Are infections in children with juvenile idiopathic arthritis more frequent than in healthy children? A prospective multicenter observational study

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) might be at a higher risk of infection. Our objectives are to describe and compare infection rates in patients with JIA vs. healthy patients.

METHODS

A prospective, multicenter observational study was performed in Spain from January 2017 to June 2019. Patients with JIA from 7 participating hospitals and children without JIA (siblings of patients with JIA, and non-JIA children from primary health centers) were followed up with quarterly questionnaires to record infection episodes. Tuberculosis, herpes zoster, and infections requiring hospital admission were considered severe infections. Rates of infection (episodes/patient/year) were compared using a generalized estimating equations model.

RESULTS

A total of 371 children (181 with and 190 without JIA) were included. The median age was 8.8 years (IQR 5.5-11.3); 75% of the patients with JIA received immunosuppressive treatment (24% methotrexate, 22% biologic, 26% both). A total of 667 infections were recorded; 15 (2.2%) were considered severe. The infection rate was 1.31 (95%CI 1.1-1.5) in JIA and 1.12 (95%CI 0.9-1.3) in non-JIA participants (p = 0.19). Age <4 years increased the infection rate by 2.5 times (2.72 vs. 1.12, p < 0.001) in both groups. The most frequent infection sites were upper respiratory (62.6% vs. 74.5%) and gastrointestinal (18.8% vs. 11.4%). There were no differences in severe infections (2.5% vs. 2%, p = 0.65) between the groups. In children with JIA, younger age and higher disease activity (JADAS71) were associated with a higher infection rate.

CONCLUSION

We found no differences in the infection rate or infection severity between patients with and without JIA. Most infections were mild. An age younger than 4 years increased the infection risk in both groups. Higher disease activity was associated with a higher infection rate.

Comparison of different scales for the evaluation of anxiety and compliance with anesthetic induction in children undergoing scheduled major outpatient surgery

INTRODUCTION

Anxiety in children triggered by a scheduled surgical intervention is a major issue due to its frequency and consequences. Preoperative anxiety is associated with increased patient fear and agitation on anesthetic induction. The aim of this study is to compare three preoperative anxiety scales for children undergoing elective outpatient surgery, and to correlate each of these tools with the degree of patient compliance on induction, as assessed by the Induction Compliance Checklist (ICC).

METHODS

An observational prospective study was performed on a cohort of children with ages between 2 and 16 years old, scheduled for outpatient surgery. Anxiety was assessed upon arrival to the hospital (M0), during transfer to the surgical unit (M1), and in the operating room during anesthetic induction (M2). Anxiety in the parents (measured with the State-Trait Anxiety Inventory, STAI) and in the children (measured with the Spence Anxiety Scale-Pediatric, SCAS-P, the State-Trait Anxiety Inventory Children, STAIC, and Modified Yale Preoperative Anxiety Scale, m-YPAS) was assessed. Compliance with anesthetic induction was assessed with ICC.

RESULTS

The study included 76 patients (72.4% male, median age 7.9 years). Anxiety scores (m-YPAS) increased as the moment of surgery approached, being greater at the entrance to the surgical unit (M0 = 26.1 ± 9.5; M1 = 31.8 ± 18.1; M2 = 33.5 ± 21.1). A strong correlation was found between ICC scale and m-YPAS at M1 (0.738) and M2 timepoints (0.794), but not with the rest of scales at M0.

CONCLUSIONS

Standard anxiety assessment scales do not predict the quality of anesthetic induction. m-YPAS scale can detect increasing anxiety in children as they approach the surgical procedure and this correlates strongly with a worse anesthetic induction, defined by higher score on ICC scale.

Neuroprotection by cannabidiol and hypothermia in a piglet model of newborn hypoxic-ischemic brain damage

OBJECTIVE

Hypothermia, the gold standard after a hypoxic-ischemic insult, is not beneficial in all treated newborns. Cannabidiol is neuroprotective in animal models of newborn hypoxic-ischemic encephalopathy. This study compared the relative efficacies of cannabidiol and hypothermia in newborn hypoxic-ischemic piglets and assessed whether addition of cannabidiol augments hypothermic neuroprotection.

