Diagnostic accuracy of the Child and Adolescent Symptom Inventory (CASI-4R) substance use subscale in detecting substance use disorders in youth

Identifying substance use disorders (SUDs) early and accurately improves case formulation and treatment. Previous studies have investigated validity and reliability of the Child and Adolescent Symptom Inventory (CASI) for anxiety, mood, and behavior problems. The present study's aim was to test if the embedded CASI Substance Use (SU) subscale can discriminate adolescents and young adults (AYA) with and without a SUD diagnosis accurately enough to justify clinical application within an evidence-based assessment framework. N = 479 outpatient AYA (age 14-21) and their caregivers completed K-SADS-PLW semistructured diagnostic interviews; caregivers completed the CASI and adolescents completed a parallel version, the Youth (self-report) Inventory (YI). K-SADS-PLW indicated that 33 youth met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for SUDs. Receiver Operating Characteristic (ROC) analyses found that both CASI and YI Substance Use subscale scores significantly identified K-SADS-diagnosed SUDs in AYA: Caregiver area under curve (AUC) = .91, p < .0005; YI(AUC) = .90, p < .0005. There was no significant difference in diagnostic accuracy between informants. Both subscales showed diagnostic and clinical utility in identifying AYA SUDs in outpatient mental health settings. Findings suggest that the CASI-4R subscale could be a helpful screening instrument for AYA SUDs. A case vignette illustrates the clinical application of study findings. Future research should examine rapport as a moderator of reporting accuracy, and replicate use of these measures under varying clinical scenarios. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Intranasal Oxytocin Modulates Decision-Making Depending on Outcome Predictability-A Randomized Within-Subject Controlled Trial in Healthy Males

Oxytocin (OT) has been extensively studied with regard to its socio-cognitive and -behavioral effects. Its potential as a therapeutic agent is being discussed for a range of neuropsychiatric conditions. However, there is limited evidence of its effects on non-social cognition in general and decision-making in particular, despite the importance of these functions in neuropsychiatry. Using a crossover/within-subject, blinded, randomized design, we investigated for the first time if intranasal OT (24 IU) affects decision-making differently depending on outcome predictability/ambiguity in healthy males. The Iowa Gambling Task (IGT) and the Cambridge Risk Task (CRT) were used to assess decision-making under low outcome predictability/high ambiguity and under high outcome probability/low ambiguity, respectively. After administration of OT, subjects performed worse and exhibited riskier performance in the IGT (low outcome predictability/high ambiguity), whereas they made borderline-significant less risky decisions in the CRT (high outcome probability/low ambiguity) as compared to the control condition. Decision-making in healthy males may therefore be influenced by OT and adjusted as a function of contextual information, with implications for clinical trials investigating OT in neuropsychiatric conditions.

Is the Finding Too Good to Be True? Moving from "More Is Better" to Thinking in Terms of Simple Predictions and Credibility

In 2018, De Los Reyes and Langer expanded the scope of the Evidence Base Updates series to include reviews of psychological assessment techniques. In keeping with the goal of offering clear "take-home messages" about the evidence underlying the technique, experts have proposed a rubric for evaluating the reliability and validity support. Changes in the research environment and pressures in the peer review process, as well as a lack of familiarity with some statistical methods, have created a situation in which many findings that appear "excellent" in the rubric are likely to be "too good to be true," in the sense that they are unlikely to generalize to clinical settings or are unlikely to be reproduced in independent samples. We describe several common scenarios in which published results are often too good to be true, including internal consistency, interrater reliability, correlation, standardized mean differences, diagnostic accuracy, and global model fit statistics. Simple practices could go a long way toward improving design, reporting, and interpretation of findings. When effect sizes are in the "excellent" range for issues that have been challenging, scrutinize before celebrating. When benchmarks are available based on theory or meta-analyses, results that are moderately better than expected in the favorable direction (i.e., Cohen's q ≥ +.30) also invite critical appraisal and replication before application. If readers and reviewers pull for transparency and do not unduly penalize authors who provide it, then change in research quality will be faster and both generalizability and reproducibility are likely to benefit.

