Safety of elective paediatric surgery during the coronavirus disease 2019 pandemic

INTRODUCTION

Corona-virus Disease 2019 (COVID-19) has had a huge impact on the delivery of healthcare worldwide, particularly elective surgery. There is a lack of data regarding risk of postoperative COVID-19 infection in children undergoing elective surgery, and regarding the utility of pre-operative COVID-19 testing, and preoperative "cocooning" or restriction of movements. The purpose of this present study was to examine the safety of elective paediatric Otolaryngology surgery during the COVID-19 pandemic with respect to incidence of postoperative symptomatic COVID-19 infection or major respiratory complications.

MATERIALS AND METHODS

Prospective cohort study of paediatric patients undergoing elective Otolaryngology surgery between September and December 2020. Primary outcome measure was incidence of symptomatic COVID-19 or major respiratory complications within the 14 days after surgery. Parents of prospectively enrolled patients were contacted 14 days after surgery and enquiry made regarding development of postoperative symptoms, COVID-19 testing, or diagnosis of COVID-19.

RESULTS

302 patients were recruited. 125 (41.4%) underwent preoperative COVID-19 RT-PCR testing. 66 (21.8%) restricted movements prior to surgery. The peak 14-day COVID-19 incidence during the study was 302.9 cases per 100,000 population. No COVID-19 infections or major respiratory complications were reported in the 14 day follow-up period.

CONCLUSION

The results of our study support the safety of elective paediatric Otolaryngology surgery during the pandemic, in the setting of community incidence not exceeding that observed during the study period.

Hematologic abnormalities as a marker of cirrhosis after Fontan completion

Background

More patients with functioning single ventricle are living into adulthood due to improved survival with the Fontan procedure. Therefore, screening and detection of late-stage complications such as Fontan Associated Liver Disease (FALD) has become increasingly important to improve outcomes. The role of hematologic abnormalities as a marker of cirrhosis in this population is evolving.

Purpose

We aimed to evaluate the value of hematologic parameters in predicting the presence of cirrhosis in the context of FALD.

Methods

This was a retrospective study of patients after Fontan completion who underwent liver biopsy between 2007 and 2019 at our institution. Biopsy slides were evaluated for the presence of cirrhosis by a single pathologist. Laboratory testing was recorded within 12 months of the liver biopsy. Univariable analysis was conducted with an alpha level of 0.05 for hypothesis testing.

Results

A total of 31 Fontan patients with liver biopsies were identified, of whom 7 patients were found to have cirrhosis (Table 1). Compared to patients with no cirrhosis on biopsy, cirrhotic patients tended to have lower hematologic counts including absolute lymphocyte count (0.78 vs 1.02, p=0.019), hemoglobin (12.5 vs 15.1, p=0.018), and platelets (131 vs 194, p=0.025). Notably, the MELD-XI score (Model for End-stage Liver Disease excluding INR) as well as its individual components, creatinine and total bilirubin, were not different between the groups.

Conclusion

Our data suggests that hematologic parameters including absolute lymphocyte count might be of value in predicting cirrhosis on liver biopsy following Fontan completion. Further research to validate these findings in other cohorts is warranted.

Funding Acknowledgement

Type of funding sources: None.

Physical Therapy Interventions and Outcome Measures for a Patient Diagnosed with Anti-NMDA Receptor Encephalitis

Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis is the most common cause of autoimmune encephalitis after acute demyelinating encephalitis. Patients usually present with acute behavioral changes, psychosis, and abnormal limb movements and can also present with symptoms of catatonia. Treatment typically consists of an immunotherapy protocol consisting of intravenous immunoglobulin, corticosteroids, and plasmapheresis. This article describes the medical treatment, physical therapy (PT) interventions, and outcomes of a 16-year-old patient with anti-NMDA receptor encephalitis with malignant catatonia. Using PT interventions such as bed mobility, transfer, and gait training, and parent education initially, and progressing to balance re-education and age-appropriate functional tasks the patient was able to progress and be discharged to home with family with a recommendation for continued PT treatment in the outpatient setting. [Pediatr Ann. 2021;50(10):e437-e443.].

