Lokesh Guglani

Echocardiographic assessment of pulmonary hypertension in infants with bronchopulmonary dysplasia: systematic review of literature and a proposed algorithm for assessment.

As survival and outcomes continue to improve in neonates born prematurely, there is an increasing need to promptly identify and treat pulmonary hypertension (PHT) in this population. Several echocardiographic indices have been used to evaluate for PHT. There is no clear consensus on how to utilize these parameters specifically for the evaluation of PHT in infants with chronic lung disease of prematurity.

Risk Factors for Development of Pulmonary Hypertension in Infants with Bronchopulmonary Dysplasia: Systematic Review and Meta-Analysis

OBJECTIVES Preterm infants with bronchopulmonary dysplasia (BPD) are at increased risk for development of Pulmonary Hypertension (PHT). We performed a systematic review and meta-analysis to identify risk factors for development of PHT in infants with BPD. STUDY DESIGN A systematic review identified risk factors for the development of PHT in infants with BPD. A meta-analysis of the pooled data was performed for each individual risk factor. RESULT Of the 20 risk factors identified, 10 were repeated more than once in nine studies. Meta analysis showed that duration of mechanical ventilation, length of stay, oligohydramnios, use of high frequency ventilation, small for gestational age, sepsis and severity of BPD were significant risk factors; while birth weight and gestational age were inversely related. CONCLUSION Several clinical variables are predictive of the development of PHT in infants with BPD. Prospective studies are needed to transform these risk factors into a risk-based scoring system.

A systematic review of psychological interventions for adult and pediatric patients with vocal cord dysfunction

Background: Vocal cord dysfunction (VCD) or paradoxical vocal-fold motion (PVFM) is a functional disorder of the vocal cords that requires multidisciplinary treatment. Besides relaxation techniques, the use of psychological interventions can help treat the underlying psychological co-morbidities. There is currently no literature that examines the effectiveness of psychological interventions for VCD/PVFM. Objectives: To review the evidence for psychological interventions used for the treatment of patients with VCD/PVFM. Data sources: We searched electronic databases for English medical literature using Pubmed (Medline), PsycInfo, Cochrane Database of Systematic Reviews, Cochrane Central Registry of Controlled Trials, and Clinicaltrials.gov. The date range for our search is from June 1964 to June 2014. Study eligibility criteria, participants, and interventions: We included studies that reported the use of psychological interventions in both adults and children diagnosed with VCD/PVFM. We included randomized controlled trials, case-control studies, retrospective chart reviews, prospective case series, and individual case reports. Results: Most reported studies are small case series or individual case reports that have described the use of interventions such as psychotherapy, behavioral therapy, use of anti-anxiety and anti-depressant medications, and hypnotherapy in conjunction with breathing exercises taught by speech therapists for symptomatic relief. Among the various psychological interventions that have been reported, there is no data regarding effectiveness and/or superiority of one approach over another in either adult or pediatric patients. Conclusions: Psychological interventions have a role to play in the management of adult and pediatric patients with VCD/PVFM. Future prospective studies using uniform approaches for treatment of associated psychopathology may help address this question.

A novel surfactant protein C gene mutation associated with progressive respiratory failure in infancy.

Mutations of the Surfactant Protein C (SPC) gene (SFTPC) have been associated with childhood interstitial lung disease (chILD) with variable age of onset, severity of lung disease, and outcomes. We report a novel mutation in SFTPC [c.435G‐>A, p.(Gln145)] that was associated with onset of symptoms in early infancy, progressive respiratory failure with need for prolonged mechanical ventilatory support, and eventual lung transplant at 1 year of age. While the mutation was not predicted to alter the amino acid sequence of the SP‐C precursor protein, analysis of SP‐C transcripts demonstrated skipping of exon 4. Because of limited data about the outcomes of infants with SFTPC mutations, we conducted a systematic review of all the SFTPC mutations reported in the literature in order to define their presenting features, clinical and radiologic features, and outcomes. Further advances in our understanding of chILD and creation of an international registry will help to track these patients and their outcomes. Pediatr Pulmonol. 2017;52:57–68.

