Leon Joseph

Predictive factors of morbidity in childhood parapneumonic effusion-associated pneumonia: a retrospective study.

Study Objective: To find the clinical and laboratory criteria that best predict a prolonged fever in children with parapneumonic effusion-associated pneumonia treated conservatively. Design: Retrospective, cohort study. Patients: Children admitted to the Shaare Zedek Medical Center between January 1, 1997, and December 31, 2006, and who had been discharged with a diagnosis of empyema and pleurisy. Measurements and Results: One hundred-twenty children were included, all of whom were treated with antibiotics; in 80 patients, a thoracic drain was introduced; in 23, pleural tap was performed; and in 17 patients, no special procedure was performed. In no case was video-assisted thoracic surgery performed. The mean total days of fever was 12.8 ± 5.9 (2–29 days), and the mean length of stay at the hospital was 11.5 ± 4.9 (3–25) days. In 44 patients (37%), a bacterial culture was positive either in blood or in pleural fluid or both. A positive blood or a positive pleural fluid culture was significantly associated with a prolonged fever as was a history of an underlying disease. Platelet counts, serum Na, serum protein, pleural lactate dehydrogenase (LDH), pleural glucose, pleural/serum LDH ratio, pleural/serum glucose ratio, and pleural fluid pH were the only factors significantly but weakly correlated with the total duration of fever or duration of fever after admission. A “fever duration” score using platelet count, pleural fluid pH, pleural/serum LDH ratio, and pleural/serum glucose ratio predicted a prolonged course of fever (>7 days) with a sensitivity of 91% (95% confidence interval: 60%–100%) and a specificity of 47% (95% confidence interval: 25%–71%). Conclusions: In children with parapneumonic effusion-associated pneumonia, a positive bacterial culture and an underlying disease are associated with prolonged fever. A low score based on platelet count, pH pleural fluid and glucose, and LDH pleural/serum ratio is associated with a prolonged fever. We speculate that children with the risk factors mentioned earlier may be the best candidates for an early aggressive approach.

Unilateral Lung Intubation for Pulmonary Air Leak Syndrome in Neonates: A Case Series and a Review of the Literature

Air leak syndrome represents a common set of complications of ventilated premature neonates and includes pneumothorax, pneumomediastinum, pulmonary interstitial emphysema, and pneumatocele. Unilateral intubation is an infrequently utilized treatment option. We report our experience of three cases of air leak syndrome in neonates, each treated with unilateral intubation, including two cases of recalcitrant pneumothorax. A review of the literature of similar neonatal cases is presented. In view of our experience and the review of the literature, we suggest that unilateral intubation is an efficient and relatively safe therapy in cases of neonatal air leak syndrome. It is also suggested that appropriate treatment duration should be at least 48 hours.

Effect of moderate elevation above sea level on blood oxygen saturation in healthy young adults.

Background: Arterial hemoglobin oxygen saturation (SaO2) decreases at an altitude of >1,500 m. There are no reports on normal SaO2 at altitudes between 0 and 1,500 m. The clinical significance of decreased SaO2 at such altitudes is unclear. Objective: To test the hypothesis that in healthy volunteers normal SaO2 at moderate altitude (MA; 725 m) is lower than that at almost sea level (SL; 43 m). Methods: SaO2 was measured by transcutaneous pulse oximetry in young healthy volunteers at MA and was compared to equivalent measurements at SL. In addition, a 6-min walk test was performed and SaO2 at the end of the walk was compared between the two locations. Results: 111 males were checked at MA and 101 at SL. At rest, nadir SaO2 was 95% at MA compared to 97% at SL. Mean SaO2 at rest was slightly higher at SL (98.53 ± 0.52) compared to MA (98.11 ± 0.8; p < 0.01). In subjects who completed the 6-min walk test, SaO2 slightly decreased after the test in both locations, by 0.38 ± 0.65% in the SL group and by 0.37 ± 1.12% in the MA group. This difference is not statistically significant by univariate analysis; however, a multiple regression analysis indicated that the drop in SaO2 was higher at MA than at low altitude. Conclusions: We found a low but significant difference in SaO2 between near-SL and at an altitude of 725 m. The clinical significance of this difference, in terms of human health, is probably minimal.

Seasonal effect on exercise challenge tests for the diagnosis of exercise-induced bronchoconstriction.

