Tony Walls

Improved outcome for children with disseminated adenoviral infection following allogeneic stem cell transplantation

Adenovirus (AdV) infections are a frequent cause of morbidity and mortality following allogeneic stem cell transplantation (SCT), and disseminated infection is associated with high mortality, particularly in paediatric SCT. Here, we describe an approach to reduce mortality from adenoviraemia by combining prospective monitoring for the occurrence of adenoviraemia using a sensitive polymerase chain reaction method, early antiviral therapy and prompt withdrawal of immunosuppression. A total of 155 consecutive paediatric SCT procedures were prospectively monitored, of which 113 (73%) transplants involved donors other than matched siblings and 126 (83%) employed T‐cell depletion. Adenoviraemia was detected in 26/155 (17%) transplants and developed exclusively in patients who had received T‐cell‐depleted grafts. Withdrawal of immunosuppression coupled with early antiviral therapy led to resolution of adenoviraemia in 19/26 (81%) patients with only five patients succumbing to disseminate AdV infection. Survival from adenoviraemia was associated with lymphocyte recovery to above 0·3 × 109/l. Mortality was closely linked with the absence of lymphocyte recovery because of profound T‐cell depletion of the graft with CD34+ magnetic‐activated cell sorting. Mortality from disseminated AdV infection was 5/26 (19%) in this study, which is significantly lower than previously reported.

Adenovirus infection after pediatric bone marrow transplantation: Is treatment always necessary?

BACKGROUND Adenovirus infections are associated with significant rates of morbidity and mortality among children after bone marrow transplantation (BMT). Many transplantation units use molecular virological methods, such as polymerase chain reaction (PCR), for surveillance for adenovirus infection and give preemptive antiviral therapy to children with evidence of disseminated adenovirus infection. This treatment strategy has never been evaluated in clinical trials. METHODS We retrospectively tested blood samples obtained from a cohort of children who had undergone BMT before the introduction of regular weekly surveillance for adenovirus infection. A total of 273 samples collected from 26 patients between May 1998 and June 2002 were tested for adenovirus infection by quantitative PCR. Virus load was quantified for each sample yielding positive test results, and the clinical notes and virological records of each child were reviewed. RESULTS Evidence of adenovirus infection was found in 11 children (42%), 7 of whom had not previously had positive test results. Receipt of T cell-depleted transplants was associated with a significantly higher incidence of adenovirus infection during the posttransplantation period. The 2 children who died from adenovirus disease developed infection within 2 weeks after transplantation, and both had very low absolute lymphocyte counts at the time of diagnosis. Seven of 11 children with blood samples that were found to be positive for adenovirus by PCR cleared the virus without antiviral therapy. CONCLUSIONS Surveillance for adenovirus by PCR is better than symptomatic testing for detecting adenovirus infection. Antiviral therapy may not be necessary for all children who develop adenovirus viremia after BMT.

The epidemiology of tuberculosis in Europe

Tuberculosis (TB) continues to be one of the most devastating and widespread infections in the world. It is estimated that in 2004 there were 8.9 million new cases of TB globally.1 In general, children make up only a small proportion of cases, but in some high-incidence countries up to 15% of all TB cases occur in children.2 In June 2005 the World Health Organization (WHO) approved a new Stop TB Strategy with the aim of dramatically reducing the global burden of TB by 2015.3 Their intention is to cure at least 85% of sputum smear-positive cases and reduce the prevalence of and deaths due to TB by 50% relative to the rates in 1990. The WHO Global tuberculosis control report shows that the greatest burden of TB is in sub-Saharan Africa and Asia, with TB case notifications in the WHO European Region constituting less than 10% of worldwide notifications.1 While notifications are an excellent source of information on adult disease, an accurate description of the burden of TB in children is very difficult to obtain. The WHO notification criteria include only cases that are sputum smear positive. Fewer than 15% of children with culture-proven TB will be sputum smear positive, with the result that only a small percentage of children with TB will be represented in the data. The quality of information provided to the WHO can also vary and in many countries surveillance data are often unreliable due to poor diagnostic facilities and reporting systems. Because of these issues the International Union Against Tuberculosis and Lung Disease has stated that reliable information on the incidence of TB in childhood can only be obtained in developed countries, which have better diagnostic and reporting systems.4 In Europe there is a huge disparity in the rates of …

Nutritional status and nutrition risk screening in hospitalized children in New Zealand

Children requiring hospitalization are at risk of malnutrition. This study aimed to define the nutritional status of paediatric inpatients in comparison with healthy children and to compare and contrast the feasibility and validity of three nutritional risk screening (NRS) tools in the hospitalized children.

Infant outcomes after exposure to Tdap vaccine in pregnancy: an observational study.

