The characteristics of the gut microbiota in patients with pulmonary tuberculosis: A systematic review

Increasing evidence has indicated dysbiosis of the gut microbiota in patients with pulmonary tuberculosis (PTB). However, the change in the intestinal microbiota varies between different studies. This systematic review was conducted to investigate the characteristics of the gut microbiota in PTB patients. The MBASE, MEDLINE, Web of Science, and Cochrane Library electronic databases were systematically searched, and the quality of the retrieved studies was evaluated using the Newcastle-Ottawa scale. A total of 12 studies were finally included in the systematic review. Compared with healthy controls, the index reflecting α-diversity including the richness and/or diversity index decreased in 6 studies, while β-diversity presented significant differences in PTB patients in 10 studies. Although the specific gut microbiota alterations were inconsistent, short-chain fatty acid-producing bacteria (including Lachnospiraceae, Ruminococcus, Blautia, Dorea, and Faecalibacterium), bacteria associated with an inflammatory state (e.g., Prevotellaceae and Prevotella), and beneficial bacteria (e.g., Bifidobacteriaceae and Bifidobacterium) were commonly noted. Our systematic review identifies key evidence for gut microbiota alterations in PTB patients, in comparison with healthy controls; however, no consistent conclusion could be drawn, due to the inconsistent results and heterogeneous methodologies of the enrolled studies. Therefore, more well-designed research with standard methodologies and large sample sizes is required.

Evening versus morning dosing regimen drug therapy for hypertension

BACKGROUND

Variation in blood pressure levels display circadian rhythms. Complete 24-hour blood pressure control is the primary goal of antihypertensive treatment and reducing adverse cardiovascular outcomes is the ultimate aim. This is an update of the review first published in 2011.

OBJECTIVES

To evaluate the effectiveness of administration-time-related effects of once-daily evening versus conventional morning dosing antihypertensive drug therapy regimens on all-cause mortality, cardiovascular mortality and morbidity, total adverse events, withdrawals from treatment due to adverse effects, and reduction of systolic and diastolic blood pressure in people with primary hypertension.

SEARCH METHODS

We searched the Cochrane Hypertension Specialised Register via Cochrane Register of Studies (17 June 2022), Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 6, 2022); MEDLINE, MEDLINE In-Process and MEDLINE Epub Ahead of Print (1 June 2022); Embase (1 June 2022); ClinicalTrials.gov (2 June 2022); Chinese Biomedical Literature Database (CBLD) (1978 to 2009); Chinese VIP (2009 to 7 August 2022); Chinese WANFANG DATA (2009 to 4 August 2022); China Academic Journal Network Publishing Database (CAJD) (2009 to 6 August 2022); Epistemonikos (3 September 2022) and the reference lists of relevant articles. We applied no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing the administration-time-related effects of evening with morning dosing monotherapy regimens in people with primary hypertension. We excluded people with known secondary hypertension, shift workers or people with white coat hypertension.

DATA COLLECTION AND ANALYSIS

Two to four review authors independently extracted data and assessed trial quality. We resolved disagreements by discussion or with another review author. We performed data synthesis and analyses using Review Manager Web for all-cause mortality, cardiovascular mortality and morbidity, serious adverse events, overall adverse events, withdrawals due to adverse events, change in 24-hour blood pressure and change in morning blood pressure. We assessed the certainty of the evidence using GRADE. We conducted random-effects meta-analysis, fixed-effect meta-analysis, subgroup analysis and sensitivity analysis.

MAIN RESULTS

We included 27 RCTs in this updated review, of which two RCTs were excluded from the meta-analyses for lack of data and number of groups not reported. The quantitative analysis included 25 RCTs with 3016 participants with primary hypertension. RCTs used angiotensin-converting enzyme inhibitors (six trials), calcium channel blockers (nine trials), angiotensin II receptor blockers (seven trials), diuretics (two trials), α-blockers (one trial), and β-blockers (one trial). Fifteen trials were parallel designed, and 10 trials were cross-over designed. Most participants were white, and only two RCTs were conducted in Asia (China) and one in Africa (South Africa). All trials excluded people with risk factors of myocardial infarction and strokes. Most trials had high risk or unclear risk of bias in at least two of several key criteria, which was most prominent in allocation concealment (selection bias) and selective reporting (reporting bias). Meta-analysis showed significant heterogeneity across trials. No RCTs reported on cardiovascular mortality and cardiovascular morbidity. There may be little to no differences in all-cause mortality (after 26 weeks of active treatment: RR 0.49, 95% CI 0.04 to 5.42; RD 0, 95% CI -0.01 to 0.01; very low-certainty evidence), serious adverse events (after 8 to 26 weeks of active treatment: RR 1.17, 95% CI 0.53 to 2.57; RD 0, 95% CI -0.02 to 0.03; very low-certainty evidence), overall adverse events (after 6 to 26 weeks of active treatment: RR 0.89, 95% CI 0.67 to 1.20; I² = 37%; RD -0.02, 95% CI -0.07 to 0.02; I² = 38%; very low-certainty evidence) and withdrawals due to adverse events (after 6 to 26 weeks active treatment: RR 0.76, 95% CI 0.47 to 1.23; I² = 0%; RD -0.01, 95% CI -0.03 to 0; I² = 0%; very low-certainty evidence), but the evidence was very uncertain.

AUTHORS' CONCLUSIONS

Due to the very limited data and the defects of the trials' designs, this systematic review did not find adequate evidence to determine which time dosing drug therapy regimen has more beneficial effects on cardiovascular outcomes or adverse events. We have very little confidence in the evidence showing that evening dosing of antihypertensive drugs is no more or less effective than morning administration to lower 24-hour blood pressure. The conclusions should not be assumed to apply to people receiving multiple antihypertensive drug regimens.

Development and validation of a model for early diagnosis of biliary atresia

BACKGROUND AND AIMS

Early diagnosis of biliary atresia (BA), particularly distinguishing it from other causes of neonatal cholestasis (NC), is challenging. This study aimed to design and validate a predictive model for BA by using the data available at the initial presentation.

METHODS

Infants presenting with NC were retrospectively identified from tertiary referral hospitals and constituted the model design cohort (n = 148); others were enrolled in a prospective observational study and constituted the validation cohort (n = 21). Clinical, laboratory, and abdominal ultrasonographic features associated with BA were assessed. A prediction model was developed using logistic regression and decision tree (DT) analyses.

RESULTS

Three predictors, namely, gamma glutamyl transpeptidase (γGT) level, triangular cord sign (TC sign), and gallbladder abnormalities, were identified as factors for diagnosing BA in multivariate logistic regression, which was used to develop the DT model. The area under the receiver operating characteristic (ROC) curve (AUC) value for the model was 0.905, which was greater than those for γGT level, TC sign, or gallbladder abnormalities alone in the prediction of BA.

CONCLUSION

A simple prediction model combining liver function and abdominal ultrasonography findings can provide a moderate and early estimate of the risk of BA in patients with NC.

Liver injury in children: signal analysis of suspected drugs based on the food and drug administration adverse event reporting system

BACKGROUND

Evidence of drug-induced liver injury is abundant in adults but is lacking in children. Our aim was to identify suspected drug signals associated with pediatric liver injury.

METHODS

Hepatic adverse events (HAEs) among children reported in the Food and Drug Administration Adverse Event Reporting System were analyzed. A descriptive analysis was performed to summarize pediatric HAEs, and a disproportionality analysis was conducted by evaluating reporting odds ratios (RORs) and proportional reporting ratios to detect suspected drugs.

RESULTS

Here, 14,143 pediatric cases were reported, specifically 49.6% in males, 45.1% in females, and 5.2% unknown. Most patients (68.8%) were 6-18 years old. Hospitalization ranked first among definite outcomes (7,207 cases, 37.2%). In total, 264 disproportionate drug signals were identified. The top 10 drugs by the number of reports were paracetamol (1,365; ROR, 3.6; 95% confidence interval (CI), 3.4-3.8), methotrexate (878; ROR, 2.5; 95% CI, 2.3-2.7), vincristine (649; ROR, 3.0; 95% CI, 2.8-3.3), valproic acid (511; ROR, 3.2; 95% CI, 2.9-3.6), cyclophosphamide (490; ROR, 2.4; 95% CI, 2.2-2.6), tacrolimus (427; ROR, 2.4; 95% CI, 2.2-2.7), prednisone (416; ROR, 2.1; 95% CI, 1.9-2.3), prednisolone (401; ROR, 2.3; 95% CI, 2.1-2.5), etoposide (378; ROR, 2.3; 95% CI, 2.1-2.6), and cytarabine (344; ROR, 2.8; 95% CI, 2.5-3.2). After excluding validated hepatotoxic drugs, six were newly detected, specifically acetylcysteine, thiopental, temazepam, nefopam, primaquine, and pyrimethamine.

CONCLUSIONS

The hepatotoxic risk associated with 264 signals needs to be noted in practice. The causality of hepatotoxicity and mechanism among new signals should be verified with preclinical and clinical studies.

