RESUMO
BACKGROUND: The increasing number of pediatric patients infected with multiresistant Helicobacter pylori strains calls for evaluation of treatment regimens. Second-line antibiotics such as tetracycline or quinolones are not licensed for children. Because in vivo resistance to metronidazole may be overcome in vivo by a high dose and prolonged intake, we evaluated the eradication rate and side effects of a high-dose triple therapy in pediatric patients with culture-proven double resistance. PATIENTS AND METHODS: In this open multicentre trial, 62 children (<18 years, body weight >15 kg) infected with an H pylori strain resistant to metronidazole and clarithromycin were treated according to body weight classes with amoxicillin (â¼ 75 mg/kg/day), metronidazole (â¼ 25 mg/kg/day) and esomeprazole (â¼ 1.5 mg/kg/day) for 2 weeks. Adherence and adverse events were assessed by a 2-week diary and telephone interviews at days 7 and 14 of treatment. Primary outcome was a negative C-urea breath test after 6 weeks. RESULTS: Of 62 patients, 5 were lost to follow-up, 12 were nonadherent, and 45 treated per protocol. Eradication rates were 66% (41/62) [confidence interval 54-78] (intention to treat) and 73% (33/45) [confidence interval 60-86] (per protocol). Success of treatment was not related to dose per kilogram body weight. Mild to moderate adverse events were reported by 21 patients, including nausea (10.8%), diarrhoea (8.9%), vomiting (7.1%), abdominal pain (5.4%), and headache (3.6%), and led to discontinuation in 1 child. CONCLUSION: High-dose amoxicillin, metronidazole, and esomeprazole for 2 weeks is a good treatment option in children infected with a double resistant H pylori strain.
Assuntos
Antibacterianos/uso terapêutico , Farmacorresistência Bacteriana Múltipla , Gastrite/tratamento farmacológico , Infecções por Helicobacter/tratamento farmacológico , Helicobacter pylori , Adolescente , Amoxicilina/administração & dosagem , Amoxicilina/efeitos adversos , Amoxicilina/uso terapêutico , Antibacterianos/administração & dosagem , Antibacterianos/efeitos adversos , Antiulcerosos/administração & dosagem , Antiulcerosos/efeitos adversos , Antiulcerosos/uso terapêutico , Criança , Pré-Escolar , Quimioterapia Combinada/efeitos adversos , Esomeprazol/administração & dosagem , Esomeprazol/efeitos adversos , Esomeprazol/uso terapêutico , Europa (Continente) , Feminino , Gastrite/microbiologia , Infecções por Helicobacter/microbiologia , Helicobacter pylori/efeitos dos fármacos , Helicobacter pylori/isolamento & purificação , Humanos , Perda de Seguimento , Masculino , Adesão à Medicação , Metronidazol/administração & dosagem , Metronidazol/efeitos adversos , Metronidazol/uso terapêutico , Testes de Sensibilidade MicrobianaRESUMO
OBJECTIVE: To determine the primary and secondary resistance to several antimicrobial agents in Spanish Helicobacter pylori clinical isolates obtained from paediatric patients from January 2002 to June 2006. METHODS: Samples were collected from gastric biopsies of symptomatic paediatric patients and H. pylori cultured according to standard microbiological procedures. Resistance was determined by E-test. Strains were considered resistant if minimal inhibitory concentration (MIC) > or = 2 mg/l for amoxycillin, > or = 4 mg/l for tetracycline, > or = 8 mg/l for metronidazole, > or = 1 mg/l for clarithromycin, MIC > or = 4 mg/l for ciprofloxacin, MIC > or = 32 mg/l for rifampicin and intermediate if MIC = 0.5 mg/l for clarithromycin, and MIC = 2 mg/l for ciprofloxacin. RESULTS: A total of 101 patients were included: 38 males and 63 females (sex ratio M/F: 0.6). Average age was 10 years (range: 4-18 years). All strains were susceptible to amoxycillin, tetracycline and rifampicin, 35.7% were resistant to metronidazole, 54.6% to clarithromycin and 1.8% to ciprofloxacin. 2.0% were intermediate to clarithromycin and 1.8% to ciprofloxacin. Double resistance to metronidazole and clarithromycin rated at 17.2%. Thirty-five patients (34.7%) had a history of treatment failure, and were considered as secondary H. pylori. Primary resistance rates to metronidazole and clarithromycin were 32.8% and 49.2%, respectively, and secondary resistance rates were 41.2% and 70.6%, respectively. CONCLUSIONS: Resistance to clarithromycin (56.6%) was higher than to metronidazole (35.7%) in the H. pylori strains studied. Clarithromycin resistance was very high even in strains from paediatric patients not previously treated for H. pylori infection.
