[How to improve guidelines with big data]. / Hoe we met big data betere richtlijnen kunnen krijgen.

Guidelines are the foundation on which we base our medical actions. However, working with guidelines has its limitations if there is no consistent program of evaluation research to support guidelines. To guarantee good quality of care, it is important to perform a correct cycle of quality. In practice, this is a time-consuming and labor-intensive process, as a result of which the validation and evaluation of guidelines is often insufficient. The emergence of new techniques will make it possible to automate these processes. To deviate from the guideline can be better considered. This requires integration of guidelines, electronic health records and new techniques. It requires cooperation at regional and national level, between healthcare providers, data and ICT specialists and politicians.

Detection of intestinal protozoa in paediatric patients with gastrointestinal symptoms by multiplex real-time PCR.

The performance of a multiplex real-time PCR for the detection of Blastocystis, Dientamoeba fragilis, Giardia lamblia, Cryptosporidium species and Entamoeba species in faecal samples was evaluated in an observational prospective study. Paediatric patients (0-18 years) presenting with gastrointestinal symptoms and suspected of having enteroparasitic disease were included. A questionnaire on gastrointestinal symptoms and the chosen treatment was completed at the start of the study and after 6 weeks. Of 163 paediatric patients (mean age, 7.8 years), 114 (70%) had a PCR-positive faecal sample. D. fragilis was detected most frequently, in 101 patients, followed by Blastocystis in 49. In faecal samples of 47 patients, more than one protozoan was detected, mainly the combination of D. fragilis and Blastocystis. Reported gastrointestinal symptoms were abdominal pain (78%), nausea (30%), and altered bowel habits (28%). Eighty-nine of the PCR-positive patients were treated with antibiotics. A significant reduction in abdominal pain was observed both in treated and in untreated patients. This study demonstrated that multiplex real-time PCR detects a high percentage of intestinal protozoa in paediatric patients with gastrointestinal symptoms. However, interpretation and determination of the clinical relevance of a positive PCR result in this population are still difficult.

Clinical implications of heart-lung interactions.

As opposed to spontaneous respiration wherein small cyclic changes in transpulmonary, negative pressure coincide with lung volume changes, positive pressure (mechanical) ventilation results in a simultaneous rise in transpulmonary pressure and lung volumes. The changes may affect biventricular cardiac loading and function in dissimilar ways, depending on baseline cardiopulmonary function. This review is intended to update current knowledge on the pathophysiology of these heart-lung interactions in helping to explain the common circulatory alterations occurring during airway pressure changes and to better understand mechanisms of disease and modes of action of treatments, during spontaneous and mechanical ventilation.

[Bacterial tracheitis as the cause of acute respiratory insufficiency in 2 teenagers]. / Bacteriële tracheïtis als oorzaak van acute respiratoire insufficiëntie bij 2 tieners.

A 13-year-old girl and a 12-year-old boy developed acute respiratory insufficiency caused by an upper airway obstruction, which necessitated intubation and mechanical ventilation. Cultures from throat swabs from the girl and boy yielded Haemophilus parainfluenzae and Streptococcus pneumoniae, respectively. Diagnoses of bacterial tracheitis were confirmed by tracheoscopy and both children were treated with antibiotics. After 11 and 4 days of mechanical ventilation, respectively, they were successfully extubated. No further complications were encountered. Bacterial tracheitis is a rare but significant cause of upper airway obstruction in children.

[Decision-making regarding life-sustaining medical treatment in a pediatric intensive-care unit]. / De besluitvorming over levensverlengend medisch handelen op een kinderintensivecareafdeling.

The complexity of the decision-making process regarding life-sustaining medical treatment was illustrated by the single case of a 12-year-old boy with severe meningococcal septicaemia. When his clinical condition deteriorated, necessitating haemodialysis and multiple amputations of the extremities, questions about the futility of treatment and the future quality of life puzzled the attending physician. In consultation with the treatment team and the parents, it was decided to continue medical treatment in this patient since there was too little prognostic certainty concerning bodily functions and morbidity and the expected future quality of life. After 60 days, the patient was discharged. Half-a-year later he was following an intensive rehabilitation programme and the possibility of renal transplantation was contemplated. Because of the consequences for the child and his family, a decision to continue life-sustaining medical treatment should be justified as thoroughly as one to withdraw or withhold treatment.

[Inspiratory stridor in a child with a retropharyngeal abscess instead of the normally expected subglottic laryngitis]. / Inspiratoire stridor bij een kind met niet de verwachte laryngitis subglottica, maar een retrofaryngeaal abces.

