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Aim: To investigate if tachypneic response to hypoxia is decreased in older patients., Methods: We included all patients ≥65 years of age attending 52 Spanish emergency departments (EDs) for whom peripheral arterial oxygen saturation (SatO 2 ) measured by pulsioxymetry and respiratory rate (RR) were registered at ED arrival. We assessed the relationship between SatO2 and RR in different models, and with the best-fitting model, we independently analyzed this relationship in four subgroups according to patient age (65-69, 70-79, 80-89, and ≥90 years). Five sensitivity analyses using different subsets of patients were carried out to check for the consistency of the results., Results: We included 7126 patients, with medians for SatO 2 and RR of 97% (interquartile range [IQR]: 94-98) and 15 bpm (IQR: 15-16), respectively. We found significant associations (P < 0.001) between SatO 2 and RR in every model tested (P < 0.001 for all), with the quadratic model obtaining the best fit (R 2 : 0.098) over those obtained with linear (R 2 : 0.096) and logarithmic (R 2 : 0.092) models. The same was observed in sensitivity analyses, with R 2 for quadratic models ranging from 0.069 in patients with low comorbidity and 0.102 in patients breathing room air. The mean RR for 100% SatO 2 was 15 bpm and increased as SatO 2 decreased, although with a progressive slowing of the slope, with a mean RR of 27 at 50% SatO 2 . We detected a decreased RR response to increasing hypoxemia according to age and, while the RR curve was higher and with a progressively steepening slope in the 972 patients aged 65-69 (mean RR of 42 bpm with 50% SatO 2 ), a progressive slowing of slope was observed in the 2693 patients aged 70-79 (mean RR of 28 with 50% SatO2), the 2582 aged 80-89 (mean RR of 25) and the 879 aged ≥90 (mean RR of 23). Sensitivity analyses provided very similar results., Conclusion: Tachypneic response to hypoxemia in older patients decreases as age advances, regardless of the reason leading to hypoxemia. Geriatr Gerontol Int 2024; 24: 1120-1129., (© 2024 Japan Geriatrics Society.)

Background: Nontuberculous mycobacterial pulmonary disease (NTM-PD) patients often have exercise intolerance. Pulmonary rehabilitation (PR) to improve such patients' conditions is often not based on its exercise pathophysiology. We have reported that the oxygen consumption (ΔF O2 ) by expiratory gas analysis, i.e., the inspired-expired-expiratory mean oxygen concentration difference, is related to the minute ventilation-carbon dioxide output (V' E -V' CO2 )-slope and oxygen uptake (V' O2 ) independent of the V' E . The aim of this study was to investigate how ΔF O2 is related to dynamic ventilatory variables, chest computed tomography (CT), and echocardiography findings in NTM-PD patients to understand their pathophysiological conditions., Methods: Clinical data of NTM-PD patients with exertional dyspnea (n = 29) who underwent incremental exercise testing, chest CT, and echocardiography at the same time were compared with those of control participants (n = 12)., Results: In the NTM-PD group, 1) peak V' O2 decreased (NTM-PD: 17.6 vs. controls: 28.7 mL⋅min -1 ⋅kg -1 ), and 2) ΔF O2 at peak exercise was negatively correlated with respiratory frequency at peak exercise (correlation coefficient: r = -0.80, p < 0.0001), V' E -V' CO2 -slope (r = -0.75, p < 0.0001), bronchiectasis CT score (r = -0.52, p = 0.0042), and the trans-tricuspid pressure gradient (r = -0.39, p = 0.0417), and positively correlated with peak V' O2 (r = 0.71, p < 0.0001) and the body mass index (r = 0.42, p = 0.0217), but it was not correlated with V' E at peak exercise and the cavity CT score., Conclusions: Exertional oxygen consumption, independent of ventilatory ability, is associated with exercise tolerance and ventilatory efficiency, while being related to tachypnea and bronchiectasis rather than cavitation in NTM-PD patients. These findings may be useful in considering exercise physiology-based PR for NTM-PD patients with exertional dyspnea., Competing Interests: Declaration of competing interest The authors have no conflicts of interest., (Copyright © 2024 The Japanese Respiratory Society. Published by Elsevier B.V. All rights reserved.)

Background: Vital signs are an essential component of the emergency department (ED) assessment. Vital sign abnormalities are associated with adverse events in the ED setting and may indicate a risk of poor outcomes after ED discharge., Clinical Question: What is the risk of adverse events among adult patients with abnormal vital signs at the time of ED discharge?, Evidence Review: Studies retrieved included 6 retrospective studies with adult patients discharged from the ED. These studies evaluated adverse outcomes in adult patients discharged from the ED with abnormal vital signs. Hypotension at discharge was associated with the highest odds of adverse events after discharge. Tachycardia was also a key predictor of adverse events after discharge and may be easily missed by ED clinicians., Conclusion: Based on the available evidence, the specific vital sign abnormality and the number of total abnormalities influence the risk of adverse outcomes after discharge. Vital sign abnormalities at the time of discharge also increase the risk of ED revisit. The most common abnormal vital sign at the time of discharge is tachycardia., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

A case report of a severely dyspnoeic kyphoscoliotic patient intended for an elective major thoracic surgery for suspected lung malignancy. With baseline near maximal breathing frequency and shallow breaths and poor lung mechanics, the first encountered anaesthetist considered this patient too high risk for lobectomy. This case illustrated the application of cardiopulmonary exercise testing to provide an objective assessment of the patient's functional capacity, ventilatory efficiency and delineation of modifiable respiratory components that guide the formulation of individualized prehabilitation programme. It also depicted the perioperative role of an off-label use of incentive spirometry in providing visual feedbacks and led to subsequent assessment breathing pattern alternation. Patient underwent the lung resection uneventfully and returned to normal lifestyle on postoperative day 4., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Tracheoesophageal fistula (TEF) is a congenital anomaly resulting from the incomplete fusion of the tracheoesophageal ridge during the third week of embryonic development. This case report presents a male neonate, born at term via normal vaginal delivery, who developed respiratory distress, persistent cough, and vomiting within hours of birth. Despite initial management with respiratory support and antibiotics, the infant's condition persisted, prompting further investigation. High-resolution computed tomography and an esophagogram revealed a suspected H-type TEF, which was confirmed via rigid bronchoscopy. Following the diagnosis, the patient underwent corrective surgery, leading to symptom resolution. This case underscores the importance of considering TEF in neonates with persistent respiratory symptoms and the need for a combination of diagnostic modalities to confirm this rare anomaly. Prompt surgical intervention is crucial to prevent complications and improve outcomes., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Reddy et al.)

Acute coronary syndrome due to a non-atherosclerotic, non-traumatic, or iatrogenic-induced spontaneous coronary artery dissection (SCAD) is a rare clinical condition that affects mostly young women of reproductive age. In this case, we present a 36-week-pregnant, 35-year-old G2P1 woman, with no previous medical history, who was admitted to our hospital with premature pre-labor contractions. During her hospitalization, she underwent a coronary artery percutaneous angiography revealing SCAD of the three coronary vessels, after an episode of acute-onset chest pain, tachypnea, EKG alterations, cardiac enzyme elevation, and bilateral pleural effusions. An emergency cesarean delivery was performed and the patient was transferred to the cardiology intensive care unit. Conservative management was decided and the woman was discharged a few days later., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Antonakopoulos et al.)

Background: To evaluate the safety and efficacy of 2.5 and 1.25 mg nebulized salbutamol on Transient Tachypnea of the Newborn (TTN) compared with placebo. Methods: We conducted a triple-blind, phase II/III parallel randomized controlled trial in two university-affiliated hospitals with neonatal intensive care units. Newborns with a confirmed diagnosis of TTN, with gestational age >35 weeks and gestational weight >2 kg were included. Cases of asphyxia, meconium aspiration syndrome, and persistent pulmonary hypertension were excluded. Ninety eligible patients were randomly allocated in three intervention groups (2.5 mg salbutamol, 1.25 mg salbutamol, and placebo), and a single-dose nebulized product was prescribed 6 hours after the birth. Safety outcomes included postintervention tachycardia, hyperglycemia, hypokalemia, and changes in blood pressure. To evaluate the efficacy, the duration of postintervention tachypnea, TTN clinical score, and clinical and paraclinical respiratory indices were assessed. Parents, Outcome assessors, and data analyzer were blind to the intervention. Results: There was no adverse reaction, including tachycardia, hypokalemia, and jitteriness. Both groups of salbutamol recipients showed significant improvement regarding respiratory rate, TTN clinical score, and oxygenation indices compared with the placebo ( p -values <0.001). Nonstatistically significant higher hospital stay was observed in the placebo group. Single 2.5 mg salbutamol nebulization showed a little better outcome than the dose of 1.25 mg, although we could not find statistical superiority. Conclusion: The newly applied single high dose of 2.5 mg nebulized salbutamol is safe in treating TTN and leads to notable faster improvement of respiratory status without any considerable adverse reaction. Registry code: IRCT20190328043133N1.

