Short term starvation potentiates the efficacy of chemotherapy in triple negative breast cancer via metabolic reprogramming.

BACKGROUND: Chemotherapy (CT) is central to the treatment of triple negative breast cancer (TNBC), but drug toxicity and resistance place strong restrictions on treatment regimes. Fasting sensitizes cancer cells to a range of chemotherapeutic agents and also ameliorates CT-associated adverse effects. However, the molecular mechanism(s) by which fasting, or short-term starvation (STS), improves the efficacy of CT is poorly characterized. METHODS: The differential responses of breast cancer or near normal cell lines to combined STS and CT were assessed by cellular viability and integrity assays (Hoechst and PI staining, MTT or H2DCFDA staining, immunofluorescence), metabolic profiling (Seahorse analysis, metabolomics), gene expression (quantitative real-time PCR) and iRNA-mediated silencing. The clinical significance of the in vitro data was evaluated by bioinformatical integration of transcriptomic data from patient data bases: The Cancer Genome Atlas (TCGA), European Genome-phenome Archive (EGA), Gene Expression Omnibus (GEO) and a TNBC cohort. We further examined the translatability of our findings in vivo by establishing a murine syngeneic orthotopic mammary tumor-bearing model. RESULTS: We provide mechanistic insights into how preconditioning with STS enhances the susceptibility of breast cancer cells to CT. We showed that combined STS and CT enhanced cell death and increased reactive oxygen species (ROS) levels, in association with higher levels of DNA damage and decreased mRNA levels for the NRF2 targets genes NQO1 and TXNRD1 in TNBC cells compared to near normal cells. ROS enhancement was associated with compromised mitochondrial respiration and changes in the metabolic profile, which have a significant clinical prognostic and predictive value. Furthermore, we validate the safety and efficacy of combined periodic hypocaloric diet and CT in a TNBC mouse model. CONCLUSIONS: Our in vitro, in vivo and clinical findings provide a robust rationale for clinical trials on the therapeutic benefit of short-term caloric restriction as an adjuvant to CT in triple breast cancer treatment.

The impact of COVID-19 on paediatric emergency department visits. A one-year retrospective study.

BACKGROUND: The number of paediatric emergency department (ED) visits and hospital admissions was recorded in a tertiary referral centre during the first year of the COVID-19, March 2020-February 2021, and compared with those of the preceding year. METHODS: The number of visits and admissions and the reason of visit and admission were prospectively recorded from 15,087 patients' files. RESULTS: A substantial decline in the total number of visits and increase in the admission rate were documented during the COVID-19 year compared to the preceding year (10691 vs 4396 patients, 22.59% vs 18.15% (OR: 1.316, CI 95%: 1.208-2.242, p < 0.0001), respectively). Fever and/or respiratory symptoms were the commonest reported symptoms in both periods. Possible explanations include: (i) restricted overall infection transmission due to confinement and self-protective measures, (ii) avoidance of unnecessary hospital visits in the absence of severe symptoms and (iii) reduced or delayed access to medical care due to parental fear of children's exposure to COVID-19. CONCLUSION: This study is the first worldwide to investigate the impact of COVID-19 on ED visits and admissions throughout the whole year of the pandemic, and to highlight the need for re-evaluation of future protective strategies to infections, adjustment of health-care systems and parental education so that medical care in a health-care setting is sought in a more appropriate manner. IMPACT: A significant decline in paediatric ED visits and increase in the admission rate was observed during the first year of COVID-19 in a tertiary referral centre, possibly due to reduced overall infection transmission, limited ED overuse, but also ED underuse due to parental fear of children's exposure to SARS-CoV-2. COVID-19 may serve as an opportunity for societies to re-evaluate future strategies to infections, adjust health-care systems accordingly, and reinforce parents to seek medical care more appropriately. Although the incidence of critical illness in children due to COVID-19 and in general is low, special attention should be devoted to identifying children at risk early.

Seasonal variation and epidemiological parameters in children from Greece with type 1 diabetes mellitus (T1DM).

