Saturday, 29 February 2020
P LP MEDICOLEGAL ISSUES
Physician Botches Pediatric Lumbar Puncture, Family Collects; More
The family of a child who was partially paralyzed after receiving treatment at a hospital in the state of Washington will receive a $10 million settlement, the News Tribune reports.
A few months after she was born, the child of Chante Ramirez — identified by her initials "JL" in court records — was diagnosed with acute lymphoblastic leukemia. As part of JL's treatment, Ramirez brought her to Mary Bridge Children's Hospital, in Tacoma. The hospital is a member of MultiCare, a large not-for-profit healthcare organization. There, she was treated by a doctor who worked for Pediatrics Northwest, a multispecialty pediatric group with two offices in Tacoma and offices and clinics elsewhere in the state of Washington.
On August 3, 2017, the doctor administered a chemotherapy injection to then 13-month-old JL. Following the injection, Ramirez noticed that her child had become unusually irritable and had ceased moving her legs.
Ramirez requested that JL be evaluated. She was informed that her baby's spinal cord had been injured, resulting in partial paraplegia. Ramirez sued both MultiCare and Pediatrics Northwest.
According to a sworn declaration by one of her attorneys, the injury occurred because the doctor who had treated JL performed the lumbar puncture "higher than customary and most likely done at the T12-L1 level," which is a "clear violation of the standard of care" when injecting the lumbar region of an infant.
JL has undergone one hip surgery to improve her mobility and will likely need additional procedures in the years ahead, although she will always be wheelchair dependent.
A spokesperson for MultiCare declined to comment on the details of the case but did express the organization's "sincere sympathy to the Ramirez family," adding "we are so very sorry for their experience."
Pediatric Northwest didn't respond to the News Tribune's requests for comment.
New Proposal Would Make It Harder to Seek Punitive Damages Against Physicians
A proposal under consideration by Missouri lawmakers could have a major impact on whether punitive damages are awarded in personal injury cases, including medical malpractice suits, according to a report in the News Tribune.
The proposal, spearheaded by state Sen. Bill White (R), would place an additional burden of proof on plaintiffs seeking punitive damages in a personal injury lawsuit. (Punitive damages are intended to punish defendants for their negligence; compensatory damages are aimed at offsetting plaintiffs' losses.)
If the bill passes into law, plaintiffs seeking damages intended to punish a defendant would be required to submit convincing evidence at the beginning of the trial that the defendant had intentionally harmed them — that is, had acted in a willful, wanton, or reckless manner. In the absence of such proof, plaintiffs wouldn't typically be permitted to file for punitive damages.
In arguing for his proposal, White says that trial attorneys often pursue such filings to intimidate defendants into settling, because compensatory awards are covered by liability insurance whereas punitive damages aren't. (In Missouri, half the punitive damages awarded end up being covered under the state's Tort Victims Compensation Fund.)
SG POP UP AND POP OUT ON THE PLANET
SPECK -- MICROSPECK ,,,, BIG MAN
PREDATOR MIND SET ---- WHAT TO GET NEXT ,,,,,, CROUCHING FOR SOMETHING
PREDATOR MIND SET ---- WHAT TO GET NEXT ,,,,,, CROUCHING FOR SOMETHING
Somewhere, something incredible is waiting to be known.” ― Carl Sagan
Somewhere, something incredible is waiting to be known.”
― Carl Sagan
N AN PREDICTORS X NN GUT ANOMALY
Antenatal predictors of intestinal pathologies in fetal bowel dilatation
First published:19 February 2020
Conflict of interest: None declared.
Abstract
Aim
Fetal bowel dilatation (FBD) in the late trimester of pregnancy can be related with varies of prognosis. Our aims were to obtain antenatal factors that might have relevance for the distinct prognosis with FBD.
Methods
Seven features of 68 pregnancies presented with FBD were assessed. The best cut‐off value to predict intestinal outcomes was selected using receiver‐operating characteristics curves, and the effective variables were included into a logistic regression model.
Results
The best cut‐off valves to predict intestinal pathologies were 14.5 mm of fetus dilated loop and 37.7 weeks of gestational age at delivery, respectively. The congenital gastrointestinal tract anomalies included 24 cases (92.3%) of intestine atresia, 1 case (3.85%) of small intestine volvulus and 1 case (3.85%) of midgut malrotation.
