Early discontinuation of intravenous antimicrobial therapy in pediatric oncology patients with febrile neutropenia

BACKGROUND: There are no standard criteria for when to discontinue intravenous antimicrobial therapy (IVAMT) in children with febrile neutropenia (FN), but it is now common to discontinue IVAMT and discharge patients with an absolute neutrophil count (ANC) ≤ 500 /mm(3). The purpose of this study was to evaluate the outcome of a large cohort of children with FN who had IVAMT discontinued with an ANC ≤ 500 /mm(3) METHODS: A retrospective chart review was completed of patients in the Northern Alberta Children's Cancer Program with FN and no apparent clinical source of fever from June 1, 1997 to July 1, 2002. RESULTS: Out of a total of 275 patients, 127 (46%) had at least one episode of FN, with FN occurring in patients with sarcomas more commonly than in those with leukemia/ lymphoma and least in those with other solid tumors. In 59 of 276 episodes of FN (21%) patients had a microbiologically defined infection at admission. Of the 217 remaining episodes, 112 of 199 patients (56%) with known neutrophil counts had IVAMT discontinued before their absolute neutrophil count (ANC) reached 500 /mm(3 )at the discretion of the clinician. Fever recurred in only two of these patients after discharge, and there were no bacterial infections diagnosed after parenteral antibiotics were discontinued. CONCLUSION: Even without use of standard criteria for early discharge, clinicians appear to be skilled at selecting children with FN who can safely have IVAMT discontinued with an ANC ≤ 500 /mm(3)

Echinococcal disease in Alberta, Canada: more than a calcified opacity

BACKGROUND: Most cases of echinococcal disease (ED) acquired in Canada are thought to be due to the sylvatic form of Echinococcus granulosus, which may be more benign than ED due to either Echinococcus multilocularis or the pastoral form of E. granulosus. There are limited descriptions of the clinical course and outcome of Canadian patients with ED in the modern era. METHODS: A retrospective chart review was performed of patients hospitalized with echinococcal disease (ED) from 1991 to 2001 in Edmonton, Alberta. RESULTS: Forty-two cases of ED were identified of which 19 were definite, 3 probable, and 20 possible. Further analysis was limited to the 22 definite and probable cases, of which 77% were female and 41% aboriginal, with an age range of 5 to 87 years. Nine patients (40%) had pulmonary involvement and 11 (50%) hepatic involvement. One patient had an intracardiac mass presenting as a cerebrovascular event and one had a splenic cyst. Seven of the 22 patients had combined surgical resection and medical treatment, six had surgical resection of the cyst alone, four had cyst aspiration, one had medical treatment alone and four had no specific treatment. There was no mortality attributable to ED but three patients died of unrelated illnesses. CONCLUSION: Echinococcal disease in northern Alberta has a marked diversity of clinical presentations, and generally has a good prognosis despite a wide variety of therapeutic interventions

Differing instructional needs for children of similar reading achievement grades two, four, and six

Thesis (Ed.M.)--Boston Universit

Swine Influenza (H3N2) Infection in a Child and Possible Community Transmission, Canada

Seropositivity to the same strain was demonstrated in the child and in multiple other community members

Multi‐scale heterogeneity in vegetation and soil carbon in exurban residential land of southeastern Michigan, USA

Exurban residential land (one housing unit per 0.2–16.2 ha) is growing in importance as a human‐dominated land use. Carbon storage in the soils and vegetation of exurban land is poorly known, as are the effects on C storage of choices made by developers and residents. We studied C storage in exurban yards in southeastern Michigan, USA, across a range of parcel sizes and different types of neighborhoods. We divided each residential parcel into ecological zones (EZ) characterized by vegetation, soil, and human behavior such as mowing, irrigation, and raking. We found a heterogeneous mixture of trees and shrubs, turfgrasses, mulched gardens, old‐field vegetation, and impervious surfaces. The most extensive zone type was turfgrass with sparse woody vegetation (mean 26% of parcel area), followed by dense woody vegetation (mean 21% of parcel area). Areas of turfgrass with sparse woody vegetation had trees in larger size classes (> 50 cm dbh) than did areas of dense woody vegetation. Using aerial photointerpretation, we scaled up C storage to neighborhoods. Varying C storage by neighborhood type resulted from differences in impervious area (8–26% of parcel area) and area of dense woody vegetation (11–28%). Averaged and multiplied across areas in differing neighborhood types, exurban residential land contained 5240 ± 865 g C/m2 in vegetation, highly sensitive to large trees, and 13 800 ± 1290 g C/m2 in soils (based on a combined sampling and modeling approach). These contents are greater than for agricultural land in the region, but lower than for mature forest stands. Compared with mature forests, exurban land contained more shrubs and less downed woody debris and it had similar tree size‐class distributions up to 40 cm dbh but far fewer trees in larger size classes. If the trees continue to grow, exurban residential land could sequester additional C for decades. Patterns and processes of C storage in exurban residential land were driven by land management practices that affect soil and vegetation, reflecting the choices of designers, developers, and residents. This study provides an example of human‐mediated C storage in a coupled human–natural system.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/122437/1/eap1313.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/122437/2/eap1313_am.pd

