NKCC1 inhibition improves sleep quality and EEG information content in a Down syndrome mouse model

In several brain disorders, the hyperpolarizing/inhibitory effects of GABA signaling through Cl-permeable GABAA receptors are compromised, leading to an imbalance between neuronal excitation and inhibition. For example, the Ts65Dn mouse model of Down syndrome (DS) exhibits increased expression of the Cl- importer NKCC1, leading to depolarizing gamma aminobutyric acid (GABA) signaling in the mature hippocampus and cortex. Inhibiting NKCC1 with the Food and Drug Administration (FDA)-approved diuretic bumetanide rescues inhibitory GABAergic transmission, synaptic plasticity, and cognitive functions in adult Ts65Dn mice. Given that DS individuals and Ts65Dn mice show sleep disturbances, and considering the key role of GABAergic transmission in sleep, we investigated whether NKCC1 upregulation contributes to sleep abnormalities in adult Ts65Dn mice. Chronic oral administration of bumetanide ameliorated the spectral profile of sleep, sleep architecture, and electroencephalogram (EEG) entropy/complexity, accompanied by a lower hyperactivity in trisomic mice. These results offer a potential avenue for addressing common sleep disturbances in DS.

The impact of sleep disorders on quality of life in patients with epilepsy

OBJECTIVE

We aimed to explore the prevalence of sleep disorders and their impact on the quality of life (QoL) in patients with epilepsy (PWE) in western China.

METHODS

This cross-sectional study included PWE aged ≥14 years who were assessed using QoL in epilepsy-31 inventory (QOLIE-31), Insomnia Severity Index (ISI), STOP-BANG questionnaire, Epworth sleepiness scale (ESS), Pittsburgh sleep quality index (PSQI), Chinese version of Neurological Disorders Depression Inventory for Epilepsy (CNDDI-E) and Generalized Anxiety Disorder-7 (GAD-7). The impact of sleep disorders, depression and anxiety on all aspects of QOLIE-31 scores in PWE were assessed.

RESULTS

A total of 458 PWE were enrolled. Mean QOLIE-31 score was 51.27±9.69. Relevant assessment scales showed that 10.3 % of the patients suffered from insomnia, 12.9 % of the cohort had a high risk of obstructive sleep apnea (OSA), 33.0 % of the patients had excessive daytime sleepiness (EDS), 48.0 % of the patients reported poor sleep, while 46.3 % and 36.5 % of the patients reported depression and anxiety, respectively. The stepwise multivariate linear regression analysis highlighted that depression(β=-0.638, 95 %CI:0.876∼-0.401, p < 0.05), anxiety(β=-0.508, 95 %CI:0.708∼-0.307, p < 0.05), EDS(β=-0.210, 95 % CI:0.364∼-0.057, p = 0.007), number of antiseizure medications (ASMs)(β=-1.268, 95 % CI:2.318∼-0.217, p = 0.018), insomnia(β=-0.161, 95 % CI:0.292∼-0.030, p = 0.016) and seizure frequency(β=-0.570, 95 % CI:1.129∼-0.011, p = 0.046) were the main factors that influenced the total score of QOLIE-31 in PWE.

CONCLUSIONS

PWE showed a high prevalence of sleep disorders, especially insomnia, OSA and EDS, which significantly reduced the QoL of PWE in western China. Addressing sleep and psychiatric disorders might improve the overall QoL of PWE.

Prenatal opioid exposure alters pain perception and increases long-term health risks in infants with neonatal opioid withdrawal syndrome

Background

Opioids are often prescribed for pain relief, yet they pose risks such as addiction, dependence, and overdose. Pregnant women have unique vulnerabilities to opioids and infants born to opioid-exposed mothers could develop neonatal opioid withdrawal syndrome (NOWS). The study of opioid-induced epigenetic changes in chronic pain is in its early stages. This study aimed to identify epigenetic changes in genes associated with chronic pain resulting from maternal opioid exposure during pregnancy.

Methods

We analyzed DNA methylation of chronic pain-related genes in 96 placental tissues using Illumina Infinium Methylation EPIC BeadChips. These samples comprised 32 from mothers with infants prenatally exposed to opioids who needed pharmacologic NOWS management (+Opioids/+NOWS), 32 from mothers with prenatally opioid-exposed infants not needing NOWS pharmacologic treatment (+Opioids/-NOWS), and 32 from unexposed control subjects (-Opioids/-NOWS).

Results

The study identified significant methylation changes at 111 CpG sites in pain-related genes among opioid-exposed infants, with 54 CpGs hypomethylated and 57 hypermethylated. These genes play a crucial role in various biological processes, including telomere length regulation (NOS3, ESR1, ESR2, MAPK3); inflammation (TNF, MAPK3, IL1B, IL23R); glucose metabolism (EIF2AK3, CACNA1H, NOTCH3, GJA1); ion channel function (CACNA1C, CACNA1H, CLIC4, KCNQ5); autophagy (CTSS, ULK1, ULK4, ATG5); oxidative stress (NGF, NRG1, OPRM1, ATP1A2); aging (GRIA1, NGFR, PRLR, EIF4E); cytokine activity (TRPV4, RUNX1, CXCL8, IL18R1); and the risk of suicide (ADORA2A, ANKK1, GABRG2, IGSF9B). These epigenetic changes may influence 48 signaling pathways-including cAMP, MAPK, GnRH secretion, estrogen signaling, morphine addiction, circadian rhythms, and insulin secretion-profoundly affecting pain and inflammation-related processes.

Conclusion

The identified methylation alterations may shed light on pain, neurodevelopmental changes, and other biological mechanisms in opioid-exposed infants and mothers with OUD, offering insights into NOWS and maternal-infant health. These findings may also pave the way for targeted interventions and improved pain management, highlighting the potential for integrated care strategies to address the interconnected health of mothers and infants.

Food Hypersensitivity: Distinguishing Allergy from Intolerance, Main Characteristics, and Symptoms-A Narrative Review

Background/Objectives: Food hypersensitivity remains an understudied and overlooked subject globally. It is characterized by adverse reactions to dietary substances, potentially triggered by various mechanisms. Food allergy, a subset of food hypersensitivity, denotes an immune response to food proteins categorized into immunoglobulin IgE-mediated or non-IgE-mediated reactions. Conversely, food intolerance, another facet of food hypersensitivity, refers to non-immunological reactions, in which the human body cannot properly digest certain foods or components, leading to gastrointestinal discomfort and other non-immune-related symptoms. The main objective of this study was to determine and differentiate the differences, characteristics, and types of food hypersensitivity. Methods: This study involved a comprehensive review of key research from 1990 onward, including review articles, prospective studies, nested case-control studies, and meta-analyses. Results: Recognizing these differences is essential for healthcare professionals to ensure accurate diagnosis, effective management, and improved patient outcomes, while also aiding dietitians in providing optimal nutritional and dietary guidance. Conclusions: there are big differences between the main characteristics, such as symptoms, complications, and treatments between allergies, and food intolerances. Commonly reported trigger foods include cow milk, gluten, eggs, nuts, and seafood.

Exposure to potentially harmful excipients in neonates admitted to intensive care units using compounded medicines

BACKGROUND

Compounding allows the use of medicines in paediatric patients that are not always available in appropriate dosages. Some of the commonly used excipients have been associated with toxicity events in neonates.

OBJECTIVES

To evaluate the exposure to potentially harmful excipients (PHEs) in neonates using compounded medicines and admitted to the neonatal intensive care unit (NICU) of a university hospital in Portugal.

METHODS

Observational study with neonates using the 10 most prescribed compounded liquid oral medicines with a PHE in a hospital NICU. The daily intake of excipients listed in the European Study of Neonatal Exposure to Excipients (ESNEE) was calculated in NICU newborns (September 2019 to August 2020) by summing the daily dose of excipients in the compounded and all commercial medicines prescribed (Ethics CHUSJ CE-OP84-2021).

RESULTS

65 neonates used the 10 most prescribed compounded medicines containing a PHE. These neonates had 629 prescriptions, with 139 containing at least 1 PHE (31 different compounded or commercial medicines), resulting in 241 exposures to an ESNEE PHE: 125 propylparaben (89.9% of the prescriptions), 98 propylene glycol (70.5%), 6 benzyl alcohol (4.3%), 5 ethanol (3.6%), 4 sodium benzoate (2.9%), 2 sorbitol (1.4%) and 1 polysorbate 80 (0.7%). Excessive daily intakes of propylene glycol were found in 49 newborns (75.4%), followed by benzyl alcohol in 5 newborns (7.7%). One neonate was exposed to an excessive amount of 5 ESNEE PHEs and 2 other neonates to 3 ESNEE PHEs.

CONCLUSIONS

The frequent use of PHEs in compounded medicines for neonates was identified, and neonates were exposed to PHEs exceeding the maximum recommended daily intake. Propylene glycol was the excipient most associated with these events.