Conclusion
Fetal dilated loops and gestational age at delivery are both an independent risk factor for predicting intestinal pathologies of newborns, which should arouse high attention.
P CR NN SEPTIC ARTHRITIS X WRIST
An unreported case of Streptococcus cristatus septic arthritis of wrist in a neonate
Gaurav Gupta, Manu Chaudhary, Aliraza Khunt, Viral Shah, Maulin M Shah
Journal of Clinical Orthopaedics and Trauma 2020, 11 (2): 328-331
Septic Arthritis of the wrist is rare in the paediatric population due to its extraarticular metaphysis. We report here a case of wrist septic arthritis in a neonate caused by an uncommon causative organism, Streptococcus cristatus. A 15 days old male child was referred with the complaint of swelling and decreased movement of the left wrist for 5 days. Local examination revealed warm, tender, erythematous and fluctuant swelling over the dorso-ulnar aspect of the left wrist. Ultrasonography of the affected region was suggestive of focal fluid collection in the wrist and periosteal elevation of the distal ulna. Aspiration followed by arthrotomy of the wrist joint was performed and multiple holes were made in the distal ulnar metaphysis using 0.8mm k-wire. The pus culture was positive for Streptococcus cristatus, sensitive to vancomycin, which was given for a total of 4 weeks. At one year follow up the child had a full, painless range of motion with no functional deficit. Final follow up x rays of the left wrist were normal. Streptococcus cristatus strains are described as Gram-positive, catalase-negative cocci, approximately 1 μm in diameter growing in chains and were originally isolated from the human throat and oral cavities. Its association with bone and joint infections has not been described in the literature. To our knowledge, this is the first case of isolated septic arthritis of wrist in a 15 days old child caused by Streptococcus cristatus. To conclude, wrist septic arthritis in a neonate is a rare entity. With the advanced diagnostics, species-level identification of rare organism like Streptococcus cristatus is possible along with antibiotic sensitivity for appropriate therapy. Early surgical decompression and intravenous culture-directed antibiotics are the mainstays of management.
P RN CMV IN NEONATE X VALGANCICLOVIR
Cytomegalovirus infection during pregnancy: State of the science
Marianne Leruez-Ville, Ina Foulon, Robert Pass, Yves Ville
American Journal of Obstetrics and Gynecology 2020 February 24
Cytomegalovirus is the most common congenital infection, affecting 0.5-2% of all live births and the main non-genetic cause of congenital sensorineural hearing loss and neurological damage. Congenital CMV can follow maternal primary infection or non-primary infection. Sensori-neurological morbidity is confined to the first trimester with up to 40-50% of infected neonates developing sequelae after first trimester primary infection. Serological testing before 14 weeks is critical to identify primary infection within three months around conception but is not informative in women already immune before pregnancy. In Europe and the US, primary infection in the first trimester are mainly seen in young parous women with a previous child below 3. Congenital CMV should be evoked on prenatal ultrasound when the fetus is small for gestation, shows echogenic bowel, effusions, or any cerebral anomaly. Although the sensitivity of routine ultrasound in predicting neonatal symptoms is around 25%, serial targeted ultrasound and MRI of known infected fetuses show over 95% sensitivity for brain anomalies. Fetal diagnosis is done by amniocentesis from 17 weeks. Prevention consists of both parents avoiding contact with body fluids from infected individuals, especially toddlers, from before conception until 14 weeks. Candidate vaccines failed to provide more than 75% protection for >2 years in preventing CMV infection. Medical therapies such as CMV hyperimmune globulins aim to reduce the risk of vertical transmission but 2 RCTs have not found any benefit. Valaciclovir given from the diagnosis of primary infection up to amniocentesis decreased vertical transmission rates from 29.8% to 11.1% in the treatment group in an RCT of 90 pregnant women. In a phase II open label trial, oral valaciclovir (8g/day) given to pregnant women with a mildly symptomatic fetus was associated with a higher chance of delivering an asymptomatic neonate (82%), compared with an untreated historical cohort (43%). Valganciclovir given to symptomatic neonates is likely to improve hearing and neurological symptoms, the extent of which and the duration of treatment are still debated. In conclusion, congenital CMV infection is a public health challenge. In view of recent knowledge on diagnosis, pre- and postnatal management, health care providers should re-evaluate screening programs in early pregnancy and at birth.
