Thomas Bourke

Misdiagnosis in the time of meningitis

Distinguishing viral illness from serious bacterial infection is notoriously difficult. Many of the symptoms currently recommended as “screening” questions for A/H1N1 flu such as fever, coryza, sore throat, headache, muscle aches, vomiting, and diarrhoea may also be present …

Emergency department attendance following 4-component meningococcal B vaccination in infants

Introduction In September 2015, the UK became the first country in the world to introduce the 4-component meningococcal B vaccine(4CMenB) into the routine vaccine schedule for infants. 4CMenB is known to cause fever in infants. Infants presenting with fever, particularly those under 3 months, have a significant risk of serious bacterial infection(SBI). Method Between September 2015 and January 2016, we performed a prospective audit of management of infants between 30 and 180 days attending the regional paediatric emergency department(ED) in Northern Ireland, within 4 days of receiving 4CMenB. Results 35 ED attendances in infants aged 30–180 days were due to symptoms occurring after primary vaccinations including 4CMenB, representing an estimated 0.8% of the vaccinated population in the catchment area. 86% of infants presented after the first vaccine and parents reported giving paracetamol to 94% of infants. 80% of infants presented with fever. Blood tests were performed in 62% of infants and leucocytosis was present in 73%. All cultures taken were negative and 51% were admitted to hospital. 100% of final diagnoses were vaccine related (diagnosis made by exclusion). Discussion In this study, an estimated 0.8% of the vaccinated population in the catchment area attended ED with symptoms occurring after primary vaccinations including 4CMenB. Infants with fever have a higher risk of SBI, but infants with fever in the post-vaccination period may not have the same risk. Further data are essential to inform national guidelines on investigation and management of fever in infants following vaccination with 4CMenB, possibly incorporating a less-invasive approach.

Clinical and Cost-Effectiveness of Procalcitonin Test for Prodromal Meningococcal Disease–A Meta-Analysis

Background Despite vaccines and improved medical intensive care, clinicians must continue to be vigilant of possible Meningococcal Disease in children. The objective was to establish if the procalcitonin test was a cost-effective adjunct for prodromal Meningococcal Disease in children presenting at emergency department with fever without source. Methods and Findings Data to evaluate procalcitonin, C-reactive protein and white cell count tests as indicators of Meningococcal Disease were collected from six independent studies identified through a systematic literature search, applying PRISMA guidelines. The data included 881 children with fever without source in developed countries.The optimal cut-off value for the procalcitonin, C-reactive protein and white cell count tests, each as an indicator of Meningococcal Disease, was determined. Summary Receiver Operator Curve analysis determined the overall diagnostic performance of each test with 95% confidence intervals. A decision analytic model was designed to reflect realistic clinical pathways for a child presenting with fever without source by comparing two diagnostic strategies: standard testing using combined C-reactive protein and white cell count tests compared to standard testing plus procalcitonin test. The costs of each of the four diagnosis groups (true positive, false negative, true negative and false positive) were assessed from a National Health Service payer perspective. The procalcitonin test was more accurate (sensitivity=0.89, 95%CI=0.76-0.96; specificity=0.74, 95%CI=0.4-0.92) for early Meningococcal Disease compared to standard testing alone (sensitivity=0.47, 95%CI=0.32-0.62; specificity=0.8, 95% CI=0.64-0.9). Decision analytic model outcomes indicated that the incremental cost effectiveness ratio for the base case was £-8,137.25 (US

Out-of-hospital extracorporeal life support—When is it appropriate?

-13,371.94) per correctly treated patient. Conclusions Procalcitonin plus standard recommended tests, improved the discriminatory ability for fatal Meningococcal Disease and was more cost-effective; it was also a superior biomarker in infants. Further research is recommended for point-of-care procalcitonin testing and Markov modelling to incorporate cost per QALY with a life-time model.

Bilateral total parenteral nutrition pleural effusions in a 5-week-old male infant

