Stockman Year Book of Pediatrics 2013

Pediatrics
1. Auflage 2013
ISBN: 978-1-4557-7310-7
Verlag: Elsevier HealthScience EN
Format: EPUB
Kopierschutz: Adobe DRM (»Systemvoraussetzungen)

E-Book, Englisch, Band Volume 2013, 100 Seiten

Reihe: Year Books

The Year Book of Pediatrics brings you abstracts of the articles that reported the year's breakthrough developments in pediatrics, carefully selected from more than 500 journals worldwide. Expert commentaries evaluate the clinical importance of each article and discuss its application to your practice. There's no faster or easier way to stay informed! This annual covers all aspects of pediatric care from infectious diseases and immunology, adolescent medicine, therapeutics and toxicology, child development, dentistry and otolaryngology and neurology and psychiatry. The Year Book of Pediatrics publishes annually in December of the preceding year.

Autoren/Hrsg.

Stockman, III James A.

Leseproben

Tonsillectomy in Children with Periodic Fever with Aphthous Stomatitis, Pharyngitis, and Adenitis Syndrome
Garavello W, Pignataro L, Gaini L, et al (Univ of Milano-Bicocca, Monza, Italy; Univ of Milan; et al) J Pediatr 159:138-142, 2011§
J.A. Stockman, III, MD Evidence Ranking B Expert Rating 3 Abstract
Objective To seek evidence supporting a role for tonsillectomy or adenotonsillectomy in the management of affected children with periodic fever with aphthous stomatitis, pharnygitis, and adenitis (PFAPA) syndrome. Study Design
A comprehensive literature search was conducted to identify all published English-language observational and randomized studies evaluating the efficacy of tonsillectomy or adenotonsillectomy on PFAPA syndrome. A combination of keywords was used to identify relevant articles. Results
A total of 15 studies including 149 treated children were found, including 13 observational noncomparative studies and 2 randomized controlled trials. The pooled rate of complete resolution emerging from the combined analysis of all treated children was 83% (95% CI, 77%-89%). A meta-analysis of the two randomized controlled trials showed homogeneity of the results (P = .37, Breslow-Day test) and a common odds ratio for complete resolution of 13 (95% CI, 4-43; P < .001). Conclusions
Surgery appears to be a possible option for management of PFAPA syndrome. Available evidence is limited, however, and the precise role of surgery remains to be clarified. We suggest considering this option when symptoms markedly interfere with the child’s quality of life and medical treatment has failed. Commentary
Periodic fever with aphthous stomatitis, pharyngitis, and adenitis is a syndrome that has been around since 1987, achieving the acronym PFAPA some 2 years later.1 The disorder typically occurs in young children (younger than age 5 years) and is characterized by short periods of illness lasting 3 to 4 days that recur regularly every 3 to 8 weeks for several years. The cycles occur on a strict and regular basis. In between, these youngsters feel perfectly well. PFAPA is frequently discussed together with other periodic fever syndromes, but its cause is unknown, and it is not understood whether this is primarily genetic in origin or due to some underlying initial infectious process. It produces disturbances in innate immunity that are quite complex. Flairs are accompanied by increased serum levels of activated T-lymphocyte chemokines and proinflammatory cytokines. Cases in family members with similar periodic episodes of fever are beginning to suggest a possible role of both genetics and the environment. Given that the etiology of PFAPA remains an enigma, so too does the precise management. A possible treatment for PFAPA is a single dose of prednisone (1–2 mg/kg body mass) at the beginning of each fever episode. A single dose usually terminates the fever within several hours. However, in some children, steroids cause the fever episodes to occur more frequently (and more regularly). In such cases, care providers have switched to the use of colchicine, which is used in the treatment of familial Mediterranean fever. The role of tonsillectomy has remained uncertain. In one study, adenotonsillectomy was found to be totally effective in resolving symptoms.2 A comprehensive review of the literature on PFAPA published in 2006, however, observed only weak evidence on the effectiveness of tonsillectomy in this syndrome and concluded that tonsillectomy should not be performed.3 Garavello et al have jumped into the tonsillectomy debate by doing an electronic database search of all objective studies published in the English language between January 1987 and May 2010 examining the effect of tonsillectomy or adenotonsillectomy in the management of PFAPA syndrome. The authors conducted 2 separate analyses to evaluate the magnitude of the effect of tonsillectomy. First they evaluated the benefits emerging from clinical series. The main objective was to determine the absolute