Based on what parameters is safe to discontinuate inhaled corticosteroids in children with asthma?

OBJECTIVE: Remission of childhood asthma has not been widely studied. Patients in clinical remission continue to have some degree of bronchial hyperresponsiveness (BHR). The aim of this study was to investigate whether clinical parameters and lung function test are good parameters for discontinuation of inhaled corticosteroids (ICS) in asthmatic children, including patients with persistent BHR, as measured by the methacholine challenge test (MCT). METHODS: One year after discontinuation of inhaled corticosteroids (ICS), MCT was performed in a group of 40 asthmatic children to confirm or exclude BHR. In all patients, ICS treatment was discontinued based on the same parameters: symptoms, spirometry, daily PEF, and negative bronchodilator test. After achieving complete asthma control for at least 6 to 12 months, ICS treatment was stepped down and discontinued. Clinical course and spirometry were followed up after ICS discontinuation. RESULTS: Positive MCT was found in 50% of the patients. There was no statistically significant difference between the positive and negative MCT groups in age at initiation and discontinuation of ICS therapy, duration of ICS therapy, duration of stepping down period, FEV1, and PEF at the time of withdrawal of ICS and one year later. ICS treatment had to be restarted in two patients from the positive MCT group, due to recurrence of asthma symptoms. CONCLUSION: Clinical parameters, normal spirometry, daily PEF values, and a negative bronchodilator test are good parameters for discontinuing ICS treatment in asthmatic children, even in patients with persistent BHR. Children should continue to be monitored, as symptoms may recur.

Value of thymic stromal lymphopoietin as a biomarker in children with asthma.

BACKGROUND: Thymic stromal lymphopoietin (TSLP), an epithelium-derived pro-inflammatory cytokine, activates distinct immune and non-immune cells. It has been shown to be a master regulator of type 2 immune responses. Limited information is available on TSLP in childhood asthma. The aim of the present study was to find out whether there is association between TSLP concentrations and asthma phenotypes or disease activity. METHODS: A total of 207 children with asthma and 100 healthy children aged 1-13 years were enrolled. This study examined serum TSLP concentrations using ELISA Kit in asthma patients and controls, analyzed its correlation with asthma phenotypes and pulmonary function. We also examined TSLP concentrations in 23 patients during stable asthma and in acute asthma exacerbation. RESULTS: The serum concentrations of TSLP were significantly elevated in asthma patients compared with healthy controls (p < 0.05), but there was no significant difference (p > 0.05) in TSLP concentrations between three different asthma phenotypes (allergic asthma, virus induced asthma and nonallergic asthma). There was no significant correlation between TSLP concentrations and FEV1pred% (r = 0.01, p > 0.05). In the acute asthma exacerbation TSLP concentrations were not significantly different than in stable phase of disease (p > 0.05). CONCLUSION: Children with asthma have higher serum TSLP concentrations when compared to healthy controls. TSLP does not seem to be a biomarker of disease exacerbation in children. Different asthma phenotypes have similar TSLP concentration profile in peripheral blood and TSLP does not seem to be useful biomarker in asthma phenotyping in children.

PARENTAL AWARENESS OF THE DANGERS OF FOREIGN BODY INHALATION IN CHILDREN.

Background: The presence of a foreign body in the airways is a life-threatening condition and thus a medical emergency that requires timely diagnosis and treatment. If not recognized, it can lead to a number of serious complications. It is of the utmost importance to raise public awareness and educate parents and other caregivers on all aspects of this topic. Methods: This observational cross-sectional study aimed to investigate parental awareness of the dangers of foreign body aspiration. To determine the current level of knowledge of the parents, a 14- question questionnaire was designed and filled out by parents of children under 5 years of age referred for their regular check- ups. Results: The results show that majority of parents know that inhaling a foreign body is a potentially life-threatening condition and recognize which objects have a potential to cause foreign body aspiration. 36.9% of respondents said they knew what the symptoms of foreign body aspiration were, however only 15.6% offered a complete answer. 59.6% of the respondents could not specify the right course of action in case FBA occurred. 2% responded accurately. No statistically significant correlation was found between the number of children in the family nor the age and the sex of the parents and the level of knowledge about the aspiration of foreign bodies. Conclusion: This study indicates that parents are insufficiently informed on recognizing foreign body aspiration symtoms as well as providing first aid. Media-assisted campaigns and the internet are potential sources of easily accessible educational material.

HEREDITARY ANGIOEDEMA DUE TO C1-INHIBITOR DEFICIENCY IN PEDIATRIC PATIENTS IN CROATIA - FIRST NATIONAL STUDY, DIAGNOSTIC AND PROPHYLACTIC CHALLENGES.

Hereditary angioedema (HAE) is a rare autosomal dominant disease with deficiency (type I) or dysfunction (type II) of C1 inhibitor, caused by mutations in the C1-INH gene, characterized by recurrent submucosal or subcutaneous edemas including skin swelling, abdominal pain and life-threatening episodes of upper airway obstruction. The aim of this study was to investigate healthcare experiences in children with HAE due to C1 inhibitor deficiency (C1-INH-HAE) in Croatia in order to estimate the number of affected children and to recommend management protocols for diagnosis, short-term prophylaxis and acute treatment. Patients were recruited during a 4-year period at five hospitals in Croatia. Complement testing was performed in patients with a positive family history. This pilot study revealed nine pediatric patients positive for C1-INH- HAE type I, aged 1-16 years, four of them asymptomatic. Before the age of one year, C1-INH levels may be lower than in adults; it is advisable to confirm C1-INH-HAE after the age of one year. Plasma-derived C1-INH is recommended as acute and short-term prophylactic treatment. Recombinant C1-INH and icatibant are licensed for the acute treatment of pediatric patients. In Croatia, HAE is still underdiagnosed in pediatric population.

