Incomplete Kawasaki disease in patients younger than 1 year of age: a possible inherent risk factor

Kawasaki disease (KD) patients younger than 1 year of age are at especially high risk of developing coronary artery abnormalities (CAA). To define the clinical characteristics of this group, as well as the risk factors predisposing them to CAA, we reviewed the medical records of 136 KD patients younger than 1 year of age who were treated at the Korea University Medical Center from January 2001 to July 2006. Of these patients, 16 developed CAA (11.8%). The CAA(+) group had a longer duration of total fever than the CAA(−) group (9.1±3.7 days vs. 6.3±2.0 days, p=0.011), but did not differ in the duration of pre- and post-intravenous gamma-globulin (IVGG) fever. The CAA(+) group had fewer diagnostic symptoms than the CAA(−) group (2.7±1.1 vs. 4.3±1.2, p<0.001). Of the hematological findings, the CAA(+) group only differed from the CAA(−) group in having significantly higher total white blood cell (19.2±6.0 vs. 14.7±4.7 K/mm³, p=0.007) and platelet (462.9±101.0 vs. 383.6±121.1 K/mm³, p=0.014) levels. Multivariable logistic regression analysis showed that the only factors which were significantly associated with the development of CAA were the total number of symptoms (OR=0.493, 95% CI=0.293–0.829, p=0.007) and the duration of total fever (OR=1.405, 95% CI=1.092–1.808, p=0.008). Conclusively, incomplete clinical manifestations and a longer duration of total fever are significantly associated with the development of CAA in KD patients younger than 1 year of age. Therefore, these patients should be monitored for incomplete KD, especially if unexplained fever continues, and treatment to shorten the duration of total fever should be initiated. An erratum to this article can be found at     

The Epidemiology of Kawasaki Disease in an Urban Hospital: Does African American Race Protect Against Coronary Artery Aneurysms?

The etiology and pathogenesis of Kawasaki disease (KD) is largely unknown. Certain demographic factors and laboratory findings are predictive of the development of coronary artery (CA) aneurysms. The objectives of this study were to determine the epidemiology of KD patients in an urban hospital and determine risk factors associated with their development of CA abnormalities. A longitudinal case series of KD patients admitted to Children’s National Medical Center from 1990 to 2002 was examined. Age, sex, ethnic background, duration of fever prior to diagnosis, address, month diagnosed, and CA abnormalities (ectasia or aneurysms) on echocardiography were recorded. Median household income was obtained from the U.S. Census Bureau Web site. The Student t-test, logistic regression analyses, and the Kruskal–Wallis test were used, with significance assumed at p < 0.05. A total of 302 patients were evaluated. CA abnormalties were found in 27 patients (9%), with aneurysms identified in 13 patients (4%). Age was 2.9 ± 2.4 years (range, 2 months to 14 years). A total of 51 patients (16%) were ≤1 year and 35 patients (12%) were ≥5 years. Ethnic distribution was 54% (164) African American, 24% (72) Caucasian, 9% (29) Asian/Pacific Islander, 8% (23) Hispanic, and 5% (14) Middle Eastern. Only 2/164 (1.2%) African Americans developed CA aneurysms. Neighborhood median income of the cohort was $45,400 ± $21,200 ($52,200 ±$25,800 for patients with aneurysms). A total of 28% of cases clustered between December and January. Cases doubled annually in 1999–2001 compared to 1990–1998 (39 vs 19). Multivariate logistic regression found age between 1 and 5 years [p = 0.045; odds ratio, 0.31; 95% confidence interval (CI), 0.10–0.97] and African American race (p = 0.014; odds ratio, 0.15; 95% CI, 0.03–0.68) to be independently protective against CA aneurysms. Duration of fever prior to diagnosis, considered in 210 patients, was different between patients with and without aneurysms (11 ± 5.3 vs 6.5 ± 3.8 days, respectively, p = 0.0007). Multivariate logistic regression found fever longer than 5 days to be the only predictive factor associated with the development of aneurysms and any abnormality. African Americans had a shorter duration of fever than the rest of the cohort (6.03 vs 7.31 days), (p = 0.0087). The epidemiology of KD at our hospital is similar to that at other centers except for the predominance of African Americans with a shorter duration of fever prior to diagnosis and a decreased incidence of CA aneurysms compared to other ethnicities. The protective nature of African American ethnicity against the development of CA aneurysms raises speculation about the role of genetics and its interaction with immunity in the pathogenesis of KD. Paper presented at the 2003 Pediatric Academic Societies/Society for Pediatric Research Meeting, Seattle, WA, USA.     

