Hypercapnia Causes Injury of the Cerebral Cortex and Cognitive Deficits in Newborn Piglets

In critically ill newborns, exposure to hypercapnia (HC) is common and often accepted in neonatal intensive care units to prevent severe lung injury. However, as a "safe" range of arterial partial pressure of carbon dioxide levels in neonates has not been established, the potential impact of HC on the neurodevelopmental outcomes in these newborns remains a matter of concern. Here, in a newborn Yorkshire piglet model of either sex, we show that acute exposure to HC induced persistent cortical neuronal injury, associated cognitive and learning deficits, and long-term suppression of cortical electroencephalogram frequencies. HC induced a transient energy failure in cortical neurons, a persistent dysregulation of calcium-dependent proapoptotic signaling in the cerebral cortex, and activation of the apoptotic cascade, leading to nuclear deoxyribonucleic acid fragmentation. While neither 1 h of HC nor the rapid normalization of HC was associated with changes in cortical bioenergetics, rapid resuscitation resulted in a delayed onset of synaptosomal membrane lipid peroxidation, suggesting a dissociation between energy failure and the occurrence of synaptosomal lipid peroxidation. Even short durations of HC triggered biochemical responses at the subcellular level of the cortical neurons resulting in altered cortical activity and impaired neurobehavior. The deleterious effects of HC on the developing brain should be carefully considered as crucial elements of clinical decisions in the neonatal intensive care unit.

Identification and Prediction of Clinical Phenotypes in Hospitalized Patients With COVID-19: Machine Learning From Medical Records

BACKGROUND

There is significant heterogeneity in disease progression among hospitalized patients with COVID-19. The pathogenesis of SARS-CoV-2 infection is attributed to a complex interplay between virus and host immune response that in some patients unpredictably and rapidly leads to "hyperinflammation" associated with increased risk of mortality. The early identification of patients at risk of progression to hyperinflammation may help inform timely therapeutic decisions and lead to improved outcomes.

OBJECTIVE

The primary objective of this study was to use machine learning to reproducibly identify specific risk-stratifying clinical phenotypes across hospitalized patients with COVID-19 and compare treatment response characteristics and outcomes. A secondary objective was to derive a predictive phenotype classification model using routinely available early encounter data that may be useful in informing optimal COVID-19 bedside clinical management.

METHODS

This was a retrospective analysis of electronic health record data of adult patients (N=4379) who were admitted to a Johns Hopkins Health System hospital for COVID-19 treatment from 2020 to 2021. Phenotypes were identified by clustering 38 routine clinical observations recorded during inpatient care. To examine the reproducibility and validity of the derived phenotypes, patient data were randomly divided into 2 cohorts, and clustering analysis was performed independently for each cohort. A predictive phenotype classifier using the gradient-boosting machine method was derived using routine clinical observations recorded during the first 6 hours following admission.

RESULTS

A total of 2 phenotypes (designated as phenotype 1 and phenotype 2) were identified in patients admitted for COVID-19 in both the training and validation cohorts with similar distributions of features, correlations with biomarkers, treatments, comorbidities, and outcomes. In both the training and validation cohorts, phenotype-2 patients were older; had elevated markers of inflammation; and were at an increased risk of requiring intensive care unit-level care, developing sepsis, and mortality compared with phenotype-1 patients. The gradient-boosting machine phenotype prediction model yielded an area under the curve of 0.89 and a positive predictive value of 0.83.

CONCLUSIONS

Using machine learning clustering, we identified and internally validated 2 clinical COVID-19 phenotypes with distinct treatment or response characteristics consistent with similar 2-phenotype models derived from other hospitalized populations with COVID-19, supporting the reliability and generalizability of these findings. COVID-19 phenotypes can be accurately identified using machine learning models based on readily available early encounter clinical data. A phenotype prediction model based on early encounter data may be clinically useful for timely bedside risk stratification and treatment personalization.

Practice patterns and perceptions of influenza testing amongst pediatric urgent care providers

INTRODUCTION

Despite a sensitivity of 50% to 70% the rapid influenza diagnostic test (RIDT) continues to play an important role in clinical decision-making due to its quick turn-around time, high specificity, relative simplicity of use, and low cost.

METHODS

A quantitative study using a web-based survey was distributed to 110 members of the Society of Pediatric Urgent Care aimed to assess RIDT use for diagnosis and management of influenza in outpatient pediatric patients.

RESULTS

Responses from 61 providers were received. Forty-two percent (95% CI 29.5-54.5%) of respondents report higher confidence in their diagnosis of influenza with the aid of a positive RIDT. 28% of respondents (95% CI 16.6-39.4%) report a higher likelihood of prescribing antiviral medications to low-risk patients if an RIDT is positive than without laboratory confirmation.

CONCLUSION

Most pediatric urgent care respondents reported higher confidence in their diagnosis and higher likelihood of prescribing antivirals with a positive RIDT rather than by clinical symptoms alone.

Neuroprotective effect of Src kinase in hypoxia-ischemia: A systematic review

Background

Hypoxic-ischemic encephalopathy (HIE) is a major cause of neonatal morbidity and mortality worldwide. While the application of therapeutic hypothermia has improved neurodevelopmental outcomes for some survivors of HIE, this lone treatment option is only available to a subset of affected neonates. Src kinase, an enzyme central to the apoptotic cascade, is a potential pharmacologic target to preserve typical brain development after HIE. Here, we present evidence of the neuroprotective effects of targeting Src kinase in preclinical models of HIE.

