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Purpose Antibiotic exposure among hospitalized children is very high. With inappropriate antimicrobial use resulting in increased rates of antimicrobial resistance, the implementation of antibiotic stewardship programs is critically needed. This survey study aimed to identify current practice and knowledge about antibiotic stewardship and infection control among paediatricians in tertiary care paediatric hospitals in and around Munich, Germany. Methods A prospective cross-sectional study based on an anonymous questionnaire, structured into different sub-sections regarding antibiotic use, antimicrobial resistance, antibiotic stewardship and infection control, was conducted between 1st of May and 30th of June 2016 in five paediatric hospitals. Results In total, 111 paediatricians across all grades were eligible for participation. The overall proportion of correct answers for all sub-sections of the survey ranged from 54.1% correct answers in the antibiotic handling and bacterial resistance section to 72.9% correct answers in the hospital hygiene/infection control section. In general, knowledge across all categories was similar for junior doctors, middle-grade doctors or consultants. Advocating empiric use of narrow-spectrum instead of broad-spectrum antibiotics was considered to be the most difficult measure to implement in daily practice (36.9%). De-escalation from broad-spectrum empirical therapy to targeted treatment was considered the easiest measure to achieve (43.2%). Conclusion Our results demonstrate that principles of antimicrobial stewardship and aspects of hospital hygiene/infection control are not satisfactorily known among hospital-based paediatricians in and around Munich. We identified four important target areas for future educational interventions that should play a more prominent role in both pre- and postgraduate medical training.

Model-based segmentation (MBS) is a variant of active surfaces and active shape models that has successfully been used to segment anatomical structures such as the heart or the brain. We propose to integrate neural networks (NNs) into MBS for boundary detection. We formulate boundary detection as a regression task and use a NN to predict the distances between a surface mesh and the corresponding boundary points. The proposed approach has been applied to two tasks — prostate segmentation in MR images and the segmentation of the left and right ventricle in MR images. For the first task, data from the Prostate MR Image Segmentation 2012 (PROMISE12) challenge has been used. For the second task, a diverse database with cardiac MR images from six clinical sites has been used. We compare the results to the popular U-net approaches using the nnU-net implementation that is among the top performing segmentation algorithms in various challenges. In cross-validation experiments, the mean Dice scores are very similar and no statistically significant difference is observed. On the PROMISE12 test set, nnU-net Dice scores are significantly better. This is achieved by using an ensemble of 2D and 3D U-nets to generate the final segmentation, a concept that may also be adapted to NN-based boundary detection in the future. While the U-net provides a voxel labeling, our approach provides a 3D surface mesh with pre-defined mesh topology, establishes correspondences with respect to the reference mesh, avoids isolated falsely segmented regions and ensures proper connectivity of different regions.

We report the severe mercury poisoning of a 4-year-old child by a so far unknown route of exposure, namely, by skin-to-skin contact. The child was admitted to the hospital with episodic pain in his extremities, tachycardia, hypertension, increased sweating, behavioral changes and weight loss. Extensive examinations eventually revealed an acute mercury poisoning. The initial mercury levels were 19 µg/L in urine (reference level 0.4 µg/L) and 37 µg/L in blood (reference level 0.8 µg/L). A facial cream bought online, containing approximately 18% mercury, was identified as the primary source of intoxication. The symptoms improved after disposal of the cream and chelation therapy. Further analyses, home visits and interviews suggested that the child was accidently intoxicated by skin-to-skin contact with the mother, although other routes of exposure such as dust ingestion and surface-to-skin contact cannot be excluded. The mercury levels in urine and blood samples of the child and other family members as well as in domestic dust samples decreased considerably over time.

Papillomas of the fallopian tube are exceedingly rare benign tumors, and only very few cases have been reported in the literature. Clinically, they may present as a mass lesion or occur without symptoms. Histomorphologically, they are papillary tumors covered by nonatypical epithelium with occasional ciliated or goblet cells growing in the lumen, and they are most frequently located in the infundibular region of the fallopian tube. They require a number of differential diagnostic evaluations and can be mistaken for either other benign tumors or malignant neoplasms. Because of their rare occurrence, molecular data about this entity have been lacking so far. Herein, a case of a papilloma with a BRAF (c.1799T>A) mutation (V600E) in a 45-yr-old woman with tumor-like dilation of the fallopian tube is presented.

Background: Dizygotic twin pregnancies with discordant manifestation of abnormalities with unclear etiology are of interest because they arise in the same environment. Case report: We present a dizygotic third trimester twin placenta with discordant villous maturation, one placenta lacking developed syncytiocapillary membranes. The twins were eutrophic with no perinatal or postnatal complications. Conclusions: Discordant manifestation of villous maturation in dizygotic twin placentas could be a hint for a genetic rather than an environmental etiology. Villous maturation defect may be underrecognized and has been associated with perinatal morbidity and stillbirth in the late third trimester. Proper recognition is important because of the increased recurrence risk of villous dysmaturity.

