Budesonide reduces hospital admission rates in preschool children with acute wheezing.

BACKGROUND: The object of this study was to determine whether high doses of inhaled budesonide provide additional benefits to a standardized treatment regimen that includes systemic steroids and salbutamol in preschool patients presented to the emergency department (ED) with acute wheezing attacks. Methods This randomized, double-blind, placebo-controlled, parallel group trial was conducted in children, 6 months-6 years with moderate or severe acute wheezing epizode, as determined based on a pulmonary index score (PIS) of 7-13 points. We compared the addition of budesonide 3 mg versus placebo to standard acute asthma treatment, which included salbutamol and a single 1 mg/kg dose of methylprednisolone given at the beginning of therapy. The primary outcome was differences in hospitalization rates within 4 hr. Secondary outcome was difference in median PIS between treatment groups at 2 hr. Results One hundred patients were enrolled. Cumulative hospitalization rate at 120, 180, and 240 min were 0.72, 0.62, and 0.58 in placebo group; and 0.44, 0.30, and 0.24 in budesonide group. Discharged rate in budesonide group was significantly higher than the placebo group (log-rank = 12.407 ve P < 0.001). Expected mean discharged times were 200.4 (95%CI = 185.3-215.5) min in placebo group and 164.4 (95%CI = 149.4-179.4) min in budesonide group. Median (25-75%) PIS at the 120th min was significantly lower in budesonide group than the placebo group (5 [4-8] vs. 8 [5-9] respectively, P = 0.006). Conclusions The addition of budesonide nebulization may decrease the admission rate of preschool children who have moderate to severe acute wheezing epizodes. Pediatr Pulmonol. 2017;52:720-728. © 2017 Wiley Periodicals, Inc.

The Addition of Inhaled Budesonide to Standard Therapy Shortens the Length of Stay in Hospital for Asthmatic Preschool Children: A Randomized, Double-Blind, Placebo-Controlled Trial.

BACKGROUND: Asthma exacerbations lead to frequent emergency visits and hospitalizations, and are associated with high morbidity and occasionally mortality. New therapeutic strategies are needed. We sought to investigate whether the addition of high-dose inhaled budesonide to standard therapy would shorten the length of stay (LOS) in hospital of children admitted for asthma exacerbations. METHODS: The study was designed as a single-center, double-blind, placebo-controlled and parallel-group trial. Children aged 7-72 months and admitted with an asthma exacerbation clinical asthma score (CAS) of between 3 and 9 were allocated to either the budesonide (n = 50) or the placebo (n = 50) group. Hospital LOS was compared between children who received 2 mg/day of budesonide versus placebo in addition to standard management of asthma exacerbation involving oxygen inhalation and ß2-agonist, anticholinergic and oral corticosteroid therapy. All patients were assessed every 4 h. Children with a CAS <3, a peripheral oxygen saturation >95% and normal pulmonary function, and those with a symptom-free period of at least 4 h after salbutamol treatment were discharged. RESULTS: Total hospital LOS was significantly shorter in the budesonide group than in the placebo group (median: 44 vs. 80 h, respectively; p = 0.01). When compared with placebo, the number of inpatients was significantly less in the budesonide group at all the assessed end points (Kaplan-Meier; p = 0.022). Additionally, nebulized budesonide was found to reduce the overall cost of treatment. CONCLUSION: We demonstrated that, for children hospitalized for asthma exacerbations, an additional 2 mg/day of nebulized budesonide significantly reduced hospital LOS as well as the overall cost of treatment.

Neuron-specific enolase and S100B protein in children with carbon monoxide poisoning: children are not just small adults.

