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The 58th Bubble Wrap

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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 UK and Ireland) to point out something that has caught their eye.

Article 1: Which patients require a specialist retrieval team for interhospital transfer?

Slater A, Crosbie D, Essenstam D, et al. Decision-making for children requiring interhospital transport: assessment of a novel triage tool Arch Dis Child 2021;106:1184–1190.

What’s it about? 

Deciding when to use a specialist retrieval team PETS knowledge when transporting sick children has been a subjective decision in the past due to a lack of a\specific triage tool.

This article is about a single state (Queensland) project to develop a tool (Queensland Paediatric Transport Triage Tool) that would assist in separating children referred for interhospital transport into “critical” and “acute” categories. The tool includes physiological triggers as well as the Children’s Early Warning Tool (CEWT). Of note, trauma patients are not included in this tool. The tool was implemented at the centralised state-wide service that coordinates aeromedical and ground transport of paediatric patients. Data were collected on arrival at transfer destinations over 12 months from 1 Mar 2016 to 28 Feb 2017. Over 1800 transfers were analysed. 574 (32%) of children were transferred via a retrieval team.

The goals were to assess the accuracy of the tool by measuring what percentage of transports needed retrieval teams, and what percentage were admitted to an ICU.

Sensitivity and specificity for needing a retrieval team were both above 90% based on their data. 23% of children (412) required ITU admission after transfer (sensitivity of tool to predict ITU admission >95% and specificity around 80%).

Why does it matter? 

This introduces the use of an objective tool that can both identify children at increased risk of deterioration, thus needing specialist retrieval teams, as well as ones that are at of low risk of deterioration. It also allows for more subjectivity for when coordinators feel retrieval is still necessary without objective data. 

Clinically Relevant Bottom Line:

The tool predicted the need for retrieval or ICU admission with high sensitivity and specificity. Children categorised as acutely ill, rather than critically ill, are generally suitable for interhospital transport without a retrieval team.

Reviewed by: Justin Hensley

Article 2: So you’ve tested the genes, but what does it mean?

Shag, M., Selvanathan., A, Baynam., G., et al. (2022) Paediatric genomic testing: Navigating genomic reports for the general paediatrician. Journal of Paediatric and Child Health, Vol 58, pp 8 – 15, doi:10.1111/jpc.15703

What’s it about? 

In Australia, Medicare rebates (claiming money) have been introduced for two types of genetic testing – Whole Exome Sequencing (WES) and Whole Genome Sequencing (WGS). Paediatricians can arrange testing for children aged 10 years or younger with a suspected monogenic condition based on the presence of either 1) moderate global developmental delay (GDD) or 2) dysmorphic facial features and one or more major structural congenital anomalies.

Interpreting WES or WGS results can be difficult, as identification of genetic variations can be benign or pathogenic and may require genetic testing of other family members, additional investigations such as neuroimaging or biochemical tests, as well as clinical examination findings and patient phenotype.

The authors provide a great reference guide to the common genomic language, clearly explaining the importance of genetic variances which can be pathogenic, benign or variants of unknown significance. They present four hypothetical cases to help better understand the process towards a genetic diagnosis.

Why does it matter? 

Early diagnosis of genetic conditions can have significant impacts on patient care such as:

  • Early referral to appropriate subspecialty services and allied health services
  • Provision of appropriate medical care
  • Identification of ongoing surveillance testing for common disease complications
  • Securing financial support from government programs i.e. in Australia, the National Disability Access Scheme
  • Family planning with genetic services with accurate recurrence risks and recommendations for assisted reproduction with preimplantation genomic testing
  • Guidance towards other genetic testing as required for the patient and family members

Clinically Relevant Bottom Line:

Identifying a genetic diagnosis in a child with GDD or dysmorphism with congenital structural anomalies can be a long and difficult process. The responsibility does not lie on the paediatrician’s shoulders alone. A multi-disciplinary team approach involving genetic services, genetic counsellors, subspeciality teams and allied health staff should be involved to ensure the patient, and their families, are well supported through the diagnostic journey, and beyond.

Reviewed by: Tina Abi Abdallah

Article 3: Do more intubation attempts increase the risk of adverse events in the paeds ED?

Abid ES, Miller KA, Monuteaux MC, et al Association between the number of endotracheal intubation attempts and rates of adverse events in a paediatric emergency department. Emergency Medicine Journal  Published Online First: 06 December 2021. doi: 10.1136/emermed-2021-211570

What’s it all about?

This American study at the impact of repeated endotracheal intubation attempts on paediatric patients in the ED over a 14-year period. It has been suggested that repeated attempts can lead to an increase in adverse outcomes. A secondary measure was to look at whether the introduction of video laryngoscopy halfway through the study had an impact.

