We read with interest the recent article in Archives of Disease in
Childhood concerning Paracetamol induced hepatotoxicity [1] and discussed
it at Derbyshire Children’s Hospital’s Journal club. We found the
management algorithm useful for knowing which patients we need to refer to
a specialist unit.
However, we felt that some clarification is needed regarding the
issue of repeat blood tests i...
We read with interest the recent article in Archives of Disease in
Childhood concerning Paracetamol induced hepatotoxicity [1] and discussed
it at Derbyshire Children’s Hospital’s Journal club. We found the
management algorithm useful for knowing which patients we need to refer to
a specialist unit.
However, we felt that some clarification is needed regarding the
issue of repeat blood tests in two situations.
1. In Management A (paracetamol level below the treatment line and
an overdose <150mg/kg) the authors suggests observation and repeat
bloods in 24 hours. Our current practice, as guided by Toxbase [2], is
not to do any further blood tests on children who do not require
treatment. They stay in hospital to see CAMHS and are often discharged
before 24 hours. They did not present any evidence for repeating blood
tests in those not requiring N-acetylcysteine (NAC). This practice would
increase our current admission times.
2. Management B suggested blood tests 8-12 hourly whilst on NAC.
Again our current practice is to perform blood tests at the end of the
NAC, which is usually about 16 hours later. Depending on these blood
results we make the decision whether to continue the NAC or not. We are
not sure that performing blood tests sooner on all patients, or on some
patients, and would this change our management.
It would be helpful to know the evidence behind these issues.
References:
1. Mahadevan S, McKiernan P, Davies P, Kelly D. Paracetamol induced
hepatotoxicity. Archives of Disease in Childhood. 2006; 91: 598-603.
I have read the comments on the Consensus Statement with great
interest. On the whole, I felt the document recommendations were to be
commended and provide us with an excellent guide for optimal care, in
particular with regard to surgical and psychological advice and support.
However, I admit to being very uneasy about the way nomenclature was
included in this meeting. Various CAH support grou...
I have read the comments on the Consensus Statement with great
interest. On the whole, I felt the document recommendations were to be
commended and provide us with an excellent guide for optimal care, in
particular with regard to surgical and psychological advice and support.
However, I admit to being very uneasy about the way nomenclature was
included in this meeting. Various CAH support groups ( from the U.S.A ,
UK. New Zealand and Australia) wrote a joint letter, expressing our
concern to the organisers prior to the event, that no representatives of
CAH were consulted. Although we appreciate it was not a deliberate
exclusion and received a thoughtful and reassuring response, I found it
rather unsettling to discover that such a vital aspect was added at the
last minute and was not included in the proposed agenda we received.
Terminology is such an important issue and not one that should be regarded
lightly and perhaps if it had been discussed beforehand, with more
Worldwide interested parties invited/involved for views and input in the
debate the current discontent could have been avoided?
The majority of the CAH community do not agree that the condition
should be regarded as Intersexed and although I feel that Disorders of Sex
Development will be a slightly more acceptable term (certainly to
parents), I still feel it is not strictly applicable to CAH. Unlike the
other conditions, we cannot deny that CAH is a disorder (of the adrenal
gland) and have to admit to preferring this to the alternative; 'disease'!
I have to agree though that 'disorder' is not an ideal term in the context
of this new nomenclature and understand and agree with the discontent
expressed by others. I conclude that finding a term that suits all the
conditions currently under the Intersex/DSD umbrella was never going to be
an easy task but I feel more thought, consideration and preparation into
this aspect (which obviously went into the rest of the issues discussed)
may have prevented such avid criticism and awarded the
organisers/consensus group with the praise they undoubtedly deserve.
We read with interest the article by Paton and colleagues[1]
reporting the results of low dose Synacthen tests in children prescribed
fluticasone proprionate (FP). The finding of flat adrenal responses in
2.8% of children tested (all prescribed greater than or equal to 1,000
micrograms of FP per day) provides further evidence of the potential
dangers of high doses.
