Pediatric Syncope: Is the Diagnostic Guideline Implemented and Adhered to?

BACKGROUND: We sought to investigate adherence to the current pediatric syncope guideline in the emergency department and its impact on the frequency of missed or unnecessary diagnostic measures. For the first time, in 2014 updated guideline defines indispensable basic diagnostic measures and a consecutive algorithm for safe clinical decision making. PATIENTS AND METHOD: We analyzed retrospectively 314 pediatric patients, 166 were presented before and 148 after publication of this guideline update. RESULTS: After guideline publication, 54 patients (36.5%) were not treated in accordance with the guideline and 2 (0.63%) cases caused by epileptic seizures were initially misdiagnosed as reflex syncope. Among these 54 patients, 32 (59.3%) inpatient admissions were inappropriate, as well as 11 (20.4%) electroencephalographies, 4 (7.4%) sleep-deprivation EEGs, 2 (3.7%) magnetic resonance imaging, 5 (9.3%) urine diagnostics and 32 (59.3%) blood tests. In 21 cases (38.9%), the medical history was insufficient. ECG was missed in 42 patients (77.8%). There was no significant difference between the pre- and post-guideline groups concerning diagnostic work-up (p=0,12). DISCUSSION: This non-compliance with the guideline did not cause a large number of misdiagnosed epileptic seizures (1.4%) or adverse outcomes but led to waste of resources in healthcare system and undue burdens on patients and their families. CONCLUSION: In addition to establishment of clinical guidelines, the need for additional measures and strategies to promote their implementation seems obvious.

Validation and Reference Values for Three-Dimensional Echocardiographic Right Ventricular Volumetry in Children: A Multicenter Study.

BACKGROUND: Functional assessment of the right ventricle using real-time three-dimensional echocardiography (RT3DE) has fundamental relevance in young patients with congenital heart disease. Reference values for the pediatric population are scarce. This multicenter study was designed to (1) validate new evaluation software for RT3DE and (2) establish pediatric reference values. METHODS: For validation, right ventricular (RV) end-diastolic volume (EDV) and end-systolic volume (ESV) were determined from real-time three-dimensional echocardiographic data sets of 38 subjects (n = 17 healthy individuals and n = 21 patients with congenital heart disease) using new dedicated evaluation software (RV-Function 2.0) and compared with cardiac magnetic resonance investigations of the same patient cohort. In a prospective multicenter design, 360 real-time three-dimensional echocardiographic data sets of healthy children (172 girls) were analyzed. To create reference centiles, the cohort was subdivided into group I (children <7 years of age, n = 136 [female and male]), group II (girls 7-18 years of age, n = 106), and group III (boys 7-18 years of age, n = 118). RESULTS: Using RT3DE, RV volumes were slightly higher than using cardiac magnetic resonance (EDV, 0.8 ± 5.8% [limits of agreement, -10.8% to 12.5%; r = 0.993]; ESV, 2.0 ± 13.1% [limits of agreement, -24.2% to 28.2%; r = 0.989). Reproducibility was promising (intraobserver variability, 3.9 ± 11.4% for EDV and -1.7 ± 13.4% for ESV [intraclass correlation coefficient range, 0.94-0.98]; interobserver variability, 1.9 ± 11.8% for EDV and -0.3 ± 22.8% for ESV [intraclass correlation coefficient range, 0.85-0.96]). Regarding functional parameters, no significant gender differences were found among children in group I. In contrast, children in groups II and III differed in RV volumes, dimensional parameters, and tricuspid annular plane systolic excursion (P < .005); the children did not differ in deformation parameters. Feasibility was 90%. CONCLUSIONS: RT3DE yields accurate and reproducible RV volumes. The calculated percentile curves may facilitate the clinical use of RT3DE to analyze RV function in children.

Calculation of pediatric left ventricular mass: validation and reference values using real-time three-dimensional echocardiography.

BACKGROUND: Reference values for left ventricular mass (LVM) are important echocardiographic tools for the follow-up of pediatric patients with cardiac disease. Cardiac magnetic resonance (CMR) imaging is currently regarded as the gold standard. The aims of this study were to validate LVM calculated using real-time three-dimensional echocardiography (RT3DE) and to establish pediatric reference values. METHODS: For validation, 40 subjects (20 patients) consecutively underwent CMR (3-T TX Achieva, 25 cardiac phases/slice) and RT3DE (iE33 or Vivid E9, four subvolumes) in a single-center approach. The quantification of CMR data by the disk summation method as standard (mean LVM, 84.2 ± 53 g; range, 17.7-231.7 g) was compared with RT3DE. In a multicenter prospective design, 434 healthy children were investigated using standard software (LV-Analysis version 3.1). RESULTS: In comparison with CMR, RT3DE provided a slight overestimation of LVM of only 2.5 ± 11.3% (r = 0.990, intraclass correlation coefficient = 0.995), and there was low intraobserver (mean, 0.9 ± 7.1%; scatter, 13.2% to -15.0%; r = 0.996; intraclass correlation coefficient = 0.998) and interobserver (mean, 1.5 ± 9.3%; scatter, 17.2% to -20.1%; r = 0.993; intraclass correlation coefficient = 0.996) variability. Feasibility of the multicenter approach was 76%, resulting in 332 healthy children (median age, 10.0 years; range, 0-18 years; group I range, 0-6 years; group II range, 7-18 years) with data sets providing adequate image quality. LVM was correlated with sex (group II), age (r = 0.901), height (r = 0.881), weight (r = 0.876), and body surface area (r = 0.898). Unisex percentiles for 0 to 6 years of age and separated according to gender from 7 to 18 years of age were established. Mean calculation time for RT3DE was <3 min. CONCLUSIONS: In children, LVM calculation presuming excellent real-time three-dimensional echocardiographic data sets is accurate, quick, and reproducible. The percentiles provided are based on a large sample size and may be useful for clinical practice.

Lack of serologic immunity against vaccine-preventable diseases in children after thoracic transplantation.

We investigated whether children after heart- (HTx) or heart-lung transplantation (HLTx) show protective antibody levels against recