While it has been suggested that alterations in the composition of gut microbial metabolites may play a causative role in the pathophysiology of autism spectrum disorder (ASD), it is not known how gut microbial metabolites are associated with ASD-specific brain alterations. In this cross-sectional, case-control observational study, (i) fecal metabolomics, (ii) task-based functional magnetic resonance imaging (fMRI), and (iii) behavioral assessments were obtained from 43 ASD and 41 neurotypical (NT) children, aged 8-17. The fMRI tasks used socio-emotional and sensory paradigms that commonly reveal strong evoked brain differences in ASD participants. Our results show that fecal levels of specific tryptophan-related metabolites, including kynurenate, were significantly lower in ASD compared to NT, and were associated with: 1) alterations in insular and cingulate cortical activity previously implicated in ASD; and 2) ASD severity and symptoms (e.g., ADOS scores, disgust propensity, and sensory sensitivities). Moreover, activity in the mid-insula and mid-cingulate significantly mediated relationships between the microbial tryptophan metabolites (indolelactate and tryptophan betaine) and ASD severity and disgust sensitivity. Thus, we identify associations between gut microbial tryptophan metabolites, ASD symptoms, and brain activity in humans, particularly in brain regions associated with interoceptive processing.

While exteroceptive sensory processing is a hallmark of autism spectrum disorder, how interoceptive processing may impact and contribute to symptomatology remains unclear. In this comprehensive narrative review on interoception in autism, we discuss: 1) difficulties with assessing interoception; 2) potential interoceptive differences; 3) interactions between neural systems for interoception, attention, sensorimotor processing, and cognition; and 4) potential differences in neural circuits involved in interoception. In general, there are mixed findings on potential interoception differences in autism. Nevertheless, some data indicate differences in integration of interoceptive and exteroceptive information may contribute to autism symptomatology. Neurologically, interoceptive processing in autism may be impacted by potential differences in the development, morphometry, and connectivity of key interoceptive hubs (vagal processing, brainstem, thalamus, insula), though much work is needed on this topic.

In the original publication [...].

Prior studies show differences in empathy and affect-recognition ability between those with autism spectrum disorder (ASD) and typically developing (TD) individuals. Autistic individuals also exhibit increased behavioral, gastrointestinal, and sleep issues. In the current study, we explored the differences in empathy and affect recognition between the ASD and TD groups; and we investigated their associations with conditions co-occurring in ASD. A total of 54 TD and 56 ASD children (8–17 years) were included. As compared to the TD group, the ASD group showed lower scores for affect recognition and perspective taking (PT) and higher scores for personal distress (PD). Interestingly, results from hierarchical linear regressions suggested that disparities in the PD and PT between the groups were primarily attributable to attenuated levels of alexithymia, rather than being mediated by the presence of an autism diagnosis. Differences in affect-recognition ability, however, were mediated by both an autism diagnosis and alexithymia. We also found significant correlations between empathy and affect recognition and measures of related conditions common in ASD. Alexithymia, hence, contributes to difficulties in empathy while both alexithymia and autism are associated with affect-recognition ability in ASD. Additionally, the association between affect recognition and empathic ability with co-occurring conditions in ASD needs to be considered during assessments and interventions.

Neuro-occupation was developed to study the relationship between the nervous system and occupation. Pragmatic implications of neuro-occupation have not been previously summarized. This study aimed to determine how neuro-occupation has been defined, applied across relevant fields, and evolved over time. We performed a scoping review following the Arksey and O'Malley framework. Twenty-five works related to neuro-occupation published between 1997 and 2020 were included. We found that neuro-occupation evolved from utilization primarily in the United States to an international term applied to different clinical populations. Common themes were: (a) the reciprocal relationship between the nervous system and occupations; (b) the Intention, Meaning, and Perception (IMP) model of neuro-occupation; and (c) pragmatic implications for occupational therapy practice and interventions. We suggest an updated definition of neuro-occupation. In addition, we contend that although the term neuro-occupation was developed in response to historical debates in occupational therapy, continued use creates more confusion than clarity.

