Obstructive sleep apnea in a 5 month old with tonsillar hypertrophy secondary to congenital neutropenia: Case report and literature review

Publication date: Available online 5 January 2017
Source:International Journal of Pediatric Otorhinolaryngology
Author(s): O.G. Ahmed, E.M. Lambert
Tonsillectomy and adenoidectomy (T&A) is the primary surgical treatment for obstructive sleep apnea (OSA) in children with tonsillar and adenoid hypertrophy (TAH). We present the case of a 5-month old male with congenital neutropenia who developed severe TAH during treatment with granulocyte colony-stimulating factor (G-CSF). He had severe OSA, decreased oral intake, and failure to thrive (FTT) which all improved after undergoing a successful intracapsular T&A. We describe a successful procedure to help alleviate symptoms of OSA and FTT in this young infant with congenital neutropenia who developed TAH during treatment with G-CSF. It highlights the need for further research into the pathophysiology of TAH in immunocompromised children and the effects of G-CSF on Waldeyer's Ring.



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Otorhinolaryngology/Head and Neck Surgery in a low income country: The Haitian experience

Publication date: February 2017
Source:International Journal of Pediatric Otorhinolaryngology, Volume 93
Author(s): Maxwell P. Kligerman, Anahuma Alexandre, Patrick Jean-Gilles, David Walmer, Mack Cheney, Anna H. Messner
ObjectiveLittle is known regarding the diagnosis and management of pediatric surgical conditions of the head and neck in low-income countries. Haiti, the western hemisphere's poorest country, recently developed its first Otorhinolaryngology (ORL) department at the Hopital de L'Universite d'Etat d'Haiti (HUEH). This manuscript assesses the caseload at HUEH with a special emphasis on pediatric cases, with the aim of characterizing ORL related conditions and their treatments in low-income countries.MethodsWe conducted a retrospective chart review of surgical case logs at HUEH for the calendar year of 2014 and recorded patient age, diagnosis, and surgical intervention for all ORL surgeries.ResultsA total of 229 ORL surgeries were performed at HUEH during this time. The average age of the patient was 21.8 years and 54.2% of patients were 18 years or younger. The five most common diagnoses were tonsillar hypertrophy (23.6%), ingested foreign body (18%), mandibular fracture (9.2%), unspecified head or neck mass (6%), and thyroid goiter (4.8%). The five most common surgeries performed were tonsillectomy (23.6%), foreign body retrieval (17.9%), open reduction of mandibular fracture with direct skeletal fixation (6.9%), thyroidectomy (7.9%), and excision of unspecified mass. Trauma accounted for 33.6% of all ORL surgeries.ConclusionsDiseases related to the head and neck constitute a common yet underserved surgical problem. Strengthening ORL surgical capacity in Haiti should focus on improving capacity for the most common conditions including tonsillar disease, ingested foreign bodies, and facial trauma, as well as improving capacity for rarely performed surgeries, such as ear surgery, nose and sinus surgery, and cancer resections.



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A population based analysis of the implementation of pediatric facemasks in girls youth lacrosse

Publication date: February 2017
Source:International Journal of Pediatric Otorhinolaryngology, Volume 93
Author(s): Andrew Walls, David Kasle, Nicole Aaronson, Earl Harley, Erik Waldman
ObjectiveTo determine the incidence, relative risk reduction, odds ratio and absolute risk reduction of head and ear injuries associated with the implementation of pediatric facial eye guards in lacrosse events.Study designCross Sectional Review of a National Database.Study locationNational Emergency Injury Survelliance System.MethodsOur group retrospectively reviewed a nationwide sampling estimate of 809 patients who presented to emergency rooms with head and ear injuries during lacrosse events. The database was queried for lacerations, fractures, hemorrhages, abrasions and punctures associated with the face and ear. Incidence, relative risk, odds ratio and absolute risk reductions were calculated both five years before and five years after the introduction of the facial mask guard in 2006 to determine benefit.ResultsOf the 809 women's lacrosse injuries, 199 were localized to the facial region and 56 to the ear. After the implementation of the facial mask mandate, there was a significant decrease in the total incidence and relative risk of facial lacerations (P = 0.01, RR = 0.08 vs 0.01) and facial abrasions (P = 0.02, RR = 0.28 vs 0.12) respectively. Furthermore, there was a significant decrease in the odds of obtaining a facial laceration (OR: 0.16 95% CI:0.07–0.37), facial fractures (OR: 0.01, 95% CI:0.03–0.35) and abrasion (OR: 0.11, 95% CI:0.08–0.18) with facemask use. Unfortunately, there was no difference in total incidence, relative risk or odds of obtaining ear injury.ConclusionIt appears that the implementation of the mandate for female athletes to utilize the facemask starting in 2006 has provided a reduction in specific facial injuries. Further discussion should be continued in order to reduce further risk to the remaining head and neck region including the ears and neck with additional protective equipment.



