FC038: Efficacy of Levamisole for Maintaining Remission after the First Flare of Steroid Sensitive Nephrotic Syndrome in Children: The Nephrovir-3 Randomized Controlled Trial

BACKGROUND AND AIMS

In children with Steroid Sensitive Nephrotic Syndrome (SSNS), relapse after the first flare occurs in 80% of cases, whatever the dosage or duration of initial steroid therapy. Therefore, there is an unmet need for early interventions to reduce the incidence of relapse and subsequent steroids and immunosuppressive drug exposure. Levamisole is an antihelmintic drug with an immunomodulatory action that reduces relapses in children with frequent relapses or steroid-dependant NS. NEPHROVIR-3 is the first trial to assess the efficacy of levamisole in increasing duration of initial remission after the diagnosis of INS.

METHOD

NEPHROVIR-3 is a multicentric placebo-controlled randomized trial (1:1), in 38 centres of the Paris area, France. Patients were included at INS diagnosis and randomized, when steroid sensitive within 4 weeks, to receive either levamisole 2.5 mg/kg/48 h or placebo for 6 months, in addition to the French steroid protocol (18 weeks-3990 mg/m2). Primary outcome was the relapse-free survival at 1 year. The effect of the study drug was analysed by a Cox proportional hazard model stratified on centre.

RESULTS

Between September 2017 and February 2020, 86 patients were included, median age at INS onset was 5 years (IQ 3–7), with 69% of boys. At 4 weeks, 68 of them were randomized. Median time to remission was 8.5 days (IQ 6–12). Relapse-free survival at 12 months was 53.8% [95 confidence interval (95% CI) 34.7–69.5] in the levamisole group versus 20.9% (7.2–39.4) in the placebo group (P = .007). The risk of relapse associated with levamisole was HR = 0.37 (95% CI 0.15–0.89).

CONCLUSION

Early treatment with levamisole at the first flare of childhood SSNS significantly improves relapse-free survival at 1 year.

MO511: Epidemiology of Idiopathic Nephrotic Syndrome in Children Before and During Covid-19 Pandemic in Paris Area

BACKGROUND AND AIMS

The aetiology of idiopathic nephrotic syndrome (INS) remains partially unknown. Viral infections have been reported to be associated with INS onset and relapse. The COVID-19 pandemic led to several national lockdowns aimed at limiting virus transmission. In France, schools were closed during the first lockdown (15 March–11 May 2020). Circulation of other respiratory viruses was lower due to restrictive lockdown measures. We hypothesized that these lockdown measures would be associated with a decrease in the incidence of idiopathic nephrotic syndrome in children. The aim of this study was to describe the incidence of INS over the last 4 years and during the lockdown measures and to compare this incidence with the 2007–10 period (NEPHROVIR-1 cohort).

METHOD

A written questionnaire was sent to corresponding the paediatricians of all 37 hospitals in the Paris area. Children aged 1–15 years with INS onset between January 2017 and December 2020 and living in the Paris area were included. Clinical data were collected from medical charts. To estimate incidence, population-based denominators were obtained from the National Institute for Statistics and Economic Studies (INSEE). For analyses, we separated the study period into two periods: during lockdown measures (2 months) and the rest of the time (46 months).

RESULTS

A total of 95% of centres responded to the questionnaire. On the whole, 248 cases of INS were reported, 94% of whom were steroid sensitive. The median age at diagnosis was 5.6 years. Male/female ratio was 2.1: 1. Annual incidences of INS were 2.66, 2.49, 2.91 and 2.40/100 000 children under age 15 years in 2017, 2018, 2019 and 2020, respectively, with no significant difference between years. There was also no difference between annual incidence of the 2017–20 period and the NEPHROVIR-1 cohort period (2007–10) (P = .6). The incidence of INS during the lockdown measures was 0.51 versus 2.71 for the rest of the study period (P = .03). During week 15 (6–12 April 2020), with the highest number of hospital admissions for COVID-19, no case were reported.