Long-term economic evaluation of the recombinant Mycobacterium tuberculosis fusion protein (EC) test for the diagnosis of Mycobacterium tuberculosis infection

Background: Tuberculosis continues to be a significant global burden. Purified protein derivative of tuberculin (TB-PPD) is one type of tuberculin skin test (TST) and is used commonly for the auxiliary diagnosis of tuberculosis. The recombinant Mycobacterium tuberculosis fusion protein (EC) test is a new test developed in China. Objective: Evaluate the long-term economic implications of using the EC test compared with the TB-PPD test to provide a reference for clinical decision-making. Methods: The target population was people at a high risk persons of being infected with Mycobacterium tuberculosis. The outcome indicator was quality-adjusted life years (QALY). A cost-utility analysis was used to evaluate the long-term economic implications of using the EC test compared with the TB-PPD test. We employed a decision tree-Markov model from the perspective of the whole society within 77 years. Results: Compared with the TB-PPD test, the EC test had a lower cost but higher QALY. The incremental cost-utility ratio was -119,800.7381 CNY/QALY. That is, for each additional QALY, the EC test could save 119,800.7381 CNY: the EC test was more economical than the TB-PPD test. Conclusion: Compared with the TB-PPD test, the EC test would be more economical in the long term for the diagnosis of M. tuberculosis infection according our study.

Clinical Characteristics of Pulmonary Tuberculosis in Children Tested by Xpert MTB/RIF Ultra

BACKGROUND

The Xpert MTB/rifampicin Ultra (Xpert Ultra) assay improves the early diagnosis of active tuberculosis (TB) in children. Clinical evaluation is paramount for the interpretation of any positive Xpert Ultra test, especially those with low quantities of DNA.

METHODS

In this study, 391 children with suspected TB who were tested with Xpert Ultra were enrolled. The clinical characteristics and Xpert Ultra results were further analyzed.

RESULTS

The sensitivity and specificity of Xpert Ultra were 45.0% (149/331) and 96.7% (58/60), respectively. Children with higher semiquantitative scales of Xpert Ultra showed higher percentages of a positive MTB culture, positive acid-fast bacilli staining, severe type of disease, fever, cough and expectoration, a higher white blood cell count and higher C-reactive protein concentrations (all P < 0.01). Among 44 children with an Xpert Ultra trace result, there were no differences in clinical characteristics between confirmed cases and unconfirmed TB cases.

CONCLUSIONS

The prevalence of trace is relatively high and can be considered positive in paucibacillary children. Clinical presentations are associated with bacterial load quantified by Xpert Ultra. The interpretation of Xpert Ultra trace results based on clinical information is important for the diagnosis of TB.

Liver sinusoidal endothelial S1pr2 regulates experimental liver fibrosis through YAP/TGF-β signaling pathway

The hepatic vascular niche plays an important role in the pathological process of liver fibrosis. Liver sinusoidal endothelial cells (LSECs) predominantly compose hepatic vascular niches. Endothelial cell (EC)-expressing sphingosine 1-phosphate receptor 2 (S1pr2) plays an essential role in the regulation of vascular functions. Nevertheless, it remains unknown whether liver LSEC-S1pr2 might modulate pathological liver fibrosis. In this study, liver fibrosis was induced by hepatotoxin carbon tetrachloride (CCl₄ ). The expression of S1pr2 is significantly downregulated in liver sinusoidal endothelial cells after CCl₄ treatment. The loss of S1pr2 in LSECs significantly alleviated liver fibrosis after chronic insult, whereas the overexpression of S1pr2 in LSECs accentuated liver fibrogenesis. In vivo experiments further revealed that the deficiency of S1pr2 in LSECs dampened hepatic stellate cell (HSC) activation, while overexpression of S1pr2 in LSECs enhanced HSC activation with more extracellular matrix component production. Mechanistically, LSEC-S1pr2 activates the YAP signaling pathway to potentiate the transactivation of TGF-β, which acts on HSCs in a paracrine manner, and thus aggravated liver fibrosis. Taken together, our results uncover a novel pathological mechanism of liver fibrosis in which LSEC-S1pr2 plays an important role in modulating the development of liver fibrosis, providing a future novel therapy target against liver fibrogenesis.

Prediction of women and Children's hospital outpatient numbers based on the autoregressive integrated moving average model

Objective

To evaluate the predictive value of the autoregressive integrated moving average (ARIMA) product seasonal model for the daily outpatient volume of paediatric internal medicine departments in hospitals.

Methods

The daily outpatient volume of paediatric internal medicine recorded by the hospital information system of the Chengdu Women's and Children's Central Hospital from 1 January 2011 to 31 December 2020 was collected. Using the data from 1 January 2011 to 31 December 2019, the seasonal summation ARIMA model of the time product was established by fitting the tseries program in the R-3.6.3 software. The monthly outpatient volume from January to December 2020 was predicted, and the prediction effect was evaluated according to the mean absolute percentage error (MAPE) between the predicted value and the actual value.

Results

The outpatient volume of paediatric internal medicine in the hospital from 2011 to 2019 showed an upward trend, with obvious seasonal fluctuations. The optimal model was the ARIMA model ([3,4], 1,2) × (1,1,0) 12, with an Akaike information criterion of 3116.656 and a Bayesian information criterion of 3217.412. The model's residual was a white noise sequence (x² = 7.56, P = 0.819), and the MAPE between the predicted value and the actual value of the model was 9.56%. Within a 95% confidence interval of the predicted value, the prediction accuracy of the model was high.

Conclusion

The ARIMA multiplicative seasonal model established in this study is suitable for the short-term prediction of the outpatient volume.

[Etiological diagnostic value of metagenomic next-generation sequencing in peritoneal dialysis-related peritonitis]

Objective: To explore the etiological diagnostic value of metagenomic next-generation sequencing (mNGS) in peritoneal dialysis (PD)-related peritonitis. Methods: The study was a retrospective cohort study. The clinical data of patients with PD-related peritonitis who were treated and underwent microbial cultivation and mNGS test at the same time from June 2020 to July 2021 in the Affiliated Drum Tower Hospital, Medical School of Nanjing University were analyzed. The positive rate, detection time and consistency between mNGS test and traditional microbial culture were compared. Results: A total of 18 patients with age of (50.4±15.4) years old and median dialysis time of 34.0 (12.4, 62.0) months were enrolled in the study, including 11 males and 7 females. Pathogenic microorganisms were isolated in 17 patients by mNGS test, with a positive rate of 17/18, which was higher than 13/18 of microbial culture, but the difference was not statistically significant (P=0.219). Both mNGS test and microbial culture isolated positive pathogenic bacteria in 12 patients, and mNGS test isolated the same types of pathogenic bacteria as microbial cultivation did in 11 patients. In five patients with negative microbial culture, mNGS test also isolated pathogenic microorganisms, including 3 cases of Staphylococcus epidermidis, 1 case of Mycobacterium tuberculosis and 1 case of Ureaplasma urealyticum. In 1 patient, microbial culture isolated pathogenic bacteria (Escherichia coli) whereas mNGS test did not. The detection time of mNGS was 25.0 (24.0, 27.0) h, which was significantly shorter than 89.0 (72.8, 122.0) h of microbial culture (Z=3.726, P<0.001). Conclusions: mNGS test can improve the detection rate of pathogenic microorganisms in PD-related peritonitis and greatly shorten the detection time, and has good consistency with microbial culture. mNGS may provide a new approach for pathogen identification of PD-related peritonitis, especially refractory peritonitis.

Staphylococcus aureus bacteremia complicated with non-traumatic mediastinal abscess in children: A case report

Background

Staphylococcus aureus bacteremia complicated with non-traumatic mediastinal abscess rarely occurs in children. Herein, we report a case of S. aureus bacteremia in a previously healthy 15-month-old boy, which was complicated with a non-traumatic mediastinal abscess, followed by recovery without surgery.

Case presentation

A previously healthy 15-month-old boy presented to the hospital with a high fever, accompanied by chills, lethargy, tachycardia, tachypnea, and slight cough. Contrast-enhanced computerized tomography revealed mediastinal abscess and blood culture analysis showed the presence of S. aureus which was methicillin-susceptible. With prompt initiation of antibiotic treatment, with appropriate duration, the patient successfully recovered without surgical drainage upon discharge.

Conclusions

Staphylococcus aureus bacteremia complicated with non-traumatic mediastinal abscess is rare in children, and early recognition and appropriate management are essential for a successful outcome.

Recombinant mycobacterium tuberculosis fusion protein for diagnosis of mycobacterium tuberculosis infection: a short-term economic evaluation

Objectives

Recombinant Mycobacterium tuberculosis fusion protein (EC) was anticipated to be used for the scale-up of clinical application for diagnosis of Mycobacterium tuberculosis infection in China, but it lacked a head-to-head economic evaluation based on the Chinese population. This study aimed to estimate the cost-utility and the cost-effectiveness of both EC and tuberculin pure protein derivative (TB-PPD) for diagnosis of Mycobacterium tuberculosis infection in the short term.

