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The 61st 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 the UK and Ireland) to point out something that has caught their eye.

Article 1:

What is the prevalence of a prolonged QTc interval in adolescents presenting to the Emergency Department with alcohol intoxication?

de Veld L, van der Lely N, Hermans BJM, van Hoof JJ, Wong L, Vink AS. QTc prolongation in adolescents with acute alcohol intoxication. Eur J Pediatr. 2022 Apr 28. doi: 10.1007/s00431-022-04471-2. Epub ahead of print. PMID: 35482092.

What’s it about? 

This single centre, retrospective observational study aimed to determine the prevalence of QTc prolongation in adolescents who present with alcohol intoxication. The QTc (Bazett and Fridericia) were calculated and compared to a reference ECG (when one was available).They used pre-determined age and sex specific cut-off values for QTc at 95th centile to determine prolongation and noted any risk factors for Torsade de Pointes (TdP) ( QTc > 500 ms or > 60 ms change from baseline).

317 adolescents were included in the analysis. 10.1% were on pre-existing medications associated with a QT prolongation and a baseline ECG was available in 10.7%.The QTc for females was higher (422ms vs 404ms, p=<0.001).  

The proportion of QTc above 95% cut-off was 11% for females and 16.9% males (no statistical difference between sex p=0.13).No patient in this study had a QTc of over 500ms.

Those on pre-existing medications known to cause QTc prolongation did not appear at increased risk.

34 patients had a baseline ECG for comparison, 4 of which had a prolongation of over 60ms; a risk factor for TdP. Each of these had an additional contributing factor i.e., hypokalaemia, metoclopramide administration or concurrent drug use. Only 10% of patients had a reference ECG for comparison so we cannot truly know if the QTc prolongation observed here was due to alcohol consumption or was the patient’s baseline.

Why does it matter? 

Presentations due to alcohol intoxication are increasing in the adolescent population. Age specific changes to the QT interval become apparent during puberty so it is important to understand the effect of alcohol during this period. Intoxicated patients often present a challenge to the clinician to determine how far to investigate. This study contributes to this decision-making process. 

Clinically Relevant Bottom Line

In this study, QTc prolongation is seen in over 10% of adolescents presenting with alcohol intoxication. This study supports the use of ECG as a minimum investigation in intoxicated adolescents.

Reviewed by:

Anna Russell

Article 2:

Pediatric patients brought by emergency medical services to the emergency department

Ramgopal S, Varma S, Janofsky S, Martin-Gill C, Marin J R. Paediatric patients brought by emergency medical services to the emergency department.  Pediatr Emerg Care. 2022 Feb 1;38(2):e791-e798.

What’s it about? 

The objective of this study was to describe the patient characteristics and ED management of pediatric patients brought to the ED from the scene by EMS (Emergency Medical Services).

They performed a cross-sectional analysis of the National Hospital Ambulatory Medical Care Survey (NHAMCS), a nationally representative sample survey of visits to US ED’s. They analyzed data from 2014-2017, totaling 124 million encounters. 3.8% (4.7M encounters) were brought by EMS, and 96.2% (119.3M encounters) were not brought in by EMS.

Patients transported by EMS were of higher acuity compared with patients not transported by EMS. Univariable analysis revealed several variables associated with having a higher odds of scene EMS transport among pediatric patients: being of black ethnicity, having private insurance, living in a metropolitan area, requiring a diagnostic evaluation (imaging study, blood test), abnormal vital signs, having a procedure, ED disposition of admission or transfer, trauma or poisoning diagnoses and being an adolescent. Variables associated with having a lower odds of scene EMS transport among pediatric patients included age younger than 12 years, presenting to pediatric or nonmetropolitan hospitals, arrival on a weekend day, longer length of time to initial evaluation upon arrival to the ED and medication administration.

Why does it matter? 

Because of the relatively low frequency of pediatric transports for an individual EMS provider or agency when compared with the overall transport population, a systematic approach to readiness for pediatric patients is paramount. Also, EMS transports to non-pediatric facilities more often, and they may not have the correct capabilities.

Clinically Relevant Bottom Line:

Pediatric patients transported by EMS are sicker than kids not transported by EMS, and they receive faster care. EDs and EMS systems need to be capable of caring for this patient population.

Reviewed by:

Justin Hensley

Article 3:

“Quiet” fever in the Emergency Department

Geller JE, Strickland PO, Bucher JT. The use of the word “quiet” in the emergency department is not associated with patient volume: A randomized controlled trial. The American Journal of Emergency Medicine, Volume 56, 2022, https://doi.org/10.1016/j.ajem.2022.03.020.

What’s it about?

Even though we live in the modern era of evidence-based medicine, there are still superstitions among healthcare professionals. Using the word “quiet” has long been a controversial term to use in the Emergency Department. Many EM healthcare professionals believe that if the word “quiet” is said then the department will immediately get busier.

Previous studies performed in both a paediatric ED and a microbiology department did not show a difference between using vs not using the word “quiet” on workload or ED attendances.

The aim of the study was to evaluate the potential association between the word “quiet” and ED crowdedness. This was a single center randomized controlled trial performed at a US adult University Hospital ED.

400+ ED staff members were surveyed for a total of 506 surveys. The trial was carried out on a convenience sample of 47 shifts over a 30-day period. Using a random number generator, each day started with either “has it been quiet in here?” (intervention) or without saying the intervention phrase (control). A survey was completed by the staff three hours later. Survey included 3 questions (perception of crowdedness, perception of how many patients entered the ED and if the belief of using the word “quiet” play a role on how busy the ED gets) and was assessed using a visual analogue scale.

Results showed that there was no difference between using the word “quiet” vs not using on patient volume and perception of increased patient volumes. There was a significant difference on perception of crowdedness and volume of patients based on the pre-existing perception of word “quiet” on busyness in a stratified analysis.