CONCLUSION

Over the last decade, the incidence of childhood INS was stable in the Paris area. In 2020, no peak of incidence occurred concomitantly with the COVID pandemic. In addition, during lockdown measures, the incidence of INS was significantly lower. Interestingly, incidence of other respiratory viral infections was reported decreased during lockdown measures. Together, these results argue again for a link between INS onset and viral infections, while COVID-19 does not appear to be a significative trigger for nephrotic syndrome onset in children.

Varicella post-exposure management for pediatric oncology patients

INTRODUCTION

The objective was to evaluate health care providers' (HCP) adherence to and efficacy of varicella post-exposure prophylaxis (PEP) recommendations. It was an observational, prospective, multicenter study set in Ile-de-France, France.

METHODS

All children under 18 with a cancer diagnosis, currently or within 3months of receiving cancer treatment, regardless of varicella zoster virus (VZV) serostatus or previous personal history of varicella, were eligible. Study participants with significant exposure were reviewed prospectively for PEP indications. Main outcome measures were the percentage of exposure situations for which HCP were guideline-compliant, the proportion of available VZV serostatuses and the incidence of breakthrough varicella after different PEP approaches.

RESULTS

A total of 51 patients from 15 centers were enrolled after 52 exposure episodes. Median age at exposure was 5 years (range, 1-15). Exposure within the household led to 38% of episodes. Prophylactic treatment consisted in specific anti-VZV immunoglobulins (V-ZIG) (n=19) or in oral aciclovir (n=15). No prophylactic treatment was given for 18 patients (in compliance, n=16). In compliance with guidelines, 17 patients received V-ZIG, 11 did not develop varicella (65%, [95% CI, 39-90%]); 15 received aciclovir, 13 did not develop varicella (87%, [95% CI, 67-100%]). Breakthrough varicella occurred in 11 patients, with simple clinical course in all cases; in 8/47 (17%) episodes when PEP was guideline-compliant versus 3/5 (60%) when not.

DISCUSSION

Recommendations have been respected and are efficient. PEP needs to be standardized and a study carried out to define the optimal approach. Anti-VZV immunization of seronegative family members should be encouraged.

Dosage form suitability in vulnerable populations: A focus on paracetamol acceptability from infants to centenarians

INTRODUCTION

Medicine acceptability is a multi-faceted concept driven by both product and user characteristics. Although a key factor for treatment effectiveness, especially in vulnerable populations, knowledge of those medicine features that best promote individual user acceptability remains fragmented. Focusing on paracetamol, this study has explored the appropriateness of pharmaceutical products in different dosage forms to achieve adequate patient acceptability from infants to centenarians.

METHODS

This observational, multicentre, prospective study was carried out in 10 hospitals, 8 nursing homes and over 150 community dispensaries. Observers reported several behaviours/events evaluating acceptability for 1016 different pharmaceutical product uses in paediatrics (<18y.) and 1288 in the elderly (≥65y.). Using mapping and clustering, a multivariate approach offered an intelligible reference framework for each population, providing comprehensive scores: positively or negatively accepted.

RESULTS

Among all the evaluations supporting the acceptability reference frameworks, there were 502 reports on paracetamol products intake. Herein we focused on the 5 products with ≥30 evaluations. Although oral suspension and powder for oral solution were positively-accepted in the paediatric group, the powder had a higher rate of negative patient reaction (p<0.001). Of those that received this formulation, 72% were ≤8y., and therefore suitable to receive the better accepted oral suspension. In the elderly, patients with swallowing disorders were preferentially treated with such powders (p<0.001), which were less often fully taken than orally disintegrating tablets (p<0.001). Even in those patients ≥90y., capsule formulations appeared to be the best accepted product in patients without swallowing alterations, and thus could be a suitable alternative to the powder in this population.

CONCLUSIONS

By better integrating patient characteristics when choosing dosage forms, clinicians and caregivers may improve treatment acceptability and adherence. Moreover, hospitals and healthcare institutions could optimise purchasing to best suit their local population, disseminating information to help staff align specific dosage forms to targeted patients.

