Cerebral Edema During Treatment of Diabetic Ketoacidosis:
Fall In Ketoacid Levels and Consequent Fall In Osmolality May Be A Culprit
Inward and Chambers[1] have called for a rethink of the management
of diabetic ketoacidosis. In their article they quote a study by Grove L M
and colleagues[2] suggesting that pediatricians overestimated the quantum
of dehydration in DKA. Over correction of dehydrat...
Cerebral Edema During Treatment of Diabetic Ketoacidosis:
Fall In Ketoacid Levels and Consequent Fall In Osmolality May Be A Culprit
Inward and Chambers[1] have called for a rethink of the management
of diabetic ketoacidosis. In their article they quote a study by Grove L M
and colleagues[2] suggesting that pediatricians overestimated the quantum
of dehydration in DKA. Over correction of dehydration is implicated in
precipitating cerebral edema.
On the face of it, it seems implausible that pediatricians who are so
adapt at estimating dehydration in the context of gastroenteritis,
diarrhea, and vomiting should err in estimating the dehydration in DKA,
unless the dehydration of DKA has special features. Hypertonicity may be
that special feature. We hypothesize that hypertonic dehydration can
result in the tongue appearing dry and parched and when this is combined
with acidotic respiration of DKA, the treating pediatrician may classify
the child as more severely dehydrated than he or she actually is.
In a study of DKA we found that the mean osmolality at admission was
318 (SD 12.9, Range 291-337).[3] Further we also found that the
calculated osmolality {Calculated osmolality=1.86(Na + + K + ) + Urea +
Glucose} [4] was only 289 (Range 282 - 304) . This suggests hypertonicity
is common in DKA and calculated osmolality underestimates the true
osmolality. The mean osmolar gap was 29 (Range 14-48).
The osmolar gap between true and the calculated osmolality, is made up of
unmeasured substances like ketoacids. The osmolality of ketoacids have
been ignored in the past, as they are considered to be osmotically
inactive and not contributing to osmotonicity.[5] A study done by us
(sent for publication) has demonstrated that ketoacids (acetoacetates)
are osmotically active. (Acetoacetate can influence fluid shifts across a
semipermeable membranes. This is in contrast to urea, which is not
osmotically active) Osmolality, osmolar gap and ketone bodies are not
measured routinely during the management of DKA. A rapid fall in ketone
body level can result in a fall in osmolality and osmoticity of the serum
and lead to cerebral edema.
In a recent paper looking at the risk factors for development of cerebral
edema in DKA[6] the author noted that since none of the ‘relevant
variables’ - serum glucose concentration at presentation, change in serum
glucose concentration during therapy, rate of fluid and sodium
administration were associated with the risk of cerebral edema, their data
did not support the theory that a rapid decrease in extra cellular
osmolality during treatment results in osmotic mediated swelling.
Osmolality and osmolar gap were not measured, nor was ketone body levels
studied (Personal communication Glaser N ). Our studies demonstrates that
the ketone level is probably a 'relevant variable ' that needs to be
estimated before we can be certain that rapid decrease in extra-cellular
osmolality did not occur.
In summary we suggest that changes in ketone body levels be considered, as
a factor that can be partially responsible for the cerebral edema often
seen during treatment of DKA .We will be glad to share our data at any
summit of experts convened to study the enigma of cerebral edema in DKA.
(2) Grove LM, Nobel-Jamieson CM, Barnes ND et al. Assessment of
dehydration, fluid balance and insulin requirement in diabetic
ketoacidosis. Proc Br Paediatr Assoc Annual Meet 1995; 67:26.
(3) Puliyel J, Puliyel M, Hincliffe R. Hypertonicity in diabetic
ketoacidosis. Proceedings of International Symposium on Diabetes. Chaing
Mai Thailand Jan 26 - 29 1997.
(4) Varley H, Gowenlock AH, Bell M. Practical Clinical Biochemistry. 5
Th ed. London, William Heinemann Medical Books Ltd, 1980: 776-777.
(5) Van der Meulen JA, Klip A, Grinstein S. Possible mechanism for
cerebral edema in diabetic ketoacidosis. Lancet 1987; ii 306-8.
(6) Glaser N, Bernett P, McCaslin I, et al. Risk factors for cerebral
edema in children with diabetic ketoacidosis. N Engl J Med 2001; 344: 264-
9.
