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Objective To explore the long-term prognosis of children with protracted bacterial bronchitis (PBB), and to provide reference for the clinical diagnosis and treatment of PBB. Methods The general data, clinical manifestations, auxiliary examinations and treatment plans of 123 children with clinical diagnosis of PBB admitted to the hospital from April 2018 to May 2021 were collected. The patients were followed up for 25-62 months after discharge (median follow-up time was 38 months) to understand and analyze the prognosis of children with PBB. According to whether there was a recurrence of wet cough (wet cough) after discharge, they were divided into the symptomatic group (46 cases) and the cured group (77 cases). The patients were divided into the recurrent group (19 cases) and the non-recurrent group (104 cases) according to whether there was recurrent PBB (PBB attack＞3 times/year). Results During the follow-up period, 37. 4% (46/123) of the children developed wet cough again, 15. 4% (19/123) were diagnosed as recurrent PBB, and 1. 6% (2/123) were diagnosed as bronchiectasis. Compared with the cured group, the proportion of neutrophils in bronchoalveolar lavage fluid, the proportion of spontaneous delivery, the proportion of asthma and upper airway cough syndrome in the symptomatic group were significantly increased, and the differences were statistically significant (P＜0. 05). The proportion of lymphocytes in bronchoalveolar lavage fluid in the recurrent group was significantly lower than that in the non-recurrent group, and the proportion of asthma was significantly higher than that in the non-recurrent group, the differences were statistically significant (P＜0. 05). Conclusion Nearly one-third of children with PBB will have wet cough again after discharge, and the frequency and proportion of wet cough will gradually decrease with time each year. A small number of children will have recurrent PBB, and a very small number of children will progress to bronchiectasis. [ABSTRACT FROM AUTHOR]

Objective To investigate the predictive value of lung ultrasound B-line score (LUBS) combined with diaphragm ultrasound in mechanical ventilation withdrawal outcome of severe respiratory failure children. Methods Totally 110 children with severe respiratory failure who received mechanical ventilation were divided into the successful group (83 cases) and failed group (27 cases) . Both groups underwent bedside lung ultrasound examination within 30 minutes of the spontaneous breathing test, and LUBS was calculated. Diaphragmatic ultrasound was performed to measure diaphragmatic movement, and diaphragmatic rapid shallow breathing index (D-RSBI) and the change rate of diaphragmatic thickness were calculated. We analyze the predictive value of LUBS and diaphragm ultrasound in the outcome of mechanical ventilation withdrawal in children with severe respiratory failure. Results The respiratory rate, APACHEⅡ score, LUBS and D-RSBI in the successful group were lower than those in the failed group, and the diaphragm mobility and diaphragm thickness change rate were higher than those in the failed group (all P<0. 05) . Multivariate Logistic regression analysis showed that LUBS, APACHEⅡ score and D-RSBI were risk factors for withdrawal failure in children with severe respiratory failure, while diaphragm mobility and diaphragm thickness change rate were protective factors (all P<0. 05) . Pearson correlation analysis showed that LUBS was negatively correlated with the degree of diaphragm movement and the change rate of diaphragm thickness in children with severe response failure (r=–0. 375, –0. 411, respectively； both P<0. 05), but was positively correlated with D-RSBI (r=0. 526, P<0. 05) . The receiver operating characteristic curve analysis showed that the area under the curve of LUBS, diaphragm mobility, diaphragm thickness change rate and D-RSBI in predicting withdrawal failure of children with severe respiratory failure was 0. 773, 0. 805, 0. 848 and 0. 808, respectively, and the area under the curve of all indexes combined in predicting withdrawal failure of children with severe respiratory failure was 0. 943. Conclusion LUBS combined with diaphragmatic ultrasound has certain predictive value in mechanical ventilation withdrawal outcome of patients with severe respiratory failure, and the combination of the two can further improve its predictive value [ABSTRACT FROM AUTHOR]

Organ donation from deceased children is an important part of deceased organ donation, which significantly differs from adult organ donation. To standardize functional maintenance, evaluation and application of donor kidneys from deceased children, Branch of Organ Transplantation of Chinese Medical Association initiated the formulation of "Guidelines for Functional Maintenance, Evaluation and Application of Donor Kidneys from Deceased Children in China" based on the levels of evidence and strengthens of recommendation of Oxford Center for Evidence-based Medicine of 2009. Regarding 29 clinical problems related to functional maintenance, evaluation and application of donor kidneys from deceased children, 33 recommendations were given in this guideline, aiming to standardize the operation process, provide guidance for clinical work and comprehensively enhance the quality of organ donation and transplantation. [ABSTRACT FROM AUTHOR]

Objective To analyze the risk factors of refractory mycoplasma pneumoniae pneumonia (RMPP) in children, and to explore their predictive value. Methods Totally 244 children with mycoplasma pneumoniae pneumonia (MPP) were selected. The children were divided into the RMPP group (n=65) and the general mycoplasma pneumoniae pneumonia (GMPP) group (n=197) based on whether they had RMPP. We compared the demographic information (gender, age), clinical manifestations, and signs (heat peak, heat duration, hypoxemia, decreased auscultatory respiratory sounds in the lungs, concomitant extrapulmonary complications, and plastic bronchitis), primary laboratory indicators within 24 hours of admission ［serum circ_0054633, white blood cell count (WBC), neutrophil count (NE), neutrophil/ lymphocyte ratio (NLR), platelet count (PLT), C-reactive protein (CRP), procalcitonin (PCT), interleukin 6(IL-6), lactate dehydrogenase (LDH), ferritin (FER), erythrocyte sedimentation rate (ESR), alanine aminotransferase (ALT), creatine kinase-MB (CK-MB), and D-dimer (D-D)］, imaging features (atelectasis, pleural effusion). The statistically different data were included in the multivariate Logistic regression model to analyze the influencing factors of RMPP. The predictive value was analyzed by receiver operating characteristic (ROC) curve. Results There were no statistically significant differences in gender, age, heat peak, WBC, NE, PLT, CRP, PCT, ESR, ALT, or CK-MB levels between the two groups (all P>0. 05). The duration of fever in the RMPP group was longer than that in the GMPP group. Hypoxemia, decreased respiratory sounds, extrapulmonary complications, plastic bronchitis, atelectasis, and the proportion of pleural effusion were all higher in the RMPP group than those in the GMPP group, and the serum circ-0054633, NLR, IL-6, LDH, FER, and D-D levels were all higher than those in the GMPP group (all P<0. 05). The results of multivariate Logistic regression analysis showed that fever duration (OR=1. 499, 95% CI：1. 243-1. 808), hypoxemia (OR=10. 638, 95% CI：2. 747-41. 203), concomitant extrapulmonary complications (OR=2. 948, 95% CI：1. 174-7. 404), serum circ： 054633(OR=6. 283, 95% CI：2. 729-14. 465), serum IL-6(OR=1. 018, 95% CI：1. 004-1. 032), and atelectasis (OR= 3. 157, 95% CI ：1. 246-8. 000 ) were all independent risk factors for children with MPP progressing to RMPP ( all P<0. 05). The ROC curve analysis results showed that the critical values of fever duration, serum circ054633, and serum IL-6 in predicting RMPP were 9. 50 d, 3. 12, and 25. 98 pg/mL, respectively. Their sensitivities in predicting RMPP were 76. 6%, 80. 9%, and 66. 0%, with specificities of 73. 0%, 69. 4%, and 63. 8%, and the area under the curve of 0. 768, 0. 802, and 0. 678, respectively (all P<0. 05). Conclusion The fever duration > 9. 50 days, hypoxemia, concurrent extrapulmonary complications, serum circ-0054633 level > 3. 12, serum IL-6 > 25. 98 pg/mL, and atelectasis are risk factors for RMPP in children. Among them, heat duration, serum circ-0054633, and IL-6 have good predictive value. [ABSTRACT FROM AUTHOR]

Objective To investigate the clinical characteristics and risk factors of the occurrence of hypoxic hepatitis (HH) in children with shock. Methods Clinical data (general situation, clinical situation and prognosis) of 234 children with different types of shock admitted to the pediatrics department of Hainan Women and Children's Medical Center from January 2016 to December 2023 were collected. Serum biochemical indexes on day 1 (d1), day 2 (d2), day 3 (d3), day 5 (d5), day 7 (d7) of children with shock were collected, including serum alanine aminotransferase (ALT), glutamate aminotransferase (AST), lactate dehydrogenase (LDH), alkaline phosphatase (ALP), albumin (ALB), total bilirubin (TBIL), urea nitrogen (BUN), C reactive protein (CRP), international standardized time (INR) and lactate. And the clinical characteristics and risk factors of the occurrence of HH in children with shock were analyzed. Results A total of 234 cases (150 cases of males)of different types of shock in children were enrolled, ages ranged from 1 month to 16 years old. According to whether developed HH, the children with shock were divided into HH group (32 cases) and non-HH group (202 cases). The total incidence of HH was 13.7% (32/234). Septic shock was the main disease of the occurrence of HH in children with shock, accounting for 65.63% (21/32). According to the prognosis, children with shock combined HH were divided into survival group (17 cases) and death group (15 cases). The case fatality rate of children with shock combined HH was 46.9%. The ALT and AST values in children with shock combined HH were more than 20 times of the upper limits of normal ranges. The peak values of enzymatic indexes in the survival group appeared at the onset time d 1 to d 2, they were close to the normal ranges at the onset time d7, while the enzymatic indexes in the death group were higher than the normal ranges during the whole disease stage. Compared with the survival group, the peak values of ALT, AST, ALP, TBIL, CRP, BUN, and INR in the death group were obviously higher (P < 0.05, both). The lowest value of ALB in the death group was lower than that in the survival group (P < 0.05). The results of multivariate Logistic regression analysis showed that pediatric critical illness score (PCIS), lactate, multiple organ dysfunction syndrome (MODS), decompensated shock and cardiogenic shock were the risk factors for the occurrence of HH in children with shock(P < 0.05 or 0.01), and left ventricular ejection fraction(LVEF) and mean arterial pressure (MAP) were the risk factors of the death of HH in children with shock (P < 0.01). Conclusions Children with shock who have the risk factors as decreased PCIS, increased lactate level, MODS, decompensated shock and cardiogenic shock are apt to suffer from HH. Poor prognosis in the children with shock combined HH is associated with worse condition and lower LVEF. There is a high fatality rate of shock combined HH in children, so that liver function indicators should be closely monitored to early detect HH, and reasonable treatment should be given. [ABSTRACT FROM AUTHOR]

