A pregnant woman with hepatitis A and Guillain-Barré

Guillain-Barré syndrome (GBS) is often preceded by an infectious disease. A case of GBS after hepatitis A in a pregnant woman is described. The patient was treated with intravenous immunoglobulin and had full recovery with no neurologic sequelae. She gave birth in term to a healthy baby. This is the first reported case in the English literature of a triple condition of hepatitis A, GBS, and pregnancy.

On the mean kinetic energy of the proton in strong hydrogen bonded systems

The mean atomic kinetic energies of the proton, Ke(H), and of the deuteron, Ke(D), were calculated in moderate and strongly hydrogen bonded (HB) systems, such as the ferro-electric crystals of the KDP type (XH2PO4, X = K, Cs, Rb, Tl), the DKDP (XD2PO4, X = K, Cs, Rb) type, and the X3H(SO4)2 superprotonic conductors (X = K, Rb). All calculations utilized the simulated partial phonon density of states, deduced from density functional theory based first-principle calculations and from empirical lattice dynamics simulations in which the Coulomb, short range, covalent, and van der Waals interactions were accounted for. The presently calculated Ke(H) values for the two systems were found to be in excellent agreement with published values obtained by deep inelastic neutron scattering measurements carried out using the VESUVIO instrument of the Rutherford Laboratory, UK. The Ke(H) values of the M3H(SO4)2 compounds, in which the hydrogen bonds are centro-symmetric, are much lower than those of the KDP type crystals, in direct consistency with the oxygen-oxygen distance ROO, being a measure of the HB strength.

Identification in Israel of 2 Jewish Creutzfeld-Jakob disease patients with a 178 mutation at their PrP gene

Among the dozen known mutations in the PrP gene which segregate with the inherited prion diseases, only 2 mutations have been described in Israel so far: the codon 200 mutation in Creutzfeldt-Jakob disease (CJD) affected Libyan Jews, and the codon 102 mutation in 1 Jewish Gerstmann-Straussler-Scheinker (GSS) affected pedigree of German origin. We report here 2 unrelated CJD178 cases affected by a unique phenotype: aphemia, apraxia, uncontrolled laugh and no ataxia. As opposed to other CJD178 patients, in these patients, the signal transduction protein 14-3-3, recently suggested as a CJD marker, was detected in the cerebrospinal fluid samples by immunostaining. The D178N mutation, known to be linked to 2 different phenotypes: Fatal Familial Insomnia (FFI) and CJD, was not described so far among Jews. The phenotype reported here, although it shares a common Va1129/Asn178 haplotype with the previously described CJD178, may point to a different clinical subtype of CJD178.

Platelet-activating factor acetylhydrolase is a biomarker of severe anaphylaxis in children

BACKGROUND

There is limited ability to predict the severity of allergic reactions in children. Data derived predominantly from adults have implicated the platelet-activating factor pathway as a potential contributor to severe anaphylaxis. In this study, we sought to prospectively assess involvement of key components of the platelet-activating factor pathway in pediatric patients with anaphylaxis.

METHODS

Forty-six pediatric patients (<18 years) presenting with acute anaphylaxis were assessed. Anaphylaxis severity was graded and serum anaphylaxis markers were measured acutely and in 36 children who returned for follow-up >4 weeks after their acute presentation. These markers were compared with pediatric laboratory reference sera.

RESULTS

Severe anaphylaxis was experienced by 12/46 (26%) and mild-moderate anaphylaxis in 34/46 (74%) children. Platelet-activating factor acetylhydrolase (PAF-AH) activity was inversely associated with severe anaphylaxis: 9/12 children with severe anaphylaxis had reduced PAF-AH activity as compared with 14/34 with mild-moderate anaphylaxis (p < .05). Furthermore, 3/3 children who required intensive care had markedly reduced mean PAF-AH (nmol/ml/min) (13.73, 95%CI: 7.42-20.03) versus 20/23 who required ward/emergency department care (17.81, 95%CI: 16.80-18.83; p < .05). In children with anaphylaxis, PAF-AH during acute anaphylaxis was unchanged relative to the child's basal levels (mean, 17.26, 95%CI: 16.10-18.42 vs 17.50, 95%CI: 16.21-18.78, p = .63) and was lower than healthy pediatric controls (mean 19.21; 95%CI:18.21-20.21; p < .05).

