Can omalizumab be used effectively to treat severe conjunctivitis in children with asthma? A case example and review of the literature

A 14-year-old girl with poorly controlled asthma attended the difficult-to-treat asthma clinic for review. Although she has eosinophilia and significantly raised immunoglobulin E levels, she is not currently a candidate for omalizumab (Xolair). She also suffers from chronic urticaria, eosinophilic eosophagitis and severe conjunctivitis. You wonder if omalizumab would be effective in treating her multiple atopic conditions, in particular her troublesome conjunctivitis. PubMed was searched using the following search terms: (Omalizumab) or (Xolair) and (conjunctivitis). Searches were conducted in November 2020. Abstracts were selected for full text review if the study population identified asthma as a comorbidity. Non-paediatric studies and those that were not written in English were excluded. The use of omalizumab has the potential to be effective in the treatment of conjunctivitis associated with asthma and other atopic conditions. However, research is needed to address the question, in the form of multicenter, double-blind randomized control trials.     

Should the lateral chest radiograph be routine in the diagnosis of pneumonia in children? A review of the literature

OBJECTIVE:

To assess the evidence of the additive diagnostic value of the lateral chest radiograph to the frontal chest radiograph in children (zero to 18 years) with suspected pneumonia in the emergency department.

METHODS:

The MEDLINE database (1966 to 2001) was searched to identify the highest level of evidence available in support of the lateral. The key words used included chest radiograph, pneumonia and chest x-ray.

RESULTS:

Only four controlled studies were identified that assessed the role of the lateral chest x-ray. Three of these studies were retrospective. In the first study, the addition of the lateral to the frontal chest x-ray in 414 children would have detected an additional nine patients (2.3%) with pneumonia. In the second study, involving 179 patients, a high level of agreement was found between the interpretations based on the frontal chest x-ray alone and those based on both views. A third study of 359 children assessed the criterion validity of a frontal chest x-ray alone. Based upon a radiologist’s interpretation of both views as the gold standard, the sensitivity of the frontal view alone was 86%. A fourth study of 158 children with suspected pneumonia revealed that the frontal view alone was diagnostic of pneumonia in 106 of 109 (97%) patients.

CONCLUSION:

There is no randomized controlled trial evidence to support the additive value of the lateral to the frontal chest x-ray in the diagnosis of children with pneumonia. Further prospective studies are required to determine if the addition of the lateral chest x-ray will modify therapy, prevent complications or whether it is cost-efficient.     

Can Destination Therapy be implemented in children with heart failure? A study of provider perceptions

DT is an established final therapeutic choice in adult patients with severe heart failure who do not meet criteria for cardiac transplantation. Patients are given VADs, without the prospect of care escalation to transplantation. VADs are now established therapy for children and are currently used as a bridge until transplantation can be performed or heart failure improves. For children who present in severe heart failure but do not meet transplantation criteria, the question has emerged whether DT can be offered. This qualitative study aimed to elicit the perspectives of early adopters of DT at one of the few institutions where DT has been provided for children. Responses were recorded and coded and themes extracted using grounded theory. Interviewees discussed: envisioning of the DT candidate; approach to evaluation for DT; contraindications to choosing DT; and concerns about choosing DT. Providers articulated two frameworks for conceptualizing DT: as a long bridge through resolution of problems that would initially contraindicate transplantation or, alternatively, as a true destination instead of transplantation. True destination, however, may not be the lasting concept for long‐term VAD use in children given improvement in prognosis for current medical contraindications and improving VAD technology.     

