9 research outputs found
Fuel price fluctuation and agricultural transportation in Iringa district, Tanzania
No full textThis study investigates the impact of rising fuel prices on the transportation of agricultural crops in Iringa District, Tanzania from 2021 to 2023. It examines how fuel price fluctuations have influenced transportation costs, market accessibility, and overall agricultural productivity. Using a mixed-methods approach, data were collected from smallholder farmers, transporters, and market traders through surveys and interviews. The findings indicate that the continuous increase in fuel prices has significantly escalated transportation costs, limiting farmers’ access to distant markets and reducing their profit margins Additionally, higher transportation expenses have contributed to increased food prices, negatively affecting consumers and overall market efficiency. The study further highlights challenges such as supply chain disruptions, decreased competitiveness of local agricultural products, and financial constraints for transport service providers. To mitigate these impacts, policy recommendations include the introduction of targeted fuel subsidies, investment in alternative transportation solutions improvements in rural infrastructure, and strengthening agricultural market linkages. Implementing these measures could help stabilize transportation costs, enhance market access, and support the resilience of smallholder farmers in Iringa District, Tanzania
Low dose time-resolved CT-angiography in pediatric patients with venous malformations using 3rd generation dual-source CT: Initial experience
No full textAbstractObjectivesTo prospectively evaluate the diagnostic value and radiation dose of time-resolved CT-Angiography (4D-CTA) in pediatric patients with venous malformations using 3rd generation dual-source CT (DSCT) at 70kVp tube voltage.MethodsBetween November 2014 and August 2015, seven children (2 male, 5 female; median age, 9 years; range 3–12 years) with suspected peripheral, non-cerebral, venous malformations were included in this feasibility study and underwent US, MRI and 4D-CTA. All three imaging modalities were analyzed and compared individually by an experienced interventional radiologist and a pediatric surgeon using a 5-point Likert scale, with regard to diagnosis of the vascular anomaly, additional information like presence of thrombophlebitis and lesion extension, flow dynamics, localization, volume and significance for treatment planning. For quantitative statistical analysis, an unifactorial analysis of variance was performed for every parameter and all three imaging modalities. Radiation dose values as expressed by the volume CT dose index (CTDIvol) and dose-length product (DLP) were recorded for of all patients.ResultsThree out of six patients had isolated type I venous malformations without peripheral venous drainage which could be demonstrated on MRI and CT. In two out of six patients a type II venous malformation with drainage into normal veins was diagnosed. In one case, 4D-CT was the only imaging modality that revealed a slow-flow venous malformation with shunting supply by a hypodynamic arterial feeder.Treatment planning4D-CTA was rated as the best imaging modality for treatment planning with agreement between radiologist and surgeon, especially with respect to the hemodynamics of the venous malformation.Conclusions4D-CTA at 70kVp is a fast imaging modality that provides comprehensive diagnostic information of venous malformations in pediatric patients and is very valuable for therapy planning. Radiation dose of 4D-CTA must be weighted against the diagnostic information as well as the potential risk for sedation and contrast administration during MRI
Large-scale nitrogen removal demonstration at the blue plains wastewater treatment plant using post-denitrification with methanol
No full textThe Chesapeake Bay Agreement of 1987 calls for an overall reduction in nutrient loading of forty percent of 1985 levels by the year 2000. Signatories to the agreement include the states located in the Bay's watershed and the District of Columbia. The District's 16.2 m3/sec (370 mgd) Blue Plains Regional Wastewater Treatment Plant is the single, largest point source of nitrogen load to the Bay, discharging approximately 18 metric tons per day. In an effort toward meeting the nitrogen reduction goal, a post-denitrification demonstration study was recently begun to access its potential for long-term implementation.
The denitrification demonstration project involves operating half of the nitrification facilities in a nitrification-denitrification mode using methanol as a carbon source for post-denitrification. The other half continues operation in a nitrification-only mode as a control. The post-denitrification process was selected for demonstration because it utilizes existing facilities and may offer substantial long-term cost savings. Objectives of the study are to demonstrate the process without a negative impact on effluent quality, to verify performance and capacity, to determine the stability and limitations of the project, and to compare the process to other nitrogen-removal technologies.
