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http://www.webmedcentral.com/images/Header_Logo.giftext/html2010-10-06T19:39:41+01:00http://www.webmedcentral.com/Dr. Zachary D JacobsInfantile Pulmonary Hemosiderosis
http://www.webmedcentral.com/article_view/907
Pulmonary hemosiderosis in infants (< 1 year of age) is a syndrome characterized by pulmonary hemorrhage and hemosiderin-laden macrophages. As there are multiple incompletely understood etiologies regarding this syndrome, this paper discusses the etiologic and pathophysiologic mechanisms, -with particular attention to Heiner’s syndrome, Wegener’s granulomatosis, and the toxigenic mold Stachybotrys. It also provides diagnostic guidelines to assist in the investigation of infantile hemoptysis and the institution of a treatment approach to the infant with IPH.text/html2010-10-31T21:25:13+01:00http://www.webmedcentral.com/Dr. Wolfgang H KunzeAdenovirus Respiratory Infections In Children. Do They Mimic Bacterial Infections?
http://www.webmedcentral.com/article_view/1098
Background: Respiratory adenovirus (ADV) infections activate acute phase proteins, so they are often interpreted as bacterial infections. The aim of this study was to monitor indicators of inflammation (C-reactive protein [CRP], white blood cell and neutrophil counts, Interleukin 6 [IL-6] levels, and lipopolysaccharide binding protein [LPB] capacity) for comparison of ADV infections with influenza and other viral respiratory illness in a pediatric population.Methods: A total of 171 patients between the ages of one month and 16 years were selected for study, of which 106 were ADV-positive, 32 were ADV-negative, and 33 were positive for influenza virus. ADV infection was confirmed via quantitative polymerase chain reaction (PCR) testing of nasopharyngeal swabs for human ADV-DNA.Results: When compared with ADV-negative and influenza-positive patients, those with ADV infections showed significantly elevated serum CRP concentrations and left-shifted leukocyte counts. IL-6 levels also differed significantly between ADV-positive and ADV-negative patients. Antibiotic therapy did not influence the course of ADV infections.Conclusions: ADV and bacterial infections may be indistinguishable clinically, necessitating additional and specific diagnostic investigation. In this respect, the judicious use of acute phase proteins (CRP, interleukins) as a differentiating feature of ADV could have merit.text/html2012-08-24T14:32:56+01:00http://www.webmedcentral.com/Dr. Sukhbir ShahidHelicobacter Pylori Infection in Children
http://www.webmedcentral.com/article_view/3664
H.pylori is a widely prevalent and important component of gastric microbiology. It is usually acquired in childhood. It is more common in poorer sections of society especially of developing countries. It can cause peptic ulcer disease and dyspepsia. It is a potent carcinogen responsible for gastric adenocarcinoma and gastric lymphoma. H.pylori infection should be suspected in children with history suggestive of hyperacidity and in those who have a first degree family member with gastric cancer. Diagnosis relies on endoscopy and biopsy. Non-invasive tests on breath, stool, serum, urine and saliva can also diagnose H.pylori infection reliably. Treatment in children involves a triple regimen comprising of proton pump inhibitor or bismuth compounds with either two antibiotics or one antibiotic and an imidazole. This eradicates the organism in >90% of the patients. The above tests may need to be repeated to confirm on clearance of the bacterial infection. Awareness of H.pylori infection is vital due to its high rate of colonization and risk of gastric malignancies.text/html2010-10-01T16:43:22+01:00http://www.webmedcentral.com/Dr. Mohd AshrafFluid Therapy in Children: A Review
http://www.webmedcentral.com/article_view/868
Fluid therapy restores circulation by expanding extracellular fluid. Intravenous fluid therapy for children with volume depletion should first restore extracellular volume with measured infusions of isotonic saline followed by defined, appropriate maintenance therapy to replace physiological and pathological losses according to principles established. To understand the fluid therapy in children, it is important to know the different types of deficits. Likewise, it would be optimal to have a brief understanding of the water and electrolyte distribution in children at differs ages.text/html2010-12-13T14:48:27+01:00http://www.webmedcentral.com/Dr. Dejan StevanovicKINDL Quality Of Life Questionnaire In Serbia: Referent Values For Healthy Children And Adolescents
http://www.webmedcentral.com/article_view/1342
The objective of this report was to present the referent values of the Serbian KINDL for healthy children and adolescents. The data from 756 children and adolescents and 618 parents were used. The mean values with standard deviations, 95% confidence intervals, and percentiles were calculated for KINDL. Additionally, the differences between genders, children and parents, and the correlations of age with the KINDL scores were given. The mean values of the subscales ranged 59.51 – 76.39 for the children and 68.96 – 79.97 for the parents. The total scores were 76.29 and 79.86, respectfully. Between the male and female subjects, no significant differences were observed. However, the majority of the scores significantly, but inversely, correlated with age. The referent values were given for gender and age.text/html2011-12-31T10:31:49+01:00http://www.webmedcentral.com/Dr. A ShrikiranDenys-Drash Syndrome - A Case Report.
http://www.webmedcentral.com/article_view/2833
A 6 month old girl first presented to us in September 2002 with anasarca and oliguria of one month duration. She was the third child in her family. Two elder sisters were healthy. Birth history and development till onset of illness were normal. On examination, her weight was 7 kg and length 64 cm. She also had hypertension and ascites. Investigations: Blood biochemistry: Blood urea 26mg/DL(9.28 mmol/L), S.creatinine 0.4mg/DL(70.7 mmol/L), S.sodium 124mmol/L, S.potassium 2.4 mmol/L, serum albumin – 1.3g/DL (13 g/L), total serum protein – 3.3g/DL (33 g/L), C3 – 54mg/DL(540 mg/L) and 24-hour urine protein of 69 mg/sq. m²/hr. VDRL test, ELISA tests for herpes simplex, rubella, HIV and for toxoplasma were negative. But ELISA test for IgM, cytomegalovirus was positive. Opthalmological evaluation revealed diffuse pigment mottling of both the fundi suggesting salt and pepper pattern of retinopathy of CMV retinitis. Mothers blood ELISA for CMV was negative. The child was diagnosed with infantile nephrotic syndrome with CMV retinitis. She was started on Captopril and Nifedipine. I.V. Ganciclovir was administered for four weeks. At the end of this period, CMV IgM was negative and oral ganciclovir could not be started due to non-availability of the drug. Her edema gradually resolved. Renal biopsy was deferred due to poor general condition of the child and non-willingness of the parents. Steroids were not tried due to its known inefficacy in infantile nephrotic syndrome and the possibility of a flare-up of CMV infection. The child continued to follow up, on treatment with captopril, nifedipine, aspirin and dipyridamole. Though she remained edema free with hypertension under control, heavy proteinuria continued. In September 2004, at 2 years 6 months of age, she was re-evaluated. USG abdomen showed bilateral grade II renal parenchymal changes. Blood urea had increased to49mg/DL (17.5 mmol/L), S.creatinine to 0.9mg/DL (80 mmol/L) and 24 hour urine protein 87 mg/sq.m/hr. The renal biopsy done, had adequate number of glomeruli, with majority of them showing varying degrees of sclerosis and an occasional glomerulus showing mild mesangial hypercellularity. The tubules are moderately atrophic with hyaline casts. The interstitium showed marked fibrosis with a moderately dense infiltrate of lymphocytes, the features suggestive of an end stage renal disease with pyelonephritic changes. Direct immunofluorescence with IgG, IgA, IgM and C3 showed non specific immune deposits.At 3 years of age she developed a mass on the left side of the abdomen in lumbar region. On examination, it was firm and