CONCLUSION

Decreased serum PAF-AH activity is a biomarker of severe anaphylaxis. Levels of this enzyme do not change from basal levels during acute anaphylaxis. Our results show that PAF-AH is a biomarker of anaphylaxis severity in children. This key regulatory enzyme may modulate susceptibility to severe anaphylaxis.

Pharmacotherapy in bronchiolitis at discharge from emergency departments within the Pediatric Emergency Research Networks: a retrospective analysis

BACKGROUND

Clinical guidelines advise against pharmacotherapy in bronchiolitis. However, little is known about global variation in prescribing practices for bronchiolitis at discharge from emergency departments. We aimed to evaluate global variation in prescribing practice (ie, inhaled salbutamol, or oral or inhaled corticosteroids) for infants with bronchiolitis at discharge from emergency departments.

METHODS

We did a planned secondary analysis of a multinational, retrospective cohort study of the Pediatric Emergency Research Networks. Previously healthy infants (aged <12 months) who were discharged with bronchiolitis between Jan 1 and Dec 31, 2013 from 38 emergency departments in Australia and New Zealand, Canada, Spain and Portugal, the UK and Ireland, and the USA were included. The primary outcome was pharmacotherapy prescription at discharge from the emergency department. Secondary outcomes were revisits to the emergency department or hospitalisations for bronchiolitis within 21 days of discharge.

FINDINGS

Of 1566 infants discharged from the emergency department, 317 (20%) were prescribed pharmacotherapy. Corticosteroid prescriptions were infrequent, ranging from 0% (0 of 68 infants) in Spain and Portugal to 6% (25 of 452) in the USA. Salbutamol prescriptions ranged from 5% (22 of 432) in the UK and Ireland to 32% (146 of 452) in the USA. Compared with the UK and Ireland, the odds of prescription of pharmacotherapy were increased in Spain and Portugal (odds ratio [OR] 9·22, 95% CI 1·70-49·96), the USA (8·20, 2·79-24·11), Canada (5·17, 1·61-16·67), and Australia and New Zealand (1·21, 0·36-4·10). After adjustment for clustering by site, pharmacotherapy at discharge was associated with older age (per 1 month increase; OR 1·23, 95% CI 1·16-1·30), oxygen saturation (per 1% decrease from 100%; 1·09, 1·01-1·18), chest retractions (1·88, 1·26-2·79), network (p=0·00050), and site (p<0·00090). 303 (19%) of 1566 infants returned to the emergency department and 129 (43%) of 303 were hospitalised. Discharge pharmacotherapy was not associated with revisits (p=0·55) or subsequent hospitalisations (p=0·50).

INTERPRETATION

Use of ineffective medications in infants with bronchiolitis at discharge from emergency departments is common, with large differences in prescribing practices between countries and emergency departments. Enhanced knowledge translation and deprescribing efforts are needed to optimise and unify the management of bronchiolitis.

FUNDING

None.

Barotrauma-induced hearing loss

With the current increase in commercial, military and sports diving to deeper depths, cases of middle and inner ear barotrauma are more frequently noted. Although most of the literature up to the late 1960s has emphasized middle ear barotrauma (MEBT), inner ear barotrauma (IEBT) is reported more frequently than before. MEBT and IEBT are major causes of diving induced hearing loss. MEBT should be treated by prevention and symptomatically when occurring. A labyrinthine window fistula necessitating surgical repair may be caused by IEBT. Although reports of IEBT are relatively few, this entity should be kept in mind and differentiated from other causes of diving-induced hearing loss. The relevant literature is reviewed and diagnosis and treatment are discussed.

True malignant mixed tumour of the parotid gland

Carcinoma ex-pleomorphic adenoma is an uncommon tumour of the parotid gland. True malignant mixed tumours of the parotid are rare and we could find only 14 such cases reported. A case of a 76-year-old man diagnosed as suffering from this entity is presented. The diagnosis was based on a series of immunohistochemical studies demonstrating the existence of two separate sarcomatous and carcinomatous elements. The clinical and histological data are presented and the literature is reviewed.

