In the latest of their numerous innovative studies of the symptoms and experiences of neonatal intensive care unit (NICU) babies with trouble swallowing (dysphagia), physicians and researchers at Nationwide Children’s Hospital and The Ohio State University College of Medicine have identified and refined which symptoms suggest treatment-worthy gastroesophageal reflux disease (GERD). The team believes its body of work on the topic will make future GERD diagnosis and treatment in infants more appropriate.
More than 10 percent of NICU babies are believed to have GERD. Despite several risks associated with acid-suppressive medication in NICU babies, such as nosocomial infections, enterocolitis, osteopenia and malabsorption of nutrients, these tiny patients are often medically treated for GERD when any common symptom of the condition is present. In such young babies, these symptoms can include feeding difficulties, gagging, coughing, arching the back or acting irritable, grimacing, vomiting, sneezing, flushing, or grunting.
“NICU infants have many aerodigestive symptoms on a daily basis. There is a perceived myth that these symptoms are due to acid GERD and therefore using acid-suppressive medications will ameliorate the symptoms. This myth is not true, and can be dangerous,” says Sudarshan Jadcherla, MD, director of the Neonatal and Infant Feeding Disorders Program at Nationwide Children’s, member of the hospital’s Division of Neonatology and senior author on the publication, released earlier this year in Dysphagia. “Using acid-suppressive therapy without a definite diagnosis and symptom association probability not only diverts attention from what might be a different, undiagnosed problem, but also creates the new problem of dealing with dosing, treatment duration decisions, side effects and sequelae.”
Dr. Jadcherla acknowledges the practical challenges to confirming acid GERD and symptom association probability, however. “Accurate documentation of troublesome symptoms is required in a timely manner so that comparisons with the actual GER event characteristics can be made,” he says.
To help overcome this clinical disconnect and determine which symptoms merit acid suppression therapy, Dr. Jadcherla and his colleagues performed 24-hour pH-impedance tests on 53 infants in the NICU at Nationwide Children’s. More than 2000 acid reflux events (AREs) were documented, allowing the team to determine whether the babies’ GERD symptoms correlated with the presence and location of acid in the esophagus.
Their findings suggest that treating apparent GERD with proton pump inhibitors may be appropriate when the baby’s acid reflux index (ARI) score is greater than 7, AREs reach the middle or proximal areas of the esophagus, and there is abnormal symptom correlation between the ARI and ARE based on pH-impedance testing.
“This approach will separate false positives from true positives, thus providing opportunities to test the effect of therapies for those with the probability of acid-GERD,” Dr. Jadcherla says. “We still have to learn whether a placebo or acid-suppressive therapy can produce the same benefits, both in the short term and long term.”
Dr. Jadcherla hopes that this research and eventual randomized control trials evaluating GERD therapies using pH-impedance testing will move neonatologists closer to an actionable, objective and more specific treatment criteria for GERD management in NICU babies.

Nationwide Children’shttps://tinyurl.com/y9d83jey

Extended shift work has historically been linked to interrupted sleep patterns and risk of injury, and is a persistent problem for emergency medical services (EMS) personnel who are tasked with delivering acute care under significant pressure.
New guidelines, written by a team led by University of Pittsburgh School of Medicine scientists and published aim to mitigate the effects of fatigue by addressing the impact of shift work and scheduling.
“The problem of fatigued EMS personnel is widespread and not isolated to one type of EMS operation or category of EMS clinician. Administrators of EMS organizations are not sufficiently equipped to address fatigue in the workplace, in part because of the absence of guidelines for fatigue risk management in the EMS setting,” said Daniel Patterson, Ph.D., lead author and assistant professor of emergency medicine at the Pitt School of Medicine
After review and analysis of more than 38,000 journal articles, conference presentations and other publications, Patterson and his colleagues gathered information on fatigue and shift work to develop the evidence-based guidelines for fatigue risk management and test the impact of the findings to create a biomathematical model for use by the EMS community to aid in shift-scheduling decisions.
The guidelines consist of five recommendations:

• Use of fatigue/sleepiness surveys to measure and monitor EMS personnel fatigue.
• Limit EMS shifts to less than 24 hours in duration.
• Give EMS personnel access to caffeine to help stave off fatigue.
• Allow EMS personnel the opportunity to nap while on duty.
• Provide education and training in fatigue risk management to EMS personnel.

Patterson and his team expect the guidelines to have a wide impact on improving practice and policies to alleviate EMS personnel fatigue, whether when driving an ambulance or caring for patients.
 “Operating the ambulance is only one aspect of EMS care,” said Patterson. “Most of the work EMS clinicians do is actually patient care. Fatigue affects decision-making abilities and overall performance, and with the pressure of delivering acute care, one wrong decision can be detrimental.”
Pitt Health Scienceshttps://tinyurl.com/y835qdwx