Multisystem inflammatory syndrome in children and Kawasaki disease

This narrative review aims to analyze and compare the current literature on multisystem inflammatory syndrome in children (MIS-C) and Kawasaki disease (KD), with a focus on case definitions, clinical features, diagnostic approaches, treatment strategies, and outcomes. Through a comprehensive review of relevant studies, including screening titles, abstracts, and full-text articles, key similarities and differences were identified. Both MIS-C and KD involve immune system dysregulation and share clinical manifestations such as rash, gastrointestinal symptoms, and cardiovascular involvement, with treatments often centered around immunomodulatory therapies. However, significant differences were observed, particularly in terms of age distribution, demographic prevalence, clinical presentation, and diagnostic criteria, with KD primarily affecting younger children and being associated more prominently with coronary artery abnormalities. While both diseases raise concerns about severe cardiac involvement and the need for intensive care, their pathogenic mechanisms have not been fully understood. Ongoing research is critical to elucidating these mechanisms, refining diagnostic criteria, and optimizing therapeutic approaches to improve outcomes for affected children. This comparative analysis is essential for advancing the understanding of both conditions, as accurately distinguishing between MIS-C and KD has significant implications for clinical decision-making and patient management. Given their overlapping yet distinct clinical features, precise differentiation is critical for ensuring timely diagnosis, optimizing therapeutic strategies, and improving patient outcomes. The concern among pediatric patients stems from the potential for severe complications, particularly cardiac involvement, which underscores the need for heightened awareness, early recognition, and evidence-based treatment strategies to minimize long-term morbidity and mortality.

Relationships between brain activity, tryptophan-related gut metabolites, and autism symptomatology

While it has been suggested that alterations in the composition of gut microbial metabolites may play a causative role in the pathophysiology of autism spectrum disorder (ASD), it is not known how gut microbial metabolites are associated with ASD-specific brain alterations. In this cross-sectional, case-control observational study, (i) fecal metabolomics, (ii) task-based functional magnetic resonance imaging (fMRI), and (iii) behavioral assessments were obtained from 43 ASD and 41 neurotypical (NT) children, aged 8-17. The fMRI tasks used socio-emotional and sensory paradigms that commonly reveal strong evoked brain differences in ASD participants. Our results show that fecal levels of specific tryptophan-related metabolites, including kynurenate, were significantly lower in ASD compared to NT, and were associated with: 1) alterations in insular and cingulate cortical activity previously implicated in ASD; and 2) ASD severity and symptoms (e.g., ADOS scores, disgust propensity, and sensory sensitivities). Moreover, activity in the mid-insula and mid-cingulate significantly mediated relationships between the microbial tryptophan metabolites (indolelactate and tryptophan betaine) and ASD severity and disgust sensitivity. Thus, we identify associations between gut microbial tryptophan metabolites, ASD symptoms, and brain activity in humans, particularly in brain regions associated with interoceptive processing.

Antioxidant-Effective Quercetin Through Modulation of Brain Interleukin-13 Mitigates Autistic-Like Behaviors in the Propionic Acid-Induced Autism Model in Rats

Overproduction of reactive oxygen species occurs when inflammation induces oxidative stress in macrophages and microglia, leading to a self-sustaining cycle of cellular damage and neuroinflammation. Oxidative stress and neuroinflammation are well-established contributors to the pathophysiology of autism spectrum disorders, which are associated with impaired neuronal function, neuronal loss, and behavioral deficits. Damaged cells, through microglial activation, release additional inflammatory mediators under conditions of oxidative stress, exacerbating neuronal damage. Quercetin, a powerful dietary antioxidant, has been shown to scavenge free radicals, reduce oxidative stress, and inhibit inflammatory pathways. Given these properties, we hypothesize that quercetin may improve learning and social skills in individuals with autism spectrum disorders by alleviating oxidative stress and reducing brain levels of inflammatory cytokines. In this study, an autism model was established in 30 rats by intraperitoneal injection of 250 mg/kg/day propionic acid (PPA) for five days. The study groups were as follows: Group 1: Normal ontrol (n = 10); Group 2: PPA + saline (PPAS, n = 10); Group 3: PPA + Quercetin (PPAQ, n = 10). All treatments were administered for 15 days. At the end of the treatment, histological and biochemical analyses of brain tissue and behavioral tests related to autistic-like behaviors were performed. Malondialdehyde, tumor necrosis factor-alpha, and interleukin-13 levels in brain homogenates were significantly higher in the PPAS group compared to the control group, indicating elevated oxidative stress and inflammation following PPA exposure. The PPAQ group significantly reduced oxidative stress parameters and inflammatory biomarkers, demonstrating its antioxidant and anti-inflammatory effects. This biochemical improvement was accompanied by preserving Purkinje cells and neuronal populations, significantly reduced in the PPAS group. Moreover, quercetin-treated rats exhibited improved social behavior and learning, which were severely impaired in the PPAS group. These findings, when interpreted together, suggest that quercetin exerts its neuroprotective effects by targeting oxidative stress and neuroinflammation, thereby preventing neuronal cell loss and alleviating behavioral deficits associated with autism spectrum disorders.

Systematic review of autistic representation in the treatment literature for pediatric chronic pain

Chronic pain disproportionately affects autistic children and young people, yet they are underrepresented in pain research. Research on psychological, physical, and pharmacological therapies for other conditions suggests modifications are required to ensure treatment accessibility and efficacy for autistic individuals. However, no such evidence base has been synthesized in pediatric pain. The aim of this review was to (1) review existing "gold-standard" treatment literature for pediatric chronic pain to determine the representation of autistic participants, and (2) review literature on treatment of chronic pain specifically in autistic children and young people to describe the current evidence landscape and identify next directions for research. 16.7% (12/72) of randomized controlled trials included in Cochrane reviews of interventions for pediatric chronic pain explicitly excluded youth with a developmental delay/disability, of which only 8.3% specifically named autism. However, 52.8% of Cochrane-included trials had criteria or protocols which may have disproportionately impacted autistic participants, such as excluding intellectual disability, psychiatric conditions, medical conditions, and/or requiring participants to communicate verbally. Twenty-nine studies of treating chronic pain in autistic children and young people were identified, of which the majority were case reports (k = 27, 93%) with large variation in pain condition, intervention applied, and outcomes measured. Given the high prevalence of chronic pain in autistic children and young people, there is an ethical imperative to ensure their representation in intervention trials, co-develop interventions that address the specific needs of autistic individuals who live with pediatric chronic pain, and to increase accessibility in chronic pain research more broadly. REGISTRATION: PROSPERO: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=491423 registered March 19 2024 Open Science Framework: https://osf.io/8na64/ registered December 18, 2023 PERSPECTIVE: Autistic children and young people (CYP) are not represented in reviews of chronic pain treatments, and the literature on treating chronic pain specifically in this population is so variable no clear conclusions can be drawn. Efforts to increase accessibility of chronic pain interventions and research for autistic CYP is needed.

Food Neophobia in Brazilian Children: A Nationwide Cross-Sectional Study Comparing Neurodivergent and Neurotypical Children with and Without Dietary Restrictions

Objective: This study aims to compare food neophobia (FN) in groups of neurodivergent and neurotypical children with and without food restrictions. Methods: This cross-sectional study used a convenience sample of participants from all Brazilian Federative Units through the snowball method. Participants were separated into four groups for comparison: neurodivergent children without dietary restrictions; neurodivergent children with dietary restrictions; neurotypical children with dietary restrictions; and neurotypical children without dietary restrictions. The Brazilian Children's Food Neophobia Questionnaire (BCFNeo) was selected and administered to caregivers of Brazilian children between four and eleven years old. The categorization of FN scores followed a previously validated protocol. Results: The sample was composed of the caregivers of 2387 children. Considering the sample as a whole (neurodiversity), the prevalence of high FN was 44.2%. Boys are significantly more neophobic (p < 0.001) than girls. FN does not decrease with age. Older children (eight to eleven years) are equally neophobic as younger children (four to seven years). The prevalence of high FN was greater in neurodivergent children (without dietary restrictions-62.8% and with dietary restrictions-62.4%) than in neurotypical children (with dietary restrictions-29.4% and without dietary restrictions-33.4%). Conclusions: FN is more prevalent in boys and neurodivergent children, regardless of food restrictions and age. More longitudinal and experimental studies are necessary to evaluate the factors influencing FN in these groups and to develop intervention strategies.

Utility of serum and urine leucine-rich alpha-2 glycoprotein 1 (LRG1) as predictors of appendicitis and complicated appendicitis in children

PURPOSE

Leucine rich alpha-2 glycoprotein 1 (LRG1) has emerged as a promising biomarker for appendicitis, especially in pediatric patients. However, the currently available data are sparse, and the biomarker must be validated in more settings and compared to standard inflammatory markers. We aimed to evaluate the diagnostic and discriminative utility of serum and urine LRG1 in children with other causes of abdominal pain (no appendicitis) versus appendicitis, and uncomplicated versus complicated appendicitis.

METHODS

The study design was prospective including children ≤ 15 years with suspected appendicitis. Blood and urine samples were collected at the time of clinical evaluation at the Pediatric Emergency Department and analyzed for concentrations of LRG1. Appendicitis diagnosis and severity were determined through histopathological examination and intraoperative findings. Group comparisons were carried out using Kruskal-Wallis test with post hoc Dunn-Bonferroni tests for pairwise comparisons. Associations between LRG1 and other laboratory and clinical variables and the odds of appendicitis and complicated appendicitis were assessed by univariate and multivariable logistic regression analyses. Diagnostic (no appendicitis versus appendicitis) and discriminative (uncomplicated versus complicated appendicitis) performance were evaluated through Receiver Operating Characteristic (ROC) curves with analyses of Areas Under the Curve (AUC). Optimal cutoffs were generated using Youden's index, and diagnostic and predictive values were calculated and compared.

