Vaccination practices in pediatric transplantation: A survey among member centers of the European reference network TransplantChild

BACKGROUND

There is considerable variation in vaccination practices between pediatric transplant centers. This study aims to evaluate active immunization attitudes and practices among ERN-TransplantChild centers and identify potential areas of improvement that could be addressed by shared evidence-based protocols.

METHODS

A cross-sectional questionnaire of attitudes and practices toward immunization of pediatric SOT and HSCT candidates and recipients was sent to a representative member of multidisciplinary teams from 27 European centers belonging to the ERN-TransplantChild.

RESULTS

A total of 28/62 SOT programs and 6/12 HSCT programs across 21 European centers participated. A quarter of centers did not have an on-site protocol for the immunizations. At the time of transplantation, pediatric candidates were fully immunized (80%-100%) in 57% and 33% of the SOT and HSCT programs. Variations in the time between vaccine administration and admission to the waiting list were reported between the centers, with 2 weeks for inactivated vaccines and variable time (2-4 weeks) for live-attenuated vaccines (LAVs). Almost all sites recommended immunization in the post-transplant period, with a time window of 4-8 months for the inactivated vaccines and 16-24 months for MMR and Varicella vaccines. Only five sites administer LAVs after transplantation, with seroconversion evaluated in 80% of cases.

CONCLUSIONS

The immunization coverage of European pediatric transplant recipients is still inconsistent and far from adequate. This survey is a starting point for developing shared evidence-based immunization protocols for safe vaccination among pediatric transplant centers and generating new research studies.

Development and use of an innovative Gap Finding Tool to create a Pharmaceutical Care Model within a paediatric oncology setting

INTRODUCTION

A paediatric cancer ward is a setting where pharmacists participate in direct patient care, acting as coordinators between the patient, caregivers and healthcare professionals. The aim of the study was to develop a Gap Finding Tool to support the setting up of a pharmaceutical care model at a Paediatric-Adolescent Cancer Ward.

METHODS

The Standards of Practice for Clinical Pharmacy Services by the Society of Hospital Pharmacists of Australia Committee of Specialty Practice in Clinical Pharmacy (2013), the American College of Clinical Pharmacy (2014) and the European Association of Hospital Pharmacists (2014) were used to compile the Gap Finding Tool. The developed Tool was tested for content validity by a panel of experts and subsequently implemented over 2 months.

RESULTS

The Gap Finding Tool comprised of nine sections with an average of eight statements each about pharmacy services that should be provided at ward level. For each statement, the rater indicates whether these contributions are provided. When the Tool was implemented at the Paediatric-Adolescent Cancer Ward, four major gaps were identified, namely, absence of a clinical pharmacist, lack of medicines information, vetting of chemotherapy prescriptions by pharmacist with limited access to patient data and lack of pharmacist-input on medicines availability. Processes requiring optimisation included discharge medication advice and documentation processes.

CONCLUSION

The developed Gap Finding Tool is an innovative tool which is versatile and can be used in ward or ambulatory clinical settings to identify gaps in pharmaceutical processes and services and compare national or regional practices to international standards.

Misalignment of hemodynamic forces in the left ventricle is associated with adverse remodeling following STEMI

Funding Acknowledgements

Type of funding sources: None.

Background

Infarct size (IS), area at risk (AAR) and microvascular obstruction (MVO) are well known predictors of adverse remodeling (aLVr) following acute myocardial infarction, while the pathogenic role of left ventricular (LV) hemodynamic forces (HDFs) is still unknown. Recent evidence suggests the role of HDFs in negative remodeling after pathogenic events. 

Purpose

To identify LV HDFs patterns associated with aLVr in reperfused ST-segment elevation MI (STEMI) patients.

