Viral suppression and adherence among HIV-infected children and adolescents on antiretroviral therapy: results of a multicenter study

ObjectiveTo evaluate treatment adherence among perinatally-infected pediatric human immunodeficiency virus (HIV) patients followed in pediatric centers in Brazil.MethodsThis was a cross-sectional multicenter study. Medical records were reviewed and adherence scale, assessment of caregivers’ quality of life (WHOQOL-BREF), anxiety, depression, and alcohol/substances use/abuse were assessed. Outcomes included self-reported 100% adherence in the last three days and HIV viral load (VL) < 50 copies/mL. Statistical analyses included contingency tables and respective statistics, and multivariable logistic regression.Results260 subjects were enrolled: 78% children and 22% adolescents; 93% of caregivers for the children and 77% of adolescents reported 100% adherence; 57% of children and 49% of adolescents had VL < 50 copies/mL. In the univariate analyses, HIV diagnosis for screening due to maternal infection, lower caregiver scores for anxiety, and higher scores in physical and psychological domains of WHOQOL-BREF were associated with 100% adherence. Shorter intervals between pharmacy visits were associated with VL < 50 copies/mL (p ≤ 0.01). Multivariable regression demonstrated that caregivers who did not abuse alcohol/other drugs (OR = 0.49; 95% CI: 0.27-0.89) and median interval between pharmacy visits < 33 days (OR = 0.97; 95% CI: 0.95-0.98) were independently associated with VL < 50 copies/mL; whereas lower caregiver scores for anxiety (OR = 2.57; 95% CI: 1.27-5.19) and children's HIV diagnosis for screening due to maternal infection (OR = 2.25; 95% CI: 1.12-4.50) were found to be independently associated with 100% adherence.ConclusionsPediatric HIV programs should perform routine assessment of caregivers’ quality of life, and anxiety and depression symptoms. In this setting, pharmacy records are essential to help identify less-than-optimal adherence.     

The prognostic value of relative renal function greater than 51% in the pelvi-ureteric junction-obstructed kidney on 99mtechnetium mercaptoacetyltriglycine study

ObjectiveObstructed kidneys with relative function (RRF) estimates >50% are occasionally noted in ^99mtechnetium mercaptoacetyltriglycine renal studies. It is thought that increased RRF might confer some benefit and/or permit delayed intervention. We compared the RRF and absolute renal function, as defined by effective renal plasma flow (ERPF), of obstructed kidneys in the ranges >51%, 40%–50% and <40% RRF before and after pyeloplasty.MethodsTwenty children, median age 13.5 months (range 3 weeks–126 months), satisfied criteria for the diagnosis of PUJ obstruction and estimated function >51% (group 1). Their pre- and post-intervention data were compared with 21 children, median age 2 months (range 1 week–126 months), with PUJ obstruction and 40%–50% RRF (group 2); and 21, median age 6 months (range two days–110 months), with RRF below 40% (group 3). Kidneys showing signs of continuing obstruction after surgery were excluded.ResultsFinal ERPF was negatively related to age: younger children, and those with a higher preoperative ERPF, recovered better than older children and those with a lower ERPF (p < 0.05). Pre- and postoperative mean ERPF in group 1 was 76 (range 21–203) and 102 (6–240) ml/min/1.73 msq respectively. In group 2, these values were 75.2 (30–187) and 130.9 (44–306) ml/min/1.73 msq, and they were 42.6 (5–179) and 80.2 (17–205) ml/min/1.73 msq in group 3. When adjustment was made for preoperative ERPF, there was no evidence that RRF grouping was related to ERPF outcome. The postoperative ERPF of seven of 20 kidneys from group 1 (>51%) was lower than the ERPF before surgery compared to 2/21 in group 2 and 4/21 in group 3, but these differences were not statistically significant (p = 0.25).ConclusionsMost kidneys in each functional range improved when obstruction was relieved. An RRF >51% in the obstructed kidney was not always prognostically beneficial, and may be a warning of impending decompensation in a minority.     

