Trochlear boss height measurement: A comparison of radiographs and MRI

BackgroundA key anatomical consideration and determinant of surgical approach in trochlear dysplasia is the trochlear boss height (TBH), traditionally defined by measurements on plain X-rays (XR). Magnetic resonance (MR) imaging is increasingly used for pre-operative planning and follow-up. However, it is unclear whether measurement of TBH on XR is applicable to MR. The aim of this study was to establish the reliability of TBH measurement on MR compared to XR.MethodsThis study used lateral knee radiographs and MR scans of 14 knees of patients with trochlear dysplasia, six knees of non-dysplastic patients with anterior knee pain (AKP), and five knees of non-dysplastic controls with no AKP. Correlation between XR and MR measurements was assessed using Pearson correlation coefficients. Agreement between methods and observers was assessed using Bland–Altman plots with 95% limits of agreement. Intra- and inter-observer reliability was assessed using intraclass correlation coefficients (ICC).ResultsBland–Altman charts showed a total width of 95% limits of agreement of 4.78 mm for XR and MR subchondral bone (SB) TBH measurements, and 6.73 mm for XR and MR cartilage TBH measurements. Inter-observer ICCs were 0.86 for XR, 0.62 for MR SB, and 0.53 for MR cartilage. The widths of the Bland–Altman 95% limits of agreement between observers were 4.79 mm (XR), 5.04 mm (MR SB) and 4.74 mm (MR cartilage).ConclusionMeasurement of TBH on MR is not directly interchangeable with XR. Adjustments need to be made to treatment thresholds based on XR measurement if MR is used instead.     

Performance of a rapid antigen test (Binax NOW® RSV) for diagnosis of respiratory syncytial virus compared with real-time polymerase chain reaction in a pediatric population

BackgroundInfants from Alaska's Yukon–Kuskokwim Delta (YKD) have a high respiratory syncytial virus (RSV) hospitalization rate (104/1000/yr). Appropriate patient management requires rapid and accurate RSV diagnosis. Antigen-based methods are often used in clinical settings, but these tests can lack sensitivity.ObjectiveWe compared Binax NOW^® RSV (BN) used for RSV diagnosis in the YKD hospital with a real-time polymerase chain reaction assay (RT-qPCR) used for viral surveillance.Study designBetween October 2005 and September 2007 we obtained nasopharyngeal washes (NPW) from children <3 years hospitalized with a lower respiratory tract infection. The NPW were tested using BN and RT-qPCR.Results79/311 (25%) children had RSV infection as determined by RT-qPCR. As compared with RT-qPCR, sensitivity and specificity of BN were 72% and 97%, respectively. The sensitivity of BN was higher in children <1 year compared with children ≥1 year (79% vs. 52%; p = 0.025), children with bronchiolitis compared with children without bronchiolitis (89% vs. 38%; p < 0.001), and children with a shorter duration of symptoms before testing (0–1 (92%) vs. 2–4 (78%) vs. 5+ (65%) days; p = 0.04). The median RSV viral load in NPW positive by BN and RT-qPCR was 1.01 × 10⁹ copies/mL vs. a median of 5.25 × 10⁷ copies/mL for NPW positive by RT-qPCR only (p < 0.001).ConclusionRT-qPCR is more sensitive than BN in detecting RSV infection. BN sensitivity is high in children with bronchiolitis, but the sensitivity is low when children present with a non-bronchiolitis illness, especially after a longer duration of symptoms before testing.     

