Embracing different languages and local differences:Coconstructive patient simulation strengthens host countries’clinical training in psychiatry

BACKGROUND Global education in psychiatry is heavily influenced by knowledge from Western,high-income countries,which obscures local voices and expertise.AIM To adapt a human simulation model to psychiatric education in a context that is specific to local languages and cultures.METHODS We conducted an observational study consisting of six human simulation sessions with standardized patients from two host countries,speaking their native languages,and following an adaptation of the co-constructive patient simulation(CCPS)model.As local faculty became increasingly familiar with the CCPS approach,they took on the role of facilitators—in their country’s native language.RESULTS Fifty-three learners participated:19 child and adolescent psychiatry trainees and 3 faculty members in Türkiye(as a group that met online during 3 consecutive months);and 24 trainees and 7 faculty in Israel(divided into 3 groups,in parallel in-person sessions during a single training day).Each of the six cases reflected local realities and clinical challenges,and was associated with specific learning goals identified by each case-writing trainee.CONCLUSION Human simulation has not been fully incorporated into psychiatric education:The creation of immersive clinical experiences and the strengthening of reflective practice are two areas ripe for development.Our adaptations of CCPS can also strengthen local and regional networks and psychiatric communities of practice.Finally,the model can help question and press against hegemonies in psychiatric training that overshadow local expertise.

Dyslipidemia and cardiovascular disease risk factors in patients with type 1 diabetes:A single-center experience

BACKGROUND Type 1 diabetes(T1D)contributes to altered lipid profiles and increases the risk of cardiovascular disease(CVD).Youth with T1D may have additional CVD risk factors within the first decade of diagnosis.AIM To examine risk factors for dyslipidemia in young subjects with T1D.METHODS Longitudinal and cross-sectional retrospective study of 170 young subjects with T1D(86 males;baseline mean age 12.2±5.6 years and hemoglobin A1c 8.4%±1.4%)were followed in a single tertiary diabetes center for a median duration of 15 years.Predictors for outcomes of lipid profiles at last visit(total cholesterol[TC],triglycerides[TGs],low-density lipoprotein-cholesterol[LDL-c],and highdensity lipoprotein-cholesterol[HDL-c])were analyzed by stepwise linear regression models.RESULTS At baseline,79.5%of the patients had at least one additional CVD risk factor(borderline dyslipidemia/dyslipidemia[37.5%],pre-hypertension/hypertension[27.6%],and overweight/obesity[16.5%])and 41.6%had multiple(≥2)CVD risk factors.A positive family history of at least one CVD risk factor in a first-degree relative was reported in 54.1%of the cohort.Predictors of elevated TC:family history of CVD(β[SE]=23.1[8.3],P=0.006);of elevated LDL-c:baseline diastolic blood pressure(DBP)(β[SE]=11.4[4.7],P=0.003)and family history of CVD(β[SE]=20.7[6.8],P=0.017);of elevated TGs:baseline DBP(β[SE]=23.8[9.1],P=0.010)and family history of CVD(β[SE]=31.0[13.1],P=0.020);and of low HDL-c levels:baseline DBP(β[SE]=4.8[2.1],P=0.022]).CONCLUSION Our findings suggest that elevated lipid profiles are associated with DBP and a positive family history of CVD.It is of utmost importance to prevent and control modifiable risk factors such as these,as early as childhood,given that inadequate glycemic control and elevation in blood pressure intensify the risk of dyslipidemia.

