Distinct clinical parameters were associated with shorter spontaneous resolution in children with non-tuberculous mycobacterial lymphadenitis

AIM

Non-tuberculous mycobacteria (NTM) lymphadenitis typically resolves spontaneously, yet factors influencing the duration remain explored. We aimed to identify clinical parameters associated with shorter spontaneous resolution.

METHODS

This cohort study included children with NTM lymphadenitis from 1 January 2015 to 1 March 2021 at Copenhagen University Hospital. Time-to-event analysis assessed clinical parameters associated with the duration of NTM lymphadenitis.

RESULTS

Sixty children (57% boys) with a median age of 24 months (range 11-84) were included; 13 (22%) received primary surgery, 13 (22%) underwent surgery after a wait-and-see period and 34 (57%) received no intervention. In children without intervention, the median duration was 10 months (range 2-25). Faster resolution was associated with parental-reported lymph node enlargement within 2 weeks (HR 2.3, 95% CI 1.0-5.0; p = 0.044), abscess on ultrasound examination (HR 3.3, 95% CI 1.5-7.3; p = 0.003) and skin discoloration and/or perforation within 3 months of onset (HR 4.3, 95% CI 1.3-14.4; p = 0.017 and HR 3.7, 95% CI 1.5-9.1; p = 0.005).

CONCLUSION

Knowledge of predictors for shorter spontaneous resolution of NTM lymphadenitis, such as rapid initial lymph node enlargement, abscess on ultrasound examination, and skin discoloration and/or perforation within 3 months of disease onset, may guide clinical management decisions concerning surgery versus a conservative approach.

[Not Available]

Neck masses are common in the paediatric population and can cause diagnostic challenges due to various differential diagnoses as summarised in this review. Neck masses in children are divided into the following categories: congenital, inflammatory/infectious and neoplastic masses. The neck masses are generally benign, but malignancy should be considered if the child is presenting with certain symptoms and findings. The objective of this review is to increase the knowledge of the common differential diagnoses of neck masses in children and to provide guidance of indications for diagnostics and treatment.

Surgical procedures in Danish children 1999-2018

OBJECTIVE

To assess if the overall utilisation of surgery in Danish children 0-5 years of age increased in the period 1999-2018 in line with the development within specialised medical services. The epidemiology on surgical procedures is scarce.

METHODS

National register-based cohort study of all Danish children born 1994-2018 (n = 1,599,573) using data on surgery in public and private hospitals from The National Patient Register and data on surgery in private specialist practice from The Health Service Register. Incidence rate ratios were calculated using Poisson regression with 1999 as the reference year.

RESULTS

During the study period 115,573 different children (7.2% of the cohort) underwent surgery. The overall incidence of surgical procedures was stable, but the use of surgery increased in neonates mainly due to an increase in frenectomy. Boys underwent more surgery than girls. In children with severe chronic disease the rate of surgery decreased in public hospitals and increased in private specialist practices.

CONCLUSION

The utilisation of surgical procedures in Danish children 0-5 years of age did not increase from 1999 to 2018. The use of available register data in the present study may inspire surgeons to conduct further studies to enhance the knowledge within the area of surgical procedures.

Trends of ankyloglossia and lingual frenotomy in hospital settings among children in Denmark

INTRODUCTION

It has been proposed that ankyloglossia and lingual frenotomy have increased. The aim of this study was to analyse the trends of ankyloglossia and lingual frenotomy among children treated in hospitals in Denmark in the 1996-2015 period.

METHODS

We included children aged 0-17 years registered with the diagnosis ankyloglossia (DQ381) or the procedure frenotomy (KEJC20) using nationwide hospital-based data from the Danish National Patient Registry in 1996-2015. The incidence during the study period and the average annual percentage change (AAPC) and age-specific incidences were calculated.

RESULTS

A total of 1,608 children were diagnosed with ankyloglossia (67% boys). The overall incidence of ankyloglossia increased from 3.2 per 100,000 in 1996 to 13.6 per 100,000 in 2015, corresponding to an AAPC of 7.1%. The age-specific incidence revealed a more than ten times higher incidence of ankyloglossia among patients less than one year old compared with those aged one year or above. In all, 3,625 frenotomy procedures were carried out (66% boys). The frequency of frenotomy increased from 5.1 per 100,000 in 1996 to 38.5 per 100,000 in 2015, corresponding to an AAPC of 11.1%. The age-specific incidence of frenotomy showed a more than thirty times higher frequency among children less than one year of age.

CONCLUSIONS

Ankyloglossia and frenotomy increased significantly during the period 1996-2015 among children in Denmark according to nationwide hospital data. Rates of both ankyloglossia and frenotomy were highest in children less than one year of age and among boys.

