Procalcitonin for reduced antibiotic exposure in ventilator-associated pneumonia: a randomised study

In patients with ventilator-associated pneumonia (VAP), guidelines recommend antibiotic therapy adjustment according to microbiology results after 72 h. Circulating procalcitonin levels may provide evidence that facilitates the reduction of antibiotic therapy. In a multicentre, randomised, controlled trial, 101 patients with VAP were assigned to an antibiotic discontinuation strategy according to guidelines (control group) or to serum procalcitonin concentrations (procalcitonin group) with an antibiotic regimen selected by the treating physician. The primary end-point was antibiotic-free days alive assessed 28 days after VAP onset and analysed on an intent-to-treat basis. Procalcitonin determination significantly increased the number of antibiotic free-days alive 28 days after VAP onset (13 (2-21) days versus 9.5 (1.5-17) days). This translated into a reduction in the overall duration of antibiotic therapy of 27% in the procalcitonin group (p = 0.038). After adjustment for age, microbiology and centre effect, the rate of antibiotic discontinuation on day 28 remained higher in the procalcitonin group compared with patients treated according to guidelines (hazard rate 1.6, 95% CI 1.02-2.71). The number of mechanical ventilation-free days alive, intensive care unit-free days alive, length of hospital stay and mortality rate on day 28 for the two groups were similar. Serum procalcitonin reduces antibiotic therapy exposure in patients with ventilator associated pneumonia.

Möbius syndrome due to brain stem tegmental necrosis

Möbius syndrome undoubtedly results from a variety of disorders affecting central or peripheral portions of appropriate cranial nerves or their target muscles. Pathological alterations observed in cranial nuclei are most often viewed as aplastic or dysplastic lesions. Two patients with Möbius syndrome with associated facial and skeletal malformations showed mineralized necrotic foci in multiple brain stem nuclei. Prenatal encephalomalacic lesions represent the pathological basis for some cases of congenital static Möbius syndrome.

Long non-coding RNA: Functional agent for disease traits

In recent years, long non-coding RNAs (lncRNAs) have attracted the attention of researchers with their involvement in all facets of life. LncRNAs are transcripts of more than 200 nucleotides which lack defined protein coding potential. Although they do not code for proteins, a large number of them are involved in regulating gene expression and translation. The presence of numerous lncRNAs in the human genome has prompted us to investigate the contribution of these molecules to human biology and medicine. In this review, we present the potential role of lncRNAs interlinked to different human diseases and genetic disorders. We also describe their role in cellular differentiation and aging and discuss their potential importance as biomarkers and as therapeutic agents.

Midregional pro-atrial natriuretic peptide and procalcitonin improve survival prediction in VAP

Ventilator-associated pneumonia (VAP) affects mortality, morbidity and cost of critical care. Reliable risk estimation might improve end-of-life decisions, resource allocation and outcome. Several scoring systems for survival prediction have been established and optimised over the last decades. Recently, new biomarkers have gained interest in the prognostic field. We assessed whether midregional pro-atrial natriuretic peptide (MR-proANP) and procalcitonin (PCT) improve the predictive value of the Simplified Acute Physiologic Score (SAPS) II and Sequential Related Organ Failure Assessment (SOFA) in VAP. Specified end-points of a prospective multinational trial including 101 patients with VAP were analysed. Death <28 days after VAP onset was the primary end-point. MR-proANP and PCT were elevated at the onset of VAP in nonsurvivors compared with survivors (p = 0.003 and p = 0.017, respectively) and their slope of decline differed significantly (p = 0.018 and p = 0.039, respectively). Patients with the highest MR-proANP quartile at VAP onset were at increased risk for death (log rank p = 0.013). In a logistic regression model, MR-proANP was identified as the best predictor of survival. Adding MR-proANP and PCT to SAPS II and SOFA improved their predictive properties (area under the curve 0.895 and 0.880). We conclude that the combination of two biomarkers, MR-proANP and PCT, improve survival prediction of clinical severity scores in VAP.

