Francis Serour

Natural history of food allergy in infants and children in Israel

BACKGROUNDnKnowledge about the natural history of food allergy, especially sesame, is scarce.nnnOBJECTIVEnTo follow the natural history of food allergies in Israel, particularly of sesame allergy.nnnMETHODSnThe survey was conducted based on clinical records and a detailed questionnaire of children diagnosed as having food allergy.nnnRESULTSnWe found 234 children with suspected food allergy. Testing detected 283 allergies in 180 patients (77%) with confirmed diagnosis. The most common allergies were to cows milk (n = 125), eggs (n = 71), sesame (n = 30), and soy (n = 23). Of those with milk allergy, 69% were IgE mediated (group 1) and 31% were non-IgE mediated (group 2). Group 1 was more likely to have an atopic background than was group 2 (P = .003), whereas group 2 was more likely to have resolution of the allergy (35 of 39 [90%] in group 2 compared with only 32 of 86 [37%] in group 1, P < .001). Allergy to soy was found in 23 children, of whom 87% manifested with gastrointestinal symptoms and 21 (91%) were also allergic to cows milk. In 19 children (83%), the allergy resolved. Thirty children had allergy to sesame, and 73% of them had an atopic background. The allergy resolved in only 9 of these patients (30%) at a mean age of 2.8 years.nnnCONCLUSIONSnThe distribution of food allergens in Israel differs from that in other countries. Non-IgE-mediated food allergy and particularly milk and soy allergy were likely to resolve completely with time. Sesame allergy was 1 of the most frequent in this cohort, was usually IgE mediated, and tended to resolve in only a few patients.

Perianal Abscess and Fistula-In-Ano in Infants: A Different Entity?

PURPOSEThe features of perianal abscess and fistula-in-ano in infants are different from those of older children, and there is controversy regarding their treatment. The aim of this study was to assess the efficacy of various methods used for their management.METHODSA retrospective analysis of the records was conducted for all infants younger than 24 months of age treated for perianal abscess, fistula-in-ano, or both from 1990 to 2002.RESULTSThe study included 98 infants. Perianal abscess was found in 77 patients (75 males), and fistula-in-ano in 21. No infant had an underlying illness. Drainage was performed by needle aspiration in 47 patients and by incision and drainage in 5. Following drainage, 43 patients received antibiotics. Altogether, 6 infants were treated with antibiotics alone and 19 with local care alone. Twenty-eight boys (36.4 percent) had an evolution toward fistula-in-ano. Patients who received antibiotics following drainage were less likely to develop fistula-in-ano than were patients who underwent a drainage procedure alone (27.9 percent vs. 66.7 percent, P < 0.05). All patients with fistula-in-ano were male and had been previously treated for perianal abscess (21 patients elsewhere and 28 in our department). Spontaneous cure of fistula-in-ano occurred in 42.9 percent of them (average 3.2 months), and 57.1 percent underwent fistulectomy for persistent fistula-in-ano. Cryptotomy was added when an involved crypt was found (11 patients, 39.3 percent). No recurrence of fistula-in-ano was noted after fistulectomy.CONCLUSIONSLocal treatment for perianal abscess during the early stage and drainage by needle aspiration during the progressive stage are effective. Antibiotics may be considered for patients undergoing drainage of perianal abscess. Fistula-in-ano can be managed conservatively for one to three months. For a persisting fistula, fistulectomy with cryptotomy (when abnormal anal crypts are found) is the preferred treatment.

Postappendectomy intra-abdominal abscess: a therapeutic approach.

Four hundred and sixty two children were operated on between January 1989 and June 1993 for acute appendicitis; 10 developed an intra-abdominal abscess. Intra-abdominal abscesses were accompanied by fever above 38 degrees C (nine out of 10 patients) and leucocytosis (mean leucocyte count 20.3 x 10(9)/l) and were detected sonographically four to 14 days after operation. Management included intravenous administration of antibiotics effective against both aerobes and anaerobes, and follow up with serial sonographic studies. Eight patients responded favourably to antibiotic treatment without any drainage procedure, with gradual shrinkage and collapse of abscesses. Two patients, in whom enlargement of collection was demonstrated on serial sonographic examination, eventually underwent percutaneous drainage under sonographic control. These results suggest that some paediatric patients with an intra-abdominal abscess after appendicectomy and who are followed up closely by sonography may be managed successfully with appropriate antibiotics alone.