FUNDING

none.

TRIAL REGISTRATION

not relevant.

Second primary cancers in pediatric head and neck cancer survivors in Denmark during 1980-2014: A nationwide study

INTRODUCTION

The survival among children with cancer has improved considerably the past decades. Consequently, more children are at risk of second primary cancers (SPC). This study aimed to investigate the incidence of SPC among pediatric head and neck cancer (HNC) patients.

METHODS AND MATERIALS

Data on children aged 0-17 years registered with a HNC in the Danish Registry of Childhood Cancer and the Danish National Patient Registry during the period 1980-2014 was obtained. SPC was defined as registration with any second malignancy that was not simultaneous with the first primary cancer (FPC) or a relapse hereof. All information was validated through review of medical charts. Standardized incidence rates (SIR) were calculated using the average incidence of all cancers in the general population of Denmark during the study period as reference.

RESULTS

Among 234 pediatric HNC patients, six patients (four females) were registered with a SPC (2.6%), corresponding to an overall SIR of 4.8. No patients were diagnosed with more than one SPC. The median age at FPC and SPC was 15.2 years (range 9-16 years) and 35.0 years (range 19-41 years). The most common tumor histology and location among the patients with SPC was nasopharyngeal lymphoepithelial carcinoma for FPC and basal cell carcinoma of the skin for SPC.

CONCLUSION

During 1980-2014 we identified six cases of SPC among 234 pediatric head and neck cancer patients in Denmark, corresponding to an overall SIR of 4.8.

Reliability and validity of The Danish pediatric voice handicap index

BACKGROUND

The pediatric voice handicap index (pVHI) questionnaire was developed in 2006 to provide parental information regarding the impact of a voice disorder on their child's life.

OBJECTIVES

The aim of this study was to make a Danish version of the original American pVHI and to validate the Danish pVHI by evaluating its internal consistency and reliability.

MATERIALS AND METHODS

The original version of the pVHI was translated into Danish. Nineteen parents of dysphonic children, diagnosed in a tertiary otolaryngology hospital department, and 43 parents of children without known voice disorder (control group) completed the questionnaire. The internal consistency, content validity including comparisons of the scores in the two groups and the test-retest reliability were assessed through statistical analysis.

RESULTS

The total pVHI scores significantly differed between the group of parents with dysphonic children and the group of parents with children without known voice disorder (p < 0.001). The internal consistency showed an excellent consistency (Chronbach's α > 0.9) of the three subdomains score and the total pVHI score. The test-re-test reliability of the total pVHI score was "strong" with a Pearson's correlation coefficient of 0.97.

CONCLUSIONS AND SIGNIFICANCE

The Danish pVHI is a valid and reliable instrument to assess the parents' perception of the impact of a voice disorder on a child's physical, social and emotional well-being.

[Evaluation and management of paediatric nasal fractures]

This is a review discussing evaluation and management of paediatric nasal fractures, which have been reported as one of the three most common facial bone fractures. Nasal fractures in children are usually treated with closed reduction after 3-5 days, while other injuries like septal haematoma must be treated at the initial presentation. It is important to pay careful attention to the nasal anatomy during the surgical management of paediatric nasal injuries, as disturbing the nasal growth zones can have an impact on future nasal development.

Survival and characteristics of pediatric salivary gland cancer: A systematic review and meta-analysis

A systematic search of PubMed, EMBASE, and the Cochrane Library for studies from 2000 to 2017 including children aged 0-19 with salivary gland cancer was performed. In 19 studies, 749 children (median age of 14.2 years, female to male ratio of 1.4:1) were included; 72% had parotid tumors and 95% underwent surgery, of whom 65% had surgery alone and 24% with adjuvant radiotherapy. Low-grade and stage mucoepidermoid carcinoma were the most frequent cancer. The 5-year overall- and disease-free survival was 94% and 83%. Recurrence was observed in 20% at a median of 1.1 years from diagnosis.

Otoacoustic Emissions for Outcome Prediction in Postanoxic Brain Injury

Background: Non-invasive, easy-to-use bedside tools to estimate prognosis in unresponsive patients with postanoxic brain injury are needed. We assessed the usefulness of otoacoustic emissions as outcome markers after cardiac arrest. Methods: Distortion product otoacoustic emissions (DPOAE) and transient evoked otoacoustic emissions (TEOAE) were measured in cardiac arrest patients whose prognosis was deemed to be poor following standard neurological assessment (n = 10). Ten patients with myocardial infarction without prior loss of consciousness served as controls. Results: Compared to controls with myocardial infarction, cardiac arrest patients with poor neurological prognosis had significantly less often preserved DPOAE (9.2 vs. 40.8% positive measurements; OR 0.15 (CI 0.07-0.30); p < 0.0001). Partially preserved DPOAE were noted in 4 cardiac arrest patients. TEOAE were not statistically different between the two groups. Conclusions: Despite their convenience, otoacoustic emissions cannot be used as reliable prognostic markers in cardiac arrest survivors. This is because we identified 4 cases with partially preserved otoacoustic emissions in a sample of 10 unresponsive post-cardiac arrest patients whose neurological condition was so poor that active treatment was withdrawn. However, we suggest that future research should address if decaying outer hair cell function over time may serve as a proxy for evolving ischemic brain damage.

