Measuring the knowledge of juvenile idiopathic arthritis among Israeli paediatricians and paediatric orthopaedic surgeons: what needs to be improved?

OBJECTIVES: Approximately 1 child in 1,000 is affected by juvenile idiopathic arthritis (JIA). Persistent, undiagnosed JIA with high disease activity interferes with daily life and carries a risk of irreversible physical and psychosocial damage. Due to its relative rarity, primary care physicians often do not recognise it. Consequently, diagnosis and referral to paediatric rheumatologists are delayed. We aimed to evaluate the knowledge of Israeli paediatricians and paediatric orthopaedic surgeons regarding the epidemiology, clinical manifestations, laboratory parameters and treatment of JIA. METHODS: An 11-item, online questionnaire regarding JIA was sent to Israeli paediatricians and paediatric orthopaedic surgeons. The questionnaire was completed by 318 paediatricians and 30 paediatric orthopaedic surgeons (total response rate 22.5%). RESULTS: The average score was 67/100 points and the pass rate was 70.1% (set at 60 points). Several factors were associated with better overall scores: paediatric residents compared to senior physicians, exposure to rheumatology during residency, and seeing more patients with JIA in the past 5 years. No significant difference was found between paediatricians and paediatric orthopaedic surgeons. The true incidence of JIA was underestimated by 40% of participants, 30-45% were not familiar with its clinical presentation (age of onset, pain characteristics, chronic uveitis symptoms), and 60% were not familiar with up-to-date treatments. CONCLUSIONS: Paediatricians and paediatric orthopaedic surgeons in Israel have gaps in knowledge regarding JIA. This could result in delayed referral and treatment, which might affect outcomes. The results of this study highlight the need for better education and exposure to a rheumatologist, to improve knowledge and recognition of JIA.

Pain management of upper limb fractures in pediatric emergency department versus general orthopedics emergency department.

Under treatment of pain is frequently reported in children even in conditions associated with severe pain such as fractures. Recent literature supports adequate and early pain treatment because extreme and uncontrolled pain can lead to hyperalgesia. Since 2017, the treatment of pediatric orthopedic cases in the "Meir" Medical Center was gradually shifted from the orthopedic general emergency department to the pediatric emergency department. The objective was to examine the differences in pain management between the orthopedic and pediatric emergency departments. Upper limb fractures were chosen as a representing case. This retrospective cohort study included children aged 0-18 years that suffered from an upper limb fracture and were admitted to the emergency department in the years 2016 and 2018. In our study, a total of 2520 children suffered from an upper limb fracture and were treated at the Meir Medical Center during the study period. 959 of these children were treated during 2016 in the general emergency department, and 1561 were treated in the pediatric emergency department during 2018. The group characteristics were similar. In the pediatric emergency department compared to general emergency department group, more children received analgesic treatment (47.85% versus 30.4%, p < .001), more opiates were given (13.9% versus 5.3%, p < .001), and the analgesic treatment was more adequate to pain severity. Additionally, sedation was performed more frequently in the pediatric emergency department (21.6% versus 9.5%, p < .001), especially for dislocated fractures (81.5% versus 31.4%, p < .001). COMPLICATIONS: Length of stay, surgery, hospitalization, and recurrent referral rates were similar between the two groups. CONCLUSIONS:  The transfer of orthopedic pediatric cases to the pediatric emergency department showed a notable improvement in pain management without an increase in complications or emergency department length of stay. WHAT IS KNOWN: • Pain management and control is a major issue to address in their treatment. • Traumatic injuries and especially fractures are common causes for ED admissions. WHAT IS NEW: • Comparing pain management and upper limb fractures treatment between general and pediatric ED. • Pain is better treated in the PED than in the GED, without an increased rate of complications.

Bulging fontanelle in febrile infants as a predictor of bacterial meningitis.

