I love the idea of blast talks – quick fire, high yield presentations with minimum slides and no bullet points! My challenge was to deliver the top PEM papers of 2015 in just 8 minutes. They wanted three in my PEM review. So I gave them six point five 🙂
Here are the papers I whizzed through in my review of PEM papers of 2015 (so far). There are full critical appraisals for most over at PEMLit.org
These papers were worthy of a quick mention because they were interesting as PEM concepts, if methodologically flawed.
Place Your Bets: Clinician Suspicion or Prediction Rule for Blunt Abdominal Trauma?
The big question: are clinicians better at predicting intra-abdominal injuries in children with blunt torso trauma than a derived clinical prediction rule?
What did they do? Secondary analysis of some existing PECARN group data from a prospective cohort study of children with blunt torso trauma. Clinicians completed standardised data collection forms prior to abdominal imaging, recording clinical variables influencing their decision making along with a “suspicion” of intra-abdominal injury undergoing acute intervention on an ordinal scale. This was considered positive suspicion if risk of intervention was >1% and negative if <1%. Predictions were compared with the derived clinical prediction rule (clinicians were not aware of its component parts).
What did they find? 35 patients deemed negative for clinician suspicion subsequently had acute intervention; interestingly even within this majority group of patients 3016/9252 had CT abdomen performed. Of the remaining patients positive for clinician suspicion, 168/2667 had an acute intervention.
Low risk (<1%) clinician suspicion had the following test characteristics; sensitivity 82.8% (95% CI 77.0-87.3), specificity 78.7% (95% CI 77.9-79.4%), NPV 99.6 (95% CI 99.5-99.7%), LR- 0.2 (95% CI 0.2-0.3).
Low risk on the prediction rule had the following test characteristics; sensitivity 97.0% (95% CI 93.7-98.6), specificity 42.5% (95% CI 41.6-43.4%), NPV 99.9 (95% CI 99.7-99.9%), LR- 0.1 (95% CI 0.0-0.2).
What does this mean? We’re not as smart as we think we are! We aren’t as good at identifying low risk patients as the decision rule (which is still imperfect) although we CT a lot of low risk children anyway. If the tool can be validated we might be able to reduce the number of abdominal CTs in children with blunt torso trauma.
Bouncing Back: Repeated ED Visits in Children With Meningitis/Septicaemia
The big question: How often have children, subsequently diagnosed with meningitis or septicaemia, attended an ED and been discharged in the preceding five days?
What did they do? This was a retrospective cohort study identifying children (aged 30 days to 5 years) with a diagnosis of meningitis or septicaemia and linking their data to a database to determine preceding ED attendances in the five days before their admission visit.
What did they find? Over the five years of study, 521 children were admitted with an ultimate discharge of meningitis or septicaemia of whom 125 had attended an ED in the preceding 5 days with 114 attending with apparent infection. Reassuringly those with repeated visits had similar lengths of stay, critical care use and 30-day mortality. They were interested in looking at whether reattendance was more likely if you had first attended a DGH but I’m not sure this can be extrapolated to our populations.
What does this mean? Safety netting matters! Meningitis/septicaemia may not be immediately apparent so it’s important that parents feel comfortable bringing children back to the ED if they have concerns. This is something that plays out in popular media too.
Not Hot, Not Sick? Afebrile Infants Investigated for Serious Bacterial Infection in the ED
The big question: do infants investigated for serious bacterial infection (SBI) without a history of fever have SBI?
What did they do? A retrospective analytical observational study of infants aged 0 to 60 days presenting to the ED for reasons other than fever who were investigated for SBI (defined as two or more of: urinary culture, blood culture, CSF culture). Rates of SBI were compared with patients presenting in the same age range in the same period with fever.
What did they find? 362 patients in the fever group and 217 patients in the afebrile group met inclusion criteria. Positive blood cultures with true pathogens were found in 10 febrile patients (2.8%) and 2 afebrile patients (0.9%). Positive urine cultures were found in 10 (2.7%) of the febrile group and 4 (1.8%) afebrile patients. All cases of bacterial meningitis were in the febrile group. Overall, of all patients investigated for SBI, 5 in the afebrile group (2.3%) and 20 of the febrile group (5.5%) had a documented SBI.
What does this mean? SBI can present in infants in all sorts of ways and not necessarily with fever. Have a low threshold for SBI workup infants behaving strangely/badly in the ED.
The Big Three
Getting Chilly Quickly: THAPCA-OH
The big question: does therapeutic hypothermia improve confer a survival benefit in children with out of hospital cardiac arrest?