Blood MxA protein as a marker for respiratory virus infections in young children

BackgroundType I interferon induced MxA response can differentiate viral from bacterial infections, but MxA responses in rhinovirus or asymptomatic virus infections are not known.ObjectiveTo study MxA protein levels in healthy state and during respiratory virus infection of young children in an observational prospective cohort.Study designBlood samples and nasal swabs were collected from 153 and 77 children with and without symptoms of respiratory infections, respectively. Blood MxA protein levels were measured by an enzyme immunoassay and PCR methods were used for the detection of respiratory viruses in nasal swabs.ResultsRespiratory viruses were detected in 81% of symptomatic children. They had higher blood MxA protein levels (median [interquartile range]) than asymptomatic virus-negative children (695 [345–1370] μg/L vs. 110 [55–170] μg/L; p < 0.001). Within asymptomatic children, no significant difference was observed in MxA responses between virus-positive and virus-negative groups. A cut-off level of 175 μg/L had 92% sensitivity and 77% specificity for a symptomatic respiratory virus infection. Rhinovirus, respiratory syncytial virus, parainfluenza virus, influenza virus, coronavirus, and human metapneumovirus infections were associated with elevated MxA responses. Asymptomatic virus-negative children vaccinated with a live virus vaccine had elevated MxA protein levels (240 [120–540] μg/L), but significantly lower than children with an acute respiratory infection, who had not received vaccinations (740 [350–1425] μg/L; p < 0.001).ConclusionBlood MxA protein levels are increased in young children with symptomatic respiratory virus infections, including rhinovirus infections. MxA is an informative general marker for the most common acute virus infections.     

Low mother-to-child-transmission rate of Hepatitis C virus in cART treated HIV-1 infected mothers

BackgroundMaternal transmission is the most common cause of HCV infection in children. HIV co-infection and high levels of plasma HCV-RNA have been associated with increased HCV transmission rates.ObjectivesWe assessed the vertical HCV transmission rate in the HIV–HCV co-infected group of pregnant women on cART.Study designWe conducted a retrospective study in a Dutch cohort of HIV-positive pregnant women and their children. We identified co-infected mothers. Results of the HCV tests of the children were obtained.ResultsAll 21 women were on cART at the time of delivery. We analyzed data of the 24 live-born children at risk for mother-to-child transmission (MTCT) of HCV between 1996 and 2009. HIV-RNA was <500 copies/ml during 18/24 [75%] deliveries, the median CD4⁺ cell count was 419 cells/μl (290–768). There was no transmission of HIV. The median plasma HCV-RNA in our cohort of 23 non-transmitting deliveries in 21 women was 3.5 × 10E5 viral eq/ml (IQR 9.6 × 104–1.5 × 106 veq/mL). One of 24 live-born children was found to be infected with HCV genotype 1. At the time of delivery the maternal plasma HIV-RNA was <50 copies/ml, the CD4⁺ cell count was 160 cells/μl and maternal plasma HCV-RNA was 4.6 × 10E6 veq/ml. This amounted to a prevalence of HCV-MTCT of 4%.ConclusionIn this well-defined cohort of HIV–HCV co-infected pregnant women, all treated with cART during pregnancy, a modest rate of vertical HCV transmission was observed.     

High expression of OX40 (CD134) and 4-1BB (CD137) molecules on CD4+CD25high cells in children with type 1 diabetes

PurposeDespite the rapidly rising incidence of diabetes in children, with the highest rise in children < 5 years of age, data on mechanisms that trigger severe beta-cells damage are limited. The aim of the study was to assess the frequency of OX40 (CD134) or 4-1BB (CD137) positive cells in the peripheral blood of children with newly diagnosed type 1 diabetes (T1D) in comparison to healthy controls.Material/methodsThe study included 33 children (mean age 7.3 ± 5.4 years) with newly diagnosed T1D and 39 age-matched healthy controls. Separate analysis was performed in children < 5 years. Flow cytometric analysis was performed using the following markers: CD4, CD25, CD137, and CD134. Fasting C-peptide level was assessed as well.ResultsThe frequency of CD4⁺CD25^highOX40⁺ was higher in T1D children than in controls (median value 3.58% vs. 1.1%, respectively; p = 0.003). Moreover, T1D children had higher frequency of CD4⁺CD25^high4-1BB⁺ cells than healthy subjects (median value 5.76% vs. 3.74%, respectively; p = 0.037). A significant correlation was noted between the age of diabetic children and the C-peptide level (r = 0.54, 95% CI [0.19–0.77], p = 0.004). In comparison with age-matched controls, children < 5 years had higher frequency of CD4⁺CD25^highOX40⁺ (p = 0.004) and CD4⁺CD25^high4-1BB⁺ cells (p = 0.079).ConclusionsOur study showed higher frequency of both OX40 and 4-1BB positive cells in T1D children in comparison to controls. It seems that observed differences might be more pronounced in children < 5 years of age than in older subjects. Further clinical studies are needed to determine the age-related differences in the immune system, in the pathogenesis of T1D.     