A 6-month-old girl presented with fever, coughing, inspiratory stridor and neck swelling. She was admitted for observation under the suspicion of spasmodic croup combined with a lymphadenitis colli. However, a rapidly progressive respiratory insufficiency developed which was found to be due to a retropharyngeal abscess. The patient was intubated and surgical drainage of the abscess followed. The postoperative clinical progress was uncomplicated. Common presenting signs of a retropharyngeal abscess include: inspiratory stridor, bulging of the pharyngeal wall, limited movement of the neck and palpable swelling of the neck. Current treatment consists of oral incision and drainage of the abscess followed by the administration of antibiotics.

[The attending physician and the certificate of natural death in children]. / De behandelend arts en de verklaring van natuurlijke dood bij kinderen.

Three children died in the paediatric intensive-care unit or emergency department. The case of a 3.5-year-old girl who died after a pneumococcal infection was considered a natural death. An 8-year-old boy suddenly collapsed and died despite resuscitation. The attending physician considered this an unnatural death. The district medical examiner, after consulting the district attorney, required an autopsy, but the cause of death could not be ascertained and the next of kin were to be examined for cardiac rhythm disorders. A 2-year-old boy died after a fall out of a window. The district medical examiner and the district attorney concluded that there was sufficient explanation for this unnatural death and that autopsy was not necessary. The attending physician has several important tasks around the time of and after death in which he or she is subject to a number of legal regulations. Knowledge of these regulations is mandatory for good medical practice.

Further evidence for an ischemic origin of perforation of the appendix in the neonatal period.

A full-term baby girl presented on the 14th day of life with an appendiceal abscess on a basis of appendicular perforation. Pathologic examination found focal transmural coagulation necrosis suggesting an ischemic origin for the perforation. It is argued that appendiceal perforation in the newborn period is a different disease entity than appendiceal perforation later in life. In the newborn, ischemia seems to be the leading pathogenetic factor, and neonatal appendiceal perforation seems, therefore, related to neonatal necrotizing enterocolitis.

Mechanical ventilation of healthy rats suppresses peripheral immune function.

This study was designed to investigate the possible effect of injurious mechanical ventilation on peripheral immune function of healthy rats. Three ventilation strategies were compared: 1) low peak inspiratory pressure (PIP)/positive end-expiratory pressure (PEEP); 2) high PIP/PEEP; and 3) high PIP/zero PEEP (ZEEP). As a reference group, healthy, nonventilated, sham-operated, anaesthetised rats were used. After 4 h, rats were sacrificed and macrophage inflammatory protein (MIP)-2 levels in lung and plasma were determined. Peripheral immune function was determined by measurement of splenic natural killer (NK) activity, mitogen-induced splenocyte proliferation and in vitro cytokine production. All immune measurements in the low PIP/PEEP group did not differ from the immune measurements in the reference group. High PIP strategies, irrespective of applied PEEP, enhanced MIP-2 levels in lung and plasma. NK cell activity, mitogen-induced splenocyte proliferation and MIP-2 and interleukin (IL)-10 production significantly decreased after high PIP/PEEP ventilation. In the high PIP/ZEEP-ventilated group, the decrease in splenocyte proliferation, MIP-2 and IL-10 production and NK cell activity was more pronounced and interferon-gamma production was also significantly lower than in the low PIP/PEEP group. These data show that high positive inspiratory pressure ventilation induces an inflammatory response in the lung, whereas at the same time the peripheral immune response is downregulated. Ventilator-induced peripheral immune suppression may contribute to poor outcome in acute respiratory distress syndrome patients.

Breath holding spells in a 3-day-old neonate: an unusual early presentation in a family with a history of breath holding spells.

Breath holding spells are common in childhood. They peak about 2 years of age and abate by 5 years of age; they are rare before 6 months of age. We report a case of cyanotic breath holding spells starting at the age of 3 days. There was a family history of breath holding spells including a three-year-old brother, patient's father, his sister, and the paternal great grandfather. Pharmacological intervention with iron replacement therapy and piracetam was not successful. We want to draw attention to the fact that breath holding spells should be included in the differential diagnosis of neonatal cyanotic spells. The course of these neonatal breath holding spells is thought to be "benign", but nevertheless, severe breath holding spells can pose problems for parents and clinicians.

[Tetanus in a young unvaccinated girl after a fall in the street]. / Tetanus bij een jong ongevaccineerd meisje na een val op straat.

A 4-year-old girl developed tetanus after she had fallen on the street a week before. She had never been vaccinated and despite pressure from the family practitioner, the parents refused to allow her to be given human anti-tetanus immunoglobulin as a matter of principle after the wound had been stitched. Seven days later she was admitted to hospital with trismus and risus sardonicus. Upon initial treatment with human anti-tetanus immunoglobulin and penicillin, and subsequently metronidazole, her clinical condition deteriorated with opisthotonus and life-threatening respiratory insufficiency, upon which she was moved to the intensive-care department where she was intubated and mechanically ventilated for two weeks. Finally she made a complete clinical recovery. Thanks to the extensive national vaccination program, tetanus has become a rare disease in the Netherlands. However, the very serious course and possible fatal outcome warrant a keen attitude and adequate treatment.