In this short report, Patel et al. presents a series of eight cases of
”symptomatic adrenal insufficiency during inhaled corticosteroid
treatment” [1]. The paper highlights several interesting points. However,
the determination of cases as “symptomatic”, the laboratory investigations
performed to establish the diagnosis, and the selection of cases, can be
seriously questioned.
In this short report, Patel et al. presents a series of eight cases of
”symptomatic adrenal insufficiency during inhaled corticosteroid
treatment” [1]. The paper highlights several interesting points. However,
the determination of cases as “symptomatic”, the laboratory investigations
performed to establish the diagnosis, and the selection of cases, can be
seriously questioned.
The authors have considered a poor growth in height and weight as a
symptom of adrenal insufficiency. In the discussion, they state that
systemic effect of conventional doses of inhaled corticosteroids will
result in increased or normal weight gain, while a poor weight gain/weight
is assumed to indicate an adrenal insufficiency. This assumption is in our
opinion not reasonable to make.
As can be calculated from Table 1 in their report, the average
deviation over time in weight is smaller (–0.66 SDS), compared to the
average deviation in height (–0.74 SDS). The observed weight deviation
may be secondary to the deviation in height, which is an unusual but well
described side effect to ICS, during the first years of treatment.
Difference in SDS between first and second measurement up to the
diagnosis of adrenal insufficiency, as calculated from figures given in
Table (1):
Case
Height SDS
Weight SDS
1
*
*
2
1.00
0.90
3
0.00
0.70
4
1.30
0.70
5
0.20
0.30
6
1.40
1.80
7
0.60
0.10
8
0.70
0.10
Average
0.74
0.66
* not assessable
The laboratory investigations performed to establish the diagnosis
are in two cases uncertain. Except during an acute adrenal crisis, basal
plasma and/or urinary steroid levels are not sufficient to give a
definitive diagnosis of adrenal insufficiency [2]. This is especially
important in the case of exogenous steroid exposure, where adrenal
adaptation to systemic levels of inhaled glucocorticosteroids occurs as a
way to protect against systemic effects of exogenous steroids [3]. To
determine adrenal function in such patients, dynamic test with ACTH is
necessary. In the report by Patel et al., standard dose Synacthen (ACTH)
has been performed for six of the cases, but the diagnosis remains unclear
in the remaining two cases (cases 6 and 7). As a consequence, these children,
who both received budesonide within the normal dose range, should not have
been included in the series.
We also agree with the commentary by Dr Russel [1] that another
reason to exclude case 7 is that the presenting symptoms included
hirsutism, hardly a feature of simple adrenal suppression.
Two children presented acutely with hypoglycaemia, and had subnormal
response to ACTH stimulation test. Both were treated with fluticasone 500 mg/day (one had stopped budesonide treatment 4 months earlier). Of the
four remaining cases, three were treated with fluticasone 500-1000 mg/day
and one was treated with beclomethasone dipropionate 600 mg/day. All had
subnormal response to ACTH stimulation test.
The conclusion from this report is that, especially in children, it is
important to step down treatment of inhaled corticosteroids when possible.
The report also indicates a greater potency for dose-related adrenal
suppression with fluticasone compared with budesonide, in accordance with
an earlier meta-analysis [4].
Bengt Lindberg
Dept of Pediatrics
Malmö University Hospital
AstraZeneca R&D Lund
Jarl Ingelf
AstraZeneca R&D Lund
Lars-Göran Carlsson
Dept of Pulmonary Medicine
Malmö University Hospital
AstraZeneca R&D Lund
References (1) Patel L, Wales JK, Kiberge MS, Massarano AA, Couriel JM and Clayton
PE. Symptomatic adrenal insufficiency during inhaled corticosteroid
treatment. Arch Dis Child 2001; 85: 330-334.
(2) Girard FO and R-D. MC. Adrenal Insufficiency. In Pediatric Endocrinology. Bertrand J, Rappaport R and S. PC. (Eds). Baltimore: Williams
& Wilkins. 1993: 333-350.
(3) Wolthers, OD and Honour JW. Hypothalamic-pituitary-adrenal
function in children with asthma and rhinitis treated with topical
glucocorticosteroids. Clin Exp Allergy 1998; 28(5): 545-550.
