Nonmyeloablative allogeneic bone marrow transplantation for orbital granulocytic sarcoma associated with t(8;21)(q22;q22) in acute myeloid leukemia

We report a nonmyeloablative allogeneic bone marrow transplant (allo-BMT) from an HLA-matched unrelated donor in a case of acute myeloid leukemia (AML), M2 with t(8;21)(q22;q22) and the presence of orbital granulocytic sarcoma (GS), who had residual tumor after conventional chemotherapy. The course of BMT was well tolerated, with no major procedure-related toxicity. The residual orbital GS regressed completely 4 months after BMT. She is currently 19 months post BMT, disease-free. To our knowledge, this is the first reported pediatric patient with AML, GS and t(8;21)(q22;q22) who received a nonmyeloablative allo-BMT.

Breath hydrogen responses in infants using lactose-rice formula and regular lactose formula

Starch thickened infant formulas have been shown to relieve regurgitation and increase caloric retention. We compared the completeness of digestion of the carbohydrates in lactose-rice formula (study formula) with routine infant formula in infants with GER. A prospective open study of 30 normal, well-nourished infants with simple regurgitation was conducted. The clinical history on regurgitation, stool pattern and baseline breath hydrogen (bH2) test were obtained at entry, with the infants still using their original routine infant formula, and after a wash out period of 7 days, during which they were fed only with study formula. Analysis of bH2 results showed lower levels of bH2 at 1, 2 and 3 hours with study formula compared with the original formula at the 2nd and 3rd hour (p<0.05). The effectiveness of the study formula in managing GER was demonstrated by the fact that 26 out of 30 had either "some improvement" or a "good response." Hardening of the stool pattern was reported in 13 of the 30 infants after 1 week of study formula. The mean of peak bH2 in study formula fed subjects with formed and firm/hard stool was significantly lower than in those with soft and pasty stool. In conclusion, this study has shown the effectiveness of rice thickened infant formulas in managing infants with GER. Rice-starch has an additional advantage of ease of digestion. The hardening of stool pattern was also frequently observed.

Intravenous gamma-globulin therapy in myocarditis complicated with complete heart block: Report of one case

Myocarditis complicated with complete heart block is rare in childhood. We report a case of 4-year-old child presented with complete heart block which may have been caused by Mycoplasma pneumoniae. Under emergent temporal pacing, patient experienced cardiogenic shock with pulmonary edema eventually. The cardiopulmonary function was improved with atrial rhythm at the 6th hour later after intravenous infusion with high-dose gamma-globulin (IVIG). The IVIG therapy may have immunomodulatory effects and serve as a potential adjunctive therapy for fulminant myocarditis.

Families of Chinese children with malignancy: the factors impact on mother's anxiety

This study examines the impact of the stress experienced by mothers during a child's cancer treatment. A descriptive correlation study has been designed to examine the relationships between uncertainty, sense of mastery, boundary ambiguity, and anxiety. The sample consists of 100 mothers recruited in two teaching hospitals in Taiwan. The sense of mastery was found to act as a mediator between uncertainty and anxiety, whereas uncertainty was a good predictor of boundary ambiguity. The first 2 months of treatment and the incidence of cancer recurrence represented a significant special experience for mothers. Nursing intervention to improve the mothers' sense of mastery and to assist families in establishing functional patterns of parent-child interaction is discussed.