Objectives: This study was designed to investigate clinical differences between pediatric patients who presented with chest pain, tachycardia, and/or tachypnea who subsequently were or were not diagnosed with myocarditis. The results were used to develop a decision tree to aid in rapid diagnosis of pediatric myocarditis., Methods: A retrospective case-control study was performed using the electronic medical records of children aged 0 to 18 years between the years 2003 and 2020 with a complaint of chest pain, tachycardia, and/or tachypnea. Patients included in the study were those diagnosed with myocarditis and those with suspected myocarditis, which was ultimately ruled out. Demographic and clinical differences between the research groups were analyzed. A decision tree was rendered using the rpart (Recursive Partitioning and Regression Trees) package., Results: Four thousand one hundred twenty-five patients were screened for eligibility. Seventy-three myocarditis patients and 292 nonmyocarditis patients were included. Compared with the control group, the study group was found to have a higher mean respiratory rate (37 ± 23 vs 23 ± 7 breaths per minute) and mean heart rate (121 ± 44 vs 97 ± 25 beats per minute) and lower mean systolic and diastolic blood pressure (102 ± 27/56 ± 17 mm Hg vs 114 ± 14/67 ± 10 mm Hg). The mean white blood cell count was greater in the case group (13 ± 6 vs 10 ± 5 × 10 3 /μL). A decision tree was rendered using simple demographic and clinical variables. The accuracy of the algorithm was 85.2%, with 100% accuracy in patients aged 0 to 2.5 years and 69% in patients aged 2.5 to 18 years., Conclusion: The clinical and laboratory characteristics described in this study were similar to what is described in the literature. The decision tree may aid in the diagnosis of myocarditis in patients 2.5 years and younger. In the population aged 2.5 to 18 years, the decision tree did not constitute an adequate tool for detecting myocarditis., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Treatment of Mycoplasma spp. pneumonia has rarely been described in domestic ferrets (Mustela putorius furo). A 10-month-old, 0.53 kg, female spayed domestic ferret was presented for oxygen-dependent, chronic dyspnea of one-month's duration. Physical examination findings included dyspnea, tachypnea, increased bronchovesicular sounds bilaterally, and an intermittent non-productive cough. Bloodwork abnormalities included a mild leukocytosis (8.6×10 3 /µL), mild neutrophilia (4.0×10 3 /µL), mild hypoalbuminemia (2.7 g/dL), mild hyperglobulinemia (3.3 g/dL), mild hyponatremia (147 mEq/L), and mild hypochloremia (111.4 mEq/L). Radiographs revealed a marked diffuse bronchial pattern with peribronchial cuffing, a mild main pulmonary artery bulge, distended caudal lobar pulmonary arteries, and decreased serosal detail within the abdomen. An echocardiogram revealed indications of moderate pulmonary hypertension and systolic anterior motion of the mitral valve. Polymerase chain reaction testing for Mycoplasma spp. was positive, and treatment was initiated with doxycycline (10 mg/kg PO q 12 h for 16 weeks), prednisolone (0.4 mg/kg PO q 12 h for 13 weeks, tapered to 0.2 mg/kg PO q 12 h for two weeks, then eventually increased to 0.7 mg/kg PO q 12 h until further notice), sildenafil (0.3 mg/kg PO q 24 h for 13 weeks), and oxygen supplementation via an oxygen cage for six weeks. On repeat echocardiogram eleven weeks after initiation of doxycycline therapy, the pulmonary hypertension had resolved. At follow up six months later, the ferret was stable on previously prescribed medications and did not require oxygen supplementation. Mycoplasma spp. and pulmonary hypertension should be considered in cases of respiratory distress in ferrets., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To compare the epidemiological and clinical characteristics of hospitalized children with respiratory syncytial virus (RSV) infection in Kunming among the pre-and post-COVID-19 era, and to establish a prediction model for severe RSV infection in children during the post-COVID-19 period. Methods: This was a retrospective study. Clinical and laboratory data were collected from 959 children hospitalized with RSV infection in the Department of Pulmonary and Critical Care Medicine at Kunming Children's Hospital during January to December 2019 and January to December 2023. Patients admitted in 2019 were defined as the pre-COVID-19 group, while those admitted in 2023 were classified as the post-COVID-19 group. Epidemiological and clinical characteristics were compared between the two groups. Subsequently, comparison of the clinical severity among the two groups was performed based on propensity score matching (PSM). Furthermore, the subjects in the post-COVID-19 group were divided into severe and non-severe groups based on clinical severity. Chi-square test and Mann-Whitney U test were used for pairwise comparison between groups, and multivariate Logistic regression was applied for the identification of independent risk factors and construction of the prediction model. The receiver operating characteristic (ROC) curve and calibration curve were employed to evaluate the predictive performance of this model. Results: Among the 959 children hospitalized with RSV infection, there were 555 males and 404 females, with an onset age of 15.4 (7.3, 28.5) months. Of which, there were 331 cases in the pre-COVID-19 group and 628 cases in the post-COVID-19 group. The peak period of RSV hospitalization in the post-COVID-19 group were from May to October 2023, and the monthly number of inpatients for each of these months were as follows: 72 cases (11.5%), 98 cases (15.6%), 128 cases (20.4%), 101 cases (16.1%), 65 cases (10.4%), and 61 cases (9.7%), respectively. After PSM for general data, 267 cases were matched in each group. The proportion of wheezing in the post-COVID-19 group was lower than that in the pre-COVID-19 group (109 cases (40.8%) vs. 161 cases (60.3%), χ 2 <0.001), while the incidences of fever, tachypnea, seizures, severe case, neutrophil-to-lymphocyte ratio (NLR), C-reactive protein and interleukin-6 levels were all higher than those in the pre-COVID-19 group (146 cases (54.7%) P <0.001), while the incidences of fever, tachypnea, seizures, severe case, neutrophil-to-lymphocyte ratio (NLR), C-reactive protein and interleukin-6 levels were all higher than those in the pre-COVID-19 group (146 cases (54.7%) vs. 119 cases (44.6%), 117 cases (43.8%) vs. 89 cases (33.3%), 37 cases (13.9%) vs . 14 cases (5.2%), 69 cases (25.8%) vs. 45 cases (16.9%), 3.6 (1.9, 6.4) vs. 2.3 (1.8, 4.6), 9.9 (7.1, 15.2) vs. 7.8 (4.5, 13.9) mg/L, 20.5 (15.7, 30.4) vs. 17.2 (11.0, 26.9) ng/L, χ 2 =5.46, 6.36, 11.47, 6.42, Z =4.13, 3.06, 2.96, all P <0.05). There were 252 cases and 107 cases with co-infection in the post-and pre-COVID-19 groups, respectively. The proportion of triple and quadruple infection in the post-COVID-19 group was higher than that in the pre-COVID-19 group (59 cases (23.4%) vs. 13 cases (12.1%), 30 cases (11.9%) vs. 5 cases (4.7%), χ 2 =5.94, 4.46, both P <0.05). Among the 252 cases with co-infection in post-COVID-19 group, the most prevalent pathogens involving in co-infections, in order, were Mycoplasma pneumoniae 56 cases (22.2%), Influenza A virus 53 cases (21.0%), Rhinovirus 48 cases (19.0%), Parainfluenza virus 35 cases (13.9%), and Adenovirus 28 cases (11.1%).The result of multivariate Logistic regression showed that age ( OR =0.70, 95% CI 0.62-0.78, P <0.001), underlying diseases ( OR =10.03, 95% CI 4.10-24.55, P <0.001), premature birth ( OR =6.78, 95% CI 3.53-13.04, P <0.001), NLR ( OR =1.85, 95% CI 1.09-3.15, P =0.023), and co-infection ( OR =1.28, 95% CI 1.18-1.38, P <0.001) were independently associated with the development of severe RSV infection in the post-COVID-19 group. The ROC curve of the prediction model integrating the above five factors indicated an area under the curve of 0.85 (95% CI In the post-COVID-19 era in Kunming, the peak in pediatric hospitalizations for RSV infection was from May to October, with declined incidence of wheezing and increased incidence of fever, tachypnea, seizures, severe cases, and rates of triple and quadruple co-infections. Age, underlying diseases, premature birth, NLR, and co-infection were identified as independent risk factors for severe RSV infection in the post-COVID-19 period. In this study, a risk prediction model for severe pediatric RSV infection was established, which had a good predictive performance.P <0.001), with an optimal cutoff of 0.21, a sensitivity of 0.83 and a specificity of 0.80. The calibration curve showed that the predicted probability in this model did not differ significantly from the actual probability ( P =0.319). Conclusions: In the post-COVID-19 era in Kunming, the peak in pediatric hospitalizations for RSV infection was from May to October, with declined incidence of wheezing and increased incidence of fever, tachypnea, seizures, severe cases, and rates of triple and quadruple co-infections. Age, underlying diseases, premature birth, NLR, and co-infection were identified as independent risk factors for severe RSV infection in the post-COVID-19 period. In this study, a risk prediction model for severe pediatric RSV infection was established, which had a good predictive performance.

