Recent Publications by CFE Educators

After severe neurocognitive decline developed in an otherwise healthy 63-year-old man, brain magnetic resonance imaging showed eosinophilic meningoencephalitis and enhancing lesions. The patient tested positive for antibodies to Baylisascaris spp. roundworms, was treated with albendazole and dexamethasone, and showed improvement after 3 months. Baylisascariasis should be considered for all patients with eosinophilic meningitis.

OBJECTIVES

To develop a Glucocorticoid Toxicity Index (GTI) to assess glucocorticoid (GC)-related morbidity and GC-sparing ability of other therapies.

METHODS

Nineteen experts on GC use and outcome measures from 11 subspecialties participated. Ten experts were from the USA; nine from Canada, Europe or Australia. Group consensus methods and multicriteria decision analysis (MCDA) were used. A Composite GTI and Specific List comprise the overall GTI. The Composite GTI reflects toxicity likely to change during a clinical trial. The Composite GTI toxicities occur commonly, vary with GC exposure, and are weighted and scored. Relative weights for items in the Composite GTI were derived by group consensus and MCDA. The Specific List is designed to capture GC toxicity not included in the Composite GTI. The Composite GTI was evaluated by application to paper cases by the investigators and an external group of 17 subspecialists.

RESULTS

Thirty-one toxicity items were included in the Composite GTI and 23 in the Specific List. Composite GTI evaluation showed high inter-rater agreement (investigators κ 0.88, external raters κ 0.90). To assess the degree to which the Composite GTI corresponds to expert clinical judgement, participants ranked 15 cases by clinical judgement in order of highest to lowest GC toxicity. Expert rankings were then compared with case ranking by the Composite GTI, yielding excellent agreement (investigators weighted κ 0.87, external raters weighted κ 0.77).

CONCLUSIONS

We describe the development and initial evaluation of a comprehensive instrument for the assessment of GC toxicity.

BACKGROUND

The boundaries for orthodontic tooth movement are set by the bony support of the dentition. This study compares the mandibular anterior alveolar housing in individuals with low, average, and high mandibular plane angles before orthodontic treatment and measures alveolar bone loss and root resorption after orthodontic treatment.

METHODS

Pretreatment cone-beam computed tomography (CBCT) images of 75 non-growing individuals, 25 in three groups: low-angle (sella-nasion to mandibular plane ≤28°), average-angle (30°-37°), and high-angle (≥39°), were analyzed. Buccolingual bone thickness was measured at the root apex, mid-root, and alveolar crest of the mandibular right central incisor. Pre- and posttreatment CBCT images of 11 low-angle, 20 average-angle, and 27 high-angle patients were compared to determine changes in the alveolus and mandibular incisor root after orthodontic treatment.

RESULTS

The pretreatment anterior alveolar bone widths were significantly different, wider in low-angle than in average- and high-angle individuals (p value = 0.000). High-angle individuals also had greater posttreatment external root resorption, even though the bony housing changed minimally.

CONCLUSIONS

Negative sequelae of orthodontic treatment are more frequently found in individuals with high mandibular plane angles and could be linked to their thin pre-existing alveolar housing.

OBJECTIVE

To identify predictors of post-operative respiratory complications in children undergoing tonsillectomy.

METHODS

Consecutive case series with chart review of children who underwent polysomnography (PSG) and subsequent tonsillectomy with or without adenoidectomy for obstructive sleep apnea (OSA). Patients with craniofacial anomalies or significant cardiopulmonary comorbidities were excluded. Rates of post-surgical respiratory complication were reviewed and compared to patient specific factors and PSG findings to identify possible risk factors.

RESULTS

Eighty-six patients (mean age 5.3 ± 2.2 years) were included. There was a statistically significant (p = 0.03) relationship between an AHI ≥40 (AHI40) and post-operative respiratory complications. AHI40 also had the greatest magnitude of association with postoperative respiratory complications (OR = 5.313). An AHI ≥25 (AHI25) was marginally significant (p = 0.067). No significant difference in outcome occurrence was found when analyzing rates of complication in patients with BMI above and below 18 (p = 0.20) or oxygen (O2) nadir above and below 80% (p = 0.09). The AHI ranged from 0 to 112.2, and no postoperative respiratory complications were identified in children with an AHI less than 10.

