Pushing Backwards: Evaluating Effectiveness of Conservative Treatment of Intestinal Intussusception.

OBJECTIVE: Intestinal intussusception (II) is a common cause for acute abdomen in children, occurring in 0.33 to 0.71 per 1000 children per year. Early diagnosis and treatment are fundamental for prevention of irreversible intestinal damage. The first line of treatment is conservative, with saline reduction enema or air reduction enema. Our goal is to evaluate results with conservative treatment of II in children. METHODS: A retrospective single-center review of all patients with diagnosis of II from January 2014 to December 2019 was performed. Demographics, clinical data, treatment option, and results were assessed. RESULTS: Thirty-eight cases were identified. The mean age was 26 months, and 68% were males. Most presented with abdominal pain (95%) and vomiting (66%), after an average of 30 hours. Rectal bleeding was present in 32% of patients. Abdominal ultrasound was performed in all patients for diagnosis. Conservative treatment was first option in 95% of patients, with a global effectiveness of 83% after 1 attempt. Saline reduction enema was more effective than air reduction enema (88% vs 70%), and patients with successful reduction were younger (24 vs 33 months), but neither reached statistical significance. Two patients had a subsequent II episode within 1 week after hospital discharge. Neither age, sex, symptoms and respective duration, rotavirus inoculation, intussuscepted bowel length, nor technique used was predictive of treatment failure or II relapse. CONCLUSIONS: Conservative treatment in II is a safe and effective option, preventing invasive surgical procedures. Effectiveness of such treatments may be as high as 88% after 1 attempt, with rapid diet reintroduction. Same-day discharge after oral feeding toleration is safe.

Identification of avoidable patients at triage in a Paediatric Emergency Department: a decision support system using predictive analytics.

BACKGROUND: Crowding has been a longstanding issue in emergency departments. To address this, a fast-track system for avoidable patients is being implemented in the Paediatric Emergency Department where our study is conducted. Our goal is to develop an optimized Decision Support System that helps in directing patients to this fast track. We evaluated various Machine Learning models, focusing on a balance between complexity, predictive performance, and interpretability. METHODS: This is a retrospective study considering all visits to a university-affiliated metropolitan hospital's PED between 2014 and 2019. Using information available at the time of triage, we trained several models to predict whether a visit is avoidable and should be directed to a fast-track area. RESULTS: A total of 507,708 visits to the PED were used in the training and testing of the models. Regarding the outcome, 41.6% of the visits were considered avoidable. Except for the classification made by triage rules, i.e. considering levels 1,2, and 3 as non-avoidable and 4 and 5 as avoidable, all models had similar results in model's evaluation metrics, e.g. Area Under the Curve ranging from 74% to 80%. CONCLUSIONS: Regarding predictive performance, the pruned decision tree had evaluation metrics results that were comparable to the other ML models. Furthermore, it offers a low complexity and easy to implement solution. When considering interpretability, a paramount requisite in healthcare since it relates to the trustworthiness and transparency of the system, the pruned decision tree excels. Overall, this paper contributes to the growing body of research on the use of machine learning in healthcare. It highlights practical benefits for patients and healthcare systems of the use ML-based DSS in emergency medicine. Moreover, the obtained results can potentially help to design patients' flow management strategies in PED settings, which has been sought as a solution for addressing the long-standing problem of overcrowding.

Behavioral and brain morphological analysis of non-inflammatory and inflammatory rat models of preterm brain injury.

Investigations using preclinical models of preterm birth have much contributed, together with human neuropathological studies, for advances in our understanding of preterm brain injury. Here, we evaluated whether the neurodevelopmental and behavioral consequences of preterm birth induced by a non-inflammatory model of preterm birth using mifepristone would differ from those after inflammatory prenatal transient hypoxia-ischemia (TSHI) model. Pregnant Wistar rats were either injected with mifepristone, and pups were delivered on embryonic day 21 (ED21 group), or laparotomized on the 18th day of gestation for 60 min of uterine arteries occlusion. Rat pups were tested postnatally for characterization of developmental milestones and, after weaning, they were behaviorally tested for anxiety and for spatial learning and memory. One month later, brains were processed for quantification of doublecortin (DCX)- and neuropeptide Y (NPY)-immunoreactive cells, and cholinergic varicosities in the hippocampus. ED21 rats did not differ from controls with respect to neonatal developmental milestones, anxiety, learning and memory functions, and neurochemical parameters. Conversely, in TSHI rats the development of neonatal reflexes was delayed, the levels of anxiety were reduced, and spatial learning and memory was impaired; in the hippocampus, the total number of DCX and NPY cells was increased, and the density of cholinergic varicosities was reduced. With these results we suggest that a preterm birth, in a non-inflammatory prenatal environment, does not significantly change neonatal development and adult neurologic outcome. On other hand, prenatal hypoxia and ischemia (inflammation) modifies developmental trajectory, learning and memory, neurogenesis, and NPY GABAergic and cholinergic brain systems.