Nutritional status and nutritional therapy in inflammatory bowel diseases

Underweight and specific nutrient deficiencies are frequent in adult patients with inflammatory bowel disease(IBD).In addition,a significant number of children with IBD,especially Crohn's disease(CD) have impaired linear growth.Nutrition has an important role in the management of IBD.In adults with CD,enteral nutrition(EN) is effective in inducing clinical remission of IBD,although it is less efficient than corticosteroids.Exclusive EN is an established primary therapy for pediatric CD.Limited data suggests that EN is as efficient as corticosteroids for induction of remission.Additional advantages of nutritional therapy are control of inflammation,mucosal healing,positive benefits to growth and overall nutritional status with minimal adverse effects.The available evidence suggests that supplementary EN may be effective also for maintenance of remission in CD.More studies are needed to confirm these findings.However,EN supplementation could be considered as an alternative or as an adjunct to maintenance drug therapy in CD.EN does not have a primary therapeutic role in ulcerative colitis.Specific compositions of enteral dietselemental diets or diets containing specific components-were not shown to have any advantage over standard polymeric diets and their place in the treatment of CD or UC need further evaluation.Recent theories suggest that diet may be implicated in the etiology of IBD,however there are no proven dietary approaches to reduce the risk of developing IBD.

Capsule endoscopy in pediatric patients

Wireless capsule endoscope (WCE) for the investigation of the small bowel is an approved technique both in adults and children (more than 10 years old). The present review provides data on the indications, diagnostic yield, adverse events and limitations of the WCE technique in children and tries to predict the future of WCE usage in this population of patients.

Burden of celiac disease in the Mediterranean area

AIM: To estimate the burden of undiagnosed celiac disease (CD) in the Mediterranean area in terms of morbidity, mortality and health cost. METHODS: For statistics regarding the population of each country in the Mediterranean area, we accessed authoritative international sources (World Bank, World Health Organization and United Nations). The prevalence of CD was obtained for most countries from published reports. An overall prevalence rate of 1% cases/total population was finally estimated to represent the frequency of the disease in the area, since none of the available conf idence intervals of the reported rates significantly excluded this rate. The distribution of symptoms and complications was obtained from reliable reports in the same cohort. A standardized mortality rate of 1.8 was obtained from recent reports. Crude health cost was estimated for the years between symptoms and diagnosis for adults and children, and was standardized for purchasing power parity to account for the different economic prof iles amongst Mediterranean countries. RESULTS: In the next 10 years, the Mediterranean area will have about half a billion inhabitants, of which 120 million will be children. The projected number of CD diagnoses in 2020 is 5 million cases (1 million celiac children), with a relative increase of 11% compared to 2010. Based on the 2010 rate, there will be about 550 000 symptomatic adults and about 240 000 sick children: 85% of the symptomatic patients will suffer from gastrointestinal complaints, 40% are likely to have anemia, 30% will likely have osteopenia, 20% of children will have short stature, and 10% will have abnormal liver enzymes. The estimated standardized medical costs for symptomatic celiac patients during the delay between symptom onset and diagnosis (mean 6 years for adults, 2 years for children) will be about €4 billion (€387 million for children) over the next 10 years. A delay in diagnosis is expected to increase mortality: about 600 000 celiac patients will die in the next 10 years, with an excess of 44.4% vs age-and sexmatched controls. CONCLUSION: In the near future, the burden of CD will increase tremendously. Few Mediterranean countries are able to face this expanding epidemic alone.

Lean Healthy Children with Short Stature Have Distinct Eating Patterns

Nutrition plays an essential role in normal linear growth in children. Knowledge of the eating styles and dietary consumption of healthy short children from developed countries is scarce. The aim of this study was to investigate the dietary patterns in idiopathic short stature （ISS） and relatively low weight children compared to children with normal stature and weight. This research is a case-control study of 86 pre-pubertal healthy children, mean age 5.9 ± 1.5 years. The study group comprised 43 ISS children; 43 age-matched children with normal stature and weight served as controls. Outcome measures included： dietary patterns and physical activity. The absolute daily average energy, protein and carbohydrate intake was significantly lower in the ISS children （P 〈 0.05）; after correcting for body surface area, no significant differences were found between groups. Intake of micronutrients calcium, iron, zinc, vitamin A and vitamin C, expressed as percentage from Recommended Dietary Allowance, was significantly lower in the ISS children （P 〈 0.05）, who had lower food responsiveness, higher satiety responsiveness, lesser enjoyment of food and were slower eaters （P 〈 0.001）. Physical activity was sedentary in both the ISS cases and controls. Our findings in healthy, pre-pubertal, relatively lean ISS children point to a distinct eating pattern with no alteration in physical activity. Understanding the differences in dietary intake and eating behaviors may be beneficial in the development of targeted nutritional intervention for lean ISS children.

