Neonatal pain response to automatic lancet versus needle heel-prick blood sampling: A prospective randomized controlled clinical trial.

BACKGROUND: Automatic lancets have been reported to be superior to manual lancets in terms of pain and treatment time. However, no studies have yet been published comparing automatic lancet and needle puncture heel-prick blood sampling. The objective of this study was to compare the pain response and efficiency between the automatic lancet and needle at the time of heel blood sampling. The design was a randomized controlled trial. The inclusion criteria for the participants were a birthweight of ≧1,500 g and a gestational age of ≧30 weeks. METHODS: The study examined a total of 105 neonates who were randomized into an automatic lancet group (n = 53) and a needle group (n = 52). The parameters measured included blood collection time, number of calf squeezes, duration of audible crying, and the Neonatal Infant Pain Scale (NIPS) score. The main outcome measure was audible crying duration. RESULTS: The duration of audible crying was significantly shorter in the automatic lancet group when compared to the needle group (median 3 s, interquartile range (IQR) 0-33 s vs median 39 s, IQR 5-91.5 s, P = 0.0023). The NIPS score at the time of puncture was significantly lower in the automatic lancet group than in the needle group (median 1, IQR 0-5 vs median 5, IQR 3-6, P = 0.0060). There was no significant difference in the blood collection time and the number of calf squeezes between the two groups. The automatic lancet was found to be less painful than the needle puncture in neonatal heel-prick blood sampling with no significant difference in blood sampling time. CONCLUSION: The automatic lancet was found to be less painful than the needle puncture in neonatal heel-prick blood sampling with no significant difference in blood sampling time.

The true distribution volume and bioavailability of mizoribine in children with chronic kidney disease.

BACKGROUND: Mizoribine (MZR) is used kidney transplant and various kidney diseases. However, few studies reported the association between pharmacokinetics and pharmacodynamics. The Pharmacokinetics Study Group for Pediatric Kidney Disease (PSPKD) used population pharmacokinetics (PPK) analysis and Bayesian analysis to investigate the usefulness of MZR. In this study, the fact that almost all MZR are excreted unchanged in urine was used to calculate its bioavailability (F) and true distribution volume (V d), and analyzed these correlation with age. METHODS: Ishida et al. reported a PPK analysis by the PSPKD. In the present study, 71 samples extracted from their study population of 105 pediatric chronic kidney disease patients aged between 1 and 20 years were investigated. The bioavailability was calculated by measuring total excreted MZR in 24 h urine samples, and this was compared to the oral dosage. The apparent distribution volume (V d/F) obtained from Bayesian analysis was then used to calculate true distribution volume (V d), and the correlation of each parameter with age was investigated. RESULTS: The median dose of MZR per weight was 5.17 mg/kg/day. Median bioavailability was 32.02%. Median V d per weight was 0.46 L/kg. There was a significant, weakly positive correlation between bioavailability and age (p = 0.026). There was also a significant, weakly negative correlation between V d per weight and age (p = 0.003). CONCLUSION: Bioavailability and V d per weight tended to decrease depending on age. The younger patient required larger dose required to obtain the maximum effect from MZR, and this is important for immunosuppressive therapy.

Ultrasonography of the internal carotid artery during therapeutic hypothermia.

The purpose of this study was to determine the accuracy of mean blood flow velocity (mean V) in the internal carotid artery (ICA) for prediction of outcome in infants with hypoxic-ischemic encephalopathy (HIE) exposed to therapeutic hypothermia (TH). Five newborns with HIE who met the criteria for TH were enrolled. Ultrasonography of the right and left ICA was performed before, during, and after TH. Mean V of the sampling point in each ICA was measured. Mean V was suppressed during TH and increased after rewarming in four infants with normal neurological development. In one infant with neurological disability, however, mean V increased during TH and decreased after therapy. In conclusion, cervical ultrasonography for ICA in infants during TH may be useful for the prediction of neurodevelopmental outcome.

Age-Adjusted Glycated Albumin at Diagnosis is more Correlated with the Product of Age and Plasma Glucose than Plasma Glucose Alone in Patients with Neonatal Diabetes Mellitus.