BACKGROUND: A positive correlation between T1DM onset and winter has been suggested by several studies. We investigated the seasonal variation of T1DM diagnosis and epidemiological parameters in children from Western Greece with T1DM. METHODS: One hundred and five patients, 44 males, aged 1-16 years were studied. The month of the diagnosis, the order of birth, gestational age, birth weight, the mode of delivery, parental age and pubertal status were recorded from the patients' files. RESULTS: The mean age at diagnosis was 8.1 ± 4.0 years. The majority of the studied patients were diagnosed during the period of October-March. The majority were born at full term, 11.7% were preterm babies and 52.3% were first born. The mean birth weight was 3266 ± 596 g. 60% were born by vaginal delivery. The majority of the patients were prepubertal at diagnosis. CONCLUSIONS: Our results are in agreement with the reported seasonal variation of T1DM onset in other regions of Greece and Europe. The positive correlation between T1DM presentation and colder temperatures may be explained by factors such as viral infections. This is the first report on epidemiological parameters that may be related to T1DM presentation in Western Greece. The study of such parameters extends the understanding on the disease as a whole. IMPACT: A seasonality of the T1DM diagnosis is shown, with a predominance of the colder months of the year. This is in agreement with previous reports from other countries. Our findings confirm previously reported data and add to the existing knowledge on T1DM in general. Additionally, this is one of the few reports on the incidence and epidemiology of T1DM in Greece and the first in the region of Western Greece. Safer and more accurate conclusions can be drawn with regards to the possible causes and predisposing factors of T1DM by the assessment of statistical data from different populations throughout the world. This offers a better understanding of T1DM and may also contribute to the identification of factors that may reduce the incidence of the disease in the future.

Association of lifestyle factors with a high prevalence of overweight and obesity in Greek children aged 10-16 years.

AIM: To investigate the prevalence of overweight, obesity and central obesity in students of primary and secondary education, and the association with lifestyle parameters. METHODS: A total of 3504 students, aged 10-16 years old, from Western Greece participated in this cross-sectional epidemiological study (participation rate: 90%). Demographic, socioeconomic, dietary, physical activity and screen time data were obtained using a questionnaire. Anthropometric measurements were also obtained. Overweight and obesity were estimated using the Centers for Disease Control and Prevention (CDC) and International Obesity Task Force (IOTF) criteria and central obesity using the WHtR ≥0.5 and IDF criteria. RESULTS: The prevalence of overweight and obesity was 19.2% and 12.1% with CDC criteria, respectively, and 20.9% and 7.2%, with IOTF criteria respectively. Central obesity was 31.1 and 32.8% using the Waist-to-Height ratio (WHtR) ≥0.5 and International Diabetes Federation (IDF) criteria respectively. Male gender, small number of meals, breakfast skipping, frequent consumption of school food and sweets and the presence of a computer in children's rooms, were identified as the strongest lifestyle factors affecting weight. CONCLUSION: Overweight, obesity and central obesity rates remain high among children and adolescents in Greece. The identification of risk factors associated with the manifestation of obesity and central obesity, may contribute to the implementation of targeted prevention and treatment interventions.

The Role of Leptin in Childhood Immune Thrombocytopenia (ITP): An Anti-Inflammatory Agent?

To investigate the effect of leptin in childhood ITP, we measured plasma leptin in 39 children with acute ITP, after treatment and in remission, and in 33 healthy age/BMI-matched controls. We also cultured ITP and control peripheral blood mononuclear cells (PBMCs) with recombinant leptin to assess its direct effect on pro/anti-inflammatory cytokine gene expression. A significant increase in leptin was observed in children with active disease compared to controls. A significant inverse correlation of leptin with platelet count was also observed in children with acute ITP. Leptin remained high after treatment with IVIg, whereas steroid treatment lowered leptin below control levels. In remission, leptin was in the control range. Cytokine gene expression was significantly increased in children with acute ITP compared with controls, with highest expression for IFN-γ and IL-10. IVIg/steroid treatment significantly decreased IFN-γ and IL-10 expression. In remission, IFN-γ and IL-10 expression remained low. Addition of leptin to PBMCs isolated from patients in remission resulted in a significant increase in IL-10 gene expression compared to controls. Further experiments with purified T-cells and monocytes identified monocytes as the source of leptin-induced IL-10. We suggest that leptin acts as an active anti-inflammatory agent in childhood ITP by promoting IL-10 secretion by monocytes.

