Does adjustment of GFR to extracellular fluid volume improve the clinical utility of cystatin C?

BACKGROUND: Cystatin C measurement has been proposed as a replacement for creatinine as a serum measure of glomerular filtration rate (GFR). It has also been suggested that GFR itself should be adjusted to the extracellular fluid volume (ECV) of a child rather than the body surface area (BSA). AIMS: To assess the potential of cystatin C compared to serum creatinine in assessing GFR and to establish whether adjustment of GFR to ECV rather than BSA affects the potential usefulness of cystatin C. METHODS: Cystatin C and plasma creatinine were measured in 64 paediatric patients undergoing 77 (51)Cr-EDTA GFR measurements over a six month period. RESULTS: 1/cystatin C concentrations were more closely related to GFR (median 98 ml/min/1.73 m(2), range 8-172) after adjustment for patient BSA (r = 0.81 versus r = 0.44). 1/Creatinine concentrations appeared to be an inferior estimate of BSA adjusted GFR (r = 0.41), even following the use of the Schwartz formula (r = 0.37). Bland Altman statistics showed cystatin C could still only predict 95% of GFR values to within +/-41 ml/min/1.73 m(2) of the (51)Cr-EDTA method. The relation between GFR and 1/cystatin C was not improved by adjusting (51)Cr-EDTA GFR to ECV rather than BSA (r = 0.76 versus r = 0.81). CONCLUSIONS: Cystatin C appears superior to serum creatinine in paediatric subjects although its performance is unlikely to supplant (51)Cr-EDTA GFR measurement. This performance is not being underestimated because of adjusting GFR to BSA rather than ECV.     

Does adjustment of GFR to extracellular fluid volume improve the clinical utility of cystatin C?

BACKGROUND—Cystatin C measurement has been proposed as a replacement for creatinine as a serum measure of glomerular filtration rate (GFR). It has also been suggested that GFR itself should be adjusted to the extracellular fluid volume (ECV) of a child rather than the body surface area (BSA).AIMS—To assess the potential of cystatin C compared to serum creatinine in assessing GFR and to establish whether adjustment of GFR to ECV rather than BSA affects the potential usefulness of cystatin C.METHODS—Cystatin C and plasma creatinine were measured in 64 paediatric patients undergoing 77 ⁵¹Cr-EDTA GFR measurements over a six month period.RESULTS—1/cystatin C concentrations were more closely related to GFR (median 98 ml/min/1.73 m², range 8-172) after adjustment for patient BSA (r = 0.81 versus r = 0.44). 1/Creatinine concentrations appeared to be an inferior estimate of BSA adjusted GFR (r = 0.41), even following the use of the Schwartz formula (r = 0.37). Bland Altman statistics showed cystatin C could still only predict 95% of GFR values to within ±41 ml/min/1.73 m² of the ⁵¹Cr-EDTA method. The relation between GFR and 1/cystatin C was not improved by adjusting ⁵¹Cr-EDTA GFR to ECV rather than BSA (r = 0.76 versus r = 0.81).CONCLUSIONS—Cystatin C appears superior to serum creatinine in paediatric subjects although its performance is unlikely to supplant ⁵¹Cr-EDTA GFR measurement. This performance is not being underestimated because of adjusting GFR to BSA rather than ECV.     

Does the length of the history influence the outcome of pneumatic reduction of intussusception in children?

Purpose  

Intussusception is the most common cause of acute abdomen in infants and preschool children. Nonoperative reduction using air enema is an established treatment in children with intussusception. The aim of this study was to determine whether length of the history influences the outcome of pneumatic reduction of intussusception in children?     

Can we alter the natural history of Crohn disease in children?

The natural history of Crohn disease is characterized by recurrent bouts of active disease, the consequences of which can severely impair sufferers' physical and social functioning. Not only does the illness cause day-to-day morbidity for children but the consequence of the chronic inflammatory process also commonly results in the need for major intestinal surgery. The present challenge facing physicians treating children with Crohn disease is to alleviate symptoms and prolong periods of remission via the use of specifically targeted therapies while minimizing toxicity and promoting normal growth and development. Although systemic corticosteroids are effective in inducing clinical remission, they are of little or no benefit in maintaining remission and can contribute to linear growth retardation. Immunomodulating drugs such as azathioprine, 6-mercaptopurine and methotrexate have proved effective for inducing and maintaining remission of active Crohn disease. These agents are now commonly prescribed in children at diagnosis, after a severe attack or after surgery or in those who become corticosteroid-dependent or corticosteroid-resistant. Their use is not without potential adverse effects and not all patients respond well to these agents. With the introduction of biologic agents, notably the tumor necrosis factor-alpha monoclonal antibody infliximab, progress has been made in targeting specific pathogenetic mechanisms of Crohn disease and potentially altering the underlying disease process. Published experience in children is currently limited, but infliximab has been shown to improve symptoms and achieve corticosteroid independence in this age group. Unresolved issues with infliximab and other emerging biologic agents, including long-term safety, necessitate a degree of caution in selecting appropriate patients for treatment and with careful monitoring of their effects. The collection of contemporary natural history data is crucial to facilitate the better integration of current and emerging therapies in an attempt to alter the natural history of Crohn disease in children.     

