To evaluate the safety and effectiveness of short-term, high-dose chlorambucil therapy in achieving long-term, drug-free remission in the treatment of sympathetic ophthalmia (SO).
Retrospective case ...series.
Sixteen patients with SO treated with high-dose, short-term chlorambucil therapy between 1970 and 2010.
Descriptive and bivariate analyses were used to characterize disease and outcomes.
Months of disease-free remission, prevalence rate of relapse, and prevalence of serious treatment-related adverse events.
Sixteen patients with SO treated with short-term, high-dose chlorambucil were identified. Patients were treated with chlorambucil for a median of 14.0 weeks (mean, 14.5 weeks; range, 12.0-19.0 weeks). Median follow-up was 98.5 months (mean, 139.1 months; range, 48-441 months) from initiation of chlorambucil therapy. Control of inflammation was achieved in 100% of patients. Thirteen patients (81.3%) maintained vision of 20/40 or better in the sympathizing eye. Four patients (25%) relapsed after a median of 83 months (mean, 131 months) after cessation of systemic therapy. Seventy-five percent of relapses were controlled with topical therapy only. Conjunctival Kaposi's sarcoma developed in 1 patient. No patient demonstrated systemic malignancy.
Short-term, high-dose chlorambucil therapy provides sustained periods of drug-free remission. With median follow-up of more than 8 years (mean, 11.6 years; range, 4-37 years), there was a low rate of recurrence and minimal long-term serious health consequences or adverse events. Because SO may be a lifelong condition and because chlorambucil therapy may offer long-term, drug-free remission, this treatment may be worth considering early in the decision-making process for severe sight-threatening disease.
Objective To use observation to understand how decisions about higher-risk treatments, such as biologics, are made in pediatric chronic conditions. Methods Gastroenterology and rheumatology providers ...who prescribe biologics were recruited. Families were recruited when they had an outpatient appointment in which treatment with biologics was likely to be discussed. Consent/assent was obtained to video the visit. Audio of the visits in which a discussion of biologics took place were transcribed and analyzed. Our coding structure was based on prior research, shared decision making (SDM) concepts, and the initial recorded visits. Coded data were analyzed using content analysis and comparison with an existing model of SDM. Results We recorded 21 visits that included discussions of biologics. In most visits, providers initiated the decision-making discussion. Detailed information was typically given about the provider's preferred option with less information about other options. There was minimal elicitation of preferences, treatment goals, or prior knowledge. Few parents or patients spontaneously stated their preferences or concerns. An implicit or explicit treatment recommendation was given in nearly all visits, although rarely requested. In approximately one-third of the visits, the treatment decision was never made explicit, yet steps were taken to implement the provider's preferred treatment. Conclusions We observed limited use of SDM, despite previous research indicating that parents wish to collaborate in decision making. To better achieve SDM in chronic conditions, providers and families need to strive for bidirectional sharing of information and an explicit family role in decision making.
Early-season insect management is complex in the Mid-South region of the United States. A complex of multiple pest species generally occurs simultaneously at subthreshold levels in most fields. ...Neonicotinoids are the only insecticide seed treatment widely used in soybean, Glycine max L., production. An analysis was performed on 170 trials conducted in Arkansas, Louisiana, Mississippi, and Tennessee from 2005 to 2014 to determine the impact of neonicotinoid seed treatments in soybean. The analysis compared soybean seed treated with a neonicotinoid insecticide and a fungicide with soybean seed only treated with the same fungicide. When analyzed by state, soybean yields were significantly greater in all states when neonicotinoid seed treatments were used compared with fungicide-only treatments. Soybean treated with neonicotinoid treatments yielded 112.0 kg ha-1, 203.0 kg ha-1, 165.0 kg ha-1, and 70.0 kg ha-1, higher than fungicide-only treatments for Arkansas, Louisiana, Mississippi, and Tennessee, respectively. Across all states, neonicotinoid seed treatments yielded 132.0 kg ha-1 more than with fungicide-only treated seed. Net returns from neonicotinoid seed treatment usage were US$1,203 per ha-1 compared with US$1,172 per ha-1 for fungicide-only treated seed across the Mid-South. However, economic returns for neonicotinoid seed treatments were significantly greater than fungicide-only treated seed in 4 out of the 10 yr. When analyzed by state economic returns the neonicotinoid seed treatments were significantly greater than fungicide-only treated seed in Louisiana and Mississippi. These data show that in some areas and years, neonicotinoid seed treatments provide significant economic benefits in Mid-South soybean.
