Croup as Unusual Presentation of Post-transplantation Lymphoproliferative Disorder after Liver Transplantation in an 18-month-old Child.

Post-transplantation lymphoproliferative disorder (PTLD) is a serious complication of solid organ transplantation that occurs due to immunosuppression and other risk factors. PTLD may present with involvement of other organs and with unusual presentation. The presentation is often extranodal (e.g., in the gastrointestinal tract, lung, or the central nervous system). Herein, we report on a 1.5-year-old girl who underwent liver transplantation almost 5 months prior to admission. She was on medications such as tacrolimus and prednisolone. Her presentation was started with symptoms of the upper respiratory infection followed by croupy cough and respiratory distress with no response to usual treatments. She had respiratory arrest during broncoscopy. Therefore, emergency tracheostomy was done. Biopsy from the paratracheal mass revealed large B cell non-Hodgkin lymphoma (PTLD, monomorphic and high grade). This case presentation shows that persistent upper airway symptoms, particularly stridor and croupy cough, in children who underwent liver transplant should be further evaluated; the physician needs to have a high degree of clinical suspicion for the diagnosis of PTLD in this situation.

Pharmacokinetic Comparison of Omeprazole Granule and Suspension Forms in Children: A Randomized, Parallel Pilot Trial.

Although, omeprazole is widely used for treatment of gastric acid-mediated disorders. However, its pharmacokinetic and chemical instability does not allow simple aqueous dosage form formulation synthesis for therapy of, especially child, these patients. The aim of this study was at first preparation of suspension dosage form omeprazole and second to compare the blood levels of 2 oral formulations/dosage forms of suspension & granule by high performance liquid chromatography (HPLC). The omeprazole suspension was prepared; in this regard omeprazole powder was added to 8.4% sodium bicarbonate to make final concentration 2 mg/ml omeprazole. After that a randomized, parallel pilot trial study was performed in 34 pediatric patients with acid peptic disorder who considered usage omeprazole. Selected patients were received suspension and granule, respectively. After oral administration, blood samples were collected and analyzed for omeprazole levels using validated HPLC method. The mean omeprazole blood concentration before usage the next dose, (trough level) were 0.12±0.08 µg/ml and 0.18±0.15 µg/ml for granule and suspension groups, respectively and mean blood level after dosing (C2 peak level) were 0.68±0.61 µg/ml and 0.86±0.76 µg/ml for granule and suspension groups, respectively. No significant changes were observed in comparison 2 dosage forms 2 h before (P=0.52) and after (P=0.56) the last dose. These results demonstrate that omeprazole suspension is a suitable substitute for granule in pediatrics.

Is Helicobacter pylori infection a risk factor for childhood periodic syndromes?

BACKGROUND AND OBJECTIVES: Helicobacter pylori (H. pylori) infection has been assumed to have roles in various extra-digestive diseases. The current study was designed to evaluate the incidence of H. pylori infection in patients with cyclic vomiting syndrome and its possible role in the etiology of this disease. DESIGN AND SETTING: In this case-control study, 120 cases with diagnoses of cyclic vomiting or abdominal migraine who were registered at the Gastroenterology Clinic at Shiraz University of Medical Sciences from 2010 to 2013 were enrolled. MATERIALS AND METHODS: Primarily information regarding the patients' diseases were collected with a data gathering sheet, and fresh morning stool samples were collected from the patients and examined for H. pylori stool antigen with the H. pylori Ag EIA test kit. The results were compared with those of healthy children from the control group. RESULTS: A total of 120 patients with cyclic vomiting (47.5%) and abdominal migraine (52.5%) with a mean age of 7.1 ± 3.4 (range 2-16 years) and a male-to-female ratio of 1.6 were included. The HPs Ag tests were positive in only 7 (5.8%) patients in our case group, and the HPs Ag tests were positive in 13 (13%) of the children in the control group; this difference was statistically insignificant. CONCLUSION: Our study did not support H. pylori infection as an etiological factor in CV or AM.

Supplemental arginine administered in ovo or in the feed reduces the susceptibility of broilers to pulmonary hypertension syndrome.

1. Two experiments were conducted to determine if in ovo and in-feed arginine (ARG) supplementation is effective in the prevention of pulmonary hypertension syndrome (PHS) in broiler chickens reared at high altitude. 2. In Experiment I, a total of 300 fertile eggs were divided into two equal groups. On d 5 of incubation, one group was injected with 0.5 ml of ARG (20 mg/ml) and the other remained untreated and served as controls. After hatching, male chicks (64 chickens per treatment) were selected and given a commercial maize-soyabean meal diet up to 48 d of age. 3. In Experiment II, a total of 128 male broiler chickens (Ross 308) were randomly assigned to two treatments, a control group that were fed on a basal diet that met ARG requirements and the second was fed on the basal diet supplemented with 1.5 g ARG per kg of diet. 4. Cumulative mortality from ascites was recorded in both experiments. Results from Experiment I indicated that in ovo injection of ARG significantly decreased ascites mortality of broilers (18.8 vs. 43.8%). Results from Experiment II showed a similar effect so that ascites mortality in the group that were given Arg supplement was significantly lower than the control (28.1 vs. 43.8%).

