Meropi Tzoufi

Provocation of Neurocardiogenic Syncope During Head-up Tilt Testing in Children: Comparison Between Isoproterenol and Nitroglycerin

OBJECTIVE. Although nitroglycerin- and isoproterenol-augmented tilt tests are of equal value in the diagnosis of neurocardiogenic syncope in adults, no data exist in children. We compared the sensitivity and specificity of the 2 tests in a pediatric population. PATITENS AND METHODS. We studied 85 patients (33 boys; mean age: 11.6 ± 2.9 years). Of them, 56 had a diagnostic history of neurocardiogenic syncope, whereas 29 served as controls. After a negative passive phase, they were randomly assigned to either intravenous isoproterenol or sublingual nitroglycerin, and tilt was continued for 20 minutes. RESULTS. Sensitivity was 0.78 for the isoproterenol test and 0.79 for the nitroglycerin test, but specificity was significantly higher for isoproterenol test compared with nitroglycerin test. In patients with a positive test, the duration of the recovery period was significantly longer after nitroglycerin (8.4 ± 2.7 minutes) than after isoproterenol (5.1 ± 1.6 minutes). CONCLUSIONS. Nitroglycerin- and isoproterenol-augmented tilt tests are associated with equal sensitivity in the diagnosis of neurocardiogenic syncope in children and adolescents. However, nitroglycerin results in more false-positive tests and produces more prolonged vasovagal symptoms. Our data do not support the routine use of nitroglycerin in the evaluation of syncope in this age group.

Vitamin D and Stroke: Promise for Prevention and Better Outcome

The role of vitamin D (VitD) has recently been expanded beyond bone homeostasis and regulation of calcium levels. VitD deficiency has been proposed as a new risk factor for cardiovascular disease, including stroke. Low 25(OH)VitD levels are very common among post-stroke patients, probably due to their limited mobility and decreased sunlight exposure along with a higher prevalence of malnutrition, and they have been associated with previous and incident cerebrovascular events. Contributing mechanisms have been linked to the association of VitD deficiency with the presence of hypertension, diabetes mellitus and atherosclerosis. Moreover, there is experimental evidence demonstrating that VitD exerts neuroprotective effects, such as stimulation of neurotrophic factors, quenching of oxidative hyperactivity and regulation of neuronal death, as well as antithrombotic properties. It is plausible that VitD supplementation could be a beneficial intervention for the prevention and/or treatment of cerebrovascular disease possibly by decreasing the aforementioned cerebrovascular risk factors and simultaneously by improving neurologic and cognitive functions, thereby reducing falls and fractures in post-stroke patients. However, study results are still conflicting and data from large, randomized clinical trials are needed to clarify these speculations.

Conventional MRI and magnetisation transfer imaging of tumour-like multiple sclerosis in a child.

Abstract. Tumefactive multiple sclerosis is a rare entity in children. Differential diagnosis includes other mass lesions such as neoplasm and abscess. A case of tumefactive multiple sclerosis in a child is presented. The open-ring pattern of enhancement on conventional MRI and magnetisation transfer imaging was important for the initial diagnosis and the evaluation of the course of the disease.

A prospective multicenter study of childhood encephalitis in Greece.

Encephalitis is associated with significant childhood morbidity and mortality worldwide, however not much is known about the contemporary epidemiology and outcome. In this prospective multicenter pediatric encephalitis study conducted in Greece for 3 years, 42 cases were diagnosed and the presumptively or definitely causative pathogen was identified in 24 (57.1%). Leading pathogens included herpes viruses (10 patients), enteroviruses (6), and Streptococcus pneumoniae (2). No fatalities were observed; however, deficits remained in 5 of 42 (11.9%) children.

Anticonvulsant drugs for pediatric migraine prevention: An evidence-based review

Background: The use of anticonvulsant drugs for the prevention of migraine in children and adolescents has been supported in the past.

Blue rubber bleb nevus syndrome with simultaneous neurological and skeletal involvement

Blue rubber bleb nevus syndrome (BRBNS) is a rare disorder characterized by venous malformations usually affecting the skin and the gastrointestinal tract. These skin haemangiomas are present at birth and deteriorate as the body grows, causing primarily cosmetic problems. The haemangiomas of the gastrointestinal tract may appear later in life and may bleed, causing chronic anaemia, or may present with severe complications such as rupture, intestinal torsion, and intussusception. Other organs may also be involved. This article describes a 13-year-old boy with multiple haemangiomas of the skin, the mucous membranes, and the gastrointestinal tract, which caused anaemia and ileoileic intussusception. In this patient, the nervous system was significantly affected with a haemangioma of the left occipital lobe, with complications of stroke. He also had multiple paravertebral heamangiomas, which caused pressure signs and symptoms. This boy suffered from complex partial and generalized seizures and cerebral palsy. Multiple skeletal anomalies were also present from birth. In the relevant literature, this is the first case of BRBNS with simultaneous neurological and skeletal involvement. Such cases should be recognized early, as they can lead to serious multiple health problems and handicaps.