A double-blind placebo-controlled randomized trial on probiotics in small bowel bacterial overgrowth in children treated with omeprazole

ObjectiveTo evaluate the incidence of small bowel bacterial overgrowth (SBBO) in children treated with omeprazole, and to test whether probiotics influence the incidence.MethodsA double-blinded, placebo-controlled trial was performed in 70 children treated orally during four weeks with 20 mg omeprazole per day. Lactobacillus rhamnosus R0011 (1.9 × 10⁹ cfu) and Lactobacillus acidophillus R0052 (0.1 × 10⁹ cfu) were simultaneously given daily to 36 subjects (probiotic group), while 34 subjects received placebo (placebo group). The diagnosis of SBBO was based on the development of suggestive symptoms, in combination with a positive glucose breath test.ResultsAfter one month of proton pump inhibitor (PPI) treatment, 30% (21/70) had a positive breath test suggesting SBBO; of these 62% were symptomatic. Five children developed SBBO-like symptoms, but had a negative breath test; and 44 (63%) were symptom free and had a negative breath test. There was no difference in the incidence of positive breath tests in the probiotic versus the placebo group (33% vs 26.5%; p = 0.13).ConclusionsSince symptoms suggesting SBBO developed in 26% of PPI-treated children, and since the glucose breath test was abnormal in 72% of these, this side-effect should be more frequently considered. The probiotic tested did not decrease the risk to develop SBBO.     

Hemodynamic effects of increased intra-abdominal pressure in critically ill children

ObjectiveTo evaluate the influence of intra-abdominal pressure on the cardiac index (CI) at different intra-abdominal hypertension grades achieved when performing an abdominal compression maneuver (ACM). Evaluating the effectiveness of the ACM in distending the left internal jugular vein (LIJV).MethodsProspective observational study conducted in the PICU of a quaternary care teaching hospital. Participants underwent the ACM and the IAP was measured with an indwelling urinary catheter. At each IAH grade reached during the ACM, the CI was measured by transthoracic echocardiography and the LIJV cross-sectional area (CSA) was determined by ultrasonography.ResultsTwenty-four children were included (median age and weight of 3.5 months and 6.37 kg, respectively). The median CI observed at baseline and during IAH grades I, II, III, and IV were 3.65 L/min/m² (IQR 3.12−4.03), 3.38 L/min/m² (IQR 3.04−3.73), 3.16 L/min/m² (IQR 2.70−3.53), 2.89 L/min/m² (IQR 2.38−3.22), and 2.42 L/min/m² (IQR 1.91−2.79), respectively. A 25% increase in the LIJV CSA area was achieved in 14 participants (58%) during the ACM.ConclusionThe ACM significantly increases IAP, causing severe reversible impairment in the cardiovascular system and is effective in distending the LIJV in just over half of the subjects. Even low levels of HIA can result in significant cardiac dysfunction in children. Therefore, health professionals should be aware of the negative hemodynamic repercussions caused by the increased IAP.     

Association between family structure,maternal education level,and maternal employment with sedentary lifestyle in primary school-age children

ObjectiveTo determine the association between family structure, maternal education level, and maternal employment with sedentary lifestyle in primary school-age children.MethodData were obtained from 897 children aged 6 to 12 years. A questionnaire was used to collect information. Body mass index (BMI) was determined using the age- and gender-specific Centers for Disease Control and Prevention definition. Children were categorized as: normal weight (5^th percentile ≤ BMI < 85^th percentile), at risk for overweight (85^th ≤ BMI < 95^th percentile), overweight (≥ 95^th percentile). For the analysis, overweight was defined as BMI at or above the 85^th percentile for each gender. Adjusted odds ratios (adjusted ORs) for physical inactivity were determined using a logistic regression model.ResultsThe prevalence of overweight was 40.7%, and of sedentary lifestyle, 57.2%. The percentage of non-intact families was 23.5%. Approximately 48.7% of the mothers had a non-acceptable educational level, and 38.8% of the mothers worked outside of the home. The logistic regression model showed that living in a non-intact family household (adjusted OR = 1.67; 95% CI = 1.04-2.66) is associated with sedentary lifestyle in overweight children. In the group of normal weight children, logistic regression analysis show that living in a non-intact family, having a mother with a non-acceptable education level, and having a mother who works outside of the home were not associated with sedentary lifestyle.ConclusionLiving in a non-intact family, more than low maternal educational level and having a working mother, appears to be associated with sedentary lifestyle in overweight primary school-age children.     