Exercise challenge test (ECT) may help in the diagnosis of asthma. Asthma is season dependent (relative summer nadir).This study was designed to prospectively show that ECT sensitivity decreases when performed in summer and/or out of personal asthma season. We performed two ECTs in 49 patients with suspected asthma, at baseline and at least 6 months later. Test positivity was defined as a ≥10% drop of forced expiratory volume in 1 second after exercise. Patients were defined as having exercise-induced bronchoconstriction (EIB) if at least one of the two tests was positive. We analyzed the impact of season and of patient-reported asthma season on ECT sensitivity. We performed 21 ECTs in the summer and 77 in other seasons. Summer tests were positive in 14.3% of patients versus 33.8% in other seasons (p = 0.11). In patients with confirmed EIB, the sensitivity (95% CI) of a summer test was 0.25 (0.007-0.57), compared with 0.76 (0.58-0.89) in other seasons. Tests performed out of personal asthma season were positive in 10.0% of tests compared with 37.1% of tests during personal asthma season (p = 0.007). In patients with confirmed EIB, the sensitivity (95% CI) of a test performed out of asthma season was 0.27 (0.07-0.61), compared with 0.74 (0.55-0.87) during season. The sensitivity of ECT performed in the summer or outside of the personal asthma season is about one-third of ECT performed not in the summer or during personal asthma season. We suggest performing ECTs during personal asthma season and not in the summer if there is no asthma season known.

High-Flow Nasal Cannula Therapy for Obstructive Sleep Apnea in Children

INTRODUCTION Over the last decade, high-flow nasal cannula (HFNC) therapy has become an increasingly important and popular mode of noninvasive respiratory support. HFNC facilitates delivery of humidified and heated oxygen at a high flow rate and generates positive airway pressure. METHODS We present five cases of children with OSA without adenotonsillar hypertrophy who were treated with HFNC. RESULTS We demonstrated a statistically significant improvement in apnea-hypopnea index and nadir oxygen saturation in this small cohort. CONCLUSION We present our successful experience of treating severe OSA with HFNC in the home setting. Further randomized controlled trials are needed to determine whether HFNC could be considered as an established alternative for CPAP in OSA in children.

Ultrasound velocity through the tibia is not affected by prolonged inhaled steroid therapy in children.

To evaluate in a prospective, cross‐sectional cohort study the impact of inhaled corticosteroids (ICS) on bone speed of sound (SOS) in asthmatic children.

Sinus vein thrombosis as presenting finding in the congenital central hypoventilation syndrome: An insight on the pathophysiology of the association

Congenital central hypoventilation syndrome (CCHS) is an increasingly recognized diagnosis causing central hypoventilation and may be definitively diagnosed by genetic testing. Previous authors reported the association between CCHS and central sinus venous thrombosis (CSVT) and hypothesized that CCHS could be secondary to CSVT. We report a case of CCHS with the typical PHOX2B mutation who also suffered from CSVT. We assume that effects, secondary to CCHS, upon the central venous system may explain the etiological connection between CSVT and CCHS including dysautoregulation, venous stasis or polycythemia. We believe that CCHS should be included in the differential diagnosis of patients with CSVT accompanied by respiratory abnormalities. Pediatr. Pulmonol. 2011; 46:826–828.

Conservative treatment of a large post‐infectious pneumatocele

the live virus polio vaccine is used, as adverse reactions to OPV in healthy infants without any obvious immunodeficiencies can occur, as in our case. In 2000, theAmericanAcademy of Pediatrics changed their policy to recommend only inactivated poliovirus vaccine (IPV) for routine childhood immunization, because they considered VAPP would not be eliminated unless the use of OPV was stopped. Recently, some countries including the USA and Germany have changed their national policies to recommend vaccination with IPV alone instead of OPV. Therefore, we believe that the introduction of IPV should be seriously considered in Japan.

Sex-linked difference in blood oxygen saturation

It is not known whether SpO2 in healthy volunteers is affected by sex.

Early neonatal pyloric stenosis after exposure to maternal macrolide therapy

Abstract A case of neonatal pyloric stenosis, presenting very early in life, accompanied by massive aspiration is described. We speculate that early intrauterine exposure to maternal azithromycin therapy was linked to the disease.