Foxb1 -expressing neurons occur in the dorsal premammillary nucleus (PMd) and further rostrally in the parvafox nucleus, a longitudinal cluster of neurons in the lateral hypothalamus of rodents. The descending projection of these Foxb1 + neurons end in the dorsolateral part of the periaqueductal gray (dlPAG). The functional role of the Foxb1 + neuronal subpopulation in the PMd and the parvafox nucleus remains elusive. In this study, the activity of the Foxb1 + neurons and of their terminal endings in the dlPAG in mice was selectively altered by employing chemo- and optogenetic tools. Our results show that in whole-body barometric plethysmography, hM3Dq-mediated, global Foxb1 + neuron excitation activates respiration. Time-resolved optogenetic gain-of-function manipulation of the terminal endings of Foxb1 + neurons in the rostral third of the dlPAG leads to abrupt immobility and bradycardia. Chemogenetic activation of Foxb1 + cell bodies and ChR2-mediated excitation of their axonal endings in the dlPAG led to a phenotypical presentation congruent with a 'freezing-like' situation during innate defensive behavior., Competing Interests: RC, DR, SN, AB, PS, GA, MC No competing interests declared, (© 2023, Cola et al.)

Purpose To achieve ultra-high temporal resolution (approximately 20 msec) in free-breathing, real-time cardiac cine MRI using golden-angle radial sparse parallel (GRASP) reconstruction amplified with view sharing (VS) and k-space-weighted image contrast (KWIC) filtering. Materials and Methods Fourteen pediatric patients with congenital heart disease (mean age [SD], 9 years ± 2; 13 male) and 10 adult patients with arrhythmia (mean age, 62 years ± 8; nine male) who underwent both standard breath-hold cine and free-breathing real-time cine using GRASP were retrospectively identified. To achieve high temporal resolution, each time frame was reconstructed using six radial spokes, corresponding to acceleration factors ranging from 24 to 32. To compensate for loss in spatial resolution resulting from over-regularization in GRASP, VS and KWIC filtering were incorporated. The blur metric, visual image quality scores, and biventricular parameters were compared between clinical and real-time cine images. Results In pediatric patients, the incorporation of VS and KWIC into GRASP (ie, GRASP + VS + KWIC) produced significantly ( P < .05) sharper x-y-t (blur metric: 0.36 ± 0.03, 0.41 ± 0.03, 0.48 ± 0.03, respectively) and x-y-f (blur metric: 0.28 ± 0.02, 0.31 ± 0.03, 0.37 ± 0.03, respectively) component images compared with GRASP + VS and conventional GRASP. Only the noise score differed significantly between GRASP + VS + KWIC and clinical cine; all visual scores were above the clinically acceptable (3.0) cutoff point. Biventricular volumetric parameters strongly correlated ( R 2 > 0.85) between clinical and real-time cine images reconstructed with GRASP + VS + KWIC and were in good agreement (relative error < 6% for all parameters). In adult patients, the visual scores of all categories were significantly lower ( P < .05) for clinical cine compared with real-time cine with GRASP + VS + KWIC, except for noise ( P = .08). Conclusion Incorporating VS and KWIC filtering into GRASP reconstruction enables ultra-high temporal resolution (approximately 20 msec) without significant loss in spatial resolution. Keywords: Cine, View Sharing, k-Space-weighted Image Contrast Filtering, Radial k-Space, Pediatrics, Arrhythmia, GRASP, Compressed Sensing, Real-Time, Free-Breathing Supplemental material is available for this article. © RSNA, 2024.

Respiratory muscle endurance training reportedly has beneficial effects on whole-body endurance performance. We produced a novel high-intensity interval (HII) protocol and characterized the associated physiological responses and respiratory muscle fatigue. Peak oxygen uptake of respiratory muscle (V̇O2peakRM) was estimated during the respiratory incremental test. The HII session consisted of five 3-minute hyperpnea periods at 100%V̇O2peakRM interspersed with 2-minute periods at 40%V̇O2peakRM (25 min total). The high-intensity continuous (HIC) session involved a single time-to-end bout of hyperpnea at 100%V̇O2peakRM. The moderate-intensity continuous (MIC) session involved 25 min of hyperpnea at 60% of maximal voluntary ventilation. V̇O2RM was recorded continuously, and maximal inspiratory pressure (PImax) was assessed before and after the sessions. HII session: V̇O2RM gradually increased as the sets proceeded, whereas PImax decreased significantly. HIC session: V̇O2RM increased progressively, and the time to end was 6.5 ± 0.5 min. PImax decreased significantly. MIC session: V̇O2RM did not change for 25 min, and PImax remained unchanged. The duration of V̇O2RM at near- and supra-maximal levels in the HII session (10 ± 1 min) was longer than that in the HIC session (4 ± 1 min). The decrease in PImax was larger in the HII session (-12 ± 3 %) than MIC session (-4 ± 3 %). The HII protocol is characterized by a longer time to maximally stimulate the aerobic energy system of respiratory muscle than the HIC protocol and greater inspiratory muscle fatigue than the traditional MIC protocol. These results suggest that the HII protocol could enhance the efficacy of respiratory muscle training programs., Competing Interests: Declaration of Competing Interest The authors declare that there is no conflict of interest in this study., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Many rapid response system (RRS) events are activated using multiple triggers. However, the patterns in which multiple RRS triggers occur together to activate RRS events are unknown. The purpose of this study was to identify these patterns (RRS trigger clusters) and determine their association with outcomes among hospitalized adult patients., Methods: RRS events among adult patients from January 2015 to December 2019 in the Get With The Guidelines- Resuscitation registry's MET module were examined (n = 134,406). Cluster analysis methods were performed to identify RRS trigger clusters. Pearson's chi-squared and ANOVA tests were used to examine differences in patient characteristics across RRS trigger clusters. Multilevel logistic regressions were used to examine the associations between RRS trigger clusters and outcomes., Results: Six RRS trigger clusters were identified. Predominant RRS triggers for each cluster were: tachypnea, new onset difficulty in breathing, decreased oxygen saturation (Cluster 1); tachypnea, decreased oxygen saturation, staff concern (Cluster 2); respiratory depression, decreased oxygen saturation, mental status changes (Cluster 3); tachycardia, staff concern (Cluster 4); mental status changes (Cluster 5); hypotension, staff concern (Cluster 6). Significant differences in patient characteristics were observed across clusters. Patients in Clusters 3 and 6 had an increased likelihood of in-hospital cardiac arrest (p < 0.01). All clusters had an increased risk of mortality (p < 0.01)., Conclusions: We discovered six novel RRS trigger clusters with differing relationships to adverse patient outcomes. RRS trigger clusters may prove crucial in clarifying the associations between RRS events and adverse outcomes and aiding in clinician decision-making during RRS events., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Introduction: We determined if the heart rate (HR) monitoring performance of a wireless and nonadhesive belt is non-inferior compared to standard electrocardiography (ECG). Secondary objective was to explore the belt's respiratory rate (RR) monitoring performance compared to chest impedance (CI)., Method: In this multicenter non-inferiority trial, preterm and term infants were simultaneously monitored with the belt and conventional ECG/CI for 24 h. HR monitoring performance was estimated with the HR difference and ability to detect cardiac events compared to the ECG, and the incidence of HR-data loss per second. These estimations were statistically compared to prespecified margins to confirm equivalence/non-inferiority. Exploratory RR analyses estimated the RR trend difference and ability to detect apnea/tachypnea compared to CI, and the incidence of RR-data loss per second., Results: Thirty-nine infants were included. HR monitoring with the belt was non-inferior to the ECG with a mean HR difference of 0.03 beats per minute (bpm) (standard error [SE] = 0.02) (95% limits of agreement [LoA]: [-5 to 5] bpm) (p < 0.001). Second, sensitivity and positive predictive value (PPV) for cardiac event detection were 94.0% (SE = 0.5%) and 92.6% (SE = 0.6%), respectively (p ≤ 0.001). Third, the incidence of HR-data loss was 2.1% (SE = 0.4%) per second (p < 0.05). The exploratory analyses of RR showed moderate trend agreement with a mean RR-difference of 3.7 breaths/min (SE = 0.8) (LoA: [-12 to 19] breaths/min), but low sensitivities and PPV's for apnea/tachypnea detection. The incidence of RR-data loss was 2.2% (SE = 0.4%) per second., Conclusion: The nonadhesive, wireless belt showed non-inferior HR monitoring and a moderate agreement in RR trend compared to ECG/CI. Future research on apnea/tachypnea detection is required., (© 2023 The Authors. Pediatric Pulmonology published by Wiley Periodicals LLC.)