P CR AHT
Subgaleal Hemorrhage Secondary to Child Physical Abuse in a 4-Year-Old Boy
Joseph P Bowens, Kelly Liker
Pediatric Emergency Care 2020 February 27
Subgaleal hemorrhage is commonly described in the neonatal population but is a rare injury in young children and adolescents. Though infrequently seen, it can follow blunt head trauma or hair pulling. This case report details a 4-year-old African American boy with massive subgaleal hemorrhage and bilateral periorbital swelling and ecchymosis as a result of hair pulling in the setting of child physical abuse. The patient was evaluated in the emergency department for swelling of his scalp several hours after reportedly bumping his head on a chair. He was discharged home after a head computed tomography only confirmed soft tissue hematoma. The following morning, the findings progressed and he returned to the emergency department. He was triaged as a trauma and initially evaluated by the emergency physician, pediatric trauma surgeon, and pediatric neurosurgeon. Head computed tomography scan confirmed diffuse scalp edema without skull fracture or intracranial pathology. The child abuse specialty service was consulted for suspected child physical abuse. Their examination revealed numerous scattered bruises on the trunk and thighs, several of which were patterned. Local police investigation resulted in the patient's grandfather confessing to striking the patient with a belt and picking him up from the ground by his hair, the latter of which is a mechanism consistent with the patient's dramatic scalp and facial findings. The authors encourage consultation by a specialist in child abuse pediatrics for subgaleal hemorrhage and/or raccoon eyes in the presence of minor trauma, as well as thorough head-to-toe skin examination for all children presenting with injuries.
B BORROWDNESS EVANESCENCE IMPERMANENCE EMPTINESS CLING DUKKHA
Pop up and pop off LYF
Rented car like LYF
Borrowed from nature. LYF
Sunyata. Emptiness
Borrowedness of LYF
DWM FAST 12-16 HRS
When should you eat to manage your weight? Breakfast, not late-night snacks
- February 28, 2020
- PLOS
- The balance between weight gain and weight gain loss is predominantly determined by what you eat, how much you eat, and by how much exercise you get. But another important factor is often neglected... it's not just how many calories you eat, but WHEN you eat them that will determine how well you burn those calories.
FULL STORY
The balance between weight gain and weight gain loss is predominantly determined by what you eat, how much you eat, and by how much exercise you get. But another important factor is often neglected... Published February 27 in the open-access journal PLOS Biology, research conducted by Kevin Kelly, Owen McGuinness, Carl Johnson and colleagues of Vanderbilt University, USA shows that it's not just how many calories you eat, but WHEN you eat them that will determine how well you burn those calories.
Your daily biological clock and sleep regulate how the food you eat is metabolized; thus the choice of burning fats or carbohydrates changes depending on the time of day or night. Your body's circadian rhythm has programmed your body to burn fat when you sleep, so when you skip breakfast and then snack at night you delay burning the fat.
The researchers monitored the metabolism of mid-aged and older subjects in a whole-room respiratory chamber over two separate 56-hour sessions, using a "random crossover" experimental design. In each session, lunch and dinner were presented at the same times (12:30 and 17:45, respectively), but the timing of the third meal differed between the two halves of the study. Thus in one of the 56-hour bouts, the additional daily meal was presented as breakfast (8:00) whereas in the other session, a nutritionally equivalent meal was presented to the same subjects as a late-evening snack (22:00). The duration of the overnight fast was the same for both sessions.
Whereas the two sessions did not differ in the amount or type of food eaten or in the subjects' activity levels, the daily timing of nutrient availability, coupled with clock/sleep control of metabolism, flipped a switch in the subjects' fat/carbohydrate preference such that the late-evening snack session resulted in less fat burned when compared to the breakfast session. The timing of meals during the day/night cycle therefore affects the extent to which ingested food is used versus stored.
This study has important implications for eating habits, suggesting that a daily fast between the evening meal and breakfast will optimize weight management.
