Publications by authors named "Sonal Shah"

78 Publications

Clinical Features, Prognostic Factors, and Treatment Interventions for Ulceration in Patients With Infantile Hemangioma.

JAMA Dermatol 2021 Mar 31. Epub 2021 Mar 31.

Department of Dermatology, School of Medicine, University of California, San Francisco.

Importance: Ulceration is a common complication of infantile hemangioma (IH), which leads to substantial morbidity. Ulceration in IH has not been systematically studied since the advent of β-blocker therapy for IH.

Objectives: To examine treatment interventions used for ulceration in IH and identify clinical prognostic indicators of healing time.

Design, Setting, And Participants: A retrospective, multicenter cohort study was conducted on 436 consecutive patients with a clinical diagnosis of ulcerated IH and available clinical photographs. Patients receiving care at tertiary referral centers evaluated between 2012 and 2016 were included; statistical and data analysis were performed from February 7 to April 27, 2020.

Exposures: Clinical characteristics, treatment interventions, course, complications, and resource use were analyzed. Treatment interventions for ulceration in IH included local (wound care, topical), systemic (β-blocker, corticosteroids), and procedural (pulsed-dye laser).

Main Outcomes And Measures: The primary end point was time to complete or nearly complete ulceration healing. Clinical characteristics were analyzed to determine the responses to most common interventions and prognostic factors for healing of ulceration.

Results: Of the 436 patients included in the study, 327 were girls (75.0%); median age at ulceration was 13.7 weeks (interquartile range, 8.86-21.30 weeks). The median heal time was 4.79 weeks (95% CI, 3.71-5.86 weeks) with wound care alone, 5.14 weeks (95% CI, 4.57-6.00 weeks) with timolol, 6.36 weeks (95% CI, 5.57-8.00 weeks) with a systemic β-blocker, and 7.71 weeks (95% CI, 6.71-10.14 weeks) with multimodal therapy. After adjusting for IH size, a dose of propranolol less than or equal to 1 mg/kg/d was associated with shorter healing time compared with higher propranolol doses (hazard ratio, 2.04; 95% CI, 1.11 to 3.73; P = .02). Size of the IH was identified as a significant prognostic factor for healing time in multivariable analysis. Increasing size of IH portends a proportionately longer time to heal of the ulceration.

Conclusions And Relevance: Despite the use of β-blockers, this cohort study found that a subset of patients with IH ulceration continued to experience prolonged IH healing times. Larger IH size appears to be a poor prognostic factor for time to heal. For patients requiring systemic therapy, initiation of propranolol at lower doses (≤1 mg/kg/d) should be considered.
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http://dx.doi.org/10.1001/jamadermatol.2021.0469DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8014192PMC
March 2021

Development and Validation of a Reversed Phase High Performance Liquid Chromatography-Photodiode Array Detection Method for Simultaneous Identification and Quantification of Coumarin, Precocene-I, β-Caryophyllene Oxide, α-Humulene, and β-Caryophyllene in Ageratum Conyzoides Extracts and Essential Oils from Plants.

J AOAC Int 2020 Jun;103(3):857-864

Kerala Veterinary and Animal Sciences University, College of Veterinary and Animal Sciences, Lakkidi, P.O. Wayanad, Pookode, Kerala, India.

Background: Ageratum conyzoides is an aromatic plant. It is considered as an invasive and cosmopolite weed, widely spread in tropical and subtropical regions. Phytochemicals such as benzopyrenes, flavonoids, and terpenoids are reported from A. conyzoides.

Objective: Development and validation of a reversed-phase HPLC-photodiode array (PDA) detection method for simultaneous identification and quantification of coumarin, precocene-I, β-caryophyllene oxide, α-humulene, and β-caryophyllene in extracts of A. conyzoides and essential oils was carried out.

Methods: Separation of analytes was achieved on a RP-18 (250 mm × 4.6 mm, 5 µm) column using a solvent system comprising of a mixture of acetonitrile and water with 0.05% trifluoroacetic acid in gradient elution mode at ambient temperature with flow rate of 1 mL/min.

Results: The retention time of coumarin, precocene-I, β-caryophyllene oxide, α-humulene, and β-caryophyllene was 4.38, 12.86, 20.10, 33.34, and 35.11 min, respectively. Limits of detection for coumarin, precocene-I, β-caryophyllene oxide, α-humulene, and β-caryophyllene were 2.5, 2.5, 2.5, 0.025, and 2.5 µg/mL, respectively. Similarly, LOQ were 10, 10, 10, 0.10, and 10 µg/mL for coumarin, precocene-I, β-caryophyllene oxide, α-humulene, and β- caryophyllene, respectively. Repeatabilities (RSD, %) values for intraday and interday precision for coumarin, precocene-I, β-caryophyllene oxide, α-humulene, and β-caryophyllene was 0.765-2.086 and 0.886-2.128; 0.879-1.672 and 0.979-1.825; 0.696-2.418 and 0.768-2.592; 1.728-2.362 and 1.965-2.378; 1.615-2.897 and 1.658-2.906, respectively.

Conclusions: The separation of five analytes was achieved within 50 min. The developed and validated HPLC-PDA method was successfully applied for identification and quantification of above five analytes in A. conyzoides extracts and essential oils. The method could be used for meeting the characterization criteria of phytoformulations.
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http://dx.doi.org/10.1093/jaoacint/qsz038DOI Listing
June 2020

Cutaneous reactions to pediatric cancer treatment: Part I. Conventional chemotherapy.

Pediatr Dermatol 2021 Jan 10;38(1):8-17. Epub 2020 Nov 10.

St. Louis Children's Hospital, St. Louis, MO, USA.

Chemotherapies often cause side effects of the skin, nails, and mucosal surfaces. These mucocutaneous toxicities contribute to morbidity and affect quality of life. Identification and management of these drug-induced eruptions is vital to allow for continuation of essential therapies. This review demonstrates the wide range of chemotherapy-induced cutaneous toxicities in children and includes clues for diagnosis as well as tips for counseling and management.
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http://dx.doi.org/10.1111/pde.14418DOI Listing
January 2021

Evaluation of Presurgical Serum Cortisol Level in Patients Undergoing Major Maxillofacial Surgery.

Ann Maxillofac Surg 2020 Jan-Jun;10(1):25-30. Epub 2020 Jun 8.

Department of Oral and Maxillofacial Surgery, Dr. D.Y. Patil Vidyapeeth, Pune, Maharashtra, India.

Background: Stress is an integral part of life. Anxiety levels may increase when it comes to being treated surgically due to road traffic accidents causing facial trauma, other pathologies or burns. The stress that is caused during a surgical procedure as well as during the treatment in debilitated patients or traumatic conditions is bound to cause disturbance in the metabolic and physiologic levels of cortisol. Therefore, a study was carried out to determine the cortisol levels just prior to surgery on the day of operation to quantify the stress levels and also aid in any preanesthetic medication changes for the patient undergoing maxillofacial surgery.