A new blood test developed by a University of Alberta physician promises to eliminate the guesswork clinicians face with an apparent heart attack.
The current gold standard test used for the clinical diagnosis of myocardial infarction (MI or death of heart muscle due to lack of blood supply)—the cardiac troponin blood test—doesn’t indicate the extent of cardiac damage, said Peter Hwang, a clinician-scientist in the Faculty of Medicine & Dentistry at the U of A.
Cardiac troponin is a protein unique to the heart, so elevated levels in the blood indicate that the heart has been damaged, explained Hwang. After digging deeper into what’s going on in the troponin release process, he found that patients with a true heart attack had more fragmented troponin than those with increased cardiac strain.
“We postulated that when cells die during a heart attack, not only would they release troponin into the bloodstream, but they would also digest the troponin through the action of activated intracellular proteases—enzymes that digest other proteins,” he said.
The study included 29 inpatients from the University of Alberta Hospital and Mazankowski Heart Institute with elevated troponin levels either with known heart attacks, or other conditions that increase cardiac demand.
“As predicted, we found that the degree of proteolytic digestion increased with increasing severity of heart injury,” he said.
“The highest degree was observed in patients with type 1 MI (the classic “heart attack”), where you have an acute blockage of a coronary artery, while the least degree was found in patients with type 2 MI, where the heart is just working harder.”
Hwang added that, while the existing troponin test is still very useful, the new test would enable clinicians to make objective decisions about treating patients when faced with less clear-cut situations.
Currently, doctors rely on clinical context when interpreting an elevated troponin level because it could just as easily be caused by running a marathon or fighting a life-threatening infection as it could by a heart attack, explained Hwang.
“Sometimes the correct answer to the question—is it a heart injury or merely strain—isn’t always obvious, even with all the clinical information,” he added.
“Suppose there is a critically ill patient (say, fighting a severe life-threatening infection) with an elevated troponin level. Is the patient having a heart attack? Or is the troponin level elevated because the heart is working hard?”
The decision clinicians make could result in sending the patient for cardiac catheterization—an invasive procedure with some risks—or continuing current management, he explained.
“This is a very real diagnostic dilemma faced by doctors treating patients. This test could resolve the challenge,” he said.
Further research is necessary before the new troponin blood test becomes the new standard in heart attack testing, added Hwang.
University of Albertawww.folio.ca/new-blood-test-could-help-physicians-tell-difference-between-heart-attack-and-heart-strain/

Johns Hopkins researchers report success with a smart phone video-based app that substitutes for a daily in-person visit by a health care worker required for tuberculosis treatment known as directly observed therapy, or DOT. The preliminary study showed that the app may be less costly and may improve privacy concerns raised by patients compared to in-person visits.
“We believe video DOT offers an alternative that appears to be as effective as an in-person daily visits by health care workers to assure compliance with drug treatment, but also empowers patients to manage their TB without added stress,” says Samuel Holzman, M.D., a research fellow in the department of infectious diseases at the Johns Hopkins University School of Medicine.
Tuberculosis is one of the few diseases in the U.S. with state and federal provisions outlining recommended and sometimes required measures to ensure that patients adhere to treatment. These recommendations include provisions for home or hospital based isolation or occasionally forced isolation for infectious individuals. Treatment for tuberculosis is effective and benefits not only the patient, but also the public by reducing the chances of ongoing transmission.
The reason for these mandates, says Holzman, is the disease’s virulence. Unlike the flu or the common cold, Mycobacterium tuberculosis, the bacteria that causes infectious tuberculosis, can hang in the air for extended periods when expelled by the coughs or saliva of patients, spreading to others across a room or through a building’s ventilation. Many people with active TB also have relatively few symptoms, allowing the bacteria to spread before a diagnosis is made.
Tuberculosis is typically treated for six months with a battery of daily antibiotics that include a multidrug combination that can be challenging patients to take. The number of side-effects related to the drugs and the motivation needed to continue the long treatment courses can cause patients to stop their treatment early without appropriate monitoring and strong support. Treatments become even more intensive when caring for multidrug or extensively drug-resistant TB, which require additional antibiotics and can take up to two years to bring under control.
 As such, most local health departments in the U.S. require that health care workers observe patients taking their medications to document that they were taken correctly and to monitor for side-effects. In most cases, in-person DOT is conducted five days a week on weekdays and is therefore costly and resource-intensive for local departments of health who absorb the costs associated with treatment.
Nonetheless, this practice helps to support patients through the difficult regimen and provides clinicians a means of tracking a patient’s progress and in-person DOT is the standard of care for TB treatment in the US and globally.  However, DOT has the potential to be logistically challenging for patients and is viewed by some patients as stigmatizing or interfering with their autonomy and privacy.
“In an era when we are focused on patient centred care, having to meet a health provider every single day is logistically challenging and can be personally invasive,” says Maunank Shah, M.D., Associate Professor of Medicine in the Department of Infectious Diseases at the Johns Hopkins University School of Medicine.
To test the effectiveness of video DOT, the researchers conducted a pilot study utilizing the widely-available smartphone application developed by emocha Mobile Health in conjunction with Shah and other clinician-scientists at the Johns Hopkins University School of Medicine.
28 adult TB patients being treated at three health departments in Maryland participated in the pilot study.  These patients had their therapy monitored using the emocha video DOT application in lieu of in-person visits by a health care worker.
The researchers found that patient adherence to treatment was approximately the same between the video DOT and in-person DOT, 94 percent and 98 percent respectively.  As importantly, when including weekends and holidays in the assessment of adherence, the researchers found that the overall proportion of prescribed doses that were verified through observation was 6 percent higher with video DOT compared to in-person DOT.
The researchers also sought to assess the app’s acceptability to patients and clinicians by conducting qualitative interviews and surveys. Ten patients and sixteen staff were interviewed and/or completed surveys after the study.  One hundred percent of the patients felt that the emocha platform was ‘easy to use’ and preferred it over in-person DOT. Staff were largely in agreement with these results and 94 percent reported they believed that video DOT was ‘effective for monitoring patient adherence’.  The researchers also reported several common themes during in depth interviews that focused on the added convenience and increased flexibility of using video DOT. Another prominent theme was the impression that in-person DOT could risk patient privacy.

John Hopkins Universitywww.hopkinsmedicine.org/news/media/releases/smartphone_app_keeps_an_eye_on_daily_tuberculosis_therapy