Social skills and psychopathology are associated with autonomic function in children:a cross-sectional observational study

In recent years,the increase of psychopathological disorders in the population has become a health emergency,leading to a great effort to understand psychological vulnerability mechanisms.In this scenario,the role of the autonomic nervous system(ANS)has become increasingly important.This study investigated the association between ANS,social skills,and psychopathological functioning in children.As an ANS status proxy,we measured heart rate variability(HRV).Infants admitted to the neonatal intensive care unit of the University Hospital of Padova because of preterm birth or neonatal hypoxic-ischemic encephalopathy were sequentially recruited from January 2011 to June 2013 and followed long-term up to school age in this cross-sectional observational study.We recorded 5 minutes of HRV immediately before measuring performance in social abilities tasks(affect recognition and theory of mind,NEPSY-II)in 50 children(mean age 7.4±1.4 years)with and without risk factors for developing neuropsychiatric disorders due to pre-/perinatal insults without major sequelae.Children also completed extensive cognitive,neuropsychological,and psychosocial assessment.Parents were assessed with psychopathological interviews and a questionnaire(CBCL 6-18).Analysis in a robust Bayesian framework was used to unearth dependencies between HRV,social skills,and psychopathological functioning.Social task scores were associated with HRV components,with high frequency the most consistent.HRV bands were also associated with the psychopathological questionnaire.Only normalized HRV high frequency was able to distinguish impaired children in the affect recognition task.Our data suggest that ANS may be implicated in social cognition both in typical and atypical developmental conditions and that HRV has cross-disease sensitivity.We suggest that HRV parameters may reflect a neurobiological vulnerability to psychopathology.The study was approved by the Ethics Committee of the University Hospital of Padova(Comitato Etico per la Sperimentazione,Azienda Opedaliera di Padova,approval No.1693 P).

幼儿锌需要量的估算

目的采用因素分析可以估算微量元素锌的需要量。通过对幼儿锌代谢平衡的测定,以所获得的数据估算幼儿的锌需要量。方法收集43例19～25月龄幼儿粪便和尿液,采用双稳定性同位素示踪方法标记同位素,分析稳定性同位素丰度,计算锌的各项代谢平衡数据。结果43例幼儿膳食摄入锌量(1.86±0.55)mg/d,锌吸收率0.35±0.12;实际吸收锌量(0.63±0.24)mg/d,肠道内源性排出锌量(0.67±0.23)mg/d。由因素分析估算得到幼儿锌的生理需要量为1.09 mg/d,锌的平均膳食需要量为3.3 mg/d。结论根据实际测得的锌代谢平衡数据,由因素分析得到的幼儿锌的生理需要量和平均膳食需要量均略高于目前美国食物和营养委员会的估计值。[临床儿科杂志,2007,25(12):1016-1019]

美国耐甲氧西林金黄色葡萄球菌感染治疗临床治疗指南(一)

美国感染病学会（IDSA）制订了治疗耐甲氧西林金黄色葡萄球菌（MRSA）患者的循证指南。该指南用于指导MRSA感染患者的治疗。该指南就多种与MRSA疾病相关的临床症状的治疗进行了论述,包括：皮肤和软组织感染（SSTI）、菌血症和感染性心内膜炎、肺炎、骨和关节感染、中枢神经系统（CNS）感染等。该指南重点介绍了关于万古霉素用量及监测,以及对万古霉素低敏的耐甲氧西林金黄色葡萄球菌菌株感染的治疗方案及治疗失败的处置。

