Pinworm (Enterobius Vermicularis) Infestation: An Updated Review

BACKGROUND

Pinworm infestation is an important public health problem worldwide, especially among children 5 to 10 years of age in developing countries with temperate climates. The problem is often overlooked because of its mild or asymptomatic clinical manifestations.

OBJECTIVE

The purpose of this article was to familiarize pediatricians with the diagnosis and management of pinworm infestation.

METHODS

A search was conducted in August 2023 in PubMed Clinical Queries using the key terms "Enterobius vermicularis," OR "enterobiasis," OR "pinworm." The search strategy included all clinical trials, observational studies, and reviews published within the past 10 years. Only papers published in the English literature were included in this review. The information retrieved from the above search was used in the compilation of the present article.

RESULTS

Enterobiasis is a cosmopolitan parasitosis caused by Enterobius vermicularis. It affects approximately 30% of children worldwide and up to 60% of children in some developing countries. Predisposing factors include poor socioeconomic conditions, inadequate sanitation, poor personal hygiene, and overcrowding. Children aged 5 to 14 years have shown the highest prevalence of enterobiasis.. Egg transmission is mainly by the fecal-oral route. Approximately 30 to 40% of infested patients do not show any clinical symptoms of the disease. For symptomatic patients, the most common presenting symptom is nocturnal pruritus ani. The diagnosis of E. vermicularis infection is best established by the cellophane tape test. The sensitivity of one single test is around 50%; however, the sensitivity increases to approximately 90% with tests performed on three different mornings. If a worm is visualized in the perianal area or the stool, a pathological examination of the worm will yield a definitive diagnosis. As pinworms and eggs are not usually passed in the stool, examination of the stool is not recommended. The drugs of choice for the treatment of pinworm infestation are mebendazole (100 mg), pyrantel pamoate (11 mg/kg, maximum 1 g), and albendazole (400 mg), all of the above-mentioned drugs are given in a single dose and repeated in two weeks. Mebendazole and albendazole are both adulticidal and ovicidal, whereas pyrantel pamoate is only adulticidal. Given their safety and effectiveness, mebendazole and albendazole are currently the best available drugs for the treatment of pinworm infestation. For pregnant women, pyrantel is preferred to mebendazole and albendazole. Treatment of all household members should be considered, especially if there are multiple or repeated symptomatic infections because reinfection is common even when effective medication is given.

CONCLUSION

In spite of effective treatment of pinworm infestation, recurrences are common. Recurrences are likely due to repeated cycles of reinfection (particularly, autoinfection) because of the short life span of adult pinworms. Good personal hygiene, such as frequent handwashing, especially after bowel movements and before meals, clipping of fingernails, avoidance of finger-sucking, nail-biting, and scratching in the anogenital area, are important preventive measures. Treatment of all household members should be considered, especially if there are multiple or repeated symptomatic infections.

Impact of "Long Covid" on Children: Global and Hong Kong Perspectives

BACKGROUND

The coronavirus disease (COVID-19) pandemic spares no nation or city, and the virus is responsible for the escalating incidence and mortality worldwide.

OBJECTIVE

This article reviews the impact of "Long Covid" on Children.

METHODS

A PubMed search was conducted in December 2021 in Clinical Queries using the key terms "COVID-19" OR "long COVID". The search was restricted to children and adolescent aged < 18 years and English literature.

RESULTS

Many large-scale studies have provided strong scientific evidence as to the detrimental and irreversible sequelae of COVID-19 on the health, psychology, and development of affected children. Many insights into managing this disease can be obtained from comparing the management of influenza. COVID-19 is generally a mild respiratory disease in children. Several syndromes, such as multisystem inflammatory syndrome in children (MIS-C) and COVID toe, are probably not specific to SARS-CoV-2. "Long COVID", or the long-term effects of SARS-CoV-2 infection, or the prolonged isolation and containment strategies on education and psychosocial influences on children associated with the pandemic, are significant.

CONCLUSION

Healthcare providers must be aware of the potential effects of quarantine on children's mental health. More importantly, healthcare providers must appreciate the importance of the decisions and actions made by governments, non-governmental organizations, the community, schools, and parents in reducing the possible effects of this situation. Multifaceted age-specific and developmentally appropriate strategies must be adopted by healthcare authorities to lessen the negative impact of quarantine on the psychological well-being of children.

Childhood Obesity: An Updated Review

BACKGROUND

Childhood obesity is an important and serious public health problem worldwide.

OBJECTIVE

This article aims to familiarize physicians with the evaluation, management, and prevention of childhood.

METHODS

A PubMed search was conducted in May, 2021, in Clinical Queries using the key terms "obesity" OR "obese". The search included clinical trials, randomized controlled trials, case-control studies, cohort studies, meta-analyses, observational studies, clinical guidelines, case reports, case series, and reviews. The search was restricted to English literature and children. The information retrieved from the above search was used in the compilation of the present article.

RESULTS

Most obese children have exogenous obesity characterized by a growth rate for height above the 50th percentile, normal intelligence, normal genitalia, and lack of historical or physical evidence of an endocrine abnormality or a congenital syndrome. Obese children are at risk for dyslipidemia, hypertension, diabetes mellitus, non-alcoholic fatty liver disease, obstructive sleep apnea, psychosocial disturbances, impaired quality of life, and shorter life expectancy. The multitude of serious comorbidities necessitates effective treatment modalities. Dietary modification, therapeutic exercise, and behavioral modification are the fundamentals of treatment. Pharmacotherapy and/or bariatric surgery should be considered for obese individuals who do not respond to the above measures and suffer from a serious comorbid condition.

CONCLUSION

Childhood obesity, once established, is often refractory to treatment. Most treatment programs lead to a brief period of weight loss, followed by rapid re-accumulation of the lost weight after the termination of therapy. As such, preventive activity is the key to solving the problem of childhood obesity. Childhood obesity can be prevented by promoting a healthy diet, regular physical activity, and lifestyle modification. Parents should be encouraged to get involved in school and community programs that improve their children's nutritional status and physical activity.