Absence of mutations in human ubiquitin fusion-degradation protein gene in tetralogy of Fallot

Congenital defects in human chromosome 22q11 deletion syndromes are associated with the 3rd and 4th pharyngeal pouch during fetal development. In the cardiovascular system, these disorders are usually apparent as conotruncal heart defects and aortic arch anomalies. UFD1L, a gene that is downregulated in dHAND-deficient mice, expressed in the mouse embryo at the branchial arch and mapped to human chromosome 22q11, has recently been strongly suspected to be responsible for the phenotypes expressed in 22q11 deletion syndromes. Its putative causal role in relevant congenital cardiovascular malformations was studied by gene dosage analysis, mutation screening and sequence analyses. Sixty cases of tetralogy of Fallot with no detectable chromosome deletion at 22q11 or 10p13 were examined, including 51 cases of simple tetralogy of Fallot, and 9 cases of tetralogy of Fallot with pulmonary atresia. None of these patients revealed deletion limited to a portion of the UFD1L gene. Although mobility shift was found by heteroduplex analysis in 24 cases at exon 4 and flanking sequences, further sequence analysis demonstrated only two silent nucleotide variations and a single nucleotide polymorphism in intron 4. Our data suggest that, although the UFD1L gene is mapped to 22q11 and is expressed during early murine development at both cardiac and cranial neural crests, it is not responsible for the majority of tetralogy of Fallot cases in humans.

Chromosome 22q11 microdeletion in conotruncal heart defects: clinical presentation, parental origin and de novo mutations

Using genotype analysis and multiplex quantitative polymerase chain reaction (PCR), chromosome 22q11 deletions were examined in 252 patients with syndromic or isolated conotruncal heart defect. Of these patients, 19 (7.5%) were found to be hemizygous for chromosome 22q11. Parental origin of the deleted chromosome was determined in 16 cases: one patient (6.3%) inherited a deleted chromosome 22 from his mother; all the others (93.7%) consisted of de novo mutations. One-third (5/15) of the de novo 22q11 deletions were of paternal origin and the remainder derived maternally. These results lend further support to our current knowledge of chromosome 22q11 microdeletion syndromes and their implications for the genetic counseling of individuals diagnosed with conotruncal heart defects. Possible mechanisms for gender-biased parental origin are discussed.

Comparison of conventional phototherapy and fiberoptic phototherapy in the very-low-body-weight infants

Phototherapy is effectively employed for the treatment of neonatal hyperbilirubinemia, but it may influence the physiological hemodynamics of the infants, such as skin blood flow, insensible water loss and the redistribution of cardiac output. This is a retrospective chart review study involved totally 42 very low birth weight prematures(birth body weight less than 1500 gm, VLBW) who received conventional or fiberoptic phototherapy. Infants with congenital malformation, severe cardiorespiratory instability and the requirement of diuretics, inotropics or blood transfusion were excluded. The body weight loss, daily intake/output and bilirubin level during the initial four days of phototherapy were analyzed. The results showed the efficacy of both methods was the same, while the fiberoptic therapy group had significantly more urine output(p < 0.05), the body weight loss was not statistically significant. It is possible that the fiberoptic therapy group had less insensible water loss and less attenuation of the decrease of renal blood flow, this resulted in more urine output.

Monozygotic twins with chromosome 22q11 microdeletion and discordant phenotypes in cardiovascular patterning

Monozygotic twins with chromosome 22q11 microdeletions offer an ideal situation to observe the association of microdeletion and disrupted cardiovascular patterning. We report monozygotic twins concordant for 22q11.2 microdeletion but discordant for cardiovascular patterning. Both twins showed identical intracardiac defects including tetralogy of Fallot with pulmonary atresia. Nevertheless, their great vessel patternings were variable. These twins show that the mispatterning of the great vessels may not correlate with intracardiac morphogenesis. The discordant development of the great vessels, especially in the pulmonary vascular system, has clinical significance for prognosis. The phenotypic variability of cardiovascular anomalies seen in 22q11 microdeletion cannot be explained on the basis of genotypic difference.

Anomalous origin of one pulmonary artery from the innominate artery: a report of two cases

Two children with an anomalous origin of one pulmonary artery from the innominate artery are reported. One was a 15-month-old boy presenting with respiratory distress. He had a right aortic arch and his left pulmonary artery originated from the innominate artery. The other was a 1-month-old girl presenting with congestive heart failure. She had a left aortic arch and her right pulmonary artery originated from the innominate artery. An understanding of the embryological pathogenesis of these anomalies has significant therapeutic implications.

