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A child with severe asthma does not respond well to inhaled β agonist plus ipratropium and oral steroid. Should you then give intravenous salbutamol or aminophylline? Researchers in London (
) have come down in favour of aminophylline. They randomised 44 children to a single bolus of salbutamol (15 μg/kg over 20 minutes then saline infusion) or aminophylline infusion (5 mg/kg over 20 minutes then 0.9 mg/kg/h). Asthma severity at 2 hours was similar in the two groups but the salbutamol group needed oxygen for longer, and stayed in hospital longer (85 v 57 hours) than the aminophylline group. More work is needed to compare salbutamol infusion or multiple boluses with aminophylline infusion (or both drugs). For partial liquid ventilation (PLV) the lungs are filled with perfluorocarbon and ventilated with gas using a conventional ventilator. There is evidence from experiments on newborn lambs that PLV with continuous distending pressure might improve lung growth. A study in six US centres (
) of 13 neonates with congenital diaphragmatic hernia and on extracorporeal life support has been said by the researchers to have produced encouraging, though not statistically significant, results. Compared with the five patients on standard mechanical ventilation the eight given PLV with continuous positive airway pressure of 5–8 cm H2O had a shorter time on ECMO (9.8 v 14.5 days), greater survival (6/8 v 2/5), and more days off the ventilator in the first 28 days (6.3 v 4.6 days). A definitive trial is needed. Nutritional rickets is common in the Arab countries. In the United Arab Emirates breast feeding rates are high and vitamin D supplements are recommended for breast feeding infants but often not given. A study of 90 Arab and South Asian (mostly Pakistani mothers and infants in Abu Dhabi (
) has confirmed that most are vitamin D deficient. At a median infant age of 6 weeks 55 of 90 mothers and 64 of 78 infants had low (<10 ng/mL) serum concentrations of 25-hydroxy vitamin D. These infants had high serum concentrations of alkaline phosphatase and parathyroid hormone. Vitamin D intake in the mothers was low. Vitamin D supplementation is important for breast feeding infants in the United Arab Emirates. Treatment with an anti-IgE antibody could prevent reactions to unintended ingestion of peanut. In a multicentre US trial (
) 84 patients aged 12–60 years were randomised to one of three dose (150, 300, or 450 mg) of a humanised IgG1 monoclonal antibody against IgE (TNX-901) or placebo given subcutaneously every four weeks for four doses. The threshold reaction dose of peanut flour determined by challenge testing increased with increasing dose of TNX-901. The highest dose of TNX-901 increased the threshold dose of peanut flour from the equivalent of half a peanut to the equivalent of nine peanuts. The amount of peanut usually involved in accidental ingestions is thought to be equivalent to one or two peanuts at most. Further studies have been stopped for the time being by legal wrangling between companies.
Causes of outbreaks of conjunctivitis include adenovirus, Haemophilus influenzae, Moraxella, and unencapsulated Streptococcus pneumoniae. An outbreak at Dartmouth College, New Hampshire between January and April 2002 (
) affected 14% of students and was found to be caused by an unencapsulated pneumococcus. An identical strain caused similar outbreaks in colleges in New York and California in 1980 and different strains caused outbreaks in Illinois in 1981 and 1996. The strain causing the Dartmouth outbreak has been identified in Europe. Risk factors for infection at Dartmouth included close contact with a case, contact lens wearing, membership of college teams, and attending college parties. Outbreaks of conjunctivitis caused by the same strain occurred later in 2002 at Princeton University and at an elementary school in Maine.
Bacterial contamination of the vagina (abnormal vaginal flora or bacterial vaginosis according to its degree) is associated with subclinical endometritis, miscarriage, and preterm delivery but treatment trials have given varying results. Now researchers in London have reported a trial of oral clindamycin in early pregnancy (around 16 weeks) in which the rate of miscarriage or preterm birth was reduced from 16% to 5% (
). The rate of spontaneous preterm delivery was reduced from 11.6% to 4.5% and of miscarriage from 4.1% to 0.8%. Despite this, treatment did not affect mean gestation at delivery, mean birthweight, the rate of low birthweight, or the rate of admission to the neonatal intensive care unit.
Better control of wound infection, resuscitation, nutrition, control of hypermetabolic response, and management of inhalation injury may all have contributed to a better prognosis after severe burns reported by some, though not all, centres in recent decades. One of the world’s leading centres for the care of burned children is in Galveston, Texas where 60% of children survive severe burns (>80% of total body surface area), often with a good quality of life after recovery. Researchers there (
; see also commentary, ibid 980–1) now insist that prognosis cannot be determined accurately early on and all severely burned children should be offered care in a specialist burns centre. Their prediction model, which proved 97% accurate, includes responses and progress over several weeks of treatment in addition to initial findings. In the UK decisions on whether to initiate treatment are often based on the total area of the burns, age, inhalation injury, and the areas of the body that are involved. There is a move to establish a few centres of excellence throughout the UK.
Consider, if you will, the speckled wood butterfly. Rapid early growth is not a good thing for this creature: it increases its susceptibility to starvation. Other animals also suffer as a result of growing too quickly too soon. Now follow up of babies included in a trial of preterm formula published in Archives in 1984 has suggested (
) that nutritionally-induced rapid growth in early infancy might predispose to type 2 diabetes and an increased risk of cardiovascular disease in later life. These researchers measured plasma concentrations of 32–33 split proinsulin (a marker of insulin resistance) in 216 adolescents who had participated in the 1980s trial and found higher concentrations (mean 7.2 v 5.9 pmol/L) in those who had been randomised to the nutrient-enriched preterm formula and had put on more weight in the first two weeks of life. Despite this, they refer to the possible adverse effects on the brain of early undernutrition in preterm infants and conclude that it might be better to promote growth in preterm infants even in the first few weeks. The implications for term infants are uncertain but infant feeding recommendations may have to be changed as knowledge advances.