Bickerstaff Brainstem Encephalitis and overlapping Guillain-Barré syndrome in children: Report of two cases and review of the literature

Bickerstaff Brainstem Encephalitis (BBE) is a rare autoimmune encephalitis, characterized by acute ophthalmoplegia, ataxia and altered state of consciousness. Together with Guillan-Barrè Syndrome (GBS) and Miller–Fisher Syndrome, it forms a spectrum of post-infectious demyelinating diseases. Overlapping forms between BBE and GBS (BBE/GBS) are described in patients with lower limbs weakness and typical signs of BBE, suggesting a combined involvement of Central and Peripheral Nervous System (PNS), but only few reported cases are focused on pediatric population.We reviewed all cases of pediatric BBE in the literature, to determine if any patient showed features suggestive for BBE/GBS. Data analysis focused on the diagnostic tests performed (e.g. anti-GQ1b antibodies), neuroimaging and nerve conduction studies (NCS). Further attention was given to the therapeutic management and to patients’ outcome. We additionally present two previously unreported pediatric cases.Our review retrieved 19 cases of BBE/GBS, only 2 of which were originally and correctly diagnosed by the authors. The prevalence was higher in male subjects (ratio 3:1) and median age at diagnosis was 8 years. Anti-GQ1b were positive in 46% of the patients, while NCS were altered in 64%. Only 25% of the patients that underwent brain MRI showed abnormal findings.The incidence of BBE/GBS has been underrated in the past, mostly due to an underestimation of the PNS involvement. We therefore suggest to investigate all patients with a clinical picture suggestive of BBE/GBS through electroencephalogram, NCS, brain and spine MRI in order to promptly achieve the correct diagnosis.     

Does pneumoperitoneum always require laparotomy? Report of six cases and review of the literature

The presence of intraperitoneal free air signals perforation of a hollow viscus in over 90% of the patients. Rarely, however, the presence of pneumoperitoneum may not indicate an intra-abdominal perforation and thus may not require laparotomy. This condition, which poses a dilemma to the surgeon faced with this problem, is termed “nonsurgical", “spontaneous” or “idiopathic" pneumoperitoneum. Six cases of nonsurgical pneumoperitoneum admitted over a 2-year period to our institution are reported, and the etiological mechanisms and the pathophysiology of the appearance of intra-abdominal free gas are reviewed. Two of the six children with nonsurgical pneumoperitoneum underwent exploratory laparotomy when clinical examination suggested an acute abdomen; no intra-abdominal pathology was documented in one of these patients. In the other children, malrotation was found. Four patients, on ventilatory support, were managed conservatively after performing a diagnostic peritoneal lavage and/or contrast studies those were negative. An appreciation of the condition and its likely etiological factors should improve awareness and possibly reduce the imperative to perform emergency laparotomy on an otherwise well patient with an unexplained pneumoperitoneum. An erratum to this article can be found at     

Can the concentration of immunomodulating factors in mature breastmilk be associated with food alergy in breastfed children?

Objectives: The aim of the study was to determine the concentration of such immunomodulating factors as transforming growth factor beta1 (TGF-β1), interleukin 10 (IL-10), tumor necrosis factor alpha (TNF-α) in mature human milk and to relate the levels of the above mentioned cytokines in mature breast milk to the occurence of food allergy in children during the first 24 months of life. Materials and methods: Data on breastfeeding, symptoms of food allergy in children and breast milk samples were collected prospectively from birth to 24 months of age from 84 mothers participating in the Polish birth cohort of "EuroPrevall" study, in the years 2005-2007. Cytokine levels were measured in the whey with commercial enzyme-linked immunosorbent assays (ELISA) kits. Results: Ten out of the eighty four (11.9%) participating children had positive SPT and/or sIgE to food antigens. In 7 out of 84 (8.4%) children DBPCFC confirmed the diagnosis of food allergy. The median concentration of TGF-β1 was 21.94 pg/ml (range 10.47-83.19), TNF-α 1.46 pg/ml (range 0.35-16.50), IL- 101.83 pg/ml (range 0.58-31.04). There was a positive correlation between the concentration of IL-10 and TGF-β1. The level of TNF-α correlated positively with the duration of lactation (p=0.04). There was no significant difference between the concentration of IL-10, TGF-β1, TNF-α, in the mature breast milk of mothers of children with symptoms of allergy and positive SPT and/or sIgE, mothers of children with positive DBPCFC and in the milk of mothers of control children. Conclusions: There was no significant difference between the concentration of IL-10, TGF-β1, TNF-α, in the mature breast milk of mothers of children with food allergy and in the breast milk of mothers of control children.     