Iron Deficiency Anemia: An Updated Review

BACKGROUND

Worldwide, iron deficiency anemia is the most prevalent nutritional deficiency disorder and the leading cause of anemia in children, especially in developing countries. When present in early childhood, especially if severe and prolonged, iron deficiency anemia can result in neurodevelopmental and cognitive deficits, which may not always be fully reversible even following the correction of iron deficiency anemia.

OBJECTIVE

This article aimed to familiarize physicians with the clinical manifestations, diagnosis, evaluation, prevention, and management of children with iron deficiency anemia.

METHODS

A PubMed search was conducted in February 2023 in Clinical Queries using the key term "iron deficiency anemia". The search strategy included all clinical trials (including open trials, non-randomized controlled trials, and randomized controlled trials), observational studies (including case reports and case series), and reviews (including narrative reviews, clinical guidelines, and meta-analyses) published within the past 10 years. Google, UpToDate, and Wikipedia were also searched to enrich the review. Only papers published in the English literature were included in this review. The information retrieved from the search was used in the compilation of the present article.

RESULTS

Iron deficiency anemia is most common among children aged nine months to three years and during adolescence. Iron deficiency anemia can result from increased demand for iron, inadequate iron intake, decreased iron absorption (malabsorption), increased blood loss, and rarely, defective plasma iron transport. Most children with mild iron deficiency anemia are asymptomatic. Pallor is the most frequent presenting feature. In mild to moderate iron deficiency anemia, poor appetite, fatigability, lassitude, lethargy, exercise intolerance, irritability, and dizziness may be seen. In severe iron deficiency anemia, tachycardia, shortness of breath, diaphoresis, and poor capillary refilling may occur. When present in early childhood, especially if severe and prolonged, iron deficiency anemia can result in neurodevelopmental and cognitive deficits, which may not always be fully reversible even with the correction of iron deficiency anemia. A low hemoglobin and a peripheral blood film showing hypochromia, microcytosis, and marked anisocytosis, should arouse suspicion of iron deficiency anemia. A low serum ferritin level may confirm the diagnosis. Oral iron therapy is the first-line treatment for iron deficiency anemia. This can be achieved by oral administration of one of the ferrous preparations, which is the most cost-effective medication for the treatment of iron deficiency anemia. The optimal response can be achieved with a dosage of 3 to 6 mg/kg of elemental iron per day. Parenteral iron therapy or red blood cell transfusion is usually not necessary.

CONCLUSION

In spite of a decline in prevalence, iron deficiency anemia remains a common cause of anemia in young children and adolescents, especially in developing countries; hence, its prevention is important. Primary prevention can be achieved by supplementary iron or iron fortification of staple foods. The importance of dietary counseling and nutritional education cannot be overemphasized. Secondary prevention involves screening for, diagnosing, and treating iron deficiency anemia. The American Academy of Pediatrics recommends universal laboratory screening for iron deficiency anemia at approximately one year of age for healthy children. Assessment of risk factors associated with iron deficiency anemia should be performed at this time. Selective laboratory screening should be performed at any age when risk factors for iron deficiency anemia have been identified.

Sleep Bruxism in Children: A Narrative Review

Sleep bruxism, characterized by involuntary grinding or clenching of the teeth and/or by bracing or thrusting of the mandible during sleep, is common in children. Sleep bruxism occurs while the patient is asleep. As such, diagnosis can be difficult as the affected child is usually unaware of the tooth grinding sounds. This article aims to familiarize physicians with the diagnosis and management of sleep bruxism in children. A search was conducted in May 2023 in PubMed Clinical Queries using the key terms "Bruxism" OR "Teeth grinding" AND "sleep". The search strategy included all observational studies, clinical trials, and reviews published within the past 10 years. Only papers published in the English literature were included in this review. According to the International classification of sleep disorders, the minimum criteria for the diagnosis of sleep bruxism are (1) the presence of frequent or regular (at least three nights per week for at least three months) tooth grinding sounds during sleep and (2) at least one or more of the following (a) abnormal tooth wear; (b) transient morning jaw muscle fatigue or pain; (c) temporary headache; or (d) jaw locking on awaking. According to the International Consensus on the assessment of bruxism, "possible" sleep bruxism can be diagnosed based on self-report or report from family members of tooth-grinding sounds during sleep; "probable" sleep bruxism based on self-report or report from family members of tooth-grinding sounds during sleep plus clinical findings suggestive of bruxism (e.g., abnormal tooth wear, hypertrophy and/or tenderness of masseter muscles, or tongue/lip indentation); "definite" sleep bruxism based on the history and clinical findings and confirmation by polysomnography, preferably combined with video and audio recording. Although polysomnography is the gold standard for the diagnosis of sleep bruxism, because of the high cost, lengthy time involvement, and the need for high levels of technical competence, polysomnography is not available for use in most clinical settings. On the other hand, since sleep bruxism occurs while the patient is asleep, diagnosis can be difficult as the affected child is usually unaware of the tooth grinding sounds. In clinical practice, the diagnosis of sleep bruxism is often based on the history (e.g., reports of grinding noises during sleep) and clinical findings (e.g., tooth wear, hypertrophy and/or tenderness of masseter muscles). In childhood, sleep-bruxism is typically self-limited and does not require specific treatment. Causative or triggering factors should be eliminated if possible. The importance of sleep hygiene cannot be over-emphasized. Bedtime should be relaxed and enjoyable. Mental stimulation and physical activity should be limited before going to bed. For adults with frequent and severe sleep bruxism who do not respond to the above measures, oral devices can be considered to protect teeth from further damage during bruxism episodes. As the orofacial structures are still developing in the pediatric age group, the benefits and risks of using oral devices should be taken into consideration. Pharmacotherapy is not a favorable option and is rarely used in children. Current evidence on the effective interventions for the management of sleep bruxism in children is inconclusive. There is insufficient evidence to make recommendations for specific treatment at this time.

Respiratory Syncytial Virus is the Most Common Causative Agent of Viral Bronchiolitis in Young Children: An Updated Review

BACKGROUND

Viral bronchiolitis is a common condition and a leading cause of hospitalization in young children.