Story Source:
Materials provided by PLOS. Note: Content may be edited for style and length.
Journal Reference:
- Kevin Parsons Kelly, Owen P. McGuinness, Maciej Buchowski, Jacob J. Hughey, Heidi Chen, James Powers, Terry Page, Carl Hirschie Johnson. Eating breakfast and avoiding late-evening snacking sustains lipid oxidation. PLOS Biology, 2020; 18 (2): e3000622 DOI: 10.1371/journal.pbio.3000622
Friday, 28 February 2020
P SEPSIS
Quality-of-Life Morbidity Common Among Children Who Survive Septic Shock
By Nancy Melville
ORLANDO, Fla -- February 21, 2020 -- Whereas the in-hospital risk of mortality associated with paediatric septic shock has plummeted in recent decades, many patients have not returned to baseline quality of life a year later, and many have substantial deterioration in health-related quality of life, according to a study presented here at the 2020 Annual Meeting of the Society of Critical Care Medicine (SCCM).
“This investigation provides the first longitudinal description of long-term mortality and clinically relevant, health-related quality-life morbidity among children encountering community-acquired septic shock,” reported Jerry J. Zimmerman, MD, Seattle Children’s Hospital, Seattle, Washington, and colleagues.
“Survival no longer expresses the complete impact for children encountering sepsis,” said Dr. Zimmerman.
Mortality rates in the paediatric septic shock population have declined substantially in developed nations, from as high as 50% to 60% in the 1950s/1960s to as low as 5% to 10%. However, the long-term mortality and morbidity among children who survive has not been well documented.
To look into outcomes, a large team of investigators with the Life After Pediatric Sepsis Evaluation (LAPSE) study analysed data on 389 children (mean age, 7.4 years; 46% girls) who were critically ill with community-acquired septic shock requiring vasoactive-inotropic support between 2013 and 2017 at 12 academic paediatric intensive care units (PICUs) in the United States.
As assessed by the Pediatric Medical Complexity Algorithm, 18% of the children studied were immunocompromised, and 51% had chronic comorbidities. The Pediatric Overall Performance Category at baseline was normal in 38% of the children.
On PICU admission, the median Pediatric Risk of Mortality score was 11.0 (range, 6.0-17.0), and the median Pediatric Logistic Organ Dysfunction score was 9.0 (range, 6.0-11.0).
Patients had a median duration of vasoactive-inotropic support of 3.0 days (range, 2.0-6.0 days) and mechanical ventilation support of 8.0 days (range, 5.0-14.0 days).
The median duration of PICU stay was 9.4 days (range, 5.6-15.4 days) and of hospital stay was 15.7 days (range, 9.2-26.0 days).
Mortality rates at 1, 3, 6, and 12 months after PICU admission for septic shock were 8%, 11%, 12%, and 13%, respectively.
At 1 month, as many as 50% of patients who survived had not regained their baseline health-related quality of life; the rate was 37% at 3 months, 30% at 6 months, and 35% at 1 year.
“After 1 year, 35% of children surviving septic shock demonstrate clinically significant deterioration in health-related quality of life that persists at least a year after PICU admission for the sepsis event,” said Dr. Zimmerman.
“Collectively, this study demonstrates substantial health related quality of life morbidity among many critically ill children surviving septic shock,” concluded the researchers.
Dr. Zimmerman noted that “for children to ultimately thrive after sepsis, clinicians and investigators alike will need to additionally focus on interventions to facilitate return to baseline functional status and health-related quality of life.”
The study was published concurrently in Critical Care Medicine (Zimmerman J et al. 2020;48:329-337. doi: 10.1097/CCM.0000000000004123).
[Presentation title: Trajectory of Mortality and Health-Related Quality of Life Morbidity Following Community-Acquired Pediatric Septic Shock]
ORLANDO, Fla -- February 21, 2020 -- Whereas the in-hospital risk of mortality associated with paediatric septic shock has plummeted in recent decades, many patients have not returned to baseline quality of life a year later, and many have substantial deterioration in health-related quality of life, according to a study presented here at the 2020 Annual Meeting of the Society of Critical Care Medicine (SCCM).