Incidence and Survival of Thyroid Cancer in Children, Adolescents, and Young Adults in Denmark: A Nationwide Study from 1980 to 2014

BACKGROUND

Thyroid cancer constitutes a major and increasing proportion of head and neck cancers in children and adolescents. The purpose of this study was to determine the incidence and survival of thyroid cancer in Danish patients aged 0-24 years from 1980 to 2014.

METHODS

Patients aged 0-24 years registered with primary thyroid cancer in the Danish Cancer Registry or the Danish Pathology Data Bank during 1980-2014 were included. Crude incidence rates and age-adjusted incidence rates (AAIR) per 100,000, average annual percent change (AAPC), and overall survival (OS) were evaluated in relation to sex, histopathological tumor type, age at diagnosis, and year of diagnosis.

RESULTS

A total of 297 thyroid cancer patients (72% female, 72% papillary carcinoma) were identified. The AAIR per 100,000 increased significantly from 0.36 in 1980 to 0.97 in 2014, with an AAPC of 2.9%. There was no significant increase in incidence among children and adolescents (0-17 years). However, among young adults (18-24 years), a significant increase in incidence was observed (AAPC 3.7%). The incidence of thyroid cancer increased with age from 0.05 among infants aged 0 years to 1.73 among young adults aged 24 years. Female patients and papillary carcinoma showed significant increase in incidence (AAPC 3.3% and 3.2%), whereas male patients and other histopathological tumor types showed no change. The 15-year OS was 99%. The lowest 15-year OS was observed among patients with medullary carcinomas at 96%. There was no significant difference in OS between groups based on histopathological tumor type, and there was no significant change in OS over time.

CONCLUSION

In this nationwide study, no change in OS was observed, but a significant increase was seen in the incidence of thyroid cancer among young adults (aged 18-24 years), mainly attributed to an increase among females and patients with papillary carcinoma. No increase in incidence was seen among children and adolescents. These findings demonstrate the excellent prognosis for children and adolescents diagnosed with thyroid cancer.

Incidence of head and neck cancer in children: A Danish nationwide study from 1978 to 2014

BACKGROUND

Pediatric head and neck malignancies are rare and only a few descriptive epidemiological studies have been published. Using unique nationwide registries, we report age-specific incidence rates of head and neck cancer (HNC) among children during four decades.

METHODS

Data were obtained from the Danish Cancer Registry. We included children aged 0-14 years diagnosed between January 1, 1978 and December 31, 2014 with extra-orbital, nonskin and nonbone HNC. Patients were divided into nine groups in regard to tumor location: oral cavity, oropharynx, nasopharynx, hypopharynx, thyroid, major salivary glands, larynx, and middle ear. Based on the World Health Organization standard population and Danish age-specific population counts, age-adjusted incidence rates (AAIR) and average annual percentage change (AAPC) were calculated and examined for trends.

RESULTS

In total, 169 children (55.6% females) were registered with a malignant tumor in the head and neck region. The AAIR increased with an AAPC of 2.2% (95% CI, 0.8-3.7%). Females showed an AAIR of 0.54 per 100,000 person years compared to that of males, with 0.41 per 100,000 person years (P < 0.01). The AAIR was higher among children aged 10-14 years compared to 0-9-year-old children (P < 0.01). Based on morphology, a significant increase in AAIR was observed for sarcomas, with an increase of 0.16-0.27 per 100,000 person years (P < 0.05).

CONCLUSIONS

The incidence rate of pediatric HNC was higher among females and evidence of increasing rates was observed during 1978-2014, explained by an increase mainly in sarcomas.

National changes in pediatric tracheotomy epidemiology during 36 years

BACKGROUND

Information on the incidence, indications and morbidity of pediatric tracheotomy from a nationwide setting is sparse.

METHODS

From the nationwide Danish National Patient Registry, we identified all cases: 0-15-year-old children registered with a first-time tracheotomy from 1979 to 2014. We extracted the date of surgery, admission, discharge, age, gender, hospital, department, hospitalization length, hospital contacts, and diagnosis-code related to the surgery. We estimated age-adjusted incidence rates (AAIR) and annual (APC) and average annual percentage change (AAPC) of tracheotomy incidence.

