Strangulated small bowel obstruction in children.

BACKGROUND: Diagnosing intestinal strangulation as a complication of small bowel obstruction (SBO) remains a considerable challenge in children. We evaluated the clinicoradiological parameters for predicting the presence of a strangulated intestine. METHODS: We reviewed the medical records of 69 pediatric patients who underwent operation for acute SBO. Regression analysis was used to identify the parameters for predicting strangulated SBO. RESULTS: Of the 69 patients with SBO, 27 patients had intestinal strangulation and were awarded one point each towards the overall clinical score: intractable continuous abdominal pain, tachycardia, white blood cell count >13,600/mm3, and abdominal distention. Patients with a clinical score ≥2 combined with the presence of ascites in ultrasound (US) results or with wall thickness and reduced wall contrast enhancement in abdominal computed tomography (CT) scans showed strong evidence for intestinal strangulation. CONCLUSION: The combination of two or more clinical parameters, including intractable continuous abdominal pain, tachycardia, leukocytosis, and abdominal distention with the presence of ascites in US or wall thickness and reduced wall contrast enhancement in, is useful for the identification of strangulated SBO. THE TYPE OF STUDY AND LEVEL OF EVIDENCE: Prognosis study; Level III.

Cysteinyl leukotriene levels correlate with 8-isoprostane levels in exhaled breath condensates of atopic and healthy children.

BACKGROUND: Cysteinyl leukotrienes are important mediators of airway inflammation, whereas 8-isoprostane is a biomarker of oxidative stress. This study evaluated the distributions of cysteinyl leukotriene and 8-isoprostane concentrations in exhaled breath condensates (EBCs) of children. The relationship between cysteinyl leukotriene and 8-isoprostane concentrations in the EBCs was also evaluated. METHODS: The EBCs were collected from 34 children with allergic respiratory diseases and 24 healthy children. All recruited children underwent pulmonary function testing every season. The severity of allergic respiratory diseases and medication status were assessed every month in children with allergic respiratory diseases. RESULTS: The EBC cysteinyl leukotriene and 8-isoprostane levels were higher in children with asthma and allergic rhinitis than in those with asthma only and healthy children. In asthmatic children, cysteinyl leukotriene and 8-isoprostane levels peaked in the summer. All children showed a clear association between EBC cysteinyl leukotriene and EBC 8-isoprostane levels. CONCLUSION: The cysteinyl leukotriene and 8-isoprostane concentrations in the EBCs of children significantly varied by season. Oxidative stress correlated with airway inflammation in children.

Effect of azithromycin on natural killer cell function.

Azithromycin (AZM), a macrolide antibiotic for treating mycoplasma infections, may exhibit anti-inflammatory activity aside from its antimicrobial effect, providing additional therapeutic benefit. Natural killer (NK) cells, a first-line innate immune defense against microbial invasions, paradoxically exert a detrimental effect in protecting mycoplasma infection. Little was known regarding the effect of AZM on NK cells. In the present study, we investigated the ability of azithromycin to influence natural killer (NK) cell function with regard to activation, apoptosis and cytotoxic function. AZM had little effect on NK receptor expression and cytotoxic function of NK-92 cells. However, AZM did show a dose-dependent suppression on IL-15-induced CD69 expression of primary NK cells. AZM inhibited the cytotoxicity against K562 cells of resting and IL-15 activated primary NK cells possibly through down-regulation of perforin expression, especially on CD16(+)CD56(+) NK subsets. AZM exerted a dose-dependent inhibition of IFN-gamma and TNF-alpha production from NK-92 cells, but did not affect the cytokine production of IL-15 activated primary NK cells. Taken together, AZM down-regulates NK cytotoxicity and cytokine production and may provide therapeutic benefits aside from its antimicrobial activity.

Umbilical cord blood immunology: relevance to stem cell transplantation.

