Nutrition in preschool children and later risk of obesity: a systematic review and meta analysis

Objectives and study: Nutrition in infants and preschool children has been suggested to influence the risk of later obesity. However, the evidence for this association is conflicting and few studies have investigated this prospectively or considered the role of energy and specific macronutrients. Here we report a systematic review and meta-analyis of studies that tested the hypothesis that nutrition in the preschool period, between the ages of 6 months and 3 years, is associated with later obesity risk. Methods: MEDLINE, EMBASE and CENTRAL databases were searched from January 1988 to June 2015 for studies reporting nutritional intake in infants and preschool children aged 6-36 months and later measures of obesity. Bibliographies of included studies were hand searched and authors and other experts consulted to identify omissions. We included all studies that investigated dietary energy and/or macronutrient intake during 6-36 months in relation to later measures of obesity. Methodological quality was assessed using the Downs and Black checklist designed specifically to appraise both randomised and non-randomised studies. The checklist was adapted to include aspects of particular relevance to studies investigating nutritional exposures. Two reviewers independently scored studies against the 28 item checklist which included questions on study reporting, external validity, internal validity (bias and confounding), and statistical power. A statistician independently scored questions relating to statistical methods and their decision was final. Data from studies amenable to meta-analysis were analysed using STATA (StataCrop 12, Texas). For continuous outcomes, results were expressed as standardised mean difference (SMD) between the high and low protein intake groups. For dichotomous outcomes, results for each study were expressed as relative risk (RR). Both dichotomous and continuous outcomes were presented with 95% confidence intervals (CI). Between-study heterogeneity was assessed by the Q and I2 statistics. Results: 24 eligible articles (comprising 16 primary studies) were included in a narrative synthesis, and 13 studies in a random-effects meta-analysis. A higher protein intake was associated with later risk of obesity in 15 studies. In 13 studies included in the meta-analysis protein in the preschool period was associated with higher BMI z-score later in childhood (pooled effect size: 0.28 z-scores, 95% CI 0.20 to 0.35)(Figure 1). There was no significant hererogeneity between studies (I2 0.0%, p = 0.932). Associations of energy, fat and carbohydrate were inconclusive. Conclusion: Our findings suggest that nutrition and particularly high protein intake in infants and preschool children is important for risk of later obesity. Although further experimental data are required to establish causality, these findings suggest that optimising the protein intake of these children could be important for their long term health

Un caso atipico di stridore e dispnea, dal sospetto diagnostico alla terapia

Si descrive un caso clinico caratterizzato da stridore e dispnea, dal sospetto diagnostico alla terapia. Il caso si segnala per la atipicità della presentazione clinica

HUMAN METAPNEUMOVIRUS RESPONSIBLE FOR A SEVERE ERYTHEMA MULTIFORME: AN UNUSUAL ASSOCIATION

Erythema Multiforme (EM) is an acute immune-mediated condition characterized by the appearance of typical target-like lesions on the skin. They most commonly appear in a symmetrical distribution on the extensor surfaces of the acral extremities and subsequently spread in a centripetal way. EM ‘major’ involves oral, genital and ocular mucosae with erosions or bullae. Although cutaneous lesions are usually asymptomatic, EM can be caused by drugs, autoimmune disease, malignancy, irradiation, sarcoidosis and in 90 percent of cases by infections (viral, bacterial, fungal). Herpes Simplex virus is the most frequent etiologic agent. Mycoplasma Pneumoniae infection is another important cause of EM, particularly in children. Laboratory findings are not specific and clinical finding are necessary for diagnosis. A skin biopsy should be performed when the diagnosis is unclear. CASE REPORT: 14 year old male came to our attention for the appearance of cutaneous lesions, accompanied by high fever. The skin appeared almost entirely affected by roundish, sharp, erythematous lesions, some of these with evident ‘coccard’ sign, other ecchymotic with hemorrhagic nuance, confluent to the trunk in large patches. No recent history of infections or drugs. Laboratory findings showed a neutrophilia (N 8810/mcl) and eosinophilia (E 980/mcl) and high inflammatory indices (PCR 4.75 mg/dl, ferritin 517 kg/ml). Peripheral smear, autoimmunity, virological and bacterial screening and instrumental examinations were negative. On the third day of admission, he performed a nasal swab (Multiplex) due to the appearance of rhinorrhea and cough. It was positive for Human Metapenumovirus (HM). On the seventh day, there was a new poussé of erythematous, itchy, coccard element on the whole body surface. He was treated with antihistaminic, steroid and antibiotic therapy with gradual rash regression, desquamation of skin lesions and defervescence. In literature it is known that HM is a common cause of upper respiratory tract infection in children. However, no further cases are reported regarding the possible relationship between skin lesions and HM. In our case the only laboratory finding associate to the EM was a positive RT-PCR for HM. This observation could lead to further scientific evaluations

