Initial Therapy In Children Research Articles

Eustachian Tube Dysfunction in Children with Adenoid Hypertrophy: The Effect of Intranasal Azelastine-Fluticasone Spray Treatment on Middle Ear Ventilation and Adenoid Tissue.

Eustachian tube dysfunction (ETD) is frequent in children with adenoid hypertrophy (AH). Although the most common treatment of AH is surgical removal of adenoid tissue, numerous studies have reported the efficacy of intranasal steroids. The effects of the intranasal steroid and azelastine combination on AH and ETD have not been reported before. In this study, we tried to determine the effects of 3-month intranasal Azelastine-Fluticasone dipropionate combination (Aze-Flu) treatment in children with ETD and AH. 100 children who had open mouth sleep, snoring, and sleep apnea and were diagnosed with AH and ETD participated in this study. The mean age was 7.73 ± 2.37 (4-14 years). The rates of adenoid tissue hypertrophy and choanal occlusion were evaluated using a rigid pediatric nasal endoscope and reassessed after 3 months of Aze-Flu nasal spray treatment. The function of the Eustachian tube (ET) was evaluated before and after medical treatment using the Eustachian tube score, the Eustachian dysfunction test-7 (ETS-7) and tubomanometry (TMM). The results were evaluated in 100 patients with AH and ETD. The adenoid tissue to choana rate was 82% before treatment and decreased to 37% after treatment. The ETS-7 test score was 6.36 before treatment and increased to 9.72 at the end of 3 months. Both the regression of the adenoid tissue and the improvement in the Eustachian function scores were statistically significant (p < 0.05). AH significantly increases the frequency of ETD. In this study, it was observed that Aze-Flu treatment was significantly effective in both regression of the adenoid tissue and Eustachian tube dysfunction. We believe that it can be applied as an initial therapy in children with AH and associated ETD.

The efficacy of pegylated interferon alpha-2a and entecavir in HBeAg-positive children and adolescents with chronic hepatitis B

Background and objectivesPegylated interferon alpha-2a (peg-IFN α-2a) and entecavir (ETV) are both recommended as the first-line antiviral drugs for chronic hepatitis B (CHB) at present. We aimed to compare the efficacy and safety between peg-IFN α-2a and ETV initial therapy in children and adolescents with CHB and investigate the potential factors affecting the treatment response during the first 48 weeks.MethodsWe retrospectively selected 70 treatment-naïve children and adolescents with CHB who received peg-IFN α-2a(n = 26) or ETV(n = 44) as initial therapy and completed 48-week follow-up for data analysis. Blood samples before treatment were collected from 26 patients of the cohort to assess the cytokine profiles.ResultsWe found that initial peg-IFN therapy results in higher rates of hepatitis B surface antigen (HBsAg) serological response (SR) but lower rates of virological and biochemical response rates compared to ETV at week 48. As for achieving hepatitis B e antigen (HBeAg) SR, peg-IFN was comparable to ETV in the univariate analysis and turned out to be better than ETV after adjustment for important baseline factors. We also found that elevated pre-treatment IL-18 level was significantly associated with HBeAg SR, and remained as the only independent factor of predicting HBeAg SR after adjustment for other important factors. No serious adverse effects of the 2 drugs were reported during the 48-week follow-up.Conclusionscomparing to ETV, peg-IFN was superior in achieving HBsAg and HBeAg SR; higher baseline IL-18 levels were independently associated with HBeAg SR in this study of children and adolescents with CHB.

Use of renin-angiotensin system inhibitors as initial therapy in children with Henoch-Schönlein purpura nephritis of moderate severity.

