Methods: A systematic review of the literatures on the use of palivizumab as therapy for RSV was conducted. The primary outcomes were progression from URTI to LRTI and survival rates. Secondary outcomes were adverse events due to palivizumab, serum palivizumab level, and RSV concentration in respiratory secretions.

Results: The search yielded 1 case report, 4 case series, and 2 randomized controlled trials (RCTs) with a total of 136 adults and children. The RCTs were not powered to look at clinical outcomes. By combining all reported clinical outcomes, 3 (12%) of 25 patients with URTI who were given palivizumab died of RSV and 5 of 88 patients with LRTI at the time of treatment died of RSV (6%). Palivizumab levels appeared to be adequate for at least 3 weeks of intravenous injection at 15 mg/kg. The therapy resulted in decreased RSV concentrations in tracheal secretions.

Conclusion: Larger RCTs will be required before palivizumab can be recommended as therapy for RSV in any clinical setting.

Key words: palivizumab; respiratory syncytial virus; respiratory tract infection

                    World J Pediatr 2010;6(4):296-300

Corresponding Author: H Hesham A-Kader, MD, M.Sc., Professor and Chief, Pediatric Gastroenterology and Nutrition, Department of Pediatrics, The University of Arizona, Tucson, AZ 85750, USA (Tel: (520) 626-4140; Fax: (520) 626-4141; Email: Hassan@peds.arizona.edu)

doi:10.1007/s12519-010-0231-y

Background: Foreign body ingestion is a common problem in the pediatric age group. Infants and young children explore objects by putting them in the mouth.

Data sources: We reviewed the most recent literatures regarding the incidence, clinical presentation, as well as the most recent advances in the diagnostic and therapeutic modalities of foreign body ingestion in children.

Results: In 2007 more than 125 000 foreign body ingestions in patients of 19 years old and younger were reported to American Poison Control Centers in the USA. The majority of ingested foreign bodies pass spontaneously.

Conclusions: Some foreign bodies can be harmful and require evaluation and intervention. The challenge in management is to distinguish the patients who require intervention from those who can be safely observed. In this review we suggest an algorithm for evaluation and management of children suspected to ingest a radiopaque foreign body.

Key words: bezoars; button batteries; coins; foreign body ingestion; meat impaction; narcotic packets; rectal foreign bodies

                  World J Pediatr 2010;6(4):301-310

Author Affiliations: Epidemiological and Health Statistics, Zhejiang University, Hangzhou 310058, China (Ren RX, Shen Y)Corresponding Author: Yi Shen, Epidemiological and Health Statistics, Zhejiang University, Hangzhou 310058, China (shenyi@zju.edu.cn)

Context: Low cord blood leptin concentration is implicated as a risk factor for small for gestational age (SGA) babies. However, the association of strength, consistency, independence, and confounding factors of this affliction has not been systematically examined.

Objective: To determine if there is a difference in cord blood leptin concentration between SGA and appropriate for gestational age (AGA) newborns, and to observe whether the sample origins, GA, pregnancy-induced hypertension (PIH) and congenital malformation (CM) are confounding factors of the meta-analysis.

Data sources and study selection: Relevant studies published between 1996 and 2007 were identified through literature searches using Ovid, Medline, PubMed, Web of Science, National Knowledge Infrastructure, Wanfang Data, and VIP China Scientific Journal Database, based on the following key words: leptin, intrauterine growth restriction, intrauterine growth retardation, fetal growth restriction, and small for gestational age.

Data extraction: A meta-analysis was conducted to analyze the difference of the cord blood leptin concentrations between SGA and AGA newborns. Then the stratified meta-analyses were repeated with a multivariate model to adjust for potential confounders, i.e., samples origin (Chinese newborns vs. non-Chinese newborns), GA (the term-newborns vs. the mixed GA newborns), PIH or CM (the newborns excluding PIH or CM vs. the newborns not excluding PIH or CM).

Data synthesis: Twenty articles including 514 SGA newborns and 1006 AGA newborns were collected. The cord leptin concentrations of SGA newborns were lower than those of AGA newborns [WMD (95%CI), -4.42 (-5.54, -3.29) ng/ml; P<0.01; n=1520 newborns]. The results of stratified meta-analyses showed similar results in Chinese vs. non-Chinese newborns and term vs. mixed GA newborns, respectively. However, the newborns not excluding PIH or CM had a wider 95%CI than the newborns excluding PIH or CM [WMD (95%CI), -4.17 (-5.00, -3.33) ng/ml vs. -4.47 (-9.61, 0.67) ng/ml)], and there was no significant difference in cord blood leptin concentrations between SGA and AGA newborns in the newborns not excluding PIH or CM (P=0.09).