Hepatitis B viral load in dried blood spots: A validation study in Zambia

BackgroundAccess to hepatitis B viral load (VL) testing is poor in sub-Saharan Africa (SSA) due to economic and logistical reasons.ObjectivesTo demonstrate the feasibility of testing dried blood spots (DBS) for hepatitis B virus (HBV) VL in a laboratory in Lusaka, Zambia, and to compare HBV VLs between DBS and plasma samples.Study designPaired plasma and DBS samples from HIV-HBV co-infected Zambian adults were analyzed for HBV VL using the COBAS AmpliPrep/COBAS TaqMan HBV test (Version 2.0) and for HBV genotype by direct sequencing. We used Bland-Altman analysis to compare VLs between sample types and by genotype. Logistic regression analysis was conducted to assess the probability of an undetectable DBS result by plasma VL.ResultsAmong 68 participants, median age was 34 years, 61.8% were men, and median plasma HBV VL was 3.98 log IU/ml (interquartile range, 2.04–5.95). Among sequenced viruses, 28 were genotype A1 and 27 were genotype E. Bland–Altman plots suggested strong agreement between DBS and plasma VLs. DBS VLs were on average 1.59 log IU/ml lower than plasma with 95% limits of agreement of −2.40 to −0.83 log IU/ml. At a plasma VL ≥2,000 IU/ml, the probability of an undetectable DBS result was 1.8% (95% CI: 0.5–6.6). At plasma VL ≥20,000 IU/ml this probability reduced to 0.2% (95% CI: 0.03–1.7).ConclusionsIn a Zambian laboratory, we observed strong agreement between DBS and plasma VLs and high sensitivity in DBS at plasma VL ≥2,000 IU/ml. As HBV treatment expands, DBS could increase access to HBV VL testing and care in SSA settings.     

Long-term follow-up for incident cirrhosis among pediatric cancer survivors with hepatitis C virus infection

BackgroundPediatric cancer patients who received blood transfusions were potentially exposed to hepatitis C virus (HCV) prior to second-generation HCV screening of blood products in 1992. Limited evidence is available about long-term incident cirrhosis in this population.ObjectivesWe aimed to estimate the overall and sex-specific incidence of cirrhosis among HCV-seropositive survivors of pediatric cancer.Study designWe identified 113HCV-seropositive pediatric cancer patients treated at St. Jude Children’s Research Hospital between 1962 and 1997, who survived ≥5 years post-diagnosis, and were followed through 2014. Our outcome was cirrhosis determined by liver biopsy or diagnostic imaging. We used a competing-risk framework to estimate the overall and sex-specific cumulative incidence and 95% confidence limits (CL) of cirrhosis at 10-year follow-up intervals.ResultsThe median duration of follow-up was 30 years (interquartile range = 28–36) post-cancer diagnosis. Cumulative incidence of cirrhosis increased at each 10-year interval from 0% after 10 years to 13% after 40 years (P_trend < 0.001). The median age at diagnosis of cirrhosis was 30 years (interquartile range = 24–38). We observed a linear trend in incidence for males (P_trend < 0.001), with a cumulative incidence of 18% (95% CL: 6.1%, 34%) after 40 years. The cumulative incidence for females was 6.5% (95% CL: 0.42%, 26%) after 40 years, but we did not observe a linear trend (P_trend = 0.99).ConclusionOur results suggest that the incidence of cirrhosis is similar between HCV-seropositive pediatric cancer survivors and the general population given similar duration of follow-up, but survivors may be diagnosed with cirrhosis at an earlier age.     

