Esophageal multichannel intraluminal impedance and pH monitoring in children: indications and limits

AIM

Aim of the study was to compare multichannel intraluminal impedance (MII)-pH monitoring versus pH only, as first-line assessment of gastroesophageal reflux (GER) in children and to define the relation between GER and symptoms as well relation between types of GER and age of children.

METHODS

All the patients with GER were divided in three groups: A, younger than 24 months, B, older than 24 months with typical symptoms and C, older than 24 months with atypical symptoms. The groups A and C underwent a combined MII-pH recording. The group B underwent a only pH recording. MII-pH measurements were performed in 89 children (63 group A and 26 group C), only pH measurements in 170 cases (group B).

RESULTS

Sixty-seven of the 247 pH measurements demonstrated abnormal reflux indices: 25.0% (group A), 28.8% (group B) and 20.8% (group C). The number of the reflux periods and the total reflux index were highest in the patients of the group B, but the number of long reflux periods was highest in the group C. Abnormal values at MII results were found in 36 cases: 41.7% in group A (high number of weakly acid refluxes events) and 45.8% in group C (similar number of acid and weakly acid events). The MII were considered pathological because of high number of reflux episodes and symptom index ≥ 50% respectively in 60.0% and 40.0% of the group A and 27.3% and 62.7% of the group C.

CONCLUSION

MII-pH study must be reserved to patients younger than 2-year old (high probability of weakly acid reflux) and children with atypical symptoms.

Anesthesia in children with asthma and rhinitis

The incidence of asthma is increasing worldwide, but morbidity and mortality are decreasing, because of improvements in medical care. Although the incidence of severe perioperative bronchospasm is relatively low in asthmatics undergoing anaesthesia, when it does occur it may be life-threatening. Preoperative assessment of asthma should include a specialized medical hystory and physical examination as well as pulmonary function testing. Potential trigger agents should be identified and avoided. In many asthmatic patients treatment with systemic corticosteroids and bronchodilators is indicated to prevent the inflammation and bronchocostriction associated with endotracheal intubation. Nonetheless, acute bronchospasm can still occur, especially at induction and emergence, and should be promptly and methodically managed.

Clinical modifications induced by drugs during the perioperative period

Total intravenous anesthesia (TIVA) can be defined as a technique in which general anesthesia is induced and maintained using only intravenous agents. TIVA has become more popular in recent times because of the pharmacokinetic and pharmacodynamic properties of propofol, the availability of short acting synthetic opioids, and the development of delivery systems. Significant differences in anatomy and physiology in adults and children and special needs of younger patients have important consequences on many aspects of anesthesia. Airway and respiratory complications are the most common causes of morbidity during general anesthesia in children. Knowledge of the functional anatomy of airways in children forms the basis in the understanding of the pathological conditions that may occur.

Problematic severe asthma in children, not one problem but many: a GA2LEN initiative

Although most children with asthma are easy to treat with low doses of safe medications, many remain symptomatic despite every therapeutic effort. The nomenclature regarding this group is confusing, and studies are difficult to compare due to the proliferation of terms describing poorly defined clinical entities. In this review of severe asthma in children, the term problematic severe asthma is used to describe children with any combination of chronic symptoms, acute severe exacerbations and persistent airflow limitation despite the prescription of multiple therapies. The approach to problematic severe asthma may vary with the age of the child, but, in general, three steps need to be taken in order to separate difficult-to-treat from severe therapy-resistant asthma. First, confirmation that the problem is really due to asthma requires a complete diagnostic re-evaluation. Secondly, the paediatrician needs to systematically exclude comorbidity, as well as personal or family psychosocial disorders. The third step is to re-evaluate medication adherence, inhaler technique and the child's environment. There is a clear need for a common international approach, since there is currently no uniform agreement regarding how best to approach children with problematic severe asthma. An essential first step is proper attention to basic care.

Clinical evaluation and treatment of acute asthma exacerbations in children

This update on treatment of asthma exacerbations in children is the result of an Italian Pediatric Society Task-force, made up of a panel of experts working in 2007-2008. The aim is to give clear indications on the use of the drugs most employed in children, grading the quality of evidence and the strength of recommendations. Suggestions on their limits due to unlicensed and off-label use are reported. The level of evidence and the strength of recommendations for different therapeutic approaches demonstrate that frequently the use of drugs in children is extrapolated from the experience in adults and that more studies are required to endorse the correct use of different drugs in asthmatic children.