Assuntos
Claritromicina/farmacologia , Resistência Microbiana a Medicamentos , Gastrite/microbiologia , Infecções por Helicobacter/microbiologia , Helicobacter pylori/efeitos dos fármacos , Metronidazol/farmacologia , Adolescente , Amoxicilina/farmacologia , Criança , Pré-Escolar , Ciprofloxacina/farmacologia , Farmacorresistência Bacteriana Múltipla , Feminino , Gastrite/tratamento farmacológico , Gastrite/epidemiologia , Infecções por Helicobacter/tratamento farmacológico , Infecções por Helicobacter/epidemiologia , Helicobacter pylori/isolamento & purificação , Humanos , Masculino , Testes de Sensibilidade Microbiana , Rifampina/farmacologia , Espanha/epidemiologia , Tetraciclina/farmacologiaRESUMO
AIM: To prospectively assess the antibacterial resistance rate in Helicobacter pylori strains obtained from symptomatic children in Europe. METHODS: During a 4-year period, 17 paediatric centres from 14 European countries reported prospectively on patients infected with H pylori, for whom antibiotic susceptibility was tested. RESULTS: A total of 1233 patients were reported from Northern (3%), Western (70%), Eastern (9%) and Southern Europe (18%); 41% originated from outside Europe as indicated by mother's birth-country; 13% were <6 years of age, 43% 6-11 years of age and 44% >11 years of age. Testing was carried out before the first treatment (group A, n = 1037), and after treatment failure (group B, n = 196). Overall resistance to clarithromycin was detected in 24% (mean, A: 20%, B: 42%). The primary clarithromycin resistance rate was higher in boys (odds ratio (OR) 1.58; 1.12 to 2.24, p = 0.01), in children <6 years compared with >12 years (OR 1.82, 1.10 to 3.03, p = 0.020) and in patients living in Southern Europe compared with those living in Northern Europe (OR 2.25; 1.52 to 3.30, p<0.001). Overall resistance rate to metronidazole was 25% (A: 23%, B: 35%) and higher in children born outside Europe (A: adjusted. OR 2.42, 95% CI: 1.61 to 3.66, p<0.001). Resistance to both antibiotics occurred in 6.9% (A: 5.3%, B: 15.3%). Resistance to amoxicillin was exceptional (0.6%). Children with peptic ulcer disease (80/1180, 6.8%) were older than patients without ulcer (p = 0.001). CONCLUSION: The primary resistance rate of H pylori strains obtained from unselected children in Europe is high. The use of antibiotics for other indications seems to be the major risk factor for development of primary resistance.
Assuntos
Anti-Infecciosos/uso terapêutico , Farmacorresistência Bacteriana , Infecções por Helicobacter/tratamento farmacológico , Helicobacter pylori/efeitos dos fármacos , Adolescente , Distribuição por Idade , Amoxicilina/uso terapêutico , Criança , Pré-Escolar , Claritromicina/uso terapêutico , Farmacorresistência Bacteriana Múltipla , Europa (Continente)/epidemiologia , Feminino , Infecções por Helicobacter/complicações , Infecções por Helicobacter/epidemiologia , Humanos , Masculino , Metronidazol/uso terapêutico , Úlcera Péptica/complicações , Estudos Prospectivos , Distribuição por Sexo , Falha de TratamentoRESUMO
Celiac disease can present great clinical heterogeneity. Its association with a series of intestinal and non-intestinal diseases, whether immunologically mediated or otherwise, presents a higher than normal frequency. We present a patient with celiac disease and Budd-Chiari syndrome of unknown cause. This association has previously been described only in isolated cases in northern Africa. The appearance of this case in Spain reveals that the coexistence of both processes in a single patient is unlikely to be due to environmental or geographical factors.