Because of its easier accessibility and less severe graft-versus-host disease, umbilical cord blood (UCB) has been increasingly used as an alternative to bone marrow for hematopoietic stem cell transplantation. Naiveté of UCB lymphocytes, however, results in delayed immune reconstitution and infection-related mortality in transplant recipients. This review updates the phenotypic and functional deficiencies of various immune cell populations in UCB compared with their adult counterparts and discusses clinical implications and possible therapeutic strategies to improve the outcome of stem cell transplantation.

Role of interleukin-15 in umbilical cord blood transplantation.

Owing to its easier accessibility and less severe graft-versus-host disease, umbilical cord blood (UCB) has been increasingly used as an alternative to bone marrow for hematopoietic stem-cell transplantation. Naiveté of UCB lymphocytes, however, results in delayed immune reconstitution and infection-related mortality in transplant recipients. This article reviews UCB immunology and addresses the potential therapeutic role of interleukin (IL)-15, a pleiotropic gamma chain signaling cytokine, in modulating immune reconstitution, graft-versus-host disease (GVHD), graft-versus-leukemia effect, and infection susceptibility during the post-UCB transplant period. Cytokine immunotherapy using IL-15 simultaneously modulates several immune compartments, thus holds promise for facilitating post-transplant recovery and augmenting antitumor effect without aggravating GVHD in the setting of UCB transplantation.

Adnexal torsion in children.

OBJECTIVES: Adnexal torsion is an acute abdominal condition often confused with other diseases in children. The objective of this study is to evaluate the diagnosis and characteristics of adnexal torsion in children. METHODS: We reviewed the medical records of all cases of children whose adnexal torsion diagnosis was proven by surgery from 1992 to 2005. Neonatal cases were excluded. RESULTS: A total of 49 cases were included in this study, with a mean age of 12.5 years. Sixteen (32.6%) cases were premenarchal girls, who were more likely to have adnexal torsion missed at first clinical diagnosis when compared with postmenarchal girls (P = 0.032). Presenting symptoms included severe abdominal pain (32%) and a history of recurrent pain of more than 2 weeks (14.2%). Abdominal gray-scale ultrasound (US) in 43 patients revealed 41 cases that were suggestive of ovarian pathology and identified 3 torsions. Seventeen patients had both US and abdominal computed tomography, but no definitive adnexal torsion was diagnosed with the combined studies. When multiple radiographic studies were used, there was a significantly longer time from studies to operation as compared with US alone. CONCLUSIONS: Ultrasound usually plays an important, but not definitive, role in diagnosis. Multiple radiographic studies with combined computed tomography and US did not provide a diagnostic advantage over US alone. Most pediatric adnexal torsion occurs in postmenarchal patients, but the potential exists for this diagnosis in premenarchal girls. Adnexal torsion should be considered in any girl with an abdominal mass and any degree of abdominal pain.

Usefulness of ultrasonography in acute appendicitis in early childhood.

OBJECTIVE: Acute appendicitis is an uncommon diagnosis in early childhood. It is frequently complicated by delays in diagnosis, perforation, and prolonged hospital stay. The aim of this study was to evaluate the usefulness of ultrasonography (US) in the management of suspected appendicitis in children younger than 3 years of age. PATIENTS AND METHODS: Seventy-one children under age 3 with acute abdomen and possible acute appendicitis, but with atypical findings, were included. All of the children underwent a US scan to rule out appendicitis. RESULTS: There were 41 positive US results for appendicitis. Three children had false-positive scan results and 2 children had false-negative results. Twenty-eight patients had ruptured appendicitis with tumor formation on US. Eighteen of the 28 patients received emergency appendectomy and the other 10 patients received initial conservative treatment with interval appendectomy. Compared with those who received emergency appendectomy, patients who received initial conservative treatment had a significantly smoother postoperative course, including shorter postoperative hospital stay and earlier postoperative oral intake. The overall sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of abdominal US to diagnose acute appendicitis in cases of atypical findings in early childhood are 95.0%, 90.3%, 92.9%, 92.6%, and 93.3%, respectively. CONCLUSIONS: US is a useful and highly accurate tool to assess acute appendicitis in early childhood. US has the potential to aid in diagnosis of early childhood appendicitis to avoid the frequent rupture with tumor formation seen at this age. Initial conservative treatment for ruptured appendicitis with tumor formation is safe and is associated with a smoother postoperative course in early childhood.

