Oral versus i.v. antibiotics for community-acquired pneumonia in children: a cost-minimisation analysis.

Community-acquired pneumonia represents a high financial burden to healthcare providers. This manuscript seeks to estimate and compare the costs of treating children hospitalised with community-acquired pneumonia, with oral and intravenous antibiotics, thus determining which treatment is cost minimising. A cost-minimisation analysis was undertaken alongside a randomised controlled non-blinded equivalence trial. 232 children (from eight paediatric centres in England) diagnosed with pneumonia, who required admission to hospital, were randomised to receive oral amoxicillin or i.v. benzyl penicillin. The analysis considered the cost to the health service, patients and society, from pre-admission until the child was fully recovered. Oral amoxicillin and i.v. benzyl penicillin have equivalent efficacy. Children treated with i.v. antibiotics were found to have significantly longer in-patient stays (3.12 versus 1.93 days; p<0.001). i.v. treatment was found to be more expensive than oral treatment ( pound1,256 versus pound769; difference pound488; 95% CI: pound233- pound750), such that treatment of community-acquired pneumonia with oral amoxicillin would result in savings of between pound473 and pound518 per child (euro545 and euro596 per child) admitted. The findings demonstrate that oral amoxicillin is a cost-effective treatment for the majority of children admitted to hospital with pneumonia.

Respiratory medicines for children: current evidence, unlicensed use and research priorities.

This European Respiratory Society task force has reviewed the evidence for paediatric medicines in respiratory disease occurring in adults and children. We describe off-licence use, research priorities and ongoing studies. Off-licence and off-label prescribing in children is widespread and potentially harmful. Research areas in asthma include novel formulations and regimens, and individualised prescribing. In cystic fibrosis, future studies will focus on screened infants and robust outcome measures are needed. Other areas include new enzyme and antibiotic formulations and the basic defect. Research into pneumonia should include evaluation of new antibacterials and regimens, rapid diagnostic tests and, in pleural infection, antibiotic penetration, fibrinolytics and surveillance. In uncommon conditions, such as primary ciliary dyskinesia, congenital pulmonary abnormalities or neuromuscular disorders, drugs indicated for other conditions (e.g. dornase alfa) are commonly used and trials are needed. In neuromuscular disorders, the beta-agonists may enhance muscle strength and are in need of evaluation. Studies of antibiotic prophylaxis, immunoglobulin and antifungal drugs are needed in immune deficiency. We hope that this summary of the evidence for respiratory medicines in children, highlighting gaps and research priorities, will be useful for the pharmaceutical industry, the paediatric committee of the European Medicines Agency, academic investigators and the lay public.

A novel hybrid stent technique to treat canine pulmonic stenosis.

Balloon valvuloplasty is routinely performed in dogs with severe pulmonic stenosis using a transvenous approach. We report a novel transventricular approach to stent the right ventricular outflow tract. An 18-month old Havanese with frequent syncope was referred with a diagnosis of severe valvular pulmonic stenosis. Transvenous approaches were unsuccessful; therefore, two Palmaz XL 29 mm by 12 mm transhepatic biliary stents were deployed across the valve using a direct right ventricular approach. The echocardiographically derived systolic pressure gradient decreased from 133 mmHg to 39 mmHg with resolution of clinical signs. The patient continues to do well after 3 years with occasional syncope when extremely excited despite pressure gradient increases to 130 mmHg at 12 months and 174 mmHg at 22 months.

Respiratory outcome in late childhood after neonatal continuous negative pressure ventilation.

BACKGROUND: The outcome in late childhood for children entered into a randomised trial of continuous negative extrathoracic pressure (CNEP) versus standard respiratory management for the treatment of neonatal respiratory distress was studied. In the original trial, there were advantages in the duration of oxygen and the prevalence of chronic lung disease for those assigned to receive CNEP. AIM: To determine whether the above differences had persisted into childhood. METHODS: Outpatient evaluation of children by a paediatrician using Spirometry (Vitalograph Spirometer 2120, Ennis, Ireland) and MicroRint (Micro Medical, Rochester, Kent, UK) techniques independently of the original trial. Parents completed questionnaires about their child's respiratory history and social-demographic information. RESULTS: 133 (65%) survivors were evaluated at 9.6-14.9 years of age. The group examined were representative of the original cohort and no significant baseline differences were observed between children evaluated who had been allocated to CNEP or standard treatments. We compared Rint (before and after bronchodilator) and forced expiratory flow, volume and vital capacity between the two study groups; none were significant. Children in the standard group had received paediatric intensive care more often (p = 0.19) and were more likely to be receiving inhaled drugs for asthma (p = 0.19; all not significant). CONCLUSIONS: No important differences were found at follow-up in late childhood in respiratory outcomes for children treated with neonatal CNEP or standard treatment. Caution should be exercised, as the original trial was not powered to show these differences, but there seems to be no long-term detriment in respiratory outcomes for children treated with CNEP in the neonatal period.

