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Original Article
Comparison of methemoglobin levels in food protein-induced enterocolitis syndrome and other gastrointestinal diseases in neonates
Eishi Makitaa,
Corresponding author
r0947em@jichi.ac.jp

Corresponding author.
, Sae Kurodaa,b, Hiroaki Satoa, Kae Itabashia, Atsuko Kawanoa, Misa Matsuuraa, Yohei Sugiyamaa, Daisuke Sugawaraa, Asami Maruyamaa, Ko Ichihashia
a Department of Pediatrics, Saitama Medical Center, Jichi Medical University, Saitama 330-8503, Japan
b Department of Pediatrics, Saitama Red Cross Hospital, Saitama 330-8553, Japan
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Comparison of methemoglobin &#40;&#37;&#41; between the food protein-induced enterocolitis syndrome &#40;FPIES group&#41; and other gastrointestinal diseases &#40;non-FPIES group&#41;&#46; Median and interquartile range are indicated by horizontal lines&#46; Differences between the two groups were evaluated using the Mann&#8211;Whitney test&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Food protein-induced enterocolitis syndrome &#40;FPIES&#41; is a non-IgE-mediated allergic disease accompanied by only gastrointestinal symptoms&#44; such as vomiting and diarrhea&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">1&#44;2</span></a> FPIES is diagnosed based on the presence of symptoms fulfilling the diagnostic criteria or positive results of the oral food challenge test&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a> There have been several reports of methemoglobinemia in severe FPIES cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">3&#8211;6</span></a> However&#44; there are no reports evaluating the methemoglobin &#40;MHb&#41; levels patients with FPIES without symptomatic methemoglobinemia&#46; If patients with FPIES show a tendency toward increased MHb levels&#44; then MHb measurements could be useful for the diagnostic prediction of FPIES&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">If the MHb levels of patients with FPIES are significantly higher than those of patients with other diseases&#44; this may be useful for the differential diagnosis of FPIES&#46; In this study&#44; we retrospectively evaluated the MHb levels of patients with neonatal-onset FPIES&#44; and we examined whether MHb levels were higher in FPIES than in other gastrointestinal diseases and neonatal transient emesis&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Patients and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Patients</span><p id="par0015" class="elsevierStylePara elsevierViewall">This study included 150 neonates admitted to the neonatal intensive care unit &#40;NICU&#41; and pediatric ward of our hospital with the chief complaint of vomiting from April 2010 to November 2018 &#40;onset in premature infants at less than one month corrected age&#41;&#46; Eleven neonates were diagnosed with FPIES &#40;FPIES group&#41;&#44; 139 neonates were diagnosed with other gastrointestinal diseases &#40;non-FPIES group&#41;&#46; Patients with symptoms that fulfilled the diagnostic criteria<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a> or patients who showed a positive result on an oral food challenge<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a> performed at a later date were diagnosed as having FPIES&#46; This study was approved by the Ethics Committee of Jichi Medical University Saitama Medical Center &#40;Approval No&#46; S19-049&#41;&#44; and the opt-out consent form was published on the home page of our clinical section&#46; The need to obtain written informed consent was waived due to the retrospective design of this study&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Patients&#8217; characteristics</span><p id="par0020" class="elsevierStylePara elsevierViewall">Data on sex&#44; gestational age&#44; birth weight&#44; age at onset&#44; duration of hospitalization&#44; existence of bloody stools&#44; vital signs when vomiting occurred&#44; final diagnosis&#44; and family history of methemoglobinemia were collected&#46; The age at which diagnosis was confirmed in FPIES cases was also assessed&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Venous blood measurements</span><p id="par0025" class="elsevierStylePara elsevierViewall">Venous blood was measured using ABL800FLEX&#174; &#40;Radiometer GmbH&#44; Denmark&#41;&#46; MHb &#40;&#37;&#41; was measured using the spectrophotometric method &#40;modified Malloy&#8211;Evelyn method&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">7</span></a> MHb &#40;&#37;&#41; levels were measured simultaneously by blood gas analyses&#46; We evaluated the MHb peak values &#40;&#37;&#41; from onset to 48<span class="elsevierStyleHsp" style=""></span>h later&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">To evaluate metabolic acidosis and the inflammatory response&#44; the lowest pH value&#44; minimum bicarbonate &#40;HCO<span class="elsevierStyleInf">3</span><span class="elsevierStyleSup">&#8722;</span>&#41; level&#44; and peak C-reactive protein &#40;CRP&#41; level were evaluated from onset to 48<span class="elsevierStyleHsp" style=""></span>h later&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Statistical analysis</span><p id="par0035" class="elsevierStylePara elsevierViewall">Patient characteristics&#44; vital signs at onset &#40;body temperature&#44; heart rate&#44; respiratory