Thus far, the process has been successful in removing nitrogen despite problems with phosphorus limitation and with the settling characteristics of the denitrification sludge. It is believed that insufficient phosphorus availability has been responsible for problems associated with settling, sludge yield, methanol use, and denitrification rates. Recently, phosphorus input to the denitrification process has been increased by reducing metal salt addition in upstream processes and preliminary results have been promising. If performance criteria are achieved without sacrificing plant capacity, the process will be continued at full scale.</jats:p
Physician-Industry Collaboration: Organizational Considerations for the Future of Innovation and Growth in Dermatology
No full textAbstractThe U.S. medical environment continues to evolve with issues from Privacy to EMR, Insurance regulations, Physician Access and Healthcare Reform, and MACRA (Medicare Access and CHIP Reauthorization Act) on the discussion table. Not since the advent of Medicare and Medicaid in the mid 1960’s, have we seen such widespread changes in the medical healthcare environment (Centers for Medicare and Medicaid Services). Physicians, industry, patients and consumers are affected by the changes. These four groups have historically worked as separate entities, but are now key stakeholders in the future of dermatology. As stakeholders collaborating in building a future together, the dermatologists/physicians will help to ensure and preserve the quality of patient care and best patient outcomes. In the Executive Forum, leaders from the Women’s Dermatologic Society and Industry, explored five important areas: 1) A five-year outlook of Dermatology and Medicine; 2) Access of Industry to Dermatologists and Trainees; 3) The New Practice Environment; 4) Doing Things Differently; and 5) Unmet Specialty Needs. The collaborative group explored solutions for our specialty and the patients we serve
Brain Abscess as a Manifestation of Hereditary Hemorrhagic Telangiectasia in a Pediatric Patient: A Case Report
No full textHereditary Hemorrhagic Telangiectasia (HHT)
is a disease defined by abnormal endothelial cell
development thatmanifests as cutaneous telangiectasias,
recurrent epistaxis, and visceral organ
arteriovenous malformations. This report’s objective
is to exhibit a unique presentation of an
uncommon disease within the pediatric population.
It also provides excellent educational value
through prioritizing the investigation of alternative
diagnoses in a pediatric patient who develops
a brain abscess without any known risk factors.
Herein we report the case of a previously
healthy 17-year-old femalewho developed sudden
aphasia and a newonset tonic-clonic seizure
after 3 days of headache and shortness of breath.
She had a past medical history of migraines and
recurrent epistaxis. Imaging confirmed a ringenhancing
lesion in her frontal lobe, which suggested
a brain abscess. She was treated with intravenous
antibiotics and steroids. Her neurological
symptoms subsided and she was discharged
home. Continuedwork-up revealed numerous
arteriovenous malformations, which
likely contributed to her brain abscess, and she
was diagnosed with HHT. HHT should be suspected
in pediatric patients who develop brain
abscesswithout any other risk factors.Additionally,
new onset neurological symptoms in pediatric
patients should be investigated promptly
with head imaging. Timely identification and
initiation of therapy is crucial due to the high
morbidity and mortality associated with brain
abscess, especially in HHT patients.
A 17-year-old female was transported to the
emergency department after suffering from a
sudden episode of inability to speak followed by
a single seizure episode at school. While in her
classroom, she reported a difficulty “finding
words” and stood up in panic fromher desk. She
approached the teacher to ask permission to
leave the room. Unable to speak, she began to
write on a sheet of paper, but her writing soon
became incoherent to both the teacher and to
herself.Her teacher sent her to the nurse’s office,
where she suffered a new-onset generalized tonic-
clonic seizure and the emergency medical
Brain Abscess as a Manifestation of Hereditary
Hemorrhagic Telangiectasia in a Pediatric Patient
¹University of South Florida College of Medicine, Tampa, FL
²Children’s Hospital at Lehigh Valley Health Network, Allentown, PA
Jose M. Soto, BS¹; Tibisay Villalobos, MD²
Corresponding Author: Jose M. Soto, BS, University of South
Florida College of Medicine, 12901 Bruce B Downs Blvd,
Tampa, FL 33612.
Email: [email protected]
The authors claim no conflicts of interest or disclosures.
AMSRJ 2015; 2(1):48-53
http://dx.doi.org/10.15422/amsrj.2015.05.005
ABSTRACT
CASE PRESENTATION
AMSRJ 2015 Volume 2, Number 1 49
service (EMS) was called. This seizure lasted a
few minutes and resolved by the time the EMS
arrived. During the seizure, she also suffered an
episode of epistaxis. She was able to communicate
on arrival to the ED, although with some
difficulty, and stated that she had a 3-day history
of headaches and shortness of breath. She also
reported a history of headaches since the age of
twelve. She stated her headaches usually begin
with an aura of “shimmering prisms and cones of
lights.” The pain is typically unilateral and acetaminophen
provides some relief. These
headacheswere sometimes associatedwith nausea
and mild photophobia. They typically resolvedwith
sleep.Over the last three days, however,
the headaches had worsened, and ibuprofen
became ineffective. She denied any recent
head trauma.
