Shen-Hao Lai

Suboptimal Vitamin D Status in a Population-Based Study of Asian Children: Prevalence and Relation to Allergic Diseases and Atopy

Background New evidence shows high prevalence of vitamin D deficiency in many countries and some studies suggest a possible link between vitamin D status and allergic diseases. The objectives of this study were to determine the prevalence of suboptimal vitamin D status in a population sample of Asian children and to investigate the relationship of vitamin D status with allergic diseases and atopy. Methods Children aged 5–18 years (Nu200a=u200a1315) in the Prediction of Allergies in Taiwanese CHildren (PATCH) study were evaluated using questionnaires, anthropometric measurements, and serum levels of 25-hydroxyvitamin D [25(OH)D] and total and specific immunoglobulin E (IgE). Results The mean concentration of serum 25(OH)D was 20.4 ng/mL (SD: 7.1 ng/mL). Vitamin D deficiency (defined as serum 25(OH)D<20 ng/mL) was present in 670 subjects (51.0%), while vitamin D insufficiency (defined as serum 25(OH)D<30 ng/mL) was observed in 1187 subjects (90.3%). Older age (P<0.001), female gender (P<0.001), higher body mass index (Pu200a=u200a0.001), winter and spring seasons (compared to summer; P both<0.001), and passive smoking (Pu200a=u200a0.011) were independently associated with low serum 25(OH)D levels. After adjusting for potential confounders, serum 25(OH)D status had no association with asthma, rhinitis, eczema, atopy, or total serum IgE (all P>0.05). Conclusions Low serum 25(OH)D levels are remarkably common in this population sample of Asian children, suggesting that millions of children living in Taiwan may have suboptimal levels of vitamin D, which should be a matter of public health concern. Our results provides epidemiological evidence against the association of vitamin D status with various allergic diseases and atopy in Asian children.

Maturation of Toll-like receptor 1-4 responsiveness during early life.

BACKGROUNDnToll-like receptors (TLRs) are part of the highly conserved components of the innate immune system, and have been investigated extensively; however, little is known about TLR function during early postnatal life, a critical period for immune maturation.nnnAIMSnIn order to achieve a more complete understanding of the ontogeny of immune system during the first years of life, our study investigated age-matched TLR1-4 responsiveness at several time points up to the age of two years.nnnSTUDY DESIGNnMononuclear cells were isolated from cord blood (n=150) and peripheral blood from infants at 6 (n=68), 12 (n=75), and 24 (n=74)months of age, and from 50 adults. Cells were stimulated with Toll-like receptor ligands (TLR1-4) and phytohemagglutinin (PHA). Stimulated cells were assessed for their production of the cytokines tumor necrosis factor alpha (TNF-α) and interleukin-6 (IL-6), and for TLR4 gene expression.nnnRESULTSnOur results suggested that cord response of IL-6 and TNF-α was not affected by allergic background. In addition, neonatal mononuclear cell had enhanced IL-6 production upon TLR1, 2, and 4 stimulations as compared to those of young children and adults. Nevertheless, after 6 months of age, the level remained comparable throughout the first two years of life. While TNF-α response to all TLR stimulations remained fairly similar during early life. This cytokine pattern closely paralleled our findings for TLR4 mRNA expression, and longitudinal cytokine changes within the same individual.nnnCONCLUSIONSnOur findings provided additional information to the understanding of immune development during early life, and offered stronger evidence of neonatal innate immunity being capable of responding adequately to TLR stimulation.

Serum 25-Hydroxyvitamin D Levels in Relation to Lung Function and Exhaled Nitric Oxide in Children

