[Enteral nutrition in pediatrics].
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Adult↗
Biomedical subjects
J H Vargas
Publications and source records attributed to J H Vargas.
OKT3 treatment of steroid-resistant rejection in pediatric liver transplant recipients.
Of a total of 187 consecutive liver grafts in 149 pediatric recipients, 59 episodes of steroid-resistant, biopsy-proven rejection (32% of grafts) were treated with OKT3 monoclonal antibody. After 59 OKT3-treated episodes, liver function at the end of treatment was normal in 40%, improved in 35%, and unchanged in 24%. Of 21 partial responses, 12 episodes eventually resolved to yield an overall complete response rate of 59%. CD3-positive T-cells greater than 5% occurred during 61% of OKT3-treated rejection episodes and was associated with impaired efficacy of OKT3 (30% complete response rate). Six grafts were re-treated with OKT3 for rejection and in all CD3-positive T-cells could not be maintained less than 5%. Of the six grafts requiring repeat OKT3, five failed-retreatment and required retransplantation. OKT3 antibodies of low titer were found prior to a second use of OKT3 in 65% of episodes. Patients treated with OKT3 after failing more than two preceding steroid courses had a significantly increased chance of graft loss (57%; p = 0.01). We conclude that this group of pediatric patients appeared less responsive to OKT3 compared to other series combining pediatric and adult recipients, possibly due to a more vigorous immune response in the child.
Antibodies↗
Serum lipid abnormalities in pediatric liver transplant patients.
UNLABELLED: Little is known about serum lipid abnormalities in pediatric liver transplant recipients. We performed a longitudinal cohort review of 102 outpatient pediatric liver recipients surviving greater than 6 months and immunosuppressed with cyclosporine and prednisone (+/- azathioprine). The median age was 6 years, median months posttransplant 25, and male-to-female ratio 1:1.5. The average cholesterol (mean of individual means) was 177 +/- 45 mg/dl and average triglyceride level 158 +/- 71 mg/dl. The mean percent of cholesterol levels greater than 170 mg/dl and triglyceride levels greater than 140 mg/dl was 47% and 50%, respectively. Age, obesity, sex, and family history of risk factors had no significant effect on cholesterol or triglyceride levels. Bivariate regression analysis showed no meaningful association between cholesterol or triglyceride levels and cyclosporine levels, cyclosporine dose, prednisone dose, or diastolic blood pressure. Triglyceride and cholesterol neither increased nor decreased with time posttransplant. The rate of change of triglyceride or cholesterol could not be predicted by the rate of change of cyclosporine levels (or dose), or prednisone dose. We found no evidence that rises or falls in cholesterol or triglyceride levels coincided with rises or falls in either cyclosporine level or prednisone dose. Cholestasis was significantly associated with increased cholesterol and triglyceride levels (P = 0.05). A multivariate analysis was unable to predict cholesterol or triglyceride levels from three predictors: cyclosporine level, prednisone dose, and liver function. The mean dietary intake of fat and cholesterol was above RDA and exercise patterns were suboptimal in school-aged children. CONCLUSIONS: 50% of children had a mean cholesterol greater than 75th percentile (170 mg/dl); 20% were above the 95th percentile; 56% had a mean triglyceride level greater than 140 mg/dl. By these criteria the majority of pediatric liver transplant patients have lipid abnormalities that may predispose them to atherosclerosis in later life.
Adolescent↗
Metabolic bone disease of total parenteral nutrition: course after changing from casein to amino acids in parenteral solutions with reduced aluminum content.
Bone disease with total parenteral nutrition (TPN) has been attributed to aluminum loading or vitamin D therapy. We studied 17 patients who first received TPN containing casein hydrolysate with high Al and ergocalciferol (25 micrograms/d) for 6-72 mo followed by TPN containing amino acids with reduced Al and ergocalciferol (5 micrograms/d) for 9-58 mo. We also did a cross-sectional study of 22 patients receiving casein and ergocalciferol (25 micrograms/d) compared with 46 patients receiving amino acids and ergocalciferol (5 micrograms/d) for 6-58 mo. Bone formation was higher and osteoid area, bone-surface stainable Al and total bone Al were lower with amino acid TPN than with casein TPN. Bone formation varied inversely with both plasma Al and bone-surface Al, suggesting that plasma or bone-surface Al, acquired during TPN, can reduce bone formation and lead to patchy osteomalacia. Serum levels of iPTH and 1,25-dihydroxyvitamin D were higher with amino acid TPN.
Aluminum↗
The importance of percutaneous liver biopsy in the management of the liver transplant recipient.
