Valve replacement in children less than 5 years of age

Between 1966 and 1984, there were 63 children less than 5 years of age who underwent 70 valve replacements (49 mitral [5 repeat], 6 aortic, 11 tricuspid [systemic ventricle; 2 repeat]), 2 tricuspid [pulmonary ventricle] and 1 multiple [mitral-aortic]) at Children's Hospital. Tissue valves were used in 20%. Since 1980, only Bj?rk-Shiley and St. Jude valves have been used. The most common indication for valve replacement was mitral regurgitation after repair of atrioventricular (AV) canal (34%). Mortality dropped considerably over time: 76% before 1979, 33% from 1979 to 1982 and 22% since 1982. More than two-thirds of fatalities were operative deaths, usually within 3 days of surgery. Actuarial survival curves for those operated on since 1980 predict 1 and 5 year survival of 73 and 51%, respectively. For the 46 operative survivors 1 and 5 year valve survival was 97 and 70%, respectively. Postoperative hemodynamics were significantly improved on elective postoperative catheterizations. All but one patient with non-tissue valves received anticoagulant therapy. Postoperative complications included thromboembolism (1.6/100 patients-years) and hemorrhage (0.8/100 patient-years). The frequency of intravascular hemolysis and endocarditis was 1.6%, comparable with adult experience. Complete heart block requiring a pacemaker developed in nine patients (14.1%), in all after AV valve replacement. Valve replacement in young children generally results in considerable hemodynamic improvement. The mortality rate remains above that observed in adults but has declined considerably for those operated on after 1980.     

Experience with marrow harvesting from donors less than two years of age

Experience in harvesting marrow for allogeneic marrow transplantation from 23 infant donors is presented. Ten donors were less than one year of age and 13 were between one and two years of age at the time of initial donation. None of these donors experienced major difficulties following the aspiration procedure. Three donors had significant medical problems diagnosed during the pre-donation evaluation. All aspirations were performed from iliac crests and all donors were given general anesthesia. Irradiated blood bank transfusions were given to 85% of the donors during the procedure. The volume of marrow obtained ranged from 11.5 to 19.3 ml/kg donor weight and contained from 2.5 to 10.4 x 10(8) nucleated cells/kg donor weight. Thus, very young children may safely donate marrow for allogeneic transplantation and the nucleated cell count obtained is substantial.     

Etiology of diarrhea in children less than five years of age in Ifakara, Tanzania

A total of 451 stool specimens were collected from children less than five years of age with acute diarrhea from Ifakara, Tanzania and processed to detect bacterial enteropathogens, parasites, and rotaviruses. These specimens were divided into 348 from the dry season and 103 from the rainy season. Overall, diarrheogenic Escherichia coli (35.7%) were the predominant enteropathogens, with enterotoxigenic E. coli, enteroaggregative E. coli, and enteropathogenic E. coli being the most prevalent. Moreover, enteroaggregative E. coli (63% versus 35.5%; P < 0.05), Shigella spp. (24% versus 12%; P < 0.05), and rotavirus (23% versus 4%; P < 0.05) were more prevalent in the dry season than in the rainy season and enterotoxigenic E. coli (51.6% versus 20%; P < 0.05) and Giardia lamblia (14% versus 1%; P < 0.05) were more prevalent in the rainy season.     

Enteropathogens associated with acute and persistent diarrhea in Bangladeshi children less than 5 years of age.

A longitudinal study of diarrhea was carried out from May 1988 to April 1989 by household surveillance of 705 children less than 5 years old in rural Bangladesh. Stool samples were examined for enteric pathogens at the beginning of each diarrheal episode. For persistent episodes, stool examination was repeated on days 15-17 of the illness. For each case of persistent diarrhea, stool samples from age-matched acute diarrheal and healthy controls were examined. Compared with healthy controls, cases of diarrhea were associated with Shigella species (P = .07) and rotavirus (P less than .05). Diffusely adherent Escherichia coli (P less than .05) and cryptosporidia (P = .07) were the only enteropathogens associated with persistent diarrhea in comparison with acute diarrhea. No more than 15% of children had the same class of pathogen identified from stool on both days 1-3 and days 15-17, indicating that persistent infection was uncommon. However, a different enteropathogen was frequently found on days 15-17, suggesting that sequential infection may be a cause of persistent diarrhea.     

