Israel Medical Association Journal

Background: Despite years of research and clinical experience with acute appendicitis, the rate of complications in the pediatric age group continues to be high.

Objective: To characterize the profile of the child with appendicitis complicared by perforation or intraabdominal abscess.

Methods: Between 1 January 1985 and 31 December 1997 in our department, 581 children under the age of 14 years were clinically diagnosed as suffering from "acute appendici­tis". The final diagnoses were: white appendix in 28 cases (4.8%), acute non-complicated appendicitis in 472 (81%), and complicated appendicitis in 81 (13.9%), including 51 cases of free perforation (8.7%) and 30 cases of intraabdominal abscess (5.2%). We retrospectively reviewed the charts of all children with complicated appendicitis and those of 70 randomly selected children with non-complicated appendicitis, and compared patient age, gender, weight percentile, past medical history, and course of the illness.

Results: The children with complicated appendicitis were significantly younger (R~4.8*10~⁷), they had higher oral and rectal temperatures (P=7.9*10-⁸), higher platelet count (P=0.0008) and lower hemoglobin level (P=0.004). No difference was found in white blood count (P=0.41). Total delay from symptom onset to surgery was 33 hours (SD 23) in the non-complicated group, 60 hours (SD 38) in the perforated appendicitis group, and 176 hours (SD 107) in the intra­abdominal abscess group (P=4.6*10-⁸). No difference in intra­hospital delay was found.

Conclusions: Children with complicated appendicitis are characterized by younger age, longer delay from symptom onset to correct diagnosis, and typical laboratory findings. Delays in diagnosis can be avoided by first considering the diagnosis of acute appendicitis in the differential diagnosis when examining any child with abdominal pain.

Background: The outcome of cardiopulmonary arrest in children is poor, with many survivors suffering from severe neurological defects. There are few data on the survival rate following cardiopulmonary arrest in children who arrived at the emergency room without a palpable pulse.

Objective: To determine the survival rate and epidemiology of cardiopulmonary arrest in children who arrived without a palpable pulse at a pediatric ER in southern Israel.

Methods: We retrospectively reviewed the medical records of all patients with cardiopulmonary arrest who arrived at the ER of the Soroka University Medical Center during the period January 1995 to June 1997.

Results: The study group included 35 patients. Resuscitation efforts were attempted on 20, but the remaining 15 showed signs of death and were not resuscitated. None of the patients survived, although one patient survived the resuscitation but succumbed a few hours later. The statistics show that more cardiopulmonary arrests occurred among Bedouins than among Jews (32 vs. 3, P0.0001).

Conclusions: The probability of survival from cardiopulmonary arrest in children who arrive at the emergency room without palpable pulse is extremely low. Bedouin children have a much higher risk of suffering from out-of-hospital cardiopulmonary arrest than Jewish children.

Background: Ulcerative colitis begins in early childhood in 4% of cases. Medical therapy is non-specific, and as many as 70% of children will ultimately require surgery. The dynamic growth, physical and psychological changes that characterize childhood are severely compromised by the complications of ulcerative colitis and its therapy.

Objective: To review the outcome of children undergoing early surgery for ulcerative colitis at a tertiary medical center in Israel.

Methods: A retrospective review was conducted of all children operated on following failure of medical therapy for ulcerative colitis during a 5 year period.

Results: Eleven children underwent a J-pouch procedure with ileo-anal anastomosis in one to three stages. Postoperative complications included recurrent pouchitis in 5 patients, intestinal obstruction in 3, fistula with incontinence in one, stricture in one, and wound infection in 4. Follow-up revealed that most of the patients have three to four soft bowel movements daily. All currently enjoy normal physical activities and a rich social life.

Conclusions: The quality of life in children with ulcerative colitis was markedly improved following J-pouch surgery. This procedure was not associated with major complications. We recommend early surgery as an alternative to aggressive medical therapy in children with this disease.

Background: Childhood poisoning continues to challenge the diagnostic and treatment skills of the pediatrician. Generally, childhood poisoning can be attributed to suboptimal parental supervision and accessibility of products with poisoning potential.