OBJECTIVE

This article provides readers with an update on the evaluation, diagnosis, and treatment of viral bronchiolitis, primarily due to RSV.

METHODS

A PubMed search was conducted in December 2021 in Clinical Queries using the key terms "acute bronchiolitis" OR "respiratory syncytial virus infection". The search included clinical trials, randomized controlled trials, case control studies, cohort studies, meta-analyses, observational studies, clinical guidelines, case reports, case series, and reviews. The search was restricted to children and English literature. The information retrieved from the above search was used in the compilation of this article.

RESULTS

Respiratory syncytial virus (RSV) is the most common viral bronchiolitis in young children. Other viruses such as human rhinovirus and coronavirus could be etiological agents. Diagnosis is based on clinical manifestation. Viral testing is useful only for cohort and quarantine purposes. Cochrane evidence-based reviews have been performed on most treatment modalities for RSV and viral bronchiolitis. Treatment for viral bronchiolitis is mainly symptomatic support. Beta-agonists are frequently used despite the lack of evidence that they reduce hospital admissions or length of stay. Nebulized racemic epinephrine, hypertonic saline and corticosteroids are generally not effective. Passive immunoprophylaxis with a monoclonal antibody against RSV, when given intramuscularly and monthly during winter, is effective in preventing severe RSV bronchiolitis in high-risk children who are born prematurely and in children under 2 years with chronic lung disease or hemodynamically significant congenital heart disease. Vaccines for RSV bronchiolitis are being developed. Children with viral bronchiolitis in early life are at increased risk of developing asthma later in childhood.

CONCLUSION

Viral bronchiolitis is common. No current pharmacologic treatment or novel therapy has been proven to improve outcomes compared to supportive treatment. Viral bronchiolitis in early life predisposes asthma development later in childhood.

Childhood pertussis is still here: An Asian city's perspectives

INTRODUCTION

Pertussis, or whooping cough, is a highly contagious respiratory infection that is caused by the bacterium Bordetella pertussis. It is one of the most common causes of death in childhood. It is also a frequent cause of chronic cough in children, adolescents, and adults.

METHODS

Global and Hong Kong perspectives of childhood pertussis were described.

RESULTS

Hong Kong has prided herself in the city's childhood immunization program. There appear to be no major outbreaks of pertussis since the 1960s. Nevertheless, pediatricians may see isolated cases of pertussis or pertussis-like cases from time to time. Occasionally, infants are severely affected with apneas and managed with ventilator supports in the PICU. Outbreaks of the notifiable disease continue to occur despite a reasonable surveillance system and vaccination program in Hong Kong. Vaccination of mothers, adolescents, and adults are efficacious methods to further reduce the risks of pertussis. Macrolides remain efficacious antibiotics especially used early during the infectious phase. Infants with pertussis may require intensive care support and morbidity is high.

CONCLUSIONS

Physicians should be reminded from time to time that outbreaks of pertussis still exist in Hong Kong and in many cities globally.

Influence of BDNF Val66Met polymorphism on excitatory-inhibitory balance and plasticity in human motor cortex

OBJECTIVE

While previous studies showed that the single nucleotide polymorphism (Val66Met) of brain-derived neurotrophic factor (BDNF) can impact neuroplasticity, the influence of BDNF genotype on cortical circuitry and relationship to neuroplasticity remain relatively unexplored in human.

METHODS

Using individualised transcranial magnetic stimulation (TMS) parameters, we explored the influence of the BDNF Val66Met polymorphism on excitatory and inhibitory neural circuitry, its relation to I-wave TMS (ITMS) plasticity and effect on the excitatory/inhibitory (E/I) balance in 18 healthy individuals.

RESULTS

Excitatory and inhibitory indexes of neurotransmission were reduced in Met allele carriers. An E/I balance was evident, which was influenced by BDNF with higher E/I ratios in Val/Val homozygotes. Both long-term potentiation (LTP-) and depression (LTD-) like ITMS plasticity were greater in Val/Val homozygotes. LTP- but not LTD-like effects were restored in Met allele carriers by increasing stimulus intensity to compensate for reduced excitatory transmission.

CONCLUSIONS

The influence of BDNF genotype may extend beyond neuroplasticity to neurotransmission. The E/I balance was evident in human motor cortex, modulated by BDNF and measurable using TMS. Given the limited sample, these preliminary findings warrant further investigation.

SIGNIFICANCE

These novel findings suggest a broader role of BDNF genotype on neurocircuitry in human motor cortex.

Juvenile Dermatomyositis: Advances in Pathogenesis, Assessment, and Management

BACKGROUND

Juvenile dermatomyositis is the most common inflammatory myopathy in the pediatric age group and a major cause of mortality and morbidity in individuals with childhood rheumatic diseases. Mounting evidence suggests that early diagnosis and timely aggressive treatment are associated with better outcomes.

OBJECTIVE

The purpose of this article is to provide readers with an update on the evaluation, diagnosis, and the treatment of juvenile dermatomyositis.

METHODS

A PubMed search was performed in Clinical Queries using the key term "juvenile dermatomyositis" in the search engine. The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. The search was restricted to English literature. The information retrieved from the above search was used in the compilation of the present article.

RESULTS

Juvenile dermatomyositis is a chronic autoimmune inflammatory condition characterized by systemic capillary vasculopathy that primarily affects the skin and muscles with possible involvement of other organs. In 2017, the European League Against Rheumatism (EULAR) and the American College of Rheumatology (ACR) developed diagnostic criteria for juvenile idiopathic inflammatory myopathies and juvenile dermatomyositis. In the absence of muscle biopsies which are infrequently performed in children, scores (in brackets) are assigned to four variables related to muscle weakness, three variables related to skin manifestations, one variable related to other clinical manifestations, and two variables related to laboratory measurements to discriminate idiopathic inflammatory myopathies from non-idiopathic inflammatory myopathies as follows: objective symmetric weakness, usually progressive, of the proximal upper extremities (0.7); objective symmetric weakness, usually progressive, of the proximal lower extremities (0.8); neck flexors relatively weaker than neck extensors (1.9); leg proximal muscles relatively weaker than distal muscles (0.9); heliotrope rash (3.1); Gottron papules (2.1); Gottron sign (3.3); dysphagia or esophageal dysmotility (0.7); the presence of anti-Jo-1 autoantibody (3.9); and elevated serum levels of muscle enzymes (1.3). In the absence of muscle biopsy, a definite diagnosis of idiopathic inflammatory myopathy can be made if the total score is ≥7.5. Patients whose age at onset of symptoms is less than 18 years and who meet the above criteria for idiopathic inflammatory myopathy and have a heliotrope rash, Gottron papules or Gottron sign are deemed to have juvenile dermatomyositis. The mainstay of therapy at the time of diagnosis is a high-dose corticosteroid (oral or intravenous) in combination with methotrexate.

