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Introduction: Competence committees (CCs) centre their work around documentation of trainees' performance; undocumented contributions (i.e. informal, unrecorded material like personal judgements, experiential anecdotes and contextual information) evoke suspicion even though they may play a role in decision making. This qualitative multiple case study incorporates insights from a social practice perspective on writing to examine the use of undocumented contributions by the CCs of two large post‐graduate training programmes, one in a more procedural (MP) speciality and the other in a less procedural (LP) one. Methods: Data were collected via observations of meetings and semi‐structured interviews with CC members. In the analysis, conversations were organised into triptychs of lead‐up, undocumented contribution(s), and follow‐up. We then created thick descriptions around the undocumented contributions, drawing on conversational context and interview data to assign possible motivations and significance. Results: We found no instances in which undocumented contributions superseded the contents of a trainee's file or stood in for missing documentation. The number of undocumented contributions varied between the MP CC (six instances over two meetings) and the LP CC (22 instances over three meetings). MP CC discussions emphasised Entrustable Professional Activity (EPA) observations, whereas LP CC members paid more attention to narrative data. The divergent orientations of the CCs—adding an 'advis[ing]/guid[ing]' role versus focusing simply on evaluation—offers the most compelling explanation. In lead‐ups, undocumented contributions were prompted by missing and flawed documentation, conflicting evidence and documentation at odds with members' perceptions. Recognising other 'red flags' in documentation often required professional experience. In follow‐ups, purposes served by undocumented contributions varied with context and were difficult to generalise; we, therefore, provide deeper analysis of two vignettes to illustrate. Conclusions: Our data suggest undocumented contributions often serve best efforts to ground decisions in documentation. We would encourage CC practices and policies be rooted in more nuanced approaches to documentation. van Enk and colleagues show that undocumented contributions in competency committees often work in service of best efforts to ground decisions in documentation. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The utility of routine therapeutic drug monitoring (TDM) in children living with HIV has not been extensively studied. The purpose of this study was to assess this strategy. METHODS: This was a single-center, prospective observational study of routine TDM for protease inhibitors (PIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs), and integrase strand transfer inhibitors (INSTIs) in children living with HIV who were receiving antiretroviral therapy (ART) between February and December 2014. Outcome measures included the proportion of serum antiretroviral (ARV) medication concentrations in the therapeutic range (target values extrapolated from adult data) and the effect of serum concentrations on virologic control, medication adherence, and toxicity. RESULTS: Forty-eight children with a median age of 13 years (interquartile range, 3-18) were included. Median viral load (VL) and CD4% were <40 copies/mL (range, <40-124) and 37.4% (range, 8.4-47.9), respectively. Adherence was considered excellent in 95.8% of patients. Of the 50 serum trough concentrations (PI n = 19 [38%]; NNRTI n = 27 [54%]; INSTI n = 4 [8%]), 66% (n = 33) were in the therapeutic range, 12% (n = 6) were subtherapeutic, and 22% (n = 11) were supratherapeutic. There was no statistically significant correlation between serum ARV concentrations and patient demographics, VL, CD4%, or adherence. No clinically significant adverse events were noted. One dose adjustment was made for a subtherapeutic serum raltegravir concentration, likely attributable to interaction with ritonavir. CONCLUSIONS: This study does not support routine TDM in healthy children living with HIV who are well controlled on antiretroviral medication regimens. A more targeted strategy, such as when adherence is questioned or when there are suspected drug interactions, may be more appropriate. [ABSTRACT FROM AUTHOR]

In case 1, we hypothesise that the cephalohaematoma developed into subgaleal abscess with bacterial seeding from the antecedent urinary tract infection. The blood culture was also negative, white cell count (WCC) was 5.7 × 10 SP 9 sp /L and C-reactive protein (CRP) was 77.4 mg/L. Cranial ultrasound showed a lentiform 8.9 × 6.9 cm collection consistent with a large uncomplicated cephalohaematoma. If the cephalohaematoma does show signs of localised infection with possible extension, appropriate imaging with high diagnostic yield for osteomyelitis (CT or magnetic resonance imaging) is warranted with consideration given to debridement. [Extracted from the article]

Introduction: The clinical competency committee (CCC) comprises a group of clinical faculty tasked with assessing a medical trainee's progress from multiple data sources. The use of previously undocumented data, or PUD, during CCC deliberations remains controversial. This study explored the use of previously undocumented data in conjunction with documented data in creating a meaningful assessment in a CCC. Methods: An instrumental case study of a CCC that uses previously undocumented data was conducted. A single CCC meeting was observed, followed by semi-structured individual interviews with all CCC members (n = 7). Meeting and interview transcripts were analyzed iteratively. Results: Documented data were perceived as limited by inaccurate or superficial data, but sometimes served as a starting point for invoking previously undocumented data. Previously undocumented data were introduced as summary impressions, contextualizing factors, personal anecdotes and, rarely, hearsay. The purpose was to raise a potential issue for discussion, enhance and elaborate an impression, or counter an impression. Various mechanisms allowed for the responsible use of previously undocumented data: embedding these data within a structured format; sharing relevant information without commenting beyond one's scope of experience; clarifying allowable disclosure of personal contextual factors with the trainee pre-meeting; excluding previously undocumented data not widely agreed upon in decision-making; and expecting these data to have been provided as direct feedback to trainees pre-meeting. Discussion: Previously undocumented data appear to play a vital part of the group conversation in a CCC to create meaningful, developmentally focused trainee assessments that cannot be achieved by documented data alone. Consideration should be given to ensuring the thoughtful incorporation of previously undocumented data as an essential part of the CCC assessment process. [ABSTRACT FROM AUTHOR]

