Distance from an Urban Sickle Cell Center and its Effects on Routine Healthcare Management and Rates of Hospitalization

The St. Jude Children’s Research Hospital (St. Jude) comprehensive sickle cell center serves a 150 mile catchment radius around Memphis, TN, USA. Full travel expenses are provided for routine and acute care visits for sickle cell disease patients living ≥35 miles from St. Jude. We compared hospitalization rates to national estimates and assessed if driving distance was a barrier to sickle cell healthcare despite the travel reimbursement policy. We evaluated the associations between hospitalizations and routine clinic visits and distance from St. Jude using negative binomial models and we conducted bias analyses by Monte Carlo simulation. We followed 545 patients (2550 patient-years) aged ≤18 years with sickle cell disease (Hb SS only) from 2007 to 2012. The hospitalization rate per patient-year was 0.65 [95% CI (confidence interval): 0.62, 0.68), significantly lower than the national rate of 1.16 (95% CI: 1.14, 1.18). Children living <35 miles from St. Jude had 1.75 (95% CI: 1.41, 2.17) times the rate of hospitalization and 1.22 (95% CI: 1.07, 1.39) times the rate of clinic visits compared to those ≥35 miles. Bias analysis suggested that under-reporting could explain the observed difference in hospitalization rates if 30.0% of patients who lived ≥35 miles from the hospital under-reported six hospitalizations over 6 years. The hospitalization rate at St. Jude in children with sickle cell disease was lower than expected from national rates. Greater distance from the sickle cell center (>35 miles) was associated with decreased hospitalization rates, despite the travel allowances that are provided for those who live ≥35 miles from the hospital.     

Distribution of Pandemic Influenza Vaccine and Reporting of Doses Administered,New York,New York,USA

In 2009, the New York City Department of Health and Mental Hygiene delivered influenza A(H1N1)pdm09 (pH1N1) vaccine to health care providers, who were required to report all administered doses to the Citywide Immunization Registry. Using data from this registry and a provider survey, we estimated the number of all pH1N1 vaccine doses administered. Of 2.8 million doses distributed during October 1, 2009–March 4, 2010, a total of 988,298 doses were administered and reported; another 172,289 doses were administered but not reported, for a total of 1,160,587 doses administered during this period. Reported doses represented an estimated 80%–85% of actual doses administered. Reporting by a wide range of provider types was feasible during a pandemic. Pediatric-care providers had the highest reporting rate (93%). Other private-care providers who routinely did not report vaccinations indicated that they had few, if any, problems, thereby suggesting that mandatory reporting of all vaccines would be feasible.     

Evaluation of sodium deficit in infants undergoing intestinal surgery

Background

Sodium is a critical growth factor for children. Severe deficits cause growth impairment and cognitive dysfunction. Both the diagnosis and risk of sodium depletion in children undergoing intestinal surgery are poorly understood.

Methods

With IRB approval, children undergoing intestinal surgery (2009–2012) who had a urine sodium measurement were retrospectively reviewed. Sodium deficits were defined: urine sodium < 30 mmol/L and < 10 mmol/L were deficient and severely deficient, respectively. Demographics, weight changes, and intake (sodium, fluid, and nutritional) were tabulated. Data were analyzed using regression analysis and Mann Whitney U tests.

Results

Thirty-nine patients, 51.3% female, with a gestational age of 32.2 weeks and weight of 1.43 kg were identified. The most common diagnoses were NEC (38.5%), intestinal atresia (20.5%), and isolated perforation (10.3%). Sodium deficiency was documented in 36/39 (92%) and 92.9% for those in continuity. Severe deficiency occurred in 64%. Urine sodium was significantly correlated with weight gain (p = 0.002). Weight gain in patients with urine sodium < 30 mmol/L was significantly decreased vs. those ≥ 30 mmol/L (+ 0.58 g/d vs. + 21.6 g/d, p = 0.016).

Conclusion

In this population, sodium depletion is common in children undergoing intestinal surgery, even when the colon is in continuity. Correction of the sodium deficit to achieve urine sodium > 30 mmol/L is associated with improved weight gain.     

The assessment of musculoskeletal pain in the clinical setting

Pain is a primary symptom in musculoskeletal conditions, and aspects of the pain experience (eg, severity) are key considerations in clinical decision-making and in the outcome of trials and interventions. Consequently, appropriate assessment of pain is essential. This article reviews the measures most commonly used in rheumatology practice, arguing that many are significantly limited in their ability to reflect the complexity of the patient's experience. The authors provide examples of alternative approaches, concluding that there is real scope for improving assessment and measurement of musculoskeletal pain in the clinical setting.     

Does overstuffing of the patellofemoral joint in total knee arthroplasty have a significant effect on postoperative outcomes?

Background

There is ongoing debate in the literature as to whether or not patellofemoral joint overstuffing has a clinically significant effect on postoperative outcomes following total knee arthroplasty (TKA). This study investigates the effect of patellofemoral joint overstuffing on patient-reported outcomes using novel methods of radiographic measurement.

The role of the Nod-like receptor family in trophoblast innate immune responses

There is a strong clinical association between intrauterine infections and pregnancy complications, such as preterm labor. The placenta functions as an active barrier whereby the trophoblast recognizes microbes through pattern recognition receptors, such as the well characterized Toll-like receptors, in order to respond to pathogens at the maternal-fetal interface. Consequently, either an inefficient or overactive placental response to an infectious trigger, may have a significant impact on pregnancy outcome. Recently the placenta has been shown to express a newly identified family of pattern recognition receptors, the cytoplasmic-based Nod-like receptors (NLRs). As a result of their restricted localization, NLRs function as intracellular receptors that respond to infectious components, which have gained access to the cytoplasmic compartment. Thus, NLRs may provide the trophoblast with a recognition system that may be critical in placental responses to microorganisms or their cell wall components that have gained access to the cell's intracellular space, or that have evaded recognition by the TLRs. This review will discuss what is currently known about the role of NOD proteins, NALP proteins, and the inflammasome at the maternal-fetal interface, and their potential role in infection-associated pregnancy complications, like preterm labor. As we learn more about their function at the maternal-fetal interface, we will have a better understanding of their function in normal pregnancy and their potential to contribute to the pathogenesis of infection- and inflammation-associated pregnancy complications.