The Utility of Novel pH-Impedance Monitoring Parameters (PSPW Index and MNBI) in Pediatric Gastroesophageal Reflux Disease Phenotypes-A Systematic Review.

Background/Objectives: Researchers have proposed two novel impedance-pH parameters, mean nocturnal baseline impedance (MNBI) and the post-reflux swallow-induced peristaltic wave (PSPW) index, to enhance the diagnosis of gastroesophageal reflux disease (GERD) and enable better predictions of the effectiveness of anti-reflux therapies. This systematic review aims to synthesize the available evidence on the utility of the PSPW index and MNBI as diagnostic tools for pediatric GERD. Methods: A systematic search of studies reporting PSPW index and MNBI values in patients with GERD was performed in PubMed, Embase, Clarivate, Scopus, Cochrane and Google Scholar databases from their beginning until April 2024. The following terms were used: GERD, children, pediatric, PSPW and MNBI. Results: Eight studies were included, describing 479 patients ranging from 2 months to 17 years old over an 8-year period in 12 pediatric centers. Four studies demonstrated that children with pathological acid exposure have a significantly lower MNBI, with a good discriminatory ability to diagnose GERD. The PSPW index showed lower values in patients with reflux hypersensitivity (RH) compared to those with functional heartburn (FH). Conclusions: Patients with pathological acid exposure tend to exhibit lower MNBI and PSPW index values compared to those with normal acid exposure. MNBI and the PSPW index show promise as diagnostic tools in distinguishing between different GERD phenotypes. Further research is needed to establish standardized diagnostic criteria and optimize the clinical applicability in GERD diagnosis and management.

Three-Dimensional Assessment of Upper Airway Volume and Morphology in Patients with Different Sagittal Skeletal Patterns.

BACKGROUND: The relationship between respiratory function and craniofacial morphology has garnered significant attention due to its implications for upper airway and stomatognathic development. Nasal breathing plays a key role in craniofacial growth and dental positioning. This study investigated upper airway morphology and volume differences among individuals with class I, II, and III skeletal anomalies. METHODS: Ninety orthodontic patients' CBCT scans were analyzed to assess the oropharynx and hypopharynx volumes. Skeletal diagnosis was established based on the cephalometric analysis. RESULTS: A significant volume change in the oropharynx and pharynx was demonstrated when comparing class II with class III anomalies (p = 0.0414, p = 0.0313). The total volume of the pharynx was increased in class III anomalies. The area of the narrowest part of the pharynx (MIN-CSA) significantly decreased in classes I and II compared to class III (p = 0.0289, p = 0.0003). Patients with Angle class III anomalies exhibited higher values in the narrowest pharyngeal segment. Gender differences were significant in pharyngeal volumes and morphologies across malocclusion classes. CONCLUSIONS: The narrowest segment of the pharynx had the highest values in patients with Angle class III. The volume of the oropharynx was found to be greater in patients with Angle class III versus patients with Angle class II.

Personalized and Complex Esthetic Oral Rehabilitation in a Case of Non-Syndromic Oligodontia.

Dental agenesis is one of the most common developmental anomalies in humans and it is frequently associated with several other oral abnormalities. The present case describes non-familial agenesis of permanent teeth in a twenty-one-year-old boy with no apparent systemic abnormalities. The treatment included a personalized and interdisciplinary approach involving endodontics, orthodontics, implant-supported restorations and prosthetic treatments. The treatment plan was thoroughly elaborated using photographic analysis, study models, orthopantomogram, CBCT and cephalograms. Virtual smile design, diagnostic waxing and mock-ups previsualized the treatment objectives. The edentulous spaces were reconstructed by inserting dental implants and monolithic zirconia implant-supported restorations. The final results showed a highly esthetic and functional rehabilitation. Periodic check-ups have shown that the stability of the result is well maintained and that the implant-supported restorations are an optimal solution for patients with multiple anodontia.

The Use of Fibers, Herbal Medicines and Spices in Children with Irritable Bowel Syndrome: A Narrative Review.