Aim: To evaluate and compare pre-surgical serum cortisol levels in patients undergoing major maxillofacial surgery under general anaesthesia.

Objective: To evaluate the serum cortisol level of patient 3 days prior to surgery, on the day of surgery and to compare and evaluate the difference seen in both the obtained values.

Methods: A prospective, randomized, in- vivo study was carried out in the Department of Oral and Maxillofacial Surgery at a teaching dental hospital. A total of 32 patients were included in this study. Inclusion and Exculsion criteria was made along with pre-opertive assessment of the patient, informed consent was obtained from all patients involved in the study. Patient blood sample, at 8 am three days prior to surgery and on the day of surgery and sent for laboratory investigations.

Result: Participants in this clinical study underwent treatment of various ailments like facial trauma, and miscellaneous pathologies like Dentigerous Cyst, Oral submucosa fibrosis, Osteomyelitis, Benign Tumor and Orthognathic surgery. The anxiety of the patients were assessed by serum cortisol level preoperatively and on the day of operation. A total of 32 patients, 26 male and 06 female were included in the study. There was statistically highly significant difference seen between the mean values obtained three days prior to surgery and on the day of surgery.

Conclusion: We have concluded from this study that the serum cortisol level shows significant increase on the day of surgery. A future study can focus on association between increased levels of serum cortisol and postoperative wound healing where patients can be divided into two groups one receiving pre-operative stress reduction protocol and other not receiving the same.
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http://dx.doi.org/10.4103/ams.ams_20_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7433954PMC
June 2020

Comparative evaluation of salivary alpha amylase level for assessment of stress during third molar surgery with and without piano music and co-relation with pain catastrophizing scale: an study.

J Korean Assoc Oral Maxillofac Surg 2020 Aug;46(4):235-239

Department of Oral & Maxillofacial Surgery, Dr. D. Y. Patil Vidyapeeth, Pune, India.

Objectives: Preoperative nervousness and anxiety are frequently encountered by individuals who undergo extractions of impacted wisdom teeth. The aim of the present study is to evaluate salivary alpha amylase (sAA) level in patients for assessment of stress during third molar surgery while listening to piano music and to determine its co-relation with pain catastrophizing scale (PCS).

Materials And Methods: Seven patients (four males and three females) indicated for surgical extraction of bilaterally impacted mandibular third molars were included. Pre-surgical patient assessments were completed, and three samples of saliva were collected during surgery-one at baseline, one 30 minutes after commencement of surgery, and one after suturing. Assessment was performed on both sides separately with and without piano music, and the samples were assessed for sAA level and correlated with the patient's self-reported PCS.

Results: Statistically significant results were obtained in patients who underwent surgical extraction while listening to piano music (=0.046). The correlation of sAA level with PCS was not significant.

Conclusion: Music demonstrated a beneficial effect on lowering the levels of stress and anxiety that a patient exhibits during any surgical procedure, and sAA can be a useful biomarker for similar assessments.
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http://dx.doi.org/10.5125/jkaoms.2020.46.4.235DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7469970PMC
August 2020

Reliability and Recommended Settings for Pediatric Circumpapillary Retinal Nerve Fiber Layer Imaging Using Hand-Held Optical Coherence Tomography.

Transl Vis Sci Technol 2020 06 30;9(7):43. Epub 2020 Jun 30.

University of Leicester Ulverscroft Eye Unit, Department of Neuroscience, Psychology and Behaviour, University of Leicester, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, Leicester, UK.

Purpose: To investigate feasibility and reliability of 3-dimensional full circumpapillary retinal nerve fiber layer (cpRNFL) analysis in children, with and without glaucoma, without the use of sedation and to recommend a protocol for hand-held optical coherence tomography use.

Methods: A cohort of pediatric glaucoma patients and normal children were imaged with hand-held optical coherence tomography to assess the feasibility of obtaining full cpRNFL. Two consecutive scans were acquired in a smaller sample to investigate test-retest repeatability and interassessor reproducibility. The cpRNFL thickness was assessed in four quadrants, at several visual angles from the optic nerve center.

Results: Scanning was attempted in both eyes of 90 children with pediatric glaucoma and 180 controls to investigate feasibility (mean age, 6.98 ± 4.42 years). Scanning was not possible in 68 eyes of glaucoma children mainly owing to nystagmus, unclear optical media, or high refractive errors. Where three-dimensional imaging was possible, success at obtaining full cpRNFL was 67% in children with glaucoma and 89% for controls. Seventeen children with pediatric glaucoma and 34 controls contributed to reliability analysis (mean age, 6.3 ± 3.63 years). For repeatability intraclass correlation coefficients across quadrants ranged from 0.63 to 0.82 at 4° and improved to 0.88 to 0.94 at 6°. Intraclass correlation coefficients for reproducibility were also highest at 6° (>0.97 across all quadrants).

Conclusions: We demonstrate that acquisition and measurement of cpRNFL thickness values using 3-dimensional hand-held optical coherence tomography volumes in awake children is both feasible and reliable and is optimal at 6° from optic nerve center.

Translational Relevance: Our recommended protocol provides guidance on how pediatric optic nerve pathologies are managed by clinicians.
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http://dx.doi.org/10.1167/tvst.9.7.43DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7414610PMC
June 2020

A retrospective multicenter study of fatal pediatric melanoma.

J Am Acad Dermatol 2020 Nov 2;83(5):1274-1281. Epub 2020 Jul 2.

Dermatology Service, Department of Medicine, Memorial Sloan Kettering Skin Cancer Center, New York, New York.

Background: Pediatric melanoma is rare and diagnostically challenging.

Objective: To characterize clinical and histopathologic features of fatal pediatric melanomas.

Methods: Multicenter retrospective study of fatal melanoma cases in patients younger than 20 years diagnosed between 1994 and 2017.

Results: Of 38 cases of fatal pediatric melanoma identified, 57% presented in white patients and 19% in Hispanic patients. The average age at diagnosis was 12.7 years (range, 0.0-19.9 y), and the average age at death was 15.6 years (range, 1.2-26.2 y). Among cases with known identifiable subtypes, 50% were nodular (8/16), 31% were superficial spreading (5/16), and 19% were spitzoid melanoma (3/16). One fourth (10/38) of melanomas arose in association with congenital melanocytic nevi.

Limitations: Retrospective nature, cohort size, and potential referral bias.

