Interfacial Tensions, Solubilities, and Transport Properties of the H2/H2O/NaCl System: A Molecular Simulation Study

Data for several key thermodynamic and transport properties needed for technologies using hydrogen (H2), such as underground H2 storage and H2O electrolysis are scarce or completely missing. Force field-based Molecular Dynamics (MD) and Continuous Fractional Component Monte Carlo (CFCMC) simulations are carried out in this work to cover this gap. Extensive new data sets are provided for (a) interfacial tensions of H2 gas in contact with aqueous NaCl solutions for temperatures of (298 to 523) K, pressures of (1 to 600) bar, and molalities of (0 to 6) mol NaCl/kg H2O, (b) self-diffusivities of infinitely diluted H2 in aqueous NaCl solutions for temperatures of (298 to 723) K, pressures of (1 to 1000) bar, and molalities of (0 to 6) mol NaCl/kg H2O, and (c) solubilities of H2 in aqueous NaCl solutions for temperatures of (298 to 363) K, pressures of (1 to 1000) bar, and molalities of (0 to 6) mol NaCl/kg H2O. The force fields used are the TIP4P/2005 for H2O, the Madrid-2019 and the Madrid-Transport for NaCl, and the Vrabec and Marx for H2. Excellent agreement between the simulation results and available experimental data is found with average deviations lower than 10%.

Improved readability and functions needed for mHealth apps targeting patients with heart failure: An app store review

To maintain their quality of life and avoid hospitalization and early mortality, patients with heart failure must recognize and respond to symptoms of exacerbation. A promising method for engaging patients in their self-care is through mobile health applications (mHealth apps). However, for mHealth to have its greatest chance for improving patient outcomes, the app content must be readable, provide useful functions and be based in evidence. The study aimed to determine: (1) readability, (2) types of functions, and (3) linkage to authoritative sources of evidence for self-care focused mHealth apps targeting heart failure patients that are available in the Apple and Google Play Stores. We systematically searched for mHealth apps targeting patients with heart failure in the Apple and Google Play Stores and applied selection criteria. Readability of randomly selected informational paragraphs were determined using Flesch-Kincaid grade level test tool in Microsoft Word. Ten mHealth apps met our criteria. Only one had a reading grade level at or below the recommended 6th grade reading level (average 9.35). The most common functions were tracking, clinical data feedback, and non-data-based reminders and alerts. Only three had statements that clearly linked the mHealth app content to trustworthy, evidence-based sources. Only two had interoperability with the electronic health record and only one had a communication feature with clinicians. Future mHealth designs that are tailored to patients' literacy level and have advanced functions may hold greater potential for improving patient outcomes.

EFFECTS OF EXERCISE ON MIR-29 AND IGF-1 EXPRESSION AND LIPID PROFILE IN THE HEART OF OVARIECTOMIZED RAT

Introduction

Menopause increases the risk of cardiovascular disease in women. The aims of the present study were to evaluate the effects of swimming training on cardiac histology and expression of miR-29 and IGF-1 in the ovariectomized rats.

Materials and methods

Thirty female Wistar rats were divided into sham and ovariectomized groups: sedentary control (OVX) and trained with 8 weeks exercise (OVX.E). On 57^th day, blood was collected and used for lipid profile measurement. In addition, heart tissue was analyzed by reverse transcription-polymerase chain reaction for IGF-1 mRNA and miR-29, and studied for histopathological changes.

Results

Ovariectomy significantly decreased miR-29 and IGF-1 expression in the heart compared to sham animals group (p<0.05). Exercise training increased miR-29 and IGF-1 expression in the trained rats and improved histology and lipid profile compared with OVX group (p<0.05).

Conclusion

Estrogen deficiency could lead to cardiac fibrosis through deregulation miR-29 and IGF-1 expression. The findings of the current study suggests a protective effect of exercise on heart against fibrotic changes in ovariectomized rats and support a potential preventive value of exercise in improving cardiac function after menopause.

