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Study Objectives: Optimal cutoff values of oximetry indices that differentiate obstructive sleep apnea (OSA) from primary snoring (PS) is not well established. Our study aimed to assess the utility of overnight oximetry indices in differentiating PS from OSA and assessing OSA severity, compared to polysomnography (PSG), in children with suspected OSA., Methods: This was a retrospective study of children (1-18 years) with snoring who underwent PSG. Patients with Down syndrome, craniofacial anomalies, known genetic syndromes, neuromuscular conditions and central apnea index ≥ 5 were excluded. Demographic data, PSG variables and oximetry indices (e.g. oxygen desaturation index [ODI 3, defined as number of ≥ 3% desaturation episodes/hour of artifact free recording time and SpO 2 nadir]) were collected., Results: Of 1,203 children (mean age 9.1±3.9 years, 67.7% males), 91.8% (847/923) ≤ 12 years and 84.3% (236/280) > 12 years had OSA. Optimal cutoff of ODI 3 for differentiating PS from OSA was 2.4 [Se: 78.8% (75.9%-81.6%), Sp: 80.5% (69.9%-88.7%)] in ≤ 12 years and 3.6 [Se: 71.1% (64.8%-76.8%), Sp: 91.1% (78.8%-97.5%)] in > 12 years. The optimal cutoff of ODI 3 for differentiating PS from mild, moderate and severe OSA categories were 2.0 [Se: 70.1% (65.3%-74.5%), Sp: 70.1% (58.6%-80.0%)]; 3.7 [Se: 82.3% (76.6%-87.1%), Sp: 94.8% (87.2%-98.6%)] and 4.3 [Se: 99.1% (96.8%-99.9%), Sp: 98.7% (93.0%-100.0%)] in ≤ 12 years; and 1.9 [Se: 78.8% (75.9%-81.6%), Sp: 80.5% (69.9%-88.7%)]; 4.1 [Se: 85.4% (72.2%-93.9%), Sp: 91.1% (78.8%-97.5%)] and 6.9 [Se: 98.4% (91.2%-100.0%), Sp: 97.8% (88.2%-99.9%)] in > 12 years, respectively., Conclusions: This study provides optimal cutoff values for ODI 3 in differentiating PS from OSA and assessing OSA severity in children. As oximetry is cheaper and widely available, ODI 3 has the potential to be incorporated into cost-effective clinical decision-making algorithms, especially in resource limited settings., (© 2024 American Academy of Sleep Medicine.)

Known for their pre-occupation with body image, self-identity creation, peer acceptance, and risk-taking behaviors, adolescents with asthma face unique challenges. Asthma is a heterogeneous disease and accurate diagnosis requires assessment through detailed clinical history, examination, and objective tests. Diagnostic challenges exist as many adolescents can present with asthma-like symptoms but do not respond to asthma treatment and risk being mis-diagnosed. Under-recognition of asthma symptoms and denial of disease severity must also be addressed. The over-reliance on short-acting beta-agonists in the absence of anti-inflammatory therapy for asthma is now deemed unsafe. Adolescents with mild asthma benefit from symptom-driven treatment with combination inhaled corticosteroids (ICS) and long-acting beta-agonist (LABA) on an as-required basis. For those with moderate-to-persistent asthma requiring daily controller therapy, maintenance and reliever therapy using the same ICS-LABA controller simplifies treatment regimes, while serving to reduce exacerbation risk. A developmentally staged approach based on factors affecting asthma control in early, middle, and late adolescence enables better understanding of the individual's therapeutic needs. Biological, psychological, and social factors help formulate a risk assessment profile in adolescents with difficult-to-treat and severe asthma. Smoking increases risks of developing asthma symptoms, lung function deterioration, and asthma exacerbations. Morbidity associated with e-cigarettes or vaping calls for robust efforts towards smoking and vaping cessation and abstinence. As adolescents progress from child-centered to adult-oriented care, coordination and planning are required to improve their self-efficacy to ready them for transition. Frequent flare-ups of asthma can delay academic attainment and adversely affect social and physical development. In tandem with healthcare providers, community and schools can link up to help shoulder this burden, optimizing care for adolescents with asthma., (© 2021. The Author(s).)

