Comparison of Two Diagnostic Methods of Vesicoureteral Reflux in Children with Urinary Tract Infection

 Introduction: Urinary tract infection is common in children and vesicoureteral reflux is one of its predisposing factors. Contrast cystography and radionuclide cystography are two common methods for the diagnosis of vesicoureteral reflux. This study compared two methods, indirect radionuclide cystography (IRC) with voiding cycling method and voiding cystoureterography with contrast (VCUG).Materials & Methods: This analytical study was conducted on 55 children with urinary tract infection who were referred to our nephrology clinic in six months. In order to diagnose urinary reflux, 109 ureters (one child had a single kidney) were evaluated using IRC and VCUG methods with a one-month interval. Kappa coefficient was used to determine the agreement rate, and the McNemar’s test was employed to compare the ability of two methods in the diagnosis of VUR.Results: The mean age of the children was 5.4 years (range: 6 months to 13 years). A total of 38 children (69%) were female and 17 (30.9%) were male. Seventy percent of the children older than three years old had urinary control. From 109 ureters, 29 (26.4%) with urinary reflux were detected by the IRC method, whereas only 15 (13.6%) were diagnosed using VCUG. Statistically, the two methods did not have agreement in the diagnosis of VUR (Kappa: 0.556, p< 0.001) and the IRC method had more power to diagnose VUR in comparison with VCUG.Conclusions: Although we observed a significant difference in the diagnostic value of two methods, the choice of diagnostic method depends on specific technical conditions. However, in ideal conditions, the IRC method is suggested to be performed since it is more powerful in the diagnosis of urinary reflux.Keywords: Vesico-Ureteral reflux; Urinary Tract Infections; Pediatrics; Diagnostic Imaging

The Ketogenic and Atkins Diets Effect on Intractable Epilepsy: A Comparison

How to Cite This Article: Ghazavi A, Tonekaboni SH, Karimzadeh P, Nikibakhsh AA, Khajeh A, Fayyazi A. The Ketogenic and Atkins Diets Effect on Intractable Epilepsy: A Comparison. Iran J Child Neurol. 2014 Summer;8(3): 12-17.AbstractObjectiveIntractable epilepsy is a major difficulty in child neurology, because the numbers of drugs that are available for treatment are limited and new treatments such as diets must be tried. Now there are some diets available for treating patients with intractable epilepsy. The oldest diet is the classic ketogenic diet and one of thenewest diets is the modified Atkins diet. Patients have a harder time accepting the classic ketogenic diet than the Atkins diet, which is easier to accept because the food tastes better. This study compares the efficacy of the ketogenic diet and the Atkins diet for intractable epilepsy in children.Materials & MethodsThis study is a clinical trial survey with sample size of 40 children with refractory epilepsy who were patients at Mofid hospital in Tehran, Iran. Initially, from Jan 2005–Oct 2007, 20 children were treated with the Atkins diet, and then from Oct 2007–March 2010, the other group was treated with the classic ketogenic diet and the results were compared. ResultsIn this study, response to treatment was greater than a 50% reduction in seizures and at the end of first, second, and third months for the ketogenic diet were 55%, 30%, and 70% and for the Atkins diet were 50%, 65%, and 70%, respectively.ConclusionThe results of this study show that there is no significant difference between the classic Ketogenic diet and the Atkins diet at the end of first, second, and third months and both had similar responses to the treatments.References Camfield CS, Canfield PR, Gordon K, Wirrell E, Dooley JM. Incidence of epilepsy in childhood and adolescents in Nova Scotia. Epilepsia, 1996 Jan;37(1):19-23.Gessner U, Sagmeister M, Horisberger B. The cost of Epilepsy in Switzerland. Int J Health Sci 1993;4:121-8.Aicardi J. Epilepsy in children. Philadelphia: Lippincott Williams & Wilkins; 2004. p. 38.4. Kossof EH. More fat and fewer seizures: dietary therapy ofepilepsy. Lancet Neurol 2004 Jul;3()7):415-20.Hassan AM, Keene DL, Whiting SE, Jacob PJ, Champagne JR, Humphreys P. Ketogenic diet in the treatment of refractory epilepsy in childhood. Pediatr. Neurol. 1999; 21: 548-552.Vining EP, Freeman JM, Ballaban-Gil K, Camfield CS, Camfield PR, Holmes GL et al. A multicenter study of the efficacy of the ketogenic diet. Arch Neurol 1998 Nov;55(11):1433-7.Nordli DR, Kuroda MM. Experience with the ketogen diet in infants. Pediatrics 2001 Jun; 108(1):129-33.Tonekaboni SH, Mostaghimi P, Mirmiran P, Abbaskhanian A, Abdollah GF, Ghofrani M, et al. Efficacy of Atkins diet as therapy for intractable epilepsy in children. Arch Iran Med 2010 Nov;13(6):492-7.Kossoff EH, Dorward JL. The modified Atkins diet. Epilepsia 2008 Nov;49 Suppl 8:37-41.Mirjavadi SAR, Tonekaboni SH, Ghazavi MR, Azarghashb E, Abdollah GF, Ghofrani M. Efficacy of ketogenic diet as a therapy for intractable epilepsy in children. Iran J Child Neurol 2010 Sep;4(2):27-36.Karimzadeh P, Tabarestani S, Mahvelati F, Tonekaboni SH, Ghofrani M. Intractable seizure disorfes; efficacy of the classic ketogenic diet. Iran J Child Neurol 2009 Jan; 3(1):15-20.Barzegar M, Ostad Rahimi AR, Eslampour Sh, Shabazi Sh. The Ketogenic diet for refractory epilepsy. Med J Tabriz Uni Med Sci Health Serv 2009;31:15-20.Lefevre F, Aronson N. Ketogenic diet for the treatment of refractory epilepsy in children: A systematic review of efficacy. Pediatrics 2000 Apr;105(4):105-9.Keene DL. A systematic review of the use of the ketogenic diet in childhood epilepsy. Pediatr Neurol 2006 Jul;35(1):1-5.Porta N, Vallee L, Boutry E, Fontaine M, Dessein AF, Joriot S, et al. Comparsion of seizure reduction and serum fatty acid levels after receiving the ketogenic and modified Atkins diet. Seizure 2009 Jun 18(5):359-64

