Effects of steroid pulse therapy on immunoglobulin-resistant Kawasaki disease

BACKGROUND

The use of intravenous immunoglobulin (IVIG) is well established as an initial therapy for Kawasaki disease (KD), but treatment for IVIG-resistant KD remains uncertain

AIM

To analyse the effects of intravenous methylprednisolone (IVMP) pulse therapy compared with additional IVIG in IVIG-resistant patients.

METHODS

IVMP was administered to patients with KD who had persistent or recurrent fever after a single dose of IVIG, at Juntendo University Hospital and affiliated medical institutions between May 2003 and March 2006. The effectiveness of the treatment and the incidence of coronary lesions in patients who received IVMP and those who received additional IVIG were retrospectively analysed and compared by chart review.

RESULTS

411 patients with KD were treated with a single dose of IVIG. Of the 63 IVIG-resistant patients, 44 were then given IVMP and 19 were given additional IVIG. Treatment was successful in 34 (77%) of the patients who received IVMP and 12 (63%) who received additional IVIG. Five of the 10 patients who did not respond to IVMP and two of the seven who did not respond to additional IVIG developed coronary artery aneurysms. Although fever initially resolved faster in the IVMP-resistant group, there was a delay in fever recurrence, which ultimately delayed the final resolution of fever.

CONCLUSIONS

The findings suggest that IVMP is an effective additional treatment for IVIG-resistant KD. However, there was a tendency for fever to recur later in IVMP-resistant patients, which could potentially delay the therapeutic decision-making process.

Octreotide prevents L-asparaginase-induced pancreatic injury in rats

OBJECTIVE

L-asparaginase (ASNase) is one of the most effective chemotherapeutic means for inducing remission in acute lymphoblastic leukemia. However, because of unknown risk factors, severe pancreatitis sometimes occurs in patients receiving ASNase. We assessed the effect of ASNase on pancreatic acinar cells and then investigated the preventive effects of octreotide against ASNase-induced pancreatic injury in rats.

MATERIALS AND METHODS

Rats received intraperitoneal injections of an Escherichia coli ASNase solution (200, 500, or 1000 IU/kg) or normal saline as a control every 24 hours for 5 days. Octreotide (3 microg/kg) was injected subcutaneously with ASNase (1000 IU/kg) every 8 hours for 5 days. Rats were sacrificed 24 hours after the last injection of ASNase or normal saline.

RESULTS

Only the rats given 1000 IU/kg ASNase had significantly increased levels of pancreatic amylase (1962 +/- 152 vs 2179 +/- 84 IU/L, p < 0.01), trypsin (27.3 +/- 3.6 vs 41.1 +/- 22.8 IU/L, p < 0.05), and pancreatic secretory trypsin inhibitor (0.03 +/- 0.09 vs 0.27 +/- 0.10 ng/mL, p < 0.01) as compared to the control group. In addition, the acinar cells showed histological damage; however, octreotide injection provided protection against histological damage and the pancreatic enzymes remained within normal limits.

CONCLUSIONS

Although ASNase by itself did not cause pancreatitis, it did cause increased levels of pancreatic enzymes and histological damage to the pancreas associated with pancreatic injury or pre-pancreatitis. Prior treatment with octreotide prevented the development of ASNase-induced pancreatic injury.

Early dietary treatments with Lorenzo's oil and docosahexaenoic acid for neurological development in a case with Zellweger syndrome

We treated a girl with Zellweger syndrome using a special infant formula supplemented with middle chain triglyceride (MCT) milk, docosahexaenoic acid (DHA), Lorenzo's oil, and Lunaria oil, which is rich in nervonic acid (C24:1). We examined the fatty acid contents of the plasma and red blood cell (RBC) membrane. Neurological development was evaluated using Denver developmental screening test and auditory brainstem response (ABR). Her delayed neurological development, liver dysfunction, and cholestasis were all improved 2 weeks after starting the dietary treatment. DHA level in RBC membranes was increased and very long chain fatty acid (VLCFA,C26:0) levels were decreased. Our findings suggest that the dietary treatment with combination of MCT milk, DHA, Lorenzo's oil, and Lunaria oil in the patients with Zellweger syndrome bring some benefits for neurological development.

