Visibility of the urethral meatus and risk of urinary tract infections in uncircumcised boys.

BACKGROUND: Uncircumcised boys are at higher risk for urinary tract infections than circumcised boys. Whether this risk varies with the visibility of the urethral meatus is not known. Our aim was to determine whether there is a hierarchy of risk among uncircumcised boys whose urethral meatuses are visible to differing degrees. METHODS: We conducted a prospective cross-sectional study in one pediatric emergency department. We screened 440 circumcised and uncircumcised boys. Of these, 393 boys who were not toilet trained and for whom the treating physician had requested a catheter urine culture were included in our analysis. At the time of catheter insertion, a nurse characterized the visibility of the urethral meatus (phimosis) using a 3-point scale (completely visible, partially visible or nonvisible). Our primary outcome was urinary tract infection, and our primary exposure variable was the degree of phimosis: completely visible versus partially or nonvisible urethral meatus. RESULTS: Cultures grew from urine samples from 30.0% of uncircumcised boys with a completely visible meatus, and from 23.8% of those with a partially or nonvisible meatus (p = 0.4). The unadjusted odds ratio (OR) for culture growth was 0.73 (95% confidence interval [CI] 0.35-1.52), and the adjusted OR was 0.41 (95% CI 0.17-0.95). Of the boys who were circumcised, 4.8% had urinary tract infections, which was significantly lower than the rate among uncircumcised boys with a completely visible urethral meatus (unadjusted OR 0.12 [95% CI 0.04-0.39], adjusted OR 0.07 [95% CI 0.02-0.26]). INTERPRETATION: We did not see variation in the risk of urinary tract infection with the visibility of the urethral meatus among uncircumcised boys. Compared with circumcised boys, we saw a higher risk of urinary tract infection in uncircumcised boys, irrespective of urethral visibility.

Early administration of systemic corticosteroids reduces hospital admission rates for children with moderate and severe asthma exacerbation.

STUDY OBJECTIVE: The variable effectiveness of clinical asthma pathways to reduce hospital admissions may be explained in part by the timing of systemic corticosteroid administration. We examine the effect of early (within 60 minutes [SD 15 minutes] of triage) versus delayed (>75 minutes) administration of systemic corticosteroids on health outcomes. METHODS: We conducted a prospective observational cohort of children aged 2 to 17 years presenting to the emergency department with moderate or severe asthma, defined as a Pediatric Respiratory Assessment Measure (PRAM) score of 5 to 12. The outcomes were hospital admission, relapse, and length of active treatment; they were analyzed with multivariate logistic and linear regressions adjusted for covariates and potential confounders. RESULTS: Among the 406 eligible children, 88% had moderate asthma; 22%, severe asthma. The median age was 4 years (interquartile range 3 to 8 years); 64% were male patients. Fifty percent of patients received systemic corticosteroids early; in 33%, it was delayed; 17% of children failed to receive any. Overall, 36% of patients were admitted to the hospital. Compared with delayed administration, early administration reduced the odds of admission by 0.4 (95% confidence interval 0.2 to 0.7) and the length of active treatment by 0.7 hours (95% confidence interval -1.3 to -0.8 hours), with no significant effect on relapse. Delayed administration was positively associated with triage priority and negatively with PRAM score. CONCLUSION: In this study of children with moderate or severe asthma, administration of systemic corticosteroids within 75 minutes of triage decreased hospital admission rate and length of active treatment, suggesting that early administration of systemic corticosteroids may allow for optimal effectiveness.

Written action plan in pediatric emergency room improves asthma prescribing, adherence, and control.

RATIONALE: An acute-care visit for asthma often signals a management failure. Although a written action plan is effective when combined with self-management education and regular medical review, its independent value remains controversial. OBJECTIVES: We examined the efficacy of providing a written action plan coupled with a prescription (WAP-P) to improve adherence to medications and other recommendations in a busy emergency department. METHODS: We randomized 219 children aged 1-17 years to receive WAP-P (n = 109) or unformatted prescription (UP) (n = 110). All received fluticasone and albuterol inhalers, fitted with dose counters, to use at the discretion of the emergency physician. The main outcome was adherence to fluticasone (use/prescribed × 100%) over 28 days. Secondary outcomes included pharmacy dispensation of oral corticosteroids, ß(2)-agonist use, medical follow-up, asthma education, acute-care visits, and control. MEASUREMENTS AND MAIN RESULTS: Although both groups showed a similar drop in adherence in the initial 14 days, adherence to fluticasone was significantly higher over Days 15-28 in children receiving WAP-P (mean group difference, 16.13% [2.09, 29.91]). More WAP-P than UP patients filled their oral corticosteroid prescription (relative risk, 1.31 [1.07, 1.60]) and were well-controlled at 28 days (1.39 [1.04, 1.86]). Compared with UP, use of WAP-P increased physicians' prescription of maintenance fluticasone (2.47 [1.53, 3.99]) and recommendation for medical follow-up (1.87 [1.48, 2.35]), without group differences in other outcomes. CONCLUSIONS: Provision of a written action plan significantly increased patient adherence to inhaled and oral corticosteroids and asthma control and physicians' recommendation for maintenance fluticasone and medical follow-up, supporting its independent value in the acute-care setting. Clinical trial registered with www.clinicaltrials.gov (NCT 00381355).