Influence of ventricular septal defect type on surgical results in children with tetralogy of Fallot

BACKGROUND

Tetralogy of Fallot (TOF) with subpulmonary ventricular septal defects (VSD) is relatively more common among Orientals than among Occidentals. This study assessed the influence of type of VSD on surgical results in children with TOF.

METHODS

Fifty-one patients with TOF (age range, 14 months to 11 years, mean 40.7 months, median 30 months, 29 boys, 22 girls) who underwent total correction by a single surgeon between January 1992 and December 1995 were retrospectively studied. Of the 51 patients, 17 patients with subpulmonary VSD were classified as group I. The remaining 34 patients with perimembranous VSD were classified as group II. All patients underwent a combined transatrial and transpulmonary surgical approach. Early postoperative results were evaluated 7 to 10 days after surgery and late postoperative results were evaluated 1 year after surgery.

RESULTS

There were no statistically significant differences between the two groups in age, sex, body weight, pulmonary to systemic flow ratio, pulmonary to aortic annulus diameter ratio or preceding palliative shunt or balloon pulmonary valvuloplasty. Nevertheless, group I patients had better oxygen saturation preoperatively (84.2 +/- 4.4% vs 80.3 +/- 7.6%, p = 0.037). During surgery, the transannular patch rate was higher in group I (100% vs 73.5%, p = 0.003). The cardiopulmonary bypass time, postoperative stay in the intensive care unit, duration of chest tube placement, early postoperative residual VSD rate, and early and late postoperative residual pulmonary stenosis rate were not significantly different between the groups. However, late postoperative residual VSD rate was 33.3% in group I and 6.45% in group II, which was statistically significant (p = 0.029). There were no significant differences in arrhythmia between the two groups.

CONCLUSIONS

Patients with TOF with subpulmonary VSD had a better preoperative oxygenation, higher transannular patch rate during surgery and a higher incidence of late residual VSD than those with TOF with perimembranous VSD.

Crude protein content and amino acid composition in Taiwanese human milk

Breast milk provides the essential nutrients for infants in readily available form. The content of nitrogen in human milk is of great importance because it relates to the growth of infants in the early stage, and the composition of nitrogenated compounds varies according to the lactational stage. Three-hundred-and-three human milk specimens were obtained from 240 healthy mothers living in two different districts in Taiwan, and 264 specimens were used for the analysis. The crude protein content, total and free amino acid compositions as well as urea content were evaluated using pooled milk samples according to different lactational stages and geographical location. The crude protein content decreased sharply from colostrum (2.51 g/100 mL) to mature milk (1.25 g/100 mL). Total amino acids account for 80-85% of the crude protein throughout the whole lactation period. Crude protein also contained 30 to 35 mg/ 100 mL urea and 41 to 48 mg/ 100 mL free amino acids as non-protein nitrogen components. The ratio of essential to non-essential amino acids remained constant throughout the lactation period in spite of a decline in amino acid content. The amino acid composition per 1 g of nitrogen varied during the lactation period. The differences of these lactational changing patterns of individual amino acids were probably reflected by variation of the protein composition during lactation. The sum of free amino acid content ranged from 43 to 50 mg/100 mL in Taipei and 40 to 45 mg/100 ml, in Kaohsiung. Although the variations of free amino acids during the lactation period differed among amino acids, glutamic acid predominated in mature milk while phosphoethanolamine was predominant in colostrum.

Comparison of the one-and-a-half-year results of closure of patent ductus arteriosus by transcatheter coils placement with surgical ligation

Patent ductus arteriosus (PDA) is a common type of congenital cardiovascular lesion. It usually needs surgical ligation in a full-term baby after 1 year of age. Transcatheter implantation of coils was introduced for the closure of small- to moderate-sized PDA in 1992. From November 1995 to November 1998, the authors closed the PDA in 153 patients by transcatheter implantation of coils and by surgical ligation in 10 patients. One hundred fourteen of them were studied for more than 1(1/2) years. The regular follow-up studies, including physical examination; electrocardiography; and pulsed, continuous-wave, and color Doppler flow mapping, were performed on day one and day 2, and 1 week, 1 month, 3 months, 6 months, and 1 year after the procedure. The results of the closure of PDA by surgical ligation or coil placement were compared and analyzed in all the patients.