Dramatic impact of morbid obesity on child lung development

ObjectiveTo assess the respiratory function and sleep characteristics of obese adults and children.MethodsAll patients with non-syndromic, severe obesity (BMI ≥ 3 z-scores for children and ≥ 40.00 kg/m² for adults), referred for pulmonary function tests at Lille University Hospital, were retrospectively included.ResultsA total of 69 children (mean ± SD BMI 36.8 ± 6.7 and mean BMI z-score 4.7 ± 1.0) and 70 adults were included (mean BMI 45.7 ± 6.2). Metabolic syndrome was diagnosed in 13 children (26%) and 40 adults (80%). Reduced lung volumes were observed in 34 children (50.0%) and 16 adults (24.0%) and both the mean functional residual capacity (FRC) and the mean residual volume (RV) were lower in children than in adults (FRC: ?1.7 ± 2.1 z-score in children vs. ?1.0 ± 1.1 in adults, P = 0.026; and RV: ?0.8 ± 1.2 z-score in children vs. ?0.1 ± 1.1 in adults, P = 0.002). The prevalence of severe obstructive sleep apnea syndrome was greater in adults (40.7% vs. 18.8%, P = 0.007). Children had a higher average oxygen saturation (median of 96.0% [91.0–98.0] vs. 93.0% [76.0–97.0] in adults, P < 0.0001).ConclusionObesity has consequences for lung volumes in children; however, a longitudinal study is needed to determine the impact on pulmonary expansion and growth.     

Percutaneous renal surgery in children with complex stones

ObjectiveWe report our experience with percutaneous nephrolithotomy (PNL) therapy for staghorn or complex pediatric renal calculi.Patients and methodsWe retrospectively analyzed the case records of 105 patients younger than 17 years who underwent PNL. The cases included 53 complex calculi analyzed in 51 patients. We defined complex calculi as either staghorn or those with a stone bulk larger than 300 mm², involving more than one calix, the upper ureter or stone in anomalous kidney.ResultsMean age of patients with complex calculi was 9.7 ± 0.7 years and stone burden was 654 ± 92.4 mm². The median duration of PNL was 90 ± 4.7 (30–220) min. Complete clearance was achieved in 39 patients (73.6%). Of these, 32 (60.4%) required a single tract, while 21 (39.6%) required multiple tracts. With subsequent shock wave lithotripsy and PNL, the clearance rate increased to 86.8%. The average hemoglobin drop was 1.6 ± 0.16 g/dL. Assessing the factors affecting the hemoglobin drop, the number of tracts (P = 0.01) and size of tracts (P = 0.002) were found to be significant. The mean change in serum creatinine concentration between preoperative and postoperative measurements was −0.01 ± 0.02 mg/dL, for both patients with a single tract and those with multiple tracts.ConclusionsPNL is safe and effective in the management of staghorn and complex renal calculi in children. Tract dilatation and number of tracts are important factors in reducing blood loss.     

The multicenter Italian birth cohort study on incidence and determinants of lower respiratory tract infection hospitalization in infants at 33 weeks GA or more: preliminary results

BackgroundRespiratory syncytial virus (RSV) causes respiratory infections during the first year of life. Very premature infants have more severe diseases and also ‘late preterm infants’ may be more susceptible to the infection.Aim of the studyTo evaluate in an Italian cohort the incidence and risk factors of severe hospitalized lower respiratory tract infection (LRTI) induced or not by RSV during the first year of life.MethodsA cohort of 33^+ 0d–34^+ 6d wGA newborns paired with two sex- and age-matched 35^+ 0d–37^+ 6d wGA and ≥ 38^+ 0d wGA newborns were enrolled. Hospitalization for LRTI induced or not by RSV during the first year of life was assessed through phone interview at the end of the RSV season (November–March) and at the completion of the first year of life. The parents were asked to report hospitalization for any reason.Results1064 neonates were enrolled (November 2009–October 2010), 697 had at least one phone follow-up by September 2010. Babies of 33^+ 0d–34^+ 6d wGA were more frequently conceived through assisted fertilization technologies, born from cesarean delivery had more frequently acute perinatal risk factors and were more frequently twins. After a mean 6 month-follow-up, we registered 29 hospitalizations for LRTI induced or not by RSV. Hospitalizations were slightly and non-significantly more frequent in 33^+ 0d–37^+ 6d wGA infants. The risk of hospitalization was significantly 60% reduced in breastfed babies and four folds significantly increased during the RSV season.ConclusionThe very preliminary data of this ongoing study suggest that in ‘late-preterm’ infants some individual/environmental characteristics of the infants play a relevant role in determining the risk of severe RSV infection.     

