Serum angiopoietin-2: a promising biomarker for early diabetic kidney disease in children and adolescents with type 1 diabetes.

Albuminuria has been considered the golden standard biomarker for diabetic kidney disease (DKD), but appears once significant kidney damage has already occurred. Angiopoietin-2 (Angpt-2) has been implicated in the development and progression of DKD in adults. We aimed to explore the association of serum Angpt-2 levels with DKD in children and adolescents with type 1 diabetes mellitus (T1DM) of short duration (3-5 years) and to evaluate the predictive power of serum Angpt-2 in the early detection of DKD prior to the microalbuminuric phase. The current cross-sectional study included 90 children divided into three age and sex-matched groups based on urinary albumin-to-creatinine ratio (UACR): microalbuminuric diabetic group (n = 30), non-albuminuric diabetic group (n = 30), and control group (n = 30). All participants were subjected to anthropometric measurements, serum Angpt-2 and fasting lipid profile (total cholesterol, triglycerides, LDL-C, HDL-C, and Non-HDL-C) assessment. Glomerular filtration rate was estimated based on serum creatinine (eGFR-Cr). Higher serum Angpt-2 levels were detected in both diabetic groups compared to controls and in microalbuminuric compared to non-albuminuric diabetic group. There was no detected significant difference in eGFR-Cr values across the study groups. Serum Angpt-2 was positively correlated with triglycerides, LDL, Non-HDL-C, HbA1c, and UACR, while UACR, HbA1c, and Non-HDL-C were independent predictors for serum Angpt-2. Serum Angpt-2 at level of 137.4 ng/L could discriminate between microalbuminuric and non-albuminuric diabetic groups with AUC = 0.960 and at level of 115.95 ng/L could discriminate between the non-albuminuric diabetic group and controls with AUC = 0.976.Conclusion: Serum Angpt-2 is a promising potent biomarker for the detection of early stage of DKD in childhood T1DM before albuminuria emerges. What is Known? • Urine albumin-to-creatinine ratio (UACR) and glomerular filtration rate (GFR) are the golden standard but late biomarkers for DKD. • Angiopoietin-2 has been implicated in the development and progression of DKD in adults with diabetes, but has not been explored in T1DM children with DKD. What is New? • Higher serum angiopoietin-2 was detected in diabetic groups compared to controls and in microalbuminuric compared to non-albuminuric group. • Angiopoietin-2 correlated positively with triglycerides, LDL, Non-HDL-C, HbA1c, and UACR. • Serum angiopoietin-2 is a promising early diagnostic biomarker for DKD in children with T1DM.

A Cervical Thymic Cyst in an Adult Female; A Case Report and Comprehensive Literature Review.

Introduction: Cervical thymic cyst accounts for (0.3-1) % of cervical cysts in children and are usually present during the first decade of life with few reported cases in adults. Herein, we present a 34-year-old female with a cervical thymic cyst. We conducted a review of all the previously reported cases as well. Case presentation: The patient complained of an anterolateral neck swelling that was noticed one year ago. It was a soft, fluctuant, mobile, non-tender swelling in the midline and the right side of the lower neck. Neck ultrasonography revealed a large thin-walled cyst, with no internal septa, echoes, or solid parts. Post-contrast MRI of the neck showed a well-defined, oblong-shaped, lobulated cystic lesion just beneath the strap muscle. The cyst extended caudally to the superior border of the anterior mediastinum at the level of the upper border of the manubrium sterni. The patient underwent excision of the swelling under general anesthesia via Kocher's collar neck incision. Connection with the thymus gland was detected behind the manubrium sterni which was separated. Pathological examination showed prominent thymic tissue confirming the diagnosis of a cervical thymic cyst. Conclusion: Adult cervical thymic cyst is very rare with a few cases reported in the literature. Surgical excision in symptomatic patients is the treatment of choice. Paper's main novel aspects: • A rare presentation of a cervical thymic cyst in an adult. • A comprehensive literature review including all the previously reported cases in one table.

COVID-19 diversity: A case of multisystem inflammatory syndrome in children masquerading as juvenile systemic lupus erythematosus.

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection may present with some systemic lupus erythematosus (SLE) manifestations intermingled with Kawasaki disease features. These emerging presentations were dubbed under the umbrella term 'multisystem inflammatory syndrome in children (MIS-C)'. A one and half-year-old girl, admitted to Mansoura University Children's Hospital (MUCH) with fever, bad general condition, vomiting, widespread maculopapular, vasculitic rash, hands and feet oedema, oral ulceration, arthralgia and lymphadenopathy. Moreover, bicytopenia, positive antinuclear, anti-double-stranded DNA antibodies and low C3 qualified her as a case of juvenile SLE. Despite the child received the initial therapy of immunosuppressive medication, her general condition deteriorated with fever persistence and rash exacerbation. At that time, the skin of her hands and feet started to peel. Thus, an expanded study for other alternatives was obligatory; SARS-CoV-2 infection testing revealed positive IgG serology, and retesting for lupus autoantibodies turned negative. HRCT chest showed bilateral basal consolidation with ground-glass appearance. Furthermore, Echo exhibited coronary artery dilation with thrombus inside. This evolution raised the concern for COVID-related MIS-C syndrome. This report provides a model of COVID-19 heterogeneity with protean immune-related manifestations. This case has a unique presentation that necessities its description, in order to provide a nidus for future studies in this new entity.