Methods

Forty-nine acute STEMI patients underwent CMR at 1 week (baseline) and 4 months (follow-up) after MI.  The following parameters were measured: left ventricular end-diastolic and end-systolic volume index for body surface area (LVEDVi and LVESVi), left ventricular ejection fraction (LVEF) and LV mass index, AAR and IS. LV HDFs were computed at baseline from cine CMR long axis datasets using a novel method based on LV endocardial boundary tracking. LV HDFs were calculated both in apex-base (A-B) and latero-septal (L-S) directions. The distribution of LV HDFs were evaluated by L-S over A-B HDFs ratio (L-S/A-B HDFs ratio %). All HDFs parameters are computed over the entire heartbeat, in systole and diastole. aLVr was defined as an absolute increase in LVESV of at least 15% (ΔLV-ESV ≥15%).

Results

Patients with aLVr (n = 18; 37%) had significant greater value of AAR (32 ± 23 vs 22 ± 18; p = 0.03) and slightly larger IS (23 ± 16 vs 15 ± 11; p= 0.07) at baseline. In patients with aLVr at FU, baseline systolic L-S HDF were lower (2.7 ± 0.9 vs 3.6 ± 1; p = 0.027) while diastolic L-S/A-B HDF ratio was significantly higher (28 ± 14 vs 19 ± 6; p = 0.03), reflecting higher grade of diastolic HDFs misalignment. At univariate logistic regression analysis, higher IS [Odd ratio (OR) 1.05; 95% confidence interval (95% CI) 1.01-1.1; p= 0.04] L-S HDFs (OR 0.41; 95% CI 0.2-0.9; p= 0.04] and higher diastolic L-S/A-B HDFs ratio (OR 1.1; 95% CI 1.01-1.2; p= 0.05) were associated with aLVr at FU (Table).  At multivariate logistic regression analysis, L-S/A-B HDF ratio remained the only independent predictor of adverse LV remodeling after correction for other baseline determinants.

Conclusion

Misalignment of diastolic HDFs following STEMI is associated with aLVr observed after 4 months.

Predictors of adverse remodeling Univariate Multivariate Parameter OR (95% CI) P OR (95% CI) P IS (%) 1.05 (1.01-1.1) 0.042 - - Systolic L-S HDF 0.41 (0.2-0.9) 0.04 - - Diastolic L-S/A-B HDF Ratio 1.1 (1.01-1.2) 0.05 1.1 (1.01-1.2) 0.04 A-B:apex-base; L-S: latero-septal; HDFs: hemodynamic forces Abstract Figure. Diastolic HDFs distribution and aLVr

Myocarditis-associated necrotizing coronary vasculitis: incidence, cause and outcome

Background

Necrotizing coronary vasculitis (NCV) is a rare entity usually associated to myocarditis (M), which incidence, cause and responsiveness to therapy is unreported.

Purpose

We set out a retrospective study to report our experience in the diagnosis and management of myocarditis-associated necrotizing coronary vasculitis (M-NCV) and patients' outcome.

Methods

Among 5180 patients undergoing endomyocardial biopsy in our institution, 1916 received a histological diagnosis of myocarditis with associated NCV in 30 (12F, 18M, mean age 47.7 years±15). NVC endomyocardial samples were retrospectively evaluated with, immunohistochemistry for Toll like Receptor 4 (TLR4) and real-time PCR for viral genomes. Serum samples were processed for anti-heart autoantibodies and inflammatory cytokine profile (ELLA assay).Identification of an immunologic pathway (virus-, TLR4+, anti-heart abs +) was followed by immunosuppression including steroids, azathioprine, cyclophosphamide, high dose immunoglobulins and anakinra. M-NCV patients were followed for 6-months with resting ECG, Holter monitoring, 2D-echo and in 45% of cases with cardiac magnetic resonance. Increase of ≥10% in left ventricular EF was classified as response to therapy. M-NCV patients were compared to a control group of 60 consecutive patients with virus + and − lymphocithic myocarditis and a control group of 30 patients with mitral stenosis and normal LV size and function, undergoing surgical repair.

