Analgesia for Pediatric Arteriovenous Fistula Cannulation in Hemodialytic Patients: A Comparison of Lidocaine Gel, Lidocaine Spray, and Needle Plate.

BACKGROUND: Children undergoing hemodialysis (HD) via arteriovenous fistula (AVF) experience approximately 300 painful punctures per year which may lead to non-compliance with HD. This study was conducted to show the effect of local anesthetics on pain perception in AVF cannulation. METHODS: This randomized clinical trial included 20 children under HD via AVF in Sheikh Children's Hospital Hemodialysis Center in February 2014. The first intervention was conducted as the baseline pain assessment (control), then every patient randomly received all three other interventions: Lidocaine gel, lidocaine spray, and needle plate, before venipuncture. Pain perception was expressed and recorded by patients using the visual analogue scale (VAS). VAS scores were compared, and a P value of <0.05 was considered significant. RESULTS: The VAS mean in lidocaine spray state, lidocaine gel state, and needle plate state was respectively 47.87, 51.31, and 49.43, which were significantly less than the control state with the VAS mean of 60.06 (lidocaine spray vs. control P value = 0.001, lidocaine gel vs. control P value = 0.001, and needle plate vs. control P value = 0.003). CONCLUSION: Our study showed that the use of needle plate, lidocaine spray, and lidocaine gel are all equally effective ways in controlling the degree of pain in AVF needling in children undergoing HD.

Effect of Low Dose Imipramine in Patients with Nocturnal Enuresis, A Randomized Clinical Trial.

INTRODUCTION: Nocturnal enuresis is a condition, which can affectthe quality of life in children. The present study was designed toinvestigate the efficacy of low-dose imipramine combined withdesmopressin on treatment of patients with primary nocturnalenuresis who were defined as desmopressin non-responders. METHODS: A randomized clinical trial was carried out on patientswith primary nocturnal enuresis. Forty children with enuresisranging from 5 to 12 years old were randomly divided into theintervention (n = 20) and control groups (n = 20). The subjects inthe intervention group were treated with desmopressin combinedwith 5 mg imipramine at bedtime, and those in the control groupwere given desmopressin alone. The patients were followed upweekly for one month. The number of wet nights was recorded. RESULTS: Two individuals in the intervention and three individualsin the control group were excluded from the study. Our findingsindicated that the age and gender showed no significant difference.Furthermore, a significant better recovery in the enuresis wasobserved in 18 of 20 patients who were treated with combinationtherapy after 1 month (P < .05). In addition, the frequency ofrecovery was significantly higher (83.3%) in the intervention group,compared with the control group (29.4%). CONCLUSION: The analysis showed that low-dose imipramine is welltolerated in clinical practice and may represent a good short-termtreatment option in combination therapy where desmopressinalone is not efficient enough.

Comparison of tacrolimus and cyclosporine for immunosuppression after renal transplantation: An updated systematic review and meta-analysis.

Kidney transplantation is usually followed by immunosuppressive therapy to prevent early rejection and prolong graft survival. The calcineurin inhibitors (CNIs) represent the most commonly used agents. However, available evidence suggests the poor outcome over the long term, maybe be due to the potential nephrotoxicity associated with CNIs. Several randomized trials have compared tacrolimus (TAC) with cyclosporine, to find the optimal agent for renal transplantation; however, studies have shown conflicting results. The aim of this study was to systematically review and update the evidence for the benefits and harm of TAC versus cyclosporine as the primary immunosuppression after renal transplantation. The study was a systematic review and meta-analysis. An electronic literature search was conducted to identify appropriated trial studies. The outcomes were presented as relative risk (RR), with 95% confidence intervals (CI). Statistical analysis used was meta-analysis. Twenty-one eligible randomized controlled trials were included in this systematic review. TAC was significantly superior to cyclosporine considering the total effect size of graft loss (RR 0.089; 95% CI0.057-0.122, P <0.001), acute rejection (RR 0.638; 95% CI 0.571-0.713, P <0.001) and hypercholeste-rolemia (RR 0.634; 95% CI, 0.539-0.746, P <0.001). On the contrary, cyclosporine seemed to be significantly superior to TAC with regard to diabetes (RR 1.891; 95% CI 1.522-2.350, P <0.001). However, no significant differences between the two CNIs were found with regard to mortality, infection, and hypertension. The review indicates that TAC is significantly superior to cyclosporine regarding graft loss, acute rejection, and hypercholesterolemia, but cyclosporine seems to be significantly superior to TAC regarding diabetes. However, further large randomized trials are suggested.