The effect of 2 mMol glutamine supplementation on HSP70 and TNF-α release by LPS stimulated blood from healthy children

OBJECTIVE

Glutamine has been shown to promote heat shock protein 70 (HSP70) release both within experimental in vitro models of sepsis (2-10 mM) and in adults post trauma (0.5 g/kg), although the efficacy varies and is dependent on the model used. The effect of glutamine supplementation on HSP70 release in children is less clear. Therefore, the aim of this study was to investigate the effect of 2 mM glutamine added to incubation media on HSP70 and inflammatory mediator release in an in vitro model of paediatric sepsis using whole blood from healthy paediatric volunteers.

METHODS

An in vitro whole blood endotoxin stimulation model using 1 μg/ml lipopolysaccharide (LPS) over a 24 h time period was used to investigate the effects of 2 mM glutamine on HSP70 and inflammatory mediator release in healthy children.

RESULTS

The addition of 2 mM glutamine to the incubation media significantly increased HSP70 release over time (p < 0.05). This was associated with an early pro-inflammatory effect on TNF-α release at 4 h (p < 0.005) which was not seen at 24 h. There was a non significant trend towards higher levels of IL-6 and IL-10 following the addition of 2 mM glutamine, which appears to differ from the response reported in adult and animal models.

CONCLUSION

Glutamine supplementation of incubation media promotes HSP70 and early TNF- α release in an in vitro model using blood samples from healthy children.

Incidence of fatal food anaphylaxis in people with food allergy: a systematic review and meta-analysis

Background

Food allergy is a common cause of anaphylaxis, but the incidence of fatal food anaphylaxis is not known. The aim of this study was to estimate the incidence of fatal food anaphylaxis for people with food allergy and relate this to other mortality risks in the general population.

Methods

We undertook a systematic review and meta-analysis, using the generic inverse variance method. Two authors selected studies by consensus, independently extracted data and assessed the quality of included studies using the Newcastle-Ottawa assessment scale. We searched Medline, Embase, PsychInfo, CINAHL, Web of Science, LILACS or AMED, between January 1946 and September 2012, and recent conference abstracts. We included registries, databases or cohort studies which described the number of fatal food anaphylaxis cases in a defined population and time period and applied an assumed population prevalence rate of food allergy.

Results

We included data from 13 studies describing 240 fatal food anaphylaxis episodes over an estimated 165 million food-allergic person-years. Study quality was mixed, and there was high heterogeneity between study results, possibly due to variation in food allergy prevalence and data collection methods. In food-allergic people, fatal food anaphylaxis has an incidence rate of 1.81 per million person-years (95%CI 0.94, 3.45; range 0.63, 6.68). In sensitivity analysis with different estimated food allergy prevalence, the incidence varied from 1.35 to 2.71 per million person-years. At age 0–19, the incidence rate is 3.25 (1.73, 6.10; range 0.94, 15.75; sensitivity analysis 1.18–6.13). The incidence of fatal food anaphylaxis in food-allergic people is lower than accidental death in the general European population.

Conclusion

Fatal food anaphylaxis for a food-allergic person is rarer than accidental death in the general population.

Electronic and magnetic structure of the Cr(001) surface

Density functional theory (DFT) calculations are carried out to study the electronic and magnetic structure of the (001) surface of chromium. Our aim is to identify and characterize the most prominent electronic surface states and make the connection with the main experimental results. We show that a low dispersive minority spin surface state at the center of the surface Brillouin zone plays a crucial role. This surface state of Δ1 symmetry at 0.58 eV above the Fermi level exhibits a predominantly dz(2) as well as pz orbital character. Local density of states (LDOS) analysis in the vacuum above the surface shows that the sharp feature originating from this surface state persists far away above the surface because of the slow decay rate of the pz wavefunction. Finally, by artificially lowering the surface magnetic moment [Formula: see text] on the outermost surface layer we find excellent agreement with experiments for [Formula: see text]. In addition, we propose that some extra spin polarized scanning tunneling spectroscopy (SP-STS) experiments should be made at smaller tip-surface distances to reveal additional features originating from the majority spin dz(2) surface state.