METHODS

One day-old HI (carotid clamp and FiO₂ 10% for 20 min) piglets were randomized to vehicle or cannabidiol 1 mg/kg i.v. u.i.d. for three doses after being submitted to normothermia or 48 h-long hypothermia with a subsequent rewarming period of 6 h. Non-manipulated piglets (naïve) served as controls. Hemodynamic or respiratory parameters as well as brain activity (aEEG amplitude) were monitored throughout the experiment. Following termination, brains were obtained for histological (TUNEL staining, apoptosis; immunohistochemistry for Iba-1, microglia), biochemical (protein carbonylation, oxidative stress; and TNFα concentration, neuroinflammation) or proton magnetic resonance spectroscopy (Lac/NAA: metabolic derangement; Glu/NAA: excitotoxicity).

RESULTS

HI led to sustained depressed brain activity and increased microglial activation, which was significantly improved by cannabidiol alone or with hypothermia but not by hypothermia alone. Hypoxic-ischemic-induced increases in Lac/NAA, Glu/NAA, TNFα or apoptosis were not reversed by either hypothermia or cannabidiol alone, but combination of the therapies did. No treatment modified the effects of HI on oxidative stress or astroglial activation. Cannabidiol treatment was well tolerated.

CONCLUSIONS

cannabidiol administration after hypoxia-ischemia in piglets offers some neuroprotective effects but the combination of cannabidiol and hypothermia shows some additive effect leading to more complete neuroprotection than cannabidiol or hypothermia alone.

3-lead electrocardiogram is more reliable than pulse oximetry to detect bradycardia during stabilisation at birth of very preterm infants

OBJECTIVES

Current neonatal resuscitation guidelines suggest the use of ECG in the delivery room (DR) to assess heart rate (HR). However, reliability of ECG compared with pulse oximetry (PO) in a situation of bradycardia has not been specifically investigated. The objective of the present study was to compare HR monitoring using ECG or PO in a situation of bradycardia (HR <100 beats per minute (bpm)) during preterm stabilisation in the DR.

STUDY DESIGN

Video recordings of resuscitations of infants <32 weeks of gestation were reviewed. HR readings in a situation of bradycardia (<100 bpm) at any moment during stabilisation were registered with both devices every 5 s from birth.

RESULTS

A total of 29 episodes of bradycardia registered by the ECG in 39 video recordings were included in the analysis (n=29). PO did not detect the start of these events in 20 cases (69%). PO detected the start and the end of bradycardia later than the ECG (median (IQR): 5 s (0-10) and 5 s (0-7.5), respectively). A decline in PO accuracy was observed as bradycardia progressed so that by the end of the episode PO offered significantly lower HR readings than ECG.

CONCLUSIONS

PO detects the start and recovery of bradycardia events slower and less accurately than ECG during stabilisation at birth of very preterm infants. ECG use in this scenario may contribute to an earlier initiation of resuscitation manoeuvres and to avoid unnecessary prolongation of resuscitation efforts after recovery.

Oral Sildenafil for Severe Pulmonary Hypertension Developing after Ibuprofen Use in a Neonate

BACKGROUND

Severe pulmonary hypertension may following ibuprofen administration for ductal closure.

CASE CHARACTERISTICS

An extremely preterm infant who developed severe pulmonary hypertension unresponsive to inhaled nitric oxide after ibuprofen administration.

OUTCOME

Pulmonary hypertension reversed after the administration of oral sildenafil, but the infant died due to complications related to bronchopulmonary dysplasia.

MESSAGE

Sildenafil may have a role in treatment of severe pulmonary hypertension after ibuprofen treatment for ductal closure.

Prenatal Exposure to Angiotensin II Receptor Blockers and Hemodynamic Effects on the Newborn

Angiotensin II receptor blockers (ARBs) are potent antihypertensive agents that block the renin angiotensin aldosterone system (RAS). Their use in pregnancy may cause malformations, oligoanuria, hypotension, and death. Hypotension is observed up to 15% of cases and is described as refractory to volume and inotropic support, although its pathophysiology is unknown. We present a case of prenatal exposure to ARBs in order to characterize the hemodynamic compromise in the newborn, help in decision-making, and guide the therapeutic approach to these patients.

Effective coil embolization of intracavernous carotid artery pseudoaneurysm with parental artery preservation following severe head trauma in a pediatric patient

BACKGROUND

Intracranial traumatic pseudoaneurysms are rare in children. If left untreated, mortality rate can be as high as 50% due to delayed rupture and disastrous bleeding. Endovascular embolization is considered the preferred treatment option because of its minimal invasiveness and negligible mortality. However, exclusion of the pseudoaneurysm with preservation of the parental vessel is not always possible. In comparison with peripheral aneurysms, intracavernous internal carotid artery lesions are technically more challenging with both open surgery and endovascular techniques.

