Awareness about the orthodontic specialty: A survey study

BACKGROUND

This study aimed to examine how well patients can differentiate between orthodontists and dentists.

METHODS

Four hundred patients who applied to the Ondokuz Mayıs University Faculty of Dentistry, Department of Oral and Maxillofacial Radiology between March and November of 2022 were queried regarding the difference between an orthodontist and a dentist via a face-to-face survey. The respondents were separated into the following two study groups: patients who had previously undergone orthodontic treatment and those who had not. Demographic data of the patients, such as age, sex, educational status, and monthly income, were also collected, and the effects of these factors on their doctor preferences were analyzed.

RESULTS

The vast majority of respondents (>85%) thought that a dentist should be an orthodontic specialist to provide orthodontic treatment. Seven percent of patients chose to receive orthodontic treatment from a dentist. Patients who chose an orthodontist for their treatment were predominantly female and had a high income and a higher level of education. Patients who had a history of orthodontic treatment were better aware of the profession of orthodontics than those who did not.

CONCLUSIONS

The results indicated that the respondents did not fully understand the clear distinction between an orthodontist and a dentist. This outcome suggests that education concerning this issue is required.

Cardiovascular outcomes improve in children with renovascular hypertension following endovascular and surgical interventions

BACKGROUND

Renovascular hypertension (RenoVH) is a cause of hypertension in children. A common cause of RenoVH is renal artery stenosis which acts by reducing blood supply to renal parenchyma and activating the renin-angiotensin-aldosterone axis, often leading to cardiac remodelling. This longitudinal observational study aims to describe occurrence of cardiovascular changes secondary to RenoVH and also any improvement in cardiac remodelling after successful endovascular and/or surgical intervention.

METHODS

All patients with RenoVH referred to our centre, who received ≥ 1 endovascular intervention (some had also undergone surgical interventions) were included. Data were collected by retrospective database review over a 22-year period. We assessed oscillometric blood pressure and eight echocardiographic parameters pre- and post-intervention.

RESULTS

One hundred fifty-two patients met inclusion criteria and had on average two endovascular interventions; of these children, six presented in heart failure. Blood pressure (BP) control was achieved by 54.4% of patients post-intervention. Average z-scores improved in interventricular septal thickness in diastole (IVSD), posterior Wall thickness in diastole (PWD) and fractional shortening (FS); left ventricular mass index (LVMI) and relative wall thickness (RWT) also improved. PWD saw the greatest reduction in mean difference in children with abnormal (z-score reduction 0.25, p < 0.001) and severely abnormal (z-score reduction 0.23, p < 0.001) z-scores between pre- and post-intervention echocardiograms. Almost half (45.9%) had reduction in prescribed antihypertensive medications, and 21.3% could discontinue all antihypertensive therapy.

CONCLUSIONS

Our study reports improvement in cardiac outcomes after endovascular + / - surgical interventions. This is evidenced by BP control, and echocardiogram changes in which almost half achieved normalisation in systolic BP readings and reduction in the number of children with abnormal echocardiographic parameters. A higher resolution version of the Graphical abstract is available as Supplementary information.

SUPPLEMENTARY INFORMATION

Gutted: constipation in children with chronic kidney disease and on dialysis

Functional constipation is a common problem in otherwise healthy children. Children with chronic kidney disease (CKD) and on dialysis have additional disease-related risk factors including the uremic milieu, fluid and dietary restrictions, and decreased physical activity, as well as treatment-related risk factors such as dialysis therapy and polypharmacy that contribute to and compound the problem. Constipation causes significant distress for children and their caregivers. In children on peritoneal dialysis, severe constipation can impede catheter function and ultrafiltration. Accumulating evidence points to a possible bidirectional relationship between constipation and CKD, potentially mediated by gut dysbiosis with consequent increased generation of gut-derived uremic toxins and disruption of intestinal epithelium integrity leading to translocation of noxious luminal contents into the circulation inducing systemic inflammation. Effective management of constipation is required but there is little published data on the safety and effectiveness of treatments in adults or children with CKD. In this review, we discuss the diagnosis and epidemiology of functional constipation, provide an overview of its pathophysiology, summarize the therapeutic management, and reflect on the challenges in children with CKD.

