Oral manifestations in HIV+ children in Mozambique

O objetivo deste estudo foi identificar a prevalência das manifestações bucais em pacientes HIV+/SIDA do Hospital Pediátrico DIA de Maputo. Foram incluídos 90 pacientes na pesquisa. Cárie dentária (índice ceod/CPOD), mucosa e fluxo salivar foram avaliados. Informações sobre alimentação e hábitos de higiene bucal foram obtidas por meio de um questionário. Para a análise estatística foram utilizados os testes t-student e qui-quadrado. A lesão oral mais frequente foi a candidíase (5,5%) e no exame extra-oral foi observada uma prevalência de alargamento da parótida de 23%. A média do ceod foi 2,6 (± 3,6) dentes, consideravelmente alta em relação ao CPOD que foi de 0,6 (±1,6) dentes, sendo esta diferença estatisticamente significante (p<0,05). A ocorrência de lesões na mucosa bucal foi maior em crianças que não faziam uso da terapia antiretroviral (TRA). O uso da TRA esteve associado com a redução da prevalência de lesões bucais em pacientes HIV+, contudo cáries rampantes foram maiores neste grupo. Pacientes HIV+ mostraram maior risco de cáries na dentadura decídua.

Forecasting the need for medical specialists in Spain: application of a system dynamics model

[EN] Background: Spain has gone from a surplus to a shortage of medical doctors in very few years. Medium and long-term planning for health professionals has become a high priority for health authorities. Methods: We created a supply and demand/need simulation model for 43 medical specialties using system dynamics. The model includes demographic, education and labour market variables. Several scenarios were defined. Variables controllable by health planners can be set as parameters to simulate different scenarios. The model calculates the supply and the deficit or surplus. Experts set the ratio of specialists needed per 1000 inhabitants with a Delphi method. Results: In the scenario of the baseline model with moderate population growth, the deficit of medical specialists will grow from 2% at present (2800 specialists) to 14.3% in 2025 (almost 21 000). The specialties with the greatest medium-term shortages are Anesthesiology, Orthopedic and Traumatic Surgery, Pediatric Surgery, Plastic Aesthetic and Reparatory Surgery, Family and Community Medicine, Pediatrics, Radiology, and Urology. Conclusions: The model suggests the need to increase the number of students admitted to medical school. Training itineraries should be redesigned to facilitate mobility among specialties. In the meantime, the need to make more flexible the supply in the short term is being filled by the immigration of physicians from new members of the European Union and from Latin America.

Komparative Analyse der humanen Chromosomenregion 11p15.3 um die Gene LMO1,TUB und der orthologen Region in der Maus