Rainich theory for type D aligned Einstein-Maxwell solutions

The original Rainich theory for the non-null Einstein-Maxwell solutions consists of a set of algebraic conditions and the Rainich (differential) equation. We show here that the subclass of type D aligned solutions can be characterized just by algebraic restrictions.Comment: 12 pages; v2: appendix with notatio

Mortality risk in patients on hemodiafiltration versus hemodialysis : a 'real-world' comparison from the DOPPS

Background. With its convective component, hemodiafiltration (HDF) provides better middle molecule clearance compared with hemodialysis (HD) and is postulated to improve survival. A previous analysis of Dialysis Outcomes and Practice Patterns Study (DOPPS) data in 1998-2001 found lower mortality rates for high replacement fluid volume HDF versus HD. Randomized controlled trials have not shown uniform survival advantage for HDF; in secondary (non-randomized) analyses, better outcomes were observed in patients receiving the highest convection volumes. Methods. In a 'real-world' setting, we analyzed patients on dialysis >90 days from seven European countries in DOPPS Phases 4 and 5 (2009-15). Adjusted Cox regression was used to study HDF (versus HD) and mortality, overall and by replacement fluid volume. Results. Among 8567 eligible patients, 2012 (23%) were on HDF, ranging from 42% in Sweden to 12% in Germany. Median follow-up was 1.5 years during which 1988 patients died. The adjusted mortality hazard ratio (95% confidence interval) was 1.14 (1.00-1.29) for any HDF versus HD and 1.08 (0.92-1.28) for HDF > 20 L replacement fluid volume versus HD. Similar results were found for cardiovascular and infection-related mortality. In an additional analysis aiming to avoid treatment-by-indication bias, we did not observe lower mortality rates in facilities usingmore HDF (versus HD). Conclusions. Our results do not support the notion that HDF provides superior patient survival. Further trials designed to test the effect of high-volume HDF (versus lower volume HDF versus HD) on clinical outcomes are needed to adequately inform clinical practices

Tropospheric winds from northeastern China carry the etiologic agent of Kawasaki disease from its source to Japan

Evidence indicates that the densely cultivated region of northeastern China acts as a source for the wind-borne agent of Kawasaki disease (KD). KD is an acute, coronary artery vasculitis of young children, and still a medical mystery after more than 40 y. We used residence times from simulations with the flexible particle dispersion model to pinpoint the source region for KD. Simulations were generated from locations spanning Japan from days with either high or low KD incidence. The postepidemic interval (1987–2010) and the extreme epidemics (1979, 1982, and 1986) pointed to the same source region. Results suggest a very short incubation period (<24 h) from exposure, thus making an infectious agent unlikely. Sampling campaigns over Japan during the KD season detected major differences in the microbiota of the tropospheric aerosols compared with ground aerosols, with the unexpected finding of the Candida species as the dominant fungus from aloft samples (54% of all fungal strains). These results, consistent with the Candida animal model for KD, provide support for the concept and feasibility of a windborne pathogen. A fungal toxin could be pursued as a possible etiologic agent of KD, consistent with an agricultural source, a short incubation time and synchronized outbreaks. Our study suggests that the causative agent of KD is a preformed toxin or environmental agent rather than an organism requiring replication. We propose a new paradigm whereby an idiosyncratic immune response, influenced by host genetics triggered by an environmental exposure carried on winds, results in the clinical syndrome known as acute KD