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Background: A bronchiolitis integrated care pathway (BICP) achieved an 87% reduction in the use of medications in our regional health service (RHS) during the 2019-2020 season., Aim: This study aimed to assess the sustainability of the changes in bronchiolitis management over 3 years after implementation of the BICP., Methods: A prospective observational study on rates of medications prescribing in children diagnosed with bronchiolitis in 135 primary care (PC) centres and eight hospital emergency departments (EDs) in the Basque Country, Spain, was conducted during the four bronchiolitis seasons between 2019 and 2023. Over this period, the deployment of BICP-related actions continued in our RHS. In addition, a strategy was designed to enhance the sustainability of the results. The main endpoint was the percentage of children prescribed salbutamol., Results: Over the 2019-2020 to 2022-2023 epidemic waves, 12 966 infants were diagnosed with bronchiolitis in PC, and 6676 infants in EDs. Rates of salbutamol use over the four waves were 5.04%, 10.54%, 8.51% and 6.05%, respectively, in PC and 3.36%, 10.02%, 7.62% and 5.77% in EDs. Rates of concomitant administration of other medications in EDs over the four waves were 3.2%, 0.2%, 1.0% and 1.9% for epinephrine and 0.4%, 0.7%, 0.3% and 0.4% for corticosteroids, respectively. In PC, prescribing rates were 5.1% and 1.8%, 10.3% and 4.1% for antibiotics and 7.8% and 4.5%, 5.7% and 2.5% for corticosteroids, respectively., Conclusions: Reductions in the use of medications for bronchiolitis achieved in 2019 through the implementation of our integrated clinical pathway have been sustained over the three subsequent waves., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

The piRNA pathway is a conserved germline-specific small RNA pathway that ensures genomic integrity and continued fertility. In C. elegans and other nematodes, Type-I piRNAs are expressed from >10,000 independently transcribed genes clustered within two discrete domains of 1.5 and 3.5 MB on Chromosome IV. Clustering of piRNA genes contributes to their germline-specific expression, but the underlying mechanisms are unclear. We analyze isolated germ nuclei to demonstrate that the piRNA genomic domains are located in a heterochromatin-like environment. USTC (Upstream Sequence Transcription Complex) promotes strong association of nucleosomes throughout piRNA clusters, yet organizes the local nucleosome environment to direct the exposure of individual piRNA genes. Localization of USTC to the piRNA domains depends upon the ATPase chromatin remodeler ISW-1, which maintains high nucleosome density across piRNA clusters and ongoing production of piRNA precursors. Overall, this work provides insight into how chromatin states coordinate transcriptional regulation over large genomic domains, with implications for global genome organization., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Paniagua et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objective: To identify the outcomes considered important, and factors influencing the patient experience, for parents and caregivers of children presenting to hospital with a severe acute exacerbation of asthma. This work contributes to the outcome-identification process in developing a core outcome set (COS) for future clinical trials in children with severe acute asthma., Design: A qualitative study involving semistructured interviews with parents and caregivers of children who presented to hospital with a severe acute exacerbation of asthma., Setting: Hospitals in 12 countries associated with the global Pediatric Emergency Research Networks, including high-income and middle-income countries. Interviews were conducted face-to-face, by teleconference/video-call, or by phone., Findings: Overall, there were 54 interviews with parents and caregivers; 2 interviews also involved the child. Hospital length of stay, intensive care unit or high-dependency unit (HDU) admission, and treatment costs were highlighted as important outcomes influencing the patient and family experience. Other potential clinical trial outcomes included work of breathing, speed of recovery and side effects. In addition, the patient and family experience was impacted by decision-making leading up to seeking hospital care, transit to hospital, waiting times and the use of intravenous treatment. Satisfaction of care was related to communication with clinicians and frequent reassessment., Conclusions: This study provides insight into the outcomes that parents and caregivers believe to be the most important to be considered in the process of developing a COS for the treatment of acute severe exacerbations of asthma., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: There is a need for pragmatic and reliable measures of sound factors that affect evidence-based practice (EBP) adoption and implementation in different languages and cultural environments. The Implementation Leadership Scale (ILS) is a brief and efficient measurement tool of strategic leadership for EBP implementation. The objective of this study was to assess the psychometric properties of the Spanish version of the ILS., Methods: The process of translation of the original ILS into Spanish consisted of forward translation, panel meeting, and back-translation. Scale face and content validity compared to that of the original version were assessed and ensured before agreement on the final version. Psychometric properties were examined in 144 healthcare professionals (family physicians, pediatricians, practice and pediatric nurses) involved in implementation or improvement research projects. ILS factor structure was tested by confirmatory factor analysis (CFA). Reliability was assessed by internal consistency analysis. The Pearson correlation between the ILS and the Organizational Support dimension of the Organizational Readiness for Knowledge Translation (OR4KT) questionnaire in the subsample of pediatricians and pediatric nurses (n = 52) was estimated for convergent validity analysis., Results: The CFA results indicated that the original four theorized first-order factors with a second-order Implementation Leadership factor fit the data well (χ 2  = 107.70; df = 45; p < 0.001). All standardized first- and second-order factor loadings were statistically significant. Fit indexes showed acceptable figures (GFI = 0.90; CFI = 0.97; RMSEA = 0.10; SRMR = 0.053). Cronbach's alpha coefficient for the four dimensions of ILS ranged from 0.90 to 0.97, while the reliability estimated for the total scale was 0.95. Results of convergent validity revealed high correlation (r = 0.56) between the ILS and the OR4KT's Organizational Support dimension., Conclusion: The CFA results demonstrated that the tested first- and second-order factor structure of the 12-item Spanish version of the ILS is consistent with the factor structure of the original tool. The availability of the ILS will allow Spanish-speaking researchers to assess and advance understanding of the implementation leadership construct as a predictor of organizational implementation context., (© 2023. BioMed Central Ltd.)

