Association between skin diseases and severe bacterial infections in children: case-control study

BACKGROUND: Sepsis or bacteraemia, however rare, is a significant cause of high mortality and serious complications in children. In previous studies skin disease or skin infections were reported as risk factor. We hypothesize that children with sepsis or bacteraemia more often presented with skin diseases to the general practitioner (GP) than other children. If our hypothesis is true the GP could reduce the risk of sepsis or bacteraemia by managing skin diseases appropriately. METHODS: We performed a case-control study using data of children aged 0–17 years of the second Dutch national survey of general practice (2001) and the National Medical Registration of all hospital admissions in the Netherlands. Cases were defined as children who were hospitalized for sepsis or bacteraemia. We selected two control groups by matching each case with six controls. The first control group was randomly selected from the GP patient lists irrespective of hospital admission and GP consultation. The second control group was randomly sampled from those children who were hospitalized for other reasons than sepsis or bacteraemia. We calculated odds ratios and 95% confidence intervals (CI). A two-sided p-value less than 0.05 was considered significant in all tests. RESULTS: We found odds ratios for skin related GP consultations of 3.4 (95% CI: [1.1–10.8], p = 0.03) in cases versus GP controls and 1.4 (95% CI: [0.5–3.9], p = 0.44) in cases versus hospital controls. Children younger than three months had an odds ratio (cases/GP controls) of 9.2 (95% CI: [0.81–106.1], p = 0.07) and 4.0 (95% CI: [0.67–23.9], p = 0.12) among cases versus hospital controls. Although cases consulted the GP more often with skin diseases than their controls, the probability of a GP consultation for skin disease was only 5% among cases. CONCLUSION: There is evidence that children who were admitted due to sepsis or bacteraemia consulted the GP more often for skin diseases than other children, but the differences are not clinically relevant indicating that there is little opportunity for GPs to reduce the risk of sepsis and/or bacteraemia considerably by managing skin diseases appropriately

A survey of national and multi-national registries and cohort studies in juvenile idiopathic arthritis: Challenges and opportunities

Background: To characterize the existing national and multi-national registries and cohort studies in juvenile idiopathic arthritis (JIA) and identify differences as well as areas of potential future collaboration. Methods: We surveyed investigators from North America, Europe, and Australia about existing JIA cohort studies and registries. We excluded cross-sectional studies. We captured information about study design, duration, location, inclusion criteria, data elements and collection methods. Results: We received survey results from 18 studies, including 11 national and 7 multi-national studies representing 37 countries in total. Study designs included inception cohorts, prevalent disease cohorts, and new treatment cohorts (several of which contribute to pharmacosurveillance activities). Despite numerous differences, the data elements collected across the studies was quite similar, with most studies collecting at least 5 of the 6 American College of Rheumatology core set variables and the data needed to calculate the 3-variable clinical juvenile disease activity score. Most studies were collecting medication initiation and discontinuation dates and were attempting to capture serious adverse events. Conclusion: There is a wide-range of large, ongoing JIA registries and cohort studies around the world. Our survey results indicate significant potential for future collaborative work using data from different studies and both combined and comparative analyses

Manipulative interventions for reducing pulled elbow in young children

BACKGROUND: Pulled elbow (nursemaid's elbow) is a common injury in young children. It results from a sudden pull on the arm, usually by an adult or taller person, which pulls the radius through the annular ligament, resulting in subluxation (partial dislocation) of the radial head. The child experiences sudden acute pain and loss of function in the affected arm. Pulled elbow is usually treated by manual reduction of the subluxed radial head. Various manoeuvres can be applied. Most textbooks recommend supination of the forearm, as opposed to pronation and other approaches. It is unclear which manoeuvre is most successful. This is an update of a Cochrane review first published in 2009. OBJECTIVES: The objective of this review is to compare the effectiveness and painfulness of the different methods used to manipulate pulled elbow in young children. SEARCH METHODS: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, LILACS, PEDro, clinical trial registers and reference lists of articles. Date of last search: July 2011. SELECTION CRITERIA: Any randomised or quasi-randomised controlled clinical trials evaluating manipulative interventions for pulled elbow were included. Our primary outcome was failure at the first attempt, necessitating further treatment. DATA COLLECTION AND ANALYSIS: Two review authors independently evaluated trials for inclusion and, for the included trials, independently assessed the risk of bias and extracted data. MAIN RESULTS: One trial with 66 children was newly included in this update. Overall, four trials with 379 children, all younger than seven years old, were included. All four trials compared pronation versus supination. One trial was at high risk of selection bias because allocation was not concealed and all four trials were at high risk of detection bias due to the lack of assessor blinding. Pronation resulted in statistically significantly less failure than supination (21/177 versus 47/181, risk ratio 0.45; 95% confidence interval 0.28 to 0.73). Pain perception was reported by two trials but data were unavailable for pooling. Both studies concluded that the pronation technique was less painful than the supination technique. AUTHORS' CONCLUSIONS: There is limited evidence from four small low-quality trials that the pronation method might be more effective and less painful than the supination method for manipulating pulled elbow in young children. We recommend that a high quality randomised trial be performed to strengthen the evidence