Mucin 1 (MUC1), a well-known tumor-associated antigen and attractive target for tumor immunotherapy, is overexpressed in most human epithelial adenomas with aberrant glycosylation. However, its low immunogenicity impedes the development of MUC1-targeted antitumor vaccines. In this study, we investigated three liposomal adjuvant systems containing toll-like receptor 4 (TLR4) agonist monophosphoryl lipid A (MPLA) and auxiliary lipids of different charges: cationic lipid dimethyldioctadecylammonium (DDA), neutral lipid distearoylglycerophosphocholine (DSPC) or anionic lipid dioleoylphosphatidylglycerol (DOPG), respectively. ELISA assay evidenced that the positively charged DDA/MPLA liposomes are potent immune activators, which induced remarkable levels of anti-MUC1 antibodies and exhibited robust Th1-biased immune responses. Importantly, the antibodies induced by DDA/MPLA liposomes efficiently recognized and killed MUC1-positive tumor cells through complement-mediated cytotoxicity. In addition, antibody titers in mice immunized with P 2 -MUC1 vaccine were significantly higher than those from mice immunized with P 1 -MUC1 or MUC1 vaccine, which indicated that the lipid conjugated on MUC1 antigen also played important role for immunomodulation. This study suggested that the liposomal DDA/MPLA with lipid-MUC1 is a promising antitumor vaccine, which can be used for the immunotherapy of various epithelial carcinomas represented by breast cancer., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Du, Zhou, Cheng, Xu, Zhang, Wang and Guo.)

Interpretation of breath sounds by auscultation has high inter-observer variability, even when performed by trained healthcare professionals. This can be mitigated by using Artificial Intelligence (AI) acoustic analysis. We aimed to develop and validate a novel breath sounds analysis system using AI-enabled algorithms to accurately interpret breath sounds in children. Subjects from the respiratory clinics and wards were auscultated by two independent respiratory paediatricians blinded to their clinical diagnosis. A novel device consisting of a stethoscope head connected to a smart phone recorded the breath sounds. The audio files were categorised into single label (normal, wheeze and crackles) or multi-label sounds. Together with commercially available breath sounds, an AI classifier was trained using machine learning. Unique features were identified to distinguish the breath sounds. Single label breath sound samples were used to validate the finalised Support Vector Machine classifier. Breath sound samples (73 single label, 20 multi-label) were collected from 93 children (mean age [SD] = 5.40 [4.07] years). Inter-rater concordance was observed in 81 (87.1%) samples. Performance of the classifier on the 73 single label breath sounds demonstrated 91% sensitivity and 95% specificity. The AI classifier developed could identify normal breath sounds, crackles and wheeze in children with high accuracy.

Exposure to a diverse microbial environment during pregnancy and early postnatal period is important in determining predisposition towards allergy. However, the effect of environmental microbiota exposure during preconception, pregnancy and postnatal life on development of allergy in the child has not been investigated so far. In the S-PRESTO (Singapore PREconception Study of long Term maternal and child Outcomes) cohort, we collected house dust during all three critical window periods and analysed microbial composition using 16S rRNA gene sequencing. At 6 and 18 months, the child was assessed for eczema by clinicians. In the eczema group, household environmental microbiota was characterized by presence of human-associated bacteria Actinomyces, Anaerococcus, Finegoldia, Micrococcus, Prevotella and Propionibacterium at all time points, suggesting their possible contributions to regulating host immunity and increasing the susceptibility to eczema. In the home environment of the control group, putative protective effect of an environmental microbe Planomicrobium (Planococcaceae family) was observed to be significantly higher than that in the eczema group. Network correlation analysis demonstrated inverse relationships between beneficial Planomicrobium and human-associated bacteria (Actinomyces, Anaerococcus, Finegoldia, Micrococcus, Prevotella and Propionibacterium). Exposure to natural environmental microbiota may be beneficial to modulate shed human-associated microbiota in an indoor environment., (© 2021 Society for Applied Microbiology and John Wiley & Sons Ltd.)

