Tuberculous chylothorax in paediatric population-a case report and systematic review of the literature.

Background: Chylothorax as part of the clinical spectrum of tuberculosis (TB) is a rare entity, especially among children. However, it is crucial for clinicians to be able to identify, correlate, and diagnose chylothorax as it poses significant morbidity to patients. Case Description: We report on a paediatric case of pleural TB complicated with complex chylothorax, and systematically reviewing the literature for cases of tuberculous chylothorax among children particularly looking at the (I) demographic, (II) clinical presentations, (III) radiological findings, and (IV) investigations among this cohort of patients. The systematic review complied to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We used three separate databases, namely PubMed, Ovid, and Scopus to search for articles with terms "chylothorax", "tuberculosis", and "children". We included article reporting on: (I) children aged below 18; (II) infected by Mycobacterium TB, and (III) written in English only. We reviewed the publications from the inception up to August 2022. After an extensive search, 7 articles were reviewed. We included 10 patients from all the reports. Most common symptoms reported were intermittent fever (n=6) and chronic cough (n=5). Other symptoms include shortness of breath and chest discomfort due to fluid accumulation and/or effusion. Typical TB symptoms like night sweat, loss of weight, and loss of appetite were present in some of the reported patients. Chest radiography was the most used diagnostic imaging modality, in which all of the reported cases noted presence of pleural effusion, with some cases proceeded with computer tomography (CT) of thorax to aid in the diagnosis. Most of the patients had lymphadenopathies and all patients underwent pleural tapping for analysis and symptomatic relief. From the pleural fluid milky appearance and biochemistry correlation, the diagnosis of chylothorax was established in all 10 patients. Every patient was tested positive for TB infection. Conclusions: Most of the cases showed similar clinical presentation, radiological findings, and laboratory investigations particularly the classic analysis findings of pleural fluid. Even though TB is not a common cause of chylothorax, clinicians should have raised suspicion of it especially after gathering full history and correlating it with the other findings.

Comparison of Pregnancy Outcome between 4 and 6 cm Cervical os Dilatation to Demarcate Active Phase of Labour: A Cross-Sectional Study.

This is a cross-sectional study comparing pregnancy outcomes between participants with 4 and 6 cm of cervical os dilatation at the diagnosis of the active phase of labour. It was conducted in a single tertiary centre involving low-risk singleton pregnancies at or beyond 37 weeks with spontaneous onset of labour. A total of 155 participants were recruited, 101 in group 1 (4 cm) and 54 in group 2 (6 cm). Both groups were similar in mean maternal age, mean gestational age at delivery, ethnicity, median haemoglobin level at delivery, body mass index, and parity. There were significantly more participants in group 1 who needed oxytocin augmentation (p < 0.001) for the longer mean duration (p = 0.015), use of analgesia (p < 0.001), and caesarean section rate (p = 0.002). None of the women had a postpartum haemorrhage or a third- or fourth-degree perineal tear, and none of the neonates required admission to the neonatal intensive care unit. There were significantly more nulliparas who had a caesarean section as compared to multiparas. A cervical os dilatation of 6 cm reduces the risk of caesarean section by 11% (95% CI, 0.01-0.9) and increases three times more the need for analgesia (AOR = 3.44, 95% CI, 1.2-9.4). In conclusion, the demarcation of the active phase of labour at a cervical os dilatation of 6 cm is feasible without an increase in maternal or neonatal complications.

The expectant management of a rare neonatal disease: transient neonatal myasthenia gravis.

BACKGROUND: Transient neonatal myasthenia gravis (TNMG) is an acquired disease which occurs in 10 to 20% of infants born to a mother with myasthenia gravis. Even though it is a self-limiting disorder, it may potentially be life-threatening if prompt diagnosis is not made, and expedient supportive respiratory management is not initiated when required. CASE: Here we describe three infants with TNMG. Two of them developed symptoms of TNMG within 24 hours of life, but one developed symptoms at 43 hours of life. One of the patients had an atypical form of TNMG with contracture and hypotonia. The other two infants survived a typical form of TNMG with hypotonia and poor sucking. All cases resolved spontaneously by one to two weeks of life with conservative management. CONCLUSIONS: Infants born to mothers with myasthenia gravis need to be monitored closely for symptoms of TNMG for the first 48 to 72 hours of life. However, the majority of infants with TNMG traverse a benign course and resolve spontaneously with expectant care.

Barriers to adherence to iron chelation therapy among adolescent with transfusion dependent thalassemia.

Study background: Thalassemia is the commonest genetic blood disorder in Malaysia which requires life-long blood transfusions. From a total of 7,984 thalassemia patients in Malaysia, adolescent age group account for the highest number of patients (2,680 patients, 33.57%). In developed countries, the average rate of adherence to long-term treatment among children and adolescents is only 58%. Sub-optimal adherence to iron chelation therapy may impact the outcome and quality of life in these patients. Thus, assessing adherence level and identification of risk factors for non-adherence is essential in optimizing management. Objectives: To determine the association between mean serum ferritin level with self-reported level of adherence to iron chelation therapy in transfusion dependent thalassemia (TDT) adolescents in Hospital Tengku Ampuan Afzan (HTAA), Kuantan and Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM), Cheras; to determine the association between socio-demographic factors and patients' knowledge on thalassemia and iron chelation therapy with the level of adherence. Materials and methods: This was a cross-sectional study conducted between 1st March 2019 and 31st March 2020. Data was collected through face-to-face interview by a single interviewer during the thalassemia clinic follow up, with content validated questionnaires. The questionnaires comprised four sections which included socio-demographic data, medication adherence questionnaire, knowledge of disease, and clinical characteristics of the participants. Results: A total of 70 participants were recruited. Results showed that only 51.4% of participants had good adherence to iron chelation therapy. There was a significant association between monthly household incomes of the family with the level of adherence to iron chelation (p-value 0.006). There was also an association between the mean serum ferritin levels with total Adherence Starts with Knowledge (ASK-12) score (p-value 0.001). However, there was no association between knowledge on thalassemia with the level of adherence. Conclusion: Adherence to iron chelation was generally unsatisfactory amongst adolescents with TDT as only 51.4% had good adherence. Low monthly household income of the family may affect adherence to iron chelation therapy in TDT patients. As adherence remains to be an issue amongst adolescent thalassemia patients, management should include regular and objective assessments to address this problem so as to optimize patient outcome.