Marco Daverio

Vaccine effectiveness against severe laboratory-confirmed influenza in children: results of two consecutive seasons in Italy

OBJECTIVE To evaluate the effectiveness of seasonal influenza vaccine in preventing Emergency Department (ED) visits and hospitalisations for influenza like illness (ILI) in children. METHODS We conducted a test negative case-control study during the 2011-2012 and 2012-2013 influenza seasons. Eleven paediatric hospital/wards in seven Italian regions participated in the study. Consecutive children visiting the ED with an ILI, as diagnosed by the doctor according to the European Centre for Disease Control case definition, were eligible for the study. Data were collected from trained pharmacists/physicians by interviewing parents during the ED visit (or hospital admission) of their children. An influenza microbiological test (RT-PCR) was carried out in all children. RESULTS Seven-hundred and four children, from 6 months to 16 years of age, were enrolled: 262 children tested positive for one of the influenza viruses (cases) and 442 tested negative (controls). Cases were older than controls (median age 46 vs. 29 months), though with a similar prevalence of chronic conditions. Only 25 children (4%) were vaccinated in the study period. The overall age-adjusted vaccine effectiveness (VE) was 38% (95% confidence interval -52% to 75%). A higher VE was estimated for hospitalised children (53%; 95% confidence interval -45% to 85%). DISCUSSION This study supports the effectiveness of the seasonal influenza vaccine in preventing visits to the EDs and hospitalisations for ILI in children, although the estimates were not statistically significant and with wide confidence intervals. Future systematic reviews of available data will provide more robust evidence for recommending influenza vaccination in children.

Patient and Process Factors Associated With Type of First Neuroimaging and Delayed Diagnosis in Childhood Arterial Ischemic Stroke

OBJECTIVES In-hospital factors contribute more to delayed diagnosis of childhood arterial ischemic stroke (AIS) than prehospital factors. We aimed to explore process and patient factors associated with type of and timing to neuroimaging in childhood AIS in the emergency department (ED). METHODS This was a retrospective hospital registry-based study of children with AIS, presenting to an Australian tertiary pediatric ED between January 2003 and December 2012. Neuroimaging data and timelines of care were also collected from referring hospitals for transferred patients. RESULTS Seventy-one AIS episodes and 19 transient ischemic attacks were recorded. The majority (56%) were initially seen at a referring hospital. Patients underwent computed tomography (CT) as first scan more frequently than magnetic resonance imaging (MRI) as first scan (61% vs. 32%) at both the referring and the tertiary hospitals. Time to first scan as CT was significantly shorter compared with MRI (median = 1.5 hours vs. 10.9 hours, p < 0.001). MRI was performed more often at the tertiary hospital (92.5% vs. 26%, p = 0.001). Median time to performance of diagnostic MRI was 15.1 hours (interquartile range = 7.1-23.5), with no significant difference between patients first presenting to a referring hospital and those directly accessing the tertiary center. Patient characteristics including age, past medical history, conscious state, focal symptoms, and signs on arrival were not associated with the type of first neuroimaging or time to diagnostic MRI. Patients presenting during weekends were less likely to receive an MRI as first scan (odds ratio [OR] = 0.3, 95% confidence interval [CI] = 0.1-0.8), while time to MRI was significantly longer for children presenting after hours (5 pm-8 am; median = 17.6 hours vs. 8.4 hours, p = 0.026). MRI overall and as first scan was associated with a higher use of sedation than CT (OR = 6.5, 95% CI = 1.3-32.9; and OR = 3.9, 95% CI = 1.3-11.8), particularly for children younger than 5 years of age (OR = 12.5, 95% CI = 3-52.4). CONCLUSIONS Strategies to improve rapid diagnosis of pediatric stroke should include shared regional hospital networks protocols to optimize local imaging strategies and where possible rapid transfer to the tertiary center. Future priorities should include development of pediatric ED physician decision support tools to differentiate stroke from mimics and the development and implementation of rapid ED imaging stroke protocols to improve access to confirmatory MRI scanning.

Paediatric recreational vehicle-related head injuries presenting to the emergency department of a major paediatric trauma centre in Australia: is there room for improvement?

This study examines clinical characteristics and helmet use of children presenting to the ED with a recreational vehicle (RV)‐related head injury (HI).