Vitamin D deficiency at pediatric intensive care admission

Objectiveto assess whether 25hydroxivitaminD or 25(OH)vitD deficiency has a high prevalence at pediatric intensive care unit (PICU) admission, and whether it is associated with increased prediction of mortality risk scores.Methodprospective observational study comparing 25(OH)vitD levels measured in 156 patients during the 12 hours after critical care admission with the 25(OH)vitD levels of 289 healthy children. 25(OH)vitD levels were also compared between PICU patients with pediatric risk of mortality III (PRISM III) or pediatric index of mortality 2 (PIM 2) > p75 [(group A; n = 33) vs. the others (group B; n = 123)]. Vitamin D deficiency was defined as < 20 ng/mL levels.Resultsmedian (p25‐p75) 25(OH)vitD level was 26.0 ng/mL (19.2‐35.8) in PICU patients vs. 30.5 ng/mL (23.2‐38.6) in healthy children (p = 0.007). The prevalence of 25(OH)vitD < 20 ng/mL was 29.5% (95% CI: 22.0‐37.0) vs. 15.6% (95% CI: 12.2‐20.0) (p = 0.01). Pediatric intensive care patients presented an odds ratio (OR) for hypovitaminosis D of 2.26 (CI 95%: 1.41‐3.61). 25(OH)vitD levels were 25.4 ng/mL (CI 95%: 15.5‐36.0) in group A vs. 26.6 ng/mL (CI 95%: 19.3‐35.5) in group B (p = 0.800).Conclusionshypovitaminosis D incidence was high in PICU patients. Hypovitaminosis D was not associated with higher prediction of risk mortality scores.     

Evaluación de la perfusión tisular periférica mediante láser Doppler en niños en estado crítico

ObjectiveTo analyze skin tissue perfusion at different sites in critically ill children.Patients and methodsA prospective observational study was performed on 41 critically ill children with a median age of 12 months and weight of 8.2 kg. Skin tissue flow was measured in each patient using laser Doppler consecutively in the foot, forearm, thigh and hypochondrium, and its association with demographic and hemodynamic variables, as well as lactate and inotropic index, was analyzed.ResultsA total of 144 tissue flow measurements were made, with a median flow of 3.2 ± 2.2 ml/min/100 g tissue. There was a moderate correlation between the tissue flow measured in central locations, abdomen-arm (r²: 0.574, P=.001), abdomen-thigh (r²: 0.423, P=.002) and thigh-arm (r²: 0.703, P<.000), but not with the peripheral measurements (sole of the foot). The limits of agreement, measured between the different locations, were wide (range 6.1 to ?2.5 ml/min/100 g). There was a slight-moderate correlation between the flow in the sole of the foot with weight (?0.355, P=.039), age (?0.343, P=.044), peripheral temperature (0.503, P=.017) and inotropic index (?0.443, P=.008).ConclusionsTissue flow in the foot correlates with weight, age, peripheral temperature and inotropic index. Further studies are needed to analyze its usefulness in assessing peripheral perfusion in situations of shock.     

Metotrexato en artritis idiopática juvenil: efectos adversos y factores asociados