Endothelial Function Evaluated by Flow-Mediated Dilatation in Pediatric Vascular Disease

The endothelial function of children with and without vascular disease, consisting of 41 controls, 24 with Kawasaki disease (KD), and 46 with diabetes mellitus (DM), was examined. Age at examination ranged from 3 to 23 years (mean, 12.0 ± 4.7). The flow-mediated dilatation (FMD) and intima-media complex in the common carotid artery were measured. In controls age at examination was not associated with FMD or intima-media complex. FMD significantly decreased in children with KD and DM compared with the control group (control vs KD or DM: 11.7 ± 14.7 vs 3.0 ± 11.0 or 6.4 ± 8.5%, respectively; p < 0.05). However, there was no significant difference for intima-media complex among the groups. Furthermore, FMD in KD patients with coronary arterial aneurysm was lower than that in KD patients without aneurysm (-0.5 ± 9.2 vs 8.3 ± 9.1%, p < 0.05). In DM patients, FMD in the high HbA1c group (HbA1c = 7%) was lower than that in the normal HbA1c group (HbA1c < 7%) (4.8 ± 8.1 vs 11.4 ± 7.8%, p < 0.05). In conclusion, FMD detected endothelial impairment in children with KD or type 1 DM regardless of overt vascular complications, and FMD impairment occurs prior to intima-media complex thickening. By measuring both FMD and intima-media complex, useful information for predicting vascular complications may be obtained.     

Natriuretic Peptide as an Adjunctive Diagnostic Test in the Acute Phase of Kawasaki Disease

Coronary arteritis rather than myocardial involvement is typically emphasized in Kawasaki disease (KD). Moreover, the criteria and the usual biological markers oversee the importance of cardiac-specific markers in diagnosing this disease. We sought to study the clinical usefulness of measuring B-type natriuretic peptide (BNP) and its N-terminal moiety (NT-proBNP) at the onset of KD. Our objective was to evaluate blood concentrations of BNP and NT-proBNP during the acute and subacute phases of KD. We conducted a prospective study comparing newly diagnosed KD patients to non-KD febrile controls. Blood specimens were collected at presentation, 6–12 h after intravenous immunoglobulin (IVIG) therapy, 1–2 weeks later, and 2–3 months later, or only upon reenrollment for controls. Forty-there KD and 19 control patients were enrolled consecutively. The mean age was 47.1 ± 34.3 and 62.2 ± 44.9 months, respectively (p = NS). Pre-IVIG NT-proBNP levels were significantly higher in KD patients than in controls (923.6 ± 1361.7 vs. 186.2 ± 198.0 ng/L; p < 0.001), with no statistical difference for BNP (141.9 ± 227.5 vs. 59.9 ± 72.4 ng/L; p = 0.112). In conclusion, our data indicate that NT-proBNP is a better marker of myocardial involvement in acute KD than BNP, particularly in cases with incomplete diagnostic criteria, and suggest that it may be a valid adjunctive diagnostic method to support the diagnosis of KD.     