Bone mineral density in children and adolescent girls with anorexia nervosa in Japan

BACKGROUND

The correlation between reduced bone mineral density (BMD) and the disease anorexia nervosa (AN) has long been established. The aim of the present study was to examine the relationship in more detail, particularly focusing on the increasing incidence of the disease occurring in adolescent patients.

METHOD

Twenty-four girls diagnosed with AN were enrolled in the study. All subjects ranged in age from 11.1 to 15.5 years, with an average age of 13.5 years. The BMD of lumbar spines and femoral necks were measured. All the values for BMD at admission were expressed as means +/- SD and patients with and without menarche were separately investigated.

RESULTS

The average BMD of lumbar spines at the time of admission was -0.51 SD in total. However, the average BMD of patients without menarche was -1.28 SD, which was significantly lower than the -0.16 SD on average in patients with menarche. As a whole the BMD of femoral necks at admission tended to be lower than that of lumbar spines. Similarly, it was lower in patients without menarche (-1.7 SD on average) than in those with menarche (-0.77 SD on average).

CONCLUSIONS

BMD was lower in children and adolescent AN patients without menarche, and such a tendency was more significant at the femoral neck region. In child AN cases without menarche, the BMD, especially at the femoral neck, needs to be measured, and later recovery should be monitored closely over a long period.

Serum free T4 and thyroid stimulating hormone levels in preterm infants and relationship between these levels and respiratory distress syndrome

BACKGROUND

There have been few studies of the thyroid stimulating hormone (TSH) surge in extremely low-birthweight (ELBW) infants, and the relationship between thyroid hormones and respiratory distress syndrome (RDS) has yet to be clarified. The present study sought to determine the serum levels of free T4 (fT4) and TSH in ELBW infants and to examine the relationship between these levels and the development of RDS.

METHODS

The authors measured serum fT4 and TSH levels soon after birth in 449 preterm infants, who were born at 22-36 weeks of gestation, and determined the associations between these levels, the incidence of RDS, and the recognized clinical factors associated with RDS.

RESULTS

Serum fT4 and TSH levels, and the fT4/TSH ratio, in the group at 22-24 weeks of gestation were significantly lower than those in the group at 28-36 weeks. The levels and ratio increased significantly with increasing gestational age. There were significant correlations between the serum fT4 level and the birthweight, Apgar score, and gender, and between the serum TSH level and the gestational age, mode of delivery, and birthweight. No significant relationship between the incidence of RDS and the serum levels of fT4 and TSH was observed.

CONCLUSION

The authors' results suggest that the serum levels of fT4 and TSH in ELBW infants are very low, and that these levels are not correlated with the occurrence of RDS.

Plasma levels of active ghrelin until 8 weeks after birth in preterm infants: relationship with anthropometric and biochemical measures

This study investigated the relationship between plasma levels of ghrelin and postnatal growth in preterm infants. The levels of active ghrelin in cord blood and in plasma in 25 very low birthweight (VLBW) infants were measured. The results indicate that the levels of circulating active ghrelin markedly increases after birth in VLBW infants, and suggest that the increased levels of ghrelin reflects the maturation of ghrelin production in the stomach and an increased physiological need for ghrelin.

Plasma exchange combined with immunosuppressive treatment in a child with rapidly progressive IgA nephropathy

Although diffuse crescentic formation in immunoglobulin A (IgA) nephropathy, histologically characterized by extensive extracapillary proliferation, is assumed to have a poor prognosis, there has still been no established treatment because of the low prevalence of the condition, especially in pediatric patients. This paper reports on a 5-year-old boy with rapidly progressive IgA nephropathy requiring dialysis for 1 month. He had been treated with plasma exchange (PE) combined with immunosuppressive treatment, including steroids and mizoribine, because renal function deteriorated rapidly despite initial treatment with intravenous methylprednisolone pulse. The histological findings at that time revealed IgA nephropathy, with large circumferential cellular crescent formation in approximately 80% of the glomeruli. Three weeks after PE initiation, serum levels of creatinine and IgA-containing immune complexes returned to normal, and urinary protein excretion gradually decreased. The second renal biopsy taken 7 months later demonstrated mild IgA nephropathy with small fibrocellular crescents. This case report indicates that PE combined with immunosuppressive treatment may benefit children with rapidly progressive IgA nephropathy, even when extensive crescent formations are present.

