A systematic review of nonpharmacological and nonsurgical therapies for gastroesophageal reflux in infants

BACKGROUND: Nonpharmacological and nonsurgical measures are often recommended for gastroesophageal reflux disease (GERD) in infants, despite ambiguous supporting evidence. OBJECTIVE: To conduct a systematic review of rigorously evaluated nonpharmacological and nonsurgical therapies for GERD in infants. DESIGN/METHODS: We searched online bibliographic databases, including MEDLINE, EMBASE, the Cochrane Collaboration and Clinical Trials Database, and alternative medicine databases for the terms gastroesophageal reflux and infants. We selected randomized controlled trials of nonpharmacological and nonsurgical GERD therapies in otherwise healthy infants. Data were extracted from the selected articles regarding reflux, emetic episodes and intraesophageal pH. RESULTS: We identified 43 relevant studies, of which 10 met the selection criteria. These studies examined positioning, pacifier use, and feeding changes. Positioning at a 60 degree elevation in an infant seat was found to increase reflux compared with the prone position. No significant difference was shown between the flat and head-elevated prone positions. The impact of pacifier use on reflux frequency was equivocal and dependent on infant position. The protein content of formula was not found to affect reflux. Although no study demonstrated a significant reflux-reducing benefit of thickened infant foods compared with placebo, 1 study detected a significant benefit of formula thickened with carob bean gum compared with rice flour (pH<4 for 5% vs 8% of time). Another study showed that if supplementing with dextrose 5% water or dextrose 10% water, the lower-osmolality fluid was associated with less reflux. CONCLUSIONS: Many conservative measures commonly used to treat GERD in infants have no proven efficacy. Although thickened formulas do not appear to reduce measurable reflux, they may reduce vomiting. Further studies with clinical outcomes are needed to answer questions about efficacy definitively.     

Can continuity of care be improved? Results from a randomized pilot study.

CONTEXT: Although continuity of care is an important component of primary care, few mechanisms for improving it have been studied. OBJECTIVE: To determine if automated reminders to providers and patient schedulers can improve continuity of care in a practice. DESIGN: Prospective randomized controlled trial. SETTING AND POPULATION: Four hundred and nine patients in the lowest tertile of continuity of care in a university-affiliated clinic with a computerized information system were randomized to 1 of 4 groups: 1) control (no reminder), 2) provider alert, 3) scheduler alert, or 4) provider and scheduler alert. MAIN OUTCOME MEASURES: Continuity of care as measured by a previously described dispersion index that ranges from 0 to 1.Results.-Initial continuity of care was.134 (standard deviation,.07). In a linear regression model, 9 months after implementation of the system, both the provider-prompt group (.027 [.006,.05]) and the provider and scheduler group (.024 [.001,.054]) were associated with increased continuity compared with the control group CONCLUSIONS: Prompting providers for patients with poor continuity of care may improve it.     

Fatal Blastoschizomyces capitatus sepsis in a neutropenic patient with acute myeloid leukemia: first documented case from Greece

Blastoschizomyces capitatus (formerly known as Geotrichum capitatum and Trichosporon capitatum) is a rare, yet an emerging, cause of invasive infections in immunosuppressed patients. Profound and prolonged neutropenia is the crucial predisposing factor for this yeast infection. Blastoschizomyces capitatus was isolated from peripheral blood cultures of a profoundly neutropenic patient with acute myeloid leukemia (M2 FAB). Despite administration of antifungal chemotherapy with liposomal amphotericin B at 4.5 mg kg(-1) daily, the patient succumbed 4 days after initiation of treatment. Infections attributed to B. capitatus have generally a poor prognosis, although the yeast shows in vitro susceptibility to antifungal agents. Low flucytosine, caspofungin acetate, voriconazole and amphotericin B minimum inhibitory concentration values were also recorded with our isolate. The clinical relevance of the in vitro susceptibility testing against the isolate and the current antifungal chemotherapy regimens against B. capitatus systemic infections are discussed.     

Neighborhood effects on posthospitalization mortality: a population-based cohort study of the elderly in Chicago

CONTEXT: Place of residence is associated with health outcomes. OBJECTIVE: To examine neighborhood effects on mortality after the onset of serious disease and to assess whether these effects vary for different sociodemographic or diagnostic subgroups. DESIGN, SETTING, PATIENTS: Our sample consists of a complete cohort of 10,557 elderly Medicare beneficiaries throughout the city of Chicago newly diagnosed and hospitalized for the first time with one of five common serious diseases in 1993 (stroke, myocardial infarction, congestive heart failure, hip fracture, and lung cancer) followed until 1999. Attributes of 51 zip code neighborhoods were obtained both from census data (1990) and from a comprehensive social survey of neighborhood residents (1994-1995). Cox proportional hazards models with robust standard errors were specified. MAIN OUTCOME MEASURE: Survival after hospitalization. RESULTS: People who lived in neighborhoods with higher socioeconomic status (SES) or with a better social environment had significantly longer survival after disease onset. We evaluated the differential impact of neighborhood attributes on survival depending on gender, race, and poverty using interaction terms. Only the interaction terms between neighborhood social-structural factors and individual poverty were significant, suggesting that neighborhood SES and social environment were especially helpful for people with higher income. Neighborhood attributes did not differ in their impact depending on the race or sex of the subjects. Analyses of cause-specific mortality showed that myocardial infarction was the primary force driving the associations between neighborhood attributes and mortality. CONCLUSIONS: Where people live matters with respect to posthospitalization mortality, but how neighborhoods affect this outcome depends on individual demographic and diagnostic characteristics. Myocardial infarction in particular may be a "neighborhood sensitive" condition. Individuals' health may depend not just on individuals' characteristics but also on their neighborhoods'.     

Long-term results of aortic valve replacement with the St. Jude Toronto stentless porcine valve

Background

Long-term survival and freedom from valve-related events of the St. Jude Toronto stentless porcine valve (SPV) are unknown. The aim of this study was to investigate late clinical outcomes after aortic valve replacement with the Toronto SPV.

Methods

Between 1992 and 2000, 200 patients (131 males, 69 females) underwent aortic valve replacement with the Toronto SPV. Mean patient age at implantation was 64.6 ± 10.9 years (range 33 to 82 years). At the time of operation, 32%, 51%, and 17% of patients were in New York Heart Association class I/II, III, and IV, respectively. Aortic stenosis, aortic insufficiency, and combined lesions were present in 64%, 13.5%, and 22.5% of patients preoperatively. Concomitant coronary artery bypass grafting was performed in 34.5% of patients.

Results

Perioperative mortality occurred in 2.5% (5/200) of patients. There were 31 late deaths. Actuarial survival at 5 and 10 years was 89.2% and 68.0%, respectively. There was no significant difference in overall actuarial survival between isolated valve patients and valve plus coronary artery bypass grafting patients, 71% versus 62% respectively, p = 0.85. Actuarial freedom from valve reoperation at 5 and 10 years was 97.6% and 79.9%, respectively. Actuarial freedom from structural valve deterioration was 98.8% at 5 years and declined to 77.9% at 10 years. Freedom from structural valve deterioration was poorer in patients with preoperative aortic insufficiency or bicuspid disease. Actuarial freedom from embolic events and endocarditis at 10 years were 94.6% and 95.9%, respectively.

Conclusions

Although early clinical results were excellent, a significant increase in hazard for structural valve deterioration occurred in late follow-up.