Conclusions: SGA babies have low cord leptin concentrations. Other factors that may influence cord leptin levels are maternal PIH and CM.

Key words: birth weight; leptin; meta-analysis; newborns

                                             World J Pediatr 2010;6(4):311-316

Isfahan, Iran

Author Affiliations: Isfahan Endocrine & Metabolism Research Center (Rezvanian H, Hashemipour M), Pediatric Preventive Cardiology Department, Isfahan Cardiovascular Research Center (Kelishadi R), Isfahan Faculty of Pharmacy, Isfahan University of Medical Sciences, Isfahan, Iran (Tavakoli N); Environmental Engineering, Science & Research University, Tehran, Iran (Poursafa P)

Corresponding Author: Roya Kelishadi, MD, Isfahan Cardiovascular Research Centre, Isfahan University of Medical Sciences, PO. Box 81465-1148, Isfahan, Iran (Tel: +98 311 3377881-8; Fax: +98 311 3373435; Email: Kelishadi@med.mui.ac.ir)

doi:10.1007/s12519-010-0232-x

Background: The efficacy of pharmacological treatment in controlling childhood obesity is controversial. We aimed to compare the effects of three types of drug regimens and placebo on generalized and abdominal obesity among obese children and adolescents who did not succeed to lose weight 3 months after lifestyle modification (diet and exercise).

Methods: This triple-masked randomized clinical trial was conducted among 180 participants aged 10-16 years. They were assigned randomly to 4 groups of equal number to receive metformin, fluoxetine, a combination of the two drugs, or placebo. The trial lasted for 12 weeks and participants were followed up for an additional 12-week period.

Results: Overall, 91.1% (n=164) of the enrolled participants completed the trial. After the 12-week trial, the body mass index decreased significantly in all groups receiving medications [approximately -1.2 (0.2) kg/m², P<0.05]. This decrease was not significant in the placebo group. Waist circumference decreased significantly in the groups receiving metformin [-2.1 (0.4) cm, P=0.03)] as well as in the group receiving a combination therapy of metformin and fluoxetine [-2.5 (0.4) cm, P=0.01)]. In the 24-week follow-up study, these anthropometric indexes were lower than the baseline in the group that had received a combination therapy of metformin and fluoxetine. No serious drug side-effects were reported.

Conclusions: A limited period of such treatment may help weight control, and might be used to encourage those children who have been refractory to weight loss for continuing the non-pharmacological programs. Our findings should be confirmed in future studies with a longer follow-up period.

Key words: abdominal obesity; childhood obesity; fluoxetine; generalized obesity; metformin; treatment

                    World J Pediatr 2010;6(4):317-322

Author Affiliations: Pediatric Intensive Care Unit (Muñoz-Bonet JI, Flor-Macián EM, Roselló PM, López-Prats JL) and Pediatric Service (Llopis MC, Lizondo A, Brines J), Hospital Clínico Universitario, Valencia, Spain

Corresponding Author: Juan I. Muñoz Bonet, MD, UCIP Hospital Clínico Universitario, Avda, Vicente Blasco Ibáñez 17, 46010 Valencia, Spain (Tel: +34963862624; Email: munoz_jua@gva.es)

Background: Acute respiratory failure (ARF) is one of the main causes for admission to pediatric intensive care unit (PICU). This study aimed to evaluate the feasibility and outcome of noninvasive ventilation (NIV) by a volumetric ventilator with a specific mode in pediatric acute respiratory failure.

Methods: A three-year prospective non-controlled study was undertaken in children with ARF who had received NIV delivered by Evita 2 Dura with NIV mode through a nonvented oronasal mask.