INTRODUCTION: The aim of this study was to evaluate the role of S100B protein and neuron-specific enolase (NSE) in children with carbon monoxide (CO) poisoning. METHODS: In this prospective, case-controlled study, children with CO poisoning were recruited. Patient demographics features and Glasgow Coma Scale (GCS) were recorded. Blood samples were collected from all children with CO poisoning at their admission to the hospital and at 3 and 6 hours after admission. Levels of NSE and S100B were measured. The control group consisted of age-matched healthy children. RESULTS: A total of 30 children with CO poisoning (mean age, 7.88 ± 3.75 years; 17 boys) and 30 healthy children (mean age, 8.16 ± 3.05 years; 7 boys) were enrolled in the study. Mean carboxyhemoglobin level (%) measured at admission was 30.05 ± 8.00. Serum NSE levels of the children with CO poisoning were significantly higher than those of children from the control group at 0 hour and also at 3 and 6 hours (P < .001, P = .001, and P = .005, respectively). Serum S100B protein levels were similar between the 2 groups at 0 and 3 and 6 hours (P > .05). Serum NSE levels of patients with CO poisoning demonstrated a negative correlation with the admission GCS scores. No correlation was found between GCS scores and S100B protein levels. CONCLUSION: We have shown that NSE levels increase in CO-associated hypoxic brain damage in accordance with clinical findings. We have also found that, contrary to the studies conducted on adults, S100B protein levels do not increase in response to hypoxic brain damage.

Assessment of ventricular functions by tissue Doppler echocardiography in children with asthma.

Patients with asthma develop pulmonary hypertension due to recurrent hypoxia and chronic inflammation, leading to right heart enlargement with ventricular hypertrophy. Patients with severe asthma can experience cor pulmonale later in life, but little is known about ventricular function during the early stages of the disease. This study aimed to investigate ventricular functions in asymptomatic children with asthma as detected by conventional echocardiography and tissue Doppler echocardiography (TDE). Fifty-one pediatric patients (mean age 10.4 ± 2.2 years) with asthma and 46 age- and sex-matched healthy children (mean age 10.9 ± 2.4 years) were studied. All subjects were examined by conventional echocardiography and TDE, and they had pulmonary function tests on spirometry. The right-ventricular (RV) wall was statistically (p = 0.01) thicker among asthmatic patients (4.7 ± 1.5 mm) compared with healthy children (3.6 ± 0.4 mm). However, conventional pulsed-Doppler indices of both ventricles did not differ significantly between asthmatic patients and healthy children (p > 0.05). The results of TDE examining RV diastolic function showed that annular peak velocity during early diastole (E'), annular peak velocity during late diastole (A') (16.4 ± 1.8 and 5.1 ± 1.4 cm/s, respectively), E'/A' ratio (3.2 ± 0.7), isovolumetric relaxation time (67.7 ± 10.2 ms) and myocardial performance index (48.1 % ± 7.0 %) of the lateral tricuspid annulus among asthmatic patients differed significantly (p = 0.01) from those of healthy children (13.2 ± 2.3, 8.2 ± 2.0 cm/s, 1.6 ± 0.5, 46.2 ± 8.7 ms, and 42.0 % ± 5.7 %, respectively). Only peak expiratory flow (PEF) rate from the pulmonary function tests was negatively correlated with the E'/A' ratio of the tricuspid annulus (r = -0.38, p = 0.01). This study showed that although the findings of clinical and conventional echocardiography were apparently normal in children with asthma, TDE showed subclinical dysfunction of the right ventricle, which is negatively correlated with PEF. These findings signify the diagnostic value of TDE in the early detection and monitoring of such deleterious effects among asthmatic patients.

Hair zinc and selenium levels in children with recurrent wheezing.