Atorvastatin Safety in Kawasaki Disease Patients With Coronary Artery Aneurysms

Statins (HMG-CoA reductase inhibitors) may decrease inflammation in postacute Kawasaki disease (KD) complicated by coronary artery aneurysm (CAA) and promote vascular remodeling. There are limited data on their safety in young children. Twenty patients with CAAs after KD (median CAA z-score = +25) were treated with 5/10 mg atorvastatin daily for a median of 2.5 years (range 0.5–6.8) starting at a median of 2.3 years (range 0.3–8.9) after acute KD (median age 9.3 years [range 0.7–14.3]). Compliance with treatment was excellent: only one patient reported minor side effects (joint pain, no change in medication). Average total cholesterol before atorvastatin was 3.73 ± 0.84 mmol/L and after atorvastatin was 3.21 ± 0.46 mmol/L (relative decrease ?14 %, p = 0.02); low-density lipoprotein cholesterol was 1.99 ± 0.76 mmol/L before and only 1.49 ± 0.27 mmol/L after (relative decrease ?20 %, p = 0.04); high-density lipoprotein was 1.39 ± 0.36 mmol/L before and 1.30 ± 0.27 mmol/L after (relative decrease ?4 %, p = 0.35); and triglycerides were 0.71 ± 0.28 mmol/L before and 0.71 ± 0.18 mmol/L after (relative decrease ?5 %, p = 0.38). Nine of 20 patients (45 %) experienced at least 1 episode of hypocholesterolemia (total cholesterol <3.1 mmol/L), and 2 patients required atorvastatin dose lowering. Transient mild increase of liver enzymes (aspartate aminotransferase/alanine aminotransferase 45–60 U/L) were seen in 7 of 20 (35 %) patients with no patients experiencing more severe increases. Only one patient experienced increased creatine phosphokinase levels (>500 U/L). Serial measurements of age- and sex-specific percentiles of weight (estimated change: 1.4 [2.7] % per year, p = 0.60), height (estimated change: ?3.2 [3.2] % per year, p = 0.32), and body mass index (estimated change: 1.0 [2.9] % per year, p = 0.73) showed no association between anthropomorphic growth and atorvastatin treatment. Atorvastatin use in very young children with KD is safe but should be closely monitored.     

Intravenous immunoglobulin preparation type: Association with outcomes for patients with acute Kawasaki disease

Manlhiot C, Yeung RSM, Chahal N, McCrindle BW. Intravenous immunoglobulin preparation type: Association with outcomes for patients with acute Kawasaki disease.
Pediatr Allergy Immunol 2010: 21: 515–521.
© 2010 John Wiley & Sons A/S To determine whether two different intravenous immunoglobulin (IVIG) preparations were equally efficacious in the treatment of Kawasaki disease (KD). Single centre retrospective review of all patients treated with IVIG for KD between January 1990 and April 2007. Comparison of IVIG (dose 2 g/kg) from two commercial preparations; Iveegam^® stabilized with sugar (lyophilized, 5 g/ml glucose, pH 6.4–7.2, IgA 10 μg/ml, 5% IgG/ml) and Gamimune^® stabilized through acidification (no sugar, pH 4.0–4.5, IgA 270 μg/ml, 5% 1990–1999, 10% 1999–2007 IgG/ml). Propensity‐adjusted differences in duration of fever after treatment initiation, frequency of retreatment with IVIG, hospital stay and maximum coronary artery z‐score. A total of 954 patients were included, 862 (90%) were treated with Iveegam^® and 92 (10%) were treated with Gamimune^®. Patients’ demographic, clinical and laboratory characteristics were similar between the two groups. In propensity‐adjusted models, Iveegam^® was found to be associated with higher probability of non‐response to IVIG (12% vs. 5%, p = 0.05) and longer median duration of fever after IVIG [1 (1–27) vs. 1 (1–8) days, p = 0.02] than Gamimune^®. Nevertheless, Gamimune^® was found to be associated with longer median duration of hospital stay [5 (2–49) vs. 4 (2–76) days, p < 0.0001] and higher median maximum coronary artery z‐score both at the end of the acute phase (+1.4 vs. +0.8, p < 0.0001) and 6–8 weeks after the acute phase (+0.7 vs. +0.4, p < 0.0001). IVIG preparations with lower IgA content and stabilized with glucose appear to be associated with improved coronary artery outcomes for patients with KD.     