Eosinopenia as a marker of diagnosis and prognostic to distinguish bacterial from aseptic meningitis in pediatrics

Procalcitonin (PCT) has proven its efficacy to distinguish bacterial from aseptic meningitis in children. Nevertheless, its use in routine is limited by its cost and availability, especially in low- and middle-income countries. It is now acknowledged that eosinopenia is a marker of infection and/or severity of the systemic inflammatory response. Although no study ever demonstrated that eosinopenia could differentiate bacterial from viral infection, we decided to conduct a study concerning meningitis in children. This bicentric and retrospective study was conducted between January 2012 and October 2018, in children hospitalized for meningitis. The white blood cell was systematically gathered at the admission to evaluate the eosinophil count. Characteristic data were compared between 2 groups: documented bacterial meningitis (DBP) and aseptic meningitis which includes documented viral meningitis (DVM) and non-documented meningitis (ND). Among 190 patients admitted for meningitis, 151 were analyzed, including DBM (n = 45), DVM (n = 73), and ND (n = 33) meningitis. Groups were comparable. Mean age was 33 ± 48 months with a sex ratio of 1.6. Mean of eosinophil count was 15 ± 34/mm³ in the DBM group versus 132 ± 167/mm³ for the aseptic meningitis group (p < 0.0001). Best threshold for the diagnosis of bacterial meningitis was an eosinophil count < 5/mm³ with a sensitivity of 80% and specificity of 73% and a likelihood ratio of 2.9. Eosinopenia seems to be a reliable and non-invasive marker of bacterial meningitis in pediatrics. The absence of extra cost makes it very interesting in low- and middle-income countries or when usual biomarkers such as PCT are unavailable.

Cartoons to improve young children's cooperation with inhaled corticosteroids: A preliminary study

INTRODUCTION

The objective of this pilot study was to evaluate if animated cartoons could increase the cooperation of young children with asthma during the delivery of their inhaled corticosteroids (ICS).

METHODS

Subjects were children aged 6-47 months having a physician diagnosis of asthma, who required an ICS therapy delivered through a pMDI/spacer twice a day for at least 2 months. Families who reported on a questionnaire that their child was frequently crying or moving during treatment delivery were asked to participate in a prospective, cross-over, randomized study. After a first week of run-in, children watched alternatively, during the delivery of ICS, either an animated cartoon for 7 days and a black screen video for another 7 days. The main outcome was the median percentage of time of non-cooperation, defined by the length of time the child was crying and/or moving divided by the length of time required for delivering ICS.

RESULTS

Parents of 50 children out of 113 (44%) reported that their child was frequently crying or moving during treatment delivery. Among these 50 children, 11 (22%) completed the study. The median percentages of time of non-cooperation (IQR 1-3) were 0% (0-3) and 56% (40-97) during the distraction and control periods, respectively, in the first group, and 100% (98-100) and 0% (0-5) during the control and distraction periods, respectively, in the second group. Animated cartoons increased cooperation up to 97% (55-100%) (P = 0.008).

CONCLUSIONS

Bad cooperation among young children with asthma during the delivery of their treatment can be dramatically improved by the use of animated cartoons.

[Teledermatology between two French hospitals: Two years of experience]

BACKGROUND

Teledermatology is currently booming. Due to the shortage of dermatologists in hospitals access to dermatological consultations is very limited in some hospitals. We present our experience of collaboration between an expert center, the dermatology department of the Victor-Dupouy Hospital Centre in Argenteuil, and all medical structures under the André-Mignot Hospital in Versailles (CHV), including 2 prison medical centers (UCSA), traditional departments and emergency department.

PATIENTS AND METHODS

Teledermatology, developed in the form of tele-expertise, began at the UCSA in November 2013. This expertise was then extended in June 2014 to the Internal Medicine department of CHV, and in December 2014 to all departments, including the emergency department. The rules and ethics of teledermatology were strictly adhered to. While UCSA could file all expertise dossiers, only urgent or difficult cases could be filed by other CHV departments.