Methods

From a Chinese societal perspective, both cost-utility analysis and cost-effectiveness analysis were performed to evaluate the economics of EC and TB-PPD for a one-year period based on clinical trials and decision tree model, with quality-adjusted life years (QALYs) as the utility-measured primary outcome and diagnostic performance (including the misdiagnosis rate, the omission diagnostic rate, the number of patients correctly classified, and the number of tuberculosis cases avoided) as the effective-measured secondary outcome. One-way and probabilistic sensitivity analyses were performed to validate the robustness of the base-case analysis, and a scenario analysis was conducted to evaluate the difference in the charging method between EC and TB-PPD.

Results

The base-case analysis showed that, compared with TB-PPD, EC was the dominant strategy with an incremental cost-utility ratio (ICUR) of saving 192,043.60 CNY per QALY gained, and with an incremental cost-effectiveness ratio (ICER) of saving 7,263.53 CNY per misdiagnosis rate reduction. In addition, there was no statistical difference in terms of the omission diagnostic rate, the number of patients correctly classified, and the number of tuberculosis cases avoided, and EC was a similar cost-saving strategy with a lower test cost (98.00 CNY) than that of TB-PPD (136.78 CNY). The sensitivity analysis showed the robustness of cost-utility and cost-effectiveness analysis, and the scenario analysis indicated cost-utility in EC and cost-effectiveness in TB-PPD.

Conclusion

This economic evaluation from a societal perspective showed that, compared to TB-PPD, EC was likely to be a cost-utility and cost-effective intervention in the short term in China.

Death from human cytomegalovirus infection in a girl with congenital thymic dysplasia

We report the case of a girl with congenital thymic dysplasia and refractory disseminated Human Cytomegalovirus (CMV) infection diagnosed by autopsy. Additionally, she was diagnosed with T-cell lymphopenia immunodeficiency and received antiviral therapy with ganciclovir (GCV) /valganciclovir (V-GCV) and enhanced foscarnet. The CMV viral load (VL) monitoring was elevated with retinitis, interstitial pneumonia, and hepatitis. The phenotype of T-cell lymphopenia was uncertain, which limited any alternative therapy by whole-exome sequencing (WES) and lymphocyte subset panel until autopsy. The girl died of progressive respiratory failure and septic shock at ten months of age. Severe disseminated CMV infection typically develops in infants with primary maternal infections and occurs earlier during gestation and in people with a weakened host immune system. Individuals with CMV infection with initial immunodeficiency are associated with a poor prognosis, which is similar to patients with secondary immunodeficiency. This case describes the difficult treatment and prognosis of CMV infection in patients with congenital immunodeficiency, highlighting the importance of early aggressive anti-CMV antiviral therapy in immunodeficiencies, VL monitoring, drug resistance and the role of T-cells in CMV infection.

The effect of the problem based learning teaching model combined with mind mapping on nursing teaching: A meta-analysis

BACKGROUND

To evaluate the effect of the problem-based learning (PBL) teaching model combined with mind mapping on nursing teaching.

METHODS

The Cochrane Library, PubMed/MEDLINE, EBSCO, OVID, Science Citation Index (SCI), China Knowledge Resource Integrated (CNKI), VIP, WF and other databases were searched for studies published from 2000 to 2021 on the application of the PBL model in nursing teaching. Literature screening and data extraction were conducted by two independent evaluators based on inclusion and exclusion criteria, and heterogeneity was analysed. A meta-analysis was performed using RevMan 5.3 software.

RESULTS

A total of 1907 papers were initially retrieved, and 8 randomized controlled studies were eventually included in the meta-analysis after screening. Theoretical test scores, practical test scores, and students' self-learning ability in the experimental group were all significantly higher than those in the control group (P < 0.05); however, practical test scores were highly heterogeneous (I² = 76%).

CONCLUSION

The PBL teaching model combined with mind mapping works well for nursing teaching in China. It can improve students' self-learning ability, which is conducive to Chinese nursing students mastering theoretical knowledge and improving practical abilities, and can be affected by a variety of factors in practical teaching.

A Novel Cross-Priming Amplification-Based Assay for Tuberculosis Diagnosis in Children Using Gastric Aspirate

Low detection rates of Mycobacterium tuberculosis (MTB) by culture and smear microscopy prevent early diagnosis of tuberculosis (TB) in children. Therefore, developing rapid and accurate diagnostic techniques are critical to achieving the global aim of minimizing childhood TB. The present study was performed to evaluate the diagnostic effectiveness of the novel cross-priming amplification-based EasyNAT MTB complex assay (EasyNAT) in childhood TB. Five hundred and six children with suspected TB were enrolled from January 2018 to October 2021. Gastric aspirate (GA) samples were tested by bacterial culture, acid-fast bacillus microscopy, EasyNAT, Xpert MTB/RIF (Xpert), or Xpert MTB/RIF Ultra (Xpert Ultra). Among 239 children simultaneously tested by EasyNAT and Xpert methods, both assays showed similar sensitivities in total active TB cases [22.6% (31/137) vs. 26.3% (36/137), p = 0.441] and in bacteriologically confirmed TB cases [both 60.0% (9/15)]. The two assays presented similar specificities of 98.0% (100/102) and 99.0% (101/102), respectively (p = 1.000). Among 267 children who were simultaneously tested with EasyNAT and Xpert Ultra, Xpert Ultra demonstrated higher sensitivity than EasyNAT in total active TB cases [50.9% (89/175) vs. 30.3% (53/175), p < 0.001]. EasyNAT and Xpert Ultra yielded similar specificities, at 97.8% (90/92) and 100.0% (92/92), respectively (p = 0.155). These findings indicated that Xpert Ultra was superior to EasyNAT despite its higher cost and EasyNAT was not inferior to Xpert in the diagnosis of childhood TB using GA samples. EasyNAT may therefore be a suitable alternative diagnostic method for childhood TB based on its cost-effectiveness, speed, and accuracy.

[Effect of Echinococcus granulosus hydatid cyst fluid protein on allergic rhinitis induced by ovalbumin in mice]

OBJECTIVE

To investigate the protective effect of Echinococcus granulosus hydatid cyst fluid protein (HCFP) on ovalbumin (OVA)-induced allergic rhinitis (AR) in mice.

METHODS

Twenty-four BALB/c mice at ages of 8 to 10 weeks, each weighing approximately 20 g, were randomly divided into four groups, including groups A (blank control group), B (blank intervention group), C (AR model group) and D (AR+HCFP intervention group), with 6 mice in each group. On days 0, 2, 4, 6, 8, 10 and 12, mice in groups A, B, C and D were injected with 200 μL sterile phosphate buffered saline (PBS), 200 μL sterile PBS containing 20 μg HCFP, 200 μL sterile PBS containing 50 μg OVA and 5 mg Al(OH)₃ gel, and 200 μL sterile PBS containing 50 μg OVA, 5 mg Al(OH)₃ gel and 20 μg HCFP, respectively. On days 14 to 20, mice in groups A, B, C and D were administered with 40 μL sterile PBS, 40 μL sterile PBS containing 20 μg HCFP, 40 μL sterile PBS containing 2 mg OVA and 40 μL sterile PBS containing 2 mg OVA and 20 μL HCFP by nasal drop, respectively. Mouse behavioral changes were observed and behavioral scores were estimated. The serum levels of interferon-γ (IFN-γ), interleukin-4 (IL-4), IL-5, IL-10, transforming growth factor-β (TGF-β) and OVA-specific IgE antibody (OVA-sIgE) were measured using enzyme-linked immunosorbent assay (ELISA), and the pathological changes of mouse nasal mucosa were observed by hematoxylin and eosin (HE) staining.

RESULTS

The mean behavioral score was significantly greater in Group C (6.83 ± 0.50) than in groups A (1.17 ± 0.52) and B (1.33 ± 0.52) (P < 0.05), while a lower mean behavioral score was estimated in Group D (3.50 ± 0.50) than in Group C (P < 0.05). There were significant differences among the groups in terms of serum IFN-γ (F = 4.08, P < 0.05), IL-4 (F = 275.90, P < 0.05), IL-5 (F = 96.82, P < 0.05), IL-10 (F = 77.67, P < 0.05), TGF-β (F = 9.98, P < 0.05) and OVA-sIgE levels (F = 44.69, P < 0.05). The serum IFN-γ level was significantly lower in Group C than in groups A, B and C (P < 0.05), and the serum levels of IL-4, IL-5 and OVA-sIgE were significantly higher in Group C than in groups A, B and C (P < 0.05), while the serum IL-10 and TGF-β levels were significantly greater in Group D than in Group C (P < 0.05). Microscopy showed apparent loss of nasal mucosa cilia, increased number and enlargement of goblet cells, interstitial edema and submucous vascular dilation in Group C, while the pathological changes of nasal mucosa were alleviated in Group D relative to Group C.

