Evaluation of effectiveness, hyperkalaemia, and hepatotoxicity of trimethoprim-sulphamethoxazole prophylaxis for Pneumocystis jirovecii pneumonia in paediatric patients: A single-centre retrospective study

BACKGROUND

American guidelines recommend trimethoprim-sulphamethoxazole (TMP-SMX) for preventing Pneumocystis jirovecii pneumonia (PJP) in paediatric patients at doses of 5-10 mg/kg/d of the TMP component, administered either daily, three times weekly, or twice weekly. However, limited studies describe the effectiveness and safety of these prophylactic regimens. Our study aimed to assess the clinical effectiveness and incidence of adverse events associated with each TMP-SMX regimen in paediatric patients, and to identify risk factors for adverse events.

METHODS

We collected data regarding the onset of PJP, hyperkalaemia, and hepatotoxicity in patients aged 0-18 years who underwent prophylaxis with TMP-SMX from July 2018 to June 2023.

RESULTS

A total of 215 paediatric patients met the inclusion criteria. No patients developed PJP. Hyperkalaemia occurred in 14.7%, patients receiving TMP-SMX daily, 15.4% receiving it three times weekly, and 15.5% receiving it twice weekly. Hepatotoxicity was most frequent in patients receiving TMP-SMX twice weekly (19%), followed by those receiving it three times weekly (7.7%), and daily (5.9%). Younger patients were significantly more prone to developing hyperkalaemia or hepatotoxicity. Patients aged <1 year had the highest incidences of hyperkalaemia (56.5%), and those aged 1-2 years had the highest incidence of hepatotoxicity (25%).

CONCLUSIONS

No patient developed PJP under various dosage prophylactic regimens of TMP-SMX. However, our findings suggest the need to monitor potassium levels and hepatic function in patients undergoing any of the three TMP-SMX regimens. In particular, patients aged <1 year old and 1-2 years old face a higher risk of hyperkalaemia and hepatotoxicity, respectively.

Emergence of ceftazidime-avibactam resistance in blaKPC-33-harbouring ST11 Klebsiella pneumoniae in paediatric patient

Carbapenem-resistant Klebsiella pneumoniae (CRKP) poses immense threats to the health of infected patients worldwide, especially children. This study reports the infection caused by CRKP in a paediatric intensive care unit (PICU) child and its drug-resistant mutation during the treatment. Twelve Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae strains were isolated from the child. Broth microdilution method, plasmid transformation assay, and whole genome sequencing (WGS) were performed to investigate the antimicrobial susceptibility, resistance mechanisms, and genetic structural features of CRKPs. The results showed that 12 strains were highly resistant to most available antimicrobial agents. Among them, K. pneumoniae FD11 and K. pneumoniae FD12 were resistant to ceftazidime-avibactam (CZA, MIC >64 mg/L) and restored the carbapenem susceptibility (Imipenem, MIC =0.25 mg/L; Meropenem, MIC =2 mg/L). The patient improved after treatment with CZA in combination with aztreonam. Plasmid transformation assay demonstrated that the blaKPC-33-positive transformant increased MICs of CZA by at least 33-fold and 8-fold compared with the recipient Escherichia coli DH5α and blaKPC-2-positive transformants. WGS analysis revealed that all strains belonged to the ST11-KL64 type and showed highly homologous (3-26 single nucleotide polymorphisms [SNPs]). A single base mutation (G532T) of blaKPC-2 resulted in a tyrosine to aspartic acid substitution at Ambler amino acid position 179 (D179Y), which conferred CZA resistance in K. pneumoniae. This is the first report of a drug-resistant mutation evolving into blaKPC-33 during the treatment of blaKPC-2-positive CRKP in paediatric-infected patients. It advises clinicians that routine sequential antimicrobial susceptibility testing and KPC genotyping are critical during CZA therapy in children infected with CRKP.

