The Pattern of Anemia in Pediatric Solid Tumors Prior to and after Chemotherapy- A Retrospective Cohort Study.

BACKGROUND: Solid pediatric tumors refer to cancers that affect children and adoles-cents, and they present unique challenges due to their distinct biological characteristics and their vulnerability to young patients. This study aims to shed light on addressing anemia and the causes of anemia in patients with solid pediatric tumors. MATERIALS AND METHODS: This retrospective cohort comprised 200 healthy children as controls and 235 patients with solid tumors. The study was conducted at first Affiliated Hospital of Zhengzhou University between January 2020 and June 2023. We evaluated different parameters of blood components in controls and patients with solid tumors such as medulloblastoma, neuroblastoma, rhabdomyosarcoma, germ cell tumors, hepatoblastoma and nephroblastoma before and patients with only these tumors 3 weeks after the first cycle of chemotherapy. Further, we evaluated the relationship between serum ferritin and the weight of patients and assessed the relationship be-tween anemia and metastasis to the bone marrow in patients with neuroblastoma and hepatoblas-toma. RESULTS: We observed various combinations of derangements in blood parameters such as hemo-globin, red blood cells, mean corpuscular volume, mean corpuscular hemoglobin, mean corpuscu-lar hemoglobin concentration, hematocrit, red cell distribution width, white blood cells, and plate-let in medulloblastoma, neuroblastoma, rhabdomyosarcoma, germ cell tumors, hepatoblastoma and nephroblastoma before and 3 weeks after first cycle of chemotherapy. We found a significant correlation between serum ferritin levels and weight in neuroblastoma patients who are ≤ 2 years (p = 0.022). Involvement of tumor cells in bone marrow correlates with decreased Hb levels in both neuroblastoma (CI = 93.21-106.68, p = 0.001) and hepatoblastoma (CI = 113.36-121.00, p = 0.001). CONCLUSION: Anemia may manifest as an early symptom in neuroblastoma, hepatoblastoma, and nephroblastoma. Also, anemia may be worse in patients with neuroblastoma and hepatoblastoma after chemotherapy and might warrant anemia therapy.

Hyperemesis gravidarum and the risk of offspring morbidity: a longitudinal cohort study.

PURPOSE: Hyperemesis gravidarum has the potential to affect the long-term health of offspring. We examined whether maternal hyperemesis gravidarum was associated with the risk of hospitalization for childhood morbidity. METHODS: We conducted a longitudinal cohort study of 1,189,000 children born in Quebec, Canada, between April 2006 and March 2021. The main exposure measure was maternal hyperemesis gravidarum requiring hospitalization in the first or second trimester. The outcome was any pediatric admission between birth and 16 years of age, with follow-up ending in March 2022. We used Cox regression models adjusted for maternal and socioeconomic factors to estimate hazard ratios (HR) and 95% confidence intervals (CI) for the association between maternal hyperemesis gravidarum and childhood hospitalization. RESULTS: Among 1,189,000 children, 6904 (0.6%) were exposed to maternal hyperemesis gravidarum. Hospitalization rates at age 16 years were higher for children exposed to hyperemesis gravidarum than unexposed children (47.6 vs 43.9 per 100 children). Relative to no exposure, hyperemesis gravidarum was associated with a 1.21 times greater risk of any hospitalization before 16 years (95% CI 1.17-1.26). Hyperemesis gravidarum was associated with hospitalization for neurologic (HR 1.50, 95% CI 1.32-1.71), developmental (HR 1.51, 95% CI 1.29-1.76), digestive (HR 1.40, 95% CI 1.30-1.52), and allergic disorders (HR 1.39, 95% CI 1.24-1.56). When contrasted with preeclampsia, hyperemesis gravidarum was a stronger risk factor for these outcomes. CONCLUSIONS: Maternal hyperemesis gravidarum is associated with an increased risk of childhood hospitalization, especially for neurologic, developmental, digestive, and atopic disorders. WHAT IS KNOWN: • Hyperemesis gravidarum is associated with neurodevelopmental disorders in offspring. • However, the effect of hyperemesis gravidarum on other childhood morbidity is unclear. WHAT IS NEW: • In this longitudinal cohort study of 1.2 million children, maternal hyperemesis gravidarum was associated with a greater risk of hospitalization before age 16 years. • Exposure to hyperemesis gravidarum was associated with developmental, neurologic, atopic, and digestive morbidity in childhood.