Mesenteric lymphatic malformation associated with small-bowel volvulus – two cases and a review of the literature

Cystic mesenteric lymphatic malformations are uncommon abdominal masses, which can cause abdominal signs and symptoms for a wide variety of reasons. Symptoms owing to volvulus are uncommon and have not been illustrated previously in the radiology literature. We present two cases to illustrate volvulus as a complication of mesenteric lymphatic malformations and how imaging can aid in the diagnosis of this complication. While uncommon, volvulus should be considered in any child with sonographic findings of an abdominal lymphatic malformation and acute abdominal pain.     

Can you age bruises accurately in children? A systematic review

Aims: To investigate whether it is possible to determine the age of a bruise in a child in clinical practice by means of a systematic review. Methods: An all language literature search up to 2004. Included studies assessed the age of bruises in live children less than 18 years old. Excluded: review articles, expert opinion, and single case reports. Standardised data extraction and critical appraisal forms were used. Two reviewers independently reviewed studies. Results: Of 167 studies reviewed, three were included: two studies described colour assessment in vivo and one from photographs. Although the Bariciak et al study showed a significant association between red/blue/purple colour and recent bruising and yellow/brown and green with older bruising, both this study and Stephenson and Bialas reported that any colour could be present in fresh, intermediate, and old bruises. Results on yellow colouration were conflicting. Stephenson and Bialas showed yellow colour in 10 bruises only after 24 hours, Carpenter after 48 hours, and Bariciak et al noted yellow/green/brown within 48 hours. Stephenson and Bialas reported that red was only seen in those of one week or less. The accuracy with which clinicians correctly aged a bruise to within 24 hours of its occurrence was less than 40%. The accuracy with which they could identify fresh, intermediate, or old bruises was 55–63%. Intra- and inter-observer reliability was poor. Conclusion: A bruise cannot accurately be aged from clinical assessment in vivo or on a photograph. At this point in time the practice of estimating the age of a bruise from its colour has no scientific basis and should be avoided in child protection proceedings.     

Rehabilitation of adolescent patients with scoliosis--what do we know? A review of the literature

Different opinions exist about the efficacy of conservative scoliosis treatment. Because this divergence of opinion corresponds to a great variety of standards applied, it is also not surprising that the results of conservative treatment differ a lot. Scoliosis normally does not have such dramatic effects that immediate surgery would be indicated. Moreover, it is clear that functional and physiological impairments of scoliosis patients--including pain, torso deformity, psychological disturbance and pulmonary dysfunction--require therapeutic intervention. The triad of out-patient physiotherapy, intensive in-patient rehabilitation and bracing has proven effective in conservative scoliosis treatment in central Europe. Indication, content and results of the individual treatment procedures are described and discussed. The positive outcomes of this practice validate a policy of offering conservative treatment as an alternative to scoliosis patients, including those for whom surgery is discussed.     

Can the Mantoux test be used in BCG vaccinated children?

This prospective trial was realized in 371 children previously vaccinated with BCG in the first month of life in whom the Mantoux tuberculin test was done and read 48-72 hours afterwards. Among 371 BCG-vaccinated children, 106 (28.57%) were Mantoux reactive, 10 of whom with clinical tuberculosis. There was no statistically significant difference in the tuberculin test between the control group (59 non-BCG-vaccinated children) and 180 vaccinated children, considering those under 6 years old. When we compared by age, we verified that just 36.36% of the children at the age 2 reacted positively to PPD.     

