Heparin therapy in the Chinese--lower doses are required

Warfarin requirements are lower in the Chinese, but it is not known if this applies to heparin. We investigated the optimal dose for heparin therapy in Chinese patients, and to assess relationship between i.v. heparin dosage and anticoagulation efficacy. One hundred Chinese patients requiring intravenous heparin therapy were given an initial bolus followed by continuous intravenous infusion. The main outcome measures were: (i) Efficacy of anticoagulation assessed by blood coagulation studies (APTT) compared to heparin dosage, (ii) Determinants of dosage variation-age, gender, body weight, height, indication for heparin therapy and number of medications, other disease, and serum albumin level. It was found that the mean therapeutic infusion dose requirement of heparin was 848.7 +/- 274.7 units/h, 79% required a dose of 1000 units/h or less. Heparin dose correlated negatively with age (r = -0.40; p < 0.001) and positively with weight (r = 0.44 p < 0.001) and height (r = 0.49; p < 0.001). Chinese subjects require lower heparin doses (about 800 units/h) than usually recommended for Caucasians (usual dose 1000-1500 units/h). This can be partly explained by the lower body weight in Chinese patients.     

Intra-operative radiation therapy in pediatric neuroblastoma

External beam irradiation (EBRT) has been shown to improve response rates and event-free survival in children with neuroblastoma and regional lymph node metastases. Irradiation during surgical exposure (intra-operative radiotherapy, IORT) with displacement of adjacent radiosensitive organs out of the treatment field allows for more precise delineation of the target volume and significantly reduces the amount of normal tissue exposed to irradiation. We have incorporated IORT into the treatment regimen of 24 children with neuroblastoma between the years of 1983-1991. IORT was directed to any residual tumor or the tumor bed; the median dose of radiation was 1,000 cGY, equivalent to 3,000 cGY of conventional EBRT. There were 11 males and 13 females. Two patients had stage II, 12 patients had stage III, and 10 patients had stage IV disease. Ten children received IORT for suspected recurrent or persistent neuroblastoma. Twelve patients were disease-free survivors following IORT with a median follow-up of 54 months. For those patients with stage III disease, seven children were disease-free survivors, while only three of 10 patients with stage IV disease survived (median follow-up 30 months). Disease-free Survival (DFS) correlated with the achievement of local tumor control in children with both stage III and IV neuroblastoma. There was limited morbidity and no episodes of obstructive uropathy were encountered. We conclude that IORT appears to be well tolerated and may have therapeutic benefit for a select group of patients with neuroblastoma. IORT merits future exploration by prospective study.     

Heparin induced thrombocytopenia. Experiences in 12 heart surgery patients

A heparin induced thrombocytopenia Type II (HIT) is a dangerous complication of heparin therapy. Bleeding, but above all serious thromboembolic complications, which may result in crippling disabilities or even death, can develop. Twelve heart surgery patients who were diagnosed with a HIT Type II are reported. Seven of the patients were diagnosed post operatively, the other five pre-operatively. Two of these patients underwent heart surgery with r-Hirudin (Behringwerke AG, Marburg, Germany) on cardiopulmonary bypass and two on Orgaran (AKZO Organon, the Netherlands). Of the seven post operative HIT patients, four had had a bypass operation and each had received a mitral or aortic valve replacement. Another patient had received an artificial biventricular support system (Berlin Heart) and was diagnosed with HIT Type II post operatively. Because of his special condition, this patient underwent anticoagulation with Orgaran and heart transplantation with Orgaran on a heart lung machine. Upon suspicion of HIT Type II, heparin therapy was immediately halted and an alternative treatment of Orgaran or r-Hirudin was begun. One patient encountered bleeding of a gastric ulcer on Orgaran therapy. Heart surgery patients, especially patients with an artificial support system, are potentially lethally threatened by serious thromboembolic complications accompanying HIT Type II. Therefore, these patients must be diagnosed as early as possible. Orgaran along with r-Hirudin are effective heparin substitutes in patients with HIT Type II. These medications can be widely administered to heart surgery patients pre-, intra-, and post operatively without complication.     

Topiramate use in pediatric patients

Topiramate (TPM), a new antiepileptic medication, is efficacious as adjunctive therapy in adults with partial onset seizures. Its efficacy as adjunctive therapy in children was evaluated in two randomized double-blind placebo-controlled trials involving childhood epileptic encephalopathy (the Lennox-Gastaut syndrome) and partial onset seizures. In these studies, topiramate adjunctive therapy resulted in a significant reduction in drop attacks (tonic or atonic seizures) in patients with the Lennox Gastaut syndrome and a significant reduction in partial onset seizures in children with refractory partial epilepsy. In both trials, TPM's efficacy improved as the dose escalated from the double-blind phase to the open-label portion. The minimally effective topiramate dose for adjunctive therapy in children with refractory epilepsy appears to be 6 mg/kg/day. Topiramate was well tolerated with mild or moderate side effects, predominantly related to the central nervous system. Practical tips are provided that may increase the chance that topiramate will be effective and well tolerated. The most important advice is a "start low, go slow" approach. An initial TPM dose of 0.5-1 mg/kg/day followed by weekly increments of 0.5-1 mg/kg is usually well tolerated. Based on these studies, topiramate appears to be an important addition to our pediatric AED armamentarium.     

