The value of Holter monitoring in the assessment of Pediatric patients

Aims: Holter monitoring (HM) has been established as one of the most effective noninvasive clinical tools in the diagnosis, assessment and risk stratification of cardiac patients. However, studies in the pediatric age group are limited. The present work aims at determining the value of HM in the diagnosis and management of children. Settings and Design: Retrospective study conducted at a tertiary referral arrhythmolology service.Methods and Material: Holter records of 1319 pediatric patients (54.1% males and 45.9% females) were reviewed. Their average age was 6.7± 4.1 years (5 days-16 years). Indications for which Holter monitoring was done were analysed as well as all the abnormalities diagnosed and factors that may increase Holter yield.Statistical analysis used: Statistical Package of social science (SPSS) version 9,0 was used for analysis of data. Results: The most common indications were palpitations (19.8%), syncope (17.8%), cardiomyopathy (12.6%), chest pain (10%), evaluation of antiarrhythmic therapy (6.8%), postoperative assessment (2.6%) and complete AV Block (2.4%). A sum of 141 Holter recordings were found abnormal with a total diagnostic yield of 10.7%. The highest contribution to diagnosis was in postoperative assessment (32.4%) and in cardiomyopathy (19.9%) where the most common abnormalities were frequent supraventricular / ventricular premature beats, supraventricular tachycardia, ventricular tachycardia and AV block. Diagnostic yield was low in patients with palpitations (5.7%) and syncope (0.4%). An abnormal ECG was significantly associated with a higher diagnostic yield (p=0.0001). None of the children with chest pain had abnormal Holter recordings.Conclusions: HM has an extremely valuable role in the assessment of high risk patients (postoperative and cardiomyopathy). However in children with palpitations, syncope and chest pain HM has a low yield. In this group of patients an abnormal ECG is more likely to be associated with abnormal Holter recordings

Evaluation, Validation & Implementation of a Computerized Diagnostic Decision Support System in Primary Practice

Background: Medical diagnosis may be the most complex task attempted by humans. Studies estimate that 95% of diagnoses in outpatient care are accurate, implying that the annual rate of inaccurate diagnoses is 12 million in the US alone, with the potential for patient harm in about half. A well-researched differential might reduce inaccurate diagnoses by offering alternatives matching the patient’s symptoms. This study searched the literature for articles evaluating the diagnostic performance of commercially available computerized diagnostic decision support systems. This search led to selecting Isabel Pro, developed by Isabel Healthcare, Ltd. of Haslemere, UK. Evaluation and Validation: A computerized diagnostic decision support system should respond adequately to four questions: What is the “diagnostic retrieval accuracy”? Does it perform as well as clinicians? When provided with the differential, do clinicians improve diagnostic accuracy? Is it easily incorporated into routine practice? The project validated the diagnostic retrieval accuracy of Isabel Pro using 46 cases with a previously confirmed diagnosis. The confirmed diagnosis appeared in Isabel Pro’s differential in 24 cases (52.2%), outperforming even internal medicine faculty (47%). Using those 24 cases and the differentials produced, the author conducted a diagnostic challenge that involved 120 McGovern Medical School residents. The residents produced 406 diagnoses, of which 105 (25.9%) were correct without the differentials, and 37 were correct post-consultation, a 9.1% absolute improvement. In responses, 75.1% of the participants agreed the differentials would be helpful in routine practice, and 64.1% agreed they would consult the differentials if available. Implementation: The project successfully proposed Isabel Pro as a solution to UT practice leadership on September 16, 2021, and incorporated the system into the Epic EHR as a menu line link on November 30, 2021. This system-wide integration also included a QR code for downloading Isabel Pro to a mobile device. Usage of Isabel Pro in the practices of UTPhysicians began on December 8, 2021. Results: The project concluded data collection after 86 days on March 4, 2022, with usage showing a steady increase in the final three weeks. The project produced 73 unique users (37 faculty and 36 residents). The user survey responses showed 83.3% agreeing they would consult the differential generated by Isabel Pro if available at every patient encounter (+19.2% compared to the challenge survey) and 77.8% agreeing that the suggestions would be helpful in routine practice (+2.7% compared to the challenge survey). More than one-third (36.8%) responded that they changed their diagnosis in response to the differential. Limitations: Only usage statistics were analyzed; the system records no reason for the clinician discontinuing a diagnostic session. Only 20 participants responded out of 73 (27.4%), so even though the respondents represented a spread of experience levels, the results may not represent the total number of potential users. The project covered a limited period of 86 days. Conclusions: Diagnostic inaccuracy is a significant patient safety concern. Studies show that computerized diagnostic decision support systems improve diagnostic accuracy, but they are not wide implementation lags despite these findings. This project demonstrated the feasibility of implementing such a well-known system in academic medical practice. The responses to the surveys demonstrate favorable opinions about the system’s perceived usefulness. Active communication and dissemination programs may be essential to improve and sustain use

