Background:
Only a fraction of pediatric trauma patients are treated in pediatric-specific facilities, leaving the remaining to be seen in centers that must decide to admit the patient to a pediatric ...or adult unit. Thus, there may be inconsistencies in pediatric trauma admission practices among trauma centers.
Objective:
Describe current practices in admission decision making for pediatric patients.
Methods:
An email survey was distributed to members of three professional organizations: The American Association for the Surgery of Trauma, Society of Trauma Nurses, and Pediatric Trauma Society. The survey contained questions regarding pediatric age cutoffs, institutional placement decisions, and scenario-based assessments to determine mitigating placement factors.
Results:
There were 313 survey responses representing freestanding children's hospitals (114, 36.4%); children's hospitals within general hospitals (107, 34.2%), and adult centers (not a children's hospital; 90, 28.8%). The mean age cutoff for pediatric admission was 16.6 years. The most reported cutoff ages were 18 years (77, 25.6%) and 15 years (76, 25.2%). The most common rationales for the age cutoffs were “institutional experience/tradition” (139, 44.4%) and “physician preference” (89, 28.4%).
Conclusion:
There was no single widely accepted age cutoff that distinguished pediatric from adult trauma patients for admission placement. There was significant variability between and within the types of facilities, with noted ambiguity in the definition of a “pediatric” patient. Thresholds appear to be based primarily on subjective criteria such as traditions or preferences rather than scientific data. Institutions should strive for objective, evidence-based policies for determining the appropriate placement of pediatric patients.
Kra monkeys (Macaca fascicularis), a natural host of Plasmodium knowlesi, control parasitaemia caused by this parasite species and escape death without treatment. Knowledge of the disease progression ...and resilience in kra monkeys will aid the effective use of this species to study mechanisms of resilience to malaria. This longitudinal study aimed to define clinical, physiological and pathological changes in kra monkeys infected with P. knowlesi, which could explain their resilient phenotype.
Kra monkeys (n = 15, male, young adults) were infected intravenously with cryopreserved P. knowlesi sporozoites and the resulting parasitaemias were monitored daily. Complete blood counts, reticulocyte counts, blood chemistry and physiological telemetry data (n = 7) were acquired as described prior to infection to establish baseline values and then daily after inoculation for up to 50 days. Bone marrow aspirates, plasma samples, and 22 tissue samples were collected at specific time points to evaluate longitudinal clinical, physiological and pathological effects of P. knowlesi infections during acute and chronic infections.
As expected, the kra monkeys controlled acute infections and remained with low-level, persistent parasitaemias without anti-malarial intervention. Unexpectedly, early in the infection, fevers developed, which ultimately returned to baseline, as well as mild to moderate thrombocytopenia, and moderate to severe anaemia. Mathematical modelling and the reticulocyte production index indicated that the anaemia was largely due to the removal of uninfected erythrocytes and not impaired production of erythrocytes. Mild tissue damage was observed, and tissue parasite load was associated with tissue damage even though parasite accumulation in the tissues was generally low.
Kra monkeys experimentally infected with P. knowlesi sporozoites presented with multiple clinical signs of malaria that varied in severity among individuals. Overall, the animals shared common mechanisms of resilience characterized by controlling parasitaemia 3-5 days after patency, and controlling fever, coupled with physiological and bone marrow responses to compensate for anaemia. Together, these responses likely minimized tissue damage while supporting the establishment of chronic infections, which may be important for transmission in natural endemic settings. These results provide new foundational insights into malaria pathogenesis and resilience in kra monkeys, which may improve understanding of human infections.
Plasmodium knowlesi
poses a health threat throughout Southeast Asian communities and currently causes most cases of malaria in Malaysia. This zoonotic parasite species has been studied in
Macaca ...mulatta
(rhesus monkeys) as a model for severe malarial infections, chronicity, and antigenic variation. The phenomenon of
Plasmodium
antigenic variation was first recognized during rhesus monkey infections.
Plasmodium
-encoded variant proteins were first discovered in this species and found to be expressed at the surface of infected erythrocytes, and then named the Schizont-Infected Cell Agglutination (SICA) antigens. SICA expression was shown to be spleen dependent, as SICA expression is lost after
P. knowlesi
is passaged in splenectomized rhesus. Here we present data from longitudinal
P. knowlesi
infections in rhesus with the most comprehensive analysis to date of clinical parameters and infected red blood cell sequestration in the vasculature of tissues from 22 organs. Based on the histopathological analysis of 22 tissue types from 11 rhesus monkeys, we show a comparative distribution of parasitized erythrocytes and the degree of margination of the infected erythrocytes with the endothelium. Interestingly, there was a significantly higher burden of parasites in the gastrointestinal tissues, and extensive margination of the parasites along the endothelium, which may help explain gastrointestinal symptoms frequently reported by patients with
P. knowlesi
malarial infections. Moreover, this margination was not observed in splenectomized rhesus that were infected with parasites not expressing the SICA proteins. This work provides data that directly supports the view that a subpopulation of
P. knowlesi
parasites cytoadheres and sequesters, likely
via
SICA variant antigens acting as ligands. This process is akin to the cytoadhesive function of the related variant antigen proteins, namely Erythrocyte Membrane Protein-1, expressed by
Plasmodium falciparum
.
