Detection of Pulmonary Embolism in High-Risk Children.

OBJECTIVE: To evaluate 2 commonly used adult-based pulmonary embolism (PE) algorithms in pediatric patients and to derive a pediatric-specific clinical decision rule to evaluate children at risk for PE, given the paucity of data to guide diagnostic imaging in children for whom PE is suspected. STUDY DESIGN: We performed a single-center retrospective study among 561 children <22 years of age undergoing either D-dimer testing or radiologic evaluation (computed tomography or ventilation-perfusion scan) in the emergency department setting for concern of PE. A diagnosis of PE required radiologic confirmation and anticoagulant treatment. We evaluated the test characteristics of the Wells criteria and Pulmonary Embolism Rule-out Criteria (PERC) low-risk rule and used recursive partition analysis to derive a clinical decision rule. RESULTS: Among the 561 patients included in the study, 36 (6.4%) were diagnosed with PE. The Wells criteria demonstrated a sensitivity and specificity of 86% and 60%, respectively. The sensitivity and specificity of the PERC were 100% and 24%, respectively. A clinical decision rule including the presence of oral contraceptive use, tachycardia, and oxygen saturation <95% demonstrated a sensitivity and specificity of 90% and 56%, respectively, a positive and negative likelihood ratio of 2.0 and 0.2, and a positive and negative predictive value of 0.12 and 0.99, respectively. CONCLUSIONS: The risk of PE is low among children not receiving estrogen therapy and without tachycardia and hypoxia in those with an initial suspicion of PE. Application of the PERC rule and Wells criteria should be used cautiously in the pediatric population.

Parechovirus infection as a cause of necrotising enterocolitis in a premature neonate.

Parechovirus is becoming increasingly recognised as a cause of morbidity in the neonatal population. It is widely known to cause sepsis, encephalitis and myocarditis. We report a case of parechovirus as a possible cause of necrotising enterocolitis in a premature neonate. The infant, who was born at 28 weeks' gestation, deteriorated at 1 month of life with fever and abdominal distension and had evidence of intramural bowel gas on imaging. Parechovirus was subsequently isolated from naso-oropharyngeal and rectal swabs, and he was managed medically with antibiotics and cessation of enteral feeds.

Impact of Australian mandatory 'No Jab, No Pay' and 'No Jab, No Play' immunisation policies on immunisation services, parental attitudes to vaccination and vaccine uptake, in a tertiary paediatric hospital, the Royal Children's Hospital, Melbourne.

INTRODUCTION: 'No Jab, No Play' and 'No Jab, No Pay' mandatory immunisation policies were introduced in the state of Victoria and Australia-wide, respectively, in January 2016. They restrict access to childcare/kindergarten and family assistance payments respectively, for under-vaccinated children. We aimed to describe the proportion of attendees to immunisation services of a tertiary hospital, the Royal Children's Hospital Melbourne (RCH), who were motivated by the policies to discuss or catch-up vaccination. We explored the association between motivation by policies, vaccine hesitancy (VH) and intent to seek medical exemption, with vaccine-uptake. METHODS: Parents/Guardians and clinicians completed surveys October 2016-May 2017 from the nurse-led immunisation Drop in Centre (DIC) or physician-led Specialist Immunisation Clinic (SIC). Vaccine-uptake was measured using the Australian Immunisation Register (AIR) at baseline, 1 and 7 months post-attendance. The association between vaccine-uptake, motivation by policies and VH was explored by logistic regression. RESULTS: Of 607 children, 393 (65%) were from the DIC and 214 (35%) SIC. 74 (12%) parents were motivated by the policies to attend immunisation services and 19% were VH. Only 50% of VH parents planned to catch-up vaccination for enrolment to childcare/kindergarten. Seven months post-attendance there was no association between motivation by policies and full vaccination status (difference 10%, OR 0.42, CI 0.17-1.1, p 0.08). Fewer children were fully immunised at 7 months if their parents were VH (difference 18%; OR 0.24, CI 0.1-0.54, p < 0.001) or seeking medical exemption (difference 33%, OR 0.08, CI 0.01-0.6, p 0.015). CONCLUSION: The 'No Jab' policies motivated attendance to a tertiary immunisation service. However, children of vaccine hesitant parents and those seeking medical exemption to immunisation were less likely to be fully immunised after attendance, than at baseline. The 'No Jab' policies may not be changing vaccination behavior as intended for vaccine hesitant parents who are one of the key target groups, with further evaluation required.