Current status of long term ventilation of children in the United Kingdom: questionnaire survey

ObjectivesTo identify the number and current location of children, aged 0 to 16 years, requiring long term ventilation in the United Kingdom, and to establish their underlying diagnoses and ventilatory needs.DesignPostal questionnaires sent to consultant respiratory paediatricians and all lead clinicians of intensive care and special care baby units in the United Kingdom.SubjectsAll children in the United Kingdom who, when medically stable, continue to need a mechanical aid for breathing.Results141 children requiring long term ventilation were identified from the initial questionnaire. Detailed information was then obtained on 136 children from 30 units. Thirty three children (24%) required continuous positive pressure ventilation by tracheostomy over 24 hours, and 103 received ventilation when asleep by a non-invasive mask (n=62; 46%), tracheostomy (n=32; 24%), or negative pressure ventilation (n=9; 7%). Underlying conditions included neuromuscular disease (n=62; 46%), congenital central hypoventilation syndrome (n=18; 13%), spinal injury (n=16; 12%), craniofacial syndromes (n=9; 7%), bronchopulmonary dysplasia (n=6; 4%), and others (n=25; 18%). 93 children were cared for at home. 43 children remained in hospital because of home circumstances, inadequate funding, or lack of provision of home carers. 96 children were of school age and 43 were attending mainstream school.ConclusionsA significant increase in the number of children requiring long term ventilation in the United Kingdom has occurred over the past decade. Contributing factors include improved technology, developments in paediatric non-invasive ventilatory support, and a change in attitude towards home care. Successful discharge home and return to school is occurring even for severely disabled patients. Funding and home carers are common obstacles to discharge.

Key messages

• The number of children requiring long term ventilatory support has increased substantially in the past 8 years
• Ventilatory support at home is the best option for meeting the child’s psychological needs and enhancing quality of life
• The majority of children dependent on long term ventilation live at home and attend mainstream schools
• A shift of care has occurred from intensive care units to less acute areas

     

重症肺炎患儿俯卧位与仰卧位机械通气的临床效果比较及其脱机结局的影响因素分析

摘要 目的：比较重症肺炎患儿俯卧位与仰卧位机械通气的临床效果,并分析其脱机结局的影响因素。方法：选择2020年5月~2021年12月期间在我院重症监护室（ICU）住院的重症肺炎患儿120例作为研究对象。根据机械通气体位方式的不同将患儿分为仰卧组（n=52）和俯卧组（n=68）,对比仰卧组、俯卧组的临床症状改善时间和血气分析指标[动脉血氧分压（PaO₂）、动脉血二氧化碳分压（PaCO₂）、平均动脉压（MAP）]。记录仰卧组、俯卧组的死亡例数、脱机成功和脱机失败例数,计算死亡率、脱机失败发生率。采用单因素及多因素Logistic回归分析脱机失败的影响因素。结果：俯卧组的发热消失时间、肺部啰音消失时间、呼吸改善时间短于仰卧组（P<0.05）。两组治疗5 d后 PaO₂、MAP较治疗前升高,PaCO₂较治疗前下降（P<0.05）;俯卧组的PaO₂、MAP高于仰卧组,PaCO2低于仰卧组（P<0.05）。两组患儿死亡率组间对比未见统计学差异（P>0.05）。俯卧组的脱机失败率低于仰卧组（P<0.05）。在120例患儿中,死亡7例,根据重症肺炎患儿脱机结局将剩余113例分为脱机成功组（n=72）和脱机失败组（n=41）,脱机失败组、脱机成功组在年龄、急性生理与慢性健康评分系统II（APACHE II）评分、病程、先天性病史、D-二聚体（D-D）、白蛋白（ALB）、血乳酸、脑尿钠肽（BNP）方面对比有统计学差异（P<0.05）。多因素Logistic回归分析结果显示：年龄偏小、APACHE II评分偏高、D-D偏高、ALB偏低、先天性病史均是重症肺炎患儿脱机结局的影响因素（P<0.05）。结论：与仰卧位相比,俯卧位机械通气用于重症肺炎患儿可获得更好的临床效果和脱机成功率,且患儿的脱机结局受到年龄、APACHE II评分、D-D、ALB、先天性病史的影响。     