measured 7x 7 cm in size. CT scan study of the abdomen revealed heterogeneously enhancing soft tissue density lesion, measuring 9x 7.3 cm arising from the anterior renal parenchyma of the left kidney. Another similar mass of size 3x 2.2 cm was seen located in the anterior aspect of the interpolar region of the right kidney. Radiological findings favoured the diagnosis of bilateral Wilms’ tumour (Fig 1&2). Fine needle aspiration ( FNA) from both the renal masses were performed under ultrasound guidance using separate needle and syringe and the smears were fixed in absolute alcohol, stained with Papanicolaou stain and separately analysed. The smears from both the right and left renal masses were cellular and showed diffuse sheets and clusters of blastemal cells having round to oval nucleus with fine chromatin, indistinct nucleolus and scanty basophilic cytoplasm. An occasional mitosis was seen (1/10hpf). At places rosette like arrangement of blastemal cells with no central fibrillary material, suggestive of epithelial differentiation was observed. A few spindle shaped cells admixed with blastemal cells was noted (Fig 3). The cytologic features were diagnostic of classic Wilms’ tumor involving both the kidneys.Karyotyping revealed a normal 46, XX genotype. Renal function progressively deteriorated with increasing S.creatinine level. Child was started on combination chemotherapy with Vincristine, Actinomycin D and Doxorubicin. However the response was poor without significant decrease in the mass size and renal failure progressed further. Child finally succumbed to the illness with in 6 months of detection of the tumour.text/html2012-01-06T14:46:54+01:00http://www.webmedcentral.com/Dr. Chaitanya VarmaVirtual Reality as a Tool in Pediatric Rehabilitation
http://www.webmedcentral.com/article_view/2857
This article reviews the usefulness of virtual reality technology in pediatric rehabilitation.text/html2015-10-06T14:57:16+01:00http://www.webmedcentral.com/Dr. Maya BorleTitle : Congenital Malformations: Patterns and Prevalence at Birth
http://www.webmedcentral.com/article_view/4988
We studied two thousand ,three hundred and twenty four newborns born a tertiary care hospital ,for congenital malformations. Out of these 1251 were males ,1071 were females and two babies had inderminate gender.We found 56 Congenital malformations in 45 newborns. Rate per 1000 live births was found to be 24.Rate of occurrence was higher with higher parity, higher maternal age, consanguinity, and multiple pregnancies.text/html2011-04-29T11:31:13+01:00http://www.webmedcentral.com/Dr. T. K DavisSubmandibular Sialadenitis and Lymphadenitis in Neonates: Epidemiology and Relation of Secular Trends in the Incidence of Staphylococcus Aureus Sepsis
http://www.webmedcentral.com/article_view/1873
Background: Only 17 cases of neonatal submandibular sialadenitis have been described in neonates. These infections are frequently caused by gram-positive cocci. We unexpectedly observed multiple cases of sialadenitis and cervical adenitis in our regional NICU within a few years, as staphylococcal aureus infections have become more prevalent in the hospital and community. Therefore, we postulated a relationship between staphylococcus aureus sepsis and sialadenitis or cervical lymphadenitis in neonates.Methods: This is a descriptive analysis of neonates identified retrospectively from our database between the years 1993-2007. Sialadenitis or Lymphadenitis were diagnosed clinically, and most confirmed radiographically. Staphylococcal sepsis was diagnosed if blood and/or cerebrospinal fluid cultures were positive for S. aureus. Trend analyses were performed using statistical process control g-charts.Results: There were 12 neonates with confirmed sialadenitis and/or lymphadenitis infection (incidence 0.1/1000 NICU admissions), all occurring in or after 1999, with incidence peaking at ~ 4/1000 in 2005-2007. Drainage of 6 lesions yielded MRSA in 4, MSSA in 2; none were sterile. MSSA was isolated from blood in 2 patients with undrained lesions. All neonates were preterm, had feeding tubes, and received assisted ventilation prior to diagnosis. The overall incidence of nosocomial staphylococcal aureus was 0.9/1000 admissions, significantly increasing to ~20/1000 in 2003-2005. The incidence of sialadenitis/lymphadenitis was more closely related to that of MRSA than MSSA sepsis, and it was not temporally associated with any single identifiable changes in care practices.Conclusion: Submandibular sialadenitis/lymphadenitis has been diagnosed more frequently in our regional NICU. We speculate that prematurity and oral or nasal instrumentation may be risk factors, in a context of increasing prevalence of MRSA colonization. Awareness of this diagnosis will facilitate early identification and initiation of appropriate therapy.text/html2011-11-14T15:00:25+01:00http://www.webmedcentral.com/Dr. Yvan VandenplasSaccharomyces boulardii in Acute Gastroenteritis in Children
http://www.webmedcentral.com/article_view/1627
Objective: To evaluate Saccharomyces boulardii in the management of gastroenteritis in children in Togo, Benin and Côte d’Ivoire.Methods: Prospective descriptive study, conducted by healthcare personnel in the 3 West African countries between May and December 2006. Well-nourished, (1 month -15 years old) children without chronic disease presenting with acute diarrhea (defined as more than 3 loose or liquid stools per 24-hour period, which started < 4 days before enrolment) were included. Stool frequency, consistency, and tolerance of treatment were evaluated at each visit.Results: 66 investigators recruited 331 patients. The patients were predominantly male; 81% were less than 3 years old (mean age 25.6 months). The mean duration of the diarrhea before enrolment was 1.6 days. The average number of stools returned to normal (2.43 stools per day) from day 2. S. boulardii was well tolerated in 93% of cases. The treatment was shown to be effective in close to 98% of the children.Conclusion: 81% of the children recruited were less than 3 years old. A daily dose of 500 mg S. boulardii was well tolerated, confirming the value of S. boulardii in diarrhea in children, in combination with oral rehydration therapy and early feeding.text/html2011-12-30T16:25:42+01:00http://www.webmedcentral.com/Dr. Suneel MundkurA Possibile role of Antenatal Vitamin K Administration in Preventing Epiphyseal Stippling in Fetal Hydantoin Syndrome
http://www.webmedcentral.com/article_view/2810
The effect of conventional anti-convulsant, Phenytoin, on bone health is described in the literature. There is increasing evidence on the role of Vitamin K in bone health and in prevention of osteoporotic fractures (4) We report a case of a newborn with fetal hydantoin syndrome associated with epiphyseal stippling and consider a possible protective role of antenatal administration of vitamin K to mothers on phenytoin to prevent vitamin K induced epiphyseal stippling in the neonate.text/html2011-12-30T16:24:47+01:00http://www.webmedcentral.com/Dr. A ShrikiranA Rare Case of Methotrextate Induced Pancreatitis in Acute Leaukemia Patient.
http://www.webmedcentral.com/article_view/2820
Acute pancreatitis is recognized with increasing frequency in the pediatric population as a result of trauma, billiary tract disease, viral illness, states of intracranial hypertension and steroids1. Children with acute lymphoblastic leukemia (ALL) treated with L-asparaginase represent an additional group at risk to develop pancreatitis1, 2. Pancreatitis, which is usually mild and self limited may begin any time during treatment or even up to 16 weeks after discontinuation of treatment with L-asparaginase3. Corticosteroids are capable of inducing acute pancreatitis in children. The incidence of clinical pancreatitis seems much higher in patients receiving combination chemotherapy comprising L-asparaginase, corticosteroids and other agents2, 4. Methotrexate has never been reported to be linked to pancreatitis.6 Here we report a case where methotrexate seems to be the most likely agent to have caused acute pancreatitis.text/html2011-12-31T10:33:36+01:00http://www.webmedcentral.com/Dr. Chaitanya VarmaMultiple Cafe Au lait Spots.