Detection of previously unrecognized daytime desaturation in children with chronic lung disease.

PRIMARY OBJECTIVE: The prime rationale of this research is to investigate the possible occurrence of previously unrecognized episodes of desaturation apparent in preterm infants with chronic lung disease as they freely move around a non-artificial environment. RESEARCH DESIGN: The study comprises 58 hours of telemetric recordings of SpO2, heart rate, body movement and temperature, along with full ECG and photoplethysmographic waveforms for eight preterm subjects in their home environment. MAIN OUTCOME/RESULTS: The data is analysed for remarkable events, more particularly periods of spontaneous desaturation. Statistical results for all case studies are collated into a table along with examples of graphical analysis. CONCLUSIONS: This study has shown that some patients are prone to episodes of hypoxemia during the course of normal daily activity or daytime sleep that would usually go unrecognized and that more effective management of supplemental oxygen treatment may be possible with continual unobtrusive monitoring.

Respiratory complications of the rheumatological diseases in childhood.

Pleuropulmonary manifestations of rheumatological diseases are rare in children but pose a significant risk to overall morbidity and mortality. We have reviewed the literature to provide an overview of the respiratory complications of the commonest rheumatological diseases to occur in children (juvenile systemic lupus erythematosus, scleroderma, juvenile dermatomyositis, mixed connective tissue disease, granulomatosis with polyangitis and juvenile idiopathic arthritis). Pulmonary function testing in these patients can be used to refine the differential diagnosis and establish disease severity, but also has a role in ongoing monitoring for respiratory complications. Early detection of pulmonary involvement allows for prompt and targeted therapies to achieve the best outcome for the child. This is best achieved with joint specialist paediatric rheumatology and respiratory reviews in a multidisciplinary setting.

Effect of Vishamashana on health: A survey study.

INTRODUCTION: Ayurveda has a novel concept of Vishamashana. Vishamashana means taking food irregularly or without following a particular time. AIMS: In the present era, due to the competitiveness in each and every field of life, today's individual does not get sufficient time for taking food and to maintain its quantity and quality. Vishamashana became a very common habit and trend in the modern developed era. As per the Ayurvedic Siddhanta, Vishamashana aggravates all the three Doshas and it is also said to be an important cause of vitiating the Agni. Hence, present survay was conducted to assess the effect of Vishamashana on health. MATERIAL AND METHODS: survey study has been done on 100 persons having habit of Vishamashana. Persons were divided into two groups: Group A for volunteers and Group B for patients. A special proforma was prepared for the assessment of health status based on Swastha Lakshanas of Charaka Samhita and Kashyapa Samhita. RESULTS: In the survey study, majority of patients of Group B were found to have Avara health status and Group A had Madhyama health Status.

An automated quasi-continuous capillary refill timing device.

Capillary refill time (CRT) is a simple means of cardiovascular assessment which is widely used in clinical care. Currently, CRT is measured through manual assessment of the time taken for skin tone to return to normal colour following blanching of the skin surface. There is evidence to suggest that manually assessed CRT is subject to bias from ambient light conditions, a lack of standardisation of both blanching time and manually applied pressure, subjectiveness of return to normal colour, and variability in the manual assessment of time. We present a novel automated system for CRT measurement, incorporating three components: a non-invasive adhesive sensor incorporating a pneumatic actuator, a diffuse multi-wavelength reflectance measurement device, and a temperature sensor; a battery operated datalogger unit containing a self contained pneumatic supply; and PC based data analysis software for the extraction of refill time, patient skin surface temperature, and sensor signal quality. Through standardisation of the test, it is hoped that some of the shortcomings of manual CRT can be overcome. In addition, an automated system will facilitate easier integration of CRT into electronic record keeping and clinical monitoring or scoring systems, as well as reducing demands on clinicians. Summary analysis of volunteer (n = 30) automated CRT datasets are presented, from 15 healthy adults and 15 healthy children (aged from 5 to 15 years), as their arms were cooled from ambient temperature to 5°C. A more detailed analysis of two typical datasets is also presented, demonstrating that the response of automated CRT to cooling matches that of previously published studies.

Inhaled beta2-agonists for treating non-specific chronic cough in children.