An Efficient Approach to Perform MR-assisted PET Data Optimization in Simultaneous PET/MR Neuroimaging Studies

A main advantage of PET is that it provides quantitative measures of the radiotracer concentration, but its accuracy is confounded by several factors, including attenuation, subject motion, and limited spatial resolution. Using the information from one simultaneously acquired morphological MR sequence with embedded navigators, we propose an efficient method called MR-assisted PET data optimization (MaPET) to perform attenuation correction (AC), motion correction, and anatomy-aided reconstruction. Methods: For attenuation correction, voxel-wise linear attenuation coefficient maps were generated using an SPM8-based approach method on the MR volume. The embedded navigators were used to derive head motion estimates for event-based PET motion correction. The anatomy provided by the MR volume was incorporated into the PET image reconstruction using a kernel-based method. Region-based analyses were carried out to assess the quality of images generated through various stages of PET data optimization. Results: The optimized PET images reconstructed with MaPET was superior in image quality compared to images reconstructed using only attenuation correction, with high SNR and low coefficient of variation (5.08 and 0.229 in a composite cortical region compared to 3.12 and 0.570). The optimized images were also shown using the Cohen's d metric to achieve a greater effect size in distinguishing cortical regions with hypometabolism from regions of preserved metabolism in each individual for different diagnosis groups. Conclusion: We have shown the spatiotemporally correlated data acquired using a single MR sequence can be used for PET attenuation, motion and partial volume effects corrections and the MaPET method may enable more accurate assessment of pathological changes in dementia and other brain disorders.

MR-assisted PET motion correction in simultaneous PET/MRI studies of dementia subjects

BACKGROUND

Subject motion in positron emission tomography (PET) studies leads to image blurring and artifacts; simultaneously acquired magnetic resonance imaging (MRI) data provides a means for motion correction (MC) in integrated PET/MRI scanners.

PURPOSE

To assess the effect of realistic head motion and MR-based MC on static [¹⁸ F]-fluorodeoxyglucose (FDG) PET images in dementia patients.

STUDY TYPE

Observational study.

POPULATION

Thirty dementia subjects were recruited.

FIELD STRENGTH/SEQUENCE

3T hybrid PET/MR scanner where EPI-based and T₁ -weighted sequences were acquired simultaneously with the PET data.

ASSESSMENT

Head motion parameters estimated from high temporal resolution MR volumes were used for PET MC. The MR-based MC method was compared to PET frame-based MC methods in which motion parameters were estimated by coregistering 5-minute frames before and after accounting for the attenuation-emission mismatch. The relative changes in standardized uptake value ratios (SUVRs) between the PET volumes processed with the various MC methods, without MC, and the PET volumes with simulated motion were compared in relevant brain regions.

STATISTICAL TESTS

The absolute value of the regional SUVR relative change was assessed with pairwise paired t-tests testing at the P = 0.05 level, comparing the values obtained through different MR-based MC processing methods as well as across different motion groups. The intraregion voxelwise variability of regional SUVRs obtained through different MR-based MC processing methods was also assessed with pairwise paired t-tests testing at the P = 0.05 level.

RESULTS

MC had a greater impact on PET data quantification in subjects with larger amplitude motion (higher than 18% in the medial orbitofrontal cortex) and greater changes were generally observed for the MR-based MC method compared to the frame-based methods. Furthermore, a mean relative change of ∼4% was observed after MC even at the group level, suggesting the importance of routinely applying this correction. The intraregion voxelwise variability of regional SUVRs was also decreased using MR-based MC. All comparisons were significant at the P = 0.05 level.

DATA CONCLUSION

Incorporating temporally correlated MR data to account for intraframe motion has a positive impact on the FDG PET image quality and data quantification in dementia patients.

LEVEL OF EVIDENCE

3 Technical Efficacy: Stage 1 J. Magn. Reson. Imaging 2018;47:1288-1296.

Diagnostic Accuracy of the CASI-4R Psychosis Subscale for Children Evaluated in Pediatric Outpatient Clinics

Diagnostic accuracy of the Diagnostic and Statistical Manual of Mental Disorders-oriented Child and Adolescent Symptom Inventory (CASI-4R) Psychotic Symptoms scale was tested using receiver operating characteristic analyses to identify clinically significant psychotic symptoms. Participants were new outpatients (N = 700), ages 6.0 to 12.9 years (M = 9.7, SD = 1.8) at 9 child outpatient mental health clinics, who participated in the Longitudinal Assessment of Manic Symptoms (LAMS) Study baseline assessment. Because LAMS undersampled participants with low mania scores by design, present analyses weighted low scorers to produce unbiased estimates. Psychotic symptoms, operationally defined as a score of 3 or more for hallucinations or 4 or more for delusions based on the Schedule for Affective Disorders and Schizophrenia (K-SADS) psychosis items, occurred in 7% of youth. K-SADS diagnoses for those identified with psychotic symptoms above threshold included major depressive disorder, bipolar spectrum disorder, attention deficit/hyperactivity disorder, posttraumatic stress disorder, psychotic disorders, and autism spectrum disorder. The optimal psychosis screening cut score (maximizing sensitivity and specificity) was 2.75+ (corresponding diagnostic likelihood ratio [DiLR] = 4.29) for the parent version and 3.50+ (DiLR = 5.67) for the teacher version. The Area under the Curve for parent and teacher report was .83 and .74 (both p < .001). Parent report performed significantly better than teacher report for identifying psychotic symptoms above threshold (p = .03). The CASI-4R Psychosis subscale (J) appears clinically useful for identifying psychotic symptoms in children because of its brevity and accuracy.