Conclusions: Pediatric melanoma can be fatal in diverse clinical presentations, including a striking prevalence of Hispanic patients compared to adult disease, and with a range of clinical subtypes, although no fatal cases of spitzoid melanoma were diagnosed during childhood.
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http://dx.doi.org/10.1016/j.jaad.2020.06.1010DOI Listing
November 2020

Comparison of thermoplastic masks and knee wedge as immobilization devices for image-guided pelvic radiation therapy using Cone Beam Computed Tomography.

Indian J Cancer 2020 Apr-Jun;57(2):182-186

Department of Radiation Oncology, Gujarat Cancer Research Institute, Ahmedabad, Gujarat, India.

Introduction: Pelvic radiotherapy is generally performed with the use of an immobilization and positioning device.

Aim And Objective: The objective of the study was to ascertain and compare setup errors between the two positioning devices.

Materials And Methods: A total of 35 patients of stage II and III cervical cancers were enrolled in the study and divided into two groups, one using knee wedge and the other using thermoplastic pelvic mask as an immobilization device. Radiation was planned by four field box conformal technique. The random and systematic setup errors were then calculated for each patient in both the groups in the mediolateral (ML), superoinferior (SI), and anteroposterior (AP) directions.

Results: The translational mean setup variation in the lateral, longitudinal, and vertical direction is 0.17 ± 0.24, -0.12 ± 0.48, and -0.18 ± 0.27 cm for thermoplastic pelvic mask and -0.03 ± 0.26, -0.04 ± 0.48, and -0.09 ± 0.37 cm for knee wedge, respectively. The systematic setup error and random errors were 0.24, 0.48, 0.27 cm and 0.31, 0.60, and 0.40 cm for thermoplastic mask and 0.26, 0.48, and 0.37 cm and 0.38, 0.37, and 0.45 cm for knee wedge in ML, SI, and AP axis, respectively. The one way analysis of variance test was applied to compare the setup errors in between the three axes for both the immobilization devices. To compare the positioning accuracy of thermoplastic mask and knee wedge, Student's t-test was applied. Both the tests were found to be insignificant (P value > 0.05).

Conclusion: Thermoplastic mask and knee wedge are equally effective as immobilization devices for treating cervical cancers with conformal techniques.
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http://dx.doi.org/10.4103/ijc.IJC_602_18DOI Listing
November 2020

Systemic immunosuppressive therapy for inflammatory skin diseases in children: Expert consensus-based guidance for clinical decision-making during the COVID-19 pandemic.

Pediatr Dermatol 2020 May 16;37(3):424-434. Epub 2020 May 16.

Department of Dermatology, University of California San Francisco School of Medicine, San Francisco, California, USA.

Background/objectives: The COVID-19 pandemic has raised questions about the approach to management of systemic immunosuppressive therapies for dermatologic indications in children. Change to: Given the absence of data to address concerns related to SARS-CoV-2 infection and systemic immunosuppressive therapies in an evidence-based manner, a Pediatric Dermatology COVID-19 Response Task Force (PDCRTF) was assembled to offer time-sensitive guidance for clinicians.

Methods: A survey was distributed to an expert panel of 37 pediatric dermatologists on the PDCRTF to assess expert opinion and current practice related to three primary domains of systemic therapy: initiation, continuation, and laboratory monitoring.

Results: Nearly all respondents (97%) reported that the COVID-19 pandemic had impacted their decision to initiate immunosuppressive medications. The majority of pediatric dermatologists (87%) reported that they were pausing or reducing the frequency of laboratory monitoring for certain immunosuppressive medications. In asymptomatic patients, continuing therapy was the most popular choice across all medications queried. The majority agreed that patients on immunosuppressive medications who have a household exposure to COVID-19 or test positive for new infection should temporarily discontinue systemic and biologic medications, with the exception of systemic steroids, which may require tapering.

Conclusions: The ultimate decision regarding initiation, continuation, and laboratory monitoring of immunosuppressive therapy during the pandemic requires careful deliberation, consideration of the little evidence available, and discussion with families. Consideration of an individual's adherence to COVID-19 preventive measures, risk of exposure, and the potential severity if infected must be weighed against the dermatological disease, medication, and risks to the patient of tapering or discontinuing therapies.
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http://dx.doi.org/10.1111/pde.14202DOI Listing
May 2020

Management of infantile hemangiomas during the COVID pandemic.

Pediatr Dermatol 2020 May 16;37(3):412-418. Epub 2020 May 16.

University of Minnesota, Minneapolis, Minnesota, USA.

The COVID-19 pandemic has caused significant shifts in patient care including a steep decline in ambulatory visits and a marked increase in the use of telemedicine. Infantile hemangiomas (IH) can require urgent evaluation and risk stratification to determine which infants need treatment and which can be managed with continued observation. For those requiring treatment, prompt initiation decreases morbidity and improves long-term outcomes. The Hemangioma Investigator Group has created consensus recommendations for management of IH via telemedicine. FDA/EMA-approved monitoring guidelines, clinical practice guidelines, and relevant, up-to-date publications regarding initiation and monitoring of beta-blocker therapy were used to inform the recommendations. Clinical decision-making guidelines about when telehealth is an appropriate alternative to in-office visits, including medication initiation, dosage changes, and ongoing evaluation, are included. The importance of communication with caregivers in the context of telemedicine is discussed, and online resources for both hemangioma education and propranolol therapy are provided.
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http://dx.doi.org/10.1111/pde.14196DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7262142PMC
May 2020

The use of Velscope to assess cellular changes occuring in oral premalignancy.

J Oral Biol Craniofac Res 2020 Apr-Jun;10(2):99-103. Epub 2020 Mar 14.

Dept. of Oral and Maxillofacial Surgery, Dr. D.Y. Patil Vidyapeeth, Pune, India.

Objectives: To improve visualization of suspicious lesions of the oral mucosa and to assess the accuracy of Velscope in assessing cellular changes occurring in oral premalignancy for early diagnosis.

Materials And Methods: In this prospective, randomized in-vivo clinical study a total of 250 patients who gave history of chewing tobacco were screened. The selection of the site of biopsy was taken based on the area of loss of fluorescence identified by the Velscope within the lesion. Routine blood investigations were done. A biopsy was performed to confirm the findings of clinical examination. The data was collected and analysed.

Results: Among 200 patients only 110 underwent incisional biopsy. Of these only 89 patients showed neoplastic changes. Of the control biopsies, none of them showed any dysplastic changes. Out of 106 who exhibited speckling under autofluorescence, only 89 showed dysplastic changes whereas only 17 showed no dysplastic changes. Out of these 17 specimens, the histopathological diagnosis of 5 was coated tongue, 3 were pigmented lesions, 3 were geographic tongue and 2 were mucositis. Of the remaining 4, the histopathological diagnosis of 1 was oral submucous fibrosis, 1 was lichen planus and 2 were frictional keratosis.