Analysis of factors conditioning inappropriate visits in a paediatric emergency department

Recent studies estimated that about 20-30% of visits in a paediatric emergency department (PED) are inappropriate. Nonurgent visits have been negatively associated with crowding and costs, causing longer waiting and dissatisfaction among both parents and health workers. We aimed to analyze possible factors conditioning inappropriate visits and misuse in a PED. We performed a cross-sectional study enrolling children accessing an Italian PED from June 2022 to September 2022 who received a nonurgent code. The appropriateness of visits, as measured by the "Mattoni SSN" Project, comprises combination of the assigned triage code, the adopted diagnostic resources, and outcomes. A validated questionnaire was also administered to parents/caregivers of included children to correlate their perceptions with the risk of inappropriate visit. Data were analyzed using independent-samples t-tests, Wilcoxon-Mann-Whitney tests, chi-square tests, and Fisher's exact tests. The factors that were found to be associated with inappropriate visits to the PED were further evaluated by univariable and multivariable logistic regression analyses. Almost half (44.8%) of nonurgent visits resulted inappropriate. Main reasons for parents/caregivers to take their children to PED were (1) the perceived need to receive immediate care (31.5%), (2) the chance to immediately perform exams (26.7%), and (3) the reported difficulty in contacting family paediatrician (26.3%). Inappropriateness was directly related to child's age, male gender, acute illness occurred in the previous month, and skin rash or abdominal pain as complaining symptoms.     Conclusion: This study highlights the urgent need to finalize initiatives to reduce misuse in accessing PED. Empowering parents' awareness and education in the management of the most frequent health problems in paediatric age may help to achieve this goal. What is Known: • About 20-30% of pediatric urgent visits are estimated as inappropriate. • Several factors may be associated with this improper use of the emergency department, such as the misperception of parents who tend to overrate their children's health conditions or dissatisfaction with primary care services. What is New: • This study evaluated almost half of pediatric emergency department visits as inappropriate adopting objective criteria. • Inappropriateness was directly related to the child's age, male gender, acute illness that occurred in the previous month, and skin rash or abdominal pain as complaining symptoms. Educational interventions for parents aimed at improving healthcare resource utilization should be prioritized.

coli from strictly defined community-acquired UTI in paediatric patients: a multicentric study

BACKGROUND

Urinary tract infection (UTI) in children is a common bacterial infection. The emergence of extended-spectrum beta-lactamases (ESBLs) poses a major challenge against the treatment of uropathogens. We aimed to characterize the E. coli isolates recovered from children with UTI for their resistance profile and circulating sequence types (ST).

METHODS

Children (> 1.5-18 years of age) from different community health centres of India with symptoms of UTI were enrolled. Isolates causing significant bacteriuria were identified by Matrix-Assisted Laser Desorption Ionization Time of Flight Mass Spectrometry (MALDI-TOF MS) and tested for antimicrobial susceptibility by the automated system, VITEK-2 (Biomeriux, Durhum, US). Nineteen E. coli isolates (15 ESBL positive and 4 ESBL negative) were sequenced in Oxford Nanopore platform followed by core-genome phylogeny, accessory genome cluster analysis, identification of sequence types, mobile genetic elements, genetic antimicrobial resistance markers. The correlation between detection of antimicrobial resistance genes with phenotypic resistance profiles was also investigated.

RESULTS

Eleven percent of children had significant bacteriuria [male:female-1:1, > 50% were 11-18 years of age group]. E. coli was predominant (86%) followed by K. pneumoniae (11%). Susceptibility of E. coli was highest against fosfomycin (100%) followed by carbapenems (90.7%) and nitrofurantoin (88.8%). ST131 (15.8%) and ST167 (10.5%) found as high-risk clones with the presence of plasmid [IncFIB (63.1%), IncFIA (52.6%)], and composite transposon [Tn2680 (46.6%)] in many isolates. Few isolates coharboured multiple beta-lactamases including blaNDM-5 (33.3%), blaOXA-1 (53.3%), blaCTX-M-15 (60%) and blaTEM-4 (60%).

CONCLUSIONS

This study highlights horizontal transmission of resistance genes and plasmids in paediatric patients at community centers across the nation harbouring multidrug-resistant genes such as blaNDM-5 and blaCTX-M-15 associated with high-risk clones ST131 and ST167. The data is alarming and emphasizes the need for rapid identification of resistance markers to reduce the spread in community. To our knowledge, this is the first multicentric study targeting paediatric UTI patients from the community setting of India.

Outcomes of allogeneic haematopoietic stem cell transplantation for paediatric patients with MLL-rearranged acute myeloid leukaemia

Background

The presence of mixed-lineage leukaemia rearrangement (MLL-r) in paediatric patients with acute myeloid leukaemia (AML) is a poor prognostic predictor. Whether allogeneic haematopoietic stem cell transplantation (allo-HSCT) is beneficial in such cases remains unclear.

Methods

We evaluated the outcomes and prognostic factors of allo-HSCT in 44 paediatric patients with MLL-r AML in the first complete remission (CR1) between 2014 and 2019 at our institution.