CONCLUSION

For mild to moderate active muscle disease, early aggressive treatment with high-dose oral prednisone alone or in combination with methotrexate is the cornerstone of management. Pulse intravenous methylprednisolone is often preferred to oral prednisone in more severely affected patients, patients who respond poorly to oral prednisone, and those with gastrointestinal vasculopathy. Other steroid-sparing immunosuppressive agents such as cyclosporine and cyclophosphamide are reserved for patients with contraindications or intolerance to methotrexate and for refractory cases, as the use of these agents is associated with more adverse events. Various biological agents have been used in the treatment of juvenile dermatomyositis. Data on their efficacy are limited, and their use in the treatment of juvenile dermatomyositis is considered investigational.

Onychomycosis: An Updated Review

Background: Onychomycosis is a common fungal infection of the nail.

Objective: The study aimed to provide an update on the evaluation, diagnosis, and treatment of onychomycosis.

Methods: A PubMed search was completed in Clinical Queries using the key term “onychomycosis”. The search was conducted in May 2019. The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews published within the past 20 years. The search was restricted to English literature. Patents were searched using the key term “onychomycosis” in www.freepatentsonline.com.

Results: Onychomycosis is a fungal infection of the nail unit. Approximately 90% of toenail and 75% of fingernail onychomycosis are caused by dermatophytes, notably Trichophyton mentagrophytes and Trichophyton rubrum. Clinical manifestations include discoloration of the nail, subungual hyperkeratosis, onycholysis, and onychauxis. The diagnosis can be confirmed by direct microscopic examination with a potassium hydroxide wet-mount preparation, histopathologic examination of the trimmed affected nail plate with a periodic-acid-Schiff stain, fungal culture, or polymerase chain reaction assays. Laboratory confirmation of onychomycosis before beginning a treatment regimen should be considered. Currently, oral terbinafine is the treatment of choice, followed by oral itraconazole. In general, topical monotherapy can be considered for mild to moderate onychomycosis and is a therapeutic option when oral antifungal agents are contraindicated or cannot be tolerated. Recent patents related to the management of onychomycosis are also discussed.

Conclusion: Oral antifungal therapies are effective, but significant adverse effects limit their use.Although topical antifungal therapies have minimal adverse events, they are less effective than oral antifungal therapies, due to poor nail penetration. Therefore, there is a need for exploring more effective and/or alternative treatment modalities for the treatment of onychomycosis which are safer and more effective.

Giardiasis: An Overview

BACKGROUND

Giardiasis is an important cause of waterborne and foodborne diarrhea, daycare center outbreaks, and traveler's diarrhea.

OBJECTIVE

The study aimed to provide an update on the evaluation, diagnosis, and treatment of giardiasis.

METHODS

A PubMed search was completed in Clinical Queries using the key terms "giardiasis", "Giardia lamblia", "Giardia duodenalis" and "Giardia intestinalis". The search strategy included metaanalyses, randomized controlled trials, clinical trials, observational studies, and reviews. The search was restricted to the English literature. Patents were searched using the key term "giardiasis" from www.freepatentsonline.com.

RESULTS

Giardiasis is caused by the protozoan parasite Giardia lamblia. The parasite is transmitted by the fecal-oral route, frequently through ingestion of contaminated water and food or person-to person transmission. Risk factors for infection include children in day-care settings, child-care workers, institutionalized individuals, travelers in endemic areas, ingestion of contaminated or recreational water, immunodeficiency, cystic fibrosis, and oral-anal sex. Approximately 50 to 75% of infected children are asymptomatic. Other children present acute or chronic diarrhea. Direct fluorescent antibody tests that detect intact organisms, enzyme immunoassays that detect soluble antigens, and multiplex real-time polymerase chain reaction assays that detect specific genes of the parasite in stool samples have improved sensitivity and specificity compared with microscopic examination of stool specimens for the detection of Giardia trophozoites or cysts. Drugs used in the treatment of symptomatic giardiasis are reviewed in this study. Moreover, recent patents related to the management of giardiasis are also discussed.

CONCLUSION

Metronidazole, tinidazole, and nitazoxanide are drugs of choice. Resistance to common antigiardial drugs has increased in recent years, therefore, the search for new molecular targets for antigiardial drugs is urgently needed. In general, treatment of asymptomatic carriers is not recommended. Purification of water supply is an important preventive measure.

Travelers' Diarrhea: A Clinical Review

Background:

Travelers’ diarrhea is the most common travel-related malady. It affects millions of international travelers to developing countries annually and can significantly disrupt travel plans.

Objective:

To provide an update on the evaluation, diagnosis, treatment, and prevention of traveler’s diar-rhea.

Methods:

A PubMed search was completed in Clinical Queries using the key term “traveler’s diarrhea”. The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. The search was restricted to English literature. Patents were searched using the key term “traveler’s diarrhea” from www.freepatentsonline.com.