Non-alcoholic Wernicke's Encephalopathy Masquerading As CNS Relapse of Acute Myeloid Leukemia.

While Wernicke's encephalopathy (WE) is mostly caused by thiamine deficiency secondary to chronic alcohol use, other conditions that may affect one's nutritional status, such as bariatric surgery, hyperemesis gravidarum, chronic gastrointestinal disease, HIV/AIDS, and certain malignancies, may also lead to this outcome. We are discussing one such case, WE, in a young man with acute myeloid leukemia (AML) who underwent chemotherapy. The patient presented with blurred vision, paresthesia, weakness, and vomiting. Although he denied alcohol abuse, his symptoms, physical exam findings, and MRI results were consistent with WE. Treatment with thiamine resulted in a significant improvement in his visual disturbances and mental status. The authors highlight the importance of recognizing WE in non-alcoholic patients, particularly those undergoing prolonged hospitalization and chemotherapy, as nutritional deficiencies can develop. They recommend thiamine supplementation for patients receiving chemotherapy and those with poor oral intake. The case underscores the need for high clinical suspicion and early intervention in atypical cases of WE.

Concomitant Occurrence of Peripheral Neuropathy and Vision Loss Due to Multivitamin Deficiency After Bariatric Surgery.

Vitamin deficiencies, especially after Bariatric surgery, are common and, when not properly addressed, can lead to debilitating complications. Bariatric procedures, to variable degrees, alter the anatomy and physiology of the gastrointestinal; this alteration makes these patients more susceptible to developing nutritional deficiencies. Peripheral neuropathy is one of the complications that can arise from nutritional deficiencies, and it can cause severe functional impairment. Vision loss is a relatively uncommon complication after weight loss procedure. Changes in the retinal nerve fiber layer, choroidal thickness, and visual fields due to hypovitaminosis result in nutritional optic neuropathy and retinopathy. The main retinal complication is nyctalopia (night blindness), which is caused by vitamin A deficiency. We present a case of concomitant peripheral neuropathy and vision loss secondary to reduced levels of multiple vitamins following gastric bypass surgery. This case highlights the need for regular vitamin level monitoring and appropriate replenishment in patients after bariatric surgery to prevent significant morbidities.

Case report: A Boy with an inability to walk; do not forget about scurvy.

Scurvy, a condition caused by vitamin C deficiency, is characterized by a syndrome of multisystem disorder due to defective collagen production and antioxidative function. This condition is infrequent in this modern era; thus, it is often not within the list of differential diagnoses. The broad clinical picture is generally overlooked as other systemic illnesses, resulting in an extensive investigation that delays the diagnosis. Herein, we report a case of an 8-year-old boy with underlying autism spectrum disorder who presented with lower limb pain and other constitutional symptoms. Examination revealed multiple hyperpigmented scars over the upper and lower limbs and gingival hyperpigmentation. With history of picky eating habits and clinical symptoms supported by radiographic findings, scurvy was suspected and subsequently confirmed based on a low level of ascorbic acid. With vitamin C supplementation and proper nutritional support, the patient recovered well.

Silicon attenuates nutritional disorder of phosphorus in seedlings of Eucalyptus grandis × Eucalyptus urophylla.

BACKGROUND: Nutritional disorders of phosphorus (P), due to deficiency or toxicity, reduce the development of Eucalyptus spp. seedlings. Phosphorus deficiency often results in stunted growth and reduced vigor, while phosphorus toxicity can lead to nutrient imbalances and decreased physiological function. These sensitivities highlight the need for precise management of P levels in cultivation practices. The use of the beneficial element silicon (Si) has shown promising results under nutritional stress; nevertheless, comprehensive studies on its effects on Eucalyptus spp. seedlings are still emerging. To further elucidate the role of Si under varying P conditions, an experiment was conducted with clonal seedlings of a hybrid Eucalyptus spp. (Eucalyptus grandis × Eucalyptus urophylla, A207) in a soilless cultivation system. Seedlings were propagated using the minicutting method in vermiculite-filled tubes, followed by treatment with a nutrient solution at three P concentrations: a deficient dose (0.1 mM), an adequate dose (1.0 mM) and an excessive dose (10 mM), with and without the addition of Si (2mM). This study assessed P and Si concentration, nutritional efficiency, oxidative metabolism, photosynthetic parameters, and dry matter production. RESULTS: Si supply increased phenolic compounds production and reduced electrolyte leakage in seedlings provided with 0.1 mM of P. On the other hand, Si favored quantum efficiency of photosystem II as well as chlorophyll a content in seedlings supplemented with 10 mM of P. In general, Si attenuates P nutritional disorder by reducing the oxidative stress, favoring the non-enzymatic antioxidant system and photosynthetic parameters in seedlings of Eucalyptus grandis × Eucalyptus urophylla. CONCLUSION: The results of this study indicate that Eucalyptus grandis × Eucalyptus urophylla seedlings are sensitive to P deficiency and toxicity and Si has shown a beneficial effect, attenuating P nutritional disorder by reducing the oxidative stress, favoring the non-enzymatic antioxidant system and photosynthetic parameters.