Cases of Henoch-Schönlein purpura nephritis (HSPN) with moderate severity were demonstrated to achieve good prognosis after treatment with renin-angiotensin system (RAS) inhibitors. However, some patients required additional treatment for recurrence after remission. This study aimed to clarify the effect of RAS inhibitors in HSPN cases with moderate severity, including the proportion of cases with recurrence and their response to additional treatment. Among 126 patients diagnosed with HSPN between 1996 and 2019, 71 patients with clinicopathologically diagnosed HSPN of moderate severity, defined as ISKDC grade II-IIIa and serum albumin ≥ 2.5 g/dL, were investigated. Proteinuria became negative after RAS inhibitor treatment alone in all 71 cases. However, 16 (22.5%) had recurrence. Eleven recurrent cases achieved negative proteinuria again following additional treatment. At the last follow-up (median 46.5 months; IQR, 23.2-98.2), 5 patients had persistent mild proteinuria; no patients had estimated glomerular filtration rate < 90 mL/min/1.73 m2. The pathological findings in all recurrent cases were ISKDC grade IIIa. The 16 recurrent cases had significantly higher proportions of glomeruli with global/segmental sclerosis (25.0 vs. 0%, P < 0.001) and tubular atrophy/interstitial fibrosis (37.5 vs. 12.7%, P =0.0 24) than 55 cases without recurrence. Japanese childhood HSPN cases with moderate severity had good outcomes without need for corticosteroids or immunosuppressants, when prescribed RAS inhibitor treatment. Even in recurrent cases, abnormal proteinuria was transient, and prognosis was excellent. A higher resolution version of the Graphical abstract is available as Supplementary information.

Study of the outcome of pediatric patients with aplastic anemia treated with immunosuppressive therapy-Single center experience

Background: Immunosuppressive therapy is the Initial therapy for children with severe Aplastic anemia (SAA) and lacking a matched related donor. Cyclosporine A (Cy A) alone has been tried as single agent in resource poor Countries. Patients and Methods: This retrospective study was done to assess the outcome of immunosuppressive therapy (IST) in SAA children. It included 23 patients treated at Ain Shams University Pediatrics Hospitals between 2011- 2019 with IST, they received rabbit anti-thymocyte globulin (r ATG) plus (Cy A) (Group I, 8 patients) or Cy A alone (Group II, 15 patients). The median follow- up duration was 59 months. Results: one patient (4.3%) developed AML clone. another patient (4.3%) developed PNH clone. There was no significant difference in response between the two groups, Complete response was 34.7%, 43.5%, and 47.8% and partial response was 34.7%, 26.1%, 21.7% at 3, 6, and 12 months, respectively in the whole cohort. NR was present in 30.4% at 3, 6, and 12 months. Hypertension in 62.5% and higher levels of ALT, total and direct bilirubin were observed in group I as compared to group II. HAAA was clinically evident in 7 patients; 4 of them were hepatitis A, 1 was EBV, and 2 were seronegative for all viruses. At presentation they had significantly higher level of ALT, total bilirubin, and direct bilirubin. Conclusion: IST is an effective therapy in patients with SAA with overall response of 70%. Cy A alone can be an effective therapy in developing countries.

Prognostic value of lymph node ratio in children and adolescents with papillary thyroid cancer.

Neck lymph node (LN) metastasis is a common feature of paediatric papillary thyroid cancer, and LN ratio (LNR) is defined as the ratio of the number of positive LNs excised to the total number of removed. Unlike in adults, few data are available regarding the clinical implication of LNR in the paediatric population. Our purpose was to investigate the association of LNR with clinical outcomes in paediatric papillary thyroid cancer. The study retrospectively reviewed 136 consecutive children and adolescents with papillary thyroid cancer and LN involvement but no initial distant metastasis. Initial treatment, included in all patients a total thyroidectomy with central and/or lateral neck dissection followed by radioactive iodine ablation. Within the neck dissections, total number of LNs removed, total positive LNs and LN ratios were determined. The effect of clinicopathologic characteristics and intraoperative findings on persistent and recurrent diseases were analysed by univariate and multivariate analyses. Median number of positive LNs was 9, and median LNR was 0.4. During a median follow-up of 49months (range, 12.0-139months), persistent disease occurred in 43 (31.6%) patients. The multivariable analysis showed that age and LNR were the independent factors predictive of persistent disease. Patients with a LNR >0.34 exhibited a threefold higher risk of persistent disease after initial therapy than the counterparts (P=.02). Our findings suggest that LNR was an independent determinant predictive of persistent disease after initial therapy in children and adolescents with papillary thyroid cancer.