Neuroborreliosis presenting as acute disseminated encephalomyelitis.

We report a case of a 5-year-old boy with acute disseminated encephalomyelitis as the initial presentation of neuroborreliosis. Parents report an upper-airway infection a few days before the development of acute encephalopathy, mild facial palsy, and seizures. The patient needed mechanical ventilation for 10 days, and after extubation, he presented hypotonia, ataxia, dysarthria, as well as weak gag and cough reflexes. Brain magnetic resonance imaging showed hyperintense lesions on T2- and fluid-attenuated inversion recovery sequences on the right subcortical occipital and parietal region, left posterior arm of the internal capsule, and in the medulla oblongata. Borrelia burgdorferi was identified in the plasma and cerebrospinal fluid by polymerase chain reaction and in the plasma by Western blotting. He was treated with ceftriaxone, methylprednisolone, and human immunoglobulin. Recovery was partial.

Repurposed Edaravone, Metformin, and Perampanel as a Potential Treatment for Hypoxia-Ischemia Encephalopathy: An In Vitro Study.

Hypoxia-ischemia encephalopathy results from the interruption of oxygen delivery and blood flow to the brain. In the developing brain, it can lead to a brain injury, which is associated with high mortality rates and comorbidities. The hippocampus is one of the brain regions that may be affected by hypoxia-ischemia with consequences on cognition. Unfortunately, clinically approved therapeutics are still scarce and limited. Therefore, in this study, we aimed to test three repurposed drugs with good pharmacological properties to evaluate if they can revert, or at least attenuate, the deleterious effects of hypoxia-ischemia in an in vitro model. Edaravone, perampanel, and metformin are used for the treatment of stroke and amyotrophic lateral sclerosis, some forms of epileptic status, and diabetes type 2, respectively. Through cell viability assays, morphology analysis, and detection of reactive oxygen species (ROS) production, in two different cell lines (HT-22 and SH-SY5Y), we found that edaravone and low concentrations of perampanel are able to attenuate cell damage induced by hypoxia and oxygen-glucose deprivation. Metformin did not attenuate hypoxic-induced events, at least in the initial phase. Among these repurposed drugs, edaravone emerged as the most efficient in the attenuation of events induced by hypoxia-ischemia, and the safest, since it did not exhibit significant cytotoxicity, even in high concentrations, and induced a decrease in ROS. Our results also reinforce the view that ROS and overexcitation play an important role in the pathophysiology of hypoxia-ischemia brain injury.

Omalizumab in the treatment of eosinophilic esophagitis and food allergy.

Omalizumab is currently used in severe asthma and has been tried in other allergic disorders. The authors report two patients with multiple food allergies and eosinophilic esophagitis on a very restrictive diet who have been treated with omalizumab, in order to improve food intolerance--the major distressing factor in their lives. The patients significantly improved in the reported symptoms. However, no improvement was seen regarding esophageal endoscopy and histology. Given the poor histological and endoscopy response, eosinophilic esophagitis persistence is unlikely to be IgE dependent. Omalizumab may improve the quality of life of patients with severe food allergy by improving symptoms, but it does not appear to change endoscopic and histological features of eosinophilic esophagitis in a short follow-up.

Neonatal hypoxic-ischaemic encephalopathy: Motor impairment beyond cerebral palsy.

