Elastic intramedullary nailing in unstable fractures of the paediatric tibial diaphysis: a systematic review

PURPOSE

The majority of paediatric tibial fractures can be managed conservatively. However, there is a small but significant group of patients that require surgical intervention for several indications, most notably, unstable fractures. There are various surgical options, each with its own advantages and risks. This review establishes the current available evidence for the use of elastic intramedullary nails in this group.

METHODS

A systematic review of the currently available literature was performed. The relevant studies were then critically appraised.

RESULTS

Seven applicable retrospective case series were identified, with the outcomes from a total of 210 (range 16-60) patients considered. The mean time to union ranged from 7 to 21 weeks. Reported complications included small numbers each of delayed union, non-union, malunion, leg length discrepancy and infection.

CONCLUSIONS

There is only a small body of evidence currently published on this topic. The evidence published so far concludes that elastic intramedullary nailing represents an effective and reliable method to treat an unstable fracture of the tibial diaphysis in the paediatric patient, where conservative management is not appropriate.

A Comparative Study of Induction, Maintenance and Recovery Characteristics of Sevoflurane and Halothane Anaesthesia in Pediatric Patients (6 months to 6 years)

PATIENTS #ENTITYSTARTX00026;

METHODS

In a randomized , double blind clinical study, we studied 30 children, aged 6 months to 6 years, to compare halothane and sevoflurane anaesthesia in patients undergoing short surgical procedures under general anaesthesia. All the patients were premedicated with atropine 0.02mg kg(-1)and midazolam 0.1mg kg(-1)body weight intravenously and received inhalation induction using nitrous oxide in oxygen supplemented with either halothane (maximum inspired concentration of 5%) or sevoflurane (maximum inspired concentration of 8%). Induction was by inhalation of increasing concentrations of sevoflurane (1%) or halothane (0.5%) in the vaporizing setting after every three breaths of the patient.

RESULTS

Time to loss of eyelash reflex and tracheal intubation was more rapid using sevoflurane. Cardiac arrhythmias were significantly more frequent during halothane than sevoflurane anaesthesia. Psychomotor recovery was more rapid after sevoflurane anaesthesia. Children who received sevoflurane had comparatively less nausea and vomiting and the incidence of clinically important side effects was significantly less with sevoflurane anaesthesia.

CONCLUSION

We conclude that induction with sevoflurane in nitrous oxide and oxygen leads to fast loss of consciousness and provides ideal conditions for managing the airway without supplemental opioids or muscle relaxants with haemodynamic stability and is therefore a reasonable alternative to halothane for paediatric patients.

C1q nephropathy: a true immune complex disease or an immunologic epiphenomenon?

We describe a 16-year-old Caucasian boy who presented with steroid-sensitive nephrotic syndrome aged 2 years. His clinical course was one of frequent relapses and severe steroid dependence. To manage this, he was sequentially treated with levamisole, then oral cyclophosphamide before being started on ciclosporin. A renal biopsy performed prior to commencement of ciclosporin confirmed minimal change disease on light microscopy. The immunohistochemistry and electron microscopy findings were in keeping with this. His complement levels were normal and his lupus serology negative. He remained on ciclosporin therapy for 8 years and had two further renal biopsies to detect ciclosporin-induced renal damage. Both biopsies showed evidence of increasing amounts of C1q deposition on immunohistochemistry and the presence of immune deposits on electron microscopy. As he had continued negative lupus serology, this was compatible with a diagnosis of C1q nephropathy. In addition both biopsies had changes compatible with chronic mild ciclosporin nephrotoxicity. This case is the first report describing in detail a paediatric patient with evolving C1q nephropathy who was treated successfully with rituximab. We discuss the role of C1q in this clinicopathological entity and question its significance.

HAART and risk of tuberculosis in HIV-infected South African children: a multi-site retrospective cohort

SETTING

Four human immunodeficiency virus (HIV) clinics located at South African tertiary hospitals.

OBJECTIVE

To assess the effectiveness of highly active antiretroviral therapy (HAART) in reducing incident tuberculosis (TB) in HIV-infected children.

DESIGN

Retrospective cohort.