Methods

We performed a comprehensive literature search using the National Library of Medicine's MEDLINE database to compile studies examining the impact of Src kinase regulation on neurodevelopment in animal models. Each eligible study was assessed for bias.

Results

Twenty studies met the inclusion criteria, and most studies had an intermediate risk for bias. Together, these studies showed that targeting Src kinase resulted in a neuroprotective effect as assessed by neuropathology, enzymatic activity, and neurobehavioral outcomes.

Conclusion

Src kinase is an effective neuroprotective target in the setting of acute hypoxic injury. Src kinase inhibition triggers multiple signaling pathways of the sub-membranous focal adhesions and the nucleus, resulting in modulation of calcium signaling and prevention of cell death. Despite the significant heterogeneity of the research studies that we examined, the available evidence can serve as proof-of-concept for further studies on this promising therapeutic strategy.

Solithromycin in Children and Adolescents With Community-acquired Bacterial Pneumonia

BACKGROUND

Solithromycin is a new macrolide-ketolide antibiotic with potential effectiveness in pediatric community-acquired bacterial pneumonia (CABP). Our objective was to evaluate its safety and effectiveness in children with CABP.

METHODS

This phase 2/3, randomized, open-label, active-control, multicenter study randomly assigned solithromycin (capsules, suspension or intravenous) or an appropriate comparator antibiotic in a 3:1 ratio (planned n = 400) to children 2 months to 17 years of age with CABP. Primary safety endpoints included treatment-emergent adverse events (AEs) and AE-related drug discontinuations. Secondary effectiveness endpoints included clinical improvement following treatment without additional antimicrobial therapy.

RESULTS

Unrelated to safety, the sponsor stopped the trial prior to completion. Before discontinuation, 97 participants were randomly assigned to solithromycin (n = 73) or comparator (n = 24). There were 24 participants (34%, 95% CI, 23%-47%) with a treatment-emergent AE in the solithromycin group and 7 (29%, 95% CI, 13%-51%) in the comparator group. Infusion site pain and elevated liver enzymes were the most common related AEs with solithromycin. Study drug was discontinued due to AEs in 3 subjects (4.3%) in the solithromycin group and 1 (4.2%) in the comparator group. Forty participants (65%, 95% CI, 51%-76%) in the solithromycin group achieved clinical improvement on the last day of treatment versus 17 (81%, 95% CI, 58%-95%) in the comparator group. The proportion achieving clinical cure was 60% (95% CI, 47%-72%) and 68% (95% CI, 43%-87%) for the solithromycin and comparator groups, respectively.

CONCLUSIONS

Intravenous and oral solithromycin were generally well-tolerated and associated with clinical improvement in the majority of participants treated for CABP.

Computational analysis of cortical neuronal excitotoxicity in a large animal model of neonatal brain injury

BACKGROUND

Neonatal hypoxic brain injury is a major cause of intellectual and developmental disability. Hypoxia causes neuronal dysfunction and death in the developing cerebral cortex due to excitotoxic Ca²⁺-influx. In the translational piglet model of hypoxic encephalopathy, we have previously shown that hypoxia overactivates Ca²⁺/Calmodulin (CaM) signaling via Sarcoma (Src) kinase in cortical neurons, resulting in overexpression of proapoptotic genes. However, identifying the exact relationship between alterations in neuronal Ca²⁺-influx, molecular determinants of cell death, and the degree of hypoxia in a dynamic system represents a significant challenge.

METHODS

We used experimental and computational methods to identify molecular events critical to the onset of excitotoxicity-induced apoptosis in the cerebral cortex of newborn piglets. We used 2-3-day-old piglets (normoxic [Nx], hypoxic [Hx], and hypoxic + Src-inhibitor-treatment [Hx+PP2] groups) for biochemical analysis of ATP production, Ca²⁺-influx, and Ca²⁺/CaM-dependent protein kinase kinase 2 (CaMKK2) expression. We then used SimBiology to build a computational model of the Ca²⁺/CaM-Src-kinase signaling cascade, simulating Nx, Hx, and Hx+PP2 conditions. To evaluate our model, we used Sobol variance decomposition, multiparametric global sensitivity analysis, and parameter scanning.

RESULTS

Our model captures important molecular trends caused by hypoxia in the piglet brain. Incorporating the action of Src kinase inhibitor PP2 further validated our model and enabled predictive analysis of the effect of hypoxia on CaMKK2. We determined the impact of a feedback loop related to Src phosphorylation of NMDA receptors and activation kinetics of CaMKII. We also identified distinct modes of signaling wherein Ca²⁺ level alterations following Src kinase inhibition may not be a linear predictor of changes in Bax expression. Importantly, our model indicates that while pharmacological pre-treatment significantly reduces the onset of abnormal Ca²⁺-influx, there exists a window of intervention after hypoxia during which targeted modulation of Src-NMDAR interaction kinetics in combination with PP2 administration can reduce Ca²⁺-influx and Bax expression to similar levels as pre-treatment.

CONCLUSIONS

Our model identifies new dynamics of critical components in the Ca²⁺/CaM-Src signaling pathway leading to neuronal injury and provides a feasible framework for drug efficacy studies in translational models of neonatal brain injury for the prevention of intellectual and developmental disabilities.