BACKGROUND: Research investigating neuromotor function in the absence of cerebral palsy (CP) for children who had neonatal HIE is limited. AIMS: To investigate school-age neurological and neuromotor function, and correlations with attention, neonatal Magnetic Resonance Imaging (MRI), and neuromotor assessments at toddler age. METHODS: Twenty-seven children with neonatal HIE without CP who underwent hypothermia treatment and a comparison group of 20 children were assessed at age 5-7 years for Minor Neurological Dysfunction (MND; simplified Touwen), motor skills (Movement Assessment Battery for Children-2; MABC-2), parental concern over motor function (MABC Checklist), general cognition (Wechsler Preschool and Primary Scale of Intelligence-IV, WPPSI), and attention (DuPaul ADHD Rating Scale). Neurological examination and motor development, using Bayley-3 scales, at age 24-months was extracted from the clinical database. Clinical neonatal MRI was assessed for hypoxic-ischaemic injury. RESULTS: In the HIE group, MND was more prevalent (p = 0.026) and M-ABC performance (total score p = 0.006; balance subtest p = 0.008) was worse; parents were more concerned about children's motor function (p = 0.011). HIE group inattention scores were higher (p = 0.032), which correlated with lower MABC-2 scores (rs = -0.590, p = 0.004). Neurological examination at 24-months correlated with MND (rs = 0.437, p = 0.033); Bayley-3 motor scores did not correlate with M-ABC-2 scores (rs = 368, p = 0.133). Neonatal MRI findings were not associated with school-age MND (rs = 0.140, p = 0.523) or MABC-2 (rs = 0.300, p = 0.165). CONCLUSIONS: Children with neonatal HIE, without CP, treated with hypothermia may be more likely to develop MND and motor difficulties than typically developing peers. Inattention may contribute to motor performance. In the absence of CP, neonatal MRI and toddler age assessment of motor development have limited predictive value for school-age outcome. Since this was an exploratory study with a small sample size, findings should be confirmed by a definite larger study.

Epilepsy in paediatric patients with Parry-Romberg syndrome: A review of the literature.

BACKGROUND: Parry-Romberg syndrome (PRS) is a rare disorder characterized by unilateral slow progressive facial atrophy that can be associated with neurologic manifestations, namely seizures. There is scarce data about seizures in paediatric patients with PRS. The aim of our work was to clarify the clinical features of paediatric patients with PRS and seizures. METHODS: We performed a literature review based on a literature search using PubMed and EMBASE databases. We included original articles in which the main diagnosis was PRS and the patients were 17 years old or less when the first seizure occurred. RESULTS: We included 40 patients. Most of the patients had previously normal development and had their first seizure in the first decade of life. Neurologic examination was abnormal in 56 % of patients. Seizures are typically focal, frequently with impaired awareness, and became refractory in about 40 % of patients. Few patients have generalized seizures. On electroencephalogram, epileptic discharges are generally focal, on the same side as the facial atrophy, without a predominant cerebral lobe localization. Brain MRI is almost always abnormal, typically with T2 subcortical hyperintensities, and sometimes brain atrophy or calcifications. In addition to the classic antiepileptic drugs, immunosuppressive drugs should be considered as potential epilepsy treatment. CONCLUSION: To the best of our knowledge, this is the first review dedicated to the characteristics of paediatric patients with PRS and epilepsy. Seizures are usually focal, became refractory in 40 %, and have a significant impact on the quality of life and neurodevelopment of patients.

Prognosis of decompensated heart failure: role of NT-proBNP.

BACKGROUND: The prognostic value of natriuretic peptides in heart failure (HF) is well established. The objective of this study was to evaluate the role of NT-proBNP in predicting outcome in decompensated HF. METHODS: Patients admitted with decompensated HF to our Internal Medicine Department between November 2002 and April 2004 with at least two measurements of NT-proBNP (within 24 hours of admission and on discharge) were analyzed. Patients discharged alive were followed for up to 6 months. The primary endpoint was death or readmission. RESULTS: We included 304 patients (72.7+/-11.6 years of age, 53.9% female, 49.3% ischemic etiology). Echocardiography was performed in 73.7%. Left ventricular systolic function (LVSF) was preserved in 20.7%, mildly to moderately depressed in 32.2% and severely depressed in 20.7%. There was a significant decrease in median NT-proBNP levels during hospitalization (from 7006 to 3796 pg/ml, p<0.001). The patients were classified in three groups according to NT-proBNP variation: 1 decreasing by at least 30% (n=162); 2 - no significant variation (n=95); and 3 - increasing by at least 30% (n=47). The primary endpoint was observed in 43% of the patients. In univariate analysis, variables predictive of outcome were: NT-proBNP at discharge (> median: HR=2.72; 95% CI=1.89-3.92): variation in NT-proBNP levels during hospitalization (group 2 vs. group 1 - HR=2.28; 95% CI=1.52-3.42; group 3 vs. group 1 - HR=4.82; 95% CI=3.11-7.49); renal failure (creatinine >2 mg/dL - HR=1.65; 95% CI=1.07-2.53); and treatment with ACE-Is (HR=0.59; 95% CI=0.39-0.89). After adjustment for NYHA class at discharge, pulse pressure, LVSF, renal function and hemoglobin, only NT-proBNP at discharge and NT-proBNP variation remained independent predictors of prognosis (NT-proBNP at discharge > median: HR=2.02; 95% CI=1.28-3.2; NT-proBNP variation: group 2 vs. group 1 - HR=2.24; 95% CI=1.37-3.66; group 3 vs. group 1 - HR=3.85; 95% CI=2.24-6.63). CONCLUSION: Our results extend previous reports on the value of NT-proBNP in predicting outcome after discharge in patients hospitalized due to decompensated HF, and demonstrate its potential usefulness and applicability in clinical practice.