Childhood community-acquired pneumonia

Background: Community-acquired pneumonia is a leading cause of morbidity and mortality in children worldwide. New, rapid methods are needed to improve the microbiologic diagnosis of pneumonia in clinical practice. The increasing incidence of parapneumonic empyema in children accentuates the importance of the identification of the causative agent and clinical predictors of empyema. Aims and methods: Two prospective studies were conducted to find feasible diagnostic methods for the detection of causative agents of pneumonia. The usefulness of pneumolysin-targeted real-time PCR in the diagnosis of pneumococcal disease was studied in children with pneumonia and empyema, and the clinical utility of induced sputum analysis in the microbiologic diagnosis of pneumonia was investigated in children with pneumonia. In addition, two retrospective clinical studies were performed to describe the frequency and clinical profile of influenza pneumonia in children and the frequency, clinical profile and clinical predictors of empyema in children. Results: Pneumolysin-PCR in pleural fluid significantly improved the microbiologic diagnosis of empyema by increasing the detection rate of pneumococcus almost tenfold to that of pleural fluid culture (75 % vs. 8 %). In whole blood samples, PCR detected pneumococcus in only one child with pneumonia and one child with pneumococcal empyema. Sputum induction provided good-quality sputum specimens with high microbiologic yield. Streptococcus pneumoniae (46 %) and rhinovirus (29 %) were the most common microbes detected. The quantification results of the paired sputum and nasopharyngeal aspirate specimens provided support that the majority of the bacteria (79 %) and viruses (55 %) found in sputum originated from the lower airways. Pneumonia was detected in 14 % of children with influenza infection. A history of prolonged duration of fever, tachypnea, and pain on abdominal palpation were found to be independently significant predictors of empyema. Conclusions: Pneumolysin-targeted real-time PCR is a useful and rapid method for the diagnosis of pneumococcal empyema in children. Induced sputum analysis with paired nasopharyngeal aspirate analysis can be of clinical value in the microbiologic diagnosis of pneumonia. Influenza pneumonia is an infrequent and generally benign disease in children with rare fatalities. Repeat chest radiograph and ultrasound imaging are recommended in children with pneumonia presenting with clinical predictors of empyema and in children with persistent fever and high CRP levels during hospitalization.Siirretty Doriast

Combining Free Text and Structured Electronic Medical Record Entries to Detect Acute Respiratory Infections

The electronic medical record (EMR) contains a rich source of information that could be harnessed for epidemic surveillance. We asked if structured EMR data could be coupled with computerized processing of free-text clinical entries to enhance detection of acute respiratory infections (ARI).A manual review of EMR records related to 15,377 outpatient visits uncovered 280 reference cases of ARI. We used logistic regression with backward elimination to determine which among candidate structured EMR parameters (diagnostic codes, vital signs and orders for tests, imaging and medications) contributed to the detection of those reference cases. We also developed a computerized free-text search to identify clinical notes documenting at least two non-negated ARI symptoms. We then used heuristics to build case-detection algorithms that best combined the retained structured EMR parameters with the results of the text analysis.An adjusted grouping of diagnostic codes identified reference ARI patients with a sensitivity of 79%, a specificity of 96% and a positive predictive value (PPV) of 32%. Of the 21 additional structured clinical parameters considered, two contributed significantly to ARI detection: new prescriptions for cough remedies and elevations in body temperature to at least 38°C. Together with the diagnostic codes, these parameters increased detection sensitivity to 87%, but specificity and PPV declined to 95% and 25%, respectively. Adding text analysis increased sensitivity to 99%, but PPV dropped further to 14%. Algorithms that required satisfying both a query of structured EMR parameters as well as text analysis disclosed PPVs of 52-68% and retained sensitivities of 69-73%.Structured EMR parameters and free-text analyses can be combined into algorithms that can detect ARI cases with new levels of sensitivity or precision. These results highlight potential paths by which repurposed EMR information could facilitate the discovery of epidemics before they cause mass casualties