Conclusion: False positive findings are possible in presence of highly inflamed tissues, and it is possible that use of Velscope alone may result in failure to detect regions of dysplasia, but it has its use definitely to improve clinical decision making about the nature of oral lesions and aids in decisions to biopsy regions of concern. Use of the scope has allowed practitioners to identify the best region for biopsy. It is much better to occasionally sample tissue that turns out to be benign than to fail to diagnose dysplastic or malignant lesions. However, poor specificity is a major limitation for using it as a screening tool.
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http://dx.doi.org/10.1016/j.jobcr.2020.03.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7082544PMC
March 2020

Comparing intra-oral wound healing after alveoloplasty using silk sutures and n-butyl-2-cyanoacrylate.

J Korean Assoc Oral Maxillofac Surg 2020 Feb 26;46(1):28-35. Epub 2020 Feb 26.

Department of Oral and Maxillofacial Surgery, Dr. D. Y. Patil Vidyapeeth, Pune, India.

Objectives: The need for proper wound closure is of paramount importance after any intra-oral surgery. Various wound closure techniques have been described in literature using traditional non-absorbable suture materials. These include like synthetic absorbable sutures, surgical staples and tissue adhesives. Cyanoacrylates are among the most commonly used biocompatible tissue adhesives. To evaluate and compare intraoral wound healing using 3-0 silk sutures and n-butyl-2-cyanoacrylate after alveoloplasty.

Materials And Methods: A total of 20 patients requiring bilateral alveoloplasty in the same arch (upper or lower) were included in this study. Patients with any pre-existing pathology or systemic disease were excluded. After alveoloplasty was performed, the wound was closed using 3-0 braided silk sutures on one side, and using n-butyl-2-cyanoacrylate bio adhesive on the other side. Patients were evaluated based on the following parameters: time required to achieve wound closure; the incidence of immediate and postoperative hemostasis; the time to the use of the first rescue medication; the side where pain first arises; and the side where wound healing begins first.

Results: Compared to 3-0 silk sutures, cyanoacrylate demonstrated better hemostatic properties, reduced operative time, reduced postoperative pain and better wound healing.

Conclusion: These data suggest that cyanoacrylate glue is an adequate alternative to conventional sutures to close the surgical wound after alveoloplasty, and better than are 3-0 silk sutures.
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http://dx.doi.org/10.5125/jkaoms.2020.46.1.28DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7049767PMC
February 2020

Parsing components of risk of premature mortality in the children of mothers with severe mental illness.

Schizophr Res 2020 04 21;218:180-187. Epub 2020 Jan 21.

Neuropsychiatric Epidemiology Research Unit, School of Population and Global Health, The University of Western Australia, Perth, Australia; Centre for Clinical Research in Neuropsychiatry, Division of Psychiatry, Medical School, The University of Western Australia, Perth, Australia.

Introduction: Children of mothers with severe mental illness are at increased risk of premature death including in infancy and early childhood. Importantly, these children are also more likely to be exposed to adverse socio-demographic risk factors and serious obstetric complications which, of themselves, may increase risk for childhood mortality. We examined mortality outcome at different ages up to 5 years taking account of these risks.

Method: We used linked data across Western Australian whole-population psychiatric, inpatient, death, and midwives' registers to identify 15,486 births to mothers with severe mental illness and 452,459 births to mothers with no mental illness. Multivariable models were adjusted for exposure to adverse socio-demographic risk factors and serious obstetric complications.

Results: Overall risk of premature death was increased amongst children of mothers with severe mental illness (2.3%, 354 deaths) compared with children of mothers with no mental illness (1.4%, 6523 deaths); the same was true for specific risk of stillbirth, neonatal, post‑neonatal and early childhood deaths. Risk was substantially attenuated after adjustment for adverse socio-demographic exposures, and further still after adjustment for exposure to serious obstetric complications. We observed no effects for the timing of maternal illness diagnosis.

Conclusions: To minimise the risk of premature mortality in the children of mothers with severe mental illness, priority should be given to the prompt diagnosis of maternal mental illness with targeted delivery of high quality antenatal and psychiatric care, as well as social and structural supports for affected families that continue after birth.
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http://dx.doi.org/10.1016/j.schres.2020.01.006DOI Listing
April 2020

Pain Medications Before IUD Placement.

Am Fam Physician 2020 01;101(2):119-120

Southern Illinois University School of Medicine, Carbondale, IL, USA.

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January 2020

Comparison of minimally invasive versus conventional open harvesting technique for iliac bone graft in secondary alveolar bone grafting in cleft palate patients: a systematic review.

J Korean Assoc Oral Maxillofac Surg 2019 Oct 30;45(5):241-253. Epub 2019 Oct 30.

Department of Oral and Maxillofacial Surgery, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, India.

This study evaluated and compared the donor site morbidity following minimally invasive and conventional open harvesting of iliac bone for secondary alveolar bone grafting in cleft palate patients. A thorough electronic search of PubMed, Google Scholar, EMBASE, and an institutional library and manual search of various journals was done; Inclusion criteria: 1) full-text articles using a minimally invasive or conventional open harvesting technique for iliac bone for secondary alveolar grafting in cleft palate patients and 2) articles published between January 1, 2001 and June 30, 2017 and Exclusion criteria: 1) articles published in languages other than English, 2) case reports, case series, animal studies, in vitro studies, and letters to the editor, and 3) full-text article unavailable even after writing to the authors. Preliminary screening of 274 studies excluded 223 studies for not meeting the eligibility criteria. Of the remaining 51 studies, 19 were removed for being duplicates. Of the remaining 32 studies, 15 were excluded after reading the abstract. Of the 17 studies that were left, 2 were excluded because they were in a language other than English, and 2 were excluded because the study group did not mention cleft palate patients. Thus, 13 studies providing results for a total of 654 patients were included in this qualitative synthesis. Minimally invasive bone graft harvest techniques are better than the conventional open iliac bone harvest method because they offer shorter operative time, decreased requirement for pain medications, less pain on discharge, and a shorter hospital stay.
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http://dx.doi.org/10.5125/jkaoms.2019.45.5.241DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6838348PMC
October 2019

Off-label use of dupilumab for pediatric patients with atopic dermatitis: A multicenter retrospective review.

J Am Acad Dermatol 2020 Feb 10;82(2):407-411. Epub 2019 Oct 10.

Saint Louis University, Department of Dermatology, St. Louis, Missouri.

Background: Atopic dermatitis (AD) is a common, chronic type 2 inflammatory skin disease, typically starting in infancy, with increased risk for subsequent extracutaneous atopic morbidities. Dupilumab is the first biologic agent targeting type 2 inflammation approved by the U.S. Food and Drug Administration (USFDA); it was licensed in 2017 for adults with moderate to severe AD and 2 years later for adolescents. Systemic treatment for pediatric AD remains a significant unmet medical need.