Objective To investigate the association between sleep duration in children and post -traumatic stress disorder (PTSD) and its three core symptoms: intrusion, avoidance, and hyperarousal. Methods Data from the Chengdu ChildrenJ s Positive Growth Cohort (CPCD) collected in June 2021 and June 2022 during the period of the COVID-19 epidemic were used. The Children s Revised Impact of Events Scale-13 (CRIES-13) was used to measure PTSD symptoms, and sleep status were collected. Spearman analysis was used to explore the between PTSD and its three core symptoms and sleep duration and sleep quality. The cross-lagged panel model was used to explore the between sleep duration and PTSD symptoms. Results A total of 5 035 children aged 7 to 15 years were included. The detection rates of PTSD in the two rounds were 14.5% and 9.9%, respectively. Sleep duration was positively associated with PTSD and PTSD avoidance symptoms in both rounds (P< 0.05). PTSD avoidance symptoms and sleep duration in the previous survey predicted PTSD avoidance symptoms and sleep duration in the following survey (6=0.06, P<0.05). Conclusion There is a bidirectional predictive relationship between the sleep duration of children and adolescents and avoidance symptoms in PTSD, suggesting that prolonged sleep is one of the mechanisms used by children and adolescents with PTSD symptoms to avoid traumatic memory. [ABSTRACT FROM AUTHOR]

Objective: To explore significance of eosinophil and eosinophil/lymphocyte ratio （ELR） in predicting allergic asthma in children in different seasons. Methods: Retrospective analysis of children with asthma who visited pediatric respiratory department outpatient clinic and ward of Shandong Provincial Hospital Affiliated to Shandong First Medical University from January 2021 to December 2021, whose allergen specific IgE （sIgE） and peripheral blood cell analysis were complete. sIgE≥0.35 kUA/L were included in allergic asthma group, sIgE<0.35 kUA/L and total allergen IgE<60 kUA/L were included in non-allergic asthma group. General data and changes in peripheral blood cells of two groups were analyzed. Results: There were 1 378 qualified subjeats, including 999（ 72.5%） in allergic asthma group and 379 （27.5%） in non-allergic asthma group. Number of visits in allergic asthma group varied seasonally, with the most in autumn. Peripheral blood lymphocyte count （LYMPH）, eosinophil count （EOS） and ELR were all higher in children with allergic asthma than in children with non-allergic asthma （P<0.05）, and platelet/lymphocyte ratio （PLR） was lower than that in children with non-allergic asthma （P<0.05）. Peripheral blood LYMPH, PLT, EOS and ELR of children with allergic asthma differed between four seasons, which were higher than those of non-allergic asthma in each season in EOS and ELR, LYMPH was significantly higher than that of children with non-allergic asthma in autumn, and PLT was significantly lower than that of children with non-allergic asthma in spring （P<0.05）. EOS predicted AUC of spring, summer, autumn and winter were 0.79, 0.77, 0.71 and 0.64 in children with allergic asthma, and ELR predicted AUC were 0.72, 0.48, 0.73 and 0.68 in children with allergic asthma. Conclusion: Allergic asthma in children is seasonally variable and peaks in autumn. EOS and ELR in peripheral blood cells in children with allergic asthma are higher than in children with non-allergic asthma in each season of year, LYMPH is significantly higher than children with nonallergic asthma in the fall, and PLT is lower than in children with non-allergic asthma in spring, suggesting that allergic asthma type Ⅱ inflammation persists, and EOS and ELR have predictive value for children's allergic asthma. [ABSTRACT FROM AUTHOR]

Objective Summarize the clinical and genetic characteristics of atypical Rett syndrome and developmental epileptic encephalopathy caused by IQSEC2 gene variation. Methods and Results From May 2020 to April 2022, Anhui Provincial Children's Hospital diagnosed and treated 4 children with atypical Rett syndrome and developmental epileptic encephalopathy caused by IQSEC2 gene variation, including 2 males and 2 females were a pair of identical twins. They all had comprehensive developmental delay before onset. At the age of 2 years, all cases gradually exhibited clinical manifestations of atypical Rett syndrome, such as frequent clapping, biting, sleep disorders (increased sleep or difficulty falling asleep), and grinding teeth, followed by developmental regression and seizures. The initial age of epilepsy was from 2 years and 2 months to 2 years and 10 months. All cases started with generalized tonic-clonic seizure, with epileptic spasm occurring between 2 and 11 months of course. Case 2, Case 3 and Case 4 were also accompanied by focal seizures. Four cases with VEEG background of 4-6 Hz θ wave, the VEEG during the interictal phase was a broad multifocal sharp slow complex wave. In Case 2, Case 3 and Case 4, MRI was abnormal, mainly with increased depth of cerebral hemispheric sulcus and gyrus. The whole exome sequencing suggested pathogenicity and possible pathogenic variations in the IQSEC2 gene, Case 1 and Case 2 were frameshift mutations of c. 608dup (p. Gln204Profs*35), while Case 3 and Case 4 were nonsense mutations of c.2231C>A (p.Ser744Ter) and c.2521C>T (p. Gln841Ter), respectively. The four mutation sites have not been reported domestically or internationally. All cases received treatment with multiple antiepileptic seizure medicine. The last follow-up age was from 4 years and 3 months to 6 years and 3 months. All cases were unable to walk alone and had no active language. There were no seizures in Case 1 for 3 years, occasional seizures in Case 2 and Case 4, and frequent seizures in Case 3. Conclusions IQSEC2 gene variation can manifest as atypical Rett syndrome, which can be accompanied by refractory epileptic spasms. Both males and females have severe phenotypes, and the severity of clinical phenotypes at the same mutation site varies. Our report enriches the variation spectrum and clinical phenotype spectrum of the IQSEC2 gene, expands the genetic spectrum of Rett syndrome and developmental epileptic encephalopathy, and provides value for the clinical diagnosis, treatment and subsequent research of this disease. [ABSTRACT FROM AUTHOR]

Copyright of Practical Pharmacy & Clinical Remedies is the property of Editorial Department of Practical Pharmacy & Clinical Remedies and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Asian Journals of Ecotoxicology is the property of Gai Kan Bian Wei Hui and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

BACKGROUND: Nowadays, there are increasing reports on the digitization and visualization system of acupuncture points for adults in traditional Chinese medicine, and the digitization and visualization system of acupuncture points for children in traditional Chinese medicine and the simulation system of acupuncture manipulation for Mongolian medicine training have been reported. However, there are no reports on relevant systems for children in Mongolian medicine. OBJECTIVE: To develop a simulation system of acupuncture points for children in Mongolian medicine, in the hope that it can be used for clinical teaching, manipulation practice and research on acupuncture safety. METHODS: Based on the tomographic anatomical dataset of preschool boys, a three-dimensional (3D) digital virtual anatomical model of children with multiple internal organs and tissues was constructed by using PhotoShop.2021 and Digihuman Reconstruction System software. The relevant annotation information database of 27 acupoints such as Dinghui acupoint of Mongolian medicine was compiled by the Unity database language. The Mongolian gold needle and silver needle were selected to record the acupuncture point teaching video on the 3D printed head and neck resin model of children. In Unity3D software, children’s anatomical model, acupoint annotation information database and acupuncture operation video were integrated and coded, and a 3D digital children’s Mongolian acupuncture acupoint visualization system integrating simulation acupuncture training, clinical teaching and acupuncture safety research was successfully created. RESULTS AND CONCLUSION: This study was based on real children’s specimens. In order to reduce the error of two-dimensional segmentation, the manual layer-by-layer segmentation section image method was used to ensure the accuracy of the 3D model to the greatest extent. The Digihuman Reconstruction System was used to extract and save the individual segmentation data while maximizing the accuracy of the 3D model. PhotoShop.2021 software was used to complete the 3D reconstruction of the outer skin of the head and neck of children and the internal bony structure, cervical spinal cord, blood vessels and nerves, muscles and ligaments. After 3D reconstruction, the basic morphology of each independent structure and the integrity of the overall contour were verified in MeshLab software and the final fine adjustment and anatomical position confirmation were conducted using 3-matic research 13.0 software. The real anatomical morphology of the head and neck of preschool children was successfully simulated and restored. Unity3D software was used to integrate the 3D model of children, acupuncture operation video and acupoint annotation database, and the 3D digital Mongolian acupuncture acupoint visualization system for children was successfully constructed. Based on the real continuous fault ultra-thin dataset of preschool boys in China, China’s first 3D digitization and visualization system of acupuncture points in the head and neck of children in Mongolian medicine was developed. Compared with the previous acupuncture soft works, this system is more suitable for the anatomical morphological development characteristics of Asian children, and has a high value of application in the fields of research on the safety of acupuncture in Mongolian medicine, clinical teaching and acupuncture simulation training. [ABSTRACT FROM AUTHOR]