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Biopsy, Needle↗
A prospective study on the use of monoclonal anti-T3-cell antibody (OKT3) to treat steroid-resistant liver transplant rejection.
Conventional treatment of acute liver allograft rejection has included high doses of corticosteroids and antithymocyte globulin. Urgent retransplantation was the only option for patients who failed to respond. We report our initial experience with the use of monoclonal anti-T3-cell antibody (OKT3) in 25 patients with acute hepatic allograft rejection that was resistant to steroid and/or antithymocyte globulin therapy. Twenty-four of 25 patients had a response to OKT3, which was complete in 14 and partial in ten. With a mean follow-up of 8.2 months, allograft salvage has been 80% and patient survival 88%; two patients underwent successful retransplantation. Side effects have been mild and well tolerated. Repeated rejection has occurred in 40% of patients, but these episodes have responded to steroid therapy. We conclude that OKT3 is well tolerated and highly effective in reversing severe episodes of acute hepatic allograft rejection that is resistant to high-dose steroid therapy.
Acute Disease↗
SZ phenotype alpha-1-antitrypsin deficiency with paucity of the interlobular bile ducts.
A child is reported whose alpha-1-antitrypsin phenotype is SZ and who has chronic cholestatic liver disease that began in the neonatal period. Liver biopsy demonstrated paucity of the interlobular bile ducts, marked hepatocellular deposition in periportal areas of PAS-positive, diastase-resistant granules, and bridging portal fibrosis. The association of paucity of the interlobular bile ducts with SZ phenotype alpha-1-antitrypsin deficiency has not been reported previously.
Bile Ducts, Intrahepatic↗
Pediatric liver transplantation at UCLA.
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Arteriovenous Shunt, Surgical↗
Improved survival in very short small bowel of infancy with use of long-term parenteral nutrition.
Thirteen children with very short small bowel (less than or equal to 38 cm jejunoileum) beginning in the first month of life were enrolled in a home parenteral nutrition program between 1977 and 1984. Their survival is compared with the collective reported experience with short bowel syndrome before 1972: nine (69%) of 13 have survived, compared with seven (23%) of 30 previously. Five discontinued parenteral nutrition after periods of 4 to 32 months of therapy, and have normal growth and development. Two still receive partial (50% and 60%) parenteral nutrition after 9 and 55 months, respectively, and two still receive total parenteral nutrition after 66 and 68 months of therapy, respectively; all four infants have grown normally, and three are developmentally normal. In the combined categories of 15 to 38 cm jejunoileum without the ileocecal valve and less than 15 cm jejunoileum with and without the ileocecal valve, seven (70%) of 10 have survived, compared with none (0%) of 16 before 1972; three of these discontinued parenteral nutrition. Ultimate survival with normal growth without parenteral nutrition is now possible with as little as 11 cm jejunoileum with an intact ileocecal valve and as little as 25 cm jejunoileum without an ileocecal valve.
Age Factors↗
Reduction of acute anterior shoulder dislocations using the Milch technique: a study of ski injuries.
During the 1977-78, 1978-79, and 1979-80 ski seasons, 76 acute anterior shoulder dislocations were treated by one of three Orthopedic Surgeons at the Rutland Vermont Hospital Emergency Room: 68 (89.4%) were reduced on first attempt using the Milch technique of abduction and external rotation. Four (5.2%) required general anesthesia and four were reduced using meperidine hydrochloride (Demerol, Winthrop) and diazepam (Valium, Roche) and a traction-countertraction technique. Of the 68 shoulders reduced with the Milch technique, 47 (69.1%) required no analgesics or muscle relaxants. There were no complications attributable to the technique itself. Males were injured more frequently than females in a 4.4:1 ratio. Left shoulder injuries were as common as right. Recurrent dislocations occurred more frequently in younger individuals. Fractures of the greater tuberosity were associated injuries in five (6.6%) of all dislocations. These all occurred in individuals older than age 39 years and were coincident with primary dislocations.
Adult↗
Nutritional outcomes following pediatric intestinal transplantation.
BACKGROUND: This study sought to describe the long-term nutritional outcomes of children after intestinal transplant (SBT). METHODS: Between 1991 and March 2005, 30 children received 33 SBT at a single center. Eligibility criteria included patient and graft survival >6 months. Weight, height, albumin, prealbumin, zinc (Zn), and essential fatty acid (EFA) levels were reviewed retrospectively. RESULTS: The 19 patients who met inclusion criteria had a median age at SBT of 2.9 years. The majority of patients were male, Latino, transplanted for necrotizing enterocolitis and received combined liver-SBT. All patients were weaned off total parenteral nutrition to elemental formula at a mean of 39 days post-SBT. Seventeen of 19 patients were Zn deficient and four patients were EFA deficient post-SBT. CONCLUSIONS: Pre-SBT most subjects were significantly deficient in anthropometric and biochemical parameters. Post-SBT the mean Z score for weight and height improved significantly at year 1, then leveled off in year 2. Serum protein levels improved from pre-SBT, yet remained low-normal. Zn deficiency was seen frequently after SBT and is under investigation. Children who developed EFA deficiency were on the same formula, receiving inadequate EFA supplementation. Successful SBT was associated with growth and maintenance of serum nutritional parameters but not with significant catch-up growth.