The efficacy and safety of lamotrigine for absence seizures in children and adolescents: A systematic review and meta-analysis

AimsThis systematic review and meta-analysis of randomized controlled trials (RCTs) systematically explored the effectiveness and safety of lamotrigine for absence seizures in children and adolescents. MethodsKeywords searches were conducted in Pubmed Embase Cochrane Central Register of Controlled Trials Wanfang CNKI from inception through March 2019. The RCTs comparing lamotrigine with other drugs and/or placebo for the treatment of absence seizures in children and adolescents were considered in this study. The study was conducted adhering to PRISMA guidelines. ResultsEight RCTs (n = 787) were included in our study. Among these studies, one study (N = 45 patients) used placebo as a control and seven studies (N = 742 patients) used positive drug controls. For effectiveness, there was significant difference between lamotrigine and valproate [OR = 0.42, 95%CI (0.28–0.63), I2 = 0%] or ethosuximide [OR = 0.34, 95%CI (0.22–0.53), I2 = 0%]. For adverse effects (AEs), there was no significant difference between lamotrigine and valproate [OR = 1.17, 95%CI (0.59, 2.32), I2 = 0%] or ethosuximide [OR = 0.75, 95%CI (0.47, 1.19), I2 = 92%], and the most common adverse effects of lamotrigine were Rash (7.88%), Fatigue (6.50%) and Headache (6.50%). ConclusionsAccording to current evidence, LTG is less effective than VPA and ESM, however, based on its relative safety, LTG might be reasonably tried as initial therapy in children and adolescents at risk of significant adverse effects from VPA and ESM, and future well-designed studies are needed to confirm our findings.

Radioactive iodine therapy of juvenile differentiated thyroid carcinoma

Introduction: Thyroid cancer in children and adolescents is usually a major concern for physicians, patients, and parents. Controversies regarding the aggressiveness of the clinical presentation and the ideal therapeutic approach remain among the scientific community. The current recommendations and staging systems are based on data generated by studies in adults, and this might lead to overtreating in some cases as well as undertreating in others. Our objective was to evaluate the presentation, the contribution of therapy by iodine 131 and long‒term outcome in patients with pediatric DTC and to analyze factors that can influence the success of post ablation by iodine 131. Patients and methods: In this retrospective study, presentation, therapy with iodine 131and outcome of patients with pediatric DTC (age at diagnosis ≤21y) treated in the nuclear medicine department of king Fahd medical city, between 2006 and 2018 were assessed using medical records. Results: We identified 53 patients. Overall survival was 100% after a median follow‒ up of 8 years (range 0.6–13y). Median age at diagnosis was 17.5years (range 7–21y). At initial diagnosis, 43.3% of the patients had cervical lymph node metastases; 16.9% had distant metastases. All patients underwent total thyroidectomy. Radioiodine was administered to 100%, with a median cumulative activity of 5.7GBq (range 0.81– 13.5GBq). At last known follow‒up, 18.8% of the patients had persistent disease and no patient experienced a recurrence. Conclusions:Lymph nodal and distant metastases are important predictors of the persistence of disease after initial therapy in children and adolescents with differentiated thyroid cancer.

Pretreatment behavior and subsequent medication effects in childhood absence epilepsy.