Metabolic changes in early neonatal life: NMR analysis of the neonatal metabolic profile to monitor postnatal metabolic adaptations.

BACKGROUND: A major challenge from the moment a child is delivered is the adaptation to the extrauterine life, where rapid metabolic changes take place. The study of these changes during the first days of human life may assist in the understanding of the metabolic processes that occur at this critical period, which is likely to provide significant clinical insights. To date, metabolomics has become a powerful field, ideal for the monitoring of such dynamic variations, since it offers the possibility to identify alterations in metabolic profiles, even on daily basis. METHODS: The study included 253 healthy newborns (GA 35 to 40 weeks) from the region of Western Greece. Urine samples were collected immediately after birth and at the third day of life. NMR-based metabolomics was used to compare the metabolic urinary profiles of newborns from the first and third day of their life, assessing the impact of six perinatal factors; delivery mode, prematurity, maternal smoking, gender, nutrition and neonatal jaundice. RESULTS: Analysis of urine metabolic fingerprint from the first and third day of life, coupled with multivariate statistics, provides insights into the details of early life metabolic profile differentiation. Αt the third day of life metabolic adaptations are evident, as many differences were noted in urine of healthy neonates within the first 72 h postpartum. Trends in differentiation of metabolites levels between the two groups, late preterm and term newborns, have been also observed. CONCLUSIONS: Newborn's urine metabolic profiles confirmed the rapid changes in their metabolism after birth. Further, ongoing research will enable us to develop one reference model of urinary metabolomics in healthy newborns during the period of adaptation to the extra-uterine life.

A Case Report of Salmonella enterica Meningitis in an Infant: A Rare Entity not to Forget.

INTRODUCTION: Salmonellae are gram-negative, facultatively anaerobic Enterobacteri-aceae consisting of two species, Salmonella enterica and Salmonella bongori. Invasive diseases, such as meningitis, result in hospitalization, short and long-term complications, and high mortality rates. CASE PRESENTATION: A 4-month-old baby girl was admitted to a district hospital because of diarrhea and fever. WBC count, urinalysis, urine cultures, and stool cultures were normal. She was treated with intravenous cefuroxime for 5 days. She was discharged on oral cefprozil for 5 days. After the end of therapy, she was admitted again to the same hospital with fever, diarrhea, vomits, and irri-tability. Cerebrospinal fluid examination revealed pleocytosis, while S. enterica was isolated. Em-pirical therapy with ceftriaxone, amikacin, and dexamethasone was started. Because of intracranial hypertension signs, she was transferred to the pediatric intensive care unit of our tertiary hospital. Therapy continued with intravenous ceftriaxone. Brain MRI revealed subarachnoid space dilata-tion. Increased head circumference and pulsating bregmatic fontanel led to a new cerebral MRI, in which ventricular dilatation and extraparenchymal subdural collection were noted. Ceftriaxone was changed to cefotaxime and ciprofloxacin was added. She remained clinically well; her brain MRI, a week later, showed marked improvement, and the course of intravenous antibiotics for 5 weeks was completed. Her baseline immunodeficiency screening tests were normal and repeat MRI two months post-treatment cessation did not reveal the previous abnormalities. CONCLUSION: Invasive Salmonella diseases, such as meningitis, are very uncommon in industrial countries nowadays, and the optimal management is yet not well established. Late onset of com-plications from Salmonella meningitis warrants more thorough neurodevelopmental follow-ups.

Body-Size Misperception among Overweight Children and Adolescents in Greece: A Cross-Sectional Study.