We read with interest the article by Paton and colleagues[1]
reporting the results of low dose Synacthen tests in children prescribed
fluticasone proprionate (FP). The finding of flat adrenal responses in
2.8% of children tested (all prescribed greater than or equal to 1,000
micrograms of FP per day) provides further evidence of the potential
dangers of high doses.
We recently published the results of standard dose Synacthen tests in
children recommended greater than or equal to 1,000 micrograms per day of
FP. Three of the 29 children tested were found to have complete adrenal
suppression.[2] In his editorial Russell[3] highlights compliance with
therapy as likely to be important given the fact that not all patients on
high dose FP suffer adrenal failure. In our study, the first of its kind
to our knowledge in this context, we examined compliance in terms of the
actual amount of FP prescribed over the last year in primary care relative
to that recommended by the hospital specialist. The three children with
adrenal suppression had actually only been prescribed a median of 493
micrograms of FP per day over the last year, compared to a median of 433
micrograms in the normal group. Overall, there was an inverse correlation
between actual prescribed daily FP dose and peak cortisol response to
Synacthen (rs –0.44, P =0.03).[2]
Our study was relatively small in size and used a pragmatic measure
of compliance however the results suggest that compliance with therapy
should be considered and that in reality children with adrenal suppression
may be receiving smaller doses of FP than we think.
References:
[1] Paton J, Jardine E, McNeil E, et al. Adrenal responses to low
dose synthetic ACTH (Synacthen) in children receiving high dose inhaled
fluticasone. Arch Dis Child 2006;91:808-813.
[2] Brodlie M, McMurray A, Crofton PM, et al. Strategies to screen
for adrenal suppression in children with asthma should take account of
compliance with inhaled corticosteroids. Eur J Pediatr 2006 Oct 7; [Epub
ahead of print].
[3] Russell G. Very high dose inhaled corticosteroids: panacea or
poison? Arch Dis Child 2006;91:802-803.
There is a bias in research on treatments that sometimes manifests
itself in odd ways. The preference for a one-tailed test, for instance,
may lead us to focus on whether a treatment makes things better, but leads
us to miss important details when a treatment makes things worse. This is
an important point when testing treatments against such alternatives.
There is a bias in research on treatments that sometimes manifests
itself in odd ways. The preference for a one-tailed test, for instance,
may lead us to focus on whether a treatment makes things better, but leads
us to miss important details when a treatment makes things worse. This is
an important point when testing treatments against such alternatives.
Before turning to the central point, however, there is the issue of
statistical power that was noticeable by its absence in the Olafsdottir
study [1]. It is worth noting that if a clinically meaningful difference of
.5 of a standard deviation was to be detected with a two-tailed test, then
given this sample size, there was a 63% chance of doing so (or 74% with a
one-tailed test). Such information is always worth including when a non-
result of this order is reported.
To the central point, Olafsdottir [1] et al note that a chiropractic
manipulation performed significantly better than a drug, but did not note
the plausible hypothesis that dimethicone is not only 'not better than
placebo,' but for some infants may make things worse, perhaps because
activated dimethicone used alone (ie., without an antacid component, as in
Altacite Plus) causes the large bubbles to redistribute stomach acid along
the esophagus when belching, thereby irritating the child more than the
relief that is obtained from the expulsion of gas.
The relatively high attrition rate and poor outcomes in the Wiberg [2]
study's dimethicone group is consistent with the possibility that they
used an alternative that not only doesn't work for some, but makes things
worse instead of better for others. Thus, the the comparsion of
chiropractic methods to *nocebo* is scarcely the same as a comparison
against *placebo*. It is good to see the publication of a non-result such
as that shown by Olafsdottir, et al[1] which uses a true placebo
treatment to illustrate the non-effect of chiropractic methods.
References
(1). E Olafsdottir, S Forshei, G Fluge, and T Markestad.
Randomised controlled trial of infantile colic treated with chiropractic
spinal manipulation. Arch. Dis. Child. 2001; 84: 138-141
(2). Wiberg JMM, Nordsteen J, Nilsson N. The short-term effect of
spinal manipulation in the treatment of infantile colic: A randomized
controlled clinical trial with a blinded observer. J Manipulative Physiol
Ther 1999;22:517-22.