Effect of interleukin-15 on alloreactivity in umbilical cord blood.

Interleukin(IL)-15 is a promising immunotherapeutic agent for immune reconstitution following stem cell transplantation. To investigate whether IL-15 would aggravate graft-versus-host disease (GVHD) in the setting of unrelated umbilical cord blood (CB) transplantation, we examined the effect of IL-15 on activation marker expression, proliferation and cytokine production of CB in a one-way mixed lymphocyte culture (MLC) assay. We found that IL-15 differentially enhanced CD69 and CD25 expression on CB T cells following allo-stimulation. The maximum degree of allo-specific CB proliferation was achieved on Day 6. IL-15 down-regulated the CB alloreactive proliferative response on Days 4, 6, and 8, with preferentially enhanced autologous proliferation. Exogenous IL-15 further enhanced CB TNF-alpha and IL-10 production in both autologous and allogeneic MLC 6 days after allopriming. Thus, IL-15 was effective in enhancing activation marker expression and cytokine production during CB alloreactivity, but failed to enhance allospecific proliferation. Further studies would be needed to study the role of IL-15 on GVHD in the setting of CB transplantation.

Vesicoureteral reflux in hospitalized children with urinary tract infection: the clinical value of pelvic ectasia on renal ultrasound, inflammatory responses and demographic data.

BACKGROUND: The aims of this study were to determine whether renal pelvis dilation on ultrasound was reliable in predicting vesicoureteral reflux (VUR) and to assess the relationship of other clinical information of VUR in children with urinary tract infection (UTI). METHODS: We retrospectively reviewed clinical data, renal echo, and voiding cystourethrogram (VCUG) results in hospitalized children with their first episode of UTI, aged from 1 month to 5 years, during a 1-year period. RESULTS: There were 114 children with 228 kidneys eligible for the study. Unilateral pelvis size greater than 8 mm had 2.4 (p = 0.049, 95% CI: 1.0-5.9) and 3.7 (p = 0.025, 95% CI: 1.2-11.3) times greater risk for VUR and severe reflux, respectively. The sensitivity in detecting severe reflux was 27.8%, and the specificity was 90.5%. The positive and negative predictive values in suggesting severe VUR were 20.0% and 93.6%, respectively. The sum of bilateral pelvis sizes greater than 16 mm had higher risk for VUR and severe reflux (4.1 and 4.6 times) and similar specificity and negative predictive value for severe reflux. Age, gender, C-reactive protein, leukocytosis, pyuria and acute pyelonephritis did not show significant relationships to the reflux. CONCLUSIONS: Unilateral pelvis size greater than 8 mm or the sum of the bilateral pelvis sizes greater than 16 mm was associated with VUR, especially severe VUR. The possibility of severe reflux was lower than 10% when the reverse criteria were applied. However, the dilation of the renal pelvis did not predict all VUR precisely. We concluded that VCUG should still be performed in hospitalized children with UTI.

Hyper-IgM syndrome: a case report.

Hyperimmunoglobulin M syndrome is a rare primary immunodeficiency disorder. We report a case of a 6-month-old boy who suffered from developmental delays, frequent respiratory tract infection, and unusual fungal and bacterial infection. X-linked hyperimmunoglobulin M syndrome was ultimately diagnosed with decreasing immunoglobulin-G, A, and E (immunoglobulin G = 51.3 mg/dL, immunoglobulin A = 8.32 mg/dL, immunoglobulin E <17.5 mg/dL), elevating immunoglobulin M (immunoglobulin M = 140 mg/dL), and decreasing T-cell expression of the CD40 ligand over flow cytometry. Seizure episodes and hypotonia developed with greater signal intensity at the putamen in a brain magnetic resonance imaging, which is compatible with hypoxic ischemic encephalopathy. This is the youngest proven case of hyper-IgM syndrome in Taiwan ever reported.

