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摘要： Difficult intubations (DI) in children can be associated with severe complications. There is limited published work regarding the incidence of DI and associated complications in children.1 2 We sought to assess both at Starship Children’s Hospital (SSH) as a first stage in improving our management of such children. Inclusion criteria included children ≤18 yr where an actual DI occurred or a potential DI was predicted based upon one or more of the following criteria: the presence of a known syndrome or previous surgery associated with a DI (e.g. Pierre Robin, mucopolysaccharidosis, previous cervical fusion etc.), previous documented DI, or a preoperative assessment with features suggestive of a potential DI (Table 4). Data was collected prospectively between November 2015 and November 2017 by the operating anaesthetist using a standard form and included demographic data, preoperative assessment, and anaesthetic and intubation details including any complications. Statistical analysis was performed using Statsdirect™ software. A DI was defined as Cormack and Lehane 3 or 4. Patients with C/L3,4 were then compared with those with C/L1,2 in the group. A manual search from Safer Sleep™ (SS™) anaesthetic record data was performed to provide an estimate of the total annual number of general anaesthetics (GAs) and intubations performed by SSH anaesthetists. Data was then compared with published results.1 2 [Figure presented] SS™ analysis estimated a GA rate of 10,556 cases yr–1 with 3796 (36%) children being intubated. A total of 133 patients met the inclusion criteria. Of these, 39 were C/L 3 or 4. This gave an overall DI rate of 0.19% GAs/yr or 0.51% intubations/yr. Twenty-eight percent of actual DIs were unanticipated. A known ‘high risk’ syndrome or previous surgery (P=0.001) and a documented history of DI (P=0.004) were the only significant predictors of a DI (Table 4). The complication rate in C/L3,4 cases was 13/39 (33%): one cardiac arrest associated with a can’t intu

摘要： Following exposure to tuberculosis and subsequent infection, children often progress to tuberculosis disease more rapidly than adults. And yet the natural history of tuberculosis in children, as a continuum from exposure to infection and then to disease, is poorly understood. Children are rarely diagnosed with tuberculosis infection in routine care in international settings and few receive tuberculosis infection treatment. In this Personal View, we review the most up-to- date knowledge in three areas of childhood tuberculosis infection-namely, pathophysiology, diagnosis, and treatment. We then outline what is missing in each of these three areas to generate a priority research agenda. Finally, we suggest potential study designs that might answer these questions. Understanding of pathophysiology could be improved through animal models, laboratory studies assessing the immunological responses of blood or respiratory samples to Mycobacterium spp in vitro, as well as investigating immune responses in children exposed to tuberculosis. Identification of children with sub-clinical disease and at high risk of progression to clinically overt disease, would allow treatment to be targeted at those most likely to benefit. Optimisation and discovery of novel treatments for tuberculosis infection in children should account for mechanisms of action of tuberculosis drugs, as well as child-specific factors including pharmacokinetics and appropriate formulations. To conduct these studies, a change in mindset is required, with a recognition that the diagnosis and treatment of tuberculosis infection in children is a necessary component in addressing the overall tuberculosis epidemic. Collaboration between stakeholders will be required and funding will need to increase, both for research and implementation. The consequences of inaction, however, will lead to further decades of children suffering from what should increasingly be recognised as a preventable disease.

关键词： Rasburicase   allopurinol   uric acid   paediatrics   cardiology   hyperuricemia  

摘要： Objectives: Limited data exist for management of hyperuricemia in non-oncologic patients, particularly in paediatric cardiac patients. Hyperuricemia is a risk factor for acute kidney injury and may prompt treatment in critically ill patients. The primary objective was to determine if rasburicase use was associated with greater probability normalisation of serum uric acid compared to allopurinol. Secondary outcomes included percent reduction in uric acid, changes in serum creatinine, and cost of therapy. Design: A single-centre retrospective chart review. Setting: A 20-bed quaternary cardiovascular ICU in a university-based paediatric hospital in California. Patients: Patients admitted to cardiovascular ICU who received rasburicase or intravenous allopurinol between 2015 and 2016. Interventions: None. Measurements and main results: Data from a cohort of 14 patients receiving rasburicase were compared to 7 patients receiving IV allopurinol. Patients who were administered rasburicase for hyperuricemia were more likely to have a post-treatment uric acid level less than 8 mg/dl as compared to IV allopurinol (100 versus 43%;p = 0.0058). Patients who received rasburicase had a greater absolute reduction in post-treatment day 1 uric acid (-9 mg/dl versus -1.9 mg/dl;p = 0.002). There were no differences in post-treatment day 3 or day 7 serum creatinine or time to normalisation of serum creatinine. The cost of therapy normalised to a 20 kg patient was greater in the allopurinol group ($18,720 versus $1928;p = 0.001). Conclusion: In a limited paediatric cardiac cohort, the use of rasburicase was associated with a greater reduction in uric acid levels and associated with a lower cost compared to IV allopurinol.