We welcome your interest in our paper(1) and in general agree with
your comments. However, in our paper we wanted to emphasise the actions,
which needed to be considered in the most severe cases.
We agree that it is accepted practice not to perform further blood
tests for those with paracetamol level below the treatment line at 4 hours
post overdose and an overdose <150 mg/kg. However, t...
We welcome your interest in our paper(1) and in general agree with
your comments. However, in our paper we wanted to emphasise the actions,
which needed to be considered in the most severe cases.
We agree that it is accepted practice not to perform further blood
tests for those with paracetamol level below the treatment line at 4 hours
post overdose and an overdose <150 mg/kg. However, the time of
ingestion is not always clear and paracetamol toxicity may follow multiple
doses or chronic use(2). If there is any doubt about either of these and
especially in younger children with viral infection receiving multiple
doses we suggest that it is sensible to repeat liver function tests after
24 hours.
We agree that in children who have taken paracetamol deliberatively
should undergo a psychosocial review prior to discharge, so repeating
liver function tests may not necessarily increase the hospital stay.
Should it be appropriate that they be discharged within 24 hours, than a
clinical judgement should be made on the need for repeat blood tests.
It is correct that blood tests may be repeated at the end of NAC
infusion.. But in those with the most severe illness especially where the
INR is above 2, an early blood test at 12 hours may guide further
management. This helps the team to contact a specialist liver centre for
advice and referral and in severe cases, facilitates continuation of NAC
without interruption.
S B K Mahadevan
P J McKiernan
D A Kelly
The Liver Unit
Birmingham Children’s Hospital
Steelhouse Lane
Birmingham B4 6NH
References:
1) S B K Mahadevan, P J McKiernan, P Davies, and D A Kelly
Paracetamol induced hepatotoxicity. Arch Dis Child 2006; 91:598-603.
2) Heubi JE, Barbacci MB, Zimmerman HJ. Therapeutic misadventures with
acetaminophen: hepatoxicity after multiple doses in children. J Pediatr.
1998;132(1):22-7.
I have read with interest the article by Beattie et al on
inflammatory bowel disease (IBD) in children (1). In addition to the
standard treatment methods outlined in the article, many patients try
complementary and alternative medicines (CAM) (2). McCann et al has shown
that children with chronic disease were greater than three times more
likely to use complementary and alternative medicine, usually wi...
I have read with interest the article by Beattie et al on
inflammatory bowel disease (IBD) in children (1). In addition to the
standard treatment methods outlined in the article, many patients try
complementary and alternative medicines (CAM) (2). McCann et al has shown
that children with chronic disease were greater than three times more
likely to use complementary and alternative medicine, usually without a
paediatrician’s knowledge (3). In a multi centre study done by Heuschkel
et al, over 40% of children with chronic inflammatory bowel disease used
complementary medicine in addition to conventional therapies (4). Parental
CAM usage and the number of adverse effects from conventional therapies
were the only independent predictors of CAM use in that study.
Recently interest has been shown on the effect of omega-3 fatty acid
supplementation in inflammatory bowel disease. Meister et al had shown
that IBD tissues, after incubation with an elemental diet modified in its
fatty acid composition with fish oil, show an increase in IL-1ra/IL-1beta
cytokine ratio (5). They concluded that the effect of omega-3 fatty acid
modulation was significantly more marked in ulcerative colitis (UC)
compared with Crohn’s disease (CD) and suggested that dietary treatment of
UC may be possible. A recent double blind randomised placebo controlled
study done by Romano et al showed that enteric coated omega-3 fatty acids
in addition to treatment with 5-ASA were effective in maintaining
remission of paediatric CD (6). Tenikoff et al have investigated the
effect of pre treatment with Lyprinol (Pharmalink international), the
stabilised lipid extract of the New Zealand green-lipped mussel, currently
used to relieve symptoms of arthritis, on experimentally induced IBD in
mice (7). They had shown that Lyprinol treatment significantly reduced
body weight loss, disease activity index scores, crypt area losses and
caecum and colon weights compared with fish oil treatment. They conclude
that Lyprinol may be potentially useful in the treatment of IBD and the
benefit is unlikely to be due to the omega-3 fatty acid content.