In this study, PEM trainees performed the intubation under the supervision of the ED attending. They were allowed one repeat attempt or it was attempted by the senior physician. Researchers looked at major adverse events including hypoxia <90% at any point, pneumothorax or prolonged oesophageal intubation, and minor events such as mainstem intubation or oral damage. There were 628 intubations over a 14-year period (roughly 49 per year) with a 39% adverse event rate. The most common adverse reaction was hypoxia (18.6%) followed by mainstem intubation (14%). 72% were intubated on the first attempt, 21% on second and 7% needed three or more attempts.

Why does it matter?

As the number of attempts rises the risk of adverse events increased 3 to 4-fold, with a 39% risk of one occuring. The introduction of video laryngoscopy did not reduce the number of adverse events. Unlike the UK where the anaesthetic teams perform most intubations, in this study, it was the ED physicians where four intubations in a unit per month may not be enough to maintain airway skills.

The Bottom Line:

The study highlights the importance of first look, best attempt in order to reduce adverse events.

Reviewed by: Laura Riddick

Article 4: The SCOUT – CAP Trial – Shorter courses, similar outcomes, less resistance?

Williams D, Creech C, Walter E, Martin J, Gerber J, Newland J et al. Short- vs Standard-Course Outpatient Antibiotic Therapy for Community-Acquired Pneumonia in Children. JAMA Pediatrics. 2022;.

What’s it about?

This prospective, multi-centre interventional placebo-controlled RCT compares 5 versus 10 days of β-Lactam antibiotics in Paediatric (6 months–6 years) Community-Acquired Pneumonia. 380 participants were included for the primary analysis.

The primary endpoint was the end-of-treatment response adjusted for duration of antibiotic risk (RADAR). This is a composite endpoint that ranks each child’s clinical response, resolution of symptoms, and antibiotic-associated adverse effects- to give an outcome ranking. This was subdivided further into the number of antibiotic days. There was a higher likelihood of a more desirable outcome in shorter courses, but the measure is inherently biased to prefer shorter courses. Other outcome measures were broadly similar with <10% having an inadequate clinical response in each group.

Adverse effects received from antibiotics were also measured and were less frequent with shorter courses.

Most notably, they provided genetic analysis of the resistome of throat flora in 171 participants. This showed a lower number of resistance genes per prokaryotic cell with a shorter antibiotic course.

Why does it matter?

Antibiotic resistance has been identified by the WHO as one of the top 10 global threats to humanity. We all have a role in trying to mitigate this looming threat in any way we can.

The bottom line

Along with the CAP-IT and SAFER trials, there is now good data to suggest that shorter courses of β-Lactams are at least equivalent in treating mild-moderate Paediatric community-acquired pneumonia. This study also suggests that shorter courses may have wider benefits with regard to antimicrobial stewardship.

Reviewed by: Joe Mullally

Article 5: Do adverse childhood experiences lead to vaccine hesitancy

Bellis MA, Hughes K, Ford K, et al. Associations between adverse childhood experiences, attitudes towards COVID-19 restrictions and vaccine hesitancy: a cross-sectional study. BMJ Open 2022;12:e053915. doi:10.1136/ bmjopen-2021-053915

What’s it about?

This study looked at how adverse childhood events (ACEs) affected people’s views on and behaviour during the COVID lockdown as well as their views on the COVID vaccine. It was a telephone survey on 2285 Welsh residents aged >18 during lockdown. It used 9 adverse events before the age of 18 years (physical, verbal, and sexual abuse; parental separation; exposure to domestic violence; and living with a household member with mental illness, alcohol abuse, drug abuse or who was incarcerated). They showed that adults who had increasing ACE scores were more likely to have low trust in NHS COVID-19 information,  feel unfairly restricted by the government, and want to end mandatory mask-wearing. High ACE counts (>4) were also associated with supporting the end of social distancing. Vaccine hesitancy also increased with increasing ACE counts and was 4x more likely in those with high ACE counts than those with none and was most prevalent in the younger age groups(18-29).

Why does it matter?

Approximately 50% of people in the UK are estimated to have one ACE with 10% having >4. Voluntary compliance with public measures including vaccination is key to tackling the COVID-19 pandemic. We also know that individuals with ACEs have greater health risks across their lifetime. It is imperative that we find a way to increase these individuals’ trust in the healthcare system and encourage better compliance with public health measures.

Clinically Relevant Bottom Line:

 People who have had adverse childhood events are less likely to comply with public health measures and more likely to be vaccine-hesitant. We need to do our best to recognise these individuals and support and engage them, the earlier in their life the better.

Reviewed by: Freya Guinness

If you want to join the Bubble Wrap team then drop us a line at hello@dontforgetthebubbles.com

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.

All articles reviewed and edited by Vicki Currie

About the authors

  • Vicki is a Paediatric Registrar in the West Midlands in the UK , starting PEM in September 2021. Vicki is passionate about good communication in teams and with patients along with teaching at undergraduate and postgraduate level. When not editing Bubble wrap Vicki can be found running with her cocker spaniel Scramble or endlessly chatting with friends.

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