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关键词： Nurse practitioner   physician assistant   care model   front-line provider   collaborative  

摘要： Objectives: Advanced practice providers (APPs) are being employed at increasing rates in order to meet new in-hospital care demands. Utilising the Paediatric Acute Care Cardiology Collaborative (PAC(3)) hospital survey, we evaluated variations in staffing models regarding first-line providers and assessed associations with programme volume, acuity of care, and post-operative length of stay (LOS). Study design: The PAC(3) hospital survey defined staffing models and resource availability across member institutions. A resource acuity score was derived for each participating acute care cardiology unit. Surgical volume was obtained from The Society of Thoracic Surgeons database. Pearson's correlation coefficients were used to evaluate the relationship between staffing models and centre volume as well as unit acuity. A previously developed case-mix adjustment model for total post-operative LOS was utilised in a multinomial regression model to evaluate the association of APP patient coverage with observed-to-expected post-operative LOS. Results: Surveys were completed by 31 (91%) PAC(3) centres in 2017. Nearly all centres (94%) employ APPs, with a mean of 1.7 (range 0-5) APPs present on weekday rounds. The number of APPs present has a positive correlation with surgical volume (r = 0.49, p < 0.01) and increased acuity (r = 0.39, p = 0.03). In the multivariate model, as coverage by APPs increased from low to moderate or high, there was greater likelihood of having a shorter-than-expected post-operative LOS (p < 0.001). Conclusions: The incorporation of paediatric acute care cardiology APPs is associated with reduced post-operative LOS. Future studies are necessary to understand how APPs impact these patient-specific outcomes.

关键词： Ankle   Fracture   Paediatric   Treatment   Physeal   Injury  

摘要： Introduction Paediatric ankle fractures represents about 5% of all paediatric fractures. It is the most common physis to be injured in the lower limb accounting to approximately 15-20% of all physeal injuries. This article reviews the literature on this common injury which still has many controversial areas and gives guidelines to management based on the existing evidence along with clinical experience gained from a Level I trauma center. Classification The original Salter-Harris Classification with the additional types is a good system to guide on the management. The transitional fractures form a separate group with technically two broad types-biplane and triplane injuries. Though there are many sub-types in this group with some popular eponymous fractures, the treatment principles remain the same. Management A very low threshold for CT scan is recommended when there is a clinical suspicion of fracture with a negative radiograph or an intra-articular fracture in the radiograph especially in the adolescent age group. CT scan helps in accurate quantification of the intra-articular displacement and also helps to comprehend the fracture geometry better. All the intra-articular fractures with displacement > 2 mm need perfect anatomical reduction and stabilization. Assisted closed reduction and percutaneous fixation along with arthrogram to confirm articular congruity is acceptable as long as the reduction is perfect. Irrespective of the method of treatment, in children with more than 2 years of growth remaining it is important to counsel regarding the high incidence of pre-mature physeal closure and the need for regular follow-up.

关键词： Insulin   Paediatric diabetes  

摘要： Objectives The use of continuous subcutaneous insulin infusion (CSII) in the management of paediatric patients with type 1 diabetes mellitus (T1DM) has increased substantially in the last decade. The aim of this study was to evaluate and compare glycaemic control in a population of paediatric patients with T1DM before commencing CSII compared with 2 years after commencing CSII. Methods This is a retrospective study with data collection from diabetes clinic records. Complete data were obtained on 34/45 eligible patients. Glycosylated haemoglobin (HbA1c) and body mass index (BMI) were compared 6 months pre- and 2 years post CSII commencement. Data were stratified in 6-month blocks. Results Mean HbA1c improved over 2 years post CSII with the lowest value in the first 6 months post-commencement. When gender, age, time since diagnosis and time on pump were added as covariates, results became non-significant, with only age exhibiting a statistically significant influence on glycaemic control (p = 0.03). This improved glycaemic control is associated with some increment in BMI which showed no statistical significance in the first year post-CSII. Conclusion CSII commencement is associated with significantly improved glycaemic control most notably in the first 6 months after CSII commencement. There is association between CSII commencement and increased BMI noted to be statistically significant in the second year.

