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Even with the acknowledgement that a diagnosis of thyrotoxicosis is
incompatible with a thyroid stimulating hormone(TSH) level which lies
within the normal range[1], what the author says ring true that one should
scrutinise, not only the laboratory result, but the patients as well[2].
This advice is especially relevant to thyroid disease, where laboratory
derangements may be similar to those f...
Even with the acknowledgement that a diagnosis of thyrotoxicosis is
incompatible with a thyroid stimulating hormone(TSH) level which lies
within the normal range[1], what the author says ring true that one should
scrutinise, not only the laboratory result, but the patients as well[2].
This advice is especially relevant to thyroid disease, where laboratory
derangements may be similar to those found in non-thyroidal illness. Thus,
the suppression of TSH to <0.03 mu/L,in association with normal levels
of thyroid hormone, can be a feature of so-called subclinical
hyperthyroidism[3] as well as severe non-thyroidal illness(4).
Conversely,
when normal levels of thyroid hormone are associated with elevation in
TSH, this characterises, not only subclinical primary hypothyroidism, but
also severe non-thyroidal illness[5], and even primary hypoadrenalism[6].
The "identity crisis" of thyroid function tests reaches its peak in
central hypothyroidism where, on the one hand, the association of
subnormal TSH and hypothyroxinaemia can be simulated by severe non
thyroidal ilness[7], whilst elevation in TSH to the range 5-15 mu/L, when
concurrent with hypothyroxinaemia, can simulate primary hypothyroidism[8].
The vagaries of "rogue" assays compound these difficulties,hence the need
for a dialogue between the clinician and the laboratory when interpreting
thyroid function tests.
References
(1) Supit EJ., Peiris AN
Interpretation of laboratory thyroid function tests
Southern Medical Journal 2002:95:481-5
(3) Toft A
Subclinical Hyperthyroidism
New England Journal of Medicine 2001:345:512-6
(4) Franklyn J., Black EG., Belleridge j., Shepherd MC
Comparison of second and third generation methods for measurement of serum
thyrotropin in patients with overt hyperthyroidism, patients receiving
thyroxine therapy, and those with non-thyroidal illness
Journal of Clinical Endocrinology and Metabolism 1994:78:1368-71
(5) Brent GA., Hershman JM., Braunstein GD
Patients with severe non-thyroidal illness and serum thyrotropin
concentration in hypothyroid range
Amer J Med 1986:81:463-6
(6) Topliss DJ., White EL., Stockgit JR
Significance of thyrotropin excess in untreated primary adrenal insufficiency
Journal of Clinical Endocrinology and Metabolism 1980:50:52-65
(7) Hamblin PS., Dyer SA., Mohr VS et al
Relationship between thyrotropin and thyroxine changes during recover from
severe thyroxinaemia of critical illness
Journal of Clinical Ebdocrinology and Metabolism 1986:62:717-22
(8)Wiersinga WM
Hypothyroidism and myxedema coma
Chapter 105
Endocrinology 4th Edition
Editors de Groot L and Jamieson JL
WB Saunders Co
Philadelphia, London, New York, St Louis, toronto Sydney
Van Bever et al suggest that “it is time to rethink whether there is
any causal link between aspirin and Reye’s syndrome (RS)” and that
paediatricians should consider returning to aspirin as “their first choice
antipyretic/analgesic in children” [1]. The proposal appears to originate
in the hypothesis that the decline in its use is responsible for the
increase in allergic disorders. They do no...
Van Bever et al suggest that “it is time to rethink whether there is
any causal link between aspirin and Reye’s syndrome (RS)” and that
paediatricians should consider returning to aspirin as “their first choice
antipyretic/analgesic in children” [1]. The proposal appears to originate
in the hypothesis that the decline in its use is responsible for the
increase in allergic disorders. They do not specify how the occasional
use of aspirin for a febrile illness might reverse this increase.
The virtual disappearance of RS following the warning labels on
aspirin for children and teenagers has been described as a “public health
triumph” in terms of the death and disability avoided [2]. Compelling
evidence of benefit must be presented to justify reinstatement of aspirin
in the routine treatment of febrile illness in children.
The authors argue that RS is extremely rare in patients on both short
and long term aspirin treatment for Kawasaki disease (KD) and therefore
aspirin may not be causally associated with RS. They state that only one
case of RS associated with KD has ever been reported, and that only in the
Japanese literature. However, a basic Medline search reveals another
report –from Taiwan [3].Furthermore, 14 of 361 patients reported to the
National Reye’s Syndrome Surveillance System in the USA between 1980 and
1997 for whom data on aspirin use were available, were on long term
salicylate medication for either KD or juvenile chronic arthritis [4]. The
authors of this report also cite two other studies showing a higher attack
rate of RS among children on long term salicylates for juvenile chronic
arthritis.
Bever et al’s argument fails to take account of the fact that Reye’s
syndrome has a multifactorial aetiopathogenesis: besides aspirin, the
other associated risk factors for which there is both epidemiological and
laboratory evidence are a prodromal viral infection, typically influenza
or varicella, and an innate susceptibility[5]. The latter is reflected in
the rarity of Reye’s syndrome: even in the years before aspirin warnings
the annual reported incidence was at most 1 per 100 000 children under 18
in the USA. The chances of a child even on long term aspirin having these
other two risk factors must be very small indeed and probably explains the
dearth of reports of RS in these patients. Furthermore, most cases of KD
occur in children under five whereas most cases of idiopathic RS were in
the over fives [4]. There is in fact a small excess risk of RS in children
receiving long term aspirin and, because of this, it is recommended
practice in the USA to vaccinate such patients against influenza and
varicella[4]. Perhaps paediatricians in Japan and other countries where
there is a high incidence of KD disease do the same.
It is true that the biological mechanism underlying the link between
aspirin and RS is not understood, but evidence for the association is
substantial[5] and has convinced regulatory authorities in the UK, USA,
Europe and many other countries. There are alternative, equally effective
drugs for symptomatic relief in children with febrile illnesses, which
have not been associated with this lethal condition. It is irresponsible
to encourage doctors to ignore the current guidelines on the basis of a
hypothesis for which there is no robust evidence.
References
(1). van Bever HP, Quek SC, Lim T. Aspirin, Reye syndrome, Kawasaki
disease, and allergies; a reconsideration of the links. Arch Dis Child
2004; 89: 1178
(2). Monto AS. The disappearance of Reye’s syndrome – a public health
triumph. New Engl. J Med 1999; 340: 1423-1424
(3). Lee JH, Hung HY, Huang FX. Kawasaki disease with Reye’s syndrome:
report of one case. Zhonghua Min Guo Xiao Er Ke Yi Xue HuiZa Zhi 1992; 33:
67-71
(4). Belay ED, Bresee JS, Holman RC, et al. Reye’s syndrome in the
United States from 1981 through 1997. New Engl J Med 1999; 340: 1377-1382
(5). Glasgow JFT, Hall SM. Reye’s syndrome and aspirin. In Rainsford
KD (ed) Aspirin and related Drugs, Taylor and Francis, London 2004; 555-
585
Patients with congenital heart disease (CHD) have been reported by
many authors to have high rates of hospitalisation, morbidity and
mortality associated with respiratory syncytial virus (RSV) lower
respiratory tract illness.[1-3] However, in a recent paper in the
Archives of Diseases in Children Duppenthaler et al reported a
substantially lower incidence of respiratory syncytial virus (RSV)...
Patients with congenital heart disease (CHD) have been reported by
many authors to have high rates of hospitalisation, morbidity and
mortality associated with respiratory syncytial virus (RSV) lower
respiratory tract illness.[1-3] However, in a recent paper in the
Archives of Diseases in Children Duppenthaler et al reported a
substantially lower incidence of respiratory syncytial virus (RSV)
hospitalisation in patients with “haemodynamically significant” CHD.[4]
They suggest that the rate of hospitalisation in their population of
patients from the Canton of Bern, Switzerland was as much as four times
lower than rates previously reported in the United States. Based upon
these results they concluded that the unrestricted use of palivizumab to
prevent RSV hospitalisation was not justified.