Diagnostic value of ultrasonography in spinal abnormalities among children with neurogenic bladder.

BACKGROUND: Nowadays, magnetic resonance imaging (MRI) is the gold standard for evaluation and diagnosis of spinal cord abnormalities, which are considered among the leading causes of neurogenic bladder; however, MRI is a costly imaging method and is not available at all health centers. Sporadic studies have shown the alignment of MRI with ultrasonography results in diagnosis of spinal abnormalities; although none of these studies has expressed the diagnostic value of ultrasonography. OBJECTIVE: The aim of this study was to evaluate the diagnostic value of ultrasonography in detection of spinal abnormalities in children with neurogenic bladder. METHODS: This is a cross-sectional study carried out from January 2014 to November 2015 on patients with neurogenic bladder referred to Department of Radiology, Dr. Sheikh Hospital, Mashhad University of Medical Sciences, Mashhad, Iran. All patients underwent sonography of the spinal cord and soft-tissue masses; also, a spinal MRI scan was performed. The existence of spina bifida, sacral agenesis, posterior vertebral arch defects, mass, tethered cord, myelomeningocele, lipoma and fatty infiltration, dural ectasia, hydromyelia and syringomyelia, and diastomatomyelia was recorded during each imaging scan. Chi-square and Fisher's tests were used for data analysis using SPSS 19.0 software, and the sensitivity and specificity of ultrasonography findings were calculated by MedCale 26 software. RESULTS: Forty patients with neurogenic bladder (22 males/18 females), with an average of 25.73±19.15 months, were enrolled. The most common abnormality was found in patients' MRI was tethered cord syndrome (70%). There was a significant relationship between ultrasonographic and MRI findings in spina bifida abnormalities (p=0.016), sacral agenesis (p=0.00), tethered cord (p=0.00), myelomeningocele (p=0.00), and lipoma and fatty infiltration (p=0.01). Ultrasonography had a sensitivity of 20.0%-100% and a specificity of 85.7%-100% depending on the detected type of abnormality. CONCLUSION: It seems that ultrasonography has an acceptable and desirable sensitivity and specificity in the diagnosis of most of the spinal cord abnormalities in children with a neurogenic bladder.

High doses of oral folate and sublingual vitamin B12 in dialysis patients with hyperhomocysteinemia.

INTRODUCTION: Folic acid and vitamin B12, alone or in combination have been used to reduce homocysteine (Hcy) levels in dialysis patients. OBJECTIVES: We aimed to assess the efficacy of high doses of oral folate and vitamin B12 in reducing plasma Hcy levels after a 12-week treatment. PATIENTS AND METHODS: Thirty-two dialysis patients aged 10-324 months screened for hyperhomocysteinuria. Then cases with hyperhomocysteinemia received oral folate 10 mg/day with sublingual methylcobalamin 1 mg/day for 12 weeks. In pre- and post-intervention phases plasma Hcy concentration, serum folate, and vitamin B12 levels were measured. Changes in plasma Hcy, serum folate, and vitamin B12 concentrations were analyzed by paired t tests, and P values < 0.05 were considered significant. RESULTS: Eighteen (56.2%) patients had hyperhomocysteinuria. Vitamin B12 and folate levels were normal or high in all cases. Two patients were lost due to transplant or irregular drugs consumption. Plasma Hcy levels were reduced in all, and reached normal values in 50%. A statistically significant differences between first Hcy levels with levels after intervention was found (95% CI, 5.1-8.9, P = 0.0001). CONCLUSION: Oral folate 10 mg/day in combination with sublingual vitamin B12, 1 mg/day can be considered as a favorable treatment for hyperhomocysteinemia in dialysis patients.