Results

For all the 44 patients, the 3-year overall survival (OS), event-free survival (EFS), and cumulative incidence of relapse (CIR) were 74.5%, 64.1%, and 29.1%, respectively. Among them, 37 (84.1%) patients received haploidentical (haplo)-HSCT, and the 3-year OS, EFS, and CIR were 73.0%, 65.6%, and 26.4%, respectively. The 100-day cumulative incidence of grade II–IV acute graft-versus-host disease (aGVHD) post-transplantation was 27.3%, and that of grade III–IV aGVHD was 15.9%. The overall 3-year cumulative incidence of chronic graft-versus-host disease (cGVHD) post-transplantation was 40.8%, and that of extensive cGVHD was 16.7%. Minimal residual disease (MRD)-positive (MRD +) status pre-HSCT was significantly associated with lower survival and higher risk of relapse. The 3-year OS, EFS, and CIR differed significantly between patients with MRD + pre-HSCT (n = 15; 48.5%, 34.3% and 59%) and those with MRD-pre-HSCT (n = 29; 89.7%, 81.4% and 11.7%). Pre-HSCT MRD + status was an independent risk factor in multivariate analysis.

Conclusions

Allo-HSCT (especially haplo-HSCT) can be a viable strategy in these patients, and pre-HSCT MRD status significantly affected the outcomes.

Predictors and outcome of time to presentation among critically ill paediatric patients at Emergency Department of Muhimbili National Hospital, Dar es Salaam, Tanzania

Background

Mortality among under-five children in Tanzania remains high. While early presentation for treatment increases likelihood of survival, delays to care are common and factors causing delay to presentation among critically ill children are unknown. In this study delay was defined as presentation to the emergency department of tertially hospital i.e. Muhimbili National Hospital, more than 48 h from the onset of the index illness.

Methodology

This was a prospective cohort study of critically ill children aged 28 days to 14 years attending emergency department at Muhimbili National Hospital in Tanzania from September 2019 to January 2020. We documented demographics, time to ED presentation, ED interventions and 30-day outcome. The primary outcome was the association of delay with mortality and secondary outcomes were predictors of delay among critically ill paediatric patients.

Logistic regression and relative risk were calculated to measure the strength of the predictor and the relationship between delay and mortality respectively.

Results

We enrolled 440 (59.1%) critically ill children, their median age was 12 [IQR = 9–60] months and 63.9% were males. The median time to Emergency Department arrival was 3 days [IQR = 1–5] and more than half (56.6%) of critically ill children presented to Emergency Department in > 48 h whereby being an infant, self-referral and belonging to poor family were independent predictors of delay. Infants and those referred from other facilities had 2.4(95% CI 1.4–4.0) and 1.8(95% CI 1.1–2.8) times increased odds of presenting late to the Emergency Department respectively. The overall 30-day in-hospital mortality was 26.5% in which those who presented late were 1.3 more likely to die than those who presented early (RR = 1.3, CI: 0.9–1.9). Majority died > 24 h of Emergency Department arrival (P-value = 0.021).

Conclusion

The risk of in-hospital mortality among children who presented to the ED later than 48 h after onset of illness was 1.3 times higher than for children who presented earlier than 48 h. It could be anywhere from 10% lower to 90% higher than the point estimate. However, the effect size was statistically not significant since the confidence interval included the null value Qualitative and time-motion studies are needed to evaluate the care pathway of critically ill pediatric patients to identify preventable delays in care.

Unicuspid aortic valve repair with bicuspidization in the paediatric population

OBJECTIVES

Aortic stenosis or regurgitation that requires operations in children often results from unicuspid valve morphology. In all paediatric patients with this anomaly, we have performed unicuspid valve repair by bicuspidization, creating a new commissure via adding patch material. This study reviewed our experience with this procedure.

METHODS

All patients with a unicuspid aortic valve who underwent bicuspidization at ≤18 years of age between 2003 and 2018 were evaluated. Autologous pericardium had initially been used for cusp augmentation. Since 2014, decellularized xenogeneic tissue or expanded polytetrafluoroethylene membrane has been applied.