[An infant with pain and meningeal irritation due to Guillain-Barré syndrome]. / Een zuigeling met pijn en meningeale prikkeling door het syndroom van Guillain-Barré.

In a five-month-old girl, who for a week had cried and displayed a relapse in the motor development, generalised hypotonia and meningism were found. Eventually, the results of the cerebrospinal fluid analysis and electromyography indicated Guillain-Barré syndrome. She was treated with immunoglobulins and made a quick recovery. Guillain-Barré syndrome is an acute or subacute inflammatory demyelinating polyradiculoneuropathy that can occur at any age. In children, the classic symptoms such as a flaccid paralysis and areflexia are not always predominant. Instead, pain is often the most prominent symptom, along with meningism. These symptoms are often insufficiently recognised in practice and as a result of this, delays in the diagnosis of this potentially life-threatening disease often occur.

The value of routine chest radiographs in a paediatric intensive care unit: a prospective study.

BACKGROUND: In many paediatric intensive care units (PI-CUs) chest X-ray films (CXRs) are required as part of the daily examination or after completion of invasive procedures. OBJECTIVE: First, to evaluate if the American College of Radiology (ACR) guidelines for adult patients are appropriate for paediatric patients. Second, to assess the diagnostic efficacy of the CXRs. MATERIALS AND METHODS: One-hundred-seventy-four CXRs acquired in 74 patients, either routinely or after invasive procedures, were analysed. The indication of the obtained CXRs, or the absence of indication in patients in whom no CXRs was taken, was compared with ACR guidelines. The position of medical devices was evaluated. Changes in cardiopulmonary status were noted. RESULTS: Sixty-seven percent of the CXRs were in accordance with the ACR guidelines, and in 74% of patients in whom no CXRs were taken this was also in accordance with these guidelines. Sixteen percent of the endotracheal tubes, 23% of central venous lines and 15% of nasogastric tubes were malpositioned. Changes in cardiopulmonary status, after the initial film, were noted in 63%. CONCLUSIONS: The indications for the majority of CXRs in our PICU appeared to be in accordance with ACR guidelines. The high percentage of malpositioned tubes and lines and the number of cardiopulmonary changes on CXRs in a PICU underline the value of these films. Adjustments of the ACR guidelines for particular groups of paediatric patients may limit the number of CXRs taken and may further increase diagnostic efficacy.

Low-dose dopamine in neonatal and pediatric intensive care: a systematic review.

OBJECTIVES: To assess the current use of low-dose dopamine (< 5 microg/kg per minute) to improve renal function and urine volume (UV) in neonatal (NICU) and pediatric (PICU) intensive care units, and to assess the available evidence to support this practice. DESIGN: A written survey was used to assess the current use of low-dose dopamine among all 19 NICUs and PICUs in the Netherlands. In addition, a review of the literature of clinical intervention studies in which low-dose dopamine was administered to improve renal function and UV was performed. METHODS: The clinical intervention studies focused on preterm neonates, critically ill infants and children, and those who underwent cardiac surgery. Either creatinine clearance or glomerular filtration rate and increase in UV were used to measure renal function improvement. RESULTS: Our survey showed that among the 19 NICUs and PICUs, dopamine is regularly used either to improve renal function (n = 7) or to enhance UV (n = 13). The literature review identified seven clinical studies. Of these only one was a randomized controlled trial in preterm neonates, and this showed no positive correlation between renal function and UV. The other studies were uncontrolled experiments in preterm infants that claimed positive effects on UV (n = 5) and creatinine clearance (n = 2). CONCLUSIONS: The widespread use today of low-dose dopamine in Dutch NICUs and PICUs is not supported in the literature. Evidence from well performed clinical studies to support the use of low-dose dopamine for improving renal function and UV in critically ill neonates and children is largely insufficient. In view of adverse effects, the use of low-dose dopamine in neonatal and pediatric intensive care patients should be reconsidered.

[Acute encephalopathy in children: a serious illness after an inauspicious beginning]. / Acute encefalopathie bij kinderen: een ogenschijnlijk onschuldig, maar ernstig ziektebeeld.

Three young children, 2 girls of 6 and 3.5 years and 1 boy aged 3.5 years, had complaints like vomiting and fever of what initially was thought to be a minor infection. However, their condition deteriorated within two days to such an extent that they died while being treated on the intensive care department. The rapid drop in consciousness, sometimes accompanied by convulsions, is an expression of increased intracranial pressure resulting from diffuse brain oedema, which itself is probably caused by circulating toxins. The treatment of acute toxic encephalopathy is purely symptomatic.