Pediatrician performed point-of-care ultrasound for the detection of ingested foreign bodies: case series and review of the literature

PurposeForeign body (FB) ingestions represent a common problem in children. History and physical examination are commonly not enough to diagnose a foreign body ingestion; therefore, conventional radiography is routinely used to detect them. Point-of-care ultrasound is widely used in the emergency department for several diagnostic applications but there are few articles describing the possibility to use point-of-care ultrasound to detect ingested foreign bodies, and the necessary training to get competent in this application. The main objective of this paper is to illustrate the use of point-of-care ultrasound (POCUS) to detect ingested foreign bodies. The secondary objective is to describe a limited training, necessary for emergency pediatricians, to obtain this skill.MethodsThis is a case series of eight pediatric patients who presented to the pediatric Emergency Department (ED), with suspected ingestion of FB, and were assessed with POCUS. Physician sonographers were two pediatricians and three residents in pediatrics working in two Italian Pediatric EDs. All sonographers participated in a 2-day POCUS workshop which included the most common pediatric POCUS applications.ResultsPOCUS, performed by emergency pediatricians who participated to a limited training, allowed to always identify the foreign bodies ingested.ConclusionsWe demonstrate that an appropriate and limited training allows pediatric emergency physicians to correctly identify foreign body in the esophagus or stomach. Point-of-care ultrasound in foreign body ingestion in the Emergency Department may allow to prioritize the escalation of care in children and it can contribute to reduce the time to endoscopic management when needed.Electronic supplementary materialThe online version of this article (10.1007/s40477-020-00452-z) contains supplementary material, which is available to authorized users.     

Overcoming the organization–practice barrier in sports injury prevention: A nonhierarchical organizational model

The organization of sports at the national level has seldom been included in scientific discussions of sports injury prevention. The aim of this study was to develop a model for organization of sports that supports prevention of overuse injuries. The quality function deployment technique was applied in seminars over a two‐season period to develop a national organizational structure for athletics in Sweden that facilitates prevention of overuse injuries. Three central features of the resulting model for organization of sports at the national level are (a) diminishment of the organizational hierarchy: participatory safety policy design is introduced through annual meetings where actors from different sectors of the sporting community discuss training, injury prevention, and sports safety policy; (b) introduction of a safety surveillance system: a ubiquitous system for routine collection of injury and illness data; and (c) an open forum for discussion of safety issues: maintenance of a safety forum for participants from different sectors of the sport. A nonhierarchical model for organization of sports at the national level – facilitated by modern information technology – adapted for the prevention of overuse injuries has been developed. Further research is warranted to evaluate the new organizational model in prospective effectiveness studies.     

Ultrasound-Guided Percutaneous Removal of Wooden Foreign Bodies in the Extremities with Hydro-Dissection Technique

ObjectiveWe described the technique of ultrasound (US)-guided percutaneous removal of the foreign bodies (FB) with hydro-dissection in the radiologic department and presented video files of several cases.ResultsThe mean time required for the entire procedure was approximately 20 minutes. There were no significant complications during the US-guided removal or long-term complications after the procedure. All 4 FBs were successfully removed from the soft tissue under US guidance.ConclusionUltrasound-guided percutaneous removal of the FBs with hydro-dissection in the radiology department is a less invasive and safe method over surgical removal in the operating room. Additionally, the use of a guide wire and serial dilator may help minimize soft tissue injury and facilitate the introduction of forceps.     