There are several possible methodological reasons for the disparity
in RSV hospitalisation rates in the calculations of both the numerator and
denominator. With respect to the numerator, Duppernthaler’s methods would
miss all of the nosocomial RSV disease. Furthermore, ascertaining the true
incidence of RSV hospitalisation would require that all CHD patients
admitted to the hospital undergo RSV screening, as was done in the
international multicenter trial, not just those with symptoms judged
typical of RSV.[5]
Finally, in a previous paper by the same authors in
the first four years of the study (1997/98 – 2000/1),[6] 12 of 497
patients studied aged <_5 years="years" were="were" identified="identified" with="with" chd="chd" compared="compared" to="to" _6="_6" of="of" _449="_449" aged="aged" _2="_2" in="in" this="this" study.="study." since="since" the="the" previous="previous" study="study" encompassed="encompassed" children="children" under="under" age="age" five="five" difference="difference" six="six" patients="patients" between="between" first="first" and="and" one="one" would="would" imply="imply" that="that" who="who" hospitalised="hospitalised" ages="ages" two="two" making="making" a="a" strong="strong" case="case" for="for" palivizumab="palivizumab" prophylaxis="prophylaxis" group="group" or="or" they="they" deemed="deemed" have="have" haemodynamically="haemodynamically" insignificant="insignificant" heart="heart" disease="disease" questioning="questioning" definition="definition" significant="significant" disease.="disease." p="p"/> With respect to the denominator, the author used the International
Classification of Diseases (ICD) coding as a screen for patients with
“haemodynamically significant” CHD for entry into the cardiology registry.
However, the ICD system does not allow for severity adjustment and
therefore does not distinguish between haemodyamically significant and
insignificant disease. In our recent multicenter trial, we defined
haemodynamically significant CHD as patients with cyanotic CHD, single
ventricle physiology or those with acyanotic CHD that required medical
therapy.[5]
Overall, this would account for only about 35-40% of all the
CHD patients. This would have significantly reduced the number of patients
in the denominator, increasing RSV hospitalisation incidence. Secondly, no
attempt was made to verify the accuracy of screening utilizing the ICD
system, which might have resulted in missed patients with CHD due to
inaccurate and/or inconsistent coding. Third, the calculations of child-
years of observation, as written, was assumed to equal the number of child
-years. This would be true if every child were born on 1 July, however if
births are spread out over 12 months the number of child-years should be
halved.
Thus, if the numerator were increased [for the reasons stated above]
by perhaps one and one-half to two times and the denominator were
decreased by two times [even just to account for the incorrect child-years
of observation] the actual calculated hospitalisation rate per 100 child-
years would be between 3½ and 4 times higher than the rates quoted in
Tables 3 and 4. These rates would then be comparable to the rates of CHD
in the U.S.[3] In support of this statement is a brief recalculation of
their data. The total birth cohort observed over six years was 54,947.
There were 813 RSV hospitalisations which would give a rate of 29.6 per
1000 children per year, similar to other developed countries.[4] Finally,
the calculation of relative risks for hospitalisation uses a referent
group that is not low-risk but includes children with prematurity and
chronic lung disease, that would unfairly bias the relative risk in a
lower direction. The correct referent group would be the low-risk group
as was done by Boyce, et al.[3]
We would agree with the authors that unrestricted use of palivizumab
in CHD patients is not warranted. The intention was never to use the drug
indiscriminately in CHD patients as evidenced in the cardiac trial that
restricted its use in truly haemodynamically significant young CHD
patients.[5] We disagree with the use of a NNT analysis to justify this
statement. An NNT analysis only factors in the cost from a single RSV
hospitalisation. But the CHD infant with RSV is likely to incur additional
morbidity and mortality related to future hospitalisations and/or
treatment, especially when it comes to surgical correction and thus raises
the cost of care.[7] Also, NNT analysis takes only a payer’s perspective,
and ignores the societal component of pharmaco-economics. As healthcare
providers, it is our responsibility to use costly drugs in a responsible
manner while also ensuring that these patients receive the
treatment/prevention from which they would clearly benefit.
References
(1). Moler FW, Khan AS, Meliones JN. et al. Respiratory syncytial virus
morbidity and mortality estimates in congenital heart disease patients: a
recent experience. Crit Care Med 1992;20:1406-13.