Mendelian steroid resistant nephrotic syndrome in childhood: is it as common as reported?

BACKGROUND

Primary steroid resistant nephrotic syndrome (SRNS) is thought to have either genetic or immune-mediated aetiology. Knowing which children to screen for genetic causes can be difficult. Several studies have described the prevalence of genetic causes of primary SRNS to be between 30 and 40%, but these may reflect a selection bias for genetic testing in children with congenital, infantile, syndromic or familial NS and thus may overestimate the true prevalence in a routine clinical setting.

METHODS

Retrospective electronic patient record analysis was undertaken of all children with non-syndromic SRNS and presentation beyond the first year of life, followed at our centre between 2005 and 2020.

RESULTS

Of the 49 children who met the inclusion criteria, 5 (10%) had causative variants identified, predominantly in NPHS2. None responded to immunosuppression. Of the 44 (90%) who had no genetic cause identified, 33 (75%) had complete or partial remission after commencing second-line immunosuppression and 67% of these had eGFR > 90 ml/min/1.73 m² at last clinical follow-up. Of the children who did not respond to immunosuppression, 64% progressed to kidney failure.

CONCLUSIONS

In our cohort of children with non-syndromic primary SRNS and presentation beyond the first year of life, we report a prevalence of detectable causative genetic variants of 10%. Those with identified genetic cause were significantly (p = 0.003) less likely to respond to immunosuppression and more likely (p = 0.026) to progress to chronic kidney disease. Understanding the genetics along with response to immunosuppression informs management in this cohort of patients and variant interpretation. A higher resolution version of the Graphical abstract is available as Supplementary information.

Experience of ethical dilemmas among professionals working in pediatric transplantation: An international survey

BACKGROUND

Professionals working in pediatric transplantation commonly encounter complex ethical dilemmas. Most ethical research in transplantation is related to adult practice. We aimed to gain insight into ethical issues faced by transplant professionals when dealing with pediatric transplant recipients.

METHODS

A two-stage study was designed; the first part was a questionnaire completed by 190 (80%) members of the International Pediatric Transplant Association (IPTA) from over 30 different countries. This was followed by a multidisciplinary focus group that explored the preliminary data of the survey.

RESULTS

A total of 38% (56 of 149) respondents of the questionnaire had experienced an ethical issue between 2016 and 2018. Surgeons were more likely to have encountered an ethical issue as compared with physicians (60% vs. 35.7%, p = .035). Clinicians from Europe were more likely to have experienced an ethical issue in living organ donation compared with those from North America (78.9% vs. 52.5%, p = .005), with common ethical concerns being psychosocial evaluation and follow-up care of donors. The focus group highlighted the importance of a multidisciplinary approach to ethical issues.

CONCLUSION

The results of this study can direct future research into pediatric transplantation ethics with the aim of producing educational resources, policies, and ethical guidelines.

Kidney Transplantation From Deceased Donors With Vaccine-induced Immune Thrombocytopenia and Thrombosis: An Updated Analysis of the UK Experience

BACKGROUND

The emergence and attendant mortality of vaccine-induced immune thrombocytopenia and thrombosis (VITT) as a consequence of vaccination against severe acute respiratory syndrome coronavirus 2 have resulted in some patients with VITT being considered as deceased organ donors. Outcomes after kidney transplantation in this context are poorly described. Because the disease seems to be mediated by antiplatelet factor 4 antibodies, there is a theoretical risk of transmission via passenger leukocytes within the allograft.

METHODS

We analyzed the experience of kidney transplantation from donors with VITT in the United Kingdom between January and June 2021. We followed-up all recipients of kidney-only transplants from donors with VITT to detect major postoperative complications or features of disease transmission and assess graft survival and function.