The functional role of the adenoids in speech

Illustrative cases are presented showing a variety of interrelationships between the adenoids and the activity of the velopharyngeal valve in speech. The cases presented were selected from a group of 1000 patients referred because of suspected velopharyngeal diseases. When appropriate, complete velopharyngeal assessment was made including otolaryngological speech and hearing examination, polysomnography, nasendoscopy, multiview videofluoroscopy and cephalometry. New observations are described which further elucidate the mechanism by which the adenoids may change the mechanism of velopharyngeal valving and consequently speech patterns. In conclusion, procedures involving the adenoids and tonsils and surgical correction of velopharyngeal valve abnormalities to improve respiratory function must be performed in a manner which ensures preservation of normal speech activity. Similarly, surgical correction of velopharyngeal valve abnormalities to improve speech activity must preserve its respiratory function. The velopharyngeal valve and the adeno-tonsils must be considered together whenever diagnosis and a therapeutic intervention of either of them is considered. A clinical method for patient evaluation, patient management and the development of a rational therapeutic approach is presented.

A suicide prevention strategy for youth presenting to the emergency department with suicide related behaviour: protocol for a randomized controlled trial

BACKGROUND

Suicide is a leading cause of death among adolescents in North America. Youth who present to the Emergency Department (ED) with acute suicidality are at increased risk for eventual death by suicide, thereby presenting an opportunity for secondary prevention of suicide. The current study evaluates the effectiveness of a standardized individual and family-based suicidal behaviour risk reduction intervention targeting adolescents at high-risk for suicide.

METHODS

A randomized controlled trial (RCT) will be conducted to evaluate the effectiveness of a manualized youth- and family- based suicide prevention strategy (SPS) as compared with case navigation (NAV) among adolescents aged 12 to 18 years of age who present to the ED with acute suicidal ideation (SI) or suicide risk behaviours (SRB). We will recruit 128 participants and compare psychiatric symptoms including SI/SRB, family communication, and functional impairment at baseline and follow-ups (post-intervention [6 weeks], 24 weeks). The primary outcome is change in suicidal ideation measured with the Suicide Ideation Questionnaire- Junior. SRBs are measured with the Suicide Behaviour Questionnaire. Secondary outcomes are change in depressive and anxious symptoms measured with semi-structured psychiatric interview and Screen for Child Anxiety Related Disorders; acute mental health crises measured by urgent medical (including ED) visits; family communication measured with Conflict Behaviour Questionnaire, functional impairment measured by Columbia Impairment Scale; cost effectiveness, and fidelity of implementation measured by audio recording and fidelity checklist.

DISCUSSION

Results of this study will inform a larger multi-centre RCT that will include both community and academic hospitals in urban and rural settings. Study results will be shared at international psychiatry and emergency medicine meetings, in local rounds, and via publication in academic journals and clinician-oriented newsletters. If effective, the intervention may provide a brief, scalable, and transportable treatment program that may be implemented in a variety of settings, including those in which access to children's mental health care services is challenging.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03488602, retrospectively registered April 4, 2018.

Generalized seizures following topical lidocaine administration during circumcision: establishing causation

We report a case of neonatal seizures after lidocaine administration for circumcision. A 3-month-old male infant received an overdose as evidenced by toxic lidocaine levels and developed generalized seizures shortly after. Back extrapolation of the serum lidocaine concentration to time zero was used to determine the administered dose. The Naranjo scale was used to determine causation; probable causation was defined. Particular care must be taken to administer an appropriate dose of local anesthetics in infants to avoid life-threatening seizures.

Can uvulopalatopharyngoplasty be harmful to eustachian tube function?

A study of the Eustachian tube, incorporating nasendoscopy, tympanometry and pressure swallow test was undertaken in patients undergoing uvulopalatopharyngoplasty. Marked negative middle ear pressure indicating impairment of tubal function was found during the first 7 postoperative days. In patients receiving antibiotic treatment the Eustachian tube dysfunction was significantly alleviated. This dysfunction is probably due to a postoperative infective inflammatory process in the tonsillar fossa. Antibiotic treatment is recommended for patients undergoing uvulopalatopharyngoplasty, to improve the postoperative course. Patients with middle ear abnormalities and following middle ear surgery could be high-risk candidates for this operation and should be carefully evaluated.

An objective method for evaluation of the patulous eustachian tube by using the middle ear analyzer

Patulous eustachian tube is more common than is usually presumed. The symptoms of this condition can paradoxically simulate an obstruction of the eustachian tube. The characteristic eardrum movements synchronized with breathing can be overlooked or be absent altogether and, therefore, the diagnosis in many cases is missed. We suggest using the middle ear analyzer for diagnosis and objective evaluation of the patent eustachian tube by adjusting it as for acoustic reflex testing. Our method is more sensitive than the more common method of tympanometry. Information is supplied for the patient's evaluation before and after treatment.