RESULTS

A total of 1132 children's records were included in the study. At entry to the cohort, the median (interquartile range [IQR]) age, CD4%, CD4 count and viral load of all children was respectively 6.3 years (4.1-8.8), 15% (9.0-22.2), 576 cells/mm(3) (287-960) and 160 000 copies/ml (54 941.5-449 683); 75.9% were started on HAART. The male:female ratio was 1:1, and median follow-up time was 1.7 years. In children whose follow-up included both pre-HAART and on-HAART periods, the incidence of clinically diagnosed TB was respectively 21.1 per 100 person-years (py; 95%CI 18.2-24.4) and 6.4/100 py (95%CI 4.8-8.1), and when restricted to confirmed cases, respectively 3.1/100 py (95%CI 2.2-4.2) and 0.8/100 py (95%CI 0.5-1.4). Only 23% of all cases of TB were microbiologically confirmed. Multivariate analyses showed that HAART reduced incident TB by approximately 70%, both for confirmed and all TB cases.

CONCLUSIONS

In this high TB burden country, the incidence of diagnosis of TB in HIV-infected children is at least as high as that of adults. HAART reduces incident TB, but further prospective TB preventive and diagnostic studies are urgently needed in children.

An increase in the prevalence of type 1 and 2 diabetes in children and adolescents: results from prescription data from a UK general practice database

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

Increasing antidiabetic drugs use in youths has been reported in the USA, however there is a lack of epidemiological evidence in the UK. There is an increase in the prevalence of both type 1 and 2 diabetes, but precise estimates are difficult to obtain and as such are uninformative for future health services planning.

WHAT THIS STUDY ADDS

The prevalence of children receiving insulin and oral antidiabetic drugs has increased twofold and eightfold, respectively, between 1998 and 2005. The data reflect the prevalence of both type 1 and type 2 diabetes rapidly increase in recent years. The prevalence of antidiabetic drug use increases with increasing age, especially among those aged 12-18 years. Consideration needs to be given to the funding and design of future services for children and particularly adolescents with diabetes to take account of these epidemiological findings.

AIMS

Despite evidence of an increase in the incidence of both type 1 and type 2 diabetes in youths, there are few data on the prevalence of either type in children and adolescents. The aim of this study was to investigate the prevalence of childhood diabetes over an 8-year period in the UK.

METHODS

This was a retrospective cohort study that covered 8 years (January 1998 to December 2005) of UK IMS Disease Analyzer (IMS DA) data. The cohort comprised all children and adolescents aged 0-18 years who received at least one antidiabetic drug prescription during the study period. The prevalence of antidiabetic drug prescribing was used as a proxy for diabetes itself.

RESULTS

Data were available on 505 754 children aged 0-18 years and a total of 37 225 antidiabetic prescriptions were issued. Insulin use increased significantly from 1.08 per 1000 children [95% confidence interval (CI) 0.96, 1.20] in 1998 to 1.98 (95% CI 1.80, 2.10) in 2005 (P < 0.001), more markedly in those aged 12 and 18 years. The use of oral antidiabetic drugs for diabetes treatment rose significantly from 0.006 per 1000 children in 1998 (95% CI 0.0043, 0.017) to 0.05 (95% CI 0.025, 0.080) (P < 0.001) in 2005.

CONCLUSIONS

This study indicates a significant increase in prevalence on both type 1 and type 2 diabetes treatment in children and adolescents in the UK. Thus, this supporting evidence from other sources that the prevalence of childhood diabetes is rising rapidly. Further epidemiological studies are required to investigate the aetiology and risk factors.

Neurological complications associated with the treatment of patients with congenital cardiac disease: consensus definitions from the Multi-Societal Database Committee for Pediatric and Congenital Heart Disease