(2). Simoes EAF, Sondheimer HM, Top FH Jr, et al. Respiratory syncytial
virus immune globulin for prophylaxis against respiratory syncytial virus
disease in infants and children with congenital heart disease. The Cardiac
Study Group. J Pediatr 1998;133:492-499.
(3). Boyce TG, Mellen BG, Mitchel EF Jr, et al. Rates of hospitalization for
respiratory syncytial virus infection among children in Medicaid. J
Pediatr 2000;137:865–70.
(4). Duppenthaler A, Ammann RA, Gorgievski-Hrisoho M, et al. Low incidence
of respiratory syncytial virus hospitalisations in haemodynamically
significant congenital heart disease. Arch Dis Child 2004;89:961-965.
(5). Feltes TF, Cabalka AK, Meissner HC, et al. Palivizumab prophylaxis
reduces hospitalization due to respiratory syncytial virus in young
children with hemodynamically significant congenital heart disease. J
Pediatr 2003;143:532-40.
(6). Duppenthaler A, Gorgievki-Hrisoho M, Frey U, et al. Two-year
periodicity of respiratory syncytial virus epidemics in Switzerland.
Infection 2003;31:75-80.
(7). Khongphatthanayothin A, Wong PC, Samara Y, et al. Impact of
respiratory syncytial virus infection on surgery for congenital heart
disease: postoperative course and outcome. Crit Care Med 1999;27:1974-81.
The authors of this paper on Hindu Birth Customs have highlighted
most practices which are part of hindu culture.
However some more practices which are benficial for mothers and neonates
are being mentioned here.
Place of delivery: first delivery mostly occured at girl,s parents
house,where she is sent from inlaws house about 2-3 months before
term, where she is treated as special person, ge...
The authors of this paper on Hindu Birth Customs have highlighted
most practices which are part of hindu culture.
However some more practices which are benficial for mothers and neonates
are being mentioned here.
Place of delivery: first delivery mostly occured at girl,s parents
house,where she is sent from inlaws house about 2-3 months before
term, where she is treated as special person, gets good affordable diet, rest
with no tension of any sort. This also has the benfit of abstinence ,which
helps in reduction of amniotic infection and preterm labour,as in a study
at government hospital in delhi, had noted 10-15%incidence of preterm
labour following cohabitation within last 24hours and higher incidence of
congenital pneumonia if cohabitatin was frequent within a week preceeding
delivery.
After delivery mother infant dyads are together for more period as she
is not involved in household cores as when in her own house,where as
daughter inlaw she is supposed to carry out her duries as soon after
delivery as possible.
Girl's parents in north india, give to their nursing daughters a gift of
sweetdish called panjiri which has high fat and protein content and act as
nutiernt supplement for mother for about 2 months. This practice promotes
breast milk secretion.it was noted by me that mothers who consumed more
than 5 kg of ffats in addition to family dier had 300gm more weight at 3
months than those who had <_3kg fat.="fat." p="p"/> However,due to distance and cost involved many young
couples in urban are do not avail of above good practices,
Marteau et al took exception to the following phrase in our paper:
“Our model differs from the three-dimensional typology proposed by
Marteau et al, which incorporated uptake as a measure of informed choice
[ref]. In our view, uptake represents a consequence rather than the goal
of informed choice and was therefore excluded as a measure [ref].”
Marteau et al took exception to the following phrase in our paper:
“Our model differs from the three-dimensional typology proposed by
Marteau et al, which incorporated uptake as a measure of informed choice
[ref]. In our view, uptake represents a consequence rather than the goal
of informed choice and was therefore excluded as a measure [ref].”
and went on to raise the following issues which we wish to address in
this reply:
1. That we drew upon their conceptualization and measure of informed
choice in a way that misrepresented their definition and measure of
informed choice.
2. That the definition and the measure of informed choice must
include a measure of uptake or “behaviour”.
3. That the goal of informed choice is not for everyone to have
positive attitudes towards undergoing the procedure, but rather that
people act consistently with their own values (whatever they are).
