Host and environmental factors influencing respiratory secretion of pro-wheezing biomarkers in preterm children

Cytokines are actively secreted by the respiratory mucosa of preterm children and participate in the pathogenesis of wheezing. This study aimed to identify the factors that could potentially influence respiratory secretion of cytokines in these children. A nasopharyngeal aspirate (NPA) was collected from 77 preterm children 1 yr after birth. NPAs from 14 healthy, 1-yr-old term children were collected in parallel. 27 cytokines were measured in the NPAs using a multiplex assay. Multivariate stepwise regression analysis with Bonferroni correction evidenced that the variable [daycare attendance] was associated with higher levels of [monocyte chemoattractant protein-1 (MCP-1), IL-6, vascular endothelial growth factor (VEGF), IL-1β, IL-10, tumor necrosis factor (TNF)-α]; [male sex] with higher levels of (MCP-1, VEGF, and IL-1β); [smokers at home] was associated with higher levels of MCP-1 (p < 0.0013). In turn, [prophylaxis with palivizumab] was associated with lower levels of (IL-6, IL-7) (p < 0.0013). All these mediators participate in the pathogenesis of asthma and recurrent wheezing. Preterm children secreted higher levels of chemokines (interferon-gamma inducible protein-10, macrophage inflammatory protein-1α, Eotaxin, MCP-1), growth factors (platelet-derived growth factor-bb, VEGF, fibroblast growth factor-basic, granulocyte macrophage colony-stimulating factor), Th1 (IL12, interferon-γ), Th2 (IL-9, IL-13), Th17 (IL-6, IL-17) cytokines, and immunomodulatory mediators (IL1RA and granulocyte colony-stimulating factor) than term children. In conclusion, we have identified for the first time a group of individual and environmental factors influencing respiratory secretion of cytokines in preterm children at the long term after birth. To know these factors could help to prevent the instauration of conditions linked to the appearance of chronic respiratory diseases such as wheezing or asthma.

Melatonin in epilepsy and febrile seizures

A study on melatonin rhythm in children with generalized idiopathic epilepsy and simple fever is presented in this article. A population of 40 children was divided into 4 groups, namely, epilepsy, febrile seizure, and 2 control groups. Salivary melatonin was measured by means of radioimmunoassay. Friedman 2-way analysis of variance (ANOVA) and Wilcoxon tests were employed to assess the existence of melatonin rhythm. Comparison across groups was performed by means of ANOVA and Mann-Whitney tests. Higher melatonin levels were found at night, with a peak at 04:00 h in all groups. Significant diurnal rhythm was also detected for these levels. No significant overall differences between case and control groups were found for melatonin levels, though patients showed lower peak melatonin values than controls at 04:00 h with a significant difference in the febrile seizure group (10.70 vs 19.5 pg/mL respectively; P<.04). Our data support the presence of diurnal rhythm in blood melatonin concentrations in children with epileptic and febrile seizures. Comparison between case and control groups showed lower peak concentrations in the febrile seizure group with respect to healthy controls.

Nasopharyngeal aspirate cytokine levels 1 yr after severe respiratory syncytial virus infection

Respiratory syncytial virus (RSV) infection is an important cause of recurrent wheezing in infants. Nevertheless, the link between RSV infection and wheezing has yet to be elucidated at the molecular level. Here, we present a preliminary study on the evolution of the immune response in the respiratory tract at long-term after RSV infection. Twenty-seven immune mediators were profiled in nasopharyngeal aspirates (NPAs) obtained from 20 children hospitalized due to a severe infection by RSV at discharge from hospital and again 1 yr later. The same mediators were profiled in parallel in NPAs from 12 healthy controls. In the year following discharge, 85% (17/20) of children of the RSV group suffered at least one episode of wheezing documented by the pediatrician. On the contrary, wheezing episodes were observed only in 25% (3/12) of children in the control group. While most of the mediators profiled returned to normal levels by 1 yr after discharge from hospital, RSV children showed a persistent nasal hyper-secretion of VEGF, G-CSF, IL-10, IL-6, IFN-gamma, IL-7 and IL-13. In previous works VEGF, IL-10 and IFN-gamma have been put in relation with the pathogenesis of post-virus induced asthma. G-CSF, IL-6, IL-7 and IL-13 are increased in respiratory and plasma samples of asthmatic patients. Here, we evidence for the first time a persistent elevation of these mediators as late as 1 yr after severe RSV disease resolution, reinforcing their possible implication in the pathogenesis of wheezing.