(4) Lipworth BJ. Systemic adverse effects of inhaled corticosteroid
therapy: A systematic review and meta-analysis. Arch Int Med
1999;159(9):941-955
I'm unable to find any consideration of the cost of atomoxetine in
the article. This is unfortunate as the article is positive towards this
new drug , but ignores it's significantly increased cost when compared to
methylphenidate.
Locally we feel this should not be a first line drug due
to it's cost , unless there are clear contraindications to
methylphenidate.
I read with interest the article. I recently had an experience when a
2-month-old infant, born term, 3.3 kg was admitted with clinical diagnosis
of Bronchiolitis. Since we do not have facilities for virology we cannot
claim microbiological confirmation. This infant had severe respiratory distress
and wheeze with low-grade fever. She was given IVF,Cont.Oxygen at 3.5 l/mt
as well as antibiotics. On th...
I read with interest the article. I recently had an experience when a
2-month-old infant, born term, 3.3 kg was admitted with clinical diagnosis
of Bronchiolitis. Since we do not have facilities for virology we cannot
claim microbiological confirmation. This infant had severe respiratory distress
and wheeze with low-grade fever. She was given IVF,Cont.Oxygen at 3.5 l/mt
as well as antibiotics. On the 4th day in hospital I noticed a pansystolic
murmur in the tricuspid area as well as hepatomegaly of 4 cm. The chest was
too noisy to aid any meaningful clinical finding. Color Doppler Echo showed
Pulmonary Hypertension with Tricuspid regurgitation. She was treated with
Digoxin,Lasix and Continuous humidified Oxygen. She gradually improved and
was discharged on day 10. She was readmitted once after a month,for 2 days,when she continued to have mild pul HT. After a month she was
readmitted with respiratory distress. CDE showed complete resolution of
Pul.HT. But she developed a sudden respiratory arrest from which she could
not be resuscitated.
I am sending this letter since it appears similiar to the one described. [1]
Dr Santhosh R.Gopal,DCH,DNB*
Paediatrician
District Hospital
Trichur, South India
References
(1) P Casano, M Pons Odena, F J Cambra, J M Martín, and A Palomeque. Bordetella pertussis infection causing pulmonary hypertension. Arch Dis Child 2002;86:453.
As a member of the International Consensus Conference on Intersex,
and an
affected adult, I supported the new nomenclature, which replaces both
"intersex" and "hermaphrodite" with "disorders of sex development" (DSDs).
But it would be a mistake to consider "DSD" to be a synonym for either
"intersex" or "hermaphrodite."
Medical management of intersex has been treated as if it were utterly...
As a member of the International Consensus Conference on Intersex,
and an
affected adult, I supported the new nomenclature, which replaces both
"intersex" and "hermaphrodite" with "disorders of sex development" (DSDs).
But it would be a mistake to consider "DSD" to be a synonym for either
"intersex" or "hermaphrodite."
Medical management of intersex has been treated as if it were utterly
different from other areas of medicine and, as a result, has lagged behind
while other areas have benefited from advances in ethics and in the use of
evidence. The Consensus Statement is a welcome first step in bringing the
treatment of conditions affecting sex development into conformity with the
rest of medical practice.
The older terms "intersex" and "hermaphrodite" clearly label the
whole
person, not a medical condition that the person has. Awkward constructions
like "hermaphroditism" and "intersex conditions" are attempts to
circumvent
this problem Further, the older terms imply a gender identity, and often
one
that contradicts the patient's actual gender identity.
"Disorders of sex development" is not a synonym for the older terms:
it refers
to the underlying physiology that causes the atypical sex anatomy. With
the
new nomenclature, a patient with, for example, partial Androgen
Insensitivity
Syndrome will
not be labeled *a* male pseudo-hermaphrodite, nor *an* intersexual.
Rather,
the
patient *has* an endocrine disorder, one of the endocrine disorders that
affects
sex development. Some individuals with this genetic disorder have male
gender identity, some female, and indeed some have a more complex and
less common gender identity. Precisely because of the broad range of
possible identities, and because people do not experience their gender
identity as a disorder, it is imperative that the nomenclature for the
underlying cause of the atypical sex anatomy *not* imply any gender
identity.
