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Successful elimination of extended-spectrum betalactamase(ESBL)-producing nosocomial bacteria at a neonatal intensive care unit
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Borb¨¢la Sz¨¦l, Zsolt Reiger, Edit Urb¨¢n, Andrea L¨¢z¨¢r, Krisztina Mader, Ivelina Damjanova, Kamilla Nagy, Gyula T¨¢losi |
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Background: Extended-spectrum beta-lactamase (ESBL)-producing Gram-negative bacteria are highly dangerous to neonates. At our Neonatal Intensive Care Unit (NICU), the presence of these bacteria became so threatening in 2011 that immediate intervention was required.
Methods: This study was conducted during a nearly two-year period consisting of three phases: retrospective (9 months), educational (3 months) and prospective (9 months). Based on retrospective data analysis, a complex management plan was devised involving the introduction of the INSURE protocol, changes to the antibiotic regimen, microbiological screening at short intervals, progressive feeding, a safer bathing protocol, staff hand hygiene training and continuous monitoring of the number of newly infected and newly colonized patients. During these intervals, a total of 355 patients were monitored.
Results: Both ESBL-producing Enterobacter cloaceae and Klebsiella pneumoniae were found (in both patients and environmental samples). In the prospective period a significant reduction could be seen in the average number of both colonized (26/167 patients; P=0.029) and infected (3/167 patients; P=0.033) patients compared to data from the retrospective period regarding colonized (72/188 patients) and infected (9/188 patients) patients. There was a decrease in the average number of patient days (from 343.72 to 292.44 days per months), though this difference is not significant (P=0.058). During the prospective period, indirect hand hygiene compliance showed a significant increase (from the previous 26.02 to 33.6 hand hygiene procedures per patient per hospital day, P<0.001).
Conclusion: Colonizations and infections were rolled back successfully in a multi-step effort that required an interdisciplinary approach. |
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[Abstract] [Full Text] [PDF]
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Impact of relocation and environmental cleaning on reducing the incidence of healthcare-associated infection in NICU
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Qiu-Fang Li, Hong Xu, Xiao-Ping Ni, Rong Lin, Hui Jin, Ling-Ya Wei, Dan Liu, Lin-Hai Shen, Jie Zha, Xin-Fen Xu, Bo Wu |
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Background: Hospital environment remains a risk for healthcare-associated infections (HAIs). This was a prospective study to evaluate the comprehensive impact of relocating a neonatal intensive care unit (NICU) to a new facility and improved environmental cleaning practice on the presence of methicillin-resistant Staphylococcus aureus (MRSA) on inanimate surfaces and the incident rate of HAIs.
Methods: New environmental cleaning measures were adopted after the NICU was moved to a new and better-designed location. The effect of moving and the new environmental cleaning practice was investigated by comparing the positive number of MRSA on ward surfaces and the incidence density of HAIs between the baseline and intervention periods.
Results: Only 2.5% of environmental surfaces were positive for MRSA in the intervention period compared to 44.0% in the baseline period (P<0.001). Likewise, the total incident rate of HAIs declined from 16.8 per 1000 cot-days to 10.0 per 1000 cot-days (P<0.001).
Conclusion: The comprehensive measures of relocating the NICU to a new facility design with improved environmental cleaning practice are effective and significantly reduce the incidence of HAIs. |
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[Abstract] [Full Text] [PDF]
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Prediction of signifi cant hyperbilirubinemia in term neonates by early non-invasive bilirubin measurement
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Manish Jain, Akash Bang, Anju Tiwari, Shuchi Jain |
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Background: Neonatal jaundice is a common problem. We evaluated the utility and best cut-off values of 24- and 48-hour transcutaneous bilirubin indices (TcBI) in predicting subsequent significant hyperbilirubinemia and evaluated various associated maternal and fetal risk factors.