Numerous studies have shown that quality improvement methods can reduce the use of medications in the management of bronchiolitis. Our objective is to identify factors related to the overuse of salbutamol in the treatment of bronchiolitis before and after an improvement initiative. Observational study of sociodemographic and clinical factors associated with the use of salbutamol in children diagnosed with bronchiolitis. This was a secondary analysis of a prospective cohort study conducted at 135 primary care (PC) centers and eight pediatric emergency departments (ED) in the Osakidetza/Basque Health Service (Spain) in two epidemic seasons between which a bronchiolitis integrated care pathway (BICP) had been implemented: pre-intervention season from October 2018 to March 2019 and post-intervention season from October 2019 to March 2020. Generalized linear mixed models were used to estimate association of studied variables on use of salbutamol over the two seasons. Four thousand one hundred thirty-four ED attendances and 8573 PC visits were included, of which 1936 (46.8%). And 4067 (47.4%) occurred in the post-intervention period respectively. Six independent risk factors were associated with overuse of salbutamol in both seasons: age ≥ 1 year, aOR 2.32 (2.01 to 2.68) in PC centers, and aOR 6.84 (4.98 to 9.39) in EDs; being seen in the last third of the bronchiolitis season, aOR 1.82 (1.51 to 2.18) in PC centers and aOR 1.78 (1.19 to 2.64) in EDs; making more than one visit to the PC center, aOR 4.18 (3.32 to 5.27) or the ED, aOR 2.06 (1.59 to 2.66); being seen by a general practitioner, aOR 1.97 (1.58 to 2.46) in PC centers; and having a more severe episode, aOR 3.01 (1.89 to 4.79) in EDs.     Conclusion:There are factors associated with salbutamol overuse in children diagnosed with bronchiolitis in PC and emergency settings that persist after the deployment of quality improvement initiatives. What is Known: • Quality improvement initiatives have been shown to decrease the use of non-evidence-based treatments and testing in bronchiolitis. • The magnitude and pattern of change in the use of medications linked to the quality improvement initiatives are not uniform across the same health service. What is New: • Children diagnosed with bronchiolitis ≥ 1 year of age, seen in the last third of the bronchiolitis season, attending more than once, treated by a general practitioner, and/or with more severe episodes are more likely to be treated with salbutamol. • These factors may remain present despite the implementation of improvement initiatives focused on reducing the use of medications in the management of bronchiolitis., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