Transcatheter stent treatment for congenital peripheral pulmonary arterial stenosis

A total of 5 Johnson and Johnson stents were implanted in two patients with significant residual peripheral pulmonary arterial stenosis. These were a 15-year-old boy with post-open heart surgery for tetralogy of Fallot and a 3 8/12 year-old boy with D-transposition of great vessels. Immediately after balloon dilatation and implantation of the stents, the diameter of the narrowing pulmonary arteries increased significantly from 6.0 +/- 0.8 mm to 13.5 +/- 1.7 mm (P < 0.001) and the systolic pressure gradients across the stenosis of peripheral pulmonary artery dropped significantly from 33.0 +/- 16.0 mmHg to 10.2 +/- 4.4 mmHg (P < 0.01). One year later, repeated cardiac catheterization was performed on both patients. In the patient with tetralogy of Fallot, a 20 mmHg pressure gradient was found between the main and left pulmonary artery. This patient then received another stent implantation to release the residual stenosis. The boy with D-transposition of great vessels had only 9 mmHg gradient between main and right pulmonary artery. Transcatheter placement of the stent is a feasible and effective method to treat certain patients with significant pulmonary arterial stenosis if surgical correction can not be performed.

Intratracheal oxygen administration during bronchoscopy in newborns: comparison between two different weight groups of infants

BACKGROUND

The development of ultrathin fiberoptic bronchoscopy (FB) has made the examination of neonatal airways a practical possibility. The aim of this study was to assess the effects of intratracheal oxygen (ITO) administration on blood oxygenation and carbon dioxide (CO2) changes during FB in different body-weight infants.

METHODS

Newborns suspected of having airway problems, but in a stable cardiopulmonary condition were studied. An ultrathin (outside diameter, 2.2 mm) fiberoptic bronchoscope that was modified by adding an external tube (internal diameter, 0.3 mm; outside diameter, 0.64 mm) to deliver oxygen was used. For ITO administration, a low oxygen flow rate of 0.1 l/kg/min was delivered directly into the trachea. Oxygenation and CO2 measurements were obtained at five different stages: 1) just before FB (baseline); 2) with the tip of the bronchoscope at the supralarynx; 3) with the tip at the carina without ITO; 4) with the tip at the carina with ITO; and 5) 15 minutes after FB. Forty infants were studied completely and divided into two groups according to their body weight: 1) the light-weight group (< 2,500 g), 21 infants; and 2) the heavy-weight group (> or = 2,500 g), 19 infants.

RESULTS

In both groups, arterial blood oxyhemoglobin saturation and oxygen tension decreased significantly (p < 0.05) when the tip of the bronchoscope advanced from the nostril to the supralarynx, and further decreased (p < 0.01) when at the carina level. Small infants had greater decrements of both oxygenation measurements (p < 0.05) than the large infants. After ITO administration, both oxygenation measurements increased significantly (p < 0.001) and returned to baseline following FB. Both end tidal pressure of CO2 (P(ET)CO2) and arterial CO2 tension (PaCO2) significantly increased from the baseline when the FB tip was advanced from the supralarynx to the carina (p < 0.05). During ITO administration, the PaCO2 increased (p < 0.01) but the P(ET)CO2 decreased (p < 0.001). After FB, both CO2 measurements returned to baseline. The pH only decreased during ITO administration.

CONCLUSIONS

We conclude that FB causes significant hypoxemia and hypercapnia in newborns, especially in underweight infants. Appropriate ITO can be considered a safe and beneficial technique for maintaining oxygenation during FB. P(ET)CO2 monitoring may mask true blood CO2 retention during ITO administration.