rate&#44; blood pressure&#44; and peripheral artery oxygen saturation&#41;&#44; and blood test data were evaluated retrospectively&#44; and the FPIES and non-FPIES groups were compared&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Results are expressed as medians &#40;ranges&#41;&#46; For statistical comparisons between the FPIES group and the non-FPIES group&#44; we used the Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test for continuous variables and Fisher&#39;s exact test for categorical variables&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">For MHb levels&#44; a receiver operating characteristic &#40;ROC&#41; analysis was performed with the differentiation between FPIES and other diseases as the index&#59; the area under the curve &#40;AUC&#41; was also evaluated&#44; and sensitivity and specificity at the cut-off value were determined&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">All statistical analyses were performed using EZR 1&#46;33 software &#40;Saitama Medical Center&#44; Jichi Medical University&#44; Saitama&#44; Japan&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">8</span></a></p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Results</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patients</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">FPIES group</span><p id="par0055" class="elsevierStylePara elsevierViewall">Eleven patients met the diagnostic criteria for acute FPIES based on the International Consensus Guidelines 2017<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a> &#40;FPIES group&#41;&#46; Of the 11 cases&#44; 11 had frequent vomiting&#44; seven had bloody stools&#44; four had diarrhea&#44; 11 had lethargy&#44; four had pallor&#44; three had dehydration&#44; and five had acidemia&#46; The time between antigen intake and onset was one hour in 8 cases&#44; 1&#46;5<span class="elsevierStyleHsp" style=""></span>h in one case&#44; and two hours in two cases&#46; All patients met the symptom criteria of severe FPIES&#46; All 11 patients in the FPIES group were suffering from FPIES due to cow&#39;s milk protein &#40;cow&#39;s milk formula&#41; and did not display symptomatic methemoglobinemia&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">As cow&#39;s milk was the cause of FPIES&#44; the patients were preferentially fed breast milk and therapeutic formula milk if needed&#46; Nine patients were fed the extensively hydrolyzed formula &#91;New MA-1&#174; or MA-mi&#174; &#40;Morinaga Milk Industry Co&#46;&#44; Ltd&#46; Japan&#41;&#93;&#44; and two patients received amino acid-based formula &#91;Elental P&#174; &#40;EA Pharma Co&#46;&#44; Ltd&#46;&#44; Japan&#41;&#93;&#46; Five patients were diagnosed with FPIES by an oral food challenge approach&#46; For the oral food challenge&#44; a single dose ingestion of cow&#39;s milk formula was given&#46; The dose of cow&#39;s milk formula was determined by the attending physician&#46; The dose was 5<span class="elsevierStyleHsp" style=""></span>ml in two cases&#44; 20<span class="elsevierStyleHsp" style=""></span>ml in one case&#44; 30<span class="elsevierStyleHsp" style=""></span>ml in one case and 80<span class="elsevierStyleHsp" style=""></span>ml in one case&#46; Symptoms were frequent vomiting&#44; lethargy&#44; and pallor in all five patients&#46; The time from ingestion to symptoms was one hour in four cases and two hours in one case&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In all patients with suspected FPIES due to the ingestion of cow&#39;s milk during the neonatal period&#44; avoidance of the use of cow&#39;s milk was started&#46; However&#44; the median age at a definitive FPIES diagnosis was five months &#40;range 0&#8211;15&#41;&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Non-FPIES group</span><p id="par0070" class="elsevierStylePara elsevierViewall">The 36&#47;139 cases in the non-FPIES group included 15 cases of neonatal melena&#44; five cases of Hirschsprung disease &#40;among them&#44; one case was combined with congestive enteritis&#41;&#44; four cases of midgut volvulus&#44; three cases of esophageal atresia&#44; two cases of hypertrophic pyloric stenosis&#44; two cases of duodenal stenosis&#44; and one case each of duodenal atresia&#44; ileal atresia&#44; gastric perforation&#44; gastric volvulus&#44; and necrotizing enterocolitis&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The 103&#47;139 patients in the non-FPIES group underwent a detailed examination to determine the cause of vomiting &#40;blood test&#44; chest&#8211;abdominal radiography&#44; head&#44; heart&#44; and abdominal ultrasonography&#41;&#44; but the test results were normal&#46; For the patients&#44; small amounts of enteral nutrition &#40;oral feeding or tube feeding&#41; were started after fasting for several hours to one day&#46; The feeding amount was gradually increased&#44; and the patients remained hospitalized until weight gain was confirmed&#46; Because the symptoms gradually improved&#44; the cause of vomiting was considered transient and to be attributed to immaturity in the neonatal period&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Patient characteristics</span><p id="par0080" class="elsevierStylePara elsevierViewall">Patient characteristics and vital signs at onset in the FPIES group and non-FPIES group are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; The median age