A complication is an event or occurrence that is associated with a disease or a healthcare intervention, is a departure from the desired course of events, and may cause, or be associated with suboptimal outcome. A complication does not necessarily represent a breech in the standard of care that constitutes medical negligence or medical malpractice. An operative or procedural complication is any complication, regardless of cause, occurring (1) within 30 days after surgery or intervention in or out of the hospital, or (2) after 30 days during the same hospitalization subsequent to the operation or intervention. Operative and procedural complications include both intraoperative/intraprocedural complications and postoperative/postprocedural complications in this time interval. The MultiSocietal Database Committee for Pediatric and Congenital Heart Disease has set forth a comprehensive list of complications associated with the treatment of patients with congenital cardiac disease, related to cardiac, pulmonary, renal, haematological, infectious, neurological, gastrointestinal, and endocrine systems, as well as those related to the management of anaesthesia and perfusion, and the transplantation of thoracic organs. The objective of this manuscript is to examine the definitions of operative morbidity as they relate specifically to the neurological system. These specific definitions and terms will be used to track morbidity associated with surgical and transcatheter interventions and other forms of therapy in a common language across many separate databases. Although neurological injury and adverse neurodevelopmental outcome can follow procedures for congenital cardiac defects, much of the variability in neurological outcome is now recognized to be more related to patient specific factors rather than procedural factors. Additionally, the recognition of pre and postoperative neurological morbidity requires procedures and imaging modalities that can be resource-intensive to acquire and analyze, and little is known or described about variations in "sampling rate" from centre to centre. The purpose of this effort is to propose an initial set of consensus definitions for neurological complications following congenital cardiac surgery and intervention. Given the dramatic advances in understanding achieved to date, and those yet to occur, this effort is explicitly recognized as only the initial first step of a process that must remain iterative. This list is a component of a systems-based compendium of complications that may help standardize terminology and possibly enhance the study and quantification of morbidity in patients with congenital cardiac malformations. Clinicians caring for patients with congenital cardiac disease may be able to use this list for databases, initiatives to improve quality, reporting of complications, and comparing strategies of treatment.

Correlations between subdural empyema and paraclinical as well as clinical parameters amongst urban malay paediatric patients

Paediatric subdural empyema is frequently seen in developing Asean countries secondary to rinosinusogenic origins. A cross-sectional analysis on the surgical treatment of intracranial subdural empyema in Hospital Kuala Lumpur (HKL), a major referral center, was done in 2004. A total number of 44 children who fulfilled the inclusion criteria were included into this study. The methods of first surgery, volume of empyema on contrasted CT brain, improvement of neurological status, re-surgery, mortality and morbidity, as well as the demographic data such as age, gender, sex, duration of illness, clinical presentation, probable origin of empyema, cultures and follow-up were studied. Chi-square test was performed to determine the association between surgical methods and the survival of the patients, neurological improvement, clearance of empyema on CT brain, re-surgery and long morbidity among the survivors. If the 20% or more of the cells were having expected frequency less than five, then Fisher's Exact test was applied. The level of significance was set at 0.05. SPSS version 12.0 was used for data entry and data analysis. There were 44 patients who were less than 18 years. Their mean age was 5.90 ± 6.01 years. There were 30 males (68.2%) and 14 females (31.8%) involved in the study. Malays were majority with 28 (63.6%) followed by Indian 8 (18.2%), Chinese 5 (11.4%) and others 3 (6.8%). The variables which were under interest were gender, race, headache, vomiting, seizures, sign of meningism, cranial nerve palsy, thickness site of abscess, first surgical treatment, improvement in neurological deficit, clearance of CT and whether re-surgery was necessary. All variables were found not to be associated with Henk W Mauser Score for PISDE grading. Comparison between this urban study and a rural setting study by the same corresponding author in the same period on subdural empyema was done. Common parameters were compared and it was found out that seizures were more prevalent in urban study where the patients are more than one year old (p=0.005). Mortality was much higher in urban study than the rural one (p=0.040). The larger proportion of urban group had volume of abscess less than or equal to 50 ml (p=< 0.001).

A significant reduction in paediatric post-tonsillectomy vomiting through audit

INTRODUCTION

Postoperative vomiting occurs more frequently after tonsillectomy than any other commonly performed paediatric operation. Postoperative vomiting is also the commonest cause of morbidity and re-admission following tonsillectomy. We present a successful completed audit cycle and literature review on the subject.

PATIENTS AND METHODS

Data on the risk factors for postoperative vomiting, whether the patient vomited and details of the patient's vomitus were collected prospectively on consecutive patients and compared with a gold standard. Changes in practice were agreed and a second cycle performed.

RESULTS

Two cycles and a total of 107 patients were included in the audit. A significant reduction in vomiting from 27% to 11% was achieved following the introduction of routine use of intravenous dexamethasone during surgery.

CONCLUSIONS

This simple prospective audit of paediatric post-tonsillectomy vomiting has resulted in a statistically significant reduction in vomiting which would appear to be due to use of intra-operative steroids.

