Chronic kidney disease stages 3-5 in Iranian children: need for a school-based screening strategy: the CASPIAN-III study

There is scarce epidemiological data on early and asymptomatic stages of chronic kidney disease [CKD] in children, especially from developing countries. In this study, we investigated the frequency of CKD stages 3-5 among general students of Isfahan [a large province of Iran], and compared the findings with those derived from the main pediatric nephrology referral center of province. This study was performed among 712 Isfahani school students [377 boys] aged 7-18 years, as part of the baseline survey of a national surveillance system. Blood samples were analyzed for blood urea nitrogen, creatinine, and cystatin C. Glomerular filtration rate [GFR] was calculated based on two 2009 Schwartz equations [the "updated" and the "new" equations]. CKD was defined as GFR <60 ml/min/1.73 m2. Additionally, a retrospective analysis of clinical records of children with stages 3-5 CKD referred to main referral center of province from November 2001 to December 2011 was made. The mean age of students was 12.2 +/- 2.4 years. In students' screening, the frequency of CKD was 1.3% and 1.7% based on the updated Schwartz and the new Schwartz equation, respectively. The referral center survey revealed an annual incidence of 14.5 per million age-related population [pmarp], and a prevalence of 118.8 pmarp in our province. The prevalence of asymptomatic and undetected low GFR in Iranian children is higher than what is reflected from the reports of referral centers. Simple screening programs like annual urinalysis among high-risk school students should be considered

Left atrial appendage occlusion

Left atrial appendage [LAA] occlusion is a treatment strategy to prevent blood clot formation in atrial appendage. Although, LAA occlusion usually was done by catheter-based techniques, especially percutaneous trans-luminal mitral commissurotomy [PTMC], it can be done during closed and open mitral valve commissurotomy [CMVC, OMVC] and mitral valve replacement [MVR] too. Nowadays, PTMC is performed as an optimal management of severe mitral stenosis [MS] and many patients currently are treated by PTMC instead of previous surgical methods. One of the most important contraindications of PTMC is presence of clot in LAA. So, each patient who suffers of severe MS is evaluated by Trans-Esophageal Echocardiogram to rule out thrombus in LAA before PTMC. At open heart surgery, replacement of the mitral valve was performed for 49-year-old woman. Also, left atrial appendage occlusion was done during surgery. Immediately after surgery, echocardiography demonstrates an echo imitated the presence of a thrombus in left atrial appendage area, although there was not any evidence of thrombus in pre-pump TEE. We can conclude from this case report that when we suspect of thrombus of left atrial, we should obtain exact history of previous surgery of mitral valve to avoid misdiagnosis clotted LAA, instead of obliterated LAA. Consequently, it can prevent additional evaluations and treatments such as oral anticoagulation and exclusion or postponing surgeries including PTMC

Late-onset multiple sclerosis in Isfahan, Iran

Multiple sclerosis [MS] typically affects young adults; however, the first symptoms can occur after age 50 and is classified as late-onset MS [LOMS]. In this retrospective study, we extracted the records of 3522 MS patients [2716 females and 806 males] registered in the Isfahan MS Society [IMSS] from 2003 to 2010. Next, we searched for LOMS cases. We aimed to compare these cases with 1698 non-LOMS subjects also extracted from the IMSS database. We found 48 LOMS patients [28 females and 20 males], which gave a crude frequency of 1.36%. The frequency by sex of LOMS in males [2.4%] was significantly greater than in females [1.0%, P = 0.002]. The mean age at onset was 55.1 +/- 4.3 years. The female to male ratio of 1.4:1 in these patients was significantly lower than in non-LOMS subjects [3.37:1, P= 0.003]. The leading pattern of MS was relapsing-remitting [RR] in 62.5%, followed by primary progressive [PP] in 27.1%, and secondary progressive [SP] in 10.4%. Predominant presenting symptoms and signs were motor disturbances [35.4%], followed by brainstem [25%], optic neuritis [22.9%], and sensory related deficits [18.7%]. The mean progression index [PI] in LOMS patients [0.88 +/- 0.48] was significantly higher than in non-LOMS cases, 0.37 +/- 0.17 [P< 0.0001]. In comparing LOMS patients with the non-LOMS cohort, there was a higher frequency of the PP pattern and a higher PI in the LOMS group. In comparing other high-risk populations with the Isfahan cohort, LOMS formed a lower percentage of the total Isfahan MS population