Objective: To analyze off-label use of dupilumab in children with AD.

Methods: Multicenter retrospective review that evaluated children who were prescribed dupilumab for moderate to severe AD.

Results: One hundred eleven of 124 patients (89.5%) gained access to dupilumab after a mean of 9 weeks. The dosing range was 4 to 15.5 mg/kg for the loading dose and 2.0 to 15.3 mg/kg every other week for maintenance. The range was widest for 6- to 11-year-olds and was related to use of either full or half of adult dosing. Associated morbidities, treatment response, and adverse events were comparable to those in previous adolescent and adult trials.

Limitations: The retrospective design of the study limited uniform data collection.

Conclusion: Access to dupilumab was achievable for the majority of children after a mean 9-week delay because of insurance payment denial. This review supports dupilumab response and tolerability in children. Optimal dosing for patients younger than 12 years has not been defined. Availability of the drug in 2 different concentrations is an important safety issue.
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http://dx.doi.org/10.1016/j.jaad.2019.10.010DOI Listing
February 2020

An study comparing efficacy of 0.25% and 0.5% bupivacaine in infraorbital nerve block for postoperative analgesia.

J Dent Anesth Pain Med 2019 Aug 30;19(4):209-215. Epub 2019 Aug 30.

Department of Oral and Maxillofacial Surgery, Dr. D.Y. Patil Vidyapeeth, Pune, Maharashtra, India.

Background: Pain is an unpleasant sensation ranging from mild localized discomfort to agony and is one of the most commonly experienced symptoms in oral surgery. Usually, local anesthetic agents and analgesics are used for pain control in oral surgical procedures. Local anesthetic agents including lignocaine and bupivacaine are routinely used in varying concentrations. The present study was designed to evaluate and compare the efficacy of 0.25% and 0.5% bupivacaine for postoperative analgesia in infraorbital nerve block.

Methods: Forty-one patients undergoing bilateral maxillary orthodontic extraction received 0.5% bupivacaine (n = 41) on one side and 0.25% bupivacaine (n = 41) on the other side at an interval of 7 d. The parameters evaluated for both the bupivacaine concentrations were onset of action, pain during procedure (visual analog scale score [VAS]), and duration of action. The results were noted, tabulated, and analyzed using the Wilcoxon signed rank test.

Results: The onset of action of 0.5% bupivacaine was quicker than that of 0.25% bupivacaine, but the difference was not statistically significant (P = 0.306). No significant difference was found between the solutions for VAS scores (P = 0.221) scores and duration of action (P = 0.662).

Conclusion: There was no significant difference between 0.25% bupivacaine and 0.5% bupivacaine in terms of onset of action, pain during procedure, and duration of action. The use of 0.25% bupivacaine is recommended.
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http://dx.doi.org/10.17245/jdapm.2019.19.4.209DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6726887PMC
August 2019

A cross-country time and motion study to measure the impact of electronic medication management systems on the work of hospital pharmacists in Australia and England.

Int J Med Inform 2019 09 18;129:253-259. Epub 2019 Jun 18.

Centre of Medical Informatics, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Medical School, The Old Medical School, Edinburgh, United Kingdom.

Background: Qualitative studies have provided important insights into how hospital pharmacists' work changes when electronic medication management (EMM) systems are introduced. Quantitative studies of work practice change are rare. Despite the use of EMM systems internationally, there are no cross-country comparative studies of their impact on health professionals' work. We aimed to quantify and compare the type and magnitude of changes in hospital pharmacists' work pre- and post-EMM implementation in two countries.

Methods: Parallel, direct observational, time and motion studies of pharmacists in Australia and England pre- and post-EMM implementation. 20 pharmacists were observed: 9 in an Australian 440-bed hospital (155 h); and 11 pharmacists in a 500-bed English hospital (258 h). The Work Observation Method By Activity Timing (WOMBAT) software was used to collect observational data. Proportions of observed time in 11 tasks by study period (pre- versus post-EMM) and site, time spent with others or alone, and using different tools (e.g computers, paper) were calculated. Magnitude of changes between pre- and post-EMM by task and country were determined using z-tests for proportions adjusting for multiple testing.

Results: At baseline, Australian and English pharmacists spent the greatest proportion of time in medication review. Post-EMM, time in medication review (Australia 21.6%-27.5%; England 27.1%-33.8%) and history-taking (Australia 7.6%-13.3%; England 19.5%-28.9%) significantly increased. Despite country differences in these tasks at baseline, the magnitude of changes did not significantly differ. English pharmacists increased time engaged in medication discussions with patients post-EMM (from 5.9% to 10.8%; p = 0.01). The Australian rate did not change (18.0%-27.2%; p = 0.09), but was higher at baseline. Post-EMM, Australian pharmacists spent 63.4% of time working alone, compared to 92.0% for English pharmacists.

Conclusions: EMM systems impacted the same core areas of work and had a similar magnitude of effect on pharmacists' work in both countries. Anticipated reductions in medication review and history taking were not observed.
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http://dx.doi.org/10.1016/j.ijmedinf.2019.06.011DOI Listing
September 2019

Natural Human Infections With Plasmodium cynomolgi and Other Malaria Species in an Elimination Setting in Sabah, Malaysia.

J Infect Dis 2019 11;220(12):1946-1949

Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.

To determine the presence and species composition of malaria infections, we screened a subset of samples collected during a cross-sectional survey in Northern Sabah, Malaysia using highly sensitive molecular techniques. Results identified 54 asymptomatic submicroscopic malaria infections, including a large cluster of Plasmodium falciparum and 3 P. knowlesi infections. We additionally identified 2 monoinfections with the zoonotic malaria Plasmodium cynomolgi, both in individuals reporting no history of forest activities or contact with macaques. Results highlight the need for improved surveillance strategies to detect these infections and determine public health impacts.
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http://dx.doi.org/10.1093/infdis/jiz397DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6834065PMC
November 2019

Detection and characterisation of optic nerve and retinal changes in primary congenital glaucoma using hand-held optical coherence tomography.

BMJ Open Ophthalmol 2019 24;4(1):e000194. Epub 2019 Jun 24.

Ophthalmology, University of Leicester, Leicester, UK.

Objective: To investigate (1) the feasibility of scanning the optic nerve (ON) and central retina with hand-held optical coherence tomography (HH-OCT) without sedation or anaesthesia in primary congenital glaucoma (PCG), (2) the characteristics of ON changes in comparison with adult primary open-angle glaucoma (POAG) in comparison with matched controls, (3) the sensitivity and specificity of ON parameters for diagnosis, and (4) changes of foveal morphology.

