A reappraisal of childhood drowning in a pediatric emergency department

BackgroundIn the present study, we aimed to investigate the demographic and clinical features, laboratory and radiologic characteristics, management, and outcomes of pediatric drowning patients in order to identify predictors of hospital admission, and to evaluate the need for respiratory support, and prognosis.MethodsIn this retrospective chart review, children aged 0 to 18 years who presented to the pediatric emergency department due to drowning between July 2009 and September 2019 were included. Demographics, initial vital signs, clinical findings, laboratory and radiologic results, and the need for respiratory support or cardiopulmonary resuscitation in the emergency department were recorded. Subjects were divided into 6 groups using the Szpilman classification system.ResultsA total of 89 patients were enrolled. Among the children who were admitted to the hospital, initial Szpilman score, crepitations on lung auscultation, and pathologic chest X-ray (CXR) findings were higher and Glasgow Coma Score and oxygen saturation (SpO 2) levels were lower than those of children who were discharged from the emergency department. A Szpilman score of ≥4, a lactate level of >2 mmol/L, and pathologic CXR findings were identified as predictors of hospital admission. Of the 89 patients, 22 (24.7%) underwent non-invasive ventilation (NIV) treatment and were classified as grade 3 or 4 according to the Szpilman score. Length of stay in the pediatric intensive care unit (PICU) and in the hospital was lower in patients who underwent NIV. As the Szpilman score increased as of grade 3, a positive correlation was observed with lactate levels (p <0.001, r: 0.552) and the total length of stay in the hospital (p: 0.001, r : 0.491), both of which gradually increased.ConclusionThe Szpilman score was associated with the duration of hospital stay and the degree of hypoxia, so it could help the physician make rapid decisions on ventilation strategy. Application of NIV in the emergency department shortened the length of stay in the PICU and in the hospital, suggesting that it can be used more often in pediatric emergency settings.     

Information and anxiety: a critical reappraisal

A series of British and North American research studies into information-giving and the relief of patient anxiety is reviewed The research results are inconsistent and the theory that information relieves anxiety in hospitalized patients appears to be an oversimplification It is argued that 'information' is conventionally viewed as a neutral and objective entity which can be transmitted to patients in semantic form through language However, recent advances in the philosophy of language suggest that human communication depends less on the decoding of semantic information than upon the inferences which recipients draw from context Communication, therefore, becomes a problem-solving process in which communicators selectively present what they know in order to induce recipients to infer the intended meanings This inferential model of communication provides a theoretical basis from which research studies can be reappraised Viewed from an inferential perspective, the results suggest that patient anxiety can be relieved more reliably by the use of re-framing and empowering interventions than by the presentation of information in a neutral way with no direct attempt to influence the inferences which patients may make     

Migraine preventive medications: a reappraisal

Newer acute care migraine medications demonstrate improved rapidity of action, consistent effectiveness, excellent safety profiles, and rarely cause rebound headaches. Their use could decrease the need for migraine-preventive medication. The present analysis derives a formula that can be used by practitioners to determine the cost-effectiveness of various migraine-preventive medications relative to selected acute-care medications. We propose a measure called the cost-equivalent number (CEN), the number of headaches per month at which the cost of the preventive medication equals the cost savings in acute-care treatment realized by using the preventive medication. The use of the CEN individualizes the decision of whether to use a migraine-preventive medication, weighing both the efficacy and cost of the preventive medication against the cost of the acute-care medication. A CEN lower than the migraine frequency suggests that use of a preventive medication will be cost-effective.     

Second-degree atrioventricular block: a reappraisal

In this review, we discuss the various forms and causes of second-degree atrioventricular (AV) block and the reasons they remain poorly understood. Both type I and type II block characterize block of a single sinus P wave. Type I block describes visible, differing, and generally decremental AV conduction. Type II block describes what appears to be an all-or-none conduction without visible changes in the AV conduction time before and after the blocked impulse. Although the diagnosis of type II block is possible with an increasing sinus rate, absence of sinus slowing is an important criterion of type II block because a vagal surge (generally a benign condition) can cause simultaneous sinus slowing and AV nodal block, which can superficially resemble type II block. The diagnosis of type II block cannot be established if the first postblock P wave is followed by a shortened PR interval or is not discernible. A pattern resembling a narrow QRS type II block in association with an obvious type I structure in the same recording (e.g., Holter) effectively rules out type II block because the coexistence of both types of narrow QRS block is exceedingly rare. Concealed His bundle or ventricular extrasystoles confined to the specialized conduction system without myocardial penetration and depolarization can produce electrocardiographic patterns that mimic type I and/or type II block (pseudo-AV block). All correctly defined type II blocks are infranodal. A narrow QRS type I block is almost always AV nodal, whereas a type I block with bundle branch block barring acute myocardial infarction is infranodal in 60% to 70% of cases. A 2:1 AV block cannot be classified in terms of type I or type II block, but it can be nodal or infranodal. Infranodal blocks require pacing regardless of form or symptoms. The widespread use of numerous disparate definitions of type II block appears primarily responsible for many of the problems surrounding second-degree AV block. Adherence to the correct definitions provides a logical and simple framework for clinical evaluation.     

