Comparative analysis of dimethyl fumarate and fingolimod in relapsing–remitting multiple sclerosis

Journal of Neurology - Dimethyl fumarate and fingolimod are oral disease modifying treatments (DMTs) that reduce relapse activity and slow disability worsening in relapsing–remitting multiple...     

Bildgebende Diagnostik des Neonatal stroke

A cerebral artery infarction is an important differential diagnosis in the newborn with neurological abnormalities. Based on clinical data, its incidence is estimated to be 1 in 4000 newborns. Since the course is often subclinical, the true incidence is probably higher. DIAGNOSIS: Cerebral ultrasound and Doppler sonography as readily available screening tools play a central role in the initial diagnosis of neonatal cerebral infarction. Definitive diagnosis is made by computed tomography or magnetic resonance imaging. Beside symptomatic anticonvulsive therapy, treatment aims at the prevention of secondary ischemic injury. DISCUSSION: Three term infants with different clinical courses of neonatal stroke are presented to sensitize the clinician and the radiologist for this probably underdiagnosed entity. The role of imaging modalities in the diagnosis and follow-up of neonatal cerebral infarction is discussed.     

Systemic thromboembolism in children. Data from the 1-800-NO-CLOTS Consultation Service

Thromboembolism (TE) has recently been recognized as a clinical entity in children. Determining the clinical characteristics of pediatric TE is an important first step in dealing with this new disorder. The paper summarizes 1776 consecutive children with systemic TE referred to 1-800-NO-CLOTS telephone consultation service. 1-800-NO-CLOTS is a free consultation service for clinicians managing pediatric TE. Patient information was collected immediately using standardized forms. In children with systemic TE, infants under one year of age (47%) including neonates (26%) represented the largest distinct pediatric age group. Age-related differences were seen in TE locations, associated conditions, and risk factors. However, venous TE was the most frequent manifestation (74%). Neonates and children with cardiac disorders were more likely to have an arterial TE than a venous TE Beyond the neonatal period, venous TE associated with a central line is more likely to occur than arterial TE. Children with ALL were 5.7 times more likely to have a venous TE than an arterial TE. TE were infrequent in otherwise healthy children with 90% of children having at least one risk factor. Central catheters were the single most common risk factor associated with TE, present in 2/3 of children. Ultrasound was most frequently employed for diagnosis of TE. Finally, there was marked heterogeneity in treatment of children with TE. In children, neonates form the largest single group with TE. TE usually occur only in the presence of one or more risk factors with catheters being the single most important factor.     

A case series of 72 neonates with renal vein thrombosis. Data from the 1-800-NO-CLOTS Registry

Neonatal renal vein thrombosis (RVT) is a well-recognized clinical entity which is associated with serious morbidity. However, current information regarding RVT has been restricted to case reports and small case series. In this study, it was our objective to describe patient demographics, clinical presentation, location and risk factors of RVT. For our study design, we looked at a case series of 72 neonates with RVT referred to the 1-800-NO-CLOTS consultation service between 9/1996 and 8/2001. Data on age, gender, associated conditions, prothrombotic disorders, family history, location of the thrombosis, diagnostic techniques, and treatment were prospectively recorded using a standardized form. Our results show that RVT affected males (65%, CI 52-76%) significantly more often than females (35%, CI 24-48%). Median age at presentation was 2 days (0-21 days). RVT was unilateral in 72% (left side: 67%,CI 49-81%; right side: 33%, CI 19-51%), and bilateral in 28%. The majority (83%) had at least one associated condition: Prematurity (54%), central venous lines (17%), a diabetic mother (13%), asphyxia (6%), infections (6%). Prothrombotic testing was performed in 21 neonates. Activated protein C resistance was found in 8 children (38%), other defects in three. This is the largest case series of neonatal RVT to date. Data from the study show that i) male infants are affected twice as often as females and ii) there appears to be a left-sided predominance of neonatal RVT. Neonatal RVT is only infrequently associated with the presence of a catheter as compared to thrombosis at other sites. The majority of infants have associated conditions with prematurity being most frequent. A small subset of neonates were screened for prothrombotic abnormalities and 50% of the children screened were positive.     

Evaluation of the Cerebral Function Monitor as a tool for neurophysiological surveillance in neonatal intensive care patients

BACKGROUND: Cerebral function in critically ill infants is difficult to assess and would certainly require continuous monitoring. Therefore, this study was performed to evaluate the Cerebral Function Monitor (CFM) as a tool for continuous neurophysiological surveillance in the Neonatal Intensive Care Unit (NICU). PATIENTS: A total of 40 neurological risk neonates were included in the study. They were classified on the basis of their primary diagnoses as infants with clinically manifest seizures, suspected seizure activity, intracranial hemorrhage (ICH) and hypoxic-ischemic encephalopathy (HIE). A group of 20 neurologically normal (preterm and full-term) infants served as controls. RESULTS AND CONCLUSION: All patients with seizures showed pathologic patterns in both the CFM and the conventional EEG tracings. The patients with ICH showed depressed amplitudes, an increase in discontinuous activity, and a high incidence of seizure activity. The patients with HIE were characterized by depressed activities correlating with the severity of the pathology. Our results indicate that the CFM is a very helpful tool for neurophysiological surveillance in high-risk neonates.     