Background: Abdominal trauma is one of the common reasons for emergency visits yet there is paucity of data about the subject in the horn of Africa. This study was aimed at determining the determinants of adverse management outcomes of blunt abdominal trauma among operated patients at Wolaita Sodo University Teaching and Referral Hospital, Ethiopia., Methods: This was a three-year retrospective review conducted among 128 patient records selected using purposive sampling in which all records for the patients operated for a diagnosis of blunt abdominal trauma during the study period were included. A pretested checklist was used to extract the data relating to adverse outcomes and characteristics of the patients. A descriptive analysis followed by logistic regression was done., Results: Of the 128 patients, adverse management outcomes related to blunt abdominal trauma occurred in 52%. Patients residing in rural areas (adjusted odds ratio 3.23, 95% confidence interval: 1.13-9.24) and those with tachycardia, (adjusted odds ratio = 3.25, 95% confidence interval: 1.19-8.83) or tachypnea (adjusted odds ratio 3.25, 95% confidence interval: 1.19-8.83) were more likely to have adverse management outcomes., Conclusion: Adverse management outcomes are relatively high and associated with rural residence and deranged vital signs (tachycardia and tachypnea). Close monitoring targeting patients from rural residence and those presenting with tachycardia and tachypnea is recommended., (© 2023. The Author(s).)

Vagal sensory inputs to the brainstem can alter breathing through the modulation of pontomedullary respiratory circuits. In this study, we set out to investigate the localised effects of modulating lateral parabrachial nucleus (LPB) activity on vagally-evoked changes in breathing pattern. In isoflurane-anaesthetised and instrumented mice, electrical stimulation of the vagus nerve (eVNS) produced stimulation frequency-dependent changes in diaphragm electromyograph (dEMG) activity with an evoked tachypnoea and apnoea at low and high stimulation frequencies, respectively. Muscimol microinjections into the LPB significantly attenuated eVNS-evoked respiratory rate responses. Notably, muscimol injections reaching the caudal LPB, previously unrecognised for respiratory modulation, potently modulated eVNS-evoked apnoea, whilst muscimol injections reaching the intermediate LPB selectively modulated the eVNS-evoked tachypnoea. The effects of muscimol on eVNS-evoked breathing rate changes occurred without altering basal eupneic breathing. These results highlight novel roles for the LPB in regulating vagally-evoked respiratory reflexes., Competing Interests: Declaration of Competing Interest The authors declare they have no competing interest of relevance to this study., (Copyright © 2023 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Acoustic respiration rate (RRa) monitoring is a method of continuously measuring respiratory rate using a signal from an acoustic transducer placed over the airway. The purpose of the present study is to examine how the averaging time and respiratory pause time settings of an RRa monitor affect the detection time of sudden respiratory rate changes., Methods: A total of 40 healthy adult volunteers were included in the study. First, we measured the apnea detection time (apnea test) by dividing them into two groups (N = 20 each), one with a respiratory pause time setting of 20 s and the other with 40 s. Each group performed two apnea tests with an averaging time setting of 10 and 30 s. Next, we measured the tachypnea detection time (tachypnea test) for half of the subjects (N = 20) with two averaging time settings of 10 and 30 s. For each test, three measurements were taken, and the average of the three measurements was recorded., Results: There was no significant difference in the apnea detection time between the averaging time set at 10 and 30 s regardless of whether the respiratory pause time was set at 20 or 40 s. However, the apnea detection time was significantly shorter with the respiratory pause time of 20 s than 40 s, regardless of whether the averaging time was set at 10 or 30 s (p < 0.001). The tachypnea detection time was shorter with the averaging time of 10 s than 30 s (p < 0.001). Furthermore, the apnea detection time and tachypnea detection time were much longer than the actual settings., Conclusions: The results of the current study show that in the measurement of RRa, the apnea detection time is more affected by the respiratory pause time setting than the averaging time setting; however, the tachypnea detection time is significantly affected by the averaging time setting., (© 2023. The Japanese Society of Anesthesiologists.)

Background and objective A facemask is often indicated for the control of the spread of airborne pathogens. At the peak of the COVID-19 pandemic, there was mass enforcement of mask use across the globe. Pregnant women were not excluded. While several studies have been conducted to evaluate and compare the efficacy of various mask types, data on their effects on pregnant women during exercise are scarce. The objective of this study was to evaluate and compare the effects of N95 and surgical facemasks on the cardiopulmonary functions of pregnant women during moderate-intensity exercise. Methods A prospective randomized study was conducted among 104 healthy women with advanced singleton pregnancies performing moderate-intensity exercise wearing either surgical or N95 masks during routine antenatal care. Their respiratory rates were counted, and arterial oxygen saturation (SPO 2 ) and radial pulses (heart rates) were recorded with a mobile digital pulse oximeter at baseline and after 30 minutes of exercise. The mean values were calculated. Data analysis was done using Statistical Product and Service Solutions (SPSS, version 25; IBM SPSS Statistics for Windows, Armonk, NY). An independent t-test was used to compare the mean SPO 2 and radial pulse between the two groups. Chi-square was used to examine differences in categorical variables. The level of significance was set at 0.05. Results Their demographic profiles and measured baseline parameters were comparable. Following a 30-minute exercise, the N95 mask group had lower mean SPO 2 compared to the surgical mask group (95.5% versus 97.0%; P=0.028, 95%CI; -2.607 to 0.15). Further, the N95 group recorded a higher mean heart rate than the surgical mask group ((97.23 b/m versus 95.02b/m, respectively, mean difference (MD)=2.212, P=0.021, 95%Cl: 1.249-3.672). The mean respiratory rates were also higher among women in the N95 mask group (32.1 c/m versus 29.08 c/m, MD=3.018, 95%CI: 1.392-4.662, P=0.001). Conclusion The study, comparing the relative effects of the surgical and N95 facemask on the cardiorespiratory functions of exercising pregnant women, findings suggest that surgical facemasks may be better tolerated in advanced pregnancy when performing routine antenatal aerobic exercise in comparison with N95 masks., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Akpan et al.)

Flexible bronchoscopes are increasingly being used in diagnostic and therapeutic medicine and have obviated the need for and risks associated with general anesthesia. Here the authors present the case of a 2-y-old girl who was diagnosed with isolated pulmonary Langerhans cell histiocytosis by histopathology; a lung biopsy sample was obtained using a cryoprobe via a flexible bronchoscope. The girl was brought in with complaints of loss of weight, appetite loss, and rapid breathing for the past 2 mo. Examination revealed hypoxia, tachypnea, clubbing with failure to thrive, and bilateral crepitations on auscultation. Imaging studies showed ground-glass opacities with multiple cystic lesions in both lungs. A preliminary diagnosis of LCH was made, and transbronchial cryobiopsy was done via a flexible bronchoscope. Histopathology confirmed the diagnosis with Cluster of differentiation 1a (CD1a) staining. A flexible bronchoscope can be a useful tool for obtaining lung biopsy samples using a cryoprobe in children., (© 2023. The Author(s), under exclusive licence to Dr. K C Chaudhuri Foundation.)