The pharmacological treatment of postherpetic neuralgia (PHN) is unsatisfactory, and there is a clinical need for new approaches. Several drugs under advanced clinical development are addressed in this review. A systematic literature search was conducted in three electronic databases (Medline, Web of Science, Scopus) and in the ClinicalTrials.gov register from 1 January 2016 to 1 June 2023 to identify Phase II, III and IV clinical trials evaluating drugs for the treatment of PHN. A total of 18 clinical trials were selected evaluating 15 molecules with pharmacological actions on nine different molecular targets: Angiotensin Type 2 Receptor (AT2R) antagonism (olodanrigan), Voltage-Gated Calcium Channel (VGCC) α2δ subunit inhibition (crisugabalin, mirogabalin and pregabalin), Voltage-Gated Sodium Channel (VGSC) blockade (funapide and lidocaine), Cyclooxygenase-1 (COX-1) inhibition (TRK-700), Adaptor-Associated Kinase 1 (AAK1) inhibition (LX9211), Lanthionine Synthetase C-Like Protein (LANCL) activation (LAT8881), N-Methyl-D-Aspartate (NMDA) receptor antagonism (esketamine), mu opioid receptor agonism (tramadol, oxycodone and hydromorphone) and Nerve Growth Factor (NGF) inhibition (fulranumab). In brief, there are several drugs in advanced clinical development for treating PHN with some of them reporting promising results. AT2R antagonism, AAK1 inhibition, LANCL activation and NGF inhibition are considered first-in-class analgesics. Hopefully, these trials will result in a better clinical management of PHN.

Objectives: A bronchiolitis integrated care pathway (BICP) proved useful in reducing the use of unnecessary medications at a local level. The aim of this study was to reduce overtreatment by scaling up the BICP across our regional health service in the 2019 and 2020 bronchiolitis season., Methods: We conducted a quality improvement (QI) initiative in 115 primary care (PC) centers and 7 hospitals in the Basque Country, Spain, from October 2019 to March 2020. The primary outcome measure was the percentage of children prescribed salbutamol comparing the rate to that in the previous bronchiolitis season (October 2018-March 2019). Secondary outcomes were the use of other medications. Balancing measures were hospitalization and unscheduled return rates., Results: We included 8153 PC visits, 3424 emergency department (ED) attendances, and 663 inpatient care episodes, of which 3817 (46.8%), 1614 (47.1%), and 328 (49.4%) occurred in the postintervention period, respectively. Salbutamol use decreased from 27.1% to 4.7%, 29.5% to 3.0%, and 44.4% to 3.9% (P &lt; .001) in PC centers, Eds, and hospital wards, respectively. In PC, corticosteroid and antibiotic prescribing rates fell from 10.1% to 1.7% and 13.7% to 5.1%, respectively (P &lt; .001). In EDs and hospital wards, epinephrine use rates fell from 14.2% to 4.2% (P &lt; .001) and 30.4% to 19.8% (P = .001), respectively. No variations were noted in balancing measures., Conclusions: The scaling up of the BICP was associated with significant decreases in the use of medications in managing bronchiolitis across a regional health service without unintended consequences., (Copyright © 2022 by the American Academy of Pediatrics.)

The role of spinal glia in the development and maintenance of chronic pain has become over the last years a subject of increasing interest. In this regard, toll-like receptor 4 (TLR4) signaling has been proposed as a major trigger mechanism. Hence, in this study we explored the implications of TLR4 inhibition in the periphery and primarily in the CNS, focusing on the impact this inhibition renders in pain development and glia activation in the dorsal horn in two models of pain. Making use of a synthetic cluster of differentiation 14 (CD14)/TLR4 antagonist, the effect of TLR4 blockade on tactile allodynia and heat hyperalgesia was evaluated in osteoarthritic and postoperative rat models. An in vitro parallel artificial membrane permeation assay was performed to determine the proneness of the drug to permeate the blood-brain barrier prior to systemic and central administration. Findings suggest a dominant role of peripheral TLR4 in the model of incisional pain, whilst both peripheral and central TLR4 seem to be responsible for osteoarthritic pain. That is, central and peripheral TLR4 may be differently involved in the etiopathology of diverse types of pain what potentially seems a promising approach in the management of pain., (Copyright © 2022 The Authors. Published by Elsevier Masson SAS.. All rights reserved.)