Examining Conductive Education: Linking Science, Theory, and Intervention

Recognized in many European countries and Canada as a valid form of therapeutic and educational rehabilitation, conductive education (CE) emphasizes cognitive and motor learning principles for movement reeducation. This article illustrates how CE incorporates motor control and motor learning theories in conjunction with unique facilitation concepts, including rhythmic intention, task series, tailored low-tech equipment, and traditional facilitation concepts such as developmental sequence, manual facilitations, and multimodal interventions. Uniquely, CE brings together task series practice and learning, including a lying program, sitting program, standing program, and walking program, along with activities of daily living within a group treatment model. The conductor uses cadence and rhythmic intention to encourage movement exploration in a scripted plan of care. The participants are active learners and use CE slatted equipment to help support movements. Full participation, to the best of the learners' ability, is realized with activity modifications made by the conductor. Increased motor control arises through repetition, practice, functional context, and sensory feedback that provide guidance for intention and voluntary movement. Motor control and motor learning theories are foundational principles of CE. Individuals with neurologic injuries, including cerebral palsy, stroke syndrome, Parkinson disease, and traumatic brain injury, can benefit from CE. To date, although research studies cannot objectively compare one person's movement skills with another's, new research surrounding motor control and motor learning illustrates and supports the principles and practice of CE. CE is an educational therapy model for teaching and developing new movement skills for individuals with neurologic impairments. This article connects the current science of movement and describes the unique principles involved with CE delivery as an intervention for individuals with neurologic impairments.

The ALERT-B questionnaire: A screening tool for the detection of gastroenterological late effects after radiotherapy for prostate cancer

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ALERT-B provides an effective screening tool for gastroenterological late effects.

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84.4% and 95.7% of patients demonstrated complications at 6 and 12 months post-treatment.

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ROC curves at baseline indicated an AUC of 0.867 compared to the GSRS diarrhoea subscale.

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ROC curves at baseline indicated an AUC of 0.765 compared to the EPIC bowel subscale.

There is an increasing need to measure treatment-related side effects in normal tissues following cancer therapy. The ALERT-B (Assessment of Late Effects of RadioTherapy - Bowel) questionnaire is a screening tool that is composed of four items related specifically to bowel symptoms. Those patients that respond with a “yes” to any of these items are referred on to gastroenterologist in order to improve the long-term consequences of these side effects of radiological treatment. Here we wish to test the ability of this questionnaire to identify these subsequent gastroenterological complications by tracking prostate cancer patients that were positive with respect to ALERT-B. We also carry out receiver-operator curve (ROC) analysis for baseline data for an overall ALERT-B questionnaire score with respect to subscale data for the Gastrointestinal Symptom Rating Scale (GSRS) and the Expanded Prostate Cancer Index Composite (EPIC-26) questionnaire. 84.4% and 95.7% of patients identified by the ALERT-B questionnaire demonstrated complications diagnosed at 6 and 12 months post-treatment, respectively. ROC curve analysis of baseline data showed that ALERT-B detected clinically relevant levels of side effects established at baseline by the GSRS diarrhoea subscale (AUC = 0.867, 95% CI = 0.795 to 0.926) and at the minimally important level of side effects for the EPIC bowel subscale (AUC = 0.765, 95% CI = 0.617 to 0.913). These results show that ALERT-B provides a simple and effective screening tool for identifying gastroenterological complications after treatment for prostate cancer.

