Is early primary repair for correction of tetralogy of Fallot comparable to surgery after 6 months of age?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether early primary repair for correction of tetralogy of Fallot (TOF) resulted in better outcomes than surgery after 6 months of age. Altogether 650 relevant papers were identified using the below mentioned search, eight papers represented the best evidence to answer the specific question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We conclude that early primary repair of TOF has been shown to be comparable to later repair, with several retrospective series concluding that there is no increase in mortality with children under 6 months of age. Freedom from reintervention has also been shown to be similar irrespective of the age primary repair is undertaken. However, it has been observed that length of intensive care unit stay, period of mechanical ventilation and the need for inotropes is increased in patients undergoing primary repair at <3 months of age.     

The Fetal Safety of Hydrocortisone-Pramoxine (Proctofoam-HC) for the Treatment of Hemorrhoids in Late Pregnancy

ObjectiveFetal safety has never been studied for any drug used in the treatment of hemorrhoids. Proctofoam-HC is a combination of a corticosteroid and a local anaesthetic that is proven effective for the treatment of hemorrhoids. The objective of this study was to assess prospectively the fetal safety of third trimester exposure to Proctofoam-HC.MethodsIn a multicentre study, 240 women exposed to Proctofoam-HC in the third trimester and a similar number of control pregnant women were followed up postnatally.ResultsWhen compared to controls exposure to Proctofoam-HC was not associated with any adverse fetal effects on birth weight, gestational age, rates of prematurity, or pre- or postnatal complications.ConclusionProctofoam-HC is safe to use in the treatment of hemorrhoids in late pregnancy.     

Considering complementary and alternative medicine alternatives in cases of life-threatening illness: applying the best-interests test

In this article we explore decision-making about treatment when a child faces a life-threatening illness but conventional treatment presents substantial risk and uncertain benefit. When is it acceptable for parents to decide to use complementary and alternative medicine as an alternative, rather than a complement, to conventional care? We use the example of a young child suffering from progressive glycogen storage disease, for whom liver transplant offers the only prospect of a cure. Without a liver transplant, the disease usually results in death within a few years. However, experience using transplant to treat this illness has been limited, success is far from ensured, and the risks (including death and continued progression of the disease) are substantial. The child's parents, who are first-generation immigrants, consider the risks of the transplant unjustified because it still does not offer good prospects for a healthy future. They believe that traditional Chinese medicine could help remediate their daughter's disease. In the article we (1) review parents' obligation to make treatment decisions in the best interests of their child, (2) explain limits on parents' decision-making authority, (3) explore how "best interests" are determined, focusing on cases of serious illness for which conventional treatment is risky and benefit is possible but uncertain, (4) explain the standard of care that physicians must meet in advising about treatment, and (5) outline factors that clinicians and parents should take into account when making decisions.     

Concluding comments: maximizing good patient care and minimizing potential liability when considering complementary and alternative medicine

Our goal for this supplemental issue of Pediatrics was to consider what practitioners, parents, patients, institutions, and policy-makers need to take into account to make good decisions about using complementary and alternative medicine (CAM) to treat children and to develop guidelines for appropriate use. We began by explaining underlying concepts and principles in ethical, legal, and clinical reasoning and then used case scenarios to explore how they apply and identify gaps that remain in practice and policy. In this concluding article, we review our major findings, summarize our recommendations, and suggest further research. We focus on several key areas: practitioner and patient/parent relationships; decision-making; dispute resolution; standards of practice; hospital/health facility policies; patient safety; education; and research. Ethical principles, standards, and rules applicable when making decisions about conventional care for children apply to decision-making about CAM as well. The same is true of legal reasoning. Although CAM use has seldom led to litigation, general legal principles relied on in cases involving conventional medical care provide the starting point for analysis. Similarly, with respect to clinical decision-making, clinicians are guided by clinical judgment and the best interests of their patient. Whether a therapy is CAM or conventional, clinicians must weigh the relative risks and benefits of therapeutic options and take into account their patient's values, beliefs, and preferences. Consequently, many of our observations apply to conventional and CAM care and to both adult and pediatric patients.     

Categorization and characterization of lesions of the orbital apex

Introduction  

The apex of the orbit is formed by the union of the lesser and greater wings of the sphenoid bone and acts as an osseous tunnel for numerous neurovascular structures entering the orbit from the cranial vault. Lesions of the orbital apex are clinically important as they can have an adverse effect on vision. A broad range of lesions can occur here, and our purpose is to organize the pathologic processes which occur in the orbital apex into logical imaging differentials, establish an organized approach to image analysis, and present examples of representative lesions.     

Modified subretinal dye extrusion technique (MORE-DETECH): subretinal diluted trypan blue for detecting occult retinal breaks in retinal detachment after endotamponade removal

To investigate the effectiveness of a new technique for the identification of occult retinal breaks in retinal redetachment after removal of silicone oil endotamponade. The technique involves injection of subretinal dye and extrusion through the unidentified breaks. A prospective interventional case series. Main outcome measures were rate of break detection, rate of retinal attachment at 3 months after removal of endotamponade, and improvement in visual acuity after surgery. A total of 21 patients fulfilled the study criterion. The occult rhegma could be identified successfully in all except two cases (90.4 % success). In most cases the rhegma was identified at the posterior edge of the laser retinopexy scar. Complete retinal attachment could be seen in all cases at 12 weeks after removal of silicone oil. The mean visual acuity improved from logMAR 1.4, preoperatively to logMAR 0.81 (p = 0.001) postoperatively. Subretinal dye injection was useful in detecting occult retinal breaks in patients with retinal redetachment and was helpful in preventing surgical failure.     

An Economic Toolkit for Identifying the Cost of Emergency Medical Services (EMS) Systems: Detailed Methodology of the EMS Cost Analysis Project (EMSCAP)

Calculating the cost of an emergency medical services (EMS) system using a standardized method is important for determining the value of EMS. This article describes the development of a methodology for calculating the cost of an EMS system to its community. This includes a tool for calculating the cost of EMS (the “cost workbook”) and detailed directions for determining cost (the “cost guide”). The 12‐step process that was developed is consistent with current theories of health economics, applicable to prehospital care, flexible enough to be used in varying sizes and types of EMS systems, and comprehensive enough to provide meaningful conclusions. It was developed by an expert panel (the EMS Cost Analysis Project [EMSCAP] investigator team) in an iterative process that included pilot testing the process in three diverse communities. The iterative process allowed ongoing modification of the toolkit during the development phase, based upon direct, practical, ongoing interaction with the EMS systems that were using the toolkit. The resulting methodology estimates EMS system costs within a user‐defined community, allowing either the number of patients treated or the estimated number of lives saved by EMS to be assessed in light of the cost of those efforts. Much controversy exists about the cost of EMS and whether the resources spent for this purpose are justified. However, the existence of a validated toolkit that provides a standardized process will allow meaningful assessments and comparisons to be made and will supply objective information to inform EMS and community officials who are tasked with determining the utilization of scarce societal resources. ACADEMIC EMERGENCY MEDICINE 2012; 19:1–7 © 2012 by the Society for Academic Emergency Medicine