Treatment of Steroid and Cyclosporine-Resistant Idiopathic Nephrotic Syndrome in Children

Steroid-resistant nephrotic syndrome (SRNS) in children carries a significant risk of progression to end-stage renal failure (ESRF). We report a two-step protocol adapted in children with SRNS. Thirty-seven SRNS were treated with cyclosporine A (CyA) in association with prednisolone (alternate day) for 6 months (first-step treatment). Twelve patients (32.4%) went into complete remission, and 2 (5.4%) got partial remission. The other 23 cases who were steroid and CyA resistant entered a second-step treatment with withdrawing steroids, with CyA (5 mg/kg/day) in association with mycophenolate mofetil (MMF) 30 mg/kg/day for 6 months. Complete remission was observed in 11 cases (47.82%) and partial remission in 2 cases (8.7%). After two steps of treatment, 27/37 children went into total remission. In steroid and CyA-resistant INS, the association of MMF with CyA was able to induce remission in about half cases without relevant side effects

Treatment of Complicated Henoch-Schönlein Purpura with Mycophenolate Mofetil: A Retrospective Case Series Report

Background. Henoch-Schönlein purpura (HSP) is the most common childhood vasculitis with an incidence of approximately 10 per 100 000 children. There is some evidence to support steroid therapy in the treatment of severe abdominal pain, severe nephritis, and central nervous system involvement. However, the routine use of corticosteroids is controversial. Frequent relapses, lack of response to steroid, steroid dependency, and steroid side effects may occur in some patients. Mycophenolate mofetil (MMF) gains increasing popularity in the treatment of autoimmune disorders, but hitherto, the available evidence to support the use of MMF in HSP is limited to some case study reports. Case Presentation. We report six children with HSP who failed to respond to systemic steroid therapy, whereas MMF successfully treated the manifestations of the disease. Conclusion. The manifestations of HSP disappeared mainly during the first week of treatment with MMF and all the patients were in a complete remission at the end and after discontinuation of the therapy. In our experience, MMF appeared to be safe and effective for the maintenance of remission in the HSP patients

Evaluation of quantitative urinary CRP (C-reactive protein) level in children with urinary tract infection

