Adrienne Stolfi

Alterations in the gut microbiome of children with severe ulcerative colitis.

Background: Although the role of microbes in disease pathogenesis is well established, data describing the variability of the vast microbiome in children diagnosed with ulcerative colitis (UC) are lacking. This study characterizes the gut microbiome in hospitalized children with severe UC and determines the relationship between microbiota and response to steroid therapy. Methods: Fecal samples were collected from 26 healthy controls and 27 children hospitalized with severe UC as part of a prospective multicenter study. DNA extraction, polymerase chain reaction (PCR) amplification of bacterial 16S rRNA, and microarray hybridization were performed. Results were analyzed in GeneSpring GX 11.0 comparing healthy controls with children with UC, and steroid responsive (n = 17) with nonresponsive patients (n = 10). Results: Bacterial signal strength and distribution showed differences between UC and healthy controls (adjusted P < 0.05) for Phylum, Class, Order, Family, Genus, and Phylospecies levels with reduction in Clostridia and an increase in Gamma‐proteobacteria. The number of microbial phylospecies was reduced in UC (266 ± 69) vs. controls (758 ± 3, P < 0.001), as was the Shannon Diversity Index (6.1 ± 0.23 vs. 6.49 ± 0.04, respectively; P < 0.0001). Steroid nonresponders harbored fewer phylospecies than responders (142 ± 49 vs. 338 ± 62, P = 0.013). Conclusions: Richness, evenness, and biodiversity of the gut microbiome were remarkably reduced in children with UC compared with healthy controls. Children who did not respond to steroids harbored a microbiome that was even less rich than steroid responders. This study is the first to characterize the gut microbiome in a large cohort of pediatric patients with severe UC and describes changes in the gut microbiome as a potential prognostic feature. (Inflamm Bowel Dis 2012)

Active learning in a Year 2 pathology curriculum

Purpose  Team‐based learning (TBL) has been successfully used in non‐medical curricula, but its effectiveness in medical education has not been studied extensively. We evaluated the impact of TBL on the academic performance of Year 2 medical students at Wright State University by comparing this active learning strategy against a traditional method of case‐based group discussion (CBGD).

Efficacy of probiotics in the treatment of pediatric atopic dermatitis: a meta-analysis of randomized controlled trials

BACKGROUND Several articles describing the efficacy of probiotics in atopic dermatitis (AD) have been published. However, not all studies support a similar outcome. OBJECTIVE To determine whether probiotics are efficacious in treating AD and to explore whether type of probiotic used, duration of therapy, patient age, severity of disease, and IgE sensitization are factors in determining efficacy. METHODS For this meta-analysis of randomized controlled trials describing the efficacy of probiotics in AD, a comprehensive search was performed of databases through January 2008. Three reviewers independently evaluated the studies for methodological qualities. All the data were analyzed, and forest plots were evaluated for the overall efficacy of probiotics in AD and the therapeutic benefit to subgroups of selected patient populations. RESULTS Eleven studies were identified, and data from 10 studies (n = 678) were available to analyze. There was an overall statistically significant difference favoring probiotics compared with placebo in reducing the Scoring of Atopic Dermatitis Severity Index score (mean change from baseline, -3.01; 95% confidence interval, -5.36 to -0.66; P = .01). Children with moderately severe disease were more likely to benefit. Duration of probiotic administration, age, and type of probiotic used did not affect outcome. CONCLUSION Data from this meta-analysis suggest a modestrole for probiotics in pediatric AD. The effect is seen in moderately severe rather than mild disease.

Predictors of failure in infants with viral bronchiolitis treated with high-flow, high-humidity nasal cannula therapy*.

