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Mikhael M.,University of Texas at Dallas | Brown L.S.,Parkland Health and Hospital System | Rosenfeld C.R.,University of Texas at Dallas
Journal of Pediatrics | Year: 2014

Objective To validate established neonatal neutrophil reference ranges (RRs) and determine the utility of serial measurements of neutrophil values in the first 24 hours to predict the absence of neonatal early-onset sepsis (EOS). Study design Retrospective study of 2073 admissions to the neonatal intensive care unit (2009-2011). Neonates were classified as blood culture-positive, proven EOS (n = 9), blood culture-negative but clinically suspect EOS (n = 292), and not infected (n = 1292). Neutrophil values from 745 not-infected neonates without perinatal complications were selected to validate RR distributions. Positive and negative predictive values were calculated; area under receiver operating characteristic curves (AUCs) were constructed to predict the presence or absence of EOS. Neutrophil value scores were established to determine whether serial neutrophil values predict the absence of EOS. Results Seventy-seven percent of admissions to the neonatal intensive care unit were evaluated for EOS: 9 (0.56%) had proven EOS with positive blood culture ≤37 hours; 18% had clinically suspect EOS. Neutropenia occurred in preterm neonates, and nonspecific neutrophilia was common in uninfected neonates. The distribution of neutrophil values differed significantly between study groups. The specificity for absolute total immature neutrophils and immature to total neutrophil proportions was 91% and 94%, respectively, with negative predictive value of 99% for proven and 78% for proven plus suspect EOS. Absolute total immature neutrophils and immature to total neutrophil proportions had the best predictability for EOS >6 hours postnatal with an AUC ∼0.8. Neutrophil value scores predicted the absence of EOS with AUC of 0.9 and 0.81 for proven and proven plus suspect EOS, respectively. Conclusion Age-dependent neutrophil RRs remain valid. Serial neutrophil values at 0, 12, and 24 hours plus blood culture and clinical evaluation can be used to discontinue antimicrobial therapy at 36-48 hours. © 2014 Mosby Inc. Source


Kapadia V.S.,University of Texas Southwestern Medical Center | Chalak L.F.,University of Texas Southwestern Medical Center | Sparks J.E.,University of Texas Southwestern Medical Center | Allen J.R.,Parkland Health and Hospital System | And 2 more authors.
Pediatrics | Year: 2013

OBJECTIVE: To determine whether a limited oxygen strategy (LOX) versus a high oxygen strategy (HOX) during delivery room resuscitation decreases oxidative stress in preterm neonates. METHODS: A randomized trial of neonates of 24 to 34 weeks' gestational age (GA) who received resuscitation was performed. LOX neonates received room air as the initial resuscitation gas, and fraction of inspired oxygen (FIO2) was adjusted by 10% every 30 seconds to achieve target preductal oxygen saturations (SpO2) as described by the 2010 Neonatal Resuscitation Program guidelines. HOX neonates received 100% O2 as initial resuscitation gas, and FIO2 was adjusted by 10% to keep preductal SpO2 at 85% to 94%. Total hydroperoxide (TH), biological antioxidant potential (BAP), and the oxidative balance ratio (BAP/TH) were analyzed in cord blood and the first hour of life. Secondary outcomes included delivery room interventions, respiratory support on NICU admission, and short-term morbidities. RESULTS: Forty-four LOX (GA: 306 3 weeks; birth weight: 1678 ± 634 g) and 44 HOX (GA: 30 ± 3 weeks; birth weight: 1463 ± 606 g) neonates were included. LOX decreased integrated excess oxygen (∑FIO2 3 time [min]) in the delivery room compared with HOX (401 ± 151 vs 662 ± 249; P < .01). At 1 hour of life, BAP/TH was 60% higher for LOX versus HOX neonates (13 [9-16] vs 8 [6-9]) μM/U.CARR, P < .01). LOX decreased ventilator days (3 [0-64] vs 8 [0-96]; P < .05) and reduced the incidence of bronchopulmonary dysplasia (7% vs 25%; P < .05). CONCLUSIONS: LOX is feasible and results in less oxygen exposure, lower oxidative stress, and decreased respiratory morbidities and thus is a reasonable alternative for resuscitation of preterm neonates in the delivery room. © 2013 by the American Academy of Pediatrics. Source