关键词： Optical coherence tomography   Macula   Fovea   Childhood   Children   Paediatric reference database  

摘要： Purpose Optical coherence tomography (OCT) software is used to classify abnormality of macular thickness by colour category based on reference data from adult series. We assessed the impact of using paediatric reference thickness values for macular thickness instead of adult reference values. Methods Cross-sectional study. Primary and tertiary healthcare setting. Out of 140 healthy participants aged 5 to 18 years, 126 were eligible, 83% from European origin. Following a dilated eye examination and cycloplegic refraction, participants underwent macular scanning with OCT (Topcon 3D OCT-2000). Macular thickness paediatric reference values were recorded by spherical equivalent (SE) and sex, and the specific agreement between paediatric and adult reference values below or equal to percentile 5 and above percentile 95 was estimated. The absolute interocular differences for all macular parameters were determined. Results Multivariate regression analysis confirmed statistically independent positive associations between SE and average thickness, total volume, and temporal and inferior outer quadrants (allpvalues <= 0.003). The analysis also revealed higher values in males for average thickness, central thickness, and all inner macula quadrants (allpvalues <= 0.039). The use of the adult database only detected 49% of the extreme values (<= p5 and > p95) in our paediatric sample. The 95th percentile limits for absolute interocular differences for all macular parameters ranged from 12 to 17 mu m. Conclusions OCT-based macular reference values for paediatric SE and sex improve detection of children with abnormal macular thicknesses. Interocular differences exceeding standard references for macular parameters should be considered for further examinations.

关键词： Appendicitis   Paediatric surgery   Appendectomy   Post-appendectomy complications  

摘要： Purpose In general, an appendectomy is presumed to have a limited burden of disease. However, in current literature, reported complication rates vary. This study aims to provide additional insights in the incidence of post-appendectomy complications in children with acute appendicitis. Methods This retrospective cohort study included children (0-17 years old) that underwent appendectomy at our tertiary referral centre for suspected acute appendicitis (January 2011-December 2018). Children referred to our centre, and those that underwent non-operative treatment were excluded. Post-appendectomy complications were recorded from electronic medical charts using predefined definitions and classified as severe (Clavien-Dindo III-IV) or less severe (Clavien-Dindo I-II). Results A total of 131 children were included. Simple and complex appendicitis was diagnosed in 66 (50%) and 60 (46%) children, respectively. A non-inflamed appendix was seen in five (4%) children. One or more complications were identified in 33 (25%) patients. Eight (12%) children with simple appendicitis developed a complication, three of these were severe. In children with complex appendicitis, 23 (38%) children developed a complication, 14 of these were severe. Conclusion This study shows a high rate of complications compared with current literature, both in children with simple and complex appendicitis. This is probably the result of our definition of complications and being a tertiary referral centre receiving more severe appendicitis cases. However, these results still show that appendectomy is not always a routine procedure with only few complications. Substantiating the need to keep optimizing treatment for children with appendicitis.

关键词： Hydrocephalus   Paediatric   Trauma   Injury  

摘要： Introduction Predictive factors for post-traumatic hydrocephalus (PTH) in adults have been elucidated but remain uncertain for children. We aimed to identify the prevalence of PTH in paediatric patients and identify clinical/radiological factors which may increase the probability of children developing PTH. Methods This was a retrospective study of all patients < 16 years old admitted to our unit with traumatic brain injury (TBI) between March 2013 and June 2018, 108 patients in total. Patients were classified as mild (13-15), moderate (9-12) or severe (3-8) TBI based on admission GCS. Three independent reviewers collected data from case notes. CT scans were reviewed for hydrocephalus using Evan's index. Two-tailed Fisher's exact tests with apvalue < 0.05 were considered statistically significant. Results Median patient age was 7 years, and 65% were males (n = 70). PTH wasn't identified in any patients with mild/moderate TBI (n = 79). In cases of severe TBI (n = 29), three patients developed PTH requiring ventriculoperitoneal shunting (10%;p = 0.02). Radiological features which were significantly more common in the PTH group were intraventricular haemorrhage (p = 0.05) and subarachnoid haemorrhage (p = 0.03). There was also a trend towards a statistically significant association with subdural haematoma (p = 0.07). The need for other neurosurgical procedures, such as fracture elevation and craniotomy, did not increase the probability of developing with PTH (p = 0.08). Discussion The prevalence of PTH in our study is 2.7%. Factors which may be associated with a higher probability of developing PTH may include IVH, SAH, severity of TBI, and subdural haematoma. We propose a national prospective multicentre database of paediatric PTH. The data collected on prevalence, presentation, risk factors, and management could guide contemporary management and improve the outcomes of children with PTH.

