We have confirmed that the International Society for Peritoneal Dialysis (ISPD) dosing guideline for vancomycin in CAPD and APD patients produces adequate serum concentrations of the antibiotics in the vast majority. However, large incremental dosing of vancomycin is needed if day-5 levels are low; especially for not-anuric patients. Whilst evidence of gentamicin toxicity in PD remains controversial, ISPD dosing regimen resulted in high levels for>50% patients. High gentamicin concentrations did not correlate with treatment success, but switching gentamicin to ceftazidime at day 5 appeared safe and limited aminoglycoside exposure. Increasing vancomycin and gentamicin concentrations do not appear to improve cure rates and alternative strategies (such as combination treatment) should be considered for future research.
ImportancePhysical abuse is a common but preventable cause of long-term childhood morbidity and mortality. Despite the strong association between abuse in an index child and abuse in contact children, there is no guidance outlining how to screen the latter, significantly more vulnerable group, for abusive injuries. Consequently, the radiological assessment of contact children is often omitted, or variably performed, allowing occult injuries to go undetected and increasing the risk of further abuse.ObjectiveTo report an evidence-based and consensus-derived set of best practices for the radiological screening of contact children in the context of suspected child physical abuse.Evidence ReviewThis consensus statement is supported by a systematic review of the literature and the clinical opinion of an internationally recognized group of 26 experts. The modified Delphi consensus process comprised 3 meetings of the International Consensus Group on Contact Screening in Suspected Child Physical Abuse held between February and June 2021.FindingsContacts are defined as the asymptomatic siblings, cohabiting children, or children under the same care as an index child with suspected child physical abuse. All contact children should undergo a thorough physical examination and a history elicited prior to imaging. Contact children younger than 12 months should have neuroimaging, the preferred modality for which is magnetic resonance imaging, and skeletal survey. Contact children aged 12 to 24 months should undergo skeletal survey. No routine imaging is indicated in asymptomatic children older than 24 months. Follow-up skeletal survey with limited views should be performed if abnormal or equivocal at presentation. Contacts with positive findings should be investigated as an index child.Conclusions and RelevanceThis Special Communication reports consensus recommendations for the radiological screening of contact children in the context of suspected child physical abuse, establishing a recognized baseline for the stringent evaluation of these at-risk children and providing clinicians with a more resilient platform from which to advocate for them.
Pulmonary embolism associated with intravenous immunoglobulin therapy TO THE EDITOR: Intravenous immunoglobulin (IVIG) therapy has gained popularity for the treatment of neuromuscular diseases (i.e., myasthenia gravis, inflammatory myopathy, chronic inflammatory demyelinating polyneuropathy), although adverse events are associated with high-dose IVIG infusions. 1,2 Common adverse reactions to IVIG therapy are anxiety, headache, fever, chills, chest pain, dyspnea, nausea, and abdominal pain. 3 More serious adverse events include anaphylaxis, hemolytic anemia, hepatitis C, and thrombosis. 3 Studies have shown documented effects of IVIG on blood rheology. It increases plasma viscosity in a dose-related response and may also activate platelets. 2-4 Highdose IVIG therapy is approximately 24-54 g/d. 4 Case Report. A 55-year-old white man presented to the emergency department (ED) complaining of chest pain and shortness of breath for 5 days in mid-2002. The patient's past medical history included sleep apnea, hypertension, deepvein thrombosis (DVT), peripheral neuropathy, and immunosuppressive syndrome. He had no history of diabetes or heart or lung disease, and his family history was noncontributory. Current medications included warfarin for treatment of DVT caused by Port-A-Cath and IVIG for peripheral neuropathy. He also used oxycodone/acetaminophen and amitriptyline as needed. The patient used continuous positive airway pressure for sleep apnea. His last IVIG infusion had been administered 7 days prior to the ED visit. Abnormal laboratory test findings in ED were international normalized ratio (INR) 1.73 (normal 2-3), partial thromboplastin time 45.7 seconds (21-35), pH 7.47 (7.36-7.44), and pO 2 60 mmHg (90-100). A computed tomography scan of the chest discovered bilateral pulmonary embolism in the right lower and left upper lobes. He was admitted to the hospital with severe stenosis extending to the occlusion of the left subclavian vein, and his left inominate vein was thrombosed by >5 cm. The patient had a history of thrombosis, and now bilateral pulmonary emboli were noted without obvious triggering factors. Upon further investigation, we found that the patient had been evaluated at another institution for peripheral neuropathy of unknown origin in 2000. He suffered from severe burning, tingling, numbness, and pain in his extremities that was incapacitating when he was not receiving IVIG. He had developed his first DVT in late 2001. At that time, the patient started IVIG infusions twice weekly. Due to cost issues, the infusions were decreased to once a week at the beginning of 2002. After evaluating all potential causes for thrombosis, including the subtherapeutic INR upon admission, IVIG was determined to be the most probable cause of pulmonary embolism according to the Naranjo probability scale, 5 and the patient was advised to discontinue IVIG therapy. Inpatient treatment for pulmonary embolism included enoxaparin and warfarin and, on discharge, the patient was prescribed subcutaneous enoxaparin 100 mg twice ...
Occupational therapy was associated with positive functional outcomes for patients with MS. Future treatment protocols should include cognitive skills training, community reintegration, and self-care, because these treatments were found to be significantly correlated with positive changes in FIM scores.
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