IntroductionMethotrexate (MTX) is the drug of choice for juvenile idiopathic arthritis. Its clinical efficacy is limited due to the development of adverse effects (AEs).Patients and methodsA retrospective observational study was conducted on the AEs associated with MTX therapy in children diagnosed with juvenile idiopathic arthritis followed-up in a tertiary hospital between 2008 and 2016.ResultsThe study included a total of 107 patients, of whom 71 (66.3%) were girls (66.3%). The median age at diagnosis was 6.4 years (IQR 3.1-12.4), with a median follow-up of 45.7 months (IQR 28.8-92.4). There were 48 patients (44.9%) with oligoarthritis, and 26 children (24.3%) with rheumatoid-factor negative polyarthritis. Of these, 52/107 (48.6%) developed AEs, with the most frequent being gastrointestinal symptoms (35.6%) and behavioural problems (35.6%). An age older than 6 years at the beginning of therapy increased the risk of developing AEs, both in the univariate (OR=3.5; 95% CI: 1.5-7.3) and multivariate (12% increase per year) analyses. The doses used, administration route, or International League of Associations for Rheumatology (ILAR) classification, were not associated with the development of AEs. Twenty children required a dosage or route of administration modification, which resolved the AE in 11 (55%) cases. MTX was interrupted due to the development of AEs in 37/107 patients (34.6%), mainly due to increased plasma transaminases (n = 14, 37.8%), gastrointestinal symptoms (n = 9, 24.3%) and behavioural problems (n = 6, 16.3%).ConclusionsMTX is the therapy of choice for patients with juvenile idiopathic arthritis, but 50% of the children develop some form of AE. Although the AEs are not severe, they lead to interruption of therapy in 35% of the children.     

Safety of botulinum toxin type A in children younger than 2 years

BackgroundBotulinum toxin type A (BoNT-A) has been used in many indications and is licensed for the treatment of spasticity in children older than 2 years. However, there are few reports of BoNT-A treatment in patients younger than 2 years of age.AimsTo review retrospectively the safety data from all infants treated with botulinum toxin type A (BoNT-A) before 2 years of age in a paediatric neurology unit.MethodsThere were 74 infants: 28 received the first dose before 1 year of age, and 46 between the ages of 1 and 2 years.ResultsIn the first year of life, the most frequent indication was obstetric brachial palsy (OBP) (71.4% of cases) and in the second year, cerebral palsy (CP) (73.9%). Both Botox^® and Dysport^®, the two commercially-available BoNT-A products in Spain, were used. The average starting dose by session was 6.55 U/kg body weight Botox in infants in their first year of life, and 8.4 U/kg body weight Botox and 21.1 U/kg body weight Dysport in the second year of life. Only 3.6% of cases treated in the first year and 6.5% of those treated in the second experienced adverse events (AEs), which consisted of mild weakness or tiredness lasting 1–4 days.ConclusionsBoNT-A has a good safety profile in infants younger than 2 years old. AEs are similar to those found in older children.     

Osteomielitis aguda: epidemiología,manifestaciones clínicas,diagnóstico y tratamiento

Background and aimsThe present study focuses on the epidemiology, clinical and laboratory data, and management of osteomyelitis in a pediatric third level hospital.MethodologyAll cases of children under 15 years-old admitted with osteomyelitis between 2000 and 2011 were retrospectively reviewed until July 2006, then prospectively from then until 2011.ResultsA total of 50 patients were identified (52% males) with median age at diagnosis of 2 years. Principal onset manifestations were pain (94%), functional impairment (90%) and fever (72%). The femur (32%), fibula (28%) and calcaneus (22%) were most affected bones.Leucocytosis > 12.000/μl was found in 56%, elevated ESR > 20 mm/h in 26%, and elevated CRP > 20 mg/L in 64%. Blood culture was positive in 20%, with group A streptococcus being the most frequently isolated bacteria (11%).All diagnoses were confirmed by a ⁹⁹Tc scintigraphy bone scan.Antibiotic therapy was initially intravenously (mean time of administration: 10 days ± 3 SD), followed by oral medication (mean time of administration: 18 days ± 6 SD). Surgery was necessary in 3 patients. Evolution of all cases was excellent, despite 3 exceptions that resolved over time.ConclusionsThe current short-term intravenous therapy led to shorter hospitalizations. There were no statistically significant differences between time from clinical onset or in CRP levels at discharge compared to long-term therapies prior to 2006.     