A phase one, single-dose, open-label, clinical safety and PET/MR imaging study of 68Ga-DOTATOC in healthy volunteers

This prospective pilot study provides a dynamic whole body PET/MR image database, clinical safety, biodistribution profile and dosimetry of ⁶⁸Ga-DOTATOC in healthy subjects, to establish a baseline and standard reference for its use in diagnosis and treatment response evaluation among patients with somatostatin receptor expressing neoplastic diseases. Dynamic whole body PET/MR imaging was performed in 12 healthy subjects (male/female: 8/4) after injection of 242.39 ± 53.38 MBq (mean ± SD) ⁶⁸Ga-DOTATOC. Images were acquired 15, 60, 120, and 240 minutes post injection. Subjects were assessed at baseline and after ⁶⁸Ga-DOTATOC PET/MR by monitoring vital signs, 12-lead electrocardiograms, complete blood count, comprehensive metabolic panel, and urinalysis. Adverse events were monitored for one week after injection. Organ dosimetry was estimated using OLINDA/EXM 1.1 software. Radiotracer was exclusively eliminated via urinary tract (18.8 ± 1.0% of injected dose within 4 hours) and no redistribution was observed. Bladder wall, spleen and kidneys received the highest radiation exposure (0.64 ± 0.1 mSv/MBq, 0.29 ± 0.14 mSv/MBq, and 0.1 ± 0.02 mSv/MBq, respectively). Mean effective dose yielded 0.048 ± 0.007 mSv/MBq. No adverse events were reported during the one-week follow-up period. Follow-up laboratory tests and electrocardiograms showed no changes compared to the baseline. The use of MRI provided valuable anatomical information and eliminated the risk of radiation exposure compared to CT.

Diagnostic Efficiency of the Child and Adolescent Symptom Inventory (CASI-4R) Depression Subscale for Identifying Youth Mood Disorders

This study examined the diagnostic and clinical utility of the Child and Adolescent Symptom Inventory-4 R (CASI-4 R) Depressive and Dysthymia subscale for detecting mood disorders in youth (ages 6-12; M = 9.37) visiting outpatient mental health clinics. Secondary analyses (N = 700) utilized baseline data from the Longitudinal Assessment of Manic Symptoms study. Semistructured interviews with youth participants and their parents/caregivers determined psychiatric diagnoses. Caregivers and teachers completed the CASI-4 R. CASI-4 R depressive symptom severity and symptom count scores each predicted mood disorder diagnoses. Both caregiver scores (symptom severity and symptom count) of the CASI-4 R subscale significantly identified youth mood disorders (areas under the curve [AUCs] = .78-.79, ps < .001). The symptom severity version showed a small but significant advantage. Teacher symptom severity report did not significantly predict mood disorder diagnosis (AUC = .56, p > .05), whereas the teacher symptom count report corresponded to a small effect size (AUC = .61, p < .05). The CASI-4 R Depression scale showed strong incrememental validity even controlling for the other CASI-4 R scales. Caregiver subscale cutoff scores were calculated to assist in ruling in (diagnostic likelihood ratio [DLR] = 3.73) or ruling out (DLR = 0.18) presence of a mood disorder. The CASI-4 R Depressive subscale caregiver report can help identify youth mood disorders, and using DLRs may help improve diagnostic accuracy.

Empirically supported psychosocial interventions for bipolar disorder: Current state of the research

OBJECTIVES

Bipolar disorder requires psychiatric medications, but even guideline-concordant treatment fails to bring many patients to remission or keep them euthymic. To address this gap, researchers have developed adjunctive psychotherapies. The purpose of this paper is to critically review the evidence for the efficacy of manualized psychosocial interventions for bipolar disorder.