Methods And Analysis: HH-OCT (Envisu 2300; Leica Microsystems) was used to investigate ON and foveal morphology of 20 children with PCG (mean age 4.64±2.79) and 10 adult patients with POAG (mean age 66.8±6.94), and compared with age-matched, gender-matched and ethnicity-matched healthy controls without sedation or anaesthesia.

Results: HH-OCT yielded useful data in 20 out of 24 young children with PCG. Patients with PCG had significantly deeper cup changes than patients with POAG (vs respective age-matched controls, p=0.014). ON changes in PCG are characterised by significant increase in cup depth (165%), increased cup diameter (159%) and reduction in rim area (36.4%) as compared with controls with high sensitivity (81.5, 74.1% and 88.9%, respectively) and specificity (85.0, 80.0% and 75.0%, respectively). Patients with PCG have a significantly smaller width of the macula pit (p<0.001) with non-detectable external limiting membrane.

Conclusion: HH-OCT has the potential to be a useful tool in glaucoma management for young children. We have demonstrated the use of HH-OCT in confirming a diagnosis of glaucoma within the studied cohort and found changes in disc morphology which characterise differently in PCG from POAG.
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http://dx.doi.org/10.1136/bmjophth-2018-000194DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6597657PMC
June 2019

Assessment of the anterior segment of patients with primary congenital glaucoma using handheld optical coherence tomography.

Eye (Lond) 2019 08 18;33(8):1232-1239. Epub 2019 Mar 18.

Ophthalmology Group, University of Leicester, Leicester, UK.

Purpose: To investigate the potential of handheld optical coherence tomography (HH-OCT) in assessing the anterior segment of the eye in patients with primary congenital glaucoma.

Design: A prospective, case-controlled observational study.

Participants: Twenty-two patients with primary congenital glaucoma (PCG, 9 females and 13 males; mean age 4.36 ± 3.4 years) and age-, gender- and ethnicity-matched healthy participants.

Methods: Anterior OCT was performed in all participants using a high-resolution HH SD-OCT device (Envisu 2300, Leica Microsystems, Germany) without anaesthesia or sedation.

Results: Anterior HH-OCT in PCG visualised Haab's striae in 14.3%, uneven internal cornea in 9.5% and epithelial thickening in 11.9% of patients with central corneal thickening (CCT, p < 0.001). CCT was significantly correlated with the intraocular pressure (IOP, p < 0.001). The flat iris with a thin collarette zone was found in 59.5%, anterior iris insertion in 11.90% of eyes affected by PCG. Two independent examiners showed sensitivity and specificity of 87% and 77%, respectively, by instating iris thinning and flattening of the anterior profile.

Conclusions: Anterior HH-OCT has significant potential to improve diagnosis and management of PCG. Clinically relevant information can be obtained non-invasively and without sedation. High specificity makes anterior HH-OCT an important adjunct for management of PCG. Excellent visualisation of the iris insertion on OCT indicates potential for AS OCT to assist with surgical planning, including decision on the type of surgery and location of the incision.
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http://dx.doi.org/10.1038/s41433-019-0369-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7005739PMC
August 2019

Calculation of dose volume parameters and indices in plan evaluation of HDR interstitial brachytherapy by MUPIT in carcinoma cervix.

Indian J Cancer 2018 Jul-Sep;55(3):238-241

Department of Radiotherapy, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India.

Background: Evaluation of a HDR- interstitial brachytherapy plan is a challenging job. Owing to the complexities and diversity of the normalization and optimization techniques involved, a simple objective assessment of these plans is required. This can improve the radiation dose coverage of the tumour with decreased organ toxicity.

Aim: To study and document the various dose volume indices and parameters required to evaluate a HDR interstitial brachytherapy plan by Volume normalization and graphical optimization using MUPIT (Martinez Universal Perineal Interstitial Template) in patients of carcinoma cervix.

Settings And Design: Single arm, retrospective study.

Methods And Materials: 35 patients of carcinoma cervix who received EBRT and HDR brachytherapy using MUPIT, were selected. The dose prescribed was 4 Gray/Fraction in four fractions (16Gy/4) treated twice daily, at least 6 hours apart. CTV and OARs were delineated on the axial CT image set. Volume normalization and graphical optimization was done for planning. Coverage Index (CI), Dose homogeneity index (DHI), Overdose index (OI), Dose non-uniformity ratio (DNR), Conformity Index (COIN) and dose volume parameters i.e. D2cc, D1cc, D0.1cc of rectum and bladder were evaluated.

Statistical Analysis: SPSS version 16 was used.

Results And Conclusion: CI was 0.95 ± 1.84 which means 95% of the target received 100% of the prescribed dose. The mean COIN was 0.841 ± 0.06 and DHI was 0.502 ± 0.11. D2cc rectum and bladder was 3.40 ± 0.56 and 2.95 ± 0.62 respectively which was within the tolerance limit of this organs. There should be an optimum balance between these indices for improving the quality of the implant and to yield maximum clinical benefit out of it, keeping the dose to the OARs in limit. Dose optimization should be carefully monitered and an institutional protocol should be devised for the acceptability criteria of these plans.
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http://dx.doi.org/10.4103/ijc.IJC_643_17DOI Listing
June 2019

An Unusual Variant of a Common Palatal Salivary Gland Tumor: Case Report of a Pleomorphic Adenoma with Significant Lipomatous Metaplasia.

Case Rep Dent 2018 25;2018:2052347. Epub 2018 Dec 25.

New York University College of Dentistry, 345 E 24th St, Room 837, NY, New York 10010, USA.

Introduction: Salivary gland tumors are relatively common in the junction of the hard and soft palate area of the oral cavity. Pleomorphic adenoma is considered the most common benign salivary gland tumor in this location. Some of the rarer subtypes of this tumor may have a misleading clinical presentation. Recognition of these variants is important since long-standing pleomorphic adenomas have the potential to become malignant.

Case Presentation: A healthy 24-year-old male was referred for a painless, large, slowly growing, exophytic swelling of the right hard and soft palate. Interestingly, the lesion was yellowish in color and soft to palpation, suggestive of an innocuous lipoma or cystic lesion. An incisional biopsy was performed and the diagnosis was consistent with pleomorphic adenoma with a significant adipose tissue component. The patient was referred to an oral surgeon and underwent a complete surgical excision. Upon two-year follow-up, the patient is doing well with no recurrences.

Conclusion: This case highlights a rare microscopic variant of pleomorphic adenoma with altered clinical presentation that led to an erroneous clinical diagnosis. The importance of taking a biopsy for definitive diagnosis and appropriate management is reinforced.
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http://dx.doi.org/10.1155/2018/2052347DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6323424PMC
December 2018

The impact of computerised physician order entry and clinical decision support on pharmacist-physician communication in the hospital setting: A qualitative study.