Purpose To assess prospectively the integrity of pronator quadratus (PQ) muscle repair following volar plate fixation of distal radius fractures and to compare the clinical and radiographic outcomes ...of durable versus failed repairs in 24 subjects. In addition, by grading the degree of PQ injury, an attempt was made to correlate failure of repair with the PQ injury severity. Methods The extent of PQ injury was graded for each fracture. After fracture fixation, the PQ muscle was repaired along its radial and distal borders. Radiopaque hemoclips were attached to each side of the PQ repair, 2 radially and 2 distally. The distance between these markers at time 0 versus x-rays taken at approximately 2 weeks, 6 weeks, and 3 months was recorded. Clip displacement of 1 cm or more compared to time 0 indicated repair failure. Results One of 24 repairs (4%) failed at 3 months. No statistical difference was noted between the type of PQ injury and wrist flexion/extension, pronation/supination, and grip strength. Conclusions Pronator quadratus repairs after volar plate fracture fixation are generally durable. They withstand forces that occur at the distal radius during the healing process with a 4% failure rate. No correlation was shown between type of PQ injury and radiographic failure of the repair. Type of study/level of evidence Therapeutic II.
Congenital cardiac anomalies are associated with immunologic perturbations. Surgical thymectomy, thoracic duct manipulation, and protein- losing enteropathy (PLE), a condition related to stressed ...Fontan hemodynamics, presumably contribute to low peripheral absolute lymphocyte counts (ALCs) and quantitative immunoglobulins. Clinical significance of lymphopenia and hypogammaglobulinemia in single-ventricle survivors requires additional study.
Although immunologic laboratory anomalies are common in this population, we hypothesize that clinically significant immunodeficiency requiring intervention is rarely required.
A retrospective chart review of the immunologic parameters of patients enrolled in the Single Ventricle Survivorship Program (SVSP) at the Children's Hospital of Philadelphia was performed.
The age range of the 178 SVSP patients was 3 to 26 years, with a median of 10.8 years. Most of the SVSP patients had some degree of lymphopenia. In the non-PLE group, the range of ALCs varied from 530 to 5322 cells/μL, with 17 patients without PLE maintaining an ALC of less than 1000 cells/μL. Among those with PLE, the median ALC and the IgG level were lower (672 cells/μL and 200 mg/dL, respectively) than in those without (1610 cells/μL and 868 mg/dL, respectively). Despite lymphopenia in the majority, few were severely clinically affected: 24% had delayed clearance of cutaneous viral infections, 63% had atopy, and 1 died of EBV-associated Hodgkin lymphoma. Immunoglobulin replacement was clinically indicated for 3 patients, 1 of whom had common variable immunodeficiency. Four patients with normal splenic function were treated with daily antibiotic prophylaxis.
Patients with repaired single-ventricle physiology often demonstrate T-cell lymphopenia and hypogammaglobulinemia. A significant portion of patients without PLE also have lymphopenia. The most common clinical manifestation was delayed clearance of cutaneous viral infections, but significant systemic opportunistic infections were not seen despite laboratory abnormalities and lack of antimicrobial prophylaxis.
Neonicotinoid seed treatments are one of several effective control options used in corn, Zea mays L., production in the Mid-South for early season insect pests. An analysis was performed on 91 ...insecticide seed treatment trials from Arkansas, Louisiana, Mississippi, andTennessee to determine the value of neonicotinoids in corn production systems.The analysis compared neonicotinoid insecticide treated seed plus a fungicide to seed only with the same fungicide.When analyzed by state, corn yields were significantly higher when neonicotinoid seed treatments were used compared to fungicide only treated seed in Louisiana and Mississippi. Corn seed treated with neonicotinoid seed treatments yielded 111, 1,093, 416, and 140 kg/ha, higher than fungicide only treatments for Arkansas, Louisiana, Mississippi, andTennessee, respectively. Across all states, neonicotinoid seed treatments resulted in a 700 kg/ha advantage compared to fungicide only treated corn seed. Net returns for corn treated with neonicotinoid seed treatment were $1,446/ha compared with $1,390/ha for fungicide only treated corn seed across the Mid-South. Economic returns for neonicotinoid seed treated corn were significantly greater than fungicide-only-treated corn seed in 8 out of 14 yr. When analyzed by state, economic returns for neonicotinoid seed treatments were significantly greater than fungicide-only-treated seed in Louisiana. In some areas, dependent on year, neonicotinoid seed treatments provide significant yield and economic benefits in Mid-South corn.
