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Height in chronic kidney disease
September 2013 Volume 163 Number 3
Height in chronic kidney disease — Thomas R. Welch, MD
Outcomes of late onset Candida sepsis in extremely low birth weight infants — Sarah S. Long, MD
Copyright ª 2013 by Mosby Inc.
S
hort stature is a common accompaniment of childhood-onset chronic kidney disease (CKD). When recombinant human growth hormone (rhGH) became available, children with CKD were among the first and largest groups of children in whom this agent was used. It clearly works, and the new generation of pediatric nephrologists rarely sees the severe "renal dwarfism" that once was commonplace in pediatric nephrology practice. Of course, short stature is not necessarily bad for overall health per se. The argument for treating it in CKD always has been one of improved quality of life for affected children. Although a reasonable suggestion, it never has been tested carefully. In the current issue of The Journal, the Chronic Kidney Disease in Children Study Group report careful assessment of quality of life, by both patients and their families, in a large group of children with CKD followed for several years. This allowed for longitudinal assessment of quality of life during therapy with rhGH. The parents’ assessments of quality of life in the social and physical domains were significantly improved in children receiving rhGH; interestingly, the assessments of adolescents themselves were not so positive. These data are complicated and deserve very careful reading. Indeed, one may come to more than one conclusion from them. In any case, this report represents the best available data set addressing this problem. Article page 736<
I
nvestigators of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network, enrolled 1515 infants with extremely low birth weight (ELBW; <1000 g) and suspected sepsis to investigate the relative importance of etiologic agent of sepsis on outcome. Ninety percent of enrolled infants (1317/1515) were examined for neurodevelopmental outcome at 18 months of age. Investigators were able to compare outcomes for those suspected of sepsis who had proven Candida infection versus proven bacterial infection versus no proven infection, as well as perform a post hoc comparison with a cohort of 864 ELBW infants concurrently enrolled in the registry who were not suspected of late onset sepsis (LOS). Neurodevelopmental impairment was found in 31% of ELBW infants with Candida and 31% with non-Candida LOS and/or meningitis. Compared with infants in the registry who had never been screened for sepsis, those with Candida infection were more likely to have neurodevelopmental impairment (OR 1.83, 95% CI 1.01. 3.33 and P = .047). Dramatically increased mortality and disability following Candida sepsis was apparent in infants with birth weight <750 grams—50% mortality and 33% of survivors having neurodevelopmental impairment. This study helps rectify discrepant findings in studies without the current study’s clear comparison groups. It also urges a better understanding of Candida disease and prevention to optimize outcomes for this exquisitely vulnerable population. Article page 680<
613
Predicting outcome of symptomatic CMV infection — Sarah S. Long, MD
Chorioamnionitis and neurodevelopment — Alan H. Jobe, MD, PhD
Association of asthma and herpes zoster in children — Sarah S. Long, MD
614
I
n this issue of The Journal, investigators from Spain report the use of clinical, biochemical, and neuroimaging findings in the neonatal period in infants with congenital cytomegalovirus (CMV) infection to predict long-term neurodevelopmental outcome. The strengths of the study are the performance of multiple biochemical tests on the neonate’s cerebrospinal fluid (ie, neuron-specific enolase and b2-microglobulin, the latter of which is thought to be a reflection of local cell turnover), neuroimaging studies, long-term follow-up to an average age of 8.7 years (range 19 months to 18 years), and extensive neurodevelopmental testing (eg, cognitive, behavioral, motor, visual, auditory). Results show that adjusted head circumference 2 SD below expected, cerebrospinal fluid b2-microglobulin of $ 8 mg/L, or moderate to severe neuroimaging abnormalities, individually and especially when combined, have excellent predictive value for moderatesevere disability. These findings will not only aid clinicians but will better inform clinical trials of potential therapies. Article page 828<
T
he association between clinical and/or histological chorioamnionitis and poor neurodevelopmental outcomes or death in newborns has been debated, with multiple positive and negative studies in the literature. This association for preterm birth perhaps is even more controversial. As more is learned about the types of infections that are associated with premature delivery, any interpretation of an outcome relative to a simple diagnosis of chorioamnionitis is inadequate. Some pregnancies are complicated by chronic and indolent infections with single or multiple organisms not normally considered to be pathogenic, and others result in preterm deliveries with clear pathogens. Inflammation-associated preterm labor may be primarily from the endometrium and minimally involve the fetus, or the fetus may mount a systemic inflammatory response. In this issue of The Journal, Salas et al carefully characterized and graded cord inflammation to better identify the severity of the inflammation for a large number of preterm deliveries. They report that a severe fetal inflammatory response was associated with death or a poor neurodevelopmental outcome in preterm infants. The logical association between fetal exposure to inflammation and brain injury becomes apparent with a better assessment of the inflammation. No doubt adverse outcomes will associate with specific organisms, the duration of the fetal exposure, and characteristics of the fetal and maternal inflammatory responses. Much more needs to be learned about how to assess fetal risks to better direct the timing of delivery. Article page 652<
T