Dutch general practitioners' referral of children to specialists: a comparison between 1987 and 2001

Background: Although children are frequently referred to specialists, detailed information on referral patterns of them is scarce. Even less information is available on how referral patterns evolve over time. Aims: To examine current referral patterns for children aged 0–17 years and compare these with referral patterns reported for 1987. Design of study: Data were analysed from two national cross-sectional surveys, performed in 2001 (91 general practices) and in 1987 (103 general practices). Setting: Dutch general practice. Method: All new referrals to specialists were assessed by age, sex, International Classification of Primary Care (ICPC) category, specialty referred to, and specific episodes of disease. Referral measures were quantified as new referrals per 1000 person–years and per 100 new episodes, a measure of likelihood of a young person with a specific diagnosis to be referred. Rates in 2001 were compared with those from 1987. Results: Referral rates decreased from 138 per 1000 person–years in 1987, to 84 per 1000 person–years in 2001. Age differences in referral rates were similar in both surveys. Compared with 1987, more boys than girls were referred to specialists. The overall likelihood of a condition being referred decreased from 8.0 per 100 episodes in 1987 to 6.5 per 100 episodes in 2001. Reasons for referral had also changed by 2001, particularly for the ear, nose, and throat (ENT) specialist and ophthalmologist. Moreover, referral rates for acute otitis media, refractive disorders, and vision problems decreased two- to fourfold in 2001. Conclusion: Presently, Dutch general practitioners tend to manage more health problems themselves and refer less young people to specialists

Epidemiology of unintentional injuries in childhood: a population-based survey in general practice

This study aimed to assess the incidence of unintentional injuries presented in general practice, and to identify children at risk from experiencing an unintentional injury. We used the data of all 0-17-year-old children from a representative survey in 96 Dutch general practices in 2001. We computed incidence rates and multilevel multivariate regression analysis in different age strata and identified patient and family characteristics associated with an elevated injury risk. Nine thousand four hundred and eighty-four new injury episodes were identified from 105 353 new health problems presented in general practice, giving an overall incidence rate of 115 per 1000 person years (95% confidence interval [CI] = 113 to 118). Sex and residence in rural areas are strong predictors of injury in all age strata. Also, in children aged 0-4 years, a higher number of siblings is associated with elevated injury risk (> or =3 siblings odds ratio [OR] = 1.57, 95% CI = 1.19 to 2.08) and in the 12-17-year-olds, ethnic background and socioeconomic class are associated with experiencing an injury (non-western children OR = 0.67, 95% CI = 0.54 to 0.81; low socioeconomic class OR = 1.39, 95% CI = 1.22 to 1.58). Unintentional injury is a significant health problem in children in general practice, accounting for 9% of all new health problems in children. In all age groups, boys in rural areas are especially at risk to experience an injury

Epidemiology of unintentional injuries in childhood: a population-based survey in general practice