RESULTS

A total of 510 children (328 boys, 63%) underwent tracheotomy. The median age at surgery was 8 years. The AAIR was 1.4/100,000 person-years (range 1.0-1.8) from 1980 to 2014. During 1979-2014, the AAPC decreased - 0.9% (95% confidential interval - 2.4; 0.8, p < 0.3). From 1979 to 2003 the APC decreased - 4.1% (95% CI - 5.4; - 2.8, p < 0.001) and from 2003 to 2014 the APC increased 6.6% (95% CI 2.0; 11.5, p < 0.001). Infants had the highest incidence (4.0/100,000 years) compared with the 12-15-year-olds (AAIR: 0.4/100,000 years). From 1979 to 2014 the most common indication for tracheotomy among children aged 0-2 years was congenital malformations (n = 48, 30%) and among children aged 3-11 and 12-15 years the most common indication was trauma (respectively n = 67, 36% and n = 85, 52%). During 2006-2014 the most common indications for all ages was neurological impairment (n = 25, 21%) and neoplasms (n = 20, 17%).

CONCLUSIONS

Pediatric tracheotomy was a rare surgical procedure with decreasing incidence rates from 1980-89 to 1990-99 and increasing incidence rates from 2000-2009 to 2010-2014. Indications and postoperative morbidity have changed adjunct to the treatment of chronic disorders.

Mesenchymal stem cell therapy for laryngotracheal stenosis: A systematic review of preclinical studies

Background

Laryngotracheal stenosis (LTS) can be either congenital or acquired. Laryngeal stenosis is most often encountered after prolonged intubation. The mechanism for stenosis following intubation is believed to be hypertrophic scarring. Mesenchymal stem cells (MSCs) therapy has shown promising results in regenerative medicine. We aimed to systematically review the literature on MSC therapy for stenosis of the conductive airways.

Methods

PubMed, EMBASE, Google Scholar and the Cochrane Library were systematically searched from January 1980–January 2017 with the purpose of identifying all studies addressing the effect of MSC therapy on the airway. We assessed effect on inflammation, fibrosis, and MSC as a component in tissue engineering for treating defects in the airway.

Results

We identified eleven studies (n = 256 animals) from eight countries evaluating the effect of MSCs as a regenerative therapy in the upper airways. The studies indicate that MSC therapy may lead to a more constructive inflammatory response as well as support tissue regeneration.

Conclusion

There may be a favorable effect of MSCs in inhibiting inflammation and as a component in tissue engineering. Given the heterogeneous nature of the included animal studies, any clear conclusion regarding the effect of tracheal stenosis in human subjects cannot be drawn. The included preclinical studies are however encouraging for further research.

Indications, risk of lower airway infection, and complications to pediatric tracheotomy: report from a tertiary referral center

BACKGROUND

Although pediatric tracheotomy is potentially life-saving, the procedure is associated with high risk of complications, and indications have changed the last decade. We report indications, complications, and lower airway infections (LAIs) to pediatric tracheotomy performed at a tertiary referral center.

METHODS

We identified all children (<18 years) who underwent tracheotomy at our institution during 2008-2015. A review of hospital records was performed to extract data on indication of the procedure, complications, and information on pre- and postoperative LAI.

RESULTS

At a median age of 8 years (range: 4 months to 17 years), a total of 69 tracheotomies were performed. Neuromuscular disease (n = 21) was the most common cause for tracheotomy. The postoperative complication rate was 22%; early complications (<30 days) occurred in four patients, and nine patients encountered late complications such as wound granulation and tracheocutaneous fistula. Children without LAI prior to tracheotomy were at increased risk of LAI from the initial 30-days following surgery (OR: 2.91, 95% CI: 1.17-7.21; p = .02). Fifty-three percent (10/19) of all LAIs following tracheotomy were caused by Staphylococcus aureus (p < .01).

CONCLUSIONS

Pediatric tracheotomy was associated with considerable rates of minor early and late complications and high risk of short-term LAI. The main cause leading to tracheotomy was neuromuscular disease.

Exercise-induced inspiratory symptoms in school children

BACKGROUND AND AIMS

Exercise-induced inspiratory symptoms (EIIS) have multiple causes, one of which is exercise-induced laryngeal obstruction (EILO). There is limited knowledge regarding EIIS in children, both in primary care practices and in pediatric asthma clinics. The aim of this study was to describe the feasibility of a diagnostic methodology and its results in a cohort of children with EIIS referred to our tertiary pediatric pulmonary center.