The impact of progressive pelvic floor muscle exercise and manual therapy in a patient postpartum who met the criteria for sacroiliac joint pain based on Laslett's cluster of provocation signs

Sacroiliac joint (SIJ) pain has been identified as a primary or contributing source of pain in patients with low back pain. The Laslett cluster of SIJ pain provocation tests has the strongest evidence for noninvasive clinical testing. The purpose of this report was to describe the impact of physical therapy treatments for a patient postpartum with SIJ pain who satisfied the Laslett cluster. Specifically, the goal was to assess the impact of progressive pelvic floor muscle exercise and manual therapy. The Modified Oswestry Low Back Pain Disability Questionnaire (MODI) was the primary outcome measure used in this case. In addition, the Numeric Pain Rating Scale (NRPS) and Global Rating of Change (GROC) were used as secondary outcome measures. In this case report, the patient responded to the combined interventions with decreases in MODI, NRPS and GROC. Further research is warranted to develop stronger evidence to identify specific interventions for the treatment of SIJ pain.

Kynurenine pathway metabolism and the neurobiology of treatment-resistant depression: Comparison of multiple ketamine infusions and electroconvulsive therapy

Current first-line antidepressants can take weeks or months to decrease depressive symptoms. Low dose ketamine, an N-methyl-D-aspartate (NMDA) receptor antagonist, shows potential for a more rapid antidepressant effect, with efficacy also evident in previously treatment-resistant populations. However, a greater understanding of the physiological mechanisms underlying such effects is required. We assessed the potential impact of ketamine infusion on neurobiological drivers of kynurenine pathway metabolism in major depression (HPA axis hyperactivity, inflammation) in patients with treatment-resistant depression compared to gender-matched healthy controls. Furthermore, we assessed these biomarkers before and after electroconvulsive therapy (ECT), which is currently the gold standard for management of treatment-resistant depression. As previously demonstrated, treatment with ketamine and ECT was associated with improved depressive symptoms in patients. At baseline, waking cortisol output was greater in the ECT cohort, kynurenine was greater in the ketamine cohort, and kynurenic acid was lower in patients compared to healthy controls, although inflammatory markers (IL-6, IL-8, IL-10 or IFN-γ) were similar in patients and controls. Furthermore, in patients who responded to ECT, the cortisol awakening response was decreased following treatment. Despite a trend towards reduced kynurenine concentrations in those who responded to ketamine, ketamine was not associated with significant alterations in any of the biomarkers assessed.

DVD Versus Physiotherapist-Led Inhaler Education: A Randomised Controlled Trial

Correct technique with inhalers is vital for therapeutic effect. Efficacy of DVD inhaler instruction was investigated. Secondary aims were to examine feasibility of an inhaler technique outcome measure, and to compare knowledge and self-efficacy after DVD or individual education. This was a randomised controlled trial conducted in a regional hospital paediatric ward, involving new or existing paediatric inhaler users. Inhaler technique was assessed pre-education in existing inhaler users. Participants were then randomised to message equivalent education by DVD or individually with a physiotherapist. Inhaler technique, self-efficacy and knowledge were assessed immediately post- and three months after education. Twenty one participants received DVD or individual education. There were no significant differences between groups for technique, self-efficacy or knowledge at any time. The outcome measure was feasible for use in a research study. DVD education was equivalent to individual instruction to teach parents how to use inhalers with their child.

Modelling a demand driven biogas system for production of electricity at peak demand and for production of biomethane at other times

Four feedstocks were assessed for use in a demand driven biogas system. Biomethane potential (BMP) assays were conducted for grass silage, food waste, Laminaria digitata and dairy cow slurry. Semi-continuous trials were undertaken for all feedstocks, assessing biogas and biomethane production. Three kinetic models of the semi-continuous trials were compared. A first order model most accurately correlated with gas production in the pulse fed semi-continuous system. This model was developed for production of electricity on demand, and biomethane upgrading. The model examined a theoretical grass silage digester that would produce 435kWe in a continuous fed system. Adaptation to demand driven biogas required 187min to produce sufficient methane to run a 2MWe combined heat and power (CHP) unit for 60min. The upgrading system was dispatched 71min following CHP shutdown. Of the biogas produced 21% was used in the CHP and 79% was used in the upgrading system.

