What is the outcome of rheumatic carditis in children with Sydenham's chorea?

We evaluated the echocardiographic features of 69 children diagnosed with Sydenham's chorea at the first attack of acute rheumatic fever. By echocardiography, carditis was detected in 71% of cases and silent carditis was shown in 28.9% of cases at initial presentation. Most patients had mild or moderate valvular regurgitation. Sixty-three cases were followed from 1-10 years. The improvement rate in valvulitis in cases with silent carditis (29.4%) was not different than in cases with clinical carditis (18.5%) (p > 0.05). Persistence of valvular pathologies occurred in 72.2% of cases with carditis in the long-term follow-up (> 2 years). Most patients (88.8%) complied with secondary prophylaxis, so relapse of carditis was exclusively prevented in our patients. Recurrence of chorea was identified in 20.6% of cases and was not associated with clinical or laboratory evidence for streptococcal reinfection. Patients with chorea usually had mild carditis, and carditis showed resolution. Relapse of carditis in our population was exclusively prevented with secondary prophylaxis. Recurrence of chorea was not rare, despite regular treatment with benzathine penicillin.     

What is the right dose of epinephrine?

OBJECTIVE: To review the findings and discuss implications of studies on high-dose epinephrine (0.1 mg/kg) during cardiopulmonary resuscitation in children. DESIGN: A critical appraisal of "A Comparison of High-Dose and Standard-Dose Epinephrine in Children with Cardiac Arrest" by Perondi et al. (N Engl J Med 2004; 350:1722-1730), with literature review. FINDINGS: Retrospective studies investigating the use of high-dose epinephrine during pediatric cardiopulmonary resuscitation demonstrate conflicting results with respect to return of spontaneous circulation and survival. The randomized controlled trial by Perondi et al. demonstrates decreased survival with the use of high-dose epinephrine and no difference in return of spontaneous circulation when compared with the standard dose. CONCLUSIONS: There is no benefit from the use of high-dose epinephrine in pediatric cardiopulmonary resuscitation. There is potential harm from such dosing. The cumulative evidence against the use of high-dose epinephrine during pediatric cardiopulmonary resuscitation is strong.     

What is the role of tonsillectomy in children?]

Tonsillectomy is mandatory in the case of chronic airway obstruction associated with tonsillar hypertrophy and in the case of a unilateral enlarged tonsil which may be malignant. Tonsillectomy may be indicated in recurrent tonsillitis. More rarely, tonsillectomy is performed in children for tonsil bleeding or chronic tonsillitis. Allergy and bleeding disorders are not a contraindication for tonsillectomy.     

What is the role of enhanced recovery after surgery in children? A scoping review

Purpose

Enhanced recovery after surgery (ERAS) pathways are standard practice in adult specialties resulting in improved outcomes. It is unclear whether ERAS principles are applicable to Paediatric Surgery. We performed a scoping review to identify the extent to which ERAS has been used in Paediatric Surgery, the nature of interventions, and outcomes.

Methods

Pubmed, Cochrane library, Google Scholar, and Embase were searched using the terms enhanced recovery, post-operative protocol/pathway, fast track surgery, and paediatric surgery. Studies were excluded if they did not include abdominal/thoracic/urological procedures in children.

Results

Nine studies were identified (2003–2014; total 1269 patients): three case control studies, one retrospective review and five prospective implementations, no RCTs. Interventional elements identified were post-operative feeding, mobilisation protocols, morphine-sparing analgesia, reduced use of nasogastric tubes and urinary catheters. Outcomes reported included post-operative length of stay (LOS), time to oral feeding and stooling, complications, and parent satisfaction. Fast-track programmes significantly reduced LOS in 6/7 studies, time to oral feeding in 3/3 studies, and time to stooling in 2/3 studies.

Conclusion

The use of ERAS pathways in Paediatric surgery appears very limited but such pathways may have benefits in children. Prospective studies should evaluate interventions used in adult ERAS on appropriate outcomes in the paediatric setting.

     

What is the place of genetics in the pathogenesis of pre-eclampsia?

It is most unlikely that there is a single 'pre-eclampsia (PE) gene'. We are probably looking for a cluster of polymorphisms which, possibly in conjunction with environmental factors, predispose to the development of the condition. Accurate phenotyping is vital for any genetic studies of PE, and since the disease is only clinically-detectable in the second half of pregnancy, is particularly difficult. It is increasingly likely that there is a fetal genetic contribution which can only be examined after birth. Candidate genes examined on the basis of displayed or hypothetical pathophysiological effects, but for which no evidence of association or linkage has been found have included HLA-DRbeta, HLA-G, and tumour necrosis factor alpha (chromosome 6), angiotensin-converting enzyme (chromosome 17) and CuZn superoxide dismutase (chromosome 21). Chromosomal exclusion mapping and a pedigree study suggest a role for genes on chromosomes 1, 3, 4, 9 or 18. Two genes concerned with clotting, those for factor 5 and methylenetetrahydrofolate reductase, lie on chromosome 1. Both have polymorphisms present in significantly higher frequency in women with PE, as well as showing functional abnormality. They probably predispose to the development of the condition, without being necessary for it. The angiotensinogen (Aogen) gene also lies on chromosome 1. The renin-angiotensin system may be activated during the early stages of PE and subsequently suppressed. In some populations, a relatively common polymorphism is present in raised frequency in women with PE, but it is also raised in non-pregnant hypertensive subjects. However, it is in partial linkage disequilibrium with another polymorphism which shows significantly distorted transmission from mother to fetus in PE pregnancies. Furthermore, its expression is significantly raised in the decidual spiral arteries; abnormal placentation is a feature of PE. We have also shown that a relatively common polymorphism in the angiotensin AT1 receptor gene (chromosome 3) is associated with raised density of the receptor. Thus far, studies of candidate genes have been on a small scale and have very much reflected the pathophysiological research interests of the investigators. The multifaceted nature of PE and the difficulties of accurate phenotyping require the accumulation of a large, very carefully phenotyped, database. It is hoped that funding will become available this year in the UK to allow the collection of such a database. The introduction of chip technology should allow genome scanning of the resource.     