Cardiac manifestations of fatal enterovirus infection during the 1998 outbreak in Taiwan

BACKGROUND

An outbreak of hand-foot-and-mouth disease caused by enterovirus infection occurred in Taiwan in 1998 and more than 70 infants and children with fulminant courses died. We compared the cardiac manifestations of fatal cases with patients who survived the enterovirus infection.

METHODS

A total 187 patients with enterovirus infection were treated at Taichung Veterans General Hospital between April and June 1998. Enterovirus infection was diagnosed by history, clinical features, polymerase chain reaction study and/or viral culture. Cardiac examinations including complete physical examinations, electrocardiography and echocardiography were performed on seven cases (group I) with or without central nervous system (CNS) involvement, 30 patients with CNS involvement (group II), and 150 patients without CNS involvement (group III).

RESULTS

There were no significant differences in sex distribution, days of fever, heart rate, systemic blood pressure or time from the onset of symptoms to hospital admission among the three groups. All group I patients had features of acute congestive heart failure, pulmonary edema and neurologic signs except one who presented with right-sided heart failure and neurologic signs. The echocardiographic findings of group I were a lower fractional shortening, lower ejection fraction, and more severe and higher incidence of mitral regurgitation (p < 0.01) than in groups II and III, but there were no significant differences in end-systolic wall stress, left ventricular end-diastolic internal dimension and incidence of pericardial effusion among the three groups.

CONCLUSIONS

We conclude that seven infants and children (group I) died due to either severe cardiomyopathy or encephalopathy. The possible pathogenesis of enterovirus infection leading to death is reviewed and analyzed.

The effects of social interactive training on early social communicative skills of children with autism

Growing attention has been directed at the relation between early social communicative skills of children with autism and subsequent development of these children's social and communicative functioning. We reviewed 16 empirical studies that investigated the effects of social interactive interventions designed to increase early social communicative skills of young children with autism by increasing their role as initiator of social interactions. To identify factors relating to treatment effectiveness, we analyzed studies in relation to participant characteristics, settings, target behaviors, training methods, and results. To determine durability of treatment, we analyzed generalization effects across persons, settings, stimuli, and time. Increases were found for social and affective behaviors, nonverbal and verbal communication, eye contact, joint attention, and imitative play. Limited generalization or maintenance of target behaviors was reported. Findings are discussed in relation to critical variables that may relate to treatment effectiveness in future research and practice efforts.

Transcatheter closure of atrial septal defect with a CardioSEAL device

Transcatheter closure of an interatrial septal defect (ASD) with a CardioSEAL device was successfully performed on 12 Taiwanese children. There were five boys and seven girls, aged from 3.6-13.9 (8.3+/-3.2) years and with body weight of 15-57 (33.7+/-14.7) kgs. After one year of follow-up studies, which included physical examination, ECG, chest X-ray and echocardiography, complete closure of ASD was achieved in nine (75%) patients. Two children with a trivial residual shunt were asymptomatic and without audible cardiac murmur. A girl had a small residual left to right atrial shunt by color Doppler echocardiography, but without audible cardiac murmur. There were no immediate or intermediate complications. Transcatheter implantation of the CardioSEAL device is a safe and proper treatment for children with non-complicated small to medium secundum ASD.

Positron emission tomography for the assessment of myocardial viability in Kawasaki disease using different therapies

13N-ammonia and 18F-fluorodeoxyglucose positron emission tomography (PET) of the heart were performed on 30 children with a history of Kawasaki disease. The results indicated PET abnormalities in 61.1% of patients during the acute and subacute stages and in 41.2% of patients in the convalescent stage of Kawasaki disease. Two-dimensional echocardiography and coronary angiography could not predict the myocardial viability and perfusion as well as PET. Different therapies during the acute stage of the disease did not effectively prevent myocardial damage, despite the absence of coronary arterial abnormalities. The patients who received 400 mg x kg(-1) x day(-1) of intravenous immunoglobulin (IVIG) for 5 days had a significantly lower incidence of PET abnormalities than those who received a single dose of 2000 mg x kg(-1) IVIG (P < 0.05).