“This investigation provides the first longitudinal description of long-term mortality and clinically relevant, health-related quality-life morbidity among children encountering community-acquired septic shock,” reported Jerry J. Zimmerman, MD, Seattle Children’s Hospital, Seattle, Washington, and colleagues.
“Survival no longer expresses the complete impact for children encountering sepsis,” said Dr. Zimmerman.
Mortality rates in the paediatric septic shock population have declined substantially in developed nations, from as high as 50% to 60% in the 1950s/1960s to as low as 5% to 10%. However, the long-term mortality and morbidity among children who survive has not been well documented.
To look into outcomes, a large team of investigators with the Life After Pediatric Sepsis Evaluation (LAPSE) study analysed data on 389 children (mean age, 7.4 years; 46% girls) who were critically ill with community-acquired septic shock requiring vasoactive-inotropic support between 2013 and 2017 at 12 academic paediatric intensive care units (PICUs) in the United States.
As assessed by the Pediatric Medical Complexity Algorithm, 18% of the children studied were immunocompromised, and 51% had chronic comorbidities. The Pediatric Overall Performance Category at baseline was normal in 38% of the children.
On PICU admission, the median Pediatric Risk of Mortality score was 11.0 (range, 6.0-17.0), and the median Pediatric Logistic Organ Dysfunction score was 9.0 (range, 6.0-11.0).
Patients had a median duration of vasoactive-inotropic support of 3.0 days (range, 2.0-6.0 days) and mechanical ventilation support of 8.0 days (range, 5.0-14.0 days).
The median duration of PICU stay was 9.4 days (range, 5.6-15.4 days) and of hospital stay was 15.7 days (range, 9.2-26.0 days).
Mortality rates at 1, 3, 6, and 12 months after PICU admission for septic shock were 8%, 11%, 12%, and 13%, respectively.
At 1 month, as many as 50% of patients who survived had not regained their baseline health-related quality of life; the rate was 37% at 3 months, 30% at 6 months, and 35% at 1 year.
“After 1 year, 35% of children surviving septic shock demonstrate clinically significant deterioration in health-related quality of life that persists at least a year after PICU admission for the sepsis event,” said Dr. Zimmerman.
“Collectively, this study demonstrates substantial health related quality of life morbidity among many critically ill children surviving septic shock,” concluded the researchers.
Dr. Zimmerman noted that “for children to ultimately thrive after sepsis, clinicians and investigators alike will need to additionally focus on interventions to facilitate return to baseline functional status and health-related quality of life.”
The study was published concurrently in Critical Care Medicine (Zimmerman J et al. 2020;48:329-337. doi: 10.1097/CCM.0000000000004123).
[Presentation title: Trajectory of Mortality and Health-Related Quality of Life Morbidity Following Community-Acquired Pediatric Septic Shock]
P MEDICAL COMPLEXITY CLASSIFICATION
TABLE 1
COE4CCN Consensus Definitions of 3 Levels of Medical Complexity
| Condition Description | Potential Examplea | |
|---|---|---|
| Children with C-CDa | ||
| Significant chronic conditions in ≥2 body systems: | Type 1 diabetes and static encephalopathy; type 1 diabetes and depression; developmental delay and chronic pulmonary conditions | |
| Significant chronic condition is defined as a physical, mental or developmental condition that can be expected to last at least a year, will use health care resources above the level for a healthy child, require treatment of control of the condition, and the condition can be expected to be episodically or continuously debilitating. | ||
| Body systems include: cardiac, craniofacial, dermatologic, endocrinologic, gastrointestinal, genetic, genitourinary, hematologic, immunologic, mental health, metabolic, musculoskeletal, neurologic, ophthalmologic, otologic, pulmonary/respiratory, and renal. | ||
| OR | A progressive condition that is associated with deteriorating health with a decreased life expectancy in adulthood. | Muscular dystrophy, cystic fibrosis, paraplegia, quadriplegia, malignancy |
| OR | Continuous dependence on technology for at least 6 months. | Tracheostomy ± ventilator assistance, renal dialysis, gastrostomy tube, cerebrospinal fluid shunt |
| OR | Malignancies: progressive or metastatic malignancies that affect life function. Exclude those in remission for >5 years. | Lymphoma, leukemia, brain tumor |
| Children with NC-CD | ||
| Chronic conditions that last at least 1 year: These conditions are commonly lifelong but can be episodic with periods of good health between episodes. They include physical, developmental, or mental health conditions that may persist into adulthood but may also resolve either secondary to the natural history of the disease or as a result of surgical intervention. These conditions involve a single body system, are not progressive, can vary widely in severity, and result in highly variable health care utilization. | Type 1 diabetes, atrial septal defect, asthma, depression, attention-deficit/hyperactivity disorder | |
| Children without CD | ||
| Acute nonchronic conditions: A physical, developmental or mental health condition that is not expected to last >1 year. These children may temporarily (for <1 year) use health care resources above the normal level for a healthy child. | Ear infection, pneumonia, diarrhea and dehydration, bronchiolitis | |
| Healthy: No acute or chronic health conditions. These children do not use health care resources above the normal level for a healthy child. | NA | |
NA, not applicable.
