulmonary index scores (mean ± SD) were also similar (IB: 6.6 ± 2.0 vs non-IB: 6.3 ± 2.5; P = 0.53). Only one patient (1.0%) treated with IB experienced vomiting, which resolved spontaneously.

CONCLUSION

The metered-dose inhaler IB was ineffective in reducing the admission rate possibly because it was less effective than a nebulizer for IB inhalation.

Postoperative Anaemia Is a Risk Factor for Bleeding-Related Event in Thromboprophylaxis Using Fondaparinux Sodium Injection after Total Knee or Hip Arthroplasty

Bleeding is a life-threating side effect of thromboprophylaxis with fondaparinux sodium (FPX) injection. The purpose of this retrospective study was to assess the risk factor for bleeding-related event following thromboprophylaxis with FPX after total knee arthroplasty (TKA) or total hip arthroplasty (THA). Adult patients undergoing TKA or THA at a single university hospital were administered FPX for thromboprophylaxis by subcutaneous injection of 1.5 or 2.5 mg per day. The risk factor for bleeding-related event was identified by propensity score-adjusted multivariate logistic analysis, and survival analysis was performed retrospectively in consideration of the identified risk factors. Two hundred and twenty-six patients who underwent TKA (n = 62) or THA (n = 164) were enrolled. Anaemia on postoperative day (POD) 1 was identified as a risk factor for bleeding-related event (odds ratio: 3.75, 95% confidence interval: 1.02-24.5, p = 0.04). Eighty of 226 patients were selected using a propensity score matching and patients with anaemia on POD1 in this population had a significantly higher incidence of bleeding-related event than those without anaemia (p = 0.0016, Ghen-Breslow-Wilcoxon test; p = 0.0015, log-rank test). These results suggest that anaemia on POD1 is an independent risk factor for bleeding-related event following thromboprophylaxis with FPX after TKA or THA.

Drug Prescriptions for Children With ADHD in Japan: A Study Based on Health Insurance Claims Data Between 2005 and 2015

Objective: The aim of this study is to investigate the trend of prescription drugs for children with ADHD in Japan. Method: Using health insurance claims data of 3,672,951 people between January 2005 and December 2015, we investigated the trend of prescription drugs for 7,856 children with ADHD. Results: After approval in 2007, the proportion of prescriptions for methylphenidate-osmotic-controlled release oral delivery system tablets was 31.4% in 2009 (adjusted odds ratio [AOR] = 2.72; 95% confidence interval [CI] = [2.12, 3.51]) and reached a plateau approximately after 2009 (AOR = 0.96; 95% CI = [0.94, 0.98]). The proportion of prescriptions for atomoxetine increased from 6.1% in 2008 to 21.8% in 2014 (AOR = 1.12; 95% CI = [1.13, 1.18]). The proportion of prescriptions for aripiprazole and ramelteon increased (all trend p < .001). Conclusion: Prescriptions of drugs for children with ADHD have changed. We need to monitor the safety of ADHD medications among children with ADHD.

Magnesium supplementation therapy to prevent cisplatin-induced acute nephrotoxicity in pediatric cancer: A protocol for a randomized phase 2 trial

Although cisplatin is one of the most effective agents against various pediatric cancers, it is sometimes difficult to manage due to its dose-limiting nephrotoxicity. Magnesium sulfate (Mg) showed a kidney-protective effect against cisplatin-induced nephrotoxicity (CIN) by regulating renal platinum accumulation both in vitro and in vivo, and the body of clinical data demonstrating the efficacy of this drug in adult cancer patients is increasing.In this open, multicenter, phase-2, randomized trial, patients under age 18 years who are scheduled to receive cisplatin-containing chemotherapy will be enrolled and randomly allocated either to an Mg supplementation arm in even-numbered chemotherapy courses (arm AB) or to another arm in odd-numbered courses (arm BA), with a 1:1 allocation. Analysis objects will be reconstructed into two groups depending on whether the chemotherapy course has Mg supplementation (group B) or not (group A). The primary endpoint is the proportion of chemotherapy courses resulting in elevated serum creatinine equal to or greater than 50% of the prechemotherapy value. For the secondary endpoints, various parameters for measuring kidney function, such as serum cystatin-C, B2M, L-FABP, NGAL, and urinary NAG in the two groups will be compared. A sample size based on alpha = 5% and 80% power requires at least 40 samples per group (ideally, 60 samples per group).If Mg demonstrates efficacy, a phase-3 study to confirm the prophylactic effect of Mg supplementation in both acute and chronic CIN will be developed using novel and better biomarkers.

