The impact of repeated mismatches in kidney transplantations performed after nonrenal solid organ transplantation

The aim of this study was to determine whether kidney transplantations performed after previous nonrenal solid organ transplants are associated with worse graft survival when there are repeated HLA mismatches (RMM) with the previous donor(s). We performed a retrospective cohort study using data from the Scientific Registry of Transplant Recipients. Our cohort comprised 6624 kidney transplantations performed between January 1, 1990 and January 1, 2015. All patients had previously received 1 or more nonrenal solid organ transplants. RMM were observed in 35.3% of kidney transplantations and 3012 grafts were lost over a median follow-up of 5.4 years. In multivariate Cox regression analyses, we found no association between overall graft survival and either RMM in class 1 (hazard ratio [HR]: 0.97, 95% confidence interval [CI] 0.89-1.07) or class 2 (HR: 0.95, 95% CI 0.85-1.06). Results were similar for the associations between RMM, death-censored graft survival, and patient survival. Our results suggest that the presence of RMM with previous donor(s) does not have an important impact on allograft survival in kidney transplant recipients who have previously received a nonrenal solid organ transplant.

Cardiac risk assessment before the use of stimulant medications in children and youth

Regulatory decisions and scientific statements regarding the management of attention-deficit hyperactivity disorder (ADHD) raise questions about the safety of medications and the appropriate pretreatment evaluation to determine suitability for treatment with medication. This is particularly true in the setting of known structural or functional heart disease. The present paper reviews the available data, including peer-reviewed literature, data from the United States Food and Drug Administration Web site on reported adverse reactions in children using stimulant medication, and Health Canada data on the same problem. A consensus-based guideline on appropriate assessment is provided, based on input from members of the Canadian Paediatric Society, the Canadian Cardiovascular Society and the Canadian Academy of Child and Adolescent Psychiatry, with specific expertise and knowledge in the areas of both ADHD and paediatric cardiology. The present statement advocates a thorough history and physical examination before starting stimulant medications, with an emphasis on the identification of risk factors for sudden death, but does not routinely recommend electrocardiographic screening or cardiac sub-specialist consultation unless indicated by history or physical examination findings. A checklist for identifying children who are potentially at risk of sudden death (independent of ADHD or medications used to treat it) is provided. Although recommendations are based on the best evidence currently available, the committee further agrees that more research on this subject is necessary to optimize the approach to this common clinical scenario.

Syncope in children and adolescents: Evaluation and treatment

Syncope in children is most often neurally mediated and usually has a natural history of spontaneous resolution or improvement. Syncope is defined as the temporary loss of consciousness resulting from a reversible disturbance of cerebral function. It is characterized by a loss of consciousness due to a lack of cerebral blood flow, rapid or sudden onset, falling of the patient, if not supported, and transiency of the attack. In children, it is most often benign, but may sometimes herald a more serious, potentially life-threatening cause. The main purpose of the present paper is to propose an evaluation scheme that will allow the physician involved in the care of children to differentiate the life-threatening causes of syncope with potential for injury or sudden death from the common, more benign neurally mediated syncope. Secondarily, the present article facilitates the identification of the patient with neurally mediated syncope who may benefit from medical therapy and distinguishes syncope from the more frequent noncardiac 'spells' of childhood.

Cardiac risk assessment before the use of stimulant medications in children and youth: A joint position statement by the Canadian Paediatric Society, the Canadian Cardiovascular Society, and the Canadian Academy of Child and Adolescent Psychiatry

Regulatory decisions and scientific statements regarding the management of attention-deficit hyperactivity disorder (ADHD) raise questions about the safety of medications and the appropriate pretreatment evaluation to determine suitability for treatment with medication. This is particularly true in the setting of known structural or functional heart disease. The present paper reviews the available data, including peer-reviewed literature, data from the United States Food and Drug Administration Web site on reported adverse reactions in children using stimulant medication, and Health Canada data on the same problem. A consensus-based guideline on appropriate assessment is provided, based on input from members of the Canadian Paediatric Society, the Canadian Cardiovascular Society and the Canadian Academy of Child and Adolescent Psychiatry, with specific expertise and knowledge in the areas of both ADHD and pediatric cardiology. The present statement advocates a thorough history and physical examination before starting stimulant medications, with an emphasis on the identification of risk factors for sudden death, but does not routinely recommend electrocardiographic screening or cardiac subspecialist consultation unless indicated by history or physical examination findings. A checklist for identifying children who are potentially at risk of sudden death (independent of ADHD or medications used to treat it) is provided. Although recommendations are based on the best evidence currently available, the committee further agrees that more research on this subject is necessary to optimize the approach to this common clinical scenario.