Background: In prior studies, central pulmonary embolism (PE) was associated with high clot burden and was considered an independent predictor for thrombolysis. Further information about predictors of adverse outcomes in these patients is needed for better risk stratification. The objective is to describe independent predictors of adverse clinical outcomes in patients with central PE., Methods: Large retrospective, observational, and single-center study of hospitalized patients with central PE. Data were gathered on demographics, comorbidities, clinical features on admission, imaging, treatments, and outcomes. Multivariable standard and Least Absolute Shrinkage and Selection Operator (LASSO) machine learning logistic regressions and sensitivity analyses were used to analyze factors associated with a composite of adverse clinical outcomes, including vasopressor use, mechanical ventilation, and inpatient mortality., Results: A total of 654 patients had central PE. The mean age was 63.1 years, 59% were women, and 82% were African American. The composite adverse outcome was observed in 18% (n = 115) of patients. Serum creatinine elevation (odds ratio [OR] = 1.37, 95% CI = 1.20-1.57; p = 0.0001), white blood cell (WBC) count elevation (OR = 1.10, 95% CI = 1.05-1.15; p < 0.001), higher simplified pulmonary embolism severity index (sPESI) score (OR = 1.47, 95% CI = 1.18-1.84; p = 0.001), serum troponin elevation (OR = 1.26, 95% CI 1.02-1.56; p = 0.03), and respiratory rate increase (OR = 1.03, 95% CI = 1.0-1.05; p = 0.02) were independent predictors of adverse clinical outcomes., Conclusion: Among patients with central PE, higher sPESI score, WBC count elevation, serum creatinine elevation, serum troponin elevation, and respiratory rate increase were independent predictors of adverse clinical outcomes. Right ventricular dysfunction on imaging and saddle PE location did not predict adverse outcomes., Competing Interests: Declaration of competing interest The authors have no competing interest to disclose. None declared., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Childhood interstitial lung disease (chILD) is a collective term for a group of rare lung disorders of heterogeneous origin. Surfactant dysfunction disorders are a cause of chILD with onset during the neonatal period and infancy. Clinical signs of tachypnea and hypoxemia are nonspecific and usually caused by common conditions like lower respiratory tract infections. We report on a full-term male newborn who was readmitted to the hospital at 7 days of age with marked tachypnea and poor feeding during the respiratory syncytial virus season. After exclusion of infection and other, more common congenital disorders, chILD was diagnosed using chest computed tomography and genetic analysis. A likely pathogenic heterozygous variant of SFTPC (c.163C>T, L55F) was detected by whole exome sequencing. The patient received supplemental oxygen and noninvasive respiratory support and was treated with intravenous methylprednisolone pulses and hydroxychloroquine. Despite the treatment, his respiratory situation deteriorated continuously, leading to several hospitalizations and continuous escalation of noninvasive ventilatory support. At 6 months of age, the patient was listed for lung transplant and transplanted successfully aged 7 months., (Copyright © 2023 by the American Academy of Pediatrics.)

Objective: To use clinical, lung ultrasound, and gas exchange data to clarify the evolution of lung aeration and function in neonates with respiratory distress syndrome (RDS) and transient tachypnea of the neonate (TTN), the most common types of neonatal respiratory failure., Study Design: In this prospective observational cohort study, lung aeration and function were measured with a semiquantitative lung ultrasound score (LUS) and transcutaneous blood gas measurement performed at 1 hour (time point 0), 6 hours (time point 1), 12 hours (time point 2), 24 hours (time point 3) and 72 hours (time point 4) of life. Endogenous surfactant was estimated using lamellar body count (LBC). LUS, oxygenation index (OI), oxygen saturation index (OSI), and transcutaneous pressure of carbon dioxide (PtcCO 2 ) were the primary outcomes. All results were adjusted for gestational age., Results: Sixty-nine neonates were enrolled in the RDS cohort, and 58 neonates were enrolled in the TTN cohort. LUS improved over time (within-subjects, P < .001) but was worse for the RDS cohort than for the TTN cohort at all time points (between-subjects, P < .001). Oxygenation improved over time (within-subjects, P = .011 for OI, P < .001 for OSI) but was worse for the RDS cohort than for the TTN cohort at all time points (between-subjects, P < .001 for OI and OSI). PtcCO 2 improved over time (within-subjects, P < .001) and was similar in the RDS and TTN cohorts at all time points. Results were unchanged after adjustment for gestational age. LBC was associated with RDS (β = -0.2 [95% CI, -0.004 to -0.0001]; P = .037) and LUS (β = -3 [95% CI, -5.5 to -0.5]; P = .019)., Conclusions: For the first 72 hours of life, the RDS cohort had worse lung aeration and oxygenation compared with the TTN cohort at all time points. CO 2 clearance did not differ between the cohorts, whereas both lung aeration and function improved in the first 72 hours of life., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Stimulation of the dorsolateral periaqueductal grey matter (dlPAG) in rats evokes an active defensive behaviour together with a cardiorespiratory response characterised by tachypnoea, tachycardia and hypertension. The dlPAG neurons involved in these responses are excitatory, presumably glutamatergic, due to the presence of vesicular glutamate transporter VGLUT2 within their axon terminals. Previously, our group described a functional interaction between dlPAG and the pontine A5 region. Accordingly, in the present work, in order to characterize the role of glutamate within this interaction, experiments were carried out in spontaneously breathing anaesthetized rats (sodium pentobarbitone 60 mg/kg i.p., suplemented with 20 mg/kg i.p.). The cardiorespiratory response evoked by electrical stimulation of the dlPAG (1 ms pulses, 20-50 μA, given at 100 Hz, during 5 s) was analysed before and after the microinjection, within the A5 region, of either kynurenic acid (non-specific glutamate receptor antagonist; 5-10 nmol), DAP-5 (NMDA antagonist; 1 pmol), CNQX (non-NMDA antagonist; 1 pmol) or MCPG (metabotropic antagonist; 0,1 nmol). Kynurenic acid decreased the intensity of both the tachypnoea (p < 0,001) and tachycardia (p < 0,001) induced by dl-PAG stimulation. Blockade of no-NMDA receptors reduced the increase of respiratory frequency, heart rate and pressor response to dl-PAG stimulation (p < 0,01, p < 0,001, p < 0,05 respectively). Blockade of either NMDA or metabotropic receptors reduced the dlPAG-evoked tachycardia and pressor response (p < 0,01; p < 0,05 respectively). These results suggest a neuromodulatory role for A5 region via glutamate neurotransmission of the dlPAG-evoked cardiorespiratory response, confirming the role of the ventrolateral pons in the neuronal circuits involved in respiratory and heart rate control., (© 2022. The Author(s).)

Background: The leading infectious cause of death in children worldwide is pneumonia. Pneumonia claimed the lives of 740,180 kids under the age of five in 2019, accounting for 14% of all fatalities and 22% of deaths in kids between the ages of 1 and 5. Children and families worldwide are affected by pneumonia, but South Asia and Africa have the highest fatality rates., Objective: This study aims to determine the clinical risk factors and radiological assessment of the World Health Organization (WHO)-defined severe pneumonia in Pakistani hospitalized children., Material and Methods: This cross-sectional study was carried out in the pediatric department of the Hayatabad Medical Complex between January 2021 and December 2021. The study included kids who had a fever, cough, and fast or difficulty breathing between the ages of 2 and 60 months. All of the included clinical pneumonia cases were acquired in the community., Results: A total of 360 clinically confirmed patients with pneumonia who presented with fever, cough, and fast or difficulty breathing were enrolled. Age ranged between 2 and 60 months, with a mean age of ±31 months. There were 168 (46.7%) males and 192 (53.3%) females. About 232 (64.4%) had radiological pneumonia, while the rest of the pneumonia cases 128 (35.5%) were without a radiological diagnosis. The most common presenting complaint was noisy breathing 119 (33%), followed by refusal of feeds 81 (22.5%), lethargy 69 (19.2%), seizure 40 (11.1%), nasal drainage 29 (8%), and abdominal pain 22 (6.1%)., Conclusion: The most specific clinical finding of radiographic pneumonia was bronchial breathing, while tachypnea was the most sensitive sign., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Karim et al.)

Objective: To analyze respiratory problems of full term newborn babies during their first hours of life, compare parameters related to the length of neonatal intensive care unit (NICU) in-patient stay, and discuss perinatal care practices, which could prevent consequences, and/or reduce associated costs of NICU hospitalization., Material and Methods: Retrospective chart review between July 31st 2017 and March 2nd 2018 in a tertiary maternity hospital. Chi-square testing analyzed qualitative data. Mann-Whitney test was used for quantitative variables. Multiple linear regression models determined odds ratios for associations were found to be significant in univariate analyses., Results: 86 babies with respiratory problems were studied. Delivery mode was vaginal in 11.6% and caesarean section in 88.4% of newborns. About 52.3% of admitted newborns had transient tachypnea and improved relatively quickly. Newborns resuscitated in (P = 0.004) or admitted to the NICU from the delivery room (P = 0.000) displayed greater need for O2 administration. Twenty neonates were intubated; 16 of them were administered surfactant. Infection (P &lt; 0.05), abnormal chest x-ray (P = 0.022), and the severity of respiratory system morbidity (P &lt; 0.05) prolonged neonatal in-patient stay. Respiratory problems (P = 0.003) and intubation (P = 0.032) incurred greater hospitalization costs. Breastfeeding initiation before the 3rd day of life (P = 0.031), and O2 administration for more than 72 h (P = 0.036) were significantly associated with the length of in-patient stay in the multivariate regression analysis., Conclusion: Mandating the presence of a pediatrician in the delivery room would optimize justified direct NICU admissions and reduce the possibility of delayed diagnosis of respiratory distress during rooming-in. NICU in-patient stay in full term neonates should be based on combining diagnostic markers of sepsis, such as procalcitonin or interleukin-6. A specific protocol regarding surfactant administration in intubated full term infants is also necessary. The severity of respiratory system morbidity is not the key determinant of infant feeding. Maternal information regarding infant health and breastfeeding abilities may improve breastfeeding rates.