Teratoma of the mastoid region in a newborn

Teratomas are congenital tumours arising from pluripotent cells and usually consisting of tissue arising from all 3 embryonic germ layers. Teratomas are quite uncommon in head and neck sites and to date only 150 such cases have been reported. A rare case of teratoma of the mastoid region in a newborn is reported. The method of diagnosis and treatment are discussed and the literature is reviewed.

Comparative safety of anti-epileptic drugs among infants and children exposed in utero or during breastfeeding: protocol for a systematic review and network meta-analysis

BACKGROUND

Epilepsy affects about 1% of the general population. Anti-epileptic drugs (AEDs) prevent or terminate seizures in individuals with epilepsy. Pregnant women with epilepsy may continue taking AEDs. Many of these agents cross the placenta and increase the risk of major congenital malformations, early cognitive and developmental delays, and infant mortality. We aim to evaluate the comparative safety of AEDs approved for chronic use in Canada when administered to pregnant and breastfeeding women and the effects on their infants and children through a systematic review and network meta-analysis.

METHODS

Studies examining the effects of AEDs administered to pregnant and breastfeeding women regardless of indication (e.g., epilepsy, migraine, pain, psychiatric disorders) on their infants and children will be included. We will include randomized clinical trials (RCTs), quasi-RCTs, non-RCTs, controlled before-after, interrupted time series, cohort, registry, and case-control studies. The main literature search will be executed in MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials. We will seek unpublished literature through searches of trial protocol registries and conference abstracts. The literature search results screening, data abstraction, and risk of bias appraisal will be performed by two individuals, independently. Conflicts will be resolved through discussion. The risk of bias of experimental and quasi-experimental studies will be appraised using the Cochrane Effective Practice and Organization of Care Risk-of-Bias tool, methodological quality of observational studies will be appraised using the Newcastle-Ottawa Scale, and quality of reporting of safety outcomes will be conducted using the McMaster Quality Assessment Scale of Harms (McHarm) tool. If feasible and appropriate, we will conduct random effects meta-analysis. Network meta-analysis will be considered for outcomes that fulfill network meta-analysis assumptions.The primary outcome is major congenital malformations (overall and by specific types), while secondary outcomes include fetal loss/miscarriage, minor congenital malformations (overall and by specific types), cognitive development, psychomotor development, small for gestational age, preterm delivery, and neonatal seizures.

DISCUSSION

Our systematic review will address safety concerns regarding the use of AEDs during pregnancy and breastfeeding. Our results will be useful to healthcare providers, policy-makers, and women of childbearing age who are taking anti-epileptic medications.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014008925.

Study of Toynbee phenomenon by combined intranasopharyngeal and tympanometric measurements

The Toynbee maneuver, swallowing when the nose is obstructed, leads in most cases to pressure changes in one or both middle ears, resulting in a sensation of fullness. Since first described, many varying and contradictory comments have been reported in the literature concerning the type and amount of pressure changes both in the nasopharynx and in the middle ear. In our study, the pressure changes were determined by catheters placed into the nasopharynx and repeated tympanometric measurements. New information concerning the rapid pressure variations in the nasopharynx and middle ear during deglutition with an obstructed nose was obtained. Typical individual nasopharyngeal pressure change patterns were recorded, ranging from a maximal positive pressure of +450 to a negative pressure as low as -320 mm H2O.

Increased rate of major birth malformations in infants with neonatal “asymmetric crying face”: A hospital-based cohort study

Asymmetric crying face (ACF) is a minor anomaly found in 3-8 per 1,000 births, which may be associated with other anomalies. Previous studies on this topic included small groups of selected subjects, resulting in large variations in findings. The aim of this study was to examine the characteristics and associated anomalies of newborn infants with ACF compared with the general population of newborn infants. The study included newborn infants delivered between 1993 and 2003 at the Department of Neonatology of Rabin Medical Center, Israel. Charts of all newborns diagnosed with ACF were reviewed for obstetric and neonatal details, then compared with non-ACF newborns. ACF was diagnosed in 258 of 67,289 newborns (0.38%), with left-side predominance (77%). Major malformations were found in 7% of ACF infants, 3.5-fold higher than in the total Israeli population. Mild anomalies were present in 15% of the ACF group, and deformations in 4.6%. There was a higher rate of forceps deliveries in the ACF group (RR = 2.73, 95% CI = 1.37-5.42). ACF was more prevalent among females, and the male:female ratio was lower in the ACF group (0.86 vs. 1.06, P = 0.05). The rate of low-birth-weight infants was 3.9% among ACF infants and 9.6% in the control group (RR = 0.41, 95% CI = 0.23-0.76). No significant between-group difference was found for rates of primiparity, macrosomia, prematurity, postmaturity, or size-for-gestational-age. Thus, ACF is associated with a high rate of major malformations. This should prompt clinicians to seek for additional birth defects in ACF infants.