Effects of school nurse-led health education to reduce malnutrition among primary school children in Bangladesh: Cluster nonrandomized controlled trial.

Background: Malnutrition is a major health concern among children especially in low and middle-income countries. However, there are limited studies on school health in Bangladesh. This study aimed to reduce malnutrition among primary school children in Bangladesh by increasing awareness and knowledge through school nurse-led health education. Methods and Materials: A prospective, open-label, parallel-group (1:1), cluster nonrandomized controlled trial on primary school children conducted in rural Bangladesh. The study lasted 13 months between September 2021 and September 2022. Four schools were selected and assigned to the intervention and control groups (CGs). Next, school nurses provided evidence-based health education to the children in the intervention group (IG) for 9 months to improve awareness and knowledge of malnutrition. Data were collected at baseline, midline, and endline. Results: Overall, 604 children were enrolled at the baseline; among them, 455 (CG, n = 220; IG, n = 235) completed the study. Changes in the malnutrition rate-the primary outcome-were not significant (P = 0.225). However, after adjusting the endline data with baseline and sociodemographic data, the children's body mass index improved significantly in the IG than in the CG (P < 0.05). Changes in eating behavior, and awareness and knowledge of malnutrition-the secondary outcomes-significantly differed between the groups (P < 0.001). Conclusion: The school nurse-led health education program significantly improved primary school children's awareness and knowledge of malnutrition. This study revealed the effectiveness of school nurses in reducing malnutrition among children, which may decrease future morbidity and mortality rates in children.

Case series of retinal vein occlusions showing early recovery using oral l-methylfolate.

This case series describes the aggregate rate of recovery in five consecutive subjects (six eyes) with retinal vein occlusion (RVO) who received l-methylfolate and other vitamins via Ocufolin®, a medical food. Subjects were followed for 10-33 months by a single ophthalmologist. Ocufolin® was prescribed at the time of diagnosis and subjects remained on the regimen throughout the time of observation. Examinations were performed in an un-masked fashion at 3-month intervals with recording of best corrected visual acuity (BCVA), average retinal nerve fiber layer (ARNFL) and central macular thickness (CMT), and fundus (examination of the retina, macula, optic nerve, and vessels) photography. Testing was done for vitamin deficiencies, vascular and coagulable risk factors, and methylenetetrahydrofolate reductase (MTHFR) polymorphisms. Vitamin deficiencies and vascular risk factors were found in all subjects, and all four tested subjects carried at least one MTHFR polymorphism. By the end of the study period BCVA in all subjects was 20/25 or better. Cystoid macular edema was identified and measured by optical coherence tomography (OCT). The percent change was calculated and plotted at 3-month intervals using the percent change in thickness from the time of diagnosis and percent change toward normative values for ARNFL and CMT. The total reduction in thickness of ARNFL and CMT from time of diagnosis was 44.19% and 30.27%, respectively. The comparison to normative data shows a reduction of ARNFL from 164.2% to 94% and CMT from 154.4% to 112.7% of normal thickness (100%). Plots showed the aggregate recovery was most rapid over the first 3 months and slowed over the next 3 months with most of the recovery taking place within 6 months of treatment. The rate of improvement in BCVA and resolution of retinal thickening was found to be better than predicted on historical grounds. No subjects progressed from nonischemic to ischemic RVO. Vitamin deficiencies, vascular risk factors, and genetic predisposition to oxidative stress were common in this RVO series. It appears that addressing these factors with Ocufolin® had a salutary effect on recovery.

Nutritional Problems Among Special Needs Children in a Rural Special Needs Children Home Near Chennai.