A child with primary Sjögren syndrome and a review of the literature

Primary Sj?gren syndrome (pSS) is an uncommon disease in childhood. Childhood pSS might have different clinical manifestations than adult pSS. We describe a 13-year-old girl with multiple episodes of bilateral parotid swelling lasting 2 years. Her history included severe arthralgia, local edema, and purpura episodes since 9 years of age. During her 3-week hospitalization, 2 episodes of parotid swelling occurred, which both resolved in 48 hours. Ultrasonography and magnetic resonance images of parotid glands showed parenchymal inhomogeneity related to adipose degeneration and nodular pattern. Investigations showed elevated erythrocyte sedimentation rate, the presence of hypergammaglobulinemia, positive antinuclear antibody, and elevated rheumatoid factor, anti-Sj?gren syndrome antigen A, and anti-Sj?gren syndrome antigen B. Histopathologic examination of labial minor salivary glands revealed focal periductal lymphocytic infiltrate and sialoduct ectasia. She was diagnosed as having pSS. Recurrent parotid swelling is a more characteristic feature of disease in children, and this finding should alert the clinician to the possible diagnosis of pSS.     

Role of observational studies in supporting extrapolation of efficacy data from adults to children with epilepsy — A systematic review of the literature using lacosamide as an example

Extrapolation of efficacy data from adults to children is accepted for focal epilepsy – the antiepileptic drug, lacosamide, has been approved for the treatment of children ≥4 years of age on this basis. Since many small-scale, open-label studies are reported in the literature before approval, a systematic review was conducted to ascertain whether results of these could be used to support extrapolation in epilepsy in the future. In the absence of randomised trials, a second analysis was conducted for reports on lacosamide use in adults with generalized epilepsies. Twenty-seven articles were included in the paediatric qualitative synthesis, and 14 in the adult. Paediatric studies were analysed separately based on seizure type: focal, generalised and mixed. In focal epilepsy, safety and seizure-related findings mirrored those observed in the adult Phase II/III trials, supporting the feasibility of data extrapolation. Few studies reported outcomes in children with epilepsies associated with generalised seizures, and those that included children with different seizure types, mostly did not provide results separately. Lacosamide treatment appeared beneficial for children and adults experiencing tonic-clonic and myoclonic seizures. Reports of seizure aggravation were inconsistent and, in many cases, could not be clearly attributed to lacosamide. Given the absence of sufficient data, evidence for the feasibility of extrapolation was not as clear-cut as it was in focal epilepsy. These results highlight the complexities of conducting trials in the generalised epilepsy setting, and the importance of studies in the real-life setting and of analysing efficacy data per generalized seizure type and syndrome.     

Is physiotherapy effective in the management of child and adolescent conversion disorder? A systematic review

Child and adolescent conversion disorder has the potential to impart significant burden on health‐care services and affect quality of life. Clinically, physiotherapists are involved in conversion disorder management; however, no systematic reviews have examined physiotherapy effectiveness in its management. The aim of this review is to identify the efficacy of physiotherapy management of child and adolescent conversion disorder. A search of multiple databases (Medline, CINAHL, Embase, PsychINFO, PEDro and the Cochrane Library) was completed along with manual searching of relevant reference lists to identify articles including children 0–18 years with a diagnosis of conversion disorder who received physical management. Two independent reviewers screened titles and abstracts using criteria. Data were extracted regarding study characteristics, functional outcome measures, length of stay, physiotherapy service duration and resolution of conversion symptoms. Methodological quality was assessed using a tool designed for observational studies. Twelve observational studies were included. No functional outcome measures were used to assess the effectiveness of the treatment protocols in the case studies. Resolution of symptoms occurred in all but two cases, with conversion symptoms still present at 11 months and at 2 years. Length of stay varied from 3 days to 16 weeks, with similar variation evident in length of physiotherapy service provision (2.5 weeks to 16 weeks). There was limited and poor quality evidence to establish the efficacy of physiotherapy management of child and adolescent conversion disorders. More rigorous study designs with consistent use of reliable, valid and sensitive functional outcome measures are needed in this area.     