RESULTS

172 children were included. 132 (77%) had appendicitis and 56 (42%) of these had complicated appendicitis. The median age was 10 (IQR 8-12) years and 98 (57%) were boys. Serum concentrations of LRG1 did not differ significantly between the groups. Urine LRG1 was significantly higher among children with complicated appendicitis and no appendicitis compared to children with uncomplicated appendicitis (p < 0.001). In the logistic regression analysis of all children with suspected appendicitis, increased serum LRG1 was associated with a decreased odds of appendicitis (OR 0.96 [95% CI 0.93-0.99], p = 0.008). This association remained after adjustment for age, sex and symptom duration (aOR 0.95 [0.92-0.98], p = 0.003). Urine LRG1 was not associated with the odds of appendicitis. Neither serum nor urine LRG 1 were significantly associated with the odds of complicated appendicitis. When it comes to diagnosing appendicitis, both serum and urine LRG1 had AUC values of 0.39. However, urine LRG had a specificity of 95% and a PPV of 83%. The discriminative performance of serum LRG1 was poor, but the AUC for urine LRG1 of 0.65 was better than the ones for leukocytes, neutrophils and neutrophil percentages. Still, it was lower than the AUCs for C-reactive protein (CRP) and Appendicitis Inflammatory Response (AIR) score. Urine LRG1 has a high specificity and PPV for all cases of appendicitis, and correctly identifies cases of complicated appendicitis to a greater extent than some of the currently available inflammatory markers. Still, the regression analyses show no significant associations between urine LRG1 and appendicitis and complicated appendicitis in children.

CONCLUSION

In contrast to previous studies, in this cohort serum LRG1 was associated with decreased odds of appendicitis, shedding some doubt over the clinical utilization of serum LRG1 as a biomarker for appendicitis in children.

The Inclusion of Fathers in Parent Coaching Interventions for Young Autistic Children: A Systematic Review

Parent-mediated interventions are fundamental in supporting parents of autistic children. In particular, parent coaching has emerged as a key component of such interventions. However, the characteristics of such interventions remain underexplored. Therefore, the current review aimed to synthesise characteristics of parent-coaching interventions for young autistic children (<6 years). Specifically, the review aimed to investigate the extent to which fathers are being included in parent-coaching interventions. A systematic review of the literature was conducted following PRISMA guidelines. A total of 5 studies which met the strict inclusion criteria were included in the final analysis. Studies were summarised regarding participant information, study design, intervention characteristics, dependent variables, study outcomes and social validity findings. Results revealed that only 2 fathers were represented in the included studies, which included 94 parent-child dyads overall. Although limited to two studies, outcomes indicated that parent-coaching can be successfully implemented with fathers. Findings concerning other intervention characteristics are also discussed. Overall, this review highlights the need for more in-depth research into fathers' experiences of parent-coaching interventions and related child outcomes.

The Relationship Between Tranquility Level and Professional Satisfaction in Nurses

Aim: The study was conducted to determine the level of tranquility and professional satisfaction in nurses working in two different cities. Background: Peace of mind, the expectation of all individuals throughout life, is essential in the nursing profession, which performs patient care and treatment. The satisfaction of the service and care provided to others is related to the mental peace and satisfaction of the nurse. Methods: The study is a descriptive type. The study was conducted in three hospitals in two provinces. No sample selection was made, and data were collected from 546 nurses who agreed to participate in the study. The nurse recognition form, tranquility scale, and professional satisfaction scale were used to collect the data. Results: Nurses' tranquility and professional satisfaction levels were moderate. The level of tranquility of postgraduate and single nurses was significantly higher. The level of tranquility and professional satisfaction was significantly higher in nurses with adequate income, professional experience, years of working in an organization of 11 years or more, and a managerial position. The professional satisfaction score was significantly higher in nurses working at "X" training and research hospital. A positive correlation was found between the tranquility and professional satisfaction scales. Conclusion: Sufficiency of income level, professional experience, continuity in the institution, and working in a managerial position positively affected the level of tranquility and professional satisfaction. In this context, institution managers should implement policies to ensure organizational continuity. Implications for Nursing Management: The positive relationship between tranquility and professional satisfaction emphasizes the importance of increasing nurse tranquility in institutions. Regulation of working environments affects nurses' levels of tranquility, and regular implementation of practices such as recognition and promotion will increase professional satisfaction and tranquility and will positively reflect on the quality of care. In metropolitan cities where professional satisfaction is higher, conducting studies that include external and internal factors are recommended to reveal the reason for the difference.

Allergic and immunologic evaluation of children with celiac disease

Introduction

Celiac disease (CD) and allergic diseases are immune-mediated disorders with overlapping clinical and immunologic features. The association between CD and selective immunoglobulin (Ig) A deficiency (sIgAD) is well-established, but limited data exist on the relationship between CD, other antibody deficiencies, and allergic diseases in children. This study aimed to evaluate the prevalence of allergic manifestations and immunologic abnormalities in children with CD.

Methods

This prospective study included children with biopsy-confirmed CD, followed at a gastroenterology clinic from August 2022 to February 2023. Participants underwent comprehensive immunologic and allergic evaluation, including serum immunoglobulin levels, vaccine antibody responses, lymphocyte subgroup analysis, and allergy testing as clinically indicated.

Results

The cohort included 76 patients with a median age of 11 years and a median age at CD diagnosis of 5.8 years. Allergic manifestations included aeroallergen sensitivity (22.4%), allergic rhinitis (15.8%), allergic conjunctivitis (13.2%), food allergy (5.3%), and asthma and eczema (3.9% each). Immunologic evaluations revealed normal profiles in 69.7% of patients, while abnormalities included partial IgM deficiency (6.6%), unclassified hypogammaglobulinemia (5.3%), sIgAD (2.6%), and transient hypogammaglobulinemia of infancy (2.6%). Elevated IgE levels were observed in 13.2% of patients.

Conclusion

This study highlighted a significant prevalence of allergic diseases and immunologic abnormalities in children with CD, extending beyond the commonly recognized association with sIgAD. These findings underscore the importance of comprehensive immunologic and allergic evaluation in children with CD.

Symptoms of attention deficit hyperactivity disorder and emotional behavioral problems: The mediating effect of executive function

The aim was to investigate the symptoms of attention deficit hyperactivity disorder (ADHD) and emotional behavioral problems, with focus on studying the mediating effect of executive function. A total of 240 children with ADHD aged 6-10 years old participated. They all met the diagnostic criteria for ADHD in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition. SPSS 26.0 was used for statistical analysis. Mean interpolation was used to interpolate missing values of a small number of questionnaire items. One-way analysis of variance was used for comparison between multiple groups. Pearson correlation analysis was used for correlation between variables. The results of this study showed that inattention and hyperactivity-impulsivity scores of children with ADHD were positively correlated with the scores of emotional and behavioral problems (EBPs), that is, the more severe the attention deficit and hyperactivity-impulsivity symptoms were, the more severe the EBPs were. The hyperactivity-impulsivity score of children with ADHD positively predicted their behavioral regulation index (BMI) and metacognition index (MI) scores. The BMI score positively predicted the emotional and behavioral problem scores of children with ADHD, while the MI score had no statistically significant predictive effect on the emotional and behavioral problem scores of children with ADHD. These findings suggest that interventions targeting executive function-particularly behavioral regulation-may help mitigate emotional and behavioral difficulties in children with ADHD.

Subthreshold Autism and ADHD: A Brief Narrative Review for Frontline Clinicians

Background: Epidemiological studies have shown that neurodevelopmental disorders (NDDs), such as autism spectrum disorder (ASD) and attention deficit/hyperactivity disorder (ADHD) are more prevalent in the general childhood population, compared to cases that are formally diagnosed in clinical cohorts. This suggests that many children and youths have NDD which are never diagnosed clinically, causing impairments in some domains of their daily life. There is increasing recognition of the concept of a "subthreshold" condition, sometimes used to describe the presence of potentially impairing variations in the neurodevelopmental profile that do not meet criteria for a diagnosis. The aim of this narrative review is to appraise the published literature about common themes regarding subthreshold conditions in relation to autism and ADHD, identifying any practical lessons that may be applicable to frontline neurodevelopmental clinicians. Methods: We searched electronic databases including PMC and PubMed using various combinations of keywords, including "Subthreshold", "subclinical", "neurodevelopmental", "childhood", "ADHD" and "ASD". Results: The identified themes include definitions, prevalence, assessment tools, lifetime impairments, NDD classification models, management, raising public awareness, and future research directions. Conclusions: The authors propose that a "subthreshold condition" should be recorded when NDDs do not meet current diagnostic criteria if there is evidence of significant, persisting impairment in at least one setting.