Firstly, our two-dimensional (knowledge and attitude) model was
adapted from our previous work on the social change that underpins public
health interventions [1]. It preceded the three-dimensional (knowledge,
attitude and up-take/behaviour) model by Marteau et al [2] and was first
presented at an international conference in Manchester in 1999 [3]. It was
conceived from an earlier work on the management of corporate change by
Professor Paul Strebel of the International Institute for Management
Development (IMD) in Switzerland as was acknowledged in the earlier report
[1]. We have simply contextualized this earlier model for infant hearing
screening in this paper and highlighted the difference with a generic
model [2]. The authors’ subtle claim to originality is therefore
inaccurate.
The last two points on the definition, goal and measure of informed
choice are inter-related. The word “choice” in the context of our paper is
defined as “the act of choosing” (Webster Collegiate Dictionary) rather
than the actual choice that is made among available options. The General
Medical Council (GMC) for instance stipulates that healthcare workers
“must take appropriate steps to find out what patients want to know and
ought to know about their condition and its treatment” [4]. The readiness
or willingness to accept screening is reflected in parental attitude
(positive or negative) towards screening. It is immoral to ignore a
negative attitude towards a public health intervention that is in the
patient’s best interest especially when it emanates from personal or
cultural values; or even unfavourable past experience [5]. Our model is
intended as a guide for healthcare workers to facilitate positive attitude
towards infant screening without attempting to coerce or frighten parents
into giving consent. From this point, it is entirely the parents’
responsibility to give or withhold consent and to accept the consequences
of that decision. To suggest that parents should be allowed to act
consistently with their values (whatever they are) shows a lack of
understanding of the challenge of offering public health intervention
particularly where parental doubts exist [6-9]. It also overlooks cases
where parental perception towards non-life threatening conditions such as
infant hearing loss may be non-challant [1]. A recent article perhaps
sums up the principle underlying our model: a doctor believes in facts,
but a manager believes in perceptions [10].
The expectation in any screening programme is that there is high
uptake and that this is based on informed consent. But this must not be
confused with the goal of our paper which was to examine the route to
informed choice/decision-making. An “assessment of the consistency between
attitudes and screening behaviour” is an academic exercise that is
irrelevant for our purpose.
In summary, our model is a simple and practical tool that seeks to
promote positive parental attitude towards infant hearing screening in
cross-cultural settings. Sadly, the authors failed to comprehend this
crucial context which perhaps explains their inability to relate their
commentary to child health interventions or specifically to infant hearing
screening. However, we are pleased to observe a common ground on this
subject – that knowledge and attitude are key determinants of parental
decision-making (and perhaps also, readiness) for infant hearing
screening.
References
(1). Olusanya BO. Hearing impairment prevention in a developing
country: making things happen. Int J Pediatr Otorhinolaryngology
2000;55:167-71
(2). Marteau TM, Dormandy E, Michie S. A measure of informed choice.
Health Expect 2001;4:99-108
(3). International Association of Physicians in Audiology. The Xth
International Symposium on Audiological Medicine, Manchester, UK, July 11
– 14, 1999
(4). General Medical Council. Seeking patients’ consent: the ethical
considerations. London: General Medical Council, 1999.
(5). Olusanya BO. Polio-vaccination boycott in Nigeria. Lancet
2004;363:1912
(6). Elliman DAC, Bedford HE. MMR vaccine- worries are not justified.
Arch Dis Child 2001;85:271-274
(7). Campion EW. Suspicions about safety of vaccines. N Engl J Med
2002;347:1474-1475
(8). Alfredsson R, Svensson E, Trollfors B, Borres MP. Why do parents
hesitate to vaccinate their children against measles, mumps and rubella?
Acta Paediatr 2004;93:1232-1237
(9). Bellaby P. Communication and miscommunication of risk:
understanding UK parents’ attitudes to combined MMR vaccination. BMJ
2003;327:725-728
(10). McCarthy M. As a doctor you believe in facts, but as a manager
you must believe in perceptions. Lancet 2004;364:1991
In their article, A.R.Gatrad et al attempt to build a prototype for
Hindu birth customs. Being a Hindu, I myself felt quite surprised at not
being aware of many customs and rituals referred to in the article.