METHODS

This study analyzed consecutively collected data in children from East Denmark and Greater Copenhagen referred during a 3½ years period. The continuous laryngoscopy exercise (CLE) test directly visualizes the larynx using a flexible laryngoscope during a maximal exercise test. A post-test questionnaire evaluated the subjective impact of the examination.

RESULTS

The study included 60 children (37 girls/23 boys) with a mean age of 14 years (range 9-18). The feasibility of the CLE test was 98%; 18 children (35%) had EILO, while 33 children (61%) showed no abnormalities. Other laryngeal abnormalities were observed in three children before the exercise test. Asthma medication was successfully discontinued in 13 (72%) children with EILO. A significantly greater proportion of children shown to have EILO in the CLE test reported coping better with their EIIS than children with negative test (85% vs. 45%; P = 0.03).

CONCLUSIONS

Continuous laryngoscopy during exercise is feasible and useful for identifying children with EILO. A correct diagnosis of EILO can help relieve patient anxiety, improve their coping with symptoms, and prevent unnecessary long-term and potentially harmful asthma treatments involving high-dose inhaled steroids. Pediatr Pulmonol. 2016;51:1200-1205. © 2016 Wiley Periodicals, Inc.

Clinical effects of sinus surgery and adjuvant therapy in cystic fibrosis patients - can chronic lung infections be postponed?

BACKGROUND

The paranasal sinuses can be a bacterial reservoir for pulmonary infections in patients with cystic fibrosis (CF) METHODOLOGY: In this prospective, non-randomised, uncontrolled, intervention cohort study, the clinical effect of sinus surgery followed by two weeks` intravenous antibiotics, 6 months` antibiotic nasal irrigations was assessed in 106 CF patients.

RESULTS

One year after sinus surgery, the prevalence of intermittently colonised patients had decreased by 38%, while the prevalence of non-colonised patients had increased by 150%. The frequency of pulmonary samples with CF pathogens was reduced after surgery. Specific IgG against P. aeruginosa decreased after six months. Additionally, the self reported symptoms of chronic rhinosinusitis and quality of life improved.

CONCLUSION

Combined sinus surgery and postoperative systemic and topical antibiotic treatment significantly reduced the frequency of pulmonary samples positive for CF pathogens in the first year after sinus surgery.

The effect of sinus surgery with intensive follow-up on pathogenic sinus bacteria in patients with cystic fibrosis

BACKGROUND

Most patients with cystic fibrosis (CF) have chronic rhinosinusitis; their sinuses are often colonized with bacteria that can initiate and maintain deleterious pulmonary infections. Theoretically, eradication of the sinus bacteria should reduce the frequency of lung infections and thereby reduce pulmonary morbidity. This article addressed whether bacteria in CF sinuses are eligible for eradication by sinus surgery and postoperative treatment.

METHODS

A prospective study including 58 CF patients, who had extensive sinus surgery and growth of Pseudomonas aeruginosa, Achromobacter xylosoxidans, and/or Burkholderia multivorans in their sinuses, was initiated. All patients followed a systematic postoperative treatment program of nasal irrigations with saline and colistimethate sodium and systematic endoscopic cleansing. All patients had follow-up examinations including sinus cultures; each side of the nose was cultured separately.

RESULTS

At the 6-month follow-up visit, 49 patients were cultured; 66 of 98 maxillary-ethmoidal complexes (67%) showed no growth of pathogenic bacteria. Some patients were not free from CF pathogenic bacteria at all cultures; however, 20 (41%) patients had no bilateral regrowth (p < 0.01) and 4 patients had no unilateral regrowth at any time during 6 months of follow-up. The eradication of CF pathogens was accomplished in patients from all three lung infection groups: intermittently colonized, chronically infected, and lung transplanted. The patient with the longest follow-up had no bacterial growth for 3 years.

CONCLUSION

Extensive sinus surgery combined with intensive follow-up can eradicate pathogenic bacteria from CF sinuses.

Chronic diseases, chromosomal abnormalities, and congenital malformations as risk factors for respiratory syncytial virus hospitalization: a population-based cohort study

BACKGROUND

Little is known about how chronic conditions other than prematurity, heart disease, and Down syndrome affect the risk and severity of hospitalization for respiratory syncytial virus (RSV). We assess the risk and severity of RSV hospitalization in children with chronic conditions in this register-based, population-based cohort study.

METHODS

Data on RSV tests, maternal smoking, siblings, single parenthood, mode of delivery, gestational age at birth, major surgery, asthma diagnosis, chronic conditions, and hospitalization and discharge dates were obtained from the Danish RSV database, the National Patient and Birth Registries, and the Civil Registration System.