"Disorder" is a word commonly used in medicine. The causes of
atypical sex
anatomy include genetic disorders and endocrine disorders. Use of the word
"disorder" in the new nomenclature makes clear that DSDs are similar in
many
ways to other, more familiar disorders.
That is, the principles of medical ethics must apply. For example:
* Deceiving or misleading a patient about her condition is not
acceptable;
* The importance of using evidence to determine interventions applies
(e.g.
the performance of surgery based on a "belief" is not acceptable);
* DSDs are conditions that the patient will live with during
[throughout] their
entire lives.
* Medicine can help, but no intervention (including appearance
altering
surgeries during infancy) will eliminate the condition.
A euphemism like "variation" would fail to make these implications
clear, and
would allow the single-minded focus on gender to the exclusion of other
health issues and the need for psychosocial support to continue.
I thank Dr Edge and other correspondents and am gratified that none
dissents from the view of Dr Inward and myself that the assessment and
fluid management of DKA in childhood needs multispecialty review. Perhaps
this is underway: if not then should our College President - Elect invite
his Newcastle colleague Sir George Alberti to convene and chair it?
The Consortium on Disorders of Sex Development (“DSD Consortium”) has
recommended that in venues where the medical care of infants is
considered, the term "Disorders of Sex Development" and the initialism
“DSD” be used in favor of the term “intersex.” While both “DSD” and
“intersex” are “umbrella” terms (meaning that they encompass people born
with a variety of discrete conditions but having important f...
The Consortium on Disorders of Sex Development (“DSD Consortium”) has
recommended that in venues where the medical care of infants is
considered, the term "Disorders of Sex Development" and the initialism
“DSD” be used in favor of the term “intersex.” While both “DSD” and
“intersex” are “umbrella” terms (meaning that they encompass people born
with a variety of discrete conditions but having important features in
common), the former has recently been adopted to aid in classifying
conditions involving sex development. Prior to the adoption of “DSD” as
the preferred term, there was apparently some confusion about whether
certain medical conditions properly fell under the heading of “intersex.”
The Consortium's avowed aim in preferring “DSD” is to support improved
medical care for children born with such conditions. To that end it has
produced two publications entitled Clinical Guidelines For The Management
of Disorders of Sex Development In Childhood and Handbook for Parents,
both of which employ “DSD” nomenclature almost exclusively.
A large and diverse number of adults treated for these same
conditions have spearheaded this movement for improved care. They are
committed to an open, honest and productive dialog between the medical
community on the one hand, and patients and their families on the other.
Many if not most of these adults have adopted, and prefer to continue to
identify with, the term “intersex” as a way of classifying their
conditions and to speak about their bodies and their experiences. They
find the word “intersex” empowering because it provides a sense of
community and allows people with many different conditions to band
together to work toward better medical care and social justice.
There is a splendid and powerful array of narrative and poetry, prose
and biography, and websites and scholarly publications which reflect the
many facets of what it is like for individuals to be born and raised, and
now living, as intersex individuals. Many of these works have been
incorporated into compelling anthologies which have resulted in a long
overdue voice for the silenced, a point of entry into the experience for
the non-intersex world, and a shift in the medical care of children born
with such conditions. Some of these writings may seem frank, raw and
perhaps even bitter, no doubt in part because in the past there was less
appreciation by the medical community of the psychological needs of
intersex patients. These works remain relevant for the current generation
of children and their parents who are confronting the challenging issues
described in the Parents Handbook.
It would be a mistake to to advocate that “intersex” be replaced with
“DSD” within such community, in the same way that people with a variety of
different conditions identify themselves using terms which may vary from
the terms employed by their health care providers. For example, instead of
using a diagnosis such as “achondroplasia,” many individuals with such
conditions have banded together using the term “Little People” because it
reflects their history, culture, and real-life experience.
It would also be regrettable if the term "Disorder of Sex
Development" were to be adopted even in a clinical setting for other than
an interim period until a more appropriate term is adopted. DSD embraces
the notion that morphology trumps identity, and that intersex is a
pathology. It is not mere political correctness which compels a change
from "Disorder" to "Variation" as proposed by Dr. Diamond and Professor
Beh. Instead, such change is a beginning point in having medicine reorient
its thinking about the validity and acceptability of intersex bodies in
their natural state.