Effects of temperature on power output and contraction kinetics in the locomotor muscle of the regionally endothermic common thresher shark (Alopias vulpinus).

The common thresher shark (Alopias vulpinus) is a pelagic species with medially positioned red aerobic swimming musculature (RM) and regional RM endothermy. This study tested whether the contractile characteristics of the RM are functionally similar along the length of the body and assessed how the contractile properties of the common thresher shark compare with those of other sharks. Contractile properties of the RM were examined at 8, 16 and 24 °C from anterior and posterior axial positions (0.4 and 0.6 fork length, respectively) using the work loop technique. Experiments were performed to determine whether the contractile properties of the RM are similar along the body of the common thresher shark and to document the effects of temperature on muscle power. Axial differences in contractile properties of RM were found to be small or absent. Isometric twitch kinetics of RM were ~fivefold slower than those of white muscle, with RM twitch durations of about 1 s at 24 °C and exceeding 5 s at 8 °C, a Q(10) of nearly 2.5. Power increased approximately tenfold with the 16 °C increase in temperature, while the cycle frequency for maximal power only increased from about 0.5-1.0 Hz over this temperature range. These data support the hypothesis that the RM is functionally similar along the body of the common thresher shark and corroborate previous findings from shark species both with and without medial RM. While twitch kinetics suggest the endothermic RM is not unusually temperature sensitive, measures of power suggest that the RM is not well suited to function at cool temperatures. The cycle frequency at which power is maximized appeared relatively insensitive to temperature in RM, which may reflect the relatively cooler temperature of the thresher RM compared to that observed in lamnid sharks as well as the relatively slow RM phenotype in these large fish.

Is a lumbar puncture necessary when evaluating febrile infants (30 to 90 days of age) with an abnormal urinalysis?

OBJECTIVES: Guidelines for the management of febrile infants aged 30 to 90 days presenting to the emergency department (ED) suggest that a lumbar puncture (LP) should be performed routinely if a positive urinalysis is found during initial investigations. The aim of our study was to assess the necessity of routine LPs in infants aged 30 to 90 days presenting to the ED for a fever without source but are found to have a positive urine analysis. METHODS: We retrospectively reviewed the records of all infants aged 30 to 90 days, presenting to the Montreal Children's Hospital ED from October 2001 to August 2005 who underwent an LP for bacterial culture, in addition to urinalysis and blood and urine cultures. Descriptive statistics and their corresponding confidence intervals were used. RESULTS: Overall, 392 infants were identified using the microbiology laboratory database. Fifty-seven patients had an abnormal urinalysis. Of these, 1 infant (71 days old) had an Escherichia coli urinary tract infection, bacteremia, and meningitis. This patient, however, was not well on history, and the peripheral white blood cell count was low at 2.9 × 109/L. Thus, the negative predictive value of an abnormal urinalysis for meningitis was 98.2%. CONCLUSIONS: Routine LPs are not required in infants (30-90 days) presenting to the ED with a fever and a positive urinalysis if they are considered at low risk for serious bacterial infection based on clinical and laboratory criteria. However, we recommend that judicious clinical judgment be used; in doubt, an LP should be performed before empiric antibiotic therapy is begun.

Embedding Child Rights Principles and Practises in Mega Sport Event Planning.