Neonatal transient eosinophilic colitis causes lower gastrointestinal bleeding in early infancy

BACKGROUND

Lower gastrointestinal bleeding (LGB), particularly in newborns, is of serious concern and requires urgent investigation and hospital care. Whereas allergic proctocolitis caused by food protein is a significant cause of LGB in infants with eosinophilia, there are several cases of diseases with symptoms similar to those of allergic proctocolitis but without an apparent allergic reaction influence.

PATIENTS AND METHODS

We examined 2 neonates using rectosigmoidoscopy who showed eosinophilia and experienced fresh LGB soon after birth and before their first feedings. Serum eosinic cationic protein (ECP) and platelet activating factor (PAF) levels were also examined in the second case to confirm the involvement of eosinophils for its pathogenesis.

RESULTS

Both patients were in a clinically stable condition, and their abdomens were soft. The results of their blood analyses, abdominal radiographs, and stool cultures were normal, but they had gross eosinophilia: the eosinophil counts were 9014/mm3 (patient 1) and 1955/mm3 (patient 2). Rectosigmoidoscopy with colonic mucosal biopsy revealed nodular lymphoid hyperplasia with a pale mucosal surface and massive oozing with diffuse eosinophilic infiltration in the lamina propria. In patient 2 the serum ECP and PAF levels were elevated to 123 microg/L (normal, <14.7) and 13.1 micromol/L/min (normal, <6). A few days after intravenous hydration therapy, LGB was no longer detected, and the serum ECP and PAF levels returned to normal.

CONCLUSIONS

Inasmuch as these infants had LGB similar to allergic proctocolitis without any allergic reactions, we suggest that infiltrated eosinophils in the colonic mucosa could be involved in the pathogenesis of LGB in early infancy.

Effects of oral administration of bifidobacterium breve on fecal lactic acid and short-chain fatty acids in low birth weight infants

OBJECTIVES

Short-chain fatty acids (SCFAs) are known to provide energy to colonocytes, whereas overproduction of SCFAs can cause mucosal injury in premature infants. Our objective was to investigate the effects of the oral administration of Bifidobacterium breve M-16V (B breve) on fecal lactic acid and SCFAs in low birth weight (LBW) infants.

PATIENTS AND METHODS

Fecal lactic, acetic, propionic, and butyric acids from 66 premature infants were analyzed by high-performance liquid chromatography at 0, 2, and 4 weeks after birth. The subjects included 22 extremely LBW (ELBW, <1000 g), 22 very LBW (VLBW, <1500 g), and 22 LBW (<2500 g) infants. The infants were divided into two groups: those with and those without B. breve supplementation.

RESULTS

In the control groups, fecal acetic acid and total SCFA concentrations were significantly increased at 2 weeks in the VLBW and LBW infants (P < 0.05) and at 4 weeks in the ELBW, VLBW, and LBW infants (P < 0.01 for each) compared with those at week 0. Fecal lactic acid concentrations showed a similar pattern during follow-up, but the differences were not significant. Four weeks after B breve administration, the fecal butyric acid concentrations were significantly decreased in the ELBW and VLBW infants (P < 0.05 each), and the ratio of the acetic acid concentrations to the total SCFAs was significantly increased compared with those of the control groups in the ELBW (P < 0.05), VLBW (P < 0.05), and LBW infants (P < 0.01).

CONCLUSIONS

Oral administration of B breve reduces the production of butyric acid, which may be helpful in protecting LBW infants from digestive diseases such as necrotizing enterocolitis.