Video analysis of communication in paediatric consultations in primary care

BACKGROUND

There is a paucity of research evidence concerning communication in paediatric consultations between GPs, adults, and child patients.

AIM

This study was carried out to identify features of the interaction between a doctor, a child patient aged 6-12 years, and their carer in the consultation associated with the child's participation.

DESIGN OF STUDY

A qualitative analysis of video recordings of 31 primary care paediatric consultations was undertaken, using strategies from the methodology of conversation analysis.

SETTING

Primary care, Suffolk, UK.

METHOD

NHS GPs from three primary care trusts (PCTs), were invited to participate in this study. Sixteen volunteers from this sample took part.

RESULTS

Analysis of the interaction in the consultations revealed that the children had little involvement. Children participated when invited to do so, and took more time than adults to answer a doctor's question. An adult carer was less likely to answer on behalf of a child, when they were in a position to see that the doctor's gaze was directed at the child, and the doctor addressed the child by name. Adult carers, who had not voiced their own concerns first, were seen to interrupt doctor-child talk. In consultations where the participants sat in a triangular arrangement, all parties being an equal distance apart, triadic talk was noted.

CONCLUSION

Child involvement in the primary care consultation is associated with adult carers being able to voice their own concerns early in the consultation, and children being invited to speak with the appropriate recipient design.

The British Paediatric Surveillance Unit: the first 20 years

The BPSU has made a major contribution to paediatric medical epidemiology across the world

Effective treatment strategies for paediatric community-acquired pneumonia

Pneumonia is the leading cause of death in children under 5 years of age worldwide and a cause of morbidity in a considerable number of children. A number of studies have sought to identify the ideal choice of antibiotics, route of administration and optimum duration of treatment based on the most likely aetiological agents. Emerging bacterial resistance to antibiotics is also an important consideration in treatment. However, inconsistent clinical and radiological definitions of pneumonia make comparison between studies difficult. There is also a lack of well designed adequately powered randomised controlled trials. This review describes the difficulties encountered in diagnosing community-acquired pneumonia, aetiology, treatment strategies with recommendations and highlights areas for further research.

Aquacel ag® in paediatric burns - a prospective audit

A variety of dressings are used for the management of paediatric burns. Aquacel Ag® is a silver-impregnated hydrofibre that releases silver within the dressing for up to two weeks. It has been reported in the literature that it is a beneficial dressing for the management of partial-thickness burns. It promotes an appropriate environment for re-epithelialization of the burn wound. The aim of this study was to evaluate the use and outcomes of Aquacel Ag® dressing in paediatric burn patients. This was a prospective audit carried out in the period January-July 2005. The healing time was satisfactory. The dressing normally adheres to the burn wound for up to two weeks and thus requires less frequent changes. In our study, patients required three to four outer dressing changes. However, Aquacel Ag® has not been compared with other dressings. Overall pain requirements were reduced during subsequent dressing changes. It was also easy to apply the dressing in the majority of our patients. Non-adherence was one of the problems encountered but, overall, Aquacel Ag® appeared to be a safe, effective, and comfortable dressing.

Evaluation of radiation dose and image quality following changes to tube potential (kVp) in conventional paediatric chest radiography

PURPOSE

A study of radiation dose and image quality following changes to the tube potential (kVp) in paediatric chest radiography.

MATERIALS AND METHOD

A total of 109 patients ranging from 1 month to 15 years were included in two phases of the study. Phase 1 investigated the range of entrance surface air kerma (ESAK) values received from patients exposed to the existing exposure factors. In the second phase, new exposure factors using recommended values of tube potential (kVp) with reduced mAs were used. ESAK values were measured using thermoluminescent dosemeters (TLDs). Image quality in both phases was evaluated using image quality criteria proposed by the Council of the European Communities (CEC). Results of both techniques were analysed for any differences.

RESULTS

The overall mean ESAK before the changes was 0.22 mGy (range: 0.05-0.43) Following changes in tube potential, the overall mean reduced to 0.15 mGy (range: 0.03-0.38), a significant reduction by 34%. The interquartile range was reduced from 45% to 40%. However, doses to those below a year in age still remained high. Assessment of image quality was found to have no significant differences as far as the two techniques used were concerned. However, higher image scores were achieved using higher kVps.

CONCLUSION

Significant dose reduction was achieved through appropriate changes in tube potential and reduction of mAs without any loss in image quality.