Does renal transplant in children with LUTD improve their bladder function?

Much is still unknown about LUT function after receiving renal graft. Graft function was the main focus of different studies discussing the same issue. However, these studies ignored the effects of the graft on lower tract function and more demand for bladder cycling and growth of the child. Therefore, we aimed at evaluating the LUT function after RT into patients with LUTD. We enrolled a retrospective cohort of 83 live renal transplant children with LUTD. The 44 patients in Group (A) had a defunctionalized bladder, and the 39 patients in Group (B) had underlying LUT pathology . All patients had clinical and urodynamic evaluation of LUT functions at least 1 year after RT. We found that the improvement in patients with impaired bladder compliance was 73% in Group (A) and 60% in Group (B), with no statistically significant difference between the study groups. In Group (B), there was statistically significant worsening of MFP (8.4%) and mean PVR (79.9%) after RT. In Group (A), mild but stable significant improvement of all clinical and urodynamic parameters was observed. Serum creatinine was significantly worse in patients with pathological LUTD compared with those with defunctionalized bladder but without significant effect on graft survival. All LUT variables seemed to have no adverse effect on graft survival except for use of CIC and augmented bladder. Incident UTI independent of LUT variables accounted for 20% of graft creatinine change.     

Does the size of nasogastric tubes affect gastroesophageal reflux in children?

BACKGROUND: To evaluate the effects of nasogastric tube insertion and different nasogastric tube sizes on gastroesophageal reflux in children. METHODS: During a prospective randomized study, 29 patients aged 1 month to 4 years (median, 9 months) underwent 24 hours of continuous esophageal pH monitoring to rule out gastroesophageal reflux as the cause of severe pulmonary problems. Each patient was monitored without nasogastric tube for 16 hours (baseline), and thereafter the first nasogastric tube, small (8-Fr) or large (10-Fr or 12-Fr), was placed. Four hours later, the original nasogastric tube was replaced by a new one of large (instead of small) size or of small (instead of large) size. We selected the times of wakefulness in these study periods and compared the number of reflux episodes (NREs), the number of reflux episodes that lasted more than 5 minutes (NRE>5), and the percentage of time with esophageal pH less than 4 (PTP<4). RESULTS: The 12-Fr group in comparison with the 8-Fr group and baseline showed significant difference (P<0.05) in the NRE>5 and PTP<4 parameters. No significant differences were found when comparing 8-Fr versus 10-Fr groups and baseline. In children with (n = 20) and without (n = 9) gastroesophageal reflux, comparison of the various reflux parameters between baseline and the different sizes of nasogastric tubes showed the same results. CONCLUSIONS: Size of the nasogastric tubes is a significant factor in predisposing the child to gastroesophageal reflux. Large nasogastric tubes interfere with the clearance of the refluxed acid from the esophagus.     

Does machine learning have a role in the prediction of asthma in children?

Asthma is the most common chronic lung disease in childhood. There has been a significant worldwide effort to develop tools/methods to identify children’s risk for asthma as early as possible for preventative and early management strategies. Unfortunately, most childhood asthma prediction tools using conventional statistical models have modest accuracy, sensitivity, and positive predictive value. Machine learning is an approach that may improve on conventional models by finding patterns and trends from large and complex datasets. Thus far, few studies have utilized machine learning to predict asthma in children. This review aims to critically assess these studies, describe their limitations, and discuss future directions to move from proof-of-concept to clinical application.     

Can asthma education improve the treatment of acute asthma exacerbation in young children?

