The Impact of Tacrolimus as Rescue Therapy in Children Using a Double Immunosuppressive Regimen After Heart Transplantation

Background. Organ transplant recipients with refractory rejection or intolerance to the prescribed immunosuppressant may respond to rescue therapy with tacrolimus. We sought to evaluate the clinical outcomes of children undergoing heart transplantation who required conversion from a cyclosporine-based, steroid-free therapy to a tacrolimus-based regimen. Methods. We performed a prospective, observational, cohort study of 28 children who underwent conversion from cyclosporine-based, steroid-free therapy to a tacrolimus-based therapy for refractory or late rejection or intolerance to cyclosporine. Results. There was complete resolution of refractory rejection episodes and adverse side effects in all patients. The incidence rate (X100) of rejection episodes before and after conversion was 7.98 and 2.11, respectively (P <= .0001). There was a 25% mortality rate in patients using tacrolimus after a mean period of 60 months after conversion. Conclusion. Tacrolimus is effective as rescue therapy for refractory rejection and is a therapeutic option for pediatric patients.

Postural adjustment after an unexpected perturbation in children with haemophilia

. Children with haemophilia often bleed inside joints and muscles, which may impair postural adjustments. These postural adjustments are necessary to control postural balance during daily activities. The inability to quickly recover postural balance could elevate the risk of bleeding. To determine whether children with haemophilia have impaired postural adjustment after an unexpected perturbation compared with healthy children. Twenty children with haemophilia comprised the haemophilic group (HG), and 20 healthy, age-paired children comprised the control group (CG). Subjects stood on a force plate, and 4% of the subjects body weight was applied via a pulley system to a belt around the subjects trunks. The centre of pressure (COP) displacement was measured after the weight was unexpectedly released to produce a controlled postural perturbation followed by postural adjustment to recover balance. The subjects postural adjustments in eight subsequent intervals of 1 s (t1t8), beginning with the moment of weight removal, were compared among intervals and between groups. The applied perturbation magnitudes were the same for both groups, and no difference was observed between the groups in t1. However, the COP displacement in t2 in the HG was significantly higher than in the CG. No differences were observed between the groups in the other intervals. Within-group analysis showed that the COP was higher in t2 than in t4 (P = 0.016), t5 (P = 0.001) and t8 (P = 0.050) in the HG. No differences were observed among intervals in the CG. Children with haemophilia demonstrated differences in postural adjustment while undergoing unexpected balance perturbations when compared with healthily children.

Cochlear implant in postlingual children: functional results 10 years after the surgery

The benefits of cochlear implants (CI) for communication skills are obtained over the years. There are but a few studies regarding the long-term outcomes in postlingual deaf children who grew up using the electronic device. Aim: To assess the functional results in a group of postlingual children, 10 years after using a CI. Methods: Ten postlingual deaf children, implanted before 18 years of age, participated in this study. We assessed: sentence recognition and speech intelligibility. We documented: device use and function and the patient's academic/occupational status. Study design: series. Results: The mean scores were 73% for sentence recognition in silence and 40% in noise. The average write-down intelligibility score was 92% and the average rating-scale intelligibility score was 4.15. There were no cases of device failure. Regarding educational/vocational status, three subjects graduated from the University. Five quit education after completing high school. Eight subjects had a professional activity. Conclusion: This study showed that cochlear implantation is a safe and reliable procedure. The postlingual profoundly hearing-impaired children after 10 years of CI use developed satisfactory levels regarding speech perception and intelligibility, and completed at least high school and were inserted in the labor market. Clinical Trials Registry: NCT01400178.

