The neurology of coeliac disease in childhood: what is the evidence? A systematic review and meta‐analysis

Aim The aim of this article was to review and conduct a meta‐analysis of the paediatric literature on the neurology of coeliac disease. Method We conducted a review of paediatric studies published in English assessing neurological illness in coeliac disease identified through a MEDLINE search (1950–2009). Calculation of computed relative risk, odds ratio, and risk difference was performed using the fixed effect method if applicable. Results Fifteen studies were analysed (11 772 participants). The meta‐analysis showed that (1) the relative risk of epilepsy in individuals with coeliac disease, and of coeliac disease in individuals with epilepsy, compared with the general population, was 2.1 and 1.7, respectively, and the risk difference was close to zero, indicating that it was probably a chance association; and (2) the relative risk of headache in individuals with the disease compared with comparison groups was 3.2. In two studies, cerebellar ataxia was documented in 2.7 to 5.4% of participants; in two further studies, the risk of cerebellar dysfunction was zero. Two studies found an association between coeliac disease and peripheral neuropathy. Brain white matter lesions were recorded in two other studies. An association between autism and coeliac disease is disputed. Interpretation Children with coeliac disease are at risk of developing neurological complications, but the risk is lower than in adulthood. The discrepancy might be due to short disease duration, early elimination of gluten from the diet, stricter adherence to diet, or different susceptibility to immune‐mediated disorders.     

Classification of a traumatic brain injury: the Glasgow Coma scale is not enough

Background: Classifying the severity of a traumatic brain injury (TBI) solely by means of the Glasgow Coma scale (GCS) is under scrutiny, because it overlooks other important clinical signs. Clinicians treating patients with acute TBI are well placed to suggest which variables, in addition to the GCS, should concur in a new classification of TBI. Methods: In Italy, acute TBI patients are treated by anaesthetists, and so we asked them, in a questionnaire survey, to rate the weight they give to the GCS and to other clinical variables in their approach to TBI. Because sedation may underestimate GCS scores, we also inquired whether anaesthetists select sedatives that allow drug‐free GCS scores. The questionnaire was distributed to 1334 anaesthetists attending courses on neurotrauma; the response rate was 63%. Results: Two thirds of the respondents believe that the definition of severe TBI should include, in addition to GCS scores, pupil reactivity to light and computer tomogram (CT) findings, the variables that guide Italian anaesthetists in TBI management. Most respondents (68.2%) administer sedation which allows prompt neurological evaluation and reliable GCS scoring. A minority of respondents (9.3%) withhold or antagonize sedation, delay tracheal intubation or allow patient–ventilator asynchrony. Conclusions: Italian anaesthetists would welcome a definition of TBI severity that includes CT findings and pupil reactivity in addition to the GCS.     

Transfemoral Pediatric Permanent Pacing:

COSTA, R., et al.: Transfemoral Pediatric Permanent Pacing: Long-term Results. The femoral vein has been used as an alternative conduit to implant pacemakers in children of any weight. Such method associates endocardial pacing and good cosmetics. The aim of this study was to evaluate prospectively, since 1981, the long-term follow-up of 99 children, from newborn to 13 years old (average   = 4.1 ± 3.6   years, 56 girls), who underwent the implantation of pacemakers via the femoral vein. Atrioventricular block was present in 88% of patients, of congenital etiology in 39% and postoperative in 54%. Single chamber pacemakers were implanted in 92% of patients. During a mean follow-up of 5.3 ± 5.0 years (maximum   = 18.2   years), 5 patients died of cardiac causes, 4 of infection, 2 suddenly, and 3 of unknown causes. The 5-, 10- and 15-year actuarial survival rates were 83.7%, 75.7%, and 75.7%, respectively. Transfemoral leads were used for a mean of 48.9 ± 44.0 months. Reasons for lead explantations were pacing failure in five patients, infection in eight, and elective in nine. The 2-, 5- and 10-year actuarial survivals of transfemoral leads were 87.6%, 73.8%, and 31.8%, respectively. The mean lead survival was 97 months. Overall, 105 reoperations were performed, 38 for battery depletion, 24 for body growth, 14 for infection or pocket revisions, and 27 for miscellaneous reasons. In conclusion, the durability and overall long-term performance of transfemoral leads were excellent. (PACE 2003; 26[Pt.II:487–491)     

Recurrence Rates and Long-Term Follow-Up After Laser Resurfacing as a Treatment for Widespread Actinic Keratoses in the Face and on the Scalp

BACKGROUND: Diffuse widespread actinic keratoses are difficult to treat, have a tendency toward higher recurrence rates, and therefore require ablative treatment. Laser resurfacing is one of the treatment modalities that can treat whole surface areas. OBJECTIVE: To evaluate patients who underwent laser resurfacing for widespread actinic keratoses with long-term follow-up for recurrence rates, time until new lesions occur, and the most common side effects. METHODS: Retrospective case-control study from 25 patients who underwent laser resurfacing for widespread actinic keratoses on the scalp, forehead, or full face at our department. Follow-up varied from 7 to 70 months. Recurrence rates, adverse effects, and improvement were analyzed through chart analysis. RESULTS: The mean average follow-up was 39 months. Forty-four percent of the patient shad no recurrence during the time period. Fifty-six percent of the patients developed new lesions after treatment but only a few. Of the recurrences, 20% occurred within 1 year and 36% occurred after 1 year. The most common short- and long-term side effects were infections (12%), hypopigmentation (48%), hyperpigmentation (8%), acne (12%), milia (12%), scar formation (8%), and atrophic and/or easily bruised skin (20%). CONCLUSION: Laser resurfacing is an effective treatment modality for diffuse widespread actinic keratoses with long-term recurrence-free intervals.