Developing sustainable research careers for KL2 scholars: The importance of an inclusive environment and mentorship.

INTRODUCTION: The National Clinical and Translational Science Award (CTSA) Consortium 2.0 has developed common metrics as a collaborative project for all participating sites. Metrics address several important aspects and functions of the consortium, including workforce development. The first workforce development metrics to be proposed for all CTSA hubs include the proportion of CTSA-supported trainees and scholars with sustainable careers in translational research and the diversity and inclusiveness of programs. METHODS AND RESULTS: The University of Utah Center for Clinical and Translational Science (CCTS), a CTSA hub, has been actively engaged in mentoring translational scientists for the last decade. We have developed programs, processes, and institutional policies that support translational scientists, which have resulted in 100% of our KL2 scholars remaining engaged in translational science and in increasing the inclusion of individuals under-represented in medicine in our research enterprise. In this paper, we share details of our program and what we believe are evidence-based best practices for developing sustainable translational research careers for all aspiring junior faculty members. CONCLUSIONS: The University of Utah Center for Clinical and Translational Science has been integral in catalyzing interactions across the campus to reverse the negative trends seen nationally in sustaining clinician scientists. Our programs and processes can serve as a model for other institutions seeking to develop translational scientists.

MEF2C haploinsufficiency syndrome: Report of a new MEF2C mutation and review.

INTRODUCTION: MEF2C haploinsufficiency syndrome is characterized by severe intellectual disability, epilepsy, stereotypic movements, minor dysmorphisms and brain abnormalities. We report the case of a patient with a new MEF2C mutation, comparing his clinical and imaging features to those previously reported in the literature. CASE REPORT: A 10 year-old boy first came to pediatric neurology clinic at the age of 11 months because of severe psychomotor delay, without regression. He presented generalized hypotonia, poor eye contact, hand-mouth stereotypies, strabismus and minor facial dimorphisms. Epileptic seizures started at 26 months of age and were refractory. Brain MRI showed a slight increase in periventricular white matter signal and globally enlarged CSF spaces. Molecular analysis revealed a de novo, pathogenic and causative MEF2C mutation. DISCUSSION: MEF2C haploinsufficiency syndrome was recently recognized as a neurodevelopmental disorder. Severe intellectual disability with inability to speak and epilepsy are universal features in patients with MEF2C mutations, although mild cognitive and speech disorders have been reported to occur in patients with duplications. Epilepsy might be absent in patients with partial deletions. Abnormal movement patterns are very common in patients with MEF2C haploinsufficiency. Delayed myelination seems to be more commonly observed in patients with MEF2C mutations, while malformations of cortical development were only reported in patients with microdeletions. Although MEF2C haploinsufficiency prevalence is yet to be determined, it should be considered in the differential diagnosis of patients with severe intellectual disability and Rett-like features.

Novel STXBP1 mutations in 2 patients with early infantile epileptic encephalopathy.

The authors describe 2 patients with early infantile epileptic encephalopathy caused by 2 novel mutations involving the STXBP1 gene. The authors suggest that in spite of the rarity of STXBP1 mutations, molecular analysis of STXBP1 gene should be performed in patients with early infantile epileptic encephalopathy, after exclusion of ARX mutations in male patients and CDKL5 mutations in female patients. The potential mechanisms explaining the variable clinical phenotypes caused by STXBP1 mutations are discussed and the designation of early-onset epileptic encephalopathies, including an updated genetic classification, is proposed to encompass the epileptic encephalopathies beginning in the first 6 months of life.

Syndrome of transient headache and neurologic deficits with cerebrospinal fluid lymphocytosis (HaNDL): a pediatric case report.