Adolescent↗
Long-term home parenteral nutrition in pediatrics: ten years of experience in 102 patients.
One hundred two pediatric patients received all or part of their nutritional needs parenterally at home during the past decade. All received total parenteral nutrition (TPN) at night during an 8- to 12-h infusion. Patients with short bowel syndrome (33%), inflammatory bowel disease (23%), chronic intractable diarrhea (15%), chronic idiopathic intestinal pseudo-obstruction syndrome (10%), and malignancy (10%) made up the largest groups. The mean duration of parenteral support was 735 days (range, 90-3650 days); the mean number of catheters per patient was 2.1 (range, 1-8). Twenty-one patients continue to receive full or partial home TPN: four for more than 10 years and seven for more than 5 years. Fifty-one no longer require it and have had healing of mucosa or bowel adaptation. Complications related to administration of fluid and electrolytes were quite rare. Biotin deficiency was recognized once. Thirty-one have died, but only 13 deaths were related to TPN. Sepsis in nine and liver failure in two were the most common causes of death in the TPN-related group. Three of 21 still on home TPN have graduated either from high school or college. All but one of the school age children attend regular school; one attends a school for the medically disabled, another attends a school for the mentally gifted.
Adolescent↗
Corticosteroids and anterior cruciate ligament repair.
A two group (N = 62) historical comparative design was used to study patients undergoing ACL repair. This retrospective study examined the effect of corticosteroids on analgesic use during hospitalization, the length of hospitalization, and the 1st day of ambulation. Thirty-one ACL repair patients receiving a standard protocol of intravenous intraoperative and oral postoperative corticosteroids (experimental group) were compared to 31 similarly aged ACL repair patients who received similar surgical repair and medical therapy but no steroids (control group). Patients with chronic disease or current steroid use were not included in the study. Even though the experimental group had a higher incidence of coincidental injuries of the knee (meniscal and/or collateral ligament injuries), the group used 50% less analgesics while hospitalized (means = 14.19 doses) than the control group (means = 21.29). Similarly, the experimental group had a length of stay 59% less long (means = 3.61 days versus means = 5.74 days) and ambulated 38% more quickly (means = 1.93 days versus means = 2.67 days) than the control group. No differences were noted between groups in incidence of postoperative infection or problems with wound healing after a 1 year followup.
Adolescent↗
Plug into consumer thinking.
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Community Participation↗
Chronic intestinal pseudo-obstruction syndrome in pediatrics. Results of a national survey by members of the North American Society of Pediatric Gastroenterology and Nutrition.
A total of 87 cases of chronic intestinal pseudo-obstruction were identified as fitting the criteria for the syndrome. Five families, three with autosomal dominant inheritance, accounted for 15 cases. The remainder were single cases in families, indicating either autosomal recessive inheritance, spontaneous mutation, or acquired disease. Of the 87 patients, 47 were male; 19 patients were symptomatic at birth and 37 (43%) within the first month of life; 64% were diagnosed by the first year of age and the remainder were diagnosed by 18 years of age. Patients currently range in age from 3 months to 24 years. Abdominal distension in 70, vomiting in 50, and constipation in 50 of the 87 cases were the three commonest presenting symptoms. Diarrhea and failure to thrive were present in 20 cases. Urinary tract infection and failure to void were present in 10 cases. Diagnosis was established by clinical presentation, radiographic studies, and at exploratory laparotomy. Esophageal motility was abnormal in 14 patients. Anal manometric studies were done in 16 and showed normal recto-anal inhibitory reflex in all but one. Only 34 patients had biopsy studies as part of their evaluation and, of these, only 12 were full-thickness. Abnormal plexuses were found in eight and degeneration of smooth muscles in four. There was little or no benefit from the use of any medication to promote motility. One patient with intractable pseudo-obstruction benefited from a subtotal enterectomy. Of those patients not lost to follow-up, 31.4% died; 43% of these deaths occurred within the first 6 months from complications of total parenteral nutrition. One infant had a complete spontaneous remission by 1 year of age, with normalization of radiographic findings; another had partial remission by 6 months of age.
Adolescent↗