BACKGROUND: We previously showed that glycated albumin (GA) is a useful glycemic control indicator in patients with neonatal diabetes mellitus (NDM), and that age-adjusted GA (Aa-GA) can reflect more accurately glycemic control status. Here, we investigated whether the age at diagnosis influences Aa-GA at diagnosis of NDM. METHODS: Eight patients with NDM whose GA was measured at diagnosis (age at diagnosis: 39 ± 18 days; GA: 31.3 ± 7.6%; Aa-GA: 47.1 ± 10.3%; plasma glucose: 525 ± 194 mg/dl) were included. Aa-GA was calculated as follows: Aa-GA = GA × 14.0/[1.77 × log-age (days) + 6.65]. Correlations of GA or Aa-GA at diagnosis with its logarithmically transformed age in days (log-age), plasma glucose, and their product were investigated. RESULTS: GA at diagnosis was not significantly correlated with log-age or plasma glucose. On the other hand, Aa-GA at diagnosis was significantly positively correlated with plasma glucose (R = 0.75, P = 0.031) and was more strongly positively correlated with the product of plasma glucose and log-age (R = 0.82, P = 0.012) although it was not correlated with log-age. CONCLUSION: Aa-GA at diagnosis is influenced by both age in days and plasma glucose. This finding is likely to show the aspect that age in days is almost equal to diabetes duration because glycemic control indicators including GA reflect the weighted mean of plasma glucose.

Population pharmacokinetics of mizoribine in pediatric patients with kidney disease.

BACKGROUND: The present study aimed to obtain information enabling optimisation of the clinical effect of mizoribine (MZR) in pediatric patients with kidney disease. METHODS: A total of 105 pediatric patients with kidney disease treated at our institutions were enrolled. Kidney transplant patients were excluded. Population pharmacokinetic analysis of MZR was performed based on serum concentration data. Area under the curve from time zero to infinity (AUC∞) and maximal concentration (C max) were calculated by Bayesian analysis. RESULTS: In children, the appearance of MZR in the blood tended to be slower and the subsequent rise in blood concentration tended to be more sluggish, compared to healthy adults. Apparent volume of distribution and oral clearance were also higher in children compared to adults. A significant positive correlation was observed between patient age and AUC∞. There were significant differences of AUC∞ and C max by age group. No relationship was observed between the administration method of MZR and serum concentration. CONCLUSION: The pharmacokinetics of MZR was different in children compared to adults. To obtain the expected clinical efficacy, the regular MZR dosage schedule (2-3 mg/kg/day) might be insufficient for pediatric patients. In particular, younger patients might require a higher dosage of MZR per unit body weight.

Novel DCX mutation-caused lissencephaly in a boy and very mild heterotopia in his mother.

We describe a novel mutation in DCX in a family in which a proband boy had classical lissencephaly and his mother had extremely mild subcortical band heterotopia. No factors that would make the mother's symptoms milder, such as somatic mosaicism or skewed X chromosome inactivation, were observed. From this family, we conclude that a DCX mutation causes a pleiotropic phenotype in the female even if X chromosome inactivation pattern is not skewed, and the novel missense mutation in DCX produced relatively mild dysfunction of the doublecortin protein.

A hospital-acquired outbreak of catheter-related nontuberculous mycobacterial infection in children on peritoneal dialysis.

Catheter-related nontuberculous mycobacterial infection in children with chronic renal failure on peritoneal dialysis (PD) is rare. However, there have been five such infections in infants among PD patients at our center. Although the patients were treated with antibiotics to which the organisms showed in vitro sensitivity, they were clinically drug resistant. Hence, all PD catheters needed to be removed. Thereafter, following hemodialysis treatment for approximately 1 month, the PD catheters were replaced, with no recurrence of infection. On investigation of the infection route, it was found that these bacteria had colonized around a shower head in one of the bathrooms. These findings suggest that, in cases where hot water systems at hospitals are considered at a high risk, frequent sterilization is needed, especially around the shower heads. It is also necessary to reconsider current standard practices in the management of catheter exit sites, especially if the national incidence of infection increases.

X-linked Alport syndrome caused by splicing mutations in COL4A5.