The syndrome of transient headache and neurologic deficits associated with cerebrospinal fluid lymphocytosis (HaNDL) is characterized by 1 or more episodes of severe headache, transient neurologic deficits, and lymphocytic pleocytosis in the cerebrospinal fluid. It is a benign and self limited disorder seldom reported in pediatric age. We report the case of a 14-year-old girl who suffered from 2 episodes of headache with transient focal neurologic deficits and pleocytosis consistent with the syndrome of HaNDL. This entity should be taken into account as a differential diagnosis in otherwise healthy children presenting with recurrent headache and acute neurologic deficits. Repeated use of invasive and expensive laboratory and imaging investigations can be avoided when the diagnosis of the syndrome of HaNDL is correctly established.

Expanding the phenotype of IFAP/BRESECK syndrome: a new case with severe hypogammaglobulinemia.

The ichthyosis follicular with atrichia and photophobia syndrome (IFAP) is a rare X-linked multiple congenital malformation syndrome. Some male patients have additional features including brain anomalies, intellectual disability, ectodermal dysplasia, skeletal deformities, ear or eye anomalies and kidney dysplasia/hypoplasia (BRESEK syndrome) sometimes associated with Hirschsprung disease and cleft palate or cryptorchidism (BRESHECK syndrome). We report a 5 months-old male patient with the p.R429H mutation in MBTPS2 protein, which has been reported to be associated with the most severe phenotype of patients with IFAP/BRESHECK syndrome. This patient presented with a severe IFAP/BRESHECK phenotype including ichthyosis follicular, atrichia, photophobia, brain anomalies, global developmental delay, Hirschsprung disease and kidney hypoplasia. Additional features not previously reported in IFAP syndrome, include severe hypogammaglobulinemia and congenital rectourethral fistula.

Moyamoya vascular pattern in Alagille syndrome.

We describe a girl with Alagille syndrome and a moyamoya angiographic pattern on magnetic resonance angiography. She was referred for genetic consultation because of posterior embryotoxon and peripheral pulmonary stenosis. Her facial appearance was typical, but she had no cholestasis or vertebral involvement. A heterozygous duplication of one nucleotide (a c.715dupA mutation) not previously described was identified in exon 5 of the JAG1 gene. We review similar cases in the literature and possible pathophysiologic mechanisms (e.g., the Jagged 1 and Notch signaling pathway) of this association.

Immune disease expressed in liver and platelets in an adolescent: a case report.

We report a case of a 15-year-old boy with autoimmune hepatitis lacking common serologic markers and normal gammaglobulinemia associated with immune thrombocytopenia and family history of psoriasis. He presented to our department with a 4-year history of a cervical posterior lymphadenopathy and recent petechiae. Previous laboratory results 6 months before already showed hepatocellular injury. After exclusion of other causes, the diagnosis of autoimmune hepatitis was made based on clinical grounds, associated immune disorder and histological features of liver biopsy.The authors alert for this atypical presentation of autoimmune hepatitis and associated immune thrombocytopenia.

Estudo da quantidade de jogadores em jogos reduzidos de handebol: mudança na dinâmica técnica e tática / The influence of number of players on small-sided handball games: changing on technical and tactical dynamic

O objetivo do presente estudo foi o de analisar os efeitos de diferentes formas de jogo (2 x 2, 3 x 3 e 4 x 4) de handebol no desempenho técnico e tático de alunos de Educação Física. Participaram no estudo oito alunos do sexo masculino (18,25 ± 1,04 anos de idade). Os indicadores que apresentaram diferenças significativas foram: contatos na bola, número de passes de ombro, passes de ombro completados e origem de pontos através de ataque organizado e contra-ataque. Conclui-se que as formas de jogo com menor número de alunos aumentaram a quantidade de ações técnicas e táticas, sugerindo-se estas formas numa fase inicial de aprendizagem.

The aim of this study was to verity the effects of different formats of handball game (2 vs 2, 3 vs 3 and 4 vs 4) on technical and tactical performance of Physical Education students. Eight male students (18.25 ± 1.04 years old) participated in this study. It was possible to verify significant statistical differences in the number of ball contacts, number of shoulder passes and shoulder passes completed. It was also possible to verify significant statistical differences in the organized attack and counterattack. Therefore, it was possible to conclude that smaller formats of small-sided handball games allows to increase the technical and tactical actions, thus being more appropriated to early stages of learning.