Absolute and Relative Carnitine Deficiency in Patients on Hemodialysis and Peritoneal Dialysis.

INTRODUCTION: Carnitine deficiency is commonly seen in dialysis patients. This study assessed the association dialysis and pediatric patients' characteristics with plasma carnitines levels. MATERIALS AND METHODS: Plasma carnitine concentrations were measured by tandem mass spectrometry in 46 children on hemodialysis or peritoneal dialysis. The total carnitine, free carnitine (FC), and L-acyl carnitine (AC) levels of 40 µmol/L and less, less than 7 µmol/L, and less than 15 µmol/L were defined low, respectively. An FC less than 20 µmol/L and an AC/FC ratio greater than 0.4 were considered as absolute and relative carnitine deficiencies. The correlation between carnitines levels and AC/FC ratio and age, duration of dialysis, characteristics of dialysis, and blood urea nitrogen and serum albumin concentrations were assessed. RESULTS: Absolute carnitine deficiency, low total carnitine, and low AC concentrations were found in 66.7%, 82.6%, and 51% of the patients, respectively. All of the patients had relative carnitine deficiency. Carnitine measurements were not significantly different between the hemodialysis and peritoneal dialysis groups. More severe relative carnitine deficiency was found in those with lower blood urea nitrogen levels and those on peritoneal dialysis. No linear correlation was found between carnitine levels and age, duration of dialysis, characteristics of dialysis, serum albumin level, or blood urea nitrogen level. CONCLUSIONS: Absolute and relative carnitine deficiencies are common among children on dialysis. Patients with lower blood urea nitrogen levels and peritoneal dialysis patients are more prone to severe relative carnitine deficiency.

Hypercalciuria following ceftriaxone a fact or myth.

INTRODUCTION: Nephrolithiasis is a common worldwide problem both in children and adults. Ceftriaxone as a widely used antibiotic can contribute to the formation of renal stones and hypercalciuria. OBJECTIVES: To find the effect of ceftriaxone, a widely used antibiotic, on urinary calcium excretion rate in children. PATIENTS AND METHODS: 84 infants and children over 3 months admitted to hospital for non-renal problems. They were all previously healthy children affected with a condition mandating hospitalisation. They were randomly divided into 2 groups; those who received ceftriaxone according to their physician decision as the case group and those who did not receive antibiotics as the control group. The patients urinary calcium excretion was determined as calcium to creatinine ratio in a random urine sample in the first and third day of their admission. All data was expressed by mean ± SD and analysed by t independent and chi-square tests by SPSS 16. P P value less than 0.05 was significant. RESULTS: Eighty-four cases were analysed. Calcium excretion in received and non-received ceftriaxone groups was 0.13 ± 0.06 and 0.14 ± 0.02 respectively at first day of admission ( P = 0.1). After 3 days, the urine calcium to creatinine ratio increased to 0.27 ± 0.2 and 0.26 ± 0.08 in received and non- received ceftriaxone groups ( P = 0.8). CONCLUSION: In children, urinary calcium excretion increases 2 times in average in a short time after admission because of gastroenteritis, and ceftriaxone is not different to other antibiotics for increase urinary calcium excretion in 3 days after admission.

Labial adhesion and bacteriuria.