METHODS

We conducted a search of the literature to examine recent (2007-present), randomized controlled studies of the following psychotherapy interventions for bipolar disorder: psychoeducation (PE), cognitive behavioral therapy (CBT), interpersonal and social rhythm therapy (IPSRT), dialectical behavior therapy (DBT), mindfulness-based cognitive therapy (MBCT), and family therapies such as family focused therapy (FFT).

RESULTS

All of the psychotherapy interventions appear to be effective in reducing depressive symptoms. Psychoeducation and CBT are associated with increased time to mood episode relapse or recurrence. MBCT has demonstrated a particular effectiveness in improving depressive and anxiety symptoms. Online psychotherapy interventions, programs combining one or more psychotherapy interventions, and targeted interventions centering on particular symptoms have been the focus of recent, randomized controlled studies in bipolar disorder.

CONCLUSIONS

Psychotherapy interventions for the treatment of bipolar disorder have substantial evidence for efficacy. The next challenge will to disseminate these psychotherapies into the community.

Baseline disability and poor functioning in bipolar disorder predict worse outcomes: results from the Bipolar CHOICE study

OBJECTIVE

To examine the effects of treatment on functioning impairments and quality of life and assess baseline functioning and employment status as predictors of treatment response in symptomatic individuals from the Bipolar Clinical Health Outcomes Initiative in Comparative Effectiveness (Bipolar CHOICE) study.

METHOD

Bipolar CHOICE was an 11-site, 6-month randomized effectiveness study comparing lithium to quetiapine, each with adjunctive personalized treatments (APTs). We examined post hoc (1) the effects of treatment on functioning, (2) how changes in functioning differed between treatment responders and nonresponders, and (3) whether functioning and employment status mediated treatment response in 482 participants with DSM-IV-TR bipolar I or II disorder from September 2010 to September 2013.

RESULTS

Treatment was associated with significant improvements in functioning and quality of life, regardless of treatment group (P values < .0001). Responders showed greater improvements in quality of life (Quality of Life Enjoyment and Satisfaction Questionnaire P values < .05) and functioning (Longitudinal Interval Follow-up Evaluation-Range of Impaired Functioning Tool P values < .05) than nonresponders. Unemployed or disabled participants at baseline had significantly greater illness severity at baseline than employed participants (P values < .05). Over the study duration, employed participants reported greater improvements in physical health and quality of life in leisure activities than both unemployed and disabled participants (P values < .05). Individuals who saw greater improvement in functioning and quality of life tended to show greater improvements in depressive and anxiety symptoms (P values ≤ .0001), as well as overall illness severity (P values < .001). Early (8 weeks) and very early (4 weeks) clinical changes in mood symptoms predicted changes in functioning and quality of life at 6 months (P values < .001).

CONCLUSIONS

Prior disability status was associated with a worse treatment response and prospective illness course. Results implicate functioning and employment status as important markers of illness severity and likelihood of recovery in bipolar disorder, suggesting that interventions that target functional impairment may improve outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov identifier for the Bipolar CHOICE study: NCT01331304.

An exploratory study of responses to low-dose lithium in African Americans and Hispanics

OBJECTIVES

Few prospective studies examine the impact of ethnicity or race on outcomes with lithium for bipolar disorder. This exploratory study examines differences in lithium response and treatment outcomes in Hispanics, African Americans, and non-Hispanic whites with bipolar disorder in the Lithium Treatment Moderate Dose Use Study (LiTMUS).

METHODS

LiTMUS was a six-site randomized controlled trial of low-dose lithium added to optimized treatment (OPT; personalized, evidence-based pharmacotherapy) vs. OPT alone in outpatients with bipolar disorder. Of 283 participants, 47 African Americans, 39 Hispanics, and 175 non-Hispanic whites were examined. We predicted minority groups would have more negative medication attitudes and higher attrition rates, but better clinical outcomes.

RESULTS

African Americans in the lithium group improved more on depression and life functioning compared to whites over the 6 month study. African Americans in the OPT only group had marginal improvement on depression symptoms. For Hispanics, satisfaction with life did not significantly improve in the OPT only group, in contrast to whites and African Americans who improved over time on all measures. Attitudes toward medications did not differ across ethnic/racial groups.

CONCLUSIONS

African Americans show some greater improvements with lithium than non-Hispanic whites, and Hispanics showed more consistent improvements in the lithium group. The impact of low-dose lithium should be studied in a larger sample as there may be particular benefit for African Americans and Hispanics. Given that the control group (regardless of ethnicity/race) had significant improvements, optimized treatment may be beneficial for any ethnic group.