Colorectal carcinoma in patients less than 40 years of age

The mean incidence of colorectal carcinoma in persons under age 40 in Sweden is 1.74/100,000/year. Over a 30-year period, 1950 through 1979, 1061 patients with colorectal carcinoma were seen, 48 of whom were under age 40 (21 to 39 years) and in this study were compared with older patients. Carcinoma was superimposed upon ulcerative colitis in 18 patients. All patients treated for palliation died within two years. Curability rate, 67 per cent, and the proportion of Dukes' A lesions were the same as in older patients, whereas young patients had fewer B and more C lesions. Five-year survival was 33 per cent overall and 50 per cent in curable cases, not different from the rates in older patients (33 and 47 per cent). Five-year survival was 100 per cent in stage A, 50 per cent in stage B, and 33 per cent in stage C. The age factor had no impact upon survival, and colitic origin of a carcinoma did not decrease survival more than did carcinoma itself. It is concluded that colorectal carcinoma in patients under age 40 differs in no respect from the disease in older patients.     

Rectal bleeding in patients less than 50 years of age

The study group consisted of 102 patients that presented for evaluation of rectal bleeding. All patients were 50 years of age or less and were evaluated with a flexible endoscope and an anoscope. The findings from each examination were recorded independently. Sigmoidoscopy and anoscopy were performed in 56 patients less than age 40 (group I), and colonoscopy and anoscopy were performed on 46 patients between the ages of 40 but less than 50 years (group II). Anoscopy was superior to flexible endoscopy in detecting hemorrhoids in group I (P<0.001) and group II (P<0.004). The guaiac status of patients was not influenced by the presence of hemorrhoids. Three patients in group I and eight patients in group II had polyps. The likelihood of finding a polyp was not influenced by the guaiac status of the patients. Three patients in group I and one patient in group II had anal fissures that were missed with flexible endoscopy and detected with anoscopy. Five of 102 patients were noted to have diverticula; all of these were in group II. However, this was not felt to be the source of the bleed given the clinical history. Overall, six patients had colitis; all but one of these patients were less than 40 years of age. Flexible endoscopy and anoscopy provide complimentary information in middle-aged adults with rectal bleeding.     

Colorectal adenocarcinoma in patients less than 40 years of age

From 1973 to 1985, 105 patients under 40 years of age were treated for colorectal adenocarcinoma at Roswell Park Cancer Institute. There were 51 males and 54 females. The mean age was 32 years. The majority of patients were treated for left colon or rectal carcinomas. Ninety-seven of 105 patients underwent surgical resection of their primary cancer, 70 (67 percent) of which were potentially curative. Twenty-seven patients underwent palliative resections. Dukes' A or B lesions were not seen in patients less than 20 years old, whereas these early lesions were seen in 11 percent of patients 20 to 29 years old and in 26 percent of patients greater than 30 years of age. The mean survival for patients between 20 and 29 years was 39 months and 46 months for patients 30 years and older.     

Colorectal carcinoma in patients less than 40 years of age

Between 1960 and 1979, 37 patients, ranging in age from 18 to 40 years, were treated for colorectal cancer. Symptoms typical of colorectal malignancy had been present for an average of 10.4 months; a positive family history, previous colonic disease, or immunosuppression was present in 22 patients (59 per cent). Distribution of lesions was unusual in that only 40 per cent were within reach of the sigmoidoscope, and only 7.5 per cent could be palpated on rectal examination. Dukes' staging at diagnosis was improved in distribution to that reported in the adult population (51 per cent localized vs. 40.1 per cent). Histologic characteristics of the tumors were not unusual; however, incidence of poorly differentiated (18.9 per cent) and mucin-producing (10.8 per cent) cancers was increased. Perineural invasion was associated with disseminated disease. Vascular invasion was associated with disseminated disease and poor prognosis. Overall fiver-year survival was 56.8 per cent. Five-year survival in 24 patients undergoing potentially curative resection increased to 70.8 per cent. Colorectal carcinoma in patients under 40 years of age is unusual, and delay in diagnosis is common. The distribution of lesions is more homogeneous than that seen in older patients, and high-grade malignancies are more frequent. Survival data in this series are more favorable than those generally reported. Improved five-year survival following potentially curative resection (70.8 per cent) stresses the need for early diagnosis and treatment Read at the meeting of the American Society of Colon and Rectal Surgeons, Hollywood, Florida, May 11 to 16, 1980. Supported in part by the Roessler Foundation and the American Cancer Society.     