The pathophysiology of irritable bowel syndrome in children involves multiple factors. Thus, treatment options are variable, targeting both diet and the child's and parents' behavior via pharmacological and psychological interventions or neuromodulation. Parents are increasingly interested in complementary and alternative therapies for children with irritable bowel syndrome, especially when other treatments have been tried without relieving the child's symptoms. This paper examines current evidence for the benefits and side effects of herbal remedies and spices in pediatric patients with IBS. The benefits of peppermint oil, STW5, psyllium fiber, Curcuma, ginger, and other herbal medicines are discussed based on findings in the current literature.

Examining a Resilience Mental Health App in Adolescents: Acceptability and Feasibility Study.

BACKGROUND: Resilience is defined as the ability to rely on internal characteristics and external strengths to adapt to adverse events. Although universal resilience-enhancing programs are effective for adolescents, there is a need for interventions that are more easily accessible and can be customized for individual teens. Phone apps are easy to use, can be tailored to individuals, and have demonstrated positive effects for mental health outcomes. OBJECTIVE: This study aimed to examine the feasibility and acceptability of a resilience app for adolescents. This app aimed to enhance resilience through modules focused on depression prevention, stress management, and healthy lifestyle approaches containing videos, measures, and practice suggestions. Furthermore, the study aimed to evaluate the effect of short-term app use on changes in resilience. METHODS: In study 1, individual interviews and focus groups were conducted with adolescents, parents, teachers, and clinicians to discuss possible incentives for using a mental health app, the benefits of app use, and concerns associated with app use. Feedback from study 1 led to ideas for the prototype. In study 2, individual interviews and focus groups were conducted with adolescents, parents, teachers, and clinicians to gather feedback about the resilience app prototype. Feedback from study 2 led to changes in the prototype, although not all suggestions could be implemented. In study 3, 40 adolescents used the app for 30 days to determine feasibility and acceptability. Additionally, resilience and secondary mental health outcomes were measured before and after app use. Dependent samples 2-tailed t tests were conducted to determine whether there were changes in resilience and secondary mental health outcomes among the adolescents before and after app use. RESULTS: Multiple themes were identified through study 1 individual interviews and focus groups, including app content, features, engagement, benefits, concerns, and improvement. Specifically, the adolescents provided helpful suggestions for making the prototype more appealing and functional for teen users. Study 2 adolescents and adults reported that the prototype was feasible and acceptable through the Computer System Usability Questionnaire (mean 6.30, SD 1.03) and Mobile App Rating Scale (mean 4.08, SD 0.61). In study 2, there were no significant differences in resilience and mental health outcomes after using the app for 30 days. There was variation between the participants in the extent to which they used the app, which may have led to variation in the results. The users appeared to prefer the depression module and survey sections, which provided mental health feedback. CONCLUSIONS: Qualitative and quantitative data provide evidence that youth are interested in a resilience mental health app and that the current prototype is feasible. Although there were no significant mental health changes in study 3 users, practical implications and future directions are discussed for mental health app research.

New diagnostic and therapeutic procedures applied in pediatric esophageal achalasia in a pediatric tertiary center: A case series.

Achalasia is an esophageal motor disorder that is rare in children. While the condition is uncommon, it is especially difficult to diagnose in pediatric patients; however, the ability to form a diagnosis has progressed markedly with the advent of esophageal high-resolution manometry (HRM). The aim of the present study was to highlight particularities of the diagnosis, based on esophageal HRM, as well as the treatment of achalasia in children. The current study analyzed cases of achalasia from a single pediatric tertiary center, Clinical Emergency Hospital for Children (Cluj-Napoca, Romania). The clinical data and the results of the investigations of seven children with achalasia, the first children to be evaluated using esophageal HRM in the center, were reported. The patients were aged between 11 and 18 years. All the patients were newly diagnosed with achalasia, except for one. The duration of symptoms was between 4 months and 2 years in the newly diagnosed patients. All the patients were assessed with conventional esophageal manometry and/or esophageal HRM. A multidisciplinary team contributed to the diagnosis and the management of achalasia. A total of 4 children diagnosed with type II achalasia were treated with peroral endoscopic myotomy (POEM) and 3 of the patients were treated with pneumatic dilations. Overall, achalasia is a rare but challenging condition in children. A diagnosis starts with a clinical suspicion based on swallowing disorders and upper digestive endoscopy, and is confirmed by esophageal HRM. Therapy should be adapted to the type of achalasia, the age of the children and the severity. In the present study, a relatively recent treatment option, POEM, was applied in pediatric patients with minor immediate adverse events. The report of these cases adds to the limited experience of using HRM and POEM in children with achalasia.