Predominance of Th2 cytokines, CXC chemokines and innate immunity mediators at the mucosal level during severe respiratory syncytial virus infection in children

Profiling of immune mediators in both nasal and plasma samples is a common approach to the study of pathogenesis in respiratory viral infections. Nevertheless, mucosal immunity functions essentially independently from peripheral immunity. In our study, 27 immune mediators were profiled in parallel, in nasopharyngeal aspirates (NPAs) and plasma from 22 < 2 year-old children with a severe respiratory syncytial virus infection involving the lower respiratory tract, using a multiplex assay. NPAs from 22 children with innocent heart murmurs were used as controls. Differences in mediator concentrations between NPAs from patients and controls were assessed using the Mann-Whitney test. Ratios of innate/adaptive-immunity mediators, Th2/Th1-cytokines and CXC/CC-chemokines were calculated for NPAs and plasmas and differences were assessed using the Wilcoxon test. Associations mediators, severity and leukocyte counts were studied using the Spearman-Karber test.

RESULTS

increased levels of Th1 cytokines (IL-1beta, IL-2, IL-12p70, IFNgamma, TNFalpha), Th2 cytokines (IL-13, IL-4, IL-6, IL-10), chemokines (IP-10, IL-8, MIP1alpha, MIP-1beta), growth factors (FGFb, PDGFbb, GCSF) and IL-1RA, IL-17 were observed in patient NPAs in comparison to controls. In the relative comparisons between patient NPAs and plasmas, a predominance of innate immunity mediators, Th2 cytokines and CXC chemokines was found at the mucosal level. No association between the level of each mediator in NPAs and plasma was found. In plasma, PDGFbb, VEGF, MIP-1alpha, IL-8 correlated with severity; RANTES and IL-6 correlated with leukocyte counts.

CONCLUSIONS

acute respiratory syncytial virus infection induces a relative predominance of innate-immunity mediators, Th2 cytokines and CXC chemokines in the mucosal compartment in infected children.

Bronchiolitis due to respiratory syncytial virus in hospitalized children: a study of seasonal rhythm

AIM

The objective of this study was to describe the rhythm of respiratory syncytial virus (RSV) bronchiolitis seasonal outbreaks in hospitalized children.

METHODS

Data was collected from 1324 patients, who were admitted to our hospital with bronchiolitis, over an 11-year period, from 1994 to 2004. The epidemic onset was established according to the epidemic index. Virological diagnosis was made with immunofluorescent assay from nasopharyngeal washings. Rhythm study was carried-out by spectral analysis with the fast-Fourier transformed and cosinor method.

RESULTS

Epidemics begin in September (45%) and October (55%); the highest peak was observed in January, the minimum in August and the end in February (73%), March (18%) and April (9%). When the epidemic outbreak begins sooner, the end is sooner as well. Epidemic onset varies but not its length and the onset was less variable than its conclusion. Spectral analysis showed a 12-months cyclic period along the study years and cosinor analysis demonstrated significant circannual rhythm. When data was segregated by long and short hospital stay, no significant differences were found between the rhythms. Comorbid association among bronchiolitis, otitis and gastroenteritis was very common.

CONCLUSION

Bronchiolitis epidemics onset and conclusion varies along time years in hospitalized infants and showed circannual rhythmicity with a 12-months period.

Does mild valvular aortic stenosis progress during childhood?