Pediatric sepsis phenotypes for enhanced therapeutics: An application of clustering to electronic health records

OBJECTIVE

The heterogeneity of pediatric sepsis patients suggests the potential benefits of clustering analytics to derive phenotypes with distinct host response patterns that may help guide personalized therapeutics. We evaluate the relative performance of latent class analysis (LCA) and K-means, 2 commonly used clustering methods toward the derivation of clinically useful pediatric sepsis phenotypes.

METHODS

Data were extracted from anonymized medical records of 6446 pediatric patients that presented to 1 of 6 emergency departments (EDs) between 2013 and 2018 and were thereafter admitted. Using International Classification of Diseases (ICD)-9 and ICD-10 discharge codes, 151 patients were identified with a sepsis continuum diagnosis that included septicemia, sepsis, severe sepsis, and septic shock. Using feature sets used in related clustering studies, LCA and K-means algorithms were used to derive 4 distinct phenotypic pediatric sepsis segmentations. Each segmentation was evaluated for phenotypic homogeneity, separation, and clinical use.

RESULTS

Using the 2 feature sets, LCA clustering resulted in 2 similar segmentations of 4 clinically distinct phenotypes, while K-means clustering resulted in segmentations of 3 and 4 phenotypes. All 4 segmentations identified at least 1 high severity phenotype, but LCA-identified phenotypes reflected superior stratification, high entropy approaching 1 (eg, 0.994) indicating excellent separation between estimated phenotypes, and differential treatment/treatment response, and outcomes that were non-randomly distributed across phenotypes (P < 0.001).

CONCLUSION

Compared to K-means, which is commonly used in clustering studies, LCA appears to be a more robust, clinically useful statistical tool in analyzing a heterogeneous pediatric sepsis cohort toward informing targeted therapies. Additional prospective studies are needed to validate clinical utility of predictive models that target derived pediatric sepsis phenotypes in emergency department settings.

Patient and Visit Characteristics of Pediatric Patients With High-frequency Low-acuity Emergency Department Visits

INTRODUCTION

Pediatric patients account for a disproportionate number of low-acuity emergency department (ED) visits. The aim of this study is to describe pediatric patient and visit characteristics for high-frequency users for low-acuity visits.

METHODS

This was a retrospective cohort study of children presenting to a tertiary care pediatric ED and an affiliated community ED, over a 2-year period, with at least 10 low-acuity visits. Twenty patients with the highest number of visits were classified as "superusers." We analyzed patient data from the larger sample of high-frequency users and visit specific data from superuser visits. IBM SPSS Statistics 25 (SPSS Inc., Chicago, IL) was used to perform descriptive statistics and to summarize demographic and visit specific variables.

RESULTS

We identified 181 high-frequency users with a mean number of visits of 14.3 ± 4.3 and a subpopulation of 20 superusers accounting for 434 visits. The majority of high-frequency users (89%) identified as African American and had public insurance (96.1%). Many patients received primary care affiliated with the home institution. In the first year of the study, 50.3% of high-frequency users were infants younger than 1 year at the index visit and 47.4% of superusers were infants at the index visit.Superuser visits were evenly distributed among seasons and the majority of visits occurred during the weekdays (70.7%). The majority of visits were for medical complaints (86.6%) and almost half (47.6%) resulted in some testing (24.9%) or treatment (30.6%); however, only 1.4% resulted in hospital admission.

CONCLUSIONS

In our sample, most high-frequency low-acuity ED patients were infants, African American and have public insurance. Many are seen during clinic hours and are paneled at affiliated clinics. Among superusers, the majority of the visits did not require any testing, intervention, or treatment.

A Prospective Look at Career Aspirations Among Pediatric Emergency Medicine Trainees

OBJECTIVES

Before delivering a contract negotiation workshop to pediatric emergency medicine fellows in training, we wanted to understand the group's career aspirations. We hypothesized that fellows would be interested in nonclinical skill building in addition to the clinical training.

METHODS

A 9-question survey was anonymously administered to fellows registered for the national conference using SurveyMonkey before the conference date. Six questions were quantitative, 2 were qualitative and open ended, and 1 required ranking of elements.

RESULTS

Seventy-seven (47%) of the conference attendees responded to the survey, and approximately 80 (48%) attended the workshop session.Of the 77 fellows responding when asked about desired percentage of time per week devoted to the 4 categories of clinical, research, education, and administrative work within a 40-hour week, 76 (99%) chose the clinical category with an average of 58% of total hours devoted, 71 (92%) chose education with an average of 14% of total hours, 69 (90%) chose administration with an average of 8% of total hours, and 62 (81%) chose research with an average of 11% of total hours.Seventy attendees provided 1 sentence with the description of their ideal job. Thematic analysis of these responses revealed the following 5 main themes: academic potential, clinical environment, remuneration, job location, and work-life balance.

CONCLUSIONS

Diversification in pediatric emergency medicine training is becoming a growing area of importance. Our study highlights a discrepancy in the expected time dedicated for nonclinical activities from those seen in previous workforce studies.