Evaluating Vaccination Status and Barriers in Children with Rheumatic Diseases

Background: This study aims to evaluate the vaccination status of children with rheumatic diseases (RD) compared to healthy controls (HC) and immunization barriers, as studies examining the vaccination status and factors promoting or hindering vaccination among children RD remain limited. Methods: A cross-sectional study was conducted on children with RD (in a rheumatology clinic) and HC (in a fracture clinic) at a tertiary care center in Canada. Demographics, diagnosis, treatments, and vaccine status were obtained from health records and a provincial electronic vaccine database. A patient/caregiver questionnaire was used to capture perceived immunization barriers, concerns, and satisfaction. Descriptive statistical methods were used for analysis. Results: The study involved 144 children with RD and 111 HC. Data from 94 children with RD and 86 HC, all lifelong Alberta residents, were analyzed for objective vaccination status. Most vaccines were received at rates of 80% or higher, except the influenza vaccine, which had the lowest adherence (34% in RD vs. 21% in HC). In 31% of RD children, vaccinations were withheld due to active disease, healthcare provider advice, or caregiver concerns about side effects. In 27% HC, vaccinations were withheld due to side effects. Both groups primarily relied on their family doctor for vaccination information, and 85% or more expressed satisfaction with the information received. Conclusions: Most children with RD and HC received recommended vaccines, but influenza vaccination gaps were identified. Knowledge about vaccine contraindications in RD is well understood, but perceived safety concerns limit vaccination completeness. Healthcare providers, especially family doctors, pediatricians, and rheumatologists, should be providing education resources for vaccines and be proactive in discussing the safety and necessity of vaccinations.

Autism Spectrum Disorder and Epilepsy: Pathogenetic Mechanisms and Therapeutic Implications

The co-occurrence of autism spectrum disorder (ASD) and epilepsy is a complex neurological condition that presents significant challenges for both patients and clinicians. ASD is a group of complex developmental disorders characterized by the following: (1) Social communication difficulties: challenges in understanding and responding to social cues, initiating and maintaining conversations, and developing and maintaining relationships. (2) Repetitive behaviors: engaging in repetitive actions, such as hand-flapping, rocking, or lining up objects. (3) Restricted interests: focusing intensely on specific topics or activities, often to the exclusion of other interests. (4) Sensory sensitivities: over- or under-sensitivity to sensory input, such as sounds, touch, tastes, smells, or sights. These challenges can significantly impact individuals' daily lives and require specialized support and interventions. Early diagnosis and intervention can significantly improve the quality of life for individuals with ASD and their families. Epilepsy is a chronic brain disorder characterized by recurrent unprovoked (≥2) seizures that occur >24 h apart. Single seizures are not considered epileptic seizures. Epilepsy is often idiopathic, but various brain disorders, such as malformations, strokes, and tumors, can cause symptomatic epilepsy. While these two conditions were once considered distinct, growing evidence suggests a substantial overlap in their underlying neurobiology. The prevalence of epilepsy in individuals with ASD is significantly higher than in the general population. This review will explore the epidemiology of this comorbidity, delve into the potential mechanisms linking ASD and epilepsy, and discuss the implications for diagnosis, treatment, and management.

Effectiveness of duodenal bulb biopsies in histological diagnosis of coeliac disease

Coeliac disease is an autoimmune condition with variable presentation which leads to difficulties and delays in diagnosis. A retrospective study was undertaken to investigate the effectiveness of duodenal bulb biopsies in histologic diagnosis of coeliac disease. Histology specimens were analysed from 230 patients, age ranging from 0 to 16 years over a 10-year period (2014-2024) who had raised tissue transglutaminase/endomysial antibodies and were referred for an upper gastrointestinal endoscopy to confirm/rule out coeliac disease. Biopsies taken from the proximal (D1) and distal duodenum (D2, 3, 4) were compared in 145 children who were confirmed to have the diagnosis of coeliac disease on histopathology. The results revealed that a significant number of children (56/145; 38.6%) had positive histological changes seen in proximal duodenum only with completely normal histology in distal duodenum. In comparison, only 4/145 (2.8%) children yielded positive histology result from distal duodenum with normal proximal duodenal biopsies. Proximal duodenal segment histology samples therefore had the highest sensitivity (97%), negative predictive value (95.5%), and accuracy (98%).

CONCLUSION

 Our fundings re-enforce the importance of obtaining an adequate number of proximal duodenal samples for histological analysis in children investigated for coeliac disease in order to avoid delayed or missed diagnosis in this age group.

WHAT IS KNOWN

• Coeliac disease affects 1-2% of western population though prevalence varies by the region. • A sub-set of suspected cases with anti-tissue transglutaminase (TTG) antibody titres of less than ten times the upper limit of normal require duodenal biopsies for confirmation of diagnosis.

WHAT IS NEW

• Duodenal bulb biopsies have higher sensitivity and negative predictive value when compared to distal duodenal biopsies. • Endoscopist must obtain adequate number of samples from proximal duodenum (duodenal bulb) to avoid false negative results.

Causal relationship between sleep traits and risk of Epilepsy: A Mendelian randomization study

BACKGROUND

Observational studies have identified a strong correlation between epilepsy and sleep traits, highlighting their interactive relationship. However, no studies have specifically examined the associations between sleep traits and epilepsy. In this context, we conducted a Mendelian Randomization (MR) investigation to explore the causal nature of these associations.

METHODS

We performed a two-sample Mendelian Randomization (MR) analysis model to genetically predict the causal effects of morning chronotype on epilepsy. Five MR analysis methods were conducted to analyze the final results. The inverse-variance weighted (IVW) method was used as the primary outcome. The other MR analysis methods (MR-Egger; Weighted Mode; and Weighted median (WM)) were conducted as the complement to IVW. In addition, the robustness of the MR analysis results was assessed by leave-one-out analysis.

RESULTS

In forward MR, epilepsy showed causal relationships with sleep duration (IVW beta = 0.008, P = 0.015). Specifically, doubling the odds of inheriting epilepsy may be associated with a 0.0075 standard deviation (SD) (95 % CI: 1.001 to 1.014) increase in sleep duration. In reverse MR, we found statistically significant associations between chronotype (evening preference) (OR = 1.397, p = 0.007) and insomnia (OR = 2.280, p = 0.025) and the risk of epilepsy.

CONCLUSION

Our two-sample Mendelian randomization analyses indicate that individuals with epilepsy frequently experience extended sleep duration. Additionally, we identified insomnia and chronotype (evening preference) as significant risk factors that increase the likelihood of developing epilepsy.

Slow but Steady: Similarities and Differences in Executive Functioning Between Autistic and Non-Autistic Adults

Prior research has established differences between autistic and non-autistic individuals across the domains of executive function (EF). While some early theories portrayed these differences as universal to the autism spectrum, recent findings have been quite mixed. Factors like small samples, the components of EF being measured, and the age and intelligence quotient (IQ) of those being compared may contribute to this diversity in results. Moreover, research suggests performance over time might fluctuate in different patterns for autistic and non-autistic individuals. To test EF differences and the possible influence of these factors upon them, we recruited a sample of over 900 autistic and non-autistic participants (with generally average/above average IQ levels) from 18 to 77 years of age. They completed a battery of tasks measuring inhibition, cognitive flexibility, working memory, and attentional orienting to social and nonsocial cues. We found that performance was similar between groups in our primary measures of EF, although autistic participants were consistently slower, more susceptible to the effects of spatial cueing, and more prone to certain errors in the working memory task. Differences between groups were generally not influenced by participants' age, gender, or IQ. Performance over time varied only in the working memory task. While autistic adults may still face related challenges in real life, these findings suggest that being autistic does not necessarily imply executive dysfunction on a basic cognitive level, contradicting theories assuming universal impairments therein. Moreover, the lack of influence of included demographic factors suggests that explanations for discrepancies in the literature lie elsewhere.

Bone Metabolism Defects in Children With Idiopathic Hypercalciuria: An Update

Idiopathic hypercalciuria (IH) in adults is considered to be the most common identifiable metabolic risk factor for calcium nephrolithiasis, also contributing to osteopenia and osteoporosis. Data on children and adolescents associating IH with bone metabolism show that up to one-third of such patients present with lower bone mineral density (BMD), increasing the risk of osteopenia, osteoporosis, and bone fractures in adulthood. Several factors, such as the degree of hypercalciuria and the presence of calcium urolithiasis, seem to affect the severity of bone metabolism abnormalities in children with IH. In order to follow these patients, BMD has traditionally been estimated by dual-energy X-ray absorptiometry (DXA) scan. In children, chronological age should be taken into account when measuring BMD, as well as weight, height, and BMI. In addition, biochemical bone turnover markers provide surrogate indices of bone turnover and complement the static measurements of BMD. They respond rapidly to changes in bone physiology, and their measurement can be repeated more frequently. However, since children's bone mass increases constantly until after puberty, age, sex, and pubertal stage have to be taken into consideration when assessing these markers. In addition, relevant studies in children and adolescents have shown conflicting results. Regarding the management of patients with IH, identification and appropriate treatment are of great importance in order to prevent the formation of kidney stones, as well as to improve bone metabolism defects and decrease fracture risk. Such treatment measures include dietary interventions, potassium citrate supplementation and/or thiazide diuretics, and bisphosphonates in resistant cases. This review summarizes the latest data on bone metabolism defects in children and adolescents with IH, the possible pathomechanisms involved, the biochemical markers that could be used together with DXA to follow these patients, and the available treatment options.