Large-scale discovery of novel genetic causes of developmental disorders

Despite three decades of successful, predominantly phenotype-driven discovery of the genetic causes of monogenic disorders, up to half of children with severe developmental disorders of probable genetic origin remain without a genetic diagnosis. Particularly challenging are those disorders rare enough to have eluded recognition as a discrete clinical entity, those with highly variable clinical manifestations, and those that are difficult to distinguish from other, very similar, disorders. Here we demonstrate the power of using an unbiased genotype-driven approach to identify subsets of patients with similar disorders. By studying 1,133 children with severe, undiagnosed developmental disorders, and their parents, using a combination of exome sequencing and array-based detection of chromosomal rearrangements, we discovered 12 novel genes associated with developmental disorders. These newly implicated genes increase by 10% (from 28% to 31%) the proportion of children that could be diagnosed. Clustering of missense mutations in six of these newly implicated genes suggests that normal development is being perturbed by an activating or dominant-negative mechanism. Our findings demonstrate the value of adopting a comprehensive strategy, both genome-wide and nationwide, to elucidate the underlying causes of rare genetic disorders.

Dynamic response signatures of a scaled model platform for floating wind turbines in an ocean wave basin

Understanding of dynamic behaviour of offshore wind floating substructures is extremely important in relation to design, operation, maintenance and management of floating wind farms. This paper presents assessment of nonlinear signatures of dynamic responses of a scaled tension-leg platform (TLP) in a wave tank exposed to different regular wave conditions and sea states characterized by the Bretschneider, the Pierson-Moskowitz and the JONSWAP spectra. Dynamic responses of the TLP were monitored at different locations using load cells, a camera-based motion recognition system and a laser Doppler vibrometer. The analysis of variability of the TLP responses and statistical quantification of their linearity or nonlinearity, as non-destructive means of structural monitoring from the output-only condition, remains a challenging problem. In this study, the delay vector variance (DVV) method is used to statistically study the degree of nonlinearity of measured response signals from a TLP. DVV is observed to create a marker estimating the degree to which a change in signal nonlinearity reflects real-time behaviour of the structure and also to establish the sensitivity of the instruments employed to these changes. The findings can be helpful in establishing monitoring strategies and control strategies for undesirable levels or types of dynamic response and can help to better estimate changes in system characteristics over the life cycle of the structure.

Conductive education: a functional skills program for children with cerebral palsy

Conductive education (CE) is an educational approach for children with cerebral palsy. This paper describes the history of conductive education, and the characteristics of current programs that exist in many countries. The underlying principles and the unique techniques used in CE programs are described. These include the role of the conductor or class leader; facilitations (teaching strategies) known as rhythmic intention, task series, and described equipment; and the structured program. The importance of the group setting and the impact on motivation, and the development of self-efficacy within each child are described. The perspective of children and families who pursue CE is discussed. Existing evidence evaluating CE is summarized and recommendations for expanding the evidence base are made.

The Western New York Health Resources Project: developing access to local health information

The Western New York Health Resources Project was created to fill a gap in online access to local health information resources describing the health of a defined geographic area. The project sought to identify and describe information scattered among many institutions, agencies, and individuals, and to create a database that would be widely accessible. The project proceeded in three phases with initial phases supported by grant funding. This paper describes the database development and selection of content, and concludes that a national online network of local health data representing the various geographic regions of the United States would contribute to the quality of health care in general.