Companion Animals and other Factors Affecting Young Children's Development

ABSTRACT

This study focuses on three factors presumed to affect young children's development: their age, the quality of their home environments, and the child-pet relationship. Three sets of analyses are presented: effects associated with pet ownership (pet presence), effects associated with the strength of the child-pet relationship, and the combined effects of age, home environment, and the child-companion animal relationship. This study includes both a parent survey (n = 88) and in-home assessments (n = 44) of the three- to six-year-old children. The analyses support the hypothesis that normal preschool children's intellectual, motor, and social development is associated with the presence of a companion animal and increases with their age, the quality of their home environment, and their relationship with a companion animal. While the children's age and the quality of their home environments were associated with measures of the children's cognitive, motor, and social development, the companion animal effect was limited to the young children's social development including their empathy for other children.     

Effect of Regular Yoga Practice on Respiratory Regulation and Exercise Performance

Yoga alters spontaneous respiratory regulation and reduces hypoxic and hypercapnic ventilatory responses. Since a lower ventilatory response is associated with an improved endurance capacity during whole-body exercise, we tested whether yogic subjects (YOGA) show an increased endurance capacity compared to matched non-yogic individuals (CON) with similar physical activity levels. Resting ventilation, the ventilatory response to hypercapnia, passive leg movement and exercise, as well as endurance performance were assessed. YOGA (n = 9), compared to CONTROL (n = 6), had a higher tidal volume at rest (0.7±0.2 vs. 0.5±0.1 l, p = 0.034) and a reduced ventilatory response to hypercapnia (33±15 vs. 47±15 l·min^-1, p = 0.048). A YOGA subgroup (n = 6) with maximal performance similar to CONTROL showed a blunted ventilatory response to passive cycling (11±2 vs. 14±2 l·min^-1, p = 0.039) and a tendency towards lower exercise ventilation (33±2 vs. 36±3 l·min^-1, p = 0.094) while cycling endurance (YOGA: 17.3±3.3; CON: 19.6±8.5 min, p = 0.276) did not differ. Thus, yoga practice was not associated with improved exercise capacity nor with significant changes in exercise ventilation despite a significantly different respiratory regulation at rest and in response to hypercapnia and passive leg movement.     

Effects of haloperidol and domperidone on ventilatory roll off during sustained hypoxia in cats.

In a previous work, we showed that the adult cat demonstrates a ventilatory decline during sustained hypoxia (the "roll off" phenomenon) and that the mechanism responsible for this secondary decrease in ventilation lies within the central nervous system (J. Appl. Physiol. 63: 1658-1664, 1987). In this study, we sought to determine whether central dopaminergic mechanisms could have a role in the roll off. We studied the effects of haloperidol, a peripheral and centrally acting dopamine receptor antagonist, on the ventilatory response to sustained isocapnic hypoxia (end-tidal PO2 40-50 Torr, 20-25 min) in awake cats. In vehicle control cats (n = 5), sustained hypoxia elicited a biphasic respiratory response, during which an initial ventilatory stimulation is followed by a 24 +/- 6% (P less than 0.01) reduction. In contrast, in haloperidol- (0.1 mg/kg) treated cats (n = 5) the ventilatory roll off was virtually abolished (-1 +/- 1%; P = NS). We also measured ventilatory, carotid sinus nerve (CSN) and phrenic nerve (PhN) responses to sustained isocapnic hypoxia in anesthetized animals (n = 6) to explore the influence of haloperidol on peripheral and central response during the roll off. Control responses to hypoxia showed an initial increase in ventilation, PhN, and CSN activity, followed by a subsequent decline in ventilation and PhN activity of 17 +/- 3 and 17 +/- 5%, respectively (P less than 0.05). In contrast, CSN activity remained unchanged during the roll off. Administration of haloperidol (1 mg/kg) reduced the initial increment in ventilation, while the initial increase in CSN activity was augmented.(ABSTRACT TRUNCATED AT 250 WORDS)     