OBJECTIVEnTo investigate the relationship of vitamin D status with lung function and fraction of exhaled nitric oxide (FeNO) in a population sample of children.nnnSTUDY DESIGNnA total of 1315 children aged 5-18 years were evaluated using serum 25-hydroxyvitamin D [25(OH)D] levels, spirometry, a single-breath online FeNO measurement, and questionnaires.nnnRESULTSnAfter adjusting for confounders, the mean forced vital capacity was 53.4 mL (SE, 26.5 mL; P = .045), and the mean forced expiratory volume in 1 second was 48.2 mL (SE, 23.6 mL; P = .042) lower for children with insufficient serum 25(OH)D levels (20-29.9 ng/mL) compared with those with sufficient 25(OH)D levels (≥30 ng/mL). The mean difference between children with deficient (<20 ng/mL) and sufficient levels of serum 25(OH)D was 81.9 mL (SE, 26.7 mL; P = .002) for forced vital capacity and 55.2 mL (SE, 23.7 mL; P = .020) for forced expiratory volume in 1 second. There was no significant association between serum 25(OH)D levels and FeNO after adjusting for confounders.nnnCONCLUSIONSnOur results demonstrate a significant relationship between insufficient serum vitamin D levels and worse lung function in children in the community with a suggested dose-response effect. Our findings also suggest that vitamin D status is not a significant determinant of FeNO in children in the general population.

Exclusive breastfeeding is associated with reduced cow's milk sensitization in early childhood

Although breastfed infants have consistently been reported as having fewer infections and respiratory morbidity during infancy, none have reached a definitive conclusion as to whether breastfeeding is an effective strategy to prevent allergic diseases. This study aims to investigate the relationship between exclusive breastfeeding and sequential changes of several biomarkers of allergy, such as absolute eosinophil count, total IgE level, and specific IgE level during the first 3 yrs of life.

Scoring system for empyema thoracis and help in management

Objective : To evaluate the implications of a newly defined severity scoring of empyema in children for the prediction of surgical management and to compare the length of hospitalization as an outcome measure of patients treated using medical therapy, salvage video-assisted thoracoscopic surgery (VATS)vs early elective VATS.Methods : A retrospective chart review of parapneumonic empyema of patients below 18 years of age admitted to a tertiary children’s hospital in northern Taiwan from April 1993 to December 2002 was performed. Patients were categorized into a medical group who received antibiotic therapy, needle aspirations with/without tube thoracostomy; a salvage VATS group when the patients required surgery for the relief of persistent fever > 38°C, chest pains or dyspneic respirations despite initial medical therapy; an early VATS group when the patients received elective surgery early after admission. The demographic data, clinical features, laboratory findings, and duration of hospitalization were compared using a severity score of empyema (SSE).Results :Streptococcus pneumoniae was the most common infecting organism, followed byStaphylococcus aureus, Pseudomonas aeruginosa. No organisms were recovered in 39% of patients. A pleural pH < 7.1 increases the odds of requiring surgical intervention by 6 times among this cohort. Children who required decortication of empyema had a higher severity score (mean 4.8 vs 3.0, p < 0.005). The duration of hospitalization for patients having early VATS showed a shortening stay (mean 18 vs 28 days) as compared to salvage VATS.Conclusion : A pleural pH < 7.1 and a newly designed clinical severity score of empyema ≥4 are two predictors of surgical intervention for fibrinopurulent empyema in the present study. Early elective VATS may be adopted not later than 7 days after failure of appropriate antibiotic therapy and adequate drainage of empyema to decrease the length of stay and minimize morbidity.

Value of Lung Ultrasonography in the Diagnosis and Outcome Prediction of Pediatric Community-Acquired Pneumonia with Necrotizing Change.

Background Lung ultrasonography has been advocated in diagnosing pediatric community-acquired pneumonia. However, its function in identifying necrotizing pneumonia, a complication, has not been explored. This study investigated the value of lung ultrasonography in diagnosing pediatric necrotizing pneumonia and its role in predicting clinical outcomes. Methods We retrospectively reviewed 236 children with community-acquired pneumonia who were evaluated using lung ultrasonography within 2–3 days after admission. The ultrasonographic features assessed included lung perfusion, the presence of hypoechoic lesions, and the amount of pleural effusion. Chest computed tomography was also performed in 96 patients as clinically indicated. Detailed records of clinical information were obtained. Results Our results showed a high correlation between the degree of impaired perfusion in ultrasonography and the severity of necrosis in computed tomography (r = 0.704). The degree of impaired perfusion can favorably be used to predict massive necrosis in computed tomography (area under the receiver operating characteristic curve, 0.908). The characteristics of impaired perfusion and hypoechoic lesions in ultrasonography were associated with an increased risk of pneumatocele formation (odds ratio (OR), 10.11; 95% CI, 2.95–34.64) and the subsequent requirement for surgical lung resection (OR, 8.28; 95% CI, 1.86–36.93). Furthermore, a longer hospital stay would be expected if moderate-to-massive pleural effusion was observed in addition to impaired perfusion in ultrasonography (OR, 3.08; 95% CI, 1.15–8.29). Conclusion Lung ultrasonography is favorably correlated with chest computed tomography in the diagnosis of necrotizing pneumonia, especially regarding massive necrosis of the lung. Because it is a simple and reliable imaging tool that is valuable in predicting clinical outcomes, we suggest that ultrasonography be applied as a surrogate for computed tomography for the early detection of severe necrotizing pneumonia in children.