The Singapore Preconception Study of Long-Term Maternal and Child Outcomes (S-PRESTO) is a preconception, longitudinal cohort study that aims to study the effects of nutrition, lifestyle, and maternal mood prior to and during pregnancy on the epigenome of the offspring and clinically important outcomes including duration of gestation, fetal growth, metabolic and neural phenotypes in the offspring. Between February 2015 and October 2017, the S-PRESTO study recruited 1039 Chinese, Malay or Indian (or any combinations thereof) women aged 18-45 years and who intended to get pregnant and deliver in Singapore, resulting in 1032 unique participants and 373 children born in the cohort. The participants were followed up for 3 visits during the preconception phase and censored at 12 months of follow up if pregnancy was not achieved (N = 557 censored). Women who successfully conceived (N = 475) were characterised at gestational weeks 6-8, 11-13, 18-21, 24-26, 27-28 and 34-36. Follow up of their index offspring (N = 373 singletons) is on-going at birth, 1, 3 and 6 weeks, 3, 6, 12, 18, 24 and 36 months and beyond. Women are also being followed up post-delivery. Data is collected via interviewer-administered questionnaires, metabolic imaging (magnetic resonance imaging), standardized anthropometric measurements and collection of diverse specimens, i.e. blood, urine, buccal smear, stool, skin tapes, epithelial swabs at numerous timepoints. S-PRESTO has extensive repeated data collected which include genetic and epigenetic sampling from preconception which is unique in mother-offspring epidemiological cohorts. This enables prospective assessment of a wide array of potential determinants of future health outcomes in women from preconception to post-delivery and in their offspring across the earliest development from embryonic stages into early childhood. In addition, the S-PRESTO study draws from the three major Asian ethnic groups that represent 50% of the global population, increasing the relevance of its findings to global efforts to address non-communicable diseases.

Aim: A subgroup of children with obstructive sleep apnoea (OSA) requires treatment with continuous positive airway pressure (CPAP). This study's aims were: 1) to determine if the optimal CPAP for the treatment of OSA in children correlates with body mass index (BMI); 2) to determine the correlation between polysomnographic variables and optimal CPAP in children with OSA; and 3) to develop a CPAP predictive equation for children with OSA., Methods: This was a retrospective study of children with OSA who underwent CPAP titration studies. Patients with craniofacial abnormalities (except Down syndrome) and neuromuscular diseases were excluded. Polysomnograms were done using Sandman Elite. Correlations between optimal CPAP, clinical and polysomnographic variables were analysed. A multivariable linear regression model for optimal CPAP was developed., Results: 198 children (mean±sd age 13.1±3.6 years) were studied. Optimal CPAP had a significant positive correlation with age (rho=0.216, p=0.002), obstructive apnoea-hypopnoea index (rho=0.421, p<0.001), 3% oxygen desaturation index (rho=0.417, p<0.001), rapid eye movement respiratory disturbance index (rho=0.378, p<0.001) and BMI z-score (rho=0.160, p=0.024); and a significant negative correlation with arterial oxygen saturation measured by pulse oximetry nadir (rho= -0.333, p<0.001). The predictive equation derived was:Optimal CPAP (cmH 2 O)=6.486+0.273·age (years)-0.664·adenotonsillectomy(no=1, yes=0)+2.120·Down syndrome (yes=1, no=0)+0.280·BMI z-score., Conclusion: The equation developed may help to predict optimal CPAP in children with OSA. Further studies are required to validate this equation and to determine its applicability in different populations., Competing Interests: Conflict of interest: J. Chong has nothing to disclose. Conflict of interest: R. Bajpai has nothing to disclose. Conflict of interest: O.H. Teoh has nothing to disclose. Conflict of interest: A. Pugalenthi has nothing to disclose. Conflict of interest: J.C. Allen Jr has nothing to disclose. Conflict of interest: Z.R. Cheng has nothing to disclose. Conflict of interest: S.G. Tan has nothing to disclose. Conflict of interest: M. Lim has nothing to disclose. Conflict of interest: J. Tan has nothing to disclose. Conflict of interest: A. Goh has nothing to disclose. Conflict of interest: Y.H. Tan has nothing to disclose. Conflict of interest: B. Thomas has nothing to disclose., (Copyright ©ERS 2020.)

