Respiratory Episodes Research Articles

Cardiac arrest in obstructive sleep apnea syndrome: treatment options. Case series

Clinical data of seven patients with severe obstructive sleep apnea, in whom episodes of asystole were recorded at night, is analyzed. In five of seven cases against the background of initiated CPAP therapy (all patients were compliant with the therapy), episodes of asystole were eliminated, and only two cases required the installation of a pacemaker. Conclusions are drawn about the possibility of asystole developing in the background of obstructive respiratory episodes during sleep in patients with severe OSAS and the preventive effect of CPAP therapy.

Respiratory viruses in individuals with a high frequency of animal exposure in southern and highland Vietnam.

Active surveillance for zoonotic respiratory viruses is essential to inform the development of appropriate interventions and outbreak responses. Here we target individuals with a high frequency of animal exposure in Vietnam. Three‐year community‐based surveillance was conducted in Vietnam during 2013‐2016. We enrolled a total of 581 individuals (animal‐raising farmers, slaughterers, animal‐health workers, and rat traders), and utilized reverse transcription‐polymerase chain reaction to detect 15 common respiratory viruses in pooled nasal‐throat swabs collected at baseline or acute respiratory disease episodes. A respiratory virus was detected in 7.9% (58 of 732) of baseline samples, and 17.7% (136 of 770) of disease episode samples (P < .001), with enteroviruses (EVs), rhinoviruses and influenza A virus being the predominant viruses detected. There were temporal and spatial fluctuations in the frequencies of the detected viruses over the study period, for example, EVs and influenza A viruses were more often detected during rainy seasons. We reported the detection of common respiratory viruses in individuals with a high frequency of animal exposure in Vietnam, an emerging infectious disease hotspot. The results show the value of baseline/control sampling in delineating the causative relationships and have revealed important insights into the ecological aspects of EVs, rhinoviruses and influenza A and their contributions to the burden posed by respiratory infections in Vietnam.

Tracheomalacia and Tracheobronchomalacia in Pediatrics: An Overview of Evaluation, Medical Management, and Surgical Treatment.

Tracheobronchomalacia (TBM) refers to airway collapse due to typically excessive posterior membrane intrusion and often associated with anterior cartilage compression. TBM occurs either in isolation or in association with other congenital or acquired conditions. Patients with TM typically present non-specific respiratory symptoms, ranging from noisy breathing with a typical barking cough to respiratory distress episodes to acute life-threatening events and recurrent and/or prolonged respiratory infections. There are no definitive standardized guidelines for the evaluation, diagnosis, and treatment of TBM; therefore, patients may be initially misdiagnosed and incorrectly treated. Although milder cases of TBM may become asymptomatic as the diameter of the airway enlarges with the child, in cases of severe TBM, more aggressive management is warranted. This article is an overview of the clinical presentation, evaluation, diagnosis, medical management, and surgical treatment options in pediatric tracheomalacia.

2215. Diarrheal Illness as a Risk Factor for Subsequent Respiratory Infection Among Women and Infants in Nepal

BackgroundGlobally, diarrheal and respiratory infections are responsible for nearly one-quarter of deaths in children under 5 years old. Historically these diseases have been studied separately; recent evidence suggests that preceding diarrheal disease may be a risk factor for subsequent respiratory illness. We sought to identify whether diarrhea was associated with subsequent respiratory illness in adult women and infants in Nepal.MethodsWe used data from a community-based, prospective randomized trial of maternal influenza immunization of pregnant women and their infants conducted in rural Nepal from 2011 to 2014. Diarrhea episodes were defined as at least three self-reported watery bowel movements per day for one or more days. Respiratory illness episodes were defined as the presence of fever with an additional respiratory symptom. Diarrhea and respiratory illness episodes were identified through longitudinal household-based weekly symptom surveillance. A case-crossover design was used to determine whether risk of respiratory infection was increased in the 30 days following a diarrhea episode compared with the 30 days prior.ResultsOf 3,693 women in the study and their 3,646 infants, 525 (14.2%) women experienced one or more episodes of diarrhea during pregnancy, 226 (9.4%) women experienced one or more episodes of diarrhea after pregnancy, and 342 (9.4%) infants had one or more episodes of diarrhea. The incidence of respiratory episodes during the exposure and control periods was approximately 2–5% in adults and 8–10% in infants. Preceding diarrhea was not significantly associated with respiratory infection in adult women or infants. There was a slight trend toward greater incidence of diarrhea during the exposure period among infants (Figure 1), but it was not statistically significant. These results held after a sensitivity analysis limiting follow-up time to 15 days before and after diarrhea episode.ConclusionIn this study of pregnant and postpartum women and their infants in Nepal, diarrheal illness was not a significant risk factor for subsequent respiratory illness. Disclosures All authors: No reported disclosures.