Objectives: Viral bronchiolitis is an acute infection and inflammatory disease of the respiratory tract, with infants typically presenting with the most severe symptoms. Medical management of bronchiolitis is mostly supportive. Several preliminary studies suggest potential benefit from the use of high-flow nasal cannula systems. Although high-flow nasal cannula is a well-established modality in the newborn intensive care unit, its use in the pediatric intensive care unit for acute respiratory failure is far less established. The objective of this study was to identify any laboratory and clinical variables that may predict high-flow nasal cannula failure in management of bronchiolitis in the pediatric intensive care unit. Design: The study design was a retrospective chart review of all patients admitted to the pediatric intensive care unit from 2006 to 2010 with a diagnosis of viral bronchiolitis. Inclusion criteria included the initiation of high flow nasal cannula therapy at the time of admission and age ⩽12 months. Exclusion criteria were intubation prior to admission, age >12 months, and the presence of a tracheostomy. Patients: A total of 113 patients with viral bronchiolitis met the inclusion criteria. Setting: Academic free standing Children’s Hospital in the Midwest.Interventions: Retrospective chart review. Measurements and Main Results: The data were analyzed by comparing those patients who responded to high-flow nasal cannula (n = 92) with those who were nonresponders to high-flow nasal cannula and required intubation (n = 21). No differences were noted between the groups for age, sex, or ethnicity. Mean weight and weight-for-corrected-age percentiles were significantly lower for patients who failed high-flow nasal cannula (p = .016 and .031, respectively), but weight-for-corrected-age percentile was not significant in logistic regression controlling for other variables. Respiratory rate prior to the initiation of high-flow nasal cannula also correlated strongly with respiratory deterioration (p < .001). The PCO2 was significantly higher for both before (p < .001) and after (p < .001) initiation of therapy in the nonresponder group. Pediatric Risk of Mortality III scores for the patients who failed high-flow nasal cannula were significantly higher (p < .001) than those of patients who tolerated this therapy. Conclusions: History of prematurity and the patient’s age did not increase a patient’s risk of failure. Nonresponders to high-flow nasal cannula therapy were on the onset, more hypercarbic, were less tachypnic prior to the start of high-flow nasal cannula, and had no change in their respiratory rate after the initiation of high-flow nasal cannula therapy. Nonresponders had higher pediatric risk of mortality scores in the first 24 hrs.

Parents' Perceptions of Their Children's Weight, Eating Habits, and Physical Activities at Home and at School

INTRODUCTION Parental perceptions of their young childrens weight and habits may play an important role in determining whether children develop and maintain healthy lifestyles. This study was conducted to determine perceptions of parents of third-grade children in an urban school setting regarding their childrens weight, eating habits, and physical activities. METHODS Parents anonymously completed surveys about their childs weight, eating habits, and daily activities. The survey also asked about how schools could encourage healthy eating and increased physical activity. RESULTS Overall, 26% of the parents perceived their child to be overweight and expressed concern, but 40% of these parents believed that overweight is a condition that will be outgrown. Parents who reported eating more than eight meals per week with their child were less likely to report their child as overweight and more likely to believe that their childs physical activity level was appropriate. DISCUSSION Most parents of third-grade students demonstrated concern regarding their childs weight and perceive obesity as a problem. Parents support school interventions such as nutrition education and fitness classes.

Skeletal surveys in children with burns caused by child abuse

Objective: To determine the frequency of occult fractures in children with suspicious burns compared with children with other types of physical abuse. Methods: Child abuse outpatient clinic reports and inpatient consultations from a midwest urban childrens hospital for 1989 to 2000 were reviewed. Demographic and clinical data were abstracted for patients seen because of suspected physical abuse. Patients were classified based on reason seen (burns vs other physical injuries), whether they were diagnosed as abused, and whether they had at least 1 skeletal survey. Positive skeletal surveys were defined as having a fracture that was unexplained, highly specific for abuse, or with a perpetrator confession. Results: Of 335 patients evaluated, the mean age (±SD) was 1.5 ± 1.9 years, 63% were boys, 64% were white, and 80% had skeletal surveys performed. Reasons for evaluation included 69 (21%) for burns and 266 (79%) for other injuries. After excluding patients without a final diagnosis of abuse and those presenting with obvious fractures, 5 (14%) of 36 burn patients had positive skeletal surveys compared with 45 (34%) of 133 with nonburn injuries (P = 0.02). Burn patients were older compared with those with nonburn injuries (mean ages, 1.8 ± 1.5 vs. 1.1 ± 1.6 years; P = 0.03) and were more likely to be nonwhite (69% vs. 32%; P < 0.001). Conclusions: Although young children with abusive burns have fewer occult fractures compared with those with other abusive injuries, the frequency of occult fractures is still high enough to warrant the consideration of skeletal surveys in these cases.

The Efficacy of Pediatric Advanced Life Support Training in Emergency Medical Service Providers