Assuntos
Síndrome de Budd-Chiari/complicações , Doença Celíaca/complicações , Adolescente , Humanos , Masculino , EspanhaRESUMO
OBJECTIVE: To analyse the influence of covariates on the apparent clearance (CL) of tacrolimus in paediatric liver transplant recipients being converted from cyclosporin to tacrolimus. DESIGN: Retrospective modelling study. PATIENTS AND PARTICIPANTS: 18 children, 13 girls and 5 boys, aged 4 months to 16 years (median 9.1 years) who required conversion to tacrolimus because of acute or chronic rejection or cyclosporin toxicity. METHODS: 287 whole-blood tacrolimus concentrations from therapeutic drug monitoring were used to build a nonlinear mixed-effects population model (NONMEM program) for the apparent clearance of tacrolimus. Variables considered were age, total bodyweight (TBW), body surface area (BSA), time after initiation of treatment (T), gender, haematocrit (Hct), albumin (Alb), aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma-glutamyl transpeptidase (gammaGT), alkaline phosphatase (ALP), bilirubin (BIL), creatinine clearance (CL(CR)) and dosage of concomitant corticosteroids (EST). RESULTS: TBW, T, BIL and ALT were the covariates that displayed a significant influence on CL according to the final regression model: CL (L/h) = 10.4(TBW/70)3/4 x e(-0.00032 T) x e(-0.057 BIL) x (1 - 0.079 ALT). With this model, the estimates of the coefficients of variation were 24.3% and 29.5% for interpatient variability in CL and residual variability, respectively. CONCLUSIONS: The proposed model for tacrolimus CL can be applied for a priori dosage calculations, although the results should be used with caution because of the unexplained variability in the CL. We therefore recommended close monitoring of tacrolimus whole blood concentrations, especially within the first months of treatment. The best use of the model would be its application in dosage adjustment based on therapeutic drug monitoring and the Bayesian approach.
Assuntos
Rejeição de Enxerto/metabolismo , Imunossupressores/farmacocinética , Transplante de Fígado , Dinâmica não Linear , Tacrolimo/farmacocinética , Adolescente , Corticosteroides/uso terapêutico , Alanina Transaminase/metabolismo , Bilirrubina/metabolismo , Peso Corporal/fisiologia , Criança , Pré-Escolar , Monitoramento de Medicamentos/métodos , Feminino , Rejeição de Enxerto/tratamento farmacológico , Humanos , Imunossupressores/sangue , Imunossupressores/uso terapêutico , Lactente , Masculino , Taxa de Depuração Metabólica , Análise de Regressão , Estudos Retrospectivos , Tacrolimo/sangue , Tacrolimo/uso terapêuticoRESUMO
VacA and CagA serological responses were detected in pediatric patients: 44 and 56%, respectively, in peptic ulcer (PU) patients, 33.3 and 44.4% in active chronic gastritis (ACG) patients, and 23.2 and 39.2% in non-ACG patients. Higher seroprevalence to CagA+VacA and to CagA+VacA+35-kDa antigen was found among PU patients. However, a low level of sensitivity and specificity was found for indirect detection of PU patients.