Epileptic seizures in early-onset multiple sclerosis

Early-onset multiple sclerosis [EOMS] is defined as the first presentation of symptoms in childhood [before the age of 16 years]. EOMS occurs in about 0.4% to 10.5% of multiple sclerosis [MS] patients. In this retrospective population-based study we aimed to describe the clinical/paraclinical details and frequency of epileptic seizures in Iranian EOMS patients registered with the Isfahan Multiple Sclerosis Society [IMSS] from April 2003 to July 2010. EOMS cases were extracted from the Isfahan total MS cohort and included 3522 patients. A total of 117 EOMS patients [19 males and 98 females] with a mean age at onset of 14.2 +/- 2.0 years [range: 7-16 years] were extracted from our database [3.3% of the total cohort]. Of cases, ten [one male and nine females] had experienced at least two epileptic seizures, providing a crude prevalence of 8.5%. The frequency of epilepsy in EOMS patients [3.3%, 10/117] was significantly greater [P < 0.001] than that of non-EOMS cohort [2.0%, 71/3405]. Epileptic seizures occurred before MS onset in two patients, after MS onset in seven, and at MS onset in one as the presenting symptom of the disease. Our findings mostly indicate an excessive prevalence of epileptic seizures in Iranian EOMS patients [8.5%], which is higher than any other report concerning seizures or epileptic seizures in a large MS series. These findings might be supportive of increased prevalence of epileptic seizures in EOMS

25 Hydroxyvitamin D concentrations in patients with optic neuritis as a clinically isolated syndrome and healthy controls

The onset of multiple sclerosis in the majority of the cases occurs as a clinically isolated syndrome [CIS]. We sought to assess serum levels of 25-hydroxyvitamin D [25-OHD] in CIS patients and healthy controls. In this cross-sectional study 40 patients [36 women and 4 men] with CIS manifesting as a single isolated optic neuritis and 40 Age- and sex-matched healthy controls [35 women and 5 men] were enrolled between late October 2010 and early March 2011. General vitamin D deficiency was defined as serum 25-OHD levels of lower than 20 ng/ml and was classified as mild [15 < 25-OHD <20 ng/ml], moderate [8 < 25-OHD <15 ng/ml], and severe [25- OHD <8 ng/ml]. We found no difference in the median interquartile range [IQR] between CIS patients and controls [17.95 [10.40- 29.13] vs. 17.00 [12.25-31.00]; P=0.57]. However, when stratified by the levels of deficiency, among CIS patients a significantly higher proportion had severe vitamin D deficiency in comparison to healthy controls [20% vs. 2.5%; P=0.034]. Nevertheless, the frequency of general [62.5% vs. 60%, P=0.82], mild [25% vs. 30%, P=0.80], and moderate [17.5% vs. 27.5%, P=0.42] vitamin D deficiency were not different between the two groups. Our findings do not indicate any significant difference of serum 25-OHD between CIS patients and healthy controls. However, in our series severe vitamin D deficiency was more frequent among CIS patients.

Anti-aquaporin-4 IgG in patients presenting with unilateral optic neuritis: a cohort study

Optic neuritis [ON] can be the first presentation of multiple sclerosis [MS] or neuromyelitis optica [NMO]. Anti-aquaporin-4 IgG [AQP4 IgG] is a highly specific and moderately sensitive biomarker for NMO. This study was designed to assess the rate of seropositivity for AQP4 IgG, and the short-term outcome of patients presenting with single isolated ON [SION]. A cohort of 41 consecutive patients experiencing severe [< 20 / 200] SION [not fulfilling the diagnostic criteria for MS or NMO], was prospectively recruited. Blood sampling was carried out immediately after the diagnosis of ON, and AQP4 IgG was tested qualitatively, using an indirect immunofluorescence kit. After clinical and paraclinical investigations, all the patients were followed up for a short-term period of at least 18 months. The seroprevalence among the initial ON patients was 9.7% [4 / 41]. The short-term conversion rate to MS and NMO was estimated to be about 7.3 and 4.9%, respectively. The conversion rate to NMO in initially seropositive patients was greater than that for the whole cohort [2/4 [50%] vs. 2/41 [4.9%]; P = 0.035; Odds ratio: 19.5, 95% confidence interval: 1.73 to 219.50]. AQP4 IgG seropositive SION patients were more likely to develop NMO in comparison to the total SION population. Further studies, with a longer follow-up period and larger sample sizes are warranted to assess the clinical and prognostic value of assessing AQP4 IgG in SION