Psychotherapy use in bipolar disorder: Association with functioning and illness severity

OBJECTIVE

This study examines characteristics of individuals with bipolar disorder who sought psychotherapy versus those who did not.

METHODS

Bipolar CHOICE was an 11-site comparative effectiveness study of lithium versus quetiapine in symptomatic outpatients (N = 482) with bipolar disorder. At baseline, participants' psychotherapy use within the past 3 months, mood, functioning, and overall health were assessed. Logistic regressions were used to test whether psychotherapy users and non-users differed on various demographic and clinical variables at baseline. Mixed-effects regression was used to determine whether psychotherapy groups differed on response to treatment over the 6-month study. Kaplan-Meier plots and log-rank tests were employed to test whether there were any differences in time to recovery (CGI-BP ≤ 2 for at least 8 weeks) between the groups.

RESULTS

Thirty one percent of participants reported using psychotherapy services. Psychotherapy users reported greater medication side effect burden than non-users and were more likely to have moderate to high suicide risk and at least one anxiety disorder. Participants not utilizing medications or psychotherapy had greater mania symptom severity, were younger, and less educated than medication only users. Medication only users were more likely to be married than the other participants.

CONCLUSIONS

These data suggest that a minority of individuals with bipolar disorder attend psychotherapy services, and those that do have greater illness burden.

Correlates of real world executive dysfunction in bipolar I disorder

BACKGROUND

Bipolar disorder is characterized by impairments in cognitive functioning, both during acute mood episodes and periods of euthymia, which interfere with functioning. Cognitive functioning is typically assessed using laboratory-based tests, which may not capture how cognitive dysfunction is experienced in real-life settings. Little is known about the specific illness characteristics of bipolar disorder that contribute to cognitive dysfunction in everyday life.

METHODS

Participants met DSM-IV criteria for bipolar I disorder (n = 68) in a depressed or euthymic state. Everyday executive functioning was evaluated using the Behavior Rating Inventory of Executive Functioning (BRIEF) and the Frontal Systems Behavior Rating Scale (FrSBe). Participants completed clinician rated measures of mood state (Hamilton Depression Rating Scale, Young Mania Rating Scale), prior illness course and co-morbidities (Mini International Neuropsychiatric Interview), as well as self-report measures of psychotropic medication use and medical co-morbidity.

RESULTS

Individuals in this study reported significant impairment in every domain of executive functioning. These deficits were associated with a multitude of illness factors, some directly impacted by mood symptoms and others shaped by illness chronicity, psychiatric comorbidity, medical co-morbidity, and medication use.

DISCUSSION

Executive functioning problems observed in everyday functioning in bipolar disorder are not entirely mood-state dependent. Cognitive rehabilitation for executive dysfunction should be considered an important adjunctive treatment for many individuals with bipolar disorder.

Nutrition, Exercise, and Wellness Treatment in bipolar disorder: proof of concept for a consolidated intervention

BACKGROUND

This pilot study examines the proof of concept of a consolidated Nutrition, Exercise, and Wellness Treatment (NEW Tx) for overweight individuals with bipolar disorder.

FINDINGS

Five participants completed NEW Tx, a 20-week individual cognitive behavioral therapy-based treatment comprising three modules: Nutrition teaches appropriate serving sizes and balanced diet; Exercise emphasizes increasing weekly physical activity; Wellness focuses on skills for healthy decision-making. Participants attended most sessions and reported high satisfaction with the treatment. Participants' weight, cholesterol and trigyclerides decreased over the study duration as well as number of daily calories and sugar intake. We found that weekly exercise duration more than tripled over the study duration and depressive symptoms and functioning have improved.

CONCLUSIONS

These results offer proof of concept that consolidated NEW Tx is feasible and acceptable and has the potential to improve nutrition, exercise, wellness, and mood symptoms in bipolar disorder. Future iterations of NEW Tx will reflect the strengths and lessons learned from this study.

Conversion therapy to everolimus in renal transplant recipients: results after one year

BACKGROUND

Two new diagnoses have been causing graft loss during long-term follow-up, namely, chronic nephropathy and anticalcineurinic toxicity. The advent of the mammalian target of rapamycin (m-TOR) obviates anticalcineurine toxicity and reduces posttransplant malignancy incidence with good inmunosuppressive potential. We examinated the renal and metabolic behavior in renal transplant recipients who required conversion from an anticalcineurinic (cyclosporine or tacrolimus) to an m-TOR inhibitor (everolimus) as part of their immunosuppressive maintenance therapy.