Metabolic dysfunction and immunometabolism in COVID-19 pathophysiology and therapeutics

The COVID-19 pandemic has emerged as a public health crisis and has placed a significant burden on healthcare systems. Patients with underlying metabolic dysfunction, such as type 2 diabetes mellitus and obesity, are at a higher risk for COVID-19 complications, including multi-organ dysfunction, secondary to a deranged immune response, and cellular energy deprivation. These patients are at a baseline state of chronic inflammation associated with increased susceptibility to the severe immune manifestations of COVID-19, which are triggered by the cellular hypoxic environment and cytokine storm. The altered metabolic profile and energy generation of immune cells affect their activation, exacerbating the imbalanced immune response. Key immunometabolic interactions may inform the development of an efficacious treatment for COVID-19. Novel therapeutic approaches with repurposed drugs, such as PPAR agonists, or newly developed molecules such as the antagomirs, which block microRNA function, have shown promising results. Those treatments, alone or in combination, target both immune and metabolic pathways and are ideal for septic COVID-19 patients with an underlying metabolic condition.

Epidermal Growth Factor Receptor Inhibition Reverses Cellular and Transcriptomic Alterations Induced by Hypoxia in the Neonatal Piglet Brain

Acute hypoxia (HX) causes extensive cellular damage in the developing human cerebral cortex. We found increased expression of activated-EGFR in affected cortical areas of neonates with HX and investigated its functional role in the piglet, which displays a highly evolved, gyrencephalic brain, with a human-like maturation pattern. In the piglet, HX-induced activation of EGFR and Ca²⁺/calmodulin kinase IV (CaMKIV) caused cell death and pathological alterations in neurons and glia. EGFR blockade inhibited CaMKIV activation, attenuated neuronal loss, increased oligodendrocyte proliferation, and reversed HX-induced astrogliosis. We performed for the first time high-throughput transcriptomic analysis of the piglet cortex to define molecular responses to HX and to uncover genes specifically involved in EGFR signaling in piglet and human brain injury. Our results indicate that specific molecular responses modulated by EGFR may be targeted as a therapeutic strategy for HX injury in the neonatal brain.

Exosomes in Nephropathies: A Rich Source of Novel Biomarkers

The biomarkers commonly utilized in diagnostic evaluations of kidney disease suffer from low sensitivity, especially in the early stages of renal damage. On the other hand, obtaining a renal biopsy to augment clinical decision making can lead to potentially serious complications. In order to overcome the shortcomings of currently available diagnostic tools, recent studies suggest that exosomes, cell-secreted extracellular vesicles containing a large array of active molecules to facilitate cell-to-cell communication, may represent a rich source of novel disease biomarkers. Because of their endocytic origin, exosomes carry markers typical for their parent cells, which could permit the localization of biochemical cellular alterations in specific kidney compartments. Different types of exosomes can be isolated from noninvasively obtained biofluids; however, in the context of kidney disease, evidence has emerged on the role of urinary exosomes in the diagnostic and predictive modeling of renal pathology. The current review summarizes the potential application of exosomes in the detection of acute and chronic inflammatory, metabolic, degenerative, and genetic renal diseases.

Towards Reliable ARDS Clinical Decision Support: ARDS Patient Analytics with Free-text and Structured EMR Data

In this work, we utilize a combination of free-text and structured data to build Acute Respiratory Distress Syndrome(ARDS) prediction models and ARDS phenotype clusters. We derived 'Patient Context Vectors' representing patientspecific contextual ARDS risk factors, utilizing deep-learning techniques on ICD and free-text clinical notes data. The Patient Context Vectors were combined with structured data from the first 24 hours of admission, such as vital signs and lab results, to build an ARDS patient prediction model and an ARDS patient mortality prediction model achieving AUC of 90.16 and 81.01 respectively. The ability of Patient Context Vectors to summarize patients' medical history and current conditions is also demonstrated by the automatic clustering of ARDS patients into clinically meaningful phenotypes based on comorbidities, patient history, and presenting conditions. To our knowledge, this is the first study to successfully combine free-text and structured data, without any manual patient risk factor curation, to build real-time ARDS prediction models.

Sepsis Immunometabolism: From Defining Sepsis to Understanding How Energy Production Affects Immune Response

OBJECTIVES

This review will examine current definitions and trends in sepsis management as well pathophysiologic mechanisms in animal and ex vivo studies that correlate decreased energy production with deranged inflammatory response during the septic process.

DATA SOURCES

The latest articles in the literature that focus on the role of immunometabolism and associated mechanisms in sepsis were selected.

STUDY SELECTION

The most relevant, original articles were included in the review.

DATA EXTRACTION

All pertinent data for sepsis definitions as well as changes in immunometabolic pathways during the septic process was reviewed and assessed for inclusion in this article.

DATA SYNTHESIS

Sepsis is a major cause of multiple organ dysfunction. It is the principal cause of death resulting from infection and one of the most expensive conditions treated in the United States. Despite current efforts to accurately define sepsis, novel treatments and highly trained providers, mortality rates for sepsis remain high, prompting a need for further investigation of underlying immunometabolic mechanisms to identify potential treatment targets. The definition of sepsis has shifted and changed in the past few decades due to poorly defined criteria, as well as unclear guidelines for providers with regards to management of severe sepsis and septic shock. The early identification of patients with a systemic inflammatory response that will progress to septic shock is critical since recent traditional therapeutic approaches, such as early goal-directed therapy, IV immunoglobulin, and anti-tumor necrosis factor-α antibodies have failed.

CONCLUSIONS

There are no effective anti-sepsis drug therapies due to complex inflammatory and metabolic interactions. Further studies regarding the interface between innate immunity and metabolism should be investigated to effectively address septic patient mortality rates.

