The tuberculosis spectrum: Translating basic research into pediatric clinical practice

Recent studies suggest that the classical dichotomous classification of "active" and "latent" tuberculosis (TB) is no longer acceptable since "TB infection" encompasses a wide spectrum of conditions ranging from asymptomatic to lethal disease. In an attempt to address these issues from a pediatric clinical perspective, we describe two children with microbiologically confirmed TB but lacking any clinical and radiological evidence of disease. These two cases highlight the hypothesis that TB cannot be divided in two simple categories, but it covers a wide spectrum of manifestations ranging from asymptomatic to lethal TB. The implications of these results in the context of the new TB spectrum and the related clinical issues are discussed.

Treatment of pressure sores in spina bifida patients with calcium alginate and foam dressings

STUDY DESIGN

Prospective study on local treatment of pressure sores using calcium alginate and foam dressings in spina bifida patients.

OBJECTIVE

Investigate if this sequential approach is valid and safe for selected patients with neurological impairments.

MATERIALS AND METHODS

Using European Pressure Ulcer Grading System, after clinical evaluation of local sore, selected patients of Spina Bifida Center of Rome were treated with sequential calcium alginate and foam dressings for 12 weeks. Pressure ulcere surfaces were measured monthly by ulcer tracing. The endpoints were the mean absolute areas surface reduction during every month and number of patients achieving a 50% or more during study.

RESULTS

14 patients (7 males aged 12-24 years) with spina bifida and pressure sores were treated. Mean and standard deviation of mean surface area reduction were 12.5 ± 7.5 cm 2 at start of the study versus 3.7 ± 5.2 cm 2 after 12 weeks, p < 0.001. 75% of the patients reached mean surface area reduction of 50% during trial. Dressing tolerance was good in every patient.

CONCLUSIONS

Calcium alginate and foam dressings are valid and safe approach in the treatment of pressure sores in selected patients with spina bifida. In fact, they protect the wound and create an environment favorable to healing.

IVIG treatment for VZV-related acute inflammatory polyneuropathy in a child

Acute inflammatory polyneuropathy is an inflammatory demyelinating disease triggered by an autoimmune mechanism. It follows an infection or an immunisation after a free interval of 2-30 days. We report a case of a 14-year-old boy who develops an acute rapidly progressive paraplegia, urine incontinence and positive Lasegue a week after a characteristic chickenpox rash. Spinal MRI showed diffuse thickening and leptomeningeal enhancement of cauda equina nerve roots. Intravenous immunoglobulins were given and yielded a dramatic clinical and radiological improvement. The patient was discharged without any clinical problems 1&emsp14;month after the onset of symptoms. We performed a review of the literature, discussing the different forms of varicella-zoster virus-related central and peripheral nervous system complications and management strategies for acute postinfectious encephalomyelitis/radiculitis.

Determinants of bone mineral density, bone mineral content, and body composition in a cohort of healthy children: influence of sex, age, puberty, and physical activity

Interventions directed to the recognition of abnormal bone mineral density, bone mineral content, and body composition in the pediatric age require the definition of factors influencing bone mass acquisition during growth. We have evaluated in a cross-sectional manner by dual-energy X-ray absorptiometry the impact of sex, age, puberty, and physical activity on total body areal bone mineral density, regional (lumbar and femoral) bone mineral densities, bone mineral content, and body composition (fat mass and lean mass) in a cohort of 359 healthy Italian children aged 3-14 years and investigated their specific contribution to bone mass accrual. Statistical multiple regression analysis was performed dividing the population in pre- and post-pubertal groups. Bone mineral density at the lumbar spine has resulted equally distributed in both sexes before puberty while has resulted higher at the femoral necks in males at whatever age. A significant effect on bone mass acquisition was exerted by male sex and lean mass. In the areas where the cortical bone is prevalent, males of the pre-pubertal group have presented the highest values; in the areas where the cancellous bone is prevalent, both sexes were equivalent until the age of 9 years, but after this age, females have presented higher increases, probably related to the inferior dimensional development of lumbar vertebrae. Conclusively, male sex and lean mass seem to represent independent predictors of bone mass accrual in the cortical bone of the examined children, while female sex and pubertal maturation are independent predictors of bone mass accrual in the trabecular bone.