Obstructive sleep apnea in patients with diabetes less than 40 years of age

Background and aimObstructive sleep apnea (OSA) is known to be associated with diabetes mellitus (DM). Age is factor associated with different clinical features of OSA. There is limited data on clinical differences of young DM patients with OSA versus older DM patients with OSA. This study aimed to find clinical differences of DM coexisting with OSA between young age group and older.MethodsThis is a retrospective, analytical study conducted at Srinagarind Hospital, Thailand. The inclusion criteria were adult patients diagnosed as DM with OSA. The study period was between January 2008 and December 2019. The diagnosis of OSA was made by presence of apnea hypopnea index (AHI) of ≥5 times/hour by polysomnography. Clinical predictors of OSA in young DM patients with age under 40 years were executed.ResultsThere were 56 patients in the young diabetes mellitus group, while there were 137 patients in the older diabetes mellitus group. The mean (SD) age of diagnosis for diabetes mellitus of both groups were 31.61 (6.53) and 54.68 (7.62) years, respectively. There were three independent predictors for DM in the young: atrial fibrillation (AF), body mass index (BMI) and glomerular filtration rate (GFR). Presence of AF perfectly predicted DM with OSA in age over 40 years. The adjusted odds ratio for BMI and GFR were 1.29 (95% CI 1.05, 1.58) and 1.06 (1.01, 1.13). The BMI over 32 kg/m² and GFR over 77 ml/min/m² gave sensitivity of 80.00%.ConclusionsYoung DM patients with OSA had more severe OSA, were more obese, had better renal function, and had fewer AF than the older ones.     

Intermediate-term results of percutaneous transvenous mitral commissurotomy in children less than 12 years of age.

The objectives of this study were to review the efficacy of percutaneous transvenous mitral commissurotomy (PTMC) in young children less than 12 years of age and to provide intermediate-term follow-up data. There is a paucity of information regarding the long-term efficacy of PTMC done in children less than 12 years of age. The data of 100 consecutive children less than 12 years of age (mean, 11.1 +/- 1.2 years) who underwent PTMC using Inoue balloon were analyzed retrospectively. Serial clinical and echocardiographic follow-up information of more than 6 months was available in 94 patients. The procedure was successful in 94 patients. The mean calculated mitral valve area (MVA) increased from 0.72 0.14 to 1.7 0.35 cm(2) (P 0.0001). Echocardiographic restenosis (MVA < or = 1 cm(2) or > 50% gain loss) occurred in 14 of 94 patients (16%) over a mean follow-up of 34.4 25.9 (range, 2-115) months. The improvement in New York Heart Association (NYHA) functional class was maintained in most patients (from a mean of 2.87 0.5 pre-PTMC to 1.42 0.6 at follow-up). Seven out of 14 patients with restenosis underwent a re-PTMC. The actuarial rate of good functional status (survival, no repeat interventions, and NYHA class 1 or 2) at 100 months was 75.4% 8.7%. PTMC provides excellent intermediate-term palliation even in young children with rheumatic mitral stenosis.     

Erratum: Rhinitis in children less than 6 years of age: current knowledge and challenges

[This corrects the article on p. 115 in vol. 1, PMID: 22053307.].     