关键词： epidemiology   injury   Norway   paediatric   rural health   trauma  

摘要： Background Finnmark, Northern Norway, had a mortality rate for paediatric injury in 1998-2007 that was more than twice the national average. We investigated whether this rate had decreased in 2008-2015 after improvements in emergency care. We also compared the mortality rate to rates of non-fatal injury and trauma team activation both regionally and in Norway. Methods The study was based on 4 national registries. Mortality and injury rates were calculated per 100 000 persons per year. The study population was divided into age groups;0-5, 6-10, 11-15 and 16-17 years. Results Between 1998-2007 and 2008-2015 there was an overall decrease in paediatric mortality rate due to external causes in Norway in total from 7.1 to 4.0. Despite this, in 2008-2015, the mortality rate remained 2.5 times higher in Finnmark than in Norway (9.7, RR = 2.5 CI 1.4-4.3, P = 0.001), similar to findings for 1998-2007. Finnmark had half the rate of non-fatal injuries in 1999-2007 (5052, RR = 0.6, 95% CI 0.6-0.7, P < 0.001) and in 2008-2015 (3893, RR = 0.5, 95% CI 0.5-0.6, P < 0.001) as in Norway. The rate of trauma team activation was similar in Finnmark and Norway. Conclusions The risk of injury-related death remained significantly higher, while the overall risk of non-fatal injury was significantly reduced for children in rural Northern Norway. Thus, injuries in this rural area seem to be less frequent but more severe. There is a need for detailed examination of each death to determine possible preventive measures.

摘要： In recent years, paediatric anaesthetic practice has changed. In 1997, Khine and colleagues1 published a paper challenging the long held belief that the use of a cuffed endotracheal tube in paediatrics caused subglottic stenosis and postoperative stridor. Since this paper, there have been further studies and a gradual change of routine practice to use cuffed endotracheal (ET) tubes more commonly in children requiring intubation. This change has led to an increase in availability of different endotracheal tubes for paediatric anaesthesia. We have looked at how widely important physical properties of these endotracheal tubes can vary between brands and also between sizes of tubes. A range of sample endotracheal tubes, size 3.0–5.5 mm, were sourced. Using a digital caliper, a range of physical measurements were obtained for each tube: the length of the cuff; the distance from the end of the cuff to the end of the tube; the distance from the depth mark (or centre of marks, if two were present) to the end of the tube and the width of the cuff (fully inflated). We compared these results with estimated tracheal lengths (glottis to carina) and diameters for children of varying ages.2 3 Five brands of endotracheal tubes were examined. Only limited brands made size 3 and 3.5 mm. The length from depth mark to tip and fully inflated cuff width data are shown in Table 3. Of all the cuffed tubes examined, only the MicroCuff had a consistent length, from depth mark to tip, a safe margin less than the length of the estimated glottis to carina distance. All the tubes measured had an inflated cuff diameter greater than the diameter of the trachea. The position of the cuff relative to the depth mark varied greatly between brands. Length of tube distal to the end of the cuff was also highly variable (e.g. 10.5–24 mm in size 5.5 tubes). This study showed there is a wide variability between dimensions of tubes supposedly designed for the same age children. Care must also be taken in only