http://www.webmedcentral.com/article_view/2823
Cafe au lait spots or macules are light brown to dark brown coloured hyperpigmented lesions with round or irregular borders. They are present in 95% of children with Neurofibromatosis-1 which is a neurocutaneous syndrome. It can also be seen in McCune- Albright syndrome,Tuberous sclerosis and Fanconis anemia. The lesions increase in size and become more visible by 2 years of age. Here we present multiple Cafe au lait spots in a 5 year old child who had come for routine immunization to our outpatient clinic. A thorough history and clinical examination did not reveal any other findings of NF-1 or other syndromes in which it is a feature.text/html2011-12-31T10:32:10+01:00http://www.webmedcentral.com/Dr. Suneel MundkurCoagulase Negative Staphylococcus (CONS) Infection in Neonatal ICU.
http://www.webmedcentral.com/article_view/2829
Objective: To study the mortality in CONS infection in neonates in relation to clinical and hematological profile.Design-Retrospective study.Methods: A total of 131 newborns admitted to the NICU of Kasturba Hospital, Manipal between March 2000 and February 2005 whose blood culture had grown CONS were included in the study group. They were classified into two groups-1) Neonates who recovered 2) Neonates who died of infection or discharged at request in a moribund state. The clinical features, sepsis screen parameters, birth weight, mode and place of delivery and interventions in relation to the outcome were analyzed statistically. Antibiotic sensitivity pattern was studied.Results: Out of 131 babies studied, mortality was observed in 13 cases (9.9%). The mortality in VLBW and LBW babies was 30.8% (n=4) and 7.9% (n=3) respectively. Higher mortality of 12.7% (n=10) was observed in babies delivered vaginally as compared to 5.8% (n=3) in those born by Caesarian section. Mortality in preterm babies was 16.7% (n=5) as against 7.9% (n=8) in term babies. Mortality rate was 25% (n=7) in babies with 3 or more positive sepsis parameters as compared to 5.8% (n=6) in babies with less than 3 positive parameters. A mortality of 17.4% (n=12) was seen in babies with clinical features of sepsis compared to 1.6% (n=1) in those without any clinical features. Morality rates were 12% (n=5) and 8.6% (n=8) in outborns and inborns respectively. Mortality rate of 33.3%(n=12) was observed in babies wherein interventions like ICD, umbilical catheterisation, arterial cannulation, mechanical ventilation were done compared to 1.1%(n=1) in babies where no interventions were done. In the present study the Antibiotic sensitivity pattern was Amikacin 79%(n=113), Gentamicin 73.4%(n=105) Cefotaxime 62%(n=89), Ampicillin 60.1%(n=86), Cefuroxime 49%(n=71).Conclusions: In CONS infection mortality was higher in LBW and VLBW babies, vaginal deliveries and outborns. Prognosis worsens if 3 or more sepsis screen parameters or clinical manifestation of sepsis are present. Mortality rate was higher in babies who have undergone interventions. Amikacin was the most sensitive antibiotic both invitro and in vivo.text/html2011-12-31T10:06:12+01:00http://www.webmedcentral.com/Dr. Suneel MundkurKnowledge and Beliefs about HIV/AIDS among Adolescents
http://www.webmedcentral.com/article_view/2830
Objective: To assess the level of awareness regarding HIV/AIDS among school going adolescents in Udupi district of Karnataka.Method: Total 800 students from 5 different English medium schools were given a structured HIV questionnaire and asked to fill it and return within minutes and which was analysed.Results: Though majority of students had heard about HIV/AIDS, the knowledge regarding its transmission, diagnosis and treatment and ways to prevent its spread was found to be inadequate.Conclusion: There is still a lot of scope to make the adolescents more aware of HIV/AIDS which would help them adopt a positive behavior and limit the spread of infection.text/html2012-01-01T10:53:22+01:00http://www.webmedcentral.com/Dr. Chaitanya VarmaGifted Children in Pediatric Practice
http://www.webmedcentral.com/article_view/2836
This article gives an insight into the developmental patterns and various problems of gifted children. The treating pediatrician should avoid missing such children when brought for behavioural disorders and learning disabilities.text/html2012-01-01T10:53:00+01:00http://www.webmedcentral.com/Dr. Varma Chaitanya P VSkin Branding in Indian Children: A Still Prevaling Superstition in the Modern Era
http://www.webmedcentral.com/article_view/2828
Human branding is the process in which a mark is burned into the skin of a living person, resulting in permanent scarification. This is done either with consent as a form of body modification; or under coercion, as a punishment. It may also be practiced as a "rite of passage" such as within a tribe, or to signify membership in an organisation. The most commonly seen brand marks in a pediatric practice is because the family members believe that it helps in evading or treating the offending agent.
HISTORICAL SIGNIFICANCE:
The etymology of the word “brand” could be traced back to 12th century Norse brena which meant “to burn, to light”. In Dutch, branden means "to burn", brandmerk a “branded mark”[1]. In ancient Rome slaves who tried to escape were branded with the words FUG- denoting Fugutives. During the medieval period of the middle ages, branding was one of the main ways of torturing or punishing prisoners .Army deserters used to be branded during the American Civil War [2]. text/html2012-01-29T11:12:29+01:00http://www.webmedcentral.com/Prof. Riaz AhmedsyedIctal Syncope- A Neurologist\'s Perspective
http://www.webmedcentral.com/article_view/2364
Isolated syncope is a rare manifestation of seizures in children and it's a poorly defined. A high index of suspicion is warranted when a child who's perfectly normal, devlops recurrent unexplained syncope. A detailed cardiac evaluation needs to be practised in such situation. Nevertheless, some children succumb to the illness despite rigorous management.text/html2012-01-30T11:02:10+01:00http://www.webmedcentral.com/Dr. Chaitanya Varma Harry Potter in Medical Literature: A Review
http://www.webmedcentral.com/article_view/2945
The Harry Potter books are a seven part children fantasy series written by the British author J K Rowling. Since the publication of the first in the series “Harry Potter and the Philosophers’ stone” they have become the fastest selling books in the world and have been translated into 67 different languages. The books follow the adventures of an eleven year old wizard Harry and his coming of age at the Hogwarts School of Witchcraft and Wizardry. The Harry Potter books along with the film series are considered to be one of the most successful brands in human history valued in excess of 15 billion dollars.text/html2012-02-15T11:58:41+01:00http://www.webmedcentral.com/Dr. Rahul SinhaA Unusual Presentation of Propionic Acidemia with Thrombocytosis- A Case Report
http://www.webmedcentral.com/article_view/3015
Propionic acidemia is an inborn error of metabolism due to defective enzyme, propionyl-coenzyme A (CoA) carboxylase, which results in an accumulation of propionic acid. In this report we describe a term male neonate who presented with metabolic acidosis, seizures, hypoglycemia, ketosis, hyperglycinemia, thrombocytosis, and hepatomegaly. The diagnosis was established on the basis of tandem mass spectrometry, arterial blood gas analysis, serum lactate, serum ammonia and urine organic acid analysis. We report this unusual presentation with thrombocytosis which has never been reported in literature.text/html2012-05-16T18:39:09+01:00http://www.webmedcentral.com/Dr. Jenny J CheriathuAutoamputation of Congenital Hairy Polyp in Neonate with Stridor and Respiratory Failure
http://www.webmedcentral.com/article_view/3379
Hairy polyp of the oronasopharynx is a rare developmental malformation. It is usually seen as a pedunculated tumor in the neonate. It is classified as a dermoid since it is derived from the ectoderm and mesoderm. We describe a neonate with a hairy polyp originating from the right lateral pharyngeal wall causing significant respiratory distress with cyanosis and stridor immediately after birth. Symptoms in the neonate disappeared following autoamputation of the mass. To our knowledge, this is the third case described in literature, with full recovery following autoamputation of a hairy polyp. text/html2013-02-06T13:33:43+01:00http://www.webmedcentral.com/Dr. Shiji S ChalipatEffect of Malnutrition on Severity of Presentation and Outcome of Acute Bronchiolitis
http://www.webmedcentral.com/article_view/3997
Acute viral bronchiolitis is regarded as the most common respiratory infectious disease of infancy. Malnutrition and infection are the common association which causes morbidity and mortality in these children. Present study was designed to evaluate effect of various grades of malnutrition on severity and outcome of bronchiolitis. This was a retrospective study which included 68 consecutive children aged 0-2years admitted with clinical diagnosis of acute bronchiolitis. Their clinical severity on presentation and outcome regarding duration of stay, use of antibiotics and requirement of PICU care were analysed. It was observed that children who were malnourished required longer duration of stay than who were well nourished.text/html2013-07-02T11:38:58+01:00http://www.webmedcentral.com/Dr. Bipin KumarEvaluation Of Serum C-reactive Protein In Diagnosis And Prognosis Of Neonatal Septicemia
http://www.webmedcentral.com/article_view/1643
Background: Neonatal septicemia is an overwhelming systemic infection due to gain access of pathogenic bacteria in the blood stream of neonate. C-reactive protein production is very early and sensitive response to microbial infections and has highest sensitivity, specificity and positive predictive accuracy in cases of neonatal septicemia.