Normative pulse oximetry values in healthy children: A cross-sectional study from Jeddah, Saudi Arabia

OBJECTIVES

To establish reference values for peripheral oxygen saturation levels in children using pulse oximetry. Pulse oximetry to assess peripheral oxygen saturation is widely used in pediatric care as part of vital signs monitoring. Although readings between 95% and 100% are often considered normal in clinical practice, recent studies suggest that the normal peripheral oxygen saturation range should be between 97% and 100%.

METHODS

This cross-sectional study included children aged ≤18 years attending pediatric clinics and not having respiratory distress or acute illness during their visit. Vital signs and anthropometric measurements were recorded. Oxygen saturation and pulse rate were measured using the Masimo Radical-7 pulse oximeter with age-appropriate saturation probes.

RESULTS

A total of 973 participants were enrolled in the study. The median oxygen saturation was 99%. Most participants (75.9%) exhibited oxygen saturation levels between 99% and 100%, while 24.1% had values between 97% and 98%. Importantly, no participant had an oxygen saturation below 97%. Additionally, statistical analysis showed no significant differences in oxygen saturation across age groups or genders.

CONCLUSION

The findings highlight the importance of vigilant monitoring in pediatric care, particularly when peripheral oxygen saturation values measured by pulse oximetry fall below 97%. Such readings, especially when consistently observed, should not be dismissed, as they may indicate potential underlying health issues or impending emergencies that warrant further evaluation and intervention.

OsLdh7 Overexpression in Rice Confers Submergence Tolerance by Regulating Key Metabolic Pathways: Anaerobic Glycolysis, Ethanolic Fermentation and Amino Acid Metabolism

Lactate dehydrogenase plays a key role in alleviating hypoxia during prolonged submergence. To explore the function of the OsLdh7 gene in enhancing submergence tolerance, we overexpressed this gene in rice (Oryza sativa cv. IR64) and subjected the transgenic lines to complete inundation. The overexpression lines showed enhanced viability, chlorophyll content and photosystem II (PSII) efficiency compared to wild-type (WT) plants under stress and recovery conditions. Additionally, these lines exhibited better starch accumulation and reduced reactive oxygen species (ROS) accumulation. Protein-protein interaction studies revealed that OsLdh7 interacts with OsLos2, OsPdc2, OsAlaAT2 and OsAsp2. Under submergence, enhanced enzyme activities of OsLdh7, OsAsp2 and OsAdh1 led to higher NAD+ levels, sustaining anaerobic glycolytic flux and increasing pyruvate, a critical carbon source for amino acid metabolism as well as anaerobic fermentation pathways. Elevated l-lactate levels resulted in increased activity of OsPdc2, which eventually led to enhanced ethanol production. The overexpression lines also accumulated higher levels of aspartate, glutamate and alanine, crucial for ROS reduction and energy production during recovery. These findings suggest that OsLdh7 overexpression confers tolerance to submergence stress by regulating the important metabolic pathways- anaerobic glycolysis, ethanolic fermentation and amino acid metabolism in rice.

Validating the Child Behavior Checklist 1.5-5 as a screening tool for autism spectrum disorder

Early identification of autism spectrum disorder through cost-effective screening is crucial in low- and middle-income countries. The Child Behavior Checklist 1.5-5, using the Autism Spectrum Problems and Withdrawn Syndrome subscales, has potential as a level 1 autism spectrum disorder screening tool, though its construct validity in low- and middle-income countries remains underexplored. We aimed to validate the Child Behavior Checklist 1.5-5 for autism spectrum disorder screening in a representative sample of 1292 Brazilian children aged 3-5 years and 70 autism spectrum disorder children aged 1-5 years. Confirmatory factor analysis evaluated model fit indices and correlation strength between Child Behavior Checklist items and autism spectrum disorder diagnoses. Receiver operating characteristic curves assessed the optimal cutoff score. The Autism Spectrum Problems model demonstrated good fit and reliability (comparative fit index = 0.96, root mean square error of approximation = 0.037, ω = 0.869), as did the Withdrawn Syndrome model (comparative fit index = 0.974, root mean square error of approximation = 0.034, ω = 0.776), with one item per model showing low factor loadings. A cutoff score of 6 on the Autism Spectrum Problems yielded 82.5% sensitivity and 83.4% specificity, while a cutoff of 4 on the Withdrawn scale resulted in 87.9% sensitivity and 82.2% specificity. The Child Behavior Checklist 1.5-5 Autism Spectrum Problems and Withdrawn scales are reliable level 1 autism spectrum disorder screeners for Brazilian children, with good internal consistency and construct validity.Lay abstractEarly identification of Autism Spectrum Disorder is very important, especially in low and middle-income countries, where access to resources is often limited. The Child Behavior Checklist 1.5-5 is a tool that has been used to help identify children with autism spectrum disorder through specific behavior patterns. However, its effectiveness in low- and middle-income country settings has not been thoroughly studied. This research focused on evaluating the Child Behavior Checklist 1.5-5 as a screening tool for autism spectrum disorder among Brazilian children. The study involved 1292 children aged 3-5 years from the general population and 70 children with autism spectrum disorder aged 1-5 years. Using advanced statistical methods, the study tested how well the Child Behavior Checklist identified children with autism spectrum disorder and how reliable it was in this context. The findings showed that the Child Behavior Checklist 1.5-5 performed well in identifying autism spectrum disorder, with high reliability and consistency in the results. Although one item in each of the autism spectrum problems and withdrawn syndrome subscales did not perform as strongly, the overall tool was effective. In summary, the Child Behavior Checklist 1.5-5 proves to be a reliable and valid tool for early autism spectrum disorder screening in Brazilian children. This can help ensure that more children in low- and middle-income country settings are identified early and receive the necessary support and interventions to help them thrive. Future research should continue to test this tool in different contexts to confirm its usefulness across various populations.

Utility of Monitoring Fasting Phase During Pediatric Colonic Manometry Studies

INTRODUCTION

Colonic manometry (CM) is a diagnostic procedure used to evaluate pediatric patients with refractory constipation, fecal incontinence, Hirschsprung disease, and pediatric intestinal pseudo-obstruction. Pan-colonic high-amplitude propagated contractions (HAPCs), measured by CM, reflect an intact neuromuscular function of the colon. Current guidelines recommend starting CM with fasting recording for 1-2 h, but no prior evaluation has determined the diagnostic yield of the fasting phase. We aimed to determine the utility of the fasting phase during CM studies.

METHODS

We evaluated CM studies conducted at a tertiary pediatric center (2018-2022). Fasting phases of normal CM studies were evaluated.

KEY RESULTS

In 433 included studies 241 (55.7%) females, median age (9.7 years), the average fasting recording lasted 126 min. A total of 193 (44.6%) studies exhibited fasting HAPCs, with 123 (28.4%) being pan-colonic. The presence of pan-colonic HAPCs was based solely on the fasting phase in 11 (2.5%) studies. Patients with fasting pan-colonic HAPCs were younger (median age of 6.9 vs. 9.8 years, p = 0.0001) and had a higher rate of postprandial HAPCs (69.1% vs. 25.2%, p < 0.0001). Most fasting pan-colonic HAPCs presented during the first 60 min (94/123, 76.4%). All studies demonstrated HAPCs after stimulation with bisacodyl. In analyzing just the initial 30 min of fasting on CM, only 2 (0.5%) studies would have been misclassified as abnormal, with no bisacodyl administration in these studies.

CONCLUSIONS & INFERENCES

Shortening the fasting phase minimally affects next-day CM results and could reduce patient inconvenience, hospital-related costs, and potential side effects.

The current state of pediatric gastroenterology in under-resourced nations

Background

Pediatric gastroenterology (GI) care in low- and middle-income countries (LMICs) faces substantial challenges due to limited healthcare infrastructure, inadequate resources, and a shortage of specialized healthcare professionals. These challenges lead to delayed diagnoses and treatment, exacerbating the morbidity and mortality associated with pediatric GI diseases, which include both infectious conditions like diarrhea and chronic conditions such as inflammatory bowel disease (IBD) and liver diseases.

Aim

The aim of this review is to examine the current state of pediatric GI care in LMICs, identify the key challenges these regions face, and propose strategies to improve healthcare outcomes for children affected by GI disorders.

Methods

This review synthesizes existing literature from a range of LMICs, analyzing factors such as the economic burden of healthcare, barriers to access, the availability of diagnostic and therapeutic services, and the state of pediatric hepatology and endoscopy. Studies included in the review were sourced from countries in sub-Saharan Africa, South Asia, and other LMIC regions, focusing on pediatric GI disorders and healthcare delivery.

Results

Economic burden: Families in LMICs face significant economic barriers in accessing pediatric GI care, with treatment costs often exceeding household income, especially in private healthcare settings. Healthcare access: Limited access to healthcare facilities, especially in rural areas, coupled with the shortage of trained pediatric gastroenterologists and necessary medical equipment, leads to delayed diagnoses and inadequate care for conditions like Helicobacter pylori infections and chronic liver diseases. Sanitation and infectious diseases: Poor sanitation and lack of access to clean water contribute to the high prevalence of diarrheal diseases, which can be reduced through better hygiene practices and improved infrastructure. Training gaps: The shortage of trained healthcare workers, particularly pediatric specialists, hinders effective care delivery, with healthcare workers often overburdened due to workforce migration and low salaries. Hepatology and endoscopy: Pediatric hepatology, especially in the context of viral hepatitis, and the availability of pediatric GI endoscopy are severely limited in LMICs, further complicating the management of liver diseases and GI conditions in children.

