The Emergency Department Versus the Computer: Which Is the Better Electrocardiographer?

Electrocardiograms (ECGs) are frequently ordered in the pediatric emergency department (ED). Pediatric cardiologists are generally not asked to interpret every ECG; thus, ED patient management is often guided by the ED physicians ECG interpretation. The objective of this study was to analyze the accuracy of ECG interpretation by ED physicians and a computer-generated interpretation and compare the two. A 12-month prospective study was performed in a pediatric ED. All patients (<22 years) who had an ECG in the ED were included. The ED physicians and the computer interpretation were compared to a reference standard. Each electrocardiographic diagnosis, as well as the ECG as a whole, was assigned to one of the following predetermined classes: I, normal sinus rhythm; II, minimal clinical significance; III, indeterminate clinical significance; IV, those of definite clinical significance. Both groups correctly interpreted all normal (class I) ECGs. The computer correctly interpreted approximately 75% of the class II and class III ECGs, whereas the ED physicians correctly interpreted 36% of both groups. For the class IV ECGs, both the computer and the ED physicians performed poorly, correctly interpreting just 14% and 28%, respectively. The computer proved to be more accurate than the ED physicians in interpreting ECGs of less than critical significance (classes II and III), but neither group was able to correctly interpret even a simple majority of the most significant abnormalities (class IV). We speculate that distributing the computer-generated interpretation to the ED physicians and formal review of all ED ECGs by a skilled interpreter may decrease the number of missed diagnoses.     

Do children from an inner city British school meet the recommended levels of physical activity? Results from a cross sectional survey using objective measurements of physical activity

Questionnaire surveys suggest physical activity levels in children are low, particularly among children from deprived areas. Using accelerometers, it was found that children from a deprived inner city school were active at recommended levels and had similar levels of activity to children in other studies from more affluent populations. However, this finding was dependent on the threshold used to define moderate activity.     

Caring for intubated newborns: analgesia and sedation. Collaborative discussions between the Ospedale Pediatrico Bambino Gesú and the Mayo Clinic

Pain relief and sedation are essential for critically ill newborns. Unfortunately, assessment of pain and need for sedation remain difficult. The collaborative discussions in 2007 between the Ospedale Paediatrico Bambino Gesù and the Mayo Clinic provided us with an opportunity to compare and contrast the assessment of pain, assessment of need for sedation and measures used to relieve pain/provide sedation. We began our session with a review of pain assessment tools in newborns and current options for pain relief and sedation. We discussed a pilot audit of analgesia use in the newborn intensive care unit at the Mayo Clinic and the challenges of escalating opiate doses in certain patients. Dr Marina Cuttini from Ospedale Paediatrico Bambino Gesù provided European perspectives. Discussions considered how to improve our bedside nursing assessment of newborn pain. A potential for future collaboration may be to compare analgesia doses for intubated newborns in Rome with doses used in Rochester, either by retrospective chart review or in a prospective study. We might also compare the management of opiate withdrawal in newborns. Research into non-opiate analgesia for newborns may give us new options to avoid opiate side-effects.     

Puerto Rican Families’ Experiences of Asthma and Use of the Emergency Department for Asthma Care

Puerto Ricans have been found to have higher asthma prevalence rates than non-Hispanic whites, blacks, and all other Hispanic subgroups. They also have the highest rates of emergency department (ED) use for the management of their asthma. Using a hermeneutic phenomenological approach, the aim of this study was to describe the lived experience of Puerto Rican families caring for their child's asthma and using the ED for asthma care. Six themes were generated from in-depth interviews with 10 Puerto-Rican caregivers: (1) The Folklore of Asthma, (2) Culture and the Medicine Woman, (3) In Awe of Asthma, (4) Praying to God, (5) The Decision–Time to Go, and (6) The ED Environment. The findings emphasize the necessity of establishing and maintaining a therapeutic partnership between primary care providers and families of children with asthma. The results may be used as a foundation for understanding motivations for seeking asthma care in the ED.     

The juvenile head trauma syndrome – Deterioration after mild TBI: Diagnosis and clinical presentation at the Emergency Department

Background

Annually 14.000 children with traumatic brain injury (TBI) are admitted to the Emergency Department (ED) in the Netherlands. Presentation varies and a specific entity comprises the juvenile head trauma syndrome (JHTS) with secondary deterioration after a mild trauma. As outcome of JHTS can be fatal, early recognition is essential.

Current status of Hirschsprung’s disease: based on a nationwide survey of Japan

Purpose

The diagnosis and surgical treatments of Hirschsprung’s disease (HD) have undergone various changes in the last few decades because of establishment of laparoscopic procedures. A retrospective nationwide survey for 4 decades was performed to study the changing profile of HD in Japan.

Methods

The patient data were collected in 4 phases: Group 1, between 1978 and 1982; Group 2, between 1988 and 1992; Group 3, between 1998 and 2002; and Group 4, between 2008 and 2012.

