The infantile cutaneous microbiome: A review

Recent focus on the neonatal intestinal microbiome has advanced our knowledge of the complex interplay between the intestinal barrier, the developing immune system, and commensal and pathogenic organisms. Despite the parallel role of the infant skin in serving as both a barrier and an interface for priming the immune system, large gaps exist in our understanding of the infantile cutaneous microbiome. The skin microbiome changes and matures throughout infancy, becoming more diverse and developing the site specificity known to exist in adults. Delivery method initially determines the composition of the cutaneous microbiome, though this impact appears transient. Cutaneous microbes play a critical role in immune system development, particularly during the neonatal period, and microbes and immune cells have closely intertwined, reciprocal effects. The unique structure of newborn skin influences cutaneous microbial colonization and the development of dermatologic pathology. The development of the infantile skin barrier and cutaneous microbiome contributes to future skin pathology. Atopic dermatitis flares and seborrheic dermatitis have been linked to dysbiosis, while erythema toxicum neonatorum is an immune response to the establishment of normal bacterial skin flora. Physicians who care for infants should be aware of the impact of the infantile skin microbiome and its role in the development of pathology. A better understanding of the origin and evolution of the skin microbiome will lead to more effective prevention and treatment of pediatric skin disease.     

Sensitisation to Swine Leukocyte Antigens in Patients with Broadly Reactive HLA Specific Antibodies

We have previously shown that IgG HLA specific antibodies in the sera of highly sensitised patients awaiting renal transplantation can cross-react with swine leukocyte antigens (SLA). In this study we determined the frequency of patient serum IgG HLA specific antibody binding to a porcine lymphocyte panel and the likelihood of locating a cross-match negative pig donor for sensitised patients. Serum samples (n = 82) were obtained from 35 sensitised [current IgG panel reactive antibodies (PRA) > 10%] and seven nonsensitised patients awaiting renal transplantation at Addenbrooke's Hospital, Cambridge, UK. Fifty sera had IgG HLA specific PRA of 11-84%, 20 had IgG PRA of >84% and 12 had 0% PRA (negative controls). Sera were absorbed with porcine erythrocytes to remove xenoreactive natural antibodies and tested for cross-reactive IgG HLA specific antibody binding by flow cytometry against a panel of porcine lymphocytes obtained from 23 human decay accelerating factor (hDAF) transgenic pigs. A total of 1,884 cross-match combinations were tested and 369 (20%) gave a positive porcine lymphocyte cross-match. For sera from sensitised patients with IgG PRA (11-64%), only 6 of 805 (0.75%) cross-match tests were positive. In contrast, for sera from patients with high IgG PRA (>64%), 363 of 805 (45%) cross-match tests were positive (p < 0.0001). There was no difference in the frequency of positive cross-matches between patient sera with IgG PRA 65-84% and highly sensitised patient sera with IgG PRA 85-100% [156/345 (45%) vs. 207/460 (45%)]. This study demonstrates that only patient sera with broadly reactive IgG HLA specific PRA (>64%) cross-react with porcine lymphocytes. If future clinical trials of xenotransplantation are undertaken, it may be of value to select a cross-match-negative pig organ donor for such patients.     

Beta-adrenergic blockers reduce the risk of fracture partly by increasing bone mineral density: Geelong Osteoporosis Study.

This population-based study documented beta-blocker use in 59/569 cases with incident fracture and 112/775 controls. OR for fracture associated with beta-blocker use was 0.68 (95%CI, 0.49-0.96). Beta-blockers were associated with higher BMD at the total hip (2.5%) and UD forearm (3.6%) after adjusting for age, anthropometry, and thiazide use. Beta-blocker use is associated with reduced fracture risk and higher BMD. INTRODUCTION: Animal data suggests that bone formation is under beta-adrenergic control and that beta-blockers stimulate bone formation and/or inhibit bone resorption. MATERIALS AND METHODS: We evaluated the association between beta-blocker use, bone mineral density (BMD), and fracture risk in a population-based study in Geelong, a southeastern Australian city with a single teaching hospital and two radiological centers providing complete fracture ascertainment for the region. Beta-blocker use was documented for 569 women with radiologically confirmed incident fractures and 775 controls without incident fracture. Medication use and lifestyle factors were documented by questionnaire. RESULTS: Odds ratio for fracture associated with beta-blocker use was 0.68 (95% CI, 0.49-0.96) for any fracture. Adjusting for age, weight, medications, and lifestyle factors had little effect on the odds ratio. Beta-blocker use was associated with a higher BMD at the total hip (2.5%, p = 0.03) and ultradistal forearm (3.6%, p = 0.04) after adjustment for age, anthropometry, and thiazide use. CONCLUSION: Beta-blockers are associated with a reduction in fracture risk and higher BMD.     

