Evaluating the efficacy of Seattle-PAP for the respiratory support of premature neonates: study protocol for a randomized controlled trial

BACKGROUND

At birth, the majority of neonates born at <30 weeks of gestation require respiratory support to facilitate transition and ensure adequate gas exchange. Although the optimal approach to the initial respiratory management is uncertain, the American Academy of Pediatrics endorses noninvasive respiratory support with nasal continuous positive airway pressure (nCPAP) for premature neonates with respiratory insufficiency. Despite evidence for its use, nCPAP failure, requiring intubation and mechanical ventilation, is common. Recently, investigators have described a novel method to deliver bubble nCPAP, termed Seattle-PAP. While preclinical and pilot studies are encouraging regarding the potential value of Seattle-PAP, a large trial is needed to compare Seattle-PAP directly with the current standard of care for bubble nCPAP (Fisher & Paykel CPAP or FP-CPAP).

METHODS/DESIGN

We designed a multicenter, non-blinded, randomized controlled trial that will enroll 230 premature infants (22^0/7 to 29^6/7 weeks of gestation). Infants will be randomized to receive Seattle-PAP or FP-CPAP. The primary outcome is respiratory failure requiring intubation and mechanical ventilation. Secondary outcomes include measures of short- and long-term respiratory morbidity and cost-effectiveness.

DISCUSSION

This trial will assess whether Seattle-PAP is more efficacious and cost-effective than FP-CPAP in real-world practice among premature neonates.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03085329 . Registered on 21 March 2017.

Probiotics in Clostridium difficile infection: reviewing the need for a multistrain probiotic

In the past two years an enormous amount of molecular, genetic, metabolomic and mechanistic data on the host-bacterium interaction, a healthy gut microbiota and a possible role for probiotics in Clostridium difficile infection (CDI) has been accumulated. Also, new hypervirulent strains of C. difficile have emerged. Yet, clinical trials in CDI have been less promising than in antibiotic associated diarrhoea in general, with more meta-analysis than primary papers on CDI-clinical-trials. The fact that C. difficile is a spore former, producing at least three different toxins has not yet been incorporated in the rational design of probiotics for (recurrent) CDI. Here we postulate that the plethora of effects of C. difficile and the vast amount of data on the role of commensal gut residents and probiotics point towards a multistrain mixture of probiotics to reduce CDI, but also to limit (nosocomial) transmission and/or endogenous reinfection. On the basis of a retrospective chart review of a series of ten CDI patients where recurrence was expected, all patients on adjunctive probiotic therapy with multistrain cocktail (Ecologic®AAD/OMNiBiOTiC® 10) showed complete clinical resolution. This result, and recent success in faecal transplants in CDI treatment, are supportive for the rational design of multistrain probiotics for CDI.

Clostridium difficile infection: monoclonal or polyclonal genesis?

Clostridium difficile is considered to be a leading cause of hospital-acquired diarrhea. C. difficile (CDI) infection shows a high rate of recurrence. There would have to be a predominantly monoclonal mechanism of CDI within individual patients in order for molecular epidemiologic tools such as polymerase chain reaction (PCR) ribotyping to be useful in outbreak investigation or differentiation between infection relapse versus re-infection. It was the aim of our study to determine whether CDI is of monoclonal or of polyclonal genesis. Between December 2009 and June 2010, 11 patients with nosocomial CDI were chosen arbitrarily. Five individual colonies of C. difficile were picked from each of the primary culture plates. Of 55 isolates gained, 47 were available for PCR ribotyping (eight isolates failed attempts to re-culture). Among these 47 isolates, eight different PCR ribotypes were identified. Only one of the 11 patients had a stool sample that yielded more than one ribotype (PCR ribotypes 438 and 232); this 67-year-old female cancer patient was already suffering from recurring diarrhea prior to the fatal episode of colitis which was subsequently investigated. We conclude that polyclonal infections may occasionally occur in patients with CDI. Our findings of predominantly monoclonal origin of CDI within patients suggest that molecular epidemiologic investigations can be used reliably for outbreak investigations or discrimination between relapse and re-infection.

Molecular pathogenesis of chronic Chlamydia pneumoniae infection: a brief overview

Owing to its unique host cell-dependent development cycle, Chlamydia pneumoniae occupies an intracellular niche that enables the bacterium to survive and to multiply, secluded from both the extracellular and the cytoplasmic environments. Within its separate chlamydial inclusion, it is able to genetically switch between a replicative and a persisting non-replicative state, linking the pathogen to acute as well as chronic diseases. Although its role in acute respiratory infection has been established, a potential link between chronic vascular infection with C. pneumoniae and the development of atherosclerosis remains enigmatic, in particular because chronic chlamydial infection cannot be eradicated by antibiotics. C. pneumoniae has developed numerous mechanisms to establish an adequate growth milieu involving the type III secretion-mediated release of chlamydial effector proteins that interact with cellular structures and reprogram host cell regulatory pathways. This brief overview of these pathomechanisms focuses on chronic vascular infection.