Norovirus in feces and nasopharyngeal swab of children with and without acute gastroenteritis symptoms: First report of GI.5 in Brazil and GI.3 in nasopharyngeal swab

BackgroundNoroviruses (NoVs) are an important cause of acute gastroenteritis (AGE), worldwide.ObjectivesTo evaluate the frequency, viral load and molecular profile of NoV in fecal and nasopharyngeal swab samples from hospitalized children, and to determine children’s secretor status.Study designFrom May 2014 to May 2015, 219 children were included in the study, 96 with gastroenteric symptoms and 123 without gastroenteric symptoms. All fecal and nasopharyngeal swab samples were screened by TaqMan RT-qPCR duplex (GI/GII NoV) and quality samples were characterized by genomic sequencing.ResultsNorovirus positivity rate in feces was 15.4% in asymptomatic and 18.8% in the symptomatic group. The median viral loads in feces were 2.69 × 10⁸ GC/g and 4.32 × 10⁷ GC/g from children with or without AGE symptoms, respectively. In nasopharyngeal swab samples, the NoV positivity was 11.4% in symptomatic children, with a median viral load of 2.20 × 10⁷ GC/mL and 6.5% in asymptomatic children, with an average viral load of 1.73 × 10⁶ GC/mL. In only two cases NoV was detected in both samples. A considerable genomic variability was observed in feces, with six genotypes being detected, as follows: GII.4, GII.6, GI.3 and GII.3, GI.2 and GI.5. Two GI.3 was detected in nasopharyngeal swab.ConclusionsOur data reveal considerable NoV frequencies in both nasopharyngeal and fecal samples from symptomatic and asymptomatic children. Higher viral loads were detected in samples from AGE symptomatic children, when compared to asymptomatic children. High genomic variability was observed, with this being the first report of GI.5 NoV in Brazil and of GI.3 in nasopharyngeal swab samples.     

Current outcomes of chronic active antibody mediated rejection – A large single center retrospective review using the updated BANFF 2013 criteria

BackgroundThe updated BANFF 2013 criteria has enabled a more standardized and complete serologic and histopathologic diagnosis of chronic active antibody mediated rejection (cAMR). Little data exists on the outcomes of cAMR since the initiation of this updated criteria.Methods123 consecutive patients with biopsy proven cAMR (BANFF 2013) between 2006 and 2012 were identified.ResultsPatients identified with cAMR were followed for a median of 9.5 (2.7–20.3) years after transplant and 4.3 (0–8.8) years after cAMR. Ninety-four (76%) recipients lost their grafts with a median survival of 1.9 years after diagnosis with cAMR. Mean C4d and allograft glomerulopathy scores were 2.6 ± 0.7 and 2.2 ± 0.8, respectively. 53.2% had class II DSA, 32.2% had both class I and II, and 14.5% had class I DSA only. Chronicity score >8 (HR 2.9, 95% CI 1–8.4, p = 0.05), DSA >2500 MFI (HR 2.8, 95% CI 1.1–6.8, p = 0.03), Scr >3 mg/dL (HR 3.2, 95% CI 1.6–6.3, p = 0.001) and UPC >1 g/g (HR 2.5, 95% CI 1.4–4.5, p = 0.003) were associated with a higher risk of graft loss.ConclusionscAMR was associated with poor graft survival after diagnosis. Improved therapies and earlier detection strategies are likely needed to improve outcomes of cAMR in kidney transplant recipients.     