Objective: To evaluate the pattern of acute poisoning in children with relation to different age groupings.

Methods: Pediatric patients hospitalized for acute poisoning at the Soroka Medical Center over a 5 year period (1994-98) were evaluated retrospectively. Special attention was given to poisoning in relation to age groupings.

Results: During the years 1994-98 a total of 1,143 children were admitted for acute poisoning to the Soroka Medical Center. The majority of cases occurred in children aged 2-5 and 14-18 years. Males under 14 had a higher frequency of poisoning, the poisoning usually being unintentional, whereas poisoning in females occurred mostly in the 14-18 age group and was intentional. Drugs were the most common agent of poisoning in infants (0-1 year), in older children (10-13 years), and in adolescents (14-18 years), while in children aged 2-5 and 6-9 years either cleaning products or drugs were the usual agents of poisoning. Most poisonings in children aged 2-13 occurred between 4 and 8 p.m., and for most adolescent patients (14-18 years old) between 4 p.m. and midnight. Poisoning in children aged 2-13 were usually due to accessible home products, and to medicinal errors such as overdose and improper drug administration.

Conclusions: This study defines the characteristic pattern of pediatric poisoning with respect to different age groups and gender. Unintentional childhood poisoning predominated in males and occurred mostly because of accessible home products and suboptimal parental supervision during critical hours of the day. Most adolescent poisoning occurred in females and was intentional. Parental education and intensified child supervision are indicated measures of prevention for unintentional poisoning.

Background: Inflammation is a major component in the pathogenesis of asthma. CD14 is an endotoxin (lipopolysaccharide) receptor, and is expressed mainly on monocytes and macrophages. Binding of LPS to CD14 activates the monocyte or macrophage and causes the release of different cytokines.  The soluble form of CD14 is present in serum, and its concentration increases in several clinical conditions, including infections, auto-immune disorders, allergic disorders, and lung diseases.  The possible role of CD14/sCD14 in asthma has been investigated in a few adult patients only.

Objectives: To measure serum concentrations of sCD14 in children with status asthmaticus.

Methods: We compared serum concentration of sCD14 in 10 children with status asthmaticus measured within 24 hours of admission and after recovery from the acute episode.

Results: Levels of sCD14 were significantly higher during acute asthma attacks than at recovery.

Conclusions: The elevated serum levels of sCD14 during status asthmaticus may be the result of the activation of monocytes, macrophages or other cells.  The influence of medications on serum sCD14 cannot be ruled out.  The possible use of sCD14 as a marker of lung inflammation in asthma warrants further investigation. 

________________________________

LPS= lipopolysaccharide

SCD14= soluble form of CD14

 

Background: Bronchiolitis caused by respiratory syncytial virus is one of the major causes of hospitalization in young children, especially during the winter.  Recent evidence has shown that pharmacological treatment, especially nebulized epinephrine, in addition to the traditional supportive treatment, can alleviate symptoms and shorten hospitalization, but this approach is not yet widespread.

Objectives: To determine whether the management of bronchiolitis in Israel is moving toward a stronger emphasis on pharmacological care.

Methods: A questionnaire on the diagnosis and management of bronchiolitis was completed by 27 heads of pediatric departments throughout Israel.  The questionnaire dealt with the frequency of usage of diagnostic and selected therapeutic procedures.

Results: Chest X-ray and arterial blood gases are commonly used as a diagnostic aid in more than 75% of the departments, and antibiotics are prescribed routinely in 24%.  Corticosteroids are still in use: 48% use systemic steroids, and 19% nebulized steroids.  Nebulized epinephrine is used in 22% of the departments, while nebulized beta-agonists are used frequently in two-thirds of the departments.

Conclusions: Despite convincing data that beta-agonists and steroids have no positive effect on the outcome of bronchiolitis on the one hand, and that nebulized epinephrine has advantages in children on the other, we found significant use of the former two agents and sparse use of the latter.  Greater awareness is needed among pediatricians, and measures should be introduced to incorporate the new recommendations, with further study of the effect of the old and new drugs on bronchiolitis.