To characterize pretreatment behavioral problems and differential effects of initial therapy in children with childhood absence epilepsy (CAE). The Child Behavior Checklist (CBCL) was administered at baseline, week 16-20, and month 12 visits of a randomized double-blind trial of ethosuximide, lamotrigine, and valproate. Total problems score was the primary outcome measure. A total of 382 participants at baseline, 310 participants at the week 16-20 visit, and 168 participants at the month 12 visit had CBCL data. At baseline, 8% (95% confidence interval [CI] 6%-11%) of children with CAE had elevated total problems scores (mean 52.9 ± 10.91). At week 16-20, participants taking valproic acid had significantly higher total problems (51.7 [98.3% CI 48.6-54.7]), externalizing problems (51.4 [98.3% CI 48.5-54.3]), attention problems (57.8 [98.3% CI 55.6-60.0]), and attention-deficit/hyperactivity problems (55.8 [98.3% CI 54.1-57.6]) scores compared to participants taking ethosuximide (46.5 [98.3% CI 43.4-49.6]; 45.8 [98.3% CI 42.9-48.7]; 54.6 [98.3% CI 52.4-56.9]; 53.0 [98.3% CI 51.3-54.8]). Lack of seizure freedom and elevated week 16-20 Conner Continuous Performance Test confidence index were associated with worse total problems scores. At month 12, participants taking valproic acid had significantly higher attention problems scores (57.9 [98.3% CI 55.6-60.3]) compared to participants taking ethosuximide (54.5 [95% CI 52.1-56.9]). Pretreatment and ongoing behavioral problems exist in CAE. Valproic acid is associated with worse behavioral outcomes than ethosuximide or lamotrigine, further reinforcing ethosuximide as the preferred initial therapy for CAE. NCT00088452. This study provides Class II evidence that for children with CAE, valproic acid is associated with worse behavioral outcomes than ethosuximide or lamotrigine.

Factors associated with failure of nonoperative treatment of complicated appendicitis in children

Appendicitis remains the most common cause for emergency abdominal surgery in children. Immediate appendectomy in complicated, perforated appendicitis can be hazardous and nonoperative therapy has been gaining use as an initial therapy in children. Previous studies have reported failure rates in nonoperative therapy in such cases ranging from 10% to 41%. Factors leading to treatment failures have been studied with various and disparate results. We reviewed our institutional experience in treated complicated appendicitis, with focus on those initially managed nonoperatively. MethodsRecords of all children admitted with the diagnosis of perforated appendicitis to NYU Langone Medical Center and Bellevue Hospital Center from January 1, 2003 to December 31, 2013 were reviewed. The diagnosis was made with ultrasound and/or computed tomography scan. Those with abscesses amenable to drainage underwent aspiration and drain placement by an interventional radiologist. Broad spectrum intravenous (IV) antibiotics were given until the patient became afebrile, pain free and tolerating a regular diet. Oral antibiotics were continued for an additional week and interval appendectomy was done eight weeks later. The primary outcome measure was treatment response with failure defined as those who did not improve or required readmission for additional IV antibiotics and/or early appendectomy. Multiple patient and treatment related variables, including those previously reported as predicting failure in nonoperative therapy, were studied. Continuous variables were reported as means ± standard error and compared using 2-tailed unpaired t tests; nonparametric variables were analyzed by Mann–Whitney U tests. Categorical variables were reported as medians ± interquartile ranges and compared using Chi-square testing. Statistical significance was accepted for p<.05. ResultsSixty-four patients were identified as undergoing initial nonoperative therapy. Fifty-two (81%) were categorized as treatment successes being treated nonoperatively and 12 (19%) were failures. Variables showing no significance in predicting treatment failures included duration of symptoms, presence of appendicolith, presence of phlegmon, presence of abscess, initial white blood cell count, and SIRS (Systemic Inflammatory Response Syndrome) positive. The variables that predicted failure of nonoperative therapy vs. successes were presence of bandemia (75% vs. 40%, p=0.052) and small bowel obstruction on imaging (42% vs. 15%, p=0.052) and presence of bandemia ≥15% which was highly predictive of failure (67% vs. 4%, p<0.01). ConclusionsPredicting which patients with complicated perforated appendicitis will respond well to nonoperative therapy may allow us to more effectively treat patients with complicated perforated appendicitis. In our study the presence of small bowel obstruction and bandemia, especially ≥15% correlated with treatment failure; this suggests that these select patients may need a modified treatment strategy.