The prevalence of asthma and other allergic diseases has increased markedly in the last few decades. Oxidative stress plays a central role in asthma pathogenesis, and reduced daily consumption of antioxidants is positively correlated with increased risk of asthma. Zinc (Zn) and selenium (Se) are the main antioxidant elements. In our study, we aimed to investigate hair Zn and Se levels in children with recurrent wheezing. The study included 65 patients with recurrent wheezing (RW) and 65 healthy children (HC). The hair Zn and Se levels (µg/g) of the RW group were lower in comparison with the HC group (162.43 ± 91.52 vs. 236.38 ± 126.44, P < 0.001, and 217.37 ± 83.01 vs. 280.53 ± 122.73, P < 0.001, respectively). Total antioxidant capacity (TAC) (mmol/L) of the RW group was found to be significantly lower in comparison with the HC group (1.38 ± 0.14 vs. 1.53 ± 0.20, respectively; P < 0.001). Number of wheezing episodes in the last 6 months were negatively correlated with serum TAC, hair Zn, and Se levels in RW group (r(p) = -0.291, P = 0.001; r(p) = -0.209, P = 0.017; r(p) = -0.206, P = 0.019, respectively). The number of acute respiratory tract infection (ARTI) episodes in the last 6 months was negatively correlated with serum TAC and hair Zn levels (r(p) = -0.316, P < 0.001, and r(p) = -0.196, P = 0.025, respectively). In this study, we found that TAC, hair Zn, and hair Se levels were lower in children with RW than HC and negatively correlated with wheezing episodes in the last 6 months. Also body Zn and Se levels can be reliably measured in hair samples.

The association of serum lipocalin-2 levels with metabolic and clinical parameters in obese children: a pilot study.

OBJECTIVE: We aimed to evaluate the association between serum lipocalin-2 level and clinical and metabolic parameters in obese children. METHODS: The study included obese children with a body mass index (BMI) >95th percentile who presented to Kecioren Teaching and Research Hospital with the complaint of weight gain and healthy children with a BMI <85th percentile. The height and weight of the patients were measured for compartment of anthropometric data. Fasting blood glucose, insulin, lipid profile, and serum lipocalin-2 level were measured to evaluate the laboratory parameters. RESULTS: The study included 33 obese and 34 healthy nonobese children. Comparison of data on the obese subjects with those of the healthy subjects shows differences in BMI, BMI-SDS, triglyceride, insulin, and homeostasis model assessment index-insulin resistance levels between the two groups were statistically significant (p < 0.05), whereas serum lipocalin-2 was not statistically significant (p >0.05). There was no statistically significant difference in serum lipocalin-2 levels when obese and control groups were reclassified as prepubertal and pubertal ( p >0.05). CONCLUSIONS: In this study, we did not find any relationships among serum lipocalin-2 level, anthropometric parameters, or metabolic parameters. According to the results of this study, we do not suggest routine investigation of serum lipocalin-2 level in obese subjects for risk stratification of the obesity-related complications.

Factors associated with left atrial size in obese children: an observational study.

OBJECTIVE: Left atrial size can be considered an independent risk factor for cardiovascular diseases. The measurements of left atrium may be used to assess obesity, which is an important risk factor of cardiovascular diseases. It is aimed to determine the factors that effect to the left atrial size, which is an indicator of cardiac risk in obese children without hypertension. METHODS: The cross-sectional observational study was performed between April 2008 and September 2009 at the clinic of Pediatric Cardiology. Eighty obese and 82 lean children were studied. Diagnosis of obesity was defined according to the World Health Organization classification as the standard deviation score of body mass index being over + 2 standard deviation of the same gender and age. All subjects underwent two-dimensional, M-mode, and Doppler echocardiographic studies. Student's t-test, Chi-square test, Pearson correlation analysis, and multiple stepwise regression analyses were used to compare the subjects, differences in group proportions, evaluate the relation of variables with the left atrial size, and examine the effects of significant independent variables, respectively. RESULTS: The mean age of obese patients was 11.7±2.2 years and it of lean subjects was 11.7±2.2 years. Body weight, body mass index, standard deviation score of body mass index, waist circumference, systolic and diastolic blood pressure, fasting insulin, and insulin resistance statistically increased in obese children (p<0.05). The left atrial size statistically correlated (p<0.05) with age (r=0.523), body mass index (r=0.394), waist circumference (r=0.421), diastolic blood pressure (r=0.230), insulin resistance (r=0.350), and left ventricular mass (r=0.535). It was determined that age (beta=0.491; 95% CI=0.091-0.892; p=0.001) and left ventricular mass (beta=0.055; 95% CI=0.026-0.085; p=0.017) were the most effective independent factors associated with left atrial size among other independent factors in multiple regression analysis. CONCLUSION: We found that left atrial size was mostly influenced by age and left ventricular mass in obese children. Therefore, it is important that left atrial size is follow up in childhood obesity.