Childhood obesity can affect both physical and mental health. Body-size misperception may lead to a lack of motivation to make healthy changes or to engage in unhealthy weight loss behaviors, increasing the possibility for obese children to become obese adults. To estimate the frequency of body-size misperception among children and adolescents, we conducted a cross-sectional study within another study on eating disorders in youth in Greece (National Institute of Educational Policy, act no. 04/2018). Between January and December 2019, two trained assistants visited 83 primary and secondary schools of the Region of Western Greece and interviewed 3504 children aged 10-16 years (CL 99%) and performed anthropometric measurements. Among the 3504 surveyed children, 1097 were overweight, including 424 obese, and 51 were underweight. The "perceived" BMI was not computed in 875 children (25%), who did not state their weight or height and were classified as non-responders. Weight bias was inversely related to BMI, the obese and overweight non-obese children underestimated their weight, while the underweight children overestimated it. Conversely, height bias was positively related to BMI bias. BMI bias was not related to sex, age, parental education, or place of residence. In conclusion, our study lends robust support to the existing evidence on unrealistic body images among overweight children and adolescents. Prompt recognition of such misperceptions may help in increasing motivation towards healthier eating habits, systematic physical activity, and weight-control interventions.

Identification of Novel Biomarkers in Late Preterm Neonates with Respiratory Distress Syndrome (RDS) Using Urinary Metabolomic Analysis.

Urine metabolomics is gaining traction as a means of identifying metabolic signatures associated with health and disease states. Thirty-one (31) late preterm (LP) neonates admitted to the neonatal intensive care unit (NICU) and 23 age-matched healthy LPs admitted to the maternity ward of a tertiary hospital were included in the study. Proton nuclear magnetic resonance (1H NMR) spectroscopy was employed for urine metabolomic analysis on the 1st and 3rd days of life of the neonates. The data were analyzed using univariate and multivariate statistical analysis. A unique metabolic pattern of enhanced metabolites was identified in the NICU-admitted LPs from the 1st day of life. Metabolic profiles were distinct in LPs presenting with respiratory distress syndrome (RDS). The discrepancies likely reflect differences in the gut microbiota, either due to variations in nutrient intake or as a result of medical interventions, such as the administration of antibiotics and other medications. Altered metabolites could potentially serve as biomarkers for identifying critically ill LP neonates or those at high risk for adverse outcomes later in life, including metabolic risks. The discovery of novel biomarkers may uncover potential targets for drug discovery and optimal periods for effective intervention, offering a personalized approach.

Respiratory distress syndrome (RDS) in premature infants is underscored by the magnitude of Th1 cytokine polarization.

Respiratory distress syndrome (RDS) is a common problem and the leading cause of death in premature infants (PI). The introduction of surfactant treatment for RDS management has lowered mortality and morbidity; nevertheless, some neonates do not improve and are at increased risk of pulmonary hemorrhage. Inflammation, not only local but also systemic, seems to play an important role in the pathogenesis of RDS. To determine whether cytokine patterns characterize RDS and its outcome, we measured type-1 (IL-2, TNF-α, IFN-γ, IL-6) and type-2 (IL-4, IL-5, IL-10, TGF-ß1) serum cytokines of 47 PI with established RDS and a control group of 30 healthy, appropriate for gestational age, full-term neonates. Cord blood samples were obtained at the time of delivery from PI and controls. Venous blood samples were collected from PI who received surfactant treatment and/or developed pulmonary hemorrhage. Significantly elevated cord blood cytokine levels were observed in PI at time of delivery, compared to controls, except for IL-5 and TNF-α levels that were within control range. The type-1/type-2 cytokine ratio was significantly increased in PI vs controls. Neonates who developed pulmonary hemorrhage between 2 and 3 days of life and/or died, presented the strongest Th1 and type-1 cytokine polarization that was mainly due to increased IFN-γ and TNF-α, and decreased TGF-ß1. The majority of these PI were female with very low gestational age. Overall, PI with RDS present a Th1/type-1 cytokine polarization, which persists irrespective of the treatment provided, and is amplified when complications appear. Th1 polarization is associated with poor prognosis.

Nutrition of Infants with Bronchopulmonary Dysplasia before and after Discharge from the Neonatal Intensive Care Unit.