Patterns of dysphoria in a Puerto Rican urban community

This study was undertaken to explore the prevalence of perceived dysphoria in a poor, urban, predominantly Puerto Rican community. A cross-sectional sample of 704 adult respondents were asked a single validated question, with a five-item Likert scale response, about their level of perceived dysphoria. Chi-squared analysis and Spearman's correlation coefficients were used to assess the association of level of dysphoria with social characteristics, barriers to health care, health status, and substance use. Linear regression modeling was used to control for confounding variables. Twenty percent of the respondents were dysphoric. Respondents with no health insurance or no source of health care were least likely to be dysphoric. Persons who perceived distance to the hospital and the doctor, and understanding language of the doctor and office staff as barriers to care were more likely to be dysphoric. Ethnicity was not correlated with level of perceived dysphoria; however, age, gender, and health status were found to be associated with level of dysphoria after controlling for other correlated variables. These results indicate that the psychological needs of communities need to be understood and interventions that are appropriate for the population need to be devised.

Predictors of first-contact care in a poor urban community

OBJECTIVE

The aim of the study was to identify predictors of first-contact care in a population of poor urban residents.

METHODS

Information from a community health needs survey was used for the study. The sample included adult residents in five urban census tracts with a large proportion of Puerto Rican Hispanics. Potential predictors included social characteristics, source of health insurance, perceived health status, number of chronic diseases, use of alternatives to medical care, smoking status, and problems with alcohol use.

RESULTS

A total of 826 household interviews were completed for a participation rate of 78% among eligible households. Individuals with no health insurance were six times more likely to lack a source of first-contact care, compared with those who have traditional indemnity insurance. Those who only had Medicaid were four times more likely to lack a source of first-contact care. Respondents involved in Medicaid-managed care programs had similar access to first-contact care as those with commercial insurance. Individuals who reported problems with alcohol were three times more likely to lack a source of first-contact care.

CONCLUSIONS

Health insurance is an important predictor of access to first-contact care for poor urban residents. Those who identify problems with alcohol and African-Americans have additional difficulty with access to first-contact care.

Parenteral nutrition: hospital to home

Parenteral nutrition support is the provision of essential nutrients intravenously, bypassing the intestinal tract. It is used in a variety of clinical settings and medical conditions. Parenteral nutrition is a complex technology that requires the input of many professionals, including dietitians. The role of the dietitian in parenteral nutrition support involves direct patient care, consultative services, education, program development, and research. Even though this field of practice is still developing, some common practices can be described. Nutrition assessment determination of macronutrient and micronutrient requirements, and monitoring are vital aspects of the provision of parenteral nutrition support that benefit from the knowledge and experience of a dietitian. The future of parenteral nutrition includes identification of preferred fuels for specific disease states, development of new lipid emulsions, and identification of conditionally essential nutrients.

c-jun expression in substantia nigra neurons following striatal 6-hydroxydopamine lesions in the rat

The proto-oncogene c-jun is thought to play a role in the control of growth and differentiation of many cell types. It has been demonstrated previously that damage to axons of peripheral motor or sensory neurons resulted within 24 h in substantially increased levels of the c-jun gene in the parent cell bodies. These increased levels of c-jun protein and messenger RNA are maintained if the damaged nerve is ligated, but return to basal levels if the peripheral nerve is allowed to regenerate. We have examined the expression of immediate early genes in central neurons of the rat and now show that a 6-hydroxydopamine-induced axotomy of the dopaminergic nigrostriatal pathway results in a substantial increase in the levels of c-jun (but not c-fos) messenger RNA and protein within neurons of the substantia nigra pars compacta. However, the central neuronal response differs from the peripheral nerve response in that it becomes maximal at four to eight days post-lesion and is transient, declining to control levels in nigral neurons by 14 days post-lesion. These expression patterns may be related to the differential capacity of central and peripheral neurons to regenerate. The precise role of c-jun in these processes, or in the regenerative response, is unclear but it remains possible that c-jun activation following axon damage leads to an increased expression of genes which are essential for the regenerative response. The nature of the mechanism by which c-jun levels are attenuated in central neurons is also unclear, but inhibitory factors, generated by the central environment, may play a role.