GDNF plasma levels in spina bifida: correlation with severity of spinal damage and motor function

Glial-derived neurotrophic factor (GDNF) is one of several powerful survival factors for spinal motoneurons that play a key role in sprouting, synaptic plasticity, and reorganization after spinal cord damage. The aim of this study was to investigate the expression of GDNF in plasma of children with spina bifida (SB) and to determine its correlation with both the severity of spinal cord damage and the motor function of these patients. To measure the GDNF expression, we collected plasma samples from 152 children with SB and in 149 matched controls. Endogenous GDNF levels were quantified using a two-site immuno-enzymatic assay. The statistical analysis was performed using the Mann-Whitney two-tailed two-sample test. In children with SB the mean levels of GDNF (131.2 +/- 69.6 pg/mL) were significantly higher (p < 0.001) with respect to the mean levels of the control group (102.7 +/- 6.8 pg/mL). Moreover, in open SB, the GDNF levels (139.2 +/- 81.1 pg/mL) were significantly higher (p < 0.05) with respect to closed SB (117.2 +/- 41.3 pg/mL). In terms of the motor function of patients, we found that in children with poorer motor function, the GDNF levels (134.5 +/- 67.4 pg/mL) were higher, but not statistically significant (p < 0.1), than in patients with better motor outcome (122.3 +/- 72.2 pg/mL). Our study demonstrates GDNF over-expression in children with SB. This upregulation is significantly associated with the severity of spinal cord damage in SB patients and appears to correlate with poor motor function of children, representing an important biochemical marker of the severity of spine injury.

Bone mineral density and body composition in a myelomeningocele children population: effects of walking ability and sport activity

Myelomeningocele causes serious locomotor disability, osteoporosis and pathologic fractures. The aim of this study was to investigate the relationship between body composition, bone mineral density, walking ability and sport activity in myelomeningocele children. 60 patients aged between 5 and 14 yrs with myelomeningocele (22 ambulatory and 38 non-ambulatory), were studied. Fat mass and fat-free-mass were calculated by anthropometry. The bone mineral density at lumbar and femoral neck were evaluated. Bone mineral density at the lumbar and femoral neck was lower than in the normal population. In the non-ambulaty group, bone mineral density was approximately 1 SD lower than in the ambulatory one (p < 0.01). Fat mass was greater than expected but without significantly differences between walking group (mean 26%) and wheel-chair users (25%). Patients practised sport activity had a better bone mineral density and body fat compared with other patients with the same disability. Patients with myelomeningocele have decreased bone mineral density and are at higher risk of pathologic bone fractures. All subjects showed an excess of fat as percentage of body weight and are shorter than normal children. The measurement of bone mineral density may help to identify those patients at greatest risk of suffering of multiple fractures. Walk ability and sport activity, associated with the development of muscle mass, are important factors in promoting bone and body growth, to reduce the risk of obesity and of pathological fractures.

Neurotrophic factor expression in newborns with myelomeningocele: preliminary data

BACKGROUND

Neurotrophic factors play a crucial role in the stimulation of sprouting, synaptic plasticity and reorganization after spinal cord damage. The aim of this study was to investigate the expression of some neurotrophic factors [brain derived neurotrophic factor (BDNF), glial derived neurotrophic factor (GDNF), and nerve growth factor (NGF)] in the cerebrospinal fluid (CSF) of newborns with myelomeningocele (MMC) and to determine their correlations with this malformation.

METHODS

To measure the expression of BDNF, GDNF, and NGF, we collected CSF samples of six newborns during the neurosurgical operation to correct the open MMC and of 10 matched controls. Endogenous neurotrophic factor levels were quantified using a two-site immuno-enzymatic assay. The statistical analysis was performed using the Mann-Whitney two-tailed two-sample test.

FINDINGS

In the CSF of patients analysis of neurotrophic factor expression showed a significant increase of BDNF, GDNF, and NGF compared to the mean level of the control group (445.8+/-82.3, 86.5+/-2.6, and 59.9+/-6.2 pg/mL, respectively, respect to 10.2+/-5.9, 19.9+/-11.3, and 15.3+/-2.6 pg/mL) (p<0.001).