Pediatric urgent care education: a survey-based needs assessment

Background

There is an increasing number of pediatric urgent care centers that are largely staffed by pediatric residency graduates. It is unclear if pediatric residency adequately prepares a physician to fully and successfully provide care in an urgent care setting. The goal of this study is to conduct an assessment of urgent care directors’ perceptions of recent pediatric residency graduates’ preparedness to successfully provide pediatric urgent care after graduation.

Methods

This is a 2018 cross-sectional survey of all pediatric emergency medicine division chiefs in the United States and all pediatric urgent care directors who are members of the Society for Pediatric Urgent Care. An electronic survey was distributed consisting of eight multiple choice questions regarding perceived preparedness and knowledge gaps of recent pediatric residency graduates for independent practice in urgent care. Descriptive statistics were used to analyze results and qualitative data were analyzed via an inductive thematic approach.

Results

Forty-two percent (65/154) of surveys were completed. No respondents believed that a recent pediatric residency graduate would be adequately prepared to independently practice in a pediatric urgent care and 81% of respondents recommended some additional training. Most respondents described this training as important (46%) or very important (35%). Most respondents recommended between 6 months and 1 year as the appropriate amount of time to achieve competency.

Conclusions

Despite the growing number pediatric residency graduates staffing pediatric urgent care centers, the majority of surveyed pediatric emergency medicine division chiefs and pediatric urgent care directors do not think that pediatric residency adequately prepares graduates to successfully provide urgent care to pediatric patients. We recommend further exploration of gaps in knowledge of recent pediatric residency graduates as a next step towards developing systems for further training for pediatric residency graduates to gain competency in urgent care management.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4241-8) contains supplementary material, which is available to authorized users.

Association between hemoglobin concentrations at discharge from the neonatal intensive care unit with markers of neurodevelopmental outcomes in premature neonates

BACKGROUND

Premature neonates are often subjected to multiple transfusions with red blood cells during their hospitalization in the neonatal intensive care unit (NICU). The hemoglobin threshold for transfusion prior to discharge from the NICU varies significantly among different centers. The aim of the present study is to investigate the association between hemoglobin concentration at discharge with neurodevelopmental outcomes in premature neonates.

METHODS

Retrospective observation study with regression analysis was performed with follow up assessment in the neuro-developmental outpatient clinic at 30 months of adjusted age.

RESULTS

Data from 357 neonates born at less than 37 weeks' gestation were analyzed. Sensory and motor neurodevelopment at 30 months of adjusted age, were not associated with the hemoglobin concentration at discharge (p=0.5891 and p=0.4575, respectively). There was no association between the hemoglobin concentration at discharge with fine or gross motor development (p=0.1582 and p=0.3805, respectively). Hemoglobin concentration at discharge was not associated with poor neurodevelopmental outcomes up until 30 months of adjusted age.

CONCLUSIONS

The data of the present study indicate that the hemoglobin concentration of premature neonates at the time of discharge is not associated with poorer markers of neurodevelopmental outcomes at 30 months of adjusted age. Comorbidities such as BPD and IVH that are present to premature neonates were identified as potential risk factors for certain aspects of the neurodevelopment.

Hospital-Acquired Hyponatremia in Children Following Hypotonic versus Isotonic Intravenous Fluids Infusion

Hypotonic solutions have been used in pediatrics for maintenance of intravenous (IV) hydration. However, recent randomized control trials and cohort studies have raised significant concerns for association with hospital-acquired hyponatremia (HAH). The study aimed to assess whether the use of hypotonic parenteral solutions (PS) compared with isotonic PS is associated with increased HAH risk in children with common pediatric conditions. Retrospective chart review of 472 patients aged 2 months to 18 years who received either isotonic or hypotonic PS as maintenance fluids. Administration of hypotonic PS was associated with a four-fold increase in risk of developing HAH in the univariate analysis, (unadjusted odds ratio (OR) = 3.99; 95% confidence interval (CI): 1.36–11.69, p = 0.01). Hypotonic PS were associated with HAH (p = 0.04) when adjusted for the level of admission serum CO₂. There was a mean decrease of serum sodium of 0.53 mEq/L in the hypotonic group compared to the mean increase of 4.88 mEq/L in the isotonic group. These data suggest that hypotonic PS are associated with HAH in children admitted for common pediatric conditions. Isotonic PS should be considered as a safer choice for maintenance fluid hydration.

The Neurodevelopmental Perspective of Surgical Necrotizing Enterocolitis: The Role of the Gut-Brain Axis

This state-of-the-art review article aims to highlight the most recent evidence about the therapeutic options of surgical necrotizing enterocolitis, focusing on the molecular basis of the gut-brain axis in relevance to the neurodevelopmental outcomes of primary peritoneal drainage and primary laparotomy. Current evidence favors primary laparotomy over primary peritoneal drainage as regards neurodevelopment in the surgical treatment of necrotizing enterocolitis. The added exposure to inhalational anesthesia in infants undergoing primary laparotomy is an additional confounding variable but requires further study. The concept of the gut-brain axis suggests that bowel injury initiates systemic inflammation potentially affecting the developing central nervous system. Signals about microbes in the gut are transduced to the brain and the limbic system via the enteric nervous system, autonomic nervous system, and hypothalamic-pituitary axis. Preterm infants with necrotizing enterocolitis have significant differences in the diversity of the microbiome compared with preterm controls. The gut bacterial flora changes remarkably prior to the onset of necrotizing enterocolitis with a predominance of pathogenic organisms. The type of initial surgical approach correlates with the length of functional gut and microbiome equilibrium influencing brain development and function through the gut-brain axis. Existing data favor patients who were treated with primary laparotomy over those who underwent primary peritoneal drainage in terms of neurodevelopmental outcomes. We propose that this is due to the sustained injurious effect of the remaining diseased and necrotic bowel on the developing newborn brain, in patients treated with primary peritoneal drainage, through the gut-brain axis and probably not due to the procedure itself.