Developmental Coordination Disorder (DCD) is one of the least studied and understood developmental disorders. One area that has been minimally investigated in DCD is potential issues with sensory modulation. Further, in other neurodevelopmental disorders (e.g., autism spectrum disorder (ASD)) sensory modulation is related to many other challenges (e.g., social issues, repetitive behaviors, anxiety); however, such potential relationships in children with DCD have been largely unexplored. The purpose of this study is to explore sensory modulation differences in DCD and to understand the relationships between sensory modulation and social emotional measures, behavior, and motor skills in DCD in comparison to ASD and typically developing (TD) peers. Participants (aged 8–17) and their caregivers (DCD, N = 26; ASD, N = 57; and TD, N = 53) completed behavioral and clinical measures. The results indicated that 31% of the DCD group showed sensory modulation difficulties, with the DCD group falling between the ASD and TD groups. In the DCD group, sensory modulation was significantly associated with anxiety, empathic concern, repetitive behaviors, and motor skills. Data are compared to patterns seen in ASD and TD groups and implications for interventions are discussed.

Objectives: Anxiety and anticipatory stressors are commonly experienced by children visiting the Pediatric Emergency Department (PED), but little research exists that addresses the efficacy of interventions to decrease this stress. This one-sample pretest-postest pilot study gathered preliminary data on the feasibility and effectiveness of utilizing audiobooks to reduce fear and state anxiety in children in the PED.Methods: Participants were 131 children in kindergarten through 8th grade (M = 9.4 years, 54% female), triaged urgent or emergent, presenting to the PED. Participants self-reported fear (Children's Fear Scale) and state anxiety (modified State-Trait Anxiety Inventory for Children; mSTAIC) before and after listening to an age-appropriate audiobook (two options). Data regarding patient experience were also collected. Paired samples t-test was used to examine pre–post intervention changes in fear and state anxiety.Results: Significant, albeit small, improvements in fear and the mSTAIC states of nervous, calm, happy, and relaxed were found after use of the audiobook (Cohen's dz = 0.22–0.35). Small, yet significant correlations were found between child age/grade level and improvements in fear and in the mSTAIC states of scared and relaxed, suggesting that the audiobook was more beneficial for older participants. Over 60% of participants liked the audiobook content “a lot” as well as enjoyed listening to the audiobook “a lot.” Without prompting, 15% of participants requested to listen to an additional audiobook.Conclusions: Listening to an audiobook is feasible and could be effective in decreasing fear and state anxiety for children during a waiting period in the PED. The technology is low-cost, simple, and portable. The results of this study should be interpreted with prudence due to the lack of a control group and results that, although significant, were modest based on effect size conventions; future studies should explore the impact of audiobooks on patient stress with an expanded sample size and control group.