Results

26 M-NCV patients presented with heart failure or cardiogenic shock; 3 with electrical instability; 1 with infarct-like symptoms. Cause of M-NCV included infectious agents (PVB19, HHV2, EBV and co-infection of Toxoplasma gondii and PVB19) in 4 patients; chest trauma in 1; drug-hypersensitivity in 2; hypereosinophilic syndrome in 1; primary autoimmune disease in 7; giant cells in 3; while it was idiopathic in the remaining cases. CMR imaging did not detect any qualitative difference between M-NVC and M patients. Anti-heart autoantibodies were positive in immune-mediated M-NCV and virus- M; in M-NCV patients in which anti-heart autoantibodies were positive, we found a cross-reaction with vessel walls. Myocardial expression of TLR4 was high in the immune-mediated forms and negative in the viral. Interleukins 1-beta was more elevated (p<0.001) in patients with M-NCV in comparison with virus-M patients. M-NCV patients presented a more severe clinical profile with 24% in-hospital mortality compared with 1.5% of the M group. Immunosuppression resulted in an improvement of cardiac function in 86% of M-NCV and 88% of virus-M cohort.

Conclusion

NCV can be histologically detected in up to 1.5% of a large population with myocarditis. Major causes include viral, autoreactive and autoimmune processes. Intra-hospital mortality is high (24%). Presence of an immunologic pathway is associated with a beneficial response to immunosuppression.

Funding Acknowledgement

Type of funding source: Public grant(s) – EU funding. Main funding source(s): European Project ERA-CVD

P670 RV function in adult patients with repaired tetralogy of Fallot: assessment by three-dimensional echocardiography, comparison to CMR findings and relationship to pulmonary artery distensibility

Purpose

The purpose of this study was to examine right ventricular (RV) function by three-dimensional speckle-tracking echocardiography (3DSTE) in patients after correction of tetralogy of Fallot (TF), the accuracy of 3DSTE compared to cardiovascular magnetic resonance (CMR) findings and assess pulmonary arterial (PA) distensibility in order to achieve a more comprehensive understanding of the matching between RV performance and PA load.

Methods

Twenty-one patients (mean age 39 ± 16 years) with repaired TF and twenty-one age-matched healthy subjects selected as controls were studied. CMR findings were available in 14 patients. RV volumes, RV ejection fraction (RVEF) and RV longitudinal and circumferential strains were calculated by three-dimensional echocardiography and three-dimensional speckle tracking echocardiography. The main pulmonary artery was interrogated by color, pulsed, and continuous-wave Doppler. Pulmonary regurgitation (PR) was assessed by color-flow mapping and graded as none, mild, or greater than mild using the measurement of the regurgitant jet width in relation to the outflow tract diameter. Right pulmonary artery (PA) was visualized from suprasternal view by two-dimensional echocardiography. Tissue Doppler Imaging (TDI) mode was activated in B-mode imaging to examine arterial motion, then mode was changed to color-mode with the beam line aligned perpendicular to the superior and inferior walls of the right PA. PA distensibility and strain were determined. Data analysis was performed offline.

Results

Overall, 3D RVEF and RV longitudinal strain were reduced in TF patients compared to the control group. Nine patients had moderate or moderate-to-severe PR. PA strain and distensibility were decreased (p = 0.003) compared with controls, both in the presence and absence of PR. PA strain had a positive correlation with RVEF (r = 0.79, p < 0.005) and RV strain (r = 0.82, p < 0.001). RV end-diastolic and end-systolic volumes by 3DE correlated with the respective parameters by CMR (r = 0.88,p < 0.001 and r = 0.87,p < 0.005 respectively). Patients with moderate-to-severe PR had more prominent PA strain changes (p = 0.02).

Conclusions

Three-dimensional right ventricular ejection fraction and RV strain are impaired in patients with repaired TF, in agreement with CMR data. Reduced PA strain is associated with reduced RV 3DSTE parameters and is more pronounced in the presence of pulmonary regurgitation.