Effect of Concurrent Src Kinase Inhibition with Short-Duration Hypothermia on Ca2+/Calmodulin Kinase IV Activity and Neuropathology after Hypoxia-Ischemia in the Newborn Swine Brain

BACKGROUND

Hypoxia-ischemia (HI) results in increased activation of Ca2+/calmodulin kinase IV (CaM kinase IV) mediated by Src kinase. Therapeutic hypothermia ameliorates neuronal injury in the newborn.

HYPOTHESIS

Inhibition of Src kinase concurrently with hypothermia further attenuates the hypoxia-induced increased activation of CaM kinase IV compared with hypothermia alone.

DESIGN/METHODS

Ventilated piglets were exposed to HI, received saline or a selective Src kinase inhibitor (PP2), and were cooled to 33°C. Neuropathology, adenosine triphosphate (ATP) and phosphocreatine (PCr) concentrations, and CaM kinase IV activity were determined.

RESULTS

The neuropathology mean score (mean ± SD) was 0.4 ± 0.43 in normoxia-normothermia (p < 0.05 vs. hypoxia-normothermia), 3.5 ± 0.89 in hypoxia-normothermia (p < 0.05 vs. normoxia-normothermia), 0.7 ± 0.73 in hypoxia-hypothermia (p < 0.05 vs. normoxia-normothermia), and 0.5 ± 0.70 in normoxia-hypothermia (p < 0.05 vs. hypoxia-normothermia). The CaM kinase IV activity in cerebral tissue (pmol Pi/mg protein/min; mean ± SD) was 2,002 ± 729 in normoxia-normothermia, 1,704 ± 18 in normoxia-hypothermia, 6,017 ± 2,510 in hypoxia-normothermia, 4,104 ± 542 in hypoxia-hypothermia (p < 0.05 vs. normoxia-hypothermia), and 2,165 ± 415 in hypoxia-hypothermia with PP2 (p < 0.05 vs. hypoxia-hypothermia). The hypoxic groups with and without hypothermia or Src kinase inhibitor were comparable in the levels of ATP and PCr, indicating that they were similar in their degree of energy failure prior to treatments. Hypothermia or Src kinase inhibitor (PP2) did not restore the ATP and PCr levels.

CONCLUSIONS

Hypothermia and Src kinase inhibition attenuated apoptotic cell death and improved neuropathology after hypoxia. The combination of short-duration hypothermia with Src kinase inhibition following hypoxia further attenuates the increased activation of CaM kinase IV compared to hypothermia alone in the newborn swine brain.

Effect of Src Kinase inhibition on Cytochrome c, Smac/DIABLO and Apoptosis Inducing Factor (AIF) Following Cerebral Hypoxia-Ischemia in Newborn Piglets

We have previously shown that cerebral Hypoxia-ischemia (HI) results in activation of Src kinase in the newborn piglet brain. We investigated the regulatory mechanism by which the pre-apoptotic proteins translocate from mitochondria to the cytosol during HI through the Src kinase. Newborn piglets were divided into 3 groups (n = 5/group): normoxic (Nx), HI and HI pre-treated with Src kinase inhibitor PP2 (PP2 + HI). Brain tissue HI was verified by neuropathological analysis and by Adenosine Triphosphate (ATP) and Phosphocreatine (PCr) levels. We used western blots, immunohistochemistry, H&E and biochemical enzyme assays to determine the role of Src kinase on mitochondrial membrane apoptotic protein trafficking. HI resulted in decreased ATP and PCr levels, neuropathological changes and increased levels of cytochrome c, Smac/DIABLO and AIF in the cytosol while their levels were decreased in mitochondria compared to Nx. PP2 decreased the cytosolic levels of pre-apoptotic proteins, attenuated the neuropathological changes and apoptosis and decreased the HI-induced increased activity of caspase-3. Our data suggest that Src kinase may represent a potential target that could interrupt the enzymatic activation of the caspase dependent cell death pathway.

Effect of Intranasally Delivered rh-VEGF165 on Angiogenesis Following Cerebral Hypoxia-Ischemia in the Cerebral Cortex of Newborn Piglets