Objective Pertussis vaccination during pregnancy has recently been recommended in both the USA and UK to prevent pertussis infection in infants. While there are no apparent safety concerns about the administration of Tdap vaccine during pregnancy, there is only limited safety data available. We aimed to closely monitor infants exposed to Tdap during pregnancy to look for any adverse outcomes that may be attributable to the vaccine. Design This was a prospective observational study, collecting information to evaluate the safety of Tdap vaccine for infants exposed during pregnancy. Infants were followed for between 6 and 12 months after birth, with 84% completing 12 months of follow-up. Information was obtained from objective sources including routine health visits and vaccination records wherever possible, as well as frequent parental reports. Setting The Canterbury region of New Zealand. Patients A cohort of 403 infants whose mothers had received Tdap vaccine. Main outcome measures Gestational age at birth, growth parameters, congenital anomalies, immunisation status and timeliness of immunisation, development of pertussis infection. Results There were no significant differences in birth weight, gestational age at birth, congenital anomalies or infant growth as compared with baseline population data. Infants of mothers who had received the vaccine were more likely to receive their vaccinations on time during infancy. No cases of pertussis occurred in this cohort despite high rates of disease in the community. We have not found any adverse events attributable to vaccine exposure. Conclusions These data add to the growing pool of evidence that the administration of Tdap vaccine during pregnancy is an appropriate strategy for reducing the burden of pertussis in infants. Clinical trial registration Australia New Zealand Clinical Trials Registry ACTRN12613001045707.

Assessment of nutritional status and nutritional risk in hospitalized Iranian children.

Aims:  This study aimed to define the nutritional state of children admitted to a tertiary Iranian hospital and to evaluate nutritional risk score tools in these children.

Broad‐range polymerase chain reaction for the diagnosis of Bartonella henselae endocarditis

Abstract:  We present a case of subacute bacterial endocarditis in a 10‐year‐old girl with Di‐George syndrome, congenital heart disease, and mild immunodeficiency. She was afebrile at initial presentation but was found to have massive splenomegaly, and signs of congestive heart failure. No causative organism could be identified on routine blood and tissue cultures. A detailed clinical history revealed a history that she had been scratched by a cat and developed intermittant fevers over 3 months. Bartonella henselae was identified by broad‐range 16S r‐DNA polymerase chain reaction on valvular tissue specimens.

Safety of Tdap vaccine in pregnant women: an observational study

Objectives Actively recruit and intensively follow pregnant women receiving a dose of acellular pertussis vaccine for 4 weeks after vaccination. Design and settings A prospective observational study conducted in 2 New Zealand regions. Participants Women in their 28th–38th week of pregnancy, recruited from primary care and antenatal clinics at the time of Tdap administration. Telephone interviews were conducted at 48 h and 4 weeks postvaccination. Main outcomes measures Outcomes were injection site reactions, systemic symptoms and serious adverse events (SAEs). Where available, data have been classified and reported according to Brighton Collaboration definitions. Results 793 women participated with 27.9% receiving trivalent inactivated influenza vaccine concomitantly. 79% of participants reported mild or moderate pain and 2.6% severe pain. Any swelling was reported by 7.6%, induration by 12.0% (collected from 1 site only, n=326), and erythema by 5.8% of participants. Fever was reported by 17 (2.1%) participants, 14 of these occurred within 24 h. Headache, dizziness, nausea, myalgia or arthralgia was reported by <4% of participants, respectively, and fatigue by 8.4%. During the study period, there were 115 adverse events in 113 participants, most of which were minor. At the end of the reporting period, 31 events were classified as serious (eg, obstetric bleeding, hypertension, infection, tachycardia, preterm labour, exacerbation of pre-existing condition and pre-eclampsia). All had variable onset time from vaccination. There were two perinatal deaths. Clinician assessment of all SAEs found none likely to be vaccine related. Conclusions Vaccination with Tdap in pregnant women was well tolerated with no SAE likely to be caused by the vaccine. Trial registration number ACTRN12613001045707.

What is behind the ear drum? The microbiology of otitis media and the nasopharyngeal flora in children in the era of pneumococcal vaccination

This study aims to describe the microbiology of middle ear fluid (MEF) in a cohort of children vaccinated with Streptococcus pneumoniae conjugate vaccine (PCV7) having ventilation tube insertion. Nasopharyngeal (NP) carriage of otopathogens in these children is compared with children without history of otitis media.

High rates of complications following Kingella kingae infective endocarditis in children: a case series and review of the literature.

Kingella kingae is part of the Haemophilus spp., Aggregatibacter spp., Cardiobacterium hominis, Eikenella corrodens and Kingella spp. organisms that are known to cause bacterial endocarditis. Evidence suggests it is also a common pharyngeal colonizer in children <2 years of age. We reviewed the literature to determine common complications of K. kingae infective endocarditis in children.