Introduction: Urinary tract infection (UTI) is a risk factor for kidney damage and end stage renal failure. In this study, the urinary C-Reactive Protein (CRP) level was compared between patients with UTI and patients with other infectious diseases and the role of the mean urinary CRP, as a predictive factor for renal involvement, was evaluated.Material & Methods: Urine samples were collected from patients under 15 years of age with UTI in Shahid Motahari Children's Hospital within 24 to 48 hours after hospital admission. Then, urine CRP was measured quantitatively using the ELISA method. The control group was selected among patients with various infectious diseases. Technetium Tc 99m Dimercaptosuccinic Acid (DMSA scan) and voiding cystouretrography (VCUG) were performed for children with UTI. Data were analyzed by using Mann-Whitney Test and P values less than 0.05 were considered statistically significant.Results: A total of 50 patients with UTI as the study group and 20 patients as the control group were evaluated. The mean urinary CRP was 244.8 in the study group and 179.67 in the control group. There was no significant difference in urinary CRP between the cases and the controls (P value: 0.83). The mean urinary CRP was 83.4 ± 46.02 in 9 patients with DMSA scan class 1, 224.8±320.1 in 38 patients with class 2, and 399.53 ± 46.27 in the three patients with class 3. Mann-Whitney Test showed no significant differences in urinary CRP levels between normal and abnormal DMSA scans. Four patients were positive for VUR but there was no significant relationship between VUR and urinary CRP (P value= 0.56).Conclusions: According to our findings, urine CRP does not have a diagnostic value in urinary tract infections in children and cannot predict renal damage.Keywords: Urinary tract infections; C-reactive protein; Technetium Tc 99m Dimercaptosuccinic Aci

Enabling informed policymaking for chronic kidney disease with a registry:Initiatory steps in Iran and the path forward

Objectives: Chronic kidney disease (CKD) registries have been used for more than half a century. Iran lacks a comprehensive registry to capture data of all CKD patients for an informed care planning and policy making. We aimed to identify the objectives and possible challenges for developing a CKD registry and also to define its minimum data set (MDS) in our healthcare context.Methods: This was a mixed-method study conducted in Iran from fall 2016 till summer 2017. The qualitative part included document analysis and 26 semi-structured interviews with 17 clinicians and managers involved in CKD care. This data was analyzed using the "grounded theory". Then, a modified Delphi survey was conducted. Percentages and mode values were used for analysis.Results: Our participants' leading interest in a CKD registry was centered on providing a coordinated, good-quality care for all CKD stages with particular emphasis to capture events and monitor trends for patients in earlier stages. They highlighted the required financial, technical and human resources as main challenges for a smooth registry implementation. Furthermore, a clinically oriented MDS comprising of 168 elements (with a majority having more than 90% agreement with mode 2) was extracted. It mainly collects demographics, medical history, encounter sessions, diagnostic examinations, medications, vaccinations and mortality data.Conclusions: We reported the initiatory steps taken to establish a CKD registry in an Iranian healthcare context. We focused on the information needs and priorities of our main stakeholders and based our intended registry on addressing those needs. We hope this approach will facilitate its endorsement and advance the efforts for a sustainable, good-quality CKD care. (C) 2018 Fellowship of Postgraduate Medicine. Published by Elsevier Ltd. All rights reserved

Enabling informed policymaking for chronic kidney disease with a registry:Initiatory steps in Iran and the path forward

Objectives: Chronic kidney disease (CKD) registries have been used for more than half a century. Iran lacks a comprehensive registry to capture data of all CKD patients for an informed care planning and policy making. We aimed to identify the objectives and possible challenges for developing a CKD registry and also to define its minimum data set (MDS) in our healthcare context.Methods: This was a mixed-method study conducted in Iran from fall 2016 till summer 2017. The qualitative part included document analysis and 26 semi-structured interviews with 17 clinicians and managers involved in CKD care. This data was analyzed using the "grounded theory". Then, a modified Delphi survey was conducted. Percentages and mode values were used for analysis.Results: Our participants' leading interest in a CKD registry was centered on providing a coordinated, good-quality care for all CKD stages with particular emphasis to capture events and monitor trends for patients in earlier stages. They highlighted the required financial, technical and human resources as main challenges for a smooth registry implementation. Furthermore, a clinically oriented MDS comprising of 168 elements (with a majority having more than 90% agreement with mode 2) was extracted. It mainly collects demographics, medical history, encounter sessions, diagnostic examinations, medications, vaccinations and mortality data.Conclusions: We reported the initiatory steps taken to establish a CKD registry in an Iranian healthcare context. We focused on the information needs and priorities of our main stakeholders and based our intended registry on addressing those needs. We hope this approach will facilitate its endorsement and advance the efforts for a sustainable, good-quality CKD care. (C) 2018 Fellowship of Postgraduate Medicine. Published by Elsevier Ltd. All rights reserved

Genetics of immunoglobulin-A vasculitis (Henoch-Schönlein purpura): An updated review