Academic Emergency MedicineVolume 27, Issue 11 p. 1191-1193 Research LetterFree Access The Effect of Rapid Fluid Infusions on Transabdominal Pelvic Ultrasound Timing Among Female Pediatric Patients: A Randomized Controlled Pilot Trial Todd P. Chang MD, MAcM, Corresponding Author Todd P. Chang MD, MAcM [email protected] orcid.org/0000-0002-4508-2551 Division of Emergency Medicine & Transport, Children’s Hospital Los Angeles, Los Angeles, CA Keck School of Medicine, University of Southern California, Los Angeles, CA, USA Address for correspondence and reprints: Todd P. Chang, MD, MAcM; e-mail: [email protected].Search for more papers by this authorSofronia M. Ringold, Sofronia M. Ringold Division of Emergency Medicine & Transport, Children’s Hospital Los Angeles, Los Angeles, CASearch for more papers by this authorNhan Lichtenfeld RN, Nhan Lichtenfeld RN Division of Emergency Medicine & Transport, Children’s Hospital Los Angeles, Los Angeles, CASearch for more papers by this authorPhaedra Nguyen RN, Phaedra Nguyen RN Division of Emergency Medicine & Transport, Children’s Hospital Los Angeles, Los Angeles, CASearch for more papers by this authorDelta Paz RN, Delta Paz RN Division of Emergency Medicine & Transport, Children’s Hospital Los Angeles, Los Angeles, CASearch for more papers by this authorAra Festekjian MD, Ara Festekjian MD Division of Emergency Medicine & Transport, Children’s Hospital Los Angeles, Los Angeles, CA Keck School of Medicine, University of Southern California, Los Angeles, CA, USASearch for more papers by this author Todd P. Chang MD, MAcM, Corresponding Author Todd P. Chang MD, MAcM [email protected] orcid.org/0000-0002-4508-2551 Division of Emergency Medicine & Transport, Children’s Hospital Los Angeles, Los Angeles, CA Keck School of Medicine, University of Southern California, Los Angeles, CA, USA Address for correspondence and reprints: Todd P. Chang, MD, MAcM; e-mail: [email protected].Search for more papers by this authorSofronia M. Ringold, Sofronia M. Ringold Division of Emergency Medicine & Transport, Children’s Hospital Los Angeles, Los Angeles, CASearch for more papers by this authorNhan Lichtenfeld RN, Nhan Lichtenfeld RN Division of Emergency Medicine & Transport, Children’s Hospital Los Angeles, Los Angeles, CASearch for more papers by this authorPhaedra Nguyen RN, Phaedra Nguyen RN Division of Emergency Medicine & Transport, Children’s Hospital Los Angeles, Los Angeles, CASearch for more papers by this authorDelta Paz RN, Delta Paz RN Division of Emergency Medicine & Transport, Children’s Hospital Los Angeles, Los Angeles, CASearch for more papers by this authorAra Festekjian MD, Ara Festekjian MD Division of Emergency Medicine & Transport, Children’s Hospital Los Angeles, Los Angeles, CA Keck School of Medicine, University of Southern California, Los Angeles, CA, USASearch for more papers by this author First published: 19 February 2020 https://doi.org/10.1111/acem.13945Citations: 2 The study was funded by a grant from 410 Medical, Inc. (Durham, NC), the manufacturing company of the LifeFlow device. TPC reports grant money to Children’s Hospital Los Angeles to conduct research conceived and written by Dr. Chang and Dr. Festekjian from CHLA. SR reports grant money to Children’s Hospital Los Angeles for completed research coordinator salary support conceived and written by Dr. Chang and Dr. Festekjian. NL, PN, and DP report no conflict of interest. AF reports grant money to Children’s Hospital Los Angeles to conduct research conceived and written by Dr. Chang and Dr. Festekjian from CHLA. Author contributions: TPC, SMR, and AF conceived the study idea, procured funding, and developed the protocol; NL, PN, and DP developed the protocol and provided data collection assistance; TPC performed data analysis; and all authors enrolled subjects and contributed to the writing of the manuscript. AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Transabdominal ultrasound is a common noninvasive method to evaluate abdominal pain in females who are not sexually active.1, 2 Unlike transvaginal ultrasounds, the patient’s bladder must be full to receive a high-quality sonographic view.2 Oral or intravenous (IV) fluids and bladder filling through a transurethral catheter are both used.2 For pediatric patients, transurethral catheterization raises concerns over modesty,2 favoring IV fluids. Unless performed over rapid infusion, IV infusion pumps have a maximum individual rate of 999 mL/hr, and more than one