CONCLUSIONS

E. granulosus HCFP has a protective activity against OVA-induced allergic rhinitis in mice.

Prevalence of Latent Tuberculosis Infection Among Healthy Young Children and Adolescents and a Two-step Approach for the Diagnosis of Tuberculosis Infection in Chengdu, China

BACKGROUND

China has a high burden of tuberculosis and latent tuberculosis infection (LTBI). The aim of this study was to estimate the prevalence of LTBI among healthy young children and adolescents and test a 2-step approach to explore the threshold for the diagnosis of tuberculosis infection in Chengdu, China.

METHODS

Healthy preschool children and school-going children in Chengdu, Sichuan Province, were screened for LTBI using the tuberculin skin test (TST). Preschool children with TST ≥ 5 mm also underwent interferon-γ release assay (IGRA) to explore the threshold of this 2-step approach.

RESULTS

In total, 5667 healthy young children and adolescents completed TST test between July 2020 and January 2021 and were included in the present analysis. The age of the participants ranged from 2.4 to 18 years (median 7.25 ± 4.514 years), of which 2093 (36.9%) were younger than 5 years. The overall prevalence of LTBI was 6.37% and 6.64% in children younger than 5 years old. Fourteen of the 341 preschool children with TST ≥5 mm were interferon-γ release assay positive, of which 4 showed a TST result of 5-10 mm, and 6 preschool children received preventive treatment for LTBI.

CONCLUSIONS

Healthy young children and adolescents should also be considered as important target populations for LTBI screening. TST can be recommended for first-line screening as part of a 2-step approach for LTBI screening using a positive threshold of 5 mm.

Case Report: Disseminated Mycobacterium intracellulare Infection With More Than 1-Year Follow-Up in a Young Boy With IFNGR1 Deficiency

All members of the genus Mycobacterium are collectively labeled as "non-tuberculous mycobacterium" (NTM), with the exception of the Mycobacterium tuberculosis complex and M. leprae. Recently, the incidence of NTM infection and number of cases have been increasing, but their identification remains difficult in some countries. Usually, NTM infections and diseases are associated with primary immunodeficiency diseases (PIDs), and their prognoses can be improved with a timely diagnosis and appropriate treatment. Here, we report a case of a 3-year-old boy with disseminated NTM disease (Mycobacterium intracellulare) and interferon-γ receptor 1 (IFNGR1) deficiency. He presented with skin and soft-tissue disease, disseminated osteomyelitis, and pulmonary disease. Initially, we suspected an infection due to the Bacillus Calmette-Guérin vaccine but later suspected Langerhans cell histiocytosis. Following oral treatment of azithromycin, rifampicin, and ethambutol, his condition improved progressively according to clinical and imaging manifestations. This case highlights the importance of early identification of the pathogen in a timely prescription of specific treatments in PIDs patients. We also discuss our experience of treatment of M. intracellulare disease in patients with IFNGR1 deficiency.

The Design and Evaluation of Clinical Pathway for Disease Management to Maximize Public Health Benefit

As an implementation strategy, the actual functional scope of clinical pathway (CPW) can be mastered is the basis for evaluating and improving CPW management, which is very important for bridging the evidence-to-practice gap. Here, we propose and discuss a design and evaluation model for CPWs through some theoretical lenses that may help the designer master the actual functional scope of CPWs and accumulate and refine effective key management steps of a specific disease. We can thus determine the best-optimized design with the largest net benefit that allows definition of the core management steps for a specific disease.

Use of Xpert MTB/RIF Ultra assay on stool and gastric aspirate samples to diagnose pulmonary tuberculosis in children in a high-tuberculosis burden but resource-limited area of China: Diagnosis of Childhood TB using Stool

OBJECTIVES

We analyzed the performance of Xpert MTB/RIF Ultra (Ultra) on stool and gastric aspirate (GA) samples for the diagnosis of pediatric pulmonary tuberculosis (TB) caused by Mycobacterium tuberculosis in a high burden area in China.

METHODS

Children with presumptive TB were enrolled in two hospitals in Sichuan Province (July 2019-Oct 2020). Because of the unavailable sputum for etiological tests, GA samples were aspirated and tested by bacterial culture, acid-fast bacillus microscopy and Ultra. Stool samples were tested simultaneously using Ultra and Xpert.

RESULTS

Finally, 141 children with active TB and 34 with non-TB respiratory tract infections were enrolled. Ultra-stool (60.3%, 85/141) and Ultra-GA (52.5%, 74/141) were similarly sensitive (P=0.187). Among the subset of 48 children with confirmed TB, Ultra testing was equally sensitive on stool and GA samples (85.4%, 41/48). The agreement between Ultra-stool and Ultra-GA was moderate in children with active TB (kappa value = 0.527). After integrating Ultra-GA and Ultra-stool outcomes, 70.9% (100/141) of the children were considered to have confirmed TB. The specificities of Ultra-stool and Ultra-GA were 97.1% (33/34) and 100% (34/34), respectively (P=0.314).

CONCLUSIONS

In children, stools can be used as alternative samples to GAs for Ultra tests. Stool- and GA-based Ultra are appropriate tests for bacteriological TB confirmation.

Detection of pulmonary tuberculosis in children using the Xpert MTB/RIF Ultra assay on sputum: a multicenter study

Microbiological confirmation is rare in children with active tuberculosis; therefore, a more accurate test is needed to detect pulmonary tuberculosis in children. In this multicenter study, we evaluated the utility of the Xpert MTB/RIF Ultra (Ultra) on sputum, an assay recommended by the World Health Organization to test for childhood tuberculosis in high-burden settings. Children with symptoms suggestive of tuberculosis were enrolled at three hospitals in China and categorized as having active tuberculosis or nontuberculosis. The sensitivity and specificity of Ultra were 42.1% (48/114) and 99.0% (208/210), respectively. Using three MTB culture results as the reference, the sensitivity of Ultra in the subset of 38 children with culture-positive and 76 children with culture-negative was 68.4% (26/38) and 28.9% (22/76), respectively(p < 0.001). A single MTB culture combined with a single Ultra could detect 54 (54/114,47.4%) cases with active TB, while repeated MTB culture combined with a single Ultra detected 60 (60/114, 52.6%) cases with active TB(p = 0.427). Among 155 children (58 with TB and 97 with RTIs) simultaneously tested with the Ultra and Xpert MTB/RIF (Xpert), the sensitivity of the Xpert (24.1%, 14/58) was lower than that of the Ultra (41.4%, 24/58; p = 0.048). Eight children were found to have rifampin-resistant MTB strains. The Xpert MTB/RIF Ultra assay should be implemented to test for pulmonary tuberculosis in children to achieve higher confirmation rates.

Ginseng berry concentrate prevents colon cancer via cell cycle, apoptosis regulation, and inflammation-linked Th17 cell differentiation

The Asian ginseng root (Panax ginseng C.A. Meyer) is a very commonly used herbal medicine worldwide. Ginseng fruit, including the berry (or pulp) and seed, is also valuable for several health conditions including immunostimulation and cancer chemoprevention. In this study, the anticancer and anti-proliferative effects of the extracts of ginseng berry and seed were evaluated. The ginsenosides in the ginseng berry concentrate (GBC) and ginseng seed extract (GSE) were analyzed. We then evaluated their anti-colorectal cancer potentials, including antiproliferation, cell cycle arrest, and apoptotic induction. Further investigation consisted of the berry's adaptive immune responses, such as the actions on the differentiation of T helper cells Treg, Th1, and Th17. The major constituents in GBC were ginsenosides Re and Rd, which can be compared to those in the root. The GBC significantly inhibited colon cancer cell growth, and its anti-proliferative effect involved mechanisms including G2/M cell cycle arrest via upregulation of cyclin A and induction of apoptosis via regulation of apoptotic related gene expressions. GBC also downregulated the expressions of pro-inflammatory cytokine genes. For the adaptive immune responses, GBC did not influence Th1 and Treg cell differentiation but significantly inhibited Th17 cell differentiation and thus regulated the balance of Th17/Treg for adaptive immunity. Although no ginsenoside was detected in the GSE, interestingly, it obviously enhanced colon cancer cell proliferation with the underlined details to be determined. Our results suggested that GBC is a promising dietary supplement for cancer chemoprevention and immunomodulation.

