Gastroenterology: the first 40 years

Functional gastroenterological disorders were diagnosed in over 50 per cent of patients aged 40 years and under, referred to a district general hospital combined gastroenterology clinic. Peptic ulceration, gastro-oesophageal reflux, biliary tract disease and inflammatory bowel disease accounted for almost 70 per cent of the organic disorders encountered. Malignant disease was rare. The implications for diagnostic investigation in this age group are discussed.     

Solifenacin at 3 years: a review of efficacy and safety

Now on the market in the United States for almost 3 years and available in 48 countries worldwide, solifenacin 5 mg or 10 mg once daily continues to demonstrate a profile of safety and efficacy as a treatment for incontinence, urgency, and other symptoms of OAB. More than 2.2 million patients have been treated worldwide with solifenacin. Safety and efficacy data across numerous studies in several thousand patients, along with flexible dosing, support the use of this agent as a first-line antimuscarinic treatment for OAB. Data from large randomized controlled trials such as VENUS and STAR show statistically significant superiority compared with placebo and improved outcomes over those achieved with tolterodine ER 4 mg. Solifenacin is an agent of choice for OAB-related incontinence, with more than 50% of incontinent patients reporting no incontinence episodes after 12 weeks of solifenacin therapy. In addition to improved efficacy, solifenacin offers good tolerability with a low incidence of side effects. Once-daily, flexible dosing with this agent provides 24-hour control of OAB symptoms and significantly increases warning time (the period from onset of urgency to voiding), which may also increase a patient's chance of avoiding episodes of incontinence.     

Clinical efficacy and safety of cefmenoxime in children.

A comparative clinical trial of amoxicillin-clavulanic acid and cephalexin was carried out in 80 women with bacteriuria of pregnancy. Treatment was randomly allocated and consisted of either one tablet of amoxicillin plus clavulanic acid (250 and 125 mg, respectively) three times daily or cephalexin (250 mg) three times daily for 7 days. Overall bacteriological cure rates at 2 weeks were 77% in the amoxicillin-clavulanic acid group and 74% in the cephalexin group. At 6 weeks the respective rates were 76 and 60%. Twenty-five episodes of infection were with ampicillin-resistant strains; cure rates were 82% (2 weeks) and 80% (6 weeks) in the amoxicillin-clavulanic acid group and 85 and 64%, respectively, in the cephalexin group. Differences in cure rates were not statistically significant. No significant difference in the rate of side effects was found. In particular, no toxicity to the fetus was seen which could be ascribed to either drug. Amoxicillin-clavulanic acid would appear to be a safe and effective treatment for bacteriuria of pregnancy.     

Postoperative ketamine analgesia in children: efficacy and safety after halothane anesthesia

This study was done to investigate the effectiveness and safety of ketamine analgesia after halothane anesthesia for surgery in children. After completion of a surgical procedure, ten children had ketamine (1 mg/kg) injected intravenously during maintenance of anesthesia with 1% halothane in a 60:40 nitrous oxide-oxygen mixture. Cardiovascular parameters measured with noninvasive oscillometry and transthoracic impedance plethysmography remained unchanged after administration of ketamine. Excellent analgesia and a calm anesthetic recovery were produced, without detectable cardiovascular depression. When ketamine and halothane are administered in combination, careful restriction of dosages of these agents is recommended. Interaction of higher doses of ketamine and halothane has been reported to produce hypotension and bradycardia, which can be avoided with use of subdissociative, analgesic doses of ketamine during light halothane maintenance before emergence. After halothane anesthesia in healthy children, ketamine may be considered a suitable alternative to narcotics for postoperative analgesia.     