Comparison of Rates of Hospitalization Between Single and Dual Virus Detection in a Mexican Cohort of Children and Adults With Influenza-Like Illness.

BackgroundMolecular detection methods allow for the simultaneous detection of several infectious agents. This study assesses whether co-infection with 2 viruses as compared with 1 is associated with increased hospitalization in those with acute respiratory infections.MethodsWe prospectively enrolled a cohort of pediatric and adult participants with influenza-like illness during 2010–2014 in Mexico. Clinical information and respiratory samples were collected at enrollment. Respiratory viruses were detected with multiplex polymerase chain reaction (PCR) and influenza-specific reverse transcription PCR assays. Participants were followed for 14 and 28 days after inclusion. Severity of disease, as measured by hospitalization with acute respiratory infections, was compared between single and dual viral infections.ResultsAmong 5662 participants in the study, either 1 (n = 3285) or 2 (n = 641) viruses were detected in 3926 participants. Rhinovirus (n = 1433), influenza (n = 888), and coronaviruses (n = 703) were the most frequently detected viruses (either alone or in co-infection). Bocavirus, respiratory syncytial virus (RSV), metapneumovirus, and rhinovirus cases were hospitalized more often than other viruses. Bocavirus+rhinovirus cases were hospitalized more often than those with rhinovirus alone (but not bocavirus alone). RSV cases were more likely to be hospitalized than cases with co-infections of RSV and parainfluenza virus or coronavirus. Metapneumovirus cases were hospitalized more often than those co-infected with metapneumovirus+coronavirus.ConclusionsIn this study, detection of 2 viruses did not significantly increase hospitalizations compared with single virus infections. Larger studies will allow for distinguishing between sequential and simultaneous infection and for a better understanding of the role of each virus during the evolution of acute respiratory episodes.

P.99A multiplex in situ hybridisation and immunohistochemical (ISH-IHC) assay to study developmental changes in relation to fibre type and sodium channels in human skeletal muscle and their contribution to disease severity

SCN4A codes for a skeletal muscle sodium channel (SCN) that is essential for muscle excitability and contraction. SCN4A mutations cause a number of neuromuscular phenotypes including myotonia and periodic paralysis. Infants with SCN4A mutations have common and/or severe respiratory compromise include life-threatening apnoeas, whilst adults do not. Recently we described SCN4A-linked sudden infant death. Surviving infants show a spontaneous reduction in respiratory episodes with age, even if untreated, suggesting a developmental contribution to the clinical phenotype. Lack of isoform-specific SCN monoclonal antibodies are a major bottleneck in functional and pathological studies of SCN gene mutations. To study the expression of SCNs in relation to the fibre type and developmental stage we have developed two multiplex assays for testing on whole transverse frozen sections from control human skeletal muscle biopsies (0-16 years) in whom a primary neuromuscular disorder is excluded. Samples are recruited from the MRC CNMD biobank in London. Assay 1 (ISH-IHC) includes fluorescent multiplex labelling of isoform-specific mRNA probes to SCN4A, SCN5A (ACDBio), and antibodies to pan-fast/slow myosin heavy chain and laminin alpha-2, latter used as mask for myofibre identification. Assay 2 is a fully automated multi-coloured chromogenic IHC protocol (Roche Diagnostics) allowing detection of myosin heavy chain isoforms I, IIA and IIX in a single skeletal muscle section. Further assay optimisation including creating an Assay-1-2 hybrid and developing a digital script for mRNA quantification are in progress. Age-stratified data on fibre-type composition and fibre-specific SCN4A/5A-mRNA expression will be presented. Knowledge of developmental changes in fibre-type proportions may help in understanding differences in phenotype of infants and adults with SCN4A mutations. mRNA expression data will be valuable in validating future isoform-specific SCN antibodies.