Routine neonatal circumcision: a reappraisal

Routine neonatal circumcision has long been a controversial subject. The American Academy of Pediatrics has recently outlined a new position on circumcision that is a marked departure from its previous stance. Neonatal circumcision has many potential advantages: The procedure helps prevent urinary tract infections, penile cancer, sexually transmitted diseases and, perhaps, acquired immunodeficiency syndrome. The risk of complications from the procedure is low. Fewer penile problems occur in circumcised boys than in uncircumcised boys. It is more economical to perform the procedure early in life, rather than later. No evidence shows that penile hygiene alone is as beneficial as circumcision.     

The social policy statement: a reappraisal

The social policy statement has been an extremely influential text in recent nursing history. Its potential as a guide in the future, however, depends on whether the view of the world it represents is one that nurses want to support. This article analyzes the concepts of person and society that underlie the definition of nursing. It suggests that at least two noncomplementary models of person and society are operating in the policy statement and discusses implications of those models for a theory of nursing.     

Surviving sepsis campaign: a critical reappraisal

In 2002, the declaration of Barcelona launched a worldwide campaign that proposed to decrease in sepsis-related mortality by the introduction of evidence-based medicine into the management of sepsis. This paved the way for the publication of a wide selection of recommendations entitled the Surviving Sepsis Campaign (SSC) Guidelines. Whereas most of the medical community received the guidelines with enthusiasm, dissonant voices were made public just after its publication, and in recent years, the SSC guidelines were a source of intense debate, resulting in a recent revision of the guidelines. In the midst of a large controversy, it is evident that a critical reappraisal of the SSC guidelines is timely. In our opinion, whereas many relevant aspects of the SSC guidelines have been discussed, there are three major limitations that deserve a closer look, and they are sepsis as a public health issue, the weight of the evidence behind the recommendations, and the absence of recommendations related to the prevention of sepsis. In conclusion, although we recognize that the SSC is a valuable initiative, many of its present aspects must be revised to provide a clear message for clinicians taking care of sepsis patients at bedside. New guidelines should be based on solid evidence, have no interference from the pharmaceutical or medical equipment industry, and should have a stronger preventive and public health approach.     

Economic factors and longevity in spinal cord injury: a reappraisal

Strauss D, DeVivo M, Shavelle R, Brooks J, Paculdo D. Economic factors and longevity in spinal cord injury: a reappraisal.

Objective

To review and reassess the findings of Krause and colleagues on the effect of economic and other risk factors on life expectancy after spinal cord injury, using an expanded and updated database.

Design

Pooled person-year analysis.

Setting

Model Spinal Cord Injury Systems hospitals.

Participants

A total of 7331 persons injured since 1973 who were enrolled in the National Spinal Cord Injury Database and received an evaluation between November 1995 and December 2005.

Interventions

Not applicable.

Main Outcome Measures

Mortality, determined by routine follow-up supplemented by information from the Social Security Death Index. Logistic regression models based on the predictor variables were developed to estimate the chance of dying in a given year.

Results

As in the Krause study, life expectancies of persons with the greatest handicap in economic self-sufficiency were substantially shorter than average. However, the positive effect of favorable economics was much less than previously reported, largely because having health insurance coverage through workers’ compensation was no longer a powerful (or statistically significant) predictor of survival.

Conclusions

The beneficial effect of favorable economics appears to be much less than previously reported. Further, the interpretation of the effects of modifiable factors (such as economics and social integration) is complicated by questions of cause and effect.     

To circ or not: a reappraisal

Routine circumcision remains a topic of controversy. The most recent male circumcision policy from the American Academy of Pediatrics argued that data were insufficient to recommend routine circumcision. Recent trials in Africa evaluating male circumcision for the prevention of sexually transmitted diseases have, however, revived the circumcision controversy.     

Vancomycin revisited: a reappraisal of clinical use

Vancomycin has been used for decades to treat serious systemic gram positive infections. Extensive use over time has demonstrated vancomycin is not nephrotoxic even when used in high dosage, i.e., twice the usual dose. Since vancomycin is not nephrotoxic, there is no rationale for dosing vancomycin based on serum vancomycin levels. Since vancomycin is eliminated by GFR, vancomycin dosing should be based on creatinine clearance. Vancomycin obeys "concentration dependent" kinetics and higher than usual doses may be useful in some infections (eg, osteomyelitis). Widespread vancomycin use has resulted in increased VRE prevalence worldwide. Among staphylococci, vancomycin induced cell wall thickening results in "permeability mediated" resistance to vancomycin, as well as other anti-staphylococcal antibiotics. "Permeability mediated" resistance accounts for the common clinical observation that MRSA infections treated with vancomycin often resolve slowly or not at all. Other effective MRSA antibiotics are available (eg, linezolid, daptomycin, minocycline, or tigecycline) and are more reliably effective, do not increase staphylococcal resistance or increase VRE prevalence.