Induction therapy: Why,when, and which agent?

Krischock L, Marks SD. Induction therapy: Why, when, and which agent?
Pediatr Transplantation 2010: 14:298–313. © 2010 John Wiley & Sons A/S. Abstract: The long‐term outcome of paediatric transplantation has improved over the last decade with an increase in the armamentarium of immunosuppressive agents. However, the battle against the hostile immune response at the time of and after transplantation continues. Induction therapy can reduce early injury, to optimize the long‐term allograft survival. The goal of induction immunosuppression in paediatric transplantation is to permit the use of lower doses of maintenance immunosuppressive agents without increased rates of acute allograft rejection and chronic allograft damage. The aim of this review is to summarize the current literature relating to the use of antibody agents for induction in paediatric solid organ transplantation.     

Maintaining normothermia: Why and how?

A high incidence of postnatal hypothermia has been reported in high-as well low-resource countries and it remains an independent predictor of neonatal morbidity and mortality, especially in very preterm infants in all settings. The temperature of newly born infants should be maintained between 36.5 and 37.5 °C after birth through admission and stabilization. Interventions to achieve this may include environmental temperature 23–25 °C, use of radiant warmers, exothermic mattresses, woollen or plastic caps, plastic wraps, humidified and heated gases. Skin-to-skin contact has been used, especially in low-resource settings. The combinations of these interventions applied to quality improvement initiatives, including staff training, use of checklists, and continuous feedback with the staff involved in the management of the neonate, are key factors to prevent heat loss from delivery room to admission to the neonatal intensive care unit. The admission temperature should be recorded as a predictor of outcomes as well as a quality indicator.     

Genitourinary rhabdomyosarcoma: Which treatment,how much,and when?

ObjectiveTo review the current management of pediatric genitourinary rhabdomyosarcoma (RMS).MethodsStudies performed by the Intergroup Rhabdomyosarcoma Study Group, Children's Oncology Group (COG), International Society of Paediatric Oncology (SIOP) and others over the past 10 years were reviewed to compare the use of surgery, chemotherapy, and radiotherapy for treatment of RMS and their associated outcomes.ResultsEquivalent overall survival rates were reported in the last COG and SIOP trials, with worse event-free survival rates for bladder/prostate RMS in SIOP trials. The use of radiotherapy for local control was the main difference between current COG and SIOP protocols. Surgery is used to diagnose RMS, and for local control after chemotherapy. Chemotherapy is used for systemic control of RMS, but metastatic RMS will require new approaches.ConclusionRisk stratification and risk-based therapy are being studied to decrease morbidity from treatment of RMS. The proper role of surgery vs radiotherapy for local control and whether additional treatment with second-line chemotherapy outweighs the avoidance of radiotherapy remain to be defined.     

How common are gastrointestinal disorders in children with autism?

We could identify no report that describes the prevalence of gastrointestinal disorders in a representative group of children with a diagnosis of autism compared with appropriate controls. Thus, we found no evidence upon which to base a confident conclusion as to whether gastrointestinal symptoms are more common in children with than without autism. However, the frequency of gastrointestinal symptoms observed in population-based samples of autistic children indicate that gastrointestinal problems are not nearly as common in children with autism as reports from pediatric gastroenterology clinics suggest.     

Research Review: Altered reward function in adolescent depression: what,when and how?