No effect of fluticasone propionate on linear growth in preschool children with asthma.

BACKGROUND: Eighty percent of asthmatic children develop asthma symptoms by the age of 5 years. Inhaled corticosteroids (ICS), depending on dosage, may cause linear growth reduction and adrenal gland suppression. There are few studies about linear growth of preschool children with asthma. The aim of the present study was to investigate whether there is any effect of fluticasone propionate (FP) on linear growth and adrenal gland function. METHODS: Twenty-eight children aged 18-52 months with persistent asthma receiving ICS FP 100-200 µg daily were studied for 1 year. Patients were divided into two groups according to clinical parameters: well (group 1) and poorly controlled (group 2). Height was measured every 3 months and expressed as height standard deviation score (SDS). Cumulative dose of FP expressed in mg was calculated for every patient. Early morning levels of serum adrenocorticotropic hormone (ACTH) and cortisol were assessed at the beginning and at the end of the study. RESULTS: Patients took FP for an average of 11 months in group 1 and 16 months in group 2, which was not statistically significantly different. At the end of the study height SDS difference was -0.0143 in group 1 and -0.2000 in group 2, which was not statistically significantly different (t= 0.6072, P= 0.5489). There was also no statistically significant difference for average cortisol (P= 0.4381) or ACTH (P= 0.5845) concentration at the end of the study. CONCLUSION: FP 100-200 µg daily had no effect on linear growth or on the hypothalamic-pituitary-adrenal gland axis but further follow up is necessary.

Horseshoe lung associated with diaphragmatic herniation of the liver.

Horseshoe lung is a rare congenital pulmonary anomaly in which the caudal and basal segments of the left and right lungs are joined together behind the pericardium at the height of cardiac apex. Most patients with horseshoe lung have many other cardiovascular anomalies typical of the scimitar syndrome or the hypogenetic right lung syndrome. We report on a patient with horseshoe lung not associated with scimitar syndrome, but presented with a focal diaphragmatic herniation of the liver, such as never reported before in case of horseshoe lung without associated scimitar syndrome.

Spontaneous pneumomediastinum in a healthy adolescent.

Spontaneous pneumomediastinum is a rare clinical entity defined as the presence of free air in the mediastinal structures without an apparent cause such as trauma. Spontaneous pneumomediastinum is rare in children and most frequently occurs in young male patients. It usually develops after alveolar rupture and air penetration into the pulmonary interstice, followed by air penetration towards the hila and into the mediastinum. Alveolar ruptures may be caused by various pathological and physiological processes, in children most frequently by asthma. Clinical diagnosis is based on the symptom triad including chest pain, dyspnea and subcutaneous emphysema. The diagnosis is confirmed by radiography. On differential diagnosis, esophageal perforation should be considered first, and if suspected, contrast esophagogram should be performed. Spontaneous pneumomediastinum usually resolves spontaneously in several days of treatment, which includes identification of the underlying cause (if possible), rest, analgesics and clinical monitoring. Complications involving spontaneous pneumomediastinum, such as tension pneumomediastinum and tension pneumothorax, are quite rare. A case is presented of pneumomediastinum in a 17-year-old male adolescent with no relevant history but with a clinical picture of intense retrosternal pain and subcutaneous emphysema of the neck and supraclavicular region. Thorough examinations including chest x-ray, chest computed tomography, bronchoscopy and esophagoscopy failed to identify the cause of pneumomediastinum. After eight days of conservative treatment, the pneumomediastinum symptoms completely disappeared and x-ray showed resolution of pneumomediastinum.

Rhabdomyolysis and acute renal failure in a child with para-influenza type 1 infection.

We present a rare case of para-influenza type 1 virus-induced rhabdomyolysis, complicated by acute renal failure (ARF). The child underwent continuous venovenous haemofiltration and has shown full clinical and biochemical recovery. ARF due to rhabdomyolysis in para-influenza type 1 infection in a child has, to the best of our knowledge, not been previously reported.

Clinical presentation of a patient with congenital polycythemia.

The authors describe a 19 year old male with an isolated but absolute erythrocytosis with iron deficiency without evidence for polycythemia vera as well as another causes of erythrocytosis. The polycythemia was due to a recently described von Hippel-Lindau (VHL) mutation. By stopping iron therapy there was no more requirements for phlebotomy in this patient.

Comparative analysis of azithromycin and ciprofloxacin in the treatment of chronic prostatitis caused by Chlamydia trachomatis.

A total of 89 patients, (>18 years), with symptoms of chronic prostatitis and inflammatory findings as well as the presence of Chlamydia trachomatis confirmed by DNA/RNA DIGENE hybridization method and/or by isolation, McCoy culture and Lugol stain in expressed prostatic secretion or in voided bladder urine collected immediately after prostatic massage, were examined. The patients were randomized to receive a total of 4.5 g of azithromycin for 3 weeks, given as a 3-day therapy of 1 x 500 mg weekly or ciprofloxacin 500 mg b.i.d. for 20 days. Patients' sexual partners were treated at the same time. Clinical and bacteriological efficacy were evaluated 4-6 weeks after the end of therapy. Significantly higher eradication (36/45: 17/44; P=0.0002) and a significantly higher clinical cure (31/45: 15/44; P=0.0021) were achieved in the group of patients treated with azithromycin than in the ciprofloxacin group.