Scurvy as a mimicker of osteomyelitis in a child with autism spectrum disorder.

A case of scurvy in a 10-year-old boy with autism spectrum disorder is described. His clinical presentation was initially thought to be due to osteomyelitis, for which empirical antimicrobial therapy was initiated. Further invasive and ultimately unnecessary investigations were avoided when scurvy was considered in the context of a restricted diet and classic signs of vitamin C deficiency. Infectious diseases specialists should be aware of scurvy as an important mimicker of osteoarticular infections when involved in the care of patients at risk of nutritional deficiencies.

Telesimulation: an innovative and effective tool for teaching novel intraosseous insertion techniques in developing countries.

OBJECTIVES: Telesimulation is a novel concept coupling the principles of simulation with remote Internet access to teach procedural skills. This study's objective was to determine if telesimulation could be used by pediatricians in Toronto, Ontario, Canada, to teach a relatively new intraosseous (IO) insertion technique to physicians in Africa. METHODS: One simulator was located in Toronto and the other in Gaborone, Botswana. Instructors and trainees could see one another, see inside each other's simulators, and communicate in real time. Learner's opinions and skills were evaluated. Before and after the curriculum, physicians completed a self-assessment questionnaire, a multiple-choice test, and during session 3, a demonstration of competence using an IO infusion system was timed and scored locally and via the Internet. RESULTS: Twenty-two physicians participated. The scores on the pretest ranged from 1 to 12 out of 15. The range of scores on the posttest was 10 to 15 out of 15. The mean (±SD) score on pre- and post-multiple choice testing increased by +5 (±2.75; 95% confidence interval [CI] for mean difference = 3.92 to 6.35). Based on McNemar's chi-square test, physicians reported a significant improvement in their comfort and knowledge inserting IO needles (p < 0.01), familiarity with the EZ-IO infusion system (p < 0.01), and knowledge handling the IO equipment (p < 0.01). Postintervention, all physicians reported that telesimulation teaching was a worthwhile experience, and 95% felt more prepared to manage pediatric resuscitation. There was no evidence of a difference in scoring or timing of IO insertion tasks whether measured locally or remotely (mean ± SD score difference = -0.11 ± 1.22 [95% CI = -0.66 to 0.43]; mean ± sd time difference = 0.01 ± 0.15 seconds [95% CI = -0.06 to 0.08 seconds]). CONCLUSIONS: Telesimulation is a novel method for teaching procedural skills. The session improved physicians' knowledge, self-reported confidence, and comfort level in inserting the IO needle. Accurate scoring is possible via the Internet. This modality offers potential for teaching other procedural skills over distances.

Acute treatment of paediatric migraine: a meta-analysis of efficacy.

AIM: To undertake a meta-analysis of all randomised controlled trials (RCTs) on the acute pharmacologic treatment of children and adolescents with migraine headache. METHODS: In total, 139 abstracts of clinical trials specific to the acute treatment of paediatric migraine were appraised. Inclusion criteria required clinical trials to be randomised, blinded, placebo-controlled studies with comparable endpoints. Non- English language publications were excluded. 11 clinical trials qualified for inclusion in the final meta-analysis. Two endpoints were analysed: the proportion of patients with (1) headache relief, and (2) complete pain relief, 2 h post-treatment. RESULTS: The following medications were included in the analysis: acetaminophen (n = 1), ibuprofen (n = 2), sumatriptan (n = 5), zolmitriptan (n = 1), rizatriptan (n = 2) and dihydroergotamine (n = 1). Results are expressed as a relative benefit (RB) conferred over placebo and the number needed to treat (NNT). Only ibuprofen and sumatriptan provided a statistically significant relative efficacy in comparison with placebo. Two hours post-treatment, ibuprofen was associated with an RB 1.50 (95% CI 1.15-1.95) in the generation of headache relief (NNT 2.4) and RB 1.92 (95% CI 1.28-2.86) in the production of complete pain relief (NNT 4.9). Sumatriptan rendered an RB 1.26 (95% CI 1.13-1.41) in headache relief (NNT 7.4) and an RB 1.56 (95% CI 1.26-1.93) in the production of complete pain relief (NNT 6.9). CONCLUSION: Despite the pharmacological options for the management of acute migraine, few RCTs in the paediatric population exist. Composite data demonstrate that only ibuprofen and sumatriptan are significantly more effective than placebo in the generation of headache relief in children and adolescents.

Evidence-based emergency medicine/critically appraised topic. Thrombolytic therapy for submassive pulmonary embolism?

STUDY OBJECTIVE: The purpose of this review was to determine the effectiveness of adding thrombolytics to standard heparin therapy for treatment of submassive pulmonary embolism. Patients with submassive pulmonary embolism were considered to be those with evidence of right ventricular dysfunction but without hemodynamic instability. METHODS: We searched for trials comparing thrombolytics to heparin in the Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE. We included only studies assessing the effectiveness of thrombolytic therapy for submassive pulmonary embolism and reported the patient-important outcomes of mortality, recurrent pulmonary embolism, and major hemorrhage. RESULTS: Two randomized trials met the inclusion criteria; one with a total of 256 patients presenting with submassive pulmonary embolism and the other trial including a subgroup of 46 patients with submassive pulmonary embolism. In the larger study, the relative risk (RR) for mortality, recurrent pulmonary embolism, and major hemorrhage was 1.56 (95% confidence interval [CI] 0.36 to 6.83), 1.17 (95% CI 0.30 to 4.57), and 0.23 (95% CI 0.03 to 1.97), respectively. Our post hoc subgroup analysis of the smaller trial identified 2 deaths and 5 patients with recurrent pulmonary embolism among 23 controls, whereas none of the 23 patients randomized to thrombolytics died or had recurrent pulmonary embolism. None of these findings were statistically significant. CONCLUSION: Results of randomized trials comparing the addition of thrombolytic therapy to standard heparin therapy for treatment of submassive pulmonary embolism fail to show any significant differences in clinically important outcomes.