RESULTS

There were 60 consecutive patients. The median operative age was 13 (1-18) years. Thirty patients had prior surgical or catheter valvuloplasties. Aortic regurgitation, aortic stenosis and their combination were present in 22, 11 and 27 patients, respectively. Autologous pericardium decellularized tissue and expanded polytetrafluoroethylene were used in 45, 11 and 4 patients, respectively, without intraoperative conversion to valve replacement. The overall survival was 96% at 10 years with 2 late deaths. Twenty patients underwent aortic valve reoperation due to patch degeneration (n = 11), suture dehiscence of the patch (n = 3), subaortic stenosis (n = 3) or other reasons (n = 3). Freedom from aortic valve reoperation was 73% and 50% at 5 and 10 years, respectively. Fifteen patients (25%) required valve replacement with pulmonary autograft (n = 14) or prosthesis (n = 1) 5.2 (0.2-13) years after bicuspidization at the age of 19 (10-32) years.

CONCLUSIONS

Bicuspidization is a safe and reproducible alternative to valve replacement with acceptable freedom from reoperation. It can serve as a bridge to valve replacement providing superior outcomes in adults.

Dental injuries in paediatric mandibular fracture patients

Purpose

Dental injuries (DIs) are associated with facial fractures, particularly mandibular fractures. As paediatric mandibular fractures have special features, we sought to clarify the occurrence and types of DIs among this patient group. We assessed how age, injury type, and fracture location affects the occurrence of DIs and thereby defined which patients are most susceptible.

Methods

This retrospective study included patients < 18 years with a recent mandibular fracture. Predictor variables were gender, age group, mechanism of injury, type of mandibular fracture, and other associated facial fracture(s). Types and locations of DIs and tooth loss due to injury were also reported.

Results

DIs were detected in 34.7% (n = 41) out of 118 patients. Patients with tooth injury had on average 3.5 injured teeth. A total of 16.2% of injured teeth were lost, typically at the time of the injury. Loss of at least one tooth was seen in approximately 10% of patients. Avulsion was the most common cause of tooth loss (52.2%). Non-complicated crown fracture (50.7%) was the most common DI type. Statistically significant associations between studied variables and DIs were not detected.

Conclusion

DIs are common and often multiple in paediatric mandibular fracture patients regardless of background factors. DIs often lead to tooth loss. Prompt replantation of an avulsed tooth, early detection of DIs, and prevention of tooth loss whenever possible are important to avoid permanent tooth defects.

Influence of the coronavirus 2 (SARS-Cov-2) pandemic on acute appendicitis

INTRODUCTION

Acute appendicitis (AA) is the most common abdominal surgical emergency. No specific studies have been found that evaluate the impact of the coronavirus 2 (SARS-Cov-2) pandemic on AA and its surgical management. An analysis was made on the influence of this new pathology on the clinical course of AA.

MATERIAL AND METHODS

Retrospective observational study was conducted on patients operated on for AA from January to April 2020. They were classified according to the time of the appendectomy, before the declaration of the state of alarm (Pre-COVID-19), and after its declaration (Post-COVID-19) in Spain, one the most affected countries in the world. An evaluation was made of demographic variables, duration of symptoms, type of appendicitis, surgical time, hospital stay, and postoperative complications.

RESULTS

The study included 66 patients (41 Pre-COVID-19; 25 Post-COVID-19) with mean age of 10.7 ± 3 and 9.3 ± 3.1; P = .073, respectively. Fever was found in a higher number of post-COVID-19 patients (52 vs 19.5%; P = .013), as well as a higher CRP (72.7 ± 96.2 vs 31.3 ± 36.2 mg/dL; P = .042). This group presented with a higher proportion of complicated appendicitis when compared to Pre-COVID-19 (32 vs 7.3%; P = .015). The mean hospital stay was longer in the Post-COVID-19 group (5.6 ± 5.9 vs 3.2 ± 4.3 days; P = .041). No differences were found in the time of onset of symptoms or surgical time.

CONCLUSIONS

The SARS-Cov-2 pandemic influenced the time of diagnosis of appendicitis, as well as its course, and mean hospital stay. Peritonitis was more frequently seen. As a result of the significant circumstances, delaying diagnosis and treatment of AA during SARS-Cov-2 pandemic, inappropriate management of this common surgical disorder has been noticed.

[Influence of the coronavirus 2 (SARS-Cov-2) pandemic on acute appendicitis]

INTRODUCTION

Acute appendicitis (AA) is the most common abdominal surgical emergency. No specific studies have been found that evaluate the impact of the coronavirus 2 (SARS-Cov-2) pandemic on AA and its surgical management. An analysis was made on the influence of this new pathology on the clinical course of AA.