Comparison of three methods for diagnosis of cutaneous leishmaniasis

BACKGROUND

Leishmaniasis is one of the infectious parasitic diseases of highest incidence in the world. Cutaneous Leishmaniasis (CL) has long been reported in Shiraz, Southern Iran. There is a need to find a sensitive and specific method for treatment and control of the disease.

METHODS

We have compared the sensitivity of the conventional methods microscopy and cultivation of lesion scrapes against PCR amplification of parasite kinetoplast DNA from these samples. The samples (n=219) were obtained from the patients clinically suspected of CL. The smears were stained with Giemsa for microscopy and cultured in Novy-Nicolle-McNeal (NNN) blood agar for promastigote growth. For PCR, the dry smears were scraped off the slides and DNA was extracted.

RESULTS

The positive rates from 219 specimens were 76.71%, 50.68%, and 93.61% for microscopy, cultivation, and PCR, respectively. The highest correlation was found between PCR and microscopy method (P=0.014). In PCR assay, 95.61%, 3.9%, and 0.49% of the samples were identified as Leishmania major, L. tropica, and dermatropic L. infantum, respectively.

CONCLUSION

The PCR method appears to be the most sensitive for the diagnosis of CL and is valuable for identifying the other species of Leishmania with confusing dermatropic signs.

The impact of enteral feeding protocols on nutritional support in critically ill children

BACKGROUND

Studies have shown that feeding protocols may assist in achieving optimal nutritional care in critically ill children. The present study aimed to assess the impact of enteral feeding protocols on nutritional support practices through a continuous auditing process over a defined period.

MATERIALS AND METHODS

A prospective audit on nutritional practice was initiated in 1994-1995 on all ventilated patients who were admitted for more than a complete 24-h period in the paediatric intensive care unit. The audit was repeated 1997-1998, 2001 and 2005. The collection of data on outcomes included the time taken to initiate nutritional support, the proportion of patients fed via the enteral versus parenteral route, and the proportion of children reaching 50% and 70% of the estimated average requirement (EAR) by day 3. Feeding algorithms and protocols were introduced after each audit with a view to improving practices.

RESULTS

Over the study period, time taken to initiate nutrition support was reduced from 15 h (1994-1995), 8 h (1997-1998), 5.5 h (2001) to 4.5 h (2005). The proportion of patients on parenteral feeds was reduced from 11% (1994-1995) to 4% (2005). An increase was also documented in the percentage of patients receiving a daily energy provision of 50% and 70% of the EAR by day 3 after the initiation of nutritional support (6% in 1994-1995 to 21% in 2005 for 70% of EAR).

CONCLUSION

The present study demonstrates that feeding protocols improve nutritional practices in a paediatric intensive care unit. However, protocol introduction needs to be monitored regularly through audit.

Influence of a multidisciplinary paediatric allergy clinic on parental knowledge and rate of subsequent allergic reactions

BACKGROUND

Studies have demonstrated that families of children with food allergy have significant deficiencies in their knowledge of how to avoid allergen exposure and how to manage allergic reactions. This study aims to assess the impact of a multidisciplinary paediatric allergy clinic consultation on parental knowledge of food allergy and to determine the rate of subsequent allergic reactions.

METHODS

Sixty-two subjects (<17 years) referred with food allergy were prospectively enrolled. Parental knowledge was assessed by questionnaire and EpiPen trainer. Families saw a paediatric allergist, clinical nurse specialist and dietician. Knowledge was reassessed after 3 months and rate of allergic reactions after 1 year.

RESULTS

After one visit to the paediatric allergy clinic, there was a significant improvement in parental knowledge of allergen avoidance (26.9%, P < 0.001), managing allergic reactions (185.4%, P < 0.0001) and EpiPen usage (83.3%, P < 0.001). Additionally, there was a significant reduction in allergic reactions (P < 0.001). Children with egg, milk or multiple food allergies were more likely to suffer subsequent reactions.