Using models to shape measles control and elimination strategies in low- and middle-income countries: A review of recent applications

After many decades of vaccination, measles epidemiology varies greatly between and within countries. National immunization programs are therefore encouraged to conduct regular situation analyses and to leverage models to adapt interventions to local needs. Here, we review applications of models to develop locally tailored interventions to support control and elimination efforts. In general, statistical and semi-mechanistic transmission models can be used to synthesize information from vaccination coverage, measles incidence, demographic, and/or serological data, offering a means to estimate the spatial and age-specific distribution of measles susceptibility. These estimates complete the picture provided by vaccination coverage alone, by accounting for natural immunity. Dynamic transmission models can then be used to evaluate the relative impact of candidate interventions for measles control and elimination and the expected future epidemiology. In most countries, models predict substantial numbers of susceptible individuals outside the age range of routine vaccination, which affects outbreak risk and necessitates additional intervention to achieve elimination. More effective use of models to inform both vaccination program planning and evaluation requires the development of training to enhance broader understanding of models and where feasible, building capacity for modelling in-country, pipelines for rapid evaluation of model predictions using surveillance data, and clear protocols for incorporating model results into decision-making.

3-D Miniplates Versus Conventional Miniplates in Treatment of Mandible Fractures

AIM

To study whether the use of 3-D miniplate, when compared with conventional miniplate, gives better clinical outcomes with fewer complications in patients with fracture mandible.

MATERIALS AND METHODS

A prospective study was conducted in the Department of Oral and Maxillofacial Surgery, Trauma Care Centre, on 40 patients. They were randomly divided into Group-I and Group-II with 20 patients in each group. In Group-I, 3-D miniplate was used and in Group-II, conventional miniplate was used. Parameters such as fracture stability, occlusal status, mouth opening, nerve paresthesia, infection, pain, swelling, and complications were evaluated on 1st, 7th postoperative day, 1st month and 3rd month.

RESULTS

Fracture stability and occlusion were clinically better in Group-I than in Group-II on each follow-up; however, it was not statistically significant. Infection rate was lesser in Group-I than in Group-II (p = 0.003). Mouth opening was more in Group-II than in Group-I on immediate (p = 0.001) and 7th post-op day (p = 0.002). Overall complications were lesser in Group-I than in Group-II (p > 0.005).

CONCLUSION

There is no major difference observed in clinical outcomes between 3-D miniplate and conventional miniplate. Either method of fixation can be used successfully in treatment of mandible fractures with comparable rates of complications.

Perils of Total Colonic Aganglionosis Presenting in Neonatal Age

Background: The purpose of this study is to review the cases of total colonic aganglionosis seen in the span of ten years at a pediatric surgery unit of a tertiary care public hospital in New Delhi.Methods: Medical records of eleven patients with total colonic aganglionosis were retrieved.Results: Ten out of the twelve patients were males; seven were of the Muslim community. Average recorded birth weight was 2.2 kg. Ten patients presented with features of intestinal obstruction, while two presented with perforation peritonitis. Among the cases of obstruction, Hirschsprung's disease was suspected in eight cases (one was associated with Shah-Waardenburg syndrome), one case each was preoperatively diagnosed as ileal atresia and meconium ileus. Abdominal X-rays at presentation of all the neonates except in one with Shah-Waardenburg syndrome showed multiple air fluid levels. Contrast enema was done in five patients. It showed micro-colon in two patients, and typical question mark sign, dilated small bowel with transition zone in hepatic flexure and normal caliber colon in one each. All the patients underwent exploratory laparotomy. Intra-operatively, the transition zone was seen at distal ileum in ten cases and at hepatic flexure and transverse colon in one each. Biopsies of all the twelve patients eventually showed absence of ganglion cells in entire colon. Ileostomy was done in nine cases, colostomy in two and primary Kimura's procedure in one (this patient was discharged and lost to follow up). Left colonic patch with Swenson’s pull through with ileostomy was done for one patient on colostomy. His stoma was closed; he was eventually discharged and lost to follow up. In the other patient with colostomy, the stoma was closed and an ileostomy was created. Of all the patients on ileostomy, three expired in the immediate postoperative period. Four were lost to follow up. Two underwent Kimura's procedure; and expired few months later. One patient on ileostomy is awaiting further treatment.Conclusion: Management of total colonic aganglionosis is still in its infancy in the developing world. There is a lot of scope for improvement in the management. There is a need to have a stringent follow up of patients in order to know the long-term outcomes of the disease.