Is laparoscopic appendectomy in children associated with an uncommon postoperative complication

BackgroundLaparoscopic appendectomy (LA) is controversial due to the high rate of intraabdominal abscess (IAA). We report a postlaparoscopic appendectomy complication (PLAC) observed in pediatric patients discharged after an uneventful postoperative period.MethodsIn this case series, a review of the medical records of children who underwent LA or open appendectomy (OA) during a 5-year period was performed. The diagnosis of PLAC was based on three well-defined criteria: time of appearance, clinical and laboratory findings, and ultrasonographic characteristic features.ResultsA total of 374 patients underwent appendectomy (LA, 129 patients; OA, 245 patients). One patient with conversion of LA to OA and 35 patients with gangrenous or perforated appendicitis (seven from the LA group and 28 from the OA group) were excluded from the study. After LA, nine children developed intraabdominal complications during their hospitalization (six infiltrate in the right lower quadrant and three IAA); these were also excluded. Discharge from the department was done when three conditions were fulfilled: normal body temperature, normal leukocyte count, and passage of a stool. Among the 112 LA patients, PLAC was observed in 15 (13.4%), aged 12.5 ± 2.9 years, who were discharged after LA in 2.7 ± 0.9 days. Number of PLAC and time of its appearance were not significantly different in patients with normal or pathological appendix. Sonographic findings of PLAC at admission were fluid alone (n = 11), edematous mesenteric fat (n = 7), thickening of bowel wall (n = 9), and more than one sign (n = 9). At repeated sonography, these signs were present in all patients, and IAA developed in one of them. All children were successfully treated with antibiotics for 10.1 ± 3.9 days, one of whom underwent a CT-guided percutaneous drainage for IAA.ConclusionsPLAC may be the result of a slow development of local interstitial infection in the ileocecal area due to mesothelial damage caused by CO2 pneumoperitoneum and local thermal effect produced by energized systems. This may explain its delayed appearance and the efficacy of the antibiotic treatment.

Gastroesophageal regurgitation during anesthesia and controlled ventilation with six airway devices

STUDY OBJECTIVEnTo investigate the frequency of gastroesophageal regurgitation and respiratory mechanics during positive pressure ventilation using 5 supraglottic devices or an endotracheal tube (ETT).nnnDESIGNnProspective, randomized study.nnnSETTINGnOperating rooms in a university-affiliated hospital.nnnPATIENTSn180 ASA physical status I and II patients, aged 18 to 65 years old, who underwent elective orthopedic, minor vascular, peripheral plastic, or urologic surgery during general anesthesia.nnnINTERVENTIONSnPatients were randomly allocated to one of 6 airway device groups (n = 30 each): (1) Cobra Perilaryngeal Airway; (2) Laryngeal Mask Airway (LMA) Classic; (3) LMA Fastrach; (4) LMA ProSeal; (5) laryngeal tube; and (6) ETT (SIMS Portex, Ltd, Hythe, Kent, UK). After insertion of the designated device, the lungs of each nonparalyzed patient were mechanically ventilated.nnnMEASUREMENTSnHypopharyngeal pH, peak inspiratory pressures, sealing pressures, and lung compliance were measured. Hypopharyngeal pH lower than 4 was considered a regurgitation event.nnnMAIN RESULTSnRegurgitation (episodes of pH <4) occurred in between one and 5 patients of each study group, with no statistical difference. Sealing pressures were similar among all the airway device groups.nnnCONCLUSIONSnThe frequency of gastroesophageal regurgitation in anesthetized, unparalyzed, mechanically ventilated patients was similar in patients whose lungs were ventilated with either the Cobra Perilaryngeal Airway, LMA Classic, Fastrach, ProSeal, laryngeal tube, or ETT.

Analysis of the interleukin-12/interferon-γ pathway in children with non-tuberculous mycobacterial cervical lymphadenitis

Genetic defects along the interleukin (IL)-12/interferon (IFN)−γ pathway have been found in patients with mendelian susceptibility to mycobacterial disease (MSMD) caused by live BCG vaccine or non-tuberculous Mycobacterium (NTM) species, highlighting the crucial role of this axis in human immunity to Mycobacterium. The aims of this study were to characterize healthy children presenting with cervical lymphadenitis caused by NTM and to investigate their IL-12/IFN-γ pathway. Epidemiological, clinical, laboratory and pathological findings were reviewed retrospectively. Blood samples from five patients and healthy controls were in vitro activated with BCG, BCG + IL-12 and BCG + IFN-γ and levels of IL-12p40 and IFN-γ were measured. Fourteen patients (11 males, median age 24xa0months, range 12–78xa0months) were studied. The mean duration of illness before diagnosis was 9.1xa0weeks. Mycobacterium tuberculosis purified protein derivate (PPD) was positive in all patients (mean 14.5u2009±u20099.8xa0mm). Caseous granuloma was found in all ten patients who underwent excision biopsy. However, acid fast stain was positive in only five children and cultures were positive in only three cases. The amplified M. tuberculosis direct test was negative in all tested cases. No significant differences in IL-12p40 and IFN-γ levels were found between patients and controls. In spite of the normal response as measured in the screening test, it is still possible that patients might have a monogenic/mendelian disease for which the genetic defect(s) have yet to be elucidated. Alternatively, some single nucleotide polymorphisms along the IL-12/IFN-γ axis might be associated with an isolated cervical lymph node infection and not a disseminated disease in children.