CONCLUSIONS

A single visit to a multidisciplinary allergy clinic considerably improves families' abilities to manage allergic reactions to foods with an accompanying reduction in allergic reactions. Young children with egg, milk or multiple food allergies were at greatest risk of further reactions.

Does the use of a specialised paediatric retrieval service result in the loss of vital stabilisation skills among referring hospital staff?

AIMS

To compare the proportion of airway and vascular access procedures performed by referring hospital staff on critically ill children in two discrete time periods, before and after widespread use of a specialised paediatric retrieval service.

METHODS

Transport data were obtained from retrieval logs of all children for whom a paediatric retrieval team was launched in each of two time periods (October 1993 to September 1994; and October 2000 to September 2001).

RESULTS

The overall intubation rate was similar in the first and second time periods (83.9% v 79.1%). However, 31/51 (61%) retrieved children were intubated by referring hospital staff in 1993-94, compared to 227/269 (84%) in 2000-01. Referring hospital staff gained central venous access in 11% v 18% and arterial access in 22% v 19% of retrieved children in the first and second time periods respectively. This was in spite of a significant reduction in the proportion of children on whom these procedures were performed.

CONCLUSION

Referring hospital staff are performing a greater proportion of initial airway and vascular access procedures undertaken in the stabilisation of sick children retrieved by a specialised paediatric retrieval team. The provision of this service has not resulted in the loss of vital skills at the local hospital.

A comparison of three scoring systems for mortality risk among retrieved intensive care patients

AIMS

To assess the impact of two paediatric intensive care unit retrieval teams on the performance of three mortality risk scoring systems: pre-ICU PRISM, PIM, and PRISM II.

METHODS

A total of 928 critically ill children retrieved for intensive care from district general hospitals in the south east of England (crude mortality 7.8%) were studied.

RESULTS

Risk stratification was similar between the two retrieval teams for scores utilising data primarily prior to ICU admission (pre-ICU PRISM, PIM), despite differences in case mix. The fewer variables required for calculation of PIM resulted in complete data collection in 88% of patients, compared to pre-ICU PRISM (24%) and PRISM II (60%). Overall, all scoring systems discriminated well between survival and non-survival (area under receiver operating characteristic curve 0.83-0.87), with no differences between the two hospitals. There was a tendency towards better discrimination in all scores for children compared to infants and neonates, and a poor discrimination for respiratory disease using pre-ICU PRISM and PRISM II but not PIM. All showed suboptimal calibration, primarily as a consequence of mortality over prediction among the medium (10-30%) mortality risk bands.

CONCLUSIONS

PIM appears to offer advantages over the other two scores in terms of being less affected by the retrieval process and easier to collect. Recalibration of all scoring systems is needed.

Noninvasive measurement of cardiac output in critically ill children

This study was performed to evaluate the hemodynamic status of children admitted to the intensive care unit, using suprasternal and transesophageal Doppler ultrasound, and to establish a suitable noninvasive technique to monitor trends in cardiac output in critically ill children. Twenty children were studied over a period of 6 months. The median age was 32.5 months and weight 14.5 kg. Minute distance (MD), which is a linear cardiac output parameter, was assessed. Seven simultaneous pairs of measurements of MD were made using transesophageal Doppler (TED) and suprasternal Doppler (SSD) by the same operator. Following a fluid challenge, seven repeat pairs of measurements were made. The mean percentage changes for MD by TED and SSD were 21.84 (SD 9.97) and 5.75 (SD 7.32). The average coefficients of variation for measurements of MD by TED and SSD were 2.34% and 15.98%, respectively. The mean difference in percentage change between MD, measured by TED and SSD, was 27.59 with a 95% confidence interval and wide limits of agreement. The repeatability of TED measurements was good, but the measurements by SSD were wide and erratic with poor reproducibility. Our study shows that TED is easy to use, reliable, and very useful for monitoring hemodynamic changes in critically ill children.