Results: Thirty-two episodes of ARF were observed in 26 patients. Pneumonia was observed in most of the children (46.8%). Pediatric logistic organ dysfunction (PELOD) score was 12.4%±24% (range 0-84%). Peak inspiratory pressure was 18.5±2.7 cmH₂O, positive end-expiratory pressure 5.7±1.1 cmH₂O, pressure support 10.5±2.7 cmH₂O, and mean pressure 9.2±2 cmH₂O. The clinical score was improved progressively within the first 6 hours. Before the initiation of NIV, respiratory rate was 41.7±16.3, heart rate 131.6±25.8, systolic arterial pressure 108±19.5, diastolic arterial pressure 58.2±13.9, pH 7.33±0.12, pCO₂ 55.1±20.2, SatO₂ 87.8±9.9 and FiO₂ 0.55±0.25. There was a significant improvement in the respiratory rate, heart rate, pH, pCO₂ and SatO₂ at 2-4 hours. This improvement was kept throughout the first 24 hours. The level of FiO₂ was significantly lower at 24 hours. Radiological improvement was observed after 24 hours in 17 out of 26 patients. The duration of NIV was 85.4±62.8 hours. Complications were defined as minor. Only 4 patients required intubation. All patients survived.

Conclusions: NIV can be successfully applied to infants and children with ARF using this volumetric ventilator with specific NIV mode. It should be considered particularly in children whose underlying condition warrants avoidance of intubation.

Key words:  acute respiratory failure; children; conventional volumetric ventilator;  noninvasive positive pressure ventilation; pneumonia

                     World J Pediatr 2010;6(4):323-330

Author Affiliations: Children's Hospital for Lung Diseases and Tuberculosis, Medical Center "Dr Dragiša Mišović", Belgrade 11000, Serbia (Živković Z, Cerović S); Medical Faculty, University of Belgrade, Belgrade 11000, Serbia (Vukašinović Z); Pediatric Clinic, Medical Center Podgorica, Podgorica 38220, Montenegro (Radulović S, Adžović O); Pediatric Clinic, Medical Center Niš, Niš 18000, Serbia (Živanović S); Chest Department, Regional Health Center, Sombor 25000, Serbia (Panić E); Health Center, Novi Sad 21000, Serbia (Hadnadjev M)

Corresponding Author: Zorica Živković, MD, PhD, Children's Hospital for Lung Diseases and Tuberculosis, Medical Center "Dr Dragiša Mišović", Jovana Marinovića 4, Belgrade 11000, Serbia (Tel: +381 11 2661887; Fax: +381 11 3066970; Email: zoricazivkovic@beotel.net)

Background: This is the first multi-center epidemio-logical study on the prevalence of childhood asthma in Serbia and Montenegro. The International Study of Asthma and Allergies in Childhood (ISAAC) phase 3 is a large epidemiological multinational and multicentric study on the prevalence of asthma, allergic rhinitis and eczema in children.

Methods: The 12-month period prevalence of asthma, allergic rhinitis and eczema was calculated using an ISAAC phase 3 questionnaire for two age groups: 6-7 years old and 13-14 years old.

Results: In the 13 485 children from five study centers who responded to the questionnaire, the prevalence for childhood asthma ranged from 2.5% to 9.8%, for allergic rhinoconjunctivitis (hay fever) from 4.6% to 21%, and for eczema from 8.2% to 17.2%. The prevalence of current wheezing was high in both age groups (16.5% and 12.4% respectively).

Conclusions: The prevalence of asthma is higher in 6-7 years old school children in the urban and largest cities of Belgrade and Nis, and in 13-14 years old children in Podgorica. The prevalence of asthma, allergic rhinitis and eczema in the school children of Serbia and Montenegro seems similar to that of other countries in Central and South-Eastern Europe.

Key words: asthma; children; eczema; prevalence; rhinitis

World J Pediatr 2010;6(4):331-336

Author Affiliations: Department of Cardiology, Children's Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China (Zhu WH); Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China (Shen LG); Institute of Radiology, Department of Paediatric Radiology, University Hospital Wuerzburg, 97080 Wuerzburg, Germany (Neubauer H)

Corresponding Author: Henning Neubauer, Helmuth-Zimmerer-Strasse 71, 97076 Wuerzburg, Germany (Tel: 0049-931-201-34715; Fax: 0049-931-201-34857; Email:  henning_neubauer@web.de)

Background: Pediatric patients with Takayasu arteritis were studied by analyzing clinical presentation, diagnostic images, response to multimodal therapy, and long-term outcome.

Methods: Fourteen consecutive children and adolescents (mean age: 10 years) were diagnosed with Takayasu arteritis at our institution between 1995 and 2007. They were subjected to clinical and diagnostic studies including color ultrasonography, MRI and angiography, and received interdisciplinary treatment.