Prediabetes diagnosis and treatment: A review

Prediabetes is an intermediate state of hyperglycemia with glycemic parameters above normal but below the diabetes threshold. While, the diagnostic criteria of prediabetes are not uniform across various international professional organizations, it remains a state of high risk for developing diabetes with yearly conversion rate of 5%-10%. Observational evidence suggests as association between prediabetes and complications of diabetes such early nephropathy, small fiber neuropathy, early retinopathy and risk of macrovascular disease. Several studies have shown efficacy of lifestyle interventions with regards to diabetes prevention with a relative risk reduction of 40%-70% in adults with prediabetes. While there is increasing evidence to prove the efficacy of pharmacotherapy in prevention of diabetes in adults with prediabetes, pharmaceutical treatment options other than metformin are associated with adverse effects that limit their use for prediabetes. There are no reports of systematic evaluation of health outcomes related to prediabetes in children. The effects of pharmacotherapy of prediabetes on growth and pubertal development in children remains unknown. Secondary intervention with pharmacotherapy with metformin is advocated for high-risk individuals but criteria for such consideration benefit of early intervention, long term cost effectiveness of such interventions and the end point of therapy remain unclear. Pharmacotherapy must be used with caution in children with prediabetes. Prediabetes is a condition defined as having blood glucose levels above normal but below the defined threshold of diabetes. It is considered to be an at risk state, with high chances of developing diabetes. While, prediabetes is commonly an asymptomatic condition, there is always presence of prediabetes before the onset of diabetes. The elevation of blood sugar is a continuum and hence prediabetes can not be considered an entirely benign condition. This aim of this review is to describe the challenges associated with diagnosis of prediabetes, the possible adverse medical outcomes associated with prediabetes and the treatment options and rationale for their use in context of prediabetes.

Treatment of hepatitis B virus infection in children and adolescents

Hepatitis B virus(HBV)infection is one of the main causes of morbidity and mortality worldwide.Most children acquire the infection perinatally or during early childhood and develop a chronic hepatitis characterized by a high viral replication and a low-inflammation phase of infection,with normal or only slightly raised aminotransferases.Although a conservative approach in children is usually recommended,different therapies exist and different therapeutic approaches are possible.The main goals of antiviral treatment for children with chronic HBV infection are to suppress viral replication and to warn the disease progression to cirrhosis and hepatocellular carcinoma,although these complications are rare in children.Both United States Food and Drug Administration(USFDA)and European Medicines Agency(EMA)have approved interferon alfa-2b for children aged 1 year and older,pegylated interferon alfa-2a and lamivudine for children aged 3 years and older,entecavir for use in children aged 2 years and older,and adefovir for use in those 12 years of age and older.Tenofovir disoproxil fumarate is approved by EMA for children aged 2 years and older and by USFDA for treatment in children aged 12 years and older.Finally,EMA has approved the use of tenofovir alafenamide for treatment of children aged 12 years and older or for children weighing more than 35 kg independent of age.This narrative review will provide the framework for summarizing indications to antiviral therapy in the management of chronic HBV infection in children and adolescents.

为在小儿科的胃肠的混乱的肠的 microbiome 治疗的前景和挑战

Fecal microbiome(microbiota) transplantation is an emerging treatment not only for refractory/recurrent Clostridium difficile infections and chronic gastrointestinal diseases, but also for metabolic syndrome, and even possibly for neurological disorders. This non-conventional therapy has been perhaps more appropriately designated as fecal bacteriotherapy(FB) as well. The employment of FB is spreading into pediatric gastroenterology. This focused review highlights the pediatric applications of FB and discusses hypotheses for its mechanism of action. We propose that intestinal microbiome therapy may be a more appropriate term for FB, which integrates its potential future applications.

Effect of the timing of gluten introduction on the development of celiac disease

Celiac disease(CD) is a permanent auto-immune enteropathy,triggered in genetically predisposed individuals by the ingestion of dietary gluten.Gluten is the alcohol-soluble protein component of the cereals wheat,rye and barley.CD is a multifactorial condition,originating from the interplay of genetic and environmental factors.The necessary environmental trigger is gluten,while the genetic predisposition has been identified in the major histocompatibility complex region on chromosome 6p21,with over 90% of CD patients expressing HLA DQ2 and the remaining celiac patients express DQ8.The fact that only about 4% of DQ2/8positive individuals exposed to gluten develop CD,has led to the recognition that other genetic and environmental factors are also necessary.In the last few years,several epidemiological studies have suggested that the timing of the introduction of gluten,as well as the pattern of breastfeeding,may play an important role in the subsequent development of CD.Here,we present and review the most recent evidences regarding the effect of timing of gluten introduction during weaning,the amount of gluten introduced and simultaneous breastfeeding,on the development of CD.