STATISTICS

Cox regression models were used to estimate incidence rate ratios (IRRs) for RSV hospitalization between groups stratified by sex and date of birth. Duration of RSV hospitalization was analyzed in a linear regression and reported as geometric mean ratios.

RESULTS

A total of 391 983 children aged 0-23 months were included in the analysis. A total of 10,616 (2.7%) had a diagnosis for chronic disease. IRRs (95% confidence intervals) for RSV hospitalization in children with any congenital or acquired chronic condition were 2.18 (2.01-2.36) and 2.25 (1.94-2.61), respectively. Several new risk factors for RSV hospitalization, including malformations, interstitial lung disease, neuromuscular disease, liver disease, chromosomal abnormalities, congenital immunodeficiencies, and inborn errors of metabolism, were identified. Duration of RSV hospitalization was increased in many chronic conditions.

CONCLUSIONS

Chronic disease per se is an important risk factor for RSV hospitalization.

Digoxin use and the risk of breast cancer in women

PURPOSE

Digoxin resembles estrogen chemically and may have estrogenic effect. We hypothesized that digoxin use might increase breast cancer incidence and examined if use might be associated with risk of breast cancer, categorized by estrogen receptor (ER) status. To determine if being under care for heart disease biased the findings, rate ratios in users of angina drugs were similarly evaluated as a control exposure group.

PATIENTS AND METHODS

Women using digoxin and angina drugs were identified in the nationwide Danish Prescription Database, available between 1995 and 2008. Incident breast cancers were identified in the Danish Cancer Registry and further classifying by ER status. Relative risks (RR) were compared to nonusers using age- and period-adjusted incidence rate ratios.

RESULTS

Two thousand one hundred forty-four of 104,648 women using digoxin developed breast cancer. Current digoxin users were at increased risk of breast cancer (RR, 1.39; 95% CI, 1.32 to 1.46), but risk was not increased in former users (RR, 0.91; 95% CI, 0.83 to 1.00). The increased risks in digoxin users were marginally higher for ER-positive breast cancers (RR, 1.35; 95% CI, 1.26 to 1.45) and ER unknown breast cancers (RR, 1.51; 95% CI, 1.38 to 1.64) than for ER-negative breast cancers (RR, 1.20; 95% CI, 1.03 to 1.40). Among 137,493 women exposed to angina drugs only (a comparison group with cardiovascular disease; n = 2,658 breast cancers), incidence was not increased in current or former users.

CONCLUSION

Women currently using digoxin had a significantly increased risk of breast cancer. Risk normalized when digoxin was stopped. No risk increases were observed in women using angina drugs only. The higher risk of developing ER-positive breast cancers supports an estrogen-mimicking mechanism.

Temporal trends in invasive pneumococcal disease and pneumococcal serotypes over 7 decades

BACKGROUND

Pneumococcal infections have historically played a major role in terms of morbidity and mortality. We explored historical trends of invasive pneumococcal disease (IPD) and pneumococcal serotypes in a population exposed to limited antibiotic selective pressure and conjugate pneumococcal vaccination (PCV).

METHODS

Retrospective cohort study based on nationwide laboratory surveillance data on IPD collected uninterruptedly in Denmark during 1938-2007. Changes in the reported incidence and trends of pneumococcal serotypes were explored using nonlinear regression analysis.

RESULTS

There were 25,502 IPD cases included in our study. The median incidence of IPD increased from 2.8 cases per 100,000 population (interquartile range [IQR], 1.5-2.6) during the first 4 decades to 15.7 cases per 100,000 population (IQR, 7-20.4) during the 1980s and 1990s, mainly attributed to an increase in the number of bacteremia cases. The incidence of meningitis remained relatively stable, with a median of 1.3 cases per 100,000 population (IQR, 0.9-1.6). The proportions of serotypes/groups 4 and 9 increased; the proportion of serotype 18C decreased; the proportions of serotypes 6, 7F, 14, and 23F remained stable; and serotype 2 nearly disappeared. Before the 1960s, serotypes 1, 2, 3, and 5 presented peaks every 2-3 years, becoming less frequent during the 1970s with peaks every 7-10 years. Between 20% and 90% of IPD in children <5 years were caused by PCV serotypes during the last 4 decades. Cases of IPD caused by serotype 19A increased before introduction of PCV. Between 1993 and 2007, the level of resistance to macrolides and beta-lactams was 6%.

CONCLUSIONS

The epidemiology of IPD and single serotypes has constantly changed over the past 7 decades. PCV serotypes appeared to dominate the pneumococcal population.