Results: The median time lag between the first onset of symptoms and diagnosis was 7.7 weeks. The majority of patients presented with acute severe clinical symptoms and extensive vascular lesions. Hypertension was the most common finding on first presentation (93%), followed by headache (64%), nausea (64%) and palpitation (50%). Ten patients (71%) had reduced or absent carotid, brachial or femoral pulses in one or more locations. C-reactive protein was elevated in 79% of the patients and erythrocyte sedimentation rate in 64%. Cardiovascular imaging showed extensive vasculitis of both sides of the diaphragm in 86%. Complications included renal artery stenosis (n=7), aortic dissection, thoracic aortic aneurysm and infrarenal aneurysm (all n=1). Conservative drug treatment was effective in 50%. Interventional dilatation of stenosis and surgical therapy, including aortic bypass, resection of aneurysms and nephrectomy, were necessary in the remaining patients. Follow-up for 25 months to 12 years showed that all children are well without disease-related mortality.

Conclusions: Takayasu arteritis is a rare and potentially life-threatening disease in children, likely with a prolonged subclinical course. Rapid diagnosis and interdisciplinary management help to prevent life-threatening complications.

Key words: children; complications; diagnosis; Takayasu arteritis; therapy

World J Pediatr 2010;6(4):342-347

Author Affiliations: Department of Cardiology, Children's Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China (Zhu WH); Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China (Shen LG); Institute of Radiology, Department of Paediatric Radiology, University Hospital Wuerzburg, 97080 Wuerzburg, Germany (Neubauer H)

Corresponding Author: Henning Neubauer, Helmuth-Zimmerer-Strasse 71, 97076 Wuerzburg, Germany (Tel: 0049-931-201-34715; Fax: 0049-931-201-34857; Email:  henning_neubauer@web.de)

Background: Pediatric patients with Takayasu arteritis were studied by analyzing clinical presentation, diagnostic images, response to multimodal therapy, and long-term outcome.

Methods: Fourteen consecutive children and adolescents (mean age: 10 years) were diagnosed with Takayasu arteritis at our institution between 1995 and 2007. They were subjected to clinical and diagnostic studies including color ultrasonography, MRI and angiography, and received interdisciplinary treatment.

Results: The median time lag between the first onset of symptoms and diagnosis was 7.7 weeks. The majority of patients presented with acute severe clinical symptoms and extensive vascular lesions. Hypertension was the most common finding on first presentation (93%), followed by headache (64%), nausea (64%) and palpitation (50%). Ten patients (71%) had reduced or absent carotid, brachial or femoral pulses in one or more locations. C-reactive protein was elevated in 79% of the patients and erythrocyte sedimentation rate in 64%. Cardiovascular imaging showed extensive vasculitis of both sides of the diaphragm in 86%. Complications included renal artery stenosis (n=7), aortic dissection, thoracic aortic aneurysm and infrarenal aneurysm (all n=1). Conservative drug treatment was effective in 50%. Interventional dilatation of stenosis and surgical therapy, including aortic bypass, resection of aneurysms and nephrectomy, were necessary in the remaining patients. Follow-up for 25 months to 12 years showed that all children are well without disease-related mortality.

Conclusions: Takayasu arteritis is a rare and potentially life-threatening disease in children, likely with a prolonged subclinical course. Rapid diagnosis and interdisciplinary management help to prevent life-threatening complications.

Key words: children; complications; diagnosis; Takayasu arteritis; therapy

World J Pediatr 2010;6(4):342-347

Author Affiliations: Department of Cardiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China (Guo Y, Li F, Wang J); Department of Cardiology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai 200040, China (Shen J, Yuan L); Department of Pediatric Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200092, China (Sun K)

Corresponding Author: Kun Sun, MD, PhD, Department of Pediatric Cardiology, Xinhua Hospital, 1665 Kongjiang Road, Shanghai 200092, China (Fax: +86-21- 65125173; Email: drkunsun@yahoo.com.cn)

Background: Atrioventricular septal defects (AVSDs) occur as clinical defects of several different syndromes, as autosomal dominant defects, and as sporadically occurring malformations. Consequently, there is genetic heterogeneity, but until recently, little is known about the genes involving in the pathogenesis of AVSD. CRELD1 gene, a novel cell adhesion molecule, is a candidate gene for AVSD.

