Treatment of Kawasaki disease with a moderate dose (1 g/kg) of intravenous immunoglobulin.

BACKGROUND: Kawasaki disease is an acute febrile illness recognized most often in young children. Coronary abnormality is the most serious complication preventable with intravenous immunoglobulin (IVIG) administration. Various treatment regimens of IVIG have been reported. OBJECTIVE: To determine initial treatment failure and prevalence of coronary artery abnormality (CAA) in Kawasaki disease (KD) treated with a moderate dose (1 g/kg) of intravenous immunoglobulin (IVIG). METHOD: All patients with a diagnosis of KD who had initial treatment with 1 g/kg of IVIG at Ramathibodi Hospital between 1994 and 1998 were reviewed retrospectively. RESULTS: Thirty-one of 41(76%) patients responded completely to a single treatment with a moderate dose of IVIG (group A). The second dose of 1 g/kg of IVIG was required in 7 patients (17%) due to persistent fever more than 48 hours after the initial treatment (group B), and 3 patients (7%) required 3 doses of 1 g/kg of IVIG due to persistent fever after the second dose (group C). During the convalescent phase, there were 19 per cent, 29 per cent and 100 per cent of the patients in group A, B and C, respectively who developed CAA with an overall rate of 27 per cent. After 1-year follow-up, the prevalence of CAA had decreased to 3 per cent, 0 per cent and 67 per cent in the according groups with overall rate of 9.6 per cent. Only 1 patient in group C developed a giant aneurysm of the right coronary artery. CONCLUSION: The efficacy of a moderate dose (1 g/kg) of IVIG in preventing CAA is lower than that of the high dose regimen (2 g/kg) reported previously. Short duration of fever before starting IVIG and low hemoglobin level may be the risk factors of unresponsiveness to moderate-dose IVIG.

Oral ibuprofen and indomethacin for treatment of patent ductus arteriosus in premature infants: a randomized trial at Ramathibodi Hospital.

BACKGROUND: Ibuprofen given intravenously to premature newborn infants is a proven treatment for patent ductus arteriosus (PDA). The efficacy of ibuprofen is comparable to indomethacin in many clinical trials with fewer renal side effects. However, the intravenous form of ibuprofen is not available in Thailand, whereas, the oral suspension form is widely used for antipyretic treatment in children. Therefore, the authors investigated the possibilities of using oral ibuprofen for the treatment of PDA in premature newborn infants. OBJECTIVE: To assess whether oral ibuprofen at 10 mg/kg/dose daily for 3 days was as effective as indomethacin to treat symptomatic PDA in premature infants and to compare the side effects of oral ibuprofen to indomethacin. SUBJECTS AND METHOD: Eighteen premature infants with gestational ages less than 34 weeks born at Ramathibodi Hospital who developed symptomatic PDA were randomly assigned to receive three doses of either indomethacin (oral or intravenous administration 0.2 mg/kg/dose for three doses given at 12 hourly intervals or oral ibuprofen (10 mg/kg/dose for three doses given at 24 hourly intervals). The rates of ductal closure, infants' clinical courses, side effects and complications were recorded. RESULTS: Birth weight, gestational age, gender, age onset and number of infants who had respiratory distress syndrome were similar in both groups, PDA was closed in 7 of 9 infants given ibuprofen (78%) and in 8 of 9 infants given indomethacin (89%) (p > 0.05). The mean plasma concentration of ibuprofen was 28.05 microg/ml at 1 hour after the third dose. Neonates in the ibuprofen group had more urine output. However, the increment of serum BUN and creatinine were not significantly different in both groups. There were no significant differences in duration of ventilator support as well as number of patients with bronchopulmonary dysplasia, intraventricular hemorrhage, necrotizing enterocolitis and death in both groups. CONCLUSION: Oral ibuprofen therapy is as effective as indomethacin for the treatment of PDA in premature infants and seems to have fewer renal side effects.

The right and left ventricular function after surgical correction with pericardial monocusp in tetralogy of fallot: mid-term result.

BACKGROUND: Surgical repair of tetralogy of Fallot (TOF) with reconstruction of the right ventricular (RV) outflow tract invariably results in pulmonary regurgitation (PR). Chronic PR has been associated with RV dysfunction and ventricular arrhythmia. Pericardial monocusp has recently been used at Ramathibodi Hospital to preserve pulmonary valve function. OBJECTIVES: First, to study the competency of the pericardial monocusp, one-year after correction. Second, to assess the right and left ventricular (LV) functions after surgery. Third, to assess correlation between severity of PR and the characters of electrocardiography (ECG) and chest X-ray (CXR) after correction. METHOD: A cross-sectional study was conducted in patients who, had undergone total correction for TOF at least one year ago. The past medical history was retrospectively reviewed from the medical records. The patients who underwent surgical correction with and without pericardial monocusp were recruited into group I and group II, respectively. The clinical symptoms, QRS duration from ECG, and cardio-thoracic (CT) ratio from CXR were analyzed. From the echocardiographic standpoint, the LV systolic function was determined by LV fractional shortening (LVFS), whereas the RV systolic function was determined by the tricuspid annular plane systolic excursion (TAPSE). Restrictive physiology of the RV was determined by presence of antegrade flow across the pulmonary valve during diastole. RESULTS: Sixty four patients were enrolled in the study, 7 in group I and 57 in group II. The median follow-up time after the surgery was 6.5 years, which was 3 years in group I and 7 years in group II (p < 0.01). All patients in group I (100%) and 45 (80.4%) in group II had moderate or severe PR. The severity of PR, the RV and LV systolic functions were not statistically significantly different between the two groups (p > 0.01). The median of the LVFS was 32.4 per cent, and of the TAPSE was 10.5 mm. There was no restrictive physiology of the RV in all patients. There were no significant correlations between symptoms, CT-ratio, QRS duration and the severity of PR. CONCLUSIONS: The pericardial monocusp could neither reduce severity of PR nor improve right and left ventricular functions after 3 years follow-up post-operatively. However, the right and left ventricular performances in mid-term period remained insignificantly changed and severity of PR could not be predicted from symptoms and simple laboratory investigations.