Scrotal strangulation in the differential diagnosis of acute scrotum:A case report

BACKGROUND Acute scrotal pain and swelling are common presentations in the emergency department.Urgent surgical intervention is justified in up to one-third of cases,whereas two-thirds of them should be treated conservatively.CASE SUMMARY We report a case of scrotal only strangulation in a child and review the available literature.CONCLUSION Due to its rarity,scrotal strangulation can be a diagnostic challenge.Skin ulceration and edema may well indicate the presence of a strangulation object.A high index of suspicion and appropriate physical examination,especially in patients with a mental disability or behavioral disorder,are key to early diagnosis and treatment.

宫内暴露于选择性5-羟色胺再摄取抑制剂后足月新生儿的戒断综合征

Objective:To compare the prevalence and clinical characteristics of neonatal abstinence syndrome in neonates exposed and not exposed to selective serotonin r euptake inhibitors(SSRIs)in utero.Design:Cohort study.Setting:Tertiary car e center.Patients:One hundred twenty term infants,of whom 60 had prolonged in utero exposure to SSRIs,including paroxetine hydrochloride,fluoxetine,citalo pram hydrobromide,sertraline hydrochloride,and venlafaxine hydrochloride.Main Outcome Measures:Neonatal abstinence syndrome was assessed with the Finnegan s core as follows:score of 8 or above,severe;score of 4 to 7,mild;and score o f 0 to 3,normal.All infants were followed up with a standardized protocol that included repeated Finnegan score assessments and cardiorespiratory monitoring u ntil normalization of the Finnegan score.Results:Of the 60 neonates exposed to SSRIs in utero,8 showed severe and 10 showed mild symptoms of a neonatal absti nence syndrome.All nonexposed neonates had a normal Finnegan score.In neonates who developed severe symptoms,the maximum mean daily Finnegan scores were reco rded within 2 days after birth,although maximum individual scores were recorded as long as 4 days after birth.Conclusions:Neonatal abstinence syndrome occurs in 30%of neonates exposed to SSRIs in utero.These neonates should be monitore d for at least 48 hours after birth.The longterm effects of prolonged exposure to SSRIs,particularly in neonates who develop severe symptoms,have yet to be d etermined.

结肠管壁内脾组织植入的个例报道

Splenosis is usually a sequel of splenic rupture from abdominal trauma but can be associated with elective splenectomy. Recurrence of the hematological disorder for which the patient underwent splenectomy may occur, and splenic nodules can be found anywhere in the thoracic or abdominal cavity, as well as subcutaneously. We are presenting intramural colonic splenosis, a large inoculum of the splenic tissue that has been found to have the capacity to maintain anemia and thrombocytopenia, in a child previously splenectomized because of a hematological problem.

Acute hemorrhagic edema of infancy: the experience of a large tertiary pediatric center in Israel

Background:Acute hemorrhagic edema of infancy (AHEI) is a rare leukocytoclastic vasculitis of the small vessels occurring at a young age and considered as a benign self-limited disease.Due to its low prevalence,there are limited data on the presentation and complications of this disease.Methods:All computerized files of children who were hospitalized at a tertiary pediatric center due to AHEI over a 10 year period were reviewed.Clinical,laboratory and histopathological data were collected.Results:Twenty-six patients were included in our study,accounting for 0.7 cases per 1000 admissions of children aged 2 years or less.Mean age was 12.9 months.More than two thirds of the children had preceding symptoms compatible with a viral infection.Upon admission,all patients presented with typical findings of a rash and edema.Edema was most profound over the lower extremities (73%).Concomitant viral or bacterial infections were found in six children.Skin biopsy was performed in six patients revealing leukocytoclastic vasculitis.Thirteen children (50%) had systemic involvement including joint involvement (n=9),gastrointestinal hemorrhage (n=4),microscopic hematuria (n=1) and compartment syndrome of the limb (n=1).The latter was diagnosed in a patient with familial Mediterranean fever.Conclusions:Our largest data series highlighted what is known regarding clinical and histological findings in children with AHEI.However,contrary to what was previously reported,we found a higher rate of systemic involvement.Although AHEI is a rare entity,pediatricians should be familiar with its presentation,management and our reported complications.

