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Exchange transfusion for first stroke associated with sickle cell anemia
This Month in
THE JOURNAL OF
PEDIATRICS November 2006 • Volume 149 • Number 5 Copyright © 2006 by Mosby, Inc.
THE EDITORS’ PERSPECTIVES Children treated with valproic acid have evidence of oxidative stress
Laboratory markers to discriminate between bacterial and viral infections
Michoulas et al from the University of British Columbia report increased urinary levels of 15-F2t-isoprostane compared to control groups. These results suggest that reactive oxygen species may have a role in the hepatotoxicity of valproic acid.
Peltola et al collate more than one decade of experience of concomitant measurement of peripheral white blood cell (WBC) count and serum C-reactive protein (CRP) level to distinguish bacterial versus viral infection. Their data show that high WBC is a good marker for pneumococcal but not staphylococcal infection and that CRP adds little clinical value to WBC in distinguishing bacterial from viral infection. Pursuit of the holy grail of laboratory markers continues. The clinical constellation of the context and history of illness, findings on examination and simple laboratory tests together trump any individual test. The study’s findings regarding Staphylococcus aureus remind us of important clinical concepts. For example, infection due to exotoxin- or endotoxin-producing organisms (S. aureus, S. pyogenes, gram-negative bacilli) frequently is associated with normal or low total WBC count with shift to immature forms. CRP is a measure of tissue necrosis or inflammation regardless of cause – most useful to monitor response to interventions or natural history of disease.
—Robert W. Wilmott, MD page 692
Exchange transfusion for first stroke associated with sickle cell anemia In this issue of The Journal, Hulbert et al provide new insight into the optimal urgent management of children with sickle cell disease (SCD) at the time of a first overt stroke. They performed further analysis of a previously published (J Pediatr 2002;140:34854) 14-center retrospective cohort study of management and longterm follow-up (mean 10.1 years) of 137 patients with SCD and stroke. The main finding of that analysis was that a first stroke in the absence of an antecedent or concurrent associated medical event was the major risk factor for recurrence despite chronic transfusion therapy. In the current analysis, and taking the previous finding into consideration, children whose management of first stroke was a simple transfusion versus an exchange transfusion had a 5.0 times relative risk (95% confidence interval 1.3, 18.6) of a second stroke. In another article, Uong et al report a prospective study of the value of daytime oxygen saturation measurements (SpO2) made in the first six months of life for predicting subsequent episodes of pain and acute chest syndrome. They found that awake, daytime, SpO2 values were not predictive, which stands in contrast to recent reports of nocturnal oxygen saturations predicting first time strokes and pain crises. In an accompanying editorial, Redding-Lallinger discusses the findings of these studies and optimizing the medical care and quality-of-life outcomes for children with sickle cell disease.
—Sarah S. Long, MD —Robert W. Wilmott, MD page 710 (Hulbert) page 707 (Uong) page 595 (editorial)
—Sarah S. Long, MD page 721
Another indication of immaturity resulting from maternal diabetes Maternal diabetes results in increased exposure of the fetus to high glucose levels that cause release of fetal insulin. Insulin promotes growth and delays differentiation in the fetus. The wellknown clinical correlates are an increased risk of lung immaturity resulting in respiratory distress syndrome and decreased bilirubin conjugation associated with increased hyperbilirubinia. In this issue of The Journal, Bromiker et al demonstrate that infants born to insulin-dependent mothers have less well-developed sucking patterns, which suggests neurologic immaturity. This physiologic demonstration of poor feeding behavior is consistent with the general teaching that infants of mothers with diabetes often do not feed well over the first days of life.
—Alan H. Jobe, MD, PhD page 640
The Journal of Pediatrics (ISSN 0022-3476) is published monthly by Elsevier Inc., 360 Park Avenue South, New York, NY 10010. Business and Editorial Offices: 1600 John F. Kennedy Blvd., Suite 1800, Philadelphia, PA 19103-2899. Accounting and Circulation Offices: 6277 Sea Harbor Drive, Orlando, FL 32887-4800. Periodicals postage paid at New York, NY, and additional mailing offices. POSTMASTER: Send address changes to The Journal of Pediatrics, Elsevier Periodicals Customer Service, 6277 Sea Harbor Drive, Orlando, FL 32887-4800.
