Self-care of young adolescents with type 1 diabetes

The purpose of this study was to describe the universal and health deviation self-care of adolescents with Type 1 diabetes and the associations of basic conditioning factors with universal and health deviation self-care. Subjects for this study were 152 adolescents aged between 11 and 15 years with a diagnosis of Type 1 diabetes. Data were collected in the home setting of each adolescent and his or her family. The mean universal self-care scores ranged from 66.62% to 90%. The overall mean for this sample was 75.37, indicating that these adolescents took care of their self-care needs 75% of the time. Health deviation self-care was a mean of 27.26, indicating more positive self-care behaviors and treatment adherence. Health deviation and universal self-care were significantly and positively related (r = .36, p < .001). Ethnicity and adolescent sex were statistically significant in predicting universal self-care. Adolescent age was statistically significant in predicting health deviation self-care. Health deviation self-care decreases with age, suggesting that early adolescence or late school age is an appropriate time for interventions to strengthen self-care behaviors. Furthermore, the interrelationship of the two types of self-care supports the potential for a synergistic effect of intervention.     

The use of belimumab in three cases of refractory lupus nephritis

In recent trials for the treatment of systemic lupus erythematosus (SLE), belimumab (BLM), in addition to standard immunosuppression, has been shown to improve renal and nonrenal outcomes. We report our experience using BLM in three cases of refractory lupus nephritis (LN), where renal remission was not achieved using cyclophosphamide, mycophenolate mofetil and other immunosuppressive medications. In two of the three cases, BLM therapy led to a partial remission of LN, improvement in serological markers of SLE and disease activity, which permitted a reduction in prednisolone dosing. Treatment with efficacious therapies early in the course of LN is a desirable therapeutic strategy, to achieve early remission of proteinuria and curtail the development of irreversible chronic renal damage. Further studies are needed to provide information on the effectiveness of BLM for maintenance of remission, prevention of flares and monitoring for long-term complications of B-cell modulation.     

Unrelated donor BMT recipients given pretransplant low-dose antithymocyte globulin have outcomes equivalent to matched sibling BMT: a matched pair analysis

Fifty-seven patients receiving unrelated donor (UD) BMT were matched for disease and stage with 57 recipients of genotypically matched related donor (MRD) BMT. All UD recipients were matched serologically for A and B and by high resolution for DR and DQ antigens. All patients received CsA and 'short course' methotrexate with folinic acid. Unrelated donor BMT patients also received thymoglobulin 4.5 mg/kg (6 mg/kg if <30 kg) in divided doses over 3 days pretransplant. For UD and RD BMT, respectively, incidence of acute GVHD grade II-IV was 19 +/- 6% vs 36 +/- 8%, grade III-IV 10 +/- 6% vs 18 +/- 7%, chronic GVHD 44 +/- 8% vs 51 +/- 8%, non-relapse mortality 15 +/- 5% vs 8 +/- 4% at 100 days, 28 +/- 8% vs 36 +/- 7% at 3 years. At 3 years, relapse was 45 +/- 7% vs 42 +/- 7%, and disease-free survival 39 +/- 7% vs 37 +/- 7%. None of these differences are significant. Three-year overall survival was identical at 42 +/- 7%. For 29 patients with low/intermediate risk leukemia, disease-free survival was 68 +/- 10% after UD BMT vs 59 +/- 9% for RD BMT recipients (P = NS). Corresponding figures for high risk patients were 14 +/- 7% and 21 +/- 8%, respectively. We conclude that UD BMT recipients matched as above and given pretransplant ATG have similar outcomes to recipients of MRD BMT using conventional drug prophylaxis. Unrelated donor BMT should be considered in any circumstance where MRD BMT is routine.     

Timing of antibiotics,volume, and vasoactive infusions in children with sepsis admitted to intensive care

IntroductionEarly administration of antibiotics for sepsis, and of fluid boluses and vasoactive agents for septic shock, is recommended. Evidence for this in children is limited.MethodsThe Alberta Sepsis Network prospectively enrolled eligible children admitted to the Pediatric Intensive Care Unit (PICU) with sepsis from 04/2012-10/2014. Demographics, severity of illness, and outcomes variables were prospectively entered into the ASN database after deferred consent. Timing of interventions were determined by retrospective chart review using a study manual and case-report-form. We aimed to determine the association of intervention timing and outcome in children with sepsis. Univariate (t-test and Fisher’s Exact) and multiple linear regression statistics evaluated predictors of outcomes of PICU length of stay (LOS) and ventilation days.ResultsSeventy-nine children, age median 60 (IQR 22–133) months, 40 (51 %) female, 39 (49 %) with severe underlying co-morbidity, 44 (56 %) with septic shock, and median PRISM-III 10.5 [IQR 6.0-17.0] were enrolled. Most patients presented in an ED: 36 (46 %) at an outlying hospital ED, and 21 (27 %) at the Children’s Hospital ED. Most infections were pneumonia with/without empyema (42, 53 %), meningitis (11, 14 %), or bacteremia (10, 13 %). The time from presentation to acceptable antibiotic administration was a median of 115.0 [IQR 59.0-323.0] minutes; 20 (25 %) of patients received their antibiotics in the first hour from presentation. Independent predictors of PICU LOS were PRISM-III, and severe underlying co-morbidity, but not time to antibiotics. In the septic shock subgroup, the volume of fluid boluses given in the first 2 hours was independently associated with longer PICU LOS (effect size 0.22 days; 95 % CI 0.5, 0.38; per ml/kg). Independent predictors of ventilator days were PRISM-III score and severe underlying co-morbidity. In the septic shock subgroup, volume of fluid boluses in the first 2 hours was independently associated with more ventilator days (effect size 0.09 days; 95 % CI 0.02, 0.15; per ml/kg).ConclusionHigher volume of early fluid boluses in children with sepsis and septic shock was independently associated with longer PICU LOS and ventilator days. More study on the benefits and harms of fluid bolus therapy in children are needed.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-1010-x) contains supplementary material, which is available to authorized users.     