Cardiac functions in children with growth hormone deficiency before and during growth hormone-replacement therapy.

Childhood growth hormone deficiency (GHD) decreases left-ventricular (LV) mass, but impairment of cardiac function has never been documented. The objective of this study was to assess the cardiac effects of GHD and recombinant human growth hormone (rhGH) treatment using conventional echocardiography and tissue Doppler imaging. Complete two-dimensional, M-mode, pulse-wave Doppler echocardiography and pulse-wave tissue Doppler imaging were performed in 12 children (6 male and 6 female patients) with GHD at baseline and at 5.86 ± 1.61 months after rhGH therapy. Recombinant human growth hormone treatment was associated with a significant increase in LV mass index (63.8 ± 27.1 to 79.3 ± 30.3 g/m(2); P < 0.01) and LV internal dimensions (21.4 ± 2.63 to 24.0 ± 4.13 mm in systole [P = 0.03] and 36.5 ± 3.90 to 39.5 ± 4.94 mm in diastole [P < 0.01]). There were statistical differences of parameters, such as deceleration time of early peak velocity of mitral, isovolumic relaxation time, and myocardial performance index (103 ± 15.4 to 139 ± 21.2 ms [P < 0.01], 55.5 ± 9.24 to 69.2 ± 3.74 ms [P < 0.01], and 37.8 ± 4.46 to 44.9 ± 5.44% [P < 0.01], respectively). Before and during rhGH therapy, there were no significant differences in fractional shortening of the left ventricle, peak mitral, and tricuspid wave velocities with ratios determined using conventional echocardiography and tissue Doppler imaging. In children, GHD affects heart morphology by inducing a decrease in cardiac size, but it does not modify cardiac function. Recombinant human growth hormone treatment increases cardiac mass, deceleration time of early peak velocity of the mitral valve, isovolumic relaxation time, and myocardial performance index, but it does not make a difference in other parameters of conventional echocardiography and tissue Doppler imaging.

[Silent enemy in acute rheumatic fever: subclinical carditis]. / Akut romatizmal ateste sessiz düsman: Subklinik kardit.

OBJECTIVES: Routine use of Doppler echocardiography for the initial diagnosis of acute rheumatic fever (ARF) might allow early detection and, hence, prevention of rheumatic recurrences. This study sought to determine the incidence of subclinical carditis in ARF patients. STUDY DESIGN: The study included 80 patients (64 migratory polyarthritis, 16 rheumatic chorea) who were diagnosed with ARF according to the Jones criteria, 1992 update. Rheumatic carditis was defined as the presence of the following findings on Doppler echocardiography: mitral and aortic regurgitant jets in at least two planes, the length of the jets >1 cm, and peak flow velocities of >2.5 m/sec for both mitral and aortic regurgitations persisting throughout systole and diastole, respectively. The patients diagnosed with subclinical carditis were re-evaluated at 1, 3, 6, and 12 months. RESULTS: Echocardiography revealed subclinical carditis in 25 patients (31.3%; 13 girls, 12 boys; mean age 11.4±2.5 years) with ARF. Of 64 patients with migratory polyarthritis, 34 (53.1%) had clinical carditis and 17 (26.6%) had subclinical carditis. The incidences of clinical and subclinical carditis among 16 patients with rheumatic chorea were 31.3% (n=5) and 50% (n=8), respectively. Of 20 patients who completed one-year follow-up, persistence of subclinical carditis was observed in 11 cases (55%). CONCLUSION: Clinicians should be attentive to the presence of cardiac involvement among patients with suspected ARF. Considering the high incidence of subclinical carditis, echocardiographic evidence of carditis should be used as a diagnostic criterion.