Health Service Use and Quality of Life Recovery 12 Months Following Major Osteoporotic Fracture: Latent Class Analyses of the International Costs and Utilities Related to Osteoporotic Fractures Study (ICUROS)

Major osteoporotic fractures (MOFs) are associated with a rapid decline in health-related quality of life (HRQoL); however, there is limited knowledge about which healthcare services positively affect HRQoL postfracture. This study aimed to identify specific combinations of health service use associated with recovery of HRQoL 12 months post-MOF. The analyses included 4126 adults aged ≥50 years with an MOF (1657 hip, 1354 distal forearm, 681 vertebrae, 434 humerus) participating in the International Costs and Utilities Related to Osteoporotic fractures Study (ICUROS), a multinational observational study (Australia, Austria, Estonia, France, Italy, Lithuania, Mexico, Russia, Spain, United Kingdom, and United States). HRQoL at prefracture and 12 months postfracture was measured using the EuroQoL questionnaire (EQ-5D-3L). Health service use data were collected via participant interviews and medical record reviews including in-hospital care; outpatient care; community services; and medication use. Data analyses involved two stages: (i) latent class analyses to identify different combinations of health service use (“classes”); and (ii) logistic regression to assess effects of classes on HRQoL recovery. Analyses were repeated excluding hip fractures (non-hip MOFs). Overall, 2057 MOF participants (49.9%) recovered to their prefracture HRQoL at 12-month follow-up; this proportion was higher for non-hip MOFs (n = 1439; 58.3%). Several distinct classes were identified across countries (range, 2–5 classes). Classes that were associated with increased odds of HRQoL recovery were characterized by a combination of hospital presentations without admission; outpatient department visits; allied health visits; vitamin D/calcium supplementation; and/or non-opioid analgesic use. Similar classes were observed for non-hip MOFs. Understanding country-specific healthcare service pathways that influence greater recovery of HRQoL, particularly services that are uncommon in some countries and routine in others, could improve postfracture care on a global scale. © 2020 American Society for Bone and Mineral Research (ASBMR).     

Environmental tobacco smoke and ischaemic heart disease: a case study in applying causal criteria

Background: Whether ischaemic heart disease (IHD) is caused by exposure to environmental tobacco smoke (ETS), commonly known as "passive smoking", has been debated from both epidemiological and biological perspectives. Methods and results: In this paper we use Bradford Hill criteria to synthesize results from the biological and epidemiological literature in a formal assessment of the strength of support for such a relationship. Although we find that these criteria, designed for clinical trials, do not give an ideal framework for assessment of epidemiological and biological studies, nevertheless they do provide systematic guidance for this assessment. For the general population, of the nine tests proposed by Hill we find that one (biological plausibility) seems to be supported, though not unarguably; three (strength, consistency, specificity) appear to fail by accepted standards; and the remaining five have insufficient data for a clear evaluation (biological gradient, experimental evidence, temporality, coherence, analogy). Overall, this provides at best weak support for a causal association between ETS and IHD across the general community. Conversely, there appears to be more support, especially in the biology studies, for an association between ETS and IHD for those with pre-existing disease, although epidemiological studies are limited in this area. Conclusions: One of the outcomes of this review is the identification of areas of focus for future epidemiological and biological research. First, we find that stronger associations may be found in the particular subpopulation with pre-existing IHD. In this case, more convincing biological plausibility and experimental evidence indicate a need for relevant epidemiological studies, although individual responses are very variable. Second, we identify the need for further, more detailed evaluations of the nature of vessel wall thickenings occurring in experimental models of ETS exposure. Third, we propose long-term animal studies of initiation of IHD, including direct assessment of effects on the accumulation of lipid in vessel walls, at appropriate ETS exposure levels. Short abstract We use Bradford Hill criteria to synthesize the biological and epidemiological literature so as to assess formally whether ischaemic heart disease (IHD) is caused by exposure to environmental tobacco smoke (ETS). For the general population we find, at best, weak support for causality: of nine tests, one (biological plausibility) is supported, though not unarguably; three (strength, consistency, specificity) fail; and five (biological gradient, experimental evidence, temporality, coherence, analogy) have insufficient data for clear evaluation. For the population with pre-existing IHD the biological support is possibly stronger. We identify three areas for future research: epidemiological studies of those subpopulations with pre-existing IHD; evaluation of the nature of vessel wall thickenings occurring in experimental studies; and long-term animal studies of initiation of IHD, including direct assessment of effects on the accumulation of lipid in vessel walls, at appropriate ETS levels.     

Effective Intervention Programming: Improving Maternal Adjustment Through Parent Education

This study assessed the secondary effects of a parent training intervention program on maternal adjustment, with a focus on understanding ways in which program efficacy differed for participants as a function of whether or not their children had behavior problems. Mothers (N = 99) of toddlers (2–3 years of age) were randomly assigned to receive one of three levels of intervention: (1) informational booklet (2) booklet + face-to-face parent training sessions, or (3) booklet + web-based parent training sessions. Findings indicated that all levels of intervention were associated with increases in maternal well-being for participants with typically developing children. Mothers of toddlers with behavior problems, however, did not benefit from receiving only the booklet but significantly benefitted from receiving either the face-to-face or web-based interventions. Findings are discussed in terms of efficient and efficacious program dissemination and the resulting implications for public policy.     

Advanced musculoskeletal physiotherapists in post arthroplasty review clinics: a state wide implementation program evaluation

Objective

To evaluate outcomes following a state-wide implementation of post arthroplasty review (PAR) clinics for patients following total hip and knee arthroplasty, led by advanced musculoskeletal physiotherapists in collaboration with orthopaedic specialists.