The serum and glucocorticoid-regulated kinase 1 (SGK1) is a widely expressed protein in the Central Nervous System (CNS), involved in regulating the activity of a wide variety of ion channels and transporters and physiological functions, such as neuronal excitability. SGK1.1 is a neuronal splice isoform of SGK1, expressed exclusively in the CNS, distributed in brain and cerebellum, that decreases neuronal excitability via up-regulation of M-current, linked to Kv7.2/3 potassium channels. Strategies to maintain increased SGK1.1 activity could be helpful in decreasing neuronal hyperexcitability, as occurs in neuropathic pain. Transgenic mice overexpressing SGK1.1 (B6.Tg.sgk1) offer a particularly relevant opportunity to assess the physiological involvement of this protein in nociception. Behavior and physiological nociception were evaluated in male and female B6.Tg.sgk1 and wild-type mice (B6.WT), characterizing nociceptive thresholds to different nociceptive stimuli (thermal, chemical and mechanical), as well as the electrophysiological properties of cutaneous sensory Aδ-fibres isolated from the saphenous nerve. The acute antinociceptive effect of morphine was also evaluated. Compared with B6.WT animals, male and female B6.Tg.sgk1 mice showed increased spontaneous locomotor activity. Regarding nociception, there were no differences between transgenic and wild-type mice in heat, chemical and mechanical thresholds, but interestingly, male B6.Tg.sgk1 mice were less sensitive to cold stimulus; B6.Tg.sgk1 animals showed lower sensitivity to morphine. Electrophysiological properties of cutaneous primary afferent fibres were maintained. This is the first demonstration that the SGK1.1 isoform is involved in nociceptive modulation, offering a protective effect against noxious cold stimulus in a sexually dimorphic manner. B6.Tg.sgk1 mice offer a particularly relevant opportunity to further analyze the involvement of this protein in nociception, and studies in models of chronic, neuropathic pain are warranted., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction: The COVID-19 pandemic affected nursing students dramatically when the clinical sites and the onsite classrooms closed to physical participation. This necessitated a move to virtual classrooms and virtual clinical experiences. Some nursing schools adopted telenursing to comply with their Board of Registered Nursing direct patient care requirements. Students value the hands-on nursing in a direct care facility and clinical instructors must replicate this in a virtual setting. This article discusses telenursing and Teach-Back processes with student active engagement that facilitates learning and meets the direct care requirement. The purpose is to share best practice ideas for clinical instructors to educate when clinical settings are unavailable., Methods: This innovation includes examples from five clinical instructors when in-person clinicals were not available due to the COVID-19 pandemic. They used virtual teaching and telenursing for nursing students which complied with clinical requirements of preconference, clinical experience, and post-conference. Telenursing combines case studies or shared documents, student collaboration, and includes a patient or patient actor via telehealth. Clinical instructors present a patient history or case study and allow students time for preparation. Socratic questioning helps students focus on determining the correct questions to ask. Telenursing call to the patient and teach-back questioning validated patient learning. Following the call, the instructor leads a post-conference debrief and students independently document the call., Conclusion: Five clinical instructors follow the process of pre-brief, case presentation, and debrief while students develop critical thinking, strong communication skills, documentation requirements, and utilize the nursing process of assessment, diagnosis, outcome, plan, interventions, and evaluation. Students will have future opportunities to develop hands-on skills as they return to the clinical setting., Competing Interests: Declaration of Conflict of Interests: We have no conflict of interest or funding source. This manuscript has been approved by Chamberlain University College of Nursing., (© The Author(s) 2021.)