Reduction in case fatality rate from meningococcal disease associated with improved healthcare delivery

BACKGROUND AND AIMS

The case fatality rate from meningococcal disease (MD) has remained relatively unchanged in the post antibiotic era, with 20-50% of patients who develop shock still dying. In 1992 a new paediatric intensive care unit (PICU) specialising in MD was opened. Educational information was disseminated to local hospitals, and a specialist transport service was established which delivered mobile intensive care. The influence of these changes on mortality of children with MD was investigated.

METHODS

A total of 331 consecutive children with meningococcal disease admitted to the PICU between 1992 and 1997 were studied. Severity of the disease on admission was assessed using the paediatric risk of mortality (PRISM) score. Logistic regression analysis was used to correct for clinical severity, age, and sex; death was the outcome, and year of admission, a temporal trend variable, was the primary exposure.

RESULTS

The case fatality rate fell year on year (from 23% in 1992/93 to 2% in 1997) despite disease severity remaining largely unchanged. After adjustment for age, sex, and disease severity, the overall estimate for improvement in the odds of death was 59% per year (odds ratio for the yearly trend 0.41).

CONCLUSIONS

A significant improvement in outcome for children admitted with MD to a PICU has occurred in association with improvements in initial management of patients with MD at referring hospitals, use of a mobile intensive care service, and centralisation of care in a specialist unit.

A myocardial cytotoxic process is involved in the cardiac dysfunction of meningococcal septic shock

OBJECTIVE

Myocardial dysfunction is a characteristic component of meningococcal septic shock and contributes to the persisting high mortality from the disease. Specific treatment of the myocardial failure has been hampered by the lack of understanding of its pathophysiology. We were interested to determine whether myocardial cell death was occurring in the presence of meningococcal septicemia and whether it correlated with the degree of left ventricular dysfunction and disease severity. We therefore investigated the release of cardiac troponin I (cTnI), a sensitive and specific marker of myocardial cell death, and related this to the severity of disease and cardiac dysfunction.

DESIGN

Prospective study

SETTING

Pediatric intensive care unit

SUBJECTS

Patients admitted to the pediatric intensive care unit with a diagnosis of meningococcal septicemia.

INTERVENTIONS

Serum concentrations of cTnI were determined at admission to intensive care in 101 children with meningococcal septicemia and serially in 37 children. Changes in cTnI were related to disease severity as measured by the Pediatric Risk of Mortality score and two markers of cardiac dysfunction.

MEASUREMENTS AND MAIN RESULTS

Serum concentrations of cTnI were elevated above the range for healthy children in 24% of children with meningococcal septicemia at admission and in 62% of patients within 48 hrs. The peak concentrations occurred between 12 and 36 hrs after admission. There were significant correlations between cTnI levels and disease severity and between cTnI levels and the degree of myocardial depression measured by quantitative transthoracic echocardiography and peak inotrope requirements.

CONCLUSIONS

The elevated serum concentrations of cTnI indicate that myocardial cell death is occurring in meningococcal septicemia. The relationship between cTnI and markers of myocardial function suggest that the cell death may have a role in the pathogenesis of myocardial dysfunction in meningococcal septicemia. Elucidation of the mechanism responsible for myocardial injury may lead to the development of therapeutic interventions to prevent or limit this cardiac damage.

Efficacy of chest CT in a pediatric ICU: a prospective study

STUDY OBJECTIVES

(1) To determine whether chest CT provides additional information compared with chest radiography regarding the nature of intrathoracic disease in critically ill children, (2) to determine whether such information alters clinical management, (3) to assess the role of a low-dose high-resolution CT (HRCT) protocol in pediatric ICU (PICU) patients.

DESIGN

Prospective study.

SETTING

Specialized PICU in a teaching hospital serving London and the south of England.