at onset was 16 and one days&#59; percentage of males was 64 and 46&#37;&#59; median gestational age was 38 and 38 weeks&#59; median birth weight was 2710 and 2880<span class="elsevierStyleHsp" style=""></span>g&#59; and median duration of hospitalization was 31 and six days for the FPIES group and non-FPIES group&#44; respectively&#46; The age of onset was higher &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; and the duration of hospitalization was longer &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; in the FPIES group than in the non-FPIES group&#59; no differences were found between the FPIES and non-FPIES groups for other items &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; There were also no differences between the FPIES group and the non-FPIES group in terms of vital signs upon the appearance of vomiting &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; None of the patients had a positive family history of methemoglobinemia or were diagnosed with hemolytic diseases&#44; which can present in combination with methemoglobinemia&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Laboratory testing</span><p id="par0085" class="elsevierStylePara elsevierViewall">Laboratory test results of the FPIES group and non-FPIES group are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; The median &#40;range&#41; of MHb &#40;&#37;&#41; was 1&#46;1 &#40;0&#46;6&#8211;10&#46;9&#41; and 0&#46;6 &#40;0&#46;3&#8211;1&#46;2&#41;&#59; that of CRP &#40;mg&#47;dl&#41; was 0&#46;71 &#40;0&#46;09&#8211;3&#46;03&#41; and 0&#46;23 &#40;0&#46;02&#8211;4&#46;41&#41;&#59; that of pH was 7&#46;37 &#40;7&#46;10&#8211;7&#46;43&#41; and 7&#46;36 &#40;7&#46;05&#8211;7&#46;46&#41;&#59; and that of HCO<span class="elsevierStyleInf">3-</span> was 21&#46;9 &#40;4&#46;8&#8211;28&#46;0&#41; and 21&#46;6 &#40;11&#46;3&#8211;24&#46;3&#41; for the FPIES group and non-FPIES group&#44; respectively&#46; MHb levels were higher in the FPIES group than in the non-FPIES group &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; With regard to CRP&#44; pH&#44; and HCO<span class="elsevierStyleInf">3-</span>&#44; no differences were found between the FPIES group and the non-FPIES group &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">ROC analysis</span><p id="par0090" class="elsevierStylePara elsevierViewall">The ROC analysis results of MHb &#40;&#37;&#41;&#44; for the differentiation between FPIES and other diseases as the index&#44; are shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#46; The AUC was 0&#46;885 &#40;95&#37; CI 0&#46;758&#8211;1&#41;&#44; with a specificity of 97&#46;1&#37; and sensitivity of 72&#46;7&#37; at a cutoff value of 1&#46;0 &#40;Youden index&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">This investigation is the first study to evaluate the MHb levels of neonates with FPIES without symptomatic methemoglobinemia&#46; FPIES is a non-IgE-mediated allergic disease that presents with only gastrointestinal symptoms&#44; such as vomiting and diarrhea&#46; There have been several reports on the presence of methemoglobinemia in severe cases of FPIES&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">3&#8211;6</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Normal hemoglobin carries divalent iron&#59; when oxidized&#44; it changes into MHb&#44; which carries trivalent iron&#46; The latter lacks oxygen transport function&#46; Increased blood MHb concentration is termed methemoglobinemia&#46; Although MHb is found under normal conditions&#44; it is usually maintained at less than 1&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">9</span></a> When MHb levels are less than 10&#8211;15&#37;&#44; it is usually asymptomatic&#46; However&#44; a higher percentage is associated with hypoxemia&#44; and tachycardia&#44; fatigue&#44; confusion&#44; and tachypnea are associated with levels above 30&#37;&#59; convulsion and lethargy are associated with levels above 50&#37;&#59; and death is associated with levels above 70&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">10</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">This study was conducted with the hypothesis that MHb levels in FPIES cases are increased even in the absence of symptoms due to methemoglobinemia&#46; As a result&#44; the MHb levels in the neonatal period were higher in the FPIES group than in the non-FPIES group&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">There are two different mechanisms for the pathogenesis of acquired methemoglobinemia&#46; According to the first mechanism&#44; methemoglobinemia is due to sepsis and&#47;or significant acidosis&#59; when the general health condition is poor&#44; a large amount of nitric oxide &#40;NO&#41; is released into the blood&#44; and hemoglobin is oxidized by NO&#44; causing an increase in MHb concentration&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">10&#8211;12</span></a> According to the second mechanism&#44; NO<span class="elsevierStyleInf">3</span><span class="elsevierStyleSup">&#8722;</span>&#44; which is increased in the intestinal tract due to enteritis&#44; is restored to NO<span class="elsevierStyleInf">2</span><span class="elsevierStyleSup">&#8722;</span> by intestinal anaerobes&#44; NO<span class="elsevierStyleInf">2</span><span class="elsevierStyleSup">&#8722;</span> is transported to the intestinal epithelia&#44; hemoglobin is oxidized