Clarke C.F.,Dynamis | Bradley K.K.,Office of the State Epidemiologist | Glowicz J.,Parkland Health and Hospital System
American Journal of Tropical Medicine and Hygiene | Year: 2013

Autochthonous human cases of leishmaniasis in the United States are uncommon. We report three new cases of cutaneous leishmaniasis and details of a previously reported case, all outside the known endemic range in Texas. Surveys for enzootic rodent reservoirs and sand fly vectors were conducted around the residences of three of the casepatients during the summer of 2006; female Lutzomyia anthophora sand flies were collected at a north Texas and southeast Oklahoma residence of a case-patient, indicating proximity of a suitable vector. Urban sprawl, climatologic variability, or natural expansion of Leishmania mexicana are possible explanations for the apparent spread to the north and east. Enhanced awareness among healthcare providers in the south central region of the United States is important to ensure clinical suspicion of leishmaniasis, diagnosis, and appropriate patient management. Copyright © 2013 by The American Society of Tropical Medicine and Hygiene. Source


Boyd N.,Parkland Health and Hospital System | Nailor M.D.,University of Connecticut
Pharmacotherapy | Year: 2011

The widespread emergence of antibiotic-resistant gram-negative organisms has compromised the utility of current treatment options for severe infections caused by these pathogens. The rate of gram-negative multidrug resistance is worsening, threatening the effectiveness of newer broad-spectrum antibiotic agents. Infections associated with multidrug-resistant Pseudomonas aeruginosa, Acinetobacter baumannii, and Enterobacteriaceae are having a substantial impact on hospital costs and mortality rates. The potential for these resistant gram-negative nosocomial pathogens must always be a primary consideration when selecting antibiotic therapy for critically ill patients. Empiric combination therapy directed at gram-negative pathogens is a logical approach for patients with suspected health care-associated infections, particularly those with risk factors for infections caused by multidrug-resistant pathogens. Although in vitro synergy tests have shown potential benefits of continued combination therapy, convincing clinical data that demonstrate a need for combination therapy once susceptibilities are known are lacking. Thus, deescalation to a single agent once susceptibilities are known is recommended for most patients and pathogens. Use of polymyxins, often in combination with other antimicrobials, may be necessary for salvage therapy. Source


Liedtke M.D.,The University of Oklahoma Health Sciences Center | Vanguri A.,Parkland Health and Hospital System | Chris Rath R.,The University of Oklahoma Health Sciences Center
Annals of Pharmacotherapy | Year: 2012

OBJECTIVE: To report a probable drug interaction between the antiretroviral TRIO regimen (ritonavir-boosted darunavir, etravirine, and raltegravir) and warfarin in an HIV-infected patient. CASE SUMMARY: In January 2010, a 50-year-old transgender female with HIV infection and recurrent deep vein thrombosis began treatment with the TRIO study regimen. Treatment had been maintained with warfarin for the past 5 years and emtricitabine monotherapy for the preceding 22 months. Emtricitabine was discontinued when the TRIO regimen was started. The mean weekly warfarin dose while the patient was receiving emtricitabine monotherapy was 13.3 mg (95% CI 12.7 to 13.8), with a mean international normalized ratio (INR) of 2.8 (95% CI 2.5 to 3.1). Following the initiation of the TRIO regimen, the mean weekly warfarin dose was increased to 19.3 mg (95% CI 18.5 to 20.1) and was maintained over the ensuing 71 weeks with a mean INR of 2.6 (95% CI 2.2 to 3.0). DISCUSSION: Information on the effect of newer antiretrovirals on warfarin metabolism, as well as the collective contribution of combination antiretroviral therapy including multiple agents that may alter warfarin metabolism, is limited. We predicted that warfarin dose requirements would change upon initiation of the TRIO regimen. Given the variability in INR that can occur with chronic warfarin treatment, weekly warfarin doses were averaged during emtricitabine monotherapy (90 weeks) and TRIO regimen (71 weeks) periods. Mean weekly warfarin doses increased by 45% (p < 0.001) following initiation of the TRIO regimen. Mean INR results for the 2 time periods were not significantly different, demonstrating that stable anticoagulation was maintained. The Horn drug interaction probability scale score to assess causation indicated a probable interaction. CONCLUSIONS: An increased weekly warfarin dose requirement is predicted when warfarin is used concurrently with the antiretroviral TRIO regimen. Increased INR monitoring is prudent when the combination is administered. Source

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