Knowledge and attitudes of adolescents towards asthma: questionnaire results before and after a school-based education program.

BACKGROUND: Previous studies on school-based education programs have reported that asthmatic and nonasthmatic adolescents, teachers and school personnel do not have enough information on asthma. However, the number of education programs including adolescents without asthma is not sufficient. The aim of the present study was to determine the knowledge of school children about asthma and to investigate whether their knowledge of asthma can be increased by an education program through a booklet distributed as a handout. METHODS: This cross-sectional prospective questionnaire survey was carried out in a private school in Ankara, Turkey, between February and April 2006. 720 adolescents in grades 6, 7 and 8 were included. Knowledge about asthma was evaluated by a scoring system before and after the education offered by means of a booklet. RESULTS: The final analysis was conducted on 642 students in total. The number of right answers in 5 categories, percentage of right answers and total questionnaire score improved significantly after the education received (p < 0.001). The total questionnaire scores of the girls (p = 0.002), those students with a university graduate mother (p = 0.006) and those with a physician parent (p = 0.041) were higher than those of the other pupils. CONCLUSION: Theoretical material in the form of a booklet can be used in a school-based asthma education program in order to improve the knowledge of adolescents about asthma.

The immunostimulant OM-85 BV prevents wheezing attacks in preschool children.

BACKGROUND: No reagents have been shown to be effective in preventing wheezing attacks provoked by acute respiratory tract illnesses (ARTIs) in preschool children. New therapeutic agents and preventive strategies are needed. OBJECTIVES: We assessed the effect of OM-85 BV (Broncho-Vaxom; OM Pharma, Geneva, Switzerland) in preventing ARTI-provoked wheezing attacks in preschool children with recurrent wheezing. METHODS: A randomized, double-blind, placebo-controlled, parallel-group study was carried out between August 2007 and September 2008. The study included 75 children with recurrent wheezing who were 1 to 6 years old. Participants were randomly assigned to groups given either OM-85 BV or a placebo (1 capsule per day for 10 days each month for 3 consecutive months) at the start of the trial. Participants were followed for 12 months, which included the administration period of the test article. RESULTS: Subjects given OM-85 BV had a lower rate of wheezing attacks. The cumulative difference in wheezing attacks between the 2 groups was 2.18 wheezing attacks per patient in 12 months; there was a 37.9% reduction in the group given OM-85 BV compared with the group given placebo (P < .001). Stepwise multiple (linear) regression analysis showed that the main difference between the OM-85 BV and placebo groups was a reduction the number of ARTIs (R = -0.805, P < .001). The duration of each wheezing attack was 2 days shorter in the group given OM-85 BV than in the group given placebo (P = .001). CONCLUSION: Administration of OM-85 BV significantly reduced the rate and duration of wheezing attacks in preschool children with ARTIs.

Relation of subepicardial adipose tissue thickness and clinical and metabolic parameters in obese prepubertal children.

BACKGROUND: The measurement of subepicardial adipose tissue thickness (SATT) has been found to be related to insulin resistance (IR) in adults. Until now, the association between SATT and IR has not been evaluated in obese prepubertal children. We aimed to determine the relation of SATT with clinical anthropometric and metabolic parameters and to provide cutoff value of SATT associated with IR in obese prepubertal children. METHODS: Fifty-two obese (mean age: 9.5 ± 1.6 years, 29 female) and 31 lean prepubertal age- and gender-matched subjects (mean age: 9.2 ± 1.4 years, 12 female) were evaluated by echocardiography. SATT was measured by transthoracic echocardiography. RESULTS: SATT (6.54 ± 1.38 mm) and homeostatic model assessment-insulin resistance (HOMA-IR) (3.2 ± 2) values of obese prepubertal subjects were significantly higher than those of the lean subjects (3.72 ± 0.57 mm and 1.6 ± 1) in the control group (both p < 0.001). Bivariate correlation analysis showed significant correlation between SATT, age, body mass index (BMI), waist circumference (WC), hip circumference (HC), waist-to-hip ratio (WHR), mid-arm circumference (MAC), triceps skin fold (TSF) thickness, insulin, and HOMA-IR (r = 0.547, r = 0.524, r = 0.543, r = 0.431, r = 0.289, r = 0.402, r = 0.400, r = 0.328, r = 0.289, p < 0.05, respectively). As an optimal cutoff point, an SATT of 4.33 mm determined IR with 93.3% sensitivity and 51% specificity. CONCLUSIONS: Our study on obese prepubertal children showed that SATT was significantly correlated with age, BMI, WC, HC, MAC, TSF, insulin, and HOMA-IR.