Can pre-neoplastic lesions be detected in gastric biopsies of children with Helicobacter pylori infection?

BACKGROUND: Active gastritis, gastric mucosal atrophy and intestinal metaplasia are lesions associated with Helicobacter pylori infection. Atrophy and intestinal metaplasia are only seen in adults. OBJECTIVES: We describe pediatric patients with atrophy and metaplasia, and compare the inflammatory response in these patients to controls. METHODS: As part of a multicenter study of pediatric H. pylori infection, gastric biopsy specimens obtained during diagnostic upper endoscopy of 19 H. pylori-infected children and 45 uninfected controls were reviewed and graded by using the updated Sydney system. The inflammatory response was characterized using immunohistochemistry for T lymphocytes, B lymphocytes, and macrophages, and TUNEL assay for apoptosis. RESULTS: Histology of H. pylori-infected and control biopsy specimens showed active gastritis in 32% and 2% respectively (P = 0.002). Mild intestinal metaplasia was found in 4 H. pylori-infected children, in two of whom it appeared to be accompanied by atrophy. Specimens from patients with H. pylori infection contained increased numbers of B lymphocytes in lymphoid nodules, and apoptosis in the superficial epithelium and inflammatory cells. T lymphocytes and macrophages appeared in similar numbers in specimens from controls and infected patients. CONCLUSIONS: We describe intestinal metaplasia associated with H. pylori infection in children. Since atrophy usually precedes intestinal metaplasia in adults, we suggest that atrophy exists in children. High numbers of B lymphocytes and apoptosis in the surface epithelium are seen in patients with H. pylori infection and may be related to the development of atrophy and intestinal metaplasia.     

Should parents assess the interpersonal skills of doctors who treat their children? A literature review

Medical consultations in which doctors display good interpersonal skills are associated with a wide range of positive health outcomes. Obtaining the perceptions of patients, or parents in paediatric settings, regarding the interpersonal skills demonstrated by their doctors could provide feedback on doctor behaviours that influence health outcomes. It could also offer an alternative to more traditional methods of assessing interpersonal skills, such as using standardized patients. Patient perceptions of doctor interpersonal skills are most commonly obtained through patient-completed satisfaction questionnaires. A literature review was conducted with the aim of examining the potential role of parent perceptions in the evaluation of paediatric interviews. Studies identified were reviewed for information regarding the rationale for obtaining parent perceptions, the reliability and validity of measures used, the association between parent evaluations and specific doctor interview behaviours and the acceptability and feasibility of obtaining this information. Practical applications of the information obtained from parent evaluations were also sought. There was considerable support for the inclusion of patient evaluations in the assessment of the interpersonal skills of medical students and doctors. Reliable and valid measurement of patient evaluations can be obtained and patients are willing to provide this information. A clear association between specific doctor interview behaviours and parent satisfaction ratings was demonstrated. However, the important issue of feasibility and acceptability to doctors and medical students of obtaining patient perceptions of interpersonal skills, was not addressed. Patient evaluations of the interpersonal skills displayed by their doctors should be a component of clinical skills assessments. Information obtained from parents relating to the care of children could provide feedback to doctors regarding their personal interviewing style. In order to make full use of the information obtained from parents, there is a need for further study to establish the sensitivity of parent evaluations and methods to facilitate the process of obtaining this information.     

Acute rheumatic fever associated with Henoch-Schönlein purpura: report of three cases and review of the literature

Aim: To describe a possible relationship between Henoch‐Schönlein purpura and rheumatic fever. Methods: Patients with features of both diseases were identified by reviewing the hospital records. Medline and reference lists from published articles were used to search for previous reports of the two conditions occurring simultaneously. Results: Three newly described cases, and three previous reports of Henoch‐Schönlein purpura associated with rheumatic carditis or chorea were identified. Conclusions: The coexistence of these two disorders in some patients supports the view that Group A streptococcus may have a pathogenic role in Henoch‐Schönlein purpura.