Spontaneous coronary artery dissection in association with cabergoline therapy.

Spontaneous coronary artery dissection (SCAD) is a rare but increasingly recognised cause of acute coronary syndrome. While numerous risk factors are associated with SCAD, one potential cause is coronary artery vasospasm. The use of cabergoline-an ergot derivative and dopamine agonist that may induce vasospasm-has been associated with SCAD in one other case report worldwide. Here, we describe SCAD in a 37-year-old woman on long-term cabergoline therapy with no other cardiac risk factors. Cabergoline-induced SCAD should be considered in patients presenting with an acute coronary syndrome who are treated with this medication.

Renal allograft loss during transition to adult healthcare services among pediatric renal transplant patients.

BACKGROUND: Transition to adult care occurs at age 18 during a vulnerable adolescent period for pediatric renal transplant (RTx) patients. METHODS: We examined renal allograft loss and hospitalization for RTx biopsy or rejection before and after transition to adult care using clinical and administrative health records of children who underwent RTx (1992-2002) in Ontario, Canada. Life-table analyses examined event rates/100 person years according to age at first RTx. RESULTS: A total of 115 patients were included (57% men; mean age at first transplant 13.9+/-3.7 years). Allograft loss rates were similar across ages 14.0 to 23.9 years. No increase in allograft loss was observed during transition period (ages 18.0-19.9 years). Hospitalizations for RTx rejection or biopsy were much lower after age 18. CONCLUSIONS: Our findings do not support an increased risk of allograft loss after transition to adult care, although there is less hospital use for rejection or biopsy suggesting that differences exist in use of care before complete allograft loss after transition to adult care.

Screening for kidney disease in children on World Kidney Day in Jalisco, Mexico.

World Kidney Day (WKD) is intended to raise awareness and increase detection of chronic kidney disease (CKD), but most emphasis is placed on adults rather than children. We examined yield of screening for CKD and hypertension among poor children in Mexico. On WKD (2006, 2007), children (age < 18 years) without known CKD were invited to participate at two screening stations. We measured body mass index (BMI), blood pressure, and serum creatinine, and performed dipstick urinalysis. The Schwartz equation was used to estimate glomerular filtration rate (GFR; reduced GFR defined as < 60 ml/min per 1.73 m(2)). Proteinuria and hematuria were defined by a reading of >or= 1+ protein or blood on dipstick. Hypertension was defined by gender, age, and height-specific norms. In total, 240 children were screened (mean age 8.9 +/- 4.1 years; 44.2% male). Proteinuria and hematuria were detected in 38 (16.1%) and 41 (17.5%), respectively; 15% had BMI > 95th percentile for age. Reduced GFR was detected in four (1.7%) individuals. Systolic hypertension was more prevalent in younger children (age 0-8 years, 19.6%; age 9-13 years, 7.1%; age 14-17 years, 5.3%) suggesting a possible white-coat effect. Hematuria, proteinuria, hypertension and obesity were frequently detected among children in a community based screening program in Mexico. This form of screening might be useful in identifying children with CKD and hypertension in developing nations.

Incidence and risk factors for cardiovascular events and death in pediatric renal transplant patients: a single center long-term outcome study.

There are considerable mortality data associated with renal transplantation in children; however, morbidity data, especially related to CV disease, are scarce. The objectives of this study were to determine incidence of non-fatal and fatal CV events and all-cause mortality in PRTx and evaluate risk factors for these conditions. Using a population-based retrospective cohort design, 274 PRTx with or without a functioning graft was followed until death or date of last contact (median follow-up 11.9 yr). Primary outcomes (time to first fatal or non-fatal CV event and all-cause mortality after first transplant) were ascertained from chart review and linkage with administrative databases of a universal health care system. During 3073 patient-years, there were 46 deaths; 13 were because of CV disease. Twenty patients had CV events that did not result in death. Post-transplant diabetes mellitus (10.5%) was associated with increased risk of death (HR: 2.79, 95% CI: 1.04-7.44) and CV events (HR: 3.90, 95% CI: 1.31-11.59). Low estimated glomerular filtration rate at one yr post-transplant was also associated with increased risk of death. The rates of developing CV disease and dying prematurely are extraordinarily high in PRTx, underscoring the need for early and aggressive intervention to reduce the burden of suffering in this patient population.

Anemia in children with chronic kidney disease.

Anemia is a common feature of chronic kidney disease, but the management of anemia in children is complex. Erythropoietin and supplemental iron are used to maintain hemoglobin levels. The National Kidney Foundation-Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) clinical practice guidelines for the management of anemia specifically in children were recently published. Pediatric nephrologists are encouraged to use current clinical practice guidelines and best evidence in conjunction with their clinical experience to optimally manage patients with anemia.

Ambulatory blood pressure monitoring: mean blood pressure and blood pressure load.

Ambulatory blood pressure monitoring (ABPM) is commonly used to diagnose pediatric hypertension. Using ABPM, hypertension is usually defined as a mean BP greater than the 95th percentile for height. A BP load >30% (% of BP readings greater than the 95th percentile) is also used for the diagnosis of hypertension. The objective of this study was to determine the agreement between mean BP greater than the 95th percentile and 30% BP load for the diagnosis of hypertension using ABPM. All ABPM records (n =1,009) of patients referred for hypertension to a pediatric center were retrieved. Scans were excluded if: age was >19 and height <115 cm or >185 cm. Mean BP and BP loads were calculated for 728 scans. Agreement between mean BP greater than the 95th percentile for height and various BP loads were calculated using the kappa coefficient. The kappa coefficient of agreement between mean BP greater than the 95th percentile and 30% BP load was 0.56 and 0.57 for daytime systolic and diastolic BP, respectively. The agreement between mean night-time BP greater than the 95th percentile and 30% BP load was 0.70 and 0.66 for systolic and diastolic BP, respectively. Agreement between mean BP greater than the 95th percentile and 30% BP load is only moderate to good. Maximum agreement between mean BP greater than the 95th percentile and BP load is achieved at 50% BP load.

Family violence: tools for the orthopaedic surgeon.

Family violence, in the form of child abuse, adult domestic violence, and elder abuse, is a major public health problem in the United States. It leads to physical and psychological disability, loss of productivity, and even death. It can perpetuate itself through successive generations and contributes to the escalating costs of health care in this country. Family violence affects a significant proportion of the US population either as direct victims or as witnesses of abuse. As a result, orthopaedic surgeons are undoubtedly treating family violence victims, knowingly or unknowingly in their practices. Therefore, it is important that orthopaedic surgeons understand that victims of family violence often present for orthopaedic care in both emergency department and office or clinic settings. It is equally important that orthopaedic surgeons acquire the skills that are needed for the appropriate evaluation, diagnosis, treatment, and referral of such victims.