Nutrition and shock in pediatric patients

Critically ill patients, including those in shock, often present with significant metabolic derangement in protein and energy metabolism characterized by: increased protein breakdown which is not suppressed by protein or energy intake; reprioritization of protein synthesis with increased synthesis of acute-phase proteins; decreased synthesis of structural proteins; and high protein turnover. In addition, there is also glucose and lipid intolerance. Adequate nutritional and metabolic support of the critically ill child under these conditions is a challenging endeavor. Traditionally, critically ill children have received nutritional requirements based on those of healthy children despite the fact that the critically ill population is physiologically and metabolically different. Furthermore, nutritional requirements in healthy children are largely based on limited data. With emerging knowledge of non-nutritional functions of nutrients, adequacy of nutritional support and requirements will eventually depend on the goals to be achieved: nutritional, physiologic, and/or pharmacologic.     

Glaucoma drainage implants in pediatric patients

To assess the use of drainage implants in pediatric patients with glaucoma refractory to conventional medical and surgical therapy, we retrospectively reviewed 20 consecutive eyes in children 10 years of age or younger treated with 16 Molteno (three of which were removed and replaced with second Molteno shunts) and seven Baerveldt implants. The age of the patients ranged from 1 month to 10 years (mean, 3 years). The patients had undergone a mean of two previous failed glaucoma procedures (range, one to six). The mean intraocular pressure (IOP) prior to drainage tube implantation was 37 +/- 4 mm Hg, compared with a mean of 18 +/- 6 mm Hg following surgery, with average postoperative follow up of 25 months (range, 8 to 41 months). The overall success, defined as IOP < or = 21 mm Hg without further surgical therapy, was 80%. Postoperative glaucoma medications were required in 75% of patients. There were 23 complications, one of which resulted in decreased visual acuity. These findings demonstrate that drainage tube implants can be effective in lowering IOP in uncontrolled pediatric glaucomas. Patients often require postoperative glaucoma medications and close monitoring for complications.     

Safe laparoscopic access in pediatric patients

The most serious complications of laparoscopy are attributable to gaining access to the peritoneal cavity. This has traditionally been performed with a closed technique utilizing the Verres needle and subsequently with a 5 to 10 mm trocar. The risks of blind peritoneal access are magnified in pediatric patients due to the smaller abdominal cavity and the closer proximity of the great vessels. Open techniques have been devised for adults but often require a larger incision with an undesirable cosmetic result in pediatric patients. We describe a safe, open technique for laparoscopic access to the pediatric peritoneal cavity.     

Inadvertent methamphetamine poisoning in pediatric patients

To identify pre-beta-high density lipoproteins, a rapid two-dimensional separation by electrophoresis (1 hour 30 minutes) was performed on an automated Phast System. This procedure used commercially available polyacrylamide gradient gels (4-15%) and allows sensitive and reproducible results. Pre-beta-1- and pre-beta-2-high density lipoproteins were clearly identified by this method. In addition, our procedure was successfully applied to diagnosis of a patient with familial lecithin:cholesterol acyltransferase deficiency, characterized by the absence of alpha-high density lipoproteins.     

Methotrexate therapy in refractory pediatric onset systemic lupus erythematosus

OBJECTIVE: To evaluate the efficacy, safety, and corticosteroid sparing potential of methotrexate (MTX) in patients with pediatric onset systemic lupus erythematosus (SLE). METHODS: The medical records of 11 patients with SLE with onset before age 16 years were reviewed. Details of clinical features, previous therapy, indications for MTX, efficacy, toxicity, and corticosteroid reduction during MTX therapy were recorded. RESULTS: At the start of MTX treatment, 7 patients had nephritis, 3 malar rash, 3 arthritis, 2 skin vasculitis, and 2 thrombocytopenia. All patients were given MTX (12.5-17.0 mg/m2/week) as the sole drug therapy along with prednisone. Although many patients showed initial improvement and/or were able to reduce the prednisone dose, after 7 to 23 months 8 patients had a flare of SLE requiring increased doses of prednisone, one patient had unchanged SLE activity, and 2 patients were permanently discontinued from MTX because of toxicity. Side effects were observed in 8 (73%) patients, but only 2 (18%) discontinued MTX due to toxicity. CONCLUSION: MTX given as the sole drug therapy along with prednisone did not show a major corticosteroid sparing potential in our patients with pediatric onset SLE.     

Therapists'' perceptions of pediatric occupational therapy interventions in self-care

A 1177 bp cDNA fragment encoding the human milk protein beta-casein was introduced into Solanum tuberosum cells under control of the auxin-inducible, bidirectional mannopine synthase (mas1',2') promoters using Agrobacterium tumefaciens-mediated leaf disc transformation methods. Antibiotic-resistant plants were regenerated and transformants selected based on luciferase activity carried by the expression vector containing the human beta-casein cDNA. The presence of human beta-casein cDNA in the plant genome was detected by PCR and DNA hybridization experiments. Human beta-casein mRNA was identified in leaf tissues of transgenic plants by RT-PCR analysis. Human beta-casein was identified in auxin-induced leaf and tuber tissues of transformed potato plants by immunoprecipitation and immunoblot analysis. Human beta-casein produced in transgenic plants migrated in polyacrylamide gels as a single band with an approximate molecular mass of 30 kDa. Immunoblot experiments identified approximately 0.01% of the total soluble protein of transgenic potato leaf tissue as beta-casein. The above experiments demonstrate the expression of human milk beta-casein as part of an edible food plant. These findings open the way for reconstitution of human milk in edible plants for replacement of bovine milk in baby foods for general improvement of infant nutrition, and for prevention of gastric and intestinal diseases in children.     

Fluid therapy for the pediatric surgical patient

The fluid management of the pediatric surgical patient is a crucial aspect of surgical care. This article reviews the fundamental physiology of fluid replacement in children and highlights how standard formulas for fluid therapy can be modified to account for the rapidly changing physiology of the pediatric surgical patient. Novel approaches to fluid treatment of the surgical patient with oral rehydration formulas are discussed. Finally, guidelines for specific management of common pediatric surgical diseases are presented.