The 17th Bubble Wrap

With millions upon millions of journal articles being published every year, it is impossible to keep up.  Every month, we ask some of our friends from PERUKI (Paediatric Emergency Research in the UK and Ireland) to point out something that has caught their eye.

Article 1: Can we use the NEXUS head CT decision rules in children with blunt head injuries?

Gupta M, Mower WR, Rodriguez RM, Hendey GW. Validation of the Pediatric NEXUS II Head CT Decision Instrument for Selective Imaging of Pediatric Patients with Blunt Head Trauma. Acad Emerg Med. 2018 Apr 17. doi: 10.1111/acem.13431.

What’s it about? 

The authors conducted a prospective study over nine years in four emergency departments in the US. Children with a blunt head injury had the NEXUS head CT rules applied prior to having the actual head CT. 1018 patients were included; 27 required neurosurgical intervention, and 49 had significant intracranial injuries.

NEXUS correctly identified all 27 patients requiring neurosurgical intervention. It identified 48 out of 49 patients with significant intracranial injuries but incorrectly classified the 49th patient as low risk (and therefore would not have had a CT with NEXUS – although the patient was observed only).

Why does it matter? 

We have a tendency to over-CT in children with head injuries – we worry about the consequences of missing a significant injury. The use of NEXUS incorporates clinician judgement. In this study, the clinician already decided that they needed a head CT before NEXUS was applied. The implication is that it might be used to rule out the need for head CT in this group of patients.

Clinically Relevant Bottom Line

NEXUS has high sensitivity, meaning that it shouldn’t miss patients who need neurosurgical intervention. It also has low specificity, meaning there will be many false positives. Subsequently, we may end up scanning many more patients than we need to. If we use NEXUS as a rule-out (one-way) test, there may be some potential. If we use our clinical judgement to decide whether patients need a CT scan and apply NEXUS first – we may reduce some unnecessary CTs. However, NEXUS did miss a significant intracranial injury, so maybe it’s not that sensitive after all.

Reviewed by: Tessa Davis

Article 2: How about D-dimers instead of head CT scans?

Langness S, Ward E, Halbach J, Lizardo R, Davenport K, Bickler S, Kling K, Thangarajah H, Grabowski J, Fairbanks T. Plasma D-dimer safely reduces unnecessary CT scans obtained in the evaluation of pediatric head trauma. Journal of pediatric surgery. 2018 Apr 1;53(4):752-7.

What’s it about? 

TBI (Traumatic Brain Injury) related visits to the emergency department have increased substantially over the last decade. Head CT scans are considered the most definitive test in ruling out TBI but expose children to radiation. D-dimer serum analysis has been proposed as a potential biomarker for paediatric traumatic brain injury. This retrospective study aimed to estimate the efficacy of using D-dimer to predict TBI.

The authors analysed 663 patients over a 3-year period who presented head trauma. They included 403 patients with isolated head trauma in the final analysis. Subsequently, they calculated which cut-off value would be most effective in preventing head CT scans without missing significant TBI.

The paper found that using a D-dimer with a cut-off value <750 pg/µL was effective in preventing 209 CT scans (39.7%) without missing any significant TBI (isolated skull fractures were considered non-significant, n=2).

Why does it matter? 

Ionizing radiation, rising costs and potential sedation are potential side effects of CT imaging. Moreover, several screening algorithms have been suggested, but they rely on complete and accurate history taking, subjective to variation. This study suggests we can safely use D-dimer analysis <750 pg/µL as a negative predictive value to rule out significant TBI.

Clinically Relevant Bottom Line

This early study suggests that D-dimer analysis may become a useful adjunct in ruling out clinically important TBI.  More research is needed in the space and, in particular, comparison or combination with existing head injury decision rules.

Reviewed by: Anke Raaijmakers

Article 3: What about an EEG?

Koutroumanidis M., & Smith S. Use and Abuse of EEG in the Diagnosis of Idiopathic Generalized Epilepsies. Epilepsia, 46(Suppl. 9):96–107, 2005 International League Against Epilepsy https://doi.org/10.1111/j.1528-1167.2005.00320.x

What’s it all about?

This elegantly titled article notes in the introduction that “EEG interpretation is still empirical and may be completely meaningless and even misleading without knowledge of the clinical problem”; the crux of this 12-page paper published in Epilepsia in 2005, complete with examples of classical waveforms, and a neat evolution of theories of epilepsy.

Why does it matter?

With the increased availability of EEG in tertiary centres, the need to be thoughtful and rational about the usage of this investigation has evolved commensurate with the ease of access. To further inform and guide outpatient investigations, the authors discuss the usage of EEG in the diagnosis of idiopathic generalised epilepsy and its uses for other epilepsy presentations.