Participants' opinions of the limited impact of an adapted neonatal resuscitation course in a low‐resource setting

In Mozambique, midwives provide neonatal resuscitation at birth. On January 2014, we held an adapted one-day neonatal resuscitation programme (NRP) course, based on lectures, skill stations and practical scenarios, for the 16 midwives at the Central Hospital of Beira (1), the country’s second largest hospital, with about 4,500 deliveries per year (2). By using a video-recording system, we assessed the participants clinical performance before and after the modified NRP course. The course initially had a positive effect on the knowledge and manual skills of participants, but the improvement was only limited, and we wondered what factors could have been involved in this educational process (1). Our aim was to assess the opinions of the midwives about the impact of the modified NRP course on their clinical practice. In addition, we evaluated how well the midwives felt they performed neonatal resuscitation. To do this, we used a structured questionnaire based on three main areas: 12 questions that explored their knowledge about the main steps during neonatal resuscitation, four questions on their self-esteem with regard to the theoretical and practical skills acquired during the course and nine questions on the individual barriers that limited the application of the knowledge and skills they acquired during the course on their clinical practice. The questionnaire was submitted during a meeting, where the results of the original study and some anecdotal videos were presented (1). We assessed the three areas of interest by using a qualitative five-point Likert scale, where a score of one was very low, two was low, three was sufficient, four was good and five was excellent. With regard to the knowledge on neonatal resuscitation, the answers reflected a good theoretical level: 12 (75%) of the 16 midwives demonstrated good knowledge on the steps during neonatal resuscitation. Although the results and the videos recorded during the course showed that the resuscitations clearly remained below the recommended standards in terms of quality and time of execution, 13 (81%) of the 16 midwives scored their own clinical performance as good or excellent. Finally, in the midwives opinion, the scarce application of the theoretical knowledge and skills acquired during the course in clinical practice was due to the following reasons: lack of deep expertise on neonatal resuscitation (87%), work overload (81%), limited availability of equipment and structural barriers (75%). A very interesting finding was that 12 (75%) midwives thought that their intervention could not change the babys fate (Fig. 1). Our experience strengthens the findings of previous studies that have showed that a neonatal resuscitation course conducted in a low-resource setting had a limited impact on the clinical practice of participants (1). Nevertheless, the self-esteem of our sample of health caregivers remained high. This survey proves that, in addition to technical skills, organisational, structural and cultural aspects play a relevant role. Our findings may help to design future educational interventions in low-income settings (3).

Failure mode and effective analysis ameliorate awareness of medical errors: a 4-year prospective observational study in critically ill children.

Errors in are estimated to occur with an incidence of 3.7–16.6% in hospitalized patients. The application of systems for detection of adverse events is becoming a widespread reality in healthcare. Incident reporting (IR) and failure mode and effective analysis (FMEA) are strategies widely used to detect errors, but no studies have combined them in the setting of a pediatric intensive care unit (PICU).

Helmet use in preventing acute concussive symptoms in recreational vehicle related head trauma

ABSTRACT Objectives: Helmets use has proved effective in reducing head trauma (HT) severity in children riding non-motorised recreational vehicles. Scant data are available on their role in reducing concussive symptoms in children with HT while riding non-motorised recreational vehicles such as bicycles, push scooters and skateboards (BSS). We aimed to investigate whether helmet use is associated with a reduction in acute concussive symptoms in children with BSS-related-HT. Methods: Prospective study of children <18 years who presented with a BSS related-HT between April 2011 and January 2014 at a tertiary Paediatric Emergency Department (ED). Results: We included 190 patients. Median age 9.4 years (IQR 4.8–13.8). 66% were riding a bicycle, 23% a push scooter, and 11% a skateboard. 62% were wearing a helmet and 62% had at least one concussive symptom. Multivariate logistic regression analysis adjusting for age, gender, and type of vehicle showed that patients without a helmet presented more likely with headache (adjusted odds-ratio (aOR) 2.54, 95% CI 1.27–5.06), vomiting (aOR 2.16, 95% CI 1.00–4.66), abnormal behaviour (aOR 2.34, 95% CI 1.08–5.06), or the presence of at least one concussive symptom (aOR 2.39, 95% CI 1.20–4.80). Conclusions: In children presenting to the ED following a wheeled BSS-related HT helmet use was associated with less acute concussive symptoms. ABBREVIATIONS: aOR, adjusted odds ratio; APHIRST, Australasian Paediatric Head Injury Rules Study; BSS, bicycles, push scooters and skateboards; CI, confidence interval; CT, computed tomography; ED, emergency department; HT, head trauma; IQR, interquartile range; OR, odds ratio; RCH, Royal Children’s Hospital; RV, recreational vehicle.