WHEN A VIRUS HAS DIFFERENT FACES

Measles is a highly contagious viral illness, characterized by fever, malaise, cough, coryza and conjunctivitis, followed by maculopapular exanthema, which spreads cephalocaudally and centrifugally. Measles, mumps, rubella (MMR) vaccination has led to the interruption of measles virus transmission and gives protection to unvaccinated individuals via herd immunity. The morbilliform exanthema can be found in various conditions, including infectious mononucleosis. It is characterized by fever, pharyngitis, lymphadenopathy and a generalized maculopapular, urtical or petechial rash occasionally can be present, especially after administration of beta-lactams. CASE REPORT: 17 months old male was admitted in our pediatric department for the appearance, 4 days earlier, of rash and fever (T 38,8°C). The exanthema consisted of an erythematous, maculopapular, blanching rash, which began on the face and progressed to the truck and extremities involving the palms and soles. In some areas it showed confluent and hemorrhagic features. The physical examination showed the presence of laterocervical lymphadenopathy, nonpurulent conjunctivitis and pharyngitis. About 10 days earlier it was administered antibiotic therapy with Amoxicillin for a fever associated with malaise, cough and coryza. The child had no history of allergies and the MMR vaccine was repeatedly delayed and eventually not carried out for multiple episodes of respiratory infections. The laboratory tests showed leucocitosis with a normal differential count, mild elevation of transaminases, elevation of inflammatory markers and LDH; the morphological evaluation of the peripheral smear showed some activated lymphomonocitoid cells. Given the rash characteristics and the strong suspicion of measles, the patient was located in isolation and infectivological tests were performed (TORCH, Monotest, Respiratory Multiplex PCR panel and a serology for measles). They all came back negative except for the anti VCA IgM for EBV infection. The patient was treated with IV fluids and antipyretics. Antibiotic therapy was administered in order to prevent bacterial superinfections. After 72 hours the rash started to darken and then to gradually fade. The patient was dismissed with the diagnosis of maculopapular exanthema in mononucleosis infection. Clinical manifestations of infectious mononucleosis can be similar to those of measles and, especially in unvaccinated patients, can sometimes be confused with it. Maculopapular exanthema can be found in various conditions, such as common viral or bacterial infections, IgA vasculitis, Kawasaki disease or drug eruption. For this reason, it is important to consider mononucleosis in the differential diagnosis of measles, especially in case of hemorrhagic and infiltrated rash, not much described in the literatur

A CASE OF A STRANGE DYSPNEA

Infantile hemangioma is the most common benign tumor of infancy, affecting 1–2% of infants. Hemangiomas of the airway constitute an even smaller percentage, but their management can be challenging due to the potential for life threatening airway compromise. A Subglottic hemangioma (SGH) makes up 1.5% of all congenital laryngeal anomalies, it is twice more common in females than males and have been linked to low birth weight and prematurity. It is during the early proliferative phase (1–3 months of life) that patients became symptomatic, developing characteristic stridor which may progress to respiratory distress. In this early stage, a SGH is often mistaken for a more common condition such as croup. The aim of this case is to underline what a recurrent dyspnea or laryngeal stridor in the first 6 months might hide Case report A 4 months-old-girl who was born at term of natural childbirth (birth weight 2.500 kg-SGA), presented with several weeks of unremitting stridor, substernal retractions. She was diagnosed to have bronchiolitis and she had been hospitalized twice in an another hospital and treated with oral steroids and nebulized racemic epinephrine without significant improvement in her symptoms; Than she had been sent to our hospital. She had intercostal and subcostal retractions. Both lungs had equal contribution to respiration, respiratory sounds were coarse and she had both inspiratory and expiratory stridors which were more obvious on bilateral sibilant rales, and inspiratory phase. She also had wheezing. Laboratory tests, echocardiogram and electrocardiogram were normal. Her follow-up showed that she was not responding to treatment and her respiratory distress was increasing, thus she had a laryngofibroscopy that did not reveal any clear structural abnormalities, and performed a CT scan of the neck, that revealed a laryngeal mass, confirmed by an MRI of the neck, which showed a solid tissues of low intensity on T1-weighted spin-echo images and of hyperintensity on T2-weighted spinecho images (6x8 mm), compatible with SGH. After her workup was complete, she received an initial dose of propranolol at 0.5 mg/kg, which was increased to 2 mg/kg, and no adverse effects were noted. SGH is a rare but potentially lifethreatening disease. A high index of suspicion is vital for the early, accurate diagnosis of this disease. Propranolol treatment has many advantages, it is non-invasive and it has a low complication rate; thus, the use of propranolol as a first-line treatment for SGH is propose

Epidemiology and effects of bacterial infections in patients with cirrhosis worldwide