Accuracy of the CoaguChek XS for point-of-care international normalized ratio (INR) measurement in children requiring warfarin

Point-of-care INR (POC INR) meters can provide a safe and effective method for monitoring oral vitamin K antagonists (VKAs) in children. Stollery Children's Hospital has a large POC INR meter loan program for children requiring oral VKAs. Our protocol requires that POC INR results be compared to the standard laboratory INR for each child on several consecutive tests to ensure accuracy of CoaguChek XS (Roche Diagnostics, Basel Switzerland) meter. It was the objective of the study to determine the accuracy of the CoaguChek XS by comparing whole blood INR results from the CoaguChek XS to plasma INR results from the standard laboratory in children. POC INR meter validations were performed on plasma samples from two time points from 62 children receiving warfarin by drawing a venous blood sample for laboratory prothrombin (PT)-INR measurements and simultaneous INR determinations using the POC-INR meter. Agreement between CoaguChek XS INR and laboratory INR was assessed using Bland-Altman plots. Bland-Altman's 95% limits of agreement were 0.11 (-0.20; 0.42) and 0.13 (-0.22; 0.48) at the two time points, respectively. In conclusion, the CoaguChek XS meter appraisal generates an accurate and precise INR measure in children when compared to laboratory INR test results.     

Association between caesarean section and childhood obesity: a systematic review and meta‐analysis

Birth by caesarean section has been recently implicated in the aetiology of childhood obesity, but studies examining the association have varied with regard to their settings, designs, and adjustment for potential confounders. We conducted a systematic review and meta‐analysis to summarize the available evidence and to explore study characteristics as sources of heterogeneity. A search of Medline, EMBASE, and Web of Science identified 28 studies. Random effects meta‐analysis was used to calculate pooled risk ratios (RR) with 95% confidence intervals (CI). Caesarean section had a RR of 1.34 (CI 1.18–1.51) for obesity in the child compared with vaginal birth. The RR was lower for studies that adjusted for maternal pre‐pregnancy weight than for studies that did not (1.29, CI 1.16–1.44 vs. 1.55, CI 1.11–2.17). Studies that examined multiple early life factors reported lower RRs than studies that specifically examined caesarean section (1.39, CI 1.23–1.57 vs. 1.23, CI 0.97–1.56). Effect estimates did not vary by child's age at obesity assessment, study design or country income. Children born by caesarean section are at higher risk of developing obesity in childhood. Findings are limited by a moderate heterogeneity among studies and the potential for residual confounding and publication bias.     

Quantification of regional myocardial blood flow using 13N-ammonia and reoriented dynamic positron emission tomographic imaging.

BACKGROUND. Regional myocardial blood flow has been quantified using transaxial positron emission tomographic (PET) imaging and tracer kinetic modeling. However, the use of transaxial images limits the accuracy of regional partial volume corrections and the localization of the quantified regional flow values. The purpose of the present study was to overcome both problems by calculating regional flows from reoriented short-axis PET images. METHODS AND RESULTS. Twelve experiments were performed in four dogs. 13N-ammonia was injected intravenously while microspheres were administered into the left atrium during baseline, hyperemic, and low-flow conditions. Serial transaxial frames were acquired with a 15-plane PET scanner and reoriented into short-axis frames. The arterial input function and eight regional myocardial tissue activity curves were derived from the reoriented frames. The arterial input functions were corrected for ammonia metabolites, and the myocardial tissue curves were corrected for spillover of activity, partial volume effects, and heterogeneities in the image's spatial resolution introduced during reorientation. Corrections for regional partial volume were based on estimates of the regional myocardial activity thickness derived from reoriented diastolic images of the heart. The myocardial 13N-ammonia kinetics were described with a two-pool compartmental model. Values of regional myocardial blood flow by PET correlated linearly with those by microspheres (slope, 0.94; y intercept, 0.06 ml/min/g; r = 0.93) over a wide range of flows. CONCLUSIONS. Regional myocardial blood flow can be measured accurately and noninvasively from serially acquired and reoriented short-axis 13N-ammonia images, thus overcoming limitations inherent to the use of transaxially acquired images and permitting a more complete evaluation of regional blood flows throughout the left ventricular myocardium.     

Seasonality in Pediatric Cancer

Although seasonal trends in incidence and diagnosis of pediatric cancers have been widely investigated, the results have been inconclusive. A consistent seasonal trend may possibly provide etiological insights into pediatric cancers. This study aims to determine if there is a seasonal variation in cancer diagnoses in the pediatric population at the IWK Health Centre, a tertiary care center serving three Canadian provinces: Nova Scotia, New Brunswick, and Prince Edward Island. All pediatric cancer patients aged 0–20 y diagnosed from 1995 to 2015 at the center were included in this study. The annual data was divided into four seasonal periods (December to February, March to May, June to August, and September to November). The cancer diagnoses were categorized as leukemia, lymphoma, sarcoma, brain tumors, and miscellaneous. Seasonal variation was assessed by a harmonic function in a Poisson regression model. The amplitude of multiplicative change in the incidence rate caused by the seasonal variation is expressed as the incidence rate ratio (IRR). For all cancer diagnoses for the entire cohort of 1200 patients, the IRR was 1.03 [95% confidence interval (CI) 0.96–1.13]. None of the IRRs for the cancer groups indicated a statistically significant seasonality of cancer diagnosis: Leukemia 1.11 (95% CI 0.96–1.28); Lymphoma 1.17 (95% CI 0.93–1.47); Sarcoma 1.29 (95% CI 0.99–1.69); Brain tumors 1.16 (95% CI 0.97–1.38); Miscellaneous 1.09 (95% CI 0.93–1.27). The present study did not show a seasonal variation in the various cancer types in the pediatric population at the IWK.