Hepatitis D outbreak among children in a hepatitis B hyper-endemic settlement in Greenland

Hepatitis B virus (HBV) infection is endemic in Greenland with 5-10% of the population being HBsAg-positive (chronic carriers). Surprisingly, despite of the high prevalence of HBV infection, acute and chronic hepatitis B, liver cirrhosis and primary hepatocellular carcinoma appear much less frequently than expected. The reasons for the low frequencies are unknown, but as a consequence implementation of a childhood HBV vaccination programme, though debated for years, has never been instituted. We describe an outbreak of hepatitis D (HDV) infection among children in a hepatitis B hyper-endemic settlement of 133 inhabitants on the west coast of Greenland. In 2006 a total of 27% of the inhabitants were HBsAg-positive (chronic carriers) and 83% were HBcAb-positive (previously exposed). Forty-six percent of the HBsAg-positive persons were below 20 years of age. On follow-up 1 year later a total of 68% of the HBsAg-positive persons were HDV-IgG positive. Five children, who were HBsAg-positive in 2006, had HDV-seroconverted from 2006 to 2007, indicating a HDV-super-infection. Most of the HDV-IgG positive children had markedly elevated liver enzymes. In the multivariate analysis, among the HBV and HDV markers, presence of HDV-IgG was most strongly associated with elevation of liver enzymes. In conclusion, the HBV-HDV super-infection and presumed HDV outbreak in this settlement challenges the notion that HBV infection may not be as harmless in Greenland as previously anticipated. The findings strongly suggest that HBV vaccination should be included in the child-immunization program in Greenland.

Risks of invasive pneumococcal disease in children with underlying chronic diseases

OBJECTIVE

The risk of invasive pneumococcal disease is increased among children with some chronic diseases. The objective of this study was to quantify the risk of invasive pneumococcal disease in a wide range of chronic diseases.

PATIENTS AND METHODS

Cases of invasive pneumococcal disease among children (aged 0-17 years) were identified from 1977 through 2005 by using a national surveillance program in Denmark. Rate ratios were assessed in a case-control study by using 10 age- and gender-matched controls per case. Chronic diseases were defined a priori.

RESULTS

Among 1655 children with invasive pneumococcal disease, 19% had a history of chronic disease, according to our definition, versus 5% of controls. An increased risk of invasive pneumococcal disease was observed for children followed >30 days after initial hospital contact for a chronic disease, but it was also increased in children with >or=5 hospital contacts for any other reason. Children with a history of cancer, chronic renal disease, splenectomy, and transplantation were particularly susceptible to invasive pneumococcal disease. Adjusted for number of hospital contacts, the risk for children with other types of chronic disease was 1.4-fold more than for those with hospital contacts for any reason.

CONCLUSIONS

Cancer, chronic renal diseases, splenectomy, and transplantation were strongly associated with an increased risk of invasive pneumococcal disease in children. For children with other chronic diseases, their excess risk seemed to be attributable mostly to frail children having repeated hospital contact rather than their underlying condition.

Estimated effect of pneumococcal conjugate vaccination on invasive pneumococcal disease and associated mortality, Denmark 2000-2005

In order to provide an estimation of the direct and indirect benefits of pneumococcal vaccination with three protein-conjugate pneumococcal vaccines (PCV) we described the epidemiology and mortality from invasive pneumococcal disease (IPD) in Denmark between 2000 and 2005. Approximately 1080 cases were registered annually during the period. The overall incidence of IPD increased significantly, from 15.4 cases per 100,000 population in 2000 to 20.7 cases per 100,000 in 2005 (p<0.01), mainly due to an increase in bacteraemia cases. The serotype coverage in children under 5 years varied from 64% to 91% depending on the PCV used. The mean mortality proportion after IPD was 18%, with approximately 190 deaths annually. One to two deaths among children younger than 5 years and approximately 50 deaths related to IPD caused by vaccine serotypes among older age groups could be prevented annually by introducing a PCV. Approximately 70% of all deaths occurred in adults over 65 years, underlining the need for protection against IPD in this age group.

Genetic susceptibility to severe infection in families with invasive pneumococcal disease

Severe infections may be influenced by genetic constitution. The authors examined familial aggregation of invasive infections, using invasive pneumococcal disease (IPD) as the index condition to ascertain families at risk. From Danish national registers, they identified relatives of persons with IPD from 1977 through 2005. Risks of IPD, bacterial meningitis, septicemia, and any invasive infection were analyzed for relatives of IPD cases in a prospective cohort study (23 million person-years). In total, 43,134 persons were found to have an IPD case in the family. The authors observed an increased risk of invasive infections in relatives of IPD cases most likely sharing the same household (parents, offspring, siblings, half-siblings), but only regarding those events within 1 year of the index IPD diagnosis (rate ratio = 7.4, 95% confidence interval: 2.4, 23.0). After 1 year, there were no increased risks of severe infections, including IPD, in close relatives. For other relatives, no increased risks of severe infections were observed at any time. No aggregation of invasive infections in IPD relatives was found, other than for close events among relatives who most likely shared the same household. Thus, at the population level, genetic constitution appears of little importance in the development of IPD and other severe infections.