Mucosal lymphocyte subsets and HLA-DR antigen expression in paediatric Helicobacter pylori-associated gastritis

Paediatric studies may provide important insights into the immunopathology of Helicobacter pylori-associated gastritis, as mucosal changes reflect different stages of the immunoinflammatory response. We characterized, by quantitative immunohistochemistry, gastric mucosal lymphocyte phenotype and HLA-DR antigen expression and evaluated correlation with histopathology, in H. pylori-infected (Hp+ve) and uninfected children (Hp-ve). In the infected group, lamina propria CD3+ and IgA plasmocyte cell numbers were significantly higher and a trend for predominance of CD8+ over CD4+ was observed both in epithelium and lamina propria. A correlation of inflammation score with lamina propria CD3+ and CD4+ cell numbers and of CD45RO+ T lymphocytes with density of colonization was observed. The proportion of epithelial cells expressing HLA-DR antigen was significantly higher in the Hp+ve group and furthermore, glandular HLA-DR expression correlated with lamina propria CD3+ cell numbers, emphasizing the potential role of epithelial cells as antigen-presenting cells at this stage of infection.

European evidence based consensus on the diagnosis and management of Crohn's disease: special situations

This third section of the European Crohn's and Colitis Organisation (ECCO) Consensus on the management of Crohn's disease concerns postoperative recurrence, fistulating disease, paediatrics, pregnancy, psychosomatics, extraintestinal manifestations, and alternative therapy. The first section on definitions and diagnosis reports on the aims and methods of the consensus, as well as sections on diagnosis, pathology, and classification of Crohn's disease. The second section on current management addresses treatment of active disease, maintenance of medically induced remission, and surgery of Crohn's disease.

A preliminary open trial of olanzapine in paediatric acute and transient psychotic disorders

BACKGROUND

Acute and transient psychotic disorders (ATPD) have been characterized by the development of florid psychotic symptoms within 2 weeks and complete remission of symptoms. Although there are no definite guidelines, these are usually treated by antipsychotic medication.

AIM

This preliminary study examined the effectiveness of olanzapine in paediatric ATPD.

METHODS

In this 6-week open trial of olanzapine in paediatric ATPD, the patients were rated weekly on the Brief Psychiatric Rating Scale (BPRS), Clinical Global Impression (CGI) Scale and Dosage Record Treatment Emergent Symptom Scale (DOTES).

RESULTS

Twenty-three patients (11 males, 12 females; mean age 14.0+/-1.3 years; range 11-16 years) were included in the study. The mean olanzapine dosage was 12.7+/-3.9 mg/day (range 5-20 mg/day). All the patients showed significant improvement in 6 weeks. The results showed a significant decrease (p< 0.0001) in scores of BPRS (mean at baseline 46.2+/-7.0 to 21.4+/-3.9 at week 6). Severity of illness (CGI) decreased from 4.7+/-0.8 to 1.6+/-0.9 in 6 weeks. Also, global improvement (CGI) showed marked improvement in 14 (60.9%), good improvement in 8 (34.8%) and minimal improvement in 1 (4.3%) patient. Some common side-effects were dryness of mouth (n=14, 60.9%), increase in appetite (n=12, 52%), weight gain (n=12, 52%) and drowsiness (n=8, 34.8%). No patient developed extrapyramidal symptoms.

CONCLUSION

Olanzapine was safe and effective in paediatric ATPD.

Bispectral index versus COMFORT score to determine the level of sedation in paediatric intensive care unit patients: a prospective study

INTRODUCTION

Most clinicians give sedatives and analgesics according to their professional experience and the patient's estimated need for sedation. However, this approach is prone to error. Inadequate monitoring of sedation and analgesia may contribute to adverse outcomes and complications. With this in mind, data obtained continuously using nonstimulating methods such as bispectral index (BIS) may have benefits in comparison with clinical monitoring of sedation. The aim of this prospective observational trial was to evaluate the use of electroencephalographic (EEG) BIS for monitoring sedation in paediatric intensive care unit (PICU) patients.

METHODS

Forty paediatric patients (<18 years) were sedated for mechanical ventilation in a cardiac surgical and general PICU. In each paediatric patient BIS and COMFORT score were obtained. The study protocol did not influence ongoing PICU therapy. BIS and corresponding COMFORT score were collected three times for each patient. Measurements with the best starting EEG impedances were analyzed further. Deep sedation was defined as a COMFORT score between 8 and 16, and light sedation as a score between 17 and 26. Biometric and physiological data, and Pediatric Risk of Mortality III scores were also recorded.

