Use, Durability, and Risks for Discontinuation of Initial and Subsequent Biologics in a Large Pediatric-Onset IBD Cohort

BACKGROUND

Biologic medications are recommended for treatment of moderately-to-severely active Crohn disease (CD) or ulcerative colitis (UC) in children. However, many patients require sequential biologic treatment because of nonresponse or loss of response to the initial biologic.

METHODS

We analyzed pediatric inflammatory bowel disease (IBD) data from the ImproveCareNow Network registry between May 2006 and September 2016, including time to biologic initiation, choice of first subsequent biologics, biologic durability, and reasons for discontinuation.

RESULTS

Of 17,649 patients with IBD [CD: 12,410 (70%); UC: 5239 (30%)], 7585 (43%) were treated with a biologic agent before age 18 (CD: 50%; UC: 25%). Biologic treatment was more likely for CD than UC (odds ratio, 3.0; 95% CI: 2.8-3.2; P < 0.0001). First biologic agents for all patients were anti-tumor necrosis factor agents (88% infliximab, 12% adalimumab). Probability of remaining on the first biologic was significantly higher in CD than UC ( P < 0.0001). First biologics were discontinued because of loss of response (39%), intolerance (23%), and nonresponse (19%). In univariate analysis, factors associated with discontinuation of first and/or second biologics in CD include colonic-only disease, corticosteroid use, upper gastrointestinal tract involvement, and clinical and biochemical markers of severe disease. Biologic durability improved with later induction date.

CONCLUSIONS

Treatment with biologic medications is common in pediatric IBD. Patients with CD are more likely to receive biologics, receive biologics earlier in disease course, and remain on the first biologic longer than patients with UC. Multiple factors may predict biologic durability in children with IBD.

Synergistic association of fluid overload and acute kidney injury on outcomes in pediatric cardiac ECMO: a retrospective analysis of the KIDMO database

BACKGROUND

Acute kidney injury (AKI) and fluid overload (FO) are associated with poor outcomes in children receiving extracorporeal membrane oxygenation (ECMO). Our objective is to evaluate the impact of AKI and FO on pediatric patients receiving ECMO for cardiac pathology.

METHODS

We performed a secondary analysis of the six-center Kidney Interventions During Extracorporeal Membrane Oxygenation (KIDMO) database, including only children who underwent ECMO for cardiac pathology. AKI was defined using Kidney Disease: Improving Global Outcomes (KDIGO) creatinine criteria. FO was defined as < 10% (FO-) vs. ≥ 10% (FO +) and was evaluated at ECMO initiation, peak during ECMO, and ECMO discontinuation. Primary outcomes were mortality and length of stay (LOS).

RESULTS

Data from 191 patients were included. Non-survivors (56%) were more likely to be FO + than survivors at peak ECMO fluid status and ECMO discontinuation. There was a significant interaction between AKI and FO. In the presence of AKI, the adjusted odds of mortality for FO + was 4.79 times greater than FO- (95% CI: 1.52-15.12, p = 0.01). In the presence of FO + , the adjusted odds of mortality for AKI + was 2.7 times higher than AKI- [95%CI: 1.10-6.60; p = 0.03]. Peak FO + was associated with a 55% adjusted relative increase in LOS [95%CI: 1.07-2.26, p = 0.02].

CONCLUSIONS

The association of peak FO + with mortality is present only in the presence of AKI + . Similarly, AKI + is associated with mortality only in the presence of peak FO + . FO + was associated with LOS. Studies targeting fluid management have the potential to improve LOS and mortality outcomes. A higher resolution version of the Graphical abstract is available as Supplementary information.

Evidence-Based Assessment of Congenital Heart Disease Genes to Enable Returning Results in a Genomic Study

BACKGROUND

Congenital heart disease (CHD) is the most common major congenital anomaly and causes significant morbidity and mortality. Epidemiologic evidence supports a role of genetics in the development of CHD. Genetic diagnoses can inform prognosis and clinical management. However, genetic testing is not standardized among individuals with CHD. We sought to develop a list of validated CHD genes using established methods and to evaluate the process of returning genetic results to research participants in a large genomic study.

METHODS

Two-hundred ninety-five candidate CHD genes were evaluated using a ClinGen framework. Sequence and copy number variants involving genes in the CHD gene list were analyzed in Pediatric Cardiac Genomics Consortium participants. Pathogenic/likely pathogenic results were confirmed on a new sample in a clinical laboratory improvement amendments-certified laboratory and disclosed to eligible participants. Adult probands and parents of probands who received results were asked to complete a post-disclosure survey.

RESULTS

A total of 99 genes had a strong or definitive clinical validity classification. Diagnostic yields for copy number variants and exome sequencing were 1.8% and 3.8%, respectively. Thirty-one probands completed clinical laboratory improvement amendments-confirmation and received results. Participants who completed postdisclosure surveys reported high personal utility and no decision regret after receiving genetic results.

CONCLUSIONS

The application of ClinGen criteria to CHD candidate genes yielded a list that can be used to interpret clinical genetic testing for CHD. Applying this gene list to one of the largest research cohorts of CHD participants provides a lower bound for the yield of genetic testing in CHD.

Design and rationale for the supermarket and web-based intervention targeting nutrition (SuperWIN) for cardiovascular risk reduction trial

PURPOSE

The prevalence of chronic diseases is increasing largely due to suboptimal dietary habits. It is not known whether individualized, supermarket-based, nutrition education delivered by registered dietitians, utilizing the advantages of the in-store and online environments, and electronically collected purchasing data, can increase dietary quality.

METHODS AND RESULTS

The supermarket and web-based intervention targeting nutrition (SuperWIN) for cardiovascular risk reduction trial is a randomized, controlled dietary intervention study. Adults identified from a primary care network with 1 or more risk factors were randomized at their preferred store to: (1) standard of care plus individualized, point- of-purchase nutrition education; (2) standard of care plus individualized, point- of-purchase nutrition education enhanced with online shopping technologies and training; or (3) standard of care alone. Educational sessions within each store's clinic and aisles, emphasized the dietary approaches to stop hypertension (DASH) diet. The primary assessment was an intention-to-treat comparison on the effects of the dietary interventions on mean change in DASH score (90-point range) from baseline to 3 months (post-intervention). Additional outcomes included blood pressure, lipids, weight, purchasing behavior, food literacy, and intervention feedback. Between April 2019 to February 2021, 267 participants were randomized (20 excluded due to coronavirus disease pandemic). Median age was 58 years, 69% were female, 64% had a college degree, 53% worked full-time, 64% were obese, 73% were treated with blood pressure and 42% with cholesterol medications, and most had low-to-moderate diet quality.

CONCLUSION

The SuperWIN trial was designed to provide a rigorous evaluation of the efficacy of 2 novel, comprehensive, supermarket-based dietary intervention programs.

Characteristics of paediatric weight management in the United States: Associations with program retention and BMI outcomes in the paediatric obesity weight evaluation registry (POWER)

OBJECTIVE

To describe characteristics of paediatric weight management (PWM) programs across the United States and evaluate associations with program-specific retention rates and body mass index (BMI) outcomes at 6 months.

METHODS

A program profile survey was administered to 33 programs within the Paediatric Obesity Weight Evaluation Registry (POWER) to assess program staffing, services, and treatment format. Patient retention and percent of the 95th BMI percentile (%BMIp95) changes were assessed for each program.

RESULTS

At 6 months program retention rates ranged from 15% to 74% (median: 41%), and program %BMIp95 changes ranged from -9.0 to +0.5 percentage points (median: -1.7). Percent of patients with ≥5 percentage-point decrease in %BMIp95 ranged from 17% to 71% across programs (median: 29%). No associations were detected between program characteristics and retention or %BMIp95 changes.

CONCLUSIONS

Six-month patient retention and BMI outcomes vary substantially in PWM programs across the United States. Yet, no associations were found between PWM treatment factors and these program-level patient outcomes.

