Bile duct cysts in adults.

BACKGROUND: Bile duct cysts are rare and of uncertain origin. Most have been reported in young females of Asian descent, but an increasing number have occurred in Western adults. METHODS: A Medline literature search was performed to locate articles on the pathophysiological concepts, clinical behaviour and management controversies pertaining to bile duct cysts in adults. Emphasis was placed on reports from the past two decades. RESULTS AND CONCLUSION: An increasing rate of occurrence of bile duct cyst is reported in adults. Type IV cysts are more frequent in adults than children. Presentation tends to be non-specific abdominal discomfort. Related hepatobiliary or pancreatic disease frequently precedes recognition, and may complicate the postoperative course. Surgical treatment aims to relieve complications deriving from the cysts and to reduce the significant risk of malignant change within the biliary tree. Complete cyst resection, cholecystectomy and Roux-en-Y hepaticojejunostomy reconstruction is standard. Controversy exists about the role of hepatic resection in type IV and V cysts, and the role of minimally invasive and laparoscopic treatment. In general, the outcome is good and a near-zero mortality rate has been reported in institutional series over the past decade.

Eosinophil counts and urinary eosinophil protein X in children hospitalized for wheezing during the first year of life: prediction of recurrent wheezing.

UNLABELLED: Early identification of wheezing children with an increased risk of recurrent wheezing or subsequent asthma is important. The aim of the study was to determine the role of markers of eosinophil activation, along with other parameters, in the prediction of recurrent wheezing and allergic sensitization in children with early and severe wheezing. We examined 105 children without atopic dermatitis, hospitalized for wheezing during the first year of life. At a 20-mo follow-up, 101 of the children were assessed for the occurrence of recurrent wheezing (at least 3 episodes, including 1 in the previous 6 mo) and allergic sensitization (positive skin-prick test). By univariate analysis, levels of eosinophil counts at the time of hospitalization (p = 0.005, OR = 18.9), age in months (p < 0.0001, OR = 1.5), respiratory syncytial virus (RSV)-negative disease (p < 0.0001, OR = 8.8), parental atopy (p = 0.006, OR = 3.3) and male sex (0.02, OR = 2.7) were all predictive factors for recurrent wheezing at follow-up. With all parameters included in a multiple regression analysis, RSV-negative disease was not a predictive factor for recurrent wheezing. A simple model including eosinophil counts > or = 0.1 x 10(9)/L and age had a predictive accuracy of 79%, with only a 6% chance of a child being wrongly predicted as symptomatic. Urinary protein X (U-EPX) was not a predictive factor for recurrent wheezing. When included in a multiple logistic regression analysis, a level of U-EPX > or = 100 microg/mmol creatinine was the only parameter with a positive predictive value for allergic sensitization (p = 0.007, OR = 18.9), whereas age, parental allergy or parental asthma were not. CONCLUSION: Children with severe wheezing during the first year of life and subsequent recurrent wheezing are characterized by a normal or high eosinophil count in response to viral infections.

Nebulized budesonide after hospitalization for recurrent bronchial obstruction in children younger than 18 months.

A multi-center, double-blind, randomized dose-response study was performed to assess the effect of 3 months of treatment with two different doses of inhaled nebulized budesonide in children with acute recurrent bronchial obstruction (BO) causing hospitalization. Steroid-naive children younger than 18 months were included when admitted to hospital because of BO for at least the second time, and were followed-up monthly for 15 months. Forty-five of 49 subjects (43 boys, 2 girls) (mean age 9.3 months upon inclusion) completed the study. Twenty-four patients (20 boys, 4 girls) received nebulized budesonide 0.5 mg twice daily for 1 month followed by 0.25 mg daily for the next 2 months, whereas 25 children received 0.1 mg twice daily throughout the 3-month treatment period. Outcome (number of BO episodes, time to first BO after start of treatment, and use of rescue medication), as well as height/length and weight, were assessed at the start of treatment and monthly for the following 3 months, as well as for 12 months after cessation of treatment (15 months in total). There was an overall tendency towards better symptom control (fewer episodes of acute BO during treatment and follow-up, fewer hospital visits because of acute BO, lower clinical score during follow-up, and less use of rescue medication during follow-up) in the high-dose treatment group vs. the low-dose treatment group. However, the differences did not reach statistical significance for any of the outcomes. The only significant difference in effect between the groups was fewer children in the high-dose group treated openly with nebulized budesonide during follow-up. Length/height and weight gain did not differ significantly between the two treatment groups throughout the study. There was no significant dose-dependent beneficial effect of 3 months of treatment with nebulized budesonide in infants and toddlers with at least two hospitalizations for acute bronchial obstruction.

A placebo controlled trial of fluticasone propionate in asthmatic children.

Fluticasone propionate is a synthetic steroid for use by the inhaled route. It's high topical potency and low systemic bioavailability make it suitable for use in asthmatic children. A total of 258 children were randomised in a double-blind study to receive fluticasone propionate (50 micrograms bd) as the dry powder formulation inhaled via a Diskhaler inhaler, or matched placebo (with current therapy) for 4 weeks throughout which time diary cards were completed. During clinic visits lung function and adrenal function were measured. Fluticasone propionate produced a significantly greater increase in morning peak expiratory flow rate (PEFR) (adjusted mean difference over days 1-28, 17 l/min (95% CI; 10, 24); P < 0.001) and evening PEFR (adjusted mean difference over days 1-28, 16 l/min (95% CI; 9, 23); P < 0.001). In addition, diary card symptom scores, beta 2-agonist rescue and clinic lung function improved significantly on fluticasone propionate. There were few adverse events and basal plasma cortisol remained within the normal range. In conclusion fluticasone propionate at 50 micrograms bd is superior to placebo (current therapy) in the treatment of childhood asthma with no evidence of adverse effects.

Serum antibodies to dietary antigens: a prospective study of the diagnostic usefulness in celiac disease of children.

We examined 1,541 consecutive serum samples from 707 children with suspected food intolerance and 32 with treated celiac disease (CD) for IgG and IgA antibody reactivities to antigens from gluten, egg, and cow's milk by an enzyme-linked immunosorbent assay (ELISA). Samples from 72 patients showed increased IgA and/or IgG reactivity to gluten antigens; four were known CD patients not complying with a gluten-free diet, 13 were suspected CD patients challenged with gluten, and 30 most likely had CD as suggested by small intestinal villous atrophy and histological and/or clinical improvement on a gluten-free diet. The remainder with increased antigluten activity had other disorders that might have affected mucosal permeability. Nevertheless, the median IgA reactivity to gluten was significantly higher in the CD group, and the probability for CD increased from 25 to 100% when this reactivity was above 2.4 optical density (OD) units in our ELISA. Sixteen CD patients (but none of those without CD) had IgA reactivity to gluten higher than 2.4 OD units. We conclude that ELISA determinations of levels of serum antibodies reacting to dietary antigens is a valuable adjunct in the diagnosis of CD in children.

Epiglottis acuta treated with nasotracheal intubation.

Twenty children, ranging in age from 1--9 years, and one adult suffering from epiglottis acuta were treated with nasotracheal intubation performed under general anaesthesia and with ampicillin. Clinical cure was obtained in all cases with a mean intubation time of 34 hours. The diagnosis, epiglottis acuta, was suspected by the referring physician in 10 cases. The incidence of epiglottis acuta compared to laryngitis acuta was found to be 1:30. The mean hospital stay was 5.4 days. It is concluded that treatment of acute epiglottis by nasotracheal intubation in the hands of experienced anaesthesiologists and with close observation in an intesnive care unit, is a safe method of management with negligible morbidity and mortality.