RESULTS

In 26 months, 347 expertise requests were filed: 231 by prisons and 116 by the other departments of the CHV. No patients refused teledermatology. The quality of information and photographs was considered good or excellent in over 95% of cases. A response was given within 3hours in more than 50% of cases and in all cases within 24hours (on working days). Analysis of diseases diagnosed illustrates the wide variety of conditions encountered in dermatology, with different structures having their own specific features.

CONCLUSION

Our example illustrates the possibility of developing such an inter-hospital platform. However, it does not yet cater for requests made by patients to dermatologists, by dermatologists to dermatologists, or by dermatologists to the hospital teledermatology department. Acceptability was considered excellent by patients (with no refusals), physicians at the CHV, and the expert center.

[Urinary tract infection in children]

Urinary tract infection in children. The care of a child suspected of urinary infection (UI) goes through 4 stages. The diagnosis of UI is based on the presence of bacteriuria > 105 / mL, the collection of urine through a bas is unreliable and source of false positives. Localization diagnosis (acute pyelonephritis or cystitis) is based on clinical and biological signs (leukocytosis and inflammation). Etiological diagnosis is based on renal ultrasonography looking for obstructive uropathy, stones and bladder dysfunction; the search for a vesico-ureteral reflux with retrograd cystography is not systematic at first infection. The treatment of acute pyelonephritis is initiated usually intravenously for a period of 3 or 4 days. Oral antibiotics is then possible.

[The emergency department: an appropriate place for identifying troubled teens]

OBJECTIVES

The main objective of this study was to estimate the prevalence of psychological distress among adolescents seen in emergency departments, and the secondary objective was to highlight their main reasons for consulting.

METHODS

Cross-sectional study in three multicenter emergency departments receiving adolescents in Île-de-France conducted in 2010. All adolescents completed a questionnaire including the ADRS (Adolescent Depression Rating Scale, a screening questionnaire for depression) and a series of questions relating to somatization and risk behaviors.

RESULTS

The study included 346 adolescents, 320 of which were fully analyzed. The ADRS score was considered normal (score < 3) for 70.6% of the sample (n = 226), 19.4% of adolescents (n = 62) had moderate depressive symptoms (3 ≤ score < 6), and 10.0% severe depressive symptoms (score ≥ 6) (n = 32). The majority of patients consulted for trauma and less than 10% for acute psychiatric problems; 17% of adolescents who came to the emergency department for a nonpsychiatric reason had an ADRS ≥ 3, i.e., with mental distress.

CONCLUSION

The routine use of a self-administered questionnaire in the emergency services could identify adolescents with moderate to severe depressive symptoms.

Long-term outcome of children treated with rituximab for idiopathic nephrotic syndrome

BACKGROUND

Rituximab (RTX) has recently showed promising results in the treatment of steroid-dependent idiopathic nephrotic syndrome (SDNS).

METHODS

This was a retrospective multicenter study of 18 children treated with RTX for SDNS, with a mean follow-up of 3.2 years. RTX was introduced because of side effects or relapses during therapy with immunosuppressive agents. The children received one to four infusions of RTX during the first course of treatment, and subsequent infusions were given due to CD19-cell recovery (CD19 >1 %; 54 % of children) or relapse (41 %), as well as systematically (5 %).

RESULTS

Treatment with RTX maintained sustained remission without relapse in 22 % of patients and increased the duration of remission in all other patients. The time between two successive relapses was 9 months in the absence of re-treatment and 24.5 months when infusions were performed at the time of CD19-cell recovery. At the last follow-up, 44.5 % of patients were free of oral drug therapy. Of those still receiving oral drugs, all doses had been decreased. No serious adverse events occurred.

CONCLUSION

The results of this retrospective study confirm the efficacy and very good safety of RTX in the treatment of SDNS. The optimal therapeutic protocol seems to be a repeated single infusion at the time of CD19-cell recovery.

Acute neurological involvement in diarrhea-associated hemolytic uremic syndrome

BACKGROUND AND OBJECTIVES

Neurologic involvement is the most threatening complication of diarrhea-associated hemolytic uremic syndrome (D+HUS).

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We report a retrospective multicenter series of 52 patients with severe initial neurologic involvement that occurred in the course of D+HUS.