Conclusion

Improving pediatric GI care in LMICs requires addressing systemic challenges such as inadequate healthcare infrastructure, limited financial resources, and a shortage of trained professionals. Prevention strategies like vaccination, sanitation improvements, and public health education campaigns are crucial for reducing the prevalence of pediatric GI diseases. In addition, enhancing access to specialized training, healthcare services, and diagnostic tools will improve outcomes for children in resource-limited settings. Continued international collaboration and investment in local healthcare systems are essential for creating sustainable solutions and bridging the gap in pediatric GI care.

Perioperative Staff's Experiences of Premedication for Children

PURPOSE

Providing perioperative care for children who express anxiety or react with negative anxiety-associated consequences can be a challenge. The use of premedication is established as an important intervention for young children before surgery, yet research into care providers' experiences of premedication is limited. The aim of this study was to explore perioperative staff's experiences of premedication for preschool-age children.

DESIGN

A descriptive inductive qualitative study was performed based on focus group discussions.

METHODS

A purposive sample of a team from the operating department with experience in anesthetizing and caring for children in the perioperative period was interviewed in small focus groups: five preoperative and postoperative care nurses, five nurse anesthetists, and five anesthesiologists. The transcribed text was categorized using qualitative content analysis.

FINDINGS

The content analysis revealed three themes: a matter of time, do not wake the sleeping bear, and on responsive tiptoes.

CONCLUSIONS

Care providers must adapt their work to the child's emotional state of mind and needs, allowing time for the child to trust and accept the premedication and for the premedication to reach its peak effect. Premedication provides light sleep preoperatively, which requires careful treatment of the child to avoid emotional reactions, and the postoperative path is most peaceful when the premedication supports a long duration of sedation. Our findings highlight the need for safety precautions and a permissive and flexible organization with the goal of achieving a smooth and safe journey for the child in the perioperative path.

Coexistence of Sjögren's Syndrome-associated Interstitial Nephritis and Hypokalemic Nephropathy in a Patient with Distal Renal Tubular Acidosis

A 42-year-old woman presented with muscle weakness and hypokalemic distal renal tubular acidosis (dRTA). Investigations revealed concurrent Sjögren's syndrome (SS) and Hashimoto's thyroiditis contributing to hypokalemic dRTA. A renal biopsy revealed focal tubulointerstitial nephritis (TIN) suggestive of SS-related renal involvement, along with distinctive ischemic glomerular changes and tubular alterations consistent with hypokalemic nephropathy. Rapid improvement in tubular injury markers and hypobicarbonemia followed potassium supplementation, suggesting that hypokalemia contributed to proximal tubular injury. This case underscores the diagnostic challenge posed by the simultaneous presence of TIN and hypokalemic nephropathy, potentially masking hypokalemic nephropathy in patients with hypokalemic dRTA secondary to SS-TIN.

Exploring the link between celiac disease and obesity: a potential role of gut microbiome

BACKGROUND/AIMS

In today's age, celiac disease (CD) is no longer solely characterized by chronic diarrhea in a malnourished child. Obesity is gradually being acknowledged as part of CD's clinical course. Both conditions have been linked to alterations of gut microbiome. Given the difficulty of strict gluten-free diet adherence, there is a need for less restrictive adjunctive therapies. We aimed to investigate the prevalence of obesity in patients diagnosed with CD with the goal of developing new therapeutic approaches.

METHODS

Baseline data from the National Institute of Health's All of Us Research Program, was used to evaluate the relationship between CD and obesity. A retrospective cohort study was conducted where groups of individuals with CD and without CD were matched by age range and health surveys. Statistical analysis with odds ratios (OR) with 95% confidence intervals (CI) were reported.

RESULTS

The prevalence of obesity was 32.6% in the CD group compared to 18.4% in the control group (OR, 2.111; 95% CI, 1.914-2.328; P< 0.0001). Women accounted for a greater population of patients with CD and obesity. The largest percentage of patients with CD and obesity were older than 65 years. The highest percentage of individuals in both the experimental and control groups were white, followed by African Americans.

CONCLUSIONS

Our data shows a significant association between CD and increased prevalence of obesity. These results warrant further investigation into microbial changes and dietary exposures that affect the pathogenesis of both diseases.

Improving pain score and restraint duration during circumcision

The American Academy of Pediatrics (AAP) recommends providing adequate analgesia during circumcision. Ring block is the most effective method of analgesia, while topical crème (EMLA: lidocaine and prilocaine topical) alone is ineffective. We conducted a quality improvement (QI) project. The aim was to reduce pain scores and restraint duration during circumcision by 20% from baseline over six months.

Methods

We followed the standard QI process using PDSA cycles and standard QI charts.

Results

Our preintervention data over six weeks revealed significantly higher pain scores if residents performed the procedure or if EMLA was used compared to nerve block. Our intervention included but was not limited to having a new policy to stop using EMLA and have residents watch a video on ring block before performing the procedure. Data collected over subsequent 3.5 months showed that the mean restraint time was reduced by 29% by attendings and by 15% by residents, the use of EMLA cream was eliminated, mean pain score was reduced by 82% when performed by residents and by 20% by attendings, and pain score above 3 was reduced by 100% by residents and attendings. We conducted a sustainability phase over two months. We demonstrated the sustainability of reduced restraint time among attendings but to a lesser extent among residents and the sustainability of mean pain score among both.

Conclusions

We conclude that improving effective analgesia during circumcision can be achieved and sustained using the QI project.

Relationship of maternal childhood maltreatment and children's emotional-behavioral problems: parental reflection functioning and social support's role

Childhood maltreatment has profound and long-lasting effects, not only on the victims but also on their offspring when they become parents later in life. This study aimed to investigate the role of two key mediating factors-parental reflective functioning and perceived social support-in the relationship between maternal childhood maltreatment and children's emotional and behavioral problems. We conducted a cross-sectional study in Iran from March to June 2024. Mothers of preschool children (4-6 years old) with emotional or behavioral problems (N = 222; Mean age = 34.06 ± 4.2 years) completed measures of Childhood maltreatment Questionnaire (CTQ), Parental Reflective Functioning Questionnaire (PRFQ), Perceived Social Support (PSS), and children's emotional and behavioral outcomes, as assessed using the Strengths and Difficulties Questionnaire (SDQ). The SDQ includes subscales for emotional symptoms, conduct problems, hyperactivity/inattention, peer relationship problems, and prosocial behavior. Structural equation modeling (SEM) was used to assess the conceptual model. The results revealed that childhood maltreatment had no direct association with children's emotional and behavioral problems. However, childhood maltreatment was positively and indirectly related to children's emotional and behavioral problems (including emotional symptoms, conduct problems, hyperactivity/inattention, and peer relationship problems) and negatively and indirectly related to children's prosocial behavior. These associations were mediated through pre-mentalizing modes of parental reflective functioning. Additionally, the analysis revealed no significant mediating role of perceived social support in this relationship. The findings highlight the significant indirect association between childhood maltreatment and various aspects of children's emotional and behavioral problems through pre-mentalizing modes of parental reflective functioning. This underscores the critical role of enhancing parental reflective abilities to mitigate the adverse outcomes of childhood maltreatment on children's emotional regulation and behavioral adjustment.

Leveraging Machine Learning for Pediatric Appendicitis Diagnosis: A Retrospective Study Integrating Clinical, Laboratory, and Imaging Data

Background and Aims

Appendicitis is the most common surgical emergency in pediatric patients, requiring timely diagnosis to prevent complications. This study introduces an innovative approach by integrating clinical, laboratory, and imaging features with advanced machine-learning techniques to enhance diagnostic accuracy in pediatric appendicitis.

Methods

A retrospective analysis was conducted on 782 pediatric patients from the Regensburg Pediatric Appendicitis Data set. Clinical scores, laboratory markers, and imaging findings were analyzed. Statistical comparisons were performed using independent t-tests and χ 2 tests, with significance set at p < 0.05. Predictive models, including logistic regression and machine learning classifiers, were developed and evaluated using accuracy, precision, recall, and F1-score.

Results

Significant differences were observed in clinical scores (e.g., Alvarado Score and Pediatric Appendicitis Score) and laboratory markers (e.g., WBC count and neutrophil percentage) between appendicitis (AA) and non-appendicitis (Non-AA) groups (p < 0.001). Imaging features, including appendix diameter, also demonstrated diagnostic value. Among predictive models, the Random Forest classifier achieved the highest accuracy (94.5%), with strong precision (93.8%) and recall (95.2%) for appendicitis diagnosis.

Conclusion

This study represents a novel application of machine learning models, particularly Random Forest, to enhance diagnostic accuracy for pediatric appendicitis. The integration of clinical, laboratory, and imaging features offers a comprehensive and precise diagnostic framework. Further validation in diverse populations is recommended.