Steroid-induced renal dysfunctions in children with immune thrombocytopenia

Objectives The study was designed to evaluate the effect of steroid therapy on renal functions in children with immune thrombocytopenia (ITP). Background ITP is usually a benign self-limiting condition. The most appropriate initial therapy for children with ITP remains controversial. When therapy is indicated, the primary method of treatment is steroid therapy. Materials and methods The study was conducted on 33 children newly diagnosed with ITP (19 male; 14 female). The patients were classified into two main groups: group I included patients who needed corticosteroid therapy (18 patients) and group II included patients who did not need corticosteroid therapy (15 patients). Fifteen healthy age-matched and sex-matched children were included in the study as controls. All individuals were subjected to history taking, thorough clinical examination, anthropometric measurements, complete blood count, complete urine analysis, and renal function tests [blood urea, serum creatinine concentrations, and estimated glomerular filtration rate (eGFR)]. Blood samples were taken before any treatment and after an accumulative dose of 350 mg/m 2 steroid therapy for group I. Results The study revealed that ITP children who received steroids had significant increase in serum creatinine and significant decrease in eGFR without difference in blood urea, compared with those who did not receive steroids and with controls. The same was true in paired analysis on comparing ITP patients after steroid therapy with their investigations before steroid therapy. Conclusion Patients with ITP under short course of corticosteroid therapy are at risk for impaired renal functions in the form of increased serum creatinine concentration and decreased eGFR.

Survey of the Side Effects of ITP Therapies

AbstractAbstract 3327 Introduction:Adult immune thrombocytopenia (ITP) is an autoimmune disorder characterized by an isolated low platelet count. Options for initial therapy in children and adults include corticosteroids (CS), intravenous immunoglobulin (IVIG), and anti-D. Second-line treatments include splenectomy, rituximab, and the thrombopoietin receptor agonists (TPO-A) eltrombopag and romiplostim. Treatments are usually effective in raising platelet counts, but there are often associated toxicities. We designed and administered a patient survey to compare side effects reported with different ITP therapies to an off treatment control group. Methods:A literature search identified 56 distinct side effects reported by patients on medical therapy for ITP. A self-report questionnaire was designed that asked patients how frequently (never, occasionally, regularly, almost always, always) they had experienced each side effect during the last 30 days. If a respondent had experienced the side effect, he/she was also asked to indicate the level of distress associated with the symptom on a rating scale. Adult non-pregnant patients with ITP were eligible for the IRB-approved study if they were currently taking one of the following therapies, and had done so for at least 30 days: CS, rituximab plus pulse high dose dexamethasone [Dex-Ritux], eltrombopag, IVIG, romiplostim, or no therapy (control group). Clinical details were obtained from patient records. Side effects in the treatment groups were compared to the control sample using the Wilcoxon rank-sum test (alpha = .05). Results:Ninety-one eligible patients completed the survey. Eleven (12%) were on CS (9 patients on prednisone [median dose 20mg/day] and 2 on pulse high dose dexamethasone), 11 (12%) on Dex-Ritux, 21 (23%) on eltrombopag, 9 (10%) on IVIG, 22 (24%) on romiplostim, and 17 (19%) on no therapy. Sixty-two percent overall and 71% of control patients were female (n=56, n=12). One hundred percent of patients reported experiencing at least one side effect. The most commonly reported side effects were fatigue (n= 78; 86%), stress (n=70; 77%), anxiety (n=56; 62%), joint pain (n=55; 60%), and muscle pain (n=55; 60%).Most side effects reported by patients on treatment did not occur with significantly greater frequency or distress than in the control sample. Side effects that occurred with significantly greater frequency compared to the control sample were found in every treatment group except eltrombopag. Most of these symptoms were mild and not associated with greater distress compared to control patients who experienced the same side effect. The number of side effects occurring with greater frequency was 15 with romiplostim, 5 with Dex-Ritux, 3 with CS, and 2 with IVIG. Side effects that occurred with significantly greater distress compared to the control sample were found in every treatment group. Greater distress was not necessarily associated with greater frequency (see Table).Many unwanted effects, such as fatigue, insomnia, dyspepsia, and skin irritation, that have traditionally been associated with CS treatment did not occur with greater frequency or distress in that group; however, few patients were on long term or high dose CS therapy. Surprisingly, unlike published series, we found that romiplostim patients experienced fatigue with significantly greater frequency and more distress than the control group (see Figure). Conclusion:These results suggest that, while unwanted effects of ITP treatment in adults are common, the great majority are not associated with significant patient distress. Patients who participated in this study were being treated at a clinic where treatment guidelines for adult ITP favored TPO-As over CS. Thus our findings may not reflect general experience. [Display omitted] [Display omitted] Disclosures:Bussel:Amgen: Equity Ownership, Membership on an entity's Board of Directors or advisory committees, Research Funding; Cangene: Research Funding; GlaxoSmithKline: Equity Ownership, Membership on an entity's Board of Directors or advisory committees, Research Funding; Genzyme: Research Funding; IgG of America: Research Funding; Immunomedics: Research Funding; Ligand: Membership on an entity's Board of Directors or advisory committees, Research Funding; Eisai, Inc: Membership on an entity's Board of Directors or advisory committees, Research Funding; Shinogi: Membership on an entity's Board of Directors or advisory committees, Research Funding; Symphogen: Membership on an entity's Board of Directors or advisory committees; Sysmex: Research Funding; Portola: Consultancy.