Pediatric advanced life support (PALS) teaches skills unique to pediatric resuscitation. The purpose of this study was to assess the effect of PALS training among emergency medical service (EMS) providers in out-of-hospital trauma and medical resuscitations. A physician panel evaluated all EMS run sheets of pediatric traumas and medical resuscitations brought to a tertiary childrens hospital/regional trauma center over a 3-year period. In 183 responses, EMS personnel were the sole providers of medical stabilization. Evaluation included the ability to secure an airway, establish vascular access, shock recognition, and appropriate cardiac rhythm assessment and resuscitation. The panel was blinded to the PALS training status of the responding EMS squad until completion of the review. Pediatric advanced life support-trained EMS personnel responded to 36% of the resuscitations reviewed. A significant difference in successful intubations was noted in PALS-trained squads compared with squads with no PALS training (85% vs 48%; P < 0.001). A significant difference was also noted in the ability to obtain vascular access in shock/arrest cases (100% vs 70%; P < 0.001). Similarly, PALS-trained squads were more successful in intraosseous line placement than non-PALS-trained squads (100% vs 55%; P < 0.01). However, despite better procedural skills, there was no difference in mortality rates between the groups (37% PALS vs 32% non-PALS). We conclude that PALS training improves procedural skills among EMS personnel and should be strongly considered as part of EMS training.

The REPEAT study: recognizing and evaluating periodic local reactions in allergen immunotherapy and associated systemic reactions

BACKGROUND prior studies have demonstrated that large local reactions (LLRs) to subcutaneous immunotherapy do not predict systemic reactions (SRs). However, a recent study demonstrated an increase in LLRs among systemic reactors in practices using routine local reaction dose adjustments. OBJECTIVE to investigate the association between LLRs and SRs within a practice that does not dose adjust for LLRs. METHODS we performed a retrospective analysis of an electronic immunotherapy database during a 12-month period at a single site that does not dose adjust for LLRs. An LLR was defined as larger than the size of the patients palm measured at 30 minutes. Logistic regression was performed to investigate the association between SRs and LLRs after controlling for variable numbers of injections and visits among patients. RESULTS three hundred sixty patients received a total of 9,679 injections (6,609 visits). Twenty-four patients (6.7% of patients) experienced 38 LLRs (0.4% of injections, 0.6% of visits), whereas 46 patients (12.7% of patients) experienced 51 SRs (0.5% of injections, 0.77% of visits). Only 10 patients (2.8%) experienced both LLRs and SRs, and 36 of 46 SR patients (78.3%) never had an LLR. Among the 24 LLR patients, the SR rate was 1.3% (12/932) of injections and 2.0% (12/611) of visits compared with the 336 non-LLR patients for whom the SR rate was 0.4% (39/8,747) of injections and 0.7% (39/5998) of visits. Of these 24 LLR patients, 10 (41.7%) experienced at least 1 SR vs 36 of 336 non-LLR patients (10.7%). After controlling for number of injections and 1 vs 2 injections per visit, a subgroup of LLR patients were more likely to have an SR during their subcutaneous immunotherapy course (odds ratio, 4.7; 95% confidence interval, 1.9-11.7). Recurrent LLR patients (n = 10) were not more likely to experience an SR (0.4% per injection). CONCLUSIONS although LLRs do not predict SRs, a subgroup (41.7%) of LLR patients experience a higher frequency of SRs during their immunotherapy course. In light of a similar previous study, this association occurs irrespective of whether a dose adjustment protocol is used for LLRs.

The HIT study: Hymenoptera Identification Test—how accurate are people at identifying stinging insects?

BACKGROUND Stinging insects in the order Hymenoptera include bees, wasps, yellow jackets, hornets, and ants. Hymenoptera sting injuries range from localized swelling to rarely death. Insect identification is helpful in the management of sting injuries. OBJECTIVE To determine the accuracy of adults in identifying stinging insects and 2 insect nests. METHODS This was a cross-sectional, multicenter study using a picture-based survey to evaluate an individuals success at identifying honeybees, wasps, bald-face hornets, and yellow jackets. Bald-face hornet and paper wasp nest identification also was assessed in this study. RESULTS Six hundred forty participants completed the questionnaire. Overall, the mean number of correct responses was 3.2 (SD 1.3) of 6. Twenty participants (3.1%) correctly identified all 6 stinging insects and nests and only 10 (1.6%) were unable to identify any of the pictures correctly. The honeybee was the most accurately identified insect (91.3%) and the paper wasp was the least correctly identified insect (50.9%). For the 6 questions regarding whether the participant had been stung in the past by any of the insects (including an unidentified insect), 91% reported being stung by at least 1. Men were more successful at identify stinging insects correctly (P = .002), as were participants stung by at least 4 insects (P = .018). CONCLUSION This study supports the general perception that adults are poor discriminators in distinguishing stinging insects and nests with the exception of the honeybee. Men and those participants who reported multiple stings to at least 4 insects were more accurate overall in insect identification.

Effects of hyperbaric oxygen on motor function in children with cerebral palsy.

We conducted a randomized, double‐blind, controlled clinical trial to determine whether hyperbaric oxygen (HBO) improves gross motor function in children with cerebral palsy.