Viral respiratory tract infections in young children with cystic fibrosis: a prospective full-year seasonal study

BackgroundViral respiratory tract infections are common during early childhood. How they impact cystic fibrosis lung disease history in young children is poorly known. The principal aim of our study was to determinate respiratory tract infections frequency in this cystic fibrosis young population. Secondary outcomes were nature of viral agents recovered and impact of such infections.MethodsWe conducted a prospective cohort study of 25 children affected by cystic fibrosis and aged less than 2 years. Nasal samplings were taken systematically monthly or bimonthly with additional samples taken during respiratory tract infections episodes. Ten pathogens were tested by a combination of five duplex RT-PCRs or PCRs: influenza A and B, respiratory syncytial virus (RSV), metapneumovirus (MPV), rhinovirus/enterovirus(RV/EV)), coronavirus (HKU1, NL63, 229E and OC43), parainfluenza virus (1–4), adenovirus and bocavirus (Respiratory Multi-Well System MWS r-gene®, BioMérieux, Marcy l’Étoile, France). Cycle thresholds (CTs) were reported for all positive samples and considered positive for values below 40. Quantitative variables were compared using a nonparametric statistical test (Wilcoxon signed rank for paired comparisons). Pearson’s correlation coefficient (r) was used to assess relationships between two variables. Statistical analyses were performed using SAS v9.4 (SAS Institute, Cary, NC, USA) or GraphPad Prism V6.00 (GraphPad Software, La Jolla, CA, USA). The significance level was set at 0.05.ResultsThe mean age at inclusion was 9.6 ± 6.7 months. The patients had 3.4 ± 1.7 respiratory tract infections episodes per child per year. Forty-four respiratory tract infections (69%) were associated with virus: rhinovirus and enterovirus (RV/EV) were implied in 61% of them and respiratory syncytial virus (RSV) in 14%. Only one patient required hospitalization for lower respiratory tract infections. 86% of the patients were treated by antibiotics for a mean of 13.8 ± 6.2 days. RSV infections (n = 6) were usually of mild severity.ConclusionsRespiratory tract infections in young children with cystic fibrosis were of mild severity, rarely requiring hospitalization. Unsurprisingly, RV/EV were the most frequent agents. RSV-related morbidity seems low in this population. This raises the question of the usefulness of RSV preventive medication in this young population.

A randomized, placebo-controlled, double-blinded, single-centre, phase IV trial to assess the efficacy and safety of OM-85 in children suffering from recurrent respiratory tract infections