关键词： epidemiology   paediatrics   treatment outcome  

摘要： Objective: Paediatric-onset inflammatory bowel disease (IBD) is different from adult-onset IBD with respect to disease severity and its effect on growth and development. Care of paediatric IBD patients in some countries is dispersed among paediatricians and adult care providers, which may result in different outcomes. This study aims to assess the effect of care setting (paediatric vs adult-oriented) on health care utilization in adolescent IBD patients. Methods: This is a Dutch population-based cohort study based on an insurance claims database covering 4.2 million insurees (approximately 25% of the Dutch population). We identified IBD patients ages 16 to 18 years and followed them until the age of 19 years or transfer to adult care, whichever came first. We categorized patients according to care setting: paediatric versus adult-oriented. We defined outcomes as corticosteroid use, IBD-related hospital admission, IBD-related surgery, and biological use. We estimated Cox proportional hazards regression models to control for confounding by indication. Results: Among 626 patients, 380 (61%) were in paediatric and 246 (39%) in adult-oriented care. In paediatric care, patients were less likely to be treated with corticosteroids (hazard ratio [HR] 0.72, 95% confidence interval [CI] 0.52-0.99) or biologicals (HR 0.57, 95% CI 0.34-0.97), and had fewer IBD-related hospital admissions (HR 0.58, 95% CI 0.37-0.92). Conclusion: In a large and representative community cohort of adolescents with IBD, treatment in paediatric care setting was associated with significantly lower steroid and biological use, without increase in hospital admissions. These results might be used to optimize clinical care for adolescents with IBD.

关键词： iris-claw lens   paediatric aphakia   retropupillary   sutureless scleral fixation  

摘要： Purpose To compare results of sutureless transscleral intraocular lens (IOL) fixation to retropupillary iris-claw lens implantation in cases of paediatric aphakia without capsular support. Methods Thirty eyes of children with insufficient capsular support for IOL implantation were randomized to undergo sutureless transscleral IOL fixation or iris-claw lens fixation. The primary outcome was best-corrected visual acuity (BCVA). Secondary outcomes included operative time, astigmatism, central corneal thickness, endothelial cell count (ECC), IOL decentration and tilt, central foveal thickness and complications. Results There was a significant improvement in BCVA at all follow-up visits, with no significant difference between both groups. 53.3% in the transscleral-fixated IOL group and 80% in the iris-claw IOL group had a final BCVA >= 0.3. The operative time was significantly shorter in the iris-claw IOL group (p = 0.001). IOL decentration and tilt were higher in the transscleral-fixated IOL group, but the difference was not significant. The ECC was reduced by 14.6% in the transscleral-fixated IOL group and 11% in the iris-claw group at 6 months, with no significant difference between both groups (p = 0.5). In the transscleral-fixated IOL group, two eyes developed ocular hypertension and two eyes had IOL decentration, while in the iris-claw IOL group, 1 eye developed glaucoma, three eyes had haptic disenclavation, and one eye had retinal detachment. Conclusion Both techniques yielded a comparable visual outcome. Retropupillary iris-claw lens fixation is a shorter procedure and technically easier than sutureless transscleral fixation, but the risk of disenclavation should be considered especially in younger age groups. Scleral fixation is the only option in case of severe iris damage, but may be associated with more endothelial cell loss.

关键词： appendicitis   colorectal surgery   general surgery   lymphopaenia   paediatric   paediatric surgery  

摘要： Background Appendicitis is a common indication for emergent surgery in children;however, it is a small proportion of presentations with abdominal pain. As viral illness is a common differential diagnosis, lymphopaenia is used by some as a predictor against appendicitis. Furthermore, neutrophil-lymphocyte ratio (NLR) has been found to predict appendicitis. We aimed to verify if lymphopaenia predicted against appendicitis in children. Methods Retrospective review was conducted for all patients aged 15 years and under presenting with abdominal pain to our institution in 2017, and data including age, white cell count, neutrophil and lymphocyte count, NLR, C-reactive protein and diagnosis of appendicitis were recorded. Statistical analysis was performed using Stata (c). Receiver operating characteristic curves for various tests were formed and areas under curve (AUC) compared using regression, P < 0.05 was considered significant. Results A total of 1263 patients were presented, of whom 546 had their blood performed and were included, 86 had appendicitis and 460 did not. Neutrophilia was the best predictor for appendicitis (AUC = 0.86), significantly higher than NLR (0.81), P < 0.05. Lymphopaenia was a poor negative predictor of appendicitis (AUC = 0.46), and while isolated lymphopaenia was more predictive (AUC = 0.23) this was inferior to the positive prediction of neutrophilia, P < 0.05. Conclusion The value of isolated lymphopaenia to predict against appendicitis is largely accounted for inherently normal neutrophils, independently lymphopaenia has little value. NLR, while predictive, is a weaker predictor than neutrophilia.