Background: Conceptual models and recent evidence indicate that neural response to reward is altered in depression. Taking a developmental approach to investigating reward function in adolescent depression can elucidate the etiology, pathophysiology and course of depression, a disorder that typically begins during adolescence and has high rates of recurrence. Methods: This conceptual review describes the what, when and how of altered reward function in adolescent depression. With the goal of generating new, testable hypotheses within a developmental affective neuroscience framework, we critically review findings and suggest future directions. Peer‐reviewed empirical papers for inclusion in this critical review were obtained by searching PubMed, PsycInfo and ScienceDirect for the years 1990–2010. Results: A pattern of low striatal response and high medial prefrontal response to reward is evident in adolescents and adults with depression. Given the salience of social stimuli for positive affect and depression, reward function might be especially disrupted in response to social rewards. Because of changes in the dopamine system and reward function with aging, altered reward function in depression might be more evident during adolescence than later in life; however, low reward function may also be a stable characteristic of people who experience depression. Mechanisms of altered reward function in depression could include disrupted balance of corticostriatal circuit function, with disruption occurring as aberrant adolescent brain development. Conclusions: Future studies should examine responses to social rewards; employ longitudinal and prospective designs; and investigate patterns of functional connectivity in reward circuits. Understanding altered reward function in depression has potential implications for treatment development. A more rigorous approach to investigating anhedonia, threat–reward interactions and comorbid anxiety will be valuable to future progress in describing the role of reward function in the pathophysiology of depression.     

Computed tomography in children with lung disease. How,when and why? Myths and mystery unravelled

The respiratory tract is commonly affected by disease in children. There is a range of pathology which affects the lungs, including congenital abnormalities, infection and chronic conditions. Radiology plays a key role in the investigation of respiratory pathology in children. By far the commonest modality used in routine practice is the frontal chest X-ray, and in most scenarios this is sufficient for diagnostic purpose.When there is a need for more detailed imaging, computed tomography (CT) with its superior spatial resolution, is a more powerful tool. However, the better spatial resolution inherent with CT, and the resultant exquisite anatomical detail, results in a higher effective radiation dose delivered to the patient. Indeed the radiation burden as a result of CT usage is by far the most significant contribution of radiation dose as a consequence of medical diagnostic imaging. The potential resultant risk of this radiation exposure must always be balanced against the benefits gained by the patient.It is always important to justify the clinical need for an imaging technique, assessing how the test will aid patient management, and thence to optimize the technique such that the lowest radiation dose can be used to produce images which are ‘fit for purpose’ i.e. of diagnostic quality but delivered at a radiation dose which is As Low As Reasonably Achievable (ALARA principle).In this article we will discuss the techniques which may be employed to produce and optimize imaging of the thorax. We will catalogue how newer techniques may facilitate accurate radiological diagnosis and also address some important indications for CT usage in children's lung disease.     

Cough in children: when does it matter?

Cough is a common presenting symptom to paediatricians and paediatric respiratory physicians. The causes of chronic cough in childhood are significantly different from those in adults, and a different approach to diagnosis and management is needed. In most cases cause can be identified or a satisfactory label given. This review will cover the approach to cough in children and cover some specific causes of troublesome cough not discussed elsewhere in this mini-symposium.     

Does family functioning affect outcome in children with neurological disorders?

Children with neurological disorders are at increased risk of poor psychological and social adjustment. Medical factors are insufficient to explain the individual variation in outcome, so family variables have been considered. This review evaluates studies which have investigated the effect of family functioning on outcome in children with traumatic brain injuries, epilepsy and other neurological disorders. Methodological problems include the cross-sectional nature of many studies and inadequate control for confounding variables. There is good evidence that family functioning influences behavioural adjustment and adaptive functioning after traumatic brain injury. The role of family functioning in epilepsy and other neurological disorders requires further investigation. The development of effective interventions to improve family functioning may lead to important clinical benefits for children and their families.     

Post‐operative radiotherapy for Ewing sarcoma: when,how and how much?

Postoperative radiotherapy in Ewing family of tumors has undergone continuous evolution over the last few decades to establish its role in the combined modality management of these tumors. The process of evolution is still far from over. This review analyzes the evidence from major multi-institutional prospective trials as well as large retrospective institutional series in Ewing tumors to determine the current standards and controversies in postoperative radiation. The indications of PORT, radiation dose-fractionation, timing, target volumes and treatment planning, as well as the late effects are reviewed. A summary of evidence based consensus is presented and unresolved aspects are discussed. Pediatr Blood Cancer 2008;51:575-580. (c) 2008 Wiley-Liss, Inc.