BackgroundOver many years, OM-85, a lysate of 21 common bacterial respiratory pathogens, has been demonstrated to prevent respiratory recurrences in children. However, further studies are needed to explore the true importance of OM-85 in the prevention of respiratory tract infections (RTIs) in children. This study was planned to further contribute to the evaluation of the role played by OM-85 in prevention of recurrent RTIs in children.MethodsThis study was a randomized (3:3:1), placebo-controlled, double-blind, single-centre, phase IV trial carried out in Italy to assess the efficacy of OM-85 (Broncho-Vaxom®; Vifor Pharma; Meyrin 2/Geneva, Switzerland) in reducing the number of new RTI episodes in 288 children aged 1 to 6 years with a history of recurrent RTIs and to compare the efficacy of the standard 3-month regimen with that of administration of OM-85 for 6 months during a 6-month study period.ResultsThe number of RTIs and of children who experienced at least one RTI were significantly lower among patients receiving OM-85 for 3 months than among those given placebo (33% vs 65.1%, p < 0.0001). Differences were statistically significant for upper RTIs (i.e., common cold/viral pharyngitis and acute otitis media; p < 0.0001 and p = 0.006, respectively). Days of absence from day-care for children and working days lost by parents were significantly lower in the group with children treated with OM-85 for 3 months than in the placebo group (p = 0.007 and p = 0.004, respectively). No difference was seen between children who received OM-85 for 3 and those who received OM-85 for 6 months. The prevalence of atopy as well as the history of recurrent wheezing and age of the study child did not influence the results. Benefit was maximally evident among children with a history of frequent recurrences. OM-85 was well tolerated and safe, even in children who received an influenza vaccination.ConclusionsThe use of OM-85 for 3 months in 3 series of 10 consecutive days each time reduces the risk of recurrent RTIs in children, with a favourable safety profile. The greater effect observed in children prone to several respiratory episodes than in non-prone children seems to indicate that this lysate should be administered especially to children with a proven high susceptibility to RTIs.

Phylogenetic characterization of rhinoviruses from infants in Sarlahi, Nepal.

ProblemRhinoviruses (RVs), the most common causes of acute respiratory infections in young children and infants, are highly diverse genetically.ObjectiveTo characterize the RV types detected with respiratory illness episodes in infants in Nepal.Study methodsInfants born to women enrolled in a randomized trial of maternal influenza immunization in rural, southern Nepal were followed with household‐based weekly surveillance until 180 days of age. Infants with respiratory symptoms had nasal swabs tested for twelve respiratory viruses. A subset with RV alone was selected for sequencing of the VP4/2 gene to identify RV types.ResultsAmong 547 RV‐only positive illnesses detected from December 2012 to April 2014, 285 samples (52%) were sequenced. RV‐A, B, and C species were detected in 193 (68%), 18 (6%), and 74 (26%) specimens, respectively. A total of 94 unique types were identified from the sequenced samples, including 52 RV‐A, 11 RV‐B, and 31 RV‐C. Multiple species and types circulated simultaneously throughout the study period. No seasonality was observed. The median ages at illness onset were 88, 104, and 88 days for RV‐A, B, and C, respectively. The median polymerase chain reaction cycle threshold values did not differ between RV species. No differences between RV species were observed for reported respiratory symptoms, including pneumonia, or for medical care‐seeking.ConclusionsAmong very young, symptomatic infants in rural Nepal, all three species and many types of RV were identified; RV‐A was detected most frequently. There was no association between RV species and disease severity.

Postoperative pulmonary complications in contemporary cohort of patients with pulmonary hypertension.

Patients with pulmonary hypertension are at increased risk for postoperative pulmonary complications (PPCs). Herein, we review PPCs in pulmonary hypertension patients undergoing non-cardiac procedures under general anesthesia. The medical records of pulmonary hypertension patients who underwent surgery with general anesthesia between 2010 and 2017 were reviewed for PPCs. In addition we reviewed nursing-documented respiratory depressive episodes in the post-anesthesia care unit to assess the associations between these episodes and later PPCs. There were 20 PPCs among 128 patients who underwent 197 procedures (10.2 per 100 surgeries) [95% CI 6.7-15.2]. Of these, 5 occurred during anesthesia recovery and 15 following anesthesia recovery. Three-quarters of the PPCs occurred within 24 postoperative hours. All the PPCs were severe. The frequency of PPCs was significantly higher in those who experienced respiratory depression during anesthesia recovery vs. in those who did not (5/17, 29% vs. 10/175, 6%; odds ratio 5.15, 95% CI 1.58-16.81, p = 0.007). Increased PPC rates were observed among patients who were current/previous smokers and who routinely use benzodiazepines, and among those undergoing emergent surgery. With treatment, all PPCs resolved. The rate of PPCs in the population of contemporary surgical pulmonary hypertension patients was 10.2%, and three-quarters occurred during first 24 postoperative hours. Patients who had respiratory depression during anesthesia recovery were 5-fold more likely to experience later PPCs.

DOCK8 mutation diagnosed using whole-exome sequencing of the dried blood spot-derived DNA: a case report of an Iraqi girl diagnosed in Japan

BackgroundDedicator of cytokinesis 8 (DOCK8) deficiency (MIM #243700) is a rare disease, leads to a combined primary immunodeficiency (PID), and accounts for the autosomal recessive-hyper immunoglobulin E syndrome (AR-HIES). DOCK8 deficiency status characterizes by recurrent infections, atopy, and risk of cancer. Lymphoproliferative disease complicating PID, is difficult to diagnose. Our aim is to present a rare case of PID, and to the best of our knowledge, she is the first case of DOCK8 deficiency from Iraq. The genetic diagnosis was carried out in Japan using dried blood spot-based DNA transfer and whole-exome sequencing.Case presentationAn 11-year-old Iraqi girl, of double first-cousin-parents, had a history of severe eczema, food allergy, and repeated infections. She presented with a jaw mass, bilateral cervical and axillary lymphadenopathy, and immunoglobulin (Ig) assays of 20, 3.3 and 1.7-fold above maximum normal level for age of IgE, IgA and IgG, respectively, along with a low IgM, eosinophilia and lymphopenia. Based on the jaw mass biopsy, non-Hodgkin lymphoma was suggested in Iraq, whereas histopathological re-evaluation in Japan revealed the diagnosis of a polyclonal reactive proliferation spectrum of lymphoproliferative disorders/plasmacytic hyperplasia, complicating PID. Whole-exome sequencing supported the diagnosis of PID by identifying a homozygous DOCK8 mutation with previously reported pathogenicity (NM_203447:c.3332delT, p.Phe1113Leufs*2), that may be attributed to consanguinity.ConclusionsInternational collaboration using an effective DNA transportation technique and next-generation sequencing was the key to pinpoint the diagnosis of DOCK8 deficiency. Our case asserted that careful pathogenetic evaluation, in an advanced setting, was crucial for ruling out the neoplastic process. Pediatricians in areas with a high prevalence of consanguinity marriage should have a high index of suspicion of DOCK8 deficiency in patients with recalcitrant eczema, and frequent respiratory and skin infectious episodes.

Episodic viral wheeze and multiple-trigger wheeze in preschool children are neither distinct nor constant patterns. A prospective multicenter cohort study in secondary care.

To evaluate whether episodic viral wheeze (EVW) and multiple-trigger wheeze (MTW) are clinically distinguishable and stable preschool wheezing phenotypes. Children of age 1 to 4 year with recurrent, pediatrician-confirmed wheeze were recruited from secondary care; 189 were included. Respiratory and viral upper respiratory tract infection (URTI) symptoms were recorded weekly by parents in an electronic diary during 12 months. Every 3 months, diary-based symptoms were classified as EVW or MTW and compared to phenotypes assigned by pediatricians based on clinical history. We collected nasal samples for respiratory virus PCR during URTI, respiratory symptoms and in absence of symptoms. Of 660 3-month periods, the diary-based phenotype was EVW in 11%, MTW in 54% and 35% were free from respiratory episodes. Pediatrician-based classification showed 59% EVW and 26% MTW. The Kappa measure of agreement between diary-based and pediatrician-assigned phenotypes was very low (0.12, 95%CI, 0.07-0.17). Phenotypic instability was observed in 32% of cases. PCR was positive in 71% during URTI symptoms, 66% during respiratory symptoms and 38% in the absence of symptoms. This study shows that EVW and MTW are variable over time within patients. Pediatrician classification of these phenotypes based on clinical history does not correspond to prospectively recorded symptom patterns. The applicability of these phenotypes as a basis for therapeutic decisions and prognosis should be questioned.