CASE REPORT

We report the case of a successful two-stage coil embolization of a traumatic intracavernous carotid artery pseudoaneurysm with preservation of parental vessel in a 6-year-old boy.

CONCLUSION

Endovascular embolization with parental vessel preservation should be considered the first treatment option for traumatic intracavernous internal carotid artery pseudoaneurysms in children. Although treatment of pseudoaneurysms in this location may be technically difficult, it is feasible in experienced hands.

Spontaneous resolution of hypereosinophilic syndrome in an infant without treatment

We report on a 4-month-old boy with hypereosinophilic syndrome (HES) and spontaneous progressive resolution without treatment. Differential diagnosis excluded myeloproliferative, lymphocytic, familiar, associated, and overlap HES. The final diagnosis was undefined HES. Repeated measurements of blood eosinophil counts, monitoring of clonal T cells, and observation of skin lesions and organ involvement were carefully performed as an outpatient.

[Syncope in the debut of a mediastinal mass]

Pediatric syncope accounts for 3% of the consultations in emergency department. It is frequent in pediatrics, particularly in teenager girls between 15 and 19 years old, and up to a 25% of them have suffered from a syncopal episode. Most causes are benign, but the aim in its initial evaluation is ruling out those which mean any danger. Heart disease can lead to syncope in a 10-28% of cases. A detailed medical history and an exhaustive exploration are enough to rule out organic pathology in most situations. We present the case of a diffuse large B cell lymphoma located in the mediastinum diagnosed after repetitive syncopal episodes.

Comparison of the primary stabilities of conical and cylindrical endosseous dental implants: an in-vitro study

The aim of this study is to determine the differences in primary stability between conical and cylindrical dental implants. The insertion and removal torques were the parameters used to measure the primary stability of the implants. Ten conical and cylindrical dental implants were positioned in polyurethane foam blocks to simulate bone density classes D1, D2, D3 and D4. The insertion and removal torques were quantified using a digital torque gauge. The maximum insertion torque and the maximum removal torque measured for the D1 and D4 synthetic bone were significantly higher for the conical implants than the cylindrical implants. In this in-vitro model, conical implants show significantly higher primary stability than cylindrical implants for the D1 and D4 synthetic bone classes.

Unusual sites of extrapulmonary metastases of osteosarcoma after several lines of treatment

The authors report a case of peritoneal and chest wall metastases in a 17-year-old boy previously diagnosed of femur osteosarcoma with metastases in the lung and bones. Although the patient achieved complete remission after initial treatment, he presented with lung metastasis 15 months after initial diagnosis. They were resected 3 times and he received second-line chemotherapy with gemcitabine and docetaxel. However, 31 months after initial diagnosis he presented with abdominal and chest wall masses. In this report the authors discuss clinical outcomes and how unusual sites of metastasis are being increasingly reported after the use of new treatments.

Brain abscess and epidural empyema caused by Salmonella enteritidis in a child: successful treatment with ciprofloxacin: a case report

Focal intracranial infections caused by Salmonella are rare, especially those produced by S. enteritidis. We describe the case of a 26-month-old girl who underwent surgery for a frontoparietal ependymoma and presented with epidural empyema and a brain abscess due to S. enteritidis following an episode of gastroenteritis. The child was successfully treated by surgical drainage along with 9 weeks of antibiotic therapy including ciprofloxacin.

Caspase activation and apoptosis in response to proteasome inhibitors

Several studies have indicated that proteasome inhibitors (PIs) are promising anticancer agents. We have discovered that PIs have the unique ability to activate effector caspases through a mitochondrial Bcl-2 inhibitable but caspase-9 independent pathway. Stabilization of released Smac induced by blockade of the proteasome could explain the apoptosome-independent cell death induced by PIs. In fact, Smac/DIABLO critically supports this PIs-dependent caspase activation. By using a new assay, we confirm that at a single cell level both Smac and PIs can activate caspases in the absence of the apoptosome. Moreover, we have observed two PIs-induced kinetics of caspase activation, with caspase-9 being still required for the rapid caspase activation in response to mitochondrial depolarization, but dispensable for the slow DEVDase activation. In summary, our data indicate that PIs can activate downstream caspases at least in part through Smac/DIABLO stabilization.