Catch-up growth in children after repair of Tetralogy of Fallot

Purpose: To evaluate the growth of children after repair of Tetralogy of Fallot, as well as the influence of residual lesions and socio-economic status. Methods: A total of 17 children, including 10 boys with a median age of 16 months at surgery, were enrolled in a retrospective cohort, in a tertiary care university hospital. Anthropometric (as z-scores), clinical, nutritional, and social data were collected. Results: Weight-for-age and weight-for-height z-scores decreased pre-operatively and recovered post-operatively in almost all patients, most markedly weight for age. Weight-for-height z-scores improved, but were still lower than birth values in the long term. Long-term height-for-age z-scores were higher than those at birth, surgery, and 3 months post-operatively. Most patients showed catch-up growth for height for age (70%), weight for age (82%), and weight for height (70%). Post-operative residual lesions (76%) influenced weight-for-age z-scores. Despite the fact that most patients (70%) were from low-income families, energy intake was above the estimated requirement for age and gender in all but one patient. There was no influence of socio-economic status on pre- and post-operative growth. Bone age was delayed and long-term-predicted height was within mid-parental height limits in 16 children (93%). Conclusion: Children submitted to Tetralogy of Fallot repair had pre-operative acute growth restriction and showed post-operative catch-up growth for weight and height. Acute growth restriction could still be present in the long term.

Long-Term Comparison of Video-Assisted Thoracic Sympathectomy and Clinical Observation for the Treatment of Palmar Hyperhidrosis in Children Younger Than 14

The results of video-assisted thoracic sympathectomy (VATS)in children are unknown. To investigate the improvement in quality of life (QOL) of a group of 45 children who did and did not undergo VATS for the treatment of palmar hyperhidrosis (PH) 4 years after the initial evaluation. Forty-five children with PH were initially evaluated. Children were divided into two groups: 30 in the VATS group and 15 in the control group. We studied the evolution of PH, negative effect of hyperhidrosis on the QOL before the treatment, and improvement in QOL after treatment. Twenty-five patients (83.4%) in the VATS group experienced great improvement in PH, and five (16.6%) experienced partial improvement; 12 (80.0%) children from the control group had some type of improvement, and three (20.0%) had partial improvement. Two (13.3%) children in the control group and 23 (76.7%) in the VATS group had great improvement in QOL. For children with PH and poor QOL, VATS is better than no treatment. It produces better results with regard to sweating and greater improvement in QOL.

Facial symmetry evaluation after experimentally displaced condylar process fracture in methotrexate treated rats

PURPOSE: To investigate the facial symmetry of high and low dose methotrexate (MTX) treated rats submitted to experimentally displaced mandibular condyle fracture through the recording of cephalometric measurements. METHODS: One hundred male Wistar rats underwent surgery using an experimental model of right condylar fracture. Animals were divided into four groups: A - saline solution (1mL/week); B - dexamethasone (DEX) (0,15mg/Kg); C - MTX low dose (3 mg/Kg/week); D - MTX high dose (30 mg/Kg). Animals were sacrificed at 1, 7, 15, 30 and 90 days postoperatively (n=5). Body weight was recorded. Specimens were submitted to axial radiographic incidence, and cephalometric mensurations were made using a computer system. Linear measurements of skull and mandible, as well as angular measurements of mandibular deviation were taken. Data were subjected to statistical analyses among the groups, periods of sacrifice and between the sides in each group (alpha=0.05). RESULTS: Animals regained body weight over time, except in group D. There was reduction in the mandibular length and also changes in the maxilla as well as progressive deviation in the mandible in relation to the skull basis in group D. CONCLUSION: Treatment with high dose methotrexate had deleterious effect on facial symmetry of rats submitted to experimentally displaced condylar process fracture.