Patterns and predictors of smoking cessation among users of a telephone hotline

Most former cigarette smokers in the United States have stopped without formal assistance. However, a large proportion of smokers desire and seek help other than by attending formal programs. It is important to recognize what factors are likely to influence the effectiveness of smoking cessation attempts among these persons. The authors report results of a prospective cohort study of 1,552 smokers who called a stop smoking hotline to request self-help smoking cessation information. The participants were classified into three groups based on reports at the 6-month followup: 242 quitters, 497 recidivists, and 813 nonquitters. Baseline and followup data were used to evaluate three comparisons: quitters versus nonquitters, quitters versus recidivists, and recidivists versus nonquitters. Nonquitters appear to be less motivated and more doubtful of their abilities to quit successfully compared with the other two groups. Quitters appear to live in a supportive environment for smoking cessation. Heavier smokers are more hesitant to try to quit, but once they make an attempt they are as likely to succeed as lighter smokers, when other factors are kept constant. Efforts to promote environments supportive of smoking cessation are likely to result in a larger number of successful quitters. Similarly, efforts to strengthen motivation and belief in personal ability to quit are likely to encourage more nonquitters to attempt to stop smoking. Finally, it appears that some smokers need a previous quit attempt before they are able to maintain cessation successfully.

Smoking, alcohol, dentition and diet in the epidemiology of oral cancer

This matched case-control study was conducted in Western New York. The smoking, alcohol consumption, dental hygiene and diet of 290 cases were compared with those of 290 sex-, age-, and neighbourhood-matched controls. The results confirm earlier findings that cigarette smoking and alcohol consumption impart substantial risk of oral cancer. The results also confirm that poor oral hygiene increases the risk of oral cancer, although this effect is much smaller than those of cigarette smoking and alcohol consumption. The results suggest that, of macronutrients, intake of fat is more likely than those of protein or carbohydrate to be related to risk. Of micronutrients, calcium, sodium, riboflavin and retinol are associated with risk, while thiamin, niacin, and dietary fibre are associated with decreased risk. Although patterns of dietary effects are discernable, these effects are in general much weaker than are those of smoking and alcohol consumption.

Large-scale study of freedom from smoking clinics--factors in quitting

The American Lung Association's Freedom From Smoking Clinics are widely available in the community and at the worksite for smokers who wish the help of a formal group program in quitting the habit. Little has been published on their outcomes. A study of 494 smokers attending 42 Freedom From Smoking Clinics in western New York State showed that 29 percent reported not smoking about 1 year after attending the clinic sessions. There was a wide range of quit rates over different clinics, but the rates were similar for men and women and for different age groups. Those initially smoking less than one pack per day were more likely to be successful in quitting than heavier smokers. Quit rates were similar in work site groups and in the community clinics. Perceptions of having received group support at the clinic were also related to higher success rates. Research on group composition and process might be a fruitful road to raising what seems to be a ceiling on the success of current techniques.

Routine hospital admission in twin pregnancy between 26 and 30 weeks' gestation

Of 141 women with twin pregnancies, 72 were randomly assigned to outpatient care and 69 to hospital admission between 26 and 30 weeks' gestation. There were no differences between the groups in the frequencies of major maternal complications in pregnancy and labour but more of those admitted to hospital than of the outpatient group had to be admitted after 30 weeks. There were no differences between the groups in the mean birthweights of the twins by birth order, or in their mean gestation at birth whether analysed by intention to treat or by the treatment given. 22 infants were delivered before 32 weeks' gestation in the inpatient group compared with 10 in the outpatient group. With the exception of small-for-dates infants, any trend towards greater morbidity or mortality was seen in the inpatient group. The policy of routine hospital admission of women with twin pregnancies from 26 weeks' gestation is not beneficial to mother or babies and should be abandoned.

Hypospadias in the true hermaphrodite

A case is reported of a six-year-old boy who, after several attempts at the repair of hypospadias, was investigated urologically, and was found to be a true hermaphrodite. The necessity of investigation of the genitourinary tract before undertaking the repair of hypospadias is emphasized.