Chronic pain remains a major problem worldwide, despite the availability of various non-pharmacological and pharmacological treatment options. Therefore, new analgesics with novel mechanisms of action are needed. Monoclonal antibodies (mAbs) are directed against specific, targeted molecules involved in pain signaling and processing pathways that look to be very effective and promising as a novel therapy in pain management. Thus, there are mAbs against tumor necrosis factor (TNF), nerve growth factor (NGF), calcitonin gene-related peptide (CGRP), or interleukin-6 (IL-6), among others, which are already recommended in the treatment of chronic pain conditions such as osteoarthritis, chronic lower back pain, migraine, or rheumatoid arthritis that are under preclinical research. This narrative review summarizes the preclinical and clinical evidence supporting the use of these agents in the treatment of chronic pain.

Objectives: To analyze the impact of an integrated care pathway on reducing unnecessary treatments for acute bronchiolitis., Methods: We implemented an evidence-based integrated care pathway in primary care (PC) centers and the referral emergency department (ED). This is the third quality improvement cycle in the management of acute bronchiolitis implemented by our research team. Family and provider experiences were incorporated by using design thinking methodology. A multifaceted plan that included several quality improvement initiatives was adopted to reduce unnecessary treatments. The primary outcome was the percentage of infants prescribed salbutamol. Secondary outcomes were prescribing rates of other medications. The main control measures were hospitalization and unscheduled return rates. Salbutamol prescribing rate data were plotted on run charts., Results: We included 1768 ED and 1092 PC visits, of which 913 (51.4%) ED visits and 558 (51.1%) PC visits occurred in the postintervention period. Salbutamol use decreased from 7.7% (interquartile range [IQR] 2.8-21.4) to 0% (IQR 0-1.9) in the ED and from 14.1% (IQR 5.8-21.6) to 5% (IQR 2.7-8) in PC centers. In the ED, the overall epinephrine use rate fell from 9% (95% confidence interval [CI], 7.2-11.1) to 4.6% (95% CI, 3.4-6.1) ( P < .001). In PC centers, overall corticosteroid and antibiotic prescribing rates fell from 3.5% (95% CI, 2.2-5.4) to 1.1% (95% CI, 0.4-2.3) ( P =.007) and from 9.5% (95% CI; 7.3-12.3) to 1.7% (95% CI, 0.9-7.3) ( P <.001), respectively. No significant variations were noted in control measures., Conclusions: An integrated clinical pathway that incorporates the experiences of families and clinicians decreased the use of medications in the management of bronchiolitis., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