Intensivist-based deep sedation using propofol for pediatric outpatient flexible bronchoscopy

AIM To evaluate the safety and efficacy of sedating pediatric patients for outpatient flexible bronchoscopy.METHODS A retrospective chart review was conducted for all children, age 17 years or under who underwent flexible bronchoscopy under deep sedation in an outpatient hospital-based setting. Two sedation regimens were used; propofol only or ketamine prior to propofol. Patients were divided into three age groups; infants(less than 12 mo), toddlers(1-3 years) and children(4-17 years). Demographics, indication for bronchoscopy, sedative dosing, sedation and recovery time and adverse events were reviewed.RESULTS Of the total 458 bronchoscopies performed, propofol only regimen was used in 337(74%) while propofol and ketamine was used in 121(26%). About 99% of the procedures were successfully completed. Children in the propofol + ketamine group tend to be youngerand have lower weight compared to the propofol only group. Adverse events including transient hypoxemia and hypotension occurred in 8% and 24% respectively. Median procedure time was 10 min while the median discharge time was 35 min. There were no differences in the indication of the procedure, propofol dose, procedure or recovery time in either sedative regimen. When compared to other age groups, infants had a higher incidence of hypoxemia.CONCLUSION Children can be effectively sedated for outpatient flexible bronchoscopy with high rate of success. This procedure should be performed under vigilance of highly trained providers.

Central line-associated bloodstream infection among children with biliary atresia listed for liver transplantation

BACKGROUND Pre-transplant nutrition is a key driver of outcomes following liver transplantation in children.Patients with biliary atresia(BA) may have difficulty achieving satisfactory weight gain with enteral nutrition alone,and parenteral nutrition(PN) may be indicated.While PN has been shown to improve anthropometric parameters of children with BA listed for liver transplantation,less is known about the risks,particularly infectious,associated with this therapy among this specific group of patients.AIM To describe the incidence,microbiology,and risk factors of central line-associated bloodstream infection(CLABSI) among children with BA listed for liver transplantation.METHODS Retrospective review of children aged ≤ 2-years of age with BA who were listed for primary liver transplantation at Texas Children's Hospital from 2008 through2015(n = 96).Patients with a central line for administration of PN(n = 63) were identified and details of each CLABSI event were abstracted.We compared the group of patients who experienced CLABSI to the group who did not,to determine whether demographic,clinical,or laboratory factors correlated with development of CLABSI.RESULTS Nineteen of 63 patients(30%,95%CI:19,43) experienced 29 episodes of CLABSI during 4800 line days(6.04 CLABSI per 1000 line days).CLABSI was predominantly associated with Gram-negative organisms(14/29 episodes,48%)including Klebsiella spp.,Enterobacter spp.,and Escherichia coli.The sole polymicrobial infection grew Enterobacter cloacae and Klebsiella pneumoniae.Grampositive organisms(all Staphylococcus spp.) and fungus(all Candida spp.)comprised 9/29(31%) and 6/29(21%) episodes,respectively.No demographic,clinical,or laboratory factors were significantly associated with an increased risk for the first CLABSI event in Cox proportional hazards regression analysis CONCLUSION There is substantial risk for CLABSI among children with BA listed for liver transplantation.No clinical,demographic,or laboratory factor we tested emerged as an independent predictor of CLABSI.While our data did not show an impact of CLABSI on the short-term clinical outcome,it would seem prudent to implement CLABSI reduction strategies in this population to the extent that each CLABSI event represents potentially preventable hospitalization,unnecessary healthcare dollar expenditures,and may exact an opportunity cost,in terms of missed allograft offers.

Spectrum of Henoch-Schonlein Purpura in Children: A Single-Center Experience from Western Provence of Saudi Arabia

The aim of this study was to describe the common presentation, frequency, and complications of Henoch-Schonlein purpura (HSP) in patients <18 years who were followed up at King Abdulaziz University Hospital, Jeddah over the last 12 years. We performed a retrospective chart review of the medical records of all patients diagnosed as HSP. During this period, only 29 cases were reported (15 males, 14 females), with the mean age at the diagnosis 7.5 years. 82% percent of the patients had joint involvement in the form of arthritis or arthralgia;17.2% had no joint involvement. Abdominal manifestations were reported in 72.4% of the patients, while renal involvement was documented in 24.1% of the cases;two patients had scrotal involvement. Four patients (13.7%) had a recurrence within four months of HSP diagnosis. However, all patients had full recovery within a month. More research is warranted to study the prevalence, clinical manifestations, preceding factors, and complications of HSP in a Saudi-based cohort.

