The authors present the clinical case of a 14-year old girl with weight loss, anorexia, epigastric abdominal pain and postprandial vomiting with 5 months duration. There was a background of trichophagia for 2 years without evidence of alopecia or psychiatric history. The physical examination revealed an epigastric mass motionless, stony, with poorly defined limits, painful on palpation and about 7 cm diameter. Abdominal ultrasonography showed thickening of the gastric wall and antrum with gastric distension. The abdominal tomography scan and endoscopic examination revealed the presence of a bulky trichobezoar occupying almost the entire gastric lumen. It was decided to undergo gastrotomy and extraction of the bezoar. The postoperative period was uneventful.

SUMMARYAcquired inhibitors of coagulation causing bleeding manifestations are rare in children. They emerge, normally in the context of autoimmune diseases or drug ingestion, but transient and self-limiting cases can occur after viral infection. We describe, an otherwise healthy, 7-year-old girl who had gingival bleeding after a tooth extraction. The prothrombin time (PT) and the activated partial thromboplastin time (APTT) were both prolonged with evidence of an immediate acting inhibitor (lupic anticoagulant). Further coagulation studies demonstrated prothrombin (FII) deficiency and prothrombin directed (FII) antibodies. The serological tests to detect an underlying autoimmune disease were all negative. The coagulation studies normalised alongside the disappearance of the antibody. This article presents lupus anticoagulant hypoprothrombinaemia syndrome (LAHS) as a rare case of acquired bleeding diathesis in childhood. BACKGROUND

Background Lack of coordinated, high-quality care for children and young people with epilepsies is thought to contribute to preventable hospital admissions and avoidable epilepsy-related deaths, especially around the time of transition to adult services. However, these links have rarely been investigated in largescale data-linkage studies. Methods We accessed unit-level data from Round 1 (2009-11) and Round 2 (2013-14) of the Epilepsy12 national clinical audit and data on death registrations and unplanned hospital admissions. We investigated the association between unit-level performance in involving a paediatrician with epilepsy expertise, Epilepsy Specialist Nurse (ESN), and Paediatric Neurologist (PN) in Round 1 and the proportion of adolescents with epilepsy admitted to each unit who subsequently died during the study period (2009-15). We also investigated whether change in Epilepsy12 performance between the audit rounds was associated with change in the standardised ratio of observed:expected unplanned epilepsy admissions. Findings 79/1164(6•8%) of patients included in the PN analyses died; 54/1164(4•6%) deaths occurred posttransition. Regression models estimated an absolute reduction of 6.4%(95% CI 1.3-12.7%) in total mortality risk and 5•7%(0•6-10•8%) post-transition mortality risk between units where all versus no eligible patients were seen by a PN. In dichotomised analyses, units where all eligible patients were seen by a PN were estimated to have 4•6%(0•3-8•9%) absolute mortality reduction and 4•6%(1•2-8 •0%) reduction in post transition deaths compared to other units. There was no significant association between performance on other audit measures and mortality. In units where access to an ESN deteriorated, the standardised ratio of epilepsy admissions increased by a mean of 0•21 (95% CI 0•01-0•42). Interpretation Among adolescents with epilepsy, greater involvement of tertiary specialists in paediatric care predicts lower mortality in the period after transition to adult services. Reduced access to an ESN was associated with an increase in paediatric epilepsy admissions.

The authors describe a 16-year-old boy, previously healthy, who was admitted to our hospital for left-sided spontaneous pneumothorax. On physical examination he presented with marfanoid habitus. Pneumothorax was managed conservatively with resolution. Four months later he had a recurrence of left-sided pneumothorax and 1 week after that he presented with contralateral pneumothorax. He underwent video-assisted thoracoscopic surgery twice for bullectomy and pleurodesis. No further recurrence was stated. Additional investigation showed a prolapsed cardiac mitral valve and Marfan syndrome was confirmed genetically.