Her vital signs included a blood pressure of
120/73 mmHg, heart rate of 117 beats/minute,
respiratory rate of 16 breaths/minute, temperature
of 99.6° Fahrenheit.On exam, she appeared
anxious and in mild distress. Her cranial nerves
II-XII were grossly intact, and her pupils were
equally round and reactive to light. Dried blood
was found in both of her nostrils; there was no
active bleeding. There were no meningeal signs
during her neck exam. Her cardiovascular, pulmonary,
and abdominal exams were all within
normal limits. Her neurological exam was also
grossly normal with a Glasgow Coma Scale
score of 15, but she continued having difficulty
“finding words.” A complete blood count with
differential was drawn: hemoglobin was 14.8 g/
dL, hematocrit was 45.7%, white blood cells
were 14.8 cells/mcL (71% neutrophils, 18%
lymphocytes, 6% monocytes, 5% eosinophils),
and platelets were 245,000/mcL. A computed
tomography (CT) scan of her head without contrast
(Figure 1) showed an area of abnormally
low density in the left frontal lobe that was suggestive
of vasogenic edema as the grey-white
matter differentiation was maintained and the
edema primarily involved the white matter. No
evidence of intracranial hemorrhagewas found.
While air or maturing hematomas may also
cause lowdensity on CT scans, thesewere ruled
out due to the lack of a history of head trauma.
Given the history of rapid onset neurologic
symptoms and the elevated white blood cell
count, as well as imaging that suggested an area
of edemawithout obvious intracranial bleeding,
a brain abscess was suspected. Therefore, she
was admitted to the pediatric intensive care unit
and started on empiric intravenous antibiotic
therapy with ceftriaxone, metronidazole, and
vancomycin as well as levetiracetamfor seizure
prophylaxis.
Amagnetic resonance imaging (MRI) scanwith
and without contrast (Figures 2 and 3) confirmed
an area of vasogenic edema surrounding
a ring-enhancing lesion in the left frontal lobe.
Themidline shift seen on the earlierCTscanwas
also evident on theseMRI images.Although the
differential diagnosis for ring-enhancing lesions
includes glioblastoma multiforme, brain metastasis,
infarct, contusion, and neurocysticerosis,
Figure 1. Initial CT scan taken at presentation to the hospital showing an
area suggestive of vasogenic edema in the left frontal lobe (arrow) and
mild midline shift.
BRIEF REPORTS
BRAIN ABSCESS
AMSRJ 50 2015 Volume 2, Number 1
thesewere ruled out due to history and age of the
patient. A follow up magnetic resonance angiogram
(MRA) of the head (Figure 4) demonstrated
mass effect of the lesion on the medial
cerebral artery branches on the left side, but
there was no evidence of aneurysms, arteriovenous
malformations, or major vessel occlusion.
These findingswere also consistentwith a brain
abscess.
The patient continued to have headaches and six
days after admission, she became increasingly
confused and developed right upper extremity
weakness in addition to left facial drooping. A
Figure 2. T1-weighted coronalMRIwith contrast demonstrating
a left sided ring-enhancing lesion (arrow) surrounded by
vasogenic edema and also a midline shift.
Figure 3. T2-weighted transverse MRI with contrast that
highlights the area of vasogenic edema (arrow) and also further
demonstrates the midline shift seen in previous images.
Figure 4. Coronal MRA of the head showing mass effect of the
lesion on the branches of the left middle cerebral artery (arrow).
Figure 5. Repeat coronal MRI with the blue arrow pointing to
the original lesion and the red arrow pointing to the new lesion.
BRAIN ABSCESS
BRIEF REPORTS
AMSRJ 2015 Volume 2, Number 1 51
repeatMRI (Figure 5) demonstrated a new area
of enhancement and diffusion restriction inferolaterally
to the original lesion as well as increased
vasogenic edema. The following day,
she underwent a CT-guided biopsy of the original
lesion with cultures. The tissue culture grew
Micrococcus luteus/lylae. After the procedure,
IV dexamethasone was added to her antibiotics
to reduce brain tissue swelling. She continued
this treatment regime for two additional weeks
as her neurological symptoms began to subside.
