Paediatricians�� validation of learning objectives in paediatric cardiology

BACKGROUND

The current objectives for teaching paediatric cardiology to paediatric residents have not been validated and may not be relevant to current paediatric practice.

OBJECTIVES

To validate the cardiology component of the Royal College of Physician and Surgeons of Canada’s objectives for training paediatricians.

METHODS

A questionnaire was sent to practising paediatricians in Atlantic Canada. The questions were based on the Royal College of Physician and Surgeons of Canada’s training objectives. The frequency of problems seen, confidence in assessment and management of problems, and reasons for referral were identified. Clinical vignettes were followed by short questions. The outpatient referrals were reviewed to validate the questionnaire responses.

RESULTS

One hundred fifty-one questionnaires were mailed and the response rate was 60%. Murmurs were the most common problem encountered (92%). Syncope (9%), Kawasaki disease (8%) and chest pain (6%) were less frequently encountered. Paediatricians were confident in assessing and managing problems despite the low frequency of encounters. Less confidence was expressed regarding physical examination skills and interpretation of electrocardiograms. Uncertainty of the diagnosis was the most common reason for patient referral, with parental anxiety and medicolegal concerns accounting for 24% and 7% of referrals, respectively. Syncope with exercise was relatively poorly recognized as a worrisome symptom.

CONCLUSIONS

Most cardiology objectives for general paediatric training remain relevant and appropriate to clinical practice. Physical examination skills, electrocardiogram interpretation and the assessment of syncope need to be emphasized.     

Incidence of cryptorchidism and ascending testes in Trisomy 21: a 10 year retrospective review

Children with Down syndrome have an increased risk of cryptorchidism, but the reported incidence is unclear. In a proportion of these children, the testes are within the scrotum at birth but later appear to have ascended to an ectopic position. Records of patients diagnosed with trisomy 21 who had surgery for undescended testes in two tertiary paediatric centres over a 10-year period were examined. Information on liveborn males with Down syndrome was obtained from the Victorian Genetic Registry, and then the incidence of congenital and acquired undescended testes was determined. The incidence of undescended testes in Down syndrome was found to be 6.52% (24/368), with 4.35% (16/368) being acquired undescended or ascending testes. In conclusion, there is an increased incidence of cryptorchidism in Down syndrome; in particular, there is a significant proportion of acquired undescended testes.     

Early neonatal discharge guidelines: Have we dropped the ball?

OBJECTIVES:

To determine patterns of follow-up and prenatal education by family physicians and to assess whether practice patterns comply with the 1996 Canadian Paediatric Society/Society of Obstetricians and Gynecologists of Canada (CPS/SOGC) guidelines for early neonatal discharge.

DESIGN:

Mail survey.

SETTING:

A community of 300,000 people who were served exclusively for obstetrical care by a tertiary care hospital that performs 5000 deliveries per year and provides an early discharge program (EDP).

PARTICIPANTS:

Family physicians who provide prenatal and/or newborn care.

MAIN OUTCOME MEASURES:

The timing of neonatal follow-up and parental teaching by family physicians.

RESULTS:

Thirty-two per cent of the respondents scheduled their first postnatal visits two or more weeks after early discharge. There was no significant difference (P=0.7) in scheduling of follow-up for babies who were part of an EDP compared with those who were not. Fewer than 20% of physician respondents provided antenatal education in preparation for early discharge.

CONCLUSIONS:

The 1996 CPS/SOGC guidelines for physician follow-up after early neonatal discharge and for anticipatory parental education are not being followed consistently; however, these guidelines were disseminated without reinforcement. Until further study supports a change in practice guidelines, appropriate implementation strategies must be employed to ensure compliance.     

Use of rapamycin in a transplant patient who developed cyclosporin neurotoxicity

We describe the case of a paediatric kidney transplant patient who developed cyclosporin neurotoxicity on day 7 post-transplant. Consequently, her cyclosporin was stopped and she was commenced on rapamycin. Over the next 3 weeks her creatinine remained elevated and she had several episodes of biopsy proven rejection, despite increasing the initial dose of rapamycin by tenfold. Her whole blood rapamycin levels also remained well below the target range of 10–20 ng/ml. On day 38 post-transplant, the decision was made to add tacrolimus to her immunosuppression. At the same time, phenytoin, which had been commenced during her episode of cyclosporin neurotoxicity, was withdrawn. After this point her rapamycin blood levels rapidly increased to within the therapeutic range and she improved clinically. We propose that phenytoin, as a p450 cytochrome enzyme inducer, increased the metabolism of rapamycin in this patient and hence decreased the initial therapeutic effectiveness of this drug. Received: 8 February 2001 / Revised: 21 May 2001 / Accepted: 21 May 2001     