Objective: To explore the application effect of different doses of remifentanil combined with remifentanil in painless gastroscopy in children. Methods: 165 pediatric patients who underwent painless gastroscopy from May 2023 to November 2023 were selected as the study subjects. They were randomly divided into four groups using a random number table method, namely R1 (n=40), R2 (n=40), R3 group (n=40), and Matched group (n=45). Patients in the Matched group were intravenously injected with 2 mg/kg propofol and 7% fentany l μg/kg, R1, R2, R3 groups intravenous injection of fentanyl 7 μg/kg and Remazolam, R1 group Remazolam is 0.2 mg/kg. The R2 group is 0.3 mg/kg, and the R3 group is 0.4 mg/kg. Gastroscopy should be performed when all patients have improved alertness/calmness (MOAA/S) scores ≤ 1. Compare the success rate of sedation, onset time of sedation, awakening time, gastroscopy examination time, and number of times of remedial sedation among four groups of children. Evaluate the degree of sedation using MOAA/S scores before administration, after initial administration, before endoscopy, and immediately after examination. Record the changes in heart rate, blood pressure, oxygen saturation, heart rate (HR), and blood oxygen saturation (SpO2) of the four groups of children before anesthesia induction (T0), at entry (T1), and after anesthesia induction (T2), Finally, compare the incidence of adverse reactions among the four groups of children. Results: There was no difference in the recovery time and gastroscopy examination time among the four groups of patients(P>0.05). The success rate of sedation in the R3 group was higher than that in the R1 group, R2 group, and Matched group. The onset time of sedation and the number of times of remedial sedation were lower than those in the R1 group, R2 group, and Matched group (P<0.05); There was no difference in MOAA/S scores among the four groups of patients before administration and immediately after examination(P>0.05). After the first administration and before endoscopy, the MOAA/S scores of R3 group patients were lower than those of R1 group, R2 group, and Matched group (P<0.05); There was no change in blood oxygen saturation (SpO2) levels and heart rate (HR) levels at T0, T1, and T2 time in the four groups of patients, and there was no difference between the four groups(P>0.05). The HR levels of patients in the T2 and R3 groups were stable, but there were fluctuations between the R1 and R2 groups and the Matched group. The T1 and R3 group was lower than the R1 and R2 groups and the Matched group (P<0.05); The incidence of adverse reactions such as injection pain, laryngeal spasm, hypoxemia, hypotension, and bradycardia in patients in R1, R2, and R3 groups was lower than that in the Matched group (P<0.05), but there was no difference in the comparison of R1, R2, and R3 groups(P>0.05). Conclusion: The combination of Remazolam and Alfentanil can improve the sedative effect during gastroscopy in children, and Remazolam at a dose of 0.4 mg/kg is more effective. It can further improve the success rate of sedation, reduce the number of times of remedial sedation, and do not increase the awakening time. The sedative effect is better, and it can stabilize the heart rate level during the examination of children, with higher safety. [ABSTRACT FROM AUTHOR]

Pulmonary diseases are among the most common illnesses in newborns and children, and they remain a leading cause of mortality in children under five years of age. Therefore, accurate diagnosis and monitoring of these conditions are crucial. While conventional chest X-rays and CT scans have long been the primary diagnostic modalities for pulmonary diseases, they have limitations, such as inadequate identification of specific pulmonary lesions and potential radiation risks to children. In recent years, with increasing understanding of ultrasound technology, it has been found that ultrasound can complement these modalities. As a non-invasive, radiation - free diagnostic tool, pulmonary ultrasound pro- vides real-time, intuitive imaging of the lungs, allowing for rapid detection and evaluation of various pulmonary lesions and facilitating timely adjustment of treatment strategies. Ultrasound, as a real-time imaging technique, has become one of the most popular clinical diagnostic methods, especially with the advent of wearable ultrasound devices that enable rap- id, dynamic, repetitive, and even continuous clinical monitoring. Ultrasound is suitable for the diagnosis and post treatment evaluation of pediatric pulmonary diseases and has broad clinical applicability. [ABSTRACT FROM AUTHOR]

Objective To evaluate the application of flexible bronchoscopy for the removal of molds in children with plastic bronchitis (PB) and to summarize key nursing considerations. Methods A retrospective analysis was con- ducted on PB patients treated at the Respiratory Department, Guangzhou Medical University affiliated Women and Children's Medical Center from January 2019 to December 2023. Data were collected on patient demographics, timing of bronchoscopy, methods and duration of mold removal, complications, and nursing management of complications. Results The study cohort comprised 22 pediatric PB patients (17 males and 5 females) with a median age of 3.00 years (IQR: 1. 42 to 5.25 years). The mold removal techniques applied were spraying acetylcysteine solution followed by negative pressure suction (11 cases, 50.00%), biopsy forceps extraction (3 cases, 13.64%) and brush extraction (8 cases, 36.36%). The median duration of bronchoscopic manipulation for mold removal was 11. 50 minutes (IQR: 9.75 to 15. 25 minutes). The median number of bronchoscope passes through the glottis was 4 (IQR: 3 to 5). Bronchoscopic examinations were conducted once in 6 patients (27.27%), twice in 12 patients (54.55%), and three times in 4 patients (18.18%). Common complications included intraoperative hypoxia (8 cases, 36.36%), airway mucosal bleeding (4 cases, 18.18%), postoperative hypoxia (2 cases, 9.09%), and laryngeal edema (1 cases, 4.55%). All complications were effectively managed with appropriate interventions and nursing care. Conclusion Flexible bronchoscopy combined with various mold removal techniques is a safe and effective approach for managing PB in children, with manageable com- plications. The use of acetylcysteine solution spray in conjunction with negative pressure suction, biopsy forceps, and brush extraction enhances the success rate of mold removal. Proper nursing interventions are crucial for minimizing and managing procedural complications. [ABSTRACT FROM AUTHOR]

Objective To investigate the clinical characteristics of the hepatolenticular degeneration in children, and to clarify the significance of gene diagnosis in children with hepatolenticular degeneration. Methods A total of 75 patients with hepatolenticular degeneration were enrolled in the Department of Pediatrics, Peking Union Medical College Hospital from 2011 to 2018. All of them carried out a generation of gene sequencing for ATPase Cu2+ transporting beta polypeptide (ATP7B) gene and multiplex ligation-dependent probe amplification (MLPA) analysis. Results Among the 75 pediatric patients, 55 patients were asymptomatic and had elevated aminotransferases as the incidental findings. All the pediatric patients had decreased ceruloplasmin. Seventy-two of pediatric patients had 24-hour urinary copper>40 µg/d. There were 16 cases that had Kayser-Fleischer (K-F) rings. Sixteen six out of 75(21.33%) cases were diagnosed clinically and 15 cases were >7 years old. All the remaining patients needed genetic diagnosis. Sixty-six patients had two mutations and 9 patients had only one mutation, 1 had no mutation. Forty eight different mutations were found to be localized in ATP7B gene. These mutations included 32 missense mutations, 6 splice mutations, 5 deletion mutations, 2 repeated mutations, 2 insert mutations and 1 nonsense mutations. The most frequently three mutations were c. 2333G>T, p. R778L, c. 2621C>T, p. A874V, c. 2975C>T, p. P992L, whose allele frequencies were 30. 49%, 14.89%, 9.92%. Conclusions The research showed that in young aged patients, the nervous system symptoms are not obvious and the positive rate of laboratory tests are lower than adults so is a challenge to clinical diagnosis. So Genetic testing is of great significance for the early diagnosis and early treatment of disease in pediatric patients. [ABSTRACT FROM AUTHOR]

