Kawasaki disease: patients' transition journey and recommendations for adult care

BACKGROUND

Children who develop coronary artery aneurysms after Kawasaki disease are at risk for cardiovascular morbidity, requiring health care transition and lifelong follow-up with an adult specialist. Follow-up losses after health care transition have been reported but without outcome and patient experience evaluation.

OBJECTIVE

The Theoretical Domains Framework underpinned our aim to explore the required self-care behaviours and experiences of young adults' post-health care transition.

METHODS

A qualitative description approach was used for virtual, 1:1 interviews with 11 participants, recruited after health care transition from a regional cardiac centre in Ontario. Directed content analysis was employed.

RESULTS

Health, psychosocial, and lifestyle challenges were compounded by a sense of loss. Six themes emerged within the Theoretical Domains Framework categories. Participants offered novel health care transition programme recommendations.

CONCLUSIONS

The realities of health care transition involve multiple, overlapping stressors for young adults with Kawasaki disease and coronary artery aneurysms. Our findings will inform a renewed health care transition programme and will include outcome evaluation.

Changes in the electroretinogram resulting from discontinuation of vigabatrin in children

Electroretinograms (ERGs) have been recorded longitudinally in children before and during treatment with the antiepileptic drug vigabatrin for the past 3.5 years. Vigabatrin induced changes in ERG responses occur in children; the most dramatic changes occur in the oscillatory potentials. The purpose of this study was to identify changes in ERG responses associated with discontinuation of vigabatrin treatment. If vigabatrin-induced changes reverse after discontinuation of the drug we infer that the original change is not an indicator of toxicity. ERG data were analyzed from 17 children who discontinued vigabatrin therapy. The duration of treatment ranged from 5 to 52 months, the age for the first ERG ranged from 6 to 38 months (median 10 months). ERGs were tested using the standard protocol established by the International Society for Clinical Electrophysiology of Vision, with Burian-Allen bipolar contact-lens electrodes. In addition to standard responses we recorded photopic oscillatory potentials (OPs). During vigabatrin treatment OPs show a greater change than other ERG responses, with the early occurring wavelets from the photopic OPs showing the greatest change. With discontinuation of vigabatrin the amplitude of the early wavelets of the photopic OPs increased dramatically compared with amplitudes while taking the drug (paired t-test, p = 0.000075). The scotopic oscillatory potentials also show some recovery. Although changes in oscillatory potentials may occur with vigabatrin toxicity, a large change likely occurs with a non-toxic pharmacological effect of vigabatrin on GABAergic amacrine cells in the inner plexiform layer. Reduction of OPs in children on vigabatrin may not be related to toxicity.

Longitudinal changes in photopic OPs occurring with vigabatrin treatment

PURPOSE

Vigabatrin (gamma-vinyl-GABA) is an antiepileptic drug successful in the management of infantile spasms. Photopic ERGs were tested in children followed longitudinally before and during vigabatrin treatment.

METHODS

Subjects were 26 infants (age range 1.5-24 months, median 7.6 months) on vigabatrin treatment who had been tested on multiple visits (two to four visits; mean, three visits). Eighteen of these were assessed initially before starting vigabatrin therapy and eight were assessed within 1 week of initiation of the drug. ERGs were recorded at 6-month intervals. Standard ISCEV protocol with Burian-Allen bipolar contact-lens electrodes (standard flash 2.0 cd.s/m2) was used. Although ISCEV standards were followed, a higher flash intensity (set at 3.6 cd.s/m2) was chosen for single-flash cone assessment to provide a better definition of OPs. Photopic OPs were divided into categories of early OPs and late OP (OP4). Responses were compared with age corrected limits extrapolated from our lab control database.

RESULTS

Results showed differential effects of vigabatrin on the summed early OP amplitudes versus the late OP (OP4) and cone b-wave amplitude. The early OPs showed significant decrease (p = 0.0005, repeated measures analysis of variance) after 6 months and remained decreased for the duration of treatment. There was no significant change seen in the late OP. The cone b-wave amplitude showed initial increase (p = 0.04) after 6 months, followed by a decrease after 18 months; a trend similar to that of the late OP.

CONCLUSION

Early photopic OPs were disrupted more than the late OP, suggesting relative deficit in the ON (depolarizing) retinal pathways.

Comparison of measures of visual acuity in infants: Teller acuity cards and sweep visual evoked potentials

PURPOSE

This study compares the development of acuity in the same infants during one testing session using Teller acuity cards (TAC) and sweep visual evoked potentials (sVEP). We asked whether different testing methods in two centers would produce different developmental time courses.

METHODS

Forty-eight infants were tested in two centers. The standard procedure for TAC was used. For sVEP acuity, the amplitude response curve derived from time-locked cortical activity was used to extrapolate to zero response, giving an acuity estimate for each infant.

RESULTS

sVEP acuity was generally higher than TAC acuity. The rate of development was steeper for TAC than sVEP acuity with TAC starting at a much lower level. The ratio of sVEP to TAC acuity decreased exponentially with age reaching an asymptote of about 1.44 at 6 months.

CONCLUSIONS

Results were indistinguishable between centers suggesting that comparison of acuity measures obtained using variations of these methods across centers is possible.

Effect of cyclophosphamide on rats experimentally infected with Cryptococcus neoformans

This study was undertaken to establish the function of T-lymphocytes in protective immunity against a cryptococcal infection in animals treated with Cyclophosphamide (Cy) pre or post infection and to determine how they relate to the progression of the disease. Inbred Suquia rats were infected either intranasally (i.n.) or intraperitoneally (i.p.) with 10(5) viable Cryptococcus neoformans cells. The infected rats were divided in three groups. One of the groups (group I) was utilized as a control. The second group (group II) was treated with Cy 3 days before the infection. The third group (group III) was treated with Cy 3 days after the infection. At approximately 22 days post infection, C. neoformans growth in selected organs of all animals were determined. In addition, humoral and delayed-type hypersensitivity (DTH) response were assayed in the rats. When the Cy was applied after the infection the DTH was significantly diminished and inverse to the colony forming unit (CFU) which increased leading to the animals death. On the other hand, injection of the drug 3 days before infection did not modify the response, that was comparable in both treated and the control animals. In this study it were found haemagglutinating antibodies in sera from i.n. and i.p. infected rats although at minimal levels and were not present in all animals. The results show that with a low T-cell function induced as a consequence of injecting Cy after the infection, rats did not develop a normal DTH response to cryptococcal infections and were not able to control a cryptococcal infection as well as animals with normal T-cell function.

Experimental cryptococcosis in guinea pigs

A guinea pig model was used to evaluate immune response to Cryptococcus neoformans. This model shared characteristics with cryptococcosis in humans. Twenty five guinea pigs injected intraperitoneally with 10(7) viable C. neoformans cells developed disseminated disease. Forty days after infection all guinea pigs were killed and autopsy performed. C. neoformans growth in the lungs, brains, livers and spleen of the infected animals were determined. Furthermore, the immune response was characterized by moderate degree of delayed-type hypersensitivity and humoral response. In some organs was observed neutrophil and lymphocyte infiltration with presence of cryptococci cells. The infiltration observed in the organs was probably a consequence of an immune reaction.