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Indian Pediatr 2012;49:253
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K Rajeshwari
Email:
[email protected]
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Sildenafil for lymphatic malformations (N Engl J Med 2012;
366:384-386)
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Lymphatic malformations are uncommon congenital vascular anomalies that
can cause complications including obstruction of vital organs and their
function, recurrent infection, and disfigurement. Current procedural
treatments are only partially successful, and lymphatic malformations
often recur. Sildenafil selectively inhibits phosphodiesterase-5,
preventing the breakdown of cyclic guanosine monophosphate. Inhibition
of phosphodiesterase-5 decreases the contractility of vascular smooth
muscle, producing vasodilation. The drug has been approved for the
treatment of pulmonary hypertension in adults and is used off-label in
children with pulmonary hypertension and appears to be safe and
effective. Lymphatic malformations are hypothesized to develop from
primitive lymphatic sacs that arise from mesenchyme. The contraction of
thickened muscular linings may increase intramural pressure and cause
cystic dilatation. A potential explanation for the therapeutic effect
seen in this series of three children is the relaxation of smooth muscle
followed by cystic decompression. Alternatively, relaxation may allow
secondary lymphatic spaces to open, or sildenafil may normalize
lymphatic endothelial dysfunction.
Comments Sildenafil represents an encouraging
treatment for lymphatic malformations, used as monotherapy or with other
treatments.
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Antibiotic prophylaxis in elective cesarean delivery (Arch
Surg 2011 ;146(12):1404-9)
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Perioperative antibiotic prophylaxis during elective cesarean
delivery at term to reduce postoperative maternal infectious
morbidity is generally used but may not be effective on the
basis of the available data. Also, the optimal timing of
prophylactic antibiotic administration is unclear. This study
compared the effectiveness of cefazolin administered before skin
incision vs cefazolin administered after umbilical cord
clamping vs placebo in a 3-arm randomized trial. The
primary objective of the study was to compare postoperative
infectious morbidity, defined as wound infection, endometritis,
or urinary tract infection. This study recruited 1112 women
undergoing elective cesarean delivery at term into three groups:
In group 1, cefazolin was administered 20 to 30 minutes
before skin incision, in group 2 it was administered immediately
after clamping of the cord and in group 3, placebo was
administered before skin incision. The primary outcome was
observed in 4.9% women in group 1, in 3.8% in group 2 %, whereas
it was noted in 12.1% women in group 3 (P <.001 for group
1 plus group 2 vs group 3).
Comments This study
demonstrated the usefulness of prophylactic cefazolin in
elective cesarean delivery for reducing postoperative maternal
infectious morbidity.
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Diagnosis of portal hypertension (South Med J 2012;
105(1):6-10)
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This study compared findings of grayscale and color Doppler ultrasound
(CDUS) findings to that of multidetector computed tomography (MDCT)
portography in the evaluation of portal hypertension in children. Thirty
children (mean age, 11.4 years) with definitive clinical and laboratory
diagnoses of portal hypertension were included in the study. Liver
parenchymal heterogeneity was detected more often by CDUS than MDCT.
CDUS and MDCT established similar results for increased right/left lobe
ratio, lobulation of the liver contour, ascites, and splenomegaly,
portal vein thrombosis, cavernous transformation, and recanalization of
the paraumbilical vein. Collaterals were detected more by MDCT
portography than by CDUS. Esophageal collaterals and azygous vein
dilatation were seen only by MDCT portography.
Comments The combination of these two
modalities provides more comprehensive information than either alone in
the diagnosis and follow-up of portal hypertension.
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Current status of prophylactic phototherapy for preventing jaundice
(Cochrane Database Syst Rev 2012 Jan 18; 1:CD007966)
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Low birth weight and premature infants are at major risk for
hyperbilirubinemia and jaundice that can lead to bilirubin
encephalopathy. This study evaluated the efficacy and safety of
prophylactic phototherapy for preterm (<37 weeks gestational
age) or low birth weight infants (birth weight <2500 g).
Randomized controlled trials or quasi-randomised controlled
studies evaluating the effects of prophylactic phototherapy for
preterm or low birth weight infants were included for analysis.
Fixed-effect meta-analysis for the outcomes: rate of exchange
transfusion, cerebral palsy or other neurodevelopmental
impairment, peak serum bilirubin level and all-cause mortality
was done. There was no statistically significant difference in
the rate of cerebral palsy (RR 0.96; 95% CI 0.50 to 1.85; two
studies, 756 participants). The prophylactic phototherapy group
had lower peak bilirubin levels (mean difference -2.73; 95% CI
-2.89 to -2.57; six studies, 2319 participants) and had fewer
neonates with peak unconjugated serum bilirubin levels >10 mg/dL
(RR 0.27; 95% CI 0.22 to 0.33; three studies, 1090 participants)
or peak unconjugated serum bilirubin levels >15 mg/dL (RR 0.13;
95% CI 0.07 to 0.23; four studies, 1116 participants).
Comments Prophylactic phototherapy
helps to maintain a lower serum bilirubin concentration and may
have an effect on the rate of exchange transfusion and the risk
of neurodevelopmental impairment.
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