PLoS One 2018 16;13(11):e0207450. Epub 2018 Nov 16.

School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom.

Background: The implementation of Computerised Physician Order Entry (CPOE) and Clinical Decision Support (CDS) has been found to have some unintended consequences. The aim of this study is to explore pharmacists and physicians perceptions of their interprofessional communication in the context of the technology and whether electronic messaging and CDS has an impact on this.

Method: This qualitative study was conducted in two acute hospitals: the University Hospitals Birmingham NHS Foundation Trust (UHBFT) and Guy's and St Thomas' NHS Foundation Trust (GSTH). UHBFT use an established locally developed CPOE system that can facilitate pharmacist-physician communication with the ability to assign a message directly to an electronic prescription. In contrast, GSTH use a more recently implemented commercial system where such communication is not possible. Focus groups were conducted with pharmacists and physicians of varying grades at both hospitals. Focus group data were transcribed and analysed thematically using deductive and inductive approaches, facilitated by NVivo 10.

Results: Three prominent themes emerged during the study: increased communication load; impaired decision-making; and improved workflow. CPOE and CDS were found to increase the communication load for the pharmacist owing to a reduced ability to amend electronic prescriptions, new types of prescribing errors, and the provision of technical advice relating to the use of the system. Decision-making was found to be affected, owing to the difficulties faced by pharmacists and physicians when trying to determine the context of prescribing decisions and knowledge of the patient. The capability to communicate electronically facilitated a non-interruptive workflow, which was found to be beneficial for staff time, coordination of work and for limiting distractions.

Conclusion: The increased communication load for the pharmacist, and consequent workload for the physician, has the potential to impact on the quality and coordination of care in the hospital setting. The ability to communicate electronically has some benefits, but functions need to be designed to facilitate collaborative working, and for this to be optimised through interprofessional training.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0207450PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6239308PMC
April 2019

Development and Assessment of a Diagnostic DNA Oligonucleotide Microarray for Detection and Typing of Meningitis-Associated Bacterial Species.

High Throughput 2018 Oct 16;7(4). Epub 2018 Oct 16.

Public Health England, Porton Down, Salisbury SP4 0JG, UK.

Meningitis is commonly caused by infection with a variety of bacterial or viral pathogens. Acute bacterial meningitis (ABM) can cause severe disease, which can progress rapidly to a critical life-threatening condition. Rapid diagnosis of ABM is critical, as this is most commonly associated with severe sequelae with associated high mortality and morbidity rates compared to viral meningitis, which is less severe and self-limiting. We have designed a microarray for detection and diagnosis of ABM. This has been validated using randomly amplified DNA targets (RADT), comparing buffers with or without formamide, in glass slide format or on the Alere ArrayTube (Alere Technologies GmbH) microarray platform. Pathogen-specific signals were observed using purified bacterial nucleic acids and to a lesser extent using patient cerebral spinal fluid (CSF) samples, with some technical issues observed using RADT and glass slides. Repurposing the array onto the Alere ArrayTube platform and using a targeted amplification system increased specific and reduced nonspecific hybridization signals using both pathogen nucleic and patient CSF DNA targets, better revealing pathogen-specific signals although sensitivity was still reduced in the latter. This diagnostic microarray is useful as a laboratory diagnostic tool for species and strain designation for ABM, rather than for primary diagnosis.
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http://dx.doi.org/10.3390/ht7040032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6306750PMC
October 2018

Late growth of infantile hemangiomas in children >3 years of age: A retrospective study.

J Am Acad Dermatol 2019 Feb 5;80(2):493-499. Epub 2018 Oct 5.

University of California, San Francisco, California.

Background: The proliferative phase of infantile hemangiomas (IHs) is usually complete by 9 months of life. Late growth beyond age 3 years is rarely reported.

Objective: To describe the demographic and clinic characteristics of a cohort of patients with late growth of IH, defined as growth in a patient >3 years of age.

Methods: A multicenter, retrospective cohort study.

Results: In total, 59 patients, 85% of which were female, met the inclusion criteria. The mean first episode of late growth was 4.3 (range 3-8.5) years. Head and neck location (55/59; 93%) and presence of deep hemangioma (52/59; 88%) were common characteristics. Posterior fossa malformations, hemangiomas, arterial anomalies, cardiac defects, eye abnormalities (PHACE) syndrome was noted in 20 of 38 (53%) children with segmental facial IH. Systemic therapy (corticosteroid or β-blocker) was given during infancy in 58 of 59 (98%) and 24 of 59 (41%) received systemic therapy (β-blockers) for late IH growth.

Limitations: The retrospective nature and ascertainment by investigator recall are limitations of the study.

Conclusion: Late IH growth can occur in children after 3 years of age. Risk factors include head and neck location, segmental morphology, and involvement of deep dermal/subcutaneous tissues.
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http://dx.doi.org/10.1016/j.jaad.2018.07.061DOI Listing
February 2019

Congenital-type juvenile xanthogranuloma: A case series and literature review.

Pediatr Dermatol 2018 Sep 12;35(5):582-587. Epub 2018 Jul 12.

Department of Dermatology, University of California, San Francisco, CA, USA.

Background/objectives: Congenital juvenile xanthogranulomas are infrequently described in the medical literature. We report three previously unpublished cases and systematically review the literature to better characterize this variant.

Methods: We surveyed English-language articles indexed in MEDLINE (1951-March 2017) and EMBASE (1974-March 2017) for cases of congenital-onset juvenile xanthogranulomas confirmed on histopathology. Cases were divided into two categories: cutaneous only or cutaneous with systemic involvement.

Results: We identified 31 cases of congenital juvenile xanthogranulomas involving only the skin and 16 cases with systemic involvement. Congenital juvenile xanthogranulomas involving only the skin were large (> 3 cm), presented with various clinical morphologies, and showed signs of regression by 1 year of age. Atypical clinical presentations included exophytic tumors, infiltrative plaques, agminated plaques, and subcutaneous tumors. Complications included ulceration and anetodermic scarring. Infants with congenital cutaneous juvenile xanthogranulomas who also had systemic involvement typically had multiple cutaneous tumors and hepatic involvement and showed signs of spontaneous regression independent of treatment.

Conclusions: The medical literature supports that congenital juvenile xanthogranulomas behave in a fashion similar to that of juvenile xanthogranulomas of infancy or childhood. Congenital cutaneous juvenile xanthogranulomas with or without systemic involvement spontaneously regress. The varied clinical presentations in the skin may lead to misdiagnosis, inappropriate examination, and unnecessary treatments. Infants with multiple congenital cutaneous juvenile xanthogranulomas should be evaluated for systemic involvement, with a particular focus on the liver, because 72.2% of these children were found to have hepatic juvenile xanthogranulomas.
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http://dx.doi.org/10.1111/pde.13544DOI Listing
September 2018

Dosimetric analysis of the effects of the bladder volume on organs at risk (OAR) in high-dose-rate intracavitary brachytherapy in carcinoma cervix - an institutional study.