儿童气管、支气管软化的病因和气道管理初步研究

目的探讨儿童气管、支气管软化的病因和气道管理方法。方法对671例儿童进行支气管镜检查，对发现气管软化和支气管软化的病例进行病因分析，并对他们的治疗加以总结。结果（1）通过支气管镜共发现气管、支气管软化的患儿148例，其中气管软化77例，支气管软化71例。（2）气管软化中：46例为血管环畸形，11例与先天性气道畸形有关，10例合并有先天性食管闭锁伴食管气管瘘，6例与气管切开造口和机械通气相关，4例为孤立性气管软化。（3）支气管软化中：64例患有心血管畸形，6例与先天性气道畸形有关，1例为孤立性支气管软化。（4）10例异常无名动脉患儿行主动脉固定术，12例右位主动脉弓伴迷走左锁骨下动脉和双主动脉弓患儿行血管环松解术，6例肺动脉吊带的患儿行肺动脉吊带纠治术；手术中直接切除严重的气管软化段的4例。38例患儿行机械通气，4例患儿进行气管造口，治疗气管软化和支气管软化，相当程度地缓解了症状。2例在支气管内进行金属支架植入治疗支气管软化，1例获得成功，另1例需要2次植入支架；这2例患儿均在以后进行了支架远端球囊扩张。结论心血管畸形是儿童发生气管、支气管软化的主要原因。对心血管畸形进行纠治后，大多数病例症状在6个月内逐渐改善。对严重的病例，治疗还包括机械通气和气管造口。支气管内支架植入可运用于难治性的病例中，但有一定的局限性。

儿科肠外营养指南(2016版)推荐意见节译

儿科肠外营养指南英文完整版共分为14篇,刊登在2018年Clinical Nutrition 。除方法篇外,每篇均给出推荐意见列表。在此,我们将方法篇有关证据级别、推荐等级、推荐形式的相关说明以及其余13篇的推荐建议整理成中文版,供国内儿科医护人员参考学习。

欧洲儿童急性胃肠炎处理循证指南（2014年版）

1991年世界卫生组织（WHO）制订了第一版儿童急性腹泻病指南，2005年WHO和联合国儿童基金会（UNICEF）制订了第二版，我国专家在参照WHO指南的基础上，结合我国国情分别于1993年、2009年制订了中国儿童急性腹泻病的专家共识；WH0指南和我国共识对中国儿童急性腹泻病的规范诊治发挥了重要的作用，收到了良好的效果。时至今日，欧洲儿科胃肠病学、肝病学和营养协会及欧洲儿科感染病协会对2008年儿童急性胃肠炎循证指南进行更新，即“2014年版”。指南中腹泻病原、低渗口服补液盐溶液使用、营养管理和常规对症治疗与我国现行共识基本一致。另首次对儿童脱水评估和疾病严重程度评分进行量化并提出通过鼻胃管补液，这是我们可以借鉴的。重度脱水休克的治疗强调了可重复3次20ml／kg0．9％氯化钠溶液，与我国危重专业观点相一致。静脉补充液体成分与我国现行共识存在差异，与指南执笔者之一意大利学者AndreaLoVecehio进行交流，其认同我国现用液体组成。细菌感染所致腹泻使用抗生素的指征与我国现行共识相同，但在抗生素选择上存在差异，建议根据我国药典和药敏结果选择合适抗生素。由于我国社会经济、文化和医学发展等与欧洲存在差异，因此指南中的观点、方法等应结合中国特点进行应用。