aThe examples used in this document to illustrate definitions of medical complexity and chronicity are intended to demonstrate characteristics specified in the definition/descriptions. It is not our intention to imply that specific diseases and conditions are by default linked to the categories that they were used to illustrate.
| C-CD | complex chronic disease |
chronic disease -CD
|
P SEPSIS HAT
Hydrocortisone, Ascorbic Acid, Thiamine Combination Beneficial in Paediatric Septic Shock
By Nancy Melville
ORLANDO, Fla -- February 20, 2020 -- The use of an intravenous combination of hydrocortisone, ascorbic acid, and thiamine (HAT) as adjunctive therapy in the treatment of children with septic shock significantly reduces mortality, according to research presented here at the 2020 Annual Meeting of the Society of Critical Care Medicine (SCCM).
“Our results suggest that hydrocortisone, ascorbic acid, and thiamine therapy, when administered early in the clinical course, reduces mortality in children with septic shock,” stated Eric L. Wald, MD, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, and colleagues.
Interest in HAT therapy for septic shock treatment was raised when previous research showed dramatically lower mortality rates with the adjunctive treatment among adult patients with septic shock; however, some studies failed to show benefit with the combination therapy. Furthermore, no studies reported on the effect of the potentially safe and low-cost intervention among children with septic shock.
To evaluate the issue, the researchers identified 557 patients meeting septic shock criteria at a large academic paediatric intensive care unit between January 2014 and February 2019.
Of the patients, 43 were treated with HAT therapy, which was introduced at the centre in 2017. These patients were matched 1:1:1 in a propensity analysis to compare those with balanced characteristics among patients who received hydrocortisone therapy alone and controls who were untreated.
Patients treated with HAT therapy had significantly lower mortality rates than controls at 30 days (9% vs 28%; P = .03) and 90 days (14% vs 35%; P = .02). Mortality rates were also lower in patients who received HAT therapy than in those who received hydrocortisone alone at 30 days (9% vs 28%; P = .03) and 90 days (14% vs 33%; P = .04).
At 30 days, no differences were seen in the number of vasoactive inotrope-free or hospital-free days among any of the comparison groups.
“We were surprised and excited to see a substantial reduction in mortality after treating septic shock in children with a high dose of vitamin C combined with vitamin B1 and hydrocortisone,” said Dr. Wald.
“While based on a retrospective analysis, our results are especially compelling in that they are very similar to the positive outcomes found in a recent randomised controlled trial of vitamin C treatment for septic shock in adults,” he added.
Dr. Wald noted that larger studies are needed to better understand the mechanisms behind the potential benefits of the combination therapy.
“While it is still unclear why vitamin C appears to reduce mortality from septic shock, and we need to dig deeper to understand the mechanism, our results are incredibly promising,” Dr. Wald concluded. “We hope to encourage larger, multicentre studies in children with septic shock to confirm our data.”
[Presentation title: Hydrocortisone/Ascorbic Acid/Thiamine Use Associated With Lower Mortality in Pediatric Septic Shock. Abstract 25]
ORLANDO, Fla -- February 20, 2020 -- The use of an intravenous combination of hydrocortisone, ascorbic acid, and thiamine (HAT) as adjunctive therapy in the treatment of children with septic shock significantly reduces mortality, according to research presented here at the 2020 Annual Meeting of the Society of Critical Care Medicine (SCCM).