Treatment with tacrolimus and prednisolone is preferable to intravenous cyclophosphamide as the initial therapy for children with steroid-resistant nephrotic syndrome

There are limited data on the relative efficacy and safety of calcineurin inhibitors and alkylating agents for idiopathic steroid-resistant nephrotic syndrome in children. To clarify this, we compared tacrolimus and intravenous cyclophosphamide therapy in a multicenter, randomized, controlled trial of 131 consecutive pediatric patients with minimal change disease, focal segmental glomerulosclerosis, or mesangioproliferative glomerulonephritis, stratified for initial or late steroid resistance. Patients were randomized to receive tacrolimus for 12 months or 6-monthly infusions of intravenous cyclophosphamide with both arms receiving equal amounts of alternate-day prednisolone. The primary outcome of complete or partial remission at 6 months, based on spot urine protein to creatinine ratios, was significantly higher in children receiving tacrolimus compared to cyclophosphamide (hazard ratio 2.64). Complete remission was significantly higher with tacrolimus (52.4%) than with cyclophosphamide (14.8%). The secondary outcome of sustained remission or steroid-sensitive relapse of nephrotic syndrome at 12 months was significantly higher with tacrolimus than cyclophosphamide. Treatment withdrawal was higher with cyclophosphamide, chiefly due to systemic infections. Compared to cyclophosphamide, 3 patients required treatment with tacrolimus to achieve 1 additional remission. Thus, tacrolimus and prednisolone are effective, safe, and preferable to cyclophosphamide as the initial therapy for patients with steroid-resistant nephrotic syndrome.

Prognostic factors of a good response to initial therapy in children and adolescents with differentiated thyroid cancer

BACKGROUND:Therapeutic approaches in pediatric populations are based on adult data because there is a lack of appropriate data for children. Consequently, there are many controversies regarding the proper treatment of pediatric patients.OBJECTIVE:The present study was designed to evaluate patients with differentiated thyroid carcinoma diagnosed before 20 years of age and to determine the factors associated with the response to the initial therapy.METHODS:Sixty‐five patients, treated in two tertiary‐care referral centers in Rio de Janeiro between 1980 and 2005 were evaluated. Information about clinical presentation and the response to initial treatment was analyzed and patients had their risk stratified in Tumor‐Node‐ Metastasis; Age‐Metastasis‐Extracapsular‐Size; distant Metastasis‐Age‐Completeness of primary tumor resection‐local Invasion‐Size and American‐Thyroid‐Association classificationRESULTS:Patients ages ranged from 4 to 20 years (median 14). The mean follow‐up was 12,6 years. Lymph node metastasis was found in 61.5% and indicated a poor response to initial therapy, with a significant impact on time for achieving disease free status (p = 0.014 for response to initial therapy and p<0,0001 for disease‐free status in follow‐up). Distant metastasis was a predictor of a poor response to initial therapy in these patients (p = 0.014). The risk stratification systems we analyzed were useful for high-risk patients because they had a high sensitivity and negative predictive value in determining the response to initial therapy.CONCLUSIONS:Metastases, both lymph nodal and distant, are important predictors of the persistence of disease after initial therapy in children and adolescents with differentiated thyroid cancer.