Prediction of Factors Affecting Speech and Auditory Outcomes of Cochlear Implantation in Pre-Lingual Deaf Children: A Cross-Sectional Study

To determine the factors affecting speech and auditory outcomes of cochlear implantation (CI) in pre-lingual deaf children. Cross-sectional study was performed on 40 pre-lingual deaf children who underwent CI at our institution at < 6 years of age. Their speech and auditory outcomes were evaluated using Speech Intelligibility Rating Scale (SIRS) and Category of Auditory Performance (CAP). Further, the factors affecting the speech and auditory outcomes were analysed. Mean age at the time of CI was 3.5 years (P = 0.01). Post-operative speech and auditory rehabilitation therapy was received by 34 patients (P < 0.01). Implant compliance was seen in 38 patients (P = 0.01). Strong family support was received by 39 patients. Age at the time of CI, post-operative speech and auditory rehabilitation therapy, implant compliance and family support play a vital role in determining the outcome of the surgery.

Decoding Immunobiology Through Genetic Errors of Immunity

Throughout biology, the pursuit of genotype-phenotype relationships has provided foundational knowledge upon which new concepts and hypotheses are built. Genetic perturbation, whether occurring naturally or in experimental settings, is the mainstay of mechanistic dissection in biological systems. The unbiased discovery of causal genetic lesions via forward genetics in patients who have a rare disease elucidates a particularly impactful set of genotype-phenotype relationships. Here, we review the field of genetic errors of immunity, often termed inborn errors of immunity (IEIs), in a framework aimed at highlighting the powerful real-world immunology insights provided collectively and individually by these (approximately) 500 disorders. By conceptualizing essential immune functions in a model of the adaptive arsenal of rapid defenses, we organize IEIs based on immune circuits in which sensors, relays, and executioners cooperate to carry out pathogen clearance functions in an effective yet regulated manner. We review and discuss findings from IEIs that not only reinforce known immunology concepts but also offer surprising phenotypes, prompting an opportunity to refine our understanding of immune system function.

Substance use and use disorders during pregnancy and the postpartum period

Substance use and substance use disorders among pregnant and postpartum individuals have risen dramatically, necessitating enhanced clinician education and intervention strategies. This expert review offers obstetricians and gynecologists a comprehensive overview of substance use during the prenatal and postpartum periods. We discuss the epidemiology, maternal and fetal adverse effects, as well as treatment approaches for major substances: nicotine, cannabis, alcohol, benzodiazepines, stimulants, and opioids. Additionally, we address the ethical and legal implications of substance use during pregnancy and emphasize the importance of equitable and nonstigmatizing care. By integrating evidence-based practices, we aim to support obstetricians and gynecologists in providing optimal care for pregnant and postpartum individuals affected by substance use disorders.

Remote Care: The Future of Cochlear Implants

OBJECTIVE

The aims of this study were to 1) evaluate whether remote cochlear implant (CI) programming has comparable outcomes to traditional in-person CI management, 1) determine the effects of remote programming on family burden and associated costs, and 1) demonstrate feasibility and satisfaction of remote programming by patients and families for both the adult and pediatric CI populations.

STUDY DESIGN

Prospective study of one CI program.

PATIENTS AND INTERVENTION

Adult and pediatric patients with at least one CI underwent CI programming via in-person and remote visits.

MAIN OUTCOME MEASURES

CI programming parameters (impedances, neural response telemetry, upper and lower stimulation levels, datalogging), technology comfort self-report, visit burden and satisfaction, mental health and quality of life.

RESULTS

Fifteen pediatric participants (mean age: 4.17 yr; SD = 3.24) and 15 adult participants (mean age: 56.73 yr; SD = 21.11) were enrolled. In-person and remote programming sessions yielded comparable results for measuring CI programming parameters. Adult and parent participants were highly satisfied with remote programming and reported receiving excellent care. Listening effort was significantly less for the remote visit as compared to the in-person visit for adults. Burden of care to attend the in-person visit was greater for the pediatric population in terms of expenses incurred, unpaid time off work, and coordination of care for other children.

CONCLUSIONS

Remote programming is a feasible and effective service delivery model for the adult and pediatric CI population. Inclusion of remote services into postoperative CI protocols should be considered as a means of reducing barriers to hearing healthcare.

AI-Enabled Screening for Retinopathy of Prematurity in Low-Resource Settings

Importance

Retinopathy of prematurity (ROP) is the leading cause of preventable childhood blindness worldwide. If detected and treated early, ROP-associated blindness is preventable; however, identifying patients who might respond to treatment requires screening over time, which is challenging in low-resource settings where access to pediatric ophthalmologists and pediatric ocular imaging cameras is limited.

Objective

To develop and assess the performance of a machine learning algorithm that uses smartphone-collected videos to perform retinal screening for ROP in low-resource settings.

Design, Setting, and Participants

This diagnostic study used smartphone-obtained videos of fundi in premature neonates with and without ROP in Mexico and Argentina between May 12, 2020, and October 31, 2023. Machine-learning (ML)-driven algorithms were developed to process a video, identify the best frames within the video, and use those frames to determine whether ROP was likely or not. Eligible neonates born with gestational age less than 36 weeks or birth weight less than 1500 g were included on the study.

Exposures

An ML algorithm applied to a smartphone-obtained video.

Main Outcomes and Measures

The ML algorithms' ability to identify high-quality retinal images and classify those images as indicating ROP or not at the frame and patient levels, measured by accuracy, specificity, and sensitivity, compared with classifications from 3 pediatric ophthalmologists.

Results

A total of 524 videos were collected for 512 neonates with median gestational age of 32 weeks (range, 25-36 weeks) and median birth weight of 1610 g (range, 580-2800 g). The frame selection model identified high-quality retinal images from 397 of 456 videos (87.1%; 95% CI, 84.0%-90.1%) reserved for testing model performance. Across all test videos, 97.4% (95% CI, 96.7%-98.1%) of high-quality retinal images selected by the model contained fundus images. At the frame level, the ROP classifier model had a sensitivity of 76.7% (95% CI, 69.9%-83.5%); at the patient level, the classifier model had a sensitivity of 93.3% (95% CI, 86.4%-100%). At both levels, the model's sensitivity was higher than that for the panel of pediatric ophthalmologists (frame level: 71.4% [95% CI, 64.1%-78.7%]; patient level: 73.3% [95% CI, 61.0%-85.6%]). Specificity and accuracy were higher for ophthalmologist classification vs the ML model.

Conclusions and Relevance

In this diagnostic study, a process that used smartphone-collected videos of premature neonates' fundi to determine whether high-quality retinal images were present had high sensitivity to classify such images as indicating or not indicating ROP but lower specificity and accuracy than ophthalmologist assessment. This process costs a fraction of the current process for retinal image collection and classification and could be used to expand access to ROP screening in low-resource settings, with potential to help prevent the most common cause of preventable childhood blindness.

Perforated Appendicitis in a 23-Month-Old Child

Appendicitis is caused by a blockage of the appendix, leading to the proliferation of intestinal bacteria and subsequent inflammation of the appendix. Within the scope of pediatrics, appendicitis is associated with an atypical presentation, and its symptoms can overlap with other abdominal conditions, contributing to a higher risk of misdiagnosis. Despite its relatively low prevalence in patients less than four years of age, appendicitis remains a critical condition that requires prompt recognition and intervention to avoid complications and ensure favorable outcomes. We present a case of perforated appendicitis in a 23-month-old female patient who presented to the emergency department with abdominal pain. This report highlights the challenges in diagnosing appendicitis in this age group and reviews current guidelines for the evaluation of suspected appendicitis in young children. Emphasis is placed on the importance of timely diagnosis and surgical intervention to reduce complications and prevent mortality.

Diagnostic Techniques for Infantile Subglottic Hemangiomas: A Scoping Review

OBJECTIVE

Infantile subglottic hemangioma (SGH) poses a risk of airway compromise if untreated. Traditionally, operative endoscopy (OH) diagnoses SGH, but since the discovery of beta-blockers' efficacy in treating infantile hemangiomas (IHs) in 2008, and advances in endoscopic technology, nonoperative methods have emerged. This review identifies endoscopic practices for diagnosing and monitoring infantile SGH during the oral beta-blocker treatment era.

DATA SOURCES

A comprehensive literature search in October 2022 and August 2023 covered PubMed, Embase, Cochrane Library, SCOPUS, and Web of Science.

REVIEW METHODS

The search was limited to English-language studies published since 2008, considering this when propranolol was demonstrated as an effective treatment option for IH. The articles were screened for relevance based on predefined inclusion and exclusion criteria.

RESULTS

After inclusion and exclusion criteria, sixty final studies were identified, describing 240 cases of infantile SGH. Most children were diagnosed using OE alone (73.3%; n = 176/240), 23.3% (n = 56/240) using office-based laryngoscopy procedures (OBPs) followed by OE, 3.3% using OBP alone (n = 8/240). There were no reported diagnostic endoscopy-related complications. Twenty-nine studies described using endoscopy plus diagnostic imaging to either confirm an SGH lesion, characterize the extent of disease spread, or rule out other causes of presenting symptoms. The proportion of infants diagnosed with OE alone decreased from 2008 to 2023.