Objective To investigate the clinical features and prognostic factors of pediatric acute lymphoblastic leukemia with hyperleukocytosis (HL-ALL). Methods The clinical data of 427 newly diagnosed ALL children admitted to the Department of Hematology and Oncology of Kunming Children’s Hospital from January 2019 to July 2022 were retrospectively analyzed. According to the initial white blood cell count (WBC) of 100×109 /L, the children were divided into the hyperleukocytosis group and the non-hyperleukocytosis group. The clinical characteristics, major laboratory tests, overall survival (OS) and event-free survival (EFS) were compared between the two groups. Results There were 250 males and 177 females, with a male-to-female ratio of 1.41∶1. There were 92 cases (21.5%) in the hyperleukocytosis group and 335 cases (78.5%) in the non-hyperleukocytosis group. Compared with the non-hyperleukocytosis group, the hyperleukocytosis group had significantly higher proportions of children aged < 1 year and > 10 years, T lymphoblastic leukemia (T-ALL), moderate to severe hepatosplenomegaly, and high-risk risk (P < 0.05), as well as significantly higher percentage of immature cells at initial diagnosis, serum uric acid (UA) level, and lactate dehydrogenase (LDH) level (P < 0.05). The platelet count (PLT) and the proportion of hyperdiploidy at diagnosis were lower (P <0.05). The 3-year EFS and OS of the hyperleukocytosis group were lower than those of the non-hyperleukocytosis group. WBC ≥100×109 /L at diagnosis, age >10 years, age < 1 year, T-ALL, high-risk, D15 MRD positive, D33 MRD positive, CNSL, MLL rearrangement, and MEF2D rearrangement were independent risk factors for EFS and OS rates in children with ALL (P < 0.05). Conclusion The children with HL-ALL usually have a higher percentage of peripheral blood immature cells, elevated serum UA and LDH, and are often accompanied by age of onset <1 or > 10 years old, TALL, hepatosplenomegaly, and high risk. The early treatment response and prognosis of the children with HL-ALL are poor. [ABSTRACT FROM AUTHOR]

Objective To observe the levels of serum 25-hydroxyvitamin D, calcium and zinc in children, and explore the relationship between the three indexes and the growth and development of children. Methods From January 2021 to December 2022, 98 children with growth retardation treated in Zigong Maternal and Child Health Hospital were included in the growth retardation group, and 80 children with normal growth and development were taken as the normal growth and development group. The serum 25-hydroxyvitamin D, calcium, zinc level and other clinical data of the two groups were compared, and the relationship between serum 25-hydroxyvitamin D, calcium, zinc level and growth and development was analyzed. Results The levels of body length/height, weight, calcium, zinc and 25- hydroxyvitamin D in the growth retardation group were lower than those in the normal growth development group (P < 0.05). The results of point-and-column correlation analysis showed that the levels of calcium, zinc and 25- hydroxyvitamin D were negatively correlated with children's growth retardation (r < 0, P < 0.05) . Logistic regression model was established. The results showed that the levels of Size / height (95%CI:0.673～0.824), weight (95%CI:0.477～0.717), calcium (95%CI: 0.127～0.467), zinc (95%CI: 0.140～0.571) and 25- hydroxyvitamin D (95%CI: 0.130～0.461) were the protective factors for children's growth and development (or < 1 The ROC curve was drawn. The results showed that the levels of calcium, zinc and 25-hydroxyvitamin D had certain predictive value for children's growth and development (AUC = 0.601, 0.627 and 0.667), and the predictive value of The three indicators are parallel was higher (AUC = 0.808). Conclusion The growth and development of children is closely related to the level of serum 25-hydroxyvitamin D, calcium and zinc. Clinical monitoring of the level of serum 25-hydroxyvitamin D, calcium and zinc is helpful for early prediction of children's growth and development. [ABSTRACT FROM AUTHOR]

Objective To investigate the characteristics of adverse drug event (ADE) related to tacrolimus (Tac) in pediatric solid organ transplant recipients. Methods The data were retrieved from the US Food and Drug Administration Adverse Event Reporting System database from the first quarter of 2004 to the second quarter of 2023. The ADE data of pediatric organ transplant recipients with Tac as the primary suspected drug were extracted. The relationship between Tac and ADE was quantitatively analyzed by proportional imbalance method. Basic characteristics and signal strength of ADE related to Tac were analyzed. ADE related to Tac in children of different ages and different types of organ transplantation were analyzed. Results A total of 1 443 children's ADE reports involving Tac were screened, including 188 cases (13.0%) of heart transplantation, 668 cases (46.3%) of liver transplantation, 531 cases (36.8%) of kidney transplantation and 56 cases (3.9%) of lung transplantation. The median age of children was 10 years old. The top three countries with ADE reporting were the United States, France and the United Kingdom. China reported 26 cases, accounting for 1.8%. Infection and infectious diseases accounted for the highest proportion (20.96%) in ADE related to Tac, including EB virus and cytomegalovirus infection, etc. Infection and infectious diseases occupied the largest proportion of ADE related to Tac in children of different ages, whereas the pathogen types were different. Rejection, unstable immunosuppression level and renal function damage were also common ADE related to Tac in children of all ages. Nervous system disease was the main ADE in heart transplant recipients, while infection and infectious diseases were more common in liver and kidney transplant recipients. Rejection was the most common ADE in lung transplant recipients.Conclusions ADE related to Tac possess different distribution characteristics in different types of organ transplantation. Extensive attention should be paid to individualized drug monitoring and risk assessment in pediatric organ transplant recipients, thereby optimizing Tac treatment and reducing the risk of ADE. [ABSTRACT FROM AUTHOR]

Objective: To study the correlation between serum leptin (Leptin), 25-hydroxyvitamin D3 [25-(OH)D3] and glucose and lipid metabolism, growth and development and renin-angiotensin-aldosterone system (RAS) in children with simple obesity. Methods: 132 children with simple obesity admitted to Shanxi Children's Hospital from September 2021 to September 2023 were selected as observation group, and 100 healthy children who underwent physical examination during the same period were selected as control group. Serum Leptin, 25-(OH)D3, glucose and lipid metabolism indexes [fasting blood glucose (FBG), triglyceride (TG), total cholesterol (TC), low density lipoprotein (LDL-C), high density lipoprotein (HDL-C)] and RAS system indexes [renin (PRA), angiotensin-II (Ang-II), aldosterone (ALD)] were detected, and growth and development indexes [body mass index (BMI), waist circumference (WC), waist-hip ratio (WHR)] were measured. The correlation between serum Leptin, 25-(OH)D3 and glucose and lipid metabolism, growth and development and RAS indexes in children with simple obesity were analyzed by Pearson test. Results: Serum Leptin in observation group was higher than that in control group, and 25-(OH)D3 was lower than that in control group (P<0.05). FBG, TG, TC and LDL-C in observation group were higher than those in control group, while HDL-C was lower than that in control group (P<0.05). BMI, WC and WHR in observation group were higher than those in control group(P<0.05). The PRA, Ang-II and ALD in observation group were higher than those in control group(P<0.05). Pearson test showed that, serum Leptin was positively correlated with FBG, TG, TC, LDL-C, BMI, WC, WHR, PRA, Ang-II and ALD, and negatively correlated with HDL-C, 25-(OH)D3 was negatively correlated with FBG, TG, TC, LDL-C, BMI, WC, WHR, PRA, Ang-II and ALD, and positively correlated with HDL-C(all P<0.05). Conclusion: In children with simple obesity, serum Leptin is highly express and 25-(OH)D3 is lowly express, which is closely relate to glucose and lipid metabolism, growth and development, and RAS system. Serum Leptin and 25-(OH)D3 may be involve in the pathogenesis of children with simple obesity by affecting glucose and lipid metabolism, growth and development and RAS system. [ABSTRACT FROM AUTHOR]

Objective To summarize the imaging findings of intracranial central nervous system (CNS) malformations children in the high-altitude plateau (Xigaze city). Methods We retrospectively reviewed the imaging data of the suspected patients having CNS malformations, which enrolled either by the clinic or by the ultrasound in the Shigatse People’s hospital from June, 2019 to June, 2023. All imaging data were interpreted by two experienced radiologists with consensus reading. Imaging characteristics were recorded roughly by primary/secondary, supra-/subtentorial malformation type and the corresponding clinical symptoms. Results A total of 36 children were included in this study, including 19 patients ≤ 1 year old (including 2 newborns), 7 patients between 1 and 3 years old, and 10 patients >3 years old. Seven cases underwent MRI examination, others having CT scan. Polygyria and pachygyria malformation were the most common type of congenital neurological malformations (7 cases, 31.8%), followed by cystic changes of the cerebral parenchyma (3 cases, 13.6%). Cerebral atrophy was the most common type of secondary CNS abnormalities group (8 cases, 57.1%), followed by communicative hydrocephalus (3 cases, 21.4%). Five patients in the congenital group and 4 patients in the secondary CNS group had the complex malformations. There were 8 dead cases (all in the ≤1-year-old group), 12 cases having neurological sequelae, 1 case with normal development and 15 cases with loss of follow-up. There were no significant differences between primary and secondary CNS group regarding the final outcome. Conclusion In this study, gyrus developmental malformation and encephalatrophy were the most common etiologies in infants’ CNS malformations. Reasonable use of imaging modalities will help depict the complicated CNS malformations and design individual treatment. [ABSTRACT FROM AUTHOR]