BACKGROUND: The pathophysiology of so called 'cough variant asthma' has not received a great deal of research interest and opinion lies divided as to whether it is really asthma or not. The proponents of cough variant asthma suggest a therapeutic trial of medications usually used to treat asthma OBJECTIVES: To determine the effectiveness of inhaled ss2 agonists in non-specific chronic cough in children over the age of 2 years. SEARCH STRATEGY: The Cochrane Airways Group database (including MEDLINE, EMBASE and CINAHL) and the Cochrane Controlled Trials Register (CCRT) were searched. Additional searching included hand searching of medical journals through the Cochrane Collaboration, references, references of references listed in primary sources and personal communication with authors. In addition "Grey literature" including theses, internal reports, non-peer reviewed journals were sought. SELECTION CRITERIA: All randomised (randomised and quasi-randomised) controlled clinical trials in which inhaled ss2 agonists were given for chronic cough in children over 2 years of age were included. Two reviewers independently assessed articles for inclusion and methodological quality. DATA COLLECTION AND ANALYSIS: Data for trials of salbutamol versus placebo were extracted by both reviewers and entered into the Cochrane Collaboration software program Review Manager, version 4.2 MAIN RESULTS: In children presenting with isolated chronic cough there was no significant difference between salbutamol treated group and placebo group. AUTHORS' CONCLUSIONS: Salbutamol was no different from placebo in reducing the frequency of cough measured objectively or scored subjectively.

Inhaled corticosteroids for non-specific chronic cough in children.

BACKGROUND: Cough in isolation of other clinical features is known as non-specific cough, which has been defined as non-productive cough in the absence of identifiable respiratory disease or any known aetiology. In children with non-specific cough the possibility of asthma being the underlying disorder is often raised (so called cough variant asthma). The proponents of cough variant asthma suggest a therapeutic trial of medications usually used to treat asthma. OBJECTIVES: To determine the efficacy of inhaled corticosteroids in non-specific cough in children over the age of two years. SEARCH STRATEGY: Searches were conducted on Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. Searches were current as of March 2004. SELECTION CRITERIA: All randomised (randomised and quasi-randomised) controlled clinical trials in which an inhaled corticosteroid (beclomethasone (BDP), fluticasone (FP), triamcinalone (TAA) or any other corticosteroid) were given for cough in children over two years of age were included. Two review authors independently assessed articles for inclusion and methodological quality. DATA COLLECTION AND ANALYSIS: Data from trials was extracted by both review authors and entered into the Cochrane Collaboration software program RevMan Analyses 1.0.2. MAIN RESULTS: Two trials met the inclusion criteria (123 participants). One compared inhaled beclomethasone dipropionate (400 micrograms per day) with placebo and the other compared fluticasone propionate (2 mg per day for 3 days followed by 1 mg per day for 11 days) with placebo. Both studies used metered dose inhalers via a spacer. With the lower dose of inhaled corticosteroid there was no significant difference between the beclomethasone and placebo groups. With the higher dose there was a significant improvement in nocturnal cough frequency after two weeks in children presenting with persistent nocturnal cough. However, a significant but smaller improvement was also seen with placebo. AUTHORS' CONCLUSIONS: In one study beclomethasone dipropionate (400 micrograms per day) was no different from placebo in reducing the frequency of cough measured objectively or scored subjectively. There might be a small improvement with very high-dose inhaled corticosteroid but the clinical impact of this is unlikely to beneficial.

Determinants of the first inspiratory volume and functional residual capacity at birth.

We have investigated the pattern of pressure and volume changes that occur in vaginally delivered, full-term infants during the onset of spontaneous respiration. Within a few seconds of delivery of the head, simultaneous measurements were made of stomach and esophageal pressure changes together with volume changes determined at the mouth. Values obtained for volume were very similar, but pressure changes were of a greater magnitude than previously reported. A significant correlation has been shown between first inspiratory volume and functional residual capacity (FRC) at the end of the first breath (p less than 0.004). No significant relationship was found between first inspiratory pressure and FRC. However, using a calculated index of inspiratory pressure and time ("inspiratory effort"), a significant relationship of this to FRC was observed (p less than 0.02).

Continuous positive airway pressure via a single nasal catheter in preterm infants.

We present the results of giving continuous positive airway pressure (CPAP) via a single nasal catheter to 20 preterm infants. A beneficial effect in terms of reduced work of breathing (P less than or equal to 0.01) and improved pattern of respiration (P less than or equal to 0.05) are demonstrated. CPAP via a single nasal catheter does not seem to mediate effects inside the thorax unlike CPAP delivered by a tight fitting face mask. Gross variations in CPAP level may result from altering the infant's position.

Randomized trial of artificial surfactant (ALEC) given at birth to babies from 23 to 34 weeks gestation.