VitalSign: Screening, Diagnosis, and Treatment of Depression for Adolescents Presenting to Pediatric Primary and Specialty Care Settings.

Depression in youth is a critical public health concern. Nearly 13% of adolescents have experienced a depressive episode within the last year,1 and suicide is the second leading cause of death among 15- to 24-year-olds.2 Depression's negative impact spans several domains of functioning, leading to long-term effects on development.3 Recognizing the magnitude of the crisis, renewed guidelines by the US Preventive Services Taskforce and the American Academy of Pediatrics suggest that pediatric primary care providers become more active in the screening, diagnosis, and treatment of depression.4,5 Primary care settings provide optimal opportunities to identify and treat depression, while reducing stigma and barriers surrounding mental health, particularly given the limited availability and cost of psychiatric specialists. Although providers cite difficulties, including insufficient appointment time, inadequate training, discomfort addressing mental health disorders, and stigma, the management of depressed patients is feasible and efficacious in primary care.6-8 Several cost-efficient and easy-to-use depression screening tools are readily available and can be used alongside clinical interviews to diagnose and initiate treatment. In the following letter, we examine the feasibility of implementing a program focused on supporting pediatric providers in screening, diagnosing, and initiating depression treatment in youth.

10-Year Results of Standard Cross-Linking in Patients with Progressive Keratoconus in Romania.

PURPOSE: The purpose of the current study was to evaluate the long-term functional results based on keratometric measurements, spherical and cylinder equivalent in patients with progressive keratoconus treated with conventional "epi-off" corneal collagen cross-linking (CXL). METHODS: We conducted a retrospective study in which 113 eyes from 90 keratoconus-treated patients with CXL between 2006 and 2008 in Oculens Eye Clinic from Cluj-Napoca, Romania, were included. The diagnosis of keratoconus was based on corneal topography and its clinical signs. All patients were evaluated preoperatively, and a follow-up was performed at 1, 3, and 6 months and every year from 1 to 10 years after conventional CXL. RESULTS: All keratometry measurements improved significantly during the follow-up. Compared to preoperative values, the improvement of K max become statistically significant at 1 year after CXL (mean change compared to baseline -0.9 D, p < 0.001) and remained statistically significant thereafter up to 10 years (mean change compared to baseline -2.3 D, p < 0.001). As compared to preoperative values, mean spherical equivalent and mean cylinder improved during the follow-up, from a mean of -6.22 D before CXL to a mean value of -5.0 at 10 years, following CXL for spherical equivalent and from -4.4 D at baseline to -3.4 D at 10 years for cylinder (p < 0.05 for both). Uncorrected visual acuity increased, remaining statistically significant, by 0.104 logMAR at 10 years after CXL (p=0.0015), and best-corrected visual acuity increased by 0.135 logMAR at 10 years after CXL (p=0.015). We did not observe any case of severe complication. CONCLUSION: Our results show that CXL has a favorable effect on the progression of KC. The reduced K values, cylinder and spherical equivalent, and increased visual acuity remained the same 10 years after the procedure.

Single- and Multiple-Dose Pharmacokinetics of Once-Daily Formulations of Raltegravir.

A new once-daily formulation of raltegravir, an integrase strand transfer inhibitor indicated in combination with other antiretroviral drugs for the treatment of human immunodeficiency virus-1 infection, is under development. Single-dose and steady-state pharmacokinetics of 1200 mg for 2 formulations of raltegravir were characterized in 2 open-label phase 1 studies in healthy male and female subjects aged 18 to 55 years. The new raltegravir 600-mg formulation had a higher relative bioavailability compared with the 400-mg tablets. Once absorbed, both 3 × 400-mg and 2 × 600-mg dosage forms of raltegravir exhibited similar systemic pharmacokinetics; in dictating bioavailability, differences were from increased absorption that was the result of improved in vivo disintegration/dissolution. Food had a smaller effect on the pharmacokinetics of raltegravir when given as 2 × 600-mg formulation (42% vs 73% decrease in AUC0-last ). Steady state was generally reached in 2 days, with little to no accumulation with multiple-dose administration. Raltegravir 1200 mg was found to exhibit pharmacokinetic properties amenable for once-daily dosing and was generally well tolerated in healthy subjects after single and multiple doses. The new formulation improved the bioavailability of this Biopharmaceutics Classification System class II compound.