Background Special needs children have various health problems, and the most common problems are nutritional deficiency and malnourishment which leads to increased morbidity affecting their quality of life. This study aims to assess the nutritional status and health-seeking behaviour of special needs children. Methods The study was conducted among 46 special needs children at a special needs children's home. After collecting basic sociodemographic details, they were assessed for nutritional status and health-seeking behaviour using a semi-structured questionnaire followed by general and clinical examination. Results Out of these 46 special needs children, 69.6% were male and 30.4% were female. The mean age was 11.69±4.62 years. In this study, 65.22% were underweight; 6.52% were overweight; 10.87% were obese I; 4.35% were obese III; 13.04% were normal. Among them, 37% seek Government healthcare facilities for their healthcare needs. Referral advice was provided to all required children. Conclusion A high proportion of the special needs children were screened positive for nutritional deficiency and malnourishment which needs to be addressed. Interventions should be aimed at correcting the nutritional deficiency and malnourishment by involving the caretakers, mainly mothers of these children.

Angular cheilitis-an oral disease with many facets.

Cheilitis is a common inflammatory disorder of the vermillion and adjacent skin of the lips. A special type is angular cheilitis. The disease has a mixed etiology, mostly with bacterial and fungal components. Angular cheilitis may be a clinical sign of an underlying disease. It has two age peaks: one during childhood and another in adults. It becomes more frequent with aging. Clinical presentation, differential diagnoses, and treatment are discussed. Angular cheilitis is of importance in primary care of patients, in geriatrics, dentistry, pediatrics, internal medicine, and in dermatology.

Vitamin B12 Deficiency Disguised As Hemolytic Anemia: A Case Presentation.

This case report describes an 18-month-old male presenting with hemolytic anemia and lethargy, who was ultimately diagnosed with severe vitamin B12 deficiency. The child exhibited global developmental delays, including a lack of speech and walking skills. Initially suspected as intravascular hemolytic anemia, the normal reticulocyte count led to further investigation, which revealed low cobalamin (vitamin B12) levels. The patient received vitamin B12 injections, resulting in normalized cobalamin levels. Additional evaluations ruled out metabolic disorders and other etiologies for his anemia. Follow-up laboratory testing showed improved hemoglobin levels, and the patient was discharged with plans for close monitoring. The case emphasizes the importance of considering vitamin B12 deficiency in children, particularly those with developmental delays and anemia. Early diagnosis and treatment are crucial for preventing long-term neurological consequences associated with severe and prolonged cobalamin deficiency. Healthcare professionals should be aware of the impact of nutrient deficiencies on growth, development, and brain maturation in pediatric populations.

Pediatric Medicine of Galliformes.

Galliformes pediatrics covers general husbandry recommendations for gallinaceous chicks as well as information on vaccination for the average backyard poultry keeper. This article also covers basic information on common diseases affecting gallinaceous chicks in a small hobby operation. The focus lies on description of disease transmission, clinical signs, age of onset, and general prognosis and focuses less on specific treatment of individual diseases.

Do Global Dietary Nutrient Datasets Associate with Human Biomarker Assessments? A Regression Analysis.

BACKGROUND: To assess the state and trends of global nutrition, our best tools are nationally representative assessments using human biomarker assays, yet these are expensive and logistically challenging. We instead often rely on more easily produced global nutrient datasets-measures of nutrients provided by the diet-as a proxy for nutritional intake and deficiency, due to their greater geographic and temporal coverage. However, the accuracy of global nutrient datasets is questionable. OBJECTIVE: We aimed to test whether estimates of inadequate dietary intake derived from existing global nutrient datasets reliably associate with biophysical deficiency. DESIGN: We performed linear regressions of estimates of inadequate dietary nutrient intake derived from three global nutrient datasets-Global Dietary Database, Global Nutrient Database, and Global Expanded Nutrient Supply (GENuS) model-against the existing suite of nationally representative biomarker survey data for three key nutrients of global concern in two vulnerable demographic groups: zinc, folate, and vitamin A in females of childbearing age; and zinc and vitamin A in children younger than 5 y. RESULTS: We found significant associations (P < 0.1) for only 3 of 22 regressions between global nutrition datasets and biophysical deficiency: zinc for females of childbearing age from GENuS and Global Dietary Database, and zinc for children under 5 y from GENuS. Folate and vitamin A show no reliable relationship between nutrient datasets and independent biomarker surveys. Applying the successful models for zinc to the accompanying full datasets yield estimates of global zinc deficiency of 31%-37% for these demographic groups. CONCLUSIONS: We found that few estimates of nutritional inadequacy from global dietary datasets are associated with more direct measures of biophysical deficiency from biomarker studies. Researchers and policymakers must be cautious when applying global nutrient datasets to questions of global health and use them for limited applications.