Acute exacerbation of asthma requires timely and appropriate treatment. Young children are completely reliant on others in this respect. This paper aims to evaluate the effectiveness of staff asthma education programs in ensuring correct treatment for young children experiencing asthma exacerbations in formal care. A systematic review was undertaken of studies focusing on staff asthma education in relation to pharmacological treatment of acute asthma exacerbation. Three randomised controlled trials and seven uncontrolled pre‐ and post‐test intervention studies were included for review. Asthma education was found to increase staff knowledge and confidence in managing asthma. There was a distinct lack of staff performance testing and studies undertaken in the pre‐school setting. Staff asthma education appears effective in increasing asthma knowledge; however, utility of this measure is limited with respect to staff performance in treating acute asthma exacerbation. Further studies evaluating asthma education through performance are needed.     

Sonographic measurement of renal length in children: Does the position of the patient matter?

Purpose. This prospective study was designed to determine the effect of patient positioning on sonographic measurements of renal length in children.Materials and methods. Two dedicated pediatric ultrasonographers (observers A and B) measured the sonographic lengths of 48 kidneys in 25 children (two had unilateral renal agenesis). Each observer obtained the two longest possible measurements for each kidney with the patient in three positions: supine, contralateral decubitus, and prone. Patients with myelomeningocele, hydronephrosis, and renal cysts were excluded.Results. Both examiners obtained significantly higher values for renal lengths with the children lying supine (observerA P 0.0017; observer BP 0.0409) or in contralateral decubitus (observerA P 0.0001; observerB P 0.0419) than with them lying prone. There was no significant difference between the supine and decubitus measurements. The mean difference between the supine and prone measurements for the observers was 3.0 mm for observer A and 1.8 mm for observer B. The mean difference between the contralateral decubitus and prone measurements was 3.0 mm for observer A and 1.6 mm for observer B.Conclusion. Sonographic measurements of renal length made with the patient lying supine or in contralateral decubitus yield slightly higher values than those made with the patient prone.     

Does epilepsy influence the outcome of antireflux procedures in neurologically impaired children?

In neurologically impaired patients (NIP), surgical management of gastroesophageal reflux disease (GERD) has become a widespread standard. Several follow-up studies have shown a high incidence of complications and recurrent reflux. As one of the possible causes epilepsy is mentioned repeatedly in the literature. The aim of this study was to determine the effective impact of epilepsy on the postoperative outcome by comparing results of our patients suffering from epilepsy to those without this disorder. From 1984 to 1999, a total of 45 NIP underwent antireflux surgery, including 20 patients suffering from epilepsy (EP) and 25 patients without this disorder (nEP). The existence of epileptic disorders, incidence of epileptic seizures and administration of anticonvulsatory drugs as well as results of diagnostic procedures, postoperative complications and incidence and time of recurrence of pathologic GER were recorded and analysed retrospectively. Preoperatively all patients had pathologic results in 24 h pH-monitoring. Median RI was 15.75 (EP, range 5.2–28.6) and 17.55 (nEP; range 7.2–26.5). 12-months-postoperative 24 h pH-monitoring showed a median RI of 3.8 (EP; range 1.3–25.6) versus a median RI of 3.3 (nEP; range 0.7–26.3). During the long-term follow-up evaluation of 3.9 years, 17 EP suffered from persistent epileptic seizures despite medical treatment. 19 patients (42%) developed recurrent reflux. This included seven EP (35%) and 12 nEP (48%). The necessity of reoperation was higher in nEP (n = 5, 20%) than in EP (n = 1, 5%). This analysis did not show a significant correlation between recurrence of pathologic GER after fundoplication and the incidence of epileptic seizures. We consider our findings to strongly question the widespread opinion considering this correlation. We conclude, that cerebral seizures alone do not alter the operative outcome of antireflux surgery in NIP.     

Do symptoms and initial clinical probability predict the radiological diagnosis of acute sinusitis in children?

OBJECTIVE:

To evaluate the value of signs and symptoms in children for the radiological diagnosis of acute sinusitis.

DESIGN:

Prospective cohort study.

SETTING:

University-affiliated tertiary care hospital.

PATIENTS:

All children presenting with symptoms suggestive of acute sinusitis for whom sinus radiographs were ordered.

METHODS:

Data were collected on the presence of specific symptoms and the initial probability of sinusitis. Criterion-based radiological diagnoses were made.