MATERIAL AND METHODS

Retrospective observational study was conducted on patients operated on for AA from January to April 2020. They were classified according to the time of the appendectomy, before the declaration of the state of alarm (pre-COVID-19), and after its declaration (post-COVID-19) in Spain, one the most affected countries in the world. An evaluation was made of demographic variables, duration of symptoms, type of appendicitis, surgical time, hospital stay, and postoperative complications.

RESULTS

The study included 66 patients (41 pre-COVID-19; 25 post-COVID-19) with mean age of 10.7 ± 3 and 9.3 ± 3.1; P = .073, respectively. Fever was found in a higher number of post-COVID-19 patients (52 vs. 19.5%; P = 0.013), as well as a higher CRP (72.7 ± 96.2 vs. 31.3 ± 36.2 mg/dL; P = 0.042). This group presented with a higher proportion of complicated appendicitis when compared to pre-COVID-19 (32 vs. 7.3%; P = 0.015). The mean hospital stay was longer in the post-COVID-19 group (5.6 ± 5.9 vs. 3.2 ± 4.3 days; P = 0.041). No differences were found in the time of onset of symptoms or surgical time.

CONCLUSIONS

The SARS-Cov-2 pandemic influenced the time of diagnosis of appendicitis, as well as its course, and mean hospital stay. Peritonitis was more frequently seen. As a result of the significant circumstances, delaying diagnosis and treatment of AA during SARS-Cov-2 pandemic, inappropriate management of this common surgical disorder has been noticed.

Reexamining remodelling in children

OBJECTIVES

Some studies have suggested that root remodelling is unsuitable as valve-sparing aortic root replacement in children because of the increased risk of valve failure. This study reviewed our experience with root remodelling in children.

METHODS

All patients who underwent root remodelling at the age of ≤18 years between 1999 and 2016 were evaluated. In 2004, cusp effective height was measured intraoperatively and prolapse was corrected with central plication on the cusp. Suture annuloplasty was introduced after 2009 for annular dilatation.

RESULTS

There were 17 consecutive patients. The median age at operation was 14 (2.8-18) years. Aortic valve morphology was tricuspid in 10 patients, bicuspid in 5 patients, unicuspid in 1 patient and a pulmonary autograft in 1 patient. Marfan syndrome, Loeys-Dietz syndrome and other connective tissue diseases were present in 11, 1 and 2 patients, respectively. Five patients had more than moderate aortic regurgitation. The median graft size used for root remodelling was 24 (18-26) mm. Cusp repair and annuloplasty were performed in 15 and 14 patients, respectively. The mean follow-up time was 6.5 ± 4.3 years. One patient with preoperatively severely depressed ventricular function died in the hospital from persistent heart failure. One patient (operated on before 2004) required aortic valve reoperation due to cusp prolapse. One patient with a unicuspid valve had developed moderate aortic regurgitation, and the other 14 patients had mild or less regurgitation. The median diameter of the sinus of Valsalva at the last follow-up was 36 (30-43) mm, Z-score of 1.5 (-3.5 to 3.9).

CONCLUSIONS

Root remodelling can be performed in children with favourable results by appropriate cusp repair and annuloplasty.

Impact of a Camp upon Disease-Specific Knowledge and Quality of Life in Children and Adolescents with Inflammatory Bowel Disease

Children with inflammatory bowel disease (IBD) who attend residential camps derive various psycho-social benefits from their attendance. This study evaluated the impact of camp attendance on participants' disease-specific knowledge and quality of life (QOL). Prior to attending a dedicated camp for children with IBD, all campers were contacted and asked to participate in an evaluation of outcomes. Campers were asked to complete questionnaires regarding background disease status, demographic information, disease-specific knowledge (Inflammatory Bowel Disease Knowledge Inventory Device [IBD-KID]) and QOL (IMPACT-III). Assessments were completed before the camp and then again 1 month and 6 months after the camp. The camp consisted of adventure-based experiences and did not include specific IBD-related educational activities. Thirty-nine of 44 campers provided baseline information. The responders comprised 21 boys, and the median age was 14 years. Most (n = 35) were diagnosed with Crohn's disease. Twenty-five of the baseline responders were in clinical remission. Mean IBD-KID scores increased from baseline at both 1 month and 6 months (p = 0.03 and p = 0.04, respectively). Although mean QOL scores did not increase after 1 or 6 months, body image sub-scores were increased at 6 months (p = 0.015). Children and adolescents with IBD attending this residential camp demonstrated enhanced disease-specific knowledge following the camp, which was maintained 6 months following the camp. QOL scores were not increased overall at either time point. These results demonstrate a further benefit of residential camps for children and adolescents with IBD.