Objective. To design and implement an elective therapeutics course and to assess its impact on students’ attainment of course outcomes and level of confidence in applying clinical pharmacy principles ...and pharmacotherapy knowledge.
Design. A 3-credit hour elective for third-year pharmacy students was structured to include problem-based learning (PBL), journal club and case presentations, and drug information activities.
Assessment. Student achievement of curricular outcomes was measured using performance on SOAP (subjective, objective, assessment, plan) notes, case and journal club presentations, drug information activities, and peer evaluations. Results from a pre- and post-course survey instrument demonstrated significant improvement in students’ confidence in applying clinical pharmacy principles.
Conclusion. Students completing the course demonstrated increased attainment of course outcomes and confidence in their abilities to evaluate a patient case and make pharmacotherapeutic recommendations.
Projects in the life sciences continue to increase in complexity as they scale to answer deeper and more diverse questions. They employ technologies that generate increasingly large ‘omic’ datasets ...and research teams regularly include experts ranging from animal care technicians, veterinarians, human health clinicians, geneticists, immunologists, and biochemists to computer scientists, mathematical modelers, and data scientists, often located at different institutions. Providing the cyberinfrastructure support framework (IT, data management, communication, documentation, and aspects of project management related to these areas) for these projects requires a diverse set of technical tools and soft skills. These skills must be able to meet both the broad needs of data generators and consumers within the project and the needs of the larger scientific community. Here we describe recommendations for cyberinfrastructure support teams responsible for systems biology research programs. Recommendations are based on lessons learned while establishing and leading a complex, transdisciplinary, host-pathogen malaria systems biology consortium involving many institutions, a variety of disciplines, animal infectious disease models, and clinical studies. While some technical suggestions are included, the primary foci are situational and sociological challenges and tips for handling them.
Background:
Oseltamivir is frequently administered to critically ill patients with presumed influenza. It may modulate Na+, K+, and Ca2+ channels to produce bradycardia.
Objective:
To evaluate the ...association between oseltamivir and bradycardia in critically ill patients and assess parameters associated with bradycardia.
Methods:
This was a retrospective audit of 203 critically ill adults with presumed influenza receiving at least 2 doses of oseltamivir. The primary outcome was the occurrence of bradycardia, defined as a heart rate (HR) ≤59 beats per minute (BPM) while receiving oseltamivir or a decrease of ≥20 BPM compared with the lowest HR before initiating oseltamivir.
Results:
A total of 88 (43.4%) patients manifested bradycardia, 59 with HR ≤59 BPM, 19 with HR decrease of ≥20 BPM, and 10 with both. The time from first dose to bradycardia was 51.4 ± 43 hours. In all, 48 (54.6%) patients received therapies for bradycardia, including increased inotropic/vasopressor dose, electrolyte replacement, electrocardiogram, discontinuation of other medications, cardiology consult, discontinuation of oseltamivir, and pacer placement. There were no significant differences between groups with bradycardia versus without in terms of demographics, laboratory values, hospital characteristics, or oseltamivir dosing. Multivariate logistic regression showed that bradycardia was associated with baseline HR, age, past medical history of neurological issues, and positive influenza status. Between hours 6 through 126, significant differences existed between groups in actual and lowest HR.
Conclusion and Relevance:
Oseltamivir was associated with clinically relevant bradycardia in critically ill patients. Clinicians should closely monitor HR in critically ill patients receiving oseltamivir.
•Lowering the dose to organs at risk is a primary goal in mediastinal lymphoma radiotherapy.•We compared full arc and limited arc plans, with and without the use of breath-hold.•The effect of ...combining limited arc and DIBH is additive or complementary.
Radiotherapy is an effective treatment for mediastinal lymphoma but induces late effects including cardiac toxicity and secondary breast and lung cancer. Therefore reducing the dose to these organs is vital. We compared full arc volumetric modulated arc therapy (F-VMAT) against limited angle ‘Butterfly’ VMAT (B-VMAT) on free breathing (FB) and deep inspiration breath-hold (DIBH) computed tomography scans. The aim was to assess the benefits of B-VMAT over F-VMAT and to establish if the addition of DIBH results is a cumulative benefit.
F-VMAT and B-VMAT plans were calculated for 20 consecutive patients (15 females) with mediastinal lymphoma on both FB and DIBH scans. The planning target volume V95% was kept comparable between all plans while reducing organ doses as much as possible.
B-VMAT significantly reduced low lung doses (V5–10), while F-VMAT was better for higher lung doses (V20–30). DIBH further improved lung doses for both types of plans. DIBH B-VMAT produced the lowest mean lung dose. With FB, heart doses were slightly higher for B-VMAT but the maximum difference was small (0.8% for V20) and only statistically significant for V10-20. The mean heart dose increased by only 0.1 Gy. The addition of DIBH however significantly reduced heart doses. While DIBH F-VMAT had the lowest heart doses, the difference was small compared with DIBH B-VMAT. B-VMAT significantly reduced breast V4 while DIBH reduced the V10.
B-VMAT and DIBH are both effective in reducing organ doses and the dosimetric benefit is additive for some parameters and complementary for others.
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