BACKGROUND AND AIM OF THE STUDY

An increased gradient in congenital valvular aortic stenosis (AS) during follow up remains the subject of controversy, and may determine a need for treatment in pediatric patients. It is hypothesized that a valvular gradient < 40 mmHg indicates a stable tendency at follow up for congenital valvular AS.

METHODS

Twenty-five cases with valvular AS, isolated but not treated, were followed for eight years (range: 0.14-18.8 years). Clinical and complementary tests (electrocardiography, X-radiography) were undertaken. The gradient anatomy and function were measured using M-mode, two-dimensional, and Doppler echocardiography.

RESULTS

No significant changes were noted in symptoms or at physical examination. Signs of cardiac enlargement were decreased (p < 0.001), and the functional status and gradient remained stable during the follow up period (mean difference 2.38 mmHg; p = 0.74). The relationship between gradient and age showed a slowly increasing trend (r = 0.20).

CONCLUSION

The trend in gradient confirmed the stable nature of mild AS. Patients in whom gradients were < 40 mmHg at the time of diagnosis remained stable and required no treatment. Subsequent follow up control and clinical management of these patients may be performed at intervals of two years, or more.

Does mild pulmonary stenosis progress during childhood? A study of its natural course

BACKGROUND

Increase in the gradient in congenital pulmonary valvular stenosis during follow-up is a subject of controversy and could determine the need for treatment in pediatric patients.

HYPOTHESIS

It is postulated that a gradient <50 mmHg shows a stable or decreasing tendency at follow-up for congenital pulmonary valvular stenosis.

METHODS

Thirty-five patients with pulmonary stenosis, isolated and not treated, were followed for 7 years (interquartilic rank 5.7 years) at 1.5-year intervals. Clinical and complementary tests (electrocardiogram, x-ray, Doppler echocardiogram) were undertaken. The gradient was measured by Doppler and by using the clinical formula derived from the New England Study (Ellison). The changes observed from the initial to the final consultation were analyzed by means of the Student's t-test, paired Wilcoxon, and Pearson correlation coefficient.

RESULTS

No significant changes were noted on symptoms or physical examination. Signs of cardiac enlargement diminished on both ECG (R wave in V1, p<0.0001) and x-ray (cardiothoracic ratio, p<0.0007), with a decreasing gradient trend during the follow-up period (p<0.026) as well.

CONCLUSIONS

The gradient trend confirms the stable nature of mild pulmonary stenosis. In our study, we found that patients aged >6 months, whose gradients were below 40 mmHg at the time of diagnosis, remained stable and required no treatment. Furthermore, the follow-up control and clinical management of these patients may then be performed at intervals of 2 years or more.

Congenital anophthalmia: a circadian rhythm study

A circadian rhythm of heart rate and respiratory rate was seen at 1, 8, and 12 months of age in an infant born without ocular tissue, which supports the possibility that the time cues were nonphotic. No melatonin circadian rhythm was detected at any age up to 9 years of age, and this is most likely associated with the anophthalmia and lack of photic input to the suprachiasmatic nucleus. Usually circadian organization is present after the neonatal period and approaches adult levels with development.

Emergence and evolution of the circadian rhythm of melatonin in children

OBJECTIVE

To assess the age at which the circadian rhythm of melatonin begins.

METHODS

55 children, divided into groups from the neonatal period to 24 months of life, were studied. Urine samples were taken from 28 newborn babies to measure 6-sulfatoxymelatonin (aMT6s). Salivary samples were collected from infants (27 cases), to measure melatonin (aMT). aMT was measured by RIA and aMT6s by ELISA using commercial kits. Changes in the levels of aMT6s and aMT were evaluated using the Friedman test and Wilcoxon matched pair test.

RESULTS

The group aged 27-41 days showed statistically significant differences in daily aMT6s and aMT concentrations. The highest values were always found between 24.00 and 8.00 h. This day/night difference persisted from 2-3 to 13-24 months of age.