Background: Joubert syndrome is a rare genetic condition with a prevalence of 1:80,000-1:100,000. In most cases, it shows an autosomal autosomal recessive hereditary pattern, although X-linked and autosomal dominant cases have been described. The distinctive characteristic of this syndrome is the malformation at cerebral and cerebellar levels, known as the "molar tooth sign," hypotonia, and delayed neurodevelopment., Case Report: We describe the case of a newborn with transient tachypnea. However, during hospital stay, he showed other clinical signs not corresponding to the admission diagnosis, such as bradycardia, apneas, hypotonia, and alteration in swallowing mechanics. To rule out etiologies of central origin, we conducted a magnetic resonance of the brain and identified the "molar tooth sign," where the pathognomonic sign of Joubert syndrome., Conclusions: Rare genetic diseases may manifest as early as the neonatal period with non-specific signs. The early diagnosis of Joubert syndrome is reflected in better pediatric follow-up, which impacts its prognosis and the possibility of improving the patient's quality of life with a multidisciplinary management and genetic counseling., (Copyright: © 2023 Permanyer.)

Background: Data on the prevalence and type of lung function impairment in preschool and school-aged children previously diagnosed with persistent tachypnea of infancy (PTI) are scarce. Therefore, this study aims to assess pulmonary function in this age group., Methods: Children diagnosed with PTI over 3 years old were admitted for follow-up visits and healthy controls were enrolled. The study group included children who were able to complete pulmonary function tests (PFTs). Medical history, physical examination, and pulmonary function (spirometry, body plethysmography, impulse oscillometry, nitrogen multiple breath washout test, diffusing capacity for carbon monoxide [DL CO ]) were assessed., Results: Thirty-seven children (26 boys, 11 girls; median age: 5.6 years) diagnosed with PTI and 37 healthy controls were recruited. Forced expiratory volume in 1 s and forced vital capacity were significantly lower (-1.12 vs. 0.48, p = 0.002 and -0.83 vs. 0.31, p = 0.009, respectively); respiratory resistance at 5 Hz (0.06 vs. -0.62, p = 0.003), resonant frequency (1.86 vs. 1.36, p = 0.04), residual volume (RV) (2.34 vs. -1.2, p < 0.0001), RV%TLC (total lung capacity) (2.63 vs. -0.72, p < 0.0001), and specific airway resistance (5.4 vs. 2.59, p = 0.04) were significantly higher in PTI patients as compared with controls (data were presented as median z-score). Air trapping was found in 60.0%, and abnormally high lung clearance index and DL CO  were found in 73.3% and 90.9% of PTI patients, respectively., Conclusions: This study demonstrated that lung function is affected in most children with PTI. PFTs showed that peripheral airways are the major zone of functional impairment., (© 2022 Wiley Periodicals LLC.)

Exposure to aerosolized citric acid (CA, 150 mM) and prostaglandin E 2 (PGE 2 , 0.43 mM) for 10 min in guinea pigs reportedly produces the distinct cough patterns (Type I vs. II) and ventilatory responses (long-lasting hyperventilation vs. brief tachypnea) even though triggering the same cough numbers. Type I and II coughs are primarily mediated by activation of TRPV1 and EP3 receptors (a PGE 2 receptor) of vagal C-fibers respectively. Substance P (SP) and neurokinin A (NKA) released by vagal pulmonary sensory fibers peripherally are capable of affecting CA-induced cough and ventilation via preferentially activating neurokinin 1 and 2 receptors (NK 1 R and NK 2 R) respectively. This study aimed to define the impacts of CA- and PGE 2 -exposure on pulmonary SP and NKA levels and the roles of NK 1 R and NK 2 R in modulating CA- and PGE 2 -evoked cough and ventilatory responses. In unanesthetized guinea pigs, we determined: (1) pulmonary SP and NKA contents induced by the CA- or PGE 2 -exposure; (2) effects of CP-99994 and SR-48968 (a NK 1 R and a NK 2 R antagonist respectively) given by intraperitoneal injection (IP) or aerosol inhalation (IH) on the CA- and PGE 2 -evoked cough and ventilatory responses; and (3) immunocytochemical expressions of NK 1 R/NK 2 R in vagal C-neurons labeled by TRPV1 or EP3 receptors. We found that CA- and PGE 2 -exposure evoked Type I and II cough respectively associated with different degrees of increases in pulmonary SP and NKA. Applications of CP-99994 and SR-48968 via IP and IH efficiently suppressed the cough responses to CA with less impact on the cough response to PGE 2 . These antagonists inhibited or blocked the ventilatory response to CA and caused hypoventilation in response to PGE 2 . Moreover, NK 1 R and NK 2 R were always co-expressed in vagal C-neurons labeled by TRPV1 or EP3 receptors. These results suggest that SP and NKA endogenously released by CA- and PGE 2 -exposure play important roles in generating the cough and ventilatory responses to CA and PGE 2 , at least in part, via activation of NK 1 R and NK 2 R expressed in vagal C-neurons (pulmonary C-neurons)., Competing Interests: Conflict of interest All authors declare no conflict of interest, (Copyright © 2022. Published by Elsevier B.V.)

'Pant-hoot displays' are a species-typical, multi-modal communicative behaviour in chimpanzees in which pant-hoot vocalisations are combined with varied behavioural displays. In both captivity and the wild, individuals commonly incorporate striking or throwing elements of their environment into these displays. In this case study, we present five videos of an unenculturated, captive, adult male chimpanzee combining a large rubber feeding tub with excelsior (wood wool) in a multi-step process, which was then integrated into the subject's pant-hoot displays as a percussive tool or 'instrument'. During the construction process, the subject demonstrated an understanding of the relevant properties of these materials, 'repairing' the tub to be a more functional drum when necessary. We supplement these videos with a survey of care staff from the study site for additional detail and context. Although care must be taken in generalising data from a single individual, the behaviour reported here hints at three intriguing features of chimpanzee communicative cognition: (1) it suggests a degree of voluntary control over vocal production, (2) it is a so-far unique example of compound tool innovation and use in communicative behaviour and (3) it may represent an example of forward planning in communicative behaviour. Each of these would represent hitherto undocumented dimensions of flexibility in chimpanzee communication, mapping fertile ground for future research., (© 2022. The Author(s).)

Background: Up to 30% of hospitalised patients with COVID-19 require advanced respiratory support, including high-flow nasal cannulas (HFNC), non-invasive mechanical ventilation (NIV), or invasive mechanical ventilation (IMV). We aimed to describe the clinical characteristics, outcomes and risk factors for failing non-invasive respiratory support in patients treated with severe COVID-19 during the first two years of the pandemic in high-income countries (HICs) and low middle-income countries (LMICs)., Methods: This is a multinational, multicentre, prospective cohort study embedded in the ISARIC-WHO COVID-19 Clinical Characterisation Protocol. Patients with laboratory-confirmed SARS-CoV-2 infection who required hospital admission were recruited prospectively. Patients treated with HFNC, NIV, or IMV within the first 24 h of hospital admission were included in this study. Descriptive statistics, random forest, and logistic regression analyses were used to describe clinical characteristics and compare clinical outcomes among patients treated with the different types of advanced respiratory support., Results: A total of 66,565 patients were included in this study. Overall, 82.6% of patients were treated in HIC, and 40.6% were admitted to the hospital during the first pandemic wave. During the first 24 h after hospital admission, patients in HICs were more frequently treated with HFNC (48.0%), followed by NIV (38.6%) and IMV (13.4%). In contrast, patients admitted in lower- and middle-income countries (LMICs) were less frequently treated with HFNC (16.1%) and the majority received IMV (59.1%). The failure rate of non-invasive respiratory support (i.e. HFNC or NIV) was 15.5%, of which 71.2% were from HIC and 28.8% from LMIC. The variables most strongly associated with non-invasive ventilation failure, defined as progression to IMV, were high leukocyte counts at hospital admission (OR [95%CI]; 5.86 [4.83-7.10]), treatment in an LMIC (OR [95%CI]; 2.04 [1.97-2.11]), and tachypnoea at hospital admission (OR [95%CI]; 1.16 [1.14-1.18]). Patients who failed HFNC/NIV had a higher 28-day fatality ratio (OR [95%CI]; 1.27 [1.25-1.30])., Conclusions: In the present international cohort, the most frequently used advanced respiratory support was the HFNC. However, IMV was used more often in LMIC. Higher leucocyte count, tachypnoea, and treatment in LMIC were risk factors for HFNC/NIV failure. HFNC/NIV failure was related to worse clinical outcomes, such as 28-day mortality. Trial registration This is a prospective observational study; therefore, no health care interventions were applied to participants, and trial registration is not applicable., (© 2022. The Author(s).)