Recently, there has been growing concern about the lack of intentionality of mega sport event (MSE) organisers in ensuring that child rights are adequately respected, protected and promoted before, during, and after the events take place. In the context of the summer Olympic Games, reported child rights infringements have been on the rise, both in relation to abuse in sport itself and the negative consequences associated with planning and delivering the Games. In response to reports of child rights infringements, a coalition of actors, including non-governmental and civil society organisations have sought to pressure event owners and organisers to strengthen protections in the planning and delivery of their events. To date, however, child rights commitments have not been fully embedded in policies and principles guiding the planning and delivery of the Olympic Games. In this article, we explore the field of child rights in the context of the Olympic Games, focusing on a case study of the Tokyo 2020 edition. Drawing on documentary analysis and semi-structured interviews with Tokyo 2020 stakeholders and affiliates, detailed appraisal of the planning process was undertaken. Findings show that while the Japanese authorities have signed up to international child rights conventions and embedded some child participation strategies in Games-related activity, there was little evidence that Tokyo 2020 organisers had developed or implemented robust policies, principles or practises to respect, protect and promote child rights in Games planning. This absence, we argue, is because there was no requirement to embed child rights commitments during the bidding or planning phases, as the IOC had yet to enshrine human rights in its host city contract when the Games were first awarded to Tokyo. In conclusion, we argue that it is imperative the IOC embeds child rights principles and protocols in the bidding and planning processes to ensure that the risks to children are foregrounded and acted upon by host cities and their partners, elevating human rights to a position equal to other Games requirements. This study is of international significance as the evidence will aid future host city bidders to ensure children's rights are embedded in MSE policies for each nation.

Duration of fever affects the likelihood of a positive bag urinalysis or catheter culture in young children.

OBJECTIVE: To test the hypothesis that there will be a clinically significant rise in the proportion of positive bag urinalyses and catheter cultures in young children with increasing duration of fever. STUDY DESIGN: This was a prospective cohort study of 818 infants and children age 3-36 months presenting to a tertiary care emergency department with documented fever without source. Following the documentation of fever from < 1 to > or = 5 days, bag specimens were collected for urinalysis. The primary outcome was the yield of positive bag dipsticks by day, defined as positive for nitrates or more than trace leukocyte esterase. The secondary outcome was positive catheter cultures on each day of fever. RESULTS: Positive bag urinalyses increased with duration of fever: 14.8% (35/237) on day 1 versus 26.4% (43/163) on day 3 (relative risk [RR] = 1.8; 95% confidence interval [CI] = 1.2-2.7; P = .004). Positive catheter cultures increased in the same fashion: 4.8% (11/229) on day 1 versus 12.6% (20/159) on day 3 (RR = 2.6; 95% CI = 1.3-5.3; P = .005). CONCLUSIONS: The yield of positive bag urinalyses and catheter cultures increased significantly in children with fever of 3 days or longer duration.

Function of the medial red muscle during sustained swimming in common thresher sharks: contrast and convergence with thunniform swimmers.

Through convergent evolution tunas and lamnid sharks share thunniform swimming and a medial position of the red, aerobic swimming musculature. During continuous cruise swimming these muscles move uniformly out of phase with local body curvature and the surrounding white muscle tissue. This design results in thrust production primarily from the caudal fin rather than causing whole-body undulations. The common thresher shark (Family Alopiidae) is the only other fish known to share the same medial red muscle anatomy as the thunniform swimmers. However, the overall body shape and extremely heterocercal caudal fin of the common thresher is not shared with the thunniform swimmers, which have both fusiform bodies and high aspect-ratio, lunate caudal fins. Our study used sonomicrometry to measure the dynamics of red and white muscle movement in common thresher sharks swimming in the ocean to test whether the medial position of red muscle is associated with uncoupling of muscle shortening and local body bending as characteristic of thunniform swimmers. Common threshers ( approximately 60-100kg) instrumented with sonomicrometric and electromyographic (EMG) leads swam alongside of the vessel with a tail-beat frequency of approximately 0.5Hz. EMG signals confirmed that only the red muscle was active during sustained swimming. Despite the more medial position of the red muscle relative to the white muscle, its strain was approximately 1.5-times greater than that of the overlying white muscle, and there was a notable phase shift between strain trajectories in the red muscle and adjacent white muscle. These results suggest an uncoupling (shearing) of the red muscle from the adjacent white muscle. Although the magnitude of the phase shift between red and white muscle strain was relatively constant within individuals, it varied among sharks, ranging from near zero (red and white in phase) to almost 180 degrees out of phase. This extent in variability has not been documented previously for thunniform swimmers with a medial red muscle position and may be a characteristic of the thresher's unique body and caudal fin morphology. Nonetheless, the uncoupling of red and white muscle strain remains a consistent character associated with fishes having a medially positioned red muscle.

A simple case of a small elbow effusion.

An 11-month-old child presented with what initially appeared to be 2 simple problems, a small elbow effusion followed 1 week later by croup. This case history is presented to remind emergency medicine physicians of the importance of index of suspicion and recognition of the difference between common events occurring in a normal host versus common events occurring in an abnormal host.

The value of routine blood pressure measurement in children presenting to the emergency department with nonurgent problems.