Effects of iron-unsaturated human lactoferrin on hydrogen peroxide-induced oxidative damage in intestinal epithelial cells

Human milk (HM) contains various bioactive antioxidants. Lactoferrin (Lf) has been assumed to be one of the major antioxidants in HM. We examined the antioxidative properties of iron-unsaturated human Lf (apo-hLf, the major form of Lf in HM) in two intestinal epithelial cell lines: (1) An intestinal epithelial cell line (IEC-6) were preincubated for 24 h with either 50 microg/mL of apo-hLf, iron-saturated human Lf (holo-hLf), iron-unsaturated bovine transferrin (apo-bTf), or 800 ng/mL of the iron-chelating compound deferoxamine (DFX), followed by hydrogen peroxide (H2O2) challenge to induce oxidative stress. Survival rates were significantly higher in the cells preincubated with apo-hLf and DFX than those preincubated with holo-hLf. (2) Caco-2 cells were preincubated with or without apo-hLf for 24 h, followed by an H2O2 challenge. Intracellular oxidative stress was assessed by a fluorescent probe, 2',7'-dichlorodihydrofluorescein diacetate (DCF-DA). Fluorescent intensity of cell images and cell homogenates was significantly lower in the cells preincubated with apo-hLF than those preincubated without apo-hLF. Our study indicates that apo-hLf alleviates H2O2-induced oxidative damage in intestinal cells due to the iron-chelating capacity. Therefore, Lf in HM may act as an antioxidant in the gastrointestinal tract (GIT).

A prospective study on the use of mycophenolate mofetil in children with cyclosporine-dependent nephrotic syndrome

Cyclosporine A (CsA) has relieved children with steroid-dependent nephrotic syndrome (NS) from steroid toxicity. However, most patients frequently relapse again when CsA is withdrawn, resulting in the development of CsA nephropathy for its long-term use. In order to assess the efficacy of mycophenolate mofetil (MMF) therapy, we prospectively analyzed 12 children with idiopathic steroid-dependent NS requiring long-term CsA therapy with MMF for at least 6 months. Mean follow-up after starting MMF was 11 months (range 6-42). The mean MMF dose required was 610+/-95 mg/m(2)/12 h, which maintained mean predose mycophenolic acid (C0-MPA) levels of 2.4+/-1.1 mcg/ml. Treatment with MMF resulted in CsA and/or prednisolone (PSL) sparing, with a reduction in mean CsA dose from 3.5+/-1.3 to 1.5+/-2.4 mg/kg/day (p<0.01), and mean PSL dose from 0.29+/-0.16 to 0.21+/-0.11 mg/kg/day (p<0.05). Nine of 12 patients (75%) were finally able to be weaned off CsA. Mean relapse rates decreased from 2.7+/-1.6 to 0.6+/-0.9 episodes/year (p<0.01). Relapse-free ratio on MMF therapy was lower in patients whose average C0-MPA levels were less than 2 mcg/ml (p<0.05). Our experience demonstrates that MMF therapy results in significant CsA and/or steroid sparing and reduction in relapse rates in children with CsA-dependent NS.

Surgical treatment and outcome of mega-hydronephrosis due to pelviureteric junction stenosis

To study the surgical treatment and outcome of hydronephrosis secondary to pelviureteric junction obstruction (PUJS) that is so massive that the renal pelvis crosses over the vertebral column [mega-hydronephrosis (MH)]. Of the 40 cases of PUJS we treated over the past 5 years, 6 cases had MH secondary to PUJS (MH-PUJS) in 6 renal units and were reviewed. Incidence of MH was 15.0%. All had Anderson-Hynes dismembered pyeloplasty to treat obstructive renal pattern on technetium-99m diethylenetriaminepentaacetic acid (DTPA) scans in five and gait disturbance due to MH in one. The contralateral kidney was normal in five and dysplastic in one. Three had nephrostomy before pyeloplasty. Preoperative DTPA scans showed good renal function in four and poor in two. Plication of the entire dilated, lax renal parenchyma ("nephroplication") was performed in three to decrease the intra-renal pelvic cavity. Prenatal diagnosis was performed in three cases. Mean age at pyeloplasty was 3.5 years and mean duration of follow-up was 1.5 years. Postoperatively, two of the three who did not have nephroplication had prolonged but not obstructed renal pattern on DTPA scans, and the other case who did not have nephroplication had nephrectomy for non-functioning kidney caused by recurrent pyelonephritis 2 years after pyeloplasty. In the three who had nephroplication, DTPA scans showed acceptable to relatively good passage in all cases. The surgical treatment of MH-PUJS is challenging with no fixed guidelines. However, nephroplication may be useful during pyeloplasty to decrease the size of MH-PUJS.

