Tension Bullae With Peripheral Pneumothorax.

The differentiation between tension bullae, chronic tension pneumothorax, and atypical pneumothorax is difficult just from history and physical examination alone. A chest X-ray may help determine the underlying etiology; however, further imaging with computed tomography in stable patients may be necessary for accurate assessment of size, number, and location before considering any interventions. In this article, we present a rare case report of tension bullae with peripheral pneumothorax and recommend against needle thoracostomy in stable patients with tension bullae in order to obtain further imaging that may result in a change in the standard management.

Pathogens causing diarrhoea among Bangladeshi children with malignancy: Results from two pilot studies.

BACKGROUND: Diarrhoea is a frequent symptom in children with cancer, and occurs due to a composite effect of underlying disease and immunosuppression consequent to therapy, malnutrition, and non-infective aetiologies such as mucositis. In a large proportion of cases, the aetiology of diarrhoea remains unknown but is often attributed to multiple pathogens including parasites. AIM: To identify and describe the pathogens causing diarrhoea in Bangladeshi children with cancer. METHODS: Two cross-sectional pilot studies were conducted involving paediatric oncology patients with diarrhoea. Stool samples were collected from children who were hospitalised with or without being treated with chemotherapy during the study period, and had diarrhoea at any stage during their admission. In the first study, stool samples were tested by conventional microbiological methods and by polymerase chain reaction for parasites, and by immunoassays for Clostridium difficile. In the second study, conventional microbiology was conducted for bacteria and parasites including an enzyme-linked immunosorbent assay for Cryptosporidium antigen, and in a subset, immunoassays for Clostridium difficile. RESULTS: In the first study Giardia lamblia was detected in 68.5% of samples, Entamoeba histolytica in 13%, Cryptosporidium in 5.6%, non-toxigenic C. difficile in 22.4%, and other bacteria in 5.2%. In the second study, E. histolytica was detected in 10% of samples, Cryptosporidium in 4.3%, G. lamblia in 1.4%, C. difficile in 5.1%, and other bacteria in 5.7% of samples. CONCLUSION: These pilot data suggest that parasites are important aetiologies of diarrhoea in Bangladeshi children with malignancy. While molecular diagnostic tools detect an array of stool pathogens with greater sensitivity, conventional diagnostic methods are also useful.

Reorganization of motor unit activity at different sites within the human masseter muscle during experimental masseter pain.

The aims were to test the hypotheses that experimental masseter muscle pain leads to recruitment and/or derecruitment of motor units at different sites within the masseter and that the patterns of change in motor unit activity differ between sites. Single motor unit (SMU) activity was recorded at two sites within the right masseter [superior/anterior, inferior/posterior (IP)] during isometric biting tasks (ramp, step level) on an intraoral force transducer in 17 participants during three experimental blocks comprising no infusion (baseline), 5% hypertonic saline infusion (pain), or isotonic saline infusion (control). A visual analog scale (VAS) was used to score pain intensity. The VAS scores were statistically significantly greater during infusion of hypertonic saline than during infusion of isotonic saline. No significant differences in force levels and rates of force change were found between experimental blocks. In comparison with isotonic saline infusion, SMUs could be recruited and derecruited at both sites during hypertonic saline infusion. The frequency of recruitment or derecruitment, in comparison with no change, was statistically significantly greater at the IP site than at the superior/anterior site. Experimental noxious masseter stimulation results in a reorganization of motor unit activity throughout the muscle, and the pattern of reorganization may be different in different regions of the muscle.

Promotion and marketing of bioidentical hormone therapy on the internet: a content analysis of websites.

OBJECTIVE: To evaluate the quality of information presented and claims made on websites offering bioidentical hormone therapy (BHT) products or services. METHODS: A quantitative content analysis was completed on 100 websites promoting or offering BHT products or services. Websites were identified through Google search engine from September to October 2013. Search terms included "bioidentical hormone therapy" or "bioidentical progesterone," accompanied by "purchase or buy," "service," or "doctors." The Brief DISCERN instrument was used to determine the quality of the health information. RESULTS: Websites were from Canada (59%), United States (38%), and other countries (3%). Almost half of the websites originated from medical clinics (47%), and healthcare professionals offering BHT services included physicians (50%), pharmacists (19%), and naturopaths (16%). Majority of websites promoted BHT as custom-compounded formulations (62%), with only 27% indicating that BHT is also commercially available. Websites overall claimed that BHT had less risk compared with conventional hormone therapy (62%). BHT was described as having less breast cancer risk (40%), whereas over a quarter of websites described BHT as "protective" for breast cancer. Websites mainly targeted women (99%), with males mentioned in 62% of websites. Product descriptors used to promote BHT included individualization (77%), natural (70%), hormone imbalance (56%), and antiaging (50%). The mean Brief DISCERN score was 15, indicating lower quality of information. CONCLUSIONS: Claims made about BHT on the internet are misleading and not consistent with current professional organizations' recommendations. Understanding how BHT may be promoted on the internet can help healthcare professionals when educating patients.

