Cardio-pulmonary involvement in juvenile systemic lupus erythematosus

Cardio-pulmonary manifestations of systemic lupus erythematosus (SLE) are well recognized in adults. We report the occurrence of clinically significant cardio-pulmonary disease in a cohort of predominantly Caucasian children with SLE. All children with SLE attending the Royal Liverpool Children’s NHS Trust between 1995 and 2003 were reviewed. Of 29 children with SLE, 27 (93%) were Caucasian. Nine (31%) had cardio-respiratory complications: cardiac only (n = 1); respiratory only (n = 4); both cardiac and respiratory manifestations (n = 4). Median (range) duration of follow-up of affected children: four years (six months to 11 years). Six out of eight (75%) presented with respiratory complications before SLE was diagnosed. Three children had pericardial effusions, one requiring pericardiocentesis for tamponade. One had cardiac conduction defects and another significant pulmonary hypertension. Respiratory complications comprised: interstitial lung disease (n = 4), with two showing evidence of pulmonary fibrosis; pleural effusions (n = 2), pulmonary haemorrhage (n = 1) and lupus pneumonitis (n = 1). Disease course was complicated by CMV infection in one child. Lung biopsy was performed in five cases. Seven were treated with cyclophosphamide with significant improvement in symptoms/lung function. Of this predominantly Caucasian paediatric cohort with SLE, 31% had significant cardio-pulmonary involvement. All children with SLE should have regular monitoring of their cardio-respiratory status.

'Less may be best'-Pediatric parapneumonic effusion and empyema management: Lessons from a UK center

BACKGROUND

Children with empyema are managed at our center using a protocol-driven clinical care pathway. Chemical fibrinolysis is deployed as first-line management for significant pleural disease. We therefore examined clinical outcome(s) to benchmark standards of care while analyzing disease severity with introduction of the pneumococcal conjugate vaccine.

METHODS

Medical case-records of children managed at a UK pediatric center were surveyed from Jan 2006 to Dec 2012. Binary logistic regression was utilized to study failure of fibrinolytic therapy. The effects of age, comorbidity, number of days of intravenous antibiotics prior to drainage and whether initial imaging showed evidence of necrotizing disease were also studied.

RESULTS

A total of 239 children were treated [age range 4months-19years; median 4years]. A decreasing number of patients presenting year-on-year since 2006 with complicated pleural infections was observed. The majority of children were successfully managed without surgery using antibiotics alone (27%) or a fine-bore chest-drain and urokinase (71%). Only 2% of cases required primary thoracotomy. 14.7% cases failed fibrinolysis and required a second intervention. The only factor predictive of failure and need for surgery was suspicion of necrotizing disease on initial imaging (P=0.002, OR 8.69).

CONCLUSION

Pediatric patients with pleural empyema have good outcomes when clinical care is led by a multidisciplinary team and protocol driven care pathway. Using a 'less is best' approach few children require surgery.

WITHDRAWN: Inhaled bronchodilators for cystic fibrosis

This review has been withdrawn because it has been split into the following reviews: 'Long‐acting inhaled bronchodilators for cystic fibrosis' and 'Short‐acting inhaled bronchodilators for cystic fibrosis'.

The editorial group responsible for this previously published document have withdrawn it from publication.

Adrenal responses to a low-dose short synacthen test in children with asthma

OBJECTIVES

Corticosteroids are known to cause adrenal suppression. The aim of this study was to assess clinical factors affecting responses to a low dose short synacthen test (LDSST) in asthmatic children using corticosteroids.

DESIGN

Patients were recruited from secondary care paediatric asthma populations within the UK.

PATIENTS

Asthmatic children (5-18 years), receiving corticosteroids, underwent a LDSST (n = 525).

MEASUREMENTS

Demographics and corticosteroid doses were tested for association with baseline and peak (stimulated) cortisol concentrations.

RESULTS

Baseline cortisol was significantly associated with age (log baseline increased 0·04 nm per year of age, P < 0·0001), but not with gender or corticosteroid dose. Peak cortisol was significantly associated with total corticosteroid cumulative dose (decreased 0·73 nm per 200 mcg/day, P < 0·001) but not with age, gender inhaled/intranasal corticosteroid cumulative dose or number of courses of rescue corticosteroids. Biochemically impaired response (peak cortisol ≤500 nm) occurred in 37·0% (161/435) overall, including children using GINA low (200-500 mcg/day beclomethasone-CFC equivalent 32%, n = 60), medium (501-1000 mcg/day (33%, n = 57) and high (>1000 mcg/day 40%, n = 13) doses of inhaled corticosteroid (ICS) similarly, and 36·6% of those using fluticasone ICS ≥500 mcg/day (71/194). Impaired response was more frequent in patients on regular oral corticosteroids (66%, n = 27, P < 0·001).