Rate of seizures in children with shigellosis.

N Roy-Chowdhury, B Deocharan, HR Bejjanki, J Roy-Chowdhury, C Koliopoulos, S Petmezaki and T Valaes, Departments of Medicine and Molecular Genetics and the Marion Bessin Liver Research Center, Albert Einstein College of Medicine, Bronx, New York; The Metera Maternity Hospital, Athens, Greece. Correspondence to: Timos N Valaes, 53 Demetrakopoulo u Str., Voula, GR16673, Greece (Tel./fax. ‡30 1 899 1702, e-mail. patgval@ote net.gr)

Biochemical markers of bone metabolism in infants and children under intravenous corticosteroid therapy

The short-term effects of corticosteroids (CS) administered intravenously (IV) on biochemical parameters of bone metabolism were followed in infants and children. Forty-nine patients from 2 months to 10 years of age, admitted to Pediatrics Department for bronchiolitis, viral-associated wheezing and croup, were treated with IV hydrocortisone or methylprednisolone (10 or 2 mg/Kg/day, respectively) for 3 days. Blood and fasting urine were collected on admission (day 1), 2 days later (day 3) and 12 days after the end of therapy (day 15). Fifty-one children of similar age and gender without respiratory problems or bone diseases were used as controls. On day 3, suppression of the bone formation markers osteocalcin (OC) (P < 0.001) and total alkaline phosphatase (ALP) (P < 0.05) was observed, but not of the bone resorption markers of hydroxyproline, pyridinoline and calcium excretion (UHyp/UCr, UPYD/UCr and UDPD/UCr, UCa/UCr). Significant decreases were indicated in serum phosphate (Pi) and the maximum renal tubular Pi reabsorption (TmP/GFR) compared to basal (P < 0.001). No significant changes were noticed in the circulating levels of calcium (Ca), parathyroid hormone (iPTH), 25OHD, 24,25(OH)2D, 1,25(OH)2D, the insulin-like growth factor-I (IGF-I) and its binding protein-3 (IGFBP-3). Two weeks after therapy, the increase of OC to higher than basal (P < 0.01) indicated a probable activation of the osteoblasts. Serum Pi and the TmP/GFR index values that had significantly decreased by day 3 returned to pretreatment levels by day 15. When assessing the effects of the CS in relation to age, no changes were detected in the levels of OC and total ALP in the <12-month-old children, but a fall of OC was observed in the >1-year-old group (P < 0.001). In contrast to the OC, the effects on serum and renal tubular reabsorption of phosphate were similar for both groups. In conclusion, short-term IV administered CS led to significant but reversible inhibition of bone formation markers, especially detectable in the >1-year-old children, without affecting the bone resorption ones. The adverse effects on phosphate metabolism were also significant, but temporal and irrespective of age.

An Interpretative Model of Early Indicators of Specific Developmental Dyslexia in Preschool Age: A Comparative Presentation of Three Studies in Greece.

The detection of specific factors of the developmental dyslexia at an early stage, and the identification of the role of those factors responsible for its manifestation, is a fundamental area of study on dyslexia in the recent literature. The objective of the present study is to clarify that dysfunctions in the following specific domains contribute in a causal model to the occurrence of dyslexia at an early stage: phonological awareness, psychomotor ability (body shape, spatio-temporal orientation, grapho-motor ability and laterality), perception, memory, attention, prereading and prewriting skills. The results of three studies, --carried out in Greece--which revealed the above factors as main predictors of the early onset of Specific Developmental Dyslexia (SDD) and confirmed the importance of intervention methods to it, led us to the construction of the proposed, causal model. The findings of these three studies converge on the perspective that the understanding, diagnosis and treatment of dysfunctions in the above domains, from preschool age, enable the early and reliable prevention of future difficulties in the learning process of children.

Idiopathic intracranial hypertension and facial palsy: case report and review of the literature.

We present the case of an 11-year-old obese girl who presented with idiopathic intracranial hypertension affecting first the lateral abducens nerve. She received acetazolamide, but 5 days later she developed lateral, peripheral facial palsy. Imaging evaluation was normal, which primarily excluded cerebral venous thrombosis and sustained the initial diagnosis. Despite some complicating factors (obesity, elevated intracranial pressure), prednisolone was administered for a short-term period to counteract the facial palsy. Ophthalmological residuals resolved within almost 1.5 months, while facial palsy receded after 4 months. Peripheral facial palsy is an extremely rare, but not unknown condition in idiopathic intracranial hypertension. As a symptom, it should be investigated thoroughly, primarily to exclude cerebral venous sinus thrombosis, before it can be attributed to idiopathic intracranial hypertension. As far as treatment is concerned, corticosteroids can be added to the initial treatment with acetazolamide, without worsening already elevated intracranial hypertension or ophthalmologic findings.