Pediatric ovarian torsion: Case series and review of the literature

Background: Ovarian torsion in children is an uncommon cause of acute abdominal pain but mandates early surgical management to prevent further adnexal damage. The clinical presentation mimics other pathologies, such as appendicitis. We sought to more completely characterize ovarian torsion with respect to pain and ancillary studies, such as urinalysis. Methods:We performed a retrospective review of hospital charts of all patients aged 0-18 years with a diagnosis of ovarian torsion at the Children\u27s Hospital at London Health Sciences Centre, in London, Ont., from 1993 to 2008. Results:We analyzed 13 charts of patients aged 7 months to 18 years. Most patients presented with peripheral leukocytosis, vomiting and right lower quadrant pain that did not radiate or migrate. On urinalysis, about half the patients demonstrated pyuria without bacteruria. Pelvic ultrasound revealed an ovarian cyst on the same side of the pain in 11 of 13 patients. Most were found to have a hemorrhagic cyst or ovary and underwent salpingo-oophorectomy or cystectomy within 48 hours of presentation. Conclusion: Ovarian torsion should be considered in any female child with acute onset lower abdominal pain accompanied by vomiting. Pain can be characterized as constant or colicky, but unlike with appendicitis, does not typically migrate. Sterile pyuria is found in a substantial proportion of cases. Ultrasound is the most useful in - itial diagnostic modality, but the absence of flow on Doppler imaging is not always present. Conservative management with detorsion and oophoropexy is recommended. © 2013 Canadian Medical Association

E-cigarette liquid nicotine ingestion in a child: Case report and discussion

Nicotine poisoning is well described in the pediatric population, and even small oral doses may result in toxic effects. The source of nicotine is usually tobacco products and nicotine replacement products such as gum and patches. With the more frequent use of novel products such as e-cigarettes, concern has arisen regarding liquid nicotine. As there are no regulations regarding childproof bottling and packaging, there may be increased potential for unintentional ingestion of these colorfully and appealingly packaged products by children. We present and discuss a case of this nature, as we feel emergency physicians should be aware of this new mode of poisoning, and public health efforts should be made to minimize such exposures

A comparison of the epidemiology of ice hockey injuries between male and female youth in Canada

BACKGROUND: Hockey is played by youth across Canada, and its popularity has increased dramatically among females in the past decade. Despite this, there has been little epidemiological research comparing the injury patterns of young female and male hockey players. OBJECTIVE: To describe and compare injuries sustained by female and male youth hockey players using the Canadian Hospitals Injury Reporting and Prevention Program database. METHODS: In the present cross-sectional, retrospective comparison study, the Canadian Hospitals Injury Reporting and Prevention Program database was used to identify all hockey-related injuries sustained by children seven to 17.5 years of age over a 15-year period (January 1995 to December 2009). Exclusion criteria included paid professional players and children with injuries sustained while playing road hockey. RESULTS: Inclusion criteria were met by 33,233 children (2637 [7.9%] females and 30,596 [92.1%] males). Compared with males, females reported proportionately more soft tissue injuries (39.8% versus 32.6%; P\u3c0.01) and sprains/strains (21.1% versus 17.6%; P\u3c0.01). Males experienced more fractures (27.1% versus 18.2%; P\u3c0.01) and were most often injured through body checking (42.8% versus 25.7%; P\u3c0.01). Females showed a trend toward increased concussion with age, and were most often injured through collisions (28.6% versus 24.6%; P\u3c0.01). CONCLUSION: Compared with males, female hockey players sustained proportionately more soft tissue injures and sprains/strains, and showed a trend toward concussions in late adolecence. Males experienced more fractures, shoulder injuries and injuries due to body checking. Further research is required to identify risk factors for injury in female youth hockey players and to target injury prevention

Determining a Bayesian predictive power stopping rule for futility in a non-inferiority trial with binary outcomes.

Background/Aims: Non-inferiority trials investigate whether a novel intervention, which typically has other benefits (i.e., cheaper or safer), has similar clinical effectiveness to currently available treatments. In situations where interim evidence in a non-inferiority trial suggests that the novel treatment is truly inferior, ethical concerns with continuing randomisation to the inferior intervention are raised. Thus, if interim data indicate that concluding non-inferiority at the end of the trial is unlikely, stopping for futility should be considered. To date, limited examples are available to guide the development of stopping rules for non-inferiority trials. Methods: We used a Bayesian predictive power approach to develop a stopping rule for futility for a trial collecting binary outcomes. We evaluated the frequentist operating characteristics of the stopping rule to ensure control of the Type I and Type II error. Our case study is the Intranasal Ketamine for Procedural Sedation trial (INK trial), a non-inferiority trial designed to assess the sedative properties of ketamine administered using two alternative routes. Results: We considered implementing our stopping rule after the INK trial enrols 140 patients out of 560. The trial would be stopped if 12 more patients experience a failure on the novel treatment compared to standard care. This trial has a type I error rate of 2.2% and a power of 80%. Conclusions: Stopping for futility in non-inferiority trials reduces exposure to ineffective treatments and preserves resources for alternative research questions. Futility stopping rules based on Bayesian predictive power are easy to implement and align with trial aims. Trial registration: ClinicalTrials.gov NCT02828566 July 11, 2016

External cold and vibration for pain management of children undergoing needle-related procedures in the emergency department: a randomised controlled non-inferiority trial protocol.

INTRODUCTION: Needle-related procedures are considered as the most important source of pain and distress in children in hospital settings. Considering the physiological and psychological consequences that could result from these procedures, management of pain and distress through pharmacological and non-pharmacological methods is essential. Therefore, it is important to have interventions that are rapid, easy-to-use and likely to be translated into clinical practice for routine use. The aim of this study will be to determine whether a device combining cold and vibration (Buzzy) is non-inferior to a topical anaesthetic (liposomal lidocaine 4% cream) for pain management of children undergoing needle-related procedures in the emergency department. METHODS AND ANALYSIS: This study will be a randomised controlled non-inferiority trial comparing the Buzzy device to liposomal lidocaine 4% cream for needle-related pain management. A total of 346 participants will be randomly assigned in a 1:1 ratio to one of the two study groups. The primary outcome will be the mean difference in pain intensity between groups during needle-related procedures. A non-inferiority margin of 0.70 on the Color Analogue Scale will be considered. A Non-inferiority margin of 0.70 on the Color Analogue Scale will be considered. The secondary outcomes will be the level of distress during the procedure, the success of the procedure at first attempt, the occurrence of adverse events, the satisfaction of both interventions and the memory of pain 24 hours after the procedure. The primary outcome will be assessed for non-inferiority and the secondary outcomes for superiority. ETHICS AND DISSEMINATION: This study protocol was reviewed and approved by the institutional review board of the study setting. Findings of this trial will be disseminated via peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER: NCT02616419