Natural history and surgical outcomes for isolated discrete subaortic stenosis in children

OBJECTIVE

To document the natural history and surgical outcomes for discrete subaortic stenosis in children.

DESIGN

Retrospective review.

SETTING

Tertiary care paediatric cardiology centres.

PATIENTS

92 children diagnosed between 1985 and 1998.

MAIN OUTCOME MEASURES

Echocardiographic left ventricular outflow gradient (echograd), and aortic insufficiency (AI).

RESULTS

The mean (SEM) age at diagnosis was 5.3 (0.4) years; the mean echograd was 30 (2) mm Hg, with AI in 22% (19/87) of patients. The echograd and incidence of AI increased to 35 (3) mm Hg and 53% (36/68) (p < 0.05) 3.6 (0.3) years later. The echograd at diagnosis predicted echograd progression and appearance of AI. 42 patients underwent surgery 2.2 (0.4) years after diagnosis. Preoperatively echograd and AI incidence increased to 58 (6) mm Hg and 76% (19/25) (p < 0.05). The echograd was 26 (4) mm Hg 3.7 (0.4) years postoperatively, with AI in 82% (31/38) of patients. Surgical morbidities included complete heart block, need for prosthetic valves, and iatrogenic ventricular septal defects. Eight patients underwent reoperation for recurrent subaortic stenosis. The age at diagnosis of 44 patients followed medically and 42 patients operated on did not differ (5.5 (0.6) v 5. 0 (0.6) years, p < 0.05). However, the echograd at diagnosis in the former was less (21 (2) v 40 (5) mm Hg, p < 0.05) and did not increase (23 (2) mm Hg) despite longer follow up (4.1 (0.4) v 2.2 (0. 4) years, p < 0.05). The incidence of AI at diagnosis and at last medical follow up was also less (14% (6/44) v 34% (13/38); 40% (17/43) v 76% (19/25), p < 0.05).

CONCLUSIONS

Many children with mild subaortic stenosis exhibit little progression of obstruction or AI and need not undergo immediate surgery. Others with more severe subaortic stenosis may progress precipitously and will benefit from early resection despite risks of surgical morbidity and recurrence.

Potential value of fetal echocardiography in the differential diagnosis of twin pregnancy with presence of polyhydramnios-oligohydramnios syndrome

OBJECTIVE

Our purpose was to establish whether index values of cardiac performance could discriminate between the twin-twin transfusion syndrome and placental insufficiency as the etiology of the polyhydramnios-oligohydramnios sequence in monochorionic diamniotic twins.

STUDY DESIGN

Thirteen monochorionic diamniotic twin pregnancies with ultrasonographic evidence of polyhydramnios-oligohydramnios sequence had a complete echocardiography. The etiology was confirmed postnatally: placental insufficiency in eight pairs and the twin-twin transfusion syndrome in five. Intertwin comparisons were made for the following cardiac parameters: cardiothoracic index, end-diastolic thickness of the ventricular walls and septum, aortic and pulmonary artery Doppler peak velocities, ejection and acceleration times, left ventricular shortening fraction, and combined cardiac output and output indexed to fetal weight.

RESULTS

All five recipient twins had thickened ventricular walls. The left ventricular shortening fractions and outputs were significantly increased in the donor twin with twin-twin transfusion syndrome and normal in placental insufficiency.

CONCLUSION

In twin-twin transfusion syndrome the donor twin shows evidence of a hyperdynamic cardiac state. Intertwin comparison of cardiac parameters, especially the left ventricular shortening fraction, can be considered a useful tool in diagnosing the different etiologies of the polyhydramnios-oligohydraminos sequence.

Release phenomena and iterative activities in psychiatric geriatric patients

This survey was undertaken to assess the frequency of some of the so-called release phenomena and iterative activities in an aged psychiatric population. Three groups of geriatric psychiatric patients with diagnoses of (I) organic brain syndrome, including senile dementia (56), (II) functional psychoses, predominantly schizophrenia (51) and (III) chronic schizophrenia never treated by neuroleptics or other biologic agents (16), were compared with (IV) a control group of 32 elderly people in good physical and mental health.In general, for the manifestations studied, the geriatric psychiatric patients suffering from an organic brain syndrome and treated with neuroleptics differed notably from the control group. This latter group, although older, had few neurological signs of senescence and the spontaneous oral movements usually associated with the use of neuroleptics were absent. Release phenomena such as the grasp and pouting reflexes, as well as the stereotyped activities, were encountered significantly more frequently in patients with an organic brain syndrome than in the two other groups of patients. Our survey has yielded limited results with regard to the possible influence of type of illness and neuroleptic treatment on the incidence of release phenomena and iterative activities.