Effective Model of Food Allergy in Mice Sensitized with Ovalbumin and Freud's Adjuvant

To better explore the pathophysiology of FA and its therapy, we aimed to establish a simple and practicable FA model with Freund's adjuvant and introduce an easy and reliable laboratory evaluation method for assessment of inflammation in intestinal segments at different anatomical locations. BALB/c mice were sensitized with ovalbumin combined with Freund's adjuvant. Complete Freund's adjuvant was chosen for the first sensitization and two weeks later incomplete Freund's adjuvant was used for a second sensitization. Two weeks later, the sensitized mice were challenged with 50 mg ovalbumin every other day. After the 6 challenge, all mice were assessed for systemic anaphylaxis, and then sacrificed for sample collection. All sensitized mice showed anaphylactic symptoms and markedly increased levels of serum ovalbumin-specific IgE and IgG1. The activity of mast cell protease-1 (mMCPT-1) was significantly increased in the serum and interstitial fluid of the duodenum, jejunum, ileum, and colon. A successful FA model was established, of which inflammation occurred in the duodenum, jejunum, ileum, and colon. This model provides a reliable and simple tool for analysis of the mechanism of FA and methods of immunotherapy. Moreover, combined detection of ovalbumin-specific antibody and local mMCPT-1 levels could potentially be used as the major indicator for assessment of food allergy.

Invasive Klebsiella pneumoniae Infections in Community-Settings and Healthcare Settings

Objective

To assess clinical characteristics, outcomes and antimicrobial resistance of invasive Klebsiella pneumoniae (KP) infections in Chinese pediatric patients in hospital and community settings.

Methods

This retrospective study was conducted in the nine tertiary hospitals during 2016–2018. The 324 pediatric inpatients who had KP isolated from blood and cerebrospinal fluid and had complete medical records reviewed were included. We analyzed the risk factors, outcomes and antimicrobial resistance pattern of KP-infected patients based on comparison between healthcare-associated KP infections (HAI) and community-acquired infections.

Results

Of the 324 enrolled patients, 275 (84.9%) were clinically defined as HAI, including 175 (63.6%) neonates and 100 (36.4%) aged >28 days. The overall prevalence of CRKP was 38.2% (43.4% in HAI verse 8.7% in CAI, P <0.05). Prematurity (odds ratio (OR): 37.07, 95% CI: 8.29–165.84), hematologic malignancies (OR: 15.52, 95% CI: 1.89–127.14) and invasive mechanical ventilation (OR: 13.09, 95% CI: 1.66–103.56) were independent risk factors for HAI. Patients from rural area (OR: 1.94, 95% CI: 1.12–3.35), invasive mechanical ventilation (OR: 2.33, 95% CI: 1.25–4.33), antibiotic therapy prior to admission (OR: 2.33, 95% CI: 1.25–4.33) and prior hospital stay in the past 30 days (OR: 3.46, 95% CI: 1.87–6.41) were associated with healthcare-associated CRKP infections. Organ dysfunction was independently correlated with poor outcomes (OR: 2.92, 95% CI: 1.23–6.95).

Conclusion

Pediatric invasive KP infections and high prevalence of CRKP infections largely occurred in healthcare settings in China. The adequate and intensified infection control measures should be focused on high-risk hematologic patients, neonatal patients and intubated patients.

Epidemiology, risk factors and outcomes of bloodstream infection caused by ESKAPEEc pathogens among hospitalized children

Background

Bloodstream infection (BSI) resulting from ESKAPEEc pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Escherichia coli, Acinetobacter baumannii, Pseudomonas aeruginosa and Enterobacter spp) is relevant to high mortality and economic cost. Data concerning the impact of BSI due to ESKAPEEc in pediatric population was virtually scant. Our purpose was to summarize the epidemiology, risk factors and outcomes of ESKAPEEc BSI among hospitalized children.

Methods

Inpatients diagnosed with BSI with definite etiology between January 2016 and December 2018 were enrolled retrospectively at the West China Second University Hospital. Data were systematically reviewed on patients’ clinical characteristics and laboratory findings to ascertain independent predictors, clinical features and outcomes.

Results

Of the 228 patients with BSI, 174 (76.3%) were caused by ESKAPEEc (124 MDR-ESKAPEEc). Multivariate analysis demonstrated that premature and/ or low birth weight (odds ratio [OR] = 2.981, P = 0.036), previous surgery and/or trauma (OR = 5.71, P = 0.029) and source of urinary tract infection (OR = 10.60, P = 0.004) were independently associated with ESKAPEEc BSI. The independent risk factor for MRD-ESKAPEEc BSI was nosocomial infection (OR = 3.314, P = 0.037). The overall mortality rate in patients with ESKAPEEc BSI was 14.4% (25/174), and no significant difference was ascertained in mortality between MRD-ESKAPEEc and non-MRD ESKAPEEc BSI groups (13.7% vs. 11.4%, P = 0.692). In addition, previous surgery and/or trauma, thrombocytopenia, and mechanical ventilation were significant risk factors for mortality caused by ESKAPEEc BSI.

Conclusions

More than two-thirds of BSI among hospitalized children were caused by ESKAPEEc. Previous surgery and/or trauma, thrombocytopenia and mechanical ventilation increased the risk rate for mortality in ESKAPEEc BSI. The risk factors ascertained could assist physicians to early suspect ESKAPEEc BSI and MDR ESKAPEEc BSI.

Antibiotic Use Among Hospitalized Children and Neonates in China: Results From Quarterly Point Prevalence Surveys in 2019

Background: Antimicrobial resistance is a significant clinical problem in pediatric practice in China. Surveillance of antibiotic use is one of the cornerstones to assess the quality of antibiotic use and plan and assess the impact of antibiotic stewardship interventions.

Methods: We carried out quarterly point prevalence surveys referring to WHO Methodology of Point Prevalence Survey in 16 Chinese general and children’s hospitals in 2019 to assess antibiotic use in pediatric inpatients based on the WHO AWaRe metrics and to detect potential problem areas. Data were retrieved via the hospital information systems on the second Monday of March, June, September and December. Antibiotic prescribing patterns were analyzed across and within diagnostic conditions and ward types according to WHO AWaRe metrics and Anatomical Therapeutic Chemical (ATC) Classification.

Results: A total of 22,327 hospitalized children were sampled, of which 14,757 (66.1%) were prescribed ≥1 antibiotic. Among the 3,936 sampled neonates (≤1 month), 59.2% (n = 2,331) were prescribed ≥1 antibiotic. A high percentage of combination antibiotic therapy was observed in PICUs (78.5%), pediatric medical wards (68.1%) and surgical wards (65.2%). For hospitalized children prescribed ≥1 antibiotic, the most common diagnosis on admission were lower respiratory tract infections (43.2%, n = 6,379). WHO Watch group antibiotics accounted for 70.4% of prescriptions (n = 12,915). The most prescribed antibiotic ATC classes were third-generation cephalosporins (41.9%, n = 7,679), followed by penicillins/β-lactamase inhibitors (16.1%, n = 2,962), macrolides (12.1%, n = 2,214) and carbapenems (7.7%, n = 1,331).

Conclusion: Based on these data, overuse of broad-spectrum Watch group antibiotics is common in Chinese pediatric inpatients. Specific interventions in the context of the national antimicrobial stewardship framework should aim to reduce the use of Watch antibiotics and routine surveillance of antibiotic use using WHO AWaRe metrics should be implemented.

Prevalence and antimicrobial resistance patterns of bacteria isolated from cerebrospinal fluid among children with bacterial meningitis in China from 2016 to 2018: a multicenter retrospective study

Background

Pediatric bacterial meningitis (PBM) remains a devastating disease that causes substantial neurological morbidity and mortality worldwide. However, there are few large-scale studies on the pathogens causing PBM and their antimicrobial resistance (AMR) patterns in China. The present multicenter survey summarized the features of the etiological agents of PBM and characterized their AMR patterns.

Methods

Patients diagnosed with PBM were enrolled retrospectively at 13 children’s hospitals in China from 2016 to 2018 and were screened based on a review of cerebrospinal fluid (CSF) microbiology results. Demographic characteristics, the causative organisms and their AMR patterns were systematically analyzed.

Results

Overall, 1193 CSF bacterial isolates from 1142 patients with PBM were obtained. The three leading pathogens causing PBM were Staphylococcus epidermidis (16.5%), Escherichia coli (12.4%) and Streptococcus pneumoniae (10.6%). In infants under 3 months of age, the top 3 pathogens were E. coli (116/523; 22.2%), Enterococcus faecium (75/523; 14.3%), and S. epidermidis (57/523; 10.9%). However, in children more than 3 months of age, the top 3 pathogens were S. epidermidis (140/670; 20.9%), S. pneumoniae (117/670; 17.5%), and Staphylococcus hominis (57/670; 8.5%). More than 93.0% of E. coli isolates were sensitive to cefoxitin, piperacillin/tazobactam, cefoperazone/sulbactam, amikacin and carbapenems, and the resistance rates to ceftriaxone, cefotaxime and ceftazidime were 49.4%, 49.2% and 26.4%, respectively. From 2016 to 2018, the proportion of methicillin-resistant coagulase-negative Staphylococcus isolates (MRCoNS) declined from 80.5 to 72.3%, and the frequency of penicillin-resistant S. pneumoniae isolates increased from 75.0 to 87.5%. The proportion of extended-spectrum β-lactamase (ESBL)-producing E. coli fluctuated between 44.4 and 49.2%, and the detection rate of ESBL production in Klebsiella pneumoniae ranged from 55.6 to 88.9%. The resistance of E. coli strains to carbapenems was 5.0%, but the overall prevalence of carbapenem-resistant K. pneumoniae (CRKP) was high (54.5%).