Background: Vascular endothelial growth factor (VEGF) stimulates vascular genesis and angiogenesis. Cerebral Hypoxia-Ischemia (HI) leads to the reduction of vasculature in the cerebral cortex of newborn piglets. Objective: The present study tests the hypothesis that post-hypoxia intranasal administration of recombinant human VEGF₁₆₅ (rh-VEGF165) for 3 days increases the vascular density in the cerebral cortex of newborn piglets without promoting neovascularization. Design/Methods: Ventilated newborn piglets were divided into three groups (n = 5/group): normoxic (Nx), hypoxic-ischemic (HI), and HI treated with intranasal rh-VEGF165rh-VEGF165 (HI-VEGF). HI piglets were exposed to HI (0.05 FiO2) for 30 min. Recombinant h-VEGF165 (100 ng/kg) was administered 15 min after HI and then once daily for 3 days. The animals were perfused transcardially and coronal brains sections were processed for Isolectin, Hoechst, and ki-67 cell proliferation marker staining. To assess the vascular density, 30–35 fields per animal section were manually counted using image J software. Results: The vascular density (vessels/mm²) was 42.0 ± 8.0 in the Nx group, 26.4 ± 4.8 (p < 0.05 vs. Nx) in the HI group, and 46.0 ± 11.9 (p < 0.05 vs. HI) in the HI-VEGF group. When stained for newly formed vessels, via Ki-67 staining, the vascular density was 5.4 ± 3.6 in the Nx group (p < 0.05 vs. HI), 10.2 ± 2.1 in the HI group, and 10.9 ± 2.9 in the HI-VEGF group (p = 0.72 vs. HI). HI resulted in a decrease in vascular density. Intranasal rh-VEGF165rh-VEGF165 resulted in the attenuation of the HI-induced decrease in vascular density. However, rh-VEGF165 did not result in the formation of new vascularity, as evident by ki-67 staining. Conclusions: Intranasal rh-VEGF165 may prevent the HI-induced decrease in the vascular density of the brain and could serve as a promising adjuvant therapy for hypoxic-ischemic encephalopathy (HIE).

FAK-Src-paxillin system expression and disease outcome in human neuroblastoma

BACKGROUND

Neuroblastoma (NB) often presents with metastatic disease and poor survival. The need for new prognostic markers remains invaluable. The FAK-Src-Paxillin protein system is associated with aggressive phenotype in adult malignancies but is largely unexplored in pediatric NB.

OBJECTIVE

To assess FAK-Src-Paxillin protein expression in human NB cell lines and clinical cytology material and to delineate its association with survival.

DESIGN/METHODS

Western blot and immunohistochemistry were applied for FAK-Src-Paxillin expression in NB cell lines and 23 human cytology specimens, respectively. Protein expression in human clinical samples was correlated with clinicopathological parameters, MYCN amplification and survival.

RESULTS

FAK, Src and Paxillin proteins are expressed in human NB cells lines, and can be detected in clinical cytology specimens from NB patients, (59%, 32% and 33% respectively). Simultaneous FAK-Src-Paxillin expression was noted in 30% of NB patients. Children with concomitant positivity FAK, Src, and Paxillin tumors, as well as MYCN amplification, had increased mortality compared to those without.

CONCLUSIONS

FAK-Src-Paxillin system is a marker of unfavorable prognosis for human NB patients but also a promising therapeutic target.

Obesity as a Risk Factor for Urinary Tract Infection in Children

Childhood obesity is a nationwide epidemic with an estimated 16% to 18% of children and adolescents qualifying as obese and another 21% to 24% considered overweight. Obesity has been linked to an increased risk of developing serious infections. Healthcare Cost and Utilization Project-Kids' Inpatient Database 2009 was queried to analyze national trends in patient encounters, specifically those listing patients as comorbid obese and then identified those with urinary tract infection (UTI) as primary or secondary diagnosis. Propensity matching was used to calculate risk for UTI in the inpatient obese pediatric population. A total of 86 638 pediatric hospital admissions were enrolled in the study of which 41 819 included the diagnosis of obesity, and a UTI was diagnosed in 2445 of the cases. In a propensity-matched sample, matched for age, sex, race, and diabetes mellitus, the risk of UTI was increased by 45% in obese females. Obese males did not have a significantly increased risk for UTI.

The Association Between Bathing Habits and Severity of Atopic Dermatitis in Children

BACKGROUND

Atopic dermatitis is an inflammatory skin disease that frequently affects children. The current recommendations on management using lifestyle modification are highly variable, leading to confusion and uncertainty among patients.

AIM

To determine current bathing behaviors and the subsequent impact on disease severity.

METHODS

This was an observational cross-sectional study conducted at an urban pediatric emergency department. Parents were asked to fill out a questionnaire concerning the patient's bathing habits. The results were correlated with the atopic dermatitis severity determined by the SCORAD (SCORing Atopic Dermatitis) tool.

RESULTS

No difference between variables was found to be significant for bathing frequency, time spent bathing, or use of moisturizers. Multivariate analysis showed that atopic dermatitis severity increased with age greater than 2 years (P = .0004) and with greater bathing duration (P = .001).

CONCLUSION

Atopic dermatitis severity may be associated with a longer duration of bathing. The frequency of bathing does not appear to affect atopic dermatitis severity.

Foreign body injuries in children: Are the younger siblings doomed?

Background and objectives

Foreign body injury (FBI) is a considerable public health issue for children. Although the relationships of FBI with age, gender, and objects of injury have been studied, the extent to which other demographic factors influence FBI is unclear. We hypothesized that the risk for FBI increases with the number of children in the household.

Design and settings

This was a retrospective analysis of 223 patients aged 2-10 years who presented to the emergency department of an inner-city pediatric hospital and who were found to have FBI.

Patients and methods

The guardians were contacted via phone to examine the associations of FBI with income, parental educational level, number of children in the household, and birth order while controlling with a matched population of 250 patients. Statistical analyses using frequencies and univariate and multivariate analyses were performed.

Results

For each increase in the number of children, the risk of FBI increased 1.44-fold (OR = 1.442). With each increase in the number of caregivers, the risk of a FBI decreased 33% (OR = 0.673). With each increase in income category, the risk of a FBI decreased 59% (OR = 0.413).