Methods: TcBI at 24 and 48 hours and serum bilirubin levels at 72 hours of age were obtained for healthy, term, appropriate for gestational age neonates. Neonates with prematurity, birth weight <2500 g, ABO or Rh incompatibility, onset of clinical jaundice <24 hours, clinical suspicion of septicemia, positive pressure ventilation at birth, admission in neonatal intensive care unit and contraindications for BiliChek were excluded. Twently-four and 48-hour TcB indices were assessed as predictors of subsequent hyperbilirubinemia, defined as serum bilirubin >17 mg/dL after 72 hours of life and various cut-offs, and were evaluated by calculating sensitivity, specificity and predictive values.
Results: Of 500 newborns, 4.6% had significant hyperbilirubinemia, 27% had TcBI (mg/dL) <5 at 24 hours, and 27.4% had TcBI <8 at 48 hours. None of them had subsequent hyperbilirubinemia (100% negative predictive value). The percentage of newborns with subsequent hyperbilirubinemia increased from 3.4% to 13.2% as their 24-hour TcBI increased from 6 to above 9 mg/dL and from 4.2% to 7.4% as their 48-hour TcBI increased from 8 to above 11 mg/dL. The best cut-off value was TcBI (mg/dL) 7 (odd ratio=4.86, 95% confidence interval: 1.66-15.22) at 24 hours and 10 (odd ratio=2.87, 95% confidence interval: 1.04-8.29) at 48 hours. Area under the receiver operating characteristic curve for 24- and 48-hour measurements was 0.750 and 0.715, respectively. Maternal premature rupture of membranes, deep transverse arrest, post-date pregnancy, and fetal distress were significant risk factors for hyperbilirubinemia.
Conclusions: Twenty-four and 48-hour TcB indices are good predictors of subsequent hyperbilirubinemia. Twenty-four-hour TcBI had better predictive ability than 48-hour TcBI. |
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[Abstract] [Full Text] [PDF]
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High-mobility group box-1 and receptor for advanced glycation end products in preterm infants with brain injury
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Hong-Yan Lu, Jiang-Lin Ma, Ji-Yan Shan, Jie Zhang, Qiu-Xia Wang, Qiang Zhang |
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Background: High-mobility group box-1 (HMGB1) protein acts as an important pro-inflammatory mediator, which is capable of activating inflammation and tissue repair. HMGB1 can bind to its receptor such as advanced glycation end products (RAGE). RAGE, in turn, can promote the production of pro-inflammatory cytokines. Soluble RAGE (sRAGE) is a truncated form of the receptor comprising the extracellular domain of RAGE and can inhibit RAGE-activation. The objective of this study was to investigate whether HMGB1 and RAGE are involved in the development of brain injury in preterm infants.
Methods: In total, 108 infants ¡Ü34 weeks gestation at birth were divided into 3 groups according to cranial ultrasound scan: mild brain damage (n=33), severe brain damage (n=8) and no brain damage (n=67). All the placentas were submitted for pathologic evaluation. Histological chorioamnionitis (HCA) was defined as neutrophil infiltration of amniotic membranes, umbilical cord or chorionic plate. Expressions of HMGB1 and RAGE proteins were assessed by immunohistochemical analysis. The concentration of HMGB1 and sRAGE in umbilical cord blood were measured by enzyme-linked immunosorbent assay.
Results: The frequency of HCA was 30.12%. HCA was associated with elevated concentrations of HMGB1 and decreased sRAGE in umbilical cord blood. The severe brain injury group demonstrated higher cord blood HMGB1 concentrations (P<0.001) and lower sRAGE concentrations (P<0.001) than both other groups. Brain injury in the premature infants was linked to intense staining for HMGB1/RAGE, particularly in inflammatory cells.