Effect of interleukin 15 and interleukin 2 on anti-CD3-induced T-cell activation and apoptosis in children with common variable immunodeficiency.

BACKGROUND: Defective T-cell function and susceptibility to apoptosis following activation may contribute to the immunodeficiency observed in common variable immunodeficiency (CVID) patients. Interleukin (IL) 2 benefits CVID children by boosting T-cell function. OBJECTIVE: To investigate the effect of another IL-2 common gamma-chain signaling cytokine, IL-15, on T-cell activation and apoptosis of peripheral blood mononuclear cells (PBMCs) from children with CVID compared with IL-2. METHODS: Five children treated at the Chang Gung Children's Hospital, Taoyuan, Taiwan, during 1998 to 2002 who fulfilled World Health Organization criteria for CVID and 8 age-matched, healthy controls were enrolled. The PBMCs were stimulated with anti-CD3 in the presence or absence of IL-2 and IL-15 for 4 days, followed by 24-hour incubation with anti-Fas to induce apoptosis. Surface expression of CD69, CD25, and CD95 (Fas) on CD3+ T cells was evaluated by flow cytometry. The degree of apoptosis was evaluated by propidium iodide-phycoerythrin/annexin V-fluorescein isothiocyanate flow cytometric staining. RESULTS: Following anti-CD3 activation, CD69 and CD25 expression of CVID CD3+ PBMCs was enhanced to levels comparable to controls. Exogenous IL-15 resulted in further enhancement of anti-CD3-induced CD69 expression to a greater extent than that achieved with IL-2. A greater degree of apoptosis was found in CVID patients than controls following anti-CD3 stimulation (P = 0.001). IL-15 but not IL-2 further increased anti-CD3-induced apoptosis in control PBMCs (P = 0.001). In contrast, the degree of anti-CD3-induced apoptosis in CVID PBMCs was unaffected by IL-15 or IL-2. Addition of anti-Fas to cultures prestimulated with anti-CD3 further increased the apoptosis in control PBMCs but had no effect on apoptosis of CVID PBMCs. CONCLUSION: Comparable anti-CD3-induced activation and enhanced apoptosis were observed in PBMCs from children with CVID compared with controls. The degree of apoptosis in CVID PBMCs was not affected by exogenous IL-15 or anti-Fas, suggesting a preactivated status in vivo.

Improving the diagnosis of acute appendicitis in children with atypical clinical findings using the technetium-99m hexamethylpropylene amine oxime-labelled white-blood-cell abdomen scan.

BACKGROUND: Diagnosing acute appendicitis in children with equivocal signs and symptoms may be difficult. The usual approach is hospital observation and frequent re-examination. However, many surgeons are reluctant to delay surgery because of the risk of perforation and a negative laparotomy. OBJECTIVE: To assess and compare the value of the technetium-99m hexamethylpropylene amine oxime ((99m)Tc-HMPAO)-labelled white-blood-cell (WBC) abdomen scan in the diagnosis of acute appendicitis in children with atypical clinical presentation. PATIENTS AND METHODS: Fifty children with acute right lower quadrant abdominal pain and possible acute appendicitis, but atypical findings were included. After IV injection of (99m)Tc-HMPAO-labelled WBCs, serial anterior abdomen scans were obtained using a gamma camera. RESULTS: Thirty-three children underwent surgery, while 17 children were managed conservatively and were followed up for at least 1 month. Four children had false-positive results and one child had a false-negative scan result. The overall sensitivity, specificity, accuracy, positive predictive value and negative predictive value of the scan to diagnose acute appendicitis in children with atypical findings was 96.7, 80.0, 90.0, 87.8 and 94.1%, respectively. CONCLUSIONS: The (99m)Tc-HMPAO WBC abdomen scan is a potential tool for diagnosing acute appendicitis in children with atypical clinical findings. The high sensitivity and negative predictive value allows early discharge from the emergency department to avoid costly observation in hospital and potentially unnecessary surgery in those patients with negative scans.