Retrieval of bronchial foreign body with central lumen using a flexible bronchoscope

A 5 year-old boy aspirated a metal spring accidentally. The right bronchial foreign body was removed by threading the alligator of a biopsy forceps through the lumen of the spring while opening its jaws distally. This case illustrates that a foreign body with a central lumen in a child can be successfully removed using a flexible bronchoscope, thus obviating the need for general anesthesia and rigid bronchoscopy.

Spontaneous pneumomediastinum: analysis of 87 pediatric patients.

Objectives Early reports on pneumomediastinum studied the adult population, and recent analyses of pneumomediastinum in pediatric patients contain small numbers of patients. We aimed to summarize the experience of a larger number of pediatric patients with spontaneous pneumomediastinum (SPM) in a tertiary children’s facility in northern Taiwan. Methods We performed a retrospective chart review of clinical manifestations and outcome of SPM on pediatric patients who were admitted to our hospital during a 10-year period. Results Forty-three patients (49.4%) had primary SPM, with a male predominance in adolescents. None of the 16 patients younger than 6 years had primary SPM; 43 of 71 patients older than 6 years had secondary SPM (0% vs 60.6%, P < 0.05). The common causes of secondary SPM were asthmatic exacerbation, pneumonia or lower respiratory tract infections, or choking. Ten patients had normal frontal chest radiograph finding (sensitivity, 89.1%); the lateral neck radiographs clearly demonstrated subcutaneous emphysema in 9 of these 10 patients. Conclusions All patients younger than 6 years with SPM were secondary; therefore, they should be vigilantly examined for predisposing causes. For adolescent patients with SPM with no catastrophic events, asthma with exacerbation should be considered first, and extensive or invasive diagnostic examinations are not needed. Primary SPM usually requires conservative treatment only with no sequel or recurrence. Lateral neck radiograph has a higher sensitivity for the demonstration of subcutaneous emphysema in doubtful cases.

Non-infectious epiglottitis in children : Two cases report

Two young children who suffered from thermal injuries to the epiglottis after swallowing corrosive agent and hot water respectively. Findings, clinically and radiologically, in both children were similar to acute infectious epiglottitis. Both recovered quickly with close observation and parenteral antibiotics. Although Haemophilus influenzae type b (Hib) is the major pathogen of epiglottitis, in areas with low incidence of Hib infection and high vaccination rates, non-infectious epiglottic swelling should be considered first.

Connatal tuberculosis in a very premature infant

Connatal tuberculosis is increasing in incidence and the mortality and morbidity of this disease remains high. We report a 27-week-old, 896xa0g female premature infant who had mild respiratory distress syndrome after birth. She developed signs of infection, progressive pneumonia and atelectasis which did not respond to mechanical ventilation and antibiotics. At 41 days of age, Mycobacterium tuberculosis was isolated from the non-bronchoscopic bronchoalveolar lavage. The isolate was sensitive to isoniazid, rifampin, streptomycin, and pyrazinamide . Miliary tuberculosis was subsequently diagnosed in her mother on a chest X-ray film and sputum cultures. The infant was treated successfully with anti-tuberculosis drugs. She had normal growth and development at the chronological age of 20 months old. Conclusion:Connatal tuberculosis should be considered in premature infants with symptoms of sepsis refractory to antibiotics. Most premature infants with connatal tuberculosis have lung involvement, and non-bronchoscopic bronchoalveolar lavage can be a useful procedure to establish the diagnosis.