The patient was then discharged home for the
remaining five weeks of IV antibiotics. During
this time frame, her facial palsy resolved and she
regained strength in her right upper extremity.
Her headaches also improved.
During her admission, itwas discovered that she
had a past medical history significant for migraine
headaches since the age of twelve and
recurrent episodes of epistaxis. It was also revealed
that her mother had hereditary hemorrhagic
telangiectasia (HHT). There was a high
level of suspicion forHHT due to family history
and recent events, so studies of the chest to
search for pulmonary arteriovenous malformations
(PAVMs) aswell as a transcranialDoppler
studywere performed.Numerous PAVMswere
found in the patient’s left upper lobe aswell as in
her right middle lobe (Figure 6). The transcranial
Doppler study with agitated saline also
demonstrated an arteriovenous shunt in themiddle
cerebral artery. The patient met 3 of the 4
diagnostic Curacao criteria for HHT¹ (Table 1)
and itwas concluded that her undiagnosedHHT
had predisposed her to this brain abscess.
The patient completed her IV antibiotic course
and followupMRI studies demonstrated that the
brain abscess had resolved. The majority of the
PAVMs seen on arteriogram have since been
obliterated.
Figure 6. Pulmonary arteriogram demonstrating a dominant
arteriovenous malformation in the inferior aspect of the upper
lobe (arrow) along with numerous smaller malformations.
Curacao Criteria for HHT
1. Recurrent Epistaxis
2. Telangiectasias
3. Visceral Manifestations
4. Affected 1st degree relative
3-4 criteria met: definitive HHT
2 criteria met: suspected HHT
1 criteria met: unlikely to be HHT
!
Table 1. Curacao Criteria for the diagnosis of HHT
BRIEF REPORTS
BRAIN ABSCESS
AMSRJ 52 2015 Volume 2, Number 1
Epidemiology and Pathophysiology
HHT is an autosomal dominant inherited disorder
that affects 1 in 10,000 people with no preference
for either sex.² It is most common in the
Caucasian population and is 97%penetrant.²Almost
30%of patients do not have a family history
of the disease.² The genes affected by this
disorder both code for Transforming Growth
Factor-β receptors: ENG on chromosome
9q34.1 andACVRL-1 (activinAreceptor type IIlike
1) on chromosome 12q13.13.³ These genes
are crucial in the development of vascular endothelial
cells during angiogenesis and either
mutation will manifest in the same manner.
Clinical Manifestations
The syndrome is defined by telangiectasias, or
dilated post-capillary venules, of the skin, mucousmembranes
and internal organs.Cutaneous
telangiectasias typically occur on the face,
hands, and lips. When telangiectasias occur in
the nasal mucosa, they may cause spontaneous
recurrent epistaxis which is the first symptom
formore than 90%of patients.4,5More than 50%
of patients with HHT will manifest with this
symptom before the age of twenty.¹ The bleeding
can be so severe that 10-30%of patientswill
require blood transfusions over the course of
their lifetime. In roughly 40% of patients, the
gastrointestinal system is involved and can also
be the source of significant blood loss.3,6
The diagnostic Curacao criteria¹ (Table 1) require
three of the following four findings: recurrent
epistaxis, cutaneous telangiectasias, visceral
organ involvement (i.e., arteriovenous malformations
thatmay bleed) and an affected firstdegree
relative. Few patients, however, manifest
enough signs and symptoms within the first
three decades of life to meet the criteria, and
therefore, it is recommended that asymptomatic
children of HHT patients be genetically
screened for the disease.¹
Neurological manifestations
In a healthy patient, the lung capillary beds function
to filter the blood before it is pumped to the
brain, but pulmonary vascular malformations
(PAVMs) found in HHT patients compromise
this protection system.7 Large PAVMs can result
in paradoxical micro-emboli entering cerebral
circulation and subsequent ischemic brain
injury (i.e., stroke). Abscess formation can be
caused by direct seeding of pathogenic bacteria
into the brain parenchyma or secondarily after
an anoxic brain injury creates an environment
suitable for bacteria growth. About 1% of HHT
patients can develop cerebral abscess or septic
meningitis, which is significantly higher than
the general population.7 For the reasons noted
above, PAVMs are a significant source of morbidity
and mortality in HHT patients7 and they
can also lead to high-output cardiac failure in
later life.²
Brain abscesses are usually of poly-microbial
origin; only the slow growing members of the
Micrococcus genuswere isolated in this case because
empiric antimicrobial therapy had already
begun by the time of the biopsy.8, 9 It is important
to note that brain abscesses do not commonly
present with the typical cardinal signs of infection:
fever, leukocytosis, or positive blood cultures.