Objective: Determining the parameters that can predict the requirement of intensive care unit (ICU) admissions among the coronavirus disease 2019 (COVID-19) patients presented to the emergency departments (EDs)., Methods: In adult consecutive patients admitted (March 15 - April 15, 2020) to the ED of a state hospital for COVID-19, we retrospectively analyzed demographic data, symptoms, laboratory tests, and chest computed tomography (CT) on arrival., Results: We included 458 patients [213 (46.5%) females, median age 48 y]. Body temperature, respiration rate, C-reactive protein (CRP), D-dimer, ferritin values, and the number of comorbidities were significantly higher in patients admitted to the ICU than others. Also, diffuse infiltration in chest CT is more common in patients who need ICU follow-up. As a result of the binary regression analysis, a statistically significant correlation was found between the presence of dyspnea (odds ratio [OR]: 12.55), tachypnea (relative risk [RR] ≥ 18) (OR: 14.54), multiple comorbidities (≥2) (OR: 23.39), diffuse infiltration in CT (OR: 14.52), and CRP (≥45 mg/L) (OR: 4.71); and the need for ICU admission., Conclusion: It has been concluded that the presence of dyspnea and tachypnea, elevated CRP, presence of multiple comorbidities, and diffuse infiltration in CT may predict the need for ICU admissions of the patients, who presented to the EDs.

Objective: Transient tachypnea of the newborn (TTN), a common neonatal respiratory morbidity, is associated with failure of adequate clearance of fetal lung fluid. Glucocorticoids have an important role in lung maturity and the mechanisms of lung fluid clearance. The aim of this study is to assess the association between umbilical cord cortisol levels and transient TTN in late preterm and term neonates delivered by elective cesarean section (CS)., Study Design: A case-control study of 37 newborns diagnosed with TTN (cases) was compared with 40 healthy newborns (controls). All infants were delivered by elective CS without labor. Umbilical cord cortisol levels were measured using enzyme-linked immunosorbent assay., Results: Mean cord cortisol levels were significantly lower in cases than controls (131.36 vs. 233.32 nmol/L, p  = 0.0001; odds ratio [OR] = 3.7; 95% confidence interval [CI]: 1.40-9.53), respectively. Cord serum cortisol correlated inversely with the duration of tachypnea and the respiratory rate ( r  =  - 0.678 and -0.535, respectively)., Conclusion: Umbilical cord cortisol levels are significantly lower in newborns with transient TTN, and lower cortisol levels are associated with an increased respiratory rate and longer duration of admission. Antenatal glucocorticoids can be recommended for late preterm delivered by CS., Key Points: · Umbilical cord cortisol levels were lower in late preterm infants with TTN.. · Late preterm newborn with severe TTN and NICU hospitalization have lower cord cortisol levels.. · Antenatal glucocorticoids can be recommended for late preterm delivered by CS.., Competing Interests: None declared., (Thieme. All rights reserved.)

Pandemics in the early 20th century (and now with SARS-CoV-2) have been dominated by respiratory viruses damaging the lungs. Less is known about abnormal respiratory patterns from brain inflammation. One of the first descriptions of respiratory rhythm abnormalities was seen with an acute attack of epidemic encephalitis (encephalitis lethargica), and reports appeared soon after the original description in 1921. We reviewed these ill-remembered disorders of respiration rate, respiratory patterns, and respiratory tics. Most commonly, dysregulations occurred during the phase when ocular signs appeared. The early symptoms were an unrelenting tachypnea (panting) without air hunger and an inspiratory hold ( fixés en inspiration forcée ). Initially regarded as hysterical in nature, the later bizarre disorders of respiration were considered equally serious with attacks of gasping, panting, puffing, inspiratory breath holding, coughs, giggles, sighing, grunting, and moaning. These respiratory disorders were seen exclusively as part of a parkinsonian syndrome. Most remarkably, these attacks could be provoked by oxygen administration. These respiratory abnormalities with encephalitis lethargica are not well remembered. One purpose of recalling these episodes is to call attention to central causes of respiratory illness even in pandemics with respiratory viruses., (© 2022 American Academy of Neurology.)

The potential use of quick SOFA (qSOFA) score and inflammatory biomarkers as bacteremia predictors is unelucidated. Herein the aim of this study was to evaluate the diagnostic accuracy of the qSOFA score and biomarkers for predicting community-onset bacteremia. We enrolled adult outpatients with blood culture samples drawn between 2018 and 2020. Contamination, intensive care unit admission, and hemodialysis were excluded. We performed a case-control study, and analyzed 115 patients (58 with bacteremia and 57 without bacteremia). The positive likelihood ratio (LR) for bacteremia was 2.46 (95% confidence interval [CI] 0.76-9.05) for a qSOFA score ≥ 2, and 4.07 (95% CI 1.92-9.58) for tachypnea (≥ 22/min). The highest performing biomarkers were procalcitonin (area under the curve [AUC] 0.80; 95% CI 0.72-0.88), followed by presepsin (AUC 0.69; 95% CI 0.60-0.79), and C-reactive protein (AUC 0.60; 95% CI 0.49-0.70). The estimated optimal cut-off value of procalcitonin was 0.377 ng/mL, with a sensitivity of 74.1%, a specificity of 73.7%, and a positive LR of 2.82. Presepsin was 407 pg/mL, with a sensitivity of 60.3%, a specificity of 75.4%, and a positive LR of 2.46. Procalcitonin was found to be a modestly useful biomarker for predicting non-severe community-onset bacteremia. Tachypnea (≥ 22/min) itself, rather than the qSOFA score, can be a diagnostic predictor. These predictors may aid decision-making regarding the collection of blood culture samples in the emergency department and outpatient clinics., (© 2022. The Author(s).)

Objective: While administration of antenatal corticosteroids prior to term elective cesarean deliveries has been shown in international randomized controlled trials to decrease the rates of respiratory distress syndrome and transient tachypnea of the newborn, this is not a standard practice in the United States. We aim to determine if the administration of antenatal corticosteroids for fetal lung maturation within 1 week of scheduled early term cesarean delivery resulted in decreased composite respiratory morbidity., Study Design: Historical cohort study including women who underwent scheduled early term cesarean delivery of a singleton, non-anomalous neonate at Mount Sinai Hospital between May 2015 and August 2019, comparing those who completed a course of antenatal corticosteroids within 1 week of delivery to those who did not. The primary outcome was composite respiratory morbidity defined as respiratory distress syndrome, transient tachypnea of the newborn, and neonatal intensive care unit admission for respiratory morbidity. Maternal and neonatal characteristics were compared between groups using t -tests or Wilcoxon-Rank Sum tests for continuous measures and Chi-square or Fisher's exact tests for categorical measures, as appropriate. The outcomes were assessed using logistic regression., Results: History of preterm birth was significantly higher in those who received antenatal corticosteroids compared with those who did not (24.0 vs. 10.9%, p  = 0.01). Neonates who were not exposed to antenatal corticosteroids were more likely to experience the composite respiratory morbidity compared with those who were exposed (RR 4.1, 95% CI 1.2-13.7; p  = 0.02). Between 37 and 38 weeks, neonates who did not receive steroids were at increased risk of composite respiratory morbidity (RR 11.7, 95% CI 1.5-89.0, p  < 0.01), however, there was no difference for those born between 38 and 39 weeks., Conclusion: Betamethasone course administered prior to planned early term cesarean delivery was associated with a statistically significant reduction in the neonatal composite respiratory morbidity compared with routine management., Key Points: · Steroids administered prior to scheduled cesarean lead to decreased neonatal respiratory morbidity.. · Steroid administration was not associated with increased adverse neonatal outcomes.. · Steroid administration was most beneficial between 37 and 38 weeks.., Competing Interests: None declared, (Thieme. All rights reserved.)

Objective: The objective of this meta-analysis was to study the diagnostic value of lung ultrasound (LUS) for transient tachypnea of the newborn (TTN)., Methods: Embase, Cochrane Library, PubMed, Web of Science, and Google Scholar were searched, and the last search date was October 31, 2020. Studies on the diagnostic accuracy of pulmonary ultrasound for transient tachypnea were included. The quality assessment of the included study was assessed using the Diagnostic Accuracy Studies-2 tool. A meta-analysis was performed using Meta-Disc 1.4. A random-effects model was used and subgroup analysis was carried out to identify possible sources of heterogeneity., Results: A total of 378 articles were retrieved and nine studies with 3239 patients were included in the present meta-analysis. The overall quality of the included studies was moderate to high. The result of threshold analysis shows that there was no threshold effect. However, there was a significant heterogeneity caused by non-threshold effects in the included studies. A random-effects model was used. The pooled sensitivity, specificity, PLR and NLR were 0.55 (95% CI: 0.51-0.58), 0.98 (95% CI: 0.98-0.99), 58.30 (95% CI: 14.05-241.88) and 0.28 (95% CI: 0.18-0.43). The pooled DOR and AUC were 689.12 (95% CI: 68.71 to 6911.79) and 0.994. The results of subgroup analysis showed that the LUS diagnostic criteria and gold standard might be responsible for heterogeneity. Choosing "DLP combined with B line" as the diagnostic standard of LUS and choosing CXR as the gold standard could significantly improve the diagnostic performance of LUS., Conclusion: LUS is a promising method to diagnose TTN. Only DLP is not enough to diagnose TTN, while DLP combined with B-line has good diagnostic performance., Competing Interests: Conflicts of interest The authors declare no conflicts of interest., (Copyright © 2021. Published by Elsevier Editora Ltda.)