RESULTS

Verotoxigenic Escherichia coli infection was documented in 24. All except two patients had acute renal failure that required peritoneal dialysis, hemodialysis, or both techniques. A first group of eight patients remained with normal consciousness; five of them had protracted seizures. A second group of 23 patients had stuporous coma; five of these had protracted severe seizures, and 18 had a neurologic defect including pyramidal syndrome, hemiplegia or hemiparesia, and extrapyramidal syndrome. A third group of 21 patients had severe coma. Plasma exchanges were undertaken in 25 patients, 11 of whom were treated within 24 hours after the first neurologic sign; four died, two survived with severe sequelae, and five were alive without neurologic defect. Magnetic resonance imaging (MRI) for 29 patients showed that (1) every structure of the central nervous system was susceptible to involvement; (2) no correlation seemed to exist between special profile of localization on early MRI and the final prognosis; and (3) MRI did not exhibit any focal lesions in three patients. The overall prognosis of the series was marked by the death of nine patients and severe sequelae in 13.

CONCLUSIONS

Neurologic involvement is associated with a severe renal disease but does not lead systematically to death or severe disability.

Acute neurological involvement in diarrhea-associated hemolytic uremic syndrome

BACKGROUND AND OBJECTIVES

Neurologic involvement is the most threatening complication of diarrhea-associated hemolytic uremic syndrome (D+HUS).

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We report a retrospective multicenter series of 52 patients with severe initial neurologic involvement that occurred in the course of D+HUS.

RESULTS

Verotoxigenic Escherichia coli infection was documented in 24. All except two patients had acute renal failure that required peritoneal dialysis, hemodialysis, or both techniques. A first group of eight patients remained with normal consciousness; five of them had protracted seizures. A second group of 23 patients had stuporous coma; five of these had protracted severe seizures, and 18 had a neurologic defect including pyramidal syndrome, hemiplegia or hemiparesia, and extrapyramidal syndrome. A third group of 21 patients had severe coma. Plasma exchanges were undertaken in 25 patients, 11 of whom were treated within 24 hours after the first neurologic sign; four died, two survived with severe sequelae, and five were alive without neurologic defect. Magnetic resonance imaging (MRI) for 29 patients showed that (1) every structure of the central nervous system was susceptible to involvement; (2) no correlation seemed to exist between special profile of localization on early MRI and the final prognosis; and (3) MRI did not exhibit any focal lesions in three patients. The overall prognosis of the series was marked by the death of nine patients and severe sequelae in 13.

CONCLUSIONS

Neurologic involvement is associated with a severe renal disease but does not lead systematically to death or severe disability.

Savoir penser à un syndrome hémolytique et urémique (SHU)

Hemolytic uremic syndrome is a disease of nonimmune hemolytic anemia, low platelet count and renal impairment. In children below three years old, the disease is most commonly triggered by contaminated food and is the first cause of acute renal failure. Shiga-like toxin Escherichia coli (STEC) are responsible for the disease. Modalities of contamination, clinical course of bloody diarrhea and chronology of biological defects are described in this paper.

Secondary failure of plasma therapy in factor H deficiency

We report a patient with homozygous factor H deficiency leading to permanent alternate complement activation and early onset of the hemolytic uremic syndrome. He was successfully treated with weekly infusions of fresh frozen plasma over 4 years, displaying normal blood pressure while only treated with an angiotensin converting enzyme (ACE) inhibitor, a steady level of haptoglobin, low-range proteinuria and normal creatinine clearance. By the end of the fourth year of treatment, he dramatically developed a relapse of hemolytic and uremic syndrome, displaying undetectable haptoglobin, nephrotic range proteinuria and progressive renal failure. Despite a ten-fold increase in the dosage of plasma infusion through daily plasma exchange, haptoglobin remained undetectable while circulating antigenic factor H levels reached 22-24% (normal values 65-140%). Three months following the biological onset of the relapse, a bilateral nephrectomy was performed owing to uncontrolled hypertension and rapidly progressive renal failure. The molecular mechanism of plasma resistance remained unclear while antifactor H antibodies were not detected in the plasma. We suggest that protracted administration of exogenous factor H might not be a long-term strategy in homozygous factor H deficiency.