CONCLUSION

The data indicate that the circadian melatonin rhythm appears at the end of the neonatal period and persists thereafter.

Circadian changes of heart rate in West syndrome

Patterns of circadian and ultradian rhythms in the heart rate (HR) are described in a full-term baby with birth asphyxia and convulsions. A 24h HR recording was carried out at the age of 1, 15, 56, 289, and 295 days; West syndrome diagnosis was made when the patient was 3 months old. The HR showed no circadian rhythm in the follow-up, whereas it is known that the circadian rhythm appears in healthy infants at the age of 1 month and remains thereafter. This observation may be an indirect indicator of the interference of West syndrome with centers of neurological maturity.

Computer analysis of environmental temperature, light and noise in intensive care: chaos or chronome nurseries?

Lighting, noise and temperature were monitored in two perinatal nurseries. Rhythms of several frequencies were found, including prominent 24-hour rhythms with acrophases around 13:00 (light intensity) and 16:00 (noise). For light and noise, the ratio formed by dividing the amplitude of a 1-week (circaseptan) or half-week (circasemiseptan) fitted cosine curve by the amplitude of a 24-hour fitted cosine curve is smaller than unity, since 24-hour rhythms are prominent for these variables. The amplitude ratios are larger than unity for temperature in the newborns' unit but not in the infants' unit. Earlier, the origin of the about-7-day rhythms of neonatal physiologic variables was demonstrated to have, in addition to a major endogenous, also a minor exogenous component. Hence, the possibility of optimizing maturation by manipulating environmental changes can be considered, using, as gauges of development, previously mapped chronomes (time structures of biologic multifrequency rhythms, trends and noise).

Heart rate biorhythm changes during the first three months of life

Heart rate (HR) was recorded in healthy full-term newborns aged 1-90 days. The aim of this study was to study the existence of circadian and/or ultradian rhythms in HR to determine maturity. HR was recorded during 24 h, at 30-min intervals, at different postnatal ages. Six-groups were investigated: day 1 (group 1); day 7 (group 7); day 15 (group 15); day 30 (group 30); day 60 (group 60), and day 90 (group 90). The chronograms for HR showed peaks and nadirs along the 24-hour periods, and the cosinor analysis proved the existence of 3-hour ultradian rhythm in groups 1, 7 and 30, and a 12-hour ultradian rhythm in group 90 (p < 0.01 in all cases). The same type of analysis confirmed the existence of a circadian rhythm in group 30. Similar results were obtained for groups 60 and 90 (p < 0.05).

IN CONCLUSION

at birth, newborns have an endogenous ultradian period of 3 h. A circadian rhythm appears within 15-30 days of postnatal life.

Development of sleep-wakefulness rhythm in premature babies

The aims of this study were: (1) to investigate the evolution of the sleep pattern in preterm newborns during their first month of life; (2) to assess the influence of light-dark on the sleep pattern; and (3) to compare this pattern with that of full-term newborns. The population consisted of 60 healthy, preterm newborns and 63 full-term newborns, divided into four age groups, 1 week apart, throughout the first month of life. Preterm newborns were further divided into five groups according to conceptional (corrected) age. An observer took note every 30 min, for 24 h, of sleep or wakefulness in every case. The average sleeping time in preterm groups according to postnatal age remained unchanged during the first month of life: 17.57 h on day 1 and 17.15 h on day 28. When the preterm infants were re-grouped according to conceptional age, average daily sleep was 17.86 h at 32 weeks and 15.22 h at 37 weeks. The full-term newborns had an average daily sleep of 14.78 h on day 1 and 11.94 h on day 28, with a decrease throughout week 4 of life (p < 0.001). The decrease in daily sleeping time in the full-term groups, took place at the expense of the daylight span, where there was a decrease throughout the first month of life (p < 0.01). There were no differences in preterm newborns during the light and dark phases. A progressive synchronization of sleep to the light-dark was seen in the control group.(ABSTRACT TRUNCATED AT 250 WORDS)