PATIENTS

Twenty children (age range, 3 weeks to 12 years; median, 11 months) underwent chest CT during a 33-month period. Inclusion criteria were (1) inconclusive diagnosis from chest radiograph (CXR) or (2) CXR appearances inconsistent with high oxygenation or ventilatory requirements (PaO(2) to fraction of inspired oxygen ratio < 30 or mean airway pressure > 15 cm H(2)O).

INTERVENTIONS

Low-dose HRCT scans (50 mA, 2-mm slice thickness at intervals of 10 or 15 mm) were performed on 12 patients, and helical CT (50 to 250 mA; pitch, 1 to 1.5) performed on 8 patients.

MEASUREMENTS AND RESULTS

CT provided additional information regarding the nature of intrathoracic disease in 17 of 20 patients (85%) and resulted in changes to subsequent clinical management in 12 of 20 patients (60%).

CONCLUSIONS

Chest CT can add to the accuracy of intrathoracic diagnosis provided by the CXR and may directly influence the acute management of critically ill children. The CT protocol should be tailored to the clinical and radiologic question posed for each individual patient. Noncontiguous HRCT can often provide accurate assessment of pulmonary parenchymal and pleural disease at a reduced radiation dose compared with helical CT.

The orthopaedic management of peripheral ischaemia in meningococcal septicaemia in children

Between March 1993 and February 1999, 14 children aged from eight months to 14.75 years were admitted to the paediatric intensive-care unit with meningococcal septicaemia in association with severe peripheral ischaemia. Of these, 13 were operated upon, eight of whom had early fasciotomies. Five children died. Of the nine survivors, one had no amputations while in the other eight 14 limb segments were amputated. We review the case histories and propose a protocol for the early management of these children.

The orthopaedic management of peripheral ischaemia in meningococcal septicaemia in children

Between March 1993 and February 1999, 14 children aged from eight months to 14.75 years were admitted to the paediatric intensive-care unit with meningococcal septicaemia in association with severe peripheral ischaemia. Of these, 13 were operated upon, eight of whom had early fasciotomies. Five children died. Of the nine survivors, one had no amputations while in the other eight 14 limb segments were amputated. We review the case histories and propose a protocol for the early management of these children.

Emergency cranial computed tomography in the management of acute febrile encephalopathy in children

OBJECTIVE

Evaluation of the influence of emergency cranial computed tomography on the management of acute febrile encephalopathy in children.

METHODS

A retrospective study in children with acute febrile encephalopathy who underwent emergency cranial computed tomography within 12 hours of admission to the paediatric intensive care unit. All scans were evaluated by two independent radiologists.

RESULTS

Thirty nine children were included. Fourteen scans were abnormal and two had clinically insignificant incidental findings. Four children with focal neurological signs had scans demonstrating extra-axial collections. None required neurosurgical intervention. Clinically, raised intracranial pressure was present in 10 patients. Only five had cerebral oedema on computed tomography; these five children died. Emergency cranial computed tomography influenced subsequent management in no child without focal neurological signs and in only one child with focal neurology.

CONCLUSION

Emergency cranial computed tomography in acute febrile encephalopathy in children without focal neurological signs has little influence on subsequent management. Where cranial computed tomography is thought to be necessary, it should be carried out when the child's clinical condition has been stabilised.

Distribution and pathophysiology of acute lobar collapse in the pediatric intensive care unit

OBJECTIVE

The high incidence of lower lobe collapse in adult intensive care patients is well described. We aimed to document the incidence and distribution of acute lobar collapse in the pediatric intensive care setting. The influence of anatomical and pathophysiological differences between the adult and pediatric respiratory tract will be considered.

DESIGN

Retrospective review of chest radiograph series.

SETTING

Tertiary referral center for pediatric intensive care and the Department of Diagnostic Radiology in a large teaching hospital in England.

PATIENTS

Cohort of 160 patients receiving intensive care during a 2-yr period (age range, 6 days-18 yrs; median, 23 months).