Bacterial infections are common and life-threatening in patients with cirrhosis. Little is known about the epidemiology of bacterial infections in different regions. We performed a multicenter prospective intercontinental study to assess the prevalence and outcomes of bacterial and fungal infections in patients with cirrhosis. METHODS: We collected data from 1302 hospitalized patients with cirrhosis and bacterial or fungal infections at 46 centers (15 in Asia, 15 in Europe, 11 in South America, and 5 in North America) from October 2015 through September 2016. We obtained demographic, clinical, microbiology, and treatment data at time of diagnosis of infection and during hospitalization. Patients were followed until death, liver transplantation, or discharge. RESULTS: The global prevalence of multidrug-resistant (MDR) bacteria was 34% (95% confidence interval 31%-37%). The prevalence of MDR bacteria differed significantly among geographic areas, with the greatest prevalence in Asia. Independent risk factors for infection with MDR bacteria were infection in Asia (particularly in India), use of antibiotics in the 3 months before hospitalization, prior health care exposure, and site of infection. Infections caused by MDR bacteria were associated with a lower rate of resolution of infection, a higher incidence of shock and new organ failures, and higher in-hospital mortality than those caused by non-MDR bacteria. Administration of adequate empirical antibiotic treatment was independently associated with improved in-hospital and 28-day survival. CONCLUSIONS: In a worldwide study of hospitalized patients, we found a high prevalence of infection with MDR bacteria in patients with cirrhosis. Differences in the prevalence of MDR bacterial infections in different global regions indicate the need for different empirical antibiotic strategies in different continents and countries. While we await new antibiotics, effort should be made to decrease the spread of MDR bacteria in patients with cirrhosis156513681380This study was supported by a grant from the Italian Ministry of Education,University and Research (DOR1678487/16). PG is recipient of an ICREA Academia awar

Effects on the incidence of cardiovascular events of the addition of pioglitazone versus sulfonylureas in patients with type 2 diabetes inadequately controlled with metformin (TOSCA.IT): a randomised, multicentre trial

Background The best treatment option for patients with type 2 diabetes in whom treatment with metformin alone fails to achieve adequate glycaemic control is debated. We aimed to compare the long-term effects of pioglitazone versus sulfonylureas, given in addition to metformin, on cardiovascular events in patients with type 2 diabetes. Methods TOSCA.IT was a multicentre, randomised, pragmatic clinical trial, in which patients aged 50\ue2\u80\u9375 years with type 2 diabetes inadequately controlled with metformin monotherapy (2\ue2\u80\u933 g per day) were recruited from 57 diabetes clinics in Italy. Patients were randomly assigned (1:1), by permuted blocks randomisation (block size 10), stratified by site and previous cardiovascular events, to add-on pioglitazone (15\ue2\u80\u9345 mg) or a sulfonylurea (5\ue2\u80\u9315 mg glibenclamide, 2\ue2\u80\u936 mg glimepiride, or 30\ue2\u80\u93120 mg gliclazide, in accordance with local practice). The trial was unblinded, but event adjudicators were unaware of treatment assignment. The primary outcome, assessed with a Cox proportional-hazards model, was a composite of first occurrence of all-cause death, non-fatal myocardial infarction, non-fatal stroke, or urgent coronary revascularisation, assessed in the modified intention-to-treat population (all randomly assigned participants with baseline data available and without any protocol violations in relation to inclusion or exclusion criteria). This study is registered with ClinicalTrials.gov, number NCT00700856. Findings Between Sept 18, 2008, and Jan 15, 2014, 3028 patients were randomly assigned and included in the analyses. 1535 were assigned to pioglitazone and 1493 to sulfonylureas (glibenclamide 24 [2%], glimepiride 723 [48%], gliclazide 745 [50%]). At baseline, 335 (11%) participants had a previous cardiovascular event. The study was stopped early on the basis of a futility analysis after a median follow-up of 57\uc2\ub73 months. The primary outcome occurred in 105 patients (1\uc2\ub75 per 100 person-years) who were given pioglitazone and 108 (1\uc2\ub75 per 100 person-years) who were given sulfonylureas (hazard ratio 0\uc2\ub796, 95% CI 0\uc2\ub774\ue2\u80\u931\uc2\ub726, p=0\uc2\ub779). Fewer patients had hypoglycaemias in the pioglitazone group than in the sulfonylureas group (148 [10%] vs 508 [34%], p<0\uc2\ub70001). Moderate weight gain (less than 2 kg, on average) occurred in both groups. Rates of heart failure, bladder cancer, and fractures were not significantly different between treatment groups. Interpretation In this long-term, pragmatic trial, incidence of cardiovascular events was similar with sulfonylureas (mostly glimepiride and gliclazide) and pioglitazone as add-on treatments to metformin. Both of these widely available and affordable treatments are suitable options with respect to efficacy and adverse events, although pioglitazone was associated with fewer hypoglycaemia events. Funding Italian Medicines Agency, Diabete Ricerca, and Italian Diabetes Society