It is equally important that as we look forward, intersex support and
advocacy groups don’t abandon the term “intersex” even as they may work
in tandem with the medical community to adopt a new nomenclature.
"Intersex" is a term which gives meaning and purpose to, and reflects the
courage and determination of, a community which has dedicated itself—often
at considerable personal risk—to seeking improvements in care and
widespread awareness and acceptance.
Sherri Groveman Morris is an attorney, intersex patient advocate,
former member of the Board of Director of the Intersex Society of North
America and Founder of the US branch of the AIS Support Group.
With all the hoopla regarding using the term DSD as opposed to
Intersex, I
was hesitant to add my own two cents. However, after giving it a lot of
thought I decided my opinion does matter. And what I have to say is as
important as any other letter that is for or against the term DSD.
As an intersexed child at the University of Chicago Hospital, several
diagnoses were attached to me, none...
With all the hoopla regarding using the term DSD as opposed to
Intersex, I
was hesitant to add my own two cents. However, after giving it a lot of
thought I decided my opinion does matter. And what I have to say is as
important as any other letter that is for or against the term DSD.
As an intersexed child at the University of Chicago Hospital, several
diagnoses were attached to me, none of them adding any meaning to how I
felt, which was confused and alone. After hearing Cheryl Chase on
television
talk about people like herself that are born neither male or female, I
knew I
had finally found someone I could relate to.
I loved the term Intersex then, and I still do today. I felt
empowered for once
in my life. I was Intersex, not someone with PAIS, Panhypopituitarism,
Hypothyroidism and Hypogonadism. I found a term that not only defined me
but also helped me to understand that I am not alone. I quickly embraced
the
term Intersex, and with the help of Cheryl Chase became an Intersex
Activist
and Educator.
When people asked me about my “condition” I told them I had no
“condition”:
I am Intersex. I wore Intersex like a badge of honor. Nothing the doctors
did
to me mattered because I was able to forgive them through educating
others.
I can never forget the years of hospitalizations and numerous tests. But
being
Intersex made me feel like none of it mattered anymore. I was born this
way
for a reason. I was, and am, proud to be Intersex.
Through the years I watched ISNA struggle to get the message out to
the
medical profession regarding the mistreatment of Intersex children and
informing parents of the choices available to children born Intersex.
Children
born Intersex. This is why I became an Intersex Activist. I didn’t want
what
happened to me, the mistreatment I endured for almost two decades, to
happen to another child. My focus, like ISNA’s, became the children that
are
born Intersex. I have spoken at numerous colleges, universities, private
organizations, etc, on the importance of society being educated about
Intersex. My motto was one person educates two people about Intersex,
those two people educate two people about Intersex, and so on and so on.
However just because my focus was on the kids doesn’t mean that I lost
focus
on the adults that are Intersex. Those that still lived in shame and
secrecy.
Those who are not as outspoken as I am, and have not found comfort in the
term Intersex.
A lot of people confided in me that they did not embrace the term
Intersex
because they are not gay or lesbian, and they feared being stigmatized as
such. I wanted to relate, really. But I didn’t see how someone that is
Intersex
would not embrace such a powerful term. An in your face, taking back my
body, term that I love. But slowly I understood.
As more and more people began to use the term Intersex who weren't
Intersex I grew angry. How dare someone that hadn’t endured what many
Intersex people endure, someone who isn’t remotely Intersex, co-opt “my”
term.
When I first heard the term DSD, Disorder of Sexual Development, I
felt
betrayed. But gradually I realized how using the term DSD could better
help
kids born Intersex. If we talk in terms doctors can understand, they seem
to
understand us better.
That doesn’t mean that I like the term DSD or will ever embrace it, I
don’t and
I won’t. DSD is a diagnosis, and I was given enough of those as a child. I
love
being the radical in-your-face Intersex Activist and Educator that I am.
Intersex is fine!
But working in the medical field in the past, as an emergency medical
technician now, and soon to be paramedic, I understand how doctors think.
And I can understand how some parents agree with doctors that their child
is
NOT Intersex. We live in a world where language is everything. I don’t
speak
Spanish, so it would be virtually impossible for me to verbally
communicate
with someone that only speaks Spanish. When it comes to communicating
with the medical profession we have to speak their language. Using the
term
DSD to me is speaking the language of the medical profession.