Effects of extremely early enteral feeding on plasma glicentin levels in very-low-birthweight infants

AIM

Glicentin, an active component of enteroglucagon, is considered to have a significant trophic action on the intestinal mucosa. We examined the effects of extremely early enteral feedings on the postnatal and postprandial changes in plasma glicentin levels in very-low-birthweight (VLBW) infants.

METHODS

We measured the plasma glicentin concentrations before and after feedings at 1 or 2 days, 5 or 6 days and 14 days after birth in 21 VLBW infants. The subjects were randomly divided into an extremely early feeding group, which was started on breast milk within 24 h after birth, and a control group, which was started on breast milk more than 24 h after birth.

RESULTS

Plasma basal concentrations of glicentin at 5 or 6 days and at 14 days after birth were significantly higher than those at 1 or 2 days after birth in the early feeding group. The basal glicentin level at 14 days after birth was significantly higher than that at 1 or 2 days. The basal levels at 5 or 6 days and at 14 days after birth in the early feeding group were significantly higher than those in the control group. Plasma glicentin concentrations after feeding were significantly higher than those before feeding at 5 or 6 days and 14 days after birth in the early feeding group, but those levels were significantly higher only at 14 days after birth in the control group.

CONCLUSION

Our results suggest that extremely early enteral feedings may play an important role in the development of glicentin secretion and intestinal mucosal growth in the early period of life in VLBW infants.

Comparison of the phospholipid classes in human milk in Japanese mothers of term and preterm infants

BACKGROUND

Phospholipids (PLs) play an essential role in the growth and brain development of infants.

AIM

To investigate PL composition in human milk (HM), including lysophosphatidylcholine, phosphatidylethanolamine, phosphatidylinositol, phosphatidylserine, phosphatidylcholine (PC) and sphingomyelin (SM), from healthy Japanese mothers. Analyses were performed on colostrum, transitional milk and mature milk from mothers of preterm and term infants.

METHODS

HM samples were collected from mothers of 15 term infants (term group) and of 19 preterm infants (preterm group). PL composition was determined by two-dimensional thin-layer chromatography in conjunction with phosphorus analysis.

RESULTS

In both groups, the PL content (% of total lipid) of mature milk was significantly lower than in colostrum. SM and PC were the main PLs in HM, but in the preterm group, the percentage of SM in mature milk was significantly higher and PC in mature milk was significantly lower than in the term group.

CONCLUSION

The transition from colostrum to mature milk leads to an increase in SM and a decrease in PC in the HM of preterm infants, along with a decrease in PL content. This is the first report to demonstrate the differences in PL composition in HM between mothers of preterm and term infants.

Independent risk factors for chronic cyclosporine induced nephropathy in children with nephrotic syndrome

BACKGROUND

Cyclosporine A (CsA) has been widely used in children with steroid dependent and steroid resistant nephrotic syndrome (NS) because of its efficacy in relieving these patients from systemic side effects of steroids. However, its long term use is controversial, since chronic CsA induced nephropathy (CsAN) may develop in a considerable number of patients.

AIMS AND METHODS

In order to clarify the risk factors for the development of CsAN, the clinical characteristics of children with steroid dependent or steroid resistant NS taking CsA (target blood trough levels 50-150 ng/ml) for more than six months, managed at a single centre, were retrospectively analysed.

RESULTS

Thirteen of 30 children (24 boys and 6 girls) taking CsA (mean duration 43 months, range 6-144) had CsAN defined as the presence of CsA associated arteriopathy with or without striped tubulointerstitial lesions. The multivariate analysis revealed that CsA treatment for more than 36 months and an age younger than 5 years at the start of CsA treatment were independent risk factors for the development of CsAN. The univariate analysis also showed that patients with CsAN had more frequent relapses during CsA treatment than those without CsAN.