10
The neurological symptoms of brain abscesses
are due in large part to the mass effect of the
lesion on surrounding structures.Consequently,
the symptoms can include a wide spectrum of
neurologic symptoms such as aphasia, seizures,
and headaches depending on the location of the
lesion. HHT patients can also develop cerebral
vascular malformations (CAVMs), which can
manifest as various neurological symptoms.
Approximately one-quarter of HHT patients
DISCUSSION
BRAIN ABSCESS
BRIEF REPORTS
AMSRJ 2015 Volume 2, Number 1 53
will have a CAVM in their lifetime and there is
a 0.5%bleeding risk per year.¹ The treatment of
choice for arteriovenousmalformations remains
embolization of the feeding blood vessels.11
•The differential diagnosis for a pediatric
patient without any known risk factors who
develops a brain abscess should include
HHT.
•Brain abscesses are typically poly-microbial
in nature and do not present with the
usual signs of infection, such as fever, leukocytosis,
or positive blood cultures.
1. Faughnan ME, Palda VA, Garcia-Tsao G, et al. International
guidelines for the diagnosis and management of hereditary
haemorrhagic telangiectasia. Journal of medical genetics. 2011;48
(2):73-87.
2. Daroff R, ed. Bradley\u27s Neurology in Clinical Practice. 6th ed.
Philadelphia, PA: W.B. Saunders; 2012.
3.Mark Feldman LF, Lawrence Brandt, eds. Sleisenger and Fordtran\u27s
gastrointestinal and liver disease: pathophysiology, diagnosis,
management. Philadelphia, PA: Saunders Elsevier; 2010.
4. Sadick H, Sadick M, Gotte K, et al. Hereditary hemorrhagic
telangiectasia: an update on clinical manifestations and diagnostic
measures. Wiener klinische Wochenschrift. 2006;118(3-4):72-80.
5. Murtagh B, Fulgham JR. 23-year-old woman with increasing
frequency ofmigraine headaches.MayoClinic proceedings. 2002;77
(10):1105-8.
6.ChenCW, Jao SW,WuCC, et al.Red spots on the hands and red blood
in the stools. Lancet. 2008;371(9619):1190.
7. Moradi M, Adeli M. Brain abscess as the first manifestation of
pulmonary arteriovenous malformation: A case report. Advanced
biomedical research. 2014;3:28.
8. Frazier JL, Ahn ES, Jallo GI. Management of brain abscesses in
children. Neurosurgical focus. 2008;24(6):E8.
9.SelladuraiBM,SivakumaranS,AiyarS, et al. Intracranial suppuration
caused by Micrococcus luteus. British journal of neurosurgery.
1993;7(2):205-7.
10. Dong SL, Reynolds SF, Steiner IP. Brain abscess in patients with
hereditary hemorrhagic telangiectasia: case report and literature
review. The Journal of emergency medicine. 2001;20(3):247-51.
11. Meek ME, Meek JC, Beheshti MV. Management of pulmonary
arteriovenous malformations. Seminars in interventional radiology.
2011;28(1):24-31.
REFERENCES
LEARNING POINTS
BRIEF REPORTS
BRAIN ABSCES
The function and origin of the CD4+ T cell in the classical Hodgkin lymphoma microenvironment
No full textPhDClassical Hodgkin lymphoma (CHL) is a germinal centre B cell malignancy where the bulk of the tumour comprises a non-clonal immune infiltrate enriched for CD4+ T cells. The role of these cells in the pathophysiology of CHL is poorly understood. Biomarkers predictive of clinical outcome in CHL are limited. This thesis examines microenvironment biomarkers with the goal of identifying the 10-20% of patients who are not cured by conventional therapy, and also investigates the function of the CD4+ T cell in CHL.