Development of metabolic and inflammatory mediator biomarker phenotyping for early diagnosis and triage of pediatric sepsis

IntroductionThe first steps in goal-directed therapy for sepsis are early diagnosis followed by appropriate triage. These steps are usually left to the physician’s judgment, as there is no accepted biomarker available. We aimed to determine biomarker phenotypes that differentiate children with sepsis who require intensive care from those who do not.MethodsWe conducted a prospective, observational nested cohort study at two pediatric intensive care units (PICUs) and one pediatric emergency department (ED). Children ages 2–17 years presenting to the PICU or ED with sepsis or presenting for procedural sedation to the ED were enrolled. We used the judgment of regional pediatric ED and PICU attending physicians as the standard to determine triage location (PICU or ED). We performed metabolic and inflammatory protein mediator profiling with serum and plasma samples, respectively, collected upon presentation, followed by multivariate statistical analysis.ResultsNinety-four PICU sepsis, 81 ED sepsis, and 63 ED control patients were included. Metabolomic profiling revealed clear separation of groups, differentiating PICU sepsis from ED sepsis with accuracy of 0.89, area under the receiver operating characteristic curve (AUROC) of 0.96 (standard deviation [SD] 0.01), and predictive ability (Q²) of 0.60. Protein mediator profiling also showed clear separation of the groups, differentiating PICU sepsis from ED sepsis with accuracy of 0.78 and AUROC of 0.88 (SD 0.03). Combining metabolomic and protein mediator profiling improved the model (Q² =0.62), differentiating PICU sepsis from ED sepsis with accuracy of 0.87 and AUROC of 0.95 (SD 0.01). Separation of PICU sepsis or ED sepsis from ED controls was even more accurate. Prespecified age subgroups (2–5 years old and 6–17 years old) improved model accuracy minimally. Seventeen metabolites or protein mediators accounted for separation of PICU sepsis and ED sepsis with 95 % confidence.ConclusionsIn children ages 2–17 years, combining metabolomic and inflammatory protein mediator profiling early after presentation may differentiate children with sepsis requiring care in a PICU from children with or without sepsis safely cared for outside a PICU. This may aid in making triage decisions, particularly in an ED without pediatric expertise. This finding requires validation in an independent cohort.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-1026-2) contains supplementary material, which is available to authorized users.     

Doppler Echocardiographic Predictors of Mortality in Female Rats After Myocardial Infarction

BackgroundDoppler echocardiogram is useful for the evaluation of anatomical and functional changes in late myocardial infarction (MI) in rats. However, no studies have evaluated the prognostic value of echocardiographic parameters 1 week after MI.Methods and ResultsDoppler echocardiogram was performed in 84 female Wistar rats 1 week after MI to determine infarction size, left chambers dimensions, fractional area change (FAC) of the left ventricle (LV), mitral inflow and tissue Doppler, myocardial performance index (MPI), and signs of pulmonary hypertension. The 365-day follow-up showed 53.6% mortality rate. Nonsurvivors showed larger (P < .05) MI size and cavity dimensions, poorer diastolic and systolic function, and higher frequency of pulmonary hypertension. Parameters at early stage of MI associated with higher mortality risk by Cox multivariate regression model were FAC ≤37% (relative risk [RR] 3.78, 95% CI, 1.50–9.53), MPI ≥0.60 (RR 3.49, 95% CI, 1.80–6.76), LV systolic area ≥0.26 cm² (RR 4.38, 95% CI, 1.88–10.21), E/E' ratio ≥20.3 (RR 2.12, 95% CI, 1.15–4.34), and E/A ratio associated with FAC (RR 2.99, 95% CI, 1.44–6.18).ConclusionSome diastolic and systolic Doppler echocardiographic parameters in rats may be able to predict late mortality risk after MI.     

Oxytocin is an anabolic bone hormone

We report that oxytocin (OT), a primitive neurohypophyseal hormone, hitherto thought solely to modulate lactation and social bonding, is a direct regulator of bone mass. Deletion of OT or the OT receptor (Oxtr) in male or female mice causes osteoporosis resulting from reduced bone formation. Consistent with low bone formation, OT stimulates the differentiation of osteoblasts to a mineralizing phenotype by causing the up-regulation of BMP-2, which in turn controls Schnurri-2 and 3, Osterix, and ATF-4 expression. In contrast, OT has dual effects on the osteoclast. It stimulates osteoclast formation both directly, by activating NF-κB and MAP kinase signaling, and indirectly through the up-regulation of RANK-L. On the other hand, OT inhibits bone resorption by mature osteoclasts by triggering cytosolic Ca²⁺ release and NO synthesis. Together, the complementary genetic and pharmacologic approaches reveal OT as a novel anabolic regulator of bone mass, with potential implications for osteoporosis therapy.