We performed a quality improvement initiative to reduce unnecessary treatments for acute bronchiolitis (AB) in primary care (PC) and the referral paediatric emergency department (ED). The quality improvement initiative involved two seasons: 2016-2017 (preintervention) and 2017-2018 (postintervention). We distributed an evidence-based protocol, informative posters and badges with the slogan 'Bronchiolitis, less is more'. We also held interactive sessions, and paediatricians received weekly reports on bronchodilator prescription. The main outcome was the percentage of infants prescribed salbutamol. Secondary outcomes were epinephrine, antibiotic and corticosteroid prescription rates. Control measures were ED visit and hospitalisation rates, triage level, length of stay, intensive care admission and unscheduled returns with admission. We included 1878 ED and 1192 PC visits of which 855 (44.5%) and 534 (44.7%) occurred in the postintervention period, respectively. In the ED, salbutamol and epinephrine prescription rates fell from 13.8% (95% CI 11.8% to 16%) to 9.1% (95% CI 7.3% to 11.2%) (p<0.01) and 10.4% (95% CI 8.6% to 12.4%) to 9% (95% CI 7.2% to 11.1%) (n.s.), respectively. In PC, salbutamol, corticosteroid and antibiotic prescription rates fell from 38.3% (95% CI 34.6% to 42.0%) to 15.9% (95% CI 12.9% to 19.5%) (p<0.01), 12.9% (95% CI 10.5% to 15.7%) to 3.6% (95% CI 2.2% to 5.7%) (p<0.01) and 29.6% (95% CI 26.2% to 33.2%) to 9.5% (95% CI 7.2% to 12.5%) (p<0.01), respectively. No significant variations were noted in control measures. We safely decreased the use of unnecessary treatments for AB. Collaboration between PC and ED appears to be an important factor for success., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Aim: Early life adverse effects have been associated with an increased risk of suffering pain syndromes in adulthood. Although animal models are of great importance to study modifications of pain sensitivity, up to date the results obtained are contradicting due to the varied methodologies used. Therefore, the aim of the present study was to characterise, as a whole, possible modifications in visceral and somatic nociceptive responses in male and female ICR mice, submitted to two different protocols of maternal separation (MS), and possible modifications in the electrophysiological properties of peripheral nociceptive Aδ-primary afferents., Main Methods: Male and female mice were submitted to 3 or 4-8 hr of daily MS from postnatal day (PND) 2-17 and early weaned. On PND 67 von Frey, hot plate and writhing tests were performed. Afterwards electrophysiological recordings were carried out, using the in vitro skin-saphenous nerve preparation in males., Key Findings: The short separation protocol of MS did not modify nociceptive sensitivity; but when mice were separated from their dams for the long separation, mechanical pain thresholds were modified in male and female mice and visceral nociception was increased in female mice. Electrophysiological recordings showed that cutaneous Aδ-fibres were sensitised and their mechanotransduction properties were altered in both MS protocols., Significance: Although MS increases the activity and the mechanosensitivity of cutaneous Aδ-afferent fibres at both short and long periods of separation, only the longer interval of time induces nociceptive sensitivity alterations during adulthood. These results highlight the possible influence of a stress free environment during childhood to reduce nociceptive alterations in adulthood., (© 2020 International Society for Developmental Neuroscience.)

Background: The antineoplastic drugs cisplatin and vincristine induce peripheral neuropathies. The sigma-1 receptor (σ1R) is expressed in areas of pain control, and its blockade with the novel selective antagonist MR-309 has shown efficacy in nociceptive and neuropathic pain models. Our goal was to test whether this compound reduces neuropathic signs provoked by these antitumoural drugs., Methods: Rats were treated with cisplatin or vincristine to induce neuropathies. The effects of acute or repeated administration of MR-309 were tested on mechanical and thermal sensitivity, electrophysiological activity of Aδ-primary afferents in the rat skin-saphenous nerve preparation, and gastrointestinal or cardiovascular functions., Results: Rats treated with antitumourals developed tactile allodynia, while those treated with vincristine also developed mechanical hyperalgesia. These in vivo modifications correlated with electrophysiological hyperactivity (increased spontaneous activity and hyperresponsiveness to innocuous and noxious mechanical stimulation). Animals treated with cisplatin showed gastrointestinal impairment and those receiving vincristine showed cardiovascular toxicity. A single dose of MR-309 strongly reduced both nociceptive behaviour and electrophysiological changes. Moreover, its concomitant administration with the antitumourals blocked the development of neuropathic symptoms, thus restoring mechanical sensitivity, improving the impairment of feeding behaviour and gastrointestinal transit in the cisplatin-treated group along with ameliorating the altered vascular reactivity recorded in rats treated with vincristine., Conclusion: σ1R antagonist, MR-309, reduces sensorial and electrophysiological neuropathic signs in rats treated with cisplatin or vincristine and, in addition, reduces gastrointestinal and cardiovascular side effects., Significance: σ1R antagonism could be an interesting and new option to palliate antitumoural neuropathies., (© 2018 European Pain Federation - EFIC®.)