by NO<span class="elsevierStyleInf">2</span><span class="elsevierStyleSup">&#8722;</span> flowing into the blood&#44; and the MHb concentration increases&#46; In other words&#44; the balance of enzymatic activities of oxidase in the intestinal epithelia and intestinal bacterial flora changes&#44; resulting in increased nitrate and subsequent MHb oxidation&#46; This mechanism is considered to result in intestinal methemoglobinemia&#59; there are also reports on the presence of transient methemoglobinemia in patients with enteritis&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">13&#44;14</span></a> In our study&#44; the FPIES group had significantly higher MHb levels than the non-FPIES group&#44; but there was no significant difference in pH value and HCO<span class="elsevierStyleInf">3</span><span class="elsevierStyleSup">&#8722;</span> level&#46; This suggests that&#44; in the FPIES patients in our study&#44; intestinal methemoglobinemia is more important than acidosis as a mechanism by which MHb increases&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">MHb levels tend to increase during the neonatal period due to the following reasons&#46; First&#44; the pH of gastric fluid is less acidic and allows for the proliferation of bacteria&#44; such as <span class="elsevierStyleItalic">Escherichia coli</span>&#44; which restore nitrate&#46; Second&#44; MHb reductase activity of neonates is low&#44; at approximately 60&#37; of that of adults&#46; Third&#44; the level of HbF&#44; which is more easily oxidized than HbA&#44; is high&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">10&#44;15</span></a> Based on these factors&#44; mild pathological changes may be sharply reflected by the MHb level during the neonatal period&#46; It has also been reported that 13&#8211;18&#37; of patients less than two months of age with FPIES have methemoglobinemia&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">4&#44;5</span></a> Therefore&#44; in neonates with FPIES&#44; it would be beneficial to monitor any increase in MHb level&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The diagnosis of FPIES is made if the major criterion &#40;vomiting in the 1- to 4-h period after ingestion of the suspected food combined with the absence of classic IgE-mediated allergic skin or respiratory symptoms&#41; and more than three minor criteria are confirmed&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">1&#44;2</span></a> If the symptoms and causative antigen are unclear&#44; an oral food challenge is recommended&#46; However&#44; there is the risk that the oral food challenge may provoke severe symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a> Although FPIES cannot be diagnosed based on test values other than an oral food challenge&#44; a high probability of FPIES could be predicted in advance&#44; based on test values&#44; and the risk of symptom provocation due to an oral food challenge could be estimated&#46; In the case of a high risk of symptom provocation&#44; the risk of this being severe can be minimized by setting a low antigen load in the oral food challenge&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Between 2&#37; and 20&#37; of FPIES cases are atypical&#44; where a specific IgE of causative antigens is present during follow-up&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a> Typical cases are IgE negative&#44; and it is difficult to diagnose FPIES by IgE measurements&#46; Whereas neutrophil left shift&#44; eosinophilia&#44; and metabolic acidosis were confirmed in studies that evaluated blood test data from patients with FPIES&#44; there have been no studies evaluating their utility for the diagnosis of FPIES&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">4&#44;6&#44;16</span></a> In addition&#44; although the usefulness of the &#954;-casein lymphocyte stimulation test for the diagnosis of FPIES has been reported&#44; it is time-consuming and requires a specialized technique and equipment&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">17</span></a> However&#44; MHb levels can be examined in real time using common measuring instruments&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">In our study&#44; patients with high MHb levels were found to be those with severe FPIES&#46; However&#44; it is necessary to exclude causes other than FPIES that cause MHb&#46; Also&#44; the ROC analysis showed high specificity but not high sensitivity&#59; therefore&#44; low MHb values could not exclude FPIES&#46; In particular&#44; in the case of patients with mild or moderate FPIES&#44; MHb may be more difficult to increase&#46; That is to say that high MHb levels may help diagnose severe acute FPIES if other causative diseases are ruled out&#44; but careful evaluation is needed&#46;</p><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Limitations</span><p id="par0135" class="elsevierStylePara elsevierViewall">Our study has several limitations&#46; First&#44; there were no cases of infectious gastroenteritis in the non-FPIES group&#46; It has been previously reported that infectious enteritis causes methemoglobinemia in infants&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">13&#44;14</span></a> However&#44; this study focused on neonates&#44; and infectious gastroenteritis is extremely rare among patients in the NICU&#46; In addition&#44; MHb levels were not elevated in one case of