Objective To explore the imaging features of primary cardiac tumors detected by echocardiography, CT and MR in children, and to analyze the value of each examination and the clinical examination strategies. Methods The clinical, pathological and imaging data of the children with primary cardiac tumors confirmed by surgery and pathology from Jun 2008 to Feb 2022 in Children’s Hospital, Fudan University were analyzed retrospectively. Tumor size, location, motion, signal characteristics on different sequences, and pericardial involvement were evaluated on MR images. Results A total of 23 children (16 males and 7 females) were included. The age of onset ranged from 1 month to 13 years old, average on (54.45±58.57) months. While the onset age of rhabdomyomas was only (7.23±6.30) months. The clinical manifestations mainly included 6 cases of cardiac murmur, 3 cases of cardiac insufficiency, 3 cases of epilepsy, 2 cases of cerebral infarction, and 1 case of arrhythmia. Pathological results showed that there were 22 cases of benign tumors (9 cases of fibromas, 8 cases of myxomas, 4 cases of rhabdomyomas and 1 case of lipoma) and 1 case of malignant tumor (rhabdomyosarcoma). Echocardiography has a high diagnostic accuracy for myxoma. CT showed a case of malignant rhabdomyosarcoma with invasion of the pericardium and compression of the pulmonary artery and bronchus. MR showed that the fibroma had significantly late gadolinium enhancement. The signal of rhabdomyoma was equal on T1WI, and slightly increased on T2WI, perfusion and late gadolinium enhancement sequences. Myxoma had high signal on T2WI and late gadolinium enhancement. It had obvious motions in Cine sequence. The signal of lipoma on each sequence was consistent with that of fat tissue, and there was no high signal of perfusion and late gadolinium enhancement. Conclusion All types of primary cardiac tumors in children have imaging characteristics. MR has great advantages in diagnosing cardiac tumors. The clinical team needs to select the appropriate examination method according to the actual medical situation. [ABSTRACT FROM AUTHOR]

Objective To investigate disease characteristics and hospitalization costs of children with Mycoplasma Pneumoniae pneumonia (MPP) admitted to Shanghai municipal medical hospitals from 2019 to 2023. Methods Depending on the Shanghai Municipal Hospital Pediatric Alliance, we retrospectively investigated community acquired MPP pediatric patients hospitalized in 22 municipal hospitals with pediatric qualifications (including 4 children’s hospitals) in Shanghai from Jan 2019 to Dec 2023. We collected the patients' diagnosis codes, gender, age, length of hospital stay, hospitalization costs, and whether they progressed to severe Mycoplasma pneumoniae pneumonia (SMPP). Results From 2019 to 2023, a total of 29 045 hospitalized children with MPP were treated, with 6 035 cases (20.8%) identified as SMPP in the 22 hospitals. Trend analysis revealed a rising trend with years in the proportion of SMPP patients (χ² trend=365.498, P<0.001). Among the 4 children's hospitals, there were 18 710 cases with MPP, including 4 078 cases (21.8%) of SMPP. The proportion of SMPP patients also showed an increasing trend with years (χ² trend=14.548, P<0.001), and the proportion in 2023 (23.0%) was higher than that in previous years with statistical significance. There were statistical differences in the seasonal distribution of MPP cases between different years, with higher proportions in summer and autumn overall. The age distribution of hospitalized MPP children varied among different years, with school-age children accounting for the majority (56.8%) in 2023. There was no difference in the distribution of severe cases between different genders, but there were differences in the proportion of severe cases among different age groups in different years, with a gradual increase in severe cases among children aged 1 to 3 years (χ² trend= 191.567, P<0.001). The average length of hospital stay for MPP during the epidemic was higher than that during non-epidemic periods, and there were statistically significant differences in the average length of hospital stay between different years (P<0.001). The individual hospitalization costs during the epidemic were higher than in other years, and there were statistically significant differences in individual hospitalization costs between different years (P<0.001). The total hospitalization costs were still higher in 2019 and 2023. The individual hospitalization costs for SMPP were higher than for non-SMPP cases. Conclusion MPP outbreaks occurred in Shanghai in 2019 and 2023, with the higher proportions in summer and autumn overall. Compared to previous years, the number of hospitalized MPP children in Shanghai was higher in 2023, with a higher proportion of SMPP cases, especially among children under 3 years old. The individual per capita hospitalization expenses for SMPP cases were higher than for nonSMPP cases. [ABSTRACT FROM AUTHOR]

Copyright of China Tropical Medicine is the property of China Tropical Medicine Editorial Office and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of China Tropical Medicine is the property of China Tropical Medicine Editorial Office and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of China Tropical Medicine is the property of China Tropical Medicine Editorial Office and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of China Tropical Medicine is the property of China Tropical Medicine Editorial Office and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

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Copyright of Psychological Science is the property of Psychological Science Editorial Office and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

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Objective To identify epidemiological characteristics and pathogen distribution of hand, foot, and mouth disease (HFMD) in Hebei Children′s Hospital in order to support prevention and treatment of HFMD. Methods A total of 1 698 cases throat swab samples from children diagnosed as HFMD from 2016 to 2023 were collected. Real-time PCR was used to detect the specific classification of HFMD. Statistical analysis was performed according to the year, season, age, and sex and enterovirus type of HFMD in the children. Results From 2016 to 2023, the ratio of male to female patients among the 1 698 children admitted to Hebei Children′s Hospital was 1.72∶1. Among them, the highest incidence rate in summer was 778 cases, accounting for 45.8% of all cases, followed by autumn, with a total of 614 cases, accounting for 36.2% of cases. The highest incidence was recorded in age group of 1-3 years, with a total of 1 032 cases (60.8%). The lowest incidence was 38 cases in age group ＞6 years old (2.2%); There were 988 cases of HFM (58.2%) caused by different strains of enterovirus undefined(EVU) except enterovirus 71(EV71) and coxsackievirus A16(CA16). Conclusions HFMD found in Hebei Children′s Hospital from 2016 to 2023 are mainly caused by enteroviruses except EV 71 and coxsackievirus A16. High morbidity is found in children aged 1-3 years, and summer and autumn are the main epidemic seasons. This result may facilitate and support decision making and strategy development in disease prevention and control as well as to strengthen public health resources.

Objective To investigate the clinical characteristics of vasculitis caused by Mycobacterium tuberculosis infection （tuberculosis infection） and to deepen clinical professionals' understanding of this condition. Methods Clinical data of two children diagnosed with vasculitis caused by tuberculosis infection were retrospectively analyzed. Relevant studies were searched and reviewed from CNKI， Wanfang Database and PubMed by using the keywords of “vasculitis” “tuberculosis infection” and “child”. Results Two children were admitted to hospital due to recurrent fever complicated with local pain. Vascular ultrasound indicated diffuse thickening or abnormal echoes on the walls of the corresponding vessels. The purified protein derivative （PPD） test and the tuberculosis infection T-cell spot test （T-SPOT） yielded positive results. Chest CT scan suggested pulmonary inflammation， and the diagnosis of tuberculosis infection complicated with vasculitis was confirmed. After anti-tuberculosis treatment， the vascular lesions were cured. According to literature review， vasculitis caused by tuberculosis infection is mainly manifested as aortic dilation or aneurysm， and can also involve the retina and cerebral vessels， etc. Anti-tuberculosis treatment is effective for such vascular lesions. Conclusions Tuberculosis infection can cause vascular lesions， and affect the arteries and veins of different sizes. In clinical practice， for patients with prolonged fever accompanied by local pain， tuberculosis related examination and vascular ultrasound examinations should be conducted to prevent missed diagnosis and misdiagnoses.

Background Bronchial asthma (asthma) is the most common chronic respiratory disease in childhood, with long disease course and repeated attacks, which affecting the development and life quality of children. As the main providers of primary healthcare, general practitioners play important role in the early diagnosis and grading management of childhood asthma. Understanding their level of prevention and treatment services for this disease can provide suggestions for improving the quality of primary care childhood asthma prevention and treatment services. Objective To investigate the service level of primary general practitioners in the prevention and treatment of childhood asthma, and the influencing factors on the service level. Methods From April to July 2022, 22 districts (counties) were randomly selected from the 38 districts (counties) in Chongqing Municipality, and conducted a questionnaire survey on primary general practitioners in the sampling. The questionnaire was designed by the research team based on relevant guidelines and literatures, and formed through two rounds of expert consultation and pre-investigation, including four dimensions of knowledge, attitude, behavior and self-evaluation. We investigated the knowledge, attitude, behavior and self-evaluation of primary general practitioners regarding the prevention and treatment of childhood asthma and analyzed the influencing factors. Results A total of 234 general practitioners participated in the questionnaire survey. The knowledge score of general practitioners on the prevention and treatment of childhood asthma was (6.03±2.04) , with a pass rate of 44.9%; the attitude score was (49.42±4.94) , with a pass rate of 100.0%; the behavior score was (30.55±6.66) , with a pass rate of 87.2%; and the self-evaluation score was (21.57±5.30) , with a pass rate of 85.0%. Regarding the selection of referral indications, 98.7% (231/234) of the general practitioners believed that children with moderate or severe acute asthma attack that was not significantly relieved after emergency treatment needed to be referred, and 94.0% (220/234) of the general practitioners believed that children with asthma that could not be controlled effectively after standardized treatment needed to be referred. For children with poorly controlled symptoms, 33.8% (79/234) of the general practitioners would carefully analyze the cause of poor control, and 17.5% (41/234) of the general practitioners would advise patients to follow the doctor's advice, temporarily observe the condition and make an appointment for next reexamination. 33.8% (79/234) of the general practitioners held an uncertain or opposed attitude towards the diagnosis and treatment of childhood asthma in primary medical institutions. The main influencing factors of this attitude was the lack of disease-related knowledge and learning opportunities for general practitioners, reluctance of parents to visit primary medical institutions, strained pediatric doctor-patient relationship, the small number of children suffering from asthma, and the lack of related facilities and equipment. Multiple linear regression analysis showed that professional title and training experience on childhood asthma were the influencing factors of knowledge score (P