Differing urinary urea excretion among children with idiopathic hypercalciuria and/or hyperuricosuria

ObjectiveTo estimate dietary protein intake in children with idiopathic hypercalciuria (HC) and/or hyperuricosuria (HU).Patients and methodsWe compared the 24-h urinary excretion of urea, as a reflection of protein intake, in four age- and sex-matched groups, each comprising 56 consecutive children: (1) HC, (2) HU, (3) HC + HU and (4) control.ResultsUrinary urea excretion was significantly higher in HC, HU and HC + HU than in controls. HC and HU children had similar urea excretion. HC + HU children had urinary urea significantly higher than HC and HU, but urinary calcium similar to HC and urinary uric acid excretion similar to HU subjects. Urinary calcium was significantly (R² = 0.21) correlated with urea excretion in HC children only, whereas urinary uric acid was significantly (R² = 0.21) correlated with urinary urea in HU children only. No significant correlation between urinary urea and calcium or uric acid excretion was found in HC + HU patients although they had the highest urinary urea. A significant (p = 0.004) interaction between urinary urea and sodium in increasing urinary calcium excretion resulted only in the HC group.ConclusionThe association of dietary protein excess with HC and/or HU is conditioned by an individual (genetic?) predisposition and may be produced by different mechanisms.     

Factors affecting the outcome of foreskin reconstruction in hypospadias surgery

ObjectiveDespite ongoing refinement of numerous techniques, the incidence of complications following hypospadias repair is still significant. The aim of this study is to evaluate the factors that affect the success in childhood of foreskin reconstruction with hypospadias repair.Materials and methodsA retrospective study was carried out of all primary hypospadias repairs with foreskin reconstruction (n = 408) over the last 23 years. The hypospadias was coronal in 160 (39%), glanular in 114 (28%), subcoronal in 78 (19%) and distal penile in 56 (14%) cases. Foreskin reconstruction was included in 362 cases suitable for a meatal advancement (191) or distal urethral tubularization (171), and 46 cases for a flip-flap procedure (37 Mathieu, nine Barcat). Outcome analysis was of foreskin-related complications post surgery.ResultsForeskin repair was successful in 333 cases (92%) that underwent meatal advancement/distal urethral tubularization, and 33 (72%) that underwent a flip-flap operation. Complications related to the foreskin occurred in 10% of the whole group with a urethral fistula rate of 8%. The median age at surgery was 13 months (2–120 months), and the median follow-up period was 11 months (1–100 months).ConclusionsA good cosmetic and functional outcome can be achieved with foreskin reconstruction combined with a variety of hypospadias repairs. The outcome in this series was better in cases of distal hypospadias using interrupted polyglactin sutures.     

Epidemiological evaluation and survival of children with acute myeloid leukemia

ObjectiveThis study aims to describe the epidemiological characteristics and survival rates of children with acute myeloid leukemia treated in hospitals in southern Brazil and compare them with international data.MethodsA multicenter cohort study was conducted with retrospective data collection of all new patients with acute myeloid leukemia under 18 treated at five referral centers in pediatric hematology-oncology in southern Brazil between January 2005 and December 2015.ResultsOf the 149 patients with acute myeloid leukemia, 63.0% (n = 94) were male. The median age at diagnosis was 10.5 years (range 0–18 years) and 40.3% (n = 60) had a white blood cell count below 50,000/mm². The most common Franco-American-British (FAB) subtype was M3 (n = 43, 28.9%). Nine (6.0%) patients had central nervous system disease. In M3 patients, overall survival (OS) was 69.2% and 3-year event-free survival was 67.7%; in non-M3 patients, these rates were 45.3% and 36.7%, respectively. In non-M3 patients, OS was significantly different between transplanted (61.8%) and non-transplanted (38.2%) patients (p = 0.031).ConclusionsThese results show a higher prevalence of the Franco-American-British M3 subtype than that reported in the international literature, as well as a decreased OS compared with that of developed countries. Further multicenter Brazilian studies with a larger sample size are encouraged to better understand the characteristics of acute myeloid leukemia, and to improve the treatment and prognosis in this population.     