新生儿重症监护病房中氟康唑预防性给药对侵袭性念珠菌病发病和预后的影响

Objectives: We assessed the impact of intravenous fluconazole prophylaxis (FP) in extremely low birthweight (ELBW[<1000 g]) infants on the incidence of and ou tcome from invasive candidiasis (IC) in all infants admitted to a neonatal inten sive care unit (NICU). Study design: Beginning April 1, 2002, FP was given to EL BW infants aged < 5 days admitted to the NICU of Woman’s Hospital of Texas. Inf ants in NICU in whom IC developed during the first 2 years of FP (FP period) wer e compared with those with IC during 2000-2001. Results: During 2000-2001 and the FP period, the incidence of IC in ELBW infants decreased from 7%(15 of 206) to 2%(5 of 240) (P = .01), and the IC-related mortality rate decreased from 1 2%(4 of 33) to 0 (0 of 40) (P = .04); the incidence of IC increased from 0.1%( 4 of 2806) to 0.2%(8 of 3372) in infants of birth weight ≥1000 g (P = .06), an d no IC-related deaths occurred. During the FP period, IC developed in older in fants (24 vs 12 days; P = .12) who had similar risk factors for IC. Conclusion: Invasive candidiasis occurred in our NICU in spite of FP and shifted to bigger,m ore mature infants who had a better outcome.

Polyethylene glycol 3350 based colon cleaning protocol: 2 d vs 4 d head to head comparison

AIM: To compare between 2 and 4 d colon cleansing protocols. METHODS: Children who were scheduled for colonoscopy procedure (2010-2012) for various medical reasons, were recruited from the pediatric gastroenterology clinic at Marshall University School of Medicine, Huntington, WV. Exclusion criteria were patients who were allergic to the medication used in the protocols [polyethylene glycol (PEG) 3350, Bisacodyl], or chil- dren with metabolic or renal diseases. Two PEG 3350 protocols for 4 d (A) and 2 d (B) were prescribed as previously described. A questionnaire describing the volume of PEG consumed, clinical data, and side effects were recorded. Colon preparation was graded by two observers according to previously described method. Main outcome measurements: Rate of adequate colon preparation. RESULTS: A total of 78 patients were considered for final calculation (group A: 40, group B: 38). Age and stool consistency at the last day was comparable in both groups, but the number of stools/day was significantly higher in group B (P = 0.001). Adequate colonpreparation was reached in 57.5% (A) and 73.6% (B), respectively (P = 0.206). Side effects were minimal and comparable in both groups. There was no difference in children's age, stool characteristics, or side effects between the children with adequate or inadequate colon preparation. Correlation and agreement between observers was excellent (Pearson correlation = 0.972, kappa = 1.0). CONCLUSION: No difference between protocols was observed, but the 2 d protocol was superior for its shorter time. Direct comparison between different colon cleansing protocols is crucial in order to establish the "gold standard" protocol for children.

Nurse practitioner coverage is associated with a decrease in length of stay in a pediatric chronic ventilator dependent unit

AIM: To hypothesize a dedicated critical care nurse practitioner(NP) is associated with a decreased length of stay(LOS) from a pediatric chronic ventilator dependent unit(PCVDU).METHODS: We retrospectively reviewed patients requiring care in the PCVDU from May 2001 through May 2011 comparing the 5 years prior to the 5 years post implementation of the critical care NP in 2005. LOS and room charges were obtained. RESULTS: The average LOS decreased from a median of 55 d [interquartile range(IQR): 9.8-108.3] to a median of 12(IQR: 4.0-41.0) with the implementation of a dedicated critical care NP(P < 1.0001). Post implementation of a dedicated NP, a savings of 25738049 in room charges was noted over 5 years.CONCLUSION: Our data demonstrates a critical care NP coverage model in a PCVDU is associated with a significantly reduced LOS demonstrating that the NP is an efficient and likely cost-effective addition to a medically comprehensive service.

Reconstructive Surgery in the Lower Urinary Tract in Children: Can the Complication Rate Be Reduced?