Comparative Results in a Combined Procedure of Intrastromal Corneal Rings Implantation and Cross-linking in Patients with Keratoconus: A Retrospective Study.

INTRODUCTION: Corneal thinning disorders caused by keratoconus often lead to protrusion, irregular astigmatism, and even perforation. Keratoconus, like other corneal ectasia, does not have a known cause. Severe cases of keratoconus may require correction or restoration of tectonic integrity of the cornea by surgical means. Intracorneal ring segments are a new modality in the treatment of corneal ectactic disorders. A new technique of stopping the evolution of keratoconus and strengthening the cornea is combining techniques of intrastromal corneal ring implantation and corneal collagen cross-linking. The objective of the study is to compare the effectiveness of combined procedures: intrastromal corneal ring implantation followed by cross-linking, with cross-linking followed by intrastromal corneal ring implantation. METHODS: The study comprised two groups of patients with different evolutionary stages of keratoconus, which met the eligibility criteria for intrastromal corneal ring segment implantation and corneal collagen cross-linking. Group 1 included patients (41 eyes) who underwent intrastromal corneal ring implantation followed by cross-linking and group 2 (30 eyes) included patients who underwent cross-linking first followed by intrastromal corneal ring implantation. RESULTS: A decrease in Km values of about 1.5 D and refraction was observed in group 1, compared to a decrease in Km values of about 1 D and refraction in group 2. Recovery of visual acuity was higher in group 1 than group 2. CONCLUSIONS: The sequence of intrastromal corneal ring implantation followed by cross-linking proved to be more effective in reducing Km values, spherical equivalent and cylinder compared with cross-linking followed by intrastromal corneal ring implantation.

Hoping Is Coping: A Guiding Theoretical Framework for Promoting Coping and Adjustment Following Pediatric Cancer Diagnosis.

OBJECTIVE: To determine the pattern of resilience and adjustment following pediatric cancer diagnosis and to evaluate hope as a mediator of adjustment. METHODS: 61 participants with pediatric cancer completed measures of hope, depression, anxiety, and quality of life (QoL) within 4 weeks of cancer diagnosis and every 3 months for 1 year. RESULTS: Participants showed high and increasing levels of hope and QoL, as well as low and decreasing levels of depression and anxiety. Linear mixed-effects regression analyses revealed changes in depression, anxiety, and hope to be significant predictors of changes in QoL. Changes in hope were found to partially mediate the effects of depression and anxiety on QoL. CONCLUSIONS: While a variety of interventions are efficacious for treating anxiety and depression, hope theory provides a framework for choosing interventions that may more globally promote children's ability to maintain good functioning, adjustment, well-being, and QoL following cancer diagnosis.

Intraocular pressure in pediatric patients during prone surgery.

BACKGROUND: Intraoperative intraocular pressure (IOP) in the prone position and IOP changes over time have not been evaluated in pediatric surgical patients. We sought to determine time-dependent changes in IOP in children undergoing surgery in prone position. METHODS: Thirty patients undergoing neurosurgical procedures in prone position were included. Using a pulse-mode pneumatonometer, IOP was measured in supine position after induction and before emergence of anesthesia and in prone position before the start and after the end of surgery. IOP changes over time in the prone position were assessed with a linear mixed model (i.e., random slope and intercept model) to adjust for the within-patient correlation. RESULTS: IOP in prone position increased by an average of 2.2 mm Hg per hour (P < 0.001). Sixty-three percent of patients (95% confidence interval [CI], 46%-81%) had at least 1 IOP value exceeding 30 mm Hg, and 13% (95% CI, 1%-25%) had at least 1 IOP value exceeding 40 mm Hg while prone. Mean IOP increased 7 mm Hg (95% CI, 6-9) during the position change from supine to prone (P < 0.001) and decreased 10 mm Hg (95% CI, 9-12) after changing the position from prone back to supine (P < 0.001). CONCLUSIONS: Changing position from supine to prone significantly increases IOP in anesthetized pediatric patients. Moreover, the IOP continued to increase during surgery and reached potentially harmful values, especially when combined with low mean arterial blood pressures that are common during major surgery.