摘要： Objective To determine the incidence of pituitary incidentalomas in the paediatric population and among its different age subgroups as well as to identify the characteristics of these lesions. Additionally, we aim to give a perspective on the management and follow-up of these patients. Design and Patients We retrospectively studied MRI of children aged 18 years or below who underwent MRI with sellar region within their field of view between January 2010 and December 2018. Measurements Pituitary lesions were considered incidental according to the definition by the Endocrine Society. We reported the size, location and signal characteristics of each lesion. Medical charts of the subjects were reviewed for age, sex, the MRI indication and the hormonal assays levels. Results We identified 40 pituitary lesions of which 31 were incidental lesions. The incidence of pituitary incidentaloma in our cohort was 22 per 1000 patients with female predisposition ( 64.5%) and a mean age of 11 +/- 6 years. Rathke's cleft cyst was the most prevalent lesion, accounting for 67.7% followed by cystic pituitary lesions and microadenomas. The most common indications for imaging were growth disturbance (12.9%) followed by headache (9.7%). Abnormal laboratory workup was present in 13% of the subjects. Incidental lesions were more common in the older age groups compared to young children. Conclusion Incidental pituitary lesions in the paediatric population are relatively infrequent and increases with age. Rathke's cleft cyst is the most common incidentally encountered pituitary lesion followed by cystic pituitary lesions and microadenomas.

关键词： Academic surgery   Paediatrics   Resources   Innovation   Health care  

摘要： Academic pediatric surgery in Mexico has many challenges and opportunities. Work life balance, health service delivery and committements to our many students and residents must be tailored to goals and aspirations respecting talent at every opportunity when we encounter it. This article offers a perspective on the landscape and how we can shape the future in our nation to embrace new leadership in academic pediatric surgery. (c) 2021 Elsevier Inc. All rights reserved.

关键词： behavioural guidance   behavioural management   dental education  

摘要： Objectives Behavioural guidance (BG) training is an important component of preparing future dentists to manage paediatric patients, who often exhibit cooperation issues during treatment. This study investigated the acceptance of various BG techniques amongst dental students in a Malaysian institution. Methodology A paper-based survey was conducted, classroom-style, on all dental students (Year 1 to Year 5, n = 336, response rate = 84.5%) using a validated questionnaire, developed from previous literature. For each BG technique, students used a visual analogue scale to mark their acceptability score;this figure was later categorised into different acceptance levels. Students' mean acceptability scores and acceptance of each BG technique were consecutively analysed via independentttest and chi-square test (significance level,P < 0.01) using Statistical Package for the Social Sciences software. Results Across the academic year, most students cited acceptance of reinforcement techniques (eg positive reinforcement, encouraging child "not to be a coward", promising a toy) and desensitisation methods (eg tell-show-do, music/video distraction, stimulating the child's imagination, using euphemism), but not for aversive interventions (eg hand over mouth, using Papoose Board, active immobilisation) and showing needles (P > 0.01). Percentages of those who accepted communicative techniques involving parents demonstrated significant differences across subjects of different academic years, between pre-clinical and clinical groups of respondents and amongst clinical students. Other techniques with such significant differences, along with low acceptance, included modelling, voice control and disallowing the child to speak. Conclusion The findings of this study provide useful information for curricular enhancement aimed at equipping dental students with the ability to apply appropriate and effective BG techniques during patient care.