不同CRRT治疗时机对脓毒症合并急性肾功能不全患者疗效及预后的影响

目的:探讨不同持续性肾脏替代治疗(CRRT)治疗时机对脓毒症合并急性肾功能不全患者的临床疗效及预后的影响。方法:将我院ICU收治的60例脓毒症合并急性肾功能不全患者,按照CRRT治疗时机分为早期组(1-2期,n=30)和晚期组(3期,n=30)。比较两组患者治疗前后不同时点平均动脉压(MAP)、白细胞(WBC)计数、血红蛋白(HB)、血小板(PLT)计数、急性生理学与慢性健康状况(APACHE)Ⅱ评分等临床资料的变化,机械通气时间,肾功能恢复率及28 d病死率等。结果:与早期组比较,晚期组治疗后WBC计数明显升高(P0.05)。治疗后12 h、24 h、72 h,早期组ACHEⅡ评分较晚期组显著降低(P0.05)。与晚期组比较,早期组机械通气时间显著缩短,肾功能恢复明显升高,28d内病死率也明显降低(P0.05)。结论:脓毒症合并急性肾功能不全患者应早期启动CRRT治疗,最佳介入时间是KDIGO-AKI 3期之前,有助于改善患者预后。     

Inpatient Hyperglycemia and Transitions of Care: A Systematic Review

ObjectiveThe transition of diabetes care from home to hospital, within the hospital, and upon discharge is fraught with gaps that can adversely affect patient safety and length of stay. We aimed to highlight the variability in care during these transitions and point out areas where research is needed.MethodsA PubMed search was performed with a combination of search terms that pertained to diabetes, hyperglycemia, hospitalization, locations in the hospital, discharge to home or a nursing facility, and diabetes medications. Studies with at least 50 patients that were written in the English language were included.ResultsWith the exception of transitioning from intravenous insulin infusion to subcutaneous insulin and perhaps admission to the regular floors, few studies pointedly focused on transitions of care, leading us to extrapolate recommendations based on data from disparate areas of care in the hospital. There is evidence at every stage of care, starting from the entry into the hospital and ending with discharge home or to a facility, that patients benefit from having protocols in place guiding overall care.ConclusionPockets of care exist in hospitals where methods of effective diabetes management have been studied and implemented. However, there is no sustained continuum of care. Protocols and care teams that follow patients from one physical location to the other may result in improved clinical outcomes during and following a hospital stay.     

Physicians' Self-Perceptions of Care for Emerging Adults with Type 1 Diabetes

Objective: Establishing care with adult providers is essential for emerging adults with type 1 diabetes (T1D) transitioning from pediatric care. Although research evaluating the transition from pediatric to adult care has been focused primarily on patients' perceptions, little is known about the adult providers' perspectives. We sought to ascertain adult providers' perspectives of caring for the medical and psychosocial needs of this patient population.Methods: We developed and mailed a survey to 79 regional adult endocrinologists and 186 primary care physicians (PCPs) identified through 2 regional insurance plans. Questions addressed perceived aptitude in clinical aspects of diabetes management, importance and availability of diabetes team members, and opinions regarding recommended transition methods.Results: The response rate was 43% for endocrinologists and 13% for PCPs. Endocrinologists reported higher aptitude in insulin management (P<.01). PCPs reported greater aptitude in screening and treating depression (P<0.01). Although endocrinologists and PCPs did not differ in their views of the importance of care by a comprehensive team, endocrinologists reported better access to diabetes educators and dieticians than PCPs (P<.01). Recommended transition methods were described as useful.Conclusion: These preliminary results suggest that endocrinologists are better prepared to assume diabetes care of emerging adults, whereas PCPs may be better prepared to screen and treat associated depression. Future studies are needed to determine if a medical home model with cooperative management improves care for emerging adults with T1D.Abbreviations: T1D = type 1 diabetes CDE = certified diabetes educator RD = registered dietitian PCPs = primary care physicians     

Transition From Pediatric to Adult Care for Individuals With Type 1 Diabetes: Opportunities and Challenges

ObjectivesType 1 diabetes (T1D) is a chronic disease with patients across the age spectrum that has high potential for morbidity and mortality. Unfortunately, patients transitioning from pediatric to adult care continue to demonstrate worsened glycemic control in part due to lack of understanding of transition of care best practices.MethodsThis review highlights the impact of existing transition of care interventions, assessment tools, and other recently published strategies for providers to consider to improve care of adolescent and young adult (AYA) patients with T1D in both hospital- and clinic-based settings.ResultsMany barriers impact patients with T1D during the transition period and disparities by race, sex, insurance status, and comorbid illness persist. As diabetic care continues to evolve and the prevalence of adolescents and young adults living with T1D increases, an intentional approach to transition of care is more pressing than ever. While current literature on transition of care models is limited, many show promise in improving clinic attendance and decreasing hospitalization. There are critical discussions that providers should lead with AYA patients to improve their outcomes and increase diabetes self-management, such as re-addressing carbohydrate counseling, sleep hygiene, and reproductive planning.ConclusionWhile further research on transition of care is needed, many care models offer the promise of improved T1D outcomes, enhancements in our approach to care, and increased value for our health care system at large.     