Effect of a low-level laser on bone regeneration after rapid maxillary expansion

Introduction: In this study, we evaluated the effects of a low-level laser on bone regeneration in rapid maxillary expansion procedures. Methods: Twenty-seven children, aged 8 to 12 years, took part in the experiment, with a mean age of 10.2 years, divided into 2 groups: the laser group (n=14), in which rapid maxillary expansion was performed in conjunction with laser use, and the no-laser group (n=13), with rapid maxillary expansion only. The activation protocol of the expansion screw was 1 full turn on the first day and a half turn daily until achieving overcorrection. The laser type used was a laser diode (TWIN Laser; MMOptics, Sao Carlos, Brazil), according to the following protocol: 780 nm wavelength, 40 mW power, and 10 J/cm(2) density at 10 points located around the midpalatal suture. The application stages were 1 (days 1-5 of activation), 2 (at screw locking, on 3 consecutive days), 3, 4, and 5 (7, 14, and 21 days after stage 2). Occlusal radiographs of the maxilla were taken with the aid of an aluminum scale ruler as a densitometry reference at different times: T1 (initial), T2 (day of locking), T3 (3-5 days after T2), T4 (30 days after T3), and T5 (60 days after T4). The radiographs were digitized and submitted to imaging software (Image Tool; UTHSCSA, San Antonio, Tex) to measure the optic density of the previously selected areas. To perform the statistical test, analysis of covariance was used, with the time for the evaluated stage as the covariable. In all tests, a significance level of 5% (P<0.05) was adopted. Results: From the evaluation of bone density, the results showed that the laser improved the opening of the midpalatal suture and accelerated the bone regeneration process. Conclusions: The low-level laser, associated with rapid maxillary expansion, provided efficient opening of the midpalatal suture and influenced the bone regeneration process of the suture, accelerating healing. (Am J Orthod Dentofacial Orthop 2012;141:444-50)

Dental calculus formation in children and adolescents undergoing hemodialysis

This study aimed to determine whether dental calculus formation is really higher among patients with chronic kidney disease undergoing hemodialysis than among controls. Furthermore, the study evaluated correlations between dental calculus formation and dental plaque, variables that are related to renal disease and/or saliva composition. The Renal Group was composed of 30 patients undergoing hemodialysis, whereas the Healthy Group had 30 clinically healthy patients. Stimulated whole saliva and parotid saliva were collected. Salivary flow rate and calcium and phosphate concentrations were determined. In the Renal Group the saliva collection was carried out before and after a hemodialysis session. Patients from both groups received intraoral exams, oral hygiene instructions, and dental scaling. Three months later, the dental calculus was measured by the Volpe-Manhold method to determine the rate of dental calculus formation. The Renal Group presented a higher rate of dental calculus formation (p < 0.01). Correlation was observed between rate of dental calculus formation and whole saliva flow rate in the Renal Group after a hemodialysis session (r = 0.44, p < 0.05). The presence of dental calculus was associated with phosphate concentration in whole saliva from the Renal Group (p < 0.05). In conclusion, patients undergoing hemodialysis presented accelerated dental calculus formation, probably due to salivary variables.

Prevalence of hepatitis B virus infection and carriage after nineteen years of vaccination program in the Western Brazilian Amazon

Introduction: Reductions in the prevalence of hepatitis B virus (HBV) infection and carriage, decreases in liver cancer incidence, and changes in patterns of liver dysfunctions are described after hepatitis B vaccination. Methods: We conducted a population-based seroprevalence study aimed at estimating the HBV prevalence and risk of infection in the rural area of Labrea following nineteen years of HBV vaccination. Results: Half of the subjects showed total anti-HBc of 52.1% (95% CI 49.6-54.7). The HBsAg prevalence was 6.2% (95% CI 5.1-7.6). Multivariate analysis showed an inverse association between HBV infection and vaccination (OR 0.62; 95% CI 0.44-0.87). HBsAg remained independently associated with past hepatitis (OR 2.44; 95% CI 1.52-3.89) and inversely to vaccination (OR 0.43; 95% CI 0.27-0.69). The prevalence of HBeAg among HBsAg-positive individuals was 20.4% (95% CI 12.8-30.1), with the positive subjects having a median age of 11 years (1-46) p=0.0003. Conclusions: We demonstrate that HBV infection is still an important public health issue and that HBV vaccination could have had better impact on HBV epidemiology. If we extrapolate these findings to other rural areas in the Brazilian Amazon, we can predict that the sources of chronic infected patients remain a challenge. Future studies are needed regarding clinical aspects, molecular epidemiology, surveillance of acute cases, and risk groups.