Prognosis of lupus membranous nephropathy in children

The occurrence of membranous nephropathy in pediatric series of systemic lupus erythematosus has been reported only rarely, probably due to a very low frequency. One hundred fifty-four children who were seen in 100 French pediatric centers between January 2002 and April 2005 were included. Fifteen (12 girls and three boys) out of the 81 (18.5 %) children with renal involvement presented histological features of membranous nephropathy. Their ages ranged from six to 15 years old (mean=11.3) at the age of SLE diagnosis and 8/15 children were of African origin. Isolated membranous nephropathy was observed in nine patients, of whom five patients displayed a complete recovery following immunosuppressive treatment. Associated proliferative lesions were observed on the first kidney specimen in two patients and in a further renal biopsy in four other patients, leading to a less favorable course of lupus nephropathy.

Recurrence of nephrotic syndrome after renal transplantation: influence of increased immunosuppression

Recurrence of nephrotic syndrome after renal transplantation leads to graft loss within 1 year in 50-80% of patients who do not receive any specific treatment. Several treatment protocols have been proposed leading to long-term remission in 50-80% of patients. The aim of our study was to evaluate the efficiency of intensified immunosuppression, simultaneously including methylprednisolone pulses, cyclophosphamide, high-dose cyclosporine and plasma exchanges. Fourteen patients with early recurrence were treated with a protracted high-dose prednisone or IV methylprednisolone, oral cyclophosphamide, high-dose oral or IV cyclosporine, and plasma exchanges. By the end of cyclophosphamide therapy and plasma-exchange program, six out of 14 patients had no proteinuria; five had residual proteinuria without nephrotic syndrome and three experienced ongoing gross proteinuria with nephrotic syndrome. By the end of follow-up, four out of the 14 patients had lost their graft: one out of six with complete remission, one out of five with residual proteinuria and two out of three with persistent nephrotic syndrome. We conclude that multiple reinforcement of immunosuppression in patients with recurrent nephrotic syndrome following renal transplantation as performed in our patients is not more efficient than the single use of cyclophosphamide or plasma exchange or high-dose cyclosporine as reported in the literature.

[Urolithiasis in cystic fibrosis]

The prevalence of urolithiasis is higher in patients with cystic fibrosis than in the normal population. We report on a case of a 12-year-old child with cystic fibrosis who presented flank pain which revealed a calcium oxalate urolithiasis. Evolution was satisfactory with pharmacological and dietary treatment. The principal mechanisms of lithogenesis in patients with cystic fibrosis are described and preventive treatment is discussed.

[Pediatric imported malaria. Experience of the hospital center of Versailles (1997-2001)]

Few data are available about pediatric imported malaria, whereas the number of cases seems in constant increase.

PATIENTS AND METHODS

all pediatric malaria cases diagnosed by a positive thin or thick blood film at the Versailles Hospital, from January 1997 to December 2001, were studied retrospectively.

RESULTS

sixty cases of pediatric imported malaria were studied. They were 58 cases of uncomplicated malaria and 2 cases of severe malaria; 85% of the children had travelled to sub-Saharan Africa and 15% to Oceania; 90% of the children were of African origin. Plasmodium falciparum was found alone in 84% of the cases. The anti-malarial chemoprophylaxis was inappropriate in 92% of the cases. No child had profited from preventive measures against mosquitos. Fever > 37,5 degrees C was observed in 100% of the cases. The other clinical signs were present in less than 50% of the cases. The median of haemoglobin and platelet was 10.5 g/dL and 141,000/mm(3), respectively. After treatment, the evolution was good in all the cases, without relapse or any consequences.

DISCUSSION/CONCLUSION

our study, in agreement with the national data, confirms the increase in the number of case of pediatric imported malaria, and underlines the mediocrity of the prevention, in particular in term of anti-malarial chemo-prophylaxis. These data, in a context of regular increase of international travels to endemic areas, suggest the necessity to improve the information of the general public, and the urgency of a better staff training of health care workers concerning malaria, in order to improve the prevention and the treatment of this potentially fatal disease.