“Our results suggest that hydrocortisone, ascorbic acid, and thiamine therapy, when administered early in the clinical course, reduces mortality in children with septic shock,” stated Eric L. Wald, MD, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, and colleagues.
Interest in HAT therapy for septic shock treatment was raised when previous research showed dramatically lower mortality rates with the adjunctive treatment among adult patients with septic shock; however, some studies failed to show benefit with the combination therapy. Furthermore, no studies reported on the effect of the potentially safe and low-cost intervention among children with septic shock.
To evaluate the issue, the researchers identified 557 patients meeting septic shock criteria at a large academic paediatric intensive care unit between January 2014 and February 2019.
Of the patients, 43 were treated with HAT therapy, which was introduced at the centre in 2017. These patients were matched 1:1:1 in a propensity analysis to compare those with balanced characteristics among patients who received hydrocortisone therapy alone and controls who were untreated.
Patients treated with HAT therapy had significantly lower mortality rates than controls at 30 days (9% vs 28%; P = .03) and 90 days (14% vs 35%; P = .02). Mortality rates were also lower in patients who received HAT therapy than in those who received hydrocortisone alone at 30 days (9% vs 28%; P = .03) and 90 days (14% vs 33%; P = .04).
At 30 days, no differences were seen in the number of vasoactive inotrope-free or hospital-free days among any of the comparison groups.
“We were surprised and excited to see a substantial reduction in mortality after treating septic shock in children with a high dose of vitamin C combined with vitamin B1 and hydrocortisone,” said Dr. Wald.
“While based on a retrospective analysis, our results are especially compelling in that they are very similar to the positive outcomes found in a recent randomised controlled trial of vitamin C treatment for septic shock in adults,” he added.
Dr. Wald noted that larger studies are needed to better understand the mechanisms behind the potential benefits of the combination therapy.
“While it is still unclear why vitamin C appears to reduce mortality from septic shock, and we need to dig deeper to understand the mechanism, our results are incredibly promising,” Dr. Wald concluded. “We hope to encourage larger, multicentre studies in children with septic shock to confirm our data.”
[Presentation title: Hydrocortisone/Ascorbic Acid/Thiamine Use Associated With Lower Mortality in Pediatric Septic Shock. Abstract 25]
COVID 19 3 WISE MEN SYSTEM
- Doctors told of a “three wise men” system where top consultants would decide who would get rationed care;
In Wuhan, it appears that it has peaked at less than 5% of the population getting it. And we are having to make contingency plans for 70% of the population getting it, and in terms of the number of lives lost, there is a massive difference, hundreds of thousands of lives difference, if you can contain it to less than 5%.
Coronavirus bombshell as 14% of patients who recovered test positive again
PM DWM COVID19 RX REMDESIVIR
Treatment options for COVID-19
27/02/2020
Remdesivir is one of the drugs that has caused a stir in the news when it comes to treating COVID-19. There are others that are reported to have the potential to inhibit the virus. Find out the latest.
Hot off the press
This week has seen a new surge of updates from the prevention and treatment fronts of the ongoing joint efforts to tackle COVID-19, led by healthcare professionals, scientists and pharmaceutical companies (TIME, 2020). A news report from TIME magazine informed us on 25 February that batches of a new vaccine, that was developed by Moderna Therapeutics, a biotech company based in Cambridge, MA, US, was shipped by the company to the National Institute of Allergy and Infectious Diseases to be used in a phase I study in the US (TIME, 2020; Moderna Therapeutics, 2020).
The same day saw the announcement by the National Institute of Health, US, that a randomised, controlled clinical trial to evaluate the safety and efficacy of the investigational antiviral remdesivir had started. The study commencing at the University of Nebraska Medical Center in Omaha, US, is going to enrol hospitalised adults diagnosed with the virus (National Institute of Health, 2020).
The widely discussed remdesivir
Remdesivir, developed by Gilead Sciences Inc., is an investigational broad-spectrum antiviral treatment that previously showed promise in animal models for treating Middle East respiratory syndrome (MERS) and severe acute respiratory syndrome (SARS), which are caused by other coronaviruses (National Institute of Health, 2020).