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Allergen immunotherapy for IgE-mediated food allergy: a systematic review and meta-analysis

Abstract

Background

The European Academy of Allergy and Clinical Immunology (EAACI) is developing Guidelines for Allergen Immunotherapy (AIT) for IgE-mediated Food Allergy. To inform the development of clinical recommendations, we sought to critically assess evidence on the effectiveness, safety and cost-effectiveness of AIT in the management of food allergy.

Methods

We undertook a systematic review and meta-analysis that involved searching nine international electronic databases for randomized controlled trials (RCTs) and non-randomized studies (NRS). Eligible studies were independently assessed by two reviewers against pre-defined eligibility criteria. The quality of studies was assessed using the Cochrane Risk of Bias tool for RCTs and the Cochrane ACROBAT-NRS tool for quasi-RCTs. Random-effects meta-analyses were undertaken, with planned subgroup and sensitivity analyses.

Results

We identified 1814 potentially relevant papers from which we selected 31 eligible studies, comprising of 25 RCTs and six NRS, studying a total of 1259 patients. Twenty-five trials evaluated oral immunotherapy (OIT), five studies investigated sublingual immunotherapy (SLIT) and one study evaluated epicutaneous immunotherapy (EPIT). The majority of these studies were in children. Twenty-seven studies assessed desensitization and nine studies investigated sustained unresponsiveness post-discontinuation of AIT. Meta-analyses demonstrated a substantial benefit in terms of desensitization (risk ratio (RR)=0.19, 95%CI 0.12, 0.29) and sustained unresponsiveness (RR=0.20, 95%CI 0.10, 0.59). Only one study reported on disease-specific quality of life (QoL), which reported no comparative results between OIT and control group. Meta-analyses revealed that the risk of experiencing a systemic adverse reaction was higher in those receiving AIT, with a more marked increase in the risk of local adverse reactions. Sensitivity analysis excluding those studies judged to be at high risk of bias demonstrated the robustness of summary estimates of effectiveness and safety of AIT for food allergy. None of the studies reported data on health economic analyses.

Conclusions

AIT may be effective in raising the threshold of reactivity to a range of foods in children with IgE-mediated food allergy whilst receiving (i.e. desensitization) and post-discontinuation of AIT. It is however associated with a modest increased risk in serious systemic adverse reactions and a substantial increase in minor local adverse reactions. More data are needed in relation to adults, the impact on QoL and the cost-effectiveness of AIT.

This article is protected by copyright. All rights reserved.

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Allergen immunotherapy for IgE-mediated food allergy: a systematic review and meta-analysis

Abstract

Background

The European Academy of Allergy and Clinical Immunology (EAACI) is developing Guidelines for Allergen Immunotherapy (AIT) for IgE-mediated Food Allergy. To inform the development of clinical recommendations, we sought to critically assess evidence on the effectiveness, safety and cost-effectiveness of AIT in the management of food allergy.

Methods

We undertook a systematic review and meta-analysis that involved searching nine international electronic databases for randomized controlled trials (RCTs) and non-randomized studies (NRS). Eligible studies were independently assessed by two reviewers against pre-defined eligibility criteria. The quality of studies was assessed using the Cochrane Risk of Bias tool for RCTs and the Cochrane ACROBAT-NRS tool for quasi-RCTs. Random-effects meta-analyses were undertaken, with planned subgroup and sensitivity analyses.