The prognostic power of FOXP3, a marker of regulatory T cells, CD68, a macrophage marker and CD20, a B cell marker, is validated in a new patient cohort and for the first time CD68 and FOXP3 are combined in a statistically robust scoring system. The data presented challenge the assumption that the microenvironment is Th2-polarised or senescent and demonstrates relative over-expression of T-BET, a Th1 marker and under-expression of PD1, a marker of senescence/exhaustion, with little evidence for Th2 marker expression. A cytokine-enriched in vitro culture system was developed demonstrating superior proliferation and longevity of CHL-derived T cells compared to non-malignant tissue-derived controls. These cells sustain expression of markers associated with proliferation and longevity (e.g. CD27, CD28) and remain functional (express cytokines) for many weeks. A panel of CD4+ T cell-specific markers was determined capable of differentiating CHL-derived from non-malignant or non-Hodgkin lymphoma-derived CD4+ T cells, in which markers of central memory (CD62L and CCR7) and early activation (CD69) are over-represented and markers of senescence (CD57 and PD1) are under-represented. Cytokine profiles were found to resemble Th1 (expression of IL2, IFN- and TNF expression) rather than Th2 (IL4, IL13, IL21, IL10 and IL6) responses.
The data presented confirm a new prognostic biomarker signature and show a Th1 rather than Th2-dominated microenvironment enriched for cytokine-secreting functional effector CD4+ T cells and long-lived, proliferative cells resembling central memory cells rather than hypoproliferative, anergic, non-functional T cells
Comparison of ixekizumab with etanercept or placebo in moderate-to-severe psoriasis (UNCOVER-2 and UNCOVER-3): results from two phase 3 randomised trials.
No full textBACKGROUND: Ixekizumab is a humanised monoclonal antibody against the proinflammatory cytokine interleukin 17A. We report two studies of ixekizumab compared with placebo or etanercept to assess the safety and efficacy of specifically targeting interleukin 17A in patients with widespread moderate-to-severe psoriasis. METHODS: In two prospective, double-blind, multicentre, phase 3 studies (UNCOVER-2 and UNCOVER-3), eligible patients were aged 18 years or older, had a confirmed diagnosis of chronic plaque psoriasis at least 6 months before baseline (randomisation), 10% or greater body-surface area involvement at both screening and baseline visits, at least a moderate clinical severity as measured by a static physician global assessment (sPGA) score of 3 or more, and a psoriasis area and severity index (PASI) score of 12. Participants were randomly assigned (1:2:2:2) by computer-generated random sequence with an interactive voice response system to receive subcutaneous placebo, etanercept (50 mg twice weekly), or one injection of 80 mg ixekizumab every 2 weeks, or every 4 weeks after a 160 mg starting dose. Blinding was maintained with a double-dummy design. Coprimary efficacy endpoints were proportions of patients achieving sPGA score 0 or 1 and 75% or greater improvement in PASI at week 12. Analysis was by intention to treat. These trials are registered with ClinicalTrials.gov, numbers NCT01597245 and NCT01646177. FINDINGS: Between May 30, 2012, and Dec 30, 2013, 1224 patients in UNCOVER-2 were randomly assigned to receive subcutaneous placebo (n=168), etanercept (n=358), or ixekizumab every 2 weeks (n=351) or every 4 weeks (n=347); between Aug 11, 2012, and Feb 27, 2014, 1346 patients in UNCOVER-3 were randomly assigned to receive placebo (n=193), etanercept (n=382), ixekizumab every 2 weeks (n=385), or ixekizumab every 4 weeks (n=386). At week 12, both primary endpoints were met in both studies. For UNCOVER-2 and UNCOVER-3 respectively, in the ixekizumab every 2 weeks group, PASI 75 was achieved by 315 (response rate 89·7%; [effect size 87·4% (97·5% CI 82·9-91·8) vs placebo; 48·1% (41·2-55·0) vs etanercept]) and 336 (87·3%; [80·0% (74·4-85·7) vs placebo; 33·9% (27·0-40·7) vs etanercept]) patients; in the ixekizumab every 4 weeks group, by 269 (77·5%; [75·1% (69·5-80·8) vs placebo; 35·9% (28·2-43·6) vs etanercept]) and 325 (84·2%; [76·9% (71·0-82·8) vs placebo; 30·8% (23·7-37·9) vs etanercept]) patients; in the placebo group, by four (2·4%) and 14 (7·3%) patients; and in the etanercept group by 149 (41·6%) and 204 (53·4%) patients (all
Tonsillitis and sore throat in children
