Paediatric hip ultrasound.

Aims: The aim of this study was to investigate the agreement in interpretation of the quality of the paediatric hip ultrasound examination, the reliability of geometric and morphological assessment, and the relationship between these measurements. Methods: Four investigators evaluated 60 hip ultrasounds and assessed their quality based the standard plane of Graf et al. They measured geometric parameters, described the morphology of the hip, and assigned the Graf grade of dysplasia. They analyzed one self-selected image and one randomly selected image from the ultrasound series, and repeated the process four weeks later. The intra- and interobserver agreement, and correlations between various parameters were analyzed. Results: In the assessment of quality, there a was moderate to substantial intraobserver agreement for each element investigated, but interobserver agreement was poor. Morphological features showed weak to moderate agreement across all parameters but improved to significant when responses were reduced. The geometric measurements showed nearly perfect agreement, and the relationship between them and the morphological features showed a dose response across all parameters with moderate to substantial correlations. There were strong correlations between geometric measurements. The Graf classification showed a fair to moderate interobserver agreement, and moderate to substantial intraobserver agreement. Conclusion: This investigation into the reliability of the interpretation of hip ultrasound scans identified the difficulties in defining what is a high-quality ultrasound. We confirmed that geometric measurements are reliably interpreted and may be useful as a further measurement of quality. Morphological features are generally poorly interpreted, but a simpler binary classification considerably improves agreement. As there is a clear dose response relationship between geometric and morphological measurements, the importance of morphology in the diagnosis of hip dysplasia should be questioned.

Clinical thresholds for diagnosing iron deficiency: comparison of functional assessment of serum ferritin to population based centiles.

Low serum ferritin is diagnostic of iron deficiency, yet its published lower cut-off values are highly variable, particularly for pediatric populations. Lower cut-off values are commonly reported as 2.5th percentiles, and is based on the variation of ferritin values in the population. Our objective was to determine whether a functional approach based on iron deficient erythropoiesis could provide a better alternative. Utilizing 64,443 ferritin test results from pediatric electronic health records, we conducted various statistical techniques to derive 2.5th percentiles, and also derived functional reference limits through the association between ferritin and erythrocyte parameters: hemoglobin, mean corpuscular volume, mean cell hemoglobin concentration, and red cell distribution width. We find that lower limits of reference intervals derived as centiles are too low for clinical interpretation. Functional limits indicate iron deficiency anemia starts to occur when ferritin levels reach 10 µg/L, and are largely similar between genders and age groups. In comparison, centiles (2.5%) presented with lower limits overall, with varying levels depending on age and gender. Functionally-derived limits better reflects the underlying physiology of a patient, and may provide a basis for deriving a threshold related to treatment of iron deficiency and any other biomarker with functional outcomes.

A multicentric cross-sectional study to characterize the scale and impact of polypharmacy in rural Indian communities, conducted as part of health workers training.

CONTEXT: Polypharmacy and inappropriate medication usage is one of the world's most important public health issues. Yet in rural India, where medications are readily available, little is known about polypharmacy. AIM: This study explores factors related to polypharmacy in rural India to inform the response. SETTINGS AND DESIGN: A household survey was conducted by community health trainees, across 515 Indian villages collecting medication prescription and usage information for single illness in the past month. METHODS AND MATERIAL: Polypharmacy was defined as the concurrent usage of four or more medications for single illness. Data from 515 rural India villages were collected on medication usage for their last illness. Respondents who consulted one healthcare provider for this illness were included for analysis. STATISTICAL ANALYSIS USED: Bivariate logistic regression and multivariate generalized estimating equation analysis were used to explore associations with polypharmacy. RESULTS: Prevalence of polypharmacy was 13% (n = 273) in the sample and ranges between 1% and 35% among Indian states. Polypharmacy was common among prescriptions for nonspecific symptoms (15%, N = 404). People aged over 61 years compared with people aged between 20 and 60 years (OR 1.11, 95% CI 1.03-1.19) and people with income of over 3,000 INR/month (OR 1.04, 95% CI 1.00-1.07) were more likely to be prescribed four or more medications. CONCLUSIONS: The study demonstrates high rates of polypharmacy, identifies vulnerable populations, and provides information to improve the response to polypharmacy in rural India.

Fluid bolus therapy in critically ill children: a survey of practice among paediatric intensive care doctors in Australia and New Zealand.

OBJECTIVE: Fluid bolus therapy (FBT) is a widely used intervention in paediatric critical illness. The aim of this study was to describe the attitudes and practices towards FBT of paediatric intensive care doctors in Australia and New Zealand. DESIGN: An internet-based survey of paediatric intensive care doctors in Australia and New Zealand between 7 and 30 November 2016. SETTING: Paediatric intensive care units with greater than 400 admissions annually. PARTICIPANTS: Paediatric intensive care specialists and junior medical staff. MAIN OUTCOME MEASURES: Preferences for FBT and markers of fluid responsiveness. RESULTS: There were 106/175 respondents (61%); 0.9% saline and 4% albumin are used frequently or almost always by 86% and 57% of respondents respectively. The preferred volume and duration were 10 mL/kg in less than 10 minutes. The highest rated markers of fluid responsiveness were heart rate and blood pressure - rated as "good" or "very good" by 75% and 58% of respondents respectively. Central venous saturations and serum lactate were the highest rated biochemical markers. The most frequently expected magnitude of change for heart rate and blood pressure was 6-15% by 89% and 76% of respondents respectively. The preferred fluid composition for sepsis, trauma, traumatic brain injury and acute lung injury was 0.9% saline, and 4% albumin for post-operative cardiac surgery. CONCLUSIONS: Paediatric intensive care doctors prefer 0.9% saline and 4% albumin for FBT. Heart rate and blood pressure are the most preferred markers to assess fluid responsiveness. Preferences for FBT in specific conditions exist.