INTERVENTIONS

None

MEASUREMENTS AND MAIN RESULTS

Twenty-four of 160 children (15%) developed acute lobar collapse during their intensive care unit admission. Isolated right upper lobe collapse occurred in 14 patients, right upper lobe in association with one or more other lobes in five patients, and lobar collapse other than the right upper lobe in five patients. The development of lobar collapse and, in particular, right upper lobe collapse was associated with a lower median age (no collapse, 26 months; lobar collapse, 8 months; right upper lobe collapse, 4 months). Lobar collapse was significantly associated with the requirement for mechanical ventilation during admission (chi-square, 12.18; p = .005). It was observed in association with both high and low endotracheal tube positions.

CONCLUSION

The predominance of upper lobe and, in particular, right upper lobe collapse observed in pediatric intensive care patients contrasts with the high incidence of lower lobe collapse in their adult counterparts. Multiple interrelated factors are likely to be contributory and include the following: a) anatomical and physiological differences between adults and children; b) the pathophysiology of childhood respiratory disease; c) more critical positioning of endotracheal tubes in younger patients and their movement with patient positioning.

Pertussis is increasing in unimmunized infants: is a change in policy needed?

The proportion and trend in absolute number of pertussis notifications in young infants has increased each year in England and Wales since the accelerated immunization schedule was introduced. We report five infants all less than 3 months of age admitted with life threatening pertussis infection to two paediatric intensive care units. Despite aggressive cardiorespiratory support measures, three of the infants died. Pertussis remains a significant cause of morbidity and mortality in unimmunized infants. In this age group presentation is likely to be atypical and infection more severe. Public health measures to prevent the disease could be strengthened. Chemoprophylaxis should be offered to susceptible contacts and booster vaccinations against pertussis considered.

Emergency management of meningococcal disease

Meningococcal disease remains a major cause of mortality in children in the UK. Aggressive early volume resuscitation, meticulous attention to the normalisation of all physiological and laboratory parameters, and prompt referral to specialist paediatric intensive care may lead to a sharp reduction in mortality. Application of the management algorithm described in this article may be helpful to those involved in the early part of management of critically ill patients with meningococcal disease.

Avoidable deficiencies in the delivery of health care to children with meningococcal disease

OBJECTIVES

It is apparent that delays and inadequate or inappropriate management occur frequently and may contribute to the continued high mortality seen in meningococcal disease. An attempt has been made to define the major sources of delay or inappropriate treatment.

METHODS

A prospective, descriptive study of children with meningococcal disease referred to a tertiary centre paediatric intensive care and infectious disease unit. Definitions of optimal care were established at three stages: parental; general practitioner (GP)/accident and emergency (A&E) department; and hospital. Duration of symptoms and management were recorded from direct questioning of parents and carers, and from hospital records.

RESULTS

54 consecutive children with meningococcal disease were recruited to the study. Delayed parental recognition occurred in 16 children. GPs correctly diagnosed 19 of 35 children. Delay of 2.5-21 hours occurred in those who were incorrectly diagnosed. Two of 15 children who presented to the A&E department with specific features were incorrectly diagnosed. Hospital treatment was suboptimal in 71%. Shock was not recognised or treated in 50%, 20% of children had unnecessary lumbar punctures. Time from illness onset to treatment was longer in fatal disease (median 18.3, range 8-24 hours), compared with survivors (median 12, range 2-48 hours; p < 0.01, Mann-Whitney U test).

CONCLUSION

Suboptimal treatment in meningococcal disease is due to failure of parents, GPs, and hospital doctors to recognise specific features of the illness. Improvement by public education and better training of clinicians in recognition, resuscitation, and stabilisation of seriously ill children.

Systemic complications associated with bacterial tracheitis

The toxic shock syndrome, septic shock, pulmonary oedema, and the acute respiratory distress syndrome (ARDS) were recognised in four children with bacterial tracheitis. ARDS has not previously been reported in association with bacterial tracheitis. Prompt recognition of the severe systemic complications of bacterial tracheitis could lead to a decrease in the morbidity and mortality of this condition.