Elevated blood pressure in youth in pediatric weight management programs in the Pediatric Obesity Weight Evaluation Registry (POWER)

Blood pressure (BP) assessment and management are important aspects of care for youth with obesity. This study evaluates data of youth with obesity seeking care at 35 pediatric weight management (PWM) programs enrolled in the Pediatric Obesity Weight Evaluation Registry (POWER). Data obtained at a first clinical visit for youth aged 3–17 years were evaluated to: (1) assess prevalence of BP above the normal range (high BP); and (2) identify characteristics associated with having high BP status. Weight status was evaluated using percentage of the 95^th percentile for body mass index (%BMIp95); %BMIp95 was used to group youth by obesity class (class 1, 100% to < 120% %BMIp95; class 2, 120% to < 140% %BMIp95; class 3, ≥140% %BMIp95; class 2 and class 3 are considered severe obesity). Logistic regression evaluated associations with high BP. Data of 7943 patients were analyzed. Patients were: mean 11.7 (SD 3.3) years; 54% female; 19% Black non‐Hispanic, 32% Hispanic, 39% White non‐Hispanic; mean %BMIp95 137% (SD 25). Overall, 48.9% had high BP at the baseline visit, including 60.0% of youth with class 3 obesity, 45.9% with class 2 obesity, and 37.7% with class 1 obesity. Having high BP was positively associated with severe obesity, older age (15–17 years), and being male. Nearly half of treatment‐seeking youth with obesity presented for PWM care with high BP making assessment and management of BP a key area of focus for PWM programs.

Belatacept-based immunosuppression with simultaneous calcineurin inhibitor avoidance and early corticosteroid withdrawal: A prospective, randomized multicenter trial

Simultaneous calcineurin inhibitor avoidance (CNIA) and early corticosteroid withdrawal (ESW) have not been achieved primarily due to excessive acute rejection. This trial compared 2 belatacept-based CNIA/ESW regimens with a tacrolimus-based ESW regimen. Kidney transplant recipients were randomized to receive alemtuzumab/belatacept, rabbit anti-thymocyte globulin (rATG)/belatacept, or rATG/tacrolimus. The combinatorial primary endpoint consisted of patient death, renal allograft loss, or a Modification of Diet in Renal Disease-calculated eGFR of <45 mL/min/1.73 m² at 12 months. Results are reported by treatment group (alemtuzumab/belatacept, rATG/belatacept, and rATG/tacrolimus). Superiority was not observed at 1 year for the primary endpoint (9/107 [8.4%], 15/104 [14.4%], and 14/105 [13.3%], respectively; P = NS) for either belatacept-based regimen. Differences were not observed for secondary endpoints (death, death-censored graft loss, or estimated glomerular filtration rates < 45 mL/min/1.73 m² ). Differences were observed in biopsy-proved acute cellular rejection (10.3%, 18.3%, and 1.9%, respectively) (P < .001), but not in antibody-mediated rejection, mixed acute rejection, or de novo donor-specific anti-HLA antibodies. Neurologic and electrolyte abnormality adverse events were less frequent under belatacept. Belatacept-based CNIA/ESW regimens did not prove to be superior for the primary or secondary endpoints. Belatacept-treated patients demonstrated an increase in biopsy-proved acute cellular rejection and reduced neurologic and metabolic adverse events. These results demonstrate that simultaneous CNIA/ESW is feasible without excessive acute rejection.

Elucidation of de novo small insertion/deletion biology with parent-of-origin phasing

The mechanisms underlying de novo insertion/deletion (indel) genesis, such as polymerase slippage, have been hypothesized but not well characterized in the human genome. We implemented two methodological improvements, which were leveraged to dissect indel mutagenesis. We assigned de novo variants to parent-of-origin (i.e., phasing) with low-coverage long-read whole-genome sequencing, achieving better phasing compared to short-read sequencing (medians of 84% and 23%, respectively). We then wrote an application programming interface to classify indels into three subtypes according to sequence context. Across three cohorts with different phasing methods (N_trios  = 540, all cohorts), we observed that one de novo indel subtype, change in copy count (CCC), was significantly correlated with father's (p = 7.1 × 10^-4 ) but not mother's (p = .45) age at conception. We replicated this effect in three cohorts without de novo phasing (p_paternal  = 1.9 × 10^-9 , p_maternal  = .61; N_trios  = 3,391, all cohorts). Although this is consistent with polymerase slippage during spermatogenesis, the percentage of variance explained by paternal age was low, and we did not observe an association with replication timing. These results suggest that spermatogenesis-specific events have a minor role in CCC indel mutagenesis, one not observed for other indel subtypes nor for maternal age in general. These results have implications for indel modeling in evolution and disease.

Implementing a Novel Quality Improvement-Based Approach to Data Quality Monitoring and Enhancement in a Multipurpose Clinical Registry

OBJECTIVE

To implement a quality improvement based system to measure and improve data quality in an observational clinical registry to support a Learning Healthcare System.

DATA SOURCE

ImproveCareNow Network registry, which as of September 2019 contained data from 314,250 visits of 43,305 pediatric Inflammatory Bowel Disease (IBD) patients at 109 participating care centers.

STUDY DESIGN

The impact of data quality improvement support to care centers was evaluated using statistical process control methodology. Data quality measures were defined, performance feedback of those measures using statistical process control charts was implemented, and reports that identified data items not following data quality checks were developed to enable centers to monitor and improve the quality of their data.

PRINCIPAL FINDINGS

There was a pattern of improvement across measures of data quality. The proportion of visits with complete critical data increased from 72 percent to 82 percent. The percent of registered patients improved from 59 percent to 83 percent. Of three additional measures of data consistency and timeliness, one improved performance from 42 percent to 63 percent. Performance declined on one measure due to changes in network documentation practices and maturation. There was variation among care centers in data quality.

CONCLUSIONS

A quality improvement based approach to data quality monitoring and improvement is feasible and effective.

Health Outcomes of Youth in Clinical Pediatric Weight Management Programs in POWER

OBJECTIVE

To describe treatment outcomes of children and adolescents enrolled in the Pediatric Obesity Weight Evaluation Registry, a consortium of multicomponent pediatric weight management programs in the US.

STUDY DESIGN

This multicenter prospective observational cohort study, established in 2013, includes youth (2-18 years of age) with obesity enrolled from 31 Pediatric Obesity Weight Evaluation Registry (POWER) sites over a 2-year period and followed up to 12 months. Weight status was evaluated by the percentage of the 95th percentile for body mass index (%BMIp95). Associations of weight status outcomes with patient characteristics and program exposure were analyzed with multivariable mixed effects modeling.

RESULTS

We included 6454 children and adolescents (median age, 11 years; IQR, 9-14 years; 53% white, 32% Hispanic; 73% with severe obesity) who were enrolled in POWER. Median changes in %BMIp95 for this cohort were -1.88 (IQR, -5.8 to 1.4), -2.50 (IQR, -7.4 to 1.8), -2.86 (IQR, -8.7 to 1.9), at 4-6, 7-9, and 10-12 of months follow-up, respectively (all P < .05). Older age (≥12 years), greater severity of obesity, and Hispanic race/ethnicity were associated with better improvement in %BMIp95. A 5-percentage point decrease in %BMIp95 was associated with improvement in cardiometabolic risk factors.

CONCLUSIONS

Overall, treatment in pediatric weight management programs is associated with a modest median decrease in BMI as measured by change in %BMIp95. Further studies are needed to confirm these findings, as well as to identify additional strategies to enhance the effectiveness of these multicomponent interventions for youth with severe obesity.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02121132.

Assessment of tacrolimus intrapatient variability in stable adherent transplant recipients: Establishing baseline values

The purpose of this study was to determine the intrapatient (within the same patient) variability of tacrolimus in adherent patients. Daily tacrolimus trough levels were obtained at home using dried blood spot technology in kidney and liver transplant recipients. Patients were randomized to receive 3 formulations of tacrolimus, each for two 1-week periods. Adherence was monitored by patient diary, pill counts, and use of the Medication Event Monitoring System (MEMS). Variability was quantified as the coefficient of variation (CV). Comparison of CV between groups was by independent t test or one-way ANOVA as appropriate. The population was found to be adherent with a rate of 99.9% with a mean interval between the evening and morning dose of tacrolimus of 11.86 hours. The median CV for the entire population was 15.2% (range 4.8%-110%). There were no differences in CV by allograft type or tacrolimus formulation. The multivariate analysis did not identify any demographic characteristics associated with a CV > 30%. In a highly adherent population, tacrolimus did not display high intrapatient variability. Given the association between IPV and poor allograft outcomes, future studies are needed to quantitate the influence of adherence and establish target IPV goals.