BACKGROUND There is an increasing demand for reduced‐sugar products due to the worldwide prevalence of obesity, diabetes, and cardiovascular diseases. The aim of this study was to evaluate the effects of sugar (sucrose) reductions on the acceptability, preference, and quality of strawberry‐flavored yogurts. A consumer rejection threshold test and an acceptability test (N = 53) were conducted using six yogurt samples with decreasing concentrations of sugar (12–5/100 g). Additional physicochemical tests (pH, °Brix, water‐holding‐capacity, viscosity, and color) were conducted to examine the quality and shelf‐life of strawberry‐flavored yogurts with reductions of sucrose during 28 days of storage at 4 °C. RESULTS: Reduction of sucrose affected the acceptability and physicochemical characteristics of yogurts. The consumer rejection threshold showed that sucrose in strawberry‐flavored yogurts could be reduced to 5.25/100 g from an initial concentration of 12/100 g without affecting the preferences of consumers. The 71%‐sucrose (8.50/100 g of yogurt) was perceived as the most liked (6.27 using a nine‐point hedonic scale) and the most preferred (rank sum = 127.50) yogurt sample. For the physicochemical properties of yogurts, the viscosity (3263–5473 cP) decreased, and the color lightness (80.98–85.44) increased during 28 days of storage at 4 °C. CONCLUSION: Physicochemical properties and preferences were affected by the reduction of sugar. The consumer rejection threshold analysis showed that sucrose can be reduced to less than half of the initial concentration. These findings are useful to understand consumers' acceptability and shelf‐life of yogurts with reduced‐sugar formulations in the developing of new products. © 2020 Society of Chemical Industry [ABSTRACT FROM AUTHOR]

Background Respiratory syncytial virus (RSV) is a major cause of pneumonia and bronchiolitis in children. Mortality rates in previously healthy children hospitalized with RSV are <0.5%, but up to 37% in patients with underlying medical conditions. The objective of this study was to characterize factors associated with deaths among children hospitalized with RSV infection in Canadian pediatric centers. Methods This was a retrospective case series of children aged ≤18 years with RSV-associated deaths at centers affiliated with the Pediatric Investigators Collaborative Network on Infections in Canada from 2003–2013, inclusive, was performed. Cases were identified using RSV-specific International Classification of Diseases codes to capture deaths where a diagnosis of RSV infection was present. Results Eleven centers reported 79 RSV-associated deaths. RSV was regarded as primarily responsible for death in 32 cases (40.5%). Median age at death was 11 months (range, <1 month to 16 years). Thirty-nine patients (49.4%) were male. Fourteen patients (17.7%) had no known risk factors for severe RSV infection. Healthcare-associated RSV infections (HAIs) accounted for 29 deaths (36.7%), with RSV judged to be the primary cause of death in 9 of these cases. Conclusions RSV-associated deaths were predominantly associated with chronic medical conditions and immunocompromised states among infants; however, 1 in 5 deaths occurred among patients with no known risk factors for severe RSV. Mortality associated with HAI accounted for over a third of cases. These findings highlight patient groups that should be targeted for RSV prevention strategies such as infection control practices, immunoprophylaxis, and future vaccination programs. [ABSTRACT FROM AUTHOR]

Enterococcal bloodstream infections are usually treated with single-agent antibiotics. In persistent infections, synergistic combination therapy is often required with a beta-lactam and an aminoglycoside antibiotic. High-level aminoglycoside-resistant (HLAR) enterococci are increasingly prevalent and preclude the use of this combination. The use of ampicillin with a third-generation cephalosporin to treat endovascular HLAR Enterococcus infections is becoming more established in the adult population; however, the literature on treatment of such infections in children remains scarce. We report a preterm neonate with persistent HLAR Enterococcus faecalis bacteremia from day of life 9 to 17 despite treatment with ampicillin and vancomycin. On day of life 17, antibiotic treatment was switched to ampicillin and cefotaxime, with subsequent clearance of blood cultures on day of life 20. To our knowledge, this is the first report illustrating the use of ampicillin and cefotaxime for an HLAR E. faecalis infection in a neonate. [ABSTRACT FROM AUTHOR]