AECOPD并重度呼吸衰竭患者有创机械通气的治疗时机探讨及其预后的影响因素分析

摘要 目的：探讨慢性阻塞性肺疾病急性加重（AECOPD）合并重度呼吸衰竭患者有创机械通气的治疗时机,并分析其预后的影响因素。方法：选取2020年3月~2021年12月期间于首都医科大学附属北京世纪坛医院治疗的161例AECOPD合并重度呼吸衰竭患者,按照气管插管时间分为早期组（n=89）和延期组（n=72）,对比两组治疗后临床指标、血气分析指标及28 d内病死率（预后）。根据预后的不同将患者分为死亡组（n=29）和存活组（n=132）,收集患者的一般资料和实验室资料,采用Logistic回归分析预后的影响因素。结果：早期组的总机械通气时间、有创通气时间、重症监护室（ICU）住院时间均短于延期组（P<0.05）。两组治疗后动脉血二氧化碳分压（PaCO₂）较治疗前下降,氧合指数（OI）、动脉血氧分压（PaO₂）较治疗前升高,且早期组变化程度大于延期组（P<0.05）。延期组28 d内病死率为15/72（20.83%）。早期组28 d内病死率为14/89（15.73%）,两组患者的28 d病死率对比无差异（P>0.05）。单因素分析结果显示,AECOPD合并重度呼吸衰竭患者的预后影响因素与并发呼吸机相关肺炎、并发多脏器功能不全综合征、年龄、PaCO₂、血红蛋白（Hb）、血尿素氮（BUN）、白细胞计数（WBC）、pH值、中性粒细胞计数/淋巴细胞计数比值（NLR）、血小板计数/淋巴细胞计数（PLR）、C反应蛋白（CRP）、D-二聚体（D-D）、B型尿钠肽有关（P<0.05）。AECOPD合并重度呼吸衰竭患者预后不良的危险因素主要有并发呼吸机相关肺炎、并发多脏器功能不全综合征、PaCO₂偏高、年龄偏大、Hb偏低、pH值偏低、D-D偏高（P<0.05）。结论：AECOPD合并重度呼吸衰竭患者早期使用有创机械通气,可有效改善血气分析,缩短有创通气时间、总机械通气时间、ICU住院时间。并发呼吸机相关肺炎、并发多脏器功能不全综合征、PaCO₂偏高、年龄偏大、Hb偏低、pH值偏低、D-D偏高均是导致AECOPD合并重度呼吸衰竭患者预后不良的危险因素。     

脓毒症患儿预后的影响因素分析及pSOFA评分、PCIS评分及早期血乳酸测定的预测价值探讨

摘要 目的：分析脓毒症患儿预后的影响因素,并探讨儿科序贯器官衰竭评估（pSOFA）评分、小儿危重病例评分法（PCIS）评分及早期血乳酸（Lac）测定对预后的预测价值。方法：选取2020年1月～2022年5月我院儿童医学中心收治的107例脓毒症患儿,根据脓毒症患儿28 d生存情况分为死亡组48例和存活组59例。收集患儿临床资料,对患儿进行pSOFA评分、PCIS评分评价和血Lac检测。采用单因素和多因素Logistic回归分析脓毒症患儿死亡的影响因素,受试者工作特征（ROC）曲线分析pSOFA评分、PCIS评分和血Lac水平对脓毒症患儿死亡的预测价值。结果：107例脓毒症患儿28 d死亡率为44.86％（48/107）。死亡组脓毒症分级、合并器官损伤≥3个比例、机械通气比例、pSOFA评分、白细胞计数、D-二聚体、C反应蛋白、降钙素原、血Lac水平高于存活组,机械通气时间长于存活组,PCIS评分、血小板计数、白蛋白水平低于存活组（P＜0.05）。多因素Logistic回归分析显示,严重脓毒症、脓毒性休克、合并≥3个器官损伤、机械通气、pSOFA评分增加、D-二聚体升高、血Lac升高为脓毒症患儿死亡的独立危险因素,PCIS评分增加、白蛋白升高为独立保护因素（P＜0.05）。ROC曲线分析显示,pSOFA评分、PCIS评分和血Lac水平联合预测脓毒症患儿死亡的曲线下面积大于各指标单独预测。结论：脓毒症分级、合并器官损伤、机械通气、D-二聚体、白蛋白、pSOFA评分、PCIS评分、血Lac为脓毒症患儿预后的影响因素,pSOFA评分、PCIS评分和血Lac水平联合预测脓毒症患儿死亡风险的价值较高。     

Sex differences in the perceived intensity of breathlessness during exercise with advancing age.