Late evaluation of the relationship between morphological and functional renal changes and hypertension after non-operative treatment of high-grade renal injuries

Objective: To evaluate the anatomical and functional renal alterations and the association with post-traumatic arterial hypertension. Methods: The studied population included patients who sustained high grades renal injury (grades III to V) successfully non-operative management after staging by computed tomography over a 16-year period. Beyond the review of medical records, these patients were invited to the following protocol: clinical and laboratory evaluation, abdominal computed tomography, magnetic resonance angiography, DMSA renal scintigraphy, and ambulatory blood pressure monitoring. The hypertensive patients also were submitted to dynamic renal scintigraphy (Tc-99m EC), using captopril stimulation to verify renal vascular etiology. Results: Of the 31 patients, there were thirteen grade III, sixteen grade IV (nine lacerations, and seven vascular lesions), and two grade V injuries. All the patients were asymptomatic and an average follow up post-injury of 6.4 years. None had abnormal BUN or seric creatinine. The percentage of renal volume reduction correlates with the severity as defined by OIS. There was no evidence of renal artery stenosis in Magnetic Resonance angiography (MRA). DMSA scanning demonstrated a decline in percentage of total renal function corresponding to injury severity (42.2 +/- 5.5% for grade III, 35.3 +/- 12.8% for grade IV, 13.5 +/- 19.1 for grade V). Six patients (19.4%) had severe compromised function (< 30%). There was statistically significant difference in the decrease in renal function between parenchymal and vascular causes for grade IV injuries (p < 0.001). The 24-hour ambulatory blood pressure monitoring detected nine patients (29%) with post-traumatic hypertension. All the patients were male, mean 35.6 years, 77.8 % had a familial history of arterial hypertension, 66.7% had grade III renal injury, and average post-injury time was 7.8 years. Seven patients had negative captopril renography. Conclusions: Late results of renal function after conservative treatment of high grades renal injuries are favorable, except for patients with grades IV with vascular injuries and grade V renal injuries. Moreover, arterial hypertension does not correlate with the grade of renal injury or reduction of renal function.

Positive effects of zinc supplementation on growth, GH, IGF1, and IGFBP3 in eutrophic children

Zinc is an essential micronutrient for growth and development. Its deficiency causes growth retardation in children and adolescents. The present study analyzes the effect of zinc on growth hormone (GH) secretion, insulin-like growth factor 1 (IGF1), and insulin-like growth factor-binding protein 3 (IGFBP3) in normal children before puberty. Thirty normal children were studied, 15 boys and 15 girls, aged 6-9 years. They were orally supplemented with 5 mg Zn/day for 3 months and 0.06537 mg Zn/kg body weight was injected before and after oral supplementation. Dietary intake and anthropometric measurements were assessed at baseline and end of study. Plasma GH levels increased during intravenous zinc administration and IGF1 and IGFBP3 increased after oral zinc supplementation. There was a positive correlation between the areas under the curves of GH and zinc after oral supplementation. Zinc supplementation was possibly effective in improving the body zinc status of the children, secretory levels of IGF1 and IGFBP3, GH potentialization, and height.