Morbidity and severity of illness during interhospital transfer: impact of a specialised paediatric retrieval team

OBJECTIVE

To evaluate the morbidity and severity of illness during interhospital transfer of critically ill children by a specialised paediatric retrieval team.

DESIGN

Prospective, descriptive study.

SETTING

Hospitals without paediatric intensive care facilities in and around the London area, and a paediatric intensive care unit at a tertiary centre.

SUBJECTS

51 critically ill children transferred to the paediatric intensive care unit.

MAIN OUTCOME MEASURES

Adverse events related to equipment and physiological deterioration during transfer. Paediatric risk of mortality score before and after retrieval. Therapeutic intervention score before and after arrival of retrieval team.

RESULTS

Two (4%) patients had preventable physiological deterioration during transport. There were no adverse events related to equipment. Severity of illness decreased during stabilisation and transport by the retrieval team, suggested by the difference between risk of mortality scores before and after retrieval (P < 0.001). The median (range) difference between the two scores was 3.0 (-6 to 17). Interventions during stabilisation by the retrieval team increased, demonstrated by the difference between intervention scores before and after retrieval, median (range) difference between the two scores being 6 (-8 to 38) (P < 0.001).

CONCLUSIONS

Our study indicates that a specialised paediatric retrieval team can rapidly deliver intensive care to critically ill children awaiting transfer. Such children can be transferred to a paediatric intensive care unit with minimal morbidity and mortality related to transport. There was no deterioration in the clinical condition of most patients during transfer.

Lobar emphysema: long-term imaging follow-up

In a retrospective study, the authors evaluated the initial and follow-up radiographs and ventilation perfusion (V/Q) scans of 12 boys and girls with lobar emphysema who were treated conservatively and were followed up for a median of 3 years (range, 6 months to 12 years). All 12 boys and girls underwent anteroposterior and lateral chest radiography at admission and at varying intervals thereafter. Ten patients underwent V/Q lung scanning; six of these procedures were performed within 4 weeks of initial radiography. Six patients underwent follow-up V/Q scanning. Thoracic computed tomography was performed in four patients at admission. In all 12 cases gradual improvement in symptoms was paralleled by improvements in serial chest radiographs and, in six cases, by improvements in V/Q scans. The affected lobe appeared to be less hyperinflated on follow-up radiographs. For those children who showed functional improvement, ventilation improved more than perfusion, as demonstrated on the V/Q scans. At initial radiography the adjacent "collapsed" lobe was seen to function well, suggesting that it was only compressed.

Neurodevelopmental delay and focal seizures as presenting symptoms of human immunodeficiency virus I infection

Three children presenting with neurological symptoms were subsequently diagnosed as being infected with the human immunodeficiency virus I (HIV). All children showed normal development for about 12-18 months of age but later developed psychomotor and developmental regression. One child presented with generalised hypotonia, another with focal seizures, and the third with spastic quadriplegia. Two of the children showed areas of abnormal brain density on computed tomography and in one case there was calcification of the basal ganglia. In two of the children cerebrospinal fluid contained reduced amounts of total folate and elevated concentrations of neopterin. The possibility of a link between the deranged folate metabolism and the neurological symptoms in HIV infection is discussed.

The trisomy (5)(q31-qter) syndrome: study of a family with a t(5:14) translocation

We report a child with multiple malformations caused by trisomy for the distal part of the long arm of chromosome No 5. A neonatal diagnosis of Down's syndrome had previously been made on the basis of clinical examination and the detection of an additional chromosome not unlike No 21. A subsequent clinical re-evaluation, with the cooperation of the parents who permitted further studies, led to the confirmation of the true diagnosis. The mother was the carrier of a balanced translocation between chromosome No 5 and No 14. The child had severe growth and psychomotor retardation and characteristic features: microcephaly, antimongoloid slant, epicanthus, low set ears, down-turned mouth, and long upper lip. She was hypertonic and a congenital heart disease (atrial septal defect) was present. We have compared this case with others known to be trisomic for segment 5q31-qter.