In summary, practitioners caring for children and adolescents with
IBD need to be aware of the new research and developments in this field
and should adopt an open attitude, if the patients are using alternative
therapies.
Dr.R.Muhammed Specialist Registrar in Paediatrics University
Hospital of North Durham Durham
Competing interests declared: none
References:
1.. R M Beattie, N M Croft, J M Fell, N A Afzal, and R B Heuschkel
Inflammatory bowel disease Arch Dis Child 2006; 91: 426-432.
2. Day AS, Whitten KE, Bohane TD. Use of complementary and
alternative medicines by children and adolescents with inflammatory bowel
disease. J Paediatr Child Health 2004 Dec; 40(12): 681-4.
3.McCann LJ, Newell SJ. Survey of paediatric complementary and
alternative medicine use in health and chronic illnesses Arch Dis
Child.2006; 91: 173-174
4.Heuschkel R, Afzal N, Wuerth A, Zurakowski D, Leichtner A, Kemper
K, Tolia V, Bousvaros A Complementary medicine use in children and young
adults with inflammatory bowel disease Am J Gastroenterol. 2002 Feb;
97(2): 382-8.
5. Meister D, Ghosh S. Effect of fish oil enriched enteral diet on
inflammatory bowel disease tissues in organ culture: differential effects
on ulcerative colitis and Crohn's disease. World J Gastroenterol. 2005 Dec
21; 11(47): 7466-72.
6. Romano C, Cucchiara S, Barabino A, Annese V, Sferlazzas C
Usefulness of omega-3 fatty acid supplementation in addition to mesalazine
in maintaining remi.ssion in pediatric Crohn's disease: a double-blind,
randomized, placebo-controlled study. World J Gastroenterol. 2005 Dec 7;
11(45): 7118-21.
7. Tenikoff D, Murphy KJ, Le M, Howe PR, Howarth GS. Lyprinol
(stabilised lipid extract of New Zealand green-lipped mussel): a potential
preventative treatment modality for inflammatory bowel disease. J
Gastroenterol. 2005 Apr; 40(4): 361-5.
Drs Thakur and Pocha present an interesting case of spontaneous
primary pneumothorax. It is not unusual for such cases to present late. In
fact in nearly half the cases medical opinion is sought after 2 days or
more. The uncertainty about the management of primary and secondary
pneumothoraces appears to have been resolved by the revised guidelines
published by the British Thoracic Society (BTS) in 2003....
Drs Thakur and Pocha present an interesting case of spontaneous
primary pneumothorax. It is not unusual for such cases to present late. In
fact in nearly half the cases medical opinion is sought after 2 days or
more. The uncertainty about the management of primary and secondary
pneumothoraces appears to have been resolved by the revised guidelines
published by the British Thoracic Society (BTS) in 2003.
This case provides the right opportunity to highlight certain key
issues. Firstly pneumothoraces appear deceptively small on a 2-dimensional
AP chest radiograph. A pneumothorax measuring 2 cm on a chest x-ray where
the hemi thoracic diameter is 10 cm represents a loss of nearly 50% of the
lung volume. This is much larger than what x-ray appearance might suggest.
The new BTS guidelines have emphasized this by classifying pneumothoraces
into two groups, large (>/= 2 cm) and small (< 2 cm). The x-ray
shown suggests that the case presented perhaps had a large pneumothorax by
definition. The recommended management of such a patient as per the BTS
algorithm would probably be needle aspiration rather than simple
observation.
Secondly it is important to remember that in general the resolution
of spontaneous pneumothoraces is a slow process occurring at a rate of
1.25% to 1.8% of the hemithorax volume per day. A 50% pneumothorax would
therefore take approximately 4 weeks to resolve. Consequently frequent x-
rays are unwarranted. The process of resolution can be speeded up to four
times by the use of supplemental high flow (10 litres/minute) oxygen, and
this should be offered to any patient who is observed in the hospital.