Psychometric evaluation of the outcome based performance measures

The Outcome Based Performance Measures are widely used to evaluate and accredit organizations providing services to persons with disabilities. This study evaluated the interrater reliability, levels of difficulty for items, and factor groupings of this measure with 448 Nevadans with mental retardation. Results supported the measure's reliability and most of the items' levels of difficulty. Factor analysis yielded seven factors with item loadings that varied moderately from prior reports, tending to coincide with the original measure's logically-based groupings. Revisions to the measure are suggested.

Pi-conjugated ligand polymers entwined around copper centres

We describe conjugated polymers entwined around Cu1 with alternating alpha-quaterthienyl (poly[Cu(T2)2]) or 3',4',3'''',4''''-tetrahexyl-alpha-sexythienyl (poly[Cu(T3)2]) moieties and 1,10-phenanthroline complexing sites. Our strategy is to synthesise the 2,9-bis(oligothienyl)-1,10-phenanthroline precursors, then to assemble these ligands by means of Cu1 templating followed by electropolymerisation. Poly[Cu(T2)2] shows separate electroactivities for Cu redox centres and conjugated backbones, whereas the electroactivities overlap in the case of poly[Cu(T3)2]. An X-ray absorption study on these polymers in their reduced state at the Cu-K edge identifies, in both cases, four nitrogen atoms as the closest copper(I) neighbours. For poly[Cu(T2)2], the Cu1 environment is a distorted tetrahedron similar to a monomer model compound, but with a slightly higher number of steric constraints. The Cu1 environment for poly[Cu(T3)2] is a less distorted tetrahedron with an unusually short Cu1-N average bond length. Cu1 removal in poly[Cu(T2)2] induces an irreversible collapse of the structure, whereas the reversibility of Cu1 binding is almost perfect for poly[Cu(T3)2], as the hexyl chains prevent irreversible gliding of the wires after copper removal. Combined electrochemical and resistance measurements reveal that the Cu centres in poly[Cu(T2)2] play the role of mechanical support for the structure with no significant electronic interactions with the conjugated backbone, whereas in the case of poly[Cu(T3)2] copper centres contribute to the conductivity of the structure.

Controlled molecular motions in copper-complexed rotaxanes: an XAS study

The environment of the central metal of a molecular machine-like copper rotaxane was observed by XAS experiments. The wheel of the rotaxane is a hetero-bischelating macrocycle containing both bidentate (phenanthroline) and terdentate (terpyridine) moieties. The axle of the assembly contains only a bidentate moiety. Applying an external chemical stimulus-oxidation of the metal-increases the number of coordinating atoms required by the metal template from 4 to 5. This variation is consistent with the oscillation of the wheel around the axle, leading thus to the most stable environment for the metal in the Cu(II) rotaxane.

Correlates of battered women's psychological distress: severity of abuse and duration of the postabuse period

Although psychological disturbances among abused women are well documented, it is unclear whether such disturbances are a reaction to the abusive experience. The present study hypothesized that, if the disturbances are a reactive state, the severity of disturbance would be related to the time since the relationship ended as well as the severity of the psychological and physical abuse experienced. Participants were 50 abused women who completed valid MMPI-2s and revised Conflict Tactic Scales. The results indicated that MMPI-2 scores were significantly correlated with both types of abuse but not with duration of time since the abusive relationship was terminated. The MMPI-2 profiles of abused women and suggestions for research are discussed.

Objective detection of faking on role-play tests of assertion: gender differences

The validity of role-play tests of assertiveness can be reduced by the effects of faking. Kern demonstrated that faking could be detected using assessors' global judgements. The present analysis is based on Kern's 1994 videotapes, examining the effectiveness of more objective measures. Undergraduates who were low in assertiveness and instructed to fake high assertiveness on the Idiographic Role-play Test (n = 23) emitted more statements indicative of social-evaluative concerns than the veridically highly assertive testees (n = 27). Significant gender differences in the detectability of faking were also obtained. Whereas 24 female fakers and nonfakers were differentiated via verbalizations of likability, 26 male fakers and nonfakers were differentiated via empathic-assertive statements. The implications and limitations of this method to detect faking are discussed.

Differential family environments of bulimics and victims of childhood sexual abuse: achievement orientation

Although bulimics' family functioning usually is reported to be abnormal, the present study examined whether these abnormalities are specific to bulimia or whether they may be due to covariation with another problem associated with abnormal family functioning, childhood sexual abuse (CSA). Consistent with prior research, the family environments of bulimic and normal eaters, as well as abused and nonabused subjects, differed significantly. However, when eating behavior and abuse status were analyzed concurrently, significant differences between bulimics and normals failed to emerge. Abnormal family environment was associated more closely with CSA than with bulimia. The one abnormality unique to bulimia was the family's heightened emphasis on achievement. The potential importance of familial achievement orientation is discussed.