I don’t expect every Intersex Activist to embrace the term DSD. It
does feel
like a slap in the face. But it’s important that we remember why we -- why
I
-- became an Intersex Activist: FOR THE KIDS! And if meeting doctors at
their
own level by using simple medical terminology like DSD will help them to
better understand how to do a better job for children born Intersex then I
am
all for it.
I will add DSD to my curriculum when I speak, but I will NEVER EVER
forget
that I am Intersex!
I am concerned about the promotion of terminology that reinforces a
notion of disorder for people who are intersexed. I prefer a term such as
variation or atypicality.
I am concerned that people who have not had access to proper
diagnostic work-ups available now will be excluded from appropriate
treatment: people such as myself who may have had experimental
interventions many years ago, but b...
I am concerned about the promotion of terminology that reinforces a
notion of disorder for people who are intersexed. I prefer a term such as
variation or atypicality.
I am concerned that people who have not had access to proper
diagnostic work-ups available now will be excluded from appropriate
treatment: people such as myself who may have had experimental
interventions many years ago, but became alienated through such
interventions and subsequent examinations. The failure to treat people
appropriately because they fall outside an arbitrary category can be as
problematic as treating people inappropriately.
I floated a survey on the title of this letter on the internet
recently (it is still ongoing), and out of over 60 respondents, less than
10% endorsed the use of this new terminology. This ratio of 1-9 was
consistent for people who identified themselves as intersex and who had
experienced medical intervention for such in childhood.
It would appear that this terminology is being adopted with minimal
consultation in relation to those who will be affected by it who are in a
position to speak now. Part of the thrust of some proponents appears to
be precisely because it will exclude some people from treatment (as we
have seen in one or two previous responses).
Cryptorchidism, hypospadias, growing up unaware of inherent
infertility, the early-onset of undiagnosed osteoporosis along with other
such problems are not trivial; some of the attempted treatments for some
of these in the past has not been fun either. Finding out the
consequences of having such problems later in life simply because of some
other medical problem, when they could have been treated much earlier had
there been proper disclosure is no joke. Having been told that such
symptoms have nothing to do with intersex, have an unknown cause, or
haven't existed because the medical notes were lost, etc., I am not
encouraged that the adoption of new terminology will make this sort of
situation any better for people in the future.
Whilst the tone and content of the guidance for DSD is laudable, how
far this will have any authority to affect practice is unclear. If people
are specifically excluded from coverage, it is hard to see how practice in
those cases can be expected to be any different from what has gone on in
the past. Many underdeveloped males will not have a 'disorder', they will
still be males who need fixing in certain ways to ensure they become
'proper' men, and as far as I can see there will be no reason to consider
their feelings on this.
I am concerned that this approach on adoption of this terminology in
relation to a vulnerable patient-group appears to run contrary to current
trends in medicine, where such views are usually taken into account. It
is more reminiscent of a bygone era where patients had things done to them
with only limited discussion, because the Doctor always knew best.
I am also concerned that by classifying something as disorder, not
only will it serve to exclude some from appropriate treatment, it will
help justify experimental treatments carried out on some retrospectively,
and justify inappropriate experimental treatments on some in the future.
Dr Casano describe a case refractory pulmonary hypertension with
severe Bordetella pertussis infection. Their description of the
literature is incomplete. We described a further 4 cases of fatal
pulmonary hypertension (PHT)
in a series of 13 critically ill infants with B. pertussis[1]. The cases
that developed PHT all presented with severe hyperleukocytosis (WCC>100 x 10(9)/l)which was unresponsive...
Dr Casano describe a case refractory pulmonary hypertension with
severe Bordetella pertussis infection. Their description of the
literature is incomplete. We described a further 4 cases of fatal
pulmonary hypertension (PHT)
in a series of 13 critically ill infants with B. pertussis[1]. The cases
that developed PHT all presented with severe hyperleukocytosis (WCC>100 x 10(9)/l)which was unresponsive to all currently available modalities
including extra-corporeal membrane oxygenation. Hyperleukocytosis was an
independent predictor of death when corrected for presentation severity of
illness. We suggested, in line the existing histological evidence[2], that
such extreme leukocytosis prediposes to the formation of lymphocyte
aggregates in the pulmonary vasculature and increased pulmonary vascular
resistance via obstruction rather than hypoxic vasoconstriction.