Right Ventricular Diastolic Function After Repair of Tetralogy of Fallot

The objective of this study was quantitate diastolic dysfunction in the postoperative phase of tetralogy of Fallot (TOF) and to correlate it with the type of surgical procedure and clinical parameters. Fifty consecutive patients (mean age, 5.0 years; mean weight, 13.5 kg), operated for TOF during the period November 2004 to May 2005, were prospectively studied [infundibular resection, 23; infundibular resection and transannular patch (TAP), 19; right ventricle→pulmonary artery conduit, 8). Detailed echocardiography was done on postoperative days 3 and 9 with a focus on Doppler indices of right ventricular (RV) function, Antegrade late diastolic flow in the right ventricular outflow tract (RVOT) was taken as the marker of restrictive RV physiology. The previous parameters were correlated to the type of surgery and clinical indices of RV dysfunction. There was no mortality. Twenty-four patients showed restrictive RV physiology. This finding correlated with lower values of E/A ratio (0.98 ± 0.17 vs 1.33 ± 0.49, p < 0.002), tricuspid valve E-wave deceleration time (86.9 ± 21.7 vs 151.4 ± 152 msec, p < 0.05), index of myocardial performance (0.15 ± 0.06 vs 0.26 ± 0.09, p < 0.001), isovolumic relaxation time (19.4 ± 17 vs 39±30 msec, p < 0.009), and a higher central venous pressure (15.1 ± 1.5 vs 12.7 ± 1.9, p < 0.001). Restrictive RV physiology correlated with prolonged intensive case unit (ICU) stay (5.1 ± 3.7 vs 2.8 ± 2 days, p < 0.015), longer duration of inotropic support (108.3 ± 56.2 vs 55.5 ± 28.3 hours, p < 0.02), and higher dosage of diuretics. RV diastolic dysfunction is demonstrable by Doppler echocardiography in the first week following surgery for TOF and tends to be worse with TAP. Restrictive physiology demonstrated by RVOT pulse Doppler predicts longer duration of inotropic support, prolonged ICU stay, and higher dosage of diuretics.     

Maternal plasma cholesterol and duration of pregnancy: A prospective cohort study in Ghana

Low plasma cholesterol may be associated with preterm birth; however, results are mixed and limited primarily to high‐income countries. Our objective was to determine whether maternal plasma lipid concentrations are associated with pregnancy duration. We performed a nested cohort (n = 320) study of pregnant Ghanaian women enrolled in a randomized controlled trial. Total cholesterol, high‐density lipoprotein cholesterol (HDL‐C), low‐density lipoprotein cholesterol, and triglyceride concentrations were analyzed in plasma at ≤20and 36 weeks gestation as continuous variables and also categorized into low, referent, or high (<10th, 10th–90th, >90th percentile). At ≤20 weeks, plasma lipid concentrations were not associated with pregnancy duration. At 36 weeks, total cholesterol and triglyceride concentrations were not associated with pregnancy duration. Higher HDL‐C at 36 weeks was associated with a longer pregnancy duration (adjusted β‐coefficient ± standard error: 0.05 ± 0.02 days mg^?1/dL, p = .02); pregnancy duration was 5.9 ± 2.0 (mean ± standard error) days shorter among women with low HDL‐C compared with the referent group (10th–90th percentile) (p = .02) and 8.6 ± 2.6 days shorter when compared with the high HDL‐C group (p = .003). Pregnancy duration was 4.9 ± 2.1 days longer among women with low low‐density lipoprotein cholesterol at 36 weeks gestation when compared with the referent group (p = .051). Our data suggest that low HDL‐C in the third trimester of pregnancy is associated with a shorter duration of pregnancy in this study population but do not support the hypothesis that low total cholesterol is associated with a shorter pregnancy duration.     

Myocardial Layers Specific Strain Analysis for the Acute Phase of Infant Kawasaki Disease

Recently, the prevalence of infant Kawasaki disease (KD) has increased. However, the myocardial functional analysis of infant KD can be difficult and rarely reported. The purpose of this study was to investigate layer specific myocardial strain analysis for better assessment of the acute period in infant KD. The study retrospectively reviewed the echocardiographic data of 25 infant patients with KD at the acute phase. With advanced imaging, pulsed tissue Doppler velocity data, myocardial strain with three layers specific analysis was performed. Then the data were compared with 25 age-matched healthy control infants. The measures of longitudinal strain and radial strain were decreased in infant KD compared to healthy controls. The circumferential strain was significantly decreased in infant KD at all three myocardial layers, especially in the endocardial layer (KD: ?20.5 ± 6.4 % vs. control: ?25.6 ± 7.6 %, endocardium, p = 0.00001; ?14.6 ± 4.4 % vs. ?18.1 ± 4.0 %; middle myocardium, p = 0.01; ?9.7 ± 3.3 % vs. ?11.4 ± 3.8 %; epicardium, p = 0.04). The acute phase of infant KD demonstrated decreased myocardial strain measurement. Circumferential strain was the lowest in the endocardial layer. Further continuous long-term follow up for myocardial assessment should be recommended even after recovery with appropriate treatment.     