fluid bolus may be required to achieve a high-quality sonographic view. This delays the ultrasound, diagnosis, and ultimately treatment and disposition.3, 4 Emergency departments (EDs) utilize rapid IV fluid infusion primarily for critical resuscitation and septic shock.5 A manual rapid fluid infuser (LifeFlow, 410 Medical, Inc.) has been used in adult and pediatric patients with very rapid fluid infusion rates.6 Rapid infusers are not commonly used among more stable patients; however, rapid IV infusion may potentially speed up the process of obtaining a transabdominal ultrasound by expediting the bladder filling process. We proposed a pilot trial comparing standard care IV infusion versus a manual rapid IV infuser for bladder filling. We hypothesized that rapid IV infusion would lead to shorter time duration to bladder filling and to complete ultrasounds among pediatric patients requiring a transabdominal pelvic ultrasound in an ED. This was an unmasked, pilot, randomized controlled trial in an urban, tertiary care, pediatric ED with an annual census of 96,000 children. This pilot trial received institutional review board approval (Clinicaltrials.gov Identifier: NCT03712189). Female patients under 18 years of age in the ED with complaints of abdominal pain were screened for eligibility. Patients were included upon a simultaneous clinical order for a 1) transabdominal pelvic ultrasound and 2) IV fluid bolus order. We excluded patients with any of the following: 1) any fluid overload states, 2) hepatic insufficiency, 3) renal insufficiency, 4) cardiac insufficiency, 5) significant cardiac surgery history, 6) known pregnancy, or 7) diuretic or antihypertensive therapy. Critically ill patients were also excluded. The experimental group had IV fluid boluses manually administered by a designated research clinician who was not a part of the patient’s overall clinical care. The LifeFlow device is a handheld device that uses a lever system similar to that of a water gun to deliver 10-mL aliquots per manual squeeze of the handle. The device encases a 10-mL syringe attached to IV tubing. The research clinician administered the entirety of the IV fluids ordered or until the patient verbalized that the bladder felt full. Research clinicians were not allowed to start another bolus until a second clinical order was signed. The control arm was standard care. Patients received IV fluid boluses by the primary clinical nurse using the Alaris (San Diego, CA) automated pump at 999 mL/hr. More than one pump could be used simultaneously to push twice as fast (1998 mL/hr), and the clinical nurse chose the number of simultaneous pumps at his or her discretion. Participants were randomized in a 1:1 ratio into one of two groups for fluid bolus delivery: the IV infusion pump (control) or LifeFlow (experimental). Allocation was concealed until enrollment. No blinding or masking was undertaken thereafter as the two devices look and are used differently. In both arms, research staff collected all data relating to duration and amount of actual IV fluids provided and the time at which the patient verbalized a full bladder sensation. The research team had no influence over the timing, staffing, delays, nor queuing for the ultrasound. The two primary outcome variables were 1) the duration (minutes) from when the fluid delivery began to the time the patient reported a full bladder sensation and 2) the duration (minutes) from ultrasound order to completion of the ultrasound. Fluid delivery initiation was defined as the first pump of the LifeFlow device or when the nurse pressed “start” on the IV pump. The time stamp when the subject reported bladder fullness was recorded by the research staff. The ultrasound order had a time stamp on its signature by the clinical team in the electronic health records (EHRs), and the sonographers activated a time stamp for ultrasound completion, also retrieved from the EHR. Secondary outcome variables included duration required to administer each bolus individually, adverse events such as IV infiltration or fluid overload, and the final diagnosis. Descriptive statistics and Student’s t-tests were used to summarize overall data. Because our two primary outcomes were related, the alpha for the Student’s t-tests were conservatively dropped to 0.025 to minimize Type I error. Pearson’s correlations were done to confirm the relationship between the primary outcomes against the total fluid per weight (mL/kg) as a covariate; this analysis