Characteristics of Perianal Abscess and Fistula-in-Ano in Healthy Children

BackgroundProbably because of the low frequency, perianal abscess (PA) and fistula-in-ano (FIA) in children older than 2 years have not been investigated except in those with a predisposing condition such as Crohn’s disease. This study aims to summarize our experience about the characteristics and treatment of PA and FIA in healthy children.MethodsThe charts of all children older than 24 months of age treated for PA and/or FIA from 1990 to 2003 were reviewed.ResultsWe found 40 patients, 37 of them boys (92.5%), ranging from 2 to 14 years of age (average: 7.19 years). At the first examination, the diagnosis was PA in 36 patients (mean age: 6.8 years; range: 2.3–13 years), and FIA in 4 patients (mean age: 10.8 years; range: 6–14 years). The primary local treatment of PA was drainage (needle aspiration in 26 patients, and incision and drainage in 4 patients) and local care in 6 patients. All patients received antibiotics. Overall, 29 children (80.6%) had primary cure of the abscess. Evolution included recurrent abscess in 3 patients (8.3%) and FIA in 4 patients (11.1%). Crohn’s disease was diagnosed in only one boy with an abscess of long duration. No patient developed a new PA in another location or a recurrent FIA. Four male patients aged 6 to 14 years (range: 7.1 years) had a FIA of long duration. One patient underwent a fistulectomy. Crohn’s disease was found in three other children and treated conservatively.ConclusionDrainage of PA by needle aspiration associated with antibiotics is effective in children older than 2 years of age with a low rate of evolution toward FIA. Associated pathology must be ruled out in children with FIA.

The Effects of Hydration on Core Temperature in Pediatric Surgical Patients

Background Reduced vascular volume might influence body temperature by diverting heat flow from peripheral tissues to the central organs. We therefore tested the hypothesis that mild hypovolemia helps to prevent intraoperative hypothermia in pediatric patients. Methods Twenty-two pediatric patients (aged 1–3 yr) undergoing prolonged minor surgery were randomly assigned to conservative (n = 12) or aggressive (n = 10) perioperative fluid management. The conservative group fasted 8 h before surgery and received a crystalloid at 1 ml · kg−1 · h−1 during surgery. The aggressive group was allowed to drink liquids until 3 h before surgery and was given a maintenance crystalloid at 8 ml · kg−1 · h−1. Anesthesia was induced and maintained with halothane in nitrous oxide. Ambient temperature was kept near 25°C, but the patients were not actively warmed. During recovery from anesthesia, additional fluid was given to the conservative group so that perioperative fluid totaled 9.5 ml · kg−1 · h−1 in both groups. Results Intraoperative body weight remained unchanged in the aggressive group and decreased only 1% in patients managed conservatively. Heart rate was slightly greater in the conservative group (107 ± 9 vs. 95 ± 4 beats/min, P = 0.002), but blood pressure was similar. Esophageal temperature in patients whose fluid was managed conservatively increased significantly, by 0.4 ± 0.3°C, to 37.1°C; in contrast, temperature in the aggressive group decreased significantly, by 0.4 ± 0.2°C, to 36.4°C (P < 0.001 between groups). Temperatures remained significantly different 1 h after surgery. Conclusions Conservative fluid management, which decreased body weight by only 1%, prevented reduction in core body temperature, presumably by reducing dissipation of metabolic heat from the core thermal compartment to peripheral tissues.

Perianal ecthyma gangrenosum — a therapeutic dilemma

A 2-month-old premature infant was admitted to our pediatric intensive care unit because of severe Pseudomonas aeruginosa septicemia, in critical condition. A circular perianal lesion consistent with ecthyma gangrenosum developed and was treated conservatively. To our knowledge, the therapeutic dilemma between conservative and surgical management of this lesion has not been previously reported.

Sonographic findings following appendectomy for uncomplicated appendicitis in children

BackgroundLittle is known about ‘normal’ local sonographic changes occurring in the postoperative period after an uneventful appendectomy.ObjectiveTo analyse the local changes on US examination occurring after uneventful open (OA) or laparoscopic (LA) appendectomy in children with normal histology and with nonperforated acute appendicitis.Materials and methodsUS was prospectively performed in 82 children (54 boys and 28 girls) aged 1–16xa0years (mean 11.6±3.2xa0years), 3xa0days following LA (n=51, 62%) or OA (n=31, 38%) for nonperforated appendicitis. Multivariate analysis was performed using stepwise logistic regression, with the following starting variables: surgical technique, gender, pathological finding, appendix location, and histology.ResultsOf the 82 patients, 35 (42.7%) had postoperative pathological US findings such as peritoneal fluid, oedematous mesenteric fat and thickening of the bowel wall. While the overall incidence of pathological US findings between OA and LA groups was not significantly different, multivariate logistic regression analysis showed that OA is associated with a reduction by a factor of 0.35 in the odds ratio of postoperative pathological US findings (P=0.007).ConclusionPathological US findings are common in children after appendectomy, particularly after LA. Awareness of these pathological findings might prevent unnecessary postoperative treatment.