Artificial surfactant (ALEC) composed of dipalmitoylphosphatidylcholine and unsaturated phosphatidylglycerol in a ratio of 7:3 (w/w) and a dose of 50-100 mg was suspended in 1 ml of cold saline and used at birth as a prophylaxis against the respiratory distress syndrome and its complications in a two centre randomized prospective trial involving 341 babies from 23 to 34 weeks gestation regardless of their antenatal problems. The surfactant had little effect in babies above 29 weeks gestation and was most beneficial in babies under 30 weeks gestation (67 controls and 69 surfactant treated babies). In this subgroup the artificial surfactant significantly reduced the inspired oxygen and peak ventilator pressure requirements during the first 96 h, the incidence of intraventricular haemorrhages from 40% to 19% (P less than 0.01), the overall mortality from 36% to 17% (P less than 0.02), the mortality due to RDS from 31% to 9% (P less than 0.01), the need for more than 28 days oxygen from 37% to 21% (P = 0.05) and the use of pancuronium in ventilated babies from 52% to 27% (P less than 0.01). There were no apparent side effects. This protein free, artificial surfactant should be a useful addition to the therapy of babies under 30 weeks gestation to reduce the severity of their RDS and the incidence of serious complications.

Warning note on a blood gas report leading to diagnosis of acetaminophen overdose.

OBJECTIVE: To report a case of acetaminophen toxicity diagnosed after a warning note of "interfering substances" on the blood gas report, leading to early and successful treatment. DESIGN: Case report. SETTING: Tertiary-care pediatric intensive care unit. PATIENT: A 14-yr-old boy admitted unconscious with lactic academia and hyperglycemia. INTERVENTIONS: Routine investigations. MEASUREMENTS AND MAIN RESULTS: His initial investigations revealed hyperglycemia and lactic acidosis. An annotation of "interfering substances" on the blood gas report prompted us to investigate for toxic substances, and an acetaminophen overdose was confirmed. CONCLUSIONS: A persistent warning note on the blood gas report of a sick child with elevated lactate and glucose should alert the clinician to the possibility of an acetaminophen overdose.

Hydatid cyst in head of pancreas presenting with obstructive jaundice.

We report a patient with hydatid cyst in the head of the pancreas who presented with obstructive jaundice. At operation, the cyst was compressing the common bile duct and pancreatic duct. Excision of the cyst with choledochoduodenostomy was performed.

Selection of pulse oximetry equipment for ambulatory monitoring.

PRIMARY OBJECTIVE: This communication describes the initial stage of a research project concerning the monitoring of SpO2 in infants prone to periods of spontaneous oxygen desaturation whilst freely moving around their home environment. The primary aim was to determine an appropriate probe type and site together with an assessment of the suitability of two commercially available oximeter units. RESEARCH DESIGN: The study comprised 19 comparative tests, totalling 162 hours of recordings at resolution one sample every four seconds. Comparisons are drawn between probes, probe sites and pulse oximeters. MAIN OUTCOMES/RESULTS: The bias and precision is presented with respect to the probe and measurement site. Also, correlation between the trial and reference recordings is considered. CONCLUSIONS: It is concluded that ambulatory recording of SpO2 in infants utilizing equipment suitable for home monitoring can produce diagnostic data equivalent to that of the Ohmeda 3700 biox, but that an indication of movement artefact may be required for confirmation of accuracy. It became apparent that 'wrap around' probes, used on the index finger or big toe are the most suitable.

Comparative study of oral health status of mentally sub-normal, physically handicapped, juvenile delinquents and normal children of Bombay.

Prevalence study on dental caries and periodontal disease carried out in 94 mentally subnormal, 92 physically handicapped, 74 juvenile delinquents and 206 normal children (11-14-year-old) revealed high prevalence of periodontal disease in handicapped (95 to 100%) and low in normal children (54.37%). The point prevalence of dental caries was higher in normal children (84.9%, DMFS 6.19) followed by juvenile delinquents (75.67%, DMFS 4.3), physically handicapped (73.91%, DMFS 4.3) and mentally subnormal (64.9%, DMFS 4.48).

Fluoride profiles of enamel following topical application of neutral and acidulated NaF solution using x-ray photoelectron spectroscopy (ESCA)--an in vitro study.

An in vitro analysis of fluoride in the surface enamel using x-ray photo-electron spectroscopy carried out on sound untreated teeth, sound teeth treated with neutral NaF and acidulated NaF and teeth with artificial caries treated with NaF and acidulated NaF revealed Ca/F ratio at surface and 360 degrees A as 0.140:1 and 0.140:1; 0.636:1 and 0.192:1; 1.112:1 and 0.908:1. 1.2:1 and 1.289:1; 2.11:1 and 1.87:1 respectively.