Sudden unexpected death in persons less than 40 years of age

This study retrospectively assesses the underlying causes of sudden unexpected death and the occurrence of prodromal symptoms in 162 subjects (aged 9 to 39 years) over a 10-year period (1976 to 1985). Underlying cardiac diseases accounted for sudden death in 73% and noncardiac causes in 15% of subjects. In 12% of subjects, the causes were unidentifiable. Myocarditis (22%), hypertrophic cardiomyopathy (22%) and conduction system abnormalities (13%) were the major causes in 32 subjects aged less than 20 years. Major causes of 46 deaths in subjects 20 to 29 years were atherosclerotic coronary artery disease (24%), myocarditis (22%) and hypertrophic cardiomyopathy (13%). The largest number of deaths in 84 subjects aged greater than or equal to 30 years was attributed to coronary artery disease (58%), followed by myocarditis (11%). Among noncardiac causes of sudden death, intracranial hemorrhage was the most frequent (5%), followed by infectious disease (4%). Prodromal symptoms were reported by 54% of subjects; most frequent were chest pain (25%) in subjects aged greater than or equal to 20 years, and dizziness (16%) in those aged less than 20. Sudden death, which occurred during routine daily activity in 49% and during sleep in 23% of subjects, was related to physical exercise in 23% and emotional upset in 6%. Sudden unexpected death in the young is still an unresolved medical problem. The early recognition of prodromal symptoms could be crucial in the prevention of sudden death, specifically when exercise-related.     

Burden of malaria at community level in children less than 5 years of age in Togo.

A community-based baseline cross-sectional survey was conducted in three districts in Togo in September 2004 as part of a multidisciplinary evaluation of the impact of the Togo National Integrated Child Health Campaign. During this campaign, long-lasting-insecticide-treated bed nets (LLITNs) were distributed to households with children between 9 months and 5 years of age throughout the country in December 2004. The pre-intervention survey provided baseline malaria and anemia prevalence in children < 5 years of age during peak malaria transmission. Of 2,532 enrolled children from 1,740 households, 62.2% (1,352/2,172) were parasitemic and 84.4% (2,129/2,524) were anemic (hemoglobin < 11 g/dL). Moderate-to-severe anemia (< 8.0 g/dL) was found in 21.7% (543/2,524), with a peak prevalence in children 6-17 months of age and was strongly correlated with parasitemia (OR = 2.3, 95% CI: 1.8-2.5). Net ownership (mainly untreated) was 225/2,532 (8.9%). Subsequent nation-wide introduction of LLITNs and the introduction of artemisinin-based combination therapy have the potential to markedly reduce this burden of malaria.     

The Association of HIV Counseling and Testing with HIV Risk Behaviors in a Random Population-based Survey in Kisumu,Kenya

HIV testing has been promoted as a key HIV prevention strategy in low-resource settings, despite studies showing variable impact on risk behavior. We sought to examine rates of HIV testing and the association between testing and sexual risk behaviors in Kisumu, Kenya. Participants were interviewed about HIV testing and sexual risk behaviors. They then underwent HIV serologic testing. We found that 47% of women and 36% of men reported prior testing. Two-thirds of participants who tested HIV-positive in this study reported no prior HIV test. Women who had undergone recent testing were less likely to report high-risk behaviors than women who had never been tested; this was not seen among men. Although rates of HIV testing were higher than seen in previous studies, the majority of HIV-infected people were unaware of their status. Efforts should be made to increase HIV testing among this population.     

Rapid development of antiretroviral drug resistance mutations in HIV-infected children less than two years of age initiating protease inhibitor-based therapy in South Africa