RESULTS

There were 16 kidney donors and 30 single kidney transplant recipients in our study period. Of 11 preimplantation biopsies, 4 showed widespread glomerular microthrombi. After a median of 5 mo, patient and graft survival were 97% and 90%, respectively. The median 3-mo estimated glomerular filtration rate was 51 mL/min/1.73 m 2 . Two recipients had detectable antiplatelet factor 4 antibodies but no evidence of clinical disease after transplantation. Major hemorrhagic complications occurred in 3 recipients, all of whom had independent risk factors for bleeding, resulting in the loss of 2 grafts. The involvement of VITT could not be completely excluded in one of these cases.

CONCLUSIONS

The UK experience to date shows that favorable outcomes are possible after kidney transplantation from donors with VITT but highlights the need for ongoing vigilance for donor-related complications in these patients.

Long-term Efficacy and Safety of Repeated Rituximab to Maintain Remission in Idiopathic Childhood Nephrotic Syndrome: An International Study

Background: Long-term outcomes following multiple rituximab courses among children with frequently-relapsing, steroid-dependent nephrotic syndrome (FRSDNS) are unknown. Methods: A retrospective cohort study at 16 pediatric nephrology centers from 10 countries in Asia, Europe, and North America included children with FRSDNS who received ≥2 rituximab courses. Primary outcomes were relapse-free survival and adverse events. Results: 346 children (age 9.8 years, IQR 6.6-13.5; 73% boys) received 1149 rituximab courses. 145, 83, 50, 28, 22, and 18 children received 2, 3, 4, 5, 6 and ≥7 courses, respectively. Median follow-up was 5.9 years (IQR, 4.3-7.7). Relapse-free survival differed by treatment courses (clustered log-rank test p<0.001). Compared to the first course (10.0 months, 95% CI, 9.0-10.7), relapse-free period and relapse risk progressively improved following subsequent courses (12.0-16.0 months; HRadj, 0.03-0.13; 95% CI, 0.01-0.18; ps<0.001). B-cell depletion duration remained similar with repeated treatments (6.1 months, 95% CI, 6.0-6.3). Adverse events were mostly mild, most commonly hypogammaglobulinemia (50.9%), infection (4.5%), and neutropenia (3.7%). Side effects did not increase with more treatment courses nor higher cumulative dose. Only 78 of the 353 episodes of hypogammaglobulinemia were clinically significant. Younger age at presentation (2.8 vs 3.3 years; p=0.05) and at first rituximab (8.0 y vs 10.0 years; p=0.01) and history of steroid resistance (28% vs 18%; p=0.01) were associated with significant hypogammaglobulinemia. All 53 infective episodes resolved, except one patient with hepatitis B infection and another with EBV infection. There were 42 episodes of neutropenia, associated with history of steroid resistance (30% vs 20%, p=0.04). Upon last follow-up, 332 children (96%) had normal kidney function. Conclusion: Children receiving repeated rituximab for FRSDNS experience an improving clinical response. Side effects appear acceptable but significant complications can occur. These findings support repeated rituximab use in FRSDNS.

SAT0543 PREVALENCE OF FABRY’S DISEASE IN MILD AND SEVERE FMF PATIENTS

Background:

Fabry disease (FD) is a rare metabolic disorder caused by the mutations in the α-galactosidase A (GLA) gene. FD patients present with heterogeneous clinical manifestations, which may overlap with systemic diseases including familial Mediterranean fever (FMF). Recurrent episodes of fever, abdominal pain, and arthralgias can be observed in both disorders and this may lead to misdiagnosis.

Objectives:

To investigate FD prevalence in mild and severe FMF patients.

Methods:

A total of 66 FMF patients, according to the Tel-Hashomer criteria, were included in the study. Patients were grouped into mild (Group 1) and severe (Group 2) subsets according to the severity score. α-GLA enzyme activity and mutations in the GLA gene were performed. Demographic features, clinical findings, MEFV mutations and treatments were recorded.

Results:

The clinical and demographical characteristics of the patients were given in Table 1. In severe form, 27 patients were using biological drug and 40.7% had amyloidosis. Symptoms related to FD including hypohidrosis, acroparesthesias, and painful neuropathies, were not different between the groups. Only one patient in group 1 had a low GLA enzyme activity (0.1 nmol/h/ml;Normal >2.5) which also had mutations in the GLA gene but MEFV mutation test was negative. (Table 2). This patient was a 39-year-old female with recurrent abdominal pain, distal extremity pain and the presence of fever during the attacks. She was heterozygous for R301Q. In detailed history, she reported mild acroparesthesias, hypohidrosis, and tinnitus.