Conclusions: Changes of cord blood HMGB1 and sRAGE of premature infants had direct relationship with the degree of inflammation and severity of brain damage. Monitoring sRAGE and HMGB1 levels may be helpful to predict intrauterine infection and brain injury in premature infants. |
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[Abstract] [Full Text] [PDF]
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Randomized controlled trial of topical EMLA and vapocoolant spray for reducing pain during wDPT vaccination
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Navratan Kumar Gupta, Amit Upadhyay, Ajeet Kumar Dwivedi, Astha Agarwal, Vijay Jaiswal, Abhishek Singh |
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Background: Intramuscular vaccination is among the most common source of iatrogenic pain in infants. Vapocoolant sprays are rapid-acting alternative to topical anesthetics. They provide transient anesthesia via evaporation induced skin cooling, and reduce pain due to vaccine injection in children and adults. The objective was to compare the synergistic analgesic effect of eutectic mixture of local anesthetics (EMLA) with breastfeeding (EB group) and vapocoolant spay with breastfeeding (VB group) to that of only breastfeeding (BO group) during whole cell diptheria, pertussis and tetanus (wDPT) vaccination.
Methods: A double blind randomized controlled trial was done to include infants up to 3 months of age who came for their first wDPT vaccination. The primary outcome variable was the duration of cry after vaccination. Secondary outcome variables were Modified Facial Coding Score, Neonatal Infant Pain Scale and latency of onset of cry.
Results: Of the 201 eligible participants, 111 babies were excluded and remaining 90 babies were randomized into three groups of thirty each. The groups did not differ significantly in baseline characteristics. Median (interquartile range, IQR) of duration of cry was lesser [35.86 (21.07-107.75) seconds] in babies receiving EMLA cream with breast feeding (EB group) and in babies receiving vapocoolant spray with breast feeding (VB group) [32.58 (21.25-106.21) seconds] as compared to babies receiving only breast feeding (BO group) [67.5 (27.6-180) seconds] (P=0.147). Difference in median (IQR) of latency of cry was not statistically significant. Modified Facial Coding Score and Neonatal Infant Pain Scale at 1 minute and 3 minutes was significantly lower in the EB and VB group, as compared to the BO group (P<0.05).
Conclusions: Addition of topical EMLA application or vapocoolant spray to breastfeeding during wDPT vaccination does not reduce duration of cry in infants up to 3 months of age. However, they are able to show reduction in pain score and further studies are warranted to assess their effi cacy as pain relief measures in infants and children. |
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[Abstract] [Full Text] [PDF]
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Total estimated effective doses from radiologic imaging modalities of children with cancer: a single center experience
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Derya Özyör¨¹k, Suna Emir, Hacı Ahmet Demir, G¨¹lşah Bayram Kabaçam, Bahattin Tunç |
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Background: Recently, awareness of the cumulative radiation exposure for pediatric oncology patients has been increasing, together with increased survival rates and longer life expectancy. The aim of our study was to quantify the amount of ionising radiation from imaging modalities of pediatric oncology patients.
Methods: Eighty-eight patients who were diagnosed with childhood cancer and followed up for 5 years between 2004-2014 in our center were included in the study. Patients' medical fi les were reviewed retrospectively for imaging history in the first 5 years after diagnosis. Total estimated effective doses from radiologic imaging modalities were determined. Also, the basic demographic data, histologic type, stage, and outcomes of disease were collected for all patients.
Results: The individual total estimated effective doses ranged from 8.73 to 167 mSv, with a median of 62.92 mSv. Computed tomography was the greatest contributor of total effective doses. The doses ranged 21.45-113.20 mSv (median: 62.92 mSv) in Hodgkin lymphoma, 12.53-167.10 mSv (median: 52 mSv) in non-Hodgkin lymphoma, 4.13- 172.98 mSv (median: 52 mSv) in neuroblastoma, 31- 149.89 mSv (median: 63.10 mSv) in Wilms' tumor, 11.50- 73.72 mSv (median: 36.90 mSv) in germ cell tumor, 26.46- 125.86 mSv (median: 80.90 mSv) in other solid tumor and 0.02-13.31 mSv (5.25 mSv) in brain tumor subgroup. Twenty-two children (25%) died with progressive disease during the 5-year follow-up period.
Conclusions: Similar to previous studies, the total estimated effective doses in children with cancer have been found various according to diagnosis, stage and clinical course. To clarify the harmfull effects of radiation burden, prospective studies should be conducted in children with cancer. |
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[Abstract] [Full Text] [PDF]
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What is the appropriate strategy for diagnosing NAFLD using ultrasonography in obese children?
