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There is no pediatric data on whether white coat hypertension (WCH) is a precursor of sustained HTN. The objective of this study was to determine diagnosis changes on follow-up ambulatory blood pressure monitoring (ABPM) in children and adolescents diagnosed with WCH on their initial ABPM and to assess for predictive factors of progression to HTN. Retrospective review was conducted at 11 centers to identify patients with WCH diagnosed by ABPM and had repeat ABPM at least 6 months after the first study. Subjects with secondary HTN, on antihypertensive medication, and diabetes mellitus were excluded. Patients with ADHD were included in the study if medications were stable. Chart review included associated risk factors such as BMI, obstructive sleep apnea, and family history of HTN. ABPM phenotype was determined using the 2014 AHA guidelines. The association between abnormal ABPM diagnosis on follow-up and ABPM index and blood pressure load variables was assessed using univariable generalized linear mixed effect models. Significant ABPM index and load variables (based on p < 0.15) were subsequently added to a multivariable model with the following pre-specified covariates: gender, family history of HTN, age, BMI z-score, ADHD, and interval time between ABPMs. One hundred and one patients met criteria for inclusion with a median age of 14 years (80% males) and median interval time of 14 months (range: 6 – 55 months). On follow-up ABPM, 18% and 32% of patients demonstrated HTN and prehypertension respectively (18 and 32 of 101, respectively). In univariable modeling, awake and nocturnal systolic BP index ≥ 0.9 on the first ABPM were found to be significantly associated with progression to abnormal ABPM [unadjusted OR (95% CI) awake: 4.3 (1.2 – 14.6); nocturnal: 3.2 (1.0 – 10.1)]; however, these associations were not significant after adjusting for pre-specified covariates [adjusted OR (95% CI) awake: 2.7 (0.7-10.4); nocturnal: 2.6 (0.7 – 9.2)]. Approximately half of children and adolescents first diagnosed with WCH progressed to an abnormal ABPM phenotype on follow-up, suggesting that longitudinal follow-up with ABPM is indicated in pediatric WCH patients. We were unable to identify ABPM findings that might predict a higher risk for progression.

BACKGROUND: Nephrotic syndrome (NS) results in hypercoagulability and increased risk of infection. Furthermore, infection increases the risk of venous thromboembolism (VTE). Our objective was to determine the prevalence of infection, VTE, and the associated outcomes among a cohort of hospitalized children with NS. METHODS: All children with NS admitted to 17 pediatric hospitals across North America from 2010 to 2012 were included. Prevalence of infection and VTE was determined. Wilcoxon rank-sum and logistic regression were performed. RESULTS: Seven-hundred thirty hospitalizations occurred among 370 children with NS. One-hundred forty-eight children (40%) had ≥ 1 infection (211 episodes) and 11 (3%) had VTE. Those with VTE had infection more frequently (p = 0.046) and were younger at NS diagnosis (3.0 vs. 4.0 years; p = 0.008). The most common infectious pathogen identified was Streptococcus pneumoniae. The median hospital length of stay for those with infection [10 vs 5 days (p < 0.0001)] or VTE [22 vs 6 days (p < 0.0001)] was longer than those without either complication. Of those with infection, 13% had an intensive care unit (ICU) stay compared with 3.3% of those without infection. Median ICU stay was 4 days in those with VTE compared to 0 days in those without (p < 0.001). By logistic regression, only the number of ICU days was associated with VTE (OR 1.074, 95% CI 1.013–1.138). CONCLUSIONS: Hospitalized children with NS have high rates of infection. Presence of VTE was associated with infection. Both were associated with longer hospitalizations and ICU stays.