Contrary to what is mentioned in the article, the law in India stipulates
that a male be atleast 21 years and a female 18 years at the time of
marriage.
In their article, A.R.Gatrad et al attempt to build a prototype for
Hindu birth customs. Being a Hindu, I myself felt quite surprised at not
being aware of many customs and rituals referred to in the article.
Contrary to what is mentioned in the article, the law in India stipulates
that a male be atleast 21 years and a female 18 years at the time of
marriage.
Despite their very sincere intentions, the article may fail in its
purpose. Hinduism as a religion is sufficiently wide in its scope to
accomodate a very wide array of beliefs and practices. It may therefore
not be of academic relevance to the medical community to have a prototype
for birth customs in religious communities like Hindus.
I do however agree with the goal of improving understanding of
cultural groups based on self-reflection, self-awareness and acceptance of
differences. This is also highly relevant to medical professionals who
have trained overseas, many from Asian countries, and are exposed to
Western culture for the first time in United Kingdom.
Reference
Constitution of India. Hindu Marriage Act (1955) Section 5, Amendment Act
of 1978.
An expert is instructed to advise the Court and one follows the
instructions received - which usually indicate whether a paperwork or
clinical exercise is required.
If they are ambiguous or seem to limit
one's ability to do an adequate job then one should return to the Court to
explain the position and obtain further guidance.
Whilst not taking
David's position absolutely on the que...
An expert is instructed to advise the Court and one follows the
instructions received - which usually indicate whether a paperwork or
clinical exercise is required.
If they are ambiguous or seem to limit
one's ability to do an adequate job then one should return to the Court to
explain the position and obtain further guidance.
Whilst not taking
David's position absolutely on the question of seeing the child/young
person and/or parents/carers in person I do wonder if the response of
Davies and colleagues is poportionate - and temperate?
Wailoo and colleagues [1] rightly point out that the issue of bed-
sharing is highly complex and that we don’t yet understand its possible
benefits and hazards well enough to give generalised categorical advice.
However there is now enough evidence to put one fact about bed-
sharing beyond dispute: bed-sharing by parents who are smokers brings a
greatly increased risk of cot death. The CESD...
Wailoo and colleagues [1] rightly point out that the issue of bed-
sharing is highly complex and that we don’t yet understand its possible
benefits and hazards well enough to give generalised categorical advice.
However there is now enough evidence to put one fact about bed-
sharing beyond dispute: bed-sharing by parents who are smokers brings a
greatly increased risk of cot death. The CESDI SUDI study [2], which
Wailoo and colleagues commend, found that the odds ratio for bed-sharing
(at the time of death) if one of the parents was a smoker was 12.4 (95% CI
7.4-20.6), more than twice that found when parents smoked but didn’t bed-
share. The ECAS study [3] found an even greater risk. These findings
suggest that bed-sharing somehow potentiates the adverse influence of
smoking. The benefits of bed-sharing would have to be very large to
outweigh a risk of this magnitude.
For such influential authors to write a review about bed-sharing
without mentioning this important fact is irresponsible, and we hope they
will make amends by acknowledging that we now know enough about this
particular aspect of bed-sharing to discourage its practice by parents who
are smokers.
References
(1). Wailoo M, Ball H, Fleming P, Platt MW. Infants bed-sharing with
mothers. Arch Dis Child 2004; 89: 1082-3.
The short report by Duttweiler et al [1] confirms our observation
that the sub-population of RSV infected infants and children requiring
intensive care needs to be treated differently, in terms of antibiotic
treatment, from those who need routine hospital care. Bacterial sepsis is
rare in RSV ward admissions as assessed by blood culture and CSF culture
positive results [2] but secondary bacter...
The short report by Duttweiler et al [1] confirms our observation
that the sub-population of RSV infected infants and children requiring
intensive care needs to be treated differently, in terms of antibiotic
treatment, from those who need routine hospital care. Bacterial sepsis is
rare in RSV ward admissions as assessed by blood culture and CSF culture
positive results [2] but secondary bacterial respiratory infections may be
a factor that tips the balance for needing additional supportive care.