Mercury in the Oriental sole (Brachirus orientalis) near a chlor-alkali plant in the Persian Gulf, Iran.

Total mercury in muscle and liver of Oriental sole from the largest inlet in the Persian Gulf was evaluated. Fish were collected from three channels of Moses Inlet near a chlor-alkali plant. Ahamdi and Jafari channels were closest to this plant and Ghanam was farther away. We sampled in August 2007 and February 2008. The overall estimated marginal mean for total mercury in sole tissue was 2.4 ± 0.1 mg/kg wet weight. Mercury in fish was similar in August and February; but muscle from Ahmadi contained higher mercury in August (1 ± 0.2) than in February (0.5 ± 0.01). This trend was reversed in the liver (1.3 ± 0.2 and 3.7 ± 0.3).

Evaluation of cytomegalovirus infection after six months of liver transplantation in children in shiraz, southern iran.

BACKGROUND: Liver transplantation (LT) is a life-saving treatment for end-stage liver diseases (ESLD). Cytomegalovirus (CMV) infection is one of the important causes of morbidity after LT. OBJECTIVE: To evaluate the incidence of late-onset (after 6 months of LT) CMV infection in pediatric recipients. METHODS: A retrospective analysis was conducted to evaluate 50 pediatric patients who underwent LT for 8 years at the LT Unit of Nemazee Hospital affiliated to Shiraz University of Medical Sciences, Shiraz, Iran. We retrospectively investigated episodes of CMV infection after 6 months of LT proven by CMV antigenemia test. RESULTS: Three recipients (6%) developed late-onset CMV infection. These patients finally responded to ganciclovir. CONCLUSION: CMV infection is one of the most common post-LT viral infections that usually occurs in the first six months of LT. Our study shows that the incidence of late-onset CMV infection is relatively low, but it still remains a significant problem. Therefore, monitoring and management is crucial for improving the survival of children.

Evaluation of Candida infection after six months of transplantation in pediatric liver recipients in iran.

BACKGROUND: Liver transplantation (LT) is the standard treatment of end-stage liver diseases (ESLD). Invasive fungal infection is one of the important causes of morbidity and mortality after transplantation. OBJECTIVE: To determine the incidence of late-onset (after 6 months of LT) Candida infection in recipients. METHODS: A retrospective study was conducted to evaluate 50 pediatric patients after LT for 8 years at the LT Unit of Nemazee Hospital affiliated to Shiraz University of Medical Sciences, Shiraz, Iran. We followed the patients until 6 months post-LT for episodes of Candida infection proven by culture. RESULTS: One recipient (2%) developed late-onset esophageal candidiasis with improvement after intravenous amphotricin therapy but finally expired with a diagnosis of post-transplant lymphoproliferative disorder (PTLD). CONCLUSIONS: The incidence of late-onset Candida infection is not significant in pediatric liver recipient, but it still remains a significant problem. Control of Candida colonization would reduce the risk of invasive fungal infections and possibly more fatal complications.

Prevalence of zinc deficiency in 3-18 years old children in shiraz-iran.

BACKGROUND: Zinc is an essential trace element with a prominent role in human nutrition. Zinc deficiency has been linked to growth retardation, hypogonadism in males, and lack of sexual development in females. It ranges from 50% in sub-Saharan Africa to 5% in high income countries. The aim of this study is to evaluate the prevalence of zinc deficiency in healthy children in Shiraz, southern Iran. METHODS: In this study, 902 children aged 3-18 years old were randomly sampled for serum zinc level. Age, sex, weight, height, BMI, stunting and wasting indices were also recorded. With atomic absorption spectrophotometry method, the serum level of zinc less than 70 µg/dL was considered as deficient. RESULTS: Mean serum level of zinc was 122.3±55 µg/dL. The prevalence of zinc deficiency was 7.9%. There was no relationship among serum zinc level and age, sex, height, weight or BMI, but mild wasting (weight for age) and mild stunting (height for age) were significantly more prevalent among zinc deficient children compared to children with normal or high level of zinc. CONCLUSION: Zinc deficiency in Shiraz is not as prevalent as other areas of Iran. It was significantly more frequent among stunted and wasted (malnourished) children. Difference in soil zinc level, recent wide prescription of zinc supplements by pediatricians and especial pattern of nutrition, considered as possible factors responsible for lower prevalence of zinc deficiency in Shiraz, deserve more investigations.

Comparison of Child-Turcotte-Pugh and pediatric end-stage liver disease scoring systems to predict morbidity and mortality of children awaiting liver transplantation.