Methods: This study included 133 patients with AVSD and 200 healthy controls. Peripheral blood samples were collected and genomic DNA was extracted from the leukocytes. CRELD1 was amplified by polymerase chain reaction (PCR) with specific primers. The sequences of PCR products were compared between the patients and controls.

Results: In a patient, a C-to-G transition was identified at nucleotide 857 in exon 8 that resulted in a substitution of alanine for proline at amino acid 286 in the first calcium-binding EGF domain. This patient had an isolated partial AVSD and the mutation was inherited from her mother. Another mutation was detected in a patient with a partial AVSD and evidence of Down syndrome. The heterozygous c.973G>A transition in exon 9 resulted in a substitution of lysine for glutamic acid at amino acid 325 (E325K) in the second calcium-binding EGF domain.

Conclusions: Two novel CRELD1 mutations were identified in the calcium-binding EGF domain in patients with AVSD. CRELD1 is likely to be an AVSD-susceptibility gene and CRELD1 mutations may increase the risk of developing a heart defect rather than being a direct causative mutation.

Key words: atrioventricular septal defect; CRELD1; Down syndrome

World J Pediatr 2010;6(4):348-352

Background: Discharge against medical advice (DAMA) from hospital may have negative effects on the well-being of the patients. In pediatric patients the decision for DAMA is made by the parent(s). The present study aimed to evaluate the prevalence of DAMA and examine the reasons for DAMA provided by the parents.

Methods: A cross-sectional descriptive study on DAMA was conducted from March 2005 to February 2007 in the pediatric ward of Taleghani hospital in Tehran, Iran.

Results: The prevalence of DAMA was 5.3%, comprising 97 of 1842 children discharged. The age of the 97 children ranged from 1 day to 8 years, with a mean hospitalization duration of 4±3.3 days. Seventy-seven (79.4%) of the 97 children were <12 months. Thirty-four (35.1%) children were discharged within 48 hours of admission. The most commonly diagnosed diseases in these children were neonatal jaundice (37.1%), sepsis (21.6%), and gastroenteritis (16.4%). The reasons for DAMA were as follows: parent's assumption of improvement (32.9%), dissatisfactory treatment and care (29.9%), inconvenience for child hospitalization (18.5%), and financial constraints (15.5%).

Conclusions: The prevalence of DAMA in the present study was within the range of other DAMA studies in children. The majority of DAMA cases could have been prevented by more satisfactory facilities and effective communication between medical staff and the parents.

Key words: children; discharge against medical advice; hospital

                     World J Pediatr 2010;6(4):353-356

Author Affiliations: Medical Students Research Center, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran (Keshteli AH); Isfahan Endocrine and Metabolism Research Center, Isfahan University of Medical Sciences, Isfahan, Iran (Keshteli AH, Hashemipour M, Siavash M, Amini M)

Corresponding Author: Mahin Hashemipour, Isfahan Endocrine and Metabolism Research Center, Seddigheh Tahereh Research Complex, Isfahan University of Medical Sciences, Khorram street, Isfahan, Iran (Tel: +98 311 3359933; Fax: +98 311 337 3733; Email: hashemipour@med.mui.ac.ir)

Background: Despite long standing iodine supplementation in Iran the prevalence of goiter remains high in some areas. In the present study we investigated the possible role of thiocyanate as a goitrogen in the etiology of goiter in Isfahan, Iran.

Methods: A total of 2331 (6-13 year old) school children were selected by multistage random sampling. Thyroid size was estimated in each child by inspection and palpation. Urinary iodine concentration (UIC) and urinary thiocyanate (USCN) were measured.

Results: Overall, 32.9% of the 2331 students had goiter. The median UIC was 195.5 µg/L. The mean±SD of USCN in goitrous and nongoitrous subjects was 0.42±0.28 mg/dL and 0.41±0.32 mg/dL, respectively (P=0.86). USCN level in goitrous and nongoitrous boys was 0.41±0.32 mg/dL and 0.43±0.37 mg/dL, respectively (P=0.67). USCN level in goitrous and nongoitrous girls was 0.43±0.26 mg/dL and 0.40±0.28 mg/dL, respectively (P=0.43).

Conclusions: Thiocyanate overload does not play a role in high prevalence of goiter in the studied population. We suggest the role of other goitrogenic factors should be investigated in this region.