RESULTS

There was a good correlation (Spearman's rho 0.651; P = 0.001) between BIS and COMFORT score in the presence of deep sedation and low starting impedance. Receiver operating characteristic (ROC) analysis revealed best discrimination between deep and light sedation at a BIS level of 83.

CONCLUSION

In the presence of deep sedation, BIS correlated satisfactorily with COMFORT score results if low EEG impedances were guaranteed.

Longitudinal changes in photopic OPs occurring with vigabatrin treatment

PURPOSE

Vigabatrin (gamma-vinyl-GABA) is an antiepileptic drug successful in the management of infantile spasms. Photopic ERGs were tested in children followed longitudinally before and during vigabatrin treatment.

METHODS

Subjects were 26 infants (age range 1.5-24 months, median 7.6 months) on vigabatrin treatment who had been tested on multiple visits (two to four visits; mean, three visits). Eighteen of these were assessed initially before starting vigabatrin therapy and eight were assessed within 1 week of initiation of the drug. ERGs were recorded at 6-month intervals. Standard ISCEV protocol with Burian-Allen bipolar contact-lens electrodes (standard flash 2.0 cd.s/m2) was used. Although ISCEV standards were followed, a higher flash intensity (set at 3.6 cd.s/m2) was chosen for single-flash cone assessment to provide a better definition of OPs. Photopic OPs were divided into categories of early OPs and late OP (OP4). Responses were compared with age corrected limits extrapolated from our lab control database.

RESULTS

Results showed differential effects of vigabatrin on the summed early OP amplitudes versus the late OP (OP4) and cone b-wave amplitude. The early OPs showed significant decrease (p = 0.0005, repeated measures analysis of variance) after 6 months and remained decreased for the duration of treatment. There was no significant change seen in the late OP. The cone b-wave amplitude showed initial increase (p = 0.04) after 6 months, followed by a decrease after 18 months; a trend similar to that of the late OP.

CONCLUSION

Early photopic OPs were disrupted more than the late OP, suggesting relative deficit in the ON (depolarizing) retinal pathways.

Endocardial and epicardial steroid lead pacing in the neonatal and paediatric age group

AIM

To compare the performance of steroid eluting epicardial and endocardial leads in infants and children requiring permanent pacing.

METHODS

Evaluation of pacing and sensing characteristics, impedances, and longevity of 159 steroid eluting leads implanted in 95 children. Group A consisted of 24 children weighing less than 15 kg with 15 endocardial leads (five atrial, 10 ventricular) and 19 epicardial leads (five atrial, 14 ventricular). Group B consisted of 71 children weighing more than 15 kg with 106 endocardial leads (56 atrial, 58 ventricular) and 19 epicardial leads (nine atrial, 10 ventricular).

RESULTS

Group A: Stimulation thresholds were lower for ventricular endocardial leads at implant (mean (SD) 0.84 (0.54) v 1.59 (0.64) V, p < 0.014) and at two year follow up (ventricular 0.64 (0.24) v 1.65 (0.69) V, p < 0.003). Impedance and sensing thresholds did not differ significantly at implant and follow up. Group B: Stimulation thresholds were lower for ventricular endocardial leads at implant (0.72 (0.48) v 1.48 (0.58) V, p < 0.001) and at follow up (0.88 (0.46) v 1.55 (0.96) V, p < 0.009). Impedance did not differ. Sensing thresholds were also better for ventricular endocardial leads at follow up (9.1 (5.2) v 14.2 (6.4) mV, p < 0.02). Complications requiring intervention occurred in both groups (n = 7 for endocardial v n = 18 for epicardial leads).

CONCLUSIONS

Endocardial and epicardial steroid eluting leads have comparable performance in the paediatric population.

Paediatric intensive care: out of commission

Problems with commissioning paediatric intensive care stem both from difficulties in recruitment and retention of nurses, and from incoherent or nonexistent national audit. Pyramidal career structures and patterns of remuneration that concentrate on administrative responsibility over clinical skills underlie the former, whereas poor audit conceals variations in both service quality and demand. Epidemiologically superior data are required if we are to solve commissioning problems. We need to know what happened to every child from a defined population receiving intensive care and whether a lack of resources means that some children are denied intensive care.