Background. There is a misconception that elderly cancer patients cannot tolerate standard doses of chemotherapy because of the frequency and severity of myelosuppressive complications. The reactive use of colony-stimulating factors (i.e., in response to severe neutropenia) commonly observed in this setting contributes to the frequency and severity of these complications. This study evaluated the incidence of febrile neutropenia and related events in elderly cancer patients receiving pegfilgrastim beginning with cycle 1 (proactive) in comparison with pegfilgrastim initiated after cycle 1 at the physician's discretion (reactive). Methods. Patients (≥65 years of age) with either solid tumors or non-Hodgkin's lymphoma (NHL) were randomly assigned to receive pegfilgrastim either proactively or reactively. The primary endpoint was the proportion of patients experiencing febrile neutropenia. Results. There were 852 patients enrolled (median age, 72 years). Proactive pegfilgrastim use resulted in a significantly lower incidence of febrile neutropenia for both solid tumor and NHL patients compared with reactive use. Proactive pegfilgrastim use also led to fewer hospitalizations resulting from neutropenia and febrile neutropenia by approximately 50%. Antibiotic use was lower for solid tumor patients receiving proactive pegfilgrastim and equivalent in the two NHL groups. Conclusions. This is the largest, randomized, prospective trial evaluating growth factor support in typical elderly cancer patients. Proactive pegfilgrastim use effectively produced a lower incidence of febrile neutropenia and related events in elderly patients with either solid tumors or NHL receiving an array of mild to moderately neutropenic chemotherapy regimens. Pegfilgrastim should be used proactively in elderly cancer patients to support the optimal delivery of standard chemotherapy. [ABSTRACT FROM AUTHOR]

Objective: To sample dietary supplements (DS) labeled as ephedra-free to evaluate whether products met their labeling claim. Methods: One control DS product containing ephedra alkaloids and 29 DS labeled as ephedra-free were purchased from various retail locations in San Francisco. All products were sent to the California Department of Health Services (CDHS), Food and Drug Laboratory for content and quantity analysis. All laboratory personnel were blinded to product names and labeled contents. All DS products were screened for the presence of undeclared drugs, ephedra alkaloids, and heavy metals including lead, arsenic, cadmium and mercury. All products were also evaluated for compliance with the labeling requirements of the Dietary Supplement Health and Education Act (DSHEA) of 1994. Results: None of the DS labeled as ephedra-free tested positive for the presence of ephedra alkaloids; as expected, the control product did test positive. Heavy metals were detected in three ephedra-free labeled DS products. All 24 products that tested positive for caffeine listed caffeine or a botanical source of caffeine on the DS label. All but two products were in compliance with DS labeling as required by DSHEA. Conclusions: This study demonstrates that manufacturers met their labeling claims for ephedra-free products. Special attention should be given to the presence of heavy metals and other drugs like caffeine, synephrine, and botanical sources of caffeine as these ingredients have replaced ephedra. [ABSTRACT FROM AUTHOR]

Splicing and 3'-end processing (including cleavage and polyadenylation) of vertebrate pre-mRNAs are tightly coupled events that contribute to the extensive molecular network that co-ordinates gene expression. Sequences within the terminal intron of genes are essential to stimulate pre-mRNA 3'-end processing, although the factors mediating this effect are unknown. Here, we show that the pyrimidine tract of the last splice acceptor site of the human β-globin gene is necessary to stimulate mRNA 3'-end formation in vivo and binds the U2AF 65 splicing factor. Naturally occurring β-thalassaemia-causing mutations within the pyrimidine tract reduces both U2AF 65 binding and 3'-end cleavage efficiency. Significantly, a fusion protein containing U2AF 65, when tethered upstream of a cleavage/polyadenylation site, increases 3'-end cleavage efficiency in vitro and in vivo. Therefore, we propose that U2AF 65 promotes 3'-end processing, which contributes to 3'-terminal exon definition. [ABSTRACT FROM AUTHOR]

Sugar not only provides the desirable sweetness but its reduction can also alter the physico-chemical properties of foods. The objective of this study was to evaluate the effects of tagatose as a sugar substitute on selected physico-chemical properties and sensory acceptability of strawberry-flavored yogurts. Six yogurt samples with decreasing concentrations of sucrose (8.50 to 1.70 g/100 g) and increasing concentrations of tagatose (0.00 to 9.24 g/100 g) were evaluated. Physico-chemical tests (pH, lactic acid (%), °Brix, water-holding capacity (WHC), viscosity, and color) were conducted to examine the quality and shelf-life of yogurts during 28 days of storage at 4 °C. An acceptability test (n = 55) was conducted to evaluate the sensory characteristics of yogurts. Sucrose reductions by the replacement of up to 80% tagatose showed marginal effects on the selected physico-chemical properties; however, the loss of red color (a*) and increase in yellowness (b*) of the tagatose-substituted samples were significant. Strawberry yogurts with tagatose replacements had similar acceptability scores for all attributes. Sucrose reduction showed a positive effect on the purchase intent of the strawberry yogurts (an increase of 3–30%). These findings can be used to understand the effects of tagatose/sucrose formulations on the acceptability and physico-chemical properties of yogurts. [ABSTRACT FROM AUTHOR]