TRIAL REGISTRATION

UMIN-CTR (http://www.umin.ac.jp/icdr/index.html) Identifier UMIN000029215.

Trends in varicella and mumps vaccination rates in children under 3 years of age in a tertiary children's hospital in Japan

BACKGROUND

In Japan, the voluntary vaccination rate is not known accurately. Although two doses of the measles and rubella vaccines have been part of the universal vaccine program since 2006, the varicella vaccine was added in October 2014 while the mumps vaccine still remains voluntary. The aim of this study was to evaluate trends in the live measles, rubella, varicella and mumps vaccination rates in Japan.

METHODS

This retrospective cohort study was conducted at Tokyo Metropolitan Children's Medical Center between October 2012 and December 2016. Patients aged 1-2 years who were admitted to the Department of General Pediatrics were enrolled. The trend in the vaccination rate against measles, rubella, varicella, and mumps was examined.

RESULTS

The measles and rubella vaccination rate was 80-90%. The varicella vaccination rate in the second quarter of 2012, the third quarter of 2014, and the fourth quarter of 2016 was 34.6%, 67.1%, and 80.7%, respectively. The mumps vaccination rate in the second quarter of 2012, the third quarter of 2014, and the fourth quarter of 2016 was 27.6%, 59.5%, and 61.8%, respectively.

CONCLUSIONS

The varicella and mumps vaccination rate improved until 2014 despite the fact that they were voluntary vaccinations. After varicella vaccination was added to the universal vaccination program, the varicella vaccination rate continued to improve. The mumps vaccination, which was not included, failed to improve, suggesting that the universal vaccination program contributed to increasing the uptake of the vaccines it includes.

Enterovirus D68 respiratory infection in a children's hospital in Japan in 2015

BACKGROUND

Outbreaks of enterovirus D68 (EV-D68) respiratory infections in children were reported globally in 2014. In Japan, there was an EV-D68 outbreak in the autumn of 2015 (September-October). The aim of this study was to compare EV-D68-specific polymerase chain reaction (PCR)-positive and EV-D68-specific PCR-negative patients.

METHODS

Pediatric patients admitted for any respiratory symptoms between September and October 2015 were enrolled. Nasopharyngeal swabs were tested for multiplex respiratory virus PCR and EV-D68-specific reverse transcription-PCR. EV-D68-specific PCR-positive and -negative patients were compared regarding demographic data and clinical information.

RESULTS

A nasopharyngeal swab was obtained from 76 of 165 patients admitted with respiratory symptoms during the study period. EV-D68 was detected in 40 samples (52.6%). Median age in the EV-D68-specific PCR-positive and -negative groups was 3.0 years (IQR, 5.5 years) and 3.0 years (IQR, 4.0 years), respectively. The rates of coinfection in the two groups were 32.5% and 47.2%, respectively. There was no significant difference in the history of asthma or recurrent wheezing, length of hospitalization, or pediatric intensive care unit admission rate between the groups. The median days between symptom onset and admission was significantly lower for the EV-D68-positive group (3.0 days vs 5.0 days, P = 0.001). EV-D68 was identified as clade B on phylogenetic analysis. No cases of acute flaccid myelitis were encountered.

CONCLUSIONS

More than half of the samples from the children admitted with respiratory symptoms were positive for EV-D68-specific PCR during the outbreak. Asthma history was not associated with the risk of developing severe respiratory infection.

A unique phenotype of acquired Glanzmann thrombasthenia due to non-function-blocking anti-αIIbβ3 autoantibodies