Test-retest variability for quantitative two-dimensional and Doppler measurements in the fetus

OBJECTIVES

Echocardiography is used to quantitatively characterize cardiovascular function in fetuses with cardiac abnormalities and inform decisions for fetal or perinatal interventions. It is clinically important to understand the reproducibility of these measures, particularly between testers. While studies have reported intra-observer variability and inter-observer variability, little is known about test-retest variability for these measures. We hypothesized that even in a high volume echocardiography laboratory, quantitative measurements will demonstrate higher test-retest variability compared with inter-observer variability and intra-observer variability of the same measurements.

METHODS

Prospective study of uncomplicated, singleton pregnancies to evaluate fetal measures of cardiovascular function obtained by echocardiography. One sonographer obtained predefined variables, and then, a second sonographer obtained the same variables 15 minutes after the first sonographer. Separate data acquisitions were obtained by the two sonographers to evaluate test-retest variability. Intra-observer variability and inter-observer variability were also evaluated.

RESULTS

Thirty fetuses between 17- and 36-week gestation were enrolled. Time-based variables had the best intra-observer agreement and inter-observer agreement (1.2%-7.4%), while 2D (7.5%-10%), M-mode (4.9%-10.1%), and velocity-time integral (VTI; 2.6%-13.8%) measurements had poorer agreement. For all variables, test-retest agreement was worse (3%-32.1%), particularly for measurement of myocardial performance index (MPI; 19.7%-21.1%), cardiac output estimation (27.2%-27.9%), and VTI-based indices (14.7%-32.1%).

CONCLUSIONS

In a laboratory highly experienced in quantitative fetal echocardiography, intra-observer agreement and inter-observer agreement are good for most quantitative parameters. However, test-retest agreement is fair or poor for several variables, notably the MPI, cardiac output estimation, and VTI-based indices. Understanding how these measures vary between separate acquisitions is important for clinical interpretation and decision making.

Fetal somatic growth trajectory differs by type of congenital heart disease

BackgroundThe growth trajectories of common measurements, including estimated fetal weight (EFW), head circumference (HC), and abdominal circumference (AC), in fetuses with congenital heart disease (CHD) have not been described for different cardiac lesions. We hypothesized that (i) fetuses with CHD have differential growth in utero, and (ii) different categories of CHD demonstrate different in utero growth curves.MethodsWe performed a retrospective observational cohort study of pregnancies with known fetal CHD seen from January 2000 to June 2013. For analysis, the infants were divided into single ventricle (SV), biventricular conotruncal, d-transposition of great arteries (d-TGA), biventricular septal defects (SD; including atrial, ventricular, and atrioventricular SD), and all others (Other).ResultsA total of 194 newborns met inclusion criteria. There was significant differential growth of EFW in all CHD types, except d-TGA, starting with low z-scores before 25 weeks gestation, improving toward normal around 30-32 weeks gestation, and then again differential growth with advancing gestation. SV and SD groups had significant differential growth of HC starting early in gestation and linearly progressing negative z-scores with advancing gestation.ConclusionWe observed differences in the fetal growth curves throughout gestation for the major categories of CHD, including significant differential growth in even "simple" CHD, such as SD.

Creating a multi-center rare disease consortium - the Consortium of Eosinophilic Gastrointestinal Disease Researchers (CEGIR)

 Eosinophilic gastrointestinal disorders (EGIDs) affect various segments of the gastrointestinal tract. Since these disorders are rare, collaboration is essential to enroll subjects in clinical studies and study the broader population. The Rare Diseases Clinical Research Network (RDCRN), a program of the National Center for Advancing Translational Sciences (NCATS), funded the Consortium of Eosinophilic Gastrointestinal Disease Researchers (CEGIR) in 2014 to advance the field of EGIDs. CEGIR facilitates collaboration among various centers, subspecialties, patients, professional organizations and patient-advocacy groups and includes 14 clinical sites. It has successfully initiated two large multi-center clinical studies looking to refine EGID diagnoses and management. Several pilot studies are underway that focus on various aspects of EGIDs including novel therapeutic interventions, diagnostic and monitoring methods, and the role of the microbiome in pathogenesis. CEGIR currently nurtures five physician-scholars through a career training development program and has published more than 40 manuscripts since its inception. This review focuses on CEGIR's operating model and progress and how it facilitates a framework for exchange of ideas and stimulates research and innovation. This consortium provides a model for progress on other potential clinical areas.

Bioequivalence between innovator and generic tacrolimus in liver and kidney transplant recipients: A randomized, crossover clinical trial

BACKGROUND

Although the generic drug approval process has a long-term successful track record, concerns remain for approval of narrow therapeutic index generic immunosuppressants, such as tacrolimus, in transplant recipients. Several professional transplant societies and publications have generated skepticism of the generic approval process. Three major areas of concern are that the pharmacokinetic properties of generic products and the innovator (that is, "brand") product in healthy volunteers may not reflect those in transplant recipients, bioequivalence between generic and innovator may not ensure bioequivalence between generics, and high-risk patients may have specific bioequivalence concerns. Such concerns have been fueled by anecdotal observations and retrospective and uncontrolled published studies, while well-designed, controlled prospective studies testing the validity of the regulatory bioequivalence testing approach for narrow therapeutic index immunosuppressants in transplant recipients have been lacking. Thus, the present study prospectively assesses bioequivalence between innovator tacrolimus and 2 generics in individuals with a kidney or liver transplant.

METHODS AND FINDINGS

From December 2013 through October 2014, a prospective, replicate dosing, partially blinded, randomized, 3-treatment, 6-period crossover bioequivalence study was conducted at the University of Cincinnati in individuals with a kidney (n = 35) or liver transplant (n = 36). Abbreviated New Drug Applications (ANDA) data that included manufacturing and healthy individual pharmacokinetic data for all generics were evaluated to select the 2 most disparate generics from innovator, and these were named Generic Hi and Generic Lo. During the 8-week study period, pharmacokinetic studies assessed the bioequivalence of Generic Hi and Generic Lo with the Innovator tacrolimus and with each other. Bioequivalence of the major tacrolimus metabolite was also assessed. All products fell within the US Food and Drug Administration (FDA) average bioequivalence (ABE) acceptance criteria of a 90% confidence interval contained within the confidence limits of 80.00% and 125.00%. Within-subject variability was similar for the area under the curve (AUC) (range 12.11-15.81) and the concentration maximum (Cmax) (range 17.96-24.72) for all products. The within-subject variability was utilized to calculate the scaled average bioequivalence (SCABE) 90% confidence interval. The calculated SCABE 90% confidence interval was 84.65%-118.13% and 80.00%-125.00% for AUC and Cmax, respectively. The more stringent SCABE acceptance criteria were met for all product comparisons for AUC and Cmax in both individuals with a kidney transplant and those with a liver transplant. European Medicines Agency (EMA) acceptance criteria for narrow therapeutic index drugs were also met, with the only exception being in the case of Brand versus Generic Lo, in which the upper limits of the 90% confidence intervals were 111.30% (kidney) and 112.12% (liver). These were only slightly above the upper EMA acceptance criteria limit for an AUC of 111.11%. SCABE criteria were also met for the major tacrolimus metabolite 13-O-desmethyl tacrolimus for AUC, but it failed the EMA criterion. No acute rejections, no differences in renal function in all individuals, and no differences in liver function were observed in individuals with a liver transplant using the Tukey honest significant difference (HSD) test for multiple comparisons. Fifty-two percent and 65% of all individuals with a kidney or liver transplant, respectively, reported an adverse event. The Exact McNemar test for paired categorical data with adjustments for multiple comparisons was used to compare adverse event rates among the products. No statistically significant differences among any pairs of products were found for any adverse event code or for adverse events overall. Limitations of this study include that the observations were made under strictly controlled conditions that did not allow for the impact of nonadherence or feeding on the possible pharmacokinetic differences. Generic Hi and Lo were selected based upon bioequivalence data in healthy volunteers because no pharmacokinetic data in recipients were available for all products. The safety data should be interpreted in light of the small number of participants and the short observation periods. Lastly, only the 1 mg tacrolimus strength was utilized in this study.