Clinical features of radiologically confirmed pneumonia due to adenovirus in children

BackgroundClinical features of radiologically confirmed pneumonia due to adenovirus in children have not been comprehensively evaluated.ObjectiveTo describe the detailed clinical features of radiologically confirmed adenovirus-associated pneumonia in children.Study designOf 3298 children with a throat virus culture positive for adenovirus treated at a university-affiliated hospital, from January 2000 to June 2008, in northern Taiwan, 80 hospitalized children (2.4%) with radiologically confirmed pneumonia were identified. From four children with incomplete medical records, only demographics were included for analysis.ResultsThe median age was 2.97 years, ranging from 25 days to 14 years. Seventy-three patients (96%) had fever, with a median duration of 7 days. The three most common respiratory symptoms were cough (99%), rhinorrhea (82%) and dyspnea (42%). Gastrointestinal symptoms were recorded in 80% of the patients, and neurologic symptoms in four children. Leukocytosis (WBC ≥ 15,000/μL) was noted in 19 (25%) patients. Only six patients (8%) had a normal serum C-reactive protein (CRP) value (<5 mg/L), while 48 patients (63%) had a CRP level >40 mg/L. Seventeen (21%) children required intensive care. Seventy-three patients (96%) recovered uneventfully. Sequelae were seen in two patients and death in 1. Of the 69 isolates with serotyping determination, seven serotypes were identified, with a predominant serotype (type 3 for 73%).ConclusionLess than 5% of the children with adenoviral infection had radiologically confirmed patch pneumonia. The manifestation of pneumonia caused by adenovirus was similar to that of bacterial pneumonia.     

Przeszczepianie krwi pępowinowej w polskich ośrodkach pediatrycznych: raport Polskiej Pediatrycznej Grupy ds. Transplantacji Komórek Krwiotwórczych

BackgroundCord blood transplantation (CBT) is accepted therapeutic method in transplantology since 1988. The first isolated CBT was performed on 12 October 2000 in Poznań.ObjectiveAnalysis of results of CBT in Polish pediatric centers.Patients and methodsA total numer of 19 patients (5 female, 14 male), aged 0.1–10 years (median 4.3 yrs) transplanted with cord blood between 2000–2011 in Polish pediatric centers. The initial diagnosis was: acute lymphoblastic leukemia (n = 6), acute myeloid leukemia (n = 1), myelodysplstic syndrome (n = 2), Wiskott-Aldrich syndrome (n = 3), Fanconi anemia (n = 2), adrenoleukodystrophy (n = 1), Langerhans cell histiocytosis (n = 1), chronic granulomatous disease (n = 1), Kostmann syndrome (n = 1), Sandhoff syndrome (n = 1). Pre-transplant conditioning was myeloablative in 9 patients and reduced-intensity in 10 patients. The source of cord blood was family donor in 8 cases or unrelated donor in 11 cases. Histocompatibility 6/6 HLA between donor-recipient was present in 10 cases.Results10/19 (52.6%) children stay alive, median survival 3.1 years (95%CI = 1.4–4.7), probability of 2-year survival was 0.409 ± 0.133. The cause of death was primary graft failure (n = 2), infectious complications (n = 3) or relapse (n = 4). Two children with primary graft failure had subsequent haploidentical transplantation. In multivariate analysis, generalized documented infection was the only predictive adverse factor of overall survival.ConclusionCBT is an important therapeutic option for patients lacking matched donor, offering positive outcome for a half of patients.     

CMV plasma DNAemia and risk of cancer among HIV-infected patients: A case–control study nested in the ANRS CO3 Aquitaine Cohort,France, 2002–2007