Elevated Sweat Chloride Concentration in Children Without Cystic Fibrosis Who Are Receiving Topiramate Therapy

Topiramate, which is used as an anticonvulsant and for migraine prophylaxis in children, causes oligohydrosis as a side‐effect, but its effect on sweat chloride concentrations has not been studied systematically.

Improving screening for diabetes in cystic fibrosis

PURPOSE Annual screening for cystic fibrosis-related-diabetes (CFRD) using oral glucose tolerance test (OGTT) is recommended, but national testing rates are low. The purpose of this paper is to implement the quality improvement (QI) initiative to improve cystic fibrosis (CF) annual screening rates among patients at one CF center. DESIGN/METHODOLOGY/APPROACH To improve screening for CFRD at the CF Center, the authors used the Dartmouth Microsystem Improvement Ramp method and formed a collaborative working group. A process map was created to outline the steps and a fishbone analysis was performed to identify barriers and to utilize resources for implementing new interventions. FINDINGS Prior to these interventions, 21 percent of eligible patients had completed annual screening and after the intervention, it rose to 72 percent. The initial completion rate with the first prescription was only 50 percent, but it improved steadily to 54/75 (72 percent) in response to reminder letters sent six weeks after the initial script was given. PRACTICAL IMPLICATIONS Close tracking and reminder letters can improve adherence with annual OGTT screening for CFRD among CF patients, with special emphasis on high-risk patients. ORIGINALITY/VALUE There should be a special emphasis on screening for CFRD in high-risk CF patients (those with low BMI or higher age). This QI initiative brought about several operational changes in the annual OGTT screening process that have now become the standard operating procedure at the center.

Retrieval of endobronchial foreign bodies in children: involving the cardiac catheterization lab.

Endobronchial foreign body impaction is a common occurrence, especially in the pediatric population. Bronchoscopic techniques are the standard of care for their retrieval. However, the most distally located foreign bodies are often difficult to retrieve using these techniques. A novel approach using biplane fluoroscopy, with tools usually used for intravascular foreign body retrieval, has been recently described in adults by interventional radiologists. We are the first to report 2 cases in children using this approach for distally impacted endobronchial foreign body retrieval in the cardiac catheterization laboratory. We used a collaborative approach, using flexible bronchoscopy and fluoroscopically guided catheters to reach the foreign body. The first case involved a 16-year-old girl who presented with a 4-day history of aspiration of a staple pin, which we successfully retrieved. The second case involved a 10-year-old boy who presented with a 2-month history of aspiration of the plastic eraser cap of a mechanical pencil. We were successful in reaching the distal lobule where it was lodged. However, we were unable to grasp the foreign body because of the presence of a chronic inflammatory exudate around it owing to the subacute to chronic presentation. There were no complications in either case. Thus, a collaboration of the pulmonology and interventional cardiology teams in the cardiac catheterization laboratory represents a safe and effective alternative to bronchoscopy in the management of distally placed endobronchial foreign bodies in children. Early recognition and intervention is imperative for the successful retrieval of an endobronchial foreign body.

Exploring the impact of elevated depressive symptoms on the ability of a tailored asthma intervention to improve medication adherence among urban adolescents with asthma.