INTERPRETATION

Our study shows an over-expression of neurotrophic factors in the CSF of newborns with MMC. This neurotrophin up-regulation may stimulate axonal sprouting and synaptic reorganization of the damaged neural cells at the site of spinal cord lesion. The neurotrophic factor up-regulation may represent a particularly important biochemical markers of spinal cord damage and might be associated with the severity of spine injury in MMC patients.

Patient-controlled analgesia with fentanil and midazolam in children with postoperative neurosurgical pain

BACKGROUND

Pain is the most common discomfort experienced by children undergoing major operations. It is most often not adequately treated because of inexperience and unfounded fears related to the use of opioid drugs. In adults, patient-controlled analgesia (PCA) is widely administered, while in children, its use with opioid drugs is still under evaluation for safety and efficacy.

OBJECTIVES

The objective of the study is to evaluate the safety and efficacy of an opioid drug (fentanil) administered by PCA associated with a sedative-adjuvant drug (midazolam) administered by continuous infusion in children having undergone major neurosurgical procedures.

MATERIALS AND METHODS

Sixteen children with moderate to severe postoperative pain were treated with fentanil by PCA (booster doses of 1 microg/kg) plus continuous infusion of midazolam (2 microg/kg per min) by an intravenous route. To evaluate safety and efficacy of this analgesic protocol, different subjective and objective parameters were monitored at 4-h intervals. In addition, patients' satisfaction was assessed by a questionnaire at the end of the treatment.

MAIN RESULTS

All children experienced a good degree of analgesia and did not require any other analgesic drug during the treatment. Both subjective and objective parameters improved after starting pain-relieving treatment, and no major side effects occurred. The analysis of the answers of the questionnaire administered to the children showed a high grade of satisfaction.

CONCLUSIONS

PCA with fentanil plus continuous infusion of midazolam is a safe and efficacious method for analgesia in children with moderate to severe postoperative neurosurgical pain. The association of midazolam to fentanil also contributes to control anxiety and stress in this subset of patients and does not show any important side effects.

Multidimensional study on quality of life in children with type 1 diabetes

AIM

To study the Health Related Quality of Life (HRQoL) and metabolic assessment in 33 children affected with type 1 diabetes (18 males, 15 females; mean age 10.3 years).

METHODS AND RESULTS

We used the Child Health Questionnaire-Parental Form 50 items (CHQ-PF50), measurements of metabolic control and we related them to patient management and family status. Quality of life (QoL) in diabetic children was worse than in the healthy sample. Interestingly, mean and last glycosylated hemoglobin (mean HbAlc r: -.4410 p < .01 and last HbAlc r: -.4012 p < .01), age of patients (r: -.4428; p < .009) and number of glycaemia controls (r: -.37, p < .03) were the most important parameters related to HRQoL parameters.

CONCLUSION

This multidimensional study stressed that HRQoL is influenced by the metabolic assessment. Moreover, the report examined the parental perception of QoL in children with chronic diseases. Higher number of glycaemia controls/day, better metabolic control, lower age of children and earlier onset of diabetes produced better physical and psychological aspects of QoL. In comparison with adolescent patients, in children with diabetes, factors as number of insulin injections and daily snacks, and the level of education of the mother were not so important to influence QoL. Unexpectedly, in this sample, life habits, family features, and anthropometric parameters did not correlate with specific domains of QoL.

Urodynamic Evaluation in Children With Lipomeningocele: Timing for Neurosurgery, Spinal Cord Tethering and Followup

PURPOSE

We assessed the usefulness of urodynamic testing for determining the optimal timing of surgery and for evaluating the development of bladder function in children with lipomeningocele.

MATERIALS AND METHODS

We retrospectively evaluated 64 patients (40 females) 3 to 17 years old (mean 8.5) with lipomeningocele. Patients were divided into 3 groups based on age at surgery, ie younger than 12 months (34 patients), 12 to 36 months (17) and older than 36 months (13). All patients underwent urodynamic testing preoperatively and during extended followup (mean 6.5 years, range 3 to 12).

RESULTS

Bladder capacity and mean detrusor leak pressure improved in all groups but particularly in patients operated on within the first year of life. At the end of the study mean bladder capacity was 420 cc in patients younger than 12 months, 300 cc in those 12 to 36 months old and 260 cc in those older than 36 months (p <0.01), and mean detrusor leak pressure was 37, 54 and 55 cm H(2)O, respectively (p <0.01). At the latest followup 65% of patients in the youngest group had improved urodynamic parameters vs 33% of those 12 to 36 months old and 28% of those older than 36 months.