CONCLUSIONS

Using an innovative, controlled bioequivalence study design, we observed equivalence between tacrolimus innovator and 2 generic products as well as between 2 generic products in individuals after kidney or liver transplantation following current FDA bioequivalence metrics. These results support the position that bioequivalence for the narrow therapeutic index drug tacrolimus translates from healthy volunteers to individuals receiving a kidney or liver transplant and provides evidence that generic products that are bioequivalent with the innovator product are also bioequivalent to each other.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01889758.

Impaired cerebral autoregulation in preoperative newborn infants with congenital heart disease

OBJECTIVES

To characterize cerebral autoregulation (CA) in preoperative newborn infants with congenital heart disease (CHD).

METHODS

This was a prospective, pilot study of term newborns with CHD who required intensive care. Continuous mean arterial blood pressure (MAP), cerebral tissue oxygen saturation (S_CTO₂) via near-infrared spectroscopy, and arterial oxygen saturation (SaO₂) were collected. Significant low-frequency coherence between MAP and S_CTO₂ was used to define impaired CA in 20-minute epochs. Cerebral fractional tissue oxygen extraction (FTOE) = (SaO₂ - S_CTO₂)/SaO₂ was calculated. Spearman's and rank bi-serial correlations and logistic linear models accounting for multiple measures were used to identify associations with impaired CA and coherence.

RESULTS

Twenty-four term neonates were evaluated for 23.4 ± 1.8 hours starting the first day of life. Periods of SaO₂ variability >5% were excluded, leaving 63 ± 10 epochs per subject, 1515 total for analysis. All subjects demonstrated periods of abnormal CA, mean 15.3% ± 12.8% of time studied. Significant associations with impaired CA per epoch included greater FTOE (P = .02) and lack of sedation (P = .02), and associations with coherence included greater FTOE (P = .03), lack of sedation (P = .03), lower MAP (P = .006), and lower hemoglobin (P = .02).

CONCLUSIONS

Term newborns with CHD display time-varying CA abnormalities. Associations seen between abnormal CA and greater FTOE, lack of sedation, and lower hemoglobin suggest that impaired oxygen delivery and increased cerebral metabolic demand may overwhelm autoregulatory capacity in these infants. Further studies are needed to determine the significance of impaired CA in this population.

Digoxin Use Is Associated With Reduced Interstage Mortality in Patients With No History of Arrhythmia After Stage I Palliation for Single Ventricle Heart Disease

Background

Interstage mortality (IM) remains significant after stage 1 palliation (S1P) for single‐ventricle heart disease (SVD), with many deaths sudden and unexpected. We sought to determine whether digoxin use post‐S1P is associated with reduced IM, utilizing the multicenter database of the National Pediatric Cardiology Quality Improvement Collaborative (NPCQIC).

Methods and Results

From June 2008 to July 2013, 816 infants discharged after S1P from 50 surgical sites completed the interstage to stage II palliation, transplant, or IM. Arrhythmia during S1P hospitalization or discharge on antiarrhythmic medications were exclusions (n=270); 2 patients were lost to follow‐up. Two analyses were performed: (1) propensity‐score adjusted logistic regression with IM as outcome and (2) retrospective cohort analysis for patients discharged on digoxin versus not, matched for surgical site and other established IM risk factors. Of 544 study patients, 119 (21.9%) were discharged on digoxin. Logistic regression analysis with propensity score, site‐size group, and digoxin use as predictor variables showed an increased risk of IM in those not discharged on digoxin (odds ratio, 8.6; lower confidence limit, 1.9; upper confidence limit, 38.3; P<0.01). The retrospective cohort analysis for 60 patients on digoxin (matched for site of care, type of S1P, post‐S1P ECMO use, genetic syndrome, discharge feeding route, ventricular function, tricuspid regurgitation, and aortic arch gradient) showed 0% IM in the digoxin at discharge group and an estimated IM difference between the 2 groups of 9% (P=0.04).

Conclusions

Among SVD infants in the NPCQIC database discharged post‐S1P with no history of arrhythmia, use of digoxin at discharge was associated with reduced IM.

Characteristics of Youth Presenting for Weight Management: Retrospective National Data from the POWER Study Group

BACKGROUND

There are no existing multisite national data on obese youth presenting for pediatric weight management. The primary aim was to describe BMI status and comorbidities among youth with obesity presenting for pediatric weight management (PWM) at programs within the Pediatric Obesity Weight Evaluation Registry (POWER).

METHODS

Data were collected from 2009-2010 among 6737 obese patients ages 2-17. Patients were classified in three groups by BMI (kg/m(2)) cutoffs and percent of the 95th percentile for BMI: (1) obesity; (2) severe obesity class 2; and (3) severe obesity class 3. Weighted percentages are presented for baseline laboratory tests, blood pressure, and demographics. Generalized logistic regression with clustering was used to examine the relationships between BMI status and comorbidities.

RESULTS

Study youth were 11.6 ± 3.4 years of age, 56% female, 31% black, 17% Hispanic, and 53% publicly insured. Twenty-five percent of patients had obesity (n = 1674), 34% (2337) had severe obesity class 2, and 41% (2726) had severe obesity class 3. Logistic regression revealed that males (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.5-2.0), blacks (OR, 1.7; 95% CI, 1.5-2.0), age <6 years (OR, 2.0; 95% CI, 1.5-2.6), and public insurance (OR, 1.8; 95% CI, 1.5-2.0) had a higher odds of severe obesity class 3. Severe obesity class 3 was associated with higher odds of laboratory abnormalities for hemoglobin A1c (OR, 1.7; 95% CI, 1.3-2.2), alanine aminotransferase ≥40 U/L (OR, 1.9; 95% CI, 1.3-2.6), and elevated systolic blood pressure (OR, 2.5; 95% CI, 2.0-3.0).

CONCLUSIONS

Youth with obesity need earlier access to PWM given that they are presenting when they have severe obesity with significant comorbidities.

Correlation of precordial voltages to left ventricular mass on echocardiogram in adolescent patients with hypertrophic cardiomyopathy compared with that in adolescent athletes

Electrocardiograms continue to be part of screening programs for athletes and familial hypertrophic cardiomyopathy (HC). Whether electrocardiographic (ECG) findings of left ventricular (LV) hypertrophy can distinguish between healthy populations and those with HC remains unclear. We sought to (1) analyze the relation between ECG voltage and LV mass in patients with HC and (2) evaluate ECG characteristics of patients with phenotypical HC. Retrospective cohort of patients with HC aged 13 to 18 years. Relation between ECG voltages (RV6, SV1, and RV6 + SV1) and echocardiogram measurements of LV mass was investigated using smoothing splines to display relations and compared with those in a prospectively obtained population of adolescents. Frequency of abnormal LV voltages and nonvoltage ECG changes (Q waves, T-wave changes, and ST changes) were analyzed for association with HC. Fifty-three patients with HC (72% men) were age and gender matched to 104 control patients. Smoothing splines demonstrated that parabolic rather than linear relations existed between LV mass and SV1, RV6, and RV6 + SV1 in patients with HC and not the control cohort. LV hypertrophy by ECG voltage criteria was present in 34% of patients with HC and associated with poor sensitivity (29%). In patients with HC, 56% demonstrated nonvoltage ECG abnormalities and were associated with improved sensitivity (68%) and high specificity (94%). In conclusion, there is a parabolic relation between LV voltages and LV mass in adolescents with HC that may lead to "pseudonormalization." Voltage abnormalities were associated with poor sensitivity, whereas nonvoltage criteria were associated with improved sensitivity with high specificity.