Safety and effectiveness of granulocyte and monocyte adsorptive apheresis in patients with inflammatory bowel disease in special situations: a multicentre cohort study

BACKGROUND

The available information on granulocyte and monocyte adsorptive apheresis (GMA) in patients with inflammatory bowel disease (IBD) under special situations remains unclear. We conducted a retrospective, multicentre cohort study to evaluate the safety and effectiveness of GMA in patients with IBD under special situations.

METHODS

This study included patients with ulcerative colitis (UC) or Crohn's disease who had at least one special situation feature and who had received GMA between November 2013 and March 2017. The incidence of adverse events (AEs) was compared in relation to the special situation, and patient background factors related to an AE were identified. For patients with UC, clinical remission was defined as a partial Mayo score of ≤2.

RESULTS

A total of 437 patients were included in this study. The incidence of AEs among the elderly patients (11.2%) was similar in all patients (11.4%), whereas the incidences of AEs in patients on multiple immunosuppressant medications (15.2%), patients with anaemia (18.1%) and paediatric/adolescent patients (18.9%) were higher than that in all patients (11.4%). In multivariate analysis, anaemia and concomitant immunosuppressant medications were independently associated with the incidence of AEs. Clinical remission was achieved in 46.4% of the patients with UC.

CONCLUSIONS

The incidence of AEs in the elderly patients was not higher than that in all patients, whereas the incidence of AE was higher in patients with anaemia and those on multiple immunosuppressant medications than that in all patients. GMA is a safe treatment option in elderly patients with IBD.

Paediatric Moyamoya Disease and Tourette's Syndrome: An Unusual Association Responding Favourably to Direct and Indirect Cerebral Revascularisation Surgery

BACKGROUND

Moyamoya disease, an uncommon chronic intra-cerebral arteriopathy asymmetrically affecting the proximal vasculature, is rarely associated with clinical features pertaining to movement disorders.

CASE DESCRIPTION

A 5-year-and-9-month-old boy developed repetitive episodic involuntary winking of the right eye along with ipsilateral shoulder shrugging movements in an absolutely conscious state, associated with paroxysmal shouts and loud laughs and punctuated with abusive verbal expressions (coprolalia). These episodic features, over the course of the next 1.5 years, got progressively accentuated by situations which evoked stress. In addition, there was progressive regression of verbal and cognitive milestones, emotional lability and aspects of attention deficit hyperkinetic disorder. The child was evaluated by a neurologist with magnetic resonance imaging of the brain, which showed characteristic ischaemic areas involving the basal ganglia and fronto-parietal cortical areas along the middle cerebral artery territory, predominantly on the left side. Subsequent cerebral angiography revealed extensive stenosis of bilateral (predominantly left-sided) internal cerebral arteries and middle cerebral arteries with evidence of diffuse leptomeningeal collaterals. The electroencephalography was reported to be normal. He was eventually diagnosed to be suffering from Moyamoya disease with associated Tourette's syndrome. Subsequently, the child underwent left-sided superficial temporal artery to middle cerebral artery anastomosis along with encephalo-duro-arterio-myo-synangiosis. Significant clinico-radiological improvement was noted after 3 months. The clinical deficiencies had dramatically resolved. There was evidence of excellent development of both direct and indirect surgical collaterals along the left middle cerebral artery territory. He could go back to school.

CONCLUSION

Ours is probably the first case reporting an association of paediatric Moyamoya disease with Tourette's syndrome, which significantly resolved after cerebral revascularisation surgery.

Assessing 3D paediatric foot morphology using low-dose biplanar radiography: Parameter reproducibility and preliminary values

BACKGROUND

The physical examination and weight-bearing radiography are the two main available methods for assessing the feet and lower limbs. The anatomy and function of these two structures interact with each other. These two assessment methods are affected by subjectivity and projection bias. Low-dose biplanar radiography (LDBR) is now a promising alternative for evaluating the lower limbs in children. At present, however, the foot cannot be assessed using LDBR. The objective of this study was to work towards developing a new method for 3D radiographic analysis of the paediatric foot during weight-bearing, first by determining the reproducibility of landmarks defined by LDBR then by reporting the values of the calculated radiographic parameters.

HYPOTHESIS

A new radiographic method based on LDBR can be used to obtain a 3D evaluation of the foot in paediatric patients.