T-cell re-population in HIV-infected children on highly active anti-retroviral therapy (HAART)

In this pilot study, we address the nature of the re-population of the T-cell compartment in HIV-1+ (Human Immunodeficiency Virus 1), vertically infected children placed on successful regimens of HAART (highly active anti-retroviral therapy) incorporating 2 NRTI and a protease inhibitor. The clonality of the T-cell compartment and the abundance of RTEs (Recent Thymic Emigrants) were determined 2 weeks before and 20 weeks after initiation of HAART in a subgroup of children taking part in the PENTA (Paediatric European Network for the Treatment of AIDS) 5 trial. Analysis of the clonality of the circulating T-cell compartment was assessed using CDR3 spectratyping and analysed using the Kolmogorov-Smirnov two sample test. This revealed that a high degree of T-cell clonal restriction still exists 5 months into therapy, despite the appearance of previously undetectable T-cell clones within the periphery. We detected no increase in RTE abundance in this 5 month period, as determined by PCR detection of TRECs (T-Cell Receptor Excision Circles). We conclude that the observed re-population of T cells within the periphery of treated children is heavily reliant upon the maintenance/expansion of pre-existing cells during the 5 month period immediately following the initiation of therapy.

A model for size and age changes in the pharmacokinetics of paracetamol in neonates, infants and children

AIMS

The aims of this study were to describe paracetamol pharmacokinetics in neonates and infants.

METHODS

Infants in their first 3 months of life (n = 30) were randomised to sequentially receive one of three paracetamol formulations (dose 30-40 mg kg-1) over a 2 day period. The formulations were (a) elixir, (b) glycogelatin capsule suppository and (c) triglyceride base suppository. Approximately six blood samples were taken after each dose over the subsequent 10-16 h. Data were analysed using a nonlinear mixed effect model. These neonatal and infant data were then included with data from four published studies of paracetamol pharmacokinetics (n = 221) and age-related pharmacokinetic changes investigated.

RESULTS

Population pharmacokinetic parameter estimates and their coefficients of variation (CV%) for a one compartment model with first order input, lag time and first order elimination were volume of distribution 69.9 (18%) l and clearance 13.0 (41%) l h-1 (standardized to a 70 kg person). The volume of distribution decreased exponentially with a half-life of 1.9 days from 120 l 70 kg-1 at birth to 69.9 l 70 kg-1 by 14 days. Clearance increased from birth (4.9 l h-1 70 kg-1) with a half-life of 3.25 months to reach 12.4 l h-1 70 kg-1 by 12 months. The absorption half-life (tabs) for the oral preparation was 0.13 (154%) h with a lag time (tlag) of 0.39 h (31%). Absorption parameters for the triglyceride base and capsule suppositories were tabs 1.34 (90%) h, tlag 0.14 h (31%) and tabs 0.65 (63%) h, tlag 0.54 h (31%), respectively. The tabs for elixir and capsule suppository in children under 3 months were 3.68 and 1.51 times greater than children over 3 months. The relative bioavailability of rectal formulations compared with elixir were 0.67 (30%) and 0.61 (23%) for the triglyceride base and capsule suppositories, respectively.

CONCLUSIONS

Total body clearance of paracetamol at birth is 62% and volume of distribution 174% that of older children. A target concentration above 10 mg l-1 in approximately 50% subjects can be achieved by a dose from 45 mg kg-1 day-1 at birth and up to 90 mg kg-1 day-1 in 5-year-old children. A reduced dose of 75 mg kg-1 day-1 in an 8-year-old child is sufficient because clearance is a nonlinear function of weight.

Thiopurine methyltransferase activity and its relationship to the occurrence of rejection episodes in paediatric renal transplant recipients treated with azathioprine

AIMS

Azathioprine is a prodrug commonly used in combination therapy to prevent allograft rejection after renal transplantation. After conversion to 6-mercaptopurine, the drug is metabolized into 6-thioguanine nucleotides (6-TGN) and catabolized by thiopurine methyltransferase (TPMT), an enzyme under monogenic control. The aim of this study was to evaluate the inter- and intraindividual variability of red blood cell thiopurine methyltransferase and 6-TGN concentrations and their relationship to the clinical effects of azathioprine in paediatric patients.