The role of cardiac resynchronization therapy (CRT) in patients aged ≥75 years is not well established.We identified 607 patients aged ≥75 years with left ventricular ejection fraction (LVEF) of ≤35 %, of whom 78 met the guidelines for indication of CRT. Based on the decision of the patients or attending cardiologists, 34 patients received a CRT defibrillator (CRT-D).The age of patients with a CRT indication was 80 ± 4 years, and 73 % were males. As compared with patients on medical therapy, CRT-D patients were younger (79 ± 3 vs. 83 ± 4, P 0.001), had lower LVEF (23 ± 7 vs. 27 ± 7 %, P = 0.008) and higher rate of decompensated heart failure episodes (77 vs. 55 %, P = 0.04), were more frequently New York Heart Association (NYHA) class III-IV (53 vs. 25 %, P = 0.01), and were more likely to be on beta-blockers (88 vs. 66 %, P = 0.023), anticoagulants (61 vs. 32 % P = 0.02), and anti-aldosterone drugs (82 vs. 50 %, P = 0.003). After a median follow-up of 26 months, seven patients in the CRT-D group (21 %) and 20 non-CRT patients (46 %) died (hazard ratio (HR) 0.16 [95 % confidence interval (CI) 0.06-0.46]). The end point of mortality or hospitalization was not reduced because of a similar rate of hospitalizations for heart failure of CRT-D patients. Four CRT-D patients (12 %) had received appropriate device therapy, and one had been inappropriately discharged. During follow-up, 44 % of CRT-D patients improved their LVEF by40 %.CRT-D is potentially of benefit in terms of mortality in our population; this effect persists after correction for use of beta-blockers. In patients ≥75 years, CRT indications should be similar to those accepted for younger subjects.

To cite this article: Rodriguez del Rio P, Sanchez-Garcia S, Escudero C, Pastor-Vargas C, Sanchez Hernandez JJ, Perez-Rangel I, Ibanez MD. Allergy to goat’s and sheep’s milk in a population of cow’s milk–allergic children treated with oral immunotherapy. Pediatr Allergy Immunol 2012: 23: 128–132. Abstract Background: Cow’s milk oral immunotherapy (CMOIT) is a recognized treatment for persistent cow’s milk (CM) allergy. However, further data are necessary on tolerance to milk from other mammals. Objective: To describe the clinical and immunologic features of goat’s and sheep’s milk (GSM) allergy in patients who tolerated CM after CMOIT. Methods: Fifty-eight CM-allergic patients who successfully underwent CMOIT in our department were evaluated using skin prick test (SPT), specific immunoglobulin (Ig) E determination, enzyme-linked immunoassay (ELISA), and controlled oral challenge to assess allergy to GSM. Statistical analysis was carried out to identify markers of allergy to GSM. Results: Fifteen of 58 (25.9%) patients were allergic to either goat’s or sheep’s milk or to both, as confirmed by a controlled positive oral challenge. Forty-seven percent of all positive oral challenges were classified as anaphylactic reactions. Specific IgE to CM casein, goat’s whole milk, and sheep’s whole milk was 13.2, 18.0, and 21.4 kUA/l in the group of GSM-allergic patients and 6.6, 6.5, and 6.5 kUA/l in the GSM-non-allergic patients (p

The path from Earth to Mars requires exploration missions to be increasingly Earth-independent as the foundation is laid for a sustained human presence in the following decades. NASA pioneering of Mars will expand the boundaries of human exploration, as a sustainable presence on the surface requires humans to successfully reproduce in a partial gravity environment independent from Earth intervention. Before significant investment is made in capabilities leading to such pioneering efforts, the challenges of multigenerational mammalian reproduction in a partial gravity environment need be investigated. The Multi-generational Independent Colony for Extraterrestrial Habitation, Autonomy, and Behavior health is designed to study these challenges. The proposed concept is a conceptual, long duration, autonomous habitat designed to house rodents in a partial gravity environment with the goal of understanding the effects of partial gravity on mammalian reproduction over multiple generations and how to effectively design such a facility to operate autonomously while keeping the rodents healthy in order to achieve multiple generations. All systems are designed to feed forward directly to full-scale human missions to Mars. This paper presents the baseline design concept formulated after considering challenges in the mission and vehicle architectures such as: vehicle automation, automated crew health management/medical care, unique automated waste disposal and hygiene, handling of deceased crew members, reliable long-duration crew support systems, and radiation protection. This concept was selected from an architectural trade space considering the balance between mission science return and robotic and autonomy capabilities. The baseline design is described in detail including: transportation and facility operation constraints, artificial gravity system design, habitat design, and a full-scale mock-up demonstration of autonomous rodent care facilities. The proposed concept has the potential to integrate into existing mission architectures in order to achieve exploration objectives, and to demonstrate and mature common capabilities that enable a range of destinations and missions.