Long-term survival of renal graft complicated with Burkitt lymphoma

A 10-year-old boy with steroid-resistant nephrotic syndrome developed disseminated Burkitt lymphoma 2 years after renal transplantation. Treatment consisting of reduction of immunosuppression and polychemotherapy was initiated, and induced complete tumor remission. A severe cerebellar syndrome attributed to high-dose cytarabine occurred during treatment. The patient recovered partially from this complication. Immunosuppression had to be resumed 2 years later because of a chronic rejection. Finally, at last follow-up, the patient was alive with a stable creatinine of 180 micromol/l.

Long-term survival after post-transplant lymphoproliferative disease in children

Post-transplant lymphoproliferative disease (PTLD) is a well-known complication of immunosuppressive therapy. We present a series of 19 children who developed PTLD, following renal transplantation in 11 and liver transplantation in 8. The mean time between transplantation and the onset of PTLD was 19.5 months. Two patients had T-cell PTLD and died despite intensive chemotherapy. B-cell PTLD was observed in 17 patients and was associated with proven Epstein-Barr virus infection in 9. Despite immediate reduction of immunosuppressive therapy, only 8 of these 17 patients were alive at a 5.6-year mean follow-up. None of these patients had recurrence of PTLD when immunosuppression was resumed.

[Anti-Pseudomonas aerosol therapy in cystic fibrosis: improvement with tobramycin]

Aerosol delivery of antibiotics offers the potential to achieve high antibiotic concentrations at the site of infection while reducing the risk of systemic untoward effects because of minimal resorption into the bloodstream. We reviewed knowledge acquired in this field over the two latter decades. While the earliest data were obtained with gentamycin, the most conclusive evidence presently regards aminoglycosides and colistin. Aerosol delivery of tobramycin was recently improved with the development of a new formulation for inhalation. Coupled with an adequate nebulization system, intermittent treatment with tobramycin for inhalation has been evaluated in randomized placebo-controlled studies. These studies have demonstrated a significant improvement of respiratory function.

[Urinary antimicrobial prophylaxis]

Antibiotics are usually used to prevent childhood recurrent urinary tract infections: cystitis or pyelonephritis. The mechanism of action of these antibiotics, although imperfectly known, seems to be double: the antibiotic acts by its bactericidal effect, but also probably for minimal concentrations by reducing adhesion capability of bacteria to the urothelium. The most commonly used molecules are cotrimoxazole, trimethoprime, pivmecillinam, cefaclor and nalidixic acid. However all have not been studied rigorously as for their prophylactic capacity, and in particular very little is known for patients presenting with vesico-ureteral reflux.

Successful plasma therapy in hemolytic uremic syndrome with factor H deficiency

A patient with homozygous factor H deficiency presented with hemolytic uremic syndrome (HUS) at the age of 7 months. After a 2-year period of stability, renal failure and erythrocyte fragmentation recurred between the age of 3 and 4 years. Fresh frozen plasma infusions allowed renal function to be improved and erythrocyte fragmentation to be stopped. Withdrawal of plasma therapy led to a relapse of the biological signs of HUS.

Prognosis of Streptococcus pneumoniae-induced hemolytic uremic syndrome

Streptococcus pneumoniae-induced hemolytic uremic syndrome (HUS) is known to be a severe acute disease leading to death in one-third of cases, but data regarding the long-term follow-up are lacking. A new series of 11 patients with Streptococcus pneumoniae-induced HUS associated with meningitis and pneumonia constituted a multi-center review. Among 9 patients with a severe acute infectious disease, 3 died from meningitis and 1 from neurological sequelae after a partial recovery of renal function. The mean duration of dialysis was 32 days in patients with acute renal failure who survived the acute infectious period. Cortical necrosis was documented in five of six kidney specimens. Among the 7 surviving patients, 5 developed end-stage renal failure 4-17 years later.