CONCLUSION

An alternative treatment should be seriously considered after a 36 month administration of CsA in order to prevent CsAN. Data also suggest that CsA treatment in children younger than 5 years should be avoided if possible.

Evaluation of psychosomatic stress in children by measuring salivary chromogranin A

AIM

To investigate the usefulness of salivary chromogranin A (CgA) and cortisol as stress markers, and the effects of distraction on the suppression of stress in children.

METHODS

We examined salivary CgA and cortisol responses before and after venipuncture in hospitalized children with and without distraction using a kaleidoscope.

RESULTS

Salivary CgA levels immediately after venipuncture were significantly higher than those immediately before it, and at 60 min after venipuncture they were significantly lower than those immediately after it. However, salivary cortisol showed no significant differences at any of the three time points. In contrast, distracted by the kaleidoscope, there were no significant differences in salivary CgA and cortisol levels at all three time points.

CONCLUSION

In children, salivary CgA level is a useful marker of stress. As an index of the effect of distraction, the measurement of salivary CgA is useful.

Bifidobacterium breve enhances transforming growth factor beta1 signaling by regulating Smad7 expression in preterm infants

OBJECTIVES

Transforming growth factor (TGF) beta1 displays a broad spectrum of activities in mucosal regulation, including induction of oral tolerance, potent anti-inflammatory effects, mucosal IgA expression and effects on epithelial cell proliferation and differentiation. The present study examined the effect of probiotics on the immunologic system of preterm infants in relation to TGF-beta signaling.

METHODS

Subjects comprised 19 preterm infants divided into 2 groups: receiving Bifidobacterium breve supplementation (B. breve group) and without supplementation (controls). Blood samples were collected from both groups on days 0, 14 and 28 after birth. Serum cytokine levels were measured using enzyme-linked immunosorbent assay, and expression levels of the TGF-beta signaling molecule, Smad, were examined using semiquantitative reverse transcriptase-polymerase chain reaction.

RESULTS

Serum TGF-beta1 level was elevated on day 14 and remained elevated on day 28 in the B. breve group. Level of messenger RNA expression was enhanced for Smad3 and reduced for Smad7 (antagonistic Smad) after B. breve administration relative to levels in controls on day 28.

CONCLUSIONS

These results demonstrated that the administration of B. breve to preterm infants can up-regulate TGF-beta1 signaling and may possibly be beneficial in attenuating inflammatory and allergic reactions in these infants.

Usefulness of nonbreath-hold 1-shot magnetic resonance cholangiopancreatography for the evaluation of choledochal cyst in children

OBJECTIVE

The aim of this study was to clarify the usefulness of magnetic resonance cholangiopancreatography (MRCP) for the evaluation of choledochal cyst in children.

SUBJECTS AND METHODS

MRCP was performed preoperatively in 33 patients. The MRCP findings were compared with those of endoscopic retrograde cholangiopancreatography or intraoperative cholangiopancreatography.

RESULTS

In all 33 patients, MRCP could detect choledochal cyst. The detection rate of a cyst in the main pancreatic duct was 62.2%, of abnormal union of the pancreaticobiliary junction (AUPBJ) was 53.3%, of dilatation or abnormalities of the main pancreatic duct was 75.0% and of a protein plug or stone was 76.9%. In patients under 2 years of age (group A), these findings were significantly lower than those of patients above 2 years of age (group B) [main pancreatic duct: 16.6% (1/6) vs 73.1% (19/26), P < 0.01; AUPBJ: 0.0% (0/6) vs 66.7% (16/24), P < 0.05; and protein plug or stone: 0.0% (0/2) vs 90.9% (10/11), P < 0.05]. The detection rate of AUPBJ in the patients with fusiform dilatation was superior to that of those with cystic dilatation [70% (14/20) vs 20% (2/10), P < 0.05]. In the patients with fusiform dilatation, the detection rate in group A was significantly lower than that in group B [0.0% (0/3) vs 82.4% (14/17), P < 0.01]; however, there was no significant difference between the 2 groups in the detection of cystic dilatation.

CONCLUSION

In patients older than 2 years, MRCP should be the first-choice method for confirming the diagnosis and for ensuring accurate visualization of the pancreaticobiliary system.