BACKGROUND: The pediatric end-stage liver disease (PELD) scoring system has been used widely for prioritizing children awaiting orthotopic liver transplantation (OLT). The aim of the present study was to compare the Child-Turcotte-Pugh scoring system with PELD to predict morbidity and mortality of children scheduled for OLT before the organ was available. MATERIALS AND METHODS: From 1999 to 2006, 83 infants and children were evaluated and scheduled for OLT. Child and PELD scores were determined according to the initial assessment at the time of listing. Outcome was examined using records and follow-up data. RESULTS: Among 83 patients, 12% were Child A; 53%, Child B; and 35%, Child C. The mean PELD score at listing was 19.8+/-12.8. Patients with Child scores A, B, and C displayed mean PELD scores of 7.1+/-4.9, 15.7+/-9.3, and 30.5+/-11.7, respectively. Child classification and scoring showed a positive correlation with the PELD score (Spearman's correlation coefficient: 0.666, P=.001). A higher PELD score was associated with greater morbidity and mortality. CONCLUSION: Child classification has several shortcomings; therefore, PELD scores appear to be the best metric to prioritize children listed for OLT.

Morbidity and mortality of children with chronic liver diseases who were listed for liver transplantation in Iran.

Liver transplantation is the treatment of choice for end-stage liver disease in children, but donor shortage is still a main problem in this age group. The aim of the present study is to evaluate the complications and mortality of liver disease in children waiting for transplantation. We analyzed medical records of 83 children aged <18 yr, who were listed for liver transplantation but the organ was not available for them between 1999 and 2006. The outcome was assessed from their records or follow-up data. Among the children (mean age, 8 +/- 5 yr; 50.5% boys) listed for liver transplantation, but the organ was not available for them, the common causes of cirrhosis were biliary atresia (27.7%) and cryptogenic (24.1%). The mean follow-up duration was 14 +/- 13.4 months (range 0.5-54 months). Sixty-seven (80.7%) patients developed one or more complications while awaiting transplantation. The most common complications were gastrointestinal bleeding (44.6%), spontaneous bacterial peritonitis (36.1%), infectious complications (28.9%), encephalopathy (24.1%), renal (18.1%), and pulmonary problems (10.8%). Fifty-one (61.4%) patients needed hospital admission because of complications and 26 (31.3%) patients died while awaiting transplantation. About two-thirds of children listed for liver transplantation needed hospital admission because of complications and one-third of them died without any liver transplantation. It seems that more split liver transplantation as well as the introduction of a live-related program in our center will provide many benefits to our children.

Chest pain in children and adolescents: epigastric tenderness as a guide to reduce unnecessary work-up.

Our objective was to evaluate and highlight the significance of epigastric tenderness in children and adolescents with chest pain. In a 26-months period, patients who were referred for pediatri cardiology evaluation at Shiraz University of Medical Sciences with chief complaint of chest pain were studied. Patients with epigastric tenderness were evaluated endoscopically by gastroenterologist. Patients who had positive findings on endoscopy were appropriately treated. Since there were no serious findings on cardiac evaluation, no other treatment was necessary. The patients were re-evaluated 4 weeks later. Response to therapy was defined as relief of the initial symptoms as well as epigastric tenderness. One hundred thirty-two patients were referred for evaluation of chest pain during this period. Epigastric tenderness was found in 44 (33.3%) of these patients and endoscopy was performed. Endoscopy showed positive findings in 41 (93.2%). Thirty (75%) of these patients had varying degrees of gastritis. Duodenitis was found in six (13.6%) and gasteroduodenitis in five (11.4%). Esophagitis, which was always associated with gastritis, was seen in five (11.4%). Only three (6.8%) had normal endoscopy. Urease test was positive in three (7.3%) of the specimens. Two of the patients did not return for follow up. From the remaining 39 patients who received gastroenterology treatment, resolution of symptoms was seen in 38 (97.4%). Careful history and physical examination must guide the assessment of children and adolescents referred for evaluation of chest pain. Epigastric tenderness must be used as a reliable sign to initiate a gastrointestinal evaluation.

Carpal tunnel syndrome: reappraisal of five clinical tests.

A combination of 5 clinical tests: Tinel (9, 10), Phalen (wrist flexion) (1, 2, 17), reverse Phalen (wrist extension) (4), carpal compression (11, 18), vibration (13, 14) was used in 74 hands with symptoms of carpal tunnel syndrome and proved by median sensory conduction velocity and distal latency across wrist and compared with 58 normal hands. Tinel test was the most specific and the least sensitive, vibration test was the most sensitive and the least specific. Carpal compression test was less sensitive and specific compared to Durkan's study. There was no correlation between Phalen time, reverse Phalen time, carpal compression time, and nerve conduction measurements. Cases with positive Tinel and vibration tests has slower sensory nerve conduction velocity (SNCV) compared to cases with negative results. Also patients with positive vibration tests had longer duration of symptoms in comparison to patients with negative test results. Up to now electrodiagnostic studies are the standard in diagnosing carpal tunnel syndrome and determining severity of median nerve involvement at wrist.

Isoprenaline induces biosynthesis of proline-rich proteins in the salivary glands of rat but not in sheep.

Long-term treatment of rats with isoprenaline resulted in induction of proline-rich proteins (PRPs) in the salivary glands, which were subsequently purified by TCA solubility and column chromatography. When rats were removed from beta-agonist regimen, then these proteins were no longer observed. Treatment of sheep with isoprenaline did not reveal the induction of PRPs.