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A working group of the International Union Against Tuberculosis and Lung Disease has formulated simple clinical scoring systems for screening for tuberculosis in children (International Journal of Tuberculosis and Lung Disease1998;2:116–23). They propose different scoring systems for low and high prevalence countries, each system using five criteria; contact with tuberculosis, tuberculin reactivity, cough, underweight, and fever. In low prevalence countries contact history and skin test result are all-important whereas in high prevalence countries the five criteria are given almost equal weighting. The systems tend to give high positive predictive value but low sensitivity and specificity; their value in screening children for further investigation, especially in developing countries, needs to be determined in field conditions.
About one child in 10 with sickle cell disease will have a stroke by the age of 20, the incidence being highest in 2–5 year olds. In a US multicentre trial (New England Journal of Medicine1998;339:5–11. See also editorial, Ibid: 42–4) children were selected because of increased stroke risk by virtue of increased blood flow velocity in internal carotid or middle cerebral arteries on transcranial Doppler ultrasound. A randomised trial of repeated blood transfusion (to keep haemoglobin S at 30% or less of total haemoglobin) was stopped prematurely when, after mean follow up of 18–21 months, there had been 11 strokes (10 ischaemic, one haemorrhagic) in 67 controls and one (ischaemic) in 63 patients in the transfusion group. There are problems with patient concordance and with potential complications such as iron overload and alloimmunisation but repeat transfusion in selected patients could reduce the incidence of stroke. The optimum duration of transfusion therapy is debated.
Diethylene glycol kills children. In a recent Haitian incident (Journal of the American Medical Association1998;279:1175–80. See also editorial,Ibid: 1215–6) 109 children presented with acute renal failure after taking contaminated paracetamol syrup and at least 88 died. Previous similar tragedies have occurred in the USA, Argentina, Bangladesh, Spain, Nigeria, and South Africa. How the stuff gets into the medicine and how to prevent these outbreaks seems to be largely unknown. Repeated calls for increased regulation do not seem to have worked.
Leukotrienes are produced by eosinophils and mast cells, and cause bronchoconstriction and increased mucus production. A North American multicentre trial (Journal of the American Medical Association1998;279:1181–6) has shown significant improvements in morning FEV1 and in quality of life scores in 6–14 year olds with asthma given a leukotriene blocker (montelukast) as a chewable tablet at bedtime. Other measures such as daytime asthma symptom score, nocturnal awakenings, and days off school showed no improvement. The drug was well tolerated.
Dramatic reductions in the incidence of H influenzae meningitis and epiglottitis have followed the introduction of Hib vaccination. Now data from Finland (Journal of Bone and Joint Surgery1998;80-B:471–3) have shown that the vaccine has eliminated H influenzae arthritis. Universal infant vaccination with Hib was fully established in Finland in 1988. A survey of eight Finnish hospitals showed that between 1982 and 1988 there were 61 cases of septic arthritis in children, 22 caused by H influenzae type B. No case of Hib septic arthritis has been reported in Finland since 1988. As a consequence antibacterial therapy can be aimed solely at Gram positive cocci (staphylococci, group A streptococci, and pneumococci) making it simpler, safer, and cheaper. They use clindamycin or a first generation cephalosporin but such treatment may not be appropriate in some other countries, especially in the developing world, where Gram negative bacteria still cause septic arthritis.
In MRC trials of the management of spinal tuberculosis 99% of patients in Korea and 48% in Hong Kong were aged under 15. The thirteenth report (Journal of Bone and Joint Surgery1998;80-B:456–62) confirms that the good results from ambulatory chemotherapy are maintained at 13–15 years, follow up. Some 70% did well with no central nervous system involvement, no sinuses or abscesses, no active disease on x ray, no restriction of normal physical activities, and no late relapse or late onset paraplegia. Early bed rest in hospital or plaster casting did not improve results. In Hong Kong radical excision and bone grafting improved healing and gave less eventual deformity.
A study in Australia (Diabetes Care1998;21:379–84) showed no difference in intellectual functioning between children with diabetes three months after diagnosis and controls. Yet two years later the children with diabetes had mild but significant deficits in information processing, knowledge acquisition, and reasoning ability. Children diagnosed before the age of 5 years seemed particularly susceptible. The significance of these findings for long term function and for clinical management has yet to be worked out.
Shown a picture of a baby with restrictive dermopathy (RD) (Archives of Dermatology 1998;134:577–9) Lucina would have thought first of a diagnosis of harlequin fetus. Infants with RD are usually born prematurely, they have a tense skin with erosions, fixed facial expression, fixed O-shaped mouth, micrognathia, and multiple joint contractures. Up to half of the children die as newborns. The condition is autosomal recessive. Twelve cases from the Netherlands have been added to a previously reported total of 24.
Research involving over 34 000 neonates in Italy (New England Journal of Medicine 1998;338:1709–14) has shown a prevalence of corrected QT interval (QTc) over 440 ms of about 25 per 1000. Half (12/24) of the babies who subsequently died of sudden infant death syndrome (SIDS) had such a prolonged QTc. The risk of SIDS was 40 times greater in infants with prolonged QTc (1.53% v 0.03%). Such babies might theoretically benefit from β blocker treatment but that remains speculative.
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