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Jee Hyun Lee, Su Jin Jeong |
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Background: The aim of this study is to identify obese children who are candidates for a potential diagnosis of non-alcoholic fatty liver disease (NAFLD).
Methods: We enrolled 242 obese children (122 boys and 120 girls) aged 7-16 years who were examined with abdominal ultrasonography in our pediatric obesity clinic. We compared patients in the normal group with those in the NAFLD group (mild disease, moderate to severe disease) and identified the optimal anthropometric parameters among height, weight, body mass index (BMI), waist circumference, hip circumference, waist to height ratio (WHtR), and waist to hip ratio to predict NAFLD using a receiver operating characteristic curve analysis. We also investigated risk factors associated with NAFLD for the anthropometric parameters and the biochemical model using logistic regression.
Results: The high- and low-risk groups for hepatic steatosis relative to a WHtR of 0.56 as the standard point showed significant differences in hepatic steatosis severity grade (P<0.001), BMI (P=0.004), hip circumference (P=0.090), aspartate aminotransferase (P<0.001), alanine aminotransferase (P<0.001), triglycerides (P=0.001), and the triglyceride to high-density lipoprotein (HDL) cholesterol ratio (P=0.006). Risk factors for hepatic steatosis on logistic regression analysis were male sex (odds ratio: 3.68, 95% confidence interval: 1.76-7.70), WHtR >0.56 (2.25, 1.05-4.81), and waist circumference >90th percentile (20.22, 9.21-44.36) in the anthropometric parameter model and elevated alanine aminotransferase levels (boys >25.8 U/L, girls >22.1 U/L) (6.93, 2.52-19.03), hypertriglyceridemia (>110 mg/dL) (3.80, 1.23-11.75), and triglyceride to HDL cholesterol ratio >3 (9.23, 2.95-8.83) in the biochemical parameter model.
Conclusions: A diagnostic approach to hepatic steatosis is recommended as part of the proper screening and stratification of risk factors in obese children. WHtR is a simple and convenient method of effectively identifying obese children who are candidates for hepatic steatosis screening. |
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[Abstract] [Full Text] [PDF]
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Drug-induced Stevens-Johnson syndrome and toxic epidermal necrolysis in children: 20 years study in a tertiary care hospital
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Leelawadee Techasatian, Sunee Panombualert, Rattapon Uppala, Charoon Jetsrisuparb |
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Background: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe lifethreatening skin conditions. The most common cause of these manifestations is medications. Beside discontinued of the culprit drug, systemic corticosteroids were used as a primary treatment option among pediatric population. This study aimed to explore causative drugs (drug group/ latent period), treaments, complications, and treatment outcome (morbidity, mortality, length of hospital stay) of SJS and TEN in children.
Methods: A retrospective chart was reviewed during the period of 1992 to 2012 at Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Thailand. SJS and TEN were clinically diagnosed and confirmed by pediatric dermatologists. Other possible causes other than drug induced SJS and TEN were excluded.
Results: A total of 30 patients was recorded, including 24 (80%) SJS patients and 6 (20%) TEN patients. The mean age was 6.9 years (SD 4.4). Male to female ratio was 1.5:1. Antiepileptic drug group was the most common causative drug (n=18, 60%), followed by antibiotic drug group (n=8, 26.6%), and others (n=4, 13.3%) which included nonsteroidal antiinflammtory drugs (NSAIDs) and chemotherapy drugs. Systemic corticosteroids were used in 29 patients (96.6%). Intravenous immunoglobulin was used in one TEN patient (3.3%). There was a medium correlation between time to treatment (systemic corticosteroids) and the length of hospital stay (Spearman correlation coefficient=0.63, P=0.005). Two TEN patients (6.6%) died.