The VeinViewer vascular imaging system worsens first-attempt cannulation rate for experienced nurses in infants and children with anticipated difficult intravenous access.

BACKGROUND: The VeinViewer (Luminetx, Memphis, TN) helps identify veins by projecting an image of subcutaneous vasculature on the skin surface. We tested the primary hypothesis that VeinViewer use improves cannulation success by skilled nurses in pediatric patients with anticipated difficult IV access. A secondary goal was to evaluate the relationship between obesity and cannulation success. METHODS: Patients aged 0 to 18 years were included. Anticipated cannulation difficulty was evaluated with the difficult IV access score. All cannulations were performed by members of the Intravenous Access Team. Patients were randomized to: (1) routine IV catheter insertion; or (2) insertion facilitated by the VeinViewer. The primary outcome was first-attempt insertion success. The proportion of successful insertions was evaluated using Cochran-Mantel-Haenszel χ(2) analysis to adjust for any imbalanced baseline variables. The effect of obesity on cannulation success was evaluated with multivariable logistic regression. RESULTS: Two hundred ninety-nine patients (49%) were randomly assigned to VeinViewer and 301 (51%) to routine cannulation. First-attempt cannulation success was 47% in patients assigned to VeinViewer vs 62% in patients assigned to routine cannulation, with an adjusted relative "risk" (95% confidence interval), of 0.76 (0.63-0.91). The Z-statistic of -3.6 crossed the "harm" boundary (Z < -2.41), with corresponding P value of 0.0003. The trial was stopped on statistical grounds since the harm boundary for the primary outcome was crossed. There was no association between first-attempt success and the 4-level categorization of obesity after adjusted for baseline variables (P = 0.94). CONCLUSIONS: The VeinViewer worsened first-attempt IV insertion success by skilled nurses. Surprisingly, first-attempt success for IV cannulation was not worsened by obesity.

Anesthesiology residents' medical school debt influence on moonlighting activities, work environment choice, and debt repayment programs: a nationwide survey.

BACKGROUND: The amount of education debt incurred by medical school graduates in the United States has grown considerably over the last 30 years; it has outpaced inflation to reach a mean of $158,000. With this dramatic increase in education debt, there has been limited information on how medical school debt loads of anesthesiology physicians impact their decisions concerning moonlighting and future career choices. Our aim was to survey current anesthesiology interns, residents, and fellows to assess the correlation between the amount of medical school debt they had collected and (1) their outlook toward moonlighting activities, (2) future career plans, and (3) choice of employer with a debt repayment program. METHODS: We developed a web-based survey instrument and contacted residency training programs to obtain access to their anesthesiology interns, residents, and fellows (residents). We assessed each relationship of interest using a multivariable proportional odds model, adjusting for all available baseline potential confounding factors. Second, we compared participants with >$150,000 medical school debt versus participants with no debt on the same questions of interest, each using a multivariable proportional odds model with the same covariable adjustment. RESULTS: We had access to 2386 residents through their training programs and 537 completed the survey. Those respondents with a 1-category-larger amount of medical school debt (i.e., $30,000) were associated with 7%(99.3% confidence interval: 0%, 13%) increased odds of having the desire to moonlight during residency/fellowship, and were associated with 7% (1%, 13%) decreased odds of saying they would choose a career as an academic faculty, respectively. Also, those with a larger amount of medical school debt were more likely to be swayed to be interested in an anesthesiology group with an education debt repayment program (odds ratio: 1.3 [1.22, 1.39] for 1-category increase in the debt amount); furthermore, the corresponding odds ratio was increased to 4.6 (2.8, 7.5) comparing those with >$150,000 debt with those without debt. CONCLUSIONS: In an effort to compete with private practice anesthesiology groups and to reduce the impact of debt on future career choices of residents/fellows, academic anesthesiology groups would do well to (1) promote moonlighting activities that are within the Accreditation Council for Graduate Medical Education and institutional guidelines, (2) develop financial curriculum for residents/fellows, and (3) offer debt repayment programs as an incentive for new faculty to join academic medicine.