Use of exclusive enteral nutrition is just as effective as corticosteroids in newly diagnosed pediatric Crohn's disease.

BACKGROUND: The efficacy of exclusive enteral nutrition (EEN) in induction of remission in pediatric Crohn's disease (CD) is reported to be equivalent to that of corticosteroids (CS). AIMS: Our objective was to compare the efficacy of EEN and CS in inducing remission in pediatric onset CD and the effects of the treatment on nutritional status and bone mineral density (BMD). METHODS: Medical charts were retrospectively studied for patients diagnosed with CD between 2000 and 2010 at the Stollery children's hospital in Edmonton, Alberta. Anthropometric and dual-energy X-ray absorptiometry (DXA) data were collected to assess effects of therapy; clinical remission, relapse, and severity were defined on the basis of the pediatric Crohn's disease activity index. RESULTS: To induce remission at first presentation, 36 patients (mean age 12.9 years) received EEN and 69 (mean age 11.2 years) received CS. Remission (88.9% in the EEN group versus 91.3% in the CS group (p=0.73) at 3 months) and relapse (40.6 vs. 28.6%, respectively (p=0.12) over 12 months) were similar in both treatment groups. Thirty-four patients had paired DXA scans at the time of diagnosis and one year later: 16 given EEN and 18 given CS. Change in BMD spine z-scores based on bone age adjusted for height and chronological age was greater for EEN patients but not statistically significant (Δz-score 0.30 vs. 0.03, p=0.28). CONCLUSIONS: EEN has similar efficacy to corticosteroids; however, EEN may lead to better BMD accrual. EEN should be preferred to corticosteroids as first-line therapy for induction of remission in pediatric CD.

Health-related quality of life in pediatric ulcerative colitis patients on conventional medical treatment compared to those after restorative proctocolectomy.

PURPOSE: Health-related quality of life (HRQL) is not well studied in proctocolectomy patients with pediatric onset of ulcerative colitis (UC). We aimed to (1) compare the HRQL of proctocolectomy patients with those treated with conventional therapy and (2) determine factors that influence HRQL in UC patients < 18 years. METHODS: Chart review was done on patients diagnosed with pediatric onset of UC (<18) at the Stollery Children's Hospital. HRQL was evaluated in 88 patients using disease- and age-specific questionnaires; IMPACT III (<18) and Inflammatory Bowel Disease Questionnaire (IBDQ; ≥18). Demographics, disease characteristics, disease index (PUCAI), HRQL EuroQoL visual analog scale (EQ-5D/VAS) were collected and analyzed from all patients. RESULTS: Sixty-five respondents completed the IMPACT III (74 %) and 23 patients completed the IBDQ (26 %). Thirty-three surgical patients (34 %) responded (mean IMPACT III score = 148.9 ± 12.7; mean IBDQ = 171.2 ± 40.1). There was no significant difference in IMPACT III scores of surgical patients vs. medically treated patients (148.9 ± 12.7 vs. 140.6 ± 19.4, p = 0.09). Patients with high IMPACT scores (>143 points) were most likely to be in remission (p = 0.05), they were less likely to be on medication (p < 0.05), have parent/guardian with postsecondary education (p = 0.01), did not suffer from fatigue (p < 0.01), and did not report depression (p < 0.02). The IMPACT correlation with PUCAI (adjusted r (2) = 0.33) and EQ-VAS (adjusted r (2) = 0.45) was strong. CONCLUSIONS: Surgical patients reported to have a HRQL comparable to or better than the nonsurgical patients. Depression, fatigue, parent/guardian education, and drugs influence HRQL.

Diagnosis and pharmacological management of small intestinal bacterial overgrowth in children with intestinal failure.