Methods: Total 50 clinically suspected cases and 25 healthy neonates as control were studied. Total WBC count, absolute neutrophils count, Band Cell/Neutrophil Count ratio, C-reactive protein estimation, blood culture, culture of umbilical discharge, other purulent material and urine were done. CRP levels were noted on the day of admission before instituting therapy and 5th and 10th day of treatment.
Results: 22 cases were bacteriologically positive. CRP was positive in 44 cases and one control. Thirty-five cases were survived and 15 expired. CRP value among survivors on 1st, 5th and 10th day was 18.51+/-4.21, 12.61+/-3.51 and 8.21+/-3.05 respectively; whereas, on 1st and 5th day among expired was 23.22+/-2.42 and 21+/-3.21 respectively. Mean CRP value on the 1st day and 10th day in cured survivors was 17.89+/-4.52 and 6.0+/-7.0 (p value Conclusion: Serum CRP estimation is very sensitive and reliable method. Serial measurements of serum CRP levels are useful in monitoring the course and it provides an early indication of response of treatment. It can help in decision of initiating or discontinuing antibiotic therapy. The persistence or insignificant decline of serum CRP with treatment signifies about inadequate treatment or development of complications.
Key words: neonatal septicemia, C-reactive protein, blood culture, total leucocyte count, absolute neutrophil count, band cell/ neutrophil count ratio.text/html2015-08-17T07:46:11+01:00http://www.webmedcentral.com/Dr. Sampada A TambolkarLiver Functions as a marker of severity of disease in children with Dengue fever
http://www.webmedcentral.com/article_view/4962
Objective : To study liver function in dengue infection and to correlate it with the severity of disease . Follow up liver function studied at discharge . Design : prospective cross sectional study. Methods: Fifty patients admitted with clinical diagnosis of dengue at D. Y. Patil medical college Pune were included and their liver functions were documented . Liver functions were correlated with severity of disease and followed at discharge . Results: out of 50 pts , 32 had DF ,13 DHF , 5DSS . Liver function on admission was deranged significantly in patients with DSS than DHF. Least derangement was seen in pts with DF . Liver function improved in all patients . In patients with DSS liver function remained deranged at discharge. Conclusion: severe derangement in liver function at admission indicates severe disease. This can be used as an early predictor of disease severity.
text/html2015-08-24T07:52:10+01:00http://www.webmedcentral.com/Dr. Sampada A Tambolkar To compare efficacy of 3% saline administered by pressure driven nebuliser Vs ultrasonic nebuliser in patients of Bronchiolitis
http://www.webmedcentral.com/article_view/4966
OBJECTIVE: To compare efficacy of pressure driven nebuliser vs ultrasonic nebuliser in management of Bronchiolitis using 3% saline as nebulising solution . DESIGN: Prospective randomised control trial . SETTING: Tertiary care teaching hospital in Pune . PARTICIPANTS: 75 children with clinical diagnosis of Bronchiolitis . PROCEDURE: Children were randomly administered 3%saline nebulisation through either pressure driven nebuliser or ultrasonic nebuliser . RDAI score ,RR,HR ,SPo2 , were recorded before and one hour after nebulisation . Parameters were statistically analysed. RESULTS: Baseline characteristics of both were comparable ( P > 0.05 ) . 3% saline administered with either of the two nebulisers was effective in management of Bronchiolitis ( P < 0.001 ) . When efficacy of both nebulisers was compared ,it was found that observed parameters showed significant more improvement with ultrasonic nebuliser than pressure driven nebuliser ( P < 0.001 ) . CONCLUSION: Ultrasonic nebuliser is better than pressure driven nebuliser in management of Bronchiolitis when 3% saline is used as nebulisation solution.text/html2015-09-08T04:59:10+01:00http://www.webmedcentral.com/Dr. Sampada A TambolkarStudy of Addictions and nutritional deficiencies in street children in Pune
http://www.webmedcentral.com/article_view/4973
OBJECTIVE. : To study nutritional deficiencies and addictions in street children . DESIGN : Cross sectional study . SETTING. : This study was conducted in street children in and around Pimpri , Pune by Department of Paediatrics Dr. D. Y . Patil medical college Pimpri ,Pune . PARTICIPANTS : 204 street children between 1 to 18 years in and around Pimpri ,Pune not adopted by government and non government organizations . RESULTS : Of the 126 children between 1-5 yrs ,47.6% had severe ( Gr 4) malnutrition . 14.3%,19.8%,and 18.3% children had Gr 1, Gr2, Gr3 malnutrition respectively . None of the children were well nourished . 48.5% had chronic malnutrition (were wasted and stunted ) . Multivitamin deficiencies was significantly more common in severely malnourished children ( p< 0.001). 100% children between 16-18 yrs were addicted, 60% between 11-15 yrs and ,15% between 6-10 yrs were addicted . Tobacco and Gutka were commonest addicting agents (32%) followed by misri and alcohol 19.2% and 6.4% respectively . CONCLUSION : Study concluded that all children below 5 yrs were malnourished ,severe malnutrition and chronic malnutrition (48%each) was common . 41.1% of children in 6-18 yrs age group were addicted . Tobacco and gutka were common addictions .text/html2015-09-23T09:59:09+01:00http://www.webmedcentral.com/Dr. Irfan MalikEvaluation of effect of massage with or without oil on the weight gain of low birth and very low birth weight babies
http://www.webmedcentral.com/article_view/4981
Background: Infant massage is an ancient practice used primarily in Asian and Pacific Island cultures because touch in these cultures is considered healthful both physically and spiritually. Massage therapy does have various benefits for the mother and the infant. It induces the bonding process between mother and child and causes increased weight gain and more organized sleep patterns in normal and premature infants. It even helps in the social development of the premature infant.
Material and Methods The present study was conducted on 90 neonates,12 of which dropped out because of lack of follow up . 3 children developed features of late onset septicemia and were admitted in the N.I.C.U. and thus consequently omitted from study. All the babies incuded in the study were otherwise healthy, stable babies having birth weight >1000 gm and < 2500gm with Apgar score >7 at 1 and 5 minute with no resuscitation required at birth .The mean birth weight of the study subjects was 2.0039 (± 0.15286) kg. The babies were enrolled prospectively and assigned into 1 of the following 3 subgroups.Group 1- in which the caregivers are educated about the correct technique of massage. Group 2 - in which the caregivers are advised to massage the newborns with olive oil with the correct technique (approx.40 - 50 ml per sitting). Group 3 - in which the caregivers are advised to use mustard oil for massage (approx. 40 - 50 ml per sitting).