Computed tomographic dacryocystography in children undergoing balloon dacryoplasty

PURPOSE To ascertain whether the volume and circumference of the lacrimal sac and nasolacrimal duct as measured by contrast-enhanced computed tomographic dacryocystography (CT-DCG) before and after balloon dacryoplasty could be used to predict clinical success in children with congenital nasolacrimal obstruction. METHODS Nasolacrimal ducts of children aged 2 to 6 years with clinical signs of congenital nasolacrimal duct obstruction undergoing balloon dilation were imaged with contrast-enhanced CT-DCG before and 5 minutes after the procedure. The circumference of the most dilated portion of the lacrimal sac was measured on the axial plane. The volume of contrast within the nasolacrimal duct and sac was also measured before and after the procedure. Clinical success was defined as the disappearance of signs of epiphora. RESULTS A total of 18 nasolacrimal ducts of 13 children were included. The average circumference of the most dilated portion of the lacrimal sac was 1.30 +/- 0.45 cm (range, 0.64-2.50 cm) before the procedure. The average contrast volume was 0.12 +/- 0.08 cm(3) (range, 0.01-0.38 cm(3)) before and 0.07 +/- 0.06 cm(3) (range, 0.01-0.20 cm(3)) after (P = 0.01). Data were analyzed using multivariate logistic regression with a backward variable input model; a decrease in contrast volume before and after dilation (P = 0.04) was associated with clinical success, whereas the larger size of the most dilated portion of the lacrimal sac (P = 0.01) was associated with clinical failure. CONCLUSIONS Contrast-enhanced CT-DCG provides useful information about nasolacrimal anatomy in children with congenital nasolacrimal duct obstruction. The decrease in contrast volume before and after balloon dilation was predictive of success; A larger size of the most dilated portion of the lacrimal sac was associated with clinical failure. (J AAPOS 2012;16:464-467)

Lupus erythematosus panniculitis in children and adolescents

Introduction: Lupus erythematosus panniculitis (LEP) or lupus erythematosus profundus is a rare form of chronic cutaneous manifestation affecting both adults and pediatric patients. The prevalence of this manifestation was seldom reported in juvenile systemic lupus erythematosus (JSLE). Case reports: From January 1983 to December 2010, 5,506 patients were followed at the Pediatric Rheumatology Unit of our University Hospital and 278 (5%) of them met the American College of Rheumatology classification criteria for JSLE. Two (0.7%) of them had LEP at JSLE onset. These two cases had tender deep inflammatory subcutaneous nodules or plaques at the time of diagnosis, and the histopathologic pattern evidenced lobular or mixed panniculitis with lymphocytic inflammatory cells of the fat lobule. Treatments for LEP included mainly antimalarials, systemic corticosteroids and sunscreen protection. One male patient required thalidomide and immunosuppressive drugs, including mycophenolate mofetil, cyclosporin and intravenous cyclophosphamide. However, skin lesions improved only after rituximab treatment. Discussion: LEP was rarely observed in our cohort of JSLE patients as the first lupus manifestation. Anti-CD20 monoclonal antibody therapy may be an option for refractory LEP treatment in children.

Salivary Cortisol, Alpha-Amylase and Heart Rate Variation in Response to Dental Treatment in Children

Objective. Anxiety and stress are usually related to the dental treatment situation. The objective was to investigate salivary cortisol and alpha-amylase levels (salivary biomarkers) and heart rate in children undergoing a minor dental procedure (dental prophylaxis). Study design. In total, 31 children (range 84-95 months) of both genders without caries or history of dental treatment/pain/trauma were selected. Three saliva samples were gathered: one prior to dental prophylaxis, one immediately after, and one ten minutes later Weight and height were assessed, and heart rate was evaluated prior to and during the procedure. Data were analyzed by correlation tests and t-test/Wikoxon (alpha=0.05). Results. Higher cortisol and amylase levels were observed before prophylaxis compared to afterward. Cortisol and amylase levels did not show a significant correlation, nor did salivary biomarkers and body mass index. However, heart rate and amylase levels showed a significant positive correlation. Conclusions. In the studied sample, certain anticipation of the dental treatment was observed because higher cortisol and amylase levels were observed before, rather than after, the event; moreover, a significant correlation between amylase levels and heart rate was observed. Thus, salivary biomarkers may be a valuable tool for evaluating anxiety-producing events, such as dental treatment, in children.