A sentinel fatal paediatric case of community-associated methicillin-resistant Staphylococcus aureus in Canada

Community-associated methicillin-resistant Staphylococcus aureus is an established pathogen in many centres in the United States, but has yet to establish a firm foothold in Canada. In the present article, the authors report, to their knowledge, Canada’s first fatal paediatric case of invasive disease due to community-associated methicillin-resistant S aureus and review its pathogenesis, epidemiology and treatment.     

Outcome analysis of functional endoscopie sinonasal surgery for paediatric rhinosinusitis using the Lund-Mackay-Kennedy scoring system

There are very few indications for surgical management of chronic rhinosinusitis in children. This has been partly due to the fact that the definition of what qualifies as racalcitrant sinusitis in children is still obscure. There is also significant evidence in literature that surgery, especially radical surgery, on the nose and sinuses in children would result in some interference with the growth of the facio-maxillary skeleton. The advent of Functional Endoscopie sino-nasal Surgery ( F. E. S. S. ) in recent years has changed the philosophy of surgery for paediatric rhinosinusitis and has proven to be an effective choice of management in difficult cases. We persent here our experience and preliminary results with the use of FESS in nine children with sinonasal disorders including cystic fibrosis. The usefulness of the recently described Lund- mackay and Kennedy Scoring System for chronic rhinosinusitis in terms of symptom score, radiological score, endoscopie score and surgical score has been demonstrated.     

Improved growth and clinical, nutritional, and respiratory changes in response to nutritional therapy in cystic fibrosis

To investigate the role of nutritional factors in growth and in the clinical, nurtitional, and respiratory status in cystic fibrosis, we studied 12 problem CF patients from six months before to six months after a period of supplemental parenteral nutrition. During the initial six months' observation period on appropriate conventional therapy, the patients (aged 0.5 to 11 years) had inadequate growth and weight gain, a total of 21 active pulmonary infections, and, despite dietary supplements, inadequate ad libitum nutrient intakes. After nutritional therapy, providing a balanced consistent hypercaloric intake for 21 days, catch-up weight gain occurred by one month and continued at six months; catch-up in linear growth was observed by three months and continued at six months. In addition, significantly fewer pulmonary infections were observed in the six months' post-therapy (n = 3), sustained and significant improvements were noted in clinical score and plumonary function, and there was a marked improvement in well-being and ad libitum nutrient intake. We conclude that adequate nutritional support can favorably affect growth, clinical status, and the course of chronic pulmonary disease in problem cases of CF.     

The aetiology of paediatric inflammatory vulvovaginitis

Vulvovaginitis is the most common gynaecological problem in prepubertal girls and clear-cut data on the microbial aetiology of moderate to severe infections are lacking. Many microorganisms have been reported in several studies, but frequently the paediatrician does not know the pathogenic significance of an isolate reported in vaginal specimens of girls with vulvovaginitis. A multicentre study was performed, selecting 74 girls aged 2 to 12 years old with a clinical picture of vulvovaginitis and inflammatory cells on Gram stain. All the specimens were cultured following standard microbiological techniques and the paediatricians completed a questionnaire to highlight risk factors after interviewing the parents or tutors. The data were compared with those obtained in a control group of 11 girls without vulvovaginitis attending a clinic. Streptococcus pyogenes and Haemophilus spp.were isolated in 47 and 12 cases, respectively. Upper respiratory infection in the previous month ( P <0.001) and vulvovaginitis in the previous year ( P <0.05) were identified as significant risk factors. Foreign bodies, sexual abuse, poor hygiene and bad socioeconomic situation were not identified as risk factors for the infection. Conclusion: Paediatric inflammatory vulvovaginitis is mainly caused by pathogens of the upper respiratory tract and the most common risk factor for this infection is to have suffered an upper respiratory tract infection in the previous month.Abbreviations HI Haemophilus influenzae - PIV paediatric inflammatory vulvovaginitis - SP Streptococcus pyogenes On behalf of the Spanish Study Group for Primary Care Infection