Objective To investigate the clinical characteristics of the hepatolenticular degeneration in children, and to clarify the significance of gene diagnosis in children with hepatolenticular degeneration. Methods A total of 75 patients with hepatolenticular degeneration were enrolled in the Department of Pediatrics, Peking Union Medical College Hospital from 2011 to 2018. All of them carried out a generation of gene sequencing for ATPase Cu2+ transporting beta polypeptide (ATP7B) gene and multiplex ligation-dependent probe amplification (MLPA) analysis. Results Among the 75 pediatric patients, 55 patients were asymptomatic and had elevated aminotransferases as the incidental findings. All the pediatric patients had decreased ceruloplasmin. Seventy-two of pediatric patients had 24-hour urinary copper＞40 μg/d. There were 16 cases that had Kayser-Fleischer(K-F) rings. Sixteen six out of 75(21.33%)cases were diagnosed clinically and 15 cases were＞7 years old. All the remaining patients needed genetic diagnosis. Sixty-six patients had two mutations and 9 patients had only one mutation, 1 had no mutation. Forty eight different mutations were found to be localized in ATP7B gene. These mutations included 32 missense mutations, 6 splice mutations, 5 deletion mutations, 2 repeated mutations, 2 insert mutations and 1 nonsense mutations. The most frequently three mutations were c.2333G＞T,p.R778L,c.2621C＞T, p.A874V,c.2975C＞T, p.P992L,whose allele frequencies were 30.49%,14.89%,9.92%. Conclusions The research showed that in young aged patients, the nervous system symptoms are not obvious and the positive rate of laboratory tests are lower than adults so is a challenge to clinical diagnosis. So Genetic testing is of great significance for the early diagnosis and early treatment of disease in pediatric patients.

Objective To investigate the pathogenic role of neutrophil extracellular traps （NETs） in the pathogenesis and progression of severe Mycoplasma pneumoniae pneumonia （SMPP） in children and to assess their predictive value for SMPP. Methods Children with Mycoplasma pneumoniae pneumonia （MPP） admitted to the Second Hospital of Lanzhou University from October to December 2023 were selected as the study subjects. They were divided into the non-severe group （MPP group， n = 45） and severe group （SMPP group， n = 39）. The levels of NETs in the serum and bronchoalveolar lavage fluid （BALF） of all children were measured using ELISA. Additionally， BALF from both the affected and contralateral sides was collected from children in the SMPP group， and the content of NETs in BALF was determined using ELISA. Results A significant difference was observed in the serum concentration of NETs between MPP and SMPP patients （P < 0.01）. In the SMPP group， the level of NETs in the BALF of the affected lung was significantly higher than those of the contralateral side （P < 0.001）. Serum NETs levels were significantly higher than those in BALF in SMPP group （P < 0.001）. The area under the ROC curve （AUC） for predicting SMPP based on serum NETs levels was 0.892 （95%CI 0.810-0.963， P < 0.001）， with a sensitivity of 0.821 and specificity of 0.875， and a cut-off value of 17.24 ng/mL，respectively. The AUC of the combination of serum NETs with C-reactive protein （CRP） and lactate dehydrogenase （LDH） levels for predicting SMPP was 0.974 （95%CI 0.946-1.000， P < 0.001）， with a sensitivity of 0.923 and specificity of 0.950， respectively. Conclusions Excessive activation of NETs may contribute to the incidence of SMPP and localized lung injury in children with MPP. Monitoring the serum levels of NETs， CRP and LDH can effectively predict the incidence of SMPP. The combination of NETs， CRP， and LDH yields the best predictive performance.

Objective To systematically review the progress in the application of artificial intelligence in the field of pediatric otolaryngology-head and neck surgery at home and abroad， aiming to provide reference for the development and clinical practice in the future. Methods Literature related to the application of artificial intelligence in otolaryngology，head and neck surgery were searched from PubMed， Web of Science and Embase databases in June 2024， regardless of the research type， publication date and language restrictions. Subsequently， using the National Heart， Lung， and Blood Institute Study Quality Assessment Tools （NHI-SQAT） and the Oxford 2011 Levels of Evidence （LOE）， tables were designed to assess the quality of the articles and select authentic and effective literature. Literature content was extracted， and a systematic review of current status and future prospects of artificial intelligence in this field was conducted. Results After preliminary screening of abstracts and titles， full-text reading， supplementary retrieval， and exclusion of literature that did not meet quality standards， a total of 38 articles were finally included. Artificial intelligence has been widely used in the diagnosis and treatment of pediatric otolaryngological diseases in various forms. Significant clinical effects have been achieved through methods such as machine learning and big data processing， enabling surgical assistance and the establishment of diagnostic and treatment models. In recent research， the diagnosis and treatment of pediatric otitis media， assessment of pediatric hearing loss， preoperative planning and postoperative guidance， and telemedicine are becoming the main directions of exploration and application of artificial intelligence. Conclusions Application of artificial intelligence in pediatric otolaryngology head and neck surgery at home and abroad has been gradually extended in recent years. As the use of artificial intelligence in assisted diagnosis and treatment has been gradually accepted by the medical community， the application platform for artificial intelligence will become diversified in the future.

Mycoplasma pneumoniae pneumonia （MPP） is a common cause of community-acquired pneumonia in children aged 5 and older in China. Although most affected children have favorable clinical prognosis， some cases can escalate into severe MPP due to risk factors such as pathogen resistance or co-infections， etc. These severe cases significantly jeopardize the lives of children and may lead to diverse long-term sequelae. In response to this challenge， the Children’s Medical Center of the Third Affiliated Hospital of Sun Yat-sen University， integrating current guidelines， expert consensus， and its extensive clinical experience， has devised the “412” cluster treatment strategy. This comprehensive approach encompasses treatments for anti-infection， anti-inflammatory storm， anticoagulation and antioxidant stress. Additionally， it seamlessly integrates traditional Chinese medicine with western therapies， featuring bundled respiratory management and follow-up care. This strategy provides a valuable reference for the diagnosis and treatment of severe MPP in children.

Objective To observe the systemic reactions （SRs） associated with subcutaneous immunotherapy （SCIT） using dust mite allergen and to analyze potential risk factors. Methods The occurrence of SRs among 230 patients with allergic rhinitis （AR） who received house dust mite SCIT from December 2019 to December 2022 was retrospectively analyzed， and related risk factors were identified. Results A total of 5 422 injections were given to 230 patients， with an SRs incidence rate of 2.4% per injection and 20.0% per patient. Most SRs were grade I （51.9%）， and no fatal SRs occurred. Symptoms primarily affected the respiratory system for 111 times （84.7%）. Elevated peripheral blood eosinophil count （OR （95% CI）=6.02 （1.76， 20.60）， P = 0.004） and high levels of house dust mite-specific IgE （OR （95% CI）=1.01 （1.00， 1.01）， P = 0.016） were identified as risk factors for SRs， respectively. Conclusions Children with AR allergic to dust mites may experience SRs during SCIT with standardized dust mite allergen preparations， whereas the overall safety of SCIT is good. High eosinophil count and high levels of house dust mite-specific IgE are risk factors for SRs during SCIT.

Objective To evaluate the predictive value for serum albumin-globulin ratio （A/G） for the risk of Kawasaki disease （KD） in febrile children. Methods In this single-center retrospective cohort study， the big-data platform of a certain third-tier A-level hospital was employed. Clinical and laboratory data of 432 febrile children aged 0-16 were collected. The children were divided into 4 groups based on the quartiles and median of their serum A/G ratios. The correlation between the A/G and the risk of KD was analyzed. Results The total incidence rate of KD in 432 children with fever was 14.4% （62/432）.A significant negative correlation was observed between the A/G and the risk of KD. For each increase of 0.1 in the A/G， the risk of KD was decreased by 18% （OR=0.82， 95% CI 0.76-0.88， P < 0.001）. Subgroup analysis showed a consistent negative correlation between the A/G and KD risk across different ages， genders， and biochemical markers. Conclusions A/G may be a useful biomarker for assessing the risk of KD in febrile children. As the A/G increases， the risk of KD is gradually decreased. This finding has potential clinical application value for early diagnosis and risk assessment of KD.

Objective To analyze the characteristics and related influencing factors of transfusion reactions in pediatric patients, so as to provide evidence for clinical treatment and prevention of transfusion reactions. Methods A retrospective study was conducted on children who received blood transfusions at our hospital from 2019 to 2023 in terms of the incidence, types, time of occurrence, and related influencing factors of transfusion reactions. Results A total of 69 926 transfusions were performed from 2019 to 2023, with 711 cases of transfusion reactions, resulting in an incidence of 1.02%. The incidence of transfusion reactions decreased annually from 2019 (1.89%) to 2022 (0.50%). The incidence of transfusion reactions to apheresis platelets, frozen plasma, suspended leukocyte-depleted red blood cells and cryoprecipitate coagulation factor were 2.16% (551/25 565), 0.50% (92/18 277), 0.25% (65/25 679) and 0.74% (3/405), respectively, with apheresis platelet transfusion of a significantly higher incidence compared to other blood components (P

ObjectiveTo investigate the pathogenic spectrum and molecular characteristics of infectious diarrhea among children in Putuo District of Shanghai from 2018 to 2023， and to provide scientific basis for the prevention and control of infectious diarrhea in children.MethodsFecal samples from the cases visited sentinel hospitals for children’s diarrheal disease in Putuo District， Shanghai， were collected from January 2018 to December 2023. A total of 11 species of bacteria were isolated and cultured， and 5 species of viruses were detected by real-time fluorescent polymerase chain reaction （PCR）. The molecular typing of some positive strains was analyzed by the standard pulsed-field gel electrophoresis （PFGE） method. The polymerase-capsid protein linkage region of some norovirus-positive samples was amplified by reverse transcription PCR， and was sequenced and analyzed by bioinformatics software. The Chi-square test and Fisher’s exact probability test were used to compare the pathogen-positive rates in 2018‒2019 and 2020‒2023.ResultsOf the 707 cases of children with infectious diarrhea， the total positive rate was 47.67%， with a single bacterial positivity rate of 16.27%， a single viral positivity rate of 22.63%， and a mixed positivity rate of 8.77%， respectively. The dominant pathogens were rotavirus （10.75%）， norovirus （10.33%）， enteropathogenic Escherichia coli （8.06%）， Salmonella （6.36%）， enteroaggregative Escherichia coli （5.52%）， and Campylobacter （5.23%）. Bacterial infections were predominant in summer and fall， and viral infections were predominant in winter and spring. The total positive rate decreased in 2020‒2023 compared with that of 2018‒2019 （χ2=5.753，P

Different sagittal and vertical malocclusions exhibit different characteristics in the growth, development, and final morphology of the temporomandibular joint. Different skeletal malocclusions affect the spatial and morphological characteristics of the final temporomandibular joint through different growth and development mechanisms. These mechanisms have important guiding significance for determining the etiology and guiding treatment plans of maxillofacial malocclusion in children and adolescents in clinical practice. This article summarized and analyzed morphological differences of the temporomandibular joint fossa and condyle in different sagittal and vertical malocclusions, as well as the relative position of the condyle in the fossa. It is found that there is a connection between different maxillofacial malocclusions and the characteristics of the temporomandibular joint, with the vertical direction having a more significant impact on the temporomandibular joint than the sagittal direction;the impact of vertical malocclusion on the temporomandibular joint is mainly reflected in the shape of the joint fossa and the position of the condyle in the fossa. The joint fossa of hyperdivergent malocclusion is often relatively low and flat, with the condyle located in the anterior upper position of the fossa. The joint fossa of hypodivergent is relatively narrow and deep, and the condyle is relatively backward and lower in the joint fossa. The possible mechanisms were also elaborated, providing reference for clinicians’ comprehensive diagnosis and treatment.

Objective To investigate the awareness and influencing factors of topical corticosteroid (TCS) therapy among caregivers caring for children with eczema, in order to facilitate targeted medication education and improve medication compliance of children and treatment efficacy. Methods A questionnaire survey was conducted among caregivers of children with eczema who were admitted to the dermatology department of the Children's Hospital Affiliated to the Capital Institute of Pediatrics from December 2020 to March 2021. The questionnaire included caregivers' awareness of TCS and its side effects, children in compliance with TCS treatment, and methods to access related knowledge. The influencing factors of caregivers' awareness of TCS treatment for eczema were analyzed. Results Only 22.22% (38/171) of caregivers were aware of TCS well, while 16.37% (28/171) of caregivers were not aware of TCS at all. Moreover, 9.36% (16/171) of caregivers were fully aware of the side effects of TCS. Caregivers acquired knowledge about TCS treatment mainly from "network" (46.20%), patients or people around them (38.60%) and doctors (22.81%). About 62% (106/171) of the caregivers who took care of the children completely followed doctors' orders, while 35.08% (60/171) partially followed doctors' orders. Small proportion of caregivers (5/171, 2.92%) did not use TCS at all. Awareness of TCS and TCS side effects among caregivers differed with caregivers' age, education level and occupational status (all P0.05). Conclusions Caregivers of children with eczema have little awareness of TCS for the treatment of eczema, and caregivers' awareness of TCS and medication compliance are influenced by age and education level. Clinicians should pay attention to the differences in obtaining information about disease and medication among different population, strengthen publicity and popular science, promote rational drug use, and improve skin health management of children with eczema.

Objective To investigate the clinical features and risk factors of sepsis-induced cardiomyopathy in children with sepsis， aiming to provide reference for enhancing the diagnosis and treatment levels of clinicians. Methods Clinical data of children with sepsis were retrospectively analyzed. All patients were divided into the sepsis-induced cardiomyopathy group and non-sepsis-induced cardiomyopathy group according to whether sepsis-induced cardiomyopathy occurred.Clinical characteristics and outcomes were compared between two groups. The risk factors of sepsis-induced cardiomyopathy were analyzed. Results Three hundred and ninty-eight children with sepsis were included in this study， and the incidence of sepsis-induced cardiomyopathy was 15.58%（62/398）. The age of children in the sepsis-induced cardiomyopathy group was 49 （18， 108） months， older than 19 （6， 52） months in the non-sepsis-induced cardiomyopathy group. The incidence of septic shock in the sepsis-induced cardiomyopathy group was 83.87%（52/62）， which was higher than 42.56% （143/336） in the non-sepsis-induced cardiomyopathy group. The mortality rate in the sepsis-induced cardiomyopathy group was 29.03% （18/62）， significantly higher than 14.58% （49/336） in the non-sepsis-induced cardiomyopathy group. All differences were statistically significant （all P < 0.05）.Multivariate Logistic regression analysis showed that the influence of age on sepsis-induced cardiomyopathy was statistically significant （OR=1.010， 95%CI 1.003-1.017， P = 0.006）. The higher the lactic acid level， the higher the risk of sepsis-induced cardiomyopathy， with statistical significance （OR=1.163， 95%CI 1.034-1.308， P = 0.012）. The higher the cTnI level， the higher the risk of sepsis-induced cardiomyopathy， with statistical significance （OR=9.929， 95%CI 4.651-21.197， P < 0.001）. Conclusions Compared with children with non-sepsis-induced cardiomyopathy， children with sepsis-induced cardiomyopathy are more prone to septic shock and have higher mortality. Age， lactic acid and cTnI levels are the independent influencing factors for sepsis-induced cardiomyopathy in children.

Pediatric malocclusion is common in dentistry. Some children with malocclusion combined with obstructive sleep apnea-hypopnea syndrome (OSAHS) often fail to receive appropriate treatment due to a lack of multidisciplinary diagnosis and treatment. It can cause abnormal ventilation during sleep, affecting the central nervous system and cardiovascular development and even causing neurological and behavioral problems. Pediatric OSAHS is caused by the narrowing of the upper respiratory tract, characterized by specific facial bone characteristics and neuromuscular factors and correlated with malocclusion. Due to its diverse clinical manifestations and etiology, the diagnosis and treatment of pediatric OSAHS require an interdisciplinary, personalized, and specialized approach. Questionnaires and physical examinations can be used for preliminary screening. Moreover, children's stomatology and otorhinolaryngology examinations are the basis for disease diagnosis. Polysomnography (PSG) is currently the direct diagnostic method. There are various treatment methods for OSAHS in children, and for OSAHS caused by adenoid tonsil hypertrophy, adenoidectomy and tonsillectomy are the main treatments. Othodontic treatment including mandibular advancement and rapid maxillary expansion et al is also effective for OSAHS in children with malocclusion. Currently, there is limited research on the correlation between childhood malocclusion and OSAHS, and multidisciplinary combination therapy may improve the cure rate, but there is a lack of sufficient evidence. In the future, the pathogenesis of OSAHS should be further elucidated, and research on multidisciplinary combination therapy should be promoted to achieve early intervention and treatment for potential and existing patients.

Background In order to solve the children's medical dilemmas of poor accessibility and high cost, a hierarchical medical system has been carried out in our country. No systematic research on policy analysis of children's hierarchical medical system has been reported in China at present. Objective Beijing and Shenzhen are the first pilot cities of the hierarchical medical system, but there are obvious differences in the status of community health services for children. This study aims to explore the impact of policies on community health services for children by analyzing the policies in these two cities. Methods According to the research framework of policies on community health services developed by an expert group (community first contact care, dual referral, medical alliance, salary compensation mechanism, pediatric professional training, publicity, rural medical accessibility), policy documents about hierarchical medical services for children were searched from the official website of Beijing Municipal Government, Beijing Municipal Health Commission, Shenzhen Municipal Government, and Shenzhen Municipal Health Commission. Compare the number and content of policies that meet the inclusion and exclusion criteria in the two cities and analyze similarities and differences. Results Thirty-five policy documents that fit the research framework were selected from 6 953, of which 27 were from Beijing and 8 from Shenzhen. Both cities have policies on medical alliances, wage incentives and pediatric training. Compared with Shenzhen, Beijing has policies on publicity, and rural medical accessibility, but not on community first contact care and dual referral. Conclusion It may be of great significance to improve the situation of community health services for children by implementing the community first contact care or increasing the gap in medical insurance payment ratio, completing the indications for dual referral, promoting the medical alliance, salary compensation mechanism and training of pediatric skills policies.