What did they do? A single-blinded, multicentre randomised controlled trial in which children with ROSC were randomised one-to-one to therapeutic hypothermia for 48h then normothermia for 72h, or active normothermia for 120h. The outcome of interest was survival at 12 months with good neurological function (defined as age-corrected standard score of 70 or more on the Vineland Adaptive Behaviour Scales (VABS-II)
What did they find? 295 patients were randomised:155 were randomised to hypothermia, 140 to normothermia. Survivors at 12 months with VABS-II score >70: Hypothermia 27/138 (20%), Normothermia 15/122 (12%)
Risk difference 7.3 (95% confidence interval -1.5 to 16.1)
Relative likelihood 1.54 (95% confidence interval 0.86 to 2.76, P=0.14)
What does this mean? There is insufficient evidence to reject the null hypothesis of no difference between groups but clinically that looks like a big difference – you would be justified in arguing for continuing to provide therapeutic hypothermia I think.
There’s a whole St Emlyn’s journal club post dedicated to this paper here – so please read that too 🙂
Talking Heads: Diagnostic Performance of S100B in Detecting Intracranial Injury in Children with Mild Head Trauma
The big question: can S100B rule in/rule out intracranial injury in children with mild head trauma?
What did they do? A prospective cohort of consecutive patients under 16 presenting to one of three Swiss paediatric EDs with mild head injury (acute head trauma with confusion or LOC <30mins or amnesia or transient neurological abnormality) for whom a CT was requested; these subjects also had a venous blood sample for S100B level which was not available before CTs had been reported. They then determined test characteristics for S100B in the context of CT findings. The sample size was pretty small – 80 children were enrolled.
What did they find? Only 73/80 were included in the analysis, of whom 20 had an intracranial injury. No surgical interventions were required in any case.
The ROC curve for S100B had an AUC of 0.73 (95% CI 0.60-0.86) which improved to 0.77 (95% CI 0.65-0.89) when under 2s were excluded. Using a cutoff of 0.14micrograms/L gave a sensitivity of 95% (95% CI 77%-100%) for all children (100% (95% CI 81%-100%) with under 2s excluded) and specificity 34.0% (95% CI 27%-36%).
What does this mean? We can’t yet use S100B to exclude intracranial injury in children with “mild” head injury but there is potential there following further studies in larger populations and with a priori analyses excluding under 2s.
Magic Numbers: Oxygen saturation targets in infants with bronchiolitis
The big question: is target oxygen saturation of 90% or higher equivalent to 94% or higher for resolution of illness in acute viral bronchiolitis?
What did they do? A parallel group, randomised controlled equivalence trial at 8 centres across two x 6-month winter bronchiolitis seasons.
Infants aged 6 weeks to 12 months who presented acutely with clinically diagnosed bronchiolitis and required admission randomised to standard sats monitoring or a modified monitor with skewed readings such that SpO2 90% read as 94%. Standard care therein; primary outcome measure was time to resolution of cough (as a proxy for resolution of illness)
What did they find? 308 randomised to standard care, 307 to modified care. Equivalence found in primary outcome – no difference in median time to cough resolution. The modified group also had quicker return to adequate feeding and “back to normal” time. Patients in the modified group, predictably, received supplemental oxygen in fewer cases, for a shorter period, were considered fit for discharge sooner and were discharged sooner. There were fewer serious adverse events and adverse events in the modified group. The modified group had increased HDU admissions but fewer reattendances
What does this mean? Time taken for symptom resolution was equivalent whether target SpO2 was 94% or 90% however this was an inpatient population for whom a need for admission had already been identified. The fact that the modified group were discharged more quickly might suggest that there are harms caused by the administration of oxygen (drying of nasal passages, impacting on feeding) but for us in the ED it is difficult to know how to put this into practice. Further work to be done here.
Just like all good news round-ups, I had to have an “and finally” story, and that particular accolade goes to the paper below.
The big question: does playing nursery songs plus a human heartbeat reduce anxiety scores in children and infants undergoing head CT?
What did they do? A randomised a prospective cohort of children requiring CT scan to hear children’s nursery rhymes and a human heart beat (synchronized) for three songs prior to CT. The researchers scoring anxiety (using a simple visual analogue score) were blinded to whether the child had heard the music prior to CT and pre- and post-intervention anxiety scores were compared. The modified Ramsey sedation score was used alongside the VAS.
What did they find? 32 children were in the control group with 30 in the experimental group. Initial agitation scores were similar before the intervention; the experimental group had 53% decreased in anxiety scores during the CT compared with 25% of the control group.
What does this mean? This is a pretty difficult study to develop a robust methodology for and there are lots of weaknesses BUT at the end of the day, there’s some evidence that music might be helpful in calming kids to facilitate CT scan. It’s cheap, it’s harmless – it’s worth a try 🙂
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