Antipyretic efficacy and safety of ibuprofen and acetaminophen in children

OBJECTIVE: To evaluate the antipyretic effects and safety of ibuprofen compared with acetaminophen in febrile children. DATA SOURCES: Searches of MEDLINE (1966-November 2003) and EMBASE (1988-November 2003) were conducted using the terms ibuprofen and acetaminophen. Bibliographies of selected articles were reviewed. DATA SYNTHESIS: Ibuprofen was significantly more effective than acetaminophen in reducing fever after a single dose. Ibuprofen was found to be more effective after 6 hours, but not after a longer period of time. Studies with multiple doses have also failed to show that one drug is better than the other. CONCLUSIONS: The efficacy and effectiveness of acetaminophen and ibuprofen in their recommended dosages are similar, with slightly more beneficial effects shown with ibuprofen.     

Paracetamol for feverish children: parental motives and experiences

Objective

The sale of paracetamol products for children is increasing, and more children are accidentally given overdoses, even though the use of paracetamol against fever is still under discussion. This study explores Danish parents’ use of paracetamol for feverish children and their motives for this use.

Design

A cross-sectional survey using structured interviews.

Setting

Four general practices located in city, suburb, and rural area.

Subjects

A total of 100 Danish parents with at least one child under the age of 10 years.

Main outcome measures

Number of parents administering paracetamol to feverish children, situations triggering medication of a child, parental views regarding fever and effects of paracetamol, and sources of information on fever treatment.

Results

Three in four parents use paracetamol for feverish children, mainly to reduce temperature, to decrease pain, and to help the child fall asleep. Highly educated parents medicate more often than less educated. Parents often fear fever but this does not clearly affect their use of paracetamol. Many parents believe in perceived beneficial effects of paracetamol, such as increased appetite and well-being, better sleep, and prevention of fever seizures. These expectations of paracetamol influence parental use of the drug. Parents’ main source of information on fever and paracetamol is their general practitioner (GP).

Conclusions

Danish parents regularly treat feverish children with paracetamol. Although parents contact their GP for advice on fever treatment, paracetamol is sometimes given to children on vague indications. Clearer information for parents on when to give paracetamol as fever treatment may help regulate its use.Key Words: Antipyretic, children, family practice, fever, gender, paracetamol, parents, primary healthcareThe sale of child-friendly paracetamol products is increasing in Denmark, even though use of paracetamol as treatment of fever is still being debated.

• Parents give paracetamol to improve well-being, appetite, and sleep of feverish children – research only vaguely supports this use.
• Highly educated parents medicate more often than less educated.
• Danish parents’ main source of information concerning fever and its treatment is their general practitioner.

Fever is a common symptom in childhood and a frequent reason for parents to contact their general practitioner (GP) [1]. Antipyretics are widely used for treating feverish children [2–5]. In Denmark, the most common antipyretic substance for children is paracetamol. The sale of child-friendly paracetamol products, i.e. suppositories and mixtures, has increased 23% in the last five years (55.9–68.4 defined daily doses (DDD)/1,000 inhabitants/year) [5,6].Paracetamol is considered a safe drug when taken in prescribed doses; however, overdosing may cause liver failure and death. Recent studies also show that intoxication in children happens after repeated doses only slightly above recommendations [7]. The number of Danish children (aged 0–11 years) hospitalized with paracetamol or acetylsalicylic acid (ASA) poisoning has increased from 23 in 1997 to 81 in 2006 [8].The use of paracetamol against fever is still under discussion [9,10]. Fever involves discomfort; however, the rise in body temperature is believed to assist the immune response against infection [11,12]. A minority of children experience fever seizures; these are often frightening to parents, but today if short-lasting they are considered benign [13]. Paracetamol has shown to be an effective analgesic and antipyretic; however, it is still unclear if the drug increases the well-being, the sleep, or the appetite of a feverish child [14–16]. Paracetamol has not yet proved effective in preventing fever seizures [13,17,18]. Conversely, no studies have documented a positive effect of not giving paracetamol to feverish children. NICE guidelines recommend use of paracetamol mainly in cases of fever and discomfort or pain [19].Internationally, numerous parents regularly give paracetamol against fever [2,3,20]. The most frequent reason for giving the drug to a feverish child is simply to lower the temperature. Some parents believe that paracetamol relieves their children of discomfort, and gives them more appetite and energy. [3,20,21]. Additionally, paracetamol may be a way of coping with a sick child in a busy daily life [20].Some parents fear that fever might harm their child by causing seizures, brain damage, and even death, if the temperature is high or rapidly rising. This unrealistic fear, termed fever phobia, may be linked to the wide use of antipyretics among parents [22–24]. For some parents fever is considered the disease in itself, and paracetamol is believed to cure the child [20].This study aimed at exploring:

1. to what extent and in which situations parents give their children antipyretics;
2. if parental views of the effects of paracetamol are consistent with existing evidence, and if their views influence the use of the drug;
3. if fever phobia is present among parents and if it motivates them to give paracetamol;
4. where parents seek information on handling a feverish child.

     

超声引导下儿童移植肝穿刺活检的临床分析

目的评价超声引导下儿童移植肝穿刺活检的有效性和安全性。 方法回顾性分析2018年1月至2020年12月于首都医科大学附属北京友谊医院行超声引导下移植肝穿刺活检术患儿的临床病史、实验室检查、穿刺记录、术后并发症及病理结果。采用χ²检验/Mann-Whitney U检验比较并发症组与无并发症组患儿年龄、性别、穿刺次数、血小板、凝血酶原活动度等实验室检查指标的差异。 结果共进行了180例次移植肝穿刺活检术,获取184份肝穿刺活检标本,其中176份移植肝穿刺活检,4例次移植肝和自体肝穿刺活检。所有患儿均成功穿刺,病理取材成功率为95.7%（176/184）,穿刺后未发生严重并发症,轻微并发症发生率为8.9%（16/180）。对比并发症组患儿（16例次）与无并发症组患儿（164例次）的基本情况、穿刺次数、实验室检查,发现并发症组患儿年龄更低［3.0（0.9,15.0）岁 vs 5.0（0.40,16.0）岁］,肝功能更差［天门冬氨酸氨基转移酶：62.8（22.70,659.00）U/L vs 40.60（12.70,446.20）U/L;总胆红素：9.74（3.59,43.46）μmol/L vs 9.45（2.42,751.00）μmol/L］,血小板计数更低［213.00（58.00,337.00）×10⁹/L vs 233.00（46.00,490.00）×10⁹/L］以及凝血酶原活动度更低［82.30（58.00,103.00）% vs 85.00（58.00,132.10）%］,差异均具有统计学意义（Z=-2.892、-3.211、-2.007、-3.960、-2.906,P=0.004、=0.001、=0.045、＜0.001、=0.004）;性别及每例次穿刺次数差异均无统计学意义（P均＜0.05）。 结论超声引导下儿童移植肝穿刺活检可靠、安全,具有较高的诊断率和低并发症发生率。低龄、肝功能差、血小板计数低、凝血酶原活动度低是儿童移植肝穿刺活检出血的危险因素。     

Intranasal fentanyl reduces acute pain in children in the emergency department: A safety and efficacy study

Introduction: Provision of rapid, painless and effective analgesia to children remains problematic in the prehospital and emergency setting. Intranasal fentanyl has the potential to eliminate many of the problems of narcotic administration in children. The aim of this study, conducted in a tertiary paediatric emergency department was to evaluate the safety and efficacy of intranasal fentanyl in children. Methods: Children in acute pain aged between three and 12 years inclusive were enrolled on presentation to the emergency department. Routine observations and pain scoring by the child and caregiver was undertaken prior to the child receiving fentanyl (20 µg for 3–7 year olds and 40 µg for 8–12 year olds) and at intervals of 5 min for 30 min Additional fentanyl at the dose of 20 µg was given 5 minutely as required. Caregivers and older children used a visual analogue scale (VAS) and the younger children used the Wong‐Baker faces scale (WBS). Results: Forty five children were enrolled with a mean age of 8.0 years. The median dose of fentanyl administered was 1.5 µg/kg. Mean pain score in 32 children using the VAS was 62.3 mm (95% confidence interval 53.2–69.4 mm) at presentation and reduced at 10 min to 44.6 mm (95% confidence interval 36.2–53.1 mm). In 16 children using WBS the initial mean reading was 4.0 (95% confidence interval 3.3–4.7) and reduced to 2.2 (95% confidence interval 1.3–3.1) at 10 min. Caregiver pain scores showed a mean preintervention pain score of 64.9 mm (95% confidence interval 57.7–72.2 mm) with a significant reduction at 10 min to 41.7 mm (95% confidence interval 34.7–48.6 mm). There was no significant alteration in pulse rate, respiratory rate, and blood pressure or oxygen saturations. There were no negative side‐effects. Conclusions: Early and significant reduction in pain (compared to baseline assessments) was achieved in children using intranasal fentanyl by 10 min and sustained throughout the 30 min of observations. This raises the possibility of using intranasal fentanyl in children in the prehospital setting as well as a role for this form of analgesia as triage nurse‐initiated administration in the emergency department.     