MATERIALS AND METHODS

Twenty-one first renal transplant recipients had everolimus added to their inmunosuppressive therapy combined with an antimetabolite (mycophenolate mofetil or sodium mycophenolate). The mean age of the patients was 35 +/- 17 years (range, 6 to 65). The prevalence of male recipients was 57%; the overall mean weight, 64 kg (range, 48 to 95). All patients were hispanic with 15 transplants from cadaveric donors (71%). The mean follow-up posttransplant was 18 months (range, 3 to 40) and the mean follow-up on everolimus, 10 months (range, 2 to 22).

RESULTS

There was no mortality or graft loss, but there were 3 (17%) biopsy-confirmed acute rejection episodes. There were no significant changes in metabolic function pre- or postconversion. Regarding renal function, the mean creatinine serum showed a trend to decline: preconversion 1.7 mg/dL; postconversion 1.5 mg/dL. In 10 patients, it was possible to discontinue at least one antihypertensive medication (48%).

CONCLUSIONS

Everolimus was an effective medication to manage renal transplant patients. It produced metabolic stability and low myelotoxicity, despite combination with an antimetabolite (mycophenolic acid). Also, reduction of antihypertensive medications was an additional benefits for many patients.

[Anthropometric growth patterns of preterm and full-term newborns (24-42 weeks' gestational age) at the Hospital Materno-Infantil Vall d'Hebron (Barcelona)(1997-2002]

BACKGROUND AND OBJECTIVE

Gestational age and neonatal anthropometric parameters are significant predictive factors of neonatal and adult morbidity. Our objective was to evaluate these parameters in a population of preterm and full-term newborns.

SUBJECTS AND METHOD

We retrospectively analyzed neonatal anthropometric parameters (weight, vertex-heel length and head circumference) in 1470 live preterm neonates born at 24-36 weeks' gestation between 1997 and 2002. The same parameters were prospectively analyzed in 1786 live newborns born at 37-42 weeks after uncomplicated pregnancies between 2001 and 2002. All preterm and full-term neonates were the result of single pregnancies and were born at the Hospital Materno-Infantil Vall d'Hebron in Barcelona. Only Caucasian neonates whose parents were born in Spain were included. In the group of full-term neonates all measurements were made by the same researcher.

RESULTS

The mean and standard deviation and percentile distribution values of weight, length and head circumference according to sex and gestational age are presented. These parameters progressively increased with gestational age and sexual dimorphism from the 30th week of gestation onwards, with statistically significant differences (p < 0.05) for all parameters at 38-42 weeks' gestational age. The mean gains in male full-term newborns compared with female full-term newborns were: 129.1 g of weight, 0.68 cm of length and 0.45 cm of head circumference (P < 0.05). In our population, 10th percentile values for weight and length were higher than those in other Spanish populations reported in 1988 and 1996.

CONCLUSIONS

Sexual dimorphism was found in intrauterine anthropometric growth parameters. These parameters change over time and should be updated periodically.

[Evolution of perinatal Escherichia coli disease in the era of group B Streptococcus prophylaxis]

BACKGROUND

The aim of this study was to characterize perinatal Escherichia coli disease, and to analyze its possible correlation with the employment of prophylaxis for group B streptococcal (GBS)disease.

PATIENTS AND METHOD

Between 1994 and 2000, 24 neonates born in our hospital were diagnosed of early-onset E. coli disease: 12 born to mothers who received prenatal care in our center and 12 born to mothers who were referred from other hospitals shortly before labor. Three further neonates born in other centers were also referred with the same diagnosis.

RESULTS

The annual rate did not change significantly (RR:1.065; confidence interval [CI] 95% -0.873-1.301; p = 0.533):from 0.6 per 1,000 live births in 1994 to 1.7 per 1,000 in 1997 and 0.5 in 2000. Among mothers, 92% presented obstetric risk factors including 68% with prematurity (mean 32.9 gestation weeks, median 32), 64% with prolonged rupture of membranes (mean 184 hours,median 44), and 56% with intrapartum fever. Twelve percent of mothers received intrapartum ampicillin as prophylaxis against GBS and 80% received antibiotics: prophylaxis for rupture of membranes in 6 cases, treatment of urinary tract infection in 6 cases and treatment of probable chorioamnionitis in 8 cases. Ampicillin-resistant E. coli was isolated in 81% of neonates. No significant correlation was found between ampicillin resistance and prematurity(p = 0.57), rupture of membranes (p = 0.63), intrapartum fever(p = 0.24) or death (p = 0.53).