Recurrent Langerhans cell histiocytosis at the site of prior craniotomy: case report

Tumors of the CNS represent the largest group of solid tumors found in the pediatric patient population. Langerhans cell histiocytosis (LCH) is an inflammatory lesion that may present in bone and/or soft tissue, including the CNS. Management depends on the extent of multisystem involvement, which determines resection with or without systemic chemotherapy. The authors report on the case of a child who underwent an open craniotomy for biopsy of a pituitary stalk lesion followed by neuropathological assessment, procedures used to diagnose LCH. The patient then underwent 12 months of systemic chemotherapy with subsequent resolution of the pituitary stalk lesion. Two years following pathological diagnosis, the patient presented with frontal orbital pain at the site of the prior craniotomy. Advanced imaging revealed MRI enhancement and radiotracer uptake of a soft-tissue growth at the frontal burr-hole site and MRI enhancement at a posterior burr-hole site without soft-tissue growth. The patient then underwent open biopsy and curettage that revealed LCH recurrence at the site of prior craniotomy. This case demonstrates that LCH may represent an abnormal reactive clonal proliferation of dendritic cells, rather than a de novo malignant neoplasm that can occur at sites of prior craniotomy despite systemic chemotherapy. The authors advocate close follow-up with contrast-enhanced imaging. Special attention should be given to sites of prior surgical manipulation to avoid missing distant sites of recurrence.

A case of metastatic Wilms' tumour with reversible distortion of mediastinal anatomy - a diagnostic challenge for the echocardiographer

Delineation and documentation of anatomy in the presence of significant mass pathology presents a diagnostic challenge. This often necessitates the implementation of more than one imaging modality in order to perform an adequate assessment. We present a three-year old boy with extensive distortion of mediastinal anatomy secondary to pleural metastases from a Wilms tumour. This limited the ability to accurately assess mediastinal anatomy and cardiac function at baseline. Reassessment following initiation of chemotherapy showed a significant reduction in size of metastases with complete resolution of the mediastinal distortion.

Aortic valve stenosis: non-invasive preoperative evaluation using 64-slice CT angiography

AIM

In patients affected by aortic valve stenosis (AS) it is mandatory to rule out coronary artery disease (CAD). The role of retrospectively ECG-gated 64-slice CT angiography (64-SCTA) was assessed in patients with AS referred for surgical valve replacement.

METHODS

Forty-two patients with AS underwent ECG-gated 64-SCTA of thoracic aorta, including the heart and coronary arteries, before surgical valve replacement. Images were evaluated by two independent readers and compared with surgical findings in terms of aortic valve calcification grading, valvular morphology, aortic valve annulus and sino-tubular junction diameters, and valvular area planimetry. Quantitative evaluation of cusps opening was also performed. Finally, the presence of CAD, thoracic aortic aneurysm and left ventricle hypertrophy were assessed.

RESULTS

Visualization of the aortic valve without motion artefacts was possible in 38 patients (90.5%). Valvular morphology was correctly assessed in all cases (100%). 64-SCTA correctly determined aortic valve calcification grading and the aortic valve annulus and sinotubular junction diameters in 100% of cases. The aortic valve planimetric area was assessed in 38 cases (90.5%). Ascending aortic aneurysms requiring surgical replacement were detected in 12 patients (28.6%). Significant left ventricle hypertrophy was found in 30 patients (71%).

CONCLUSION

Preoperative evaluation of patients undergoing surgical replacement for AS with 64-SCTA is feasible. 64-SCTA can rule out CAD and evaluate the status of the aortic valve and thoracic aorta in the same examination, obtaining relevant information for surgical planning.

ECHO and magnetic resonance imaging in a patient with high bleeding risk and ventricular perforation: a case report and literature review

Myocardial perforation is a complication following pacemaker implantation that may cause cardiac tamponade. We present an original case of myocardial lead perforation not complicated by acute cardiac tamponade. The patient with an acute myocardial infarct had a high bleeding risk both in the acute phase of lead insertion (anticoagulant and triple platelet anti-aggregation therapy) and after few days, the percutaneous extraction lead for the double platelet antiaggregant therapy. Torrent-Guasp's theory is considered for explaining the clinical course of patient. Echocardiography and magnetic resonance imaging (MRI) evaluation showed a diffuse pericardial non-hemorrhagic fibrinous effusion and guide the clinical management.