Results:

Between 10% and 40% of travelers develop diarrhea. The attack rate is highest for travelers from a developed country who visit a developing country. Children are at particular risk. Travelers’ diarrhea is usually acquired through ingestion of food and water contaminated by feces. Most cases are due to a bac-terial pathogen, commonly, Escherichia coli, and occur within the first few days after arrival in a foreign country. Dehydration is the most common complication. Pretravel education on hygiene and on the safe selection of food items is important in minimizing episodes. For mild travelers’ diarrhea, the use of antibi-otic is not recommended. The use of bismuth subsalicylate or loperamide may be considered. For moder-ate travelers’ diarrhea, antibiotics such as fluoroquinolones, azithromycin, and rifaximin may be used. Loperamide may be considered as monotherapy or adjunctive therapy. For severe travelers’ diarrhea, antibiotics such as azithromycin, fluoroquinolones, and rifaximin should be used. Azithromycin can be used even for the treatment of dysentery whereas fluoroquinolones and rifaximin cannot be used for such purpose. Recent patents related to the management of travelers’ diarrhea are discussed.

Conclusion:

Although travelers’ diarrhea is usually self-limited, many travelers prefer expedient relief of diarrhea, especially when they are traveling for extended periods by air or ground. Judicious use of an antimotility agent and antimicrobial therapy reduces the duration and severity of diarrhea.

Urinary Tract Infection in Children

BACKGROUND

Urinary Tract Infection (UTI) is a common infection in children. Prompt diagnosis and appropriate treatment are very important to reduce the morbidity associated with this condition.

OBJECTIVE

To provide an update on the evaluation, diagnosis, and treatment of urinary tract infection in children.

METHODS

A PubMed search was completed in clinical queries using the key terms "urinary tract infection", "pyelonephritis" OR "cystitis". The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. The search was restricted to English literature and the pediatric age group. Patents were searched using the key terms "urinary tract infection" "pyelonephritis" OR "cystitis" from www.google.com/patents, http://espacenet.com, and www.freepatentsonline.com.

RESULTS

Escherichia coli accounts for 80 to 90% of UTI in children. The symptoms and signs are nonspecific throughout infancy. Unexplained fever is the most common symptom of UTI during the first two years of life. After the second year of life, symptoms and signs of pyelonephritis include fever, chills, rigor, flank pain, and costovertebral angle tenderness. Lower tract symptoms and signs include suprapubic pain, dysuria, urinary frequency, urgency, cloudy urine, malodorous urine, and suprapubic tenderness. A urinalysis and urine culture should be performed when UTI is suspected. In the work-up of children with UTI, physicians must judiciously utilize imaging studies to minimize exposure of children to radiation. While waiting for the culture results, prompt antibiotic therapy is indicated for symptomatic UTI based on clinical findings and positive urinalysis to eradicate the infection and improve clinical outcome. The choice of antibiotics should take into consideration local data on antibiotic resistance patterns. Recent patents related to the management of UTI are discussed.

CONCLUSION

Currently, a second or third generation cephalosporin and amoxicillin-clavulanate are drugs of choice in the treatment of acute uncomplicated UTI. Parenteral antibiotic therapy is recommended for infants ≤ 2 months and any child who is toxic-looking, hemodynamically unstable, immunocompromised, unable to tolerate oral medication, or not responding to oral medication. A combination of intravenous ampicillin and intravenous/intramuscular gentamycin or a third-generation cephalosporin can be used in those situations. Routine antimicrobial prophylaxis is rarely justified, but continuous antimicrobial prophylaxis should be considered for children with frequent febrile UTI.

Sleep Terrors: An Updated Review

BACKGROUND

Sleep terrors are common, frightening, but fortunately benign events. Familiarity with this condition is important so that an accurate diagnosis can be made.

OBJECTIVE

To familiarize physicians with the clinical manifestations, diagnosis, and management of children with sleep terrors.

METHODS

A PubMed search was completed in Clinical Queries using the key terms "sleep terrors" OR "night terrors". The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. Only papers published in the English literature were included in this review. The information retrieved from the above search was used in the compilation of the present article.

RESULTS

It is estimated that sleep terrors occur in 1 to 6.5% of children 1 to 12 years of age. Sleep terrors typically occur in children between 4 and 12 years of age, with a peak between 5 and 7 years of age. The exact etiology is not known. Developmental, environmental, organic, psychological, and genetic factors have been identified as a potential cause of sleep terrors. Sleep terrors tend to occur within the first three hours of the major sleep episode, during arousal from stage three or four non-rapid eye movement (NREM) sleep. In a typical attack, the child awakens abruptly from sleep, sits upright in bed or jumps out of bed, screams in terror and intense fear, is panicky, and has a frightened expression. The child is confused and incoherent: verbalization is generally present but disorganized. Autonomic hyperactivity is manifested by tachycardia, tachypnea, diaphoresis, flushed face, dilated pupils, agitation, tremulousness, and increased muscle tone. The child is difficult to arouse and console and may express feelings of anxiety or doom. In the majority of cases, the patient does not awaken fully and settles back to quiet and deep sleep. There is retrograde amnesia for the attack the following morning. Attempts to interrupt a sleep terror episode should be avoided. As sleep deprivation can predispose to sleep terrors, it is important that the child has good sleep hygiene and an appropriate sleeping environment. Medical intervention is usually not necessary, but clonazepam may be considered on a short-term basis at bedtime if sleep terrors are frequent and severe or are associated with functional impairment, such as fatigue, daytime sleepiness, and distress. Anticipatory awakening, performed approximately half an hour before the child is most likely to experience a sleep terror episode, is often effective for the treatment of frequently occurring sleep terrors.

CONCLUSION

Most children outgrow the disorder by late adolescence. In the majority of cases, there is no specific treatment other than reassurance and parental education. Underlying conditions, however, should be treated if possible and precipitating factors should be avoided.

Hiccups: A Non-Systematic Review

BACKGROUND

Hiccups are a universal phenomenon. They are usually benign and selflimited. Persistent or intractable hiccups, although rare, can be debilitating and may indicate the presence of an underlying pathological process.

OBJECTIVE

To familiarize physicians with the pathophysiology, etiology, evaluation, and management of children with hiccups.

METHODS

A search was conducted on December 10, 2019, in Pubmed Clinical Queries using the key terms "hiccup" OR "hiccough" OR "singultus". The selected publication types included all clinical trials (including open trials, non-randomized controlled trials, and randomized controlled trials), observational studies, and reviews (including meta-analysis and narrative reviews) published within the past 10 years. Only papers published in the English literature were included in this review. The information retrieved from the above search was used in the compilation of the present article.