This study aimed to assess the incidence of unintentional injuries presented in general practice, and to identify children at risk from experiencing an unintentional injury. We used the data of all 0–17-year-old children from a representative survey in 96 Dutch general practices in 2001. We computed incidence rates and multilevel multivariate regression analysis in different age strata and identified patient and family characteristics associated with an elevated injury risk. Nine thousand four hundred and eighty-four new injury episodes were identified from 105 353 new health problems presented in general practice, giving an overall incidence rate of 115 per 1000 person years (95% confidence interval [CI] = 113 to 118). Sex and residence in rural areas are strong predictors of injury in all age strata. Also, in children aged 0–4 years, a higher number of siblings is associated with elevated injury risk (≥3 siblings odds ratio [OR] = 1.57, 95% CI = 1.19 to 2.08) and in the 12–17-year-olds, ethnic background and socioeconomic class are associated with experiencing an injury (non-western children OR = 0.67, 95% CI = 0.54 to 0.81; low socioeconomic class OR = 1.39, 95% CI = 1.22 to 1.58). Unintentional injury is a significant health problem in children in general practice, accounting for 9% of all new health problems in children. In all age groups, boys in rural areas are especially at risk to experience an injury

Changing morbidity patterns in children in Dutch general practice: 1987-2001

OBJECTIVES: To examine the presentation and pattern of childhood morbidity in general practice compared with 14 years ago. METHODS: We used data of all children aged 0-17 years from two cross-sectional surveys performed in 1987 and 2001 in general practice in the Netherlands. The total number of children in the practices participating in these surveys were 86,577 children in 1987 and 82,053 children in 2001. First of all, we compared consultation rates of children in general practice. Secondly, childhood morbidity was assessed by episodes of disease, coded according to the International Classification of Primary Care (ICPC). We compared childhood morbidity in 1987 and 2001 by assessing the distribution of episodes among ICPC chapters stratified by ethnicity, and by comparing incidence rates of most frequently presented diseases. RESULTS: Childhood consultation rates have decreased from 2.7 visits a year per child in 1987 to 2.1 in 2001. The distribution of episodes among ICPC chapters had also changed. Respiratory problems are still the most frequently presented health problem in children but the proportion has decreased from 25.5% in 1987 to 23.3% in 2001. Skin problems were presented more often (23.0% in 2001 versus 17.8 in 1987), and Western children more often presented with skin problems than with respiratory problems in 2001. Incidence rates of most respiratory diseases have decreased and specific skin diseases (dermatomycosis, impetigo and eczema) were diagnosed more often. CONCLUSION: In the Netherlands, childhood morbidity has changed. Skin diseases have become more important in general practice and respiratory problems are declining

Bone health of patients with juvenile idiopathic arthritis: a comparison between dual-energy X-ray absorptiometry and digital X-ray radiogrammetry

Juvenile idiopathic arthritis (JIA) affects bone mineral density (BMD). Dual-energy X-ray absorptiometry (DXA) is the most widely used technique to determine BMD. Digital X-ray radiogrammetry (DXR) is a feasible method for determination of cortical BMD on hand radiographs. This study aimed to compare DXR and DXA in the assessment of BMD in JIA patients. Thirty-five JIA patients with available DXA and hand radiograph within the same time period were included from the Dutch Arthritis and Biologicals in Children register. Outcome measures for BMD were Bone Health Index from DXR and BMD total body, BMD lumbar spine and Bone Mineral Apparent Density from DXA. All measures were transformed to Z-scores. Correlations were assessed with Pearson correlation coefficients. Median age of the patients (60% female) was 11.7 years. Pearson correlation coefficient was significant for the absolute scores: 0.568-0.770 (p <0.001). No significant correlation was found between the Z-scores of DXA and DXR. The BMD assessment from the DXR was correlated to DXA measures in a cohort of JIA patients, although only in absolute scores. Future steps for implementation of DXR in clinical practice include evaluation of responsiveness to change, predictive value and comparison with other imaging technique

Comparison between children and adolescents with and without chronic benign pain: consultation rate and pain characteristics.

The aim of the study was to determine whether children with chronic benign pain are in contact with their general practitioner (GP) more frequently than those without chronic benign pain. A random sample of children and adolescents aged between 0 and 18 years of age was drawn from the records of ten general practices. According to their responses to a pain questionnaire, subjects were assigned to the chronic benign pain group (n = 95) if they had pain of more than three months' duration, or to the control group (n = 105) if they had pain of less than three months' duration or no pain at all. All the subjects had an average GP consultation rate of 2.6 contacts per year. No significant age and sex differences were found. Chronic benign pain in childhood and adolescence is not related to increased use of healthcare services, suggesting that somatisation does not play a major role in children with chronic benign pain