Sonographic evaluation of diaphragmatic thickness and excursion as a predictor for successful extubation in mechanically ventilated preterm infants.

Sonographic assessment of diaphragmatic thickness and excursion has been found to be an accurate tool in predicting successful extubation of adult patients from invasive mechanical ventilation. We aimed to evaluate the accuracy of sonographic assessment of diaphragmatic thickness and excursion in predicting successful extubation of preterm infants from invasive conventional mechanical ventilation. Preterm infants less than 32 weeks gestation who required invasive conventional mechanical ventilation were evaluated by diaphragmatic sonography within 1 h of their planned extubation. Infants were classified into successful or failed extubation groups based on their ability to stay off invasive mechanical ventilation for 72 h after extubation. Inspiratory and expiratory thickness plus excursion of the right and left hemidiaphragm as well as diaphragmatic thickening fraction (DTF) measures were compared between groups. We included 43 eligible infants, of whom 34 infants succeeded and 9 infants failed extubation. Infants in the successful extubation group had a significantly higher expiratory thickness of the right and left hemidiaphragm, excursion of the right and left hemidiaphragm, inspiratory thickness of the left hemidiaphragm, and DTF of the left hemidiaphragm compared with infants who failed extubation. The receiver-operating characteristic curves showed that excursion of the right and left hemidiaphragm has the highest significant accuracy in predicting successful extubation of preterm infants among all diaphragmatic parameters (AUC is 0.98 and 0.96, respectively; p value < 0.001 for both).Conclusion: We conclude that diaphragmatic excursion is a useful indicator for successful extubation of preterm infants from mechanical ventilation. What is Known: • Invasive mechanical ventilation induces ventilator induced diaphragmatic dysfunction (VIDD) particularly when used for long time. • Assessment of diaphragmatic dimensions and functional activity has been a valuable tool in predicting successful extubation of adult patients from invasive mechanical ventilation. What is New: • Sonographic assessment of diaphragmatic dimensions can be used to predict successful extubation of preterm infants from mechanical ventilation. • Sonographic assessment of diaphragmatic excursion shows the highest sensitivity and specificity in predicting successful extubation of preterm infants.

Accelerated Coasting Does Not Affect Oocyte Maturation.

AIMS: The study aimed to assess the efficacy of accelerating the process of coasting through adding gonadotropin releasing hormone (GnRH) antagonist (GnRH-ant) on the day of triggering of oocyte maturation without withholding the GnRH agonist (GnRHa) in women at risk for developing ovarian hyperstimulation syndrome (OHSS). METHODS: Retrospective case-control study of the outcomes of GnRHa cycles in which women were at risk to develop OHSS. Women who underwent acceleration of coasting (n = 50) were compared with a control group of women who underwent usual coasting (n = 57). RESULTS: The oocyte maturation and fertilization rates were significantly higher in the accelerated coasting group than in the usual coasting group (83.05 vs. 67.62%; p < 0.001 and 79.85 vs. 65.84%; p < 0.001, respectively). The pregnancy rates were higher in the accelerated coasting group than in the usual coasting group but without statistically significant difference. The incidences of mild, moderate, and severe OHSS were not significantly different between both groups. CONCLUSION: Acceleration of coasting in cases of OHSS through treatment with GnRH-ant after pituitary suppression with GnRHa offered a novel approach to reduce estradiol level, avoid cycle cancellation, and maintain excellent oocyte maturation rate and thus high pregnancy rate with prevention of OHSS.

Changes in Doppler parameters of portal pressure after interventional management of hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) has many options for management; some of them are complicated by development of portal hypertension (PHT). Doppler ultrasound is an effective method to diagnose and monitor PHT changes after HCC ablation procedures. The aim of this study is to investigate changes in portal pressure hemodynamics of HCC patients following treatment with different interventional strategies: radiofrequency ablation (RFA), microwave ablation (MWA), and transarterial chemoembolization (TACE). A total of 60 patients with HCC were divided into three main groups, and each group received a different type of therapy (RFA, MWA, and TACE). Full medical record and basic investigations were performed including Doppler ultrasound and upper GIT endoscopy for evaluation of PHT parameters, and then repeated after three months of ablation. RFA is associated with the increased splenic artery resistive index, while MWA has no significant impact on PHT indices. TACE has led to a marked increase in liver vascular index with significant decrease in hepatic artery resistive index and PHI after treatment. No significant changes in esophageal varices were observed by upper GIT endoscopy following all ablation methods. RFA is quite safe but associated with degree of PHT. On the contrary, TACE is associated with improved PHT parameters. MWA has no significant association to development of PHT following the technique. Doppler ultrasound could be used as a reliable and effective method of evaluation of PHT post ablation for HCC.

Sonographic Evaluation of Diaphragmatic Excursion and Thickness in Healthy Infants and Children.