The present article provides a general overview of the possible diagnostic procedures available for the management of small intestinal bacterial overgrowth in pediatric patients with intestinal failure. The focus is to address current diagnostic tools and understand their associated advantages and disadvantages based on a literature search. Culture of small intestinal aspirates, noninvasive breath tests and an emerging interest in quantitative bacterial DNA fingerprinting are discussed. Proper management is critical for preventing the recurrence of small intestinal bacterial overgrowth and its related complications. Antibiotic prophylaxis is one approach to the treatment of bacterial overgrowth in intestinal failure patients. Although treatment trials can be challenging in such a vulnerable population, more investigative clinical studies examining early diagnosis, more effective control of recurrence and the prevention of associated complications must be conducted.

Is delayed diagnosis of hypothyroidism still a problem in Faisalabad, Pakistan.

OBJECTIVE: To determine the age at diagnosis of hypothyroidism, to signify the effect of delayed diagnosis on the clinical presentation of hypothyroidism and hence to emphasize the need for early diagnosis by cost effective neonatal screening. METHODS: The study was a descriptive case series carried out at the Department of Paediatrics, Allied Hospital, Faisalabad from 2004 to 2006. One hundred consecutive cases of hypothyroidism from birth to twelve years of life were included. The age at presentation and age related clinical features were determined. RESULTS: The age at diagnosis ranged from birth to 16 years. Male to female ratio was 1:1. Congenital hypothyroidism was more common than acquired(92% VS 8%). Maximum number of cases (42%) were diagnosed between 1-5 years of age while only 14% were diagnosed before 3 months of age. Developmental delay (66%), constipation (51%) and lethargy (37%) were more common symptoms while common signs were pallor (65%), short stature (61%), coarse facies (53%), wide anterior fontanellae (46%) and coarse skin (42%). CONCLUSION: Early diagnosis by neonatal screening and commencement of treatment is recommended to prevent the effects of delayed diagnosis.

Chemotherapy-induced peripheral neuropathy.

Recent advances in the development and administration of chemotherapy for malignant diseases have led to prolonged survival of patients and the promise of a return to normal lives. This progress comes with a price, however, and the nervous system is frequently the target of therapy-induced toxicity. Unlike more immediate toxicities that affect the gastrointestinal tract and bone marrow, chemotherapy-induced neurotoxicity is frequently delayed in onset and may progress over time. In the peripheral nervous system, the major brunt of the toxic attack is directed against the peripheral nerve, targeting the neuronal cell body, the axonal transport system, the myelin sheath, and glial support structures, resulting in chemotherapy-induced peripheral neuropathy.

Chemotherapy-induced peripheral neuropathy.

Recent advances in the development and administration of chemotherapy for malignant diseases have led to prolonged survival of patients and the promise of a return to normal lives. The cost of progress comes with a price, however, and the nervous system is frequently the target of therapy-induced toxicity. Unlike more immediate toxicities that affect the gastrointestinal tract and bone marrow, chemotherapy-induced neurotoxicity is frequently delayed in onset and may progress over time. In the peripheral nervous system, the major brunt of the toxic attack is directed against the peripheral nerve, targeting the neuronal cell body, the axonal transport system, the myelin sheath, and glial support structures, resulting in chemotherapy-induced peripheral neuropathy.

Seizures etiology in the newborn period.

OBJECTIVE: To determine the causes of seizures in the newborn period. DESIGN: Cross-sectional analytical study. PLACE AND DURATION OF STUDY: Neonatal Unit, Paediatric Department, Allied Hospital, Faisalabad, from April 2003 to June 2004. PATIENTS AND METHODS: A total of 200 neonates of either gender who presented with seizures or developed seizures during hospital stay were evaluated for the possible etiological factors. Blood glucose, serum calcium, blood counts, cerebrospinal fluid examination and cranial ultrasound were done in all patients while blood culture, serum creatinine, CT scan, metabolic screening and Torch antibody titre were done in selected patients guided by history, examination and initial investigations. Results were analysed using SPSS software and Chi-square test. P-value of less than 0.05 was considered significant. RESULTS: Birth asphyxia was the commonest cause of seizures in the newborn period present in 35% (n = 70) cases. Other commonly identified causes were septicaemia with or without CNS infections 34% (n = 68), metabolic abnormalities 12.5% (n = 25), and intracranial bleed 9.5% (n = 19) cases. Less common causes were kernicterus 4.5% (n = 9), hydrocephalus 1.5% (n = 3), brain malformations 1% (n = 2) and lignocaine toxicity 1% (n = 2) cases. Seizure with presumed idiopathic etiology i.e. 5th day fit was found in only 1% (n = 2) cases. CONCLUSION: Etiology of neonatal seizures was identified in 99% cases. It is concluded that neonatal seizures are rarely idiopathic, therefore, an extensive diagnostic work up is needed to establish the cause of seizures in the newborn period.