Assuntos
Anticorpos Antibacterianos/sangue , Antígenos de Bactérias/imunologia , Proteínas de Bactérias/imunologia , Gastrite/imunologia , Infecções por Helicobacter/imunologia , Úlcera Péptica/imunologia , Adolescente , Western Blotting/métodos , Criança , Pré-Escolar , Doença Crônica , Feminino , Gastrite/sangue , Gastrite/epidemiologia , Infecções por Helicobacter/sangue , Infecções por Helicobacter/epidemiologia , Helicobacter pylori/imunologia , Humanos , Masculino , Úlcera Péptica/sangue , Úlcera Péptica/epidemiologia , Valor Preditivo dos Testes , Sensibilidade e Especificidade , Estudos Soroepidemiológicos , Espanha/epidemiologiaRESUMO
The aim of this study was to examine the clinical presentation and time of hepatic artery thrombosis (HAT) after orthotopic liver transplantation (OLT), stressing the role of imaging modalities. Therapeutic options are described, such as retransplantation (Re-OLT), hepatic resections and revascularization procedures, focusing on complications and outcome in a consecutive series of 687 OLT. Over the period from 1986 to 1999, 687 OLT were carried out in 601 patients, 592 of whom were adults and 95 pediatric subjects. Of these operations 601 were primary OLT and 86 Re-OLT (71 I Re-OLT, 14 II Re-OLT and 1 III Re-OLT). In this retrospective study, we reviewed rejection episodes, time of HAT (early or late), possible cause of HAT, day of suspected diagnosis of HAT and day of confirmation of diagnosis. Clinical presentation, management, complications, outcome, survival rates and the need for Re-OLT were also recorded. The incidence of HAT was 2.47% (17/687). Early HAT (n = 9, < 30 days) was diagnosed 15.6 days after OLT (range: 3-25 days), whereas late HAT (n = 8, > 30 days) occurred 295.1 days after OLT (range: 38-1830 days). In two asymptomatic patients (2/17: 11.7%), HAT was discovered incidentally. Most of the patients (11/17: 64.7%) presented with increased liver function test values and fever. Relapsing bacteremia occurred in 7/17 cases (41.1%), whereas a biliary stricture and biliary leak were diagnosed in 3/17 (17.6%) and in 1/17 patients (5.8%), respectively. Fulminant hepatic failure was the clinical presentation in 2/17 cases (11.7%). In one case the clinical presentation was acute and chronic rejection (1/17: 5.8%). Intrahepatic abscesses were diagnosed in one case (1/17: 5.8%), as well as an intrahepatic haemorrhage (1/17: 5.8%). Doppler ultrasound (DUS) correctly revealed HAT in 9 of the 17 patients (52.9% sensitivity). In 8 of the 9 patients (88.8%) in whom HAT was diagnosed by DUS, angiography was also performed to confirm the diagnosis. Overall, angiography detected HAT in 14/17 patients (82.3% sensitivity). HAT management consisted of immediate Re-OLT in 6 patients 6.8 days (range: 3-12 days) after diagnosis. Delayed Re-OLT was performed in 6 patients 529.1 days (range: 68-1920 days) after diagnosis. The overall retransplantation rate was 70.5% (12/17). Two patients died despite undergoing intraarterial urokinase treatment. Three grafts were salvaged, but suffered biliary stricture due to ischemic cholangitis and underwent hepatico-jejunostomy. A II Re-OLT was carried out in 4 of 12 patients (33.3%). The overall mortality rate was 41.1% (7/17). One-year and 3-year overall survival rates were 58.8% (10/17) and 47.0% (8/17), respectively. Both 5- and 10-year overall survival rates were 11.7% (2/17). Although the results of OLT have improved dramatically over the past few years, HAT is still associated with substantial morbidity, a high incidence of graft failure and high mortality rates. The use of DUS to screen for HAT has permitted earlier diagnosis, but early angiographic evaluation of the hepatic arteries is still needed for accurate diagnosis of HAT and remains the gold standard. Retransplantation is the definitive solution for HAT in the majority of cases, though it is essentially the patient's clinical condition that dictates the form of management.
Assuntos
Artéria Hepática , Transplante de Fígado/efeitos adversos , Trombose/diagnóstico , Trombose/cirurgia , Adolescente , Adulto , Criança , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sensibilidade e Especificidade , Trombose/etiologiaRESUMO
Percutaneous endoscopic gastrostomy is an easy and safe technique to provide an enteral access for patients needing long-term enteral nutrition. Minor complications may occur in 9% to 13% of patients. Life-threatening complications appear in 1-3% of cases. Perforation of a hollow viscus leading to peritonitis is a rare condition; hepatic perforation after placing a percutaneous endoscopic gastrostomy (PEG) has not been reported previously. In patients with massive visceromegaly an abdominal ultrasound may help in localizing the place of punction avoiding surrounding organs.