[Tissue concentrations of beta-methyl-digoxin in children]

Beta-methyl-digoxin concentrations in adipose, skeletal muscle and myocardial tissues, were studied in 8 patients undergoing by-pass surgery because of congenital heart disease. Correlation between doses/kg, plasmatic and tissue concentrations were analysed. We found statistically correlation between doses/kg and plasmatic concentrations; doses/kg and skeletal muscle concentrations (p less than 0.01); plasmatic and skeletal muscle concentrations (p less than 0.05). Concentrations was significantly greater in myocardial than adipose tissue before extracorporeal circulation (p less than 0.01); and significantly greater than adipose (p less than 0.01) and skeletal muscle (p less than 0.05) tissues after extracorporeal circulation. Extracorporeal circulation lessens adipose and skeletal muscle concentrations, but increases myocardial concentrations significantly (p less than 0.05). It is concluded, that the behaviour of beta-methyl-digoxin, in relation with tissue concentrations, is similar to digoxin.

Effect on growth of children with cardiac dysrhythmias treated with amiodarone

We report the results of treatment with amiodarone in nine children with dysrhythmias resistant to conventional drugs, namely, one with ventricular tachycardia, two with atrial tachycardia, one with junctional tachycardia, three with reciprocal rhythm tachycardia, and two with Wolff-Parkinson-White syndrome. The initial dose was 800 mg/1.73 m2, administered for two weeks, followed by half the dose for five days a week. The duration of the treatment varied from nine months to 19 months (mean duration, 13 months). Patients were followed up for a period ranging between nine and 33 months (mean period, 17 months). A complete remission was obtained in 56% of patients and partial success in 46%. The following side effects were detected: photosensitization in two; effect on weight, height, growth velocity, and thyroid hormones in three, six, five, and six, respectively; and acceleration in bone age in three. These effects were observed from two to nine months after the beginning of treatment. They persisted for 5-18 months after treatment had been suspended. The main side effect of amiodarone in children is presumably initial hypothyroidism, followed by a biological hyperthyroid reaction. For these reasons we suggest that amiodarone should be restricted as an alternative drug for resistant critical dysrhythmias and be used only for a limited period of two years.

[Amiodarone in children. Impact on growth]

In this work, we report the results of the treatment with amiodarone applied to 9 children suffering from dysrhythmia resistant to conventional drugs. The initial dose was 800 mg/1,73 m2, administered for two weeks, followed by a 50% dose administered 5 days a week. The duration of the treatment oscillated from 9 months to 15 months (average duration: 13 months). Patients were kept under control for a period ranging between 9 and 33 months (average period: 17 months). A complete remission was obtained in 56% of the cases and partial success in 46%. The following side effects were detected: photosensitization in 2 cases; repercussion on weight, height, growth velocity, thyroid hormones and acceleration in skeletal age in 44% and 66% of them. These effects could be observed from 2 to 8 months after the beginning of the treatment. They persisted for 5 to 18 months after the treatment was arrested. The main side effect of amiodarone in children is presumably an initial effect of hypothyroidism, followed by a biological hyperthyroidism reaction. For these reasons we suggest that amiodarone should be restricted as an alternative product for resistant critical dysrhythmias and be used for a limited period of two years only.

[Bannayan syndrome with intracranial arteriovenous malformations]

Bannayan syndrome is a inheritable autosomal dominant association of hamartoma (usually hemangioma and lipoma) and macrocephaly with other inconstant features. Authors report a new family joining known criteria, with a complex intracranial arteriovenous malformation, previously not reported in the literature, conditioning outlook and treatment.

[Ebstein's anomaly. Prenatal diagnosis with bidimensional echocardiography]

The authors comment on the signs found in utero in a case of Ebstein anomaly, by obstetrics and cross-sectional ultrasonography. They emphasize the possibilities and interest of these techniques in other prenatal diagnostic problems.