Coronary risk factors in Kawasaki disease treated with additional gammaglobulin.

AIMS: To assess the hypothesis that an additional intravenous gammaglobulin (IVGG) infusion, if administered early, may prevent coronary artery lesions (CAL) in patients with Kawasaki disease (KD) who do not respond to initial IVGG therapy. METHODS: Forty four KD patients (17 with CAL and 27 without CAL), treated with additional IVGG because of persistent or recrudescent fever after initial IVGG therapy, were studied. Main outcome measures were the presence of CAL by echocardiography and the number of febrile days before and after start of additional IVGG infusion (pre- and post-additional IVGG). RESULTS: In univariate analyses, risk factors for CAL were the number of febrile days pre-additional IVGG, the number of febrile days post-additional IVGG, the number of days that initial IVGG was divided over, the white blood cell count pre- and post-additional IVGG, and the C reactive protein concentration pre-additional IVGG. In a multivariate analysis, the only independent risk factor was the number of febrile days pre-additional IVGG (> or =10 days; odds ratio 7.86; 95% CI 1.44 to 42.8; p = 0.02). CONCLUSIONS: Among KD patients with persistent or recrudescent fever after initial IVGG therapy, administration of additional IVGG before the first 10 febrile days was associated with a decreased prevalence of CAL, when compared with the prevalence in those who were retreated later. An additional IVGG infusion, if administered early, may prevent CAL in initial IVGG non-responders.     

Ultrasonography findings and symptoms in acute rotavirus gastroenteritis

Background: The aim of the present study was to better understand how clinical events in acute rotavirus gastroenteritis are depicted on ultrasonography. Methods: The relationship between abdominal ultrasonography and clinical course and symptoms was evaluated in 92 patients with acute rotavirus gastroenteritis (51 boys, 41 girls) with an average age of 30.7 ± 24.6 months. Results: Significant correlations were observed between ultrasonography score and duration of illness after ultrasonography (P= 0.0232). It was also interesting that ultrasonography findings (score: 3.1 ± 1.0 vs 3.6 ± 1.2; P= 0.0118), clinical symptoms (3.1 ± 1.7 score vs 3.8 ± 1.8 score, P= 0.0293), and duration of illness after ultrasonography (4.4 ± 1.4 days vs 3.8 ± 1.1 days, P= 0.0301) were significantly different between patients examined on ultrasonography <1 day after illness onset (n= 50, but duration of illness after ultrasonography followed only in 42) and those examined ≥2 days after onset (n= 42, but duration of illness after ultrasonography followed only in 35). Conclusion: The ability of abdominal ultrasonography to indicate severity of disease makes abdominal ultrasonography an important guide to therapy.     

Elevation of Cardiac Troponin I in the Acute Stage of Kawasaki Disease

The study was performed to investigate the level of serum cardiac troponin I (cTnI), a marker specific for myocardial damage, using a chemiluminescent immunoassay in the acute febrile stage of Kawasaki disease (KD). The study population consisted of 45 KD patients before intravenous gamma-globulin (IVGG) therapy and a control group of 20 patients without KD. Among KD patients the results from measurements of the level of cTnI were positive in 18 cases (40%) and the creatine kinase (CK)-MB was positive in 11 cases (24%), but in the control group both the cTnI and CK-MB results were negative. Seven KD patients (15.6%) showed increases in both cTnI and CK-MB that were significantly correlated with each other (p < 0.05); however, CK-MB is not heart-specific. A significant increase in the level of cTnI in the acute stage of KD suggests that acute myocarditis or myocardial cell injury begins in the early phase of the disease (p < 0.05). The serologic test for cTnI can thus be a useful method for the early diagnosis of acute myocarditis and may enable early treatment with IVGG to reduce the cardiovascular abnormalities in KD patients.     