The Journal of Pediatrics
November 2006
1A
THE JOURNAL OF
PEDIATRICS November 2006 • Volume 149 • Number 5 Copyright © 2006 by Mosby, Inc.
THE EDITORS’ PERSPECTIVES Children treated with valproic acid have evidence of oxidative stress
Laboratory markers to discriminate between bacterial and viral infections
Michoulas et al from the University of British Columbia report increased urinary levels of 15-F2t-isoprostane compared to control groups. These results suggest that reactive oxygen species may have a role in the hepatotoxicity of valproic acid.
Peltola et al collate more than one decade of experience of concomitant measurement of peripheral white blood cell (WBC) count and serum C-reactive protein (CRP) level to distinguish bacterial versus viral infection. Their data show that high WBC is a good marker for pneumococcal but not staphylococcal infection and that CRP adds little clinical value to WBC in distinguishing bacterial from viral infection. Pursuit of the holy grail of laboratory markers continues. The clinical constellation of the context and history of illness, findings on examination and simple laboratory tests together trump any individual test. The study’s findings regarding Staphylococcus aureus remind us of important clinical concepts. For example, infection due to exotoxin- or endotoxin-producing organisms (S. aureus, S. pyogenes, gram-negative bacilli) frequently is associated with normal or low total WBC count with shift to immature forms. CRP is a measure of tissue necrosis or inflammation regardless of cause – most useful to monitor response to interventions or natural history of disease.
—Robert W. Wilmott, MD page 692
Exchange transfusion for first stroke associated with sickle cell anemia In this issue of The Journal, Hulbert et al provide new insight into the optimal urgent management of children with sickle cell disease (SCD) at the time of a first overt stroke. They performed further analysis of a previously published (J Pediatr 2002;140:34854) 14-center retrospective cohort study of management and longterm follow-up (mean 10.1 years) of 137 patients with SCD and stroke. The main finding of that analysis was that a first stroke in the absence of an antecedent or concurrent associated medical event was the major risk factor for recurrence despite chronic transfusion therapy. In the current analysis, and taking the previous finding into consideration, children whose management of first stroke was a simple transfusion versus an exchange transfusion had a 5.0 times relative risk (95% confidence interval 1.3, 18.6) of a second stroke. In another article, Uong et al report a prospective study of the value of daytime oxygen saturation measurements (SpO2) made in the first six months of life for predicting subsequent episodes of pain and acute chest syndrome. They found that awake, daytime, SpO2 values were not predictive, which stands in contrast to recent reports of nocturnal oxygen saturations predicting first time strokes and pain crises. In an accompanying editorial, Redding-Lallinger discusses the findings of these studies and optimizing the medical care and quality-of-life outcomes for children with sickle cell disease.
—Sarah S. Long, MD —Robert W. Wilmott, MD page 710 (Hulbert) page 707 (Uong) page 595 (editorial)
—Sarah S. Long, MD page 721
Another indication of immaturity resulting from maternal diabetes Maternal diabetes results in increased exposure of the fetus to high glucose levels that cause release of fetal insulin. Insulin promotes growth and delays differentiation in the fetus. The wellknown clinical correlates are an increased risk of lung immaturity resulting in respiratory distress syndrome and decreased bilirubin conjugation associated with increased hyperbilirubinia. In this issue of The Journal, Bromiker et al demonstrate that infants born to insulin-dependent mothers have less well-developed sucking patterns, which suggests neurologic immaturity. This physiologic demonstration of poor feeding behavior is consistent with the general teaching that infants of mothers with diabetes often do not feed well over the first days of life.
—Alan H. Jobe, MD, PhD page 640
The Journal of Pediatrics (ISSN 0022-3476) is published monthly by Elsevier Inc., 360 Park Avenue South, New York, NY 10010. Business and Editorial Offices: 1600 John F. Kennedy Blvd., Suite 1800, Philadelphia, PA 19103-2899. Accounting and Circulation Offices: 6277 Sea Harbor Drive, Orlando, FL 32887-4800. Periodicals postage paid at New York, NY, and additional mailing offices. POSTMASTER: Send address changes to The Journal of Pediatrics, Elsevier Periodicals Customer Service, 6277 Sea Harbor Drive, Orlando, FL 32887-4800.
The Journal of Pediatrics
November 2006
1A