A Microbiologist and an Intensivist jointly assess all admissions to our
PICU. During November 2002 to January 2003 we admitted 22 patients with
RSV of whom 11 had significant secondary bacterial infections
(Staphylococcus aureus n = 5, Haemophilus species n = 5 – two mixed with
Moraxella species and Streptococcus pneumoniae n =1). We have developed a
policy of pre-emptive antibiotic treatment with cefuroxime for all RSV
admissions. This is changed to a narrower spectrum agent in the light of
bacterial culture results, or stopped at 48 hours if clinically indicated
and cultures are negative. We feel that early intervention is justified in
this selected group.
References
(1). Duttweiler L, Nadal D, Frey B. Pulmonary and systemic bacterial co-
infections in severe RSV bronchiolitis. Arch Dis Child 2004; 89:1155-1157.
(2). Purcell K, Fergie J. Concurrent serious bacterial infections in 912
infants and children hospitalized for treatment of respiratory syncytial
virus lower respiratory tract infection. Pediatr Infect Dis J 2004;
23(3):267-269.
We read with interest the recent article by Ali and Almoudaris[1]
regarding a case of BCG lymphadenitis. They commented that the treatment
is controversial, but the evidence suggests otherwise. We recently
performed a literature search for evidence regarding treatment of BCG
lymphadenitis which showed that there are two recognised outcomes:
regression or suppuration with peroration, drainage and...
We read with interest the recent article by Ali and Almoudaris[1]
regarding a case of BCG lymphadenitis. They commented that the treatment
is controversial, but the evidence suggests otherwise. We recently
performed a literature search for evidence regarding treatment of BCG
lymphadenitis which showed that there are two recognised outcomes:
regression or suppuration with peroration, drainage and sinus formation.
Several treatments have been used to treat these lesions including topical
antibiotics, systemic antibiotics or antituberculous medication as well as
needle aspiration and surgical excision.
A recent metanalysis [2] examined controlled trials on the treatment
of BCG lymphadenitis, and in the 237 children included in the analysis
there was no difference in the rate of suppuration in those treated with
oral drugs and no difference between treatment with erythromycin or
isoniazid. Treatment therefore did not decrease the risk of suppuration
and on the basis of this metanalysis no medical therapy could be advised.
A further study [3] into the natural progression of BCG adenitis
showed that with a conservative approach in a series of 20 cases there was
spontaneous resolution in 85% of them, with three developing suppurative
changes which resolved after spontaneous perforation and drainage.
Caglayan [4] looked at 120 infants who developed regional adenitis and
again there was no difference in referral for total surgical excision
between treated and non-treated groups.
Aspiration was shown to be a useful treatment choice by Banani [5] in
77 patients with fluctuant and suppurative BCG adenitis, in which this
treatment led to earlier resolution (95% by 6 months compared to 65% in
non treated group) Spontaneous resolution was also less in the aspirated
group (7% vs. 44%).
The same holds true for treatment of BCG abscesses where much of the
published data regarding the medical management is in the form of
anecdotal reports of treatment with Erythromycin or Isoniazid [6]. There
are no randomised controlled trials looking at the effect of medical
therapy for treatment of BCG abscesses and the present recommendation in
the UK is to aspirate pus to confirm BCG and/or other organisms[7]. The
guideline makes no recommendation on the use of antimicrobials and
recognises the limited evidence.
We would therefore agree that the present evidence would suggest that
medical therapy plays no part in the treatment of BCG lymphadenitis or
abscesses and that should suppuration occur, needle aspiration would be
the best therapeutic option to hasten resolution.
References
(1). Ali S. Almoudaris M. Images in Paediatrics. BCG lymphadenitis.
Arch. Dis. Child. 2004;89(9):812
(2). Goraya J.S. Virdi V.S. Treatment of Calmette-Guerin Bacillus
Adenitis: a metanalysis. Pediatr. Infect. Dis. J. 2001;20(6);632-633
(3). Singla A. Singh S. Goraya J.S. Radhika S. Sharma M. The natural
course of nonsuppurative calmette-geurin bacillus lymphadenitis.