Assuntos
Endoscopia Gastrointestinal , Gastrostomia , Doença de Depósito de Glicogênio/cirurgia , Adolescente , Nutrição Enteral , Doença de Depósito de Glicogênio/diagnóstico por imagem , Humanos , Fatores de Risco , UltrassonografiaRESUMO
The introduction of tacrolimus as rescue therapy represents a significant advance in the prevention of late graft failure and second liver transplantation. The authors report the blood level monitoring of tacrolimus as a rescue therapy in 21 children who underwent liver transplantation, and they report the dose-concentration relationship in the presence or absence of hepatitis C virus (HCV) in these patients. This was a retrospective study conducted from May 1993 to January 1997. Indication for the conversion from cyclosporine (CsA) to tacrolimus were acute rejection (62%), chronic rejection (33%), and CsA toxicity (5%). Mean daily dose in the first month was 0.32 mg/kg, whereas at the end of the follow-up period it was 0.14 mg/kg. Tacrolimus mean whole blood concentration levels were between 7.1 ng/ml and 9.4 ng/ml, without significant differences over time. Mean daily doses in HCV+ and HCV- patients were 0.08 and 0.24 mg/kg, respectively (p < 0.01), and mean concentrations were 8.3 and 8.4 ng/ml (NS). HCV+ children required a mean dose three times lower than the dose used in HCV- children to obtain the same tacrolimus trough blood level. Therefore, doses in HCV+ children must be decreased to achieve levels within the therapeutic range.
Assuntos
Rejeição de Enxerto/tratamento farmacológico , Imunossupressores/sangue , Imunossupressores/uso terapêutico , Transplante de Fígado/imunologia , Tacrolimo/sangue , Tacrolimo/uso terapêutico , Adolescente , Criança , Pré-Escolar , Ciclosporina/efeitos adversos , Ciclosporina/uso terapêutico , Relação Dose-Resposta a Droga , Monitoramento de Medicamentos , Feminino , Seguimentos , Rejeição de Enxerto/sangue , Hepacivirus , Hepatite C/sangue , Humanos , Lactente , Masculino , Estudos RetrospectivosAssuntos
Amoxicilina/uso terapêutico , Antibacterianos/uso terapêutico , Antitricômonas/uso terapêutico , Infecções por Helicobacter/tratamento farmacológico , Metronidazol/uso terapêutico , Compostos Organometálicos/uso terapêutico , Penicilinas/uso terapêutico , Adolescente , Amoxicilina/administração & dosagem , Antibacterianos/administração & dosagem , Antitricômonas/administração & dosagem , Criança , Pré-Escolar , Quimioterapia Combinada , Infecções por Helicobacter/microbiologia , Helicobacter pylori/isolamento & purificação , Humanos , Metronidazol/administração & dosagem , Compostos Organometálicos/administração & dosagem , Penicilinas/administração & dosagem , Fatores de TempoRESUMO
Endoscopic variceal ligation (EVL) is an alternative technique to endoscopic variceal sclerotherapy (EVS) to treat esophageal varices. This method consists of mechanical ligature and thrombosis of varices using elastic rubber rings. During an 11-month period, nine pediatric patients with esophageal varices secondary to portal hypertension were treated by EVL. Extrahepatic portal vein obstruction was the cause of portal hypertension in 5 patients and in 4 cases the cause was intrahepatic disease. The average age of the patients was 8 years (range: 2-15). Five patients had bled from esophageal varices previously. Two were actively bleeding at the time of the procedure. Endoligature was performed prophylactically in four patients. Fifty varix ligations were performed in 26 separate sessions. In children older than ten years, EVL was performed under intravenous sedation. Two mild rebleeds have occurred in this group and responded to repeated ligature. Varices were reduced in grade in all patients. Six patients achieved variceal eradication. Recurrence of varices was not encountered. No major complications occurred and there were no treatment failures. These early results suggest that endoscopic ligation is a safe and effective method for the control of esophageal varices in children.
Assuntos
Varizes Esofágicas e Gástricas/cirurgia , Adolescente , Criança , Pré-Escolar , Endoscopia/métodos , Varizes Esofágicas e Gástricas/etiologia , Esofagoscopia , Feminino , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/cirurgia , Humanos , Hipertensão Portal/complicações , Ligadura/métodos , MasculinoRESUMO
We reviewed retrospectively 12 patients with Wilson's disease diagnosed during a 16-year period (1974-1989). The prevalence rate was 0.6 per 100,000 individuals. Clinical onset was hepatic (50%) or neurologic (50%), but at diagnosis (6.4 years later) 67% of patients showed several clinical manifestations: hepatic, neurologic, renal and haematologic. Among the essential diagnostic indices we find false negative results for Kayser-Fleischer ring (25%), serum ceruloplasmin (8%) and total serum copper (34%). Ten patients were treated with penicillamine. This drug was effective and well tolerated, although one patient (10%) developed membranous nephritis and required to change successively to BAL and trien. In a 61 months follow-up 5 patients (42%) died from severe liver failure. Patients with poor prognosis had a diagnostic delay and a liver failure degree significantly greater than patients with good prognosis. Our results suggest the following conclusions: a) in Spain the prevalence rate of Wilson's disease is near the lower reported rate; b) the early diagnosis of Wilson's disease is rare; c) diagnosis should be made only when several essential indices are positive; d) early hepatic transplantation showed carried out in patients with acute or chronic severe liver failure.