Children with nephrotic syndrome can develop life-threatening complications, including infection and thrombosis. While AKI is associated with adverse outcomes in hospitalized children, little is known about the epidemiology of AKI in children with nephrotic syndrome. The main objectives of this study were to determine the incidence, epidemiology, and hospital outcomes associated with AKI in a modern cohort of children hospitalized with nephrotic syndrome.Records of children with nephrotic syndrome admitted to 17 pediatric nephrology centers across North America from 2010 to 2012 were reviewed. AKI was classified using the pediatric RIFLE definition.AKI occurred in 58.6% of 336 children and 50.9% of 615 hospitalizations (27.3% in stage R, 17.2% in stage I, and 6.3% in stage F). After adjustment for race, sex, age at admission, and clinical diagnosis, infection (odds ratio, 2.24; 95% confidence interval, 1.37 to 3.65; P=0.001), nephrotoxic medication exposure (odds ratio, 1.35; 95% confidence interval, 1.11 to 1.64; P=0.002), days of nephrotoxic medication exposure (odds ratio, 1.10; 95% confidence interval, 1.05 to 1.15; P0.001), and intensity of medication exposure (odds ratio, 1.34; 95% confidence interval, 1.09 to 1.65; P=0.01) remained significantly associated with AKI in children with nephrotic syndrome. Nephrotoxic medication exposure was common in this population, and each additional nephrotoxic medication received during a hospitalization was associated with 38% higher risk of AKI. AKI was associated with longer hospital stay after adjustment for race, sex, age at admission, clinical diagnosis, and infection (difference, 0.45 [log]days; 95% confidence interval, 0.36 to 0.53 [log]days; P0.001).AKI is common in children hospitalized with nephrotic syndrome and should be deemed the third major complication of nephrotic syndrome in children in addition to infection and venous thromboembolism. Risk factors for AKI include steroid-resistant nephrotic syndrome, infection, and nephrotoxic medication exposure. Children with AKI have longer hospital lengths of stay and increased need for intensive care unit admission.

Modern surgical procedures have saved lives; however, the occurrence of post-surgical complications is still a concern. This study investigates the relationships between patients’ surgical data and the post-surgical adverse outcomes of death, cardiac injury, renal injury, and respiratory failure. We analyze these relationships through the statistical modelling of predictor variables from patients’ preoperative data and intraoperative physiological time series data, as well as the intraoperative time series of procedures performed by anesthesiologists and surgeons. In order to include this procedural data we create novel predictors to represent each patient’s time series in models. Three different statistical models are described: Random Forest (RF), Generalized Linear Models (GLM), and L1 Regularized Logistic Regression (L1). We evaluate the model results using Receiver Operating Characteristic (ROC) curves and their corresponding area under the curve (AUC) values. The GLM model performs the best for death with an AUC value of .887, and the RF model performs best for cardiac injury, renal injury and respiratory failure, with AUC values of .857, .873 and .831, respectively. For all adverse outcomes, the L1 models minimized false negatives at a threshold of .01. This paper describes the results of these models and identifies the strongest predictors of each post-surgical adverse outcome. Additionally, we create a Mixed Effects (ME) model to isolate interactions between patient types and other significant predictors. This model suggests significant interaction effects between the placement of an arterial line and patient types when predicting renal injury and respiratory failure.

