Size does matter – Age-related weight estimation in “tall n’ thin” and “tiny n’ thick” children and a new habitus-adapted alternative to the EPLS-formula

Aim of the study

Weight in kilograms is a required parameter in the emergency medical care of children. In emergent situations, obtaining an accurate weight is often not possible. In such situations, weight can be estimated by using an age-dependent formula such as the EPLS-formula (age in years + 4) × 2. As recently recognized for emergency tapes, the habitus of the child has a major influence on weight estimation. In this study, the performance of various age-dependent formulas is to be investigated, with special regard to children demonstrating non-normal growth.

Methods

The performance of various formulas for weight estimation in children growing along the 5th, 50th, and 95th percentile is investigated based on a mathematical model compared to the WHO and CDC reference percentiles using ICC and Bland–Altman methods. Additionally, a new formula for children demonstrating non-normal growth is derived by regression analysis and tested: f × age in years + 6 with the factor f being 2 for “tall n’ thin”, 3 for normal and 4 for “tiny n’ thick” children.

Results

All previously published formulas lack precision when applied to children outside the 50th percentile. The new habitus-adapted formula shows a better performance for children growing along the 5th or 95th percentile.

Conclusions

The new formula provides enhanced precision in weight estimation and can help in reducing, e.g. drug dosing errors. It should be used for weight estimation in children demonstrating non-normal weight development and in situations when superior methods such as weighing or habitus-adapted emergency tapes are not applicable.     

Sixty-four–slice computed tomographic coronary angiography: will the “triple rule out” change chest pain evaluation in the ED?

Sixty-four-slice computed tomographic (CT) coronary angiography is a new technique for the noninvasive visualization of the coronary arteries. It enables noninvasive detection of coronary plaque and determination of severity without instrumentation of the heart. Although not yet commonly used in the emergency department setting, it stands poised to dramatically change the way that patients with chest pain are evaluated. In addition to evaluation of the coronary arteries, CT angiography has long been used to evaluate patients for other dangerous causes of chest pain such as aortic dissection and pulmonary embolus. Although these new scanners excel at all of these diagnostic modalities, the true excitement is in the possibility of combining several different protocols into one, allowing for multiple causes of chest pain to be "ruled out" simultaneously. This article describes the current state of the art of cardiac CT, current state of research, and current areas of controversy.     

Endoluminal fundoplication – the Hill procedure

Endoluminal operations for reflux are currently limited by the inability to visualise and manipulate structures outside the wall of the gut. This may be possible using endoscopic ultrasound (EUS). The aim of this study was to define EUS‐anatomy of structures outside the gut which influence reflux; to place stitches in the median arcuate ligament (MAL); to perform posterior gastropexy (Hill procedure) and test the feasibility of crural repair under EUS control in pigs. In survival experiments in 14 pigs, using linear array echo‐endoscopes the MAL and part of the right crus were identified and punctured with a needle, which served as a carrier for a tag and thread. These were anchored into the muscle. An endoscopic sewing device was used allowing stitches to be placed through a 2.8?mm accessory channel to any predetermined depth. New methods allowed knot‐tying and thread‐cutting through the 2.8?mm channel of the echo‐endoscope. Stitches were placed through the gastric wall into the MAL and one just beyond the wall of the lower esophageal sphincter (LES). They were tied together and locked against the gastric wall. Preoperative manometry showed a median LES pressure of 11mm/Hg and 21?mm/Hg after stitch placement (p = 0.0028). The length of the LES increased from median 2.8?cm pre‐procedure to 3.5?cm post‐procedure. At post mortem, the force to pull the tags out of the MAL was 2.8?kg median. This study shows that transgastric gastro‐esophageal reflux surgery using stitching under EUS control can significantly increase the lower oesophageal sphincter pressure in pigs.     

Beyond the RCT – understanding the relationship between interventions,individuals and outcome – the example of neurological rehabilitation

Background.?Rehabilitation is highly complex, involving multiple processes, outcomes and stakeholders. The way we deliver our services and work with our clients and their families should be informed by research approaches that produce the wide range of knowledge needed. This article aims to explore the degree to which the dominant approach to ‘evidence’ (the randomised clinical trial or RCT) meets those needs and discuss alternate/additional ways of gaining evidence.

Methods.?A critical review of the literature allowing exploration of problems encountered in rehabilitation RCTs and alterative approaches.

Findings.?We discuss some problematic issues related to using RCTs in rehabilitation research (for example the large number of people excluded from trials, and the small numbers of people with some neurological conditions making RCTs non-viable). Alternative approaches are discussed including clinical practice improvement studies (sometimes called practice-based evidence or PBE), which provide data on patients treated in routine practice; qualitative research, which can provide an understanding of the users of health care services to ensure they are meeting their needs; and metasynthesis, which can be used to summarise several qualitative studies to enhance our understanding of the principles underlying service delivery. Finally, we explore how clinicians and commissioners often use evidence generated by forms of research other than the RCT.

Conclusion.?The best answers about how to enhance rehabilitation outcomes are likely to come from a combination and integration of the most appropriate methods. In conclusion, we urge for more joined up thinking, for learning from different fields so that we can develop more effective and appropriate health care and rehabilitation.