Conclusions: Carbamazepine was the most common causative drug of SJS and TEN in our study. The severity of skin detachment is not correlated to severity of ocular findings. However, the persistent of ocular complications up to one year is suggested for promptly appropriate ocular treatment in all SJS and TEN patients. Our data suggested that early administration of systemic corticosteroid may reduce the length of hospital stay and should be considered for the treatment of pediatric drug induced SJS and TEN. |
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[Abstract] [Full Text] [PDF]
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Relationship between postoperative complications and fi bular integrity in congenital pseudarthrosis of the tibia in children
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Yao-Xi Liu, Hai-Bo Mei, Guang-Hui Zhu, Rong-Guo He, Kun Liu, Jin Tang, Jiang-Yan Wu, Wei-Hua Ye, Xin Hu, Qian Tan, An Yan, Sheng-Xiang Huang, Xiao-Qian Tan, Ting Lei |
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Background: This study aimed to investigate the relationship between postoperative complications and fi bular integrity in congenital pseudarthrosis of the tibia (CPT) in children.
Methods: A retrospective study was performed in 59 patients with Crawford type IV CPT who were treated with combined surgical technique from 2007 to 2011. The patients were divided into two groups, the CPT with fibular pseudarthrosis (group A) and CPT with intact fi bula groups (group B), on the basis of fibula status after the union of CPT. The incidence rates of refracture, ankle valgus, tibial valgus, and limb length discrepancy in the two groups were investigated.
Results: In group A, 14 (36.8%) cases had refracture, 30 (78.9%) had ankle valgus; 27 (71%) exhibited tibial valgus with an average tibial valgus of 7¡ã (6¡ã-20¡ã), and 24 (63.2%) had limb length discrepancy with an average limb length of 1.26 cm (0.6-4.4 cm). In group B, 2 (9.5%) cases had refracture, 11 (52.4%) had ankle valgus, 8 (42.9%) had tibial valgus with an average tibial valgus deformity of 2.9¡ã (6¡ã-13¡ã), and 13 (61.9%) had limb length discrepancy with an average limb length of 1.48 cm (0.5-5 cm). Significant difference in refracture and ankle valgus was found between groups A and B (P<0.05).
Conclusions: After the union of CPT, patients with fi bular pseudarthrosis showed higher incidence of refracture and ankle valgus than those with intact fibula. Attention should be paid to the presence of fibular pseudarthrosis when managing CPT. |
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[Abstract] [Full Text] [PDF]
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Identifying key genes associated with Hirschsprung's disease based on bioinformatics analysis of RNA-sequencing data
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Wei-Kang Pan, Ya-Fei Zhang, Hui Yu, Ya Gao, Bai-Jun Zheng, Peng Li, Chong Xie, Xin Ge |
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Background: Hirschsprung's disease (HSCR) is a type of megacolon induced by deficiency or dysfunction of ganglion cells in the distal intestine and is associated with developmental disorders of the enteric nervous system. To explore the mechanisms of HSCR, we analyzed the RNA sequencing data of the expansion and the narrow segments of colon tissues separated from children with HSCR.
Methods: RNA-sequencing of the expansion segments and the narrow segments of colon tissues isolated from children with HSCR was performed. After differentially expressed genes (DEGs) were identified using the edgeR package in R, functional and pathway enrichment analyses of DEGs were carried out using DAVID software. To further screen the key genes, protein-protein interaction (PPI) network and module analyses were conducted separately using Cytoscape software.
Results: A total of 117 DEGs were identified in the expansion segment samples, including 47 up-regulated and 70 down-regulated genes. Functional enrichment analysis suggested that FOS and DUSP1 were implicated in response to endogenous stimulus. In the PPI network analysis, FOS (degree=20), EGR1 (degree=16), ATF3 (degree=9), NOS1 (degree=8), CCL5 (degree=8), DUSP1 (degree=7), CXCL3 (degree=6), VIP (degree=6), FOSB (degree=5), and NOS2 (degree=4) had higher degrees, which could interact with other genes. In addition, two significant modules (module 1 and module 2) were identified from the PPI network.
Conclusion: Several genes (including FOS, EGR1, ATF3, NOS1, CCL5, DUSP1, CXCL3, VIP, FOSB, and NOS2) might be involved in the development of HSCR through their effect on the nervous system. |
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[Abstract] [Full Text] [PDF]
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