A Randomized Trial Comparing Bangerter Filters and Patching for the Treatment of Moderate Amblyopia in Children

To determine whether visual acuity improvement with Bangerter filters is similar to improvement with patching as initial therapy for children with moderate amblyopia. Randomized, clinical trial. We enrolled 186 children, 3 to <10 years old, with moderate amblyopia (20/40-20/80). Children were randomly assigned to receive either daily patching or to use a Bangerter filter on the spectacle lens in front of the fellow eye. Study visits were scheduled at 6, 12, 18, and 24 weeks. Visual acuity in amblyopic eyes at 24 weeks. At 24 weeks, amblyopic eye improvement averaged 1.9 lines in the Bangerter group and 2.3 lines in the patching group (difference in mean visual acuities between groups adjusted for baseline acuity = 0.38 line). The upper limit of a 1-sided 95% confidence interval was 0.76 line, which slightly exceeded a prespecified noninferiority limit of <0.75 line. Similar percentages of subjects in each group improved > or =3 lines (Bangerter group 38% vs patching group 35%; P = 0.61) or had > or =20/25 amblyopic eye acuity (36% vs 31%, respectively; P = 0.86). There was a lower treatment burden in the Bangerter group as measured with the Amblyopia Treatment Index. With Bangerter filters, neither a fixation switch to the amblyopic eye nor induced blurring in the fellow eye to worse than that of the amblyopic eye was required for visual acuity improvement. Because the average difference in visual acuity improvement between Bangerter filters and patching was less than half a line, and there was lower burden of treatment on the child and family, Bangerter filter treatment is a reasonable option to consider for initial treatment of moderate amblyopia.

Results of a multicenter survey of diagnosis and treatment for bacterial meningitis in Japan

An evaluation committee was organized to evaluate 464 cases of bacterial meningitis treated at 108 nationwide medical facilities participating in this survey between April 2004 and January 2007. There were 413 evaluable cases of bacterial meningitis, including 342 children (82.8%) and 71 adults (17.2%). Haemophilus influenzae (217 cases, 63.5%) and Streptococcus pneumoniae (35 cases, 49.3%) were the most frequent pathogens for meningitis in children and adults, respectively. The most used initial therapy for children was carbapenem+cephalosporin therapy (212 cases, 61.9%). Of the 333 children included in efficacy evaluation, 320 (96.1%) were rated as remission, 10 (3.0%) as partial remission, and three (0.9%) as poor response. The combination therapy with two drugs was also most often used in adults (41 cases, 57.7%). In efficacy analysis in 60 adults, remission was observed in 50 (83.3%), partial remission in five (8.3%) and poor response in five (8.3%). In prognosis analysis, 273 (80.3%) among 340 children were alive at the end of treatment without sequelae, but one (0.3%) died by the end of treatment, and 64 (18.8%) had sequelae. Of all adults, six (8.5%) died of bacterial meningitis and 23 (32.4%) had sequelae at the end of treatment. Among the patients followed up for 1year, 26 (12.3%) of 211 children and three (7.7%) of 39 adults had sequelae. The selection of drugs and its dose level of many cases were appropriate, but the dose level of several cases was inappropriate. It is necessary to spread the method of proper antibiotic therapy.

Approaches to bedwetting: in with the old

Within the spectrum of child health concerns, bedwetting probably does not rank high in importance among pediatricians. For parents and children, however, this can become a major source of psychological distress and family discord. Not surprisingly, the mainstays of the western medical approach to bedwetting have been pharmacologic (eg, desmopressin) and technologic (eg, alarms). Behavioral interventions for bedwetting children are occasionally mentioned, but rarely studied with any precision. This issue of The Journal contains a practical study of a simple intervention, from a group in the Netherlands. The group demonstrated success from the simple expedient of taking a child from bed about 2 hours after falling asleep and placing him or her on the toilet to urinate. Although this intervention seems almost common sense, it really has never been studied as carefully as in this report. The report is placed into context in an accompanying editorial by Jackson. This brief editorial succinctly summarizes current “best practice” in this field. The last paragraph of Jackson's editorial may be the best description of the appropriate “workup” and initial therapy for children with nocturnal enuresis ever published.