The prevalence of activity-related breathlessness increases with age, particularly in women, but the specific underlying mechanisms have not been studied. This novel cross-sectional study was undertaken to examine the effects of age and sex, and their interaction, on the perceptual and ventilatory responses to incremental treadmill exercise in 73 healthy participants (age range 40-80 yr old) with normal pulmonary function. Age-related changes at a standardized oxygen uptake (Vo(2)) during exercise included significant increases in breathlessness ratings (Borg scale), ventilation (Ve), ventilatory equivalent for carbon dioxide, and the ratio of tidal volume (Vt) to dynamic inspiratory capacity (IC) (all P < 0.05). These changes were quantitatively similar in women (n = 39) and in men (n = 34). For the group as a whole, exertional breathlessness ratings increased as resting static inspiratory muscle strength diminished (P = 0.05), as exercise ventilation increased relative to capacity (P = 0.013) and as the Vt/IC ratio increased (P = 0.003) during exercise. Older women (60-80 yr old, n = 23) reported greater (P < 0.05) intensity of exertional breathlessness at a standardized Vo(2) and Ve than age-matched men (n = 16), despite similar age-related changes in ventilatory demand and dynamic ventilatory mechanics. These increases in breathlessness ratings in older women disappeared when sex differences in baseline maximal ventilatory capacity were accounted for. In conclusion, although increased exertional breathlessness with advancing age is multifactorial, contributory factors included higher ventilatory requirements during exercise, progressive inspiratory muscle weakness, and restrictive mechanical constraints on Vt expansion related to reduced IC. The sensory consequences of this age-related respiratory impairment were more pronounced in women, who, by nature, have relatively reduced maximal ventilatory reserve.     

The Role of Grandmothers in the Lives of Preschoolers Growing Up in Urban Poverty

Abstract

Little is known about how grandmothers may influence children's development, although they may frequently assist parents in the raising of their children, especially among low-income families. Data from Welfare, Children, and Families: A Three-City Study were used to explore how preschoolers function academically and psychologically over time based on grandmothers' residential status and level of caretaking responsibility. Longitudinal regression analyses suggest that children who consistently have custodial grandmothers lag behind their peers in the development of their academic achievement, whereas those in multigenerational households consistently have more socioemotional problems over time. However, many of these differences are accounted for by co-occurring family characteristics. Furthermore, children transitioning into the care of custodial grandmothers were found to have positive changes in self-regulation and socioemotional functioning, and those transitioning into multigenerational households had more problems with self-regulation over time.     

肺表面活性物质治疗新生儿呼吸窘迫综合征前给予nCPAP呼吸支持最佳时间窗的临床研究

摘要 目的：探讨肺表面活性物质（PS）治疗新生儿呼吸窘迫综合征（NRDS）前给予经鼻持续气道正压通气（nCPAP）呼吸支持的最佳时间窗。方法：选择2017年1月至2019年12月期间我院收治的NRDS患儿100例。根据随机数字表法分为A组（给予PS前预先进行小于2 h的nCPAP,n=33）、B组（给予PS前预先进行2-4 h的nCPAP,n=33）和C组（立即给予PS,n=34）。对比三组患儿的血气分析指标、肺功能指标、临床指标和并发症发生率。结果：A组、B组给予PS后4h、给予PS后24 h动脉血氧分压（PaO₂）、pH值高于C组,且B组高于A组（P<0.05）,而动脉二氧化碳分压（PaCO₂）低于C组,且B组低于A组（P<0.05）。A组、B组给予PS后4 h、给予PS后24 h潮气量（VT）、肺动态顺应性（CD）高于C组,且B组高于A组（P<0.05）,而吸气阻力（Raw）低于C组,且B组低于A组（P<0.05）。B组用药后3天内需气管插管行机械通气例数少于A组和C组,住院时间短于A组和C组（P<0.05）,A组、C组的用药后3天内需气管插管行机械通气例数、住院时间对比无明显差异（P>0.05）。三组患儿并发症发生率未见统计学差异（P>0.05）。结论：给予PS前预先进行2-4h的nCPAP,可较好地改善患儿血气分析指标和肺功能,有助于改善患儿预后。     