What is new in the management of childhood asthma?

The prevalence of asthma has increased in developed countries. The efficacy of available drugs in those with severe persistent disease is limited. This has led to a renewed search for the reasons for failures of the existing treatment and for novel concepts. Treatment with inhaled corticosteroids, and to a much lesser extent theophylline, can reduce the survival of inflammatory cells including esinophils. Emerging trends in treatments for asthma could include strategies to alter the cytokine/chemokine balance. It is evident that the current ICS are already very efficient and safe, it will be difficult to introduce further improved formulations. Perhaps the most fruitful effort shall be in developing patient friendly easy to use targeted delivery systems. The newer therapies are planned for the several upstream targets and may have potential to prevent the disease. Various potential therapies are being worked upon like-targeting prevention of T cell activation, modulation of Th-1/Th-2 differentiation, inhibition of Th-2 related cytokines, Th-1/Th-2 modulation, inhibition of downstream mediators etc. The new strategy shall perhaps lie with matching the patients and their disease with the most suitable therapy.     

What is New in the Management of Childhood Asthma?

Asthma still causes considerable morbidity and mortality globally and minimal improvement has been seen in key outcomes over the last decade despite increasing treatment costs. This review summarizes recent advances in the management of asthma in children and adolescents. It focuses on the need for personalized treatment plans based on heterogenous asthma pathophysiology, the use of the terminology ‘asthma attack’ over exacerbation to instill widespread understanding of severity, and the need for every attack to trigger a structured review and focused strategy. The authors discuss difficulties in diagnosing asthma, accuracy and use of Fractional exhaled nitric oxide both as second line test and as a method to monitor treatment adherence or guide the choice of pharmacotherapy. The authors discuss acute and long-term management of asthma. Asthma treatment goals are to minimize symptom burden, prevent attacks and (where possible) reduce risk and impact of progressive pathophysiology and adverse outcomes. The authors discuss pharmacological management; optimal use of short acting β₂ agonists, long acting muscarinic antagonist (tiotropium), use of which is relatively new in pediatrics, allergen specific immunotherapy, biological monoclonal antibody treatment, azalide antibiotic azithromycin, and the use of vitamin D. They also discuss electronic monitoring and adherence devices, direct observation of therapy via mobile device, temperature controlled laminar airflow device, and the importance of considering when symptoms may actually result from dysfunctional breathing rather than asthma.     

Prophylaxis of acute chemotherapy‐induced nausea and vomiting in children with cancer: What is the evidence?

BACKGROUND: Nausea and vomiting are preventable side effects of cancer chemotherapy for children. Antiemetics are essential, especially as treatment becomes more intensive. Many drugs are available, but adequate evidence-based recommendations are lacking. We aimed (1) to consider an evidence-based approach for pharmacological prophylaxis of chemotherapy-induced nausea and vomiting (CINV) in children, and (2) to compare this approach with antiemetic prescribing in two paediatric oncology centres. PROCEDURE: Relevant publications (Medline, Embase, CancerLit:1966-2002) were critically evaluated using pre-defined criteria. Evidence-based statements summarising their findings were formulated, and evidence basis proposed. Current prescribing practice was then compared with this evidence basis in Welsh children under 16 receiving chemotherapy at Llandough Hospital, Cardiff or Alder Hey Children's Hospital, Liverpool between 1 January 2001 and 31 December 2001. RESULTS: Of 213 studies retrieved, 82 provided evidence. Our evidence basis recommends combination 5HT3-antagonist/corticosteroid for highly emetogenic chemotherapy, 5HT3-antagonist alone for moderate emetogenicity, and no antiemetic for other chemotherapy. Forty-four children in Cardiff (0.6-16.9 yrs) and 14 in Liverpool (0.8-16.2 yrs) were included in the audit. Differences in prescribing practice between the centres were not significant. In 109/159 (69%) of chemotherapy courses (35, 87 and 100% of high, moderate and low emetogenicity, respectively), antiemetics were selected in accordance with evidence basis. Seventy percent of prescribed doses were as evidence basis recommended. CONCLUSIONS: We present an evidence basis for prescribing prophylactic antiemetics to children undergoing chemotherapy. Prescribing practices in these two centres treating Welsh children were similar. Both differed from the evidence basis we propose. Deviations were greatest for regimens of high emetogenicity, where effective emetic control is most crucial.