[Continuous Holter electrocardiogram in children. Analysis of 100 traces]

Authors analyse the value of the Holter system for diagnosis and follow-up of cardiac dysrhythmias. They report their experience from 100 records performed to 87 patients, who were between one day and 14 years old. Among them, 58 were male and 42 female. The recorder and analyser were automatics holter II/Quickscan, and the program was 24 hours in all cases. For the study of results, patients were divided in five groups (34 dysrhythmias; 18 neurologic; 10 were normal control; 20 newborns between 1 and 7 days; and 17 in a miscellaneous group). They emphasized on the possibility of the system to be performed in pediatric patients, even in the youngest; on the worth of records from neurologic with normal clinical examinations; on diagnostic aspects of undetected dysrhythmias by ECG (30%), and to know the normal values from the control group. Tables and figures show rhythm types and quantitative values; finally they comment on artifacts and indications.

[Ventricular tachycardia in a healthy child. Electrophysiological study and review of the literature]

Report of a healthy child with ventricular tachycardia is the reason for a review on the literature on this subject. Diagnosis can be made with usual electrocardiographic criteria and surely by electrophysiologic studies. Latter technique allows to study the origin, mechanism, efficiency of drugs and the type of pace-maker in case of drug treatment failure. Case report exemplifies all these aspects, and the essentials about etiology, symptoms, diagnosis and treatment are mentioned in the literature review.

[Rheumatic carditis and its future (author's transl)]

Authors report results of the study of a series of rheumatic heart disease in 34 children between three and 14 years old, followed-up from one month to 14 years (mean six years and six months), and another one of 14 adults operated because of cardiac sequelae, in whom the average age was 48. The most significant results are: more common in autumn-winter (62%) and females (60%); family history of rheumatic fever (55%); low social level; mitral predominance with mitral regurgitation in children and stenosis in adults; during puberty age; without symptoms in the joints in 36%, and with better prognosis since 1974. Parameters with prognostic value in the prediction of sequelae were: family history of rheumatic fever; rural environment; increase in cardiac volume, PR prolongation in the ECG and inadequate treatment and prophylaxis. 36% of the mitral lesions and 20% of the aortic ones disappeared. The main conclusion is the need for intensive treatment during the acute period of the disease and continuous prevention during the rest of their lives of cardiac sequelae.

[Ventricular septal defect: Prognosis of spontaneous closure (author's transl)]

In a series of 150 cases of isolated ventricular septal defect (VSD), the authors have found 25 cases (16%) of spontaneous closure over an average period of observation of 20 months. The closure was observed in 32% of the cases before 6 months and in 60% before 12 months, with a range between 1 month and 8 years. The number of out patient with was 7 per case on average. A large group of parameters was taken into account in every case; from some of them, indicators of prognosis of closure were obtained, among them: early appearance of the murmur, descending shape, muscular character of the VSD, absence of symptoms and diastolic rumble, presence of ejection clic and normality in ECG and XRay.

[Functional evaluation of pancreas cystic fibrosis. Correlations and value of the echocardiogram versus other methods (author's transl)]

The results of a correlation of various parameters used in the functional evaluation of 12 cases of pancreas cystic fibrosis (PCF) are reported. Three clinical scores were measured by four separate observers and average score was taken. Electrocardiogram, phono, vectorcardiogram, pH, blood gases, radiology, spirometry, erythropoietin, blood counts and echocardiogram were also recorded. Each of these were correlated. In the echocardiogram (EC), right and left systolic time intervals, wall and cavity of the right ventricle and the left ventricular function were measured. Some correlations were found to have a statistical significance: the data attained from the EC, clinical score and the spirometry. However, blood count, blood gases, erythropoietin and pH were found to have no statistical significance. The EC was found to be the most accurate and sensitive method of recognising the initial stages of pulmonary hypertension in PCF; detecting its presence at as early an age as six years (on average). These results present a strong argument for the use of the EC as a vital part of each exam of PCF.