CONCLUSIONS

Our results suggest that perinatal E. coli disease is not related with the employment of prophylaxis against GBS disease. Instead, it seems to be related with prematurity, prolonged gestation in premature rupture of membranes and exposure to antibiotics.

Treatment of hydrops fetalis with hemofiltration

The treatment of hydrops fetalis, a critical state of extravascular fluid overload in the newborn, poses a great medical challenge. The aim of this study was to investigate the use of continuous arteriovenous hemofiltration (CAVH) in the treatment of five critically ill newborns with hydrops fetalis of different etiology. All patients had anasarca, oliguria not responsive to diuretics, were on mechanical ventilation, and were treated with inotropic drugs and sedation. The duration of treatment ranged from 42 to 114 h and all patients, except one who died from congenital heart disease, achieved the clinical goals of weight loss and restoration of diuresis. Regular clinical and neurological follow-up to the age of 2 years was normal for the four surviving patients. In conclusion, CAVH appears to be a safe treatment of fluid overload in newborns with hydrops fetalis.

Fungemia with Saccharomyces cerevisiae in two newborns, only one of whom had been treated with ultra-levura

Ultra-Levura (Upsamedica, Spain) is a yeast (Saccharomyces boulardii) widely used as a biotherapeutic agent. To date, few adverse effects have been reported, although fungemia with Saccharomyces cerevisiae can occur in weak and immunosuppressed patients. Reported here are two cases of fungemia with Saccharomyces cerevisiae. One patient had been treated with Ultra-Levura and the other contracted the infection from the first. This is the first report of infection with Saccharomyces boulardii (Saccharomyces cerevisiae) in a patient who was not being treated with the agent.

[High-frequency oscillatory ventilation as salvage strategy in the newborn infant. Spanish multicenter study. I]

OBJECTIVE

The aim of this study was to evaluate the results of high frequency ventilation (HFV) used as a rescue strategy in newborn infants with severe lung disease who either failed conventional mechanical ventilation (CMV) or had an air block.

PATIENTS AND METHODS

From April 1995 to June 1998, 241 infants with severe lung disease and managed according to a common protocol of HFV used as a rescue strategy were prospectively evaluated in the nine participating level III Spanish Neonatal Intensive Care Units. The most frequent diagnoses were respiratory distress syndrome (119), meconium aspiration (24), pneumonia (19) and congenital diaphragm hernia (18).

RESULTS

Mean +/- SD gestational age and birth weight were 32.0 +/- 5.5 weeks and 1,187 +/- 1,071 g, respectively. All babies were previously manages with CMV for a mean of 59 hours. HFV was started at a mean postnatal age of 82 hrs, with a mean oxygenation index (OI) of 28.3 +/- 15.3 and an a/A DO2 of 0.10 +/- 0.08. Initial mean HFV settings were: mean airway pressure 12.8 +/- 3.4 mbar, frequency 8.3 +/- 1.4 Hz, amplitude 53 +/- 20 percent, tidal volume 2.2 +/- 0.7 ml/kg and FiO2 0.88 +/- 0.2. At two hours of HFV there was a significant increase in the mean PaO2 (from 48 to 80 mmHg), with a concomitant decrease in FiO2 (from 0.88 to 0.79), PaCO2 (from 60 to 46 mmHg) and OI (from 28 to 18). Mean a/A DO2 increased from 0.10 to 0.19; these changes remained similar thereafter. HFV was suspended after a mean of 95 hrs because of improvement in 70%, death in 19% and failure to improve the clinical condition in the remaining 19%. Intrahospital death rate was 32%. The following complications were observed: pneumothorax (10%), interstitial emphysema (4%), intraventricular hemorrhage grades III and IV (14.5%) and bronchopulmonary dysplasia (35%).

CONCLUSIONS

HFV is an effective rescue strategy that improves pulmonary gas exchange within two hours of its initiation.

Nosocomial infections in pediatric patients: a prevalence study in Spanish hospitals. EPINE Working Group

BACKGROUND

The magnitude of the problem of nosocomial infection in children has never been studied in Spain.

METHODS

In 1990, a nationwide cross-sectional study was conducted to determine the prevalence of nosocomial infection and associated risk factors.