The Vest™ High-Frequency Chest Wall Oscillation System Compared with Manual Chest Wall Physiotherapy for Managing Airway Clearance in Patients with Complex Neurological Disorders: A UK-based Cost-Effectiveness Analysis

Background: Weakness in the muscles used to breathe and swallow can lead to difficulties with airway clearance for people with neurological disorders including neuromuscular disease and cerebral palsy. This can lead to aspiration and other respiratory problems which are the leading causes of death in patients with complex neurological disorders. The Vest™ system supports airway clearance through the use of High-Frequency Chest Wall Oscillation (HFCWO) to loosen secretions in the chest by reducing their viscosity. Objective: To assess the cost-effectiveness of the Vest™ system versus Manual Chest Wall Physiotherapy (MCWP) for airway clearance in patients with neurological disorders including neuromuscular disease and cerebral palsy. Methods: A decision-analytic Markov model was developed to estimate the cost-effectiveness of HFCWO and MCWP over 5- and 10-year time horizons. Costs were estimated from the perspective of the UK National Health Service and personal social services. The main input parameters in the model were: rates of respiratory infection, respiratory-related hospitalisation, antibiotic use for respiratory infection and cost of the Vest™ system. The input parameters were informed by existing clinical guidelines and literature. Sensitivity analyses were conducted to explore uncertainties around the input parameters. Results: Over 5- and 10-year time horizons, the Vest™ system results in more quality-adjusted life-years and lower costs per patient. The Vest™ system has a high probability of being cost-effective (&gt;98%) at willingness-to-pay thresholds of £20,000 and £30,000. The estimated average cost saving per patient over a 5-year time horizon is £5,660 (SD = £2362). Our results show that the Vest™ system may result in approximately £6 million cost savings per 1,000 patients with complex neurological disorders in 5 years. Per 1,000 patients, 2,442 hospital admissions and 49,868 bed days could be averted with the use of the Vest™ system. Our results were generally robust to the sensitivity analyses performed. Conclusion: The Vest™ system results in fewer respiratory infection episodes and hospitalisations, and thus less National Health Service (NHS) resource use, than current practice. Therefore, it is highly likely to be a cost-saving strategy.

The association between stressful life events and respiratory infections during the first 4years of life: The Environmental Determinants of Diabetes in the Young study.

The aim of this study was to conduct a prospective analysis of the association between negative life events (NLEs) and respiratory infections in children genetically at risk for islet autoimmunity (IA) and type 1 diabetes (T1D). Long- and short-term temporal associations between NLEs and rate of respiratory infection episodes (RIEs) in 5,618 children in The Environmental Determinants of Diabetes in the Young study for at least 1 up to 4years were analysed. All models were adjusted for demographic, day care, season of infection, and psychosocial factors associated with the rate of child RIEs between study visits. The rate of child RIEs was 26% higher in Europe (Sweden, Finland, Germany) than in the United States (rate ratio [RR]=1.26, p<0.001). However, the percentage of child NLEs (odds ratio [OR]=1.18, p<0.001) and mother NLEs (OR=1.83, p<0.001) was higher in the United States compared with Europe. In both continents (Europe, RR=1.12, p<0.001; United States, RR=1.07, p=0.006), high child cumulative NLEs (>1NLE per year since study inception) was significantly associated with an increased rate of child RIEs. This large-scale prospective study confirms observations that stress may increase the susceptibility for infections in paediatric populations and suggests at least one mechanism by which stress could increase risk for IA and T1D in genetically at risk children.

Evidence for Cross-Protection Against Subsequent Febrile Respiratory Illness Episodes From Prior Infections by Different Viruses Among Singapore Military Recruits 2009-2014.