OBJECTIVE: Blood pressure (BP) is measured at triage in most emergency departments (EDs). We aimed to determine the value of triage BP in diagnosing hypotension and true hypertension in children age > or =3 years presenting with nonurgent problems. STUDY DESIGN: In this prospective study, eligible children underwent automated BP measurement at triage. If BP was elevated, then the measurement was repeated manually. Children with a high manual BP were followed. True hypertension was defined as a manual BP >95th percentile for sex, age, and height measured on 3 occasions. RESULTS: Automated triage BP was measured in 549 children (53.4% male; mean age, 9.4 +/- 4.3 years) and was found to be elevated in 144 of them (26%). No child was hypotensive. Among the 495 patients with complete follow-up, the specificity and positive predictive value (PPV) of elevated triage BP in diagnosing true hypertension were 81.8% and 0%, respectively. A sensitivity analysis including those with incomplete follow-up, in which the population prevalence of true hypertension was assumed to be 1% to 2%, resulted in a specificity of 74.5% to 75.3% and a PPV of 3.8% to 7.5%. CONCLUSIONS: The yield of measuring BP at triage in children with nonurgent problems appears to be extremely low.

The Pediatric Respiratory Assessment Measure: a valid clinical score for assessing acute asthma severity from toddlers to teenagers.

OBJECTIVE: To determine the performance characteristics of the Preschool Respiratory Assessment Measure (PRAM) in preschool and school-aged children with acute asthma. STUDY DESIGN: In a prospective cohort study, we examined the validity, responsiveness, and reliability of the PRAM in children aged 2 to 17 years with acute asthma. The study involved more than 100 nurses and physicians who recorded the PRAM on triage, after initial bronchodilation, and at disposition. Predictive validity and responsiveness were examined using disposition as outcome. RESULTS: The PRAM was recorded in 81% (n = 782) of patients at triage. The PRAM at triage and after initial bronchodilation showed a strong association with admission (r = 0.4 and 0.5, respectively; P < .0001), thus supporting its ability to distinguish across severity levels. The responsiveness coefficient of 0.7 indicated good ability to identify change after bronchodilation. The PRAM showed good internal consistency (Cronbach alpha = 0.71) and inter-rater reliability (r = 0.78) for all patients and across all age groups. CONCLUSIONS: Good performance characteristics were observed in all age groups, making the PRAM an attractive score for assessing asthma severity and response to treatment.

Two for one: a self-management plan coupled with a prescription sheet for children with asthma.

BACKGROUND: Despite strong recommendations in the asthma guidelines, the use of written self-management plans remains low among asthmatic patients. OBJECTIVES: To develop a written self-management plan, based on scientific evidence and expert opinions, in a format intended to facilitate its dispensing by health care professionals, and to test the perception of its relevance and clarity by asthmatic children, adolescents and adults. METHODS: Inspired by previously tested self-management plans, surveys of asthma educators, expert opinions and the 2004 Canadian Asthma Guidelines, the authors simultaneously developed French and English versions of a written self-management plan that coupled with a prescription. The self-management plan was tested in parents and their asthmatic children (aged one to 17 years), and it was revised until 85% clarity and perceived relevance was achieved. RESULTS: Ninety-seven children and their parents were interviewed. Twenty per cent had a self-management plan. On the final revision, nearly all items were clear and perceived relevant by 85% or more of the interviewees. Two self-management plans were designed for clinics and acute care settings, respectively. The plans are divided into three control zones identified by symptoms with optional peak flow values and symbolized by traffic light colours. They are designed in triplicate format with a prescription slip, a medical chart copy and a patient copy. CONCLUSION: The written self-management plans, based on available scientific evidence and expert opinions, are clear and perceived to be relevant by children, adolescents and their parents. By incorporating the prescription and chart copies, they were designed to facilitate dispensing by physicians in both clinics and acute care settings.

Developing Evidence for Football (Soccer) Reminiscence Interventions Within Long-term Care: A Co-operative Approach Applied in Scotland and Spain.

Loneliness is a common experience within long-term care and, to promote well-being and quality of life among people with dementia, it is important to draw upon a repertoire of strategies that provide social stimulation, companionship, and enjoyment. This paper describes and reflects on a program of co-operative social participatory research that sought to introduce football-focused (ie, soccer-based) reminiscence based in 4 community settings within Spain and Scotland. Findings are reported and inform an original conceptual model that supports the introduction of sustainable approaches to the development of football-focused reminiscence with and for people with dementia.

Pediatric intravenous insertion in the emergency department: bevel up or bevel down?