Coronary risk factors in Kawasaki disease treated with additional gammaglobulin

Aims: To assess the hypothesis that an additional intravenous gammaglobulin (IVGG) infusion, if administered early, may prevent coronary artery lesions (CAL) in patients with Kawasaki disease (KD) who do not respond to initial IVGG therapy. Methods: Forty four KD patients (17 with CAL and 27 without CAL), treated with additional IVGG because of persistent or recrudescent fever after initial IVGG therapy, were studied. Main outcome measures were the presence of CAL by echocardiography and the number of febrile days before and after start of additional IVGG infusion (pre- and post-additional IVGG). Results: In univariate analyses, risk factors for CAL were the number of febrile days pre-additional IVGG, the number of febrile days post-additional IVGG, the number of days that initial IVGG was divided over, the white blood cell count pre- and post-additional IVGG, and the C reactive protein concentration pre-additional IVGG. In a multivariate analysis, the only independent risk factor was the number of febrile days pre-additional IVGG (⩾10 days; odds ratio 7.86; 95% CI 1.44 to 42.8; p = 0.02). Conclusions: Among KD patients with persistent or recrudescent fever after initial IVGG therapy, administration of additional IVGG before the first 10 febrile days was associated with a decreased prevalence of CAL, when compared with the prevalence in those who were retreated later. An additional IVGG infusion, if administered early, may prevent CAL in initial IVGG non-responders.     

Transthoracic Echo-Doppler Assessment of Coronary Microvascular Function Late after Kawasaki Disease

The goal of this study was to demonstrate that Doppler transthoracic echocardiography (TTE) may represent a valuable tool for the noninvasive demonstration of coronary microvascular dysfunction in children with previous Kawasaki disease (KD) by the measurement of coronary flow reserve (CFR) during cold pressor test (CPT). Twenty-five children with previous KD (mean follow-up, 4.6 ± 2.6 years) were included in the study—16 with no evidence of coronary artery lesions (CALs⁻) by TTE and 9 with coronary aneurysms (CALs⁺). Seventeen age-matched healthy subjects were also recruited. Diastolic peak velocity was measured by pulsed Doppler both at rest (DPV_Rest) and during CPT (DPV_CPT) in the anterior descending artery. CFR was calculated as DPV_CPT/DPV_Rest. KD patients demonstrated significantly higher values of DPV_Rest (0.21 ± 0.05 vs 0.13 ± 0.01 cm/sec, p < 0.0001) and DPV_CPT (0.33 ± 0.07 vs 0.27 ± 0.03 cm/sec, p < 0.005). CFR was reduced in KD compared to control subjects (1.5 ± 0.4 vs 2.1 ± 0.2, p < 0.0001). CFR was decreased in a similar manner in both CALs⁺ patients (1.4 ± 0.4, p = 0.002 vs controls) and CALs⁻ patients (1.6 ± 0.4, p < 0.0001 vs controls). Doppler TTE at rest and during CPT may represent a valuable modality for CFR evaluation in children with a history of KD. CFR is significantly reduced in KD patients independently of the presence of CALs.     

Coronary magnetic resonance angiography and vessel wall imaging in children with Kawasaki disease

Background In patients with Kawasaki disease (KD) serial evaluation of the distribution and size of coronary artery aneurysms (CAA) is necessary for risk stratification and therapeutic management. Objective To apply whole-heart coronary MR angiography (CMRA) and black-blood coronary vessel wall imaging in children with KD. Materials and methods Six children (mean age 4.6 years, range 2.5–7.8 years) with KD underwent CMRA using a free-breathing, T2-prepared, three-dimensional steady-state free-precession (3D-SSFP), whole-heart approach with navigator gating and tracking. Vessel walls were imaged with an ECG-triggered and navigator-gated double inversion recovery (DIR) black-blood segmented turbo spin-echo sequence. Results There was complete agreement between CMRA and conventional angiography (n=6) in the detection of CAA (n=15). Excellent agreement was found between the two techniques in determining the maximal diameter (mean difference 0.2±0.7 mm), length (mean difference 0.1±0.8 mm) and distance from the ostium (mean difference −0.8±2.1 mm) of the CAAs. In all subjects with a CAA, abnormally thickened vessel walls were found (2.5±0.5 mm). Conclusions CMRA accurately defines CAA in free-breathing sedated children with KD using the whole-heart approach and detects abnormally thickened vessel walls. This technique may reduce the need for serial X-ray coronary angiography, and improve risk stratification and monitoring of therapy. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Single-incision laparoscopic surgery (SILS) for children with Crohn’s disease

Purpose

Single-incision laparoscopic surgery (SILS) has been described in adults with Crohn’s disease, but its use in pediatric Crohn’s patients has been limited. The purpose of this study was to review our experience with SILS in pediatric patients with Crohn’s disease.