Racial disparities in selected micronutrient deficiencies after bariatric surgery: A systematic review.

BACKGROUND: Bariatric surgery has been associated with numerous micronutrient deficiencies. Several observational studies have found that these deficiencies are more common in racially/ethnically minoritized patients. OBJECTIVES: To conduct a systematic review to investigate whether racially/ethnically minoritized patients experience worse nutritional outcomes after bariatric surgery. SETTING: University of Wisconsin-Madison. METHODS: PubMed, CINAHL, PsychINFO, and Cochrane databases were queried. We searched for manuscripts that reported micronutrient levels or conditions related to micronutrient deficiencies according to race/ethnicity (White, African American/Black, and Hispanic) after laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass between 2002 and 2022. Eleven micronutrients (vitamins A, B1 [thiamine], B12, D, E, K, calcium, copper, folate, iron, and zinc), and four conditions (anemia, bone loss, fractures, and hyperparathyroidism) were assessed. RESULTS: Abstracts from 953 manuscripts were screened; 18 full-text manuscripts were reviewed for eligibility, and ten met the inclusion criteria. Compared to White patients, African Americans had a higher prevalence of thiamine, vitamin D, and vitamin A deficiencies. There were no differences in calcium and vitamin B12 deficiencies. The other six micronutrients were not assessed according to race/ethnicity. Hyperparathyroidism was more prevalent in African Americans than White patients in the three studies that evaluated it. The prevalence of fractures was mixed. Anemia and bone loss were not evaluated according to race/ethnicity. CONCLUSIONS: Although the literature on micronutrient outcomes following bariatric surgery according to race/ethnicity is limited, African Americans appear to experience a higher prevalence of vitamin deficiencies and associated conditions. Qualitative and quantitative research to explore these disparities is warranted.

Low serum vitamin D in North Indian multi-drug resistant pulmonary tuberculosis patients: the role of diet and sunlight.

Background: Tuberculosis (TB) and malnutrition are major global health problems, with multidrug-resistant (MDR) TB complicating international efforts. The role of vitamin D in susceptibility to and as an adjunctive treatment for TB is being studied extensively, although no study has included MDR-TB patients in context to dietary profile with vitamin D levels and sunlight exposure.Objective: This study aimed to estimate vitamin D serum levels and examine their association with dietary intake of vitamin D and sun exposure in patients with MDR-TB.Methods: North Indian participants were enrolled in three groups: MDR-TB, drug-susceptible pulmonary TB (DS-PTB), and healthy controls. All consenting participants underwent the estimation of macro- and micronutrient intake and sunlight exposure using structured questionnaires. Serum biochemistry, including 25-hydroxyvitamin D and calcium levels, was measured, and the correlation between variables was determined.Results: 747 participants were enrolled. Significant differences among the three groups were found in mean serum 25-hydroxyvitamin D levels, body mass index, macronutrient intake, dietary vitamin D and calcium content, and sun exposure index (SEI). All except sun exposure (SEI was highest in DS-PTB patients) were found to follow the trend: MDR-TB < DS-PTB < healthy controls. The mean serum vitamin D levels of all groups were deficient and correlated positively with dietary intake and SEI.Conclusion: In this study's we found significant association of serum vitamin D concentrations, dietary intake and sunlight exposure in MDR-TB, DS-PTB patients and healthy controls. Dietary intake may be more important than sun exposure in determining serum levels. However, the significance of this finding is uncertain. Further studies are required to confirm the association, direction, and potential for vitamin D supplementation to treat or prevent MDR-TB infection.

[Causes and Countermeasures of Complications After Bariatric Surgery].

Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy characterized by simple operation and few postoperative complications have gradually become the two most commonly used surgical methods in clinical practice.A series of complications often occur after bariatric surgery,including gallstone disease,anemia,malnutrition,gastroesophageal reflux disease,kidney stones,and birth defects in offspring of women of childbearing age.There are controversies regarding the causes and countermeasures of these complications.This article mainly reviews the risk factors and countermeasures for the complications after bariatric surgery.

Malnutrition Following One-Anastomosis Gastric Bypass: a Systematic Review.