Wives' reported role changes following a husband's stroke: a pilot study

The purpose of this pilot study was to look at changes in the roles of wives when their spouses became disabled due to a stroke. Data collection tools included Buxbaum's Marital Role Questionnaire, which was administered first in the rehabilitation hospital and again at home 2 weeks after the spouses' discharge. Ten subjects participated in this study. Results suggest that (a) wives' responsibilities increased significantly after the husband's stroke, (b) wives' satisfaction with household responsibilities decreased significantly after the husband's stroke, and (c) wives' degree of marital unhappiness increased significantly after the husband's stroke. The hypothesis that wives' social activities decreased significantly after a husband's stroke was not supported. The study showed the need for healthcare professionals to assess wives whose husbands had strokes and to evaluate their ability to perform such basic family roles as economic provider, homemaker, and financial manager.

A review of transfusion-associated AIDS litigation: 1984 through 1993

BACKGROUND

Since 1984, hundreds of lawsuits have been filed against health care providers in the United States, alleging transmission of human immunodeficiency virus by transfusion. While anecdotal reports of jury verdicts have been published, no quantitative study to identify trends in transfusion-associated AIDS litigation has been undertaken.

STUDY DESIGN AND METHODS

To identify trends in lawsuits filed against health care providers alleging human immunodeficiency virus infection transmitted via transfusion, 163 legal actions were analyzed. Included were those for which the authors provided legal defense or consultation (n = 79) and cases reported nationally (n = 84). Cases were analyzed as to characteristics of defendant(s), date of transfusion and case filing, liability theories, and verdict, if applicable.

RESULTS

Defendants were blood centers (74% of cases), hospitals (58%), and physicians (53%). Of physicians, surgeons were named in 78 percent of cases; 42 percent of these surgeons were cardiothoracic surgeons. Nationally, 14 cases have resulted in plaintiff awards totalling $75,420,798. Physicians have been liable for 41 percent of that sum, blood banks 31 percent, and hospitals 26 percent. Of the 10 liability theories raised, the most frequent were claims of medical negligence (46% of cases), failure to identify high-risk donors (45%), lack of informed consent (39%), and failure to conduct surrogate testing (39%). Twenty-six trial results favorable to health care providers were noted nationally, 17 occurring in the San Francisco Bay Area, where case filings peaked before 1990 (40/56) and where new case filings decreased (1990, 5; 1991, 3; 1992, 1; 1993, 0) as verdicts favoring health care providers were reported.

CONCLUSION

Transfusion-associated AIDS litigation began with verdicts against blood banks, but has expanded to suits against physicians and hospitals that are based on theories of medical negligence and informed consent. Despite widely publicized verdicts for plaintiffs, health care professionals have successfully defended these lawsuits, and in one center of early litigation, a sharp decrease in new case filings has been observed.

Detection of faking on role-play tests of assertiveness

Faking and demand characteristics can represent significant threats to the validity of role-play tests of social competence. The present study examined whether faking could be detected via the global judgments of experienced and inexperienced assessors. 26 undergraduates low in assertiveness were induced to fake their performances on the Idiographic Role-play Test via instructions and information. Experienced judges successfully differentiated faking subjects from highly assertive subjects (n = 27) who had been provided with information and nonfaking instructions (98% accuracy). Inexperienced assessors correctly classified 79% of the subjects. Within the discussed limitations of this study, it appears that it is possible to detect faking on role-play tests of assertiveness.

Relationships between bulimia, childhood sexual abuse, and family environment

Prior studies investigating the relationship between childhood sexual abuse and bulimia have yielded mixed to weak empirical support for such an association. The current research, utilizing relatively restrictive definitions of abuse and bulimia, obtained significant associations between bulimia, sexual abuse, and a chaotic family environment in female college students. Among abuse victims, severity of abuse was also associated with bulimia. Although some analyses suggested that a chaotic family environment moderated the abuse--bulimia association, sexual abuse, and family environment appeared to combine in an additive manner to increase the probability of bulimia.

Fakability of two different role-play methodologies for assessing assertion

The fakability of two methodologically different role-play tests of assertion was examined, 30 undergraduates low in assertiveness were tested and retested on the Behavioral Assertiveness Test--Revised and the Idiographic Role-play Test. Half of the testees were instructed to fake assertion during the second testing. Analysis indicated that both tests were fakable; however, testees reported more difficulty faking the latter test than the former. The detection of faking may be possible, particularly on role-play tests employing an idiographic methodology.