PATIENTS AND METHODS

Two biplanar radiographs in perpendicular planes were obtained simultaneously in a standardised position using the EOS system (EOS^® Imaging, Paris, France) in each of 10 healthy children. To assess measurement uncertainty, two observers performed 3D reconstructions of each of the 10 feet three times (60 reconstructions). The standard error of reproducibility of the anatomic landmarks and clinical parameters was computed. Measurement uncertainty was then estimated based on the 95% confidence interval (95%CI). To obtain reference values, the mean±SD of each variable was computed after checking that the data were normally distributed.

RESULTS

Reproducibility was high for the anatomical landmarks of interest, calcaneal pitch angle, tibio-calcaneal angle on the lateral view, and first metatarsal pitch angle (95%CI<5%). The values of these angles in the study population are reported.

DISCUSSION AND CONCLUSION

The data reported here pave the way towards developing new parameters for describing 3D foot morphology and for simultaneously assessing the lower limb and foot in the standing position.

LEVEL OF EVIDENCE

I.

Eradication of early P. aeruginosa infection in children <7 years of age with cystic fibrosis: The early study

OBJECTIVE

Antibiotic eradication treatment is the standard-of-care for cystic fibrosis (CF) patients with early Pseudomonas aeruginosa (Pa)-infection; however, evidence from placebo-controlled trials is limited.

METHODS

This double-blind, placebo-controlled trial randomised CF patients <7 years (N = 51) with early Pa-infection to tobramycin inhalation solution (TOBI 300 mg) or placebo (twice daily) for 28 days with an optional cross-over on Day 35. Primary endpoint was proportion of patients having throat swabs/sputum free of Pa on Day 29.

RESULTS

On Day 29, 84.6% patients in the TOBI versus 24.0% in the placebo group were Pa-free (p < 0.001). At the end of the cross-over period, 76.0% patients receiving TOBI in the initial 28 days were Pa-free compared to 47.8% receiving placebo initially. Adverse events were consistent with the TOBI safety profile with no differences between TOBI and placebo.

CONCLUSION

TOBI was effective in eradicating early Pa-infection with a favourable safety profile in young CF patients.

TRIAL REGISTRATION NUMBER

NCT01082367.

A Paediatric Acute Promyelocytic Leukaemia Patient Harbouring a Cryptic PML-RARA Insertion due to a Complex Structural Chromosome 17 Rearrangement

Acute promyelocytic leukaemia with PML-RARA fusion is usually associated with the t(15;17)(q24.1;q21.1) translocation but may also arise from complex or cryptic rearrangements. The fusion usually resides on chromosome 15 but occasionally on others. We describe a cryptic PML-RARA fusion within a novel chromosome 17 rearrangement. We performed interphase fluorescence in situ hybridisation (FISH) using a dual-fusion PML-RARA probe, followed by reverse transcriptase-polymerase chain reaction (RT-PCR) for PML-RARA, karyotyping, and metaphase FISH using RARA break-apart, locus-specific, and subtelomere probes for chromosome 17. An 850K SNP microarray was also employed. Interphase and metaphase FISH showed atypical results involving a single PML-RARA fusion, no second fusion, but instead separate diminished PML and RARA signals. RT-PCR confirmed PML-RARA fusion; however, karyotyping detected only an altered chromosome 17. Metaphase FISH showed the single fusion and diminished 5' RARA signals located unexpectedly in the subtelomeric short-arm and long-arm regions of the rearranged chromosome 17, respectively. SNP microarray revealed no copy number abnormality. This paediatric patient with PML-RARA fusion reflects a cryptic insertion that resides within a complex and novel chromosome 17 rearrangement. This rearrangement likely arose via 7 chromosome breaks with the insertion occurring first followed by sequential paracentric and then pericentric inversions.

Delayed Presentation of Isolated Jejunal Perforation Following Accidental Trauma

Blunt abdominal trauma can injure any abdominal organs which had significant morbidity and mortality in paediatric age group. It can lead to duodenal, jejunal or rather any bowel perforation. Isolated jejunal perforation still remains rare entity with less documented reports in specifically paediatric age group. We hereby present a case of three-year-old female child with isolated jejunal perforation, post history of fall from height. Early exploration and prompt surgical intervention led to successful outcome in this patient.