Objective: To investigate the outcomes and safety of endovascular compared with surgical clipping for multiple intracranial aneurysms., Material and Methods: 98 patients with 260 multiple intracranial aneurysms were treated with endovascular, surgical clipping, combined treatment, and observation. Data were retrospectively studied following treatment and at follow-up., Results: In the endovascular group, 44 aneurysms were treated with coils only and 29 aneurysms were treated with stent deployment. The complete occlusion rate was 65%, and the total complication rate was 12% with no permanent deficit. After angiographic follow-up for 1-90 (mean 62) months, the total recurrence rate was 18.3%. In the clipping group, 65 aneurysms were clipped. The complete occlusion rate was 90.8%, and the complication rate was 10.9% with 1 permanent deficit. After follow-up for 11-71 (mean 49) months, the angiographic recurrence rate was 1.5%. In the combination group, 20 aneurysms were treated endovascularly. The complete occlusion rate was 78.9%, and the complication rate was 15.8% with no permanent deficit. Twenty-eight aneurysms were treated surgically with the complete occlusion rate of 89.3%, the complication rate of 20% and 3 permanent deficits. After follow-up for 1-93 (mean 58) months, the angiographic recurrence rate was 33.3% for embolization and 3.6% for clipping. Seventy-four aneurysms for observation had 2.7% regrowth rate within 1-3 years., Conclusion: Endovascular embolization has an accepted complication rate but no neurological deficits compared with surgical clipping and may be a better approach for multiple intracranial aneurysms than surgical clipping., (Copyright © 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Objective: To assess the effectiveness and complications of rigid endoscopy (RE) and flexible endoscopy (FE) for the extraction of esophageal foreign bodies (FBs) in adults., Methods: A retrospective analysis was conducted on the medical records of 171 adult patients with the upper esophageal FB impaction treated at Peking University Third Hospital, Beijing, China, between January 2008 and December 2012., Results: In the study, 126 patients with the upper esophageal foreign body impaction were treated with RE, while 45 patients received FE. (1)The size of FBs in FE group was the same as RE group(P = 0.495, P = 0.125). (2)The period impacted in the esophagus of RE group (25.8 ± 28.6) h was longer than that of FE group (13.9 ± 14.5) h (P = 0.009). (3)71.4% of the patients in RE and 88.9% in FE group went to hospital for treatment within 24 hours from being impacted, while 15.1% in RE group and 8.9% in FE group were between 24 and 48 hours.13.5% in RE and 2.2% in FE group went to hospital beyond 48 hours.(4)The proportion of FBs puncturing into one or two esophageal walls in RE group (67.5%) was higher than that in FE group (35.6%).(5) The positive rates with the upper gastrointestinal barium contrast and chest X-ray or abdominal plain film were 98.3%,23.6% and 100%,14.3% for diagnosing esophageal FBs in RE and FE groups.(6)The successful rate, complication rate and perforation rate were 100%,38.1% and 6.3%and 95.6%,48.9%,and 2.2% in RE and FE groups, respectively with no statistical difference (P > 0.05)., Conclusion: Both RE and FE were effective in the extraction of upper esophageal FBs with no difference in the complication and perforation rates. But FE was cheaper and no need for general anesthesia.

Objective: To analyze the related factors of complications and treatment efficacy with flexible endoscopy for esophageal foreign body (FB)., Methods: In a retrospective study with consecutive data, 101 adults including 52 males and 49 females with esophageal FB impaction between January 2005 and December 2012 admitted into Department of Gastroenterology's Endoscopic Unit at Peking University Third Hospital were included, aged (49 ± 21) years., Results: (1) FB impaction in upper and middle esophagus accounted for 87.1% (n = 88) of all esophageal FBs. No significant difference existed in interval time from impaction to removal of FB impacted between upper, middle and lower esophagus (P > 0.05) . (2) Patients with esophageal FB seeking hospital treatment accounted for 82.2% (n = 83) within 24 h and 99.0% (n = 100) within 48 h. Food lump, fish bone, chicken bone and fruit seeds accounted for 76.2% (n = 77). (3) Positive rates were 91.3% (21/23) and 24.1% (7/29) with upper gastrointestinal barium contrast and chest or abdominal plain film. The success rate was 94.1% (n = 95) with flexible endoscopy for removal of FB. (4) Denture was the most difficult FB for removal. Four patients in all 11 patients with denture impacted were not removed successfully with flexible endoscopy. (5) The complication (except for mild scratch) rate was 48.5% (n = 49) and the perforation rate 3.0% (n = 3) . Whether complications took place or not was independent of age, location of impaction, time from impaction to removal and size of FB (all P > 0.05) , but dependent on piercing into esophageal wall, concomitant with esophageal stricture and types of FB (all P < 0.01) . Whether perforation or not was independent of any above factor., Conclusion: Esophageal FB should be removed as soon as possible within 24 h especially for those with sharp edges and piercing into esophageal wall.