Adrenocortical status in infants and children with sepsis and septic shock

BackgroundThe benefit from corticosteroids remains controversial in sepsis and septic shock and the presence of adrenal insufficiency (AI) has been proposed to justify steroid use.AimTo determine adrenal state and its relation with outcome in critical children admitted with sepsis to PICU of Cairo University, Children Hospital.MethodsThirty cases with sepsis and septic shock were studied. Cortisol levels (CL) were estimated at baseline and after high-dose short ACTH stimulation in those patients and in 30 matched controls. Absolute AI was defined as basal CL < 7 μg/dl and peak CL < 18 μg/dl. Relative AI was diagnosed if cortisol increment after stimulation is <9 μg/dl.ResultsOverall mortality of cases was 50%. The mean CL at baseline in cases was higher than that of controls (51.39 μg/dl vs. 12.83 μg/dl, p = 0.000). The mean CL 60 min after ACTH stimulation was higher than that of controls (73.38 μg/dl vs. 32.80 μg/dl, p = 0.000). The median of %rise in cases was lower than that of controls (45.3% vs. 151.7%). There was a positive correlation between basal and post-stimulation cortisol with number of system failure, inotropic support duration, mechanical ventilation days, and CO₂ level in blood. There was a negative correlation between basal and post stimulation cortisol with blood pH and HCO₃.ConclusionRAI is common with severe sepsis/septic shock. It is associated with more inotropic support and has higher mortality. Studies are warranted to determine whether corticosteroid therapy has a survival benefit in children with RAI and catecholamine resistant septic shock.     

Botulinum toxin-A (Botox®) intradetrusor injections in children with neurogenic detrusor overactivity/neurogenic overactive bladder: A systematic literature review

ObjectivesDescribe and discuss the efficacy and safety of botulinum toxin type A (BTX-A) intradetrusor injections in children with neurogenic detrusor overactivity (NDO) and urinary incontinence or overactive bladder symptoms of neurogenic origin (NOAB).MethodsA MEDLINE and EMBASE search for clinical studies involving BTX-A injected into the detrusor of children with NDO or NOAB was performed, prior to data analysis.ResultsA total of six articles evaluating the efficacy and safety of Botox^® in patients with NDO and incontinence/NOAB were selected. The underlying neurological disease was myelomeningocele in 93% of patients. Most were over 2 years of age. The most common amount of Botox injected was 10–12 U/kg with a maximal dose of 300 U, usually as 30 injections of 10 U/ml in the bladder (excluding the trigone) under cystoscopic guidance and general anaesthesia. Most of the studies reported a significant improvement in clinical (65–87% became completely dry) as well as urodynamic (in most studies mean maximum detrusor pressure was reduced to <40 cm H₂O and compliance was increased >20 ml/cm H₂O) variables, without major adverse events.ConclusionsBotox injections into the detrusor provide a clinically significant improvement and seem to be very well tolerated in children with NDO and incontinence/NOAB refractory to antimuscarinics.     

Lorazepam versus diazepam–phenytoin combination in the treatment of convulsive status epilepticus in children: A randomized controlled trial

BackgroundConvulsive status epilepticus demands urgent and appropriate management with anticonvulsants. Intravenous diazepam is an established drug in the management of convulsive status epilepticus in adults as well as in children. The efficacy of intravenous lorazepam has not been well established in children.ObjectiveTo determine whether intravenous lorazepam is as efficacious as diazepam–phenytoin combination in the treatment of convulsive status epilepticus in children.Study designRandomized controlled trial.MethodsA total of 178 children were enrolled in the study; 90 in the lorazepam group and 88 in the diazepam–phenytoin combination group. Enrolled subjects were between 1 and 12 years with a clinical diagnosis of convulsive status epilepticus, presenting in pediatric emergency of a tertiary care hospital. They were randomized to receive either intravenous lorazepam (0.1 mg/kg) or intravenous diazepam (0.2 mg/kg)–phenytoin (18 mg/kg) combination at admission and were followed up for subsequent 18 h.ResultsThe overall success rate of therapy was 100% in both the groups. There was no statistically significant difference in the two groups (lorazepam versus diazepam–phenytoin combination) in the median time taken to stop the seizure [20 s in both groups], the number of subjects requiring more than one dose of the study drug to stop the presenting seizure [lorazepam 6(6.7%) versus diazepam–phenytoin combination: 14 (15.9%); adjusted RR (95% CI) = 0.377 (0.377, 1.046); P = 0.061] and the number (%) of patients having respiratory depression [lorazepam 4(4.4%) versus diazepam–phenytoin combination 5 (5.6%)]. None of the patients in the two groups required additional anticonvulsant drug to stop the presenting seizure. No patient required mechanical ventilation and none of the patients in the two groups required cross-over to the alternative regimen.ConclusionLorazepam is as efficacious and safe as diazepam–phenytoin combination. We recommend use of lorazepam as a single drug to replace the two drug combination of diazepam–phenytoin combination to control the initial seizure in pediatric convulsive status epilepticus.