he incidence of asthma and herpes zoster (HZ) rose concurrently at the end of the 20th century. Investigators took advantage of the setting of Olmstead County, Minnesota, where medical care is “virtually self-contained,” to perform a population-based epidemiologic study to explore whether HZ was associated with asthma. The study was performed before substantial use of varicella vaccine, and no case had received systemic corticosteroid in the three months prior to HZ. Twenty-three percent of cases of HZ had asthma compared with 12.6% of matched controls (aOR: 2.09, 95% CI 1.24-3.52; P = .006). The authors provide arguments about why detection bias is likely not responsible for their finding. They conclude that asthma may be an unrecognized risk factor for reactivation of non—airway-related latent VZV infection and speculate that altered cell-mediated innate immune response could be the biologic link. Article page 816<
Vol. 163, No. 3
Screening contacts of physically abused children — Robert W. Wilmott, MD
Best practices for controlling multidrugresistant microbes in the NICU — Sarah S. Long, MD
September 2013
T
he household contacts of physically abused children are at increased risk of nonaccidental injury. However, there are no current guidelines for screening such contacts, and current practice varies among institutions. In this issue of The Journal, Lindberg et al report a prospective study of 1918 contacts of 1196 children referred for evaluation of possible abuse in 20 US centers. The authors identified injuries or disclosures of abuse in 9.4% of contacts and found that recommended screening procedures, such as skeletal survey, neuroimaging, interviews, and physical examination of contact children, often were not performed. The authors conclude that, despite a high risk of injury, completion of screening in contacts of potentially abused children is poor and that current practices should be re-evaluated. Article page 730<
I
n this issue of The Journal, Cantey et al describe the occurrence and control of a nosocomial outbreak of multidrug-resistant Klebsiella pneumoniae infection/colonization in the neonatal intensive care unit (NICU) at Parkland Memorial Hospital, Dallas, Texas. Following septicemia of the index case and two additional fatal cases of infection within 48 hours, a multidisciplinary team (ie, medical, administrative, supportive, and environmental services) formulated a multidimensional control and investigation plan. Although single interventions were not studied, the rapid success of meticulous implementation of multiple standard infection control and prevention practices (eg, staffing, spacing, cohorting, auditing cleaning effectiveness, auditing hand hygiene beyond washing/gelling, frequent microbiologic screening of infants) stands as an example of “best practices.” This report is particularly useful because the outbreak occurred after good practices of antibiotic stewardship, including minimal use of broad-spectrum antibiotics and mitigation, without closing the NICU to new admissions or performing microbiologic sampling of healthcare personnel. Article page 672<
615
Height in chronic kidney disease — Thomas R. Welch, MD
Outcomes of late onset Candida sepsis in extremely low birth weight infants — Sarah S. Long, MD
Copyright ª 2013 by Mosby Inc.
S
hort stature is a common accompaniment of childhood-onset chronic kidney disease (CKD). When recombinant human growth hormone (rhGH) became available, children with CKD were among the first and largest groups of children in whom this agent was used. It clearly works, and the new generation of pediatric nephrologists rarely sees the severe "renal dwarfism" that once was commonplace in pediatric nephrology practice. Of course, short stature is not necessarily bad for overall health per se. The argument for treating it in CKD always has been one of improved quality of life for affected children. Although a reasonable suggestion, it never has been tested carefully. In the current issue of The Journal, the Chronic Kidney Disease in Children Study Group report careful assessment of quality of life, by both patients and their families, in a large group of children with CKD followed for several years. This allowed for longitudinal assessment of quality of life during therapy with rhGH. The parents’ assessments of quality of life in the social and physical domains were significantly improved in children receiving rhGH; interestingly, the assessments of adolescents themselves were not so positive. These data are complicated and deserve very careful reading. Indeed, one may come to more than one conclusion from them. In any case, this report represents the best available data set addressing this problem. Article page 736<
I
nvestigators of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network, enrolled 1515 infants with extremely low birth weight (ELBW; <1000 g) and suspected sepsis to investigate the relative importance of etiologic agent of sepsis on outcome. Ninety percent of enrolled infants (1317/1515) were examined for neurodevelopmental outcome at 18 months of age. Investigators were able to compare outcomes for those suspected of sepsis who had proven Candida infection versus proven bacterial infection versus no proven infection, as well as perform a post hoc comparison with a cohort of 864 ELBW infants concurrently enrolled in the registry who were not suspected of late onset sepsis (LOS). Neurodevelopmental impairment was found in 31% of ELBW infants with Candida and 31% with non-Candida LOS and/or meningitis. Compared with infants in the registry who had never been screened for sepsis, those with Candida infection were more likely to have neurodevelopmental impairment (OR 1.83, 95% CI 1.01. 3.33 and P = .047). Dramatically increased mortality and disability following Candida sepsis was apparent in infants with birth weight <750 grams—50% mortality and 33% of survivors having neurodevelopmental impairment. This study helps rectify discrepant findings in studies without the current study’s clear comparison groups. It also urges a better understanding of Candida disease and prevention to optimize outcomes for this exquisitely vulnerable population. Article page 680<