METHODS

In the present study, the inter- and intraindividual variations in red blood cell TPMT activity and 6-TGN concentrations and their relationship to the actions of azathioprine were evaluated during the first year after renal transplantation in 22 paediatric patients.

RESULTS

6-TGN concentration reached steady-state values after 6 months and correlated negatively with TPMT activity (P=0.004). Initial TPMT activity (median: 20.8 nmol h-1 ml-1, range 7.8-34.6) and 6-TGN concentration at steady-state (median: 80 pmol 8 x 10(8-1) cells, range not detected to 366) were not related to the occurrence of rejection episodes during the period of the study. In contrast, TPMT activity and the percentage difference in TPMT activity from the day of transplantation determined at month 1 were higher in the patients with rejection episodes by comparison with those that did not reject during the first 3 months or the first year following transplantation (P<0.005).

CONCLUSIONS

We report a relationship between TPMT activity and occurrence of rejection in paediatric kidney transplant patients undergoing azathioprine therapy. These data suggest a link between high red blood cell TPMT activity and poor clinical outcome probably caused by rapid azathioprine catabolism.

Subglottic haemangioma: Controversies in management

OBJECTIVE

To discuss treatment modalities for subglottic haemangioma (SGH).

METHODOLOGY

Case report of two children definitively managed by different modalities.

RESULTS

Management by CO₂ laser vaporization in one child, and laser followed by interferon 2-alpha in the second child were both successful in controlling the SGH without the need for tracheostomy.

CONCLUSIONS

The stepped-care approach at John Hunter Children's Hospital, Newcastle, New South Wales, is presented. Both laser surgery and interferon can help control SGH. Careful surveillance and interdisciplinary cooperation are essential to achieve a good outcome.

[Analytical morphometry in the study of biological forms: description of the procedure and oriented software]

Background

More than 2 out of 3 children and adolescents in the United States experience trauma by the age of 16 years. Exposure to trauma in early life is linked to a range of negative mental health outcomes throughout the lifespan, particularly co-occurring symptoms of posttraumatic stress (PTS), anxiety, and depression. There has been an increasing uptake of digital mental health interventions (DMHIs) among youths, particularly for anxiety and depression. However, little is known regarding the incidence of trauma exposure and PTS symptoms among youths participating in DMHIs and whether PTS symptoms impact anxiety and depressive symptom treatment response. Moreover, it is unclear whether participation in a DMHI for anxiety and depressive symptoms is associated with secondary effects on PTS symptoms among trauma-exposed youths.

Objective

This study aims to use retrospective data from youths participating in a DMHI to (1) characterize rates of trauma, PTS, and comorbid anxiety and depressive symptoms; (2) determine whether trauma exposure and elevated PTS symptoms impact the improvement of comorbid anxiety and depressive symptoms throughout participation in care; and (3) determine whether participation in a non–posttraumatic DMHI is linked to reductions in PTS symptoms.

Methods

This study was conducted using retrospective data from members (children ages 6 to 12 years) involved in a pediatric collaborative care DMHI. Participating caregivers reported their children’s trauma exposure. PTS, anxiety, and depressive symptom severity were measured monthly using validated assessments.

Results

Among eligible participants (n=966), 30.2% (n=292) reported at least 1 traumatic event. Of those with trauma exposure and elevated symptoms of PTS (n=119), 73% (n=87) exhibited elevated anxiety symptoms and 50% (n=59) exhibited elevated depressive symptoms. Compared to children with no trauma, children with elevated PTS symptoms showed smaller reductions per month in anxiety but not depressive symptoms (anxiety: F 2,287=26.11; P <.001). PTS symptoms also decreased significantly throughout care, with 96% (n=79) of participants showing symptom reductions.

Conclusions

This study provides preliminary evidence for the frequency of trauma exposure and comorbid psychiatric symptoms, as well as variations in treatment response between trauma-exposed and nontrauma-exposed youths, among participants in a pediatric collaborative care DMHI. Youths with traumatic experiences may show increased psychiatric comorbidities and slower treatment responses than their peers with no history of trauma. These findings deliver compelling evidence that collaborative care DMHIs may be well-suited to address mental health symptoms in children with a history of trauma while also highlighting the critical need to assess symptoms of PTS in children seeking treatment.