Remdesivir was one of the drugs speculated to have potential efficacy against COVID-19 in a commentary in the journal Nature Reviews Drug Discovery, earlier in February (Li and De Clercq, 2020).
Other potential treatment options
In the above-mentioned commentary, the authors argued that drugs approved for other conditions can be repurposed for COVID-19, based on the functional similarities between the virus and the targets of these drugs. More importantly, these drugs have recently shown inhibitory effects on the virus (Li and De Clercq, 2020).
The analysis listed the following agents as possible candidates to treat COVID-19 infection (Li and De Clercq, 2020):
Virally targeted agents:
- Nucleoside analogues:
- favipiravir - approved for influenza treatment
- ribavirin - approved for treating hepatitis C virus (HCV) and respiratory syncytial virus
- galidesivir - originally developed for HCV
- Protease inhibitors:
- disulfiram - approved for alcohol dependence
- lopinavir - approved for HIV
- ritonavir - approved for HIV
- Griffithsin:
A red-algae-derived lectin that binds to oligosaccharides on the surface of various viral glycoproteins, including HIV glycoprotein 120 and SARS coronavirus spike glycoprotein
Host-targeted agents:
- Pegylated interferon-2a and -2b - approved for the treatment of hepatitis B virus (HBV) and HCV
- Small molecule agents:
- chloroquine - used in treatment and prevention of malaria
- nitazoxanide - approved for diarrhoea treatment
Some of these drugs are already being tested against COVID-19 in clinical trials (Li and De Clercq, 2020).
More in development
Existing drugs are not the only option to target COVID-19. On 20 February, Columbia University, US, announced that four of their research teams were to share a $2.1 million grant to develop drugs or antibodies aimed to prevent the virus from replicating (Columbia University Irving Medical Center, 2020). The teams’ approach will be split into four tracks and will use drug screening, enzyme production, synthetic chemistry or antibody isolation from patients to develop new drugs in the following categories:
- protease inhibitors
- polymerase inhibitors
- nucleotide analogues
- monoclonal antibodies
Upcoming:
Data on the clinical course of the disease is accumulating as more and more cases are being reported from around the world. What are the clinical outcomes of newly diagnosed and critically ill patients? What are the pathological findings? Watch this space.
References
- TIME. COVID-19 vaccine shipped, and drug trials start. Accessed February 2020
BLUSHING X SOCIAL ANXTY DISORDER
unique contribution of blushing to the development of social anxiety disorder symptoms
P Breast milk reduces the risk of chest infections, urinary infections, gastroenteritis and diabetes
Breast milk reduces the risk of chest infections, urinary infections, gastroenteritis and diabetes
BBTBR X ANTI MOMENT BB
The antimatter factory about to solve the universe's greatest mystery
Why is there something rather than nothing? We’re finally making enough antimatter to extract an answer – and it might reveal the dark side of the universe too
SURE, the big bang is cool, in a hot sort of way. The beginning of all things. Space, time, matter and energy bursting into existence from a pinprick of infinite temperature and density. Space racing away from itself faster than the speed of light. Maybe even the making of a multiverse.
But a second moment shortly afterwards doesn’t get half the press. Perhaps that is because it is when precisely nothing happened. Call it an anti-moment.
It is when all the matter that suddenly and inexplicably came into being in the big bang equally suddenly and inexplicably failed to go out of being again. When it didn’t cease to be available to create stars, galaxies, planets, an unquantified quantity of questioning life and, on one world at least, some highly embarrassed physicists who predicted exactly that. “The fact that we are a world completely dominated by matter is completely un-understood,” says Chloé Malbrunot at particle physics lab CERN, near Geneva, Switzerland. “Theory says we shouldn’t be here.”
After decades trying to understand why we are here, we could now be nearing a breakthrough on multiple fronts. And the answer probably isn’t the one we first thought of. There is even a slim chance it could explain not only what happened after the big bang, but also great mysteries of our universe today, such as the nature of dark matter and dark energy. “We are just one experiment away from a revolution in our understanding,” says Jeffrey Hangst at CERN.
Read more: https://www.newscientist.com/article/mg24532710-900-the-antimatter-factory-about-to-solve-the-universes-greatest-mystery/#ixzz6FEYQlqSL
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