S-(-)equol production is developmentally regulated and related to early diet composition

S-(-)7-hydroxy-3-(4'-hydroxyphenyl)-chroman, or S-(-)equol, a biologically active intestinally derived bacterial metabolite of the soy isoflavones daidzin/daidzein, is not produced in neonatal life. Because its synthesis is dependent on equol-producing bacteria, we hypothesized that early nutrition may influence equol production. This prospective 2.5-year study determined the frequency of S-(-)equol production in healthy infants (n = 90) fed breast milk, soy infant formula, or cow's milk formula in their first year. Urinary S-(-)equol and daidzein were quantified by mass spectrometry after a standardized 3.5-day soy isoflavone challenge. Infants were tested at 6, 9, 12, 18, 24, and 36 months of age, and 3-day diet records were obtained at each visit to explore the effect of early and postweaning (>12 months) macronutrient and micronutrient dietary composition and S-(-)equol production. Use of antibiotics was also recorded. At age 6 months, none of the breast-fed infants produced S-(-)equol, whereas 3.8% and 6.0%, respectively, of soy and cow's milk formula-fed infants were equol producers. By age 3 years, 50% of the formula-fed infants were equol producers, compared with 25% of breast-fed infants. Use of antibiotics was prevalent among infants and may have impacted the stability of S-(-)equol production. No significant differences among the groups were observed in postweaning dietary intakes of total energy, carbohydrate, fiber, protein, fat, saturated fatty acids, or polyunsaturated fatty acids and the propensity to make S-(-)equol. In conclusion, S-(-)equol production is developmentally regulated and initially related to diet composition with the proportion of equol producers increasing over the first 3 years of life, with a trend for formula feeding favoring S-(-)equol production.

Dietary factors influence production of the soy isoflavone metabolite s-(-)equol in healthy adults

S-(-)equol, an intestinally derived metabolite of the soy isoflavone daidzein, is proposed to enhance the efficacy of soy diets. Adults differ in their ability to produce equol when consuming soy foods for reasons that remain unclear. Therefore, we performed a comprehensive dietary analysis of 143 macro- and micronutrients in 159 healthy adults in the United States (n = 89) and Australia (n = 70) to determine whether the intake of specific nutrients favors equol production. Three-d diet records were collected and analyzed using Nutrition Data System for Research software and S-(-)equol was measured in urine by mass spectrometry. Additionally, in a subset of equol producers and nonproducers (n = 10/group), we examined the long-term stability of equol producer status by retesting 12, 18, and 24 mo later. Finally, the effect of oral administration of the antibiotic metronidazole (500 mg/d for 7 d) on equol production was examined in 5 adults monitored during a 4-mo follow-up period. Equol producers accounted for 30.3% and 28.6% of the United States and Australian participants, respectively (overall frequency, 29.6%). No significant differences were observed for total protein, carbohydrate, fat, saturated fat, or fiber intakes between equol producers and nonproducers. However, principal component analysis revealed differences in several nutrients, including higher intakes of polyunsaturated fatty acids (P = 0.039), maltose (P = 0.02), and vitamins A (P = 0.01) and E (P = 0.035) and a lower intake of total cholesterol (P = 0.010) in equol producers. During a 2-y period, equol producer status remained unchanged in all nonproducers and in 80% of equol producers, whereas metronidazole abolished equol production in only 20% of participants. In conclusion, these findings suggest that major differences in the macronutrient content of the diet appear not to influence equol production, but subtle differences in some nutrients may influence the ability to produce equol, which was a relatively stable phenomenon.

Molecular diagnosis of eosinophilic esophagitis by gene expression profiling

BACKGROUND & AIMS

Gene expression profiling provides an opportunity for definitive diagnosis but has not yet been well applied to inflammatory diseases. Here we describe an approach for diagnosis of an emerging form of esophagitis, eosinophilic esophagitis (EoE), which is currently diagnosed by histology and clinical symptoms.

METHODS

We developed an EoE diagnostic panel (EDP) comprising a 96-gene quantitative polymerase chain reaction array and an associated dual-algorithm that uses cluster analysis and dimensionality reduction using a cohort of randomly selected esophageal biopsy samples from pediatric patients with EoE (n = 15) or without EoE (non-EoE controls, n = 14) and subsequently vetted the EDP using a separate cohort of 194 pediatric and adult patient samples derived from both fresh or formalin-fixed, paraffin-embedded tissue: active EoE (n = 91), control (non-EoE and EoE remission, n = 57), histologically ambiguous (n = 34), and reflux (n = 12) samples.

RESULTS

The EDP identified adult and pediatric patients with EoE with approximately 96% sensitivity and approximately 98% specificity, and distinguished patients with EoE in remission from controls, as well as identified patients exposed to swallowed glucorticoids. The EDP could be used with formalin-fixed, paraffin-embedded tissue RNA and distinguished patients with EoE from those with reflux esophagitis, identified by pH-impedance testing. Preliminary evidence showed that the EDP could identify patients likely to have disease relapse after treatment.

CONCLUSIONS

We developed a molecular diagnostic test (referred to as the EDP) that identifies patients with esophagitis in a fast, objective, and mechanistic manner, offering an opportunity to improve diagnosis and treatment, and a platform approach for other inflammatory diseases.

PedsQL eosinophilic esophagitis module: feasibility, reliability, and validity

OBJECTIVE

Eosinophilic esophagitis (EoE) is a chronic esophageal inflammatory condition with a paucity of information on health-related quality of life (HRQOL). The objective of the study was to report on the measurement properties of the PedsQL EoE Module.

METHODS

The PedsQL EoE Module was completed in a multisite study by 196 pediatric patients with EoE and 262 parents of patients with EoE.

RESULTS

The PedsQL EoE Module scales evidenced excellent feasibility (0.6%-3.1% missing), excellent group comparison reliability across total scale scores (patient α 0.93; parent proxy α 0.94), good reliability for the 7 individual scales (patient α 0.75-0.87; parent proxy α 0.81-0.92), excellent test-retest reliability (patient intraclass correlation coefficient 0.88; parent intraclass correlation coefficient 0.82), demonstrated no floor effects and low ceiling effects, and demonstrated a high percentage of scaling success for most scales. Intercorrelations with the PedsQL Generic Core Scales were in the medium (0.30) to large (0.50) range. PedsQL EoE Module scores were worse among patients with active histologic disease (≥ 5 eos/hpf) compared with those in remission (patient self-report: 63.3 vs 69.9 [P < 0.05]; parent proxy report: 65.1 vs 72.3 [P < 0.01]), and those treated with dietary restrictions compared with those with no restrictions (patient self-report: 61.6 vs 74.3 [P < 0.01]; parent proxy report: 65.5 vs 74.7 [P < 0.01]).

CONCLUSIONS

The results demonstrate excellent measurement properties of the PedsQL EoE Module. Patients with active histologic disease and those treated with dietary restrictions demonstrated worse PedsQL scores. The PedsQL EoE Module may be used in the evaluation of pediatric EoE disease-specific HRQOL in clinical research and practice.

Abnormal circumferential strain is present in young Duchenne muscular dystrophy patients

Advances in management of non-cardiac issues in Duchenne muscular dystrophy (DMD) have improved such that DMD-associated cardiac disease has become the leading cause of death for such patients. Cardiac dysfunction measured by standard transthoracic echocardiographic methods, e.g., fractional shortening (FS) and ejection fraction (EF), is rarely present during the first decade of life. The current study used transthoracic echocardiogram (TTE) to assess strain (ε), an indicator of regional ventricular function, in young DMD patients. A retrospective review of the TTE database was performed. TTE results from DMD patients <8 years (n = 63) performed during 2009 to 2010 were compared with TTE results from an unaffected control group (n = 61). Feature tracking analysis software was used to measure total circumferential strain (ε cc) as well as segmental ε cc based on the American Society of Echocardiography 16-segment model. Although there were no differences in FS, the absolute value for left-ventricular (LV) ε cc at the mid-chamber level was decreased in DMD (-21.7 % ± 3.8 % vs. -19.8 % ± 4.2 %, p < 0.01; unaffected vs. DMD). Segmental ε(cc) was similarly affected in the anteroseptal segment (-23.0 % ± 6.1 % vs. -18.9 % ± 7.0 %, p = 0.001; controls vs. DMD), the inferior segment (-20.7 % ± 5.16 % vs. -17.7 % ± 6.1 %, p = 0.003; controls vs. DMD), and the inferolateral segment (-18.3 % ± 6.2 % vs. -15.9 % ± 6.7 %, p = 0.04; controls vs. DMD). In the present study we demonstrate both total and segmental LV ε cc (anteroseptal, inferior, and inferolateral segments) abnormalities at the mid-chamber level in a large group of young DMD patients with normal FS. These novel findings substantiate that the disease process is present and results in abnormal myocardial function before standard measures detect global dysfunction.