Pediatr. Infect. Dis. J. 2002;21(5):446-447
(4). Caglayan S. Yegin O. Kayran K. Timocin N. Kasgira E. Gun M. Is
medical therapy effective for regional lymphadenitis following BCG
vaccination? Am. J. Dis. Child. 1987;141:1213-1214
(5). Banani S.A. Alborzi A. Needle aspiration for suppurative post-BCG
adenitis. Arch. Dis. Child. 1994;71:446-447
(6). Makwana N. Riordan F.A.I Is medical therapy effective in the
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(7). Grange J.M. Complications of Bacillus Calmette-Guerin (BCG)
vaccination and immunotherapy and their management. Communicable disease
and Public Health. 1998;1(2):84-88
Dear Editor,
Even with the acknowledgement that a diagnosis of thyrotoxicosis is incompatible with a thyroid stimulating hormone(TSH) level which lies within the normal range[1], what the author says ring true that one should scrutinise, not only the laboratory result, but the patients as well[2].
This advice is especially relevant to thyroid disease, where laboratory derangements may be similar to those f...
Dear Editor,
Van Bever et al suggest that “it is time to rethink whether there is any causal link between aspirin and Reye’s syndrome (RS)” and that paediatricians should consider returning to aspirin as “their first choice antipyretic/analgesic in children” [1]. The proposal appears to originate in the hypothesis that the decline in its use is responsible for the increase in allergic disorders. They do no...
Dear Editor,
Patients with congenital heart disease (CHD) have been reported by many authors to have high rates of hospitalisation, morbidity and mortality associated with respiratory syncytial virus (RSV) lower respiratory tract illness.[1-3] However, in a recent paper in the Archives of Diseases in Children Duppenthaler et al reported a substantially lower incidence of respiratory syncytial virus (RSV)...
Dear Editor,
The authors of this paper on Hindu Birth Customs have highlighted most practices which are part of hindu culture. However some more practices which are benficial for mothers and neonates are being mentioned here.
Place of delivery: first delivery mostly occured at girl,s parents house,where she is sent from inlaws house about 2-3 months before term, where she is treated as special person, ge...
Dear Editor,
Marteau et al took exception to the following phrase in our paper:
“Our model differs from the three-dimensional typology proposed by Marteau et al, which incorporated uptake as a measure of informed choice [ref]. In our view, uptake represents a consequence rather than the goal of informed choice and was therefore excluded as a measure [ref].”
and went on to raise the foll...
Dear Editor,
In their article, A.R.Gatrad et al attempt to build a prototype for Hindu birth customs. Being a Hindu, I myself felt quite surprised at not being aware of many customs and rituals referred to in the article. Contrary to what is mentioned in the article, the law in India stipulates that a male be atleast 21 years and a female 18 years at the time of marriage.
Despite their very sinc...
Dear Editor,
An expert is instructed to advise the Court and one follows the instructions received - which usually indicate whether a paperwork or clinical exercise is required.
If they are ambiguous or seem to limit one's ability to do an adequate job then one should return to the Court to explain the position and obtain further guidance.
Whilst not taking David's position absolutely on the que...
Dear Editor,
Wailoo and colleagues [1] rightly point out that the issue of bed- sharing is highly complex and that we don’t yet understand its possible benefits and hazards well enough to give generalised categorical advice.
However there is now enough evidence to put one fact about bed- sharing beyond dispute: bed-sharing by parents who are smokers brings a greatly increased risk of cot death. The CESD...
Dear Editor,
The short report by Duttweiler et al [1] confirms our observation that the sub-population of RSV infected infants and children requiring intensive care needs to be treated differently, in terms of antibiotic treatment, from those who need routine hospital care. Bacterial sepsis is rare in RSV ward admissions as assessed by blood culture and CSF culture positive results [2] but secondary bacter...
Dear Editor,
We read with interest the recent article by Ali and Almoudaris[1] regarding a case of BCG lymphadenitis. They commented that the treatment is controversial, but the evidence suggests otherwise. We recently performed a literature search for evidence regarding treatment of BCG lymphadenitis which showed that there are two recognised outcomes: regression or suppuration with peroration, drainage and...
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