Clinical dysentery in hospitalized children

BACKGROUND

Clinical dysentery is a severe presentation of an enteric infection. The aim of the study was to evaluate the impact of a serious bacterial etiology in clinical dysentery in hospitalized children and determine if children at high risk can be identified on the basis of clinical or laboratory parameters.

PATIENTS AND METHODS

A prospective study design was used. The study population included 60 children admitted to our department with clinical dysentery over a 16-month period. Fresh stool specimens were collected on days 1, 2 and 3. The clinical and laboratory data of the children were analyzed.

RESULTS

Clinical dysentery accounted for 1.7% of all pediatric hospitalizations during this period. Stool cultures were positive for Shigella spp. in 18 children (30%), and Salmonella spp. in 15 children (25%), Campylobacter jejuni was identified in one patient (2%). There were no significant differences in clinical characteristics or laboratory parameters between children with positive and negative stool cultures.

CONCLUSION

40% of the children hospitalized for clinical dysentery were eligible for antibiotic treatment. Early administration of empiric antibiotic treatment is justified in children hospitalized for clinical dysentery in Israel. Clinical or laboratory parameters were unable to differentiate those with clinical dysentery at risk of serous bacterial pathogens in stool.

Squamous and basal cell cancers directly invading major salivary glands

Epidermoid carcinoma of the skin of the head and neck may uncommonly involve the parotid gland by either direct extension or metastases to the parotid lymph nodes. The parotid gland contains a rich network of superficial and deep nodes, draining a large area of the facial region, with the preauricular, cheek, ear, and eyelid dominating. Few patients with direct parenchymal invasion of the parotid gland by a simultaneously existing squamous or basal cell carcinoma were reported. We could find no report discussing direct tumoral invasion into the submandibular salivary gland. Three patients with squamous cell carcinomas and 2 with basal cell carcinomas of the skin directly involving the underlying salivary glands are presented. The few authors discussing this subject concur that treatment should include resection of the primary tumor along with parotidectomy. Elective neck dissection and irradiation are proposed. The course of disease, treatment, and survival of our patients are discussed.

Large T-cell lymphoma in a 13-year-old girl with hyperimmunoglobulinemia E syndrome

Large T-cell lymphoma was diagnosed in a 13-year-old girl with hyperimmunoglobulinemia E syndrome (HIES). Her past medical history included severe dermatitis, recurrent pneumonia, urinary tract infections, mucocutaneous herpetic infections, fungal skin infections, and staphylococcal sepsis. The diagnosis of HIES, based on the clinical features and a serum IgE level of >20000 IU/ml, was established when the girl was 6 years old. This is the eighth case of lymphoma in a patient with HIES reported in the English-language medical literature. HIES has not usually been considered a predisposing factor for malignancy, but in view of the rarity of HIES and the young age of the patients, this association seems to be more than coincidental. A link between lymphoma and Epstein-Barr virus (EBV) infection in patients with HIES has been proposed. Serological tests for EBV in our patient were positive 6 years prior to the development of the lymphoma; however, examination for EBV DNA in the lymph node biopsy failed to detect EBV in the tumor.

Brain acetylcholinesterase after parathion poisoning: a comparative quantitative histochemical analysis post-mortem

The regional distribution of AChE inhibition by parathion in the human brain was examined in a comparative study of the brains of 2 victims of lethal parathion intoxication and 2 control brains matched for age and sex. AChE activity in discrete brain regions was studied by quantitative histochemistry of 40 microns-thick sagittal or coronal cryostat sections from the 4 brains. The inhibition of human brain AChE by parathion is regionally selective. The biggest decreases were observed in the cerebellum, some thalamic nuclei and cortex. Only a moderate decrease (10-30%) was observed in the substantia nigra and basal ganglia, while no effect at all was seen in white matter regions. Detailed knowledge of the brain regions affected by parathion poisoning may explain some of the clinical manifestations of organophosphate poisoning.