Table 1.

Demographic and clinical findings

All patientsn: 66Group 1n: 32Group 2n: 34p-valueAge, median (min./max.)34 (17/64)27 (17/59)36 (18/64)0.192Male, n (%)36 (54.5)14 (43.8)22 (64.7)0.137Disease duration, median (min./max.)20.5 (1/57)12.5 (2/50)25 (1/57)0.006Family history of FMF, n (%)41 (62.1)22 (68.8)19 (57.6)0.443Alpha-galactosidase A (nmol/h/ml), median (min./max.)5.9 (0.1/16)5.6 (0.1/9.6)6 (3.1/16)0.330Abdominal pain, n (%)58 (87.9)31 (96.9)27 (79.4)0.030Fever, n (%)54 (81.8)25 (78.1)29 (85.3)0.532Arthritis, n (%)34 (51.5)10 (31.3)24 (70.6)0.003Pleuritis, n (%)31 (47)19 (59.4)12 (35.3)0.083Painful neuropathy, n (%)23 (34.8)13 (40.6)10 (29.4)0.440Acroparesthesias, n (%)9 (13.6)6 (18.8)3 (8.8)0.240Angiokeratomas, n (%)0 (0)0 (0)0 (0)-Cardiac abnormalities1 (1.5)1 (3,1)0 (0)0.485Tinnitus, n (%)4 (6.1)3 (9.4)1 (2.9)0.274Hearing loss, n (%)2 (3)2 (6.2)00.086Hypohydrozis, n (%)2 (3)1 (3.1)1 (2.9)0.965Cornea verticillata, n (%)0 (0)0 (0)0 (0)-Proteinüria, n (%)13 (19.7)2 (6.3)11 (32.4)0.012Colchine dosing (mg/day), median (min./max.)2 (1/3)1 (1/2)2 (1/3)<0.001Table 2.

MEFV mutant alleles and GLA mutations

All patientsn: 66Group 1n: 32Group 2n: 34Alpha -galactosidase A (GLA) gene mutations, n (%)1 (1.5)1 (3.1)0 (0)M694V mutations, n (%)47 (35.6)17 (26.5)30 (44.1)Non-M694V mutations, n(%)36(27.2)20 (31.2)16 (23.5)

Conclusion:

In this study, we showed the following: 1) the FD rate in the total FMF group was 1.5% (3.1% in group 1), 2) none of the patients in the severe FMF subset had abnormal enzyme activity or mutations related with FD, 3) symptoms related with FD such as hearing loss, hypohidrosis, acroparesthesias, and painful neuropathies also noted in FMF patients particularly in the milder group. Based on our results, FD should be considered in the differential diagnosis of FMF particularly in patients with atypical symptoms.

Disclosure of Interests:

None declared

Lithium toxicity in a neonate owing to false elevation of blood lithium levels caused by contamination in a lithium heparin container: case report and review of the literature

Lithium toxicity in a neonate can occur owing to antenatal exposure as a result of maternal treatment for psychiatric illnesses. False elevation of lithium levels has been reported in the paediatric population when the sample was mistakenly collected in a lithium heparin container. A term, male infant was born to a mother who was on lithium treatment for a psychiatric illness. On day 1, the infant was jittery, had a poor suck with difficulties in establishing feeds. Blood taken from the infant approximately 8 hours after birth demonstrated a lithium level of 4.9 mmol/L (adult toxic level w1.5 mmol/L). However, the sample for lithium levels was sent in a lithium heparin container and the probability of false elevation was considered. He was closely monitored in the neonatal intensive care unit and his hydration was optimised with intravenous fluids. Clinically, he remained well and commenced feeding, and his jitteriness had decreased the following day. A repeat blood lithium level, collected in a gel container, was only 0.4 mmol/L. The initially raised lithium level was owing to contamination from the lithium heparin container.