RESULTS

Overdistension of the stomach is the most commonly identifiable cause of acute hiccups, followed by gastroesophageal reflux and gastritis. Other causes of hiccups, notably persistent and intractable hiccups, include an underlying gastrointestinal, neurological, cardiovascular, pulmonary, infectious, and psychogenic disorder. Persistent or intractable hiccups can be a harbinger of serious medical pathology. A detailed history and thorough physical examination may provide clues for the etiology of the hiccups. The treatment of hiccups should be directed at the underlying cause whenever possible. Bouts of acute hiccups less than 48 hours rarely require medical intervention as they usually resolve within minutes. Treatment may be considered when hiccups are bothersome, persistent, or intractable. Treatment modalities include lifestyle changes, physical maneuvers, pharmacotherapy and, very rarely, surgical intervention.

CONCLUSION

Acute hiccups are usually benign and self-limiting. Persistent or intractable hiccups can be a harbinger of serious medical pathology. The underlying cause should be treated if possible. There are no formal guidelines for the treatment of hiccups. Currently, most of the methods proposed are based on case reports and anecdotal evidence. Terminating an episode of hiccups can be very challenging for a clinician but may tremendously improve the patient's quality of life. It is hoped that future well-designed and better-powered studies will provide us with more information on the efficacy of various treatment modalities for hiccups.

Breath-Holding Spells in Pediatrics: A Narrative Review of the Current Evidence

BACKGROUND

Breath-holding spells are common, frightening, but fortunately benign events. Familiarity with this condition is important so that an accurate diagnosis can be made.

OBJECTIVE

To familiarize physicians with the clinical manifestations, diagnosis, evaluation, and management of children with breath-holding spells.

METHODS

A PubMed search was completed in Clinical Queries using the key term "breath-holding spells". The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. Only papers published in the English literature were included in this review. The information retrieved from the above search was used in the compilation of the present article.

RESULTS

Breath-holding spells affect 0.1 to 4.6% of otherwise healthy young children. The onset is usually between 6 and 18 months of age. The etiopathogenesis is likely multifactorial and includes autonomic nervous system dysregulation, vagally-mediated cardiac inhibition, delayed myelination of the brain stem, and iron deficiency anemia. Breath-holding spells may be cyanotic or pallid. The former are usually precipitated by anger or frustration while the latter are more often precipitated by pain or fear. In the cyanotic type, the child usually emits a short, loud cry, which leads to a sudden involuntary holding of the breath in forced expiration. The child becomes cyanosed, rigid or limp, followed by a transient loss of consciousness, and a long-awaited inspiration and resolution of the spell. In the pallid type, crying may be minimal or "silent". The apneic period in the pallid type is briefer than that in the cyanotic type prior to the loss of consciousness and posture. The episode in the pallid type then proceeds in the same manner as a cyanotic spell except that the child in the pallid type develops pallor rather than cyanosis. In both types, the entire episode lasts approximately 10 to 60 seconds. The spells usually disappear spontaneously by 5 years of age.

CONCLUSION

Although breath-holding spells are benign, they can be quite distressing to the parents. Confident reassurance and frank explanation are the cornerstones of treatment. Underlying cause, if present, should be treated. Interventions beyond iron supplementation may be considered for children with severe and frequent breath-holding spells which have a strong impact on the lifestyle of both the child and family.

Community-Acquired Pneumonia in Children

BACKGROUND

Community-acquired pneumonia is an important cause of morbidity in developed countries and an important cause of morbidity and mortality in developing countries. Prompt diagnosis and appropriate treatment are very important.

OBJECTIVE

To provide an update on the evaluation, diagnosis, and treatment of community-acquired pneumonia in children.

METHODS

A PubMed search was completed in Clinical Queries using the key term "communityacquired pneumonia". The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. Patents were searched using the key term "community-acquired pneumonia" from www.google.com/patents, http://espacenet.com, and www. freepatentsonline.com.

RESULTS

Generally, viruses, notably respiratory syncytial virus, are the most common cause of community- acquired pneumonia in children younger than 5 years. Streptococcus pneumoniae is the most common bacterial cause across all age groups. Other important bacterial causes in children younger than 5 years include Haemophilus influenzae, Streptococcus pyogenes, Staphylococcus aureus, and Moraxella catarrhalis. In children 5 years or older, in addition to S. pneumoniae, other important bacterial causes include Mycoplasma pneumoniae and Chlamydophila pneumonia. In the majority of cases, bacterial and viral pneumonia cannot be reliably distinguished from each other on clinical grounds. In practice, most children with pneumonia are treated empirically with antibiotics; the choice of which depends on the patient's age and most likely pathogen. Recent patents related to the management of community-acquired pneumonia are discussed.

CONCLUSION

In previously healthy children under the age of 5 years, high dose amoxicillin is the treatment of choice. For those with type 1 hypersensitivity to penicillin, clindamycin, azithromycin, clarithromycin, and levofloxacin are reasonable alternatives. For children with a non-type 1 hypersensitivity to penicillin, cephalosporins such as cefixime, cefprozil, cefdinir, cefpodoxime, and cefuroxime should be considered. In previously healthy children over the age of 5 years, macrolides such as azithromycin and clarithromycin are the drugs of choice.