Immunoglobulin-A vasculitis (IgAV) is classically a childhood small-sized blood vessel vasculitis with predominant involvement of the skin. Gastrointestinal and joint manifestations are common in patients diagnosed with this condition. Nephritis, which is more severe in adults, constitutes the most feared complication of this vasculitis. The molecular bases underlying the origin of IgAV have not been completely elucidated. Nevertheless, several pieces of evidence support the claim that genes play a crucial role in the pathogenesis of this disease. The human leukocyte antigen (HLA) region is, until now, the main genetic factor associated with IgAV pathogenesis. Besides a strong association with HLA class II alleles, specifically HLA-DRB1 alleles, HLA class I alleles also seem to influence on the predisposition of this disease. Other gene polymorphisms located outside the HLA region, including those coding cytokines, chemokines, adhesion molecules as well as those related to T-cells, aberrant glycosylation of IgA1, nitric oxide production, neoangiogenesis, renin-angiotensin system and lipid, Pyrin and homocysteine metabolism, may be implicated not only in the predisposition to IgAV but also in its severity. An update of the current knowledge of the genetic component associated with the pathogenesis of IgAV is detailed in this review.Acknowledgements: RL-Mis supported by the Miguel Servet I programme of the Spanish Ministry of Economy and Competitiveness through the grant CP16/ 00033. FG is recipient of a Sara Borrell postdoctoral fellowship from the “Instituto Carlos III de Salud” at the Spanish Ministry of Health (Spain) (CD15/00095). SR-M is supported by funds from the RETICS Program (RIER) (RD16/0012/0009). FDC is supported by the Ramón y Cajal programme of the Spanish Ministry of Economy and Competitiveness through the grant RYC-2014-16458

The efficacy of rituximab in treatment of childhood steroid resistant and steroid dependent nephrotic syndrome: a systematic review and Meta-analysis

Corticosteroid resistant and dependent nephrotic syndrome in children is a challenge and there are some difficulties in treating such patients. We reviewed the current studies that evaluated therapeutic role of a relatively new immunosuppressive drug “rituximab” in reducing proteinuria and reduction of relapse rate in less than 16 year old patients with non-responsive or steroid dependent nephrotic syndrome. We searched Medline, Embase, web of science and Cochrane library with appropriate keywords and conducted the complete remission, relapse rate and the mean number of relapses 12 month after therapy on Meta-analysis. We put the data on two different subgroups; steroid resistant nephrotic syndrome and steroid dependent or frequent relapser nephrotic syndrome. In Steroid Resistant Nephrotic syndrome children, the complete remission was 0.27 (0.2- 0.34). In Steroid Dependent Nephrotic syndrome patients, the overall standard mean differences of mean number of relapses 12 mo after treatment in pooled four studies (56 cases) was 2.63 (2.03, 3.24). In these dependent patients, the data on relapse rate after treatment pooled on 6 studies (162 cases) and yield to the rate of 0.42 (0.15, 0.69) with the range of 0.09 to 0.83. In conclusion, Rituximab is a reasonable therapy for Steroid Dependent and Steroid Resistant Nephrotic syndrome children. In view of paucity of randomized data, we suggest to perform newer controlled multicenter studie

The efficacy of rituximab in treatment of childhood steroid resistant and steroid dependent nephrotic syndrome: a systematic review and Meta-analysis

Corticosteroid resistant and dependent nephrotic syndrome in children is a challenge and there are some difficulties in treating such patients. We reviewed the current studies that evaluated therapeutic role of a relatively new immunosuppressive drug “rituximab” in reducing proteinuria and reduction of relapse rate in less than 16 year old patients with non-responsive or steroid dependent nephrotic syndrome. We searched Medline, Embase, web of science and Cochrane library with appropriate keywords and conducted the complete remission, relapse rate and the mean number of relapses 12 months after therapy on Meta-analysis. We put the data on two different subgroups steroid resistant nephrotic syndrome and steroid dependent or frequent relapser nephrotic syndrome. In Steroid Resistant Nephrotic syndrome children, the complete remission was 0.27 (0.2- 0.34). In Steroid Dependent Nephrotic syndrome patients, the overall standard mean differences of mean number of relapses 12 months after treatment in pooled four studies (56 cases) was 2.63 (2.03, 3.24). In these dependent patients, the data on relapse rate after treatment pooled on 6 studies (162 cases) and yield to the rate of 0.42 (0.15, 0.69) with the range of 0.09 to 0.83. In conclusion, Rituximab is a reasonable therapy for Steroid Dependent and Steroid Resistant Nephrotic syndrome children. In view of paucity of randomized data, we suggest to perform newer controlled multicenter studies