RESULTS

Among 38,489 patients surveyed, 4081 were pediatric patients. Three hundred forty-five patients (8.4%) had active nosocomial infection at the time of the survey. Pediatric intensive care units (29.7%), hematology (23%), and special units (22%) showed the highest rates. Infections were most common in patients younger than 1 year (prevalence, 12.3%). Frequencies of nosocomial infection by site were as follows: bloodstream, 22.1%; urinary tract, 13.1%; lower respiratory tract, 12.3%; postoperative wound, 8%; gastrointestinal tract, 7.6%; skin, 6.5%; eye, 5.8%; and others 24.6%. The factors most closely associated with a higher prevalence of nosocomial infection in pediatrics were as follows: age younger than 1 year, surgery, moderate and severe baseline risk, number of diagnoses, and all categories of extrinsic risk factors. The most frequent etiologic agents were gram-positive bacteria (45.8%).

CONCLUSIONS

Although the overall prevalence is at an acceptable level, future efforts should be focused on developing more effective prevention strategies in specific areas.

[Myocardial contusion with and without coronary artery involvement]

We present the first case of myocardial contusion secondary to blunt chest trauma with injury in two different areas, with and without coronary lesions. The akinesis of the anterolateral wall was secondary to the obstruction of the left anterior descending coronary artery and the severe hypokinesis of the posterior wall, without lesion of the right coronary artery, was probably related with the compression between the sternum and vertebral column.

[Surgical approach in persistent neonatal pneumothorax]

837 neonates required mechanical ventilation at the Neonatal Intensive Unit in the last five years. 136 of them developed tension pneumothorax. Authors report our experience in these patients, who underwent next protocol: 1. Early diagnosis. 2. Underwater-seal drainage. 3. Suction drainage. 4. Selective intubation of contralateral bronchus. 5. Surgical closure. We explain step to step the protocol, specially in the 15 neonates who needed surgery. In such cases, surgical survival was 100%, in the postoperative phase 93% and total survival reached 78.5%. Therefore, we recommend surgery closure in patients who maintain pulmonary fistula in spite of an aggressive conservative treatment.

Survival from symptomatic nemaline myopathy in the newborn period

We report a patient with nemaline myopathy of sporadic genetical character, who presented with respiratory insufficiency in the neonatal period and has been followed for 4 years. The evolution towards progressive improvement is described in detail, particularly the therapeutic problems posed by the respiratory insufficiency and the alterations of swallowing. This is the first patient reported in the literature who has survived symptomatic nemaline myopathy presenting in the newborn period. The experience of this case may justify the use of exceptional therapeutic measures in other patients.

[Primary hyperlipoproteinemia in childhood (author's transl)]

Type V hyperlipoproteinemia is an unusual entity in children. Only 6 cases have been described so far to our knowledge. Authors present a 9 year old male that came for diagnosis of a hepatosplenomegaly. There was no evidence of abdominal pain, xanthomas or pancreatitis. Secondary disorders such as uncontrolled insulinopenic diabetes mellitus, glycogen storage disease, administration of estrogen compounds, nephrotic syndrome or uremia, and dysglobulinemias were excluded. His father presented the same lipoprotein pattern suggesting a dominant mode of inheritance. The administration of heparin showed a good response of serum proteinlipase.

Traumatic pharyngeal pseudodiverticulum in neonates and infants. Two case reports and review of the literature

Thirty one cases of pharyngeal pseudodiverticulum have been reported in the literature; twenty nine were diagnosed during the neonatal period. Respiratory distress, increased oral secretions, difficulty with feeding and the impossibility of passing a nasogastric catheter were the most common symptoms and/or signs. Pneumomediastinum, pneumothorax, cervical emphysema and ectopic location of a feeding catheter, alone or in combination, were identified in the chest roentgenograms of 16 patients. Esophagography and/or endoscopy were the diagnostic methods of choice. The exact location of the perforation was identified in 18 patients. Most of the perforations were in either the posterior pharyngeal wall or in the pyriform sinuses. The survival rate was as good amongst the medically treated patients as in those who underwent surgery.

[Acceleration of postnatal development, hypertony, enlargement of the middle phalanges and of the distal metaphyses of the femur, peculiar facies: a case of Weaver's syndrome?]

A child is described with accelerated bone maturation, large dysplastic ears, and hypertelorism. These are features of both the Marshall-Smith and Weaver's syndrome. The child was mentally retarded and had enlargement of the middle phalanges, features only seen in Marshall-Smith syndrome. However, there was also enlargement of the metaphyses, a characteristic of Weaver's syndrome. The possiblity that these syndromes may represent different manifestations of the same entity is discussed.