Pdxdc1 modulates prepulse inhibition of acoustic startle in the mouse

Current antipsychotic medications used to treat schizophrenia all target the dopamine D2 receptor. Although these drugs have serious side effects and limited efficacy, no novel molecular targets for schizophrenia treatment have been successfully translated into new medications. To identify novel potential treatment targets for schizophrenia, we searched for previously unknown molecular modulators of acoustic prepulse inhibition (PPI), a schizophrenia endophenotype, in the mouse. We examined six inbred mouse strains that have a range of PPI, and used microarrays to determine which mRNA levels correlated with PPI across these mouse strains. We examined several brain regions involved in PPI and schizophrenia: hippocampus, striatum, and brainstem, found a number of transcripts that showed good correlation with PPI level, and confirmed this with real-time quantitative PCR. We then selected one candidate gene for further study, Pdxdc1 (pyridoxal-dependent decarboxylase domain containing 1), because it is a putative enzyme that could metabolize catecholamine neurotransmitters, and thus might be a feasible target for new medications. We determined that Pdxdc1 mRNA and protein are both strongly expressed in the hippocampus and levels of Pdxdc1 are inversely correlated with PPI across the six mouse strains. Using shRNA packaged in a lentiviral vector, we suppressed Pdxdc1 protein levels in the hippocampus and increased PPI by 70%. Our results suggest that Pdxdc1 may regulate PPI and could be a good target for further investigation as a potential treatment for schizophrenia.

Proteinuria in Children: Evaluation and Differential Diagnosis

Although proteinuria is usually benign in the form of transient or orthostatic proteinuria, persistent proteinuria may be associated with more serious renal diseases. Proteinuria may be an independent risk factor for the progression of chronic kidney disease in children. Mechanisms of proteinuria can be categorized as glomerular, tubular, secretory, or overflow. A history, a physical examination, and laboratory tests help determine the cause. Transient (functional) proteinuria is temporary. It can occur with fever, exercise, stress, or cold exposure, and it resolves when the inciting factor is removed. Orthostatic proteinuria is the most common type in children, especially in adolescent males. It is a benign condition without clinical significance. Persistent proteinuria can be glomerular or tubulointerstitial in origin. The urine dipstick test is the most widely used screening method. Although a 24-hour urine protein excretion test is usually recommended for quantitation of the amount of protein excreted in the urine, it may be impractical in children. A spot, first-morning urine test for a protein-to-creatinine or protein-to-osmolality ratio is a reliable substitute. Treatment of proteinuria should be directed at the underlying cause. Patients with active urinary sediments, hematuria, hypertension, hypocomplementemia, renal insufficiency with depressed glomerular filtration rate, or signs and symptoms suggestive of vasculitic disease may require referral to a pediatric nephrologist and a renal biopsy.

Seasonal and perennial allergic conjunctivitis

Seasonal and perennial allergic conjunctivitis are IgE-mediated, hypersensitivity conditions characterized by ocular pruritus, epiphora, and hyperemia. Proper diagnosis is usually made clinically based on history and physical examination. Diagnostic procedures are rarely necessary. Non-pharmacological measures, such as environmental modification and proper eye care, should be considered for all patients with allergic conjunctivitis. Pharmacological interventions may also be required. Milder cases can be treated with short-term topical ophthalmic therapy such as a decongestant/ antihistamine combination, a mast cell stabilizer, or a multi-action agent. Moderate to severe cases may require longer usage of the above agents and/or the addition of an oral antihistamine. Refractory cases may necessitate the use of topical ophthalmic corticosteroids and topical NSAIDs. Immunotherapy, whether via the subcutaneous route or the intranasal route, should be considered in the treatment of persistent severe cases refractory to conventional treatment. Despite all the available therapeutic agents, there continues to be a constant need to discover more effective ways to treat seasonal and perennial allergic conjunctivitis. This article also discusses recent patents related to the field.

Uncoupling the dopamine D1-D2 receptor complex: a novel target for antidepressant treatment

Depression, or major depressive disorder (MDD), is a serious mental illness that causes substantial worldwide disability. Current antidepressant medications mostly target the serotonin and norepinephrine neurotransmitter systems. These drugs are ineffective in many patients, and there are limited options for treatment-resistant depression. The dopamine neurotransmitter system has recently been identified as another modulator of mood and depressive symptoms, and a recently discovered interaction between the dopamine D1 and D2 receptor may be a novel antidepressant target.

Proteinuria in children

Proteinuria is common in children and may represent a benign condition or a serious underlying renal disease or systemic disorder. Proteinuria may occur secondary to glomerular or tubular dysfunction. Although a 24-hour urine protein excretion test is usually recommended, it may be impractical in children. A spot, first-morning urine test for protein/creatinine ratio can be useful in this situation. Proteinuria is usually benign, in the form of transient or orthostatic proteinuria. Persistent proteinuria may be associated with more serious renal diseases. Clinical features from the history, physical examination, and laboratory tests help determine the cause of proteinuria. Treatment should be directed at the underlying cause. Patients with active urinary sediments, persistent and gross hematuria, hypertension, hypocomplementemia, renal insufficiency with depressed glomerular filtration rate, or signs and symptoms suggestive of vasculitic disease may require a renal biopsy and referral to a pediatric nephrologist.

Seasonal and perennial allergic conjunctivitis

Seasonal and perennial allergic conjunctivitis are IgE-mediated, hypersensitivity ophthalmic conditions characterized by ocular pruritus, epiphora, and hyperemia. Proper diagnosis is usually made clinically based on history and physical examination. Diagnostic procedures are rarely necessary. Non-pharmacological measures, such as environmental modification and proper eye care, should be considered for all patients with allergic conjunctivitis. Pharmacological interventions may also be required. Milder cases can be treated with short-term topical ophthalmic therapy such as a decongestant/antihistamine combination, a mast cell stabilizer, or a multi-action agent. Moderate to severe cases may require longer usage of the above agents or the addition of an oral antihistamine. Refractory cases may necessitate the use of topical ophthalmic corticosteroids and/or immunotherapy. Despite all the available therapeutic agents, there continues to be a constant need to discover more effective ways to treat seasonal and perennial allergic conjunctivitis. This review article also discusses recent patents related to the field.

Melanonychia striata in Chinese children and adults

BACKGROUND

There is considerable racial variation in the occurrence of melanonychia striata. The prevalence of melanonychia striata in the Chinese population is not known. The purpose of this study was to investigate the prevalence and characteristics of melanonychia striata in a Chinese population of patients.

METHODS

Two thousand, four hundred and fifty-seven Chinese patients attending an Asian medical clinic were examined for the presence of melanonychia striata in a cross-sectional prevalence survey. The examinations were carried out as part of the routine medical care provided to these patients. Patients of mixed racial background were excluded. The fingernails and toenails of each patient were examined, and the presence or absence of melanonychia striata, the anatomic distribution of the lesion, and the age and sex of the patient were recorded.