BackgroundCMV reactivation, which enhances immune senescence, could be associated with a higher risk of cancer.ObjectivesWe compared the prevalence of positive CMV DNAemia in HIV-infected patients with and without cancer.Study designThis case–control study, nested in the ANRS-CO3 Aquitaine Cohort, included patients with a first diagnosis of cancer (2002–2007) as cases. Two controls were matched per case.Cancer risk was estimated using conditional logistic regression models, an Odds Ratio (OR) of 2 could be detected with 80% power. The variables considered were: ≥1 positive CMV DNAemia, CD4+ and CD8+ counts, HIV plasma load. Plasma CMV DNA was retrospectively quantified within the 3-year period preceding the endpoint.ResultsThe 143 cases (93 non-AIDS-related and 50 AIDS-related cancers) and 284 controls had a median age of 47 years (IQR: 41–56). At the time of diagnosis or censorship, for cases and controls, median values were respectively, for CD4+ count: 327 cells/mm³ (IQR: 164–514) and 416 (IQR: 275–582), and for HIV plasma load: 2.6 log₁₀ copies/mL (IQR: 1.7–4.7) and 1.7 log₁₀ copies/mL (IQR: 1.7–3.3). We performed 2056 CMV PCR; 14 cases (9.8% [95% CI: 4.9–14.7]) and 19 controls (6.7% [CI: 3.8–9.6]) presented ≥1 positive PCR. CMV DNAemia was not associated with the risk of cancer (unadjusted and adjusted p-values = 0.19 and 0.54, respectively). HIV load >500 copies/mL was independently associated with a higher risk of cancer (OR = 2.02; p = 0.002; 95% CI: 1.29–3.17).ConclusionThis large case–control study did not show any differential exposure to positive CMV plasma DNAemia between cancer cases and controls.     

Impact of travel on the seroprevalence of hepatitis A in children

BackgroundRecent data about hepatitis A virus (HAV) seroprevalence in industrialized countries and the impact of travels to endemic areas are sparse or absent, particularly for children.ObjectiveTo determine the impact of travel to endemic areas on HAV seroprevalence and estimate the overall HAV seroprevalence in children in France. To identify risk factors for positive HAV serologic results.Study designThis prospective multicentre cross-sectional seroprevalence study took place in eight paediatric emergency units throughout France. Children 1–16 years of age following all inclusion and exclusion criteria were included. Demographic, socioeconomic, and travel data were prospectively collected with a standardized questionnaire before measurement of specific HAV antibodies. HAV seroprevalence was determined and its association with diverse variables assessed by univariate and multivariate analyses.Results430 children were included, of whom 116 had travelled to endemic areas. The HAV seroprevalence in the overall population was 5% (95%CI, 3–7) and was higher among the travellers (12% [95%CI, 6–18]) than among the others (2% [95%CI, 0–3]), OR = 7.0 [95%CI, 2.6–18.8]. Risk factors identified for positive serologic results for HAV were travel to an endemic area >7 days (adjusted OR [aOR] = 4.3 [95%CI, 1.5–12]), age of 14–16 years (aOR = 7.7 [95%CI, 1.6–38.3]) and mother's birth in an endemic area (aOR = 5.2 [95%CI, 1.8–14.8]).ConclusionStatistical evidence showed that travel to endemic areas and parents’ place of birth both play a role in HAV serologic results in children with a significant difference of HAV seroprevalence between traveller and non-traveller children in France.     

Use of cardiac magnetic resonance imaging to evaluate cardiac structure,function and fibrosis in children with infantile Pompe disease on enzyme replacement therapy