OBJECTIVES: M-mode sonography is a noninvasive method for detection of diaphragmatic excursion and thickness. A few studies have assessed diaphragmatic kinetics in children with diaphragmatic paresis and paralysis, but to our knowledge, no data about normal values in pediatrics are available. The aims of this study were to determine reference values for diaphragmatic excursion and thickness, as evaluated by sonography in healthy infants and children, and identify correlations between them and anthropometric measurements, age, and sex. METHODS: A total of 400 healthy participants aged between 1 month and 16 years, divided into 4 equal groups (group 1, 1 month-2 years; group 2, 2-6 years; group 3, 6-12 years); and group 4, 12-16 years) were studied. M-mode sonography was used to measure the excursion and thickness of the right and left hemidiaphragms (using the liver and spleen as acoustic windows, respectively). RESULTS: Reference values for diaphragmatic excursion and thickness were determined in different age groups of healthy infants and children. There were no significant differences with respect to sex. Significant positive correlations were found between excursion of the right hemidiaphragm and body weight in all age groups (r = 0.52, 0.25, 0.27. and 0.20; P < .001, .013, .011, and .047 for groups 1-4, respectively). We plotted percentile curves for right diaphragmatic excursion against body weight. CONCLUSIONS: This study provides reference values for diaphragmatic excursion and thickness in healthy infants and children. Percentile curves for right diaphragmatic excursion plotted against body weight were plotted.

Pathological profile of biopsied Egyptian children with primary nephrotic syndrome: 15-year single center experience.

BACKGROUND: Primary nephrotic syndrome (PNS) in children is a common problem worldwide. The pathological pattern of PNS differs between countries. However, data on the pathological pattern of PNS in Egyptian children are scant. This study was conducted to determine indications and results of renal biopsy in Egyptian children with PNS from a single tertiary children's hospital. METHODS: Medical records of all children with PNS aged 3 months-18 years who underwent renal biopsy from 1998 to 2012 at Mansoura University Children's Hospital were retrospectively reviewed. RESULTS: A total of 741 patients (441 males, 300 females) underwent 798 biopsies of which only four specimens were insufficient. Mean age at time of biopsy was 7.4 ± 3.6 years. The main indication for biopsy was steroid resistance (n = 354, 44.4%) followed by atypical PNS (n = 234, 29.3%) of which gross hematuria was the most common cause. Minimal change disease (MCD) and its variants were the most frequent pathology (n = 431, 54.3%) irrespective of biopsy indication, and incidence of focal segmental glomerulosclerosis was observed to be increasing over the years. CONCLUSION: This is the first large study on the pathological pattern of PNS in children from Egypt, and it shows that MCD is the most frequent underlying pathology and steroid resistance is the most frequent indication for biopsy.

Primary focal segmental glomerulosclerosis in Egyptian children: a 10-year single-centre experience.

Primary focal segmental glomerulosclerosis (FSGS) in children accounts for 7-20% of all cases of idiopathic nephrotic syndrome (NS). To evaluate the clinical course of children with primary FSGS, the records of 72 patients with biopsy-proven FSGS admitted between 1995 and 2008 were retrospectively analysed. Forty-eight patients were male (66.7%). The mean age at presentation was 76.5 +/- 54 (range 12-192) months. The mean duration of follow-up was 76.3 +/- 42 (range 9-156) months. Seventeen patients (23.6%) presented with gross haematuria at initial presentation, 15 (20.8%) presented with hypertension and 10 patients (14%) presented with chronic renal insufficiency (CRI). The initial response to oral prednisolone was steroid resistance in 63 patients (87.5%) and steroid dependence in 4 patients (5%), while 5 patients (6.9%) were biopsied from the start because of atypical presentation. According to pathological classification, there were the tip variant (2%), collapsing variant (6%), perihilar variant (7%) and NOS (not otherwise specified; 85%). At the last clinical visit, 12 patients (16.7%) were in complete remission and 11 (15.3%) had progressed to CRI. Renal survival rates at 5 and 10 years were 93% and 68%, respectively. In conclusion, in this study we had a low percentage of FSGS, and fewer patients presenting with gross haematuria and hypertension compared with previous reports. In addition, the short-term overall renal survival seems to be better in our cohort.

Modified Sofield-Millar operation: less invasive surgery of lower limbs in osteogenesis imperfecta.

We present the results of intramedullary rodding of long bones of the lower limbs in children with osteogenesis imperfecta using a modified Sofield-Millar operation. Fourteen patients (mean age at primary operation was 5 years 11 months) were treated with a modified Sofield-Millar operation which allows minimal bone exposure, preservation of the periosteum and keeping the number of osteotomies to the minimum. Union was achieved in all cases within 7 weeks. Of the 14 patients (29 bones) treated with nonelongating rods, rod revisions were needed in 13 patients (26 bones). We found no statistically significant difference between the width of the bone immediately postoperatively and at the final follow-up. The walking ability was improved in four patients. Advantages of less invasive surgery in osteogenesis imperfecta are rapid bone union, no bone atrophy or nonunion, better postoperative mobility and small scars.