Zorgzame vrienden en buren als mantelzorgers van oudere volwassenen: een vergelijking met kinderen

This study compared informal care to older, non-coresiding adults provided by friends and neighbours and informal care by children or their partners. Using data from a Dutch representative survey among informal caregivers conducted by CBS and SCP, caregivers of friends (n=133), neighbours (n=108) and parents (n=1,008) were compared with one another to investigate care that friends and neighbours provide to the elderly non-coresiding adults (age 55 and over). Nine percent of those providing care to someone outside the household were friends and nine percent were neighbours. Friends, like children, usually provide long-lasting care, up to four or five years. Friends are similar to neighbours in the number of hours that they provide care. Friends and neighbours experience a lower caregiver burden than children. However, when fulfilling multiple caring tasks, both friends and children, have a greater chance of experiencing higher levels of burden. When there were other caregivers to help, friends experienced a small reduction in burden. Friends and neighbours deserve to be recognized as informal caregivers by policy makers and they deserve attention and support along with family caregivers.     

Effect of recolonisation with "interfering" alpha streptococci on recurrences of acute and secretory otitis media in children: randomised placebo controlled trial

ObjectiveTo study the effect of recolonisation with α streptococci with the ability to inhibit the growth of otopathogens (“interfering” activity) on the recurrence of acute otitis media in susceptible children and the effect on the frequency of secretory otitis media.DesignDouble blind, randomised, placebo controlled study.SettingEar, nose, and throat clinic with three doctors.Participants130 children prone to otitis media aged between 6 months and 6 years, 108 of whom were eligible and followed for 3 months.InterventionsChildren with no recurrences during the last month received phenoxymethylpenicillin (n=22), and those with a recurrence within 1 month received amoxicillin clavulanic acid (n=86), both twice daily for 10 days. These were followed by a streptococcal or placebo solution sprayed into the nose for a further 10 days. At day 60 the same spray was started for another 10 days.ResultsAt 3 months 22 children (42%) given the streptococcal spray were healthy and had a normal tympanic membrane compared with 12 (22%) of those given placebo. This difference was shown separately for recurrences of both acute otitis media and secretory otitis media.ConclusionsSelected bacteria with the ability to inhibit the growth of common otopathogens can be used to protect against recurrent acute otitis media and secretory otitis media in children.     

Multimodal home care intervention for dependent older people “Live better at home”: Protocol of a randomized clinical trial

BackgroundThe intensity of the home care interventions for dependent older people offered in Spain may not be sufficient to help keep older people living at home, being the institutionalization in a nursing home (NH) an unavoidable consequence.ObjectiveTo evaluate the effect of intensification in home care interventions on users with grade II or III dependency, as well as training for their informal caregivers in order to delay or avoid their institutionalization in a NH.MethodsA randomized clinical trial with two parallel arms and blinded assessment will be conducted at the community level in two municipalities in Catalonia (Spain). The study will include those older people (aged 65 and over) living in the community, with degree II or III of dependency, users of the public home care unwilling to be institutionalized and with a main informal caregiver in charge, who will also participate in the study. The assessments will be performed monthly up to 15 months, when the intervention will be finished. The main outcome will be the time until the willingness for admission to a NH. Secondary variables will be composed of sociodemographic, health, psychosocial, resource use, and follow-up variables. A multivariate Cox regression model will be carried out to estimate the effectiveness of the intervention.DiscussionA multimodal home care intervention could improve the health and psychosocial status of dependent people and their informal caregivers and facilitate their permanence at home.Trial registrationNCT05567965     

Hair trace element concentrations in autism spectrum disorder (ASD) and attention deficit/hyperactivity disorder (ADHD)