Treatment of partial seizures in childhood : an overview.

The treatment of partial seizures in children is based on the use of first generation and recently introduced antiepileptic drugs as well as nonpharmacological treatments such as the ketogenic diet, vagus nerve stimulation and surgical therapy. The present review discusses the efficacy and tolerability of different treatment options for partial seizures in childhood. Few adjunctive or monotherapy, placebo-controlled or comparative trials of the first-generation antiepileptic drugs and some of the more recently introduced antiepileptic drugs have been performed in children. This can be explained by the fact that it is only relatively recently (1989) that the International League against Epilepsy proposed that randomised, controlled trials be included among the required criteria for assessing the efficacy and tolerability of an antiepileptic agent. This led to controlled, comparative trials among older antiepileptic drugs (phenobarbital, phenytoin, carbamazepine and valproic acid), both in adults and in paediatric patients, being performed relatively 'late', based on when these drugs were first introduced. Carbamazepine and valproic acid may still be considered as first-line antiepileptic therapies for children with partial seizures. Phenobarbital and phenytoin are mostly considered as last choice drugs because of their adverse event profiles. The new generation of antiepileptic agents has added to the first- and second-line treatment options for paediatric partial seizures. To date, there are sufficient data to support the clinical use of some of the recently introduced antiepileptic drugs (e.g. oxcarbazepine, topiramate, gabapentin and lamotrigine) as adjunctive or first-line monotherapy. Because of the risk of visual field constriction with vigabatrin, the use of this drug is currently limited to patients refractory to other medications. Tiagabine, felbamate, levetiracetam and zonisamide have been shown to be effective in adults with partial seizures; however, at present there are not yet enough data on the efficacy of these drugs in children to support consideration of their use as either first-line or add-on therapy in this patient population, although controlled studies are expected shortly. Furthermore, the use of felbamate is considerably limited by rare, but severe, hepatic and haematological toxicity. Controlled trials for paediatric partial seizures are still lacking for the ketogenic diet and vagus nerve stimulation, though they may represent, in given patients, useful adjunctive alternative treatments for refractory partial seizures. In conclusion, further trials are needed to determine an optimal sequence of first- and second-line therapies and to establish whether other newer antiepileptic drugs merit consideration as initial therapy in children with partial seizures.

Diagnostic certainty for acute otitis media

Our primary objective was to assess diagnostic accuracy for acute otitis media (AOM) relative to the criterion standard established by the United States Agency for Healthcare Research and Quality: middle-ear effusion (MEE) plus onset in the past 48 h of signs or symptoms of middle-ear inflammation. A secondary objective was to assess the potential reduction in antibiotic usage that could be achieved if clinicians managed AOM according to a consensus guideline developed by the New York Region Otitis Project (NYROP). A convenience sample of primary care practitioners were surveyed after diagnosing AOM in 135 children aged 0.3–11.8 years (median 2.4 years). Clinicians expressed high certainty for AOM diagnosis in 122/135 episodes (90%). The prevalence of true AOM was 70% with a positive predictive value for high certainty of 76%. Of the 40 false-positive diagnoses, 35 did not have MEE and 5 did not have acute signs or symptoms. The relative risk for receiving an antibiotic was 1.50 times higher when clinicians expressed certainty ( P=0.005), which produced 31/120 (26%) potentially unnecessary antibiotic prescriptions. Initial antibiotics would not have been prescribed for 29% of episodes using the NYROP guidelines. More judicious use of antibiotics may result if clinicians deferred initial therapy in children without definitive AOM, particularly when the presence of MEE is uncertain.

Lamivudine (LMV) versus LMV+interferon (IFN) alpha as initial therapy for children with chronic hepatitis B (first year results)

Lamivudine (LMV) versus LMV+interferon (IFN) alpha as initial therapy for children with chronic hepatitis B (first year results)

Lamivudine (LMV) versus LMV+interferon (IFN) alpha as initial therapy for children with chronic hepatitis B (first year results)

Lamivudine (LMV) versus LMV+interferon (IFN) alpha as initial therapy for children with chronic hepatitis B (first year results)