Ziel der vorliegenden Arbeit war die vergleichende Sequenzierung und nachfolgende Analyse des syntänen chromosomalen Abschnitts auf dem kurzen Arm des humanen Chromosoms 11 in der Region 11p15.3 mit den Genen LMO1, TUB und dem orthologen Genomabschnitt der Maus auf Chromosom 7 F2. Die im Rahmen dieser Arbeit durchgeführte Kartierung dieser beiden chromosomalen Bereiche ermöglichte die Komplettierung einer genomischen Karte auf insgesamt über eine Megabase, die im Kooperationssequenzierprojekt der Universitäts-Kinderklinik und dem Institut für Molekulargenetik in Mainz erstellt wurde. Mit Hilfe von 28 PAC- und Cosmid-Klonen konnten in dieser Arbeit 383 kb an genomischer DNA des Menschen und mit sechs BAC- und PAC-Klonen 412 kb an genomischer DNA der Maus dargestellt werden. Dies ermöglichte erstmals die exakte Festlegung der Reihenfolge der in diesem chromosomalen Abschnitt enthaltenen Gene und die genaue Kartierung von acht STS-Markern des Menschen, bzw. vier STS-Sonden der Maus. Es zeigte sich dabei, dass die chromosomale Orientierung telomer-/centromerwärts des orthologen Bereichs in der Maus im Vergleich zum Menschen in invertierter Ausrichtung vorliegt. Die Sequenzierung von drei humanen Klonen ermöglichte die Bestimmung von 319.119 bp an zusammenhängender genomischer DNA. Dadurch konnte die genaue Lokalisation und Strukturaufklärung der Gene LMO1, ein putatives Tumorsuppressorgen, das mit der Entstehung von Leukämien assoziiert ist, und TUB, ein Transkriptionsmodulator, der in die Fettstoffwechselregulation involviert ist, vorgenommen werden. Für das murine Genom wurden 412.827 bp an neuer DNA-Sequenz durch Sequenzierung von ebenfalls drei Klonen generiert. Der im Vergleich zum Menschen ca. 100 kb größere Genombereich beinhaltete zudem die neuen Gene Stk33 und Eif3. Es handelte sich dabei um zwei Gene, die erst im Rahmen dieser Arbeit entdeckt und charakterisiert wurden. Die parallele Bearbeitung beider Genombereiche ermöglichte eine umfassende komparative Analyse nach kodierenden, funktionellen und strukturgebenden Sequenzabschnitten in beiden Spezies. Es konnten dabei für beide Organismen die Exon-Intron-Strukturen der Gene LMO1/Lmo1 und TUB/Tub geklärt. Zudem konnten vier neue Exons und zwei neue speziesspezifischer Spleißvarianten für TUB/Tub beschrieben werden. Die Identifizierung dieser neuen Spleißvarianten offenbart neue Möglichkeiten für alternative Regulation und Funktion, oder für eine veränderte Proteinstruktur, die weitere Erklärungsansätze für die Entstehung der mit diesen Genen assoziierten Erkrankungen zulässt. In der sequenzierten, größeren Genomsequenz der Maus konnte in den flankierenden, nicht mit der sequenzierten Humansequenz überlappenden Bereich das neue Gen Eif3 in seiner Exon-Intron-Struktur und die beiden letzten Exons 11 und 12 des Gens Stk33 kartiert und charakterisiert werden. Die umfangreiche Sequenzanalyse beider sequenzierter Genombereiche ergab für den Abschnitt des Menschen insgesamt 229 potentielle Exonsequenzen und für den Bereich der Maus 527 mögliche Exonbereiche. Davon konnten beim Menschen explizit 21 Exons und bei der Maus 31 Exons als exprimierte Bereiche identifiziert und experimentell mittels RT-PCR, bzw. durch cDNA-Sequenzierung verifiziert werden. Diese Abschnitte beschrieben nicht nur die Exonbereiche der oben genannten vier Gene, sondern konnten auch neuen nicht weiter definierten EST-Sequenzen zugeordnet werden. Mittels des Interspeziesvergleiches war darüber hinaus auch die Analyse der nichtkodierenden Intergen-Bereiche möglich. So konnten beispielsweise im ersten Intron des LMO1/Lmo1 sieben Sequenzbereiche mit Konservierungen von ca. 90% bestimmt werden. Auch die Charakterisierung von Promotor- und putativ regulatorischen Sequenzabschnitten konnte mit Hilfe unterschiedlicher bioinformatischer Analyse-Tools durchgeführt werden. Die konservierten Sequenzbereiche der DNA zeigen im Durchschnitt eine Homologie von mehr als 65% auf. Auch die Betrachtung der Genomorganisation zeigte Gemeinsamkeiten, die sich meist nur in ihrer graduellen Ausprägung unterschieden. So weist ein knapp 80 kb großer Bereich proximal zum humanen TUB-Gen einen deutlich erhöhten AT-Gehalt auf, der ebenso im murinen Genom nur in verkürzter Version und schwächer ausgeprägt in Erscheinung tritt. Die zusätzliche Vergleichsanalyse mit einer weiteren Spezies, den orthologen Genomabschnitten von Fugu, zeigte, dass es sich bei den untersuchten Genen LMO1 und TUB um sehr konservierte und evolutiv alte Gene handelt, deren genomisches Organisationsmuster sich auch bei den paralogen Genfamilienmitglieder innerhalb derselben Spezies wiederfindet. Insgesamt konnte durch die Kartierung, Sequenzierung und Analyse eine umfassende Datenbasis für die betrachtete Genomregion und die beschriebenen Gene generiert werden, die für zukünftige Untersuchungen und Fragestellungen wertvolle Informationen bereithält.