CONCLUSION

Children with asthma can develop biochemical adrenal suppression at similar frequencies for all ICS preparations and doses. The clinical consequence of biochemical suppression needs further study.

Inhaled bronchodilators for cystic fibrosis

BACKGROUND

Recurrent wheeze and breathlessness are common in people with cystic fibrosis, and bronchodilators are commonly prescribed. Despite their wide-scale and often long-term use, there is limited objective evidence about their efficacy in cystic fibrosis.

OBJECTIVES

To evaluate the effectiveness of inhaled bronchodilators in children and adults with cystic fibrosis.

SEARCH STRATEGY

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic databases searches, and handsearches of relevant journals and abstract books of conference proceedings. Latest search of the Group's Trials Register: August 2005

SELECTION CRITERIA

Randomised or quasi-randomised trials comparing inhaled bronchodilators to placebo or another inhaled bronchodilator in people with CF, diagnosed clinically and by sweat or genetic testing and at all stages and severity of lung disease.

DATA COLLECTION AND ANALYSIS

The authors independently extracted data and assessed trial quality. If data were missing, the primary author was contacted where possible. The data were subgrouped into classes of bronchodilator and for each class into short-term effects (less than one week) and long-term effects (greater or equal to one week).

MAIN RESULTS

The search identified 43 references. Fourteen trials, with a total of 257 participants, were suitable for inclusion. The trials were all cross-over in design; in this case a meta-analysis was not possible. There were varied conclusions from the different trials, reflecting their heterogeneity. Compared to placebo, short-acting beta-2 agonists increased forced expiratory volume at one second (FEV(1)) in the short term in three out of five trials, and in the long-term increased peak expiratory flow rate in individuals who had been shown to have bronchial hyperreactivity or bronchodilator responsiveness or both. Compared to placebo, long-acting beta-2 agonists increased FEV(1) and forced expiratory flow between 25% and 75% of expiratory flow (FEF 25-75%) in the short term in participants known to have bronchodilator responsiveness, but produced inconsistent results in long-term trials. Short acting-anticholinergics had no consistent effect on lung function tests in either the short or the long term. We found no published trials of fenoterol, formoterol or tiotropium and the use of these agents in cystic fibrosis cannot be supported.

AUTHORS' CONCLUSIONS

It was not possible to determine fully the effectiveness of inhaled bronchodilators in cystic fibrosis as a meta-analysis was not possible. However, both short and long-acting beta-2 agonists can be beneficial both in the short and long term in individuals with demonstrable bronchodilator responsiveness or bronchial hyperrresponsiveness.

Asthma in adolescence

The care of adolescents with asthma has been largely neglected, yet adolescents have particular needs that differ from those of children or adults with asthma. There are over 800,000 teenagers in the UK who suffer from asthma and underdiagnosis and poor treatment are common. The prevalence and level of morbidity from asthma in adolescents are as high as or higher than the rates in younger schoolchildren. Poor symptom control frequently reflects poor compliance with treatment. The beliefs and fears of teenagers about their asthma and its treatment are often not recognised or addressed in clinical consultations. Improved communication on the part of health professionals, which results in negotiating simple management plans that are tailored to the individual patient's concerns and goals, is more likely to improve compliance and asthma control than are complex plans made unilaterally by the doctor. The transition of care from the paediatric to the adult clinic remains a challenge for paediatricians and there is a lack of consensus over the best method of achieving this.

Assessment of the child with recurrent chest infections

The child with recurrent chest infections presents the clinician with a difficult diagnostic challenge. Does the child have a simply-managed cause for their symptoms, such as recurrent viral respiratory infections or asthma, or is there evidence of a more serious underlying pathology, such as bronchiectasis? Many different disorders present in this way, including cystic fibrosis, a range of immunodeficiency syndromes, and congenital abnormalities of the respiratory tract. In some affected children, lung damage follows a single severe pneumonia: in others it is the result of inhalation of food or a foreign body. The assessment of these children is demanding: it requires close attention to the history and examination, and in selected cases, extensive investigations. Early and accurate diagnosis is essential to ensure that optimal treatment is given and to minimise the risk of progressive or irreversible lung damage. The aim of this chapter is to examine the causes of recurrent chest infections and to describe how this complex group of children should be assessed and investigated.