Bronchopulmonary dysplasia (BPD) represents a severe sequela in neonates born very prematurely. The provision of adequate nutritional support in this high-risk population is challenging. The development of the lungs and physical growth are closely linked together in infants with BPD. Growth deficiency has been associated with pulmonary dysfunction, whereas improvement in respiratory status results in growth acceleration. Currently, there is not enough data regarding optimal nutritional strategies in this population. Nutrition in these infants should provide sufficient calories and nutrients to establish growth, avoid growth retardation and assist alveolarization of the lungs. Meticulous follow-up is mandatory during and after discharge from the Neonatal Intensive care Unit (NICU) to minimize growth retardation and improve lung function. Despite the significant literature supporting the contribution of growth and nutrition in the avoidance of BPD, there is limited research regarding interventions and management of infants with established BPD. Our aim was to review clinical strategies applied in everyday clinical practice and identify debates on the nutritional approach of newborns with BPD. Well-organized interventions and clinical trials regarding the somatic development and nutrition of infants with BPD are warranted.

Knowledge and Attitudes of Medical and Nursing Students in Greece Regarding Child Abuse and Neglect.

Data on the knowledge and attitudes of healthcare practitioners in training regarding child abuse and neglect (CAN) are scarce. The aim of this study was to investigate the knowledge and attitudes regarding CAN of medical and nursing students in Greek universities. We performed a questionnaire-based e-survey on a convenience sample of students and recruited 609 students (366 medical and 243 nursing). An unsatisfactory level of knowledge in the field was reported overall. Most of the students (92.2%) were aware of their future responsibility to protect vulnerable children and report suspected cases of CAN; at the same time, they were willing to obtain further education. Based on the above, appropriate training in the undergraduate curriculum should be developed in order to strengthen future healthcare practitioners and boost their confidence in dealing with suspected cases of CAN and protect children's welfare.

Phagocytic ability of neutrophils and monocytes in neonates.

BACKGROUND: Infections by a variety of pathogens are a significant cause of morbidity and mortality during perinatal period. The susceptibility of neonates to bacterial infections has been attributed to immaturity of innate immunity. It is considered that one of the impaired mechanisms is the phagocytic function of neutrophils and monocytes. The purpose of the present study was to investigate the phagocytic ability of neonates at birth. METHODS: The phagocytic ability of neutrophils and monocytes of 42 neonates was determined using the Phagotest flow cytometry method, that assesses the intake of E. Coli by phagocytes, in cord blood and in peripheral blood 3 days after birth. Fifteen healthy adults were included in the study as controls. RESULTS: The phagocytic ability of neutrophils in the cord blood of neonates was significantly reduced compared to adults. The 3rd postnatal day the reduction of phagocytic ability of neutrophils was no longer significant compared to adults. The phagocytic ability of monocytes did not show any difference from that of adults either at birth or the 3rd postnatal day. CONCLUSIONS: Our findings indicate that the intake of E. Coli by phagocytes is impaired at birth in both preterm and full term neonates compared to adults. This defect is transient, with the phagocytic ability in neonates reaching that of the adults 3 days after birth.

Supernumerary umbilical vein in a hydropic neonate with hypertrophic cardiomyopathy.

The anomalies of the umbilical vessels are uncommon, with the exception of a single umbilical artery. We report a term female infant with fetal hydrops, hypertrophic cardiomyopathy, and a four-vessel umbilical cord consisting of two umbilical arteries and two umbilical veins. The presence of two veins in the umbilical cord has been attributed to persistence of both the normal left umbilical vein and the caudal part of the right umbilical vein. This fetal vascular pathology has been reported very rarely and may be associated with increased risk of congenital malformations and adverse perinatal outcome.

Knowledge and Attitudes of School Teachers on Vaccination in Greece.