Data on the development of antiretroviral drug resistance in HIV-1-infected children receiving protease inhibitor (PI)-based antiretroviral therapy (ART) are limited. We examined antiretroviral resistance among a cohort of 323 South African HIV-infected children <2 years old exposed to nevirapine for prevention of mother-to-child transmission. Ritonavir (RTV) was used initially for 138 children who were <6 months old or receiving antimycobacterial therapy; otherwise children received lopinavir/ritonavir (LPV/r)-based ART. HIV-1 population sequencing of the pol gene was conducted on all pretreatment samples and on posttreatment samples for children who did not achieve HIV-1 plasma RNA <400 copies/ml by 52 weeks. Among children in the cohort, 38 died, 22 had <24 weeks follow-up, 209 achieved virologic suppression, and 54 did not. Of 41 children without virologic suppression with posttreatment HIV genotype data available, major resistance mutations were found in 32 (78%): 14 (36%) had PI mutations including V82A, M46I, and L90M; 29 (71%) had M184V/I; and three had NNRTI mutations (K103N, Y181C, and G190A). Among the children who did not achieve virologic suppression, none of the seven children treated exclusively with LPV/r developed PI-related mutations, compared with 14 of 32 (44%) who received RTV-based regimens (p=0.036); PI genotypes were unavailable for two children. Seventy-eight percent of children without virologic suppression developed resistance mutations that impact second-line ART options. Only children who received RTV-based ART developed major PI-related resistance mutations, and use of this regimen should be avoided.     

HIV increases the risk of malaria in women of all gravidities in Kisumu,Kenya

OBJECTIVE: To study the importance of HIV infection for malaria in pregnancy in Kisumu, Kenya. SUBJECTS AND METHODS: Healthy women with an uncomplicated pregnancy of 32 weeks or more attending the prenatal clinic in the Provincial Hospital between June 1996 and March 1999 were tested for HIV and malaria after consent had been obtained. For participating women who delivered in the same hospital, a blood smear of the mother and the placenta were obtained. RESULTS: In the third trimester, 5093 women consented to testing: the prevalence of malaria and HIV was 20.1 and 24.9%, respectively. Among the 2502 screened women who delivered in the hospital, the prevalence of HIV, peripheral parasitaemia and placental malaria was 24.5, 15.2, and 19.0%, respectively. Compared with HIV-seronegative women, HIV-seropositive women were more likely to be parasitaemic, to have higher parasite densities, and to be febrile when parasitaemic. Placental infections in HIV-seropositive women were more likely to be chronic, as indicated by the presence of moderate to heavy pigment depositions. When adjusted by age, the typical gravidity-specific pattern of malaria in pregnancy disappeared in HIV-seropositive women; HIV-seropositive primigravidae had a similar risk of malaria as HIV-seropositive multigravidae. The excess malaria attributable to HIV in the third trimester increased from 34.6% among HIV-seropositive primigravidae, to 41.5% among HIV-seropositive secundigravidae, and 50.7% among HIV-seropositive gravidae with three or more pregnancies. CONCLUSION: HIV infection alters patterns of malaria in pregnant women; in areas with both infections, all pregnant women should use malaria prevention.     

The Fontan operation in infants less than 2 years of age.

Young age remains a reported risk factor for a successful Fontan operation despite improved survival rates. Since March 1978, the Fontan operation has been performed in 47 patients. To avoid a primary or secondary palliative shunt, an early Fontan procedure (Group 1: mean age 1.5 +/- 0.5 years, range 0.6 to 2) has been performed in 17 children with the outcome similar to that of the remaining 30 older patients (Group 2: mean age 7.5 +/- 5 years, range 2.4 to 23 years). Preoperatively both groups had acceptable hemodynamic status for a successful Fontan result. Operative variables including cardiopulmonary bypass time, aortic cross-clamp time and core temperature were similar between groups and did not affect mortality. The postoperative mortality rate including early surgical (0% vs. 13%, respectively), late (18% vs. 12%) and total (18% vs. 23%) was similar between Groups 1 and 2 (p greater than 0.05). Immediate postoperative arrhythmias were more frequent in Group 1 (71% vs. 25%, p less than 0.01) with no related mortality, while late arrhythmias occurred with equal frequency (29% vs. 39%, p greater than 0.05). Group 1 infants required a longer hospital stay (22 +/- 9 vs. 14 +/- 5 days, p less than 0.01). Thus, young age is not a risk factor for successful outcome of the Fontan operation in patients with acceptable preoperative hemodynamic status. An early Fontan operation may also avoid prolonged palliative procedures and their potential deleterious effects.