613
Predicting outcome of symptomatic CMV infection — Sarah S. Long, MD
Chorioamnionitis and neurodevelopment — Alan H. Jobe, MD, PhD
Association of asthma and herpes zoster in children — Sarah S. Long, MD
614
I
n this issue of The Journal, investigators from Spain report the use of clinical, biochemical, and neuroimaging findings in the neonatal period in infants with congenital cytomegalovirus (CMV) infection to predict long-term neurodevelopmental outcome. The strengths of the study are the performance of multiple biochemical tests on the neonate’s cerebrospinal fluid (ie, neuron-specific enolase and b2-microglobulin, the latter of which is thought to be a reflection of local cell turnover), neuroimaging studies, long-term follow-up to an average age of 8.7 years (range 19 months to 18 years), and extensive neurodevelopmental testing (eg, cognitive, behavioral, motor, visual, auditory). Results show that adjusted head circumference 2 SD below expected, cerebrospinal fluid b2-microglobulin of $ 8 mg/L, or moderate to severe neuroimaging abnormalities, individually and especially when combined, have excellent predictive value for moderatesevere disability. These findings will not only aid clinicians but will better inform clinical trials of potential therapies. Article page 828<
T
he association between clinical and/or histological chorioamnionitis and poor neurodevelopmental outcomes or death in newborns has been debated, with multiple positive and negative studies in the literature. This association for preterm birth perhaps is even more controversial. As more is learned about the types of infections that are associated with premature delivery, any interpretation of an outcome relative to a simple diagnosis of chorioamnionitis is inadequate. Some pregnancies are complicated by chronic and indolent infections with single or multiple organisms not normally considered to be pathogenic, and others result in preterm deliveries with clear pathogens. Inflammation-associated preterm labor may be primarily from the endometrium and minimally involve the fetus, or the fetus may mount a systemic inflammatory response. In this issue of The Journal, Salas et al carefully characterized and graded cord inflammation to better identify the severity of the inflammation for a large number of preterm deliveries. They report that a severe fetal inflammatory response was associated with death or a poor neurodevelopmental outcome in preterm infants. The logical association between fetal exposure to inflammation and brain injury becomes apparent with a better assessment of the inflammation. No doubt adverse outcomes will associate with specific organisms, the duration of the fetal exposure, and characteristics of the fetal and maternal inflammatory responses. Much more needs to be learned about how to assess fetal risks to better direct the timing of delivery. Article page 652<
T
he incidence of asthma and herpes zoster (HZ) rose concurrently at the end of the 20th century. Investigators took advantage of the setting of Olmstead County, Minnesota, where medical care is “virtually self-contained,” to perform a population-based epidemiologic study to explore whether HZ was associated with asthma. The study was performed before substantial use of varicella vaccine, and no case had received systemic corticosteroid in the three months prior to HZ. Twenty-three percent of cases of HZ had asthma compared with 12.6% of matched controls (aOR: 2.09, 95% CI 1.24-3.52; P = .006). The authors provide arguments about why detection bias is likely not responsible for their finding. They conclude that asthma may be an unrecognized risk factor for reactivation of non—airway-related latent VZV infection and speculate that altered cell-mediated innate immune response could be the biologic link. Article page 816<
Vol. 163, No. 3
Screening contacts of physically abused children — Robert W. Wilmott, MD
Best practices for controlling multidrugresistant microbes in the NICU — Sarah S. Long, MD
September 2013
T
he household contacts of physically abused children are at increased risk of nonaccidental injury. However, there are no current guidelines for screening such contacts, and current practice varies among institutions. In this issue of The Journal, Lindberg et al report a prospective study of 1918 contacts of 1196 children referred for evaluation of possible abuse in 20 US centers. The authors identified injuries or disclosures of abuse in 9.4% of contacts and found that recommended screening procedures, such as skeletal survey, neuroimaging, interviews, and physical examination of contact children, often were not performed. The authors conclude that, despite a high risk of injury, completion of screening in contacts of potentially abused children is poor and that current practices should be re-evaluated. Article page 730<
I
n this issue of The Journal, Cantey et al describe the occurrence and control of a nosocomial outbreak of multidrug-resistant Klebsiella pneumoniae infection/colonization in the neonatal intensive care unit (NICU) at Parkland Memorial Hospital, Dallas, Texas. Following septicemia of the index case and two additional fatal cases of infection within 48 hours, a multidisciplinary team (ie, medical, administrative, supportive, and environmental services) formulated a multidimensional control and investigation plan. Although single interventions were not studied, the rapid success of meticulous implementation of multiple standard infection control and prevention practices (eg, staffing, spacing, cohorting, auditing cleaning effectiveness, auditing hand hygiene beyond washing/gelling, frequent microbiologic screening of infants) stands as an example of “best practices.” This report is particularly useful because the outbreak occurred after good practices of antibiotic stewardship, including minimal use of broad-spectrum antibiotics and mitigation, without closing the NICU to new admissions or performing microbiologic sampling of healthcare personnel. Article page 672<
615