Patient-ventilator interaction: the last 40 years

Patient-ventilator synchrony is a complex issue affected by ventilator performance, patient characteristics, and the patient-ventilator interface. The history of patient-ventilator interaction includes avoidance of pharmacalogic paralysis, the development of spontaneous breathing systems, microprocessor technology to maximize interaction, and closed-loop control. While most clinicians agree that patient-ventilator synchrony is desirable, there remain no cause-and-effect data that asynchrony is associated with poor outcome.     

Cytapheresis: the first 25 years.

In vivo blood cell separator technology was originally developed in response to a perceived need for granulocytes for septic neutropenic patients. This impetus led to the development of a variety of cell separators which, paradoxically, ultimately have found their main applications in pheresis procedures other than granulocyte collection. In vivo blood cell separators are ideal for the removal of large numbers of normal or abnormal hemopoietic cells. Their early use in chronic myeloid leukemia demonstrated that leukapheresis could be used as definitive therapy for the disease. However, most hematological diseases in which the circulating malignant cells can be pheresed off have definitive and cost effective standard of care therapies, and cytapheresis is limited to specific circumstances. This paper reviews therapeutic cytapheresis and summarizes the current status of its limited specific indications.     

Linezolid: safety and efficacy in special populations

Linezolid has been in general use in the UK since 2000. Although toxicity, particularly haematological and neurological, has been an issue, linezolid has proved to be an effective alternative to glycopeptides in the treatment of Gram-positive infections. Since its original licence for the treatment of skin and soft tissue infections and pneumonia, there have been reports of its successful use in the treatment of bone and joint infections, endocarditis, and other difficult-to-treat infections.     

Evaluation of the safety and efficacy of liposomal amphotericin B (L-AMB) in children

A multicenter, uncontrolled clinical study has been conducted to evaluate the safety, efficacy, and pharmacokinetics of liposomal amphotericin B (L-AMB) in children. In this article, the safety and efficacy of L-AMB are discussed. Subjects were diagnosed with invasive fungal infection (definitely diagnosed cases), possible fungal infection (clinically diagnosed cases), and febrile neutropenia with suspected fungal infection (febrile neutropenia cases). Of the 39 subjects treated with L-AMB, 18 received a definite (11) or clinical (7) diagnosis of invasive fungal infection. In these subjects, excluding one unevaluable subject, L-AMB was effective in nine out of 17 subjects(52.9%). Of 12 febrile neutropenia cases, improvement in clinical symptoms, etc., was observed for six but these were excluded from the efficacy analysis because they concomitantly used medications that may have affected efficacy. The causative fungus was identified in four out of 39 subjects and confirmed to be eliminated by treatment with L-AMB in one subject. Adverse events possibly related to L-AMB (adverse drug reactions) were reported in 36 out of 39 subjects (92.3%). The most commonad verse drug reaction was decreased potassium in 20 out of 39 subjects (51.3%), but all these subjects recovered with appropriate treatment, for example potassium supplementation.In a Japanese Phase II clinical study of adult patients, the incidence of adverse drug reactions was 95.3%(82/86 subjects) and the efficacy was 63.6% (42/66). Taken together, these data indicate that the safety and efficacy of L-AMB are almost the same in pediatric and adult patients.