Hypertonic saline for bronchiolitis in infants

Question Recently, a 1-year-old patient returned from admission in the hospital for bronchiolitis, and the report I received indicated that he was treated with inhaled hypertonic saline, among other treatments. Is this therapy recommended for children in the acute care setting?Answer Bronchiolitis, caused mostly by respiratory syncytial virus, is very common in the winter. It is the most frequent cause of hospitalization in infancy. Several good studies have been conducted in the past decade on the use of nebulized hypertonic saline for bronchiolitis management; however, they offer conflicting results. While there might be a role for the use of nebulized hypertonic saline in children who are hospitalized with bronchiolitis for more than 3 days, treatment in other settings does not confer enough benefit to recommend its use.Bronchiolitis is the most common lower respiratory tract infection in infants and children younger than age 2 and it is the most frequent cause of hospitalization in infancy. The rate of hospital admission for bronchiolitis has increased substantially in North America over the past 2 decades; the hospital admission rate among Canadian children with bronchiolitis increased from 15 to 39 admissions per 1000 children per year.¹ Although several viruses can give a similar clinical picture of fever, cough, rhinorrhea, and a variable degree of respiratory distress, respiratory syncytial virus is the predominant pathogen responsible for acute bronchiolitis.^2,3 Despite decades of research, supportive care ensuring adequate hydration and oxygenation remains the cornerstone of therapy for these infants.⁴     

Cardiac risks and management of complications in pregnant women with congenital heart disease

There are a growing number of women with congenital heart disease reaching adulthood and contemplating and/or undergoing pregnancy. However, pregnancy imposes hemodynamic stress on the heart and this can result in maternal, fetal and neonatal complications. Most women with congenital heart disease do well during pregnancy, but some women with high-risk cardiac lesions will not tolerate the hemodynamic changes of pregnancy. Physicians must be aware of the potential risks for the mother both during and after pregnancy, the risks to the fetus and neonate, and the risks and benefits of medications and procedures used during pregnancy. For women with complex cardiac conditions, management during pregnancy benefits from multidisciplinary care involving cardiologists with expertise in pregnancy, obstetricians with expertise in maternal fetal medicine, neonatologists and obstetric anesthetists, among others. This review will focus on the cardiac risks faced by women with congenital heart disease; particularly those at high risk, and on management strategies to mitigate risk and address cardiac complications.     

The effectiveness of early mobilization after tendon transfers in the hand: A systematic review

Study DesignSystematic review.IntroductionOver the past decade, early mobilization (initiated within a week) has become an increasing trend in postoperative rehabilitation after tendon transfer surgery in the hand. However, there are no published reviews summarizing the effectiveness of early mobilization protocols in comparison with conventional immobilization in tendon transfer rehabilitation.PurposeTo systematically review available evidence on the effectiveness of early mobilization protocols to conventional immobilization protocol after tendon transfers in the hand.MethodsA literature search of the Cochrane Library, PubMed, PEDro, EMBASE, and CINAHL databases was conducted (1980 to date). Randomized controlled trials (RCTs), case–control, and other study designs were included. Six articles were eligible for inclusion in the analysis (five RCTs and one retrospective study) and 260 articles that did not meet inclusion criteria were excluded. Level of evidence (Center for Evidence-based Medicine) and methodological quality (Structured Effectiveness Quality Evaluation Scale [SEQES] score) of each study were assessed by two independent reviewers.ResultsThis review found three high quality trials (SEQES score: 35–43 of 48), with level 1b and 2b evidence, supporting early mobilization of tendon transfers. The literature reports reduced total cost, total rehabilitation time, and demonstrates that early mobilization is a safe approach with no incidence of tendon ruptures or insertion pull out. In the initial phase of rehabilitation, outcomes like range of motion, grip strength, pinch strength, total active motion of digits, deformity correction, and tendon transfer integration were significantly superior with early mobilization compared with immobilization. However, in the long term, these outcomes were similar in both the groups, suggesting that early mobilization protocol improves hand function in the initial phase of rehabilitation (four weeks) and the long-term results (two months to one year) are equivalent to immobilization.ConclusionsBased on a limited number of small studies, there is evidence of short-term benefit for early mobilization, but inconclusive findings for longer-term outcomes. Until the body of evidence increases, clinicians should consider the clinical context, their experience in optimizing patient outcomes after surgery, and the patient's preferences when selecting between early and late mobilization after tendon transfer.Level of Evidence2a.     

Lysosomal storage disorders: A review of the musculoskeletal features

The lysosomal storage disorders are a collection of progressive, multisystem disorders that frequently present in childhood. Their timely diagnosis is paramount as they are becoming increasingly treatable. Musculoskeletal manifestations often occur early in the disease course, hence are useful as diagnostics clues. Non‐inflammatory joint stiffness or pain, carpal tunnel syndrome, trigger fingers, unexplained pain crises and short stature should all prompt consideration of a lysosomal storage disorder. Recurrent ENT infections, hepatosplenomegaly, recurrent hernias and visual/hearing impairment – especially when clustered together – are important extra‐skeletal features. As diagnostic and therapeutic options continue to evolve, children with lysosomal storage disorders and their families are facing more sophisticated options for screening and treatment. The aim of this article is to highlight the paediatric presentations of lysosomal storage disorders, with an emphasis on the musculoskeletal features.