The in vivo adherence intervention for at risk adolescents with asthma: report of a randomized pilot trial

OBJECTIVE

Low-income and minority adolescents are at high risk for poor asthma outcomes, due in part to adherence. We tested acceptability, feasibility, and effect sizes of an adherence intervention for low socioeconomic status (SES) minority youth with moderate- and severe-persistent asthma. Design and Methods Single-site randomized pilot trial: intervention (n = 12; asthma education, motivational interviewing, problem-solving skills training, 1 month cell-phone with tailored text messaging) versus control (n = 14; asthma education; cell-phone without tailored messaging). Calculated effect-sizes of relative change from baseline (1 and 3 months).

RESULTS

Intervention was judged acceptable and feasible by participants. Participants (12-18 years, mean = 15.1, SD = 1.67) were 76.9% African-American, 80.7% public/no insurance. At 1 and 3 months, asthma symptoms (Cohen's d's = 0.40, 0.96) and HRQOL (PedsQL™; Cohen's d's = 0.23, 1.25) had clinically meaningful medium to large effect sizes.

CONCLUSIONS

This intervention appears promising for at-risk youth with moderate- and severe-persistent asthma.

Comparative dietary therapy effectiveness in remission of pediatric eosinophilic esophagitis

BACKGROUND

Eosinophilic esophagitis is a chronic, immune-mediated inflammatory disorder that responds to dietary therapy; however, data evaluating the effectiveness of dietary therapeutic strategies are limited.

OBJECTIVE

This study compared the effectiveness of 3 frequently prescribed dietary therapies (elemental, 6-food elimination, and skin prick and atopy patch-directed elimination diets) and assessed the remission predictability of skin tests and their utility in directing dietary planning.

METHODS

A retrospective cohort of proton-pump inhibitor-unresponsive, non-glucocorticoid-treated patients with eosinophilic esophagitis who had 2 consecutive endoscopic biopsy specimens associated with dietary intervention was identified. Biopsy histology and remissions (<15 eosinophils/high-power field) after dietary therapy and food reintroductions were evaluated.

RESULTS

Ninety-eight of 513 patients met the eligibility criteria. Of these 98 patients, 50% (n= 49), 27% (n= 26), and 23% (n= 23) received elemental, 6-food elimination, and directed diets, respectively. Remission occurred in 96%, 81%, and 65% of patients on elemental, 6-food elimination, and directed diets, respectively. The odds of postdiet remission versus nonremission were 5.6-fold higher (P= .05) on elemental versus 6-food elimination diets and 12.5-fold higher (P= .003) on elemental versus directed diets and were not significantly different (P= .22) on 6-food elimination versus directed diets. After 116 single-food reintroductions, the negative predictive value of skin testing for remission was 40% to 67% (milk, 40%; egg, 56%; soy, 64%; and wheat, 67%).

CONCLUSION

All 3 dietary therapies are effective; however, an elemental diet is superior at inducing histologic remission compared with 6-food elimination and skin test-directed diets. Notably, an empiric 6-food elimination diet is as effective as a skin test-directed diet. The negative predictive values of foods most commonly reintroduced in single-food challenges are not sufficient to support the development of dietary advancement plans solely based on skin test results.

Improved outcomes in a quality improvement collaborative for pediatric inflammatory bowel disease

OBJECTIVES

Unintended variation in the care of patients with Crohn disease (CD) and ulcerative colitis (UC) may prevent achievement of optimal outcomes. We sought to improve chronic care delivery and outcomes for children with inflammatory bowel disease by using network-based quality improvement methods.

METHODS

By using a modified Breakthrough Series collaborative structure, 6 ImproveCareNow Network care centers tested changes in chronic illness care and collected data monthly. We used an interrupted time series design to evaluate the impact of these changes.

RESULTS

Data were available for 843 children with CD and 345 with UC. Changes in care delivery were associated with an increase in the proportion of visits with complete disease classification, measurement of thiopurine methyltransferase (TPMT) before initiation of thiopurines, and patients receiving an initial thiopurine dose appropriate to their TPMT status. These were significant in both populations for all process variables (P < .01) except for measurement of TPMT in CD patients (P = .12). There were significant increases in the proportion of CD (55%-68%) and UC (61%-72%) patients with inactive disease. There was also a significant increase in the proportion of CD patients not taking prednisone (86%-90%). Participating centers varied in the success of achieving these changes.

CONCLUSIONS

Improvements in the outcomes of patients with CD and UC were associated with improvements in the process of chronic illness care. Variation in the success of implementing changes suggests the importance of overcoming organizational factors related to quality improvement success.

Soy isoflavone phase II metabolism differs between rodents and humans: implications for the effect on breast cancer risk

BACKGROUND

Human and animal studies have produced conflicting results with regard to the effect of soy isoflavones on breast cancer risk. This may be due to differences in isoflavone metabolism.

OBJECTIVE

The objective of this study was to determine whether soy isoflavone phase II metabolism differs between humans and rodents.

DESIGN

Circulating total and unconjugated isoflavone concentrations were determined by mass spectrometry in plasma samples from 7 separate studies: 1) in Sprague-Dawley rats and in 3 strains of mice fed commercial soy-containing diets; 2) in Sprague-Dawley rats gavaged with genistein; 3) in healthy adults who consumed single servings of soy nuts, soy milk, and tempeh; 4) in healthy adults subchronically given soy milk; 5) in healthy women orally administered 50 mg genistein; 6) in healthy women orally administered 20 mg pure S-(-)equol; and 7) in 6-mo-old infants fed soy infant formula and later, at age 3 y, a soy germ isoflavone supplement.

RESULTS

The proportion of unconjugated genistein in plasma from adults and infants who consumed different soy foods, pure genistein, or an isoflavone supplement was <1% in steady state and <2% at peak concentrations. By contrast, rodents fed soy-containing diets conjugate isoflavones less efficiently. The plasma percentages of unconjugated genistein concentrations in Sprague-Dawley rats and C57BL/6, nude, and transgenic AngptL4B6 mice were 4.0 ± 0.6%, 4.6 ± 0.6%, 11.6 ± 0%, and 30.1 ± 4.3%, respectively, which represent 20, 23, 58, and 150 times that in humans.

CONCLUSION

The markedly higher circulating concentrations of biologically active (unconjugated) genistein in certain strains of mice cast doubt on the value of the use of these rodents for gaining insight into the effects of isoflavones in humans, especially with regard to the effects on breast tissue.

Identification, epidemiology, and chronicity of pediatric esophageal eosinophilia, 1982-1999

BACKGROUND

Eosinophilic esophagitis (EE) is now a commonly encountered disorder that was rarely diagnosed a decade ago.

OBJECTIVE

We aimed to determine the epidemiologic and histologic features of retrospective pediatric esophageal eosinophilia before the first case of EE at our institution was recognized.

METHODS

Esophageal biopsy specimens obtained between 1982 and 1999 with reflux esophagitis were re-examined and reorganized into 2 groups based on peak esophageal eosinophil number (<15 eosinophils per high-powered field [hpf] and > or =15 eosinophils/hpf). The epidemiology and histology of the entire cohort and a population-based cohort were evaluated.