Results The weight of every subject was checked and recorded at 1st,7th and 28th post natal days The mean increase in the weight after 28 post natal days was 371.7 (± 141.3)gms {or a percentage gain in weight of 1.2323 %} in Group 1, 360.8 (± 132.4 ) gms{ or a percentage gain in weight of 1.2027 %} in Group 2 and of 353.3 (± 15 )gms.{ or a percentage gain in weight of 1.1766% } in Group 3.
Conclusion It may thus be concluded that the practice of oil massage per se has a good effect on weight gain in neonates. The type of oil does not have much bearing on the final weight at least as observed within the scope of this study.text/html2016-12-15T10:36:49+01:00http://www.webmedcentral.com/Dr. Wolfgang H KunzePredictive value of procalcitonin in respiratory adenovirus infections in children with elevated C-reactive protein levels
http://www.webmedcentral.com/article_view/5238
Abstract: Adenoviruses (ADV) often cause respiratory infections. They have, in contrast to other respiratory viruses via a potential acute phase parameter (C-reactive protein, leukocytes and interleukin 6) to trigger. ADV infections are associated with increased secretion of IL-6 and TNF-?lpha, which activates the synthesis of acute phase proteins. The exact pathogenic mechanism is still unclear.
Procalcitonin (PCT) offers the possibility, particularly at elevated CRP levels between ADP and bacterial infections to distinguish and thus avoid antibiotic prescriptions.text/html2017-11-08T05:49:51+01:00http://www.webmedcentral.com/Dr. Robert A LodderA Pilot Study of a Device and Drug Therapy for ADHD
http://www.webmedcentral.com/article_view/5354
Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by difficulty paying attention, impulsivity, and hyperactivity. The medical community has been largely unable to standardize an accepted definition of ADHD as indicated by the medical community′s differing definitions according to Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5)1 and the International Classification of Mental and Behavioural Disorders 10th revision (ICD-10)2. ICD-10 refers to disorders in this area as hyperkinetic disorders rather than attention deficit and relies upon hyperactivity to distinguish ADHD from other disorders. The DSM-5 separates patient phenotypes into three differing presentations: predominantly inattentive-type, predominantly hyperactive-impulsive type, and combined inattentive hyperactive-impulsive. Diagnosis of ADHD is predominantly based upon patient, teacher and parent responses to standardized questionnaires containing questions based on a list of criteria for diagnosing ADHD. People with ADHD are expected to have experienced at least six symptoms of inattention (predominantly inattentive-type), or hyperactivity (predominantly hyperactive-impulsive type), or both (combined) within the six months previous to the time of the assessment.
In this study, we will use specially designed training activities, that must be performed within the environment of the popular computer game Minecraft, to determine if they affect executive function, working memory, and restraint in patients diagnosed with ADHD. Various cognitive training interventions are currently under investigation for their effects on improving deficits in executive function in ADHD, and the addition of gaming elements to the cognitive training may help improve outcomes (for review, see Strahler, et al (2015) P. 5-9).3 For example, utilization of a video game format to train biofeedback skills (reduction of heart rate through slowed breathing) in children with ADHD resulted in improved scores on the ADHD Questionnaire and the Strengths and Difficulties Questionnaire.4 Gamification of the Conners Continuous Performance Test II, used to measure sustained attention, resulted in significant improvements in performance compared to the regular test in children with ADHD.5 The addition of gaming elements to standardized working memory training tasks resulted in significantly improved motivation, training performance, and working memory of children with ADHD6 and the use of a gaming task also normalized task persistence in ADHD children in a visuospatial working memory task.7 Finally, a multiple domain executive function training game resulted in improvements in the specific domains trained (inhibition, visuospatial short-term memory, and visuospatial working memory) in children with ADHD, although no benefits were seen in overall behavior ratings.8 Rationale for use of stimulant type medications to treat ADHD Amphetamines are non-catecholamine sympathomimetic amines with CNS stimulant activity. The mode of therapeutic action in ADHD is not known, but amphetamines increase extracellular dopamine and norepinephrine. These alterations in extracellular neurotransmitters are a result of amphetamine's inhibition of the Dopamine Transporter (DAT), Norepinephrine Transporter (NET), Vesicular Monoamine Transporter-2 (VMAT- 2), and Monoamine Oxidase (MAO).
DAT and NET are located in the presynaptic terminal cell membrane, where they function to clear dopamine and norepinephrine, respectively, from the synaptic cleft into the presynaptic neuron. This clearance is necessary to end the response of the postsynaptic neuron and recycle the neurotransmitters in the presynaptic neuron for subsequent repackaging and release. Thus, competitive inhibition of DAT by amphetamine prolongs the presence of dopamine in the synapse, which results in a greater degree of dopamine signaling to the postsynaptic cell. In addition to competitive inhibition of DAT function, amphetamine can reverse the direction in which dopamine is transported. This effect can further increase synaptic dopamine levels beyond the level resulting from transport inhibition alone. Although NET primarily uses norepinephrine as a substrate, it is also capable of transporting dopamine and its inhibition can increase synaptic dopamine levels.9
While DAT and NET are located in the presynaptic cell membrane, VMAT2 and MAO are located within the presynaptic nerve terminal. VMAT2 is responsible for transporting monoamine neurotransmitters into vesicles within the nerve terminal, after which they can be released into the synaptic cleft. When VMAT2 is inhibited by amphetamine, cytosolic dopamine levels will increase. The increased cytosolic dopamine can then be acted on by the "reversed" DAT and transported into the synaptic cleft. However, while in the cytosol, dopamine is also susceptible to oxidative degradation by MAO. By inhibiting MAO function, amphetamine prevents this degradation and leaves increased cytosolic dopamine available for transport into the synaptic cleft.37 In contrast, methylphenidate inhibits DAT and NET and has weaker inhibition of MAO than amphetamine.10 Thus, methylphenidate increases extracellular dopamine levels by blocking its reuptake only, rather than also increasing its release as amphetamine does.11
Rationale for use of Minecraft as add-on therapy to stimulant type ADHD medications
Diagnosis rates of ADHD in children range from 5-11%12,13 compared to 2.5% in adults14. Diagnosis of ADHD rose 42% from 2003–2004 to 2011–201215. In 2011, 3.5 million children were being treated with therapeutics as reported by their parents16. One of the issues with continued reliance upon therapeutics to treat ADHD is that increased availability tends to increase nonmedical use of amphetamine-type ADHD drugs by adolescents and young adults. In addition, parents prefer non-drug treatment options for ADHD17, and thus medical treatments for ADHD remain underutilized.18 Finally, the beneficial effects of currently available drug and behavioral therapies do not persist after discontinuation,19,20 thus making alternative treatments with benefits that continue long- term highly desirable.
Some new companies make video games designed to treat ADHD, and FDA has issued a guidance for therapeutic game designers. Lexington is becoming a hotbed of videogame development21,22. Pfizer and Shire Pharmaceuticals are funding research in videogames. Drug companies will head toward drug/device combinations, even though they currently seek prescription video games. Companies like CogCubed and Akili are developing videogames for approval as FDA regulated devices, but not drug device combinations. There is some evidence of efficacy of games, but the efficacy could be improved. The ultimate goal is to increase overall treatment efficacy and create the first FDA-approved device/drug combination for ADHD treatment.