Conclusions

S. epidermidis, E. coli and S. pneumoniae were the predominant pathogens causing PBM in Chinese patients. The distribution of PBM causative organisms varied by age. The resistance of CoNS to methicillin and the high incidence of ESBL production among E. coli and K. pneumoniae isolates were concerning. CRKP poses a critical challenge for the treatment of PBM.

Antibiotic Resistance of Helicobacter pylori Strains Isolated From Pediatric Patients in Southwest China

The number of antibiotics that are appropriate for Helicobacter pylori eradication in children is limited. Profiling regional or population-specific antibiotic resistance is essential in guiding the H. pylori eradication treatment in children. The aim of this study was to evaluate the antibiotic resistance in H. pylori strains isolated from children and adolescents in Southwest China. Gastric biopsies from 157 pediatric patients with or without previous H. pylori eradication treatment were collected for H. pylori culture. Susceptibility to amoxicillin (AML), clarithromycin (CLR), metronidazole (MTZ), levofloxacin (LEV), tetracycline (TET), furazolidone (FZD), and rifampicin (RIF) was determined by E-test or a disk diffusion assay. A total of 87 patients from three ethnic groups (Han/Tibetan/Yi) were H. pylori culture positive (55.4%). The overall resistance rates were 55.2% for CLR, 71.3% for MTZ, 60.9% for RIF, and 18.4% for LEV. No isolate was found to be resistant to AML, TET, and FZD. Among the 53 treatment-naïve pediatric patients, primary resistance rates to clarithromycin, metronidazole, levofloxacin, and rifampicin were 45.3, 73.6, 15.1, and 60.4%, respectively. Among the 34 treatment-experienced patients, secondary resistance rates to clarithromycin, metronidazole, levofloxacin, and rifampicin were 70.6, 67.6, 23.5, and 61.8%, respectively. Isolates exhibiting simultaneous resistance to clarithromycin and metronidazole were 28.3 and 52.9% among the treatment-naïve and treatment-experienced patients, respectively. In conclusion, among pediatric patients in Southwest China, resistance rates were high for clarithromycin, metronidazole, levofloxacin, and rifampicin, whereas nil resistance was found to amoxicillin, tetracycline, and furazolidone. Our data suggest that the standard clarithromycin-based triple therapy should be abandoned as empiric therapy, whereas the bismuth quadruple therapy (bismuth/PPI/amoxicillin/tetracycline) would be suitable as first-line empiric treatment regimen for this pediatric population. Tetracycline and furazolidone may be considered for treating refractory H. pylori infections in adolescent patients.

Acute development of syringomyelia following TBM in a pediatric case

Background

Syringomyelia secondary to tuberculous meningitis (TBM) is rarely reported, and is usually a late complication. Acute development of syringomyelia following TBM is an exceedingly rare condition with only a few cases published in adults and no previous reports in children.

Case presentation

We present a case of syringomyelia as an acute complication of TBM in a 12-year-old boy despite appropriate chemotherapy. The patient developed spastic paraplegia of the lower limbs with fecal and urinary retention seventeen days after the initial symptoms of TBM. He was managed successfully with continued chemotherapy and high-dose intravenous immunoglobulin (IVIG).

Conclusions

This case reminds us that syrinx formation may be responsible for early neurological deterioration in children being managed for TBM. IVIG may be considered as an effective treatment option for this situation.

Toxic epidermal necrolysis after therapeutic plasma exchange in pediatric lupus patients and associated risk factors analysis

BACKGROUND

Therapeutic plasma exchange (TPE) is an effective means of treating systemic lupus erythematosus in children and is safe for most pediatric patients with systemic lupus erythematosus, but severe complications such as toxic epidermal necrolysis (TEN) may occur, which is a life-threatening condition.

METHODS

In this study, three systemic lupus erythematosus (SLE) children developed toxic epidermal necrolysis after TPE. We analyzed their medical history, clinical manifestations, SLEDAI scores, and immunological characteristics, compared to 117 cases of SLE patients without TEN after TPE, trying to find the possible risk factors.

RESULTS

The three children with TEN after plasma exchange appeared to have a higher proportion of male (male: female = 2:1), fever (100% Vs 32.5%), erythema on the cheek (100% Vs 54.7%), itching rash (100% Vs 54.7%), ruptured rash (100% Vs 54.7%), oral ulcer (100% Vs 54.7%) and higher LDH level (1826.0 ± 1113.1 Vs 721.1 ± 799.5 U/L), but lower white blood cell count (5.5 ± 3.3 Vs 7.2 ± 4.2 × 10⁹/L), neutrophil count (4.7 ± 3.7 Vs 5.2 ± 3.6 × 10⁹/L), lymphocyte count (0.6 ± 0.5 Vs 1.5 ± 0.8 × 10⁹/L), platelet count (133.7 ± 58.1 Vs 178.5 ± 103.1 × 10⁹/L) and C-reactive protein (all normal Vs 47.9% elevated). Autoantibody spectrum revealed that positive anti-SSA seemed more common (100% Vs 42.7%) in the three children. Relative risk analysis revealed that male (OR 21.4, 95%CI 1.78-257.186), ruptured skin rash (OR 56.5, 95%CI 4.199-760.196) and rash with itching (OR 24, 95%CI 1.98-290.896) are the risk factors of SLE patients developing TEN after plasma exchange.

CONCLUSIONS

We should pay particular attention to TEN after plasma exchange in SLE patients (3/120, 2.5%). This condition may be related to male, ruptured skin rash and rash with itching. For SLE patients with risk factors. We should arrange plasmapheresis more carefully.

Microbiological profiles and antimicrobial resistance patterns of pediatric bloodstream pathogens in China, 2016-2018

OBJECTIVES

This study aimed to investigate the microbiological profiles and antimicrobial resistance patterns of bloodstream pathogens in Chinese children.

METHODS

This retrospective study was conducted at 13 tertiary hospitals in China during 2016-2018. The first bloodstream isolates of the same species from one pediatric patient < 18 years were included to this study for analysis. Antimicrobial susceptibility testing was determined based on minimum inhibitory concentrations or Kirby-Bauer disk diffusion methods according to the 2018 Clinical and Laboratory Standards Institute guidelines.

RESULTS

Overall, 9345 nonduplicate bloodstream isolates were collected. Top 10 pathogens included Coagulase-negative staphylococcus (CoNS) (44.4%), Escherichia coli (10.2%), Klebsiella pneumoniae (5.9%), Staphylococcus aureus (5.0%), Streptococcus pneumoniae (4.9%), Pseudomonas aeruginosa(2.8%), Enterococcus faecium (2.7%), Stenotrophomonas maltophilia (2.4%), Salmonella spp. (2.3%), and Streptococcus agalactiae (2.0%). The commonest pathogens apart from CoNS in age group 0-28 days, 29 days-2 months, 3-11 months, 1-5 years, and ≥ 5 years were Escherichia coli (17.2%), Escherichia coli (14.0%), Escherichia coli (7.9%), Streptococcus pneumoniae (10.7%) ,and Staphylococcus aureus (13.6%), respectively. The overall prevalence of extended-spectrum β-lactamases-producing Enterobacteriaceae, carbapenem-resistant Klebsiella pneumoniae, carbapenem-resistant Acinetobacter baumannii, and carbapenem-resistant Pseudomonas aeruginosa were 41.4, 28.4, 31.7, and 5.6%, respectively. The overall prevalence of methicillin-resistant Staphylococcus aureus, penicillin-resistant Streptococcus pneumoniae and vancomycin-resistant Enterococcus was 38.1, 28.3, and 0.7%, respectively.

CONCLUSIONS

The major bacterial pathogens have differences in different age groups, ward types, and regions in Chinese children, and the commonest causing microorganism was the Escherichia coli, especially in neonates and infants. High prevalence of important resistant phenotypes is of a serious concern.

Characterization of fever and sickness behavior regulated by cytokines during infection

In response to invasion of pathogens, hosts present fever and a series of behavioural changes including reduced grooming, reduction of foraging, decreased locomotion, withdrawing from social activities and reproductive process, which are collectively termed sickness behaviour. Fever as well as sickness behaviour are adaptive and benefit the host to reduce pathology caused by infections and opportunity costs for time away from foraging, reproduction and predator avoidance. Antipathogenic fever and sickness behaviour are mediated proximately by cytokines including pro- and anti-inflammatory cytokines. Pro-inflammation cytokines trigger these sickness responses, while anti-inflammatory cytokines constrain these responses and prevent damage to host from exaggerated responses. The present study reviews the characterization of fever and sickness behaviour regulated by cytokines during infection.