J Contemp Brachytherapy 2018 Feb 28;10(1):26-31. Epub 2018 Feb 28.

Department of Radiotherapy, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India.

Purpose: The purpose of this study was to establish a dosimetric correlation between the bladder volume and its effects on the dose received by the organs at risk (OARs) (urinary bladder, rectum, and sigmoid) during computed tomography (CT)-guided high-dose-rate (HDR) brachytherapy in carcinoma cervix, and to determine an optimum bladder volume to limit the dose to OARs.

Material And Methods: Seventy-five intracavitary applications in patients of carcinoma cervix (stage IIB, IIIA, IIIB, IVA) treated with external beam radiotherapy with concurrent chemotherapy followed by CT-based HDR intracavitary brachytherapy (tandem and ovoid type) at our institute between July 2014 to January 2016 were studied. The bladder volume at the time of imaging was noted and was correlated with the radiation dose received by bladder, rectum, and sigmoid colon.

Results: Dose volume histogram (DVH) parameters of the bladder increases by elevating the volume of the bladder. Rectum dose does not follow a continuous increasing trend. It increases up to a bladder volume of 110 cc and then starts decreasing. The highest rectal dose observed was in the bladder volume, range 70-110 cc. The minimum doses were recorded when the bladder volume was > 170 cc. Sigmoid colon DVH parameters follow a similar trend as that of the rectum.

Conclusions: A relationship exists between the volume of the OARs and the dose received by them. A bladder volume of about 70 cm or less proved better for achieving the prescribed dose limits of bladder, rectum, and sigmoid. The correlations between the bladder volume and the doses received by the OARs were not significant.
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http://dx.doi.org/10.5114/jcb.2018.74136DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5881593PMC
February 2018

Impact of a commercial order entry system on prescribing errors amenable to computerised decision support in the hospital setting: a prospective pre-post study.

BMJ Qual Saf 2018 09 23;27(9):725-736. Epub 2018 Mar 23.

University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.

Background: In this UK study, we investigated the impact of computerised physician order entry (CPOE) and clinical decision support (CDS) implementation on the rate of 78 high-risk prescribing errors amenable to CDS.

Methods: We conducted a preintervention/postintervention study in three acute hospitals in England. A predefined list of prescribing errors was incorporated into an audit tool. At each site, approximately 4000 prescriptions were reviewed both pre-CPOE and 6 months post-CPOE implementation. The number of opportunities for error and the number of errors that occurred were collated. Error rates were then calculated and compared between periods, as well as by the level of CDS.

Results: The prescriptions of 1244 patients were audited pre-CPOE and 1178 post-CPOE implementation. A total of 28 526 prescriptions were reviewed, with 21 138 opportunities for error identified based on 78 defined errors. Across the three sites, for those prescriptions where opportunities for error were identified, the error rate was found to reduce significantly post-CPOE implementation, from 5.0% to 4.0% (P<0.001). CDS implementation by error type was found to differ significantly between sites, ranging from 0% to 88% across clinical contraindication, dose/frequency, drug interactions and other error types (P<0.001). Overall, 43/78 (55%) of the errors had some degree of CDS implemented in at least one of the hospitals.

Conclusions: Implementation of CPOE with CDS was associated with clinically important reductions in the rate of high-risk prescribing errors. Given the pre-post design, these findings however need to be interpreted with caution. The occurrence of errors was found to be highly dependent on the level of restriction of CDS presented to the prescriber, with the effect that different configurations of the same CPOE system can produce very different results.
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http://dx.doi.org/10.1136/bmjqs-2017-007135DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6109251PMC
September 2018

Does This Child Have Pneumonia?: The Rational Clinical Examination Systematic Review.

JAMA 2017 Aug;318(5):462-471

Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts.

Importance: Pneumonia is a leading cause of morbidity and mortality in children. It is important to identify the clinical symptoms and physical examination findings associated with pneumonia to improve timely diagnosis, prevent significant morbidity, and limit antibiotic overuse.

Objective: To systematically review the accuracy of symptoms and physical examination findings in identifying children with radiographic pneumonia.

Data Sources And Study Selection: MEDLINE and Embase (1956 to May 2017) were searched, along with reference lists from retrieved articles, to identify diagnostic studies of pediatric pneumonia across a broad age range that had to include children younger than age 5 years (although some studies enrolled children up to age 19 years); 3644 unique articles were identified, of which 23 met inclusion criteria.

Data Extraction And Synthesis: Two authors independently abstracted raw data and assessed methodological quality. A third author resolved disputes.

Main Outcomes And Measures: Likelihood ratios (LRs), sensitivity, and specificity were calculated for individual symptoms and physical examination findings for the diagnosis of pneumonia. An infiltrate on chest radiograph was considered the reference standard for the diagnosis of pneumonia.

Results: Twenty-three prospective cohort studies of children (N = 13 833) with possible pneumonia were included (8 from North America), with a range of 78 to 2829 patients per study. The prevalence of radiographic pneumonia in North American studies was 19% (95% CI, 11%-31%) and 37% (95% CI, 26%-50%) outside of North America. No single symptom was strongly associated with pneumonia; however, the presence of chest pain in 2 studies that included adolescents was associated with pneumonia (LR, 1.5-5.5; sensitivity, 8%-14%; specificity, 94%-97%). Vital sign abnormalities such as fever (temperature >37.5°C [LR range, 1.7-1.8]; sensitivity, 80%-92%; specificity, 47%-54%) and tachypnea (respiratory rate >40 breaths/min; LR, 1.5 [95% CI, 1.3-1.7]; sensitivity, 79%; specificity, 51%) were not strongly associated with pneumonia diagnosis. Similarly, auscultatory findings were not associated with pneumonia diagnosis. The presence of moderate hypoxemia (oxygen saturation ≤96%; LR, 2.8 [95% CI, 2.1-3.6]; sensitivity, 64%; specificity, 77%) and increased work of breathing (grunting, flaring, and retractions; positive LR, 2.1 [95% CI, 1.6-2.7]) were signs most associated with pneumonia. The presence of normal oxygenation (oxygen saturation >96%) decreased the likelihood of pneumonia (LR, 0.47 [95% CI, 0.32-0.67]).

Conclusions And Relevance: Although no single finding reliably differentiates pneumonia from other causes of childhood respiratory illness, hypoxia and increased work of breathing are more important than tachypnea and auscultatory findings.
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http://dx.doi.org/10.1001/jama.2017.9039DOI Listing
August 2017