Purpose To describe outcomes after surgical management of pediatric elbow dislocation with incarceration of the medial epicondyle. Methods We conducted a retrospective case review of 11 consecutive ...children and adolescents with an incarcerated medial epicondyle fracture after elbow dislocation. All patients underwent open reduction internal fixation using a similar technique. We characterized outcomes at final follow-up. Results Average follow-up was 14 months (range, 4–56 mo). All patients had clinical and radiographic signs of healing at final follow-up. There was no radiographic evidence of loss of reduction at intervals or at final follow-up. There were no cases of residual deformity or valgus instability. Average final arc of elbow motion was 4° to 140°. All patients had forearm rotation from 90° supination to 90° pronation. Average Mayo elbow score was 99.5. Four of 11 patients had ulnar nerve symptoms postoperatively and 1 required a second operation for ulnar nerve symptoms. In addition, 1 required a second operation for flexion contracture release with excision of heterotopic ossification. Three patients had ulnar nerve symptoms at final follow-up. Two of these had mild paresthesia only and 1 had both mild paresthesia and weakness. Conclusions Our results suggest that open reduction internal fixation of incarcerated medial epicondyle fractures after elbow dislocation leads to satisfactory motion and function; however, the injury carries a high risk for complications, particularly ulnar neuropathy. Type of study/level of evidence Therapeutic IV.
Protein-losing enteropathy (PLE) is a challenging complication after a Fontan operation. Subclinical enteric protein loss may precede development of overt PLE. We evaluated the acute effects of ...Fontan circulation on enteric protein loss and mesenteric vascular resistance.
A prospective cohort study was performed evaluating enteric protein loss in children undergoing Fontan operations. Stool alpha-1 antitrypsin (A1AT) concentration was measured in the preoperative, early postoperative, and intermediate postoperative (3-9 months) periods. The intestinal circulation was characterized by Doppler-derived resistance indices of the superior mesenteric artery (SMA), and serum albumin and protein levels were obtained.
We enrolled 33 participants at a median age at operation of 3.0 years (interquartile range IQR, 2.5-3.3 years). No clinical PLE was observed. Six of the 93 stool samples obtained had elevated A1AT levels (>54 mg/dL), with 2 abnormal samples at each of the 3 time points. Two of the 5 participants with elevated stool A1AT values had significant hemodynamic disturbances requiring intervention (junctional bradycardia or tricuspid stenosis). There was no difference in SMA resistance in the preoperative versus early postoperative periods (p = 0.9). Serum albumin levels were lower in the early postoperative period compared with the preoperative period (3.2 mg/dL {IQR}, 2.9-3.5 versus 4.1 mg/dL; IQR, 3.4-4.5; p = 0.01) but did not correlate with abnormal stool A1AT concentration or SMA resistance indices.
The Fontan operation does not commonly result in acute development of increased enteric protein loss. However, increased enteric protein loss may occur in children before or after a Fontan operation, particularly when hemodynamic disturbances are present.
•A carbon price may generate substantial sequestration but not much biodiversity.•A complementary biodiversity payment may generate biodiversity services.•Supply of both services is highly variable ...under plausible global outlooks for 2050.•Domestic variables of adoption rate and agricultural productivity are influential.
Global agroecosystems can contribute to both climate change mitigation and biodiversity conservation, and market mechanisms provide a highly prospective means of achieving these outcomes. However, the ability of markets to motivate the supply of carbon sequestration and biodiversity services from agricultural land is uncertain, especially given the future changes in environmental, economic, and social drivers. We quantified the potential supply of these services from the intensive agricultural land of Australia from 2013 to 2050 under four global outlooks in response to a carbon price and biodiversity payment scheme. Each global outlook specified emissions pathways, climate, food demand, energy price, and carbon price modeled using the Global Integrated Assessment Model (GIAM). Using a simplified version of the Land Use Trade-Offs (LUTO) model, economic returns to agriculture, carbon plantings, and environmental plantings were calculated each year. The supply of carbon sequestration and biodiversity services was then quantified given potential land use change under each global outlook, and the sensitivity of the results to key parameters was assessed. We found that carbon supply curves were similar across global outlooks. Sharp increases in carbon sequestration supply occurred at carbon prices exceeding 50$tCO2−1 in 2015 and exceeding 65$tCO2−1 in 2050. Based on GIAM-modeled carbon prices, little carbon sequestration was expected at 2015 under any global outlook. However, at 2050 expected carbon supply under each outlook differed markedly, ranging from 0 to 189MtCO2yr−1. Biodiversity services of 3.32% of the maximum may be achieved in 2050 for a 1$B investment under median scenario settings. We conclude that a carbon market can motivate supply of substantial carbon sequestration but only modest amounts of biodiversity services from agricultural land. A complementary biodiversity payment can synergistically increase the supply of biodiversity services but will not provide much additional carbon sequestration. The results were sensitive to global drivers, especially the carbon price, and the domestic drivers of adoption hurdle rate and agricultural productivity. The results can inform the design of an effective national policy and institutional portfolio addressing the dual objectives of climate change and biodiversity conservation that is robust to future uncertainty in both national and global drivers.
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