To that end, this clinical trial will be conducted as an exploratory study to investigate the functional relationship between NICHQ scores, game aspects of Minecraft, and executive function. Two study groups will be included: a videogame group (ADHD drug regimen + Minecraft a minimum of 30 minutes per day, 5 times per week x 4 weeks) and a control group (ADHD drug regimen only x 4 weeks). By using a no Minecraft control group who will continue their usual ADHD medication regimen, we expect to be able to determine the effect on executive function from adding Minecraft to the usual standard of care for ADHD. (All subjects enrolled in the study will be free to play any video games or computer games that they want to play during the course of the study. However, the Minecraft group will be the only group of subjects playing in the private Minecraft Realm and doing the activities described there.) Furthermore, subjects in the control group will be taking varying doses of stimulant medications as well as different types of stimulant medications prior to enrolling in the study. This will allow for easier recruitment and, more importantly, allow for additional data to be collected. A dose response effect across dose parameters will be examined, and the introduced variance will be managed with factor analysis23. However, one potential problem in this study design is the effects of other medications used to treat ADHD (such as atypical antipsychotics or alpha-2 receptor agonists) that may have negative effects on cognitive function, and therefore confound the results. We expect that such effects will be negated by requiring that the study subjects are being treated with a stimulant medication, which would counteract the negative effects of these medications on cognitive function.
Previous studies which found effects of gaming interventions on executive function have used study durations ranging from 2-16 weeks, with 2-5 training sessions per week.3 However, a less intense schedule of 5 x 30 minute (minimum) game sessions per week for 4 weeks was chosen for this study because of concerns related to lowered compliance to study procedures. These concerns are due to the study’s taking place during the school year, when increased time demands for the study subjects could limit adherence to a more intensive intervention schedule.
Our hypothesis is that subjects in the videogame group (usual ADHD drug + Minecraft) will show improvements in NICHQ scores and executive function at the end of the 4 week game playing period compared to the control group.
Pharmaceutical therapy is the most effective monotherapy for most patients with ADHD, with the exception of the very young24. The advantages of a combining pharmaceutical therapy with behavioral therapy include lower cost, as personnel time with patients is reduced, and reduced doses of pharmaceutics (50-75%)25. Additionally, the benefits of behavior therapy are more likely to carry forward once treatment has stopped26. Behavior therapy for ADHD patients includes repetitively reducing negative behaviors with consequences and increasing positive behaviors with rewards27. One possible mechanism of action associated with the effects of Minecraft on ADHD is the opportunity for reinforcement of positive behavior and punishment for negative behaviors provided by Minecraft. Minecraft is an online medium with several built-in components similar to behavior therapy exercises but enjoyable so that children are likely to want to play. High performance in several major executive functions noted to be lacking in autistic children is positively reinforced by gameplay, in that success yields completion of a specific task, acquisition of a rare in-game item, or even character survival in a given situation28. Furthermore, Minecraft allows players to re-attempt failed challenges as characters re-spawn after death, though with certain disadvantages. This both gives players the impetus to improve in those executive functions (to prevent character death or hassle) and the ability to continue improving.
Application of executive functions in gameplay is exemplified in the following:1) Executive Functions Exemplified in Construction - A great deal of time and focus are required to acquire the necessary resources and build a desired project, particularly in Survival mode (a mode of gameplay which requires players to harvest resources while harassed by cartoon monsters); a great amount of time and self-direction are required to build an ideal structure in Creative mode as well (a mode of gameplay in which players have free, unlimited access to all resources, unlimited mobility, and no danger of character death). The construction of complex structures requires inhibition as players must work exclusively on one project to complete it in a timely fashion, working memory as players must mentally construct the project in their minds in order to place building blocks on the proper squares of the game grid, planning as players choose how much of the resources they wish to acquire and design their structures, and self-monitoring as players balance their time and the amount of risk associated with the acquisition of resources.2) Executive Function Exemplified in Mobility - Manual dexterity is required for proper placement of blocks, navigation of obstacles, and combat with cartoon monsters. All of these can be difficult, and the failure to execute these maneuvers correctly results in character death (and loss of experience and items) and/or in the frustration of traveling back to the location, often over difficult terrain.3) Executive Function Exemplified in Fluidity - Maintaining and changing mental set and emotional regulation is applicable to overcoming challenges presented in survival mode in particular, though challenges also arise in the building process in any mode, and players often have to modify their strategies in order to succeed.4) Executive Function Exemplified in General Gameplay - Focus and concentration skills are practiced as players must monitor their health and surroundings in the game to stay alive. Due to the fact that Minecraft is borderless, subjects can become lost if attention is not paid to their surroundings. While other games may also require monitoring of health, there is an element of required organizational skills that may be missing in other video games popular with this demographic. While subjects will likely have an exhaustive inventory of general supplies after having played for awhile, survival may mean the ability to find needed supplies quickly and acquisition of specialized resources is still a lengthy and sometimes difficult process (when play is conducted in Survival mode).
In contrast to the behavioral training components of Minecraft, the training of executive function is expected to yield more generalizable benefits across multiple environments, because executive function processes underlie all cognitive processes while training to modify behaviors can only affect the specific behaviors targeted.29 Moreover, training of working memory has previously been shown to increase cortical D1 receptor density.30 As dopaminergic function is compromised in ADHD31, these alterations could provide additional benefits in improving the function of patients with ADHD. In order to direct the practice of these executive functions, during this trial players will be required to work from an activity list with additional reinforcement for practicing behavior therapy type activities. A self assessment component of the trial will encourage subjects to develop self cognition or metacognition.
In addition to its effects on behavior and executive function, Minecraft could beneficially affect neurological functions underlying cognitive control. A previous study assessing the effects of a therapeutic video game designed to train multitasking ability in elderly subjects found that improvements in multitasking were associated with increases in midline frontal theta power and long-range theta coherence between the frontal and posterior brain regions as determined by two electroencephalography methods used to assess cognitive control. These improvements persisted for six months following the completion of training and reached a level comparable to that of younger adults.32
Furthermore, utilizing cognitive training activities in a gaming format is suggested to increase motivation and one’s ability to learn.33 This effect is thought to be mediated by games producing increased striatal dopamine levels34,35 that enhance long-term potentiation of neural connections in the striatum.36,37text/html2020-01-31T09:43:45+01:00http://www.webmedcentral.com/Dr. Robert A LodderTherapeutic Video Games for Attention Deficit Hyperactivity Disorder (ADHD)
http://www.webmedcentral.com/article_view/5601
Attention Deficit Hyperactivity Disorder
Diagnosis rates of ADHD in children range from 3-11% compared to 4% in adults.1-3 Diagnosis of ADHD rose 42% from 2003–2004 to 2011–2012.2 In 2011, 3.5 million children were being treated with therapeutics as reported by their parents.2 Stimulant medications such as amphetamines and methylphenidate are currently the first-line treatment for ADHD,4 although there are significant problems associated with their use. They are often misused, abused, and diverted for nonmedical purposes. Stimulant use is associated with, and, in many cases, limited by, side effects such as insomnia, gastrointestinal distress, irritability, loss of appetite, and growth suppression.4 Parents also have poor perceptions of their safety,5-7 and thus they remain underutilized as a treatment option in children.7-9 Although these medications are effective in controlling symptoms in the short term in many patients, their efficacy does not persist after discontinuation,10 many patients may experience only a partial response or no response at all,11-12 and, even with treatment, children with ADHD still suffer from greater rates of adverse long-term outcomes such as drug abuse and criminal behavior than healthy children.10
Pharmacotherapy
Pharmaceutical therapy with stimulants is the most effective monotherapy for most patients with ADHD, with the exception of the very young.13 The advantages of combining pharmaceutical therapy with behavioral therapy include lower cost, as personnel time with patients is reduced, and reduced doses of pharmaceuticals (50-75%).14 Additionally, the benefits of behavior therapy are more likely to carry forward once treatment has stopped.14 Behavior therapy for ADHD patients includes repetitively reducing negative behaviors with consequences and increasing positive behaviors with rewards.13 However, behavior therapy is not widely available to all patients, and its benefits are limited to the targeted behaviors only.7
Video games
A potential alternative approach to address these issues is to improve the cognitive processes that underlie the observed symptoms.7 One potential intervention target to do so is executive function, which is a set of top-down mental processes that regulate distracting influences and automatic, unproductive behaviors to enable self-control.15 Training of the core executive function working memory has previously been shown to increase cortical D1 receptor density.16 As dopaminergic function is compromised in ADHD17, these alterations could provide additional benefits in improving the function of patients with ADHD. To this end, computer-based programs with repeated cognitive exercises without video game elements have been used as a treatment intervention in ADHD.18 However, it is thought that delivery of these interventions in a video game format can help improve their effects by promoting a state of optimal cognitive performance and increasing the participant’s focus and motivation to complete them.18 Indeed, children with ADHD have shown reduced impairments in inhibition (but not working memory) while playing video games,19 and the addition of video game elements to executive function training tasks have resulted in improvement of working memory20,21 as well as improved working memory performance over time.21
In addition, training methods used to enhance learning have traditionally shown effects only in the specific areas targeted by the training.22 However, healthy action video game players have outperformed non-players in a broad variety of cognitive performance measures, including some executive functions such as flexibility and top-down attention, suggesting their potential usefulness as a cognitive training tool.22 Notably, improvements in these areas have been seen in randomized, controlled trials of non-players trained with either an action video game or a non-action video game (as an active control group) in the action video game group only, suggesting that action video games have a causative role on this improved performance.22 Furthermore, video gaming may be able to increase motivation and one’s ability to learn.23 This effect is thought to be mediated by games producing increased striatal dopamine levels24,25 that enhance long-term potentiation of neural connections in the striatum.26 The potential of using a video game as a therapeutic tool was further evidenced in a recent article in the journal Nature that described a video game training multitasking ability that was capable of improving measures of the neurological functions that underlie cognitive control in elderly subjects.27 Thus, by using a video-game based cognitive training intervention as part of a drug/device combination with stimulants, it could be possible to increase the efficacy of currently available treatments and/or reduce the dose of stimulants needed to control symptoms.