BackgroundFew studies have evaluated the relative cross-protection conferred by infection with different groups of viruses through studies of sequential infections in humans. We investigated the presence of short-lived relative cross-protection conferred by specific prior viral infections against subsequent febrile respiratory illness (FRI).MethodsMen enlisted in basic military training between December 2009 and December 2014 were recruited, with the first FRI as the study entry point. ResPlex II assays and real-time polymerase chain reaction assays were used to detect viral pathogens in nasal wash samples, and survival analyses were performed to determine whether infection with particular viruses conferred short-lived relative cross-protection against FRI.ResultsPrior infection with adenovirus (hazard ratio [HR], 0.24; 95% confidence interval [CI], .14–.44) or influenza virus (HR, 0.52; 95% CI, .38–.73) conferred relative protection against subsequent FRI episode. Results were statistically significant even after adjustment for the interval between enlistment and FRI (P < .001). Adenovirus-positive participants with FRI episodes tended to be protected against subsequent infection with adenovirus, coronavirus, enterovirus/rhinovirus, and influenza virus (P = .062–.093), while men with influenza virus–positive FRI episodes tended be protected against subsequent infection with adenovirus (P = .044) and influenza virus (P = .081).ConclusionPrior adenovirus or influenza virus infection conferred cross-protection against subsequent FRI episodes relative to prior infection due to other circulating viruses.

Sex-specific prevalence and trends in acute respiratory infection episodes among children less than 5 years in Nigeria.

Biological sex is an important factor that influences childhood morbidity and mortality but its role in acute respiratory infections (ARI) in children is not well understood. We investigated the trends in sex-specific prevalence of childhood ARI episodes and associated factors in Nigerian children from 1990 to 2013. This secondary analysis used data from the Nigerian Demographic Health Surveys (NDHS) collected in 1990, 1999, 2003, 2008 and 2013. Variables extracted include: two ARI-related questions, household characteristics, children's anthropometry and vaccination status. We defined ARI as maternal report of cough accompanied by short, rapid breathing. Univariate and bivariate analyses were carried out to estimate prevalence of suspected ARI and compared between male and female children. We found an initial increase followed by a decreasing trend in prevalence of ARI-related symptoms among under-5 children; from 6.7% in 1990 to 11.6% in 1999 then to 3.8% in 2013 without consistent sex differences regardless of other factors except malnutrition. In the 2003 survey, more male than female children had ARI among underweight [OR = 1.22 (95% CI: 1.04, 1.43)] and stunted [OR = 1.23 (95% CI: 1.07, 1.43)] children. Similarly, the 2008 survey showed that more male (5.8%) than female (5.4%) children in the wasted category had ARI [OR = 1.13 (95% CI: 1.07, 2.01)]. The highest prevalence of suspected ARI was consistently recorded in the North-East region. The Nigeria Demographic Health Surveys demonstrated no consistent sex differences in burden and trends of childhood pneumonia-like episodes over a 24-year period. Malnutrition has some influence on the burden of ARI-related symptoms.

Italian recommendations for diagnosis and management of congenital myasthenic syndromes.

Congenital myasthenic syndromes (CMS) are genetic disorders due to mutations in genes encoding proteins involved in the neuromuscular junction structure and function. CMS usually present in young children, but perinatal and adult onset has been reported. Clinical presentation is highly heterogeneous, ranging from mild symptoms to severe manifestations, sometimes with life-threatening respiratory episodes, especially in the first decade of life. Although considered rare, CMS are probably underestimated due to diagnostic difficulties. Because of the several therapeutic opportunities, CMS should be always considered in the differential diagnosis of neuromuscular disorders. The Italian Network on CMS proposes here recommendations for proper CMS diagnosis and management, aiming to guide clinicians in their practical approach to CMS patients.

Oral probiotics influence oral and respiratory tract infections in pediatric population: a randomized double-blinded placebo-controlled pilot study.