Key words: goiter; goitrogen; iodine deficiency; Iran; thiocyanate

                   World J Pediatr 2010;6(4):357-360

Author Affiliations: Department of Neurosurgery, the Second Affiliated Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an 710004, China (Huang SL, Shi W); Department of Surgery, Xi'an Children's Hospital, Xi'an 710003, China (Zhang LG)

Corresponding Author: Wei Shi, Department of Neurosurgery, the Second Affiliated Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an 710004, China (Tel: 86-29-87679366; Fax: 86-29-87678634; Email: sweins@163.com)

Background: Lipomyelomeningocele (LMM) is a common and severe closed neural tube defect in children. Because of the complex anatomy of LMM and the difficulty in assessing the value of surgery, the management of patients with LMM is controversial. This study was undertaken to evaluate effective techniques and procedures in surgical treatment of LMM and to assess the value of early neurosurgical intervention.

Methods: Twenty-five children with LMM aged from 2 months to 6 years underwent surgery between January 2004 and December 2006. Magnetic resonance imaging (MRI) of the spine and electromyography (EMG) of the lower limbs was conducted in all patients preoperatively. Urodynamic studies were appropriate even in asymptomatic patients. Hoffman's functional grading was used to assess the pre and postoperative status of the patients. The operation was composed of subtotal excision of lipoma, suturing of the spinal pia mater, and section of the filum terminale. Suturing of the spinal pia mater was performed in a wide process of reconstruction of meningeal layers including the dura. Follow-up lasted 1-4 years (mean 2.1 years), in which all children underwent neurological examination, EMG and MRI.

Results: After surgery a temporary neurological deterioration was found in two patients including slight weakness of a leg in one patient and urinary retention in the other, but it recovered completely a few days later. No postoperative complications were encountered. During the follow-up, 20 asymptomatic patients remained symptom-free. Symptoms disappeared totally in 2 of the 5 patients with neurological deficits, improved in one patient and stabilized in the remaining 2. MRI showed no tethered cord in all patients who underwent surgical procedures.

Conclusions: Early operation for LMM patients, even asymptomatic ones, should be performed to prevent the development of neurological deficits. Subtotal excision of lipoma, suturing of the spinal pia mater, and section of the filum terminale are recommended in the surgical treatment of LMM. The longitudinal cut of the filum terminale, a technique we have established in our surgical practice, is a simple and practical way to identify the filum terminale by visual inspection. And suturing the spinal pia mater is of extreme importance in preventing postoperative tethering.

Key words: children; filum terminale; lipomyelomeningocele; spinal pia mater; surgical treatment

                    World J Pediatr 2010;6(4):361-365

Author Affiliations: Division of Pediatric Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA (Greenspon J, Alaish SM); Department of Surgery, Wayne State University School of Medicine, Detroit, Michigan, USA (Perrone EE)

Corresponding Author: Samuel M Alaish, MD, Division of Pediatric Surgery, Department of Surgery, University of Maryland School of Medicine, 22 S. Greene St, Room N4E37, Baltimore, Maryland 21201, USA (Tel: +1-410-328-5730; Fax: +1-410-328-0652; Email: salaish@smail.umaryland.edu)

Background: Shoshin beriberi, cardiac failure secondary to a severe deficiency of the vitamin thiamine, can develop in patients following extensive intestinal resection or bypass; however, parenteral supplementation has largely eliminated this complication. Hemodynamic instability resulting from central line sepsis is a far more common complication in these parenteral nutrition-dependent patients. This case report details the diagnosis and treatment of shoshin beriberi in a patient with short bowel syndrome whose presentation mimicked central line sepsis.

Methods: A retrospective chart review was performed. Appropriate laboratory data were included.

Results: The patient was treated unsuccessfully with antibiotics and supportive measures. Resolution of symptoms was achieved only after the empiric administration of thiamine and folate.

Conclusions: This case highlights that life-threatening thiamine deficiency mimicking septic shock can develop in patients with short bowel syndrome, despite oral multivitamin administration. We recommend diligent monitoring of vitamin levels in any total parenteral alimentation dependent patient unable to receive the intravenous multivitamin complex, regardless of oral vitamin supplementation or clinical findings. 