BACKGROUND AND OBJECTIVES: X-linked Alport syndrome is caused by mutations in the COL4A5 gene. Although many COL4A5 mutations have been detected, the mutation detection rate has been unsatisfactory. Some men with X-linked Alport syndrome show a relatively mild phenotype, but molecular basis investigations have rarely been conducted to clarify the underlying mechanism. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: In total, 152 patients with X-linked Alport syndrome who were suspected of having Alport syndrome through clinical and pathologic investigations and referred to the hospital for mutational analysis between January of 2006 and January of 2013 were genetically diagnosed. Among those patients, 22 patients had suspected splice site mutations. Transcripts are routinely examined when suspected splice site mutations for abnormal transcripts are detected; 11 of them showed expected exon skipping, but others showed aberrant splicing patterns. The mutation detection strategy had two steps: (1) genomic DNA analysis using PCR and direct sequencing and (2) mRNA analysis using RT-PCR to detect RNA processing abnormalities. RESULTS: Six splicing consensus site mutations resulting in aberrant splicing patterns, one exonic mutation leading to exon skipping, and four deep intronic mutations producing cryptic splice site activation were identified. Interestingly, one case produced a cryptic splice site with a single nucleotide substitution in the deep intron that led to intronic exonization containing a stop codon; however, the patient showed a clearly milder phenotype for X-linked Alport syndrome in men with a truncating mutation. mRNA extracted from the kidney showed both normal and abnormal transcripts, with the normal transcript resulting in the milder phenotype. This novel mechanism leads to mild clinical characteristics. CONCLUSIONS: This report highlights the importance of analyzing transcripts to enhance the mutation detection rate and provides insight into genotype-phenotype correlations. This approach can clarify the cause of atypically mild phenotypes in X-linked Alport syndrome.

A complement factor B mutation in a large kindred with atypical hemolytic uremic syndrome.

PURPOSE: Gain-of-function mutations in complement factor B (CFB) were recently identified in patients with atypical hemolytic uremic syndrome (aHUS), but are extremely rare. Our purpose is to describe a large kindred with aHUS associated with a CFB mutation and to further understand CFB-mutated aHUS patients. METHODS AND RESULTS: We report a large kindred in which 3 members had aHUS. This kindred revealed that 9 of 12 members, including 2 affected patients, had persistent activation of the alternative pathway with low complement component 3 and that those 9 members showed a CFB mutation (c.1050G > C, p.Lys350Asn) in exon 8. This missense mutation was heterozygous in 8 of them and homozygous in only one. From structural studies, this mutation is shown to be located in close proximity to the Mg2-binding site within a von Willebrand factor type A domain of CFB, resulting in a gain-of-function effect of CFB and predisposition to aHUS. At present, 2 of the 3 members with aHUS have maintained normal renal function for a long-term period. CONCLUSIONS: This kindred illustrates that a CFB mutation (c.1050G > C, p.Lys350Asn) can result in aHUS. In the future, phenotype-genotype correlations and outcome in CFB-mutated aHUS patients need to be further investigated by accumulation of a number of cases.

Age effect on whole blood cyclosporine concentrations following oral administration in children with nephrotic syndrome.

The aim of this study was to investigate age-related pharmacokinetic differences of cyclosporine (CyA) in children with nephrotic syndrome. Whole blood concentrations of CyA were monitored for a total of 96 times in 36 cases. The 25 male and 11 female patients ranged in age from 1.9 to 19.7 years with a mean age of 9.1 years. Renal biopsy showed minimal change in 33 patients and focal segmental glomerulosclerosis in three patients. CyA was orally administered in two divided doses just before meals. The doses of CyA administered were adjusted such that the target value for blood concentration at 2 h post-dose (C2) was 400-450 ng/ml. The 96 subjects were divided into three groups according to age: group I, 1-5 years (n = 30); group II, 6-10 years (n = 34); and group III, ≥ 11 years (n = 32). In all subjects, peak levels (Cmax) of CyA were reached at C1 or C2. There was no significant difference between the groups for C2, area under the whole blood concentration-time curve up to 4 h post-dose (AUC0-4), and Cmax. The mean CyA doses of groups I, II, and III were 4.8 ± 1.0 mg/kg/day, 3.8 ± 0.9 mg/kg/day, and 3.0 ± 0.6 mg/kg/day, respectively, and there were significant differences between every two groups. In addition, the dose-normalized Cmax (Cmax/dose) and AUC0-4 (AUC0-4/dose) values were significantly lower in the younger group than in the older group. These findings suggested that in children, when the same concentration is targeted, the required CyA dose would vary according to age but would be significantly higher for the younger children.

Measurements of serum cystatin C concentrations underestimate renal dysfunction in pediatric patients with chronic kidney disease.