Conclusion

The results suggest that an increase in the number of children in a household is associated with a greater risk of FBI.

Atopic dermatitis is more severe in children over the age of two who have an increased body mass index

AIM

Childhood obesity increases the risk of developing atopic dermatitis, but no objective measuring tool has been used to determine whether it also affects the severity. Our aim was to determine whether an association existed between increased body mass index (BMI) or weight for length and severity of atopic dermatitis, as measured by the SCORing Atopic Dermatitis (SCORAD) index.

METHODS

Children with atopic dermatitis who presented to the emergency department at an urban children's hospital (n = 104) were assessed using the SCORAD index. We assessed the relationship between BMI percentile or weight for length percentile, based on age, and atopic dermatitis severity, using single-variable multinomial logistic regression with odds ratios.

RESULTS

A significant association was found between BMI >24 and atopic dermatitis severity for children older than 2 years. When analysed separately, a significant association between BMI percentile and SCORAD severity was found in boys but not in girls.

CONCLUSION

These data suggest that the severity of atopic dermatitis is associated with increased BMI percentile in children older than 2 years, although this association was not apparent in younger ages using weight for length. Our results indicate the need for new avenues in the prevention and treatment of these entities.

Strongyloidiasis in a healthy 8-year-old girl in north-eastern USA

A previously healthy, white 8-year-old girl presented with a 1-week history of abdominal pain and vomiting after a trip to a lake in Pennsylvania, north-eastern USA. There was marked dehydration. A raised blood eosinophilic count prompted microscopy for ova and parasites which demonstrated a heavy load of larvae of Strongyloides stercoralis. Charcot-Leyden crystals were also detected. The child received oral ivermectin and made a complete recovery.

Multi-targeted molecular therapeutic approach in aggressive neuroblastoma: the effect of Focal Adhesion Kinase-Src-Paxillin system

INTRODUCTION

Nonreceptor tyrosine kinases play key roles in the integrin system. Located at the focal adhesions, they consist of large protein complexes through which the cytoskeleton connects to the extracellular matrix. The focal adhesion kinase (FAK)-Src-paxillin complex, a major mediator of the integrin pathway, contributes to cell migration and motility. Its overexpression is increased in children with advanced neuroblastoma (NB), one of the most common malignancies of childhood, with poor survival.

AREAS COVERED

We review the most recent data on FAK-Src-paxillin and their implications in NB, the molecular structure and the regulatory mechanisms of each molecule and their interactions and up-to-date information on their use as the newest biomarkers and their potential use as therapeutic targets in NB.

EXPERT OPINION

Based on the current literature, we hypothesize that combined and concurrent inhibition of the FAK-Src-Paxillin system may result in significant tumor suppression and prevention or delay of metastasis.

Frequency of bathing in the management of atopic dermatitis: to bathe or not to bathe?

BACKGROUND

Atopic dermatitis prevalence has increased in the developed world in recent decades, and effective management is vital to improve patients' quality of life.

METHODS

A prospective, randomized, case-control study with a purposive sample of 28 children, aged 6 months to 10 years, diagnosed with atopic dermatitis. Participants received bathing instructions to be followed either daily or twice a week, with a follow-up duration of 2 weeks. Improvement of symptoms over time was measured using the SCORAD (SCORing Atopic Dermatitis) tool.

RESULTS

Overall symptoms decreased significantly at follow-up compared with baseline (difference = 5.0938, confidence interval = 0.2116 to 9.9759) but the differences in scores before and after interventions were not statistically significant between the groups (difference = -1.0937, confidence interval = -5.9759 to 3.7884).

CONCLUSIONS

The frequency of bathing did not seem to play an important role in the management of atopic dermatitis. Clinicians should focus on the need for adequate skin hydration.

The role of matrix metalloproteinases in the pathophysiology and progression of human nervous system malignancies: a chance for the development of targeted therapeutic approaches?

BACKGROUND

Matrix metalloproteinases (MMPs) are a group of zinc- dependent endopeptidases involved in the degradation of extracellular matrix components. MMPs have been implicated in a wide variety of physiological processes, such as angiogenesis, wound healing and tissue remodeling. However, recent studies have revealed a significant role for MMPs in tumorigenesis pathophysiology and prediction of patients' clinical outcome. Alterations in the regulation of MMP expression are thought to play an important role in the development and progression of central nervous system (CNS) malignancies.

OBJECTIVE/METHODS

This study provides an up-to-date review of the literature on the pathophysiologic involvement of MMPs in the development and progression of human CNS malignancies, as well as the potential use of natural and/or synthetic MMP-inhibitors (MMPIs) as a targeted therapeutic approach to this group of neoplasms.

RESULTS/CONCLUSIONS

The currently available data provide clear evidence for the involvement of MMPs in the pathophysiology of astrocytomas, glioblastomas, meningiomas, medulloblastomas/primitive neuroectodermal tumors and pituitary tumors. The use of MMPIs in the treatment of CNS malignancies has, until now, reached controversial (but mainly disappointing) results that can nevertheless provide the basis for further investigation. The co-administration of other agents, the use of surgery and/or radiation, and elimination of the MMPIs-induced adverse effects, as well as the use of antisense technology, might be the tools by which the natural and synthetic MMPIs could find their place in everyday clinical practice for the management of CNS malignancies.