OBJECTIVE: Intravenous catheters are usually inserted with the bevel facing up. Bevel down may be superior in small and/or dehydrated children. We seek to determine whether there is a difference in the success rate of intravenous insertion using these 2 methods. METHODS: We recruited children requiring an intravenous catheter in the emergency department where there was time to obtain consent. Patients were randomized to have the first attempt bevel up or bevel down. If the first attempt was unsuccessful, the alternate technique was used on second attempt. Attempts beyond 2 were not tracked. RESULTS: We recruited 428 patients. Data are available from 396 (201 bevel-up and 195 bevel-down techniques). At least 63 different nurses participated. The nurses participated in the study a median number of 2 times (maximum, 36). Four nurses used the bevel-down technique more than 10 times. The success rate on first attempt was 75.6% (95% confidence interval [CI], 69.8-81.4) for bevel up and 60% (95% CI, 53.2-66.8) for bevel down. The success rate on second attempt was 56.8% (95% CI, 45.3-68.2) for bevel up and 42.9% (95% CI, 30.3-55.5) for bevel down. In the subgroup of infants weighing less than 5 kg, there was no difference between the 2 techniques on the first attempt, with bevel up having a success of 33% (95% CI, 8.4-57.6) and bevel down 30% (95% CI, 4.1-55.9). CONCLUSIONS: The bevel-up technique performed superior to bevel-down technique in this study. The bevel-down technique might be useful in small infants.

Expectant parents' understanding of the implications and management of fever in the neonate.

OBJECTIVE: We estimated the extent to which Canadian expectant parents would seek medical care in a febrile neonate (age 30 days or less). We also evaluated expectant parents' knowledge of signs and symptoms of fever in a neonate, and explored the actions Canadian expectant parents would take to optimize the health of their child. METHODS: We conducted a cross-sectional survey of a sample of expectant parents from a large urban center in Canada. We recruited participants from waiting rooms in an obstetrical ultrasound clinic located in an urban tertiary care hospital in Montreal, Canada. We asked participants nine questions about fever in neonates including if, and how, they would seek care for their neonate if they suspected he/she were febrile. RESULTS: Among the 355 respondents, (response rate 87%) we found that 75% of parents reported that they would take their febrile neonate for immediate medical assessment, with nearly one fifth of the sample reporting that they would not seek medical care. We found no significant associations between the choice to seek medical care and expectant parents socio-demographic characteristics. CONCLUSIONS: Despite universal access to high quality health care in Canada, our study highlights concerning gaps in the knowledge of the care of the febrile infant in one fifth of expectant parents. Physicians and health providers should strive to provide early education to expectant parents about how to recognize signs of fever in the neonate and how best to seek medical care. This may improve neonatal health outcomes in Canada.

Urethral catheter knotting: Be aware and minimize the risk.

Urethral catheterization is a technique frequently used in the pediatric emergency department. Intravesicular knotting of the catheter is a rare but potentially preventable complication that can involve significant morbidity. However, because of the relative rarity of this complication there remains a persistent lack of awareness in the pediatric clinical community. The risk of intravesicular catheter knotting can be reduced with proper technique and the correct choice of catheters. We present a case report and list recommendations to minimize the risk of occurrence.

Quality assurance evaluation of a simple linear protocol for the treatment of impending status epilepticus in a pediatric emergency department 2 years postimplementation.

OBJECTIVE: To evaluate the efficacy and safety of a simple linear midazolam-based protocol for the management of impending status epilepticus in children up to 18 years of age. METHODS: This is a descriptive, quality assessment, retrospective chart review of children presenting with the chief complaint of seizure disorder in the emergency department (ED) of a tertiary care pediatric hospital and a triage category of resuscitation or urgent from April 1, 2009, to August 31, 2011. In children with at least one seizure episode in the ED treated according to the linear protocol, three main outcomes were assessed: compliance, effectiveness, and complications. RESULTS: Of the 128 children meeting the above study criteria, 68 had at least one seizure episode in the ED, and treatment was required to terminate at least one seizure episode in 46 of 68 patients (67.6%). Fifty-five seizure episodes were treated in the 46 patients: 51 of 55 seizure episodes were treated with midazolam (92.7%) and 4 of 55 with lorazepam or diazepam (7.3%). Of those treated with midazolam, 86.3% (44 of 51) were successfully treated with one or two doses of midazolam. The median seizure duration for all treated patients was 6 minutes. Of the 42 patients treated with midazolam, 7 required either continuous positive airway pressure or intubation, and two patients were treated for hypotension. One patient died of pneumococcal meningitis. CONCLUSION: This simple linear protocol is an effective and safe regimen for the treatment of impending status epilepticus in children.