[Alkaptonuria: a rare cause of urine discoloration. Report of a case in a newborn]

Alcaptonuria is a rare hereditary disease, characterized by an abnormal blackish coloration of the urine and dark pigmentation of the conjunctive tissue which is due to a deficiency in homogentisate 1,2-dioxygenase (HGO), a phenylalanine catabolizing enzyme. An accumulation of homogentisate (HGA) is then formed, and is responsible for the dark coloration which only occurs after the urine has been exposed to air over a period of time. Signs of this disorder therefore frequently remain unnoticed during childhood, because the urine requires a relatively long exposure to air before it changes color. Diagnosis is generally made at a later date, during adulthood, following complications such as ochronosis, inflammatory arthritis, or urinary calculi.

CASE REPORT

In this study, the case has been described of alcaptonuria diagnosed in a five-month old infant. No efficient cure has yet been found, although certain treatments, including high doses of vitamin C, do seem to have a beneficial effect on limiting the complications associated with this disorder. Early diagnosis whenever possible is therefore important.

CONCLUSION

This case report is interesting because of the early diagnosis involved. In the event of any abnormal coloration of the urine, diagnosis may be established via the addition of an alkylating agent, and the levels of HGA determined by chromatography.

In utero and in vitro exposure to beta-lactams impair kidney development in the rat

beta-Lactam antibiotics are widely used because of their lack of toxicity in humans. However, during pregnancy, exposure of the fetus is likely to occur because beta-lactam antibiotics cross the placenta. The potential adverse effects of two penicillins (ampicillin, amoxicillin) and of one cephalosporin (ceftriaxone) were examined in rat kidney development. Two experimental approaches were used: metanephros organ cultures to analyze the direct effect of the drug and maternal treatment to assess the consequences of in utero exposure. For in vitro experiments, metanephroi were removed from 14-d-old fetuses and grown with or without the antibiotic at a concentration ranging from 10 to 1000 microg/ml for 6 d. For in vivo experiments, pregnant rats were treated with penicillin at 100 mg/kg per d for 5 d, a period overlapping early renal organogenesis. Both penicillins alter renal development in vitro in a dose-dependent manner, from a dose of 10 microg/ml for ampicillin and 100 microg/ml for amoxicillin. In young animals exposed to penicillins in utero, a mild oligonephronia was present and cystic tubule dilation was observed in newborn and in young animals as well. Ceftriaxone weakly impairs in vitro nephrogenesis except at the dose of 1000 microg/ml that blocks kidney development completely. No effect on nephron ontogeny was observed following in utero exposure, but an interstitial inflammation was present in the medulla of 2-wk-old rats. In conclusion, these data show that beta-lactams, at therapeutic doses, are harmful to fetal rat kidneys.

[The biochemical and hematological assessment of iron metabolism]

Despite the progress in the knowledge of iron metabolism, its precise assessment remains uneasy. Serum ferritin assesses the extent of storage iron. Serum iron and the percentage of transferrin saturation evaluate the tissues' iron supply. But these parameters are indirect measurements and they do not reflect marrow iron supply. Serum transferrin receptors, red cell ferritin and red cell zinc protoporphyrin are good indicators of this iron supply to the erythroid marrow for erythropoiesis. Since the introduction of recombinant human erythropoietin, it has become apparent that an adequate iron supply to the bone marrow is essential for a satisfactory hematopoietic response. In some cases, despite a high baseline ferritin, iron may not be sufficiently released from reserves in the bone marrow, resulting in a functional iron deficiency. The percentage of hypochromic red cells and reticulocyte haemoglobin content tends to reflect direct marrow iron status.

Caring for the patient with breast cancer

The management of the patient with cancer of the breast is a challenge to the family physician. Foremost is the need to educate the patient about self-examination and the physician's role in providing a thorough clinical evaluation and the appropriate use of mammography. Once a diagnosis is established the patient requires counselling and referral to the needed specialists. Finally, the family physician is in a key position to coordinate the necessary services, provide access to rehabilitation programs and offer the necessary psychological support to the patient and her family.