Comparison of 201Tl SPET and treadmill exercise testing in patients with Kawasaki disease

About 4% of children with Kawasaki disease ultimately develop ischaemic heart disease. Therefore, the early detection, non-invasive monitoring and long-term follow-up of myocardial ischaemia are essential. We compared the sensitivity and specificity of 201Tl single photon emission tomography (SPET) and treadmill exercise in the detection of myocardial ischaemia in 23 patients (19 boys, 4 girls) with Kawasaki disease. They were divided into two groups according to the results of coronary angiography. Group I consisted of 11 patients with coronary abnormalities; Group II consisted of 12 patients with no coronary abnormalities. The sensitivity, specificity, false-positive and false-negative rates for detecting coronary arterial lesions were 72.7% (8/11), 58.3% (7/12), 38.5% (5/13) and 30% (3/10) for 201Tl SPET, and 45.5% (5/11), 100% (12/12), 0% (0/5) and 33.3% (6/18) for treadmill exercise, respectively. We conclude that 201Tl SPET is more sensitive than treadmill exercise for the detection of coronary arterial abnormalities, but that the specificity of treadmill exercise is better than that of 201Tl scintigraphy. Coronary artery lesions detected by coronary angiography have good concordance of ischaemic areas with perfusion defects detected by 201Tl SPET. When ischaemic findings on 201Tl SPET and/or positive treadmill exercise testing are noted, coronary angiography is strongly indicated to detect possible stenotic lesions in the coronary arteries.

Cytomegalovirus pericarditis with cardiac tamponade in a young infant

The principal viruses implicated in pericarditis are enteroviruses. Cytomegalovirus pericarditis is quite rare and has been reported in immunocompromised patients with acquired immunodeficiency syndrome, malignant neoplasm or organ transplantation. We report a three-month-old male infant who suffered from cough and rhinorrhea for two weeks. He developed shortness of breath for three days, and fever for one day, prior to admission. Physical examination revealed tachycardia, tachypnea, pale conjunctiva, hepatomegaly, and a muffled heart sound without significant murmur. Chest radiography showed marked enlargement of the cardiac silhouette. Echocardiography demonstrated a large amount of pericardial effusion with impaired diastolic ventricular function. After pericardial drainage and supportive treatment, the fluid gradually disappeared. Viral culture of the pericardial fluid and serologic data confirmed a cytomegalovirus infection. Cytomegalovirus pericarditis should be included in the differential diagnosis of pericardial effusion in a young infant.

The assessment of anaerobic blood culture in children

Over the past 20 years, there has been a decline in the percentage of positive blood cultures yielding anaerobic organisms. Due to the limited blood volume drawn from pediatric patients, we have assessed the value of routine anaerobic blood cultures in children. From January 1994 to December 1998, 9886 paired aerobic and anaerobic blood cultures were analyzed in the pediatric microbiology laboratory at the Taipei Veterans General Hospital. Six hundred and eighteen (6.25%) isolates were considered to be clinically important microorganisms. Staphylococci, streptococci, aerobic gram-negative bacilli, and yeasts showed more significant growth within the aerobic culture than that within the anaerobic culture. Significantly more aerobic gram-positive cocci, aerobic gram-negative bacilli, and yeasts were detected at least 1 day earlier by using the aerobic culture. Three patients with documented anaerobic bacteremia had obvious symptoms related to anaerobic infections. Our study concludes that routine use of anaerobic blood culture in pediatric patients is not necessary. Anaerobic blood cultures should be reserved for patients with diseases like intra-abdominal or oral infections, neutropenic patients on steroid therapy, pressure sores, cellulitis, and human bite wounds.