Arthroscopic excision of acetabular osteoid osteoma in a 7-year-old patient

The purpose of this study was to present the case report of a 7-year-old patient who was treated with hip arthroscopy for an acetabular osteoid osteoma. A 7-year-old patient was referred to our clinic with hip pain. In the assessment of the patient, an acetabular osteoid osteoma was detected in his right hip; it was adjacent to his triradiate cartilage. An arthroscopic surgery was planned as an alternative to open safe hip dislocation. The osteoid osteoma was completely removed with hip arthroscopy. Postoperative CT scanning and histopathological analysis confirmed the diagnosis. Exposure of the acetabulum can be problematic in paediatric patients due to the potential risks of open safe dislocation. Hip arthroscopy can safely be used for benign hip lesions in paediatric patients. Level of evidence Case report, Level V.

Patellar instability in children and adolescents

Paediatric patellar instability encompasses many anatomic entities located along a continuum of knee extensor mechanism abnormalities. Major or minor clinical manifestations may occur at a variable age. In major forms with irreducible patellar dislocation or habitual patellar dislocation during knee flexion, shortness of the quadriceps is a consistent feature. A comprehensive aetiological work-up is in order, as syndromic conditions are common. Early surgical treatment is mandatory and should be performed by an experienced paediatric orthopaedic surgeon, as the procedure is technically challenging. Minor forms are more common; they are characterised by patellar dislocation or subluxation near terminal knee extension. The diagnosis may be difficult, particularly at the acute phase. Surgery is needed in patients with recurrent dislocation or functional impairments. The semiology of patellar instability has undergone considerable development in recent years, and a three-dimensional evaluation of patellar position can now be obtained using magnetic resonance imaging. Individually tailored surgical treatment "à la carte" remains a valid approach in 2013. However, new techniques for medial patello-femoral ligament reconstruction have modified the management strategies for adults and superseded many stabilisation procedures. Adapting these new techniques to paediatric patients and developing new procedures constitute major challenges.

Proximal humerus fractures in children and adolescents

Proximal humerus fractures are rare in paediatric traumatology. Metaphyseal fractures account for about 70% of cases and epiphyseal separation for the remaining 30%. The development and anatomy of the proximal humerus explain the various fracture types, displacements, and potential complications; and also help in interpreting the radiographic findings, most notably in young children. Physicians should be alert to the possibility of an underlying lesion or pathological fracture requiring appropriate diagnostic investigations, and they should consider child abuse in very young paediatric patients. Although the management of proximal humerus fractures remains controversial, the extraordinary remodelling potential of the proximal humerus in skeletally immature patients often allows non-operative treatment without prior reduction. When the displacement exceeds the remodelling potential suggested by the extent of impaction, angulation, and patient age, retrograde elastic stable intramedullary nailing (ESIN) provides effective stabilisation. As a result, the thoraco-brachial abduction cast is less often used, although this method remains a valid option. Retrograde ESIN must be performed by a surgeon who is thoroughly conversant with the fundamental underlying principles. Direct percutaneous pinning is a fall-back option when the surgeon's experience with ESIN is insufficient. Finally, open reduction is very rarely required and should be reserved for severely displaced fractures after failure of closed reduction. When these indications are followed, long-term outcomes are usually excellent, with prompt resumption of previous activities and a low rate of residual abnormalities.

Management strategies and medication use for treating paediatric patients with concussions

AIM

To assess management strategies for paediatric patients suffering from concussions.

METHODS

A 17-item questionnaire was distributed to 1305 section members of the American Academy of Pediatrics Sections on Adolescent Health, Sports Medicine and Fitness, Community Pediatrics and School Health. The use of medications, neuropsychological testing, neuroimaging and published guidelines in concussion management was queried.

RESULTS

Two hundred and twenty respondents (17%) completed the questionnaire, of which 64% had been an attending for greater than 10 years. A majority of respondents (92%) managed patients with concussions, with 26% treating more than 24 patients per year. Most paediatricians (84%) reported using a published guideline. The majority of respondents (89%) manage the symptoms of concussed patients with medications, most commonly acetaminophen (62%) or nonsteroidal anti-inflammatory medications (54%). The use of prescriptions medications such as tricyclic antidepressants (23%), amantadine (10%) and methylphenidate (8%) was also commonly reported. Paediatricians treating >16 patients per year with concussion were more likely to prescribe tricyclic antidepressants, stimulants and agents used for sleep disturbance.

CONCLUSION

Paediatricians nationwide routinely use medications when managing patients with concussions. The pharmacological agents used differ according to number of patients treated per year. In addition, most paediatricians use published guidelines in concussion management.