Treating asthma in children with beclomethasone dipropionate: Pulvinal versus Diskhaler

Seventy-two children (mean age, 10.1 years) with stable moderate asthma who completed a 7-day run-in period were randomized to receive a 4-week treatment with beclomethasone dipropionate (200 micrograms twice daily) administered through two different powder inhalers (Pulvinal; Chiesi Farmaceutici S.p.A, Parma, Italy and Diskhaler; Glaxo-Wellcome, Evreux, France) in a parallel group design. Sixty-nine patients completed the study. Morning and evening peak expiratory flow values, the use of rescue salbutamol, and the severity of clinical symptoms were recorded daily on a diary card. Pulmonary function tests were performed at baseline and then after 2 and 4 weeks of treatment. Pulmonary function values, daily morning and evening peak expiratory flow, and most of the clinical symptoms significantly improved, although the use of rescue salbutamol significantly decreased from the second week of treatment until the end of the study in both groups. Equivalence of efficacy between groups was demonstrated for both pulmonary function and clinical parameters. We conclude that the Pulvinal inhaler is as efficacious as the Diskhaler in beclomethasone-based therapy of asthmatic children.

Gamma delta T cells are decreased in the blood of children with Bordetella pertussis infection

The biological role of T cell receptor (TCR) gamma delta bearing cells is not yet fully understood. We studied 12 children with Bordetella pertussis infection and 12 age- and sex-matched healthy controls. Patients with whooping-cough yielded significantly lower relative and absolute numbers of blood TCR-gamma delta + cells than normal controls (both p < 0.001). It is suggested that the depletion of circulating gamma delta T cells in patients with Bordetella pertussis infection might be the result of the dispatch of these cells to the site of inflammation, i.e. the bronchial mucosa. Interestingly, other human lung diseases, such as allergic bronchial asthma and sarcoidosis display similar pulmonary phenotypical features.

CD26 surface antigen expression on peripheral blood T lymphocytes from children with Down's syndrome (trisomy 21)

A phenotypical analysis carried out by two-colour flow cytometry showed that the proportion of circulating CD4+ T lymphocytes co-expressing the membrane-associated ectoenzyme dipeptidyl peptidase IV (CD26 antigen), a functional collagen receptor involved in T-cell triggering through its interaction with the CD45 protein tyrosine phosphatase, was significantly lower in 28 children with non-translocated trisomy 21 (Down's syndrome) (DS) than that calculated in the bloodstream of 27 age- and sex-matched healthy controls. Agonist anti-CD26 monoclonal antibodies (MoAbs), such as anti-1F7, not only modulate the surface expression of this molecule, but also enhance the proliferative activity of normal human T cells via the CD3- and CD2-mediated activation pathways. T-lymphocyte proliferation induced by antigen or polyclonal T-cell activators, including anti-CD3 or -CD2 MoAbs, is severely impaired in DS. Although the physiological ligand of CD26 surface structure is unknown, the fact that CD4+ T lymphocytes found in the blood of trisomic subjects are mostly CD26- (anti-1F7-) suggests that their faulty mitogenic response may be due to phenotypical and, perhaps, strictly correlated functional abnormalities.

[Infantile idiopathic pulmonary hemosiderosis. Presentation of a case]

The present report deals with a patient affected by idiopathic pulmonary hemosiderosis. The diagnosis was made by pulmonary biopsy and ultrastructural and immunological study. We are treating the patient with iron therapy and desferrioxamine.

Endoscopic retrograde cholangiopancreatography study in Alagille's syndrome: first report

Endoscopic retrograde cholangiopancreatography revealed the association between intra- and extra-hepatic biliary tree hypoplasia in an 8-year-old boy affected by Alagille's syndrome. The patient, in whom chronic cholestasis had been present from birth, presented characteristic facies, retarded growth, hepatomegaly, and splenomegaly. Chromosome studies were normal. HIDA Tc 99m appeared late in the gallbladder and emptied into the bowel after 3 h. Endoscopic retrograde cholangiopancreatography showed marked and diffuse narrowing of the extrahepatic biliary ducts and uniform narrowing of the intrahepatic ducts with reduced arborization. Menghini needle biopsy revealed no interlobular ducts in the portal tracts. The last two techniques confirmed the clinical picture and made surgical diagnosis unnecessary. This is, as far as we know, the first time endoscopic retrograde cholangiopancreatography has been used in the diagnosis of Alagille's syndrome.

[Hypoplasia of intra- and extrahepatic bile ducts associated with congenital abnormalities]

The present report deals with a patient affected by Alagille's syndrome. The clinical hallmark of this syndrome is chronic cholestasis with ductular and extrahepatic hypoplasia and associated multiple congenital malformations. The diagnosis was made by hepatobiliary scanning with TC99-HIDA, transendoscopic cholangiography and liver biopsy.

[Airline transport of premature and cardiopathic newborn infants]

Air transport to highly specialized centres would appear to be indispensable for newborns suffering from severe immaturity and for children suffering from emergency forms of cardiorespiratory insufficiency. The microclimatic conditions in the passenger compartment during normal airline flight are examined. The characteristics of the immature newborn are then discussed together with the main aspects of the care of these patients. The principal physiopathological consequences of congenital cardiopathies are also considered. Finally, the autonomous arrangement of single passenger air transport and operating modalities are illustrated.