Spontaneous pneumothorax is not an every day problem encountered by
paediatricians. The new BTS guidelines are a great asset in tackling this
problem.
Reference:
1. Henry M, Arnold T, Harvey J. BTS guidelines for management of
spontaneous pneumothorax. Thorax 2003;58:ii39.
The study conducted by Erlewy-Lajeunesse et al. is welcomed and
addresses the validity of a radicated clinical practice unsupported by
clear evidence.
In the discussion the authors clearly state that the study only
examined the short term (at one hour) impact of the combined therapy and
that longer measurement periods might present different results.
The study conducted by Erlewy-Lajeunesse et al. is welcomed and
addresses the validity of a radicated clinical practice unsupported by
clear evidence.
In the discussion the authors clearly state that the study only
examined the short term (at one hour) impact of the combined therapy and
that longer measurement periods might present different results.
However, the authors' final statement that the measured effect does
not "warrant routine use for rapid fever reduction" goes beyond the
findings of the study.
Further studies are needed to ascertain the impact of the combined
therapy on long term impact (> 4 hours) measuring not only the drop in
temperature but also estimating the number of repeat doses required to
control the pyrexia under each intervention.
It should also be noted that 15 mg/kg of paracetamol were
administered during the study while a lower dosage of 10 mg/kg is commonly
used in the hospital and GP practice setting. This could have had an
impact on the difference between combination therapy versus paracetamol
alone measured in the study.
We read the paper by Jimenez et al with interest regarding the
potential role of limited slice high resolution CT (HRCT) in children with
cystic fibrosis (1). Studies such as this utilising fewer CT sections at
greater intervals in children with diffuse lung disease warrant further
evaluation. We certainly agree with the authors’ assertion that CT should
be used judiciously in children and that tec...
We read the paper by Jimenez et al with interest regarding the
potential role of limited slice high resolution CT (HRCT) in children with
cystic fibrosis (1). Studies such as this utilising fewer CT sections at
greater intervals in children with diffuse lung disease warrant further
evaluation. We certainly agree with the authors’ assertion that CT should
be used judiciously in children and that technical parameters must be
modified in accordance with the size of the child.
We believe however that Jimenez et al have not fully addressed the
issues of radiation burden reduction in children. They have examined their
patients with different CT scanners but in all patients used ‘100-130mA,
with exposure times between 1 and 3 seconds, resulting in 100-300mAs’.
Exposure times can be machine dependent, but are now much faster with
newer multidetector CT scanners which should be widely available. The mA
they have used on their patient group is unnecessarily high in our
opinion. [The mA (milliAmperage) used is the major determinant of CT dose,
together with, albeit to a lesser degree, the kV (kilovoltage) setting of
the machine. Of note, mA multiplied by time, in seconds, equals mAs].
Examples of truly low dose HRCT techniques have been in use for some
time with authors stating that acceptable image quality can be obtained
using only 10 or 20mA, which is a fraction of the dose used by Jimenez et
al in their study (2-5). Whilst such extremely low dose techniques may not
be widely utilised, it is fair to state that lower mA studies are possible
in every day practice even with older single slice helical CT scanners.
There is a balance between diagnostic image quality [with sufficient
signal] and image noise when extremely low mA doses are used. If the dose
is too low the images may become too ‘noisy’ thus impairing the overall
acceptability of the images, and rendering them non-diagnostic. We
currently perform HRCT sections at a maximum of 30mAs in children of less
than 35kg, and use no more than 55mAs in children weighing 35-54kg in our
routine practice. To keep the radiation burden to a minimum the mA, and
thus mAs also, should be set as low as reasonably achievable (ALARA
principle) whilst maintaining diagnostic image quality.
Kieran McHugh, FRCR
Catherine Owens, FRCR.