Mycoplasma pneumoniae associated opsoclonus-myoclonus syndrome in three cases

Opsoclonus-myoclonus syndrome (OMS) is a rare acquired movement disorder occurring in all age groups, predominantly in infants. Although the exact pathogenesis is still undefined, there is strong evidence for a paraneoplastic or parainfectious immune process resulting in central nervous system dysfunction. Mycoplasma pneumoniae has been implicated in a number of immune-mediated neurologic diseases [28]. However, the association of M. pneumoniae and opsoclonus-myoclonus-ataxia syndrome is not well established so far. We present three cases with opsoclonus-myoclonus-ataxia syndrome in adolescents following an infection with M. pneumoniae. Monophasic disease course and full recovery correspond to the favorable prognosis known from parainfectious cases in young adults. This should affect therapeutic consideration. OMS should be added to the spectrum of M. pneumoniae-associated neurologic complications. Nevertheless, neuroblastoma has to be ruled out in all cases of OMS.

Hemolytic-uremic syndrome in Switzerland: a nationwide surveillance 1997-2003

Hemolytic-uremic syndrome (HUS) is a leading cause of acute renal failure in childhood. In its typical presentation, it is preceded by an episode of diarrhea mostly due to Shiga-toxin-producing Escherichia coli. There is important geographical variation of many aspects of this syndrome. Nationwide data on childhood HUS in Switzerland have not been available so far. In a prospective national study through the Swiss Pediatric Surveillance Unit 114 cases (median age 21 months, 50% boys) were reported between April 1997 and March 2003 by 38 pediatric units (annual incidence 1.42 per 10(5) children < or =16 years). Shiga-toxin-producing E. coli were isolated in 32 (60%) of tested stool samples, serotype O157:H7 in eight. Sixteen children presented with only minimal renal involvement, including three with underlying urinary tract infection. Six patients presented with atypical hemolytic-uremic syndrome, and six with HUS due to invasive Streptococcus pneumoniae infection. Mortality was 5.3%, including two out of six children with S. pneumoniae infection. The severity of thrombocytopenia and the presence of central nervous system involvement significantly correlated with mortality. In conclusion, childhood HUS is not rare in Switzerland. Contrasting other countries, E. coli O157:H7 play only a minor role in the etiology. Incomplete manifestation is not uncommon.

Benign neonatal sleep myoclonus: a review of the literature

OBJECTIVE: Neurologically normal term infants sometimes present with repetitive, rhythmic myoclonic jerks that occur during sleep. The condition, which is traditionally resolved by 3 months of age with no sequelae, is termed benign neonatal sleep myoclonus. The goal of this review was to synthesize the published literature on benign neonatal sleep myoclonus. METHODS: The US National Library of Medicine database and the Web-based search engine Google, through June 2009, were used as data sources. All articles published after the seminal description in 1982 as full-length articles or letters were collected. Reports that were published in languages other than English, French, German, Italian, Portuguese, or Spanish were not considered. RESULTS: We included 24 reports in which 164 term-born (96%) or near-term-born (4%) infants were described. Neonatal sleep myoclonus occurred in all sleep stages, disappeared after arousal, and was induced by rocking the infant or repetitive sound stimuli. Furthermore, in affected infants, jerks stopped or even worsened by holding the limbs or on medication with antiepileptic drugs. Finally, benign neonatal sleep myoclonus did not resolve by 3 months of age in one-third of the infants. CONCLUSIONS: This review provides new insights into the clinical features and natural course of benign neonatal sleep myoclonus. The most significant limitation of the review comes from the small number of reported cases.