Background During late pregnancy, the standard dose of atazanavir boosted with ritonavir (ATV/r) is increased to 400/100mg once daily and the standard dose of lopinavir boosted with ritonavir (LPV/r) is increased to 600/150mg twice daily due to physiologic and metabolic changes. These higher doses may impact the tolerability of antiretroviral therapy (ART). The objective of this study was to describe adverse events (AE) in pregnant women living with HIV receiving ATV/r vs. LPV/r. Methods This retrospective cohort included pregnant women receiving high dose ATV/r or LPV/r-based ART from Sept 2007-Dec 2014. AEs were assessed by laboratory parameters and medical chart documentation from the first visit during pregnancy through delivery. AE severity was based on the Division of AIDS Table for Grading the Severity of Adult AEs. The primary endpoint was a between-group comparison of documented AEs. Data are presented as n, percent, or median (interquartile range, IQR). Results A total of 99 patients were included (n = 41 ATV/r, n = 58 LPV/r). Patients were 29 years old (IQR 24–34), African American (43%), and living with HIV for 5 years (IQR 1–9). Baseline demographics were similar between groups. Overall, 94.8% of the LPV/r arm experienced at least one AE (n = 58), and 70.7% (n = 29) experienced an AE in the ATV/r arm (P < 0.01). There were 3.8 AEs/patient (n = 218) in the LPV/r arm and 2.6 AEs/patient (n = 106) in the ATV/r arm. Nausea/vomiting was the most common AE in each arm (n = 44 LPV/r and n = 19 ATV/r). Most AEs were grade 1 in (LPV/r: 194 (89%) and ATV/r: 81 (76%); P < 0.01); however, there were a higher number of grade 3 (n = 7 ATV/r, n = 5 LPV/r) and grade 4 (n = 2 ATV/r, n = 0 LPV/r) AEs seen in the ATV/r arm. LPV/r was discontinued in 3 patients and ATV/r was discontinued in 2 patients. There was no difference in percentage of patients with an undetectable viral load at any monitoring point including the week before end of term (n = 29/32, 90.6% ATV/r; n = 33/42, 78.6% LPV/r; P > 0.05 for all). Conclusion Patients treated with ATV/r experienced lower overall rates of AEs compared with LPV/r. The majority of AEs were grade 1 and few patients needed to discontinue ATV/r or LPV/r due to AEs. Disclosures All authors: No reported disclosures.