Acute oral and respiratory tract infections (RTIs) are highly present in the general population, and they represent one of the most impacting causes of morbidity and mortality every year. The aim of our study was to assess the clinical impact of oral probiotics on acute oral and respiratory tract infections affecting paediatric patients. This is a randomized, double-blinded placebo-controlled clinical study, where probiotics have been compared with placebo in a double-blinded investigation. 40 subjects with a recent clinical history reporting oral and respiratory tract infections were randomly selected and assigned to control (n=20) or the probiotics (n=20) group. During the 3 months before the starting, all subjects were assessed with several salivary examinations. We found significant differences in the incidence of oral and respiratory tract infections between control and probiotic group, with a marked reduction of oral and respiratory tract infections episodes in the probiotic group. Salivary examinations gave similar results in both the groups, however, despite the salivary flow, viscosity and buffering were similar, on the contrary, pH values were found to be more alkaline in patients of probiotic group. This study showed the main positive effects related to a supplementation with probiotics in order to prevent or reduce the incidence of infections onset in oral and respiratory tracts without any drugs-related adverse effects.

BREATHING CESSATION IN CHILD WITH ASTHMA AND INDUCIBLE LARYNGEAL OBSTRUCTION: WHEN TWO DIAGNOSES AREN'T ENOUGH

Introduction It is important to consider the differential of breathing cessation in a patient with established diagnoses, such as asthma and inducible laryngeal obstruction (ILO). Uncommon etiologies may masquerade as asthma or ILO exacerbations. Case Description A 5-year-old boy with history of asthma was referred for evaluation of recurrent respiratory episodes presumed to be from ILO. These episodes were characterized by complete absence of airflow, lasting 5-60 seconds with spontaneous resolution, occurring up to 20 times a day, every 3-4 days, during the day and at night, which would wake him up from sleep. Institution of pursed lip breathing was ineffective. Continuous laryngoscopy during exercise demonstrated moderate-to-severe ILO although characteristic field symptoms weren't reproduced. During 24-hour impedance probe study, he had several episodes of breathing cessation, perioral cyanosis, oxygen desaturation to the mid-60s and full-body limpness, resolving spontaneously after 45-60 seconds. Further evaluation included an electroencephalogram during an episode with no seizure activity, normal brain MRI, and normal rigid bronchoscopy. Impedance study demonstrated 100% correlation with reflux and breathing cessation, and he was diagnosed with reflux laryngospasm. A proton pump inhibitor (PPI) and promotility agent provided no relief. After Nissen fundoplication with post-surgical use of PPI and H2 blocker, there were no further respiratory events. Discussion In cases of apnea during wakefulness and sleep, it is important to consider etiologies such as seizure disorders, sleep disorders and reflux laryngospasm. Patients with gastroesophageal reflux can develop laryngospasm, a rare cause of abrupt absence of airflow caused by prolonged forceful apposition of the vocal cords.

Non-specific effects of childhood vaccines on acute childhood morbidity among HIV-exposed children in sub-Saharan Africa: a multilevel analysis

ABSTRACTWe examined the roles of determining factors responsible for acute respiratory infections and diarrhoea among immunised human immunodeficiency virus (HIV)-exposed children in sub-Saharan Africa. This study used demographic and health surveys obtained from 27 sub-Saharan African countries. The outcome variable is defined as symptoms of acute respiratory infections or episode of diarrhoea in the child of an HIV-infected mother who is vaccinated with the third dose of diphtheria-tetanus-pertussis containing vaccines. Multivariable logistic regression models were used to analyse the association between individual and contextual factors. The odds of developing symptoms of acute respiratory infections increased among those living in communities with high unemployment rate (Odds ratio = 1.15, 95% credible interval 1.05 to 1.26). The odds of developing diarrhoea increased among young mothers such that children of women aged 15–24 years were two times likely to develop diarrhoea compared to children of women aged 35–49 years (Odds ratio = 2.22, 95% credible interval 1.66 to 2.93). Public healthcare programmes should target adolescent and young women, and their family members on how to prevent diarrhoea. Efforts should be made to identify the hotspots for development of acute respiratory diseases especially in communities with high rate of unemployment and to develop strategies to combat the diseases in such communities. Initiatives such as the integrated Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea which recommends an interrelated approach for the elimination of preventable diarrhoea and pneumonia deaths should be adopted.