Favourable long-term outcome after immediate treatment of neonatal hyperammonemia due to N-acetylglutamate synthase deficiency

INTRODUCTION: N-Acetylglutamate synthase (NAGS) deficiency is a rare urea cycle disorder, which may present in the neonatal period with severe hyperammonemia and marked neurological impairment. CASE REPORT: We report on a Turkish family with a patient who died due to hyperammonemia in the neonatal period. Reduced activity of NAGS and carbamyl phosphate synthetase were found at autopsy. A second child who developed hyperammonemia on the second day of life was immediately treated with arginine hydrochloride, sodium benzoate and protein restriction. After NAGS deficiency was suspected by enzyme analysis, sodium benzoate was replaced by N-carbamylglutamate (NCG). A third child who developed slight hyperammonemia on the third day of life was treated with NCG before enzyme analysis confirmed reduced NAGS activity. Neither of the patients developed hyperammonemia in the following years. After the human NAGS gene was identified, mutation analysis revealed that the older sibling on NCG therapy was homozygous for a 971G>A (W324X) mutation. The parents and the younger sibling were heterozygous. Therapy was continued in the older sibling until now without any adverse effects and favourable neurodevelopment outcome. In the younger sibling, therapy was stopped without any deterioration of urea cycle function. CONCLUSION: NAGS deficiency can be successfully treated with NCG and arginine hydrochloride with favourable outcome. Molecular diagnostic rather than enzyme analysis should be used in patients with suspected NAGS deficiency.

Measurement issues in trials of pediatric acute diarrheal diseases: a systematic review

BACKGROUND: Worldwide, diarrheal diseases rank second among conditions that afflict children. Despite the disease burden, there is limited consensus on how to define and measure pediatric acute diarrhea in trials. OBJECTIVES: In RCTs of children involving acute diarrhea as the primary outcome, we documented (1) how acute diarrhea and its resolution were defined, (2) all primary outcomes, (3) the psychometric properties of instruments used to measure acute diarrhea and (4) the methodologic quality of included trials, as reported. METHODS: We searched CENTRAL, Embase, Global Health, and Medline from inception to February 2009. English-language RCTs of children younger than 19 years that measured acute diarrhea as a primary outcome were chosen. RESULTS: We identified 138 RCTs reporting on 1 or more primary outcomes related to pediatric acute diarrhea/diseases. Included trials used 64 unique definitions of diarrhea, 69 unique definitions of diarrhea resolution, and 46 unique primary outcomes. The majority of included trials evaluated short-term clinical disease activity (incidence and duration of diarrhea), laboratory outcomes, or a composite of these end points. Thirty-two trials used instruments (eg, single and multidomain scoring systems) to support assessment of disease activity. Of these, 3 trials stated that their instrument was valid; however, none of the trials (or their citations) reported evidence of this validity. The overall methodologic quality of included trials was good. CONCLUSIONS: Even in what would be considered methodologically sound clinical trials, definitions of diarrhea, primary outcomes, and instruments employed in RCTs of pediatric acute diarrhea are heterogeneous, lack evidence of validity, and focus on indices that may not be important to participants.

Fatal pulmonary embolism in a premature neonate after twin-to-twin transfusion syndrome

Thrombotic events are being increasingly recognized during the neonatal period. An infant girl was born at 29 weeks' gestation after a pregnancy complicated by twin-to-twin transfusion syndrome. After an initial uncomplicated clinical course, her oxygen requirement increased, which was interpreted as an early sign of bronchopulmonary dysplasia. At 3 weeks of age, she suddenly collapsed and died of severe pulmonary hypertension. At autopsy, multiple pulmonary artery emboli and several older renal vein thromboses were found. Results of genetic analyses of the infant and her family were negative for thrombophilia. Although embolism represents a frequent emergency in adults, fatal pulmonary embolism has never, to our knowledge, been described for premature infants. This case suggests that thrombotic events are underdiagnosed and that additional studies are needed to define infants at risk and optimal treatment strategies.

Causes and mechanisms of intrauterine hypoxia and its impact on the fetal cardiovascular system: a review

Until today the role of oxygen in the development of the fetus remains controversially discussed. It is still believed that lack of oxygen in utero might be responsible for some of the known congenital cardiovascular malformations. Over the last two decades detailed research has given us new insights and a better understanding of embryogenesis and fetal growth. But most importantly it has repeatedly demonstrated that oxygen only plays a minor role in the early intrauterine development. After organogenesis has taken place hypoxia becomes more important during the second and third trimester of pregnancy when fetal growth occurs. This review will briefly adress causes and mechanisms leading to intrauterine hypoxia and their impact on the fetal cardiovascular system.