RESULTS:

Three hundred ninety-two consecutive children were seen; 257 children had a radiological diagnosis of acute sinusitis (66%), 128 patients (33%) presented with complete opacity of at least one sinus and 14 (4%) children had an air-fluid level. Sensitivity, specificity, predictive values and likelihood ratios were measured for clinical findings. Classical symptoms (rhinorrhea lasting more than 10 days and purulent rhinorrhea) increased the likelihood ratios the most (1.3 and 1.34, respectively). Logistic regression showed two independent predictors: purulent rhinorrhea (odds ratio 2.0) and the presence of acute otitis media (odds ratio 2.6). The initial clinical probability was more accurate than any other single finding: high probability (likelihood ratio 2.0), intermediate probability (likelihood ratio 1.1) and low probability (likelihood ratio 0.6).

CONCLUSION:

Classical symptoms are predictive of the presence of acute sinusitis as diagnosed on sinus radiographs. The physician’s overall clinical impression, expressed as an initial probability, was superior to any single historical or examination finding in the diagnosis of acute sinusitis.     

Does diverting ileostomy improve the outcome in children with tuberculous small bowel obstruction requiring surgical intervention?

Introduction

Abdominal tuberculosis is fairly common in children. The most common clinical presentation is bowel obstruction. Depending upon the presentation, the intestinal obstruction can be either managed conservatively or by operative intervention. There are various options in patients who undergo operative treatment. This study was undertaken to analyze the results of operative intervention with and without ileostomy.

Materials and methods

This is a retrospective study carried out over a period of 10 years on 32 children who were operated for small bowel obstruction due to abdominal tuberculosis. The patients were divided into two groups (A: with ileostomy and B: without ileostomy). The relevant data and the defined outcome measures were statistically analyzed.

Results

A total of 32 children with tuberculous bowel obstruction requiring surgical intervention were studied. The patient of group A had mean duration of postoperative ileus for 2.55 days, restoration of enteral feeding within mean period of 3.55 days and had a primary hospital stay for a mean period of 9.0 days. These outcomes when compared with group B patients were statistically significant.

Conclusion

In children with bowel obstruction due to tuberculosis, diverting ileostomy decreases the morbidity by allowing early return of enteral motility, early institution of feeding and first-line ATT and decreasing the primary hospital stay.

     

The utility of the plain radiograph “shunt series” in the evaluation of suspected ventriculoperitoneal shunt failure in pediatric patients

Background To our knowledge, the sensitivity of plain radiography, known as the shunt series, in diagnosing an etiology of ventriculoperitoneal (VP) shunt malfunction in children has not been previously investigated. Objective To determine the accuracy of plain radiography in diagnosing VP shunt failure in children in whom shunt malfunction is clinically suspected. Materials and methods We retrospectively reviewed the charts of 238 children who had undergone plain radiographic examination for evaluation of clinically suspected VP shunt failure over a 5-year period. The results were compared with those of CT, MRI, and nuclear cisternography. Results Just 6.72% of patients demonstrated plain radiographic signs of shunt failure. Of patients with normal plain radiographs, 43% demonstrated shunt abnormalities on CT, MRI or cisternography. Statistical analysis indicated that no more than 10.46% (P < 0.05) of plain radiographs showed signs of failure and that the sensitivity of plain radiography for the detection of VP shunt failure is no higher than 31%. Furthermore, there was poor agreement between the results of plain radiography and those of CT, MRI and cisternography. Conclusion Children with clinically suspected VP shunt failure should proceed directly to cross-sectional or nuclear imaging, as plain radiographic examinations have low sensitivity and significant false-negative rates for detecting shunt abnormalities in all-comers. Use of the shunt series should be limited to patients who specifically have suspected mechanical causes of shunt failure.     

Does echocardiography facilitate determination of hemodynamic significance attributable to the ductus arteriosus?

Introduction  The assignment of hemodynamic significance to a patent ductus remains a challenge for neonatal intensivists. The impact is medical uncertainty and ongoing debate as to when treatment should be provided if ever. Discussion  Patent ductus arteriosus is associated with significant neonatal morbidities including necrotizing enterocolitis and brain injury; causality has not been proven. In addition, there are limited data suggesting a beneficial effect of therapeutic intervention. The inability to accurately differentiate the pathological ductus arteriosus from the innocent ductus arteriosus may contribute, in part, to the lack of scientific evidence of benefit or causality. Our group has previously proposed the need for a staging system to characterize the clinical and echocardiography impact of the ductus arteriosus. This approach requires comprehensive echocardiography evaluation to assess ductal size and the degree of pulmonary overcirculation/systemic hypoperfusion related to the transductal shunt. Conclusion  In this review, we will highlight the evidence for echocardiography markers of hemodynamic significance and speculate as to how they may facilitate improved decision making in the neonatal intensive care unit.