Objective: Reconstructive surgery of the lower urinary tract in children is reported with a high complication rate. The aim was to evaluate the complication rate at our institution. Material and methods: Between 2000 and 2010, 41 boys and 19 girls were consecutively operated on with augmentation with ileum (45), alternative CIC-channel (57) and bladder neck plasty (42) in isolation or as combined procedures in individuals with neurogenic bladder dysfunction NBD (42), bladder exstrophy-epispadias complex BEEC (13), isolated epispadias IE (2) and posterior urethral valves, PUV (3). Median age at surgery was 11 years (range 1.3 -21) and median follow-up time 7 years (1 -10). Complications were consecutively observed at follow-up according to a structured protocol. As first line care, specially trained nurses followed the patients and daily bladder irrigation was included in the CIC follow-up regimen. Results: In individuals with augmentation with ileum, of which all but one performed CIC through an alternative channel, there were stones reported in 3/45 (7%), perforation in 2/45 (4%), reoperation of CIC channel in 5/57 (9%), bowel obstruction in 3/56 (5%) and rupture of BNP in 3/39 (8%). Re-augmentation was not needed and malignancy not found. No significant difference was seen between patients with NBD and BEEC/IE. Conclusion: Complication rates were among the lowest reported for stones, perforation and reoperations of CIC channels and were average for bowel obstruction. Bladder stones and perforation were seen in individuals with bad compliance to recommended CIC-and irrigation regimens.

EFFECTS OF THE HOE 694 ON TRANSIENT INWARD CURRENT AND NA^+- CA^(2+) EXCHANGE IN GUINEA PIG CARDIOMYOCYTES

To determine the effects of HOE 694, a new and potent Na＋- H＋ exchanger blocker, on transient inward current (Iti) and Na＋- Ca2＋ exchange during hypoxia- reoxygenation in guinea pig cardiomyocytes. Methods. Cardiomyocytes were isolated from adult guinea pig ventricle. Experiment was performed in an experimental chamber that allowed the cells to be exposed to a sufficiently low O2 pressure. The cells were subjected to hypoxia and reoxygenation. The ionic currents were studied with patch clamp technique. Results. In the absence of HOE 694, hypoxia- reoxygenation induced Iti in 12 of 15 experiments; but in cardiomyocytes pretreated with HOE 694 (10～ 50μ mol/L), the incidence of Iti observed during reoxygenation was reduced to 5 of 11 experiments and 3 of 10 experiments, P Conclusions. Blockade of the Na＋- H＋ exchange by HOE 694 could reduce Ca2＋ overload upon hypoxia- reoxygenation, and inhibition of Na＋- H＋ exchange may also indirectly decrease Na＋- Ca2＋ exchange activity during hypoxia.

Laparoscopic Trainer with Pneumoperitoneum

The development of skills and abilities in laparoscopy is directly related to the use of trainers. The trainer should model the patient with all its natural complexities as closely as possible. In this article we propose a system for training the establishment of pneumoperitoneum executing the basic tasks to create the workspace in the trainer, the insertion of primary umbilical trocar and simulate some of the everyday problems in surgery. Materials and Methods. A group of electrical with biomedical engineers and laparoscopic surgeons developed a physical trainer that allows implementing the pneumoperitoneum. The system uses pneumatic electro valves that are controlled with a dedicated microprocessor. The user can program the system to set the parameters of the pneumoperitoneum. Results. This new trainer facilitated the programming of right values of parameters to distend the abdominal cavity according a specific clinical case. The model developed enables the trainee to consolidate his knowledge on establishing the parameters required within clinical practice, as well as the entry techniques. Conclusions. A new physical model for laparoscopic training was designed. The system enables the laparoscopic surgeon to set the parameters for establishing the workspace according to the clinical case. The trainer allows the surgeon to train in the Hasson technique for the introduction of the first trocar, as well as the placement of the rest of surgical instruments with video assistance. We think this new trainer system will help minimize entry-related injuries.

Grape Seed Extract and the Fetal Ductus Arteriosus: A Potential Danger of a Common Herbal Supplement

A female at 28 weeks gestation was referred to pediatric cardiology for a fetal arrhythmia. The echocardiogram revealed premature constriction of the fetal ductus arteriosus. Her work up was unremarkable except for her use of an herbal supplement, grape seed extract, which is advertised as a potent anti-inflammatory medication, and has biochemical properties similar to other medications that have been shown to cause premature ductal constriction. The use of herbal remedies increases each year. Although the public is inundated with radio, television, and internet advertisements for these products, little unbiased information regarding the possible dangers of toxicity or adverse reactions exists. As physicians, we need to be aware of these products, and counsel our patients accordingly.