Key words: central line sepsis; short bowel syndrome; thiamine deficiency

                  World J Pediatr 2010;6(4):366-368

Author Affiliations: Department of  Pediatric Surgery, Zeynep Kamil Maternal and Child Diseases Educational and Research Hospital, Department of Pediatric Surgery, Istanbul, Turkey (Sahin C, Alver D, Gulcin N, Kurt G, Celayir AC)

Corresponding Author: Aysenur Cerrah Celayir, Pediatric Surgery, and Director of Hospital, Zeynep Kamil Kadin ve Cocuk Hastaliklari Egitim ve Arastirma Hastanesi, Bashekim Arakiyeci Haci Mehmet Mah. Op.Dr.Burhanettin Ustunel Cad. No:10, 34668, Uskudar, Istanbul, Turkey (Tel: + 90 216 343 20 73; Fax: + 90 216 343 92 51; Email: celayiraysenur@gmail.com)

Background: Ingestion of foreign objects is a common problem in children. Ingestion of one more magnets may require surgical intervention because of risk of perforation.

Methods: A 4-year-old girl was admitted to our department with complaints of abdominal pain and bilious vomiting. She had been treated at another clinic with repeated abdominal X-rays because of ingestion of a magnet 5 days ago. Physical examination revealed diffuse abdominal tenderness and bilious drainage from the nasogastric tube. The magnet was observed by radiopaque imaging in the right epigastric region of the upright abdomen but there was no free air. The magnet was presumed to be in the duodenum and exploratory laparotomy was performed.

Results: During the operation, a perforation was found between the pylorus and duodenum due to the magnet. The foreign body was found to be two magnets adherent to each; the interposed and compressed tissue was necrotized and perforated between the two magnets. The necrotized segment was excised and primary anastomosis was made. The postoperative period of the patient was uneventful and she was discharged on the seventh postoperative day.

Conclusions: Ingestion of foreign objects such as one more magnets may cause intestinal perforation in early stages. If the object stays in the same location shown by repeated X-rays, surgical intervention should not be delayed.

Key words: foreign body; intestinal perforation; magnet ingestion

World J Pediatr 2010;6(4):369-371

Is presentation of ADHD subtypes different

between community and clinical samples?

Letter to the Editor

A study on a clinical sample of 171 (79.5% boys and 20.5% girls) children and adolescents with ADHD with the age range of 5.5 to 18 years indicated that the mean age of children with ADHD-predominantly hyperactive impulsive types was significantly lower than that of the other subtypes. Also, the mean age of the children with inattentive types of ADHD was higher than that of the other two subtypes. However, after considering gender as a covariant factor, there was no association between ADHD subtypes and age.^[2]

Another study on 380 clinic-referred youths aged 4-17 years reported that the symptoms of hyperactivity-impulsivity symptoms present earlier in preschool children while the inattentive type of ADHD is more common in adolescents.^[3]

Of course, both of these studies are from clinical samples. Even, they do not seem to represent clinical samples of children from the world. Children with ADHD who are referred to clinics usually suffer from severe form of the disorder. Also, most of the clinical samples of children with ADHD suffer from other co-morbid psychiatric disorders.^[4] Therefore, further studies on community samples of children with ADHD considering covariant factors should be conducted to find whether presentation of ADHD subtypes is age dependent.

Ahmad Ghanizadeh, MD

Research Center for Psychiatry and Behavioral Sciences,

Department of Psychiatry, Shiraz University of Medical Sciences, Hafez Hospital,

Shiraz, Iran

Email: ghanizad@sina.tums.ac.ir

References

1   Ramelli GP, Zanda N, Bianchetti MG, Leoni F. Age-dependent presentation in children with attention deficit hyperactivity disorder. World J Pediatr 2010;6:90.

2   Ghanizadeh A. Psychiatric comorbidity differences in clinic-referred children and adolescents with ADHD according to the subtypes and gender. J Child Neurol 2009;24:679-684.

3   Lahey BB, Applegate B, McBurnett K, Biederman J, Greenhill L, Hynd GW, et al. DSM-IV field trials for attention deficit hyperactivity disorder in children and adolescents. Am J Psychiatry 1994;151:1673-1685.

4   Ghanizadeh A, Mohammadi MR, Moini R. Comorbidity of psychiatric disorders and parental psychiatric disorders in a sample of Iranian children with ADHD. J Atten Disord 2008; 12:149-155.

doi:10.1007/s12519-010-0238-4