Objective To investigate the application value of combining the Demirjian’s method with machine learning algorithms for dental age estimation in northern Chinese Han children and adolescents. Methods Oral panoramic images of 10 256 Han individuals aged 5 to 24 years in northern China were collected. The development of eight permanent teeth in the left mandibular was classified into different stages using the Demirjian’s method. Various machine learning algorithms, including support vector regression （SVR）, gradient boosting regression （GBR）, linear regression （LR）, random forest regression （RFR）, and decision tree regression （DTR） were employed. Age estimation models were constructed based on total, female, and male samples respectively using these algorithms. The fitting performance of different machine learning algorithms in these three groups was evaluated. Results SVR demonstrated superior estimation efficiency among all machine learning models in both total and female samples, while GBR showed the best performance in male samples. The mean absolute error （MAE） of the optimal age estimation model was 1.246 3, 1.281 8 and 1.153 8 years in the total, female and male samples, respectively. The optimal age estimation model exhibited varying levels of accuracy across different age ranges, which provided relatively accurate age estimations in individuals under 18 years old. Conclusion The machine learning model developed in this study exhibits good age estimation efficiency in northern Chinese Han children and adolescents. However, its performance is not ideal when applied to adult population. To improve the accuracy in age estimation, the other variables can be considered.

Objective To estimate adolescents and children age using stepwise regression and machine learning methods based on the pulp and tooth volumes of the left maxillary central incisor and cuspid on cone beam computed tomography （CBCT） images, and to compare and analyze the estimation results. Methods A total of 498 Shanghai Han adolescents and children CBCT images of the oral and maxillofacial regions were collected. The pulp and tooth volumes of the left maxillary central incisor and cuspid were measured and calculated. Three machine learning algorithms （K-nearest neighbor, ridge regression, and decision tree） and stepwise regression were used to establish four age estimation models. The coefficient of determination, mean error, root mean square error, mean square error and mean absolute error were computed and compared. A correlation heatmap was drawn to visualize and the monotonic relationship between parameters was visually analyzed. Results The K-nearest neighbor model （R2=0.779） and the ridge regression model （R2=0.729） outperformed stepwise regression （R2=0.617）, while the decision tree model （R2=0.494） showed poor fitting. The correlation heatmap demonstrated a monotonically negative correlation between age and the parameters including pulp volume, the ratio of pulp volume to hard tissue volume, and the ratio of pulp volume to tooth volume. Conclusion Pulp volume and pulp volume proportion are closely related to age. The application of CBCT-based machine learning methods can provide more accurate age estimation results, which lays a foundation for further CBCT-based deep learning dental age estimation research.

ObjectiveTo investigate the impact of acute respiratory infections in children under 12 years old in Pudong New Area， Shanghai from 2019 to 2023.MethodsAcute respiratory infection samples of children under 12 years old from three sentinel hospitals in Pudong New Area， Shanghai from 2019 to 2023 were collected， and 42 respiratory infection pathogens， including influenza virus， adenovirus， parainfluenza virus， respiratory syncytial virus， human enterovirus/rhinovirus， human pulmonary virus， human bokavirus， coronavirus （229E， HKU1， NL63 and OC43）， and novel coronavirus， were detected with microfluidic chips. The situation of acute respiratory infections among outpatient and inpatient children in this area was analyzed for the before the implementation of non pharmacological intervention measures （2019.12‒2020.1）， during the period of non pharmacological intervention measures （2020.2‒2022.12）， and after non pharmacological intervention measures （2023.1‒2023.6）.ResultsFrom 2019 to 2023， a total of 1 770 samples were collected， and 445 pathogens were detected， with a detection rate of 25.14% （445/1 770）. The main pathogens detected during the study period were influenza virus： 8.70% （154/1 770）， respiratory syncytial virus： 4.41% （78/1 770）， human enterovirus/rhinovirus： 2.66% （47/1 770）， human adenovirus： 2.49% （44/1 770）， and parainfluenza virus： 2.20% （39/1 770）. Before the implementation of non pharmacological intervention measures， outpatients were primarily infected with influenza， parainfluenza virus， and respiratory syncytial virus， with detection rates of 8.09%， 4.49%， and 4.04%， respectively； inpatients were mainly infected with influenza， respiratory syncytial virus， and parainfluenza virus， with detection rates of 4.49%， 3.82%， and 3.15%， respectively. During the period of non pharmacological intervention measures， influenza， rhinovirus and respiratory syncytial virus were the main viruses detected in the samples of outpatient children， with detection rates of 4.04%， 3.60%， and 2.47%， respectively； inpatient samples mainly detected respiratory syncytial virus， rhinovirus， and influenza virus， with detection rates of 3.60%， 2.02%， and 1.80%， respectively. After non pharmacological intervention measures， influenza， rhinovirus and respiratory syncytial virus were the main pathogens detected in the outpatients， with detection rates of 9.89%， 2.92% and 2.02%， respectively； influenza， respiratory syncytial virus， and rhinovirus were the main pathogens detected in inpatient children， with detection rates of 6.29%， 1.57%， and 1.35%， respectively.ConclusionThe prevalence of pathogens related to acute respiratory infections in children is influenced by non pharmacological preventive measures.

ObjectiveCongenital heart disease （CHD） is a common birth defect in children， with its incidence increasing annually. Because of their special health status， the vaccination situation for children with CHD has become a focal point of attention. This paper systematically reviews the current status of vaccination among children with CHD in China to identify existing issues in vaccination efforts for children with CHD， provide guidance for increasing vaccination rates among children with CHD， reduce the incidence of vaccine-preventable diseases， and provide ideas for subsequent research.MethodsLiterature on the vaccination of children with CHD in China was searched in both Chinese and English databases， including CNKI， Wanfang Data Knowledge Service Platform， VIP， Chinese Biomedical and Web of Science， PubMed， EmBase， and the Cochrane Library. Relevant literature was identified based on inclusion and exclusion criteria， and data extraction was carried out to summarize the research results.ResultsA total of 15 studies were included. Three articles focusing on expert consensus （guideline recommendations） for vaccination of children with CHD in China all agreed that vaccination is both feasible and necessary for children with CHD. Systematic analysis found that the overall timely vaccination rate for children with CHD was between 34% and 50%， with a notable delay in vaccination. However， after professional outpatient assessment， the vast majority of children with CHD were advised to be vaccinated according to the national recommended schedule， with only about 2% of them being advised to delay vaccination. The proportion of children with CHD who reported suspected adverse events following immunization （AEFI） was low and not significantly different from that of healthy/control children.ConclusionThe safety of vaccinations for children with CHD in China is relatively high， but the total timely vaccination rate is currently low. In order to improve the coverage and timeliness of vaccination in children with CHD， it is recommended that relevant departments provide vaccination policy support. There is a lack of research on the effectiveness of vaccination in children with CHD， so further studies are urgently needed to further improve the vaccination strategy for children with CHD in China.

BackgroundNarrative exposure therapy （NET）， an integration of narrative therapy and exposure therapy， has been shown to be effective in relieving the symptoms of post-traumatic stress disorder （PTSD）， which can help patients gain a deeper understanding of their trauma and is also considered to be quite safe. PTSD is highly prevalent in children and adolescents， while the effectiveness of NET intervention varies among the subjects.ObjectiveTo systematically evaluate the effectiveness of NET for PTSD in children and adolescents， so as to provide references for the clinical application of NET.MethodsOn August 1， 2022， the Cochrane Library， PubMed， Web of Science， CINAHL， China National Knowledge Infrastructure （CNKI）， SinoMed， VIP and Wanfang database were searched from their inception to June 2022. Search was conducted with the use of a combination of medical subject heading and free text terms， and randomized controlled trials relevant to NET for PTSD in children and adolescents were collected. Then the quality of the controlled trials was evaluated according to the Cochrane Collaboration's tool for assessing risk of bias （2011）， and Meta-analysis was performed using RevMan 5.4 software.ResultsNine randomized controlled trials involving 394 children and adolescents with PTSD were included. Meta-analysis showed that NET and relaxation therapy reported comparable symptom relief in PTSD patients within 1 to 3 months after intervention （SMD=0.22， 95% CI： -0.84~1.28） and at 6 months after intervention （SMD=0.21， 95% CI： -0.75~1.17）， while NET provided greater PTSD symptom relief than routine therapy both within 1 to 3 months after intervention （SMD=-0.66， 95% CI： -1.04~-0.27） and at 6 months after intervention （SMD=-0.77， 95% CI： -1.36~-0.19）， with statistically significant differences. Regarding the alleviation of depressive symptoms， the effect was similar between NET and routine therapy within 1 to 3 months after intervention （SMD=-0.39， 95% CI： -0.98~0.21） and at 6 months after intervention （SMD=-0.74， 95% CI： -2.23~0.75）. No statistical difference was demonstrated between NET and routine therapy in relieving psychological distress （SMD=-0.54， 95% CI： -2.14~1.07） and suppressing hyperorexia （SMD=-0.17， 95% CI： -0.54~0.19） 1 to 3 months after intervention.ConclusionNET yields a better outcome and a medium- and long-term effectiveness in alleviating symptoms of PTSD in children and adolescents compared with routine therapy， while it does not offer any significant advantages in improving depression symptoms， psychological distress and hyperorexia.