A 4-yr old patient was admitted to the hospital with pain attacks in his extremities, tachycardia, hypertension, increased sweating, behavioral changes and weight loss. Extensive examinations eventually revealed an acute mercury poisoning. The mercury levels in blood and urine were 36.7 µg/l and 90 µg/g creatinine, respectively. A facial cream bought online, containing approximately 18 % mercury, was identified as the primary source of intoxication. The symptoms improved after disposal of the cream and chelation therapy. Biomonitoring of the mother and the brother, who remained asymptomatic, indicated an increased exposure to mercury, too. The mother, who had been using the cream for approximately three months, denied its application on her children. Further analyses, home visits and interviews suggested that the child was accidently intoxicated by skin-to-skin contact with the mother. Other mercury sources were excluded and mercury levels decreased considerably over time. The family will be closely monitored to exclude any long-term health issues. Lessons learnt from this case of an acute mercury intoxication is that even skin to skin contact with a mercury containing cream can have significant negative health effects for a child.

Background Congenital Central Hypoventilation Syndrome (CCHS) is a rare condition characterized by an alveolar hypoventilation due to a deficient autonomic central control of ventilation and a global autonomic dysfunction. Paired-like homeobox 2B (PHOX2B) mutations are found in most of the patients with CCHS. In recent years, the condition has evolved from a life-threatening neonatal onset disorder to include broader and milder clinical presentations, affecting children, adults and families. Genes other than PHOX2B have been found responsible for CCHS in rare cases and there are as yet other unknown genes that may account for the disease. At present, management relies on lifelong ventilatory support and close follow up of dysautonomic progression. Body This paper provides a state-of-the-art comprehensive description of CCHS and of the components of diagnostic evaluation and multi-disciplinary management, as well as considerations for future research. Conclusion Awareness and knowledge of the diagnosis and management of this rare disease should be brought to a large health community including adult physicians and health carers.

Computer scientists use animal-based phenomenon as source of inspiration to develop swarm algorithm and simulate their behaviors. One example is ants foraging. For finding food the ants are moving randomly in any direction. After they found food, they spread pheromones to make it easy for other ants to find it. The more ants, the better the pheromone trail. This pheromone-based search algorithm should increase the efficiency of food delivery. However, this phenomenon includes a problem termed ant mill, which is well known. An ant mill is happening when many ants are spreading their pheromones in a closed area. This causes an overlapping of the pheromones and creates a circle trail. Consequently, the ants move in a never-ending loop without ever reaching the food source. The result is starvation and death. In this paper, we take a closer look at three types of search algorithms. Especially pheromone-based searching algorithm, which creates ant mills and provide a solution to overcome them. Our evaluation shows that a pheromone-based search algorithm with ant mill prevention brings a significantly better food delivery.

Background: Congenital Central Hypoventilation Syndrome (CCHS) is a rare condition characterized by an alveolar hypoventilation due to a deficient autonomic central control of ventilation and a global autonomic dysfunction. Paired-like homeobox 2B (PHOX2B) mutations are found in most of the patients with CCHS. In recent years, the condition has evolved from a life-threatening neonatal onset disorder to include broader and milder clinical presentations, affecting children, adults and families. Genes other than PHOX2B have been found responsible for CCHS in rare cases and there are as yet other unknown genes that may account for the disease. At present, management relies on lifelong ventilatory support and close follow up of dysautonomic progression. Body: This paper provides a state-of-the-art comprehensive description of CCHS and of the components of diagnostic evaluation and multi-disciplinary management, as well as considerations for future research. Conclusion: Awareness and knowledge of the diagnosis and management of this rare disease should be brought to a large health community including adult physicians and health carers.

Background: Levels or fluctuations in the partial pressure of CO2 (PCO2) may affect outcomes for extremely low birth weight infants. Objectives: In an exploratory analysis of a randomized trial, we hypothesized that the PCO2 values achieved could be related to significant outcomes. Methods: On each treatment day, infants were divided into 4 groups: relative hypocapnia, normocapnia, hypercapnia, or fluctuating PCO2. Ultimate assignment to a group for the purpose of this analysis was made according to the group in which an infant spent the most days. Statistical analyses were performed with analysis of variance (ANOVA), the Kruskal-Wallis test, the χ2 test, and the Fisher exact test as well as by multiple logistic regression. Results: Of the 359 infants, 57 were classified as hypocapnic, 230 as normocapnic, 70 as hypercapnic, and 2 as fluctuating PCO2. Hypercapnic infants had a higher average product of mean airway pressure and fraction of inspired oxygen (MAP × FiO2). For this group, mortality was higher, as was the likelihood of having moderate/severe bronchopulmonary dysplasia (BPD), necrotizing enterocolitis (NEC), and poorer neurodevelopment. Multiple logistic regression analyses showed an increased risk for BPD or death associated with birth weight (p < 0.001) and MAP × FiO2 (p < 0.01). The incidence of adverse neurodevelopment was associated with birth weight (p < 0.001) and intraventricular hemorrhage (IVH; p < 0.01). Conclusions: Birth weight and respiratory morbidity, as measured by MAP × FiO2, were the most predictive of death or BPD and NEC, whereas poor neurodevelopmental outcome was associated with low birth weight and IVH. Univariate models also identified PCO2. Thus, hypercapnia seems to reflect greater disease severity, a likely contributor to differences in outcomes.