Opportunistic coeliac disease screening in undifferentiated presentations to paediatric acute care.

AIM: Coeliac disease (CD) can remain undiagnosed due to absent/atypical symptoms. We evaluated screening for CD in undifferentiated paediatric patients in the emergency department (ED). METHODS: Subjects were all patients presenting to a children's hospital ED during the study period who had blood taken. Plasma remaining after routine care was tested for tissue transglutaminase IgA (tTG IgA) and deamidated gliadin IgG (DGP IgG) antibodies. Patients with positive results were counselled and offered confirmatory testing, then gastroenterology review if warranted. RESULTS: An initial positive result for either DGP IgG or tTG IgA was found in 4.2% (44/1055). There was a normalisation of 76% (19/25) of positive DGP IgG and 44% (4/9) of tTG IgA results on repeat testing, which was not available in 27% (12/44). The prevalence of biopsy-confirmed CD was 0.7% (7/1055), including two new diagnoses and five subjects with known CD. Three likely cases could not be confirmed. All confirmed and likely cases were >10 years old. In children >10 years old, the prevalence of either biopsy-confirmed or likely CD was 3.3% (10/302). A family history of CD, growth concerns, recurrent abdominal pain and lethargy were associated with persistence of positive tests. CONCLUSION: Opportunistic testing for CD in ED requires further investigation as a CD screening strategy. Our results suggest optimal screening in this setting should be by initially testing for tTG IgA and total IgA in children >10 years old (minimising transiently positive tests). Transiently positive coeliac antibodies may also warrant further investigation as a predictor of future CD.

Reliability of the Abbreviated Westmead Post-traumatic Amnesia Scale in children: Impact of age on test results.

OBJECTIVE: This study aimed to determine the reliability of the Abbreviated Westmead Post-traumatic Amnesia Scale (A-WPTAS) in children by examining the impact of age on A-WPTAS performance. METHODS: Participants were typically developing patients with minor illnesses or injuries and/or accompanying siblings aged 5-10 years, attending a children's hospital ED. Exclusion criteria included: (i) a recent traumatic brain injury; (ii) developmental disability; (iii) recent drug administration judged to impact cognition; and/or (iv) non-English speaking background. The A-WPTAS was administered on two occasions separated by approximately 60 min. Logistic regression was used to determine the odds of passing based on age. RESULTS: A total of 125 children completed the A-WPTAS assessments. A-WPTAS pass rates were 36% for 5 year olds, 68% for 6 year olds, and exceeded 90% for 7-10 year olds. Compared with 9 year olds, 5 year olds had significantly lower odds of passing (P = 0.003), a trend that persisted for 6 year olds (P = 0.052). Among 5 and 6 year olds, failure was predominantly due to difficulty with temporo-spatial orientation items. CONCLUSIONS: The A-WPTAS is reliable for use in children aged 7 years and older, while its use in children aged 6 years and under results in an unsatisfactory high false positive rate, limiting its clinical utility. The adult-level performance of children aged 7 years onwards provides strong support for using the tool in the early management of these children with mild traumatic brain injury in Australian EDs.

Management of paediatric spontaneous pneumothorax: a multicentre retrospective case series.

OBJECTIVES: Paediatric guidelines are lacking for management of spontaneous pneumothorax. Adult patient-focused guidelines (British Thoracic Society 2003 and 2010) introduced aspiration as first-line intervention for primary spontaneous pneumothorax (PSP) and small secondary spontaneous pneumothoraces (SSP). Paediatric practice is unclear, and evidence for aspiration success rates is urgently required to develop paediatric-specific recommendations. METHODS: Retrospective analysis of PSP and SSP management at nine paediatric emergency departments across Australia and New Zealand (2003-2010) to compare PSP and SSP management. RESULTS: 219 episodes of spontaneous pneumothorax occurred in 162 children (median age 15 years, 71% male); 155 PSP episodes in 120 children and 64 SSP episodes in 42 children. Intervention in PSP vs SSP episodes occurred in 55% (95% CI 47% to 62%) vs 70% (60% to 79%), p<0.05. An intercostal chest catheter (ICC) was used in 104/219 (47%) episodes. Aspiration was used in more PSP than in SSP episodes with interventions (27% (18% to 37%) vs 9% (3% to 21%), p<0.05). Aspiration success was 52% (33% to 70%) overall and not significantly different between PSP and SSP. Aspiration success was greater in small vs large pneumothoraces (80% (48% to 95%) vs 33% (14% to 61%), p=0.01). Small-bore ICCs were used in 40% of ICCs and usage increased during the study. CONCLUSIONS: In this descriptive study of pneumothorax management, PSP and SSP management did not differ and ICC insertion was the continuing preferred intervention. Overall success of aspiration was lower than reported results for adults, although success was greater for small than for large pneumothoraces. Paediatric prospective studies are urgently required to determine optimal paediatric interventional management strategies.