RESULTS

Eight hundred seven biopsy specimens from 666 patients were re-examined; 198 patients had 15 eosinophils/hpf or greater. Among a population-based cohort of patients with 15 eosinophils/hpf or greater, there was a modest increase in incidence (P < .001; incidence rate ratio, 1.18; 95% CI, 1.09-1.28). After correcting for a 40-fold increase in the number of endoscopies during this time period, the proportion of biopsy specimens with 15 eosinophils/hpf or greater did not change (0.08 in 1982 vs 0.08 in 1996 [peak]; P = .9; incidence rate ratio, 1.02; 95% CI, 0.73-1.44). Patients who had as few as 5 eosinophils/hpf were more likely to have persistent esophageal eosinophilia on repeat esophagogastroduodenoscopy, evidence of basal layer hyperplasia, and lamina propria fibrosis compared with patients with less than 5 eosinophils/hpf (P < .001).

CONCLUSIONS

Esophageal eosinophilia at levels consistent with EE was present among 30% of patients given diagnoses of reflux esophagitis, and the incidence of esophageal eosinophilia did not change over time. Patients with 5 eosinophils/hpf or greater had evidence of other histologic abnormalities and were likely to have persistent esophageal eosinophilia.

Recommendations for safety planning, data collection, evaluation and reporting during drug, biologic and vaccine development: a report of the safety planning, evaluation, and reporting team

Background The Safety Planning, Evaluation and Reporting Team (SPERT) was formed in 2006 by the Pharmaceutical Research and Manufacturers of America.

Purpose SPERT’s goal was to propose a pharmaceutical industry standard for safety planning, data collection, evaluation, and reporting, beginning with planning first-in-human studies and continuing through the planning of the post-product-approval period.

Methods SPERT’s recommendations are based on our review of relevant literature and on consensus reached in our discussions.

Results An important recommendation is that sponsors create a Program Safety Analysis Plan early in development. We also give recommendations for the planning of repeated, cumulative meta-analyses of the safety data obtained from the studies conducted within the development program. These include clear definitions of adverse events of special interest and standardization of many aspects of data collection and study design. We describe a 3-tier system for signal detection and analysis of adverse events and highlight proposals for reducing "false positive" safety findings. We recommend that sponsors review the aggregated safety data on a regular and ongoing basis throughout the development program, rather than waiting until the time of submission.

Limitations We recognize that there may be other valid approaches.

Conclusions The proactive approach we advocate has the potential to benefit patients and health care providers by providing more comprehensive safety information at the time of new product marketing and beyond. Clinical Trials 2009; 6: 430—440. http://ctj.sagepub.com

Effect of Mild and Moderate Hepatic Impairment on Azimilide Pharmacokinetics Following Single Dose Oral Administration

Azimilide dihydrochloride (75-125 mg/day) is currently being developed for use in prolonging the time to recurrence of atrial fibrillation/flutter and for reducing the frequency of shocks in patients with an implantable cardioverting defibrillator. This study investigated the influence of mild and moderate hepatic impairment on azimilide pharmacokinetics. Six subjects each with mild and moderate hepatic impairment (Child-Pugh grades A and B, respectively) were age, weight, smoking status, and gender-matched to a healthy subject (total N = 24). Each subject was administered a single, oral dose of 100 mg azimilide dihydrochloride following an overnight fast. Blood/plasma and urine samples were collected up to 28 days and over 9 days, respectively, and analyzed using HPLC with MS/MS or UV detection. For azimilide, most parameters in subjects with mild to moderate hepatic impairment were within 25% of those observed in matched healthy subjects, with no statistically significant differences observed. For F-1292 (major metabolite in plasma), a significant decrease in AUC was observed in subjects with moderate hepatic impairment, secondary to an increase in renal clearance (CL(r)). Based on these results, no a priori dosage adjustment is required in subjects with mild to moderate hepatic impairment.

Enzymatic breakdown of poly-gamma-D-glutamic acid in Bacillus licheniformis: identification of a polyglutamyl gamma-hydrolase enzyme

A polyglutamyl gamma-hydrolase enzyme has been identified which catalyses the hydrolytic breakdown of poly-gamma-D-glutamic acid (PGA) from Bacillus licheniformis 9945a. The enzyme was found to be physically associated with the polymer and was activated by Zn2+ or Ca2+ salts. The enzyme can be solubilized from the polymer by treatment with 0.5% SDS and 1 mM ZnCl2 and can then be renatured onto exogenous PGA upon dilution below the detergent critical micellar concentration. The enzyme was partially purified by affinity chromatography, using immobilized PGA. Peptide thioesters containing one and two gamma-glutamyl units were synthesized as potential chromogenic substrates but showed no activity with the solubilized enzyme. Examination of 14C-labeled reaction products indicated that the enzyme is an endo-type hydrolase.

Risk factors for Helicobacter pylori resistance in the United States: the surveillance of H. pylori antimicrobial resistance partnership (SHARP) study, 1993-1999

BACKGROUND

Pretreatment antimicrobial resistance has an important impact on the efficacy of many Helicobacter pylori treatment regimens.

OBJECTIVE

To estimate the prevalence of H. pylori resistance to antimicrobials in the United States, to characterize risk factors associated with H. pylori antimicrobial resistance, and to explore the association between drug utilization and antimicrobial resistance patterns over time.

DESIGN

Meta-analysis using patient-level data.

SETTING

20 nationwide trials of H. pylori eradication.

PATIENTS

3624 men and women, each of whom contributed one isolate.

MEASUREMENTS

Rates of H. pylori resistance to clarithromycin, metronidazole, and amoxicillin, according to geographic region, age, sex, study year, ethnicity, ulcer status, test method, and study.

RESULTS

Overall resistance to clarithromycin, metronidazole, and amoxicillin was 10.1% (95% CI, 9.1% to 11.1% [360 of 3571 patients]), 36.9% (CI, 35.1% to 38.7% [1063 of 2883 patients]), and 1.4% (CI, 1.0% to 1.8% [48 of 3486 patients]), respectively. In multivariable analyses, multiple risk factors were associated with resistance to individual agents. Clarithromycin resistance was significantly associated with geographic region (P = 0.050), older age (P < 0.001), female sex (P < 0.001), inactive ulcer disease (P < 0.001), and study (P = 0.010). Metronidazole resistance was significantly associated with female sex (P < 0.001), earlier year of study enrollment (P = 0.036), Asian ethnicity (P < 0.001), use of an epsilometer test (P = 0.002), and study (P < 0.001). Amoxicillin resistance was low and was not significantly associated with any risk factor. In the 1990s, when rates for use of oral macrolides and metronidazole were relatively stable, clarithromycin resistance rates were stable and metronidazole resistance rates varied.

CONCLUSIONS

Clinicians should consider risk factors for antimicrobial resistance when deciding which patients should have susceptibility testing and when choosing appropriate H. pylori treatments in the empirical setting.

Standards in anterior spine surgery in pediatric patients with neuromuscular scoliosis

The authors reviewed 111 patients with neuromuscular disease who underwent anterior spine surgery for correction of scoliosis. An overall complication rate of 44.1% was found, 21.6% major and 22.5% minor. Pulmonary complications were the most common major complications, urinary tract infections the most common minor complications. The rate of complications was greater in patients with cerebral palsy, thoracoabdominal and transthoracic approaches, staged procedures, operative blood loss >1,000 mL, or previous spine surgery. In addition, statistical analysis confirmed that curve magnitude >100 degrees degrees was a risk factor for complications.