rate of resolution combining all series on this topic. A binomial distribution model was used to calculate the 95% confidence interval of this rate. Second, the authors focused on controlled studies to assess the relative rate of resolution compared with medical management. To do so, they calculated a combined estimate of the odds ratio across studies determining the natural resolution of PFAPA. The comprehensive literature review by Garavello et al documents that there remains insufficient evidence on the effectiveness of tonsillectomy for PFAPA syndrome. All studies reviewed had small sample sizes and, in most cases, the follow-up period was very short. Although there was a tendency for the benefits of surgery to be increasingly reported over the last decade or so, there was no evidence observed to definitively support the effectiveness of surgery. Also, there was no evidence to distinguish the effects of tonsillectomy versus adenotonsillectomy.4 Thus it is that most practitioners will continue to rely on the use of oral steroids to control flairs of PFAPA. In recent times, practitioners have also been using cimetidine. Cimetidine, a common H2 antagonist, has immune-modulating properties, inhibiting chemotaxis and T-cell activation and has been used with some success in doses of 150 mg once or twice a day and of 20 mg/kg/d to 40 mg/kg/d. According to 1 report, PFAPA syndrome will resolve in 28% to 44% of cases treated with cimetidine.5 If nothing else, a tincture of time cures all, as PFAPA will ultimately resolve on its own albeit only after a number of years in some cases. This commentary closes with mention about presidential illnesses, including one related to the upper airway. What president had more numerous illnesses/conditions than any other in and about the time he was in office? The answer to this question is not Franklin Roosevelt (who had polio); it is George Washington (1732-1799). Historians count 10 bouts of serious illness as well as innumerable minor ailments that affected him. Obsessive about his health, GW meticulously detailed in his diaries his physical trials and triumphs and his favored remedies. An ardent fan of the humoral medicine of the day, he enthusiastically volunteered to be bled and blistered; but hedging his bets with numerous quack therapies on the market, he also bought a pair of Elisha Perkins’s popular tractors with their persuasive claims for pain relief. It is noted that at 17 years of age he contracted the “Ague” (probably malaria) and two years later smallpox. An attack of pleurisy was followed by influenza and then dysentery. Downing large quantities of Dr James’s powders—“the most excellent medicine in the world” —Washington found his complaints lingered “in spite of the efforts of all of the Sons of Aesculapius.” By the time Washington took the oath of office in 1789, he sported glasses, was deaf to some degree, and wore false teeth. Within six weeks of his inaugural speech he was laid low again, with an abscess on his thigh that took 3 months to heal. Weathering further attacks of Agues and fevers, he survived his presidency to retire to his Mount Vernon estate in 1797 in the hope of a long and well-deserved rest. It was not to be. In December 1799, after riding all day in a storm, Washington took to his bed with a sore throat for which he gamely asked his overseer to bleed him in the absence of any professional aid. The next day his lifelong friend, Dr James Craik, and a fellow physician, Dr Gustavus Brown, bled the Founding Father twice more. Despite the objections of a third physician, Dr Elisha Dick, who proposed a tracheotomy to help the expiring pioneer to breathe, the doctors took a fourth donation of blood, amounting to a grand total of somewhere between 4 pints and 6 pints (just under three liters). Overwhelmed by his infection—possibly diphtheria or acute epiglottitis—and weak from blood loss, Washington died, making history by having the most numerous recorded presidential (including the pre- and postpresidential periods) illnesses/conditions.6 References
1. Marshall, G.S., Edwards, K.M., Lawton, A.R. PFAPA syndrome. Pediatr Infect Dis J. 1989;8:658–659. 2. Licameli, G., Jeffrey, J., Luz, J., Jones, D., Kenna, M. Effect of adenotonsillectomy in PFAPA syndrome. Arch Otolaryngol Head Neck Surg. 2008;134:136–140. 3. Leong, S.C., Karkos, P.D., Apostolidou, M.T. Is there a role for the otolaryngologist in PFAPA syndrome? A systematic review. Int J Pediatr Otorhinolaryngol. 2006;70:1841–1845. 4. Thomas, K.T., Feder, H.M., Jr., Lawton, A.R., Edwards, K.M. Periodic fever syndrome in children. J Pediatr. 1999;135:15–21. 5. Feder, H.M., Jr. Cimetidine treatment for periodic fever associated with aphthous stomatitis, pharyngitis and cervical adenitis. Pediatr Infect Dis J. 1992;11:318–321. 6. Moore, W. The first George W. BMJ. 2009;338:362. Original Article Garavello, W., Pignataro, L., Gaini, L., et al, Tonsillectomy in children...