Aim: We characterised the distress that parents experienced when their child was hospitalised for respiratory syncytial virus (RSV) infection., Methods: This survey-based, observational study was conducted during 2014-2015. Meetings were held in Spain and Italy, with 24 parents of RSV hospitalised infants and 11 healthcare professionals experienced in RSV, which identified 110 factors related to parental distress. The resulting questionnaire was completed by another 105 Spanish and Italian parents and 56 healthcare professionals, to assess the impact these factors had on parental distress, using a scale from 0 to 10 (very unimportant to very important)., Results: The five most important factors for parents were: healthcare professionals' awareness of the latest developments, readmission, reinfections, painful procedures and positive experiences with healthcare professionals. Healthcare professionals associated only medical factors with a meaningful impact on parents. Half of the six medical factors were given similar importance by both groups and the overall scoring for the 110 factors was comparable, with a correlation coefficient of 0.80. A primary concern on discharge was ongoing support., Conclusion: The relationship between parents and healthcare professionals was a significant factor in determining parental distress. Healthcare professionals appeared to have a good understanding of the overall impact on parents, particularly the key medical factors., (©2018 The Authors. Acta Paediatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Paediatrica.)

Objective: To determine whether 2 doses of dexamethasone is as effective as 5 days of prednisolone/prednisone therapy in improving symptoms and quality of life of children with asthma exacerbations admitted to the emergency department (ED)., Study Design: We conducted a randomized, noninferiority trial including patients aged 1-14 years who presented to the ED with acute asthma to compare the efficacy of 2 doses of dexamethasone (0.6 mg/kg/dose, experimental treatment) vs a 5-day course of prednisolone/prednisone (1.5 mg/kg/d, followed by 1 mg/kg/d on days 2-5, conventional treatment). Two follow-up telephone interviews were completed at 7 and 15 days. The primary outcome measures were the percentage of patients with asthma symptoms and quality of life at day 7. Secondary outcomes were unscheduled returns, admissions, adherence, and vomiting., Results: During the study period, 710 children who met the inclusion criteria were invited to participate and 590 agreed. Primary outcome data were available in 557 patients. At day 7, experimental and conventional groups did not show differences related to persistence of symptoms (56.6%, 95% CI 50.6-62.6 vs 58.3%, 95% CI 52.3-64.2, respectively), quality of life score (80.0 vs 77.7, not significant [ns]), admission rate (23.9% vs 21.7%, ns), unscheduled ED return visits (4.6% vs 3.3%, ns), and vomiting (2.1% vs 4.4%, ns). Adherence was greater in the dexamethasone group (99.3% vs 96.0%, P < .05)., Conclusion: Two doses of dexamethasone may be an effective alternative to a 5-day course of prednisone/prednisolone for asthma exacerbations, as measured by persistence of symptoms and quality of life at day 7., Clinical Trial Registration: clinicaltrialsregister.eu: 2013-003145-42., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Assessment tools to classify and prioritize patients, such as systems of triage, and indicators of severity, such as clinical respiratory scores, are helpful in guiding the flow of asthmatic patients in the emergency department., Objective: Our aim was to assess the performance of the Pediatric Assessment Triangle (PAT), triage level (TL), Pulmonary Score (PS), and initial O 2 saturation (O 2 sat), in predicting hospitalization in pediatric acute asthma exacerbations., Study Design: Retrospective study evaluating PAT, TL, and PS at presentation, and initial O 2 sat of asthmatic children in the pediatric emergency department (PED). The primary outcome measure was the rate of hospitalization. Secondary outcomes were length of stay (LOS) in the PED and admission to the pediatric intensive care unit (PICU)., Results: PAT, TL, PS, and initial O 2 sat were recorded in 14,953 asthmatic children. Multivariate analysis yielded the following results: Abnormal PAT and more severe TLs (I-II) were independent risk factors for hospitalization (odds ratio [OR] 1.6, 95% confidence interval [CI] 1.4-1.8; OR 3.4, 95% CI 2.6-4.3, respectively) and longer LOS (OR 1.5, 95% CI 1.3-1.7; OR 2.6, 95% CI 2-3.3, respectively). PS > 3 showed a strong association with hospitalization (OR 8.1, 95% CI 7-9.4), PICU admission (OR 9.6, 95% CI 3-30.9) and longer LOS (OR 6.2, 95% CI 5.6-6.9). O 2 sat < 94% was an independent predictor of admission (OR 5.2, 95% CI 4.6-5.9), PICU admission (OR 4.6, 95% CI 4.5-4.6), and longer LOS (OR 4.6, 95% CI 4.1-5.2)., Conclusions: PAT, TL, PS, and initial O 2 sat are good predictors of hospitalization in pediatric acute asthma exacerbations., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Spirulina maxima (Sm) is a cyanobacterium well known because of its high nutritive value, as well as its anti-inflammatory, anti-hyperlipidemic, antioxidant, and anti-genotoxic activities., Objective: To determine the capacity of Sm to inhibit the induction of aberrant colon crypts (AC), as well as the level of lipid peroxidation and DNA oxidative damage in mice treated with azoxymethane (AOM)., Materials and Methods: Sm (100, 400, and 800 mg/kg) was daily administered to animals by the oral route during 4 weeks, while AOM (10 mg/kg) was intraperitoneally injected to mice twice in weeks 2 and 3 of the assay. We also included a control group of mice orally administered with distilled water along the assay, as well as other group orally administered with the high dose of Sm., Results: A significant decrease in the number of AC with the three tested doses of Sm, with a mean protection of 51.6% respect to the damage induced by AOM. Also, with the three doses of the alga, we found a reduction in the level of lipoperoxidation, as well as in regard to the percentage of the DNA adduct 8-hydroxy-2'- deoxyguanosine., Conclusion: Sm possesses anti-precarcinogenic potential in vivo, as well as capacity to reduce the oxidative damage induced by AOM., Summary: Azoxymethane (AOM) induced a high number of colon aberrant crypts in mouse. It also increased the level of peroxidation and of DNA oxidation in the same organ.Spirulina maxima significantly reduced the number of AOM-induced colon aberrant crypts in mouse. It also reduced the AOM-induced lipid and DNA oxidation in mouse.The results suggest a chemopreventive potential for the tested algae.