Results

The incidence and the male/female ratio remained almost the same over time (1/4, 895 in newborns and 2.9:1 in Group 4). The patients with a family history increased to 7.1% in Group 4, in comparison to 2.8–6.0% in other groups. Regarding the extent of aganglionosis, sigmoid colon increased to 63.1% in Group 4, compared to 51.9% in Group 3. Manometry was performed less frequently in Group 4 (45.8%) than in Group 3 (66.1%). Transanal endorectal pull-through (TAEPT) was the most popular operation in Group 4 (49.6%). In addition, laparoscopy-assisted operations increased to 46.9% in Group 4, in comparison to 29.7% in Group 3. The incidence of preoperative enterocolitis and the mortality rate in Group 4 were 17.2% and 2.4%, respectively, and were markedly decreased in comparison to Group 1 (29.2% and 6.5%, respectively). The mortality rate decreased over time to 2.4% in Group 4. Over the last decade, there has been remarkable improvement in the mortality rate associated with the small intestine (aganglionosis extending orally to more than 30 cm of the terminal ileum). The rates were 25.5% in Group 4, 53.6% in Group 1, 33.3% in Group 2, and 35.5% in Group 3. In addition, the mortality rates of the remaining aganglionosis subgroups also improved.

Conclusion

Primary operations without laparotomy, including TAEPT and laparoscopy-assisted operations, have become the first choice for the definitive surgical treatment of HD in Japan. The mortality rate has decreased over time. However, the mortality rate of small intestinal aganglionosis is still relatively high. The development of new treatment strategy for small intestinal aganglionosis is called for.

     

Primary Sjögren syndrome in the paediatric age: a multicentre survey

Primary Sjögren syndrome (SS) is very rare in childhood. We collected a series of primary paediatric SS cases from different centres. A data collection form was prepared and sent to rheumatologists who were willing to participate. Data on 40 cases of primary SS with onset before the 16th birthday were collected. Almost all patients (35/40) were females, age at onset varied from 9.3 to 12.4 years (mean 10.7 years). Signs and symptoms at disease onset were mainly recurrent parotid swelling followed by sicca symptoms. Abnormal laboratory tests were found in the majority of cases. Regarding treatment, 22 patients were treated at some time with oral corticosteroids, seven with non-steroidal anti-inflammatory drugs, and five with hydroxychloroquine; two patients needed cyclosporine and one cyclophosphamide. Follow-up varied from 0 to 7.5 years from onset, without major complications in the majority of patients. Conclusion: recurrent parotid swelling is a common feature of primary Sjögren syndrome in childhood and often occurs as a presenting feature. Sicca symptoms may be rarer.Abbreviations ANA antinuclear antibodies - ENA extractable nuclear antigens - ESR erythrocyte sedimentation rate - NSAID non-steroidal anti-inflammatory drugs - RF rheumatoid factor - SS Sjögren syndrome     

Current evidence for the use of paediatric antiretroviral therapy – a PENTA analysis

The introduction of combination antiretroviral therapy has been associated with a dramatic clinical improvement in children with human immunodeficiency virus infection. However, the uptake of antiretroviral therapy has been variable across Europe. The Paediatric European Network for the Treatment of AIDS Steering Committee has performed a systematic literature review of paediatric antiretroviral therapy trials. An analysis of the evidence base for the commencement and maintenance of antiretroviral therapy was produced. Suggestions for when to commence antiretroviral therapy, which drugs to start with and how to monitor and sequence drug regimens are given. Conclusion The aim of these guidelines is to help in obtaining equity of access to a uniformly high standard of care for children with human immunodeficiency virus infection in all European countries. Received: 15 November 1999 / Accepted: 16 February 2000     

The use of refluxing ureter in the creation of a Mitrofanoff channel in children undergoing bladder augmentation: is a formal reimplantation necessary?

To study the fate of a refluxing ureteral stump used as a Mitrofanoff channel (MC) for clean intermittent catheterization (CIC), without reimplantation in augmented bladders. Ten boys and seven girls, 1–14 years old (mean 6.5 years) seen in period 1998–2005, underwent creation of MC using refluxing or potentially refluxing ureters. Concomitant bladder augmentation (BA) was performed for various abnormalities of lower urinary tract, including exstrophy epispadias complex, neurogenic bladder cloaca and posterior urethral valve. The uretero-vesical junction was maintained intact during creation of the MC. Follow-up period ranged from 2–72 months (mean 32.5 months). Satisfactory CIC was possible in 14 children while in two children the stoma became obstructed due to non-usage. Urinary leak via the ureteric MC was seen in only one patient who partially responded to anticholinergic therapy and a shortened CIC interval but this needed to be formally closed subsequently. A refluxing ureter can be used in the creation of a MC without formal reimplantation in the majority of children undergoing BA.