BackgroundThe existing data demonstrate that alteration of trace element and mineral status in children with neurodevelopmental disorders including ASD and ADHD. However, comparative analysis of the specific patterns of trace element and mineral metabolism in children with ASD and ADHD was not performed. Therefore, the primary objective of the present study was to assess hair trace element and mineral levels in boys with ADHD, ASD, as well as ADHD with ASD.MethodsBoys with ADHD (n = 52), ASD (n = 53), both ADHD and ASD (n = 52), as well as neurotypical controls (n = 52) were examined. Hair analysis was performed using inductively-coupled plasma mass-spectrometry.ResultsThe obtained data demonstrate that hair Co, Mg, Mn, and V levels were significantly reduced in children with ADHD and ASD, and especially in boys with ADHD + ASD. Hair Zn was found to be reduced by 20% (p = 0.009) only in children with ADHD + ASD as compared to healthy controls. Factor analysis demonstrated that ASD was associated with significant alteration of hair Co, Fe, Mg, Mn, and V levels, whereas impaired hair Mg, Mn, and Zn content was also significantly associated with ADHD. In regression models hair Zn and Mg were negatively associated with severity of neurodevelopmental disorders. The revealed similarity of trace element and mineral disturbances in ASD and ADHD may be indicative of certain similar pathogenetic features.ConclusionThe obtained data support the hypothesis that trace elements and minerals, namely Mg, Mn, and Zn, may play a significant role in development of both ADHD and ASD. Improvement of Mg, Mn, and Zn status in children with ASD and ADHD may be considered as a nutritional strategy for improvement of neurodevelopmental disturbances, although clinical trials and experimental studies are highly required to support this hypothesis.     

Interventions to reengage people living with HIV who are lost to follow-up from HIV treatment programs: A systematic review and meta-analysis

BackgroundOptimizing services to facilitate engagement and retention in care of people living with HIV (PLWH) on antiretroviral therapies (ARTs) is critical to decrease HIV-related morbidity and mortality and HIV transmission. We systematically reviewed the literature for the effectiveness of implementation strategies to reestablish and subsequently retain clinical contact, improve viral load suppression, and reduce mortality among patients who had been lost to follow-up (LTFU) from HIV services.Methods and findingsWe searched 7 databases (PubMed, Cochrane, ERIC, PsycINFO, EMBASE, Web of Science, and the WHO regional databases) and 3 conference abstract archives (CROI, IAC, and IAS) to find randomized trials and observational studies published through 13 April 2020. Eligible studies included those involving children and adults who were diagnosed with HIV, had initiated ART, and were subsequently lost to care and that reported at least one review outcome (return to care, retention, viral suppression, or mortality). Data were extracted by 2 reviewers, with discrepancies resolved by a third. We characterized reengagement strategies according to how, where, and by whom tracing was conducted. We explored effects, first, among all categorized as LTFU from the HIV program (reengagement program effect) and second among those found to be alive and out of care (reengagement contact outcome). We used random-effect models for meta-analysis and conducted subgroup analyses to explore heterogeneity. Searches yielded 4,244 titles, resulting in 37 included studies (6 randomized trials and 31 observational studies). In low- and middle-income countries (LMICs) (N = 16), tracing most frequently involved identification of LTFU from the electronic medical record (EMR) and paper records followed by a combination of telephone calls and field tracing (including home visits), by a team of outreach workers within 3 months of becoming LTFU (N = 7), with few incorporating additional strategies to support reengagement beyond contact (N = 2). In high-income countries (HICs) (N = 21 studies), LTFU were similarly identified through EMR systems, at times matched with other public health records (N = 4), followed by telephone calls and letters sent by mail or email and conducted by outreach specialist teams. Home visits were less common (N = 7) than in LMICs, and additional reengagement support was similarly infrequent (N = 5). Overall, reengagement programs were able to return 39% (95% CI: 31% to 47%) of all patients who were characterized as LTFU (n = 29). Reengagement contact resulted in 58% (95% CI: 51% to 65%) return among those found to be alive and out of care (N = 17). In 9 studies that had a control condition, the return was higher among those in the reengagement intervention group than the standard of care group (RR: 1.20 (95% CI: 1.08 to 1.32, P < 0.001). There were insufficient data to generate pooled estimates of retention, viral suppression, or mortality after the return.ConclusionsWhile the types of interventions are markedly heterogeneity, reengagement interventions increase return to care. HIV programs should consider investing in systems to better characterize LTFU to identify those who are alive and out of care, and further research on the optimum time to initiate reengagement efforts after missed visits and how to best support sustained reengagement could improve efficiency and effectiveness.