Results

We identified 1814 potentially relevant papers from which we selected 31 eligible studies, comprising of 25 RCTs and six NRS, studying a total of 1259 patients. Twenty-five trials evaluated oral immunotherapy (OIT), five studies investigated sublingual immunotherapy (SLIT) and one study evaluated epicutaneous immunotherapy (EPIT). The majority of these studies were in children. Twenty-seven studies assessed desensitization and nine studies investigated sustained unresponsiveness post-discontinuation of AIT. Meta-analyses demonstrated a substantial benefit in terms of desensitization (risk ratio (RR)=0.19, 95%CI 0.12, 0.29) and sustained unresponsiveness (RR=0.20, 95%CI 0.10, 0.59). Only one study reported on disease-specific quality of life (QoL), which reported no comparative results between OIT and control group. Meta-analyses revealed that the risk of experiencing a systemic adverse reaction was higher in those receiving AIT, with a more marked increase in the risk of local adverse reactions. Sensitivity analysis excluding those studies judged to be at high risk of bias demonstrated the robustness of summary estimates of effectiveness and safety of AIT for food allergy. None of the studies reported data on health economic analyses.

Conclusions

AIT may be effective in raising the threshold of reactivity to a range of foods in children with IgE-mediated food allergy whilst receiving (i.e. desensitization) and post-discontinuation of AIT. It is however associated with a modest increased risk in serious systemic adverse reactions and a substantial increase in minor local adverse reactions. More data are needed in relation to adults, the impact on QoL and the cost-effectiveness of AIT.

This article is protected by copyright. All rights reserved.

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A Longitudinal Supra-Inguinal Fascia Iliaca Compartment Block Reduces Morphine Consumption After Total Hip Arthroplasty.

Background and Objectives: The role of a fascia iliaca compartment block (FICB) for postoperative analgesia after total hip arthroplasty (THA) remains questionable. High-dose local anesthetics and a proximal injection site may be essential for successful analgesia. High-dose local anesthetics may pose a risk for local anesthetic systemic toxicity. We hypothesized that a high-dose longitudinal supra-inguinal FICB is safe and decreases postoperative morphine consumption after anterior approach THA. Methods: We conducted a prospective, double blind, randomized controlled trial. Patients scheduled for THA were randomized to group FICB (longitudinal supra-inguinal FICB with 40-mL ropivacaine 0.5%) or group C (control, no block). Standard hypothesis tests (t test or Mann-Whitney U test, [chi]2 test) were performed to analyze baseline characteristics and outcome parameters. The primary end point of the study was total morphine (mg) consumption at 24 hours postoperatively. Serial total and free ropivacaine serum levels were determined in 10 patients. Results: After obtaining ethical committee approval and written informed consent, 88 patients were included. Mean (SD) morphine consumption at 24 hours postoperatively was reduced in group FICB compared to group C: 10.25 (1.64) mg versus 19.0 (2.4) mg (P = 0.004). Using a mean dose of 2.6-mg/kg ropivacaine (range, 2-3.4 mg/kg), none of the patients had total or free ropivacaine levels above the maximum tolerated serum concentration. Conclusions: We conclude that a high-dose longitudinal supra-inguinal FICB reduces postoperative morphine requirements after anterior approach THA. Clinical Trials Registry: EU Clinical Trials Register. http://ift.tt/PmpZP1 #2014-002122-12. Copyright (C) 2017 by American Society of Regional Anesthesia and Pain Medicine.

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Epinephrine Deteriorates Pulmonary Gas Exchange in a Rat Model of Bupivacaine-Induced Cardiotoxicity: A Threshold Dose of Epinephrine.

Background and Objective: The study goal was to compare the effect of epinephrine in different doses on pulmonary gas exchange in a rat model of bupivacaine-induced cardiac depression. Methods: Twenty-four adult male Sprague-Dawley rats were divided into 4 groups (n = 6), and each group received a bupivacaine infusion (2.5 mg/kg per minute, 6 minutes) via the left femoral vein to induce cardiac depression. At the end of the bupivacaine infusion, each group was immediately given either isotonic sodium chloride solution (normal saline; NS group), 5-[mu]g/kg epinephrine (Epi5 group), 10-[mu]g/kg epinephrine (Epi10 group), or 20 [mu]g/kg epinephrine (Epi20 group). Left atrial pressures were monitored for 20 minutes after epinephrine was administered (as was the NS group). Arterial blood gas analyses were performed before bupivacaine infusion and at the end of the 20-minute monitoring period. Results: The Epi10 and Epi20 groups had lower pH (P = 0.02 and P

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