Risk factors for QRS prolongation after repaired tetralogy of Fallot

INTRODUCTION

Repaired tetralogy of Fallot is usually conducive to a normal and unrestricted lifestyle. However, occasionally, late sudden death occurs due to ventricular tachycardia. This is thought to be due to a combination of factors, including both left and right ventricular dilation, which may be associated with valvular incompetence and residual right ventricular outflow tract obstruction. Several studies have shown that QRS duration > 180 ms is a predictor for life-threatening ventricular arrhythmias.

METHODS AND RESULTS

We recalled our tetralogy population (n = 57) to identify risk factors for prolonged QRS duration on the resting ECG. Factors examined included history, demographics, symptoms, surgery, chest X-ray, ECG and echocardiography. Extensive analysis found only a significant positive correlation between QRS duration and degree of residual right ventricular outflow tract obstruction.

CONCLUSIONS

Our study suggests that residual right ventricular outflow tract gradients may be a very significant contributor to QRS prolongation. It will be interesting to see if future studies of larger cohorts confirm this finding.

Catecholaminergic nerve fibers in bronchus-associated lymphoid tissue: age-related changes

Age-related changes of the catecholaminergic nerve fibers of the trachea, bronchial smooth muscle, lung capillaries and bronchus-associated lymphoid tissue (BALT) were studied in male Wistar rats aged 3 months (young), 12 months (adult) and 24 months (old/aged). Catecholamine histo- and immuno-fluorescence techniques were used, associated with image analysis and high pressure liquid chromatography with electrochemical detection of nor-epinephrine (nor-adrenaline). In young rats, blue-green fluorescent nerve fibers supply the trachea-bronchial smooth muscle and tracheal and bronchial glands. These structures are innervated by a delicate network of nerve fibers, being rich in varicosities. Pulmonary capillaries are sparsely innervated. The highest nor-epinephrine concentration was found in the trachea and bronchi, followed by BALT. The density and the pattern of noradrenergic nerve fibers of the trachea-bronchial tree or of the pulmonary vessels were similar in young and adult rats. In aged rats, a loss of noradrenergic nerve fibers, involving primarily the supply to the smooth muscle of the trachea-bronchial tree, was observed. Fluorescence microscopic techniques demonstrated a higher sensitivity than nor-epinephrine assay in detecting changes of the sympathetic nerve supply of the trachea-bronchial tree, pulmonary vessels and BALT. The possible significance of reduced noradrenergic nerve supply of the trachea-bronchial-pulmonary tree in aged rats is discussed.

Late concomitant repair of tetralogy of Fallot and aortic valve replacement following successful pregnancy

The importance of patient follow-up after repair of tetralogy of Fallot, with special attention to the development of arrhythmias, has been widely studied. It is only recently that postoperative problems relating to the aortic root of these individuals have been looked into. The present case report refers to a patient with tetralogy of Fallot who underwent complete correction, together with aortic valve replacement at 33 years of age following a successful pregnancy. To our knowledge, this is the third report of primary repair of tetralogy of Fallot with simultaneous aortic valve replacement for severe aortic regurgitation. Our patient is unique in that she had uncorrected and unpalliated tetralogy of Fallot and severe aortic regurgitation and still went through an uneventful pregnancy and delivery. There is only one report of successful pregnancy and delivery in uncorrected tetralogy, but this was not associated with aortic regurgitation.

Aortic stenosis after uncomplicated surgical repair of tetralogy of Fallot

Tetralogy of Fallot is only rarely associated with aortic valvar disease. We present a child who had uncomplicated repair of tetralogy of Fallot at 16 months of age, and who developed mild aortic stenosis three years later, with mild to moderate aortic incompetence being seen two years subsequent to that event. No aortic valvar disease had been noted prior to surgery. No intervention is planned at this stage.