Assuntos
Degeneração Hepatolenticular/epidemiologia , Fatores Etários , Ceruloplasmina/análise , Cobre/análise , Seguimentos , Degeneração Hepatolenticular/diagnóstico , Degeneração Hepatolenticular/tratamento farmacológico , Degeneração Hepatolenticular/mortalidade , Humanos , Penicilamina/administração & dosagem , Penicilamina/efeitos adversos , Prognóstico , Estudos Retrospectivos , Fatores Sexuais , Espanha/epidemiologiaAssuntos
Transplante de Fígado/métodos , Adulto , Criança , Humanos , Fígado/anatomia & histologia , Fígado/cirurgiaRESUMO
Fifteen orthotopic liver transplants were performed from 23 April 1986 to June 1987 in 14 patients (age range 3-56 years). In 12 transplants, extracorporeal bypass was used. The installation was effected by suprahepatic and infrahepatic cava-caval and portaportal anastomoses. Arterial anastomosis was realized after reperfusing the graft through the vena porta. In 13 transplants the donor celiac trunk was anastomosed to the receptor's right hepatic artery. In one ten year-old girl, the donor celiac trunk was anastomosed to the left hepatic artery. In one patient who underwent retransplantation for rejection, the donor organ had two separate hepatic arteries and the right and left hepatic arteries were respectively anastomosed to the right and primitive hepatic arteries of the receptor. All patients were followed up periodically by Doppler echography and trimethyl-Br IDA 99 mTc scan, which, consistently confirmed the permeability of the anastomosis and dependent vessels, and the good perfusion and function of the grafts, which were free of infarcted areas. Three patients died at 30 and 31 days and postmortem studies demonstrated vascular permeability. Angiography was performed in one patient, evidencing a good vascular caliber in the hepatic arteriography.
Assuntos
Artéria Celíaca/transplante , Artéria Hepática/cirurgia , Transplante de Fígado/métodos , Reperfusão/métodos , Adolescente , Adulto , Anastomose Cirúrgica , Compostos de Anilina , Permeabilidade Capilar/fisiologia , Artéria Celíaca/diagnóstico por imagem , Artéria Celíaca/fisiopatologia , Criança , Pré-Escolar , Feminino , Glicina , Rejeição de Enxerto , Artéria Hepática/diagnóstico por imagem , Artéria Hepática/fisiopatologia , Humanos , Iminoácidos , Fígado/irrigação sanguínea , Fígado/diagnóstico por imagem , Transplante de Fígado/mortalidade , Transplante de Fígado/fisiologia , Pessoa de Meia-Idade , Compostos de Organotecnécio , Portografia , Estudos Prospectivos , Cintilografia , Fluxo Sanguíneo Regional , Taxa de Sobrevida , UltrassonografiaRESUMO
The results of a correlation of various parameters used in the functional evaluation of 12 cases of pancreas cystic fibrosis (PCF) are reported. Three clinical scores were measured by four separate observers and average score was taken. Electrocardiogram, phono, vectorcardiogram, pH, blood gases, radiology, spirometry, erythropoietin, blood counts and echocardiogram were also recorded. Each of these were correlated. In the echocardiogram (EC), right and left systolic time intervals, wall and cavity of the right ventricle and the left ventricular function were measured. Some correlations were found to have a statistical significance: the data attained from the EC, clinical score and the spirometry. However, blood count, blood gases, erythropoietin and pH were found to have no statistical significance. The EC was found to be the most accurate and sensitive method of recognising the initial stages of pulmonary hypertension in PCF; detecting its presence at as early an age as six years (on average). These results present a strong argument for the use of the EC as a vital part of each exam of PCF.