Induction and relief of nasal congestion in ferrets infected with influenza virus

Susceptible ferrets intranasally infected with influenza virus consistently responded with maximal nasal secretion of virus, febrile reaction, and influx of inflammatory cells into nasal lumen on day 2 post infection (d.p.i.). Polymorphonuclear leucocytes were the earliest predominant cell, followed by monocytes/macrophages while lymphocytes were maintained as a minor population throughout the 7-day period. Nasal congestion level, continuously monitored by computer aided active anterior rhinomanometry, was reproducibly maximal at 2 d.p.i., diminished in intensity the next day and returned to the basal level within 7 d.p.i. Nasal congestion was effectively relieved by a single intranasal dose of 0.1% oxymetazoline or 0.2% phenylephrine, or a single intragastric administration of pseudoephedrine. Intranasal delivery of a single dose of 1% pyrilamine relieved nasal congestion while 0.8% ipratropium bromide and 30% cimetidine were ineffective. These results suggested that nasal congestion is regulated by alpha-adrenergic receptors in the mucosal vasculature or by H1 histamine receptor, but is unaffected by inhibitors of nasal secretion regulated by the cholinergic nervous system. The present study indicates that the infectious rhinitis ferret model provides a reproducible nasal congestion pattern that can be objectively measured by a refined active anterior rhinomanometric system. This labour intensive measurement, however, makes it difficult either to conduct a large population animal study or to use it for a rapid throughput screening of new drugs. The temporal relation between the influx of inflammatory cells into the nasal lumen and the onset of nasal congestion underlies the model's relevance to the exploration of the pathogenic mechanism(s) during viral rhinitis.

Designing services for the elderly

Even after careful planning and a successful launch, even the best geriatric care program can not always expect smooth sailing, according to industry executives. Allen Mathies, president and chief executive officer at Huntington Memorial Hospital, cited a paradoxical side effect stemming from the success of his hospital's geriatric outreach programs. "On the one hand, by moving patients through a continuum of outpatients services, our program has helped to reduce the extraordinary costs associated with acute care hospitalization," he said. "On the other hand, those patients who are hospitalized tend to be more acutely ill. They use tremendous resources, but at a fixed reimbursement. There is a lack of recognition of our real costs by the payer." Why, then, do Huntington Memorial Hospital, Baptist Medical Center of Oklahoma, Morton F. Plant Hospital, Northwestern Memorial Hospital and other hospitals intend to continue their efforts on behalf of their communities' aging populations? The answer is that, reimbursement problems notwithstanding, benefits can be derived from making a commitment to geriatric care. "We have 19,000 people enrolled in our elder care program," Hupfeld said. "That's a powerful force. They vote. They lobby on our behalf. They support the hospital philanthropically. If you do a good job of reaching the older adults in your community, you'll find they are a powerful marketing force. They can do a lot for your image when it comes to reaching other market segments."

Developing and negotiating transfer agreements in allied health

The Kentucky Council on Higher Education has developed a statewide articulated system for allied health education. The articulated system permits entry and exit of prepared professionals at a variety of levels. The six disciplinary clusters included in the system are clinical laboratory sciences, dental auxiliaries, dietetics/nutrition, rehabilitation therapies, radiological sciences, and respiratory therapy. Competency-based education was used as the theoretical framework for developing and negotiating transfer agreements. Types of agreements included the block credit transfer agreement and the course specific transfer agreement. Agreements were negotiated between education systems and between specific programs/institutions. To date, approximately 30 transfer agreements have been negotiated. The process for negotiating transfer agreements included the following sequence: identify programs, develop a theoretical articulation model, rank order transfer agreements, determine the type of agreement, review respective curricula, determine the existing amount of transferable coursework, draft a pre-articulation agreement, schedule a meeting between faculty and administrators to discuss the agreement, and secure authorizing signatures on the final transfer agreement. Facilitators and barriers to negotiating agreements are discussed and recommendations offered for others who may be interested in developing transfer agreements.

Statewide articulation for allied health: a conceptual model in action

Under the auspices of the Kentucky Council on Higher Education, and with the aim of delineating issues in allied health education and making recommendations for alleviating the issues, an indepth, two-year study was completed in 1975. The primary recommendations pertained to the development of a statewide plan for allied health education that would result in an articulated statewide system permitting entry and exit of prepared personnel at a variety of levels and improving inter-institutional efforts to share educational resources. In the following four years a foundation was laid for developing the system. An articulated system of allied health education was developed in six disciplinary clusters to serve as a model for other states: clinical laboratory, dental auxiliaries, dietetics/nutrition, rehabilitation therapies, radiological science, and respiratory therapy programs. All levels of programs within each discipline cluster existing in Kentucky are included in the system. The study includes a design phase and an implementation phase. During the design phase, six discipline advisory groups developed articulation models for the programs in each discipline. Implementation phase accomplishments include signed transfer agreements, development of model and core curricula, design for graduate follow-up, publications, development of manpower models, and increased cooperation among project participants.

A comparison of administrator, faculty/clinician, and student needs to facilitate statewide planning in allied health education

Higher education state coordinating bodies are faced with the difficult task of developing coherent strategies and priorities for planning. To assist in this planning a needs assessment procedure involving administrators, faculty/clinicians, and students was used, and driving and restraining forces relevant to decision making were identified. The Nominal Group Technique was used to identify each population's needs which related to a statewide system for allied health education. The technique ordered the needs of each population. A kendall coefficient of concordance was calculated to test the hypothesis that there was no association between the ranks within a population. Needs were placed in two categories: those common to all three populations, and those unique to one population. Six needs common to the population were identified. Finally, the study reranked the six common needs according to perceived attainability.

Evaluating cognitive learning for radiography education

This discussion has been written to assist radiologic technology educators build better teacher-made tests. The systematic framework for test development has included defining cognitive learning objectives, constructing a test blueprint, writing clear test directions, and writing objective test items. This process enables the faculty to effectively monitor student progress, assess their own teaching effectiveness, and diagnose learning difficulties. It is hoped that this systematic approach to the assessment of cognitive learning will contribute to the education and development of a competent entry level radiologic technologist.

The school of allied health--a political model of university governance

Curtailment of direct federal funding coupled with greater governmental demands for fiscal accountability in the 1970s has led to events such as allied health program moratoria and a closer scrutiny of the fundamental goals of allied health schools. Resulting organizational stress has also stimulated an emergence of interest groups in these schools. This paper attempts to place these events in a historical and sociological context by: (1) summarizing three governance models; (2) relating these models to the organizational maturation of allied health schools in light of predictions from contemporary management theory; (3) discussing the interrelationships between organizational structure, age of allied health schools, and characteristics of allied health administrators; (4) describing variables of organizational transition that affect organizational effectiveness; and (5) making recommendations to assist schools in organizational planning so they can adjust to the potential negative impact of organizational maturation, shrinking resources, and increasing accountability. A series of recommendations from the Baldridge political model of contemporary organizational research is presented. These recommendations may help facilitate conflict resolution in schools of allied health.

Laboratory staff development practices: a statewide study

A statewide survey of staff development practices in New York State was completed to: 1) assess the current staff development practices for laboratory personnel in a variety of health care delivery settings; 2) determine the importance of selected laboratory practices to the professional growth of the laboratory staff; 3) make recommendations for staff development practices based on research findings. The study results are based on responses to a 1978 mail survey to laboratory staff employed in New York State. The most significant findings were that in over half of the laboratory settings surveyed three of six general types of laboratory staff development practices were nonexistent. Furthermore, regardless of size and/or type of laboratory setting, there were rare opportunities for staff development. The findings have implications for level of job satisfaction, level of professionalism, and even performance appraisal.

The relationship between biographic profile and job role preceptions of the allied health chair: a national study

The purpose of the study was to construct a professional profile of medical technology and physical therapy baccalaureate chairs to compare male and female respondents in the areas of (1) biographic background, (2) career aspiration, (3) influence in decision making, (4) job-related stress, (5) goals important to role as chair, (6) skills important to role as chair, and (7) perception of ideal power. The response rate to a 1978 national survey was 72%. Statistical analysis on the 25 physical therapy females, 23 physical therapy males, and 20 medical technology female respondents revealed they were comparable in terms of the above variables. The three groups shared a common biographic profile except in the areas of marital status and clinical experience. These chairs exhibited low scholarly productivity and little interest in careers in academic administration or the clinical setting. Rather, they indicated sustained interest in departmental chair status or a return to fulltime faculty status. There was also perceived high participation in decision making, low to moderate job-related stress, and high concern for personal and faculty development. They agreed that selected administrative skills were necessary to their role as chairs. Finally, they reported that a considerable amount of power was necessary to their role as chairs in their institutions. Implications for chair development and recommendations for future research are discussed.