Vaccination practices in pediatric transplantation: A survey among member centers of the European reference network TransplantChild.

BACKGROUND: There is considerable variation in vaccination practices between pediatric transplant centers. This study aims to evaluate active immunization attitudes and practices among ERN-TransplantChild centers and identify potential areas of improvement that could be addressed by shared evidence-based protocols. METHODS: A cross-sectional questionnaire of attitudes and practices toward immunization of pediatric SOT and HSCT candidates and recipients was sent to a representative member of multidisciplinary teams from 27 European centers belonging to the ERN-TransplantChild. RESULTS: A total of 28/62 SOT programs and 6/12 HSCT programs across 21 European centers participated. A quarter of centers did not have an on-site protocol for the immunizations. At the time of transplantation, pediatric candidates were fully immunized (80%-100%) in 57% and 33% of the SOT and HSCT programs. Variations in the time between vaccine administration and admission to the waiting list were reported between the centers, with 2 weeks for inactivated vaccines and variable time (2-4 weeks) for live-attenuated vaccines (LAVs). Almost all sites recommended immunization in the post-transplant period, with a time window of 4-8 months for the inactivated vaccines and 16-24 months for MMR and Varicella vaccines. Only five sites administer LAVs after transplantation, with seroconversion evaluated in 80% of cases. CONCLUSIONS: The immunization coverage of European pediatric transplant recipients is still inconsistent and far from adequate. This survey is a starting point for developing shared evidence-based immunization protocols for safe vaccination among pediatric transplant centers and generating new research studies.

Development and use of an innovative Gap Finding Tool to create a Pharmaceutical Care Model within a paediatric oncology setting.

INTRODUCTION: A paediatric cancer ward is a setting where pharmacists participate in direct patient care, acting as coordinators between the patient, caregivers and healthcare professionals. The aim of the study was to develop a Gap Finding Tool to support the setting up of a pharmaceutical care model at a Paediatric-Adolescent Cancer Ward. METHODS: The Standards of Practice for Clinical Pharmacy Services by the Society of Hospital Pharmacists of Australia Committee of Specialty Practice in Clinical Pharmacy (2013), the American College of Clinical Pharmacy (2014) and the European Association of Hospital Pharmacists (2014) were used to compile the Gap Finding Tool. The developed Tool was tested for content validity by a panel of experts and subsequently implemented over 2 months. RESULTS: The Gap Finding Tool comprised of nine sections with an average of eight statements each about pharmacy services that should be provided at ward level. For each statement, the rater indicates whether these contributions are provided. When the Tool was implemented at the Paediatric-Adolescent Cancer Ward, four major gaps were identified, namely, absence of a clinical pharmacist, lack of medicines information, vetting of chemotherapy prescriptions by pharmacist with limited access to patient data and lack of pharmacist-input on medicines availability. Processes requiring optimisation included discharge medication advice and documentation processes. CONCLUSION: The developed Gap Finding Tool is an innovative tool which is versatile and can be used in ward or ambulatory clinical settings to identify gaps in pharmaceutical processes and services and compare national or regional practices to international standards.

Recurrent Langerhans cell histiocytosis at the site of prior craniotomy: case report.

Tumors of the CNS represent the largest group of solid tumors found in the pediatric patient population. Langerhans cell histiocytosis (LCH) is an inflammatory lesion that may present in bone and/or soft tissue, including the CNS. Management depends on the extent of multisystem involvement, which determines resection with or without systemic chemotherapy. The authors report on the case of a child who underwent an open craniotomy for biopsy of a pituitary stalk lesion followed by neuropathological assessment, procedures used to diagnose LCH. The patient then underwent 12 months of systemic chemotherapy with subsequent resolution of the pituitary stalk lesion. Two years following pathological diagnosis, the patient presented with frontal orbital pain at the site of the prior craniotomy. Advanced imaging revealed MRI enhancement and radiotracer uptake of a soft-tissue growth at the frontal burr-hole site and MRI enhancement at a posterior burr-hole site without soft-tissue growth. The patient then underwent open biopsy and curettage that revealed LCH recurrence at the site of prior craniotomy. This case demonstrates that LCH may represent an abnormal reactive clonal proliferation of dendritic cells, rather than a de novo malignant neoplasm that can occur at sites of prior craniotomy despite systemic chemotherapy. The authors advocate close follow-up with contrast-enhanced imaging. Special attention should be given to sites of prior surgical manipulation to avoid missing distant sites of recurrence.

Late concomitant repair of tetralogy of Fallot and aortic valve replacement following successful pregnancy.

The importance of patient follow-up after repair of tetralogy of Fallot, with special attention to the development of arrhythmias, has been widely studied. It is only recently that postoperative problems relating to the aortic root of these individuals have been looked into. The present case report refers to a patient with tetralogy of Fallot who underwent complete correction, together with aortic valve replacement at 33 years of age following a successful pregnancy. To our knowledge, this is the third report of primary repair of tetralogy of Fallot with simultaneous aortic valve replacement for severe aortic regurgitation. Our patient is unique in that she had uncorrected and unpalliated tetralogy of Fallot and severe aortic regurgitation and still went through an uneventful pregnancy and delivery. There is only one report of successful pregnancy and delivery in uncorrected tetralogy, but this was not associated with aortic regurgitation.

Risk factors for QRS prolongation after repaired tetralogy of Fallot.

INTRODUCTION: Repaired tetralogy of Fallot is usually conducive to a normal and unrestricted lifestyle. However, occasionally, late sudden death occurs due to ventricular tachycardia. This is thought to be due to a combination of factors, including both left and right ventricular dilation, which may be associated with valvular incompetence and residual right ventricular outflow tract obstruction. Several studies have shown that QRS duration > 180 ms is a predictor for life-threatening ventricular arrhythmias. METHODS AND RESULTS: We recalled our tetralogy population (n = 57) to identify risk factors for prolonged QRS duration on the resting ECG. Factors examined included history, demographics, symptoms, surgery, chest X-ray, ECG and echocardiography. Extensive analysis found only a significant positive correlation between QRS duration and degree of residual right ventricular outflow tract obstruction. CONCLUSIONS: Our study suggests that residual right ventricular outflow tract gradients may be a very significant contributor to QRS prolongation. It will be interesting to see if future studies of larger cohorts confirm this finding.

Aortic stenosis after uncomplicated surgical repair of tetralogy of Fallot.

Tetralogy of Fallot is only rarely associated with aortic valvar disease. We present a child who had uncomplicated repair of tetralogy of Fallot at 16 months of age, and who developed mild aortic stenosis three years later, with mild to moderate aortic incompetence being seen two years subsequent to that event. No aortic valvar disease had been noted prior to surgery. No intervention is planned at this stage.