Consultant Paediatric Radiologists
Great Ormond Street Hospital for Children
London WC1N 3JH
References:
1. Jimenez S, Jimenez JR, Crespo M, et al. Computed tomography in children
with cystic fibrosis: a new way to reduce the radiation dose. Arch Dis
Child 2006;91:388-390.
2. Zwirewich CV, Mayo JR, Muller NL. Low-dose high-resolution CT of
lung parenchyma. Radiology 1991;180:413-417.
3. Naidich DP, Marshall CH, Gribbin C, et al. Low-dose CT of the
lungs: preliminary observations. Radiology 1990;175:729-731.
4. Ambrosino MM, Genieser NB, Roche KJ, et al. Feasibility of high-
resolution low-dose chest CT in evaluating the pediatric chest. Pediatr
Radiol 1994;24:6-10.
5. Lucaya J, Piqueras J, Garcia-Pena P, et al. Low-dose high-
resolution CT of the chest in children and young adults: dose co-
operation, artifact incidence, and image quality. AJR Am J Roentgenol
2000;175:985-992.
Dear Editor
Can the scrotal temperature be measured with a conventional thermometer?
Dear Editor,
We read with interest the recent article in Archives of Disease in Childhood concerning Paracetamol induced hepatotoxicity [1] and discussed it at Derbyshire Children’s Hospital’s Journal club. We found the management algorithm useful for knowing which patients we need to refer to a specialist unit.
However, we felt that some clarification is needed regarding the issue of repeat blood tests i...
Dear Editor,
I have read the comments on the Consensus Statement with great interest. On the whole, I felt the document recommendations were to be commended and provide us with an excellent guide for optimal care, in particular with regard to surgical and psychological advice and support. However, I admit to being very uneasy about the way nomenclature was included in this meeting. Various CAH support grou...
Dear Editor,
We read with interest the article by Paton and colleagues[1] reporting the results of low dose Synacthen tests in children prescribed fluticasone proprionate (FP). The finding of flat adrenal responses in 2.8% of children tested (all prescribed greater than or equal to 1,000 micrograms of FP per day) provides further evidence of the potential dangers of high doses.
We recently published the...
Dear Editor,
There is a bias in research on treatments that sometimes manifests itself in odd ways. The preference for a one-tailed test, for instance, may lead us to focus on whether a treatment makes things better, but leads us to miss important details when a treatment makes things worse. This is an important point when testing treatments against such alternatives.
Before turning to the central point,...
Dear Editor,
We welcome your interest in our paper(1) and in general agree with your comments. However, in our paper we wanted to emphasise the actions, which needed to be considered in the most severe cases.
We agree that it is accepted practice not to perform further blood tests for those with paracetamol level below the treatment line at 4 hours post overdose and an overdose <150 mg/kg. However, t...
Dear Editor,
I have read with interest the article by Beattie et al on inflammatory bowel disease (IBD) in children (1). In addition to the standard treatment methods outlined in the article, many patients try complementary and alternative medicines (CAM) (2). McCann et al has shown that children with chronic disease were greater than three times more likely to use complementary and alternative medicine, usually wi...
Dear Editor,
Drs Thakur and Pocha present an interesting case of spontaneous primary pneumothorax. It is not unusual for such cases to present late. In fact in nearly half the cases medical opinion is sought after 2 days or more. The uncertainty about the management of primary and secondary pneumothoraces appears to have been resolved by the revised guidelines published by the British Thoracic Society (BTS) in 2003....
Dear Editor,
The study conducted by Erlewy-Lajeunesse et al. is welcomed and addresses the validity of a radicated clinical practice unsupported by clear evidence.
In the discussion the authors clearly state that the study only examined the short term (at one hour) impact of the combined therapy and that longer measurement periods might present different results.
However, the authors' final stat...
Dear Editor,
We read the paper by Jimenez et al with interest regarding the potential role of limited slice high resolution CT (HRCT) in children with cystic fibrosis (1). Studies such as this utilising fewer CT sections at greater intervals in children with diffuse lung disease warrant further evaluation. We certainly agree with the authors’ assertion that CT should be used judiciously in children and that tec...
Pages