BackgroundIn patients with asthma, medication adherence is a voluntary behavior that can be affected by numerous factors. Depression is an important co-morbidity in adolescents with asthma that may significantly impact their controller medication adherence and other asthma-related outcomes. The modifying effect of depressive symptoms on an asthma intervention’s ability to improve asthma controller medication adherence among urban adolescents with asthma has not yet been reported.ObjectiveTo assess self-reported symptoms of depression as an effect modifier of the relationship between randomization group and controller medication adherence at 6-month follow-up.MethodsThese analyses use data from a randomized controlled trial (RCT) conducted in Detroit high schools to evaluate a tailored asthma management program. The intervention included referrals to school or community resources for students reporting symptoms of depression and other issues. “Elevated depressive symptoms” was defined as a positive answer to ≥ 5 of 7 questions from a validated tool included on the baseline questionnaire. Self-reported adherence to controller medication was collected at intervention onset (session 1) and at 6-month follow up. Analyses were restricted to students with report of a controller medication at baseline. Logistic regression was used to assess elevated depressive symptoms as an effect modifier of the relationship between randomization group and 6-month adherence.ResultsOf the 422 students enrolled in the RCT, a controller medication was reported at intervention onset by n = 123 adolescents (29%). Analyzing this group, we observed an interaction between elevated depressive symptoms and adherence (p = 0.073). Stratified analysis showed better adherence in treatment group adolescents meeting criteria for elevated depressive symptoms at baseline as compared to the control group (adjusted Odds Ratio [aOR] = 9.50; p = 0.024). For adolescents without elevated depressive symptoms at baseline, differences in adherence by group assignment did not reach statistical significance (aOR 1.40, p = 0.49).ConclusionsIn this sample of students reporting controller medications at baseline, report of elevated depressive symptoms at baseline and randomization to the intervention group was associated with significantly better adherence at 6-month follow up when compared to that of a control group. Larger studies are needed to evaluate the impact of depression on the relationship between adherence and asthma intervention effectiveness.

Effect of depressive symptoms on asthma intervention in urban teens

BACKGROUND The literature suggests that depression is an important comorbidity in asthma that can significantly influence disease management and quality of life (QOL). OBJECTIVE To study the effect of coexisting depressive symptoms on the effectiveness of self-management interventions in urban teens with asthma. METHODS We analyzed data from a randomized controlled trial of Puff City, a web-based, tailored asthma management intervention for urban teens, to determine whether depression modulated intervention effectiveness for asthma control and QOL outcomes. Teens and caregivers were classified as depressed based on responses collected from baseline questionnaires. RESULT Using logistic regression analysis, we found that a lower percentage of treatment students had indicators of uncontrolled asthma compared with controls (adjusted odds ratios <1). However, for teens depressed at baseline, QOL scores at follow-up were significantly higher in the treatment group compared with the control group for the emotions domain (adjusted relative risk, 2.08; 95% confidence interval, 1.2-3.63; P = .01; interpreted as emotional QOL for treatment students increased by a factor of 2.08 above controls). Estimates for overall QOL and symptoms QOL were borderline significant (adjusted relative risk, 1.57; 95% confidence interval, 0.93-2.63; P = .09; and adjusted relative risk, 1.72; 95% confidence interval, 0.94-3.15; P = .08; respectively). Among teens not depressed at baseline, no significant differences were observed between treatment and control groups in QOL domains at follow-up. CONCLUSION Our results suggest that depression modified the relationship between the effectiveness of an asthma intervention and emotional QOL in urban teens. Further assessment of self-management behavioral interventions for asthma should explore the mechanism by which depression may alter the intervention effect.

A 10-year retrospective review of pediatric lung abscesses from a single center.

Introduction: Pediatric lung abscesses can be primary or secondary, and there is limited data regarding response to treatments and patient outcomes. Objectives: To assess the clinical and microbiologic profile of pediatric patients with lung abscess and assess the differences in outcomes for patients treated with medical therapy or medical plus surgical therapy. Methods: A retrospective review of all pediatric patients ≤ 18 years of age that were treated as an inpatient for lung abscess between the dates of August 2004 and August 2014 was conducted. Patients were divided into two subgroups based on the need for surgical intervention. Results: A total of 39 patients with lung abscess (30 treated with medical therapy alone, 9 also required surgical interventions) were included. Fever, cough, and emesis were the most common presenting symptoms, and most of the patients had underlying respiratory (31%) or neurologic disorders (15%). Staphylococcus aureus was the most common organism in those that had culture results available, and ceftriaxone with clindamycin was the most common combination of antibiotics used for treatment. Comparison of medical and surgical subgroups identified the duration of fever and abscess size as risk factors for surgical intervention. Conclusions: Pediatric lung abscesses can be managed with medical therapy alone in most cases. Presence of prolonged duration of fever and larger abscess size may be predictive of the need for surgical intervention. Good clinical response to prolonged therapy with ceftriaxone and clindamycin was noted.