However, video game play has also been associated with several adverse effects. Like pharmaceuticals, the effect seen seems to be related to the amount and style of video games to which humans are exposed. First-person shooter games with violence have been associated with anxiety and fear.28 However, these associations have been found in subjects with excessive video game use or internet gaming addiction,29-37 (but see 38) and it is thought that the excessive gaming could be used as a form of escape from negative emotions rather than a causative factor for them.32-33,36 (but see 34) The negative outcomes of video game play include obesity, aggressiveness, antisocial behavior, and addiction.28 Although video games could potentially be advantageous as a learning aid, increased time spent playing video games has been associated with worse academic performance.39 Despite these concerns, there have not been any significant safety concerns reported in studies using video games for executive function training. Thus, we suspect that video game play using a schedule similar to the training interventions that have resulted in improved executive function will still have a favorable safety profile compared to pharmaceutical treatments.
Recognizing the therapeutic potential of video games, the FDA has issued a guidance for therapeutic video app developers. Pfizer and Shire Pharmaceuticals are funding research in video games, and companies like CogCubed and Akili are developing video games for approval as FDA-regulated devices. Although drug companies are currently seeking prescription video games, they must eventually move toward drug/device combinations to increase efficacy.
A recent meta-analysis concluded that the use of cognitive training interventions targeting working memory or attention alone have resulted in substantial improvement in these executive functions, with some studies also showing improvements in parent ratings of ADHD symptoms.12 The improvements in working memory have been shown to persist at 6 months40,41 and 8 months42 after completion of training. However, far transfer effects to functional areas beyond the targeted executive functions (such as improvements in academic measures) and teacher ratings of ADHD symptoms have remained largely unaffected.43-45 These inconsistencies could potentially be due to practice effects resulting from repeated assessments affecting the executive function measures and insufficient blinding procedures affecting parents’ ratings.12,18
The scope of research involving cognitive training interventions targeting multiple executive functions is more limited than for those targeting a single executive function. However, studies investigating interventions targeting multiple executive functions have shown a greater magnitude in improvement of ADHD symptoms assessed by parents compared to those targeting a single executive function.12,46-50 Although these improved effects could be due to an increased duration of training, it is possible that training strategies targeting a broader set of executive functions may be required to effectively address both the full spectrum of neuropsychological deficits present in ADHD as well as the interindividual variation of deficits among children with ADHD.12
With regard to ADHD symptom assessments by blinded raters, two recent studies investigating an intervention with added video game elements to simultaneously train multiple executive functions showed effects in teacher-rated outcomes. One intervention training working memory, inhibition, and flexibility was able to produce moderate-to-large improvements in ADHD symptoms ratings by teachers, but these effects were also obtained with the placebo intervention, suggesting that the improvements were due to general features of the intervention not related to the executive function training itself.23 Another intervention training time management, organization/planning, and cooperation resulted in small-to-moderate improvements of parent-reported daily functioning in the areas of working memory, time management, and responsibility.51 Improvements in time management were also reported by teachers in this study, suggesting that training interventions targeting skills that are directly applicable in daily life could potentially improve far transfer effects across multiple settings.51
Therefore, there is still a need to further explore the potential of using video gaming interventions to train multiple executive functions, including those that are directly utilized in daily life, as a treatment for ADHD. Our laboratory is currently conducting a pilot clinical study investigating the use of the popular online game known as Minecraft in combination with stimulant medications in subjects with ADHD. Minecraft is an online video game containing a “virtual land where users can create their own worlds and experiences, using building blocks, resources discovered on the site and their own creativity” that requires its users to apply problem solving, planning, and organizational skills for creative building and exploration.52 It has many levels of difficulty, which allows for adaptation to users with a wide range of cognitive abilities as well as potential for incremental progressions in difficulty as the user’s performance improves. Minecraft is widely available across a variety of commonly used devices, its recommended age range and content is appropriate for children, and its online world allows considerable flexibility for designing a variety of activities that challenge executive functions. In Survival Mode, Minecraft becomes an action game that should carry action game benefits.
One possible mechanism of action associated with the effects of Minecraft on ADHD is the opportunity for reinforcement of positive behavior and punishment for negative behaviors provided by Minecraft. Minecraft is an online medium with several built-in components similar to behavior therapy exercises but enjoyable so that children want to play. High performance in several major executive functions noted to be lacking in ADHD children is positively reinforced by gameplay, in that success yields completion of a specific task, acquisition of a rare in-game item, or even character survival in a given situation.53 Furthermore, Minecraft allows players to re-attempt failed challenges as characters re-spawn after death, though with certain disadvantages. This both gives players the impetus to improve in those executive functions (to prevent character death or hassle) and the ability to continue improving.
In contrast to the behavioral training components of Minecraft, the training of executive function is expected to yield more generalizable benefits across multiple environments, because executive function processes underlie all cognitive processes while training to modify behaviors can only affect the specific behaviors targeted.7 In order to direct the practice of executive functions, during this trial players are required to work from an activity list with additional reinforcement for practicing behavior therapy type activities. The activity list includes two tasks of increasing difficulty for each of the following executive function skills: planning, time management, self-regulation, sustained attention, organization, response inhibition, working memory, goal-directed persistence, flexibility, and metacognition. A self assessment component of the trial provides an additional opportunity to encourage subjects to develop metacognition. Thus, the training activities address both the underlying core executive functions (working memory, inhibition, and cognitive flexibility), as well as executive function skills utilized in school and work settings (planning, time management, self-regulation, sustained attention, organization, goal-directed persistence, and metacognition).