Severe malnutrition following one-anastomosis gastric bypass (OAGB) remains a concern. Fifty studies involving 49,991 patients were included in this review. In-hospital treatment for severe malnutrition was needed for 0.9% (n = 446) of patients. Biliopancreatic limb (BPL) length was 150 cm in five (1.1%) patients, > 150 cm in 151 (33.9%), and not reported in 290 (65%) patients. OAGB was revised to normal anatomy in 126 (28.2%), sleeve gastrectomy in 46 (10.3%), Roux-en-Y gastric bypass in 41 (9.2%), and shortening of BPL length in 17 (3.8%) patients. One hundred fifty-one (33.8%) patients responded to treatment; ten (2.2%) did not respond and was not reported in 285 (63.9%) patients. Eight (0.02%) deaths were reported. Standardisation of the OAGB technique along with robust prospective data collection is required to understand this serious problem.

Agronomic performance and remote sensing assessment of organic and mineral fertilization in rice fields.

Introduction: Rice heavily relies on nitrogen fertilizers, posing environmental, resource, and geopolitical challenges. This study explores sustainable alternatives like animal manure and remote sensing for resource-efficient rice cultivation. It aims to assess the long-term impact of organic fertilization and remote sensing monitoring on agronomic traits, yield, and nutrition. Methods: A six-year experiment in rice fields evaluated fertilization strategies, including pig slurry (PS) and chicken manure (CM) with mineral fertilizers (MIN), MIN-only, and zero-fertilization. Traits, yield, spectral responses, and nutrient content were measured. Sentinel-2 remote sensing tracked crop development. Results: Cost-effective organic fertilizers (PS and CM) caused a 13% and 15% yield reduction but still doubled zero-fertilization yield. PS reduced nitrogen leaching. Heavy metals in rice grains were present at safe amounts. Organic-fertilized crops showed nitrogen deficiency at the late vegetative stages, affecting yield. Sentinel-2 detected nutrient deficiencies through NDVI. Discussion: Organic fertilizers, especially PS, reduce nitrogen loss, benefiting the environment. However, they come with yield trade-offs and nutrient management challenges that can be managed and balanced with reduced additional mineral applications. Sentinel-2 remote sensing helps manage nutrient deficiencies. In summary, this research favors cost-effective organic fertilizers with improved nutrient management for sustainable rice production.

A rare, likely pathogenic variant causing Leber's hereditary optic neuropathy in three-generation females of an African-American family.

Purpose: We report a rare, likely pathogenic variant gene causing Leber's hereditary optic neuropathy (LHON) in three-generation female members of an African-American family. Observations: The granddaughter and mother presented with a subacute, painless visual loss in both eyes at age 10 and 42 years to legal blindness. The maternal grandmother presented with a gradual onset of moderate visual loss at age 60. The mother and grandmother reported a history of bariatric surgery and subsequent vitamin deficiencies. All three patients shared similar Optical Coherent Tomography (OCT) findings of profound thinning of ganglion cell complex (GCC) and relatively preserved peripapillary retinal nerve fiber layer thickness (pRNFL). Nuclear and mitochondrial DNA sequencing identified a 14596A > T likely pathogenic variant, p.(Ile26Met), in the MT-ND6 gene, with 100% homoplasmy in the granddaughter and mother and 65% heteroplasmy in the grandmother. The mother and grandmother were treated with idebenone in addition to vitamin supplements, with a slight improvement in their vision. Conclusions and Importance: Our patients' presentation stresses the importance of including LHON in the differential diagnosis in females presenting with unexplained bilateral, painless, severe visual loss. The OCT finding of profound GCC thinning with relatively preserved pRNFL thickness can be a red flag for LHON. A collaboration with genetic specialists to utilize expanded gene sequencing may greatly enhance our ability to identify rare pathogenic variants.

Managing the Chronically Ventilated Critically Ill Population.

Advances in intensive care over the past few decades have significantly improved the chances of survival for patients with acute critical illness. However, this progress has also led to a growing population of patients who are dependent on intensive care therapies, including prolonged mechanical ventilation (PMV), after the initial acute period of critical illness. These patients are referred to as the "chronically critically ill" (CCI). CCI is a syndrome characterized by prolonged mechanical ventilation, myoneuropathies, neuroendocrine disorders, nutritional deficiencies, cognitive and psychiatric issues, and increased susceptibility to infections. It is associated with high morbidity and mortality as well as a significant increase in healthcare costs. In this article, we will review disease burden, outcomes, psychiatric effects, nutritional and ventilator weaning strategies as well as the role of palliative care for CCI with a specific focus on those requiring PMV.