Post-hypoglycaemic hyperketonaemia does not contribute to brain metabolism during insulin-induced hypoglycaemia in humans

Summary It is controversial as to whether ketone bodies are utilized by the human brain as a fuel alternative to glucose during hypoglycaemia. To clarify the issue, we studied 10 normal volunteers during an experimental hypoglycaemia closely mimicking the clinical hypoglycaemia of patients with Type 1 (insulin-dependent) diabetes mellitus or insulinoma. Hypoglycaemia was induced by a continuous infusion of insulin (0.40 mU·kg^–1·min^–1 for 8 h, plasma insulin 180 pmol/l) which decreased the plasma glucose concentration to approximately 3.1 mmol/l during the last 3 h of the studies. Subjects were studied on two occasions, i. e. spontaneous, counterregulatory-induced post-hypoglycaemic increase in 3--hydroxybutyrate (from 0.2 to 1.1 mmol/l at 8 h), or prevention of post-hypoglycaemic hyperketonaemia (plasma -hydroxybutyrate 0.1 mmol/l throughout the study) after administration of acipimox, a potent inhibitor of lipolysis. In the latter study, glucose was infused to match the hypoglycaemia observed in the former study. The glycaemic thresholds and overall responses of counterregulatory hormones, symptoms (both autonomic and neuroglycopenic), and deterioration of cognitive function (psychomotor tests) were superimposable in the control study in which ketones increased spontaneously after onset of hypoglycaemic counterregulation, as compared to the study in which ketones were suppressed (p=NS). The fact that responses of counterregulatory hormones, symptoms and deterioration in cognitive function were not exaggerated when posthypoglycaemic hyperketonaemia was prevented, indicate that during hypoglycaemia, the counterregulatory-induced endogenous hyperketonaemia does not provide the human brain with an alternative substrate to glucose. Thus, it is concluded that during hypoglycaemia, endogenous hyperketonaemia does not contribute to brain metabolism and function.     

The metabolic effects of sodium dichloroacetate in the suckling newborn rat

Summary Subcutaneous injection of sodium dichloroacetate (1 mg/g body wt every 3 h) in suckling newborn rats caused in 6 h a fall of 2.5 mmol/l in blood glucose concentrations, and a rise of 2.4 mmol/ l in total blood ketone body levels, but no change in the high levels of plasma non esterified fatty acids. Glucose utilization, measured after intraperitoneal injection of D-glucose (2 mg/g body wt), was not increased in newborns injected with dichloroacetate. The hypoglycaemia resulted from a decrease in gluconeogenic rate, secondarily to a lowering effect of dichloroacetate on blood levels of lactate, pyruvate and alanine. The hypoglycaemia induced by dichloroacetate was completely reversed by injecting newborn rats with a mixture of gluconeogenic precursors (lactate, pyruvate and alanine). It is concluded that the high rate of gluconeogenesis observed in suckling newborn rats in sustained by an increased release of lactate and, to a much smaller extent of pyruvate and alanine, by peripheral tissues. This probably resulted from the low pyruvate dehydrogenase activity found in peripheral tissues of the newborn rat. The hyperketonaemia induced by dichloroacetate could result from an increased ketogenesis and/or a decreased ketone body utilization.     

Relationships between pre-hospital characteristics and outcome in victims of foreign body airway obstruction during meals

ObjectiveThe purpose of this study is to determine the outcome of foreign body airway obstruction according to the initial actions taken for choking victims during meals.MethodsOur subjects were patients who became unresponsive or unconscious because of foreign body airway obstruction (FBAO) during meals in the presence of bystander witnesses. We investigated the associations between outcome and the following factors: age, gender, type of foreign body, chest compressions after the patient became unresponsive or unconscious, episode of cardiac arrest, efforts by a bystander to remove the foreign body, eating-related activities of daily living, time elapsed from the 119 call to arrival of emergency medical technicians (EMTs), and time elapsed from the 119 call to hospital arrival (primary endpoint).ResultsOf the 138 patients enrolled during the study period, 35 (25.4%) received chest compressions by bystanders after becoming unresponsive or unconscious and 69 (50.0%) suffered cardiac pulmonary arrest. Chest compressions by a bystander after the victim became unresponsive or unconscious (p < 0.0001) and no CPA (p < 0.0001) were significantly related to good outcome. Chest compressions by a bystander were both associated with good neurological outcome (odds ratio, 10.57; 95% CI, 2.472–65.059, p < 0.0001). No CPA after FBAO was another independent predictor (odds ratio, 50.512; 95% CI, 13.45–284.41; p < 0.0001), but efforts to remove the foreign body before the arrival of EMTs did not affect outcome.ConclusionChest compressions by a bystander, a support received by only 25% of the patients, proved to be essential for improved outcome for choking victims who became unresponsive or unconscious. Education for lay-rescuer response to choking might further improve overall outcome.     