RESULTS

Melanonychia striata was not detected in patients aged less than 20 years. The condition was present in 0.6% of patients aged between 20 and 29 years. Thereafter, the prevalence increased gradually to 1.7% in patients aged 50 years and over. There was a significant relationship between age and the presence of melanonychia striata (chi(2) = 141, P < 0.01). There was no significant sex-related difference in the age-specific prevalence (P > 0.05). The thumbs were most frequently affected, followed by the index fingers (P < 0.001). The condition was bilateral in 40% of cases. None of the patients had involvement of more than two digits.

CONCLUSION

Melanonychia striata is uncommon in Chinese individuals, especially in those aged under 20 years. The male to female ratio is approximately equal. The thumbs are most frequently affected and the condition is often bilateral.

Regulation of alpha7-nicotinic receptor subunit and alpha7-like gene expression in the prefrontal cortex of patients with bipolar disorder and schizophrenia

OBJECTIVE

The alpha7-nicotinic receptor subunit gene (CHRNA7) is located at chromosome 15q13-14, a region previously linked with schizophrenia. Genetic association and mRNA expression studies also implicate CHRNA7 in schizophrenia. The CHRNA7 gene has a partial duplication that constitutes the alpha7-like nicotinic receptor gene (CHRFAM7A). We hypothesized that major psychoses could affect the expression of both CHRNA7 and CHRFAM7A.

METHOD

CHRNA7 and CHRFAM7A mRNA levels were measured in postmortem prefrontal cortex (donated by the Stanley Foundation) from subjects with schizophrenia, bipolar disorder and unaffected controls (n = 35 each).

RESULTS

The mRNA levels of alpha7 and alpha7-like genes have a positive correlation overall (r = 0.25; P = 0.009), however, there is no significant difference in the expression of CHRNA7 among the three diagnostic groups.

CONCLUSION

This correlation is driven by the bipolar group (r = 0.43; P = 0.009), and is absent in schizophrenia and unaffected controls, suggesting an alteration in the CHRNA7:CHRFAM7A ratio in bipolar disorder.

The interaction between TPH2 promoter haplotypes and clinical-demographic risk factors in suicide victims with major psychoses

Tryptophan hydroxylase isoform 2 (TPH2) is a rate-limiting enzyme in the biosynthesis of serotonin (5-HT) and is predominantly localized in the brain. Previous studies have suggested that there is an association between serotonergic dysfunction in the brain and suicidality. This study was designed to examine whether the -473T > A and -8396G > C polymorphisms of the TPH2 gene may be associated with completed suicide in subjects with major psychoses from the Stanley Foundation Brain Bank sample. TPH2 genotypes were determined in 69 subjects with a diagnosis of schizophrenia or bipolar disorder, among which 22 died by suicide. Genomic DNA was amplified by polymerase chain reaction and typed by automated methods. Both markers were found to be in Hardy-Weinberg equilibrium and in strong linkage disequilibrium. No association with history of suicide was found for either polymorphism. Haplotype analysis with EHAP showed no association between completed suicide and haplotype distribution (chi2 = 1.877; 3 df; P = 0.598). Nor was there any association between suicide and these genetic markers even when clinical-demographic factors were considered as covariates in the haplotype analysis. These findings suggest that these 5' marker haplotypes in the TPH2 gene do not influence suicidal behaviour.

Craniopharyngeoma presenting as psychosis, disinhibition and personality change without neurological signs

Tumors of the pituitary are associated most commonly with visual changes or endocrine abnormalities. Although a significant proportion of such tumors cause cognitive abnormalities, only a small number of cases have been reported in which the presenting symptoms are primarily 'psychiatric' in nature. The case described below highlights the importance of ancillary investigations in the evaluation of patients admitted to psychiatric wards. Despite the size and extension of the tumor, the patient showed no clear neurological signs, and screening serology was normal except for an elevated prolactin level. Only diagnostic imaging was able to reveal the presence of a calcified, cystic suprasellar mass that was confirmed to be a craniopharyngeoma by histopathology.

Identification of candidate genes for psychosis in rat models, and possible association between schizophrenia and the 14-3-3eta gene

Although the genetic contribution to schizophrenia is substantial, positive findings in whole-genome linkage scans have not been consistently replicated. We analyzed gene expression in various rat conditions to identify novel candidate genes for schizophrenia. Suppression subtraction hybridization (SSH), with polyA mRNA from temporal and frontal cortex of rats, was used to identify differentially expressed genes. Expression of mRNA was compared between adult Lewis and Fischer 344 (F344) rats, adult and postnatal day 6 (d6) F344, and adult F344 treated with haloperidol or control vehicle. These groups were chosen because each highlights a particular aspect of schizophrenia: differences in strain vulnerability to behavioral analogs of psychosis; factors that may relate to disease onset in relation to CNS development; and improvement of symptoms by haloperidol. The 14-3-3 gene family, as represented by 14-3-3gamma and 14-3-3zeta isoforms in the SSH study, and SNAP-25 were among the candidate genes. Genetic association between schizophrenia and the 14-3-3eta gene, positioned close to a genomic locus implicated in schizophrenia, and SNAP-25 genes was analyzed in 168 schizophrenia probands and their families. These findings address three different genes in the 14-3-3 family. We find a significant association with schizophrenia for two polymorphisms in the 14-3-3eta gene: a 7 bp variable number of tandem repeats in the 5' noncoding region (P=0.036, 1 df), and a 3' untranslated region SNP (753G/A) that is an RFLP visualized with Ava II (P=0.028). There was no significant genetic association with SNAP-25. The candidate genes identified may be of functional importance in the etiology, pathophysiology or treatment response of schizophrenia or psychotic symptoms. This is to our knowledge the first report of a significant association between the 14-3-3eta-chain gene and schizophrenia in a family-based sample, strengthening prior association reports in case-control studies and microarray gene expression studies.