BACKGROUND Acute disseminated encephalomyelitis (ADEM) is a disorder of the central nervous system which has been associated with preceding infection as well as vaccinations. We present a case of a 61-year-old woman with ADEM after receiving her initial vaccination for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This case highlights management of this acute condition. CASE REPORT A 61-year-old woman with history of hypertension and anxiety presented with progressive generalized weakness and difficulty with communication which began a few weeks ago, shortly after receiving the Pfizer vaccine for the novel coronavirus (COVID-19). On arrival, she was found to be encephalopathic and tachypneic, ultimately requiring emergent intubation. During her hospital course, an MRI of her brain was obtained which showed nonspecific acute versus subacute leukoencephalopathy involving the brainstem and deep white matter. Her cerebrospinal fluid showed elevated protein but was otherwise unremarkable. Further testing to rule out tick-borne illnesses, viral etiology, and multiple sclerosis were negative. Electroencephalography showed nonspecific diffuse cerebral dysfunction but no seizures or epileptiform discharges. She was treated with 5 doses of methylprednisolone 1 g and intravenous immunoglobulin (IVIG) 2 g/kg over 5 days. She had marked improvement in her neurologic status after treatment. CONCLUSIONS In conclusion, ADEM should be acknowledged as a rare but potential complication related to COVID-19 vaccination. A proper history and physical exam in addition to a thorough work-up are necessary for prompt recognition of this condition. Initial treatment should consist of steroids followed by IVIG versus plasmapheresis for those not responsive to steroids.

Objectives: To evaluate the short- and long-term outcome of late-preterm compared with term birth in twin pregnancy., Methods: This retrospective observational cohort study included all women who had a twin delivery between 1 January 2007 and 31 December 2010 recorded in the claims database of the Korea National Health Insurance, with at least one follow-up recorded in the database of the National Health Screening Program for Infants and Children. Outcomes were analyzed at the pregnancy level, with adverse outcome being defined as an adverse outcome in one or both twins, identified by a diagnosis according to the International Classification of Diseases 10 th Revision. The primary short-term outcome was composite morbidity, which included any of the following: transient tachypnea, respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage and bronchopulmonary dysplasia. Long-term adverse outcome included any neurological or neurodevelopmental outcome, defined by prespecified neurological and developmental diagnoses; these were assessed by following up all neonates until the end of 2018, by which time they were 8-11 years of age. Outcomes were compared between twins delivered late preterm (34 + 0 to 36 + 6 weeks) and those delivered at term (≥ 37 weeks)., Results: Among 17 189 women who delivered twins at ≥ 34 weeks of gestation during the study period, 5032 (29.27%) women delivered in the late-preterm period. On multivariate analysis, compared with the twins delivered at term, the late-preterm twins had an increased risk for the primary short-term outcome of composite morbidity (adjusted odds ratio (aOR), 2.09; 95% CI, 1.90-2.30), including transient tachypnea (aOR, 1.85; 95% CI, 1.64-2.09), respiratory distress syndrome (aOR, 2.31; 95% CI, 2.04-2.62), necrotizing enterocolitis (aOR, 2.10; 95% CI, 1.20-3.69) and intraventricular hemorrhage (aOR, 2.13; 95% CI, 1.46-3.11). For the long-term outcome, the late-preterm twins also had an increased risk for any neurological or neurodevelopmental outcome (adjusted hazard ratio, 1.14; 95% CI, 1.07-1.21)., Conclusions: Twins delivered in the late-preterm period have an increased risk for short- and long-term morbidity compared with twins delivered at term. These results should be considered when determining the timing of delivery in uncomplicated twin pregnancy. © 2021 International Society of Ultrasound in Obstetrics and Gynecology., (© 2021 International Society of Ultrasound in Obstetrics and Gynecology.)

The literature on neonates with SARS-CoV-2 is mainly concerned with perinatal cases, and scanty data are available about environmentally infected neonates. To fill knowledge gaps on the course and prognosis of neonatal cases, we analyzed 1-year data from the Turkish Neonatal Society in this prospective cohort study of neonates with postnatal transmission. Data from 44 neonatal intensive care units (NICUs), of neonates with positive RT-PCR results at days 5-28 of life, were extracted from the online registry system and analyzed. Of 176 cases, most were term infants with normal birth weight. Fever was the most common symptom (64.2%), followed by feeding intolerance (25.6%), and cough (21.6%). The median length of hospitalization was 9 days, with approximately one quarter of infants receiving some type of ventilatory support. Myocarditis (5.7%) was the most common complication during follow-up. Among the clinical findings, cough (odds ratio [OR]: 9.52, 95% confidence interval [CI]: 4.17-21.71), tachypnea (OR: 26.5, 95% CI: 9.59-73.19), and chest retractions (OR: 27.5, 95% CI: 5.96-126.96) were associated with more severe clinical disease. Also, there were significant differences in the C-reactive protein level, prothrombin time (PT), partial thromboplastin time, international normalized ratio, and days in the NICU (p = 0.002, p = 0.012, p = 0.034, p = 0.008, and p < 0.001, respectively) between patients with mild-moderate and severe-critical presentations. A PT above 14 s was a significant predictor of severe/critical cases, with a sensitivity of 64% and specificity of 73%., Conclusions: Our data showed that late-onset COVID-19 infection in neonates who need hospitalization can be severe, showing associations with high rates of ventilatory support and myocarditis. Cough, tachypnea, and retractions on admission suggest a severe disease course., Trial Registration: ClinicalTrials.gov identifier: NCT04401540., What Is Known: • Neonatal cases of COVID-19 infection are mainly reported as perinatal COVID-19 cases. • Neonates with perinatal transmission have a mild course and favorable prognosis., What Is New: • Among symptomatic neonates with late-onset COVID-19 infection, fever was the most common symptom, and almost one quarter of hospitalized cases needed some type of respiratory support. Myocarditis was the most common complication. • The presence of cough, tachypnea, retractions, and a PT above 14 s were associated with an increased risk of severe COVID-19., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Pneumonia has a major impact on childhood health and health care costs. This study was designed to obtain contemporary information on the clinical characteristics and etiology of community-acquired pneumonia (CAP) in children from both inpatient and outpatient settings in the USA., Methods: We conducted a prospective, multicenter, observational study of CAP among previously healthy children 2 months to 18 years of age in 6 children's hospitals in Ohio from 2015 to 2018. For pathogen detection, nasopharyngeal swabs were collected from all subjects. Blood and pleural fluid cultures were available per standard of care., Results: We enrolled a convenience sample of 441 patients: 380 hospitalized and 61 outpatients. Tachypnea and radiologic findings of consolidation and pleural effusion were more frequent among inpatients than outpatients. A pathogen was detected in 64.6% of patients: viruses in 55.6%, atypical bacteria in 8.8% and pyogenic bacteria in 4.3%. Eighteen (4.1%) patients had both viruses and bacteria detected. Rhinovirus/enterovirus (RV; 18.6%) and respiratory syncytial virus (RSV; 16.8%) were the viruses most frequently detected, and Mycoplasma pneumoniae (8.2%) and Streptococcus pneumoniae (2.3%) were the most common bacteria. Except for S. pneumoniae, which was identified more frequently in inpatients, there were no significant differences between inpatients and outpatients in the proportions of children with specific pathogens detected., Conclusions: Rhinovirus/enterovirus and RSV among viruses and M. pneumoniae and S. pneumoniae among bacteria were the most common pathogens detected in children with CAP. Tachypnea and chest radiographs with consolidation and/or pleural effusion were associated with hospitalization., Competing Interests: A.M. has received research grants from the NIH and Janssen and fees from Janssen and Roche for participation in advisory boards. O.R. has received research grants from Janssen, NIH, and the Bill & Melinda and Gates Foundation; fees from Merck, Sanofi/Medimmune, and Pfizer for participation in advisory boards; and fees from Pfizer for educational lectures. A.L.L. has received research funding and participated in advisory boards for BioFire Diagnostics. The remaining authors have no conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)