OBJECTIVE: The purpose of this study is to evaluate the clinical presentation, laboratory findings, and response to treatment in girls with labial adhesion younger than 23 months. MATERIAL AND METHODS: A retrospective chart review of all girls younger than 23 months with the diagnosis of labial adhesion was referred to Dr Sheikh children's clinic in Mashhad in northeast Iran between 1998 and 2013. RESULTS: Sixty-three patients were diagnosed with labial adhesion during the review period. Most patients were diagnosed by physicians during the physical examination or during the evaluation for their voiding problems. The most prevalent symptom among patients was dysuria and restlessness while voiding. Twenty-one (33.3%) patients had a history of urinary tract infection. 17 (26.9%) patients had sterile pyuria and 69.8% showed presence of bacteria in their urine samples. CONCLUSION: Physicians may frequently encounter pre-pubertal girls whose urinalysis may show sterile pyuria or presence of bacteria with colony counts <105 in the absence of urinary tract infection symptoms. In these cases, labial adhesion should always be suspected and genital examination should be performed.

Screening for depression in hospitalized pediatric patients.

OBJECTIVE: In chronically ill children who are hospitalized, many mood changes occur. For example, in children with cancer or renal failure, prolonged hospitalization and chemotherapy can lead to depression. With the improved survival of childhood malignancies, the effect of treatment on child's psychosocial well-being becomes increasingly relevant. In this study, we examined the prevalence of depression in hospitalized children with chronic and acute conditions in Dr Sheikh Pediatrics Hospital in Mashhad. MATERIALS & METHODS: After receiving the approval from the Ethics Committee of Mashhad University of Medical Sciences, we did this cross-sectional descriptive study, from April to June 2012 in Dr Sheikh Pediatric Hospital in Mashhad. Ninety children, between 8 to 16 years, were screened for depression. The sampling method was census. Children with a history of depressive or other mental disorders were excluded. Three groups of children (children with chronic renal disease, malignancy, and acute disease) were evaluated for depression using standard Children Depression Inventory Questionnaire (CDI). Two specifically trained nurses filled out the questionnaires at patients' bedside under the supervision of a psychiatrist. Depression scores were then analyzed by SPSS software. RESULTS: Of 90 children, 43(47.7%) were male and 47(52.2%) were female. The Children's mean age was 11±2.3 years, and the mean length of hospitalization was 8±5.3 days. Depression was detected in various degrees in 63% of patients (N=57), and 36.6% of children (N=32) had no symptoms of depression. Severe depression was not seen in any of the patients with acute illness. More than half of patients with cancer and chronic kidney disease had moderate to severe depression. There was a significant statistical relationship between the duration of illness and severity of depression. There was also a significant correlation between severity of depression and frequency of hospitalization. Children who had been hospitalized more than 3 times in the previous year, experienced more severe levels of depression. We also found a significant correlation between pubertal age and severity of depression in patients with cancers and chronic renal failure. CONCLUSION: Children who are hospitalized due to chronic conditions are at a higher risk for mood disorders in comparison with the ones with acute conditions. It is therefore advisable to consider more practical plans to improve the care for hospitalized children's mental health.

Rapid Intravenous Rehydration to Correct Dehydration and Resolve Vomiting in Children with Acute Gastroenteritis.

OBJECTIVES: The objective of this study is to evaluate the effect of rapid intravenous rehydration to resolve vomiting in children with acute gastroenteritis. METHODS: This randomized control trial was conducted in the pediatric emergency department in a tertiary care center in Tabriz, North-West of Iran. The study participants' were 150 children with acute gastroenteritis and vomiting who were moderately dehydrated, had not responded to oral rehydration therapy and without any electrolyte abnormalities. 20-30 cc/kg of a crystalloid solution was given intravenously over 2 hours and the control group was admitted in the emergency department (ED) for a standard 24 hour hydration. Effectiveness of rapid intravenous rehydration in the resolution of vomiting in children with acute gastroenteritis was evaluated. RESULTS: In 63 children of the intervention group (out of 75) vomiting was resolved after rapid IV rehydration and they were discharged. Among them, 12 that did not tolerate oral fluids were admitted. In the control group, 62 patients' vomiting was resolved in the first 4 hours after admission, and there was no significant difference between the two groups regarding resolution of vomiting. CONCLUSIONS: Rapid intravenous rehydration in children with moderate dehydration and vomiting due to gastroenteritis is effective in reducing admission rates in the ED.