Anemia in Juvenile Idiopathic Arthritis (JIA) and Other Pediatric Rheumatologic Diseases: A Retrospective Study

Objectives: The present study estimated the prevalence of anemia among children and adolescents with pediatric rheumatological diseases in a referral center, and analyzed the associated clinical and biological parameters. Methods: A retrospective chart review included 49 children with rheumatological diseases, who were diagnosed by a pediatric rheumatologist and classified according to the International League of Associations for Rheumatology (ILAR) guidelines and criteria endorsed by the American College of Rheumatologists. Anemia was defined as hemoglobin level lower than the 5th centile for the corresponding age and gender. Disease activity was indicated by serum levels of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), where available. Results: Participants were aged 2 - 18 years (mean ± SD = 10.41 ± 4.23 years), 38 (77.6%) of them had JIA, and 8 (16.3%) had systemic lupus erythematosus. The most frequent subtype of JIA was the polyarticular (16 out of 38, 42.1%), followed by systemic (14, 36.8%). The prevalence of anemia was 46.9% (95% CI = 32.5% - 61.7%), with no significant difference between JIA and other diseases or between the different JIA subtypes. Nevertheless, anemia was more frequently observed in younger patients (age 2 - 6 years: 69.2% vs <48%) and those with elevated ESR (68.8% vs 33.3%) or CRP (60.0% versus 45.2%), compared with their counterpart respectively;however, only the association with ESR was statistically significant (p = 0.049). No agreement was found between CRP and ESR (Kappa = 0.140). Conclusion: Anemia is frequent in JIA and other rheumatologic diseases in children, concerning approximately 50% of the patients and responding to anemia of inflammation as the major pathophysiological mechanism. Further research is warranted to provide more accurate insight into the pathophysiological mechanisms and clinical characteristics of anemia in pediatric rheumatological disease and to measure its morbidity, to provide efficient and evidence-based management strategies.

经导管应用amplatzer封堵器治疗室间隔肌部缺损后出现的心脏传导异常

This study examined the incidence of cardiac conduction abnormalities and ventricular arrhythmias after the transcatheter closure of muscular ventricular septal defects(MVSDs) using the Amplatzer device occluder. From the records of 27 patients who underwent 33 consecutive MVSD device closures, a low incidence of permanent and transient cardiac conduction disturbances was observed. Heart rate variability was less after the closure of multiple MVSDs compared with single MVSDs.

对0～36月龄A型流感患儿的严重细菌性感染的回顾性研究

Objective. Previous studies of febrile children who were 3 to 36 months of age and had clinically recognizable viral syndromes have shown low rates of concurrent bacteremia. We sought to determine the prevalence of serious bacterial infections (SBIs) among children with influenza A, a viral syndrome that can be established definitively by specific tests. Methods. We performed a retrospective cross-sectional study of patients who were 0 to 36 months of age and presented with fever to the emergency department (ED)-over 4 consecutive influenza seasons. Chest radiographs and urine and cerebrospinal fluid cultures also were reviewed. Results. Of 705 included patients, 163 (23%) were influenza positive (IP) and 542 (77%) were influenza negative (IN). Only 1 IP patient was bacteremic (0.6%) versus 23 of the 542 IN control subjects (4.2%). Two (1.8%) of 110 IP cases had urinary tract infections versus 38 (9.9%)-of the 382 IN control subjects. Thirteen (25.4%) of 51 IP patients had radiographic evidence of pneumonia versus 99 (41.9%) of 236 IN control subjects. There were no cases of meningitis in 41 cerebrospinal fluid samples obtained from IP patients versus 4 (2.2%) cases of culture-positive meningitis in 179 IN control subjects. A total of 16 (9.8%) SBIs were identified in the IP cases versus 153 (28.2%) in the IN control subjects. Conclusions. Febrile children with influenza A had a lower prevalence of bacteremia, urinary tract infections, consolidative pneumonia, or any SBI compared with those without influenza A infection in this study.