CONCLUSION

Operative endoscopy remains the SGH diagnostic standard, but OBP adoption is increasing. Further research is needed to determine the optimal SGH diagnosis and management approach.

LEVEL OF EVIDENCE

NA Laryngoscope, 135:1287-1294, 2025.

Associations between sleep habits and different impulsivity facets in adolescence

BACKGROUND

Sleep patterns change during adolescence due to physiological maturation and psychosocial factors, leading to progressively higher eveningness, sleep deprivation and social jetlag (SJL). These sleep changes are associated with impulsivity, a common behavioral trait in adolescence which can make those with developmental disabilities more vulnerable to behavioral, cognitive and clinical difficulties. However, it is unclear which aspects of sleep and what types of impulsivity are involved.

AIMS

To investigate the relationships between sleep/circadian variables and self-reported impulsivity.

METHODS AND PROCEDURES

Three sleep/circadian variables (time in bed on weekdays, eveningness and SJL) and five dissociable facets of self-reported impulsivity (UPPS-P scale) were answered by 389 healthy 9-17-year-olds (225 girls).

OUTCOMES AND RESULTS

A significant (but small) association between eveningness and a multivariate composed of the five facets of impulsivity (5 % of variance explained) was found and negative urgency was the main driver (4 %) of this relationship.

CONCLUSION AND IMPLICATIONS

Typically developing adolescents with high eveningness traits display slight difficulty controlling their behavior when in a state of negative affect. This finding deserves an in-depth investigation in youth with neurodevelopmental disabilities, who are more prone to presenting sleep/circadian changes, externalizing problems like impulsiveness and internalizing one such as mood alterations.

Prenatal exposure to heavy metals and childhood atopic disease

INTRODUCTION

Our objective was to determine the relationship between biomarkers of exposure to eleven heavy metals measured at birth and atopic disease in offspring up to 5.5 years.

METHODS

Heavy metals were measured in women of the ELFE cohort from: maternal urine (n = 804; arsenic [As], cadmium [Ca], cesium [Cs], chromium [Cr], cobalt [Co], nickel [Ni], antimony [Sb], tin [Sn] and vanadium [V]), hair (n = 1649; mercury [Hg]), and cord blood (n = 1525; lead [Pb]) collected at birth. Data on atopic diseases (eczema, food allergy, wheezing, asthma, and rhinitis) were collected from 2 months to 5.5 years. Five multimorbidity clusters were previously identified using latent class analysis: "asymptomatic", "early wheeze without asthma", "allergies without asthma", "asthma only", and "multimorbidity". Multinomial logistic regression was performed, using the asymptomatic cluster as the reference, to determine the relationship between heavy metal concentrations and atopic diseases.

RESULTS

Concentrations of Co were negatively associated with the multimorbidity cluster in the whole sample (OR 0.66 [95% CI 0.49, 0.89]). In boys, Cs was associated with lower odds of belonging to the early wheeze without asthma (0.71 [0.52, 0.97]) and multimorbidity clusters (0.54 [0.35, 0.82), while Sn was negatively associated with the multimorbidity cluster (0.66 [0.46, 0.96]). Results with binary outcomes supported findings from cluster analyses.

CONCLUSION

Exposure to some heavy metals assessed at delivery was inversely associated with the risk of atopic diseases, especially among boys. Further research should focus on heavy metal subtypes to distinguish between the more and less toxic forms.

The Naples pediatric food allergy (NAPFA) score: A multivariable model for the prediction of food allergy in children

BACKGROUND

Food allergy (FA) is one of the most common chronic conditions in children. Diagnostic delays and errors in FA are relevant problems in clinical practice. Non-invasive and accessible tools for FA diagnosis are highly required. We aimed to develop an easy-to-use clinical score to facilitate the diagnostic approach for pediatric FA (i.e. the NAPFA score).

METHODS

Subjects with suspected FA aged 0-14 years were prospectively evaluated at a tertiary center for pediatric allergy, gastroenterology, and nutrition. Upon completing the diagnostic workup, the subjects were diagnosed with FA based on the oral food challenge result, or with other conditions. Bootstrapped multivariable logistic regression was employed to construct two models that estimate the probability of having FA, one (M1) without the results of the allergy screening tests, while the other (M2) including them.

RESULTS

Six hundred and twenty-seven pediatric subjects were included in the study. The median (interquartile interval) age at symptom onset was 8 (3;27) months. M1 employed the following predictors: sex, age at symptoms onset, cesarean delivery, occurrence of atopic dermatitis before FA onset, first degree family members with allergy, symptoms occurrence after ingestion of specific food, and skin, gastrointestinal, respiratory, and systemic symptoms. M2 replaced the occurrence of symptoms after ingestion of specific food with the results of allergy tests. The c-statistic was 0.915 (95% bootstrapped CI: 0.895-0.937) for M1 and 0.977 (95% CI: 0.969-0.992) for M2. Both models demonstrated good internal calibration and a favorable decision analysis curve.

CONCLUSION

The NAPFA score could be an easy-to-use tool holding the potential to streamline the FA diagnostic process in pediatric age, reducing unnecessary testing, and improving patient outcomes in a variety of healthcare settings. Its external validation will possibly enable a standardized approach for identifying children with FA.

RNF135 promotes the stemness of breast cancer cells by ubiquitinating and degrading DDX58

BACKGROUND

RING finger protein 135 (RNF135) is identified as a regulator in certain cancer types. However, its role and molecular mechanisms in breast cancer are still unclear.

METHODS

Herein, we investigated the level of RNF135 in tumor tissues of breast patients using the online database and confirmed the data by real-time PCR and western blot analysis. The effects of RNF135 on stemness maintenance and migration/invasion capability of breast cells were investigated by sphere formation, flow cytometry, and transwell assays. Limiting dilution xenograft assay and metastatic model were applied to assess the implications of RNF135 in tumorigenesis, chemoresistance, and metastasis.

RESULTS

Our results revealed that RNF135 was upregulated in tumor tissues of breast patients, especially in metastatic patients. Knockdown of RNF135 suppressed stemness, and migration/invasion capability of breast cancer cells. Conversely, RNF135 overexpression enhanced the stemness and migration/invasion ability of breast cancer cells. Limiting dilution xenograft and metastatic assays demonstrated that RNF135 was required for the self-renewal of CSCs to initiate breast cancer development and metastasis. Mechanistically, DDX58 was identified as the substrate of RNF135 and RNF135 could facilitated the ubiquitination and degradation of DDX58. Notably, overexpression of DDX58 rescued the promoting effects of RNF135 on the stemness and migration/invasion ability of breast cancer cells.

CONCLUSIONS

Overall, our results implied that RNF135 promotes the stemness of breast cancer cells by ubiquitinating and degrading DDX58 and targeting of RNF135/DDX58 axis might be a feasible method to suppress tumorigenesis and metastasis of breast cancer patients.

Exploring the association between serum magnesium level and autism spectrum disorder using validated spectrofluorimetric method

Magnesium is an essential mineral in biological systems and has a significant impact on brain health. Its deficiency has been found to correlate with irregular metabolic processes and neurodevelopmental disorders. The objective of this research was to establish and validate an analytical approach based on the standard addition methodology for determining endogenous magnesium levels in the serum of autistic and healthy children. Analytically, the approach involved functionalizing fluorescent graphene quantum dots with a magnesium-phosphomolybdic acid ion pair complex, followed by measuring magnesium-induced fluorescence quenching on the functionalized graphene quantum dots, which is concentration-dependent. The approach was validated in accordance with the ICH M10 requirements for bioanalytical technique validation, and it reliably quantified magnesium concentrations in the serum of both autistic and healthy children. The study found that autistic children have considerably lower serum magnesium concentrations than healthy children (P < 0.01), indicating a correlation between magnesium deficiency and autism spectrum disorder. The average serum magnesium levels (mg/dl) recorded for the autistic and healthy groups were 2.03 ± 0.33 and 2.28 ± 0.26, respectively.

Clinical characteristics of single human rhinovirus infection and co-infection in the respiratory tract of children

Background

The human rhinovirus (HRV), when combined with other viruses, typically causes respiratory tract infections in children. However, there is a lack of adequate clinical studies on the causative agents and their symptoms in the case of mixed infections involving rhinovirus (RVs). The objective of this study was to determine the viral etiology of respiratory infections and the clinical characteristics of HRV infections in children.

Methods

This study included 438 patients, aged between 0 and 10 years with a respiratory tract infection diagnosis. A multiplex polymerase chain reaction was used to detect respiratory pathogens. The recorded clinical data of patients were extracted and subsequently analyzed.

Results

The positive rate of virus infection was 256/438 (58.45%) and the most frequently identified pathogens were the HRV, adenovirus (ADV), and respiratory syncytial virus (RSV). Notably, HRV co-infection with other pathogens accounted for 84.62% of co-infection cases. The highest co-infection rate was found for HRV with ADV (51.28%), followed by HRV with RSV (23.08%). Compared with HRV single infection, HRV and ADV co-infection was highly associated with the presence of a fever, and HRV co-infection with RSV had a higher rate of cough and pneumonia.

Conclusions

The study identified HRV as a significant pathogen in childhood respiratory infections, often co-infecting with ADV and RSV, and associated with distinct clinical manifestations such as fever and respiratory complications.