CONCLUSIONS

Urodynamic evaluation and the presence of neurological impairment have crucial roles in determining the optimal timing of surgery in patients with lipomeningocele, and in diagnosing the onset of tethered cord. Our data show that early surgical repair seems to reduce the risk of neurological deterioration of the lower urinary tract, and allows a more physiological development of urinary function.

Prevalence of latex allergy in spina bifida: genetic and environmental risk factors

AIM OF STUDY

To evaluate the prevalence of latex allergy in a population of children with spina bifida (SB) and to assess the role of early exposure to latex products and others risk factors.

INTRODUCTION

SB is related with an higher incidence of latex allergic reactions. These patients received repeated surgical procedures, implant of latex-containing materials and catheterization.

MATERIALS AND METHODS

Eighty consecutive subjects affected with SB besides answering a questionnaire, underwent a skin-prick test (SPT) to latex and the determination of the specific serum IgE (RAST CAP) to latex. 40% (32/80) of the patients showed a latex sensitization with specific IgE > 0.7 kU/I but only twelve of the 32 sensitized patients (40%) suffered from clinical reactions to latex (urticaria, conjunctivitis, angioedema, rhinitis, bronchial asthma). Number of surgical procedures, but particularly early exposure to latex and familiarity for allergy are correlated with latex allergy (p < 0.01).

CONCLUSION

Latex allergy in SB children is multifactorial situation related with a disease-associated propensity for latex sensitization, early exposure and number of surgical procedures. Prophylactic measures to avoid the exposure, not only in the sanitary environment, through the institution of latex-safe routes and every day, prevent potentially serious allergic reactions.

Loperamide cause of prolonged urinary retention after acute gastroenteritis

Urinary retention is uncommon in children and only one case has been described in literature with loperamide treatment. We report the occurrence of prolonged urinary retention in a 10-years-old girl after receiving oral loperamide for an acute gastroenteritis. The first episode of urinary retention lasted for 24 hours; radiological evaluation (Magnetic Resonance, cistography and renal ultrasound) did not find abnormality; it was necessary deplete bladder with catheterism. Previous to the gastroenteritis, diuresis has always been regular and she did not suffer for any neurological or urinary problems. Patient was submitted to, without success, percutaneous posterior tibial nerve stimulation (SANS) and recovered after one year clean intermittent catheterization.

CONCLUSION

In a period of increasing popularity of self-medical therapy for common children's diseases, paediatricians should be aware of the potential, rare and chronic effects of this type of treatment. Moreover our case suggests that reaction to loperamide should be added to the etiological list of prolonged urinary retention in young patients.

Polyethylene glycol 4000 vs. lactulose for the treatment of neurogenic constipation in myelomeningocele children: a randomized-controlled clinical trial

AIM

To compare the therapeutic effectiveness and tolerability of low daily doses of polyethylene glycol 4000 vs. lactulose in the treatment of neurogenic constipation in children with myelomeningocele.

METHODS

Sixty-seven children with chronic neurogenic constipation were randomized allocated to receive either polyethylene glycol 4000 (0.50 g/kg) or lactulose (1.5 g/kg) for 6 months. Patients or their parents reported frequency and modality of evacuation and side effects on a diary card. Primary outcome was bowel frequency > or =3/week, and the second one was side effects at the end of treatment.

RESULTS

Complete remission of constipation was reported by a significantly (P < 0.01) higher number of patients treated with polyethylene glycol compared with lactulose. At the end of the study, 46% patients of polyethylene glycol group and 22% of the lactulose group were asymptomatic. Compared with lactulose, patients treated with polyethylene glycol reported higher bowel frequency (5.1 vs. 2.9 bowel movements/week, P < 0.01) and reduction of encopresis. Neither lactulose nor polyethylene glycol caused clinically-significant serious side effects and palatability was similar.

CONCLUSIONS

Polyethylene glycol 4000 compared with lactulose provided a higher success rate, without significant side effects, for the treatment of constipation in myelomeningocele children.