Infantile fever-triggered acute liver failure caused by novel neuroblastoma amplified sequence mutations: a case report

BACKGROUND

Infantile liver failure syndrome-2 (ILFS2) is caused by neuroblastoma amplified sequence (NBAS) mutation. The disease is characterized by recurrent episodes of acute liver failure (ALF) or by liver crisis triggered by recurrent episodes of fever and complete recovery.

CASE PRESENTATION

Here, we describe the case of a Chinese girl with typical clinical manifestation of ILFS2 without exhibition of extrahepatic involvement. The patient harbored novel compound heterozygous mutations in the NBAS region (c.3386C > T (p.Ser1129Phe), c.1A > C (p.Met1Leu) and c.875G > A (p.Gly292Glu)), mutations which have not been previously reported. After administration of antipyretics and intravenous glucose and electrolyte administration, the patient recovered fully.

CONCLUSION

Through the present study, we recommend that ILFS2 should be taken into consideration during the differential diagnosis of children with recurrent, fever-triggered ALF. While the definitive diagnosis of ILFS2 remains dependent on genetic sequencing and discovery of NBAS, early antipyretic treatment is recommended to prevent liver crisis.

Correction to: Telomerase reconstitution contributes to resetting of circadian rhythm in fibroblasts

In the original article, Fig. 4b was published incorrectly in which four to five lanes in Pi-ERK and Pi-CREB panels look very similar to each other (Telomerase reconstitution contributes to resetting of circadian rhythm in fibroblasts, Mol Cell Biochem, 2008, 313:11-18). Since this image was stored in The Experiment Center of the West China Second University Hospital, Sichuan University, which was dissoluted in 2012, the original data cannot be traced. Experiments were therefore redone to verify the result and the correct version of Fig. 4b is provided in this correction.

A new insight into acute lymphoblastic leukemia in children: influences of changed intestinal microfloras

Background

Previous studies have shown that changes in intestinal microfloras are associated with both gastrointestinal (GI) and non-GI tumors. It is not clear whether there is an association between GI microflora changes and hematological malignancies.

Methods

In the current study, we used 16S rDNA gene sequencing techniques to profile the GI microbiome in children with lymphoblastic leukemia (ALL, n = 18) and matched healthy control (n = 18). Using multiple specialized software [Heatmap, Principal coordinates analysis (PCoA), Claster and Metastates], we analyzed the sequencing data for microfloral species classification, abundance and diversity.

Results

A total of 27 genera between the ALL and control groups (FDR ≤ 0.05 and/or P ≤ 0.05) showed significantly different abundance between ALL patients and healthy controls: 12 of them were predominant in healthy group and other 15 species were significantly higher in ALL group. In addition, we compared the abundance and diversity of microfloral species in ALL patients prior to and during remission stage after chemotherapy, and no significant difference was detected.

Conclusions

Compared to healthy controls, ALL patient showed significant changes of GI microfloras. Further explorations of the intestinal micro-ecology in ALL patients may provide important information to understand relationship between microfloras and ALL.

Pediatric Antibiotic Prescribing in China According to the 2019 World Health Organization Access, Watch, and Reserve (AWaRe) Antibiotic Categories

OBJECTIVES

To assess clinical indication-specific antibiotic prescribing in pediatric practice in China based on the World Health Organization (WHO) Access, Watch, and Reserve (AWaRe) metrics and to detect potential problem areas.

STUDY DESIGN

Pediatric prescription records on the 16th of each month during 2018 were sampled for all encounters at outpatient and emergency departments of 16 tertiary care hospitals via hospital information systems. Antibiotic prescribing patterns were analyzed across and within diagnostic conditions according to WHO AWaRe metrics and Anatomical Therapeutic Chemical (ATC) classification.

RESULTS

A total of 260 001 pediatric encounters were assessed, and antibiotics were prescribed in 94 453 (36.3%). In 35 167 encounters (37.2%), at least 1 intravenous antibiotic was administered. WHO Watch group antibiotics accounted for 82.2% (n = 84 176) of all antibiotic therapies. Azithromycin (n = 15 791; 15.4%) was the most commonly prescribed antibiotic, and third-generation cephalosporins (n = 44 387; 43.3%) were the most commonly prescribed antibiotic class. In at least 66 098 encounters (70.0%), antibiotics were prescribed for respiratory tract conditions, mainly for bronchitis/bronchiolitis (n = 25 815; 27.3%), upper respiratory tract infection (n = 25 184; 26.7%), and pneumonia (n = 13 392; 14.2%).

CONCLUSIONS

Overuse and misuse of WHO Watch group antibiotics for respiratory tract conditions and viral infectious diseases is common in pediatric outpatients in China. Pediatric antimicrobial stewardship should be strengthened using WHO AWaRe metrics.

Chronic tuberculous empyema in an 8-year-old boy

Mycobacterium tuberculosis (MTB) as a causative organism of empyema thoracis is rare, especially in children. An 8-year-old boy with tuberculous empyema and no history of contact with tuberculosis presented with minimal symptoms other than mild deformity of the chest wall. He had been vaccinated with bacillus Calmette-Guérin. A chest CT scan demonstrated intrathoracic lymphadenopathy, thickened and calcified pleural rind and rib thickening adjacent to the empyema. The diagnosis was confirmed by post-operative histopathological examination, positive acid-fast stains and DNA PCR. In countries with a high burden of tuberculosis, MTB should be considered in the differential diagnosis of empyema despite minimal symptoms.

Distinguishment of parasite-infected children from pediatric inpatients with both eosinophilia and effusion

Patients with both serous effusion and eosinophilia are rarely reported and geographically distributed; their early diagnosis is difficult.According to the ultimate diagnosis, patients (≤14 years) in West China Second hospital with serous effusion and eosinophilia were divided into two groups including a parasitic group and a non-parasitic group. Clinical data were collected and analyzed between the two groups. Subsequently, significant measurement indicators were evaluated by receiver operating characteristic (ROC) curve to explore the optimal cut-off points for the most appropriate sensitivity and specificity.A total of 884 patients were diagnosed with serous effusion and 61 of them displayed co-morbidity with eosinophilia during enrolled time. Among 61 patients, 34 patients had parasitic infection and 27 had non-parasitic diseases. There were statistical difference in effusion position, the levels of white blood cell count (WBC), eosinophil (EOS), EOS%, C-reactive protein (CRP) between parasitic group and non-parasitic group. ROC curve demonstrated that the areas under the curve of EOS count and EOS% were >80%, and the corresponding optimal cut-off values were 1.71 × 10/L and 25.6% for distinguishing between parasitic and non-parasitic infections in our patients.This study provided a quantified index for potentially quick and convenient indicators of pediatric patients presenting with both eosinophilia and effusion. Eosinophils were helpful to improve the initial diagnosis with awareness of parasitic diseases. For the cases with EOS > 1.71 × 10/L or EOS% > 25.6%, parasitic infection should be considered and serological tests are recommended in our region.

The relationship of gastric microbiota and Helicobacter pylori infection in pediatrics population

BACKGROUND

In recent years, the impact of Helicobacter pylori (H pylori) on the gut microbiota has attracted more attention; however, the relationship in pediatric population rarely was reported.

METHODS

Endoscopic gastric mucosal biopsy specimens from 55 children with gastrointestinal symptoms were collected, 37 of them were H pylori-positive (23 nonpeptic ulcer and 14 peptic ulcer) and 18 were H pylori-negative. In addition, 11 specimens were collected from H pylori-positive children who performed second endoscopy in 4 weeks after therapy. Microbial abundance and compositions were analyzed by 16S ribosomal RNA amplification and microbial functions were predicted using the software PICRUSt.

RESULTS

The gastric microbiota of H pylori-positive children were mainly dominated by Helicobacter in genus (95.43%). The microbiota richness and diversity of H pylori-positive children were lower than that of H pylori-negative children. No difference was found in microbiota structure between H pylori-positive children with or without peptic ulcer. The richness and compositions after therapy were closer to the characteristics of H pylori-negative children. For predicted functions, higher abundance in pathways of infection diseases, cancer and lower abundance in the pathways of amino acid, lipid, and carbohydrate metabolism were found in H pylori-positive group than H pylori-negative group.

CONCLUSION

The characteristics of gastric microbiota were affected by H pylori infection rather than disease states, and the richness and diversity of gastric species were inverse correlation with H pylori infection in children. Eradication therapy was helpful to restore shifted gastric microbiota.

The optimal timing of surgical ligation of patent ductus arteriosus in preterm or very-low-birth-weight infants: A systematic review and meta-analysis

BACKGROUND

Patent ductus arteriosus (PDA) is a particularly common problem in preterm infants. Although surgical ligation is rarely performed in many contemporary neonatal intensive care units, it remains a necessary treatment option for preterm infants with a large hemodynamically significant PDA under strict clinical criteria, and it can reduce mortality in preterm infants. However, the optimal timing of surgical ligation is still controversial. We conducted this systematic review and meta-analysis to compare the mortality and morbidity of early and late surgical ligation of PDA in preterm or very-low-birth-weight (VLBW) infants.