Few studies have assessed attitudes and beliefs of school teachers on vaccination. Our cross-sectional questionnaire-based prospective survey aims to explore vaccination coverage and relevant knowledge of school teachers in Greece. Out of the 217 respondents, 93% believe that vaccines offer protection but only 69.7% were completely vaccinated as per adults' National Immunization Schedule. In multivariate analysis, female gender, being a parent, beliefs that vaccination should be mandatory and imposing penalties to vaccine refusals are the main factors that account for teachers' "behavioral" variability towards vaccination. Strengthening the training of school teachers in health promotion should become a priority in the era of the highly anticipated vaccine against severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2).

Attitudes and beliefs of parents about routine childhood vaccination in Greece.

Vaccine hesitancy remains one of the 10 major global threats as per the WHO report in 2019. The aim of the present study is to assess attitudes and perceptions of vaccine hesitant parents in Greece with a view to implementing strategies to increase vaccine uptake. A cross-sectional questionnaire-based prospective survey was conducted between September 2019 and June 2020 on parents of children attending primary education in the city of Patras in Western Greece. Data on parental attitudes and beliefs about vaccinations were collected and analyzed. Multivariable logistic regression was used to investigate factors associated with vaccine uptake. Out of 2154 distributed questionnaires, 1227 were completed and returned (response rate 56.9%). The main vaccine information source for Greek parents was their primary care pediatrician (90.8%). Doubts still exist amongst approximately one-third of them (33.5%) regarding a possible relationship between vaccines and autism. Of note, 44% of the study participants believe that unvaccinated children could attend school. 84.6% of the parents in our cohort admitted that they had fully vaccinated their children. In the multivariable analysis, marital status (p < .002) and Greek nationality (p < .001) were found to be the most significant determinants of vaccine uptake. Overall, we found that the percentage of parents in Greece that are vaccine hesitant is small yet not negligible. Based on our results, targeted public health interventions should particularly focus on single parents and those with non-Greek nationality. Training healthcare professionals to provide adequate information is crucial to clarify misperceptions.

Endoscopic Injection Treatment of Vesicoureteral Reflux in Children: Meeting with the Factors Involved in the Success Rate.

The challenges and controversies in vesicoureteral reflux intervention guidelines resulted in a more individualized treatment planning. Endoscopic injection therapy is now widely used and is considered preferable, but still remains less successful than ureteral reimplantation. Τhe endoscopic vesicoureteral reflux approach should be risk-adapted to current knowledge, so more experience and longer-term follow-up are needed. The precise of preoperative, intraoperative, and postoperative factors that affecting endoscopic injection therapy success rates and outcome have not yet been clearly determined. The aim of this study was to investigate these associated factors. Although the reflux grade is the most well-known factor that can affect the success of the procedure, there is no agreement on which factors are the most influential for the efficacy of endoscopic reflux treatment. So, we carried out a broad review of published papers on this topic, and we presented all the potential predictive variables of endoscopic reflux resolution in children.

Application of Metabolomics in Pediatric Asthma: Prediction, Diagnosis and Personalized Treatment.

Asthma in children remains a significant public health challenge affecting 5-20% of children in Europe and is associated with increased morbidity and societal healthcare costs. The high variation in asthma incidence among countries may be attributed to differences in genetic susceptibility and environmental factors. This respiratory disorder is described as a heterogeneous syndrome of multiple clinical manifestations (phenotypes) with varying degrees of severity and airway hyper-responsiveness, which is based on patient symptoms, lung function and response to pharmacotherapy. However, an accurate diagnosis is often difficult due to diversities in clinical presentation. Therefore, identifying early diagnostic biomarkers and improving the monitoring of airway dysfunction and inflammatory through non-invasive methods are key goals in successful pediatric asthma management. Given that asthma is caused by the interaction between genes and environmental factors, an emerging approach, metabolomics-the systematic analysis of small molecules-can provide more insight into asthma pathophysiological mechanisms, enable the identification of early biomarkers and targeted personalized therapies, thus reducing disease burden and societal cost. The purpose of this review is to present evidence on the utility of metabolomics in pediatric asthma through the analysis of intermediate metabolites of biochemical pathways that involve carbohydrates, amino acids, lipids, organic acids and nucleotides and discuss their potential application in clinical practice. Also, current challenges on the integration of metabolomics in pediatric asthma management and needed next steps are critically discussed.