CONCLUSIONS

Our results indicate an association between an AHI ≥40 and respiratory complications following an adenotonsillectomy, but we were not able to observe any significant difference at a cutoff of 25. An association between BMI or O2 nadir and postoperative respiratory complication was not able to be identified. Our results support the importance of AHI as a predictor of postoperative respiratory complications in children undergoing tonsillectomy for OSA.

The goal of the study was to test the bidirectional associations between teacher-child relationship quality and behavior problems in an elementary school age sample of Chinese American immigrant children. A socioeconomically diverse sample (N = 258) of first- and second-generation Chinese American children (M ages = 7.4 and 9.2 years at Wave 1 and Wave 2, respectively; 48% girls) was recruited from schools and communities and followed for 1 to 2 years. Two waves of data on dimensions of teacher-child relationship quality (i.e., warmth, closeness, and conflict) and children's externalizing and internalizing problems were collected through parents', teachers', and children's report. Path analyses were conducted to test the bidirectional associations between teacher-child relationship quality and behavior problems, controlling for prior levels, child demographic characteristics, and teacher ethnicity. Transactional associations between teacher-child relationship quality and children's behavior problems were found for externalizing problems. That is, teacher-rated externalizing problems negatively predicted child-rated closeness, and teacher-rated conflict positively predicted parent-rated externalizing problems. On the other hand, teacher-child relationship quality did not predict subsequent internalizing problems. However, parent-rated internalizing problems negatively predicted teacher-rated warmth, and teacher-rated internalizing problems negatively predicted teacher-rated conflict. Using a multiple informant approach and a diverse sample of Chinese American immigrant children, this study extends our knowledge of the reciprocal associations between teacher-child relationship quality and children's behavior problems. Based on the results of this study, the authors provide recommendations for educators and future research with this understudied population.

STUDY DESIGN

The aim of this study is to test the effect of cartilage oligomeric matrix protein (COMP) on enhancing rhBMP-2 induced spinal fusion in a prospective 8-week interventional trial of spinal fusion in rats.

OBJECTIVE

To determine whether the amount of bone morphogenetic protein-2 (BMP-2) required to achieve spinal fusion in a pre-clinical model can be reduced by the addition of COMP.

SUMMARY OF BACKGROUND DATA

BMPs are applied clinically at supraphysiological doses to promote spinal fusion by inducing osseous growth, but dose-related limitations include ectopic bone formation and local inflammatory reactions. COMP is a matricellular BMP-binding protein expressed during endochondral ossification and fracture healing. In vitro studies demonstrate enhanced activity of BMP bound to COMP. We hypothesized that BMP bound to COMP could achieve equivalent spinal fusion rates at lower doses and with fewer complications.

METHODS

Posterolateral intertransverse process spinal fusion at L4 to L5 was performed in 36 Lewis rats. COMP (10 μg) was tested with or without "low-dose" rhBMP-2 (2 μg), and the results were compared with the "low-dose" (2 μg rhBMP-2) and "high-dose" (10 μg rhBMP-2) groups. All groups utilized insoluble collagen bone matrix carrier (ICBM). Fusion was evaluated by radiology, histology, and manual palpation. BMP release kinetics were evaluated in vitro.

RESULTS

Fusion grading of microCT images demonstrated that the fusion rate with the COMP+LoBMP was statistically equivalent to HiBMP, and significantly better than LoBMP without COMP. These results were confirmed with radiographs and manual palpation. BMP release kinetics suggest that COMP increased local concentrations of BMP due to decreased growth factor retention on the scaffold.

CONCLUSION

COMP enhances BMP-induced bone formation, enabling lower doses of BMP to achieve the same level of spinal fusion. COMP may function by affecting the availability and biological presentation of BMP-2. A decrease of BMP-2 required for fusion may reduce dose-related adverse effects, surgical costs, and improve clinical outcomes.

LEVEL OF EVIDENCE

N/A.