Perinatal and Crowding-Related Risk Factors for Invasive Pneumococcal Disease in Infants and Young Children: A Population-Based Case-Control Study

BACKGROUND

Denmark's systems of registry-based data offer a unique opportunity to examine, on a population basis, risk factors for invasive pneumococcal disease (IPD) relating to perinatal and crowding exposures among children. The main objective of this study was to identify the role of familial and day care factors in the risk of IPD among unvaccinated infants and children.

METHODS

A total of 1381 children aged 0-5 years old who experienced IPD were identified from a national surveillance program of IPD in Denmark. Risk factors were assessed in a matched, nested, case-control study that assigned 10 population control subjects to every case patient. Exposure information was obtained from several population-based, person-identifiable Danish registries.

RESULTS

Preterm birth and low birth weight significantly increased the risk of IPD among infants. In infants 0-5 months of age, the risk of IPD was high among infants who had older siblings, compared with infants of the same age who had no older siblings (adjusted rate ratio [aRR], 3.38; 95% confidence interval, 2.11-5.42), whereas the aRR was low (aRR, 0.56; 95% confidence interval, 0.47-0.65) in children aged 6-23 months. Day care attendance, compared with home care, increased the aRR of IPD 0-2 months after enrollment in a day care program (aRR, 2.28; 95% confidence interval, 1.73-3.00), whereas the aRR was 0.70; (95% confidence interval, 0.46-1.06) > or = 6 months after enrollment in children aged 6-23 months.

CONCLUSIONS

During infancy (age, 0-6 months), risk of IPD is associated with low birth weight, presumably because of lower levels of passively acquired maternal antibody. During early childhood, exposure to other young children (either siblings or through day care attendance) is clearly associated with IPD, but natural exposure appears to occur rapidly and confer durable immunity.

Risk factors for acute respiratory tract infections in young Greenlandic children

Acute respiratory infections cause considerable morbidity among Inuit children, but there is very little information on the risk factors for these infections in this population. To identify such factors, the authors performed a prospective community-based study of acute respiratory infections in an open cohort of 288 children aged 0-2 years in the town of Sisimiut, Greenland. Between July 1996 and August 1998, children were monitored weekly, and episodes of upper and lower respiratory tract infections were registered. Risk factor analyses were carried out using a multivariate Poisson regression model adjusted for age. Risk factors for upper respiratory tract infections included attending a child-care center (relative risk = 1.7 compared with home care) and sharing a bedroom with adults (relative risk = 2.5 for one adult and 3.1 for two adults). Risk factors for lower respiratory tract infections included being a boy (relative risk = 1.5), attending a child-care center (relative risk = 3.3), exposure to passive smoking (relative risk = 2.1), and sharing a bedroom with children aged 0-5 years (relative risk = 2.0 for two other children). Breastfeeding tended to be protective for lower respiratory tract infections. The population-attributable risk of lower respiratory tract infections associated with passive smoking and child-care centers was 47% and 48%, respectively. The incidence of acute respiratory infections among Inuit children may be reduced substantially through public health measures.

BCG vaccination and risk of atopy

CONTEXT

It has been suggested that BCG vaccination may protect against development of allergic diseases, particularly when given just after birth. BCG vaccination was given routinely to all infants in Greenland until 1990, when it was withdrawn from the vaccination program. Whether this resulted in an increased prevalence of atopy in children born after the stop of BCG vaccination is unknown.

OBJECTIVE

To determine whether BCG vaccination and age at BCG vaccination are associated with development of atopy.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study among schoolchildren aged 8 to 16 years in 4 towns on the northwest coast of Greenland. Participants had a blood sample drawn and information on BCG vaccination was obtained during 2 periods, November 1998 and November 2001. A total of 1686 children (79% of available children) participated, 1575 of whom had complete information on vaccination status. Atopy was defined as a positive test result in an assay that tests for IgE specific against the most common inhalant allergens in serum.

MAIN OUTCOME MEASURES

Odds ratio (OR) of atopy in BCG-vaccinated compared with unvaccinated children and OR according to age at vaccination.

RESULTS

The risk of atopy was the same in BCG-vaccinated compared with unvaccinated children after adjustment for confounders (OR, 1.03; 95% confidence interval, 0.72-1.48). The risk of atopy in BCG-vaccinated children was not associated with age at vaccination (P =.17).

CONCLUSIONS

BCG vaccination administered to infants is not associated with reduced risk of development of atopy.