Evolution of casein kinase 1 and functional analysis of new doubletime mutants in Drosophila

Circadian clocks are timing devices that rhythmically adjust organism's behavior, physiology, and metabolism to the 24-h day-night cycle. Eukaryotic circadian clocks rely on several interlocked transcription-translation feedback loops, where protein stability is the key part of the delay between transcription and the appearance of the mature proteins within the feedback loops. In bilaterian animals, including mammals and insects, the circadian clock depends on a homologous set of proteins. Despite mostly conserved clock components among the fruit fly Drosophila and mammals, several lineage-specific differences exist. Here we have systematically explored the evolution and sequence variability of insect DBT proteins and their vertebrate homologs casein kinase 1 delta (CKIδ) and epsilon (CKIε), dated the origin and separation of CKIδ from CKIε, and identified at least three additional independent duplications of the CKIδ/ε gene in Petromyzon, Danio, and Xenopus. We determined conserved regions in DBT specific to Diptera, and functionally tested a subset of those in D. melanogaster. Replacement of Lysine K224 with acidic residues strongly impacts the free-running period even in heterozygous flies, whereas homozygous mutants are not viable. K224D mutants have a temperature compensation defect with longer free-running periods at higher temperatures, which is exactly the opposite trend of what was reported for corresponding mammalian mutants. All DBTs of dipteran insects contain the NKRQK motif at positions 220-224. The occurrence of this motif perfectly correlates with the presence of BRIDE OF DOUBLETIME, BDBT, in Diptera. BDBT is a non-canonical FK506-binding protein that physically interacts with Drosophila DBT. The phylogeny of FK506-binding proteins suggests that BDBT is either absent or highly modified in non-dipteran insects. In addition to in silico analysis of DBT/CKIδ/ε evolution and diversity, we have identified four novel casein kinase 1 genes specific to the Drosophila genus.

The P-loop NTPase RUVBL2 is a conserved clock component across eukaryotes

The eukaryotic circadian clock keeps time by using a transcription-translation feedback loop, which exhibits an architecture that is conserved across a diverse range of organisms, including fungi, plants and animals1. Despite their mechanistic similarity, the molecular components of these clocks indicate a lack of common ancestry2. Our study reveals that RUVBL2, which is a P-loop NTPase enzyme previously shown to affect circadian phase and amplitude as part of mammalian clock super-complexes, influences the circadian period through its remarkably slow ATPase activity, resembling the well-characterized KaiC-based clock in cyanobacteria. A screen of RUVBL2 variants identified arrhythmic, short-period and long-period mutants that altered circadian locomotor activity rhythms following delivery by adeno-associated virus to the murine suprachiasmatic nucleus. Enzymatic assays showed that wild-type RUVBL2 hydrolyses only around 13 ATP molecules a day, a vastly reduced turnover compared with typical ATPases. Notably, physical interactions between RUVBL2 orthologues and core clock proteins in humans, Drosophila and the fungus Neurospora, along with consistent circadian phenotypes of RUVBL2-mutant orthologues across species, reinforce their clock-related function in eukaryotes. Thus, as well as establishing RUVBL2 as a common core component in eukaryotic clocks, our study supports the idea that slow ATPase activity, initially discovered in cyanobacteria, is a shared feature of eukaryotic clocks.

Pediatric Maxillary Sinus Growth Curve

Objective: Describe the growth pattern of the maxillary sinus in the pediatric population. This includes identifying growth spurts and comparing growth by side and gender. This data is intended to assist a surgeon recommending or delaying surgical treatment and to help with surgical planning.