Clinically Relevant Bottom Line

Jump to the bullet points on pages 11 and 12 for the entire list of conclusive for what EEG can and cannot offer. Remember, an interictal EEG alone cannot be used for

a) Establishing or excluding the diagnosis of epilepsy (including IGEs),
b) Providing oversimplified clues for reliable syndromic diagnosis (GSW discharges do not always indicate IGE
c)Focal changes do not necessarily suggest a symptomatic focus), and
d) Prognostication and prediction of possible relapse after the discontinuation of AED treatment.

Reviewed by: Henry Goldstein – Suggested by Dr Sophie Calvert, Paediatric Neurologist

Article 4: Winter is coming – we’d better vaccinate!

Phillips A., Beard F., Macartney K., Chan J., Gilmour R.,Saravanos G., McIntyr P. Vaccine-preventable child deaths in New South Wales from 2005 to 2014: How much is preventable? J Paediatr Child Health. 54(4):356-364, April 2018.

What’s it about?

The Australian National Immunisation Program covers 16 infectious diseases, including diphtheria, rotavirus, measles, meningococcal disease and poliomyelitis, to name a few. This paper reviewed the NSW Child Death Register and NSW Health Notifiable Conditions Register to identify any child deaths between 2005 and 2014 that may have been prevented by vaccination.

Why does it matter?

Fifty-four deaths may have been preventable with vaccination. One-third of these occurred in children with comorbidities. The most common conditions were influenza (12 deaths) and meningococcal disease (5 deaths). The paper also identified changes in maternal vaccination introduced in 2016 as another avenue to reduce child deaths from influenza.

The bottom line

Vaccines save lives. Winter is coming! Remember to check your patients’ immunisation status. We should support routine vaccinations as well as the influenza vaccine for families with children who would qualify for or benefit from it.

Reviewed by: Grace Leo

Article 5: Excuse me… Can I ask you a personal question?

Stoklosa H, Scannell M, Ma Z, Rosner B, Hughes A, Bohan JS. Do EPs change their clinical behaviour in the hallway or when a companion is present? A cross-sectional survey. Emerg Med J. 2018 Feb 7

What’s it about?

The NHS winter crisis occurs every year, with news outlets seemingly delighting in showing pictures of patients lining up in corridors waiting to be seen. Our friends in the North have done an amazing job under very trying conditions. Whilst this paper is not strictly about paediatrics, it is worth taking a look at its subject matter. Do we take less of a history when seeing the patient in the corridor?

To begin to answer this question the authors undertook a survey of 409 emergency physicians at the 2015 ACEP Scientific Assembly.

It comprised three key areas:- demographics, history taking and physical examination. The latter two used Likert scales to report various behaviours. There was a great response rate, with 409 of the 568 (72%) physicians consenting to take part. 90% reported that they had altered their history taking and 56% their physical exam if other people were present. This led to delays or failure to diagnose in 35% (of those who altered their usual history taking) and 41% (of those who did not do their usual exam).

Why does it matter?

Winter is coming for us in the South and an increase in seasonal illnesses. I think it unlikely that we will be subjected to the caseload that the UK has seen, but we still have patients show-horned into all corners of the department. We know (intuitively) that clinical care is compromised – delivery of timely antibiotics or pain relief, for example – but this paper makes it apparent that even basic history-taking is compromised, increasing the potential for error. I wonder what impact the curtains around our cubicles have?

Clinically Relevant Bottom Line

Be mindful that you may (un)consciously alter your history and physical exam technique if you are seeing a patient in the corridor. If you need to ask questions of an intimate nature, then do so in an appropriate environment.

Reviewed by: Andy Tagg

Bubble Wrap Plus

The Bubble Wrap introduced our new Plus segment last month featuring a monthly journal club reading list  from Anke Raaijmakers working with Professor Jaan Toelen & his team of the University Hospitals in Leuven. This comprehensive list of ‘articles to read’ across paediatrics is derived from 34 journals, including  major and subspecialty paediatric journals.

This month’s list features answers to intriguing questions such as: ‘Can a major increase in inhaled corticosteroids prevent asthma exacerbations?’, ‘Can CRP and neutrophil analysis guide us in our decision to perform LP in neonatal sepsis?’ and ‘What is the relation between prolonged breastfeeding and caries?’. They have also included an April’s Fools Day hoax as well, can you spot it?

You will find the list is broken down into four sections:

If we have missed out on something useful or you think other articles are absolutely worth sharing, please add them in the comments!

That’s it for this month. Many thanks to all of our reviewers who have taken the time to scour the literature so you don’t have to.