used the original alpha of 0.05. A target of 30 participants (15 per arm) was used as a pilot trial. Analyses were done on SPSS version 25. Of 31 screened subjects, one refused and 30 subjects were enrolled. Mean ± SD age (Intervention 13.9 ± 3.5 years vs. Control 13.6 ± 2.9 years), weight (58.79 ± 22.1 vs. 56.19 kg ± 14.2 kg), and total fluids provided (1482 ± 676 mL vs. 1613 ± 654 mL) did not differ between the two groups (p > 0.58). Groups did not substantially differ in clinical features. No adverse events or IV failures were noted. The LifeFlow rapid infuser device led to faster bladder filling time than the IV pump by 35.1 (97.5% confidence interval [CI] = 5.2 to 64.9) minutes. Completion of ultrasound was also faster using the LifeFlow rapid infuser by 39.6 (97.5% CI = 1.7 to 77.5) minutes. Full data are depicted in Table 1. Eleven of the 15 control group patients used two simultaneous IV pumps at an estimated rate of 1998 mL/hr. Moderate to strong associations were found between the fluid volume per weight provided and the duration of bladder filling and completion of ultrasound (r > 0.4, p < 0.03). Table 1. Time Duration (Minutes) Until Bladder Filling Complete and Until Completion of the Pelvic Ultrasound LifeFlow IV Pump p-value Difference, Mean (97.5% CI) Primary outcome: duration from fluid start to bladder full sensation (min) 26.9 ± 18.9 61.9 ± 43.6 0.01 −35.1 (−64.9 to −5.2) Duration from transabdominal pelvic ultrasound order to completion (min) 114.8 ± 31.9 154.4 ± 53.2 0.02 −39.6 (−77.5 to −1.7) Therefore, among pediatric female patients requiring a transabdominal pelvic ultrasound, rapid IV fluid infusion decreased the time to bladder filling and the time to ultrasound completion with over 30 minutes saved per patient awaiting an ultrasound. While this small pilot study was not designed to determine whether distal outcomes such as time to definitive surgical care was hastened due to rapid infusion devices, our initial results show promise that rapid IV infusion may be used to improve the efficiency of care when awaiting diagnostic testing for this target population. When considering a large population of adolescent females with lower abdominal pain, the time savings may be helpful for the child’s care but also for the overall ED efficiency and relieving crowding. Our study used a separate clinician to deliver fluids using the LifeFlow rapid infuser. While the overall bolus delivery times were very short—on average, 8 minutes—this also requires clinical personnel to manually push the fluid, taking them away from other duties. Whether expediting the patient’s care by 35 to 40 minutes is counterbalanced by the loss of 8 minutes of a clinician’s time is unknown and should be taken into consideration if a manual rapid infuser is used. In summary, a manual rapid infuser compared to a standard infusion pump can reduce the time for adolescent females requiring transabdominal ultrasounds, both for bladder filling and to complete the ultrasound. Further inquiry can determine whether this translates to faster operative or medical care and impact on overall ED flow. We thank Nicolas Ritcheson, Lorenzo Gab Pasia, and Audra Fain for their hard work and dedication. References 1Arbel-DeRowe Y, Tepper R, Rosen DJ, et al. The contribution of pelvic ultrasonography to the diagnostic process in pediatric and adolescent gynecology. J Pediatr Adolesc Gynecol 1997; 10: 3– 12. 2Waterhouse MR, Pham PK, Chang TP. Attitudes and opinions of adolescent females regarding 2 methods of bladder filling for transabdominal ultrasound. Pediatr Emerg Care 2018. https://doi.org/10.1097/PEC.0000000000001645 3Wiler JL, Gentle C, Halfpenny JM, et al. Optimizing emergency department front-end operations. Ann Emerg Med 2010; 55: 142– 60.e1. 4Poonai N, Gregory J, Thompson G, et al. Is pelvic ultrasound associated with an increased time to appendectomy in pediatric appendicitis? J Emerg Med 2014; 47: 51– 8. 5Stoner MJ, Goodman DG, Cohen DM, et al. Rapid fluid resuscitation in pediatrics: testing the American College of Critical Care Medicine guideline. Ann Emerg Med 2007; 50: 601– 7. 6Robertson G, Lane A, Piehl M, et al. Comparison of a Novel Rapid Fluid Delivery Device to Traditional Methods. 410 Medical. 2018. Available at: https://410medical.com/wp-content/uploads/2018/03/Infusion-Rate-Comparison-of-LifeFlow-to-Traditional-Methods.pdf. Accessed May 14, 2018. Citing Literature Volume27, Issue11November 2020Pages 1191-1193 ReferencesRelatedInformation