BACKGROUND: In our clinical experience, cystatin C (CysC) concentrations are not as high as expected in patients with chronic kidney disease (CKD) and high-stage renal dysfunction. We therefore investigated whether measurements of serum CysC result in an underestimation of renal dysfunction in pediatric patients with CKD. METHODS: Glomerular filtration rate (GFR) was estimated from serum creatinine (Cr) concentration, using the equation Cr-GFR (%) = [0.30 × body length (m)/serum Cr] × 100; and from serum CysC concentration, using the equation Cys-GFR (%) = (0.70/serum CysC) × 100. We investigated the relationship between GFR estimated by these 2 equations. Patients aged 2-12 years were assorted into 5 groups, based on GFR-Cr categories of <12.5, ≥12.5 to <25, ≥25 to <50, ≥50 to <75, and ≥75%, and GFR-CysC/GFR-Cr ratios were compared in these 5 groups. RESULTS: The median GFR-CysC/GFR-Cr ratio in groups of patients with GFR-Cr of <12.5, ≥12.5 to <25, ≥25 to <50, ≥50 to <75, and ≥75% were 2.28, 1.48, 1.22, 1.18 and 0.98, respectively, with statistically significant differences between any two groups (p < 0.001). CONCLUSION: Measurements of serum CysC concentrations lead to underestimation of renal dysfunction in pediatric patients with CKD.

Evaluation of limited sampling designs to estimate maximal concentration and area under the curve of mizoribine in pediatric patients with renal disease.

The aim of this study was to evaluate limited sampling designs to estimate the maximal concentration (C(max)) and area under the curve (AUC) of mizoribine in pediatric patients with renal disease. We utilized 48 serum mizoribine concentration profiles obtained from the full (6-point) sampling pharmacokinetic test, and estimated 48 individual C(max) and AUC values accurately with Bayesian analysis using the full sampling data. We then developed limited sampling models (LSM) for C(max) and AUC using 1-4 serum mizoribine concentration data points. The C(max) and AUC estimation performance of the Bayesian and LSM analysis was fairly good in the 3-point (2, 3, and 6 hr after the dose) sampling design. In addition, the C(max) estimation performance of the Bayesian and LSM analysis deteriorated only marginally even in the 1-point (3 hr) sampling design. On the other hand, the AUC estimation performance seemed to be inadequate in the 1-point (3 hr) sampling design; however, it improved markedly in the 2-point (3 and 6 hr) sampling design. These findings suggested that the 1-point (3 hr) sampling design is promising for approximate C(max) estimation, but that the 2-point (3 and 6 hr) sampling design is preferable to estimate the AUC of mizoribine.

Reference serum cystatin C levels in Japanese children.

BACKGROUND: Single measurements of serum cystatin C (cysC) concentration have generally been used to determine glomerular filtration rate (GFR) in adults. Since GFR varies to some extent among children, we attempted to determine reference serum cysC concentrations for Japanese children. METHODS: Serum cysC concentrations were determined by a latex particle-enhanced turbidimetric immunoassay in children who did not present with kidney disease or infectious disease, and the relationship between age and serum cysC level was assessed. RESULTS: We found that reference serum cysC levels gradually decreased during the first year after birth, thereafter becoming constant. Mean serum cysC concentration in children aged 1 year (0.76 ± 0.10 mg/L) was slightly higher than in children aged ≥2 years (0.70 ± 0.09 mg/L). CONCLUSION: Our reference values will be applicable for screening renal function in Japanese children.

Reference serum creatinine levels determined by an enzymatic method in Japanese children: relationship to body length.

BACKGROUND: It is necessary to set the standard serum creatinine (Cr) values for the medical care of pediatric chronic kidney disease patients. The estimated glomerular filtration rate (eGFR, ml/min/1.73 m(2)) = kappa x body length (cm)/serum Cr value (mg/dl) determined by the Jaffe method devised by Schwartz has been used clinically. However, enzymatic methods have recently been used to measure Cr instead of the Jaffe method, making it necessary to reevaluate the coefficient kappa of the above equation. Following transformation of the above formula, the normal serum Cr level should be proportional to body length: normal serum Cr value (mg/dl) = k x body length (m). METHODS: Serum Cr values were measured by an enzymatic method in children who did not present with kidney disease or infectious disease, and the relationship between the body length and serum Cr level was determined by linear regression analysis. RESULTS: We found a regression equation capable of estimating the reference value of serum Cr from body length. In children aged 1-12 years, body length (m) x 0.30 yielded a value similar to the reference serum Cr level. CONCLUSION: There have been no previous reports of the determination of reference serum Cr levels by enzymatic methods in Japanese children. Our formula will be applicable for screening of renal function in Japanese children.