The availability of portable extracorporeal life support (ECMO) hich can be used to support circulation in patients suffering from reversible cause of cardiac arrest in the community is an exciting ew development in resuscitation. However we question whether ts use was appropriate in the situation described by Arlt et al.1 The European Resuscitation guidelines are clear that ongoing systole after 20 min of Advanced Life Support (ALS) in the absence f a reversible cause is grounds for discontinuing resuscitation.2,3 n this case ECMO was commenced in a 9-year-old girl who had eceived a prolonged period of ALS without return of spontaneous irculation following a witnessed drowning of uncertain duration. lthough the authors acknowledge that drowning associated with ypothermia requires resuscitation until normothermia, they do ot report the patient’s temperature. They describe an environmenal temperature of 36 ◦C, a water temperature of 26 ◦C and refer to warm-water’ drowning when mentioning prognosis in their disussion. The authors argue that their intervention allowed transport to ospital for further treatment and prognostication. We argue that n this case prognostication could have taken place onsite, paricularly given that there were experienced clinicians present. At he time of the intervention the patient’s pupils were fixed and ilated. She had received an unspecified time of bystander CPR folowed by 50 min of ALS with an endotracheal tube in place. She had eceived 6 mg of adrenaline (at least 20 doses assuming an estiated weight < 30 kg). No account is taken of her end-tidal carbon ioxide levels which has been shown to correlate well with outomes from resuscitative efforts.4 We believe that in the absence f hypothermia the team had sufficient information to conclude hat there was little hope of restoring spontaneous circulation or a atisfactory neurological outcome. Article 3 of the United Nations convention on the rights of the hild states that any action affecting children must have their ‘best nterests’ as a primary consideration.5 It is arguable that an interention such as ECMO which maintains circulation in the absence f a reversible cause and where the other clinical indicators suggest ittle or no hope of a successful outcome is not in the best interests of he child. Such an intervention may give false hope to the families. t may result in the restoration of spontaneous circulation without ny improvement in neurological function and inappropriate use f valuable resources. It is not clear from this report if any such

Fifteen-minute consultation: the child with pica

A 5-week-old male infant was admitted to the paediatric intensive care unit with small bowel obstruction secondary to an inguinal hernia. His postoperative course was complicated by suspected migration of his left internal jugular central venous catheter into branches of the inferior thyroid artery and mediastinum. This resulted in bilateral pleural effusions which were biochemically and visually similar to the total parenteral nutrition he was receiving. After drainage of the pleural effusions he made an uneventful recovery.

Clinician’s gaze behaviour in simulated paediatric emergencies

Pica is defined as the persistent ingestion of non-nutritive substances for more than 1 month at an age at which this behaviour is deemed inappropriate. It occurs most commonly in children, in patients with learning disabilities and in pregnancy. The aetiology of pica is poorly understood and is probably multifactorial. Clinical assessment can be difficult. History and examination should be tailored to address potential complications of the substance being ingested. Complications can be life threatening. Pica often self-remits in younger children. In those with learning disabilities, however, pica may persist into adulthood. Management strategies should involve a multidisciplinary approach, and interventions are primarily behavioural in nature. There is limited evidence to support pharmacological interventions in the management of children with pica.

Ssssh for Handover: protected medical handover; optimising quality and prioritising safety—a regional initiative

Aim Differences in the gaze behaviour of experts and novices are described in aviation and surgery. This study sought to describe the gaze behaviour of clinicians from different training backgrounds during a simulated paediatric emergency. Methods Clinicians from four clinical areas undertook a simulated emergency. Participants wore SMI (SensoMotoric Instruments) eye tracking glasses. We measured the fixation count and dwell time on predefined areas of interest and the time taken to key clinical interventions. Results Paediatric intensive care unit (PICU) consultants performed best and focused longer on the chest and airway. Paediatric consultants and trainees spent longer looking at the defibrillator and algorithm (51 180 ms and 50 551 ms, respectively) than the PICU and paediatric emergency medicine consultants. Conclusions This study is the first to describe differences in the gaze behaviour between experts and novices in a resuscitation. They mirror those described in aviation and surgery. Further research is needed to evaluate the potential use of eye tracking as an educational tool.

How to use the videofluoroscopy swallow study in paediatric practice

Medical handover is one of the most commonly performed actions in the healthcare system today. While it is performed regularly, it is often not done as effectively as it could or should be. 1 Many organisations have implemented systems and structures to improve the quality and impact of their handover process. These include advocating senior presence, introducing validated handover tools and an emphasis on multidisciplinary involvement. 2 A protected handover prioritises safety, enhances communication and encourages improvement in handover effectiveness. Our local pilot and subsequent regional initiative has begun actively addressing this issue using a low-cost, interprofessional, multispeciality quality improvement initiative.

G168 An observational study of clinician’s gaze behaviour during simulated paediatric emergencies

In paediatric practice feeding, eating, drinking and swallowing difficulties are present in up to 1% of children. Dysphagia is any disruption to the swallow sequence that results in compromise to the safety, efficiency or adequacy of nutritional intake. Swallowing difficulties may lead to pharyngeal aspiration, respiratory compromise or poor nutritional intake. It causes sensory and motor dysfunction impacting on a child’s ability to experience normal feeding. Incoordination can result in oral pharyngeal aspiration where fluid or food is misdirected and enters the airway, or choking where food physically blocks the airway The incidence is much higher in some clinical populations, including children with neuromuscular disease, traumatic brain injury and airway malformations. The prevalence of dysphagia and aspiration-related disease is increasing secondary to the better survival of children with highly complex medical and surgical needs. This article aims to outline the indications for performing videofluoroscopy swallow (VFS). This includes the technical aspects of the study, how to interrupt a VFS report and some of the limitations to the study.