Neonatal diabetes mellitus accompanied by diabetic ketoacidosis and mimicking neonatal sepsis: a case report.

Neonatal diabetes mellitus (DM) develops within the first six weeks of life with basic findings including dehydration, hyperglycaemia, and mild or no ketonemia/ketonuria. It can be either transient or permanent. Here, we report a case of a one-month-old infant with permanent neonatal diabetes, due to pancreatic hypoplasia, accompanied by diabetic ketoacidosis (DKA). The hyperglycaemia and ketoacidosis resolved by the 14(th) hour of treatment, consisting of IV insulin and rehydration. Subsequently, insulin treatment was continued with neutral protamine hagedorn (NPH) insulin. Breastfeeding was started and was continued at intervals of three hours. Following initiation of breastfeeding, the stools became watery, loose, yellow-green in color, and frequent (8-10 times a day). They contained no blood or mucus. Replacement of pancreatic enzymes resulted in decreased stool frequency. Neonatal DM due to pancreatic hypoplasia and associated with DKA may mimic sepsis and should be kept in mind in all newborns who present with fever, dehydration, and weight loss.

Comparison of single 2000-microg dose treatment vs. sequential repeated-dose 500-microg treatments with nebulized budesonide in acute asthma exacerbations.

BACKGROUND: High repeated doses of inhaled corticosteroids (ICSs) are recognized as having a more rapid improvement of outcomes than a single dose of ICS in severe acute asthma. However, to our knowledge, there has been no direct comparison of the early effects of single or repeated administration of the same total dosage of ICS in children with moderate to severe exacerbations of asthma. OBJECTIVE: To compare the efficacy of a single dose of 2000 microg of nebulized budesonide with 4 repeated doses of 500 microg of nebulized budesonide in 40 children with an acute asthma exacerbation. METHODS: Randomized, double-blind, parallel study that compared the efficacy of 2000 microg of nebulized budesonide, administered in a single dose, with repeated doses (4 doses of 500 microg each) during the first 90 minutes in 40 children (mean [SD] age, 10.7 [2.4] years) with an acute asthma exacerbation that required treatment with an oral corticosteroid. Forced expiratory volume in 1 second, asthma attack score, and oxygen saturation were evaluated at 20, 40, 60, 90, 120, 180, and 240 minutes after initial treatment. Oral corticosteroids were given to all patients at 90 minutes. RESULTS: There were no significant differences in forced expiratory volume in 1 second (P = .54) at any times between the groups. Also, asthma scores and oxygen saturation were not different in either group within 90 minutes (P = .51 and P = .64, respectively) and thereafter (P = .35 and P = .87, respectively). CONCLUSION: The use of a single dose of nebulized budesonide is as effective as repeated administration of the same total dosage during the first 90 minutes before giving oral corticosteroids in children with moderate to severe exacerbations of asthma.

Bronchiolitis obliterans: a rare chronic pulmonary complication associated with Stevens-Johnson syndrome.

Pulmonary manifestations are well recognized during the acute phase of Stevens-Johnson syndrome but persistent pulmonary sequela is rarely reported. We report two boys with bronchiolitis obliterans following the acute phase of Stevens-Johnson syndrome and discuss the clinical picture and treatment of persistent pulmonary complications with reference to earlier reports.