The primary objective of this trial is to derive a functional relationship between NICHQ scores (an assessment that measures ADHD symptoms as well as the patient’s function in everyday life), game aspects of Minecraft, and executive function. All patients in this study are required to be on stimulant drugs, so the effects of varying stimulant doses on the changes in executive function can also be explored. The development of this functional relationship could ultimately enable a personalized medicine approach to the treatment of ADHD by identifying the executive functions where an individual is most deficient and predicting the stimulant drug dosage and nature and schedule of the Minecraft activities that would be most effective for treating these deficits. This strategy could potentially improve the efficacy of treatment by targeting each patient’s unique deficits, as well as reduce the time to achieve optimal treatment effects by using artificial neural networks to simulate the patients’ Minecraft therapy. (Neural networks can be programmed to perform tasks in Minecraft faster than humans.)
The executive function deficits are assessed by a patient’s pattern of responses on the NICHQ assessment, and the nature and schedule of the MInecraft activities used to correct these deficits predicted by a computational model utilizing artificial neural networks (ANNs). Artificial neural networks are a computational technique inspired by the structure and function of biological neural networks and categorized under the headings of artificial intelligence and machine learning. Due to their similarity to biological neural structures, it is possible that the learning processes that occur during the training of an ANN could be used to simulate the learning processes that occur in human subjects from the completion of cognitively demanding tasks. An abbreviated “NICHQ” which assesses behavior that can be appropriately observed in the context of the computational model will be used to measure changes of executive functioning within the model that result from the application of computational tasks that are similar to the Minecraft activities that the human subjects perform. Separate models will be developed with ANNs that show poor performance (ADHD-ANNs) and relatively good performance (control-ANNs) on these tasks. Modifications of these tasks will also be tested in this manner to determine how optimal performance improvements in the ADHD-ANNs can be produced. Finally, these modified tasks will be tested in a future clinical study to determine the external validity of the model.
The structure of these computational models will be based on three of the core executive functions: inhibitory control, working memory, and cognitive flexibility. Inhibitory control refers to the ability to suppress the influence of internal or external forces that distract one from accomplishing a goal.15 Inhibitory control works closely together with working memory, which is the ability to hold information in mind after it is no longer perceptually present and effectively manipulate it as desired.15 For example, using working memory to focus attention on accomplishing a goal helps to remove attention from distracting impulses.15 Similarly, using inhibitory control to focus attention away from distracting impulses supports the use of working memory by leaving more mental “working space” available to be directed towards accomplishing a goal.15 Cognitive flexibility involves the ability to change perspectives, which requires the simultaneous use of both inhibitory control and working memory, where inhibitory control is used to resist the influence of one’s current perspective on their actions and working memory is used to hold a new perspective in attention to change one’s actions accordingly.15
The first of the core executive functions, inhibitory control (Fig. 1), is represented by an “Impulsivity” function, the value of which will increase over time and result in the activation of a distracting activity once its value increases above a given threshold. An ANN will be able to modify the parameters of this Impulsivity function, and a repeatedly executed training procedure will be implemented where the ANN will learn to modify these parameters more effectively to prevent the distraction function from activating as training proceeds.
Secondly, working memory (Fig. 2) will utilize this inhibitory control structure, but with the inclusion of a “Goal Activation” function and a working memory mental space. This function will work similar to the Impulsivity function, but if its value crosses a given threshold, then a goal activity function will be activated (as opposed to the distractor activity function). The working memory mental space will be represented by immediate computer memory, where function instructions (for either the goal or distracting activity) and the values of their associated parameters can be efficiently accessed and manipulated by the CPU. In this case, the implemented training procedure will be designed such that the ANN will learn to simultaneously modify the parameters of both the Impulsivity and the Goal Activation function to more effectively devote computational resources towards the completion of the goal activity and consequently complete the appropriate task function more efficiently.
Finally, cognitive flexibility (Fig. 3) will utilize the described interaction between inhibitory control and working memory, but at a given time point, the conditions of the task shall be changed such that activities other than the goal activity are to be performed for a given time period. Eventually, the conditions will be switched back so that the goal activity is to be completed once again, and this pattern will then be repeated in a cyclical manner. When computational resources are to be focused on the goal activity, the training of the ANN will involve diminishing the value of the Impulsivity function while increasing the value of the Goal Activator function as described above. However, when the conditions of the task change such that the goal activity is not to be pursued, the training of the ANN will be altered to instead increase the value of the Impulsivity function while diminishing the value of the Goal Activator function. An effectively trained ANN for cognitive flexibility will be able to more rapidly perform these transitions, and devote computational power towards the goal only when appropriate based on the given conditions.text/html2021-12-20T05:06:56+01:00http://www.webmedcentral.com/Dr. Deepak GuptaAre De Novo Adverse Adulthood Experiences (AAEs) Extensions Of Adverse Childhood Experiences (ACEs) Figuratively Or Literally? Create Positive Adulthood Experiences (PAEs) Just Like Positive Childhood Experiences (PCEs) To Counter Adversities
http://www.webmedcentral.com/article_view/5752
Over the last few decades, Adverse Childhood Experiences (ACEs) [1-3] have been documented to play a role in the evolving pathophysiology among modern humans. However, humanhood does not end once childhood evolves into adulthood. Moreover, chronological age may NOT always reflect mental age [4-5] of each and every modern human unless we mysteriously stop assessing mental age after chronological age achieves adulthood as per the deemed initiation age of adulthood. However, the brain is no longer considered to stop changing itself once the deemed initiation age of adulthood is achieved because human brain variably remains plastic as well as elastic, learning and adapting, across the period of human life [6-7]. Therefore, it may be time to investigate, explore and document whether Adverse Adulthood Experiences (AAEs) as well contribute to modern humans’ pathophysiology. This is because neglect and abuse are not restricted to only childhood when adulthood too suffers from neglect and abuse although in different forms. During childhood, victims primarily suffer at the hands of parents, teachers, relatives and other adults in their lives. During adulthood, victims primarily suffer at the hands of partners, friends, employers and other peers in their lives [8]. Although the effects of adverse experiences may be more during childhood, the effects of adverse experiences cannot be zilch during adulthood because human life across its lifetime experience positive, tolerable and toxic stress [9] to variable levels and at variable time points in its lifetime. To exemplify some, human manipulators may misuse and abuse fluctuating neurotransmitters and adverse experiences as excuses for how they live and behave but their plastic and elastic brains too must have factually learnt and adapted from their adverse experiences whether during childhood or during adulthood so as to start manipulating their environments. To exemplify further, as instead of overbearing or abusive parents affecting helpless children which lead to designing of 10-11 questions in ACEs questionnaires [10], overbearing or abusive systems affecting helpless adults warrant redesigning 10-11 questions of AAEs questionnaires. To exemplify contemporary, it may be interesting to investigate and explore if ACEs/AAEs are affecting how modern humans during global pandemic are choosing whether or not to get vaccinated against SARS-CoV-2 [11-12] and whether or not COVID-19 vaccinations are inducing less antibodies among those who have had ACEs/AAEs thus providing such victims of ACEs/AAEs less protection against breakthrough COVID-19 infections/hospitalizations/deaths potentially warranting early boosters of COVID-19 vaccinations. Summarily, adverse experiences whether ACEs/AAEs have a life of their own shaping the scarring of modern human lives and warranting salvaging of those scarred modern human lives because healing processes in modern tumultuous societies seem to be maladapted despite recognizing frequent occurrence of ACEs/AAEs among their constituents. Herein comes the role of to-be-defined Positive Adulthood Experiences (PAEs) on the line of recently-defined Positive Childhood Experiences (PCEs) [13-15] to counter the adversities especially when such adversities become unavoidable during imperfect existence in the matrix because recognizing ACEs/AAEs and their role in human suffering and diseases may be very depressing creating a feeling of helplessness [16] until and unless we recognize PCEs/PAEs role in empowering humans to counter ACEs/AAEs by drawing inspirations from PCEs/PAEs inducing cross-cultural differences [17-19] in the etiopathogenesis of human suffering and diseases after having faced similar ACEs/AAEs during their lifetimes.