Essentials Acquired Glanzmann thrombasthenia (aGT) is generally caused by function-blocking antibodies (Abs). We demonstrated a unique aGT case due to marked reduction of αIIbβ3 with anti-αIIbβ3 Abs. The anti-αIIbβ3 Abs of the patient did not inhibit platelet function but reduced surface αIIbβ3. Internalization of αIIbβ3 induced by the Abs binding may be responsible for the phenotype. SUMMARY: Background Acquired Glanzmann thrombasthenia (aGT) is a bleeding disorder generally caused by function-blocking anti-αIIbβ3 autoantibodies. Aim We characterize an unusual case of aGT caused by marked reduction of surface αIIbβ3 with non-function-blocking anti-αIIbβ3 antibodies (Abs). Methods A 72-year-old male suffering from immune thrombocytopenia since his 50s showed exacerbation of bleeding symptom despite mild thrombocytopenia. Platelet aggregation was absent with all agonists but ristocetin. Analysis of αIIbβ3 expression and genetic analysis were performed. We also analyzed effects of anti-αIIbβ3 Abs of the patient on platelet function and αIIbβ3 expression. Results Surface αIIbβ3 expression was markedly reduced to around 5% of normal, whereas his platelets contained αIIbβ3 to the amount of 40-50% of normal. A substantial amount of fibrinogen was also detected in his platelets. There were no abnormalities in ITGA2B and ITGB3 cDNA. These results indicated that reduced surface αIIbβ3 expression caused a GT phenotype, and active internalization of αIIbβ3 was suggested. Anti-αIIbβ3 IgG Abs were detected in platelet eluate and plasma. These Abs did not inhibit PAC-1 binding, indicating that the Abs were non-function-blocking. Surface αIIbβ3 expression of a megakaryocytic cell line and cultured megakaryocytes tended to be impaired by incubation with the patient's Abs. After 2 years of aGT diagnosis, his bleeding symptom improved and surface αIIbβ3 expression was recovered to 20% of normal with reduction of anti-αIIbβ3 Abs. Conclusion We demonstrated a unique aGT phenotype due to marked reduction of surface αIIbβ3. Internalization induced by anti-αIIbβ3 Abs may be responsible in part for the phenotype.

Coronary Lesions and Systemic Inflammatory Response Syndrome in Kawasaki Disease

Introduction:

In patients with Kawasaki disease (KD), who later develop coronary artery lesions (CALs), several inflammatory cytokines are reportedly higher than in patients without CALs. Systemic inflammatory response syndrome (SIRS) is used as a clinical index of hypercytokinemia. The objective of this study was to determine whether SIRS is related to CAL formation.

Methods:

We conducted a retrospective cohort study of KD patients admitted to our hospital between July 2012 and July 2015. The subjects were classified into the SIRS or the non-SIRS group based on their vital signs and blood test results. Their initial treatment was determined by their Kobayashi score. We compared the incidence of CALs between the two groups.

Results:

Of 357 KD patients, 277 were included in this study and 175 (63.2%) met the SIRS criteria. The incidence of CAL formation at week 1 in the clinical course and at one month after the primary treatment was significantly higher in the SIRS group than in the non-SIRS group (17.7% vs. 7.8%, p = 0.03 and 10.9% vs. 3.9%, p = 0.03, respectively). Multivariate analyses showed that after adjusting for each variable of the Kobayashi score, SIRS was an independent risk factor for CAL formation at week 1 in the clinical course (odds ratio, 2.7; 95% confidence interval, 1.03–7.23; p = 0.04).

Conclusions:

SIRS can be a risk factor for CAL in the acute phase of KD.

Ultrasound-guided peripheral intravenous access placement for children in the emergency department

The usefulness of ultrasound guidance in peripheral intravenous access placement has yet to be established in children. In this prospective comparative study, we investigated success rates of intravenous access placement with ultrasound guidance in a pediatric emergency department. After a failed first attempt with the conventional technique, the second and third attempts were conducted using either the ultrasound guidance (a real-time, dual operator method) or the conventional technique. The success rates within the two interventional attempts were then compared. From a total of 712 participants, those with a failed first attempt were allocated to the ultrasound guidance (n = 99) and conventional technique (n = 100) groups. The success rate was significantly lower for the ultrasound guidance (65%) than for the conventional technique (84%) group (p = 0.002, chi-square test). This remained significant after adjusting for confounders with multiple logistic regression analysis (odds ratio 2.60, 95% confidence interval 1.26-5.37, p = 0.001).

CONCLUSION

Ultrasound-guided intravenous access placement using a real-time, dual operator method led to a significantly lower success rate than the conventional technique in children with one failed conventional attempt in the emergency department.

TRIAL REGISTRATION

UMIN000014730 What is Known: • Children experience a low success rate (about 60% with 1 attempt and about 90% with 4 attempts) for IV access placement. • Ultrasound guidance may lead to a decreased number of attempts and shorter procedural time with comparable overall IV success rate. What is New: • Ultrasound-guided IV placement (a real-time, dual operator method) actually led to a significantly lower IV success rate than the conventional technique in children in the emergency department. • Our result warrants further trials to determine the precise population who benefits from ultrasound guidance.

Antimicrobial Stewardship Program in a Pediatric Intensive Care Unit

We conducted an antimicrobial stewardship program in a pediatric intensive care unit. An interrupted time-series analysis revealed a significant reduction in level and trend of days of therapy per 1000 patient-days for antipseudomonal agents. No increase in adverse patient outcomes was found.