Introduction: Although it is known that children with nephrotic syndrome (NS) are at greater risk for certain complications, the frequency of these complications and predisposing risk factors are poorly defined. In particular, nephrotic syndrome has long been considered a hypercoagulable state. Risk for development of venous thromboembolism (VTE) is known to be increased in the setting of an active infection. The objective of this study was to determine the prevalence of infection and VTE among a cohort of hospitalized children with NS, and the association of these complications on outcomes. Methods: Records of hospitalized children with NS admitted to any of 17 participating pediatric hospitals across North America from 2010-2012 were included. Data including demographics, clinical pattern of NS, renal biopsy results, number of hospitalizations, nephrotoxic medication usage, infection and VTE history were recorded. Descriptive statistics were used to determine prevalence of infection and VTE. Wilcoxon rank sum was used to perform comparisons between groups. Logistic regression analysis was utilized to determine predictors of VTE development. Results: Seven-hundred thirty hospitalizations occurred among 370 children. One-hundred forty-eight children (40%) had at least 1 infection with a total of 211 infectious episodes; 11 (3%) had VTE. Those with infection were more likely to have VTE (p = 0.0457). Infections associated with VTE were C. difficile (1 subject), methicillin sensitive S. Aureus (2), Streptococcus pneumoniae (1), and unknown (3). There were no differences between those with and without infection regarding gender or ethnicity. Those with infection were younger at NS diagnosis (3.0 vs. 4.0 years; p = 0.008), and steroid resistant NS was more highly associated with infection than all other clinical diagnoses (steroid-sensitive NS, steroid-dependent NS, other) (p = 0.003). The most common types of infections encountered included peritonitis (23%), pneumonia (22%), and bacteremia (16%). Bacterial pathogens (Streptococcus pneumoniae 41%, Escherichia coli 16%, Clostridium difficile 10%) were most commonly identified. Children with VTE, infection, or both, also required significantly more days in hospital. The median hospital stay for those without infection was 5 days vs. 10 in those with infection (p< 0.0001). Similarly, median hospital days for those without VTE were 6 days as compared to 22 in those with VTE (p < 0.0001). Of those with infection, 13% had an ICU stay compared with 3.3% of those without. Those with VTE also had a median of 4 days in the intensive care unit as compared to 0 days in those without VTE (p < 0.0001). In a logistic regression analysis, only the number of ICU days was predictive of the presence of VTE (OR 1.074, 95% CI 1.013 - 1.138). Conclusions: Children with NS who are hospitalized have high rates of infection. While the rate of VTE was not high in this cohort, presence of VTE was associated with infection. Both infection and VTE were associated with longer hospitalizations and intensive care unit stays. Streptococcus pneumoniae remains the most commonly identified bacterial pathogen in children with nephrotic syndrome, though methicillin sensitive S. Aureus was identified in 2 of 11 patients with VTE. Further studies are needed to identify potentially modifiable risk factors that could minimize these complications in this already high risk population. Disclosures No relevant conflicts of interest to declare.

Free-floating thrombus in ascending aorta is a rare cause of peripheral embolism with potentially fatal consequences. We report the case of a young patient with syncope and sudden lumbar pain. Computed tomographic scan revealed a large pedunculated floating mass attached to the posterior wall of the ascending aorta, probably responsible of renal embolic infarction; transthoracic echocardiography confirmed the diagnosis. Surgery was urgently performed. The thrombus was excised, and was not related to atherosclerotic disease of the aortic wall. We conclude that once diagnosis is clear, urgent surgery must be considered to avoid any further embolic complications.

The Internet provides an efficient mechanism for Federal agencies to distribute their data to the public. However, it is imperative that such data servers have built-in mechanisms to ensure that confidentiality of the data, and the privacy of individuals or establishments represented in the data, are not violated. We describe a prototype dissemination system developed for the National Agricultural Statistics Service that uses aggregation of adjacent geographical units as a confidentiality-preserving technique. We also outline a Bayesian approach to statistical analysis of the aggregated data.

Patent foramen ovale (PFO) percutaneous closure has previously been an accepted intervention for the prevention of recurrent cryptogenic stroke on the basis of observational studies. However, randomized trials have been lacking until now. Three recently published randomized trials (CLOSURE I, PC and RESPECT) do not demonstrate the superiority of this intervention versus optimal medical therapy, therefore making this practice questionable. Nonetheless, these trials have had certain pitfalls, mainly a lower than initially estimated number of patients recruited, therefore lacking sufficient statistical power. On the other hand, different closure devices were used in the three trials. In two of them (PC and RESPECT), the Amplatzer PFO Occluder was used and the STARflex device was used in the other one (CLOSURE I). Taken altogether, a meta-analysis of these three trials does not demonstrate a statistically significant benefit of percutaneous PFO closure (1.9% vs 2.9%; P = 0.11). However, if we analyze only the PC and RESPECT trials together, in which the Amplatzer PFO Occluder was used, a statistically significant benefit of percutaneous PFO closure is observed (1.4% vs 3.0%, P = 0.04). In conclusion, our interpretation of these trials is that the use of a dedicated, specifically designed Amplatzer PFO device could possibly reduce the risk of stroke in patients with PFO and cryptogenic stroke. This consideration equally applies to patients who have no contraindications for anticoagulant or antithrombotic therapy.