No full textSurgery of the tonsils is still one of the most frequent procedures during childhood. Due to a series of fatal outcomes after hemorrhage in children in Austria in 2006, the standards and indications for tonsillectomy have slowly changed in Germany. However, no national guidelines exist and the frequency of tonsil surgery varies across the country. In some districts eight times more children were tonsillectomized than in others. A tonsillectomy in children under six years should only be done if the child suffers from recurrent acute bacterially tonsillitis. In all other cases (i.e. hyperplasia of the tonsils) the low risk partial tonsillectomy should be the first line therapy. Postoperative pain and the risk of hemorrhage are much lower in partial tonsillectomy (=tonsillotomy). No matter whether the tonsillotomy is done by laser, radiofrequency, shaver, coblation, bipolar scissor or Colorado needle, as long as the crypts are kept open and some tonsil tissue is left behind. Total extracapsular tonsillectomy is still indicated in severely affected children with recurrent infections of the tonsils, allergy to antibiotics, PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis) and peritonsillar abscess. With regard to the frequency and seriousness of the recurrent tonsillitis the indication for tonsillectomy in children is justified if 7 or more well-documented, clinically important, adequately treated episodes of throat infection occur in the preceding year, or 5 or more of such episodes occur in each of the 2 preceding years (according to the paradise criteria). Diagnosis of acute tonsillitis is clinical, but sometimes it is hard to distinguish viral from bacterial infections. Rapid antigen testing has a very low sensitivity in the diagnosis of bacterial tonsillitis and swabs are highly sensitive but take a long time. In all microbiological tests the treating physician has to keep in mind, that most of the bacterials, viruses and fungi belong to the healthy flora and do no harm. Ten percent of healthy children even bear strepptococcus pyogenes all the time in the tonsils with no clinical signs. In these children decolonization is not necessary. Therefore, microbiological screening tests in children without symptoms are senseless and do not justify an antibiotic treatment (which is sometimes postulated by the kindergartens). The acute tonsillitis should be treated with steroids (e.g. dexamethasone), NSAIDs (e.g. ibuprofene) and betalactam antibiotics (e.g. penicillin or cefuroxime). With respect to the symptom reduction and primary healing the short-term late-generation antibiotic therapy (azithromycin, clarithromycin or cephalosporine for three to five days) is comparable to the long-term penicilline therapy. There is no difference in the course of healing, recurrence or microbiological resistance between the short-term penicilline therapy and the standard ten days therapy. On the other hand, only the ten days antibiotic therapy has proven to be effective in the prevention of rheumatic fever and glomerulonephritic diseases. The incidence of rheumatic heart disease is currently 0.5 per 100,000 children of school age. The main morbidity after tonsillectomy is pain and the late haemorrhage. Posttonsillectomy bleeding can occur till the whole wound is completely healed, which is normally after three weeks. Life-threatening haemorrhages occur often after smaller bleedings, which can spontaneously cease. That is why every haemorrhage, even the smallest, has to be treated properly and in ward. Patients and parents have to be informed about the correct behaviour in case of haemorrhage with a written consent before the surgery.The handout should contain important addresses, phone numbers and contact persons. Almost all cases of fatal outcome after tonsillectomy were due to false management of haemorrhage. Haemorrhage in small children can be especially life-threatening because of the lower blood volume and the danger of aspiration with asphyxia. A massive haemorrhage is an extreme challenge for every paramedic or emergency doctor because of the difficult airway management. Intubation is only possible with appropriate inflexible suction tubes. All different surgical techniques have the risk of haemorrhage and even the best surgeon will experience a postoperative haemorrhage. The lowest risk of haemorrhage is after cold dissection with ligature or suturing. All "hot" techniques with laser, radiofrequency, coblation, mono- or bipolar forceps have a higher risk of late haemorrhage. Children with a hereditary coagulopathy have a higher risk of haemorrhage. It is possible, that these children were not identified before surgery. Therefore it is recommended by the Society of paediatrics, anaesthesia and ENT, that a standardised questionnaire should be answered by the parents before tonsillectomy and adenoidectomy. This 17-point-checklist questionnaire is more sensitive and easier to perform than a screening with blood tests (e.g. INR and PTT). Unfortunately, a lot of surgeons still screen the children preoperatively by coagulative blood tests, although these tests are inappropriate and incapable of detecting the von Willebrand disease, which is the most frequent coagulopathy in Europe. The preoperative information about the surgery should be done with the child and the parents in a calm and objective atmosphere with a written consent. A copy of the consent with the signature of the surgeon and both custodial parents has to be handed out to the parents