AAPT Diagnostic Criteria for Chronic Sickle Cell Disease Pain

Pain in sickle cell disease (SCD) is associated with increased morbidity, mortality, and high health care costs. Although episodic acute pain is the hallmark of this disorder, there is an increasing awareness that chronic pain is part of the pain experience of many older adolescents and adults. A common set of criteria for classifying chronic pain associated with SCD would enhance SCD pain research efforts in epidemiology, pain mechanisms, and clinical trials of pain management interventions, and ultimately improve clinical assessment and management. As part of the collaborative effort between the Analgesic, Anesthetic, and Addiction Clinical Trial Translations Innovations Opportunities and Networks public-private partnership with the U.S. Food and Drug Administration and the American Pain Society, the Analgesic, Anesthetic, and Addiction Clinical Trial Translations Innovations Opportunities and Networks-American Pain Society Pain Taxonomy initiative developed the outline of an optimal diagnostic system for chronic pain conditions. Subsequently, a working group of experts in SCD pain was convened to generate core diagnostic criteria for chronic pain associated with SCD. The working group synthesized available literature to provide evidence for the dimensions of this disease-specific pain taxonomy. A single pain condition labeled chronic SCD pain was derived with 3 modifiers reflecting different clinical features. Future systematic research is needed to evaluate the feasibility, validity, and reliability of these criteria. Perspective: An evidence-based classification system for chronic SCD pain was constructed for the Analgesic, Anesthetic, and Addiction Clinical Trial Translations Innovations Opportunities and Networks-American Pain Society Pain Taxonomy initiative. Applying this taxonomy may improve assessment and management of SCD pain and accelerate research on epidemiology, mechanisms, and treatments for chronic SCD pain

Intensivist-based deep sedation using propofol for pediatric outpatient flexible bronchoscopy

AIM To evaluate the safety and efficacy of sedating pediatric patients for outpatient flexible bronchoscopy. METHODS A retrospective chart review was conducted for all children, age 17 years or under who underwent flexible bronchoscopy under deep sedation in an outpatient hospital-based setting. Two sedation regimens were used; propofol only or ketamine prior to propofol. Patients were divided into three age groups; infants (less than 12 mo), toddlers (1-3 years) and children (4-17 years). Demographics, indication for bronchoscopy, sedative dosing, sedation and recovery time and adverse events were reviewed. RESULTS Of the total 458 bronchoscopies performed, propofol only regimen was used in 337 (74%) while propofol and ketamine was used in 121 (26%). About 99% of the procedures were successfully completed. Children in the propofol + ketamine group tend to be younger and have lower weight compared to the propofol only group. Adverse events including transient hypoxemia and hypotension occurred in 8% and 24% respectively. Median procedure time was 10 min while the median discharge time was 35 min. There were no differences in the indication of the procedure, propofol dose, procedure or recovery time in either sedative regimen. When compared to other age groups, infants had a higher incidence of hypoxemia. CONCLUSION Children can be effectively sedated for outpatient flexible bronchoscopy with high rate of success. This procedure should be performed under vigilance of highly trained providers

Prediction of pulmonary embolism in children

Thesis (M.A.)--Boston UniversityBackground: Pulmonary embolism (PE) is a rare condition associated with high morbidity and mortality in children. The diagnosis of PE in children is challenging, considering the often non-specific clinical signs and symptoms associated with this condition. Computed tomography with pulmonary angiography (CTPA) is currently the diagnostic gold standard, but carries the risk of radiation-induced malignancy. For these reasons, the optimal diagnostic management strategy for the care of children with suspected PE in the emergency department (ED) setting is undefined. Objectives: We sought to describe associated clinical signs and symptoms and developed a clinical decision rule for the evaluation of children with suspected PE in the ED setting. In addition, we evaluated the Modified Wells Criteria and PERC (Pulmonary Embolism Rule-out Criteria) Rule by applying these established adult clinical decision rules against our population of children diagnosed with PE. Methods: We conducted a retrospective cohort study of children less than 21 years of age undergoing diagnostic imaging for evaluation of PE from 2000 to 2012. We included children who received either a CTPA or ventilation-perfusion (V/Q) scanning for the evaluation of suspected PE. PE was defined by evidence of an occlusion in a pulmonary blood vessel or intermediate to high probability of PE reported in the diagnostic study results of the CTPA or V/Q scan, respectively. We additionally required the use of anticoagulant therapy to establish the diagnosis of PE. Results: Among 152 patients who presented to an ED setting, the prevalence of PE was 16.4%. The most frequent presenting symptoms in children with PE were chest pain (76%) and shortness of breath (44%), while the most common risk factors were presence of a CVC (16%), prolonged immobility (20%), and recent surgery (24%). The current use of oral contraceptive pill (P value = 0.010), abnormal lung exam (P value = 0.021), and oxygen saturation level (P value = 0.003) were all significant findings that were more likely to be present in patients with PE. Conclusion: Our results describe a high risk population of children evaluated for PE presenting to an ED setting. We identified several historical, clinical, and physical exam findings that are independently associated with diagnosis of PE, such as current use of OCPs, abnormal lung exam, and oxygen saturation level. Next steps will be to use our descriptive analysis to develop a clinical decision rule for the evaluation and diagnosis of PE in children in an ED setting