necrotizing enterocolitis and one case of Hirschsprung disease combined with congestive enteritis in the non-FPIES group&#46; Thus&#44; it is speculated that FPIES is a disease that is often associated with MHb elevation compared to other causes of enterocolitis&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Second&#44; patients were not tested for congenital methemoglobinemia&#46; Even though reductase activity measurement and genetic screening were not performed&#44; none of the patients had a family history of methemoglobinemia&#44; and it was confirmed that the minimum MHb of all patients was approximately 0&#8211;1&#37; during hospitalization&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Third&#44; this study is a retrospective investigation&#44; and the period and frequency of MHb measurement were not determined&#46; However&#44; as MHb levels in this study were measured at the same time during each blood gas analysis&#44; at the frequency of more than once daily&#44; the overall trend could be recognized&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Fourth&#44; our study evaluated only severe acute FPIES&#46; Since there were no patients with mild or moderate acute FPIES or chronic FPIES&#44; future research on the evaluation of MHb levels in these cases is desired&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">In conclusion&#44; high MHb levels could help the clinician diagnose FPIES in a very select group of patients &#40;those with neonatal severe FPIES&#41; once the other potential causes of high MHb levels have been excluded&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">In the future&#44; larger-scale studies&#44; as well as the investigation into the pathogenesis of elevated MHb in FPIES&#44; are warranted&#46;</p></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Unblinded ethical approval statement</span><p id="par0165" class="elsevierStylePara elsevierViewall">This study was approved by the Ethics Committee of Jichi Medical University Saitama Medical Center &#40;Approval No&#46; S19-049&#41;&#44; and the opt-out consent form was published on the home page of our clinical section&#46; The need to obtain written informed consent was waived due to the retrospective design of this study&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Funding</span><p id="par0170" class="elsevierStylePara elsevierViewall">This research did not receive any specific grant from funding agencies in the public&#44; commercial&#44; or not-for-profit sectors&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflict of interest</span><p id="par0175" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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          "titulo" => "Abbreviations"
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          "titulo" => "Introduction"
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                  "titulo" => "FPIES group"
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                  "titulo" => "Non-FPIES group"
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    "fechaRecibido" => "2019-09-02"
    "fechaAceptado" => "2020-01-29"
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            1 => "Food protein-induced enterocolitis syndrome"
            2 => "Methemoglobin"
            3 => "Milk allergy"
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          "titulo" => "Abbreviations"
          "identificador" => "xpalclavsec1273440"
          "palabras" => array:7 [
            0 => "CRP"
            1 => "FPIES"
            2 => "GI"
            3 => "HCO<span class="elsevierStyleInf">3</span><span class="elsevierStyleSup">&#8722;</span>"
            4 => "MHb"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Methemoglobinemia has been reported to be associated with severe food protein-induced enterocolitis syndrome &#40;FPIES&#41;&#46; However&#44; no reports have evaluated methemoglobin &#40;MHb&#41; levels in FPIES without symptomatic methemoglobinemia or the usefulness of MHb measurement for the diagnostic prediction of FPIES&#46; To evaluate the MHb levels of patients with neonatal-onset FPIES and determine whether MHb levels are higher in FPIES than in other gastrointestinal diseases&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Eleven neonates with severe acute FPIES &#40;FPIES group&#41; and 139 neonates with other gastrointestinal diseases &#40;non-FPIES group&#41; were included in this study&#46; Patient characteristics&#44; symptoms&#44; and venous blood test values &#40;MHb&#44; pH&#44; HCO<span class="elsevierStyleInf">3</span><span class="elsevierStyleSup">&#8722;</span>&#44; and C-reactive protein&#41; were evaluated&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The median age at onset was 16 days vs&#46; 1 day&#59; males comprised 64&#37; vs&#46; 46&#37;&#44; the median gestational age was 38 weeks vs&#46; 38 weeks&#44; the median birth weight was 2710<span class="elsevierStyleHsp" style=""></span>g vs&#46; 2880<span class="elsevierStyleHsp" style=""></span>g&#44; and the median hospitalization duration was 31 days vs&#46; 6 days for the FPIES vs&#46; non-FPIES groups&#44; respectively&#46; MHb &#40;&#37;&#41; was higher in the FPIES group than in the non-FPIES group &#91;median &#40;range&#41;&#44; 1&#46;1 &#40;0&#46;6&#8211;10&#46;9&#41; and 0&#46;6 &#40;0&#46;3&#8211;1&#46;2&#41;&#44; respectively&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#93;&#46; There were no differences in terms of pH&#44; HCO<span class="elsevierStyleInf">3</span><span class="elsevierStyleSup">&#8722;</span>&#44; and C-reactive protein &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; In the receiver operating characteristic analysis for FPIES diagnosis based on MHb &#40;&#37;&#41;&#44; the area under the curve was 0&#46;885&#44; specificity was 97&#46;1&#37;&#44; and sensitivity was 72&#46;7&#37; at a MHb cutoff of 1&#46;0&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">High MHb levels may help diagnose severe acute FPIES in neonates&#44; but careful evaluation is needed&#46;</p></span>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">FPIES group &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Non-FPIES group &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>139&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>-value<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">&#8224;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Gestational age &#40;weeks&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38 &#40;30&#8211;40&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38 &#40;29&#8211;41&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;067&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Birth weight &#40;g&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2710 &#40;1444&#8211;3440&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2880 &#40;998&#8211;3732&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sex&#44; male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;64&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">64 &#40;46&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age at onset &#40;days&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;2&#8211;39&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;0&#8211;69&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vomiting&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;100&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">139 &#40;100&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;0&#46;99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bloody stool&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;64&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Duration of hospitalization &#40;days&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31 &#40;8&#8211;65&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;1&#8211;330&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">BT &#40;&#176;C&#41; at onset&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&#46;2 &#40;36&#46;6&#8211;37&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&#46;1 &#40;36&#46;2&#8211;37&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HR &#40;&#47;min&#41; at onset&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">141 &#40;110&#8211;158&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">134 &#40;100&#8211;179&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RR &#40;&#47;min&#41; at onset&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">44 &#40;36&#8211;52&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40 &#40;30&#8211;84&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">sBP &#40;mmHg&#41; at onset&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">77 &#40;62&#8211;96&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70 &#40;45&#8211;93&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;053&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">dBP &#40;mmHg&#41; at onset&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">44 &#40;28&#8211;62&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">43 &#40;24&#8211;59&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SpO<span class="elsevierStyleInf">2</span> &#40;&#37;&#41; on room air&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100 &#40;97&#8211;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100 &#40;93&#8211;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Represents the statistical significance between the FPIES group and the non-FPIES group&#46; Differences were evaluated using the Mann&#8211;Whitney test for continuous variables or the Fisher&#39;s exact test for categorical variables&#46;</p> <p class="elsevierStyleNotepara" id="npar0010">BT&#58; body temperature&#59; dBP&#58; diastolic blood pressure&#59; FPIES&#58; food protein-induced enterocolitis syndrome&#59; HR&#58; heart rate&#59; RR&#58; respiratory rate&#59; sBP&#58; systolic blood pressure&#59; SpO<span class="elsevierStyleInf">2</span>&#58; oxygen saturation of peripheral artery&#46;</p>"
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        "tipo" => "MULTIMEDIATABLA"
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">FPIES group &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>11&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Non-FPIES group &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>139&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>-value<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">&#8224;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
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ISSN: 03010546
Original language: English
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

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