BackgroundPompe disease (acid α-glucosidase deficiency) is one of several lysosomal storage diseases amenable to treatment with enzyme replacement therapy (ERT). While echocardiography (echo) has been the standard method to evaluate the cardiac response to ERT, cardiac magnetic resonance imaging (CMR) has the advantage of a better tissue definition and characterization of myocardial fibrosis. However, CMR for Pompe disease is not frequently performed due to a high risk of sedation. We report the first use of CMR in a feasible protocol to quantify left ventricular (LV) mass, function, and the presence of myocardial fibrosis in the Pompe population.MethodsChildren with Pompe disease on ERT were assessed with transthoracic echo and CMR over a 3 year period at a single institution. Echocardiography was performed using standard techniques without sedation. CMR was performed using retrospectively gated and real-time imaging, with and without sedation. LV mass indexed to body surface area (LVMI) and ejection fraction (EF) were measured by both echo and CMR, and evaluated for change over time. Myocardial fibrosis was assessed by CMR with delayed enhancement imaging 5–10 min after gadolinium contrast using single shot inversion recovery sequences with inversion time set to null the signal from normal myocardium.ResultsSeventeen CMR scans were successfully performed in 10 subjects with Pompe disease (median age at first CMR is 9 months, range 1–38 months, 80% male), with sedation only performed in 4 studies. There was a median interval of 5 months (range 0–34 months) from the start of ERT to first CMR (baseline). At baseline, the median indexed LVMI by CMR (140.0 g/m², range 43.8–334.0) tended to be lower than that assessed by echo (median 204.0 g/m², range 52.0–385.0), but did not reach statistical significance. At baseline, CMR EF was similar to that assessed by echo (55% vs. 55%). Overall, there was no significant decrease in CMR measured LVMI over time (CMR median LVMI at baseline 94 g/m² (range 43.8–334) vs. CMR median at most recent study 44.5 g/m² (range 34–303), p = 0.44). In 5 patients with serial CMR scans over time, LVMI decreased in 2, was similar in 2, and increased in 1 patient with high sustained antibodies to exogenous enzyme. Delayed enhancement was noted in only l separate patient who also had high sustained antibodies to exogenous enzyme.ConclusionCMR is an imaging tool that is feasible to use to serially follow LVMI and EF in children with Pompe disease on ERT. Real-time imaging is adequate for quantification purposes in these patients and minimizes the need for sedation. Quantitative CMR LVMI is generally lower than echo derived LVMI. Delayed enhancement appears to be a rare finding by CMR in Pompe disease. A further follow-up is necessary to better understand the long term effects of ERT in infantile Pompe survivors, especially those with high sustained antibody titers or advanced cardiac disease at treatment outset.     

The association between parent-reported provider communication quality and child obesity status: Variation by parent obesity and child race/ethnicity

ObjectiveTo examine the association between healthcare provider communication quality and child obesity status, and the role of parent obesity and child race/ethnicity regarding this association.MethodsWe conducted a cross-sectional secondary data analysis with the 2011–2013 Medical Expenditures Panel Survey of parents with children ages 6–12 (n = 5390). We used multivariable logistic regression to examine the association of parent-reported healthcare provider communication quality (explaining well, listening carefully, showing respect, and spending enough time) with child obesity status, and effect modification by parent obesity and child race/ethnicity.ResultsParents of obese children were more likely to report that their child’s healthcare provider listened carefully (OR = 1.41, p = 0.002) and spent enough time (OR = 1.33, p = 0.022) than parents of non-obese children. Non-obese parents of obese children experienced better communication in the domains of listening carefully (p < 0.001) and spending enough time (p = 0.007). Parents of obese non-Hispanic Asian children and non-Hispanic Black children were more likely to report that providers explained things well (p = 0.043) and listened carefully (p = 0.012), respectively.ConclusionParents of obese children experienced better communication if parents were non-obese or children were non-Hispanic Black or Asian.Practice implicationsHealthcare providers should ensure effective communication with obese parents of obese children.     

Anti-mullerian hormone (AMH) is associated with natural menopause in a population-based sample: The CARDIA Women's Study

ObjectiveAMH is associated with menopausal timing in several studies. In contrast to prior studies that were restricted to women with regular cycles, our objective was to examine this association in women with either regular or irregular menstrual cycles.MethodsCARDIA is a longitudinal, population-based study that recruited adults ages 18–30 when it began in 1985–1986. AMH was measured in serum stored in 2002–2003. Natural menopause was assessed by survey in 2005–2006 and 2010–2011.ResultsAmong 716 premenopausal women, median [25th, 75th] AMH was 0.77 [0.22–2.02] ng/dL at a median age of 42 [39–45] years. Twenty-nine percent of the women (n = 207) reported natural menopause during 9 years of follow up. In fully adjusted discrete-time hazard models, a 0.5 ng/dL AMH decrement was associated with higher risk of menopause (p < 0.001). Hazard ratios varied with time since AMH measurement. The HR (95% CI) for menopause was 8.1 (2.5–26.1) within 0–3 years and 2.3 (1.7–3.3) and 1.6 (1.3–2.1) for 3–6 and 6–9 years, respectively. When restricted to women with regular menses, results were similar (e.g., HR = 6.1; 95% CI: 1.9–20.0 for 0–3 years).ConclusionAMH is independently associated with natural menopause. AMH appears most useful in identifying women at risk of menopause in the near future (within 3 years of AMH measurement).     