Therefore Dr Casano's recommendation for the early use of pulmonary
vasodilators is unlikely to be sufficient in context. We are assessing the
impact of strategies aimed at reducing lymphocyte numbers and adhesion in
addition to standard treatments for pulmonary hypertension.
References
(1)Pierce C, Klein N, Peters M. Is leukocytosis a predictor of
mortality in severe pertussis infection? Intensive Care Med 2000
Oct;26(10):1512-4
(2) Williams GD, Numa A, Sokol J, et al. ECLS in pertussis: does it
have a role? Intensive Care Med 1998;24:1089–92
Dear Editor
Cerebral Edema During Treatment of Diabetic Ketoacidosis: Fall In Ketoacid Levels and Consequent Fall In Osmolality May Be A Culprit
Inward and Chambers[1] have called for a rethink of the management of diabetic ketoacidosis. In their article they quote a study by Grove L M and colleagues[2] suggesting that pediatricians overestimated the quantum of dehydration in DKA. Over correction of dehydrat...
Dear Editor,
In this short report, Patel et al. presents a series of eight cases of ”symptomatic adrenal insufficiency during inhaled corticosteroid treatment” [1]. The paper highlights several interesting points. However, the determination of cases as “symptomatic”, the laboratory investigations performed to establish the diagnosis, and the selection of cases, can be seriously questioned.
The a...
Dear Editor,
I'm unable to find any consideration of the cost of atomoxetine in the article. This is unfortunate as the article is positive towards this new drug , but ignores it's significantly increased cost when compared to methylphenidate.
Locally we feel this should not be a first line drug due to it's cost , unless there are clear contraindications to methylphenidate.
Dear Editor
I read with interest the article. I recently had an experience when a 2-month-old infant, born term, 3.3 kg was admitted with clinical diagnosis of Bronchiolitis. Since we do not have facilities for virology we cannot claim microbiological confirmation. This infant had severe respiratory distress and wheeze with low-grade fever. She was given IVF,Cont.Oxygen at 3.5 l/mt as well as antibiotics. On th...
Dear Editor,
As a member of the International Consensus Conference on Intersex, and an affected adult, I supported the new nomenclature, which replaces both "intersex" and "hermaphrodite" with "disorders of sex development" (DSDs). But it would be a mistake to consider "DSD" to be a synonym for either "intersex" or "hermaphrodite."
Medical management of intersex has been treated as if it were utterly...
Dear Editor
I thank Dr Edge and other correspondents and am gratified that none dissents from the view of Dr Inward and myself that the assessment and fluid management of DKA in childhood needs multispecialty review. Perhaps this is underway: if not then should our College President - Elect invite his Newcastle colleague Sir George Alberti to convene and chair it?
TL Chambers
Dear Editor,
The Consortium on Disorders of Sex Development (“DSD Consortium”) has recommended that in venues where the medical care of infants is considered, the term "Disorders of Sex Development" and the initialism “DSD” be used in favor of the term “intersex.” While both “DSD” and “intersex” are “umbrella” terms (meaning that they encompass people born with a variety of discrete conditions but having important f...
Dear Editor,
With all the hoopla regarding using the term DSD as opposed to Intersex, I was hesitant to add my own two cents. However, after giving it a lot of thought I decided my opinion does matter. And what I have to say is as important as any other letter that is for or against the term DSD.
As an intersexed child at the University of Chicago Hospital, several diagnoses were attached to me, none...
Dear Editor,
I am concerned about the promotion of terminology that reinforces a notion of disorder for people who are intersexed. I prefer a term such as variation or atypicality.
I am concerned that people who have not had access to proper diagnostic work-ups available now will be excluded from appropriate treatment: people such as myself who may have had experimental interventions many years ago, but b...
Dear Editor
Dr Casano describe a case refractory pulmonary hypertension with severe Bordetella pertussis infection. Their description of the literature is incomplete. We described a further 4 cases of fatal pulmonary hypertension (PHT) in a series of 13 critically ill infants with B. pertussis[1]. The cases that developed PHT all presented with severe hyperleukocytosis (WCC>100 x 10(9)/l)which was unresponsive...
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