Methods

A retrospective review was performed for patients diagnosed with Crohn’s disease who underwent small bowel resection or ileocecectomy at a freestanding children’s hospital from 2006 to 2014. Data collected included demographic data, interval from diagnosis to surgery, operative time, length of stay, and postoperative outcomes.

Results

Analysis identified 19 patients who underwent open surgery (OS) and 41 patients who underwent SILS. One patient (2.4 %) within the SILS group required conversion to OS. Demographic characteristics were similar between the 2 cohorts. The most common indication for surgery was stricture/obstruction (SILS 70.7 % vs. OS 68.4 %, p = 0.86), and ileocecectomy was the most common primary procedure performed (SILS 90.2 % vs. OS 100 % OS). Operative times were longer for SILS (135 ± 50 vs. 105 ± 37 min, p = 0.02). However, when the last 20 SILS cases were compared to all OS cases, the difference was no longer statistically significant (SILS 123.3 ± 34.2 vs. OS 105 ± 36.5, p = 0.12). No difference was noted in postoperative length of stay (SILS 6.5 ± 2.2 days vs. OS 7.4 ± 2.2 days, p = 0.16) or overall complication rate (SILS 24.4 % vs. OS 26.3 %, p = 0.16).

Conclusion

SILS ileocecectomy is feasible in pediatric patients with Crohn’s disease, achieving outcomes similar to OS. As experience increased, operative times also became comparable.

     

Daily skin-to-skin contact in full-term infants and breastfeeding: Secondary outcomes from a randomized controlled trial

This randomized controlled trial evaluated the effect of a 5-week daily skin-to-skin contact (SSC) intervention between mothers and their full-term infants, compared with care-as-usual, on exclusive and continued breastfeeding duration during the first post-natal year. Healthy pregnant women (n = 116) from a community sample were enrolled and randomly allocated to the SSC or care-as-usual condition. SSC mothers were requested to provide one daily hour of SSC for the first five post-natal weeks. Twelve months post-partum, mothers indicated the number of exclusive and continued breastfeeding months. Multiple regression analyses were conducted using intention-to-treat, per-protocol and exploratory dose–response frameworks. In intention-to-treat analyses, exclusive and continued breastfeeding duration was not different between groups (exclusive: 3.61 ± 1.99 vs. 3.16 ± 1.77 months; adjusted mean difference 0.28, 95% confidence interval [CI] ?0.33 to 0.89; p = 0.36; continued: 7.98 ± 4.20 vs. 6.75 ± 4.06 months; adjusted mean difference 0.81, 95% CI ?0.46 to 2.08; p = 0.21). In per-protocol analyses, exclusive and continued breastfeeding duration was longer for SSC than care-as-usual dyads (exclusive: 4.89 ± 1.26 vs. 3.25 ± 1.80 months; adjusted mean difference 1.28, 95% CI 0.31–2.24; p = 0.01; continued: 10.81 ± 1.97 vs. 6.98 ± 4.08 months; adjusted mean difference 2.33, 95% CI 0.13–4.54; p = 0.04). Exploratory dose–response effects indicated that more SSC hours predicted longer exclusive and continued breastfeeding duration. This study demonstrates that for the total group, the 5-week daily SSC intervention did not extend exclusive and continued breastfeeding duration. However, for mothers performing a regular daily hour of SSC, this simple and accessible intervention may extend exclusive and continued breastfeeding duration by months. Future studies are required to confirm these promising findings. Trial registration: Netherlands Trial Register (NTR5697).     

