Retinal microcirculation imaging in sickle cell disease patients.

OBJECTIVES: To explore the feasibility of a new quantitative method for microvascular function: non-invasive retinal function imaging (RFI). in sickle cell disease (SCD) patients and healthy controls and have it benchmarked against Laser Speckle Contrast Imaging (LSCI) measurements. METHODS: The variability of Microvascular measurements was assessed in 8 SCD patients and 8 healthy matched controls. Measurements were conducted twice on two different study days. RFI was performed for assessment of arterial and venous retinal blood flow. LSCI measurements included post occlusive reactive hyperemia and IBH challenges. Measured variables included basal flow, flow upon occlusion-reperfusion and flow during an IBH. RESULTS: RFI arterial flow and venous flow and LSCI basal flow and peak flow showed excellent intra subject repeatability between days (CVC of 8.5% 9.5%, 7.6% and 7.7% respectively) and between measurements on one day (CVC of 7.0%, 7.7%, 7.6% and 4.7% respectively). RFI arterial flow (p<0.002), and RFI venous flow (p=0.007) differed significantly between SCD patients and controls in as did LSCI basal flow, maximal flow and delta flow during IBH (p<0.0001). CONCLUSIONS: RFI showed low variability for all readout measures, comparable with most microvascular measures from LSCI. The discriminating power of the RFI between SCD patients and controls demonstrate the feasibility of this device for quantitative assessment of the microcirculation in clinical research.

Undertriage in the Manchester triage system: an assessment of severity and options for improvement.

BACKGROUND: The Manchester Triage System (MTS) determines an inappropriately low level of urgency (undertriage) to a minority of children. The aim of the study was to assess the clinical severity of undertriaged patients in the MTS and to define the determinants of undertriage. METHODS: Patients who had attended the emergency department (ED) were triaged according to the MTS. Undertriage was defined as a 'low urgent' classification (levels 3, 4 and 5) under the MTS; as a 'high urgent' classification (levels 1 and 2) under an independent reference standard based on abnormal vital signs (level 1), potentially life-threatening conditions (level 2), and a combination of resource use, hospitalisation, and follow-up for the three lowest urgency levels. In an expert meeting, three experienced paediatricians used a standardised format to determine the clinical severity. The clinical severity had been expressed by possible consequences of treatment delay caused by undertriage, such as the use of more interventions and diagnostics, longer hospitalisation, complications, morbidity, and mortality. In a prospective observational study we used logistic regression analysis to assess predictors for undertriage. RESULTS: In total, 0.9% (119/13,408) of the patients were undertriaged. In 53% (63/119) of these patients, experts considered undertriage as clinically severe. In 89% (56/63) of these patients the high reference urgency was determined on the basis of abnormal vital signs. The prospective observational study showed undertriage was more likely in infants (especially those younger than three months), and in children assigned to the MTS 'unwell child' flowchart (adjusted OR<3 months 4.2, 95% CI 2.3 to 7.7 and adjusted ORunwell child 11.1, 95% CI 5.5 to 22.3). CONCLUSION: Undertriage is infrequent, but can have serious clinical consequences. To reduce significant undertriage, the authors recommend a systematic assessment of vital signs in all children.

Repeatability of the Manchester Triage System for children.

OBJECTIVE: The authors aimed to assess the repeatability of the Manchester Triage System (MTS) in children. METHODS: All emergency department nurses (n=43) from a general teaching hospital and a university children's hospital in The Netherlands triaged 20 written case scenarios using the Manchester Triage system. Second, at two emergency departments (EDs), real-life simultaneous triage of patients (<16 years) was performed by ED nurses and two research nurses. The written case scenarios and the patients included in the real-life simultaneous triage study were representative of children attending the ED, in age, problem and urgency level. The authors assessed inter-rater agreement using quadratic weighted kappa values. RESULTS: The weighted kappa between the nurses, triaging the case scenarios, was 0.83 (95% CI 0.74 to 0.91). In total, 88% (N=198) of the eligible ED patients were triaged simultaneously, with a weighted kappa of 0.65 (95% CI 0.56 to 0.72). CONCLUSIONS: The MTS showed good to very good repeatability in paediatric emergency care.

[Diagnostic image (346). A child with prominent cranial fissures]. / Diagnose in beeld (346). Een kind met geprononceerde schedelnaden.

A 2-week-old boy was presented with prominent cranial fissures. He was diagnosed with malleability post partum.

Pharmacokinetics of rectal tramadol in postoperative paediatric patients.

BACKGROUND: Postoperative analgesia in children may be improved by using tramadol. The pharmacokinetics of rectal tramadol in young children were therefore investigated. METHODS: The pharmacokinetics of rectal tramadol and its active metabolite were studied in 12 young children (age: 1-6 yr) postoperatively. On the basis of these data, a population model was constructed. Using this model, the pharmacokinetics of different doses of tramadol were calculated. RESULTS: The pharmacokinetics of rectal tramadol could be adequately described by a one-compartment model. The pharmacokinetic parameters derived from the model indicate that a low variability was present. Elimination half-life was 4.3 (0.2) h (sem) and the apparent clearance was 16.4 (1.5) litre h(-1) (sem). CONCLUSIONS: The study showed that after rectal administration, tramadol is absorbed at a reasonable rate and with a low inter-individual variability in small children. The data also suggested that a rectal dose of tramadol 1.5-2.0 mg kg(-1) is therapeutic.

[Clinical drug research in children: current international guidelines. Committee for Proprietary Medicinal Products]. / Klinisch geneesmiddelenonderzoek bij kinderen: nieuwe internationale richtlijnen. Committee for Proprietary Medicinal Products.

Drugs research in children entails a number of problems: medical-ethical, pharmacological (owing to the immaturity of the organs and the growth and development of the child) and financial (because children do not use many drugs). Consequently, children are exposed to insufficiently tested drugs and new therapeutic possibilities are withheld from them. Currently, little clinical drugs research in children is being carried out, but this is about to change. By now, European guidelines have been drawn up for the performance of clinical drugs trials according the 'good clinical practice' standards in children. In the Netherlands, a cooperative body has been set up (the Pediatric Pharmacology Network), which is to promote and coordinate paediatric pharmacological research in according with these guidelines.