Aim: To determine the characteristics of patients with dementia who died in a psychogeriatric unit, and to describe the conditions that led to their death., Material and Methods: Observational study of patients who died in the Psychogeriatric unit of Hospital de la Santa Creu de Vic during a three and a half year period., Results: Of the 554 patients admitted during the study period, we recorded a mortality of 14.6% (81 patients). The analysis of those who died showed that 67.9% were women, with a mean age of 85.8 years, with the most frequent cause being Alzheimer type dementia (37%) and being in an advanced stage (CDR3, GDS 6-7) in 72.8% of cases. On admission the following characteristics were recorded: Mini Mental State Examination (MMSE) 9.5, Barthel Index (BI) prior to entry 50.1, BI on admission 17.4, and Neuropsychiatric Inventory (NPI) 31.4. A therapeutic limitation treatment was determined for 84% of patients on admission. From the analysis of the conditions that lead to death it was noted that: In 74.1% of the patients the death was a direct result of a triggering event (the most frequent being respiratory infection), in 17.3% the death occurred by a gradual decline, with no clear precipitating factor, and in 8.6% of patients palliative sedation was required due to poorly controlled symptoms., Conclusions: Intercurrent problems were the most common factors related to the death of the patients. Most patients died in the stages prior to the established criteria for terminal dementia. In some cases patients may experience disorder behavior as a refractory symptom., (Copyright © 2012 SEGG. Published by Elsevier Espana. All rights reserved.)

We performed a 7-year registry-based retrospective study. We included 1365 infants younger than 3 months of age with fever without a source; 81 (5.9%) had <5000 leukocytes/mm(3). Among the 1021 well-appearing 29- to 90-day-old infants, prevalence of serious bacterial infection (SBI) was 13.8% for those with a normal white blood cell count, 6.8% for those with leukopenia (odds ratio, 0.45), and 36.6% for those with leukocytosis (odds ratio, 3.59). None of the 9 well-appearing febrile neonates with leukopenia developed an SBI. Leukopenia, in well-appearing young febrile infants, should not be considered as an SBI risk factor.

We analyzed 239 febrile infants <3 months of age with a positive urine culture to examine their characteristics. Patients with altered urine dipstick showed more commonly alterations of the biologic markers for bacterial infection, and Escherichia coli was more commonly isolated. Febrile young infants with positive urine culture and negative urine dipstick may not have a urinary tract infection and less aggressive management can be considered.