It is common practice to perform a lumbar puncture in infants presenting with fever and a bulging fontanelle in order to rule out bacterial meningitis. However, most of these infants have benign, self-limiting diseases. The objective was to determine whether there is an association between bulging fontanelle and bacterial meningitis in febrile infants. This retrospective cohort study included febrile children with a bulging fontanelle who underwent lumbar puncture at Meir Medical Center from 2005 through 2015. A total of 764 children ages 2-18 months underwent lumbar puncture during the study period. Among them, 304 had a bulging fontanelle and fever on evaluation and cerebrospinal fluid pleocytosis was found in 115 (37.8%), including 1 case of bacterial meningitis (0.3%). None of the infants described on admission as appearing well on presentation was found to have bacterial meningitis. Of the 764 children who underwent lumbar puncture, 10 infants were diagnosed with bacterial meningitis, and only one (10%) presented with a bulging fontanelle.Conclusion: The finding of a bulging fontanelle has very low sensitivity and specificity for bacterial meningitis. Most causes of a bulging fontanelle in febrile infants are self-limiting diseases. The routine approach of performing a lumbar puncture in febrile infants with a bulging fontanelle should be reconsidered. What is Known: • It is common to perform a lumbar puncture in febrile infants with a bulging fontanelle, to rule out bacterial meningitis. • However, there are only few researches regarding the relationship between bulging fontanelle and bacterial meningitis. What is New: • The finding of a bulging fontanelle has very low sensitivity and specificity for bacterial meningitis • The need for routine lumbar puncture in these cases should be reconsidered.

The Effect of Information Placebo on Physical Activity in Overweight and Obese Children.

PURPOSE: To assess the effect of 1 week of consuming a placebo "energy drink" compared with a week of drinking regular water on daily physical activity in obese children participating in a weight reduction multidisciplinary program. METHODS: Seventeen prepubertal (age = 128.7 [26.6] m) overweight and obese children (7 females and 10 males) participated in the study. Participants received 7 bottles of mineral water per week for 2 weeks. Different types of information were randomly provided regarding the drink consumed in each week: standard (water) versus deliberate positive information (presumed energy drink and placebo). Daily step count was measured using pedometers and compared using paired t test. RESULTS: After consuming the placebo drink, children demonstrated a significantly higher average daily step number (10,452 [4107]) compared with the days they drank water (8168 [2928], P < .005). This difference was attributed mainly to male participants. CONCLUSION: The use of placebo in the form of deliberate positive information was associated with a significant increase in real-life physical activity in overweight and obese children, especially in boys. Positive information may be used to encourage children with obesity to enhance daily physical activity and energy expenditure.

[SEVERE HYPERNATREMIA IN A TEENAGE GIRL SUFFERING FROM ANOREXIA NERVOSA].

INTRODUCTION: Hypernatremic dehydration is an uncommon condition, whose main treatment is fluid administration. In cases of extreme hypernatremia, that treatment paradoxically poses a real danger to the patient's morbidity and mortality. In very rare cases, restrictive type anorexia nervosa causes extreme dehydration that can result in elevated sodium levels. In this case study we present a teenage girl who suffers from restrictive anorexia nervosa and was admitted to the pediatric intensive care unit (PICU) with an acute confusional state, with extremely severe hypernatremia up to 203 mEq/L, combined with hyperglycemia up to 700 mg/dL. Under hypotonic electrolyte solution treatment, a gradual sodium level decrease of 8 mEq/L per day was achieved with complete normalization of sodium without any neurological damage. Moreover, glucose levels were normalized rapidly and spontaneously without additional treatment with insulin.

Ultrasound assessment of endotracheal tube depth in neonates: a prospective feasibility study.

OBJECTIVE: To examine the reliability of a novel ultrasound (US) method for assessment of endotracheal tube (ETT) position in neonates. DESIGN: Prospective, observational, single-centre, feasibility study. SETTING: Level III neonatal intensive care unit. PATIENTS: Term and preterm neonates requiring endotracheal intubation. INTERVENTION: US measurement of the ETT tip to right pulmonary artery (RPA) distance was used to determine ETT position according to one-fourth to three-fourths estimated tracheal length for weight. US demonstration of pleural sliding and diaphragmatic movement was also assessed. Chest radiography (CXR) was performed following each intubation. MAIN OUTCOME MEASURES: Agreement between US assessment of ETT tip position and CXR served as the gold standard. Sensitivity, specificity, positive and negative predictive values for each US method and correlation between ETT tip to RPA distance on US, and ETT tip to carina distance on CXR were assessed. RESULTS: Forty-two US studies were performed on 33 intubated neonates. US evaluation of ETT-RPA distance identified 100% of ETTs positioned correctly: 77% deep and 80% high, demonstrating strong agreement with CXR (kappa=0.822). Sensitivity was 78%, specificity 100%, positive predictive value 100% and negative predictive value 86%. US ETT-RPA distance strongly correlated with CXR ETT-carina distance (r=0.826). No significant agreement was found between CXR and US assessment of pleural sliding and diaphragmatic movement. No adverse events were encountered during US scans. CONCLUSION: US evaluation of ETT-RPA distance demonstrated excellent accuracy for determining ETT position in neonates compared with CXR. More research is needed to support its feasibility in clinical settings.