Impact of rapid influenza diagnostic test on physician estimation of viral infection probability in paediatric emergency department during epidemic period

BackgroundThe clinical diagnosis of influenza is difficult in the younger children.ObjectivesEvaluate the impact of rapid influenza diagnostic test (RIDT) on clinicians’ estimation of the clinical probability of influenza in children.Study designThis prospective study included children aged from 1 month to 5 years who were admitted in a university paediatric emergency department during an influenza epidemic period and presented with fever without source. The RIDT Quickvue^® was performed on nasopharyngeal aspiration and results were confirmed with immunofluorescence and/or PCR. The clinical probability of influenza and serious bacterial infection (SBI) was evaluated for each child before and after the physician(s) was informed of the RIDT results.Results170 children were included from January 15th through March 18th, 2013. After the only clinical examination, the overall clinical probability of influenza was 66.0% [CI 95%: 63.04–68.4], and was significantly increased at 92.4% [CI 95%: 89.5–95.3] in case of positive RIDT and significantly decreased at 30.8% [CI 95%: 29.0–32.5] in case of negative RIDT without knowing the results of laboratory tests. Whereas the initial clinical probability of influenza were appropriate regarding the prevalence (66.0% vs. 57.0%), the probability of SBI was overestimated (30.2% vs. 8.8%). The RIDT result positive enabled a significant decrease in orders for chest X-rays (64,4% vs. 45.8%, p < 0,05) and laboratory tests (71,1% vs. 41.1%, p < 0,05).ConclusionsThe RIDT seems to be a useful diagnostic tool for ED clinicians in epidemic conditions. Improving clinician estimation of flu probability would reduce orders for imaging and testing.     

Aseptic meningitis in adults and children: Diagnostic and management challenges

BackgroundAseptic meningitis represents a common diagnostic and management dilemma to clinicians.ObjectivesTo compare the clinical epidemiology, diagnostic evaluations, management, and outcomes between adults and children with aseptic meningitis.Study designWe conducted a retrospective study from January 2005 through September 2010 at 9 Memorial Hermann Hospitals in Houston, TX. Patients age ≥ 2 months who presented with community-acquired aseptic meningitis with a CSF white blood cell count >5 cells/mm³ and a negative Gram stain and cultures were enrolled. Patients with a positive cryptococcal antigen, positive blood cultures, intracranial masses, brain abscesses, or encephalitis were excluded.ResultsA total of 509 patients were included; 404 were adults and 105 were children. Adults were most likely to be female, Caucasian, immunosuppressed, have meningeal symptoms (headache, nausea, stiff neck, photophobia) and have a higher CSF protein (P < 0.05). In contrast, children were more likely to have respiratory symptoms, fever, and leukocytosis (P < 0.05). In 410 (81%) patients, the etiologies remained unknown. Adults were more likely to be tested for and to have Herpes simplex virus and West Nile virus while children were more likely to be tested for and to have Enterovirus (P < 0.001). The majority of patients were admitted (96.5%) with children receiving antibiotic therapy more frequently (P < 0.001) and adults receiving more antiviral therapy (P = 0.001). A total of 384 patients (75%) underwent head CT scans and 125 (25%) MRI scans; all were normal except for meningeal enhancement. All patients had a good clinical outcome at discharge.DiscussionAseptic meningitis in adults and children represent a management challenge as etiologies remained unknown for the majority of patients due to underutilization of currently available diagnostic techniques.