METHODS

This review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42019133686). We searched the databases of PubMed, Embase, the Cochrane Central Register of Controlled Trials, and the World Health Organization International Clinical Trials Registry Platform up to May 2019.

RESULTS

This review included 6 retrospective studies involving 397 premature or VLBW infants with PDA. Pooled analysis showed that compared with the late ligation group, the early ligation group had a lower fraction of inspired oxygen (FiO2) at 24 hours postoperatively (mean difference [MD] -6.34, 95% confidence interval [CI] -9.45 to -3.22), fewer intubation days (MD -19.69, 95% CI -29.31 to -10.07), earlier date of full oral feeding (MD -22.98, 95% CI -28.63 to -17.34) and heavier body weight at 36 weeks of conceptional age (MD 232.08, 95% CI 57.28 to 406.88). No significant difference in mortality or other complications was found between the early and late groups.

CONCLUSION

Our meta-analysis implies that compared with late surgical ligation, early ligation might have a better respiratory outcome and nutritional status for PDA in preterm or VLBW infants. There was no difference in mortality or postoperative complications between early and late ligation. A randomized prospective clinical trial with a possible large sample size is urgently needed to reinvestigate this conclusion.

PROSPERO REGISTRATION NUMBER

CRD42019133686.

Inappropriate antibiotic prescriptions among pediatric inpatients in different type hospitals

To investigate the situation of antibiotic consumption and to assess the inappropriate use on pediatric inpatients of different types hospitals in Sichuan, China.A cross-sectional survey of antibiotic prescriptions among hospitalized children aged 1month -14years were conducted from April 2018 to June 2018 in southwestern China. Antibiotic prescriptions were extracted from electronic records during hospitalization of each inpatient in five different types hospitals.In this study, the antibiotic prescription rate of hospitalized children was 66.9% (1176/1758). Compared with tertiary children hospital (TC) (46.1%), general hospitals and non-tertiary children hospitals has higher rate of antibiotic prescription (almost 85%) (P < .001). 93.4% of inpatients received parenteral antibiotic. Overall, the most common antibiotics were Cefoperazone and enzyme inhibitor, Cefixime and Azithromycin. Lower respiratory tract infection (LRTI) was the leading reason for antibiotic consumption in pediatric wards (56.8%), followed by upper respiratory tract infection (URTI) (22.2%). For children with LRTI, Cephalosporins were heavy prescribed, especially broad-spectrum third-generation Cephalosporins (60.3%). The antibiotic prescription proportion of URTI in general hospitals and non-tertiary children hospitals (more than 18%) was higher than TC (8.1%) (P < .001).There was inappropriate use of antibiotic in hospitalized children including overuse of parenteral administration, overprescribing of antibiotic on URTI and misuse of third-generation Cephalosporins in pediatric inpatients with LRTI. Compared with tertiary freestanding children hospital, the irrational antibiotic prescription of general hospitals and non-tertiary children hospitals were more serious. Management strategy should be implementer on quality improvement of antibiotic use.

Characterization of gut microbiota in children with pulmonary tuberculosis

Background

Gut microbiota plays a critical role in many important physiological processes and is linked with various pulmonary infectious diseases. The relationship between pulmonary tuberculosis (PTB) and gut microbiota has been poorly studied. The present study aimed to characterize gut microbiota in pediatric patients with PTB.

Methods

A case-controlled study was executed for the characterization of gut microbiota in pediatric PTB patients. Fecal samples were collected from the PTB patients and healthy controls upon admission. In addition, a one-month follow-up assessment was performed to investigate alterations in the gut microbiota post anti-tuberculosis treatment. 16SrDNA sequencing analysis of fecal DNA was completed on the Illumina MiSeq platform.

Results

Compared with healthy controls, the gut microbiota of pediatric patients with PTB was characterized by decreased microbial diversity. PTB patients further presented an up-regulation of the pro-inflammatory bacteria Prevotella, the opportunistic pathogen Enterococcus, as well as a reduction of beneficial bacteria including Ruminococcaceae, Bifidobacteriaceae and prausnitzii. One-month after anti-tuberculosis therapy, the richness of gut microbiota in PTB patients was distinctly depleted.

Conclusions

The gut microbiota of pediatric patients with PTB was significantly distinct from healthy controls. Additionally, the richness of gut microbiota in PTB patients decreased after one-month anti-tuberculosis treatment. It is hypothesized that the homeostasis of gut microbiota in PTB patients may affect the pathogenies of PTB by de-regulation of the hosts’ immune status through the gut-lung axis.

Differences between congenital-syphilis presenting as sepsis and neonatal sepsis: A case-control study

Congenital syphilis (CS) can cause serious impact on the fetus. However, congenital syphilis presenting as sepsis is a critical condition but hardly identified by the clinic for the first time. In this study, we aimed to identify the benefit of earlier and accurate diagnosis for the infants who suffer congenital syphilis presenting as sepsis.A retrospective study was performed with patients diagnosed of congenital syphilis presenting as sepsis who were the inpatients in the West China Second Hospital between 2011 and 2018. The control group was collected in the neonatal sepsis patients whose blood culture are positive.Fifty-eight patients were included in the study. In the congenital syphilis group, one patient died and 12 (41.3%) patients get worse to MODS (multiple organ dysfunction syndrome). Symptoms, signs, and lab examinations are found to be significantly different (P < .05) between two groups as below, including rash, palmoplantar desquamation, abdominal distension, splenomegaly, hepatomegaly, etc. And, at the aspect of Hb, PLT, WBC, CRP, ALT, AST, these differences occurred in the different groups. It is obvious that the prognosis of children with syphilis is worse. According to a comparison between the different outcomes in the CS, the worse outcome subgroup of patients is significantly younger and have more severely impaired liver function.Because of the high mortality of these infants, pediatricians should improve awareness of CS. Syphilis screening is recommended for pregnant women.

Dynamic construction of gut microbiota may influence allergic diseases of infants in Southwest China

Background

Gut microbes have been suggested as the possible targets in the management of allergic diseases. However, the way in which these microbes influence allergic diseases remain unclear. Forty-seven full-term newborns were selected from a 1000-infant birth cohort. Among them were 23 allergic infants, whereas 24 infants were healthy without allergic symptoms at 1 year of age. Two hundred and sixty-four fecal samples were collected at 7 time points following their birth. These fecal samples were microbiologically analyzed using 16S rRNA gene sequencing. The dynamic processes involved in gut microbiota diversity and composition in the tested infants were constructed.

Results

Healthy infants demonstrated more statistical differences in longitudinal changes in the alpha diversity of their microbiota at the time points compared with day 0 (meconium) than did allergic infants. Analysis of beta diversity showed that the fecal microbiota of days 0 and 2 comprised different communities in healthy infants, and that there were three separate communities in the fecal microbiota of day 0 of the healthy infants, those of day 2 of the healthy infants, and those of days 0–2 of the allergic infants. The relative abundance of dominant gut microbiota at phylum level varied at different time points in the healthy and diseased groups. Bifidobacterium, Escherichia-Shigella, Streptococcus, Clostridium_sensu_stricto_1, Akkermansia and Erysipelatoclostridium were significantly different between the healthy and diseased groups at a different time points.

Conclusion

The dynamic construction processes of gut microbiota during early life might be associated with the occurrence of long-term allergic diseases, with the first month following birth potentially being the most critical.

Electronic supplementary material

The online version of this article (10.1186/s12866-019-1489-4) contains supplementary material, which is available to authorized users.

The gut microbiota of hand, foot and mouth disease patients demonstrates down-regulated butyrate-producing bacteria and up-regulated inflammation-inducing bacteria

AIM

This study explored the gut microbiota of children with hand, foot and mouth disease (HFMD).

METHODS

We enrolled 15 cases with HFMD admitted to the West China Second Hospital, Sichuan University, China, from July to September 2016 at a median age of three years. The controls were 15 healthy children of a similar age who underwent routine health examinations at the hospital during the same period. Gut microbiota was analysed using high throughput 16S ribosomal deoxyribonucleic acid sequencing.

RESULTS

The gut microbiota in the HFMD patients was distinct from the controls. Compared with the controls, the composition of gut microbiota in the HFMD cases represented a reduction of two butyrate-producing bacteria, Ruminococcus (0.73 ± 1.28 versus 7.78 ± 20.01, p = 0.026) and Roseburia (0.67 ± 1.69 versus 1.61 ± 3.27, p = 0.024) and an up-regulation of Escherichia (5.26 ± 10.50 versus 1.59 ± 5.90,p < 0.01) and Enterococcus (4.12 ± 12.49 versus 0.12 ± 0.41, p = 0.015).

CONCLUSION

The dysbiosis of gut microbiota of the HFMD cases included a reduction of butyrate-producing bacteria and an up-regulation of inflammation-inducing bacteria. These may have impaired the intestinal biological mucosal barrier and host immune functions, promoting the invasion of the enterovirus.