Identification of high-risk group and therapeutic options in children with liver abscess

The outcome of children with liver abscess (LA) depends upon prompt diagnosis and intervention. We evaluated the etiology, clinical profile, various interventional modalities of management and outcome of children with LA. A total of 39 hospitalized children (mean age 7.2 ± 3.9 years) with radiologically proven LA were analyzed. Parenteral antibiotics, percutaneous drainage (PD) or open surgical drainage (OSD) was done as required. Cases with ruptured or impending rupture of LA, upper gastrointestinal bleed, jaundice, pleural effusion or consolidation were labeled as “high risk” cases. Triad of fever, pain and hepatomegaly was the most common presentation. Single abscess was present in 66.7% and right lobe was involved in 69.2% of cases. Majority of LA were pyogenic (PLA, 25/39). Amebic liver abscess (ALA) and PLA had similar clinical and laboratory profile except that multiloculated abscess on ultrasonography was a feature of PLA (12/25 vs. 0/11; p = 0.006). Cases with ALA settled significantly more often with antibiotics alone (5/11 vs. 3/25; p = 0.04) than PLA and none required surgery (0/11 vs. 7/25; p = 0.03). Subjects with “high-risk” LA (n − 26) had significantly larger abscesses, more polymorphonuclear leucocytosis (74 ± 15% vs. 61 ± 13%; p = 0.01) in peripheral blood and need of drainage (24/26 vs. 7/13; p = 0.03) than patients with average-risk LA. Based on the results, 38/39 children recovered, with complete abscess resolution in 28, over 48 ± 63.8 days. In conclusion, ALA, although similar in presentation, are uniloculated, and patients with ALA recover more often without drainage than patients with PLA. Patients with “high risk” LA are more common and have a good outcome with drainage. PD, being safe, efficacious and less invasive than OSD, should be the preferred drainage procedure.     

Patients diagnosed with Kawasaki disease before the fifth day of illness have a higher risk of coronary artery aneurysm

BACKGROUND: A fever lasting for at least 5 days is an essential characteristic of the original diagnostic criteria of Kawasaki disease (KD). However, it is not difficult for an experienced physician to confirm the diagnosis of KD before the fifth day of fever. The aim of this study is to investigate the effect of intravenous gamma globulin therapy (IVGG) in KD initiated before the fifth day of illness. METHODS: A total of 125 patients treated with IVGGwere divided into group A (IVGG was initiated before the fifth day of illness, n= 46) and group B (IVGG was initiated at the fifth day or after, n= 79). Patients' characteristics,laboratory findings, treatments and outcomes were compared between the groups. RESULTS: White blood cell count value, C-reactive protein and Harada's score showed no difference between the groups. A significantly higher average value of alanine aminotransferase(ALT) was observed in group A. Although the treatments were identical in both groups, the average duration of fever from the initial day of IVGG in group A was significantly longer than in group B. The incidence of aneurysm in group A was significantly higher than that in group B. Stepwise regression analysis using aneurysm as a dependent variable revealed that group A and ALT were significant. CONCLUSIONS: Patients diagnosed with KD before the fifth day of illness showed a poor response to IVGG. This observation might be related to high ALT values. Further examination concerning the modification of treatment in such patients is necessary.     

Incomplete clinical manifestation as a risk factor for coronary artery abnormalities in Kawasaki disease: a meta-analysis

Incomplete Kawasaki disease (KD) comprises a large proportion of the total number of cases. Although it has the potential of delaying diagnosis, it is not conclusive whether an incomplete presentation is a risk factor for coronary artery abnormalities (CAAs). We performed a meta-analysis to establish the risk of CAA in 20 studies including 4,504 cases and 32,519 controls, and the risk of giant aneurysm in two studies including 5,390 cases and 37,648 controls. The pooled results indicated that incomplete KD was associated with an increased risk of CAA [odds ratio (OR)?=?1.447, 95 % confidence interval (CI)?=?1.158–1.808, p?=?0.001]. Subgroup analyses demonstrated higher associations in patients younger than 12 months (OR?=?2.023, 95 % CI?=?1.252–3.271, p?=?0.004), Asians and Indians (OR?=?1.57, 95 % CI?=?1.234–1.999, p?<?0.001 and OR?=?7.088, 95 % CI?=?1.640–30.631, p?=?0.009, respectively). Subgroup analysis according to the period of patient enrollment before and after 2004 showed increased association of incomplete KD with CAA only among studies with patients enrolled after 2004 (OR?=?1.969, 95 % CI?=?1.240–3.127, p?=?0.004). In conclusion, incomplete KD seems to be associated with an increased risk of CAA, and this is more prominent in patients younger than 12 months, Asians and Indians.