Why does it matter?

Results of this study showed that the use of word “quiet” did not influence patient volumes or the perception of increased patient volumes and crowdedness.

Clinically Relevant Bottom Line

So, when walking into the ED and you let slip the phrase…. ‘It looks quiet in here’ you can respond to the inevitable ‘shhhhhh’ with the evidence!

Reviewed by:

Spyridon Karageorgos

Article 4:

Can honestly prescribed placebos reduce functional pain in children and young people?

Nurko S, Saps M, Kossowsky J. Effect of Open-label Placebo on Children and Adolescents With Functional Abdominal Pain or Irritable Bowel Syndrome; A Randomized Clinical Trial. JAMA Pediatr. 2022;176(4):349-356. doi:10.1001/jamapediatrics.2021.5750

What’s it about?

How many times have you discouraged a therapy on the basis that there is no evidence of beneficial effect in placebo controlled trials? Well, what if the placebo was considered the therapy?

While it is traditionally believed concealment is needed to elicit a placebo effect, recent adult open-label placebo (OLP) studies- where placebo is openly prescribed- have shown significant benefits. This study evaluated the efficacy of OLP to treat children and young people (CYP) with functional abdominal pain or irritable bowel syndrome (IBS).

This 3-centre trial in the US included 30 CYP aged 8-18 with diagnoses of functional abdominal pain or IBS. Participants were observed for 1 week prior to randomisation to 2 groups in a crossover randomised trial design. Following randomisation participants either had 3 weeks of OLP (1.5 mL of an inert liquid placebo twice a day) followed by a 3-week control period or vice versa. Standardised explanations of OLP and clinician interactions were used and Hyoscyamine (antispasmodic) was allowed as a rescue medication. Mean daily pain score was the primary outcome and rescue medication use and global symptom improvement were secondary outcomes.

Mean pain scores [SD] were lower during OLP treatment vs. control period (39.9 [18.9] vs 45.0 [14.7]; difference, 5.2; 95% CI, 0.2-10.1; P = .03). Patients took nearly twice as many hyoscyamine pills during the control period vs. OLP period (mean 3.8 [5.1] pills vs 2.0 [3.0] pills; difference, 1.8 pills; 95% CI, 0.5-3.1 pills). 46.7% reported global improvement during the OLP period vs 30.0% during the control period, but the difference was not significant (P = .32).

Children and researchers were not blinded- therefore we cannot rule out that the children may have wanted to please the researchers, or the researchers may have treated the children differently- this is an important bias to be considered in this study.

Why does it matter?

The authors report, this is the first study of children suggesting that placebos can be used in a transparent way without compromising the therapeutic placebo effect. OLP removes any need for deception and may provide an effective way to reduce pain, costs and side effects of unnecessary medications in CYP with functional pain.

Clinically Relevant Bottom Line

This is a very small study of OLP treatment in a select patient population with functional abdominal pain or IBS. Additional studies are needed to confirm effect size and longevity, validity of findings across settings and to explore acceptability of OLP for different patient groups with functional symptoms.

Reviewed by:
Akshay Patel

Article 5:

Ear examination in afebrile infants- what findings help us to diagnose Acute Otitis Media?

McLaren, Son H. MD, MS*; Shah, Nipam MBBS, MPH; Schmidt, Suzanne M. MD; Wang, Aijin MS§; Thompson, Julia MS§; Dayan, Peter S. MD, MSc*; Pruitt, Christopher M. MD;  on behalf of the Pediatric Emergency Medicine Collaborative Research Committee Otologic Examination Findings In Afebrile Young Infants Clinically Diagnosed With Acute Otitis Media, The Pediatric Infectious Disease Journal: April 13, 2022 – Volume – Issue – 10.1097/INF.0000000000003537 doi: 10.1097/INF.0000000000003537

What’s it about?

Diagnosis of Acute Otitis Media (AOM) is important in infants <90 days due to the potential risk of it being a cause for serious bacterial infection. There is little understood criteria for the diagnosis of AOM in younger infants. This was a retrospective analysis of afebrile infants <90 days over a 10 year period in 33 centres. Eligible infants were identified and then records were reviewed and coded depending on tympanic membrane findings. 1637 infants met criteria.

Otologic findings supporting the diagnosis of AOM included TM (tympanic membrane) erythema and bulging TM in 867/1160 (74.7%) and 519/1160 (44.7%) infants, respectively. In 124/1160 (10.7%) infants, TM erythema was the only documented physical examination finding supportive of AOM. Compared with infants <28 days- infants 57-90 days had higher chances of TM erythema and less likely to be diagnosed on the basis of a middle ear effusion alone.

Why does it matter?

The current American Academy of Pediatrics (AAP) guide on (AOM) recommends the following criteria for AOM: (1) moderate to severe bulging of the tympanic membrane (TM), (2) acute otorrhea not due to acute
otitis externa or (3) mild bulging of the TM with either recent ear pain or intense erythema of the TM. This is not applicable to infants <6 months old. This study gives an idea of how well findings correlate in the younger age group. What you do with that information is another question… as firstly, it looked at AFEBRILE infants and secondly AOM- most likely to be a viral cause right? However, getting a right diagnosis and communicating it to parents is clearly important- even if it doesn’t change management.

Clinically Relevant Bottom Line

In this study young afebrile infants with clinically diagnosed AOM, documented ear examination findings generally aligned with the AAP diagnostic criteria for children ≥6 months of age. Can we extrapolate the guideline to this younger age group…. more studies are needed. But its important to think about the signs you find and as ever this is another example where good documentation is paramount when looking at notes retrospectively.

Reviewed by:
Vicki Currie

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.

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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