Method: CT scans performed in patients under 18 years at a Children’s hospital from January 2006 through June 2009 were reviewed. Scans with sinus disease affecting the normal sinus anatomy were excluded. The height, width, and depth of the right and left maxillary sinuses were measured to characterize its growth pattern.

Results: The overall growth rate of each sinus from birth to age18 years is 1.98 mm3 per year. The growth from ages 1 to 7 years is 1.4 mm3 per year, 7 to 9 years is 3.1 mm3 per year, 9 to 12 years is 0.4 mm3 per year, 12 to 15 years is 4.8 mm3 per year, and 15 to 18 years is 1.5 mm3 per year. The predominant dimension contributing to growth during each growth spurt, ages 7 to 9 years and 12 to 15 years are height and depth respectively. The rate is 0.15 mm per year and 1.9 mm per year respectively.

Conclusion: Comparison of gender and side demonstrated no significant difference in height, width, or depth at each age. The maxillary sinus gradually grows from ages 1 to 7, 9 and 12 and 15 onward. Two growth spurts were identified from ages 7 and 9 and 12 and 15.

Germline Editing of Drosophila Using CRISPR-Cas9-Based Cytosine and Adenine Base Editors

Target-AID, BE3, and ABE7.10 base editors fused to the catalytically modified Cas9 and xCas9(3.7) were tested for germline editing of the fruit fly Drosophila melanogaster. We developed a guide RNA-expressing construct, white-4gRNA, targeting splice sites in the white gene, an X-chromosome located gene. Using white-4gRNA flies and transgenic lines expressing Target-AID, BE3, and ABE7.10 base editors, we tested the efficiency of stable germline gene editing at three different temperatures. Classical Cas9 generating insertions/deletions by non-homologous end joining served as a reference. Our data indicate that gene editing is most efficient at 28°C, the highest temperature suitable for fruit flies. Finally, we created a new allele of the core circadian clock gene timeless using Target-AID. This base edited mutant allele timSS308-9FL had a disrupted circadian clock with a period of ∼29 h. The white-4gRNA expressing fly can be used to test new generations of base editors for future applications in Drosophila.

0958 The Prevalence of Depression in Children With Chronic Sleep and Respiratory Disorders

Introduction

In 2017, 13.3% of US adolescents aged 12 to 17 had at least one major depressive episode (NIMH, 2019). The risk of depression is higher in children with sleep apnea, and children with depression or anxiety have a 1.2-1.8 times higher rate of asthma related ED visits. Therefore, the purpose of this study was to determine the prevalence of depression symptoms in children with chronic disorders. We hypothesized that subjects with sleep disorders would have a higher prevalence of positive depression scores than subjects with respiratory disease, and that the prevalence would be highest in subjects with both conditions.

Methods

The Patient Health Questionnaire-9 (PHQ-9) was administered to children between the ages of 12 and 18 to screen for depression as part of a pulmonary or sleep clinic visit. Each patient’s PHQ-9 results were scored as normal, mild, moderate, or severe for levels of depression severity. Additionally, a chart review was conducted to gather their demographic and clinical data.

Results

Of a total of 87 subjects,71 (81.6%) had a respiratory disorder and 40 (46.0%) subjects had a sleep disorder. Due to the amount of overlap of respiratory and sleep disorders amongst the subjects, depression severity rather than chronic disease was chosen as the primary outcome. Using multiple linear regression, when all other factors were held constant, the average depression score increased by 5.0 when patients had a combination of asthma and obstructive sleep apnea (p-value = 0.02) and also increased by 2.4 for subjects who were female (p-value = 0.01).

Conclusion

It is important to identify depression in children with chronic illness, as it can lead to higher healthcare utilization. Additionally, as mental health status may significantly impact health outcomes for patients with chronic disease, it would be beneficial to evaluate mental health in all pediatric patients with chronic disease. However, further research is needed to investigate these associations.

Support

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