Infection mechanism of biofilm‐forming Staphylococcus aureus on indwelling foreign materials in mice

Indwelling foreign‐body infections are a critical medical problem, especially in immunocompromised patients. To examine the pathogenicity of biofilm‐forming bacteria settling on foreign materials, mice implanted with plastic discs were infected with Staphylococcus aureus. After opening a wide subcutaneous pocket on the dorsal side of mice with or without temporal leukocytopenia, a plastic sheet was placed in the left subcutaneous space; subsequently, bacteria in a planktonic state were dispersed over the subcutaneous space. Bacterial numbers were examined 7 days after inoculation. In subcutaneous tissue on the right, S. aureus was found only in leukocytopenic mice. Meanwhile, bacteria were detected on the plastic and neighbouring tissue in both leukocytopenic and normal mice; however, colony‐forming analysis indicated that leukocytopenic mice possessed significantly more bacteria. Tissue reaction against bacteria was pathologically examined. Invading S. aureus induced severe inflammation. In transient leukocytopenic mice, bacterial microcolonies formed on the plastic as well as in the developed necrotic tissue – both of which were shielded from inflammatory cell infiltration – result in bacteraemia. These results indicate that biofilm‐forming S. aureus settling on indwelling foreign material are tolerant against host immunity and assault neighbouring tissue, which may lead to chronic wound infection.     

A Time Series Observation of Chinese Children Undergoing Rigid Bronchoscopy for an Inhaled Foreign Body: 3149 Cases in 1991–2010

Background:

In China, tracheobronchial foreign body (TFB) aspiration, a major cause of emergency episode and accident death in children, remains a challenge for anesthetic management. Here, we share our experience and discuss the anesthetic consideration and management of patients with TFB aspiration.

Methods:

This was a single-institution retrospective study in children with an inhaled foreign body between 1991 and 2010 that focused on the complications following rigid bronchoscopy (RB). Data including the clinical characteristics of patients and TFB, anesthetic method, and postoperative severe complications were analyzed by different periods.

Results:

During the 20-year study period, the charts of 3149 patients who underwent RB for suspected inhaled TFB were reviewed. There were 2079 male and 1070 female patients (1.94:1). A nut (84%) was the most commonly inhaled object. The study revealed a 9% (n = 284) overall rate of severe postoperative complications related to severe hypoxemia, laryngeal edema, complete laryngospasm, pneumothorax, total segmental atelectasis, and death with incidences of 3.2%, 0.9%, 1.3%, 0.3%, 0.3%, and 0.1%, respectively. The rates of preoperative airway impairment, negative findings of TFB, and adverse postoperative events have been on the rise in the past 5 years.

Conclusions:

The survey results confirmed that hypoxemia remains the most common postoperative complication in different periods. Both controlled ventilation and spontaneous ventilation were effective during the RB extraction of the foreign body at our hospital in the modern technique period. An active respiratory symptom was commonly seen in the groups with negative findings.     

国外家庭医生服务模式对中国的启示

本文通过分析英、美、德等国家庭医生制度的研究现状和实践情况,总结他国家庭医生服务模式、特点及经验,从而揭示国外家庭医生制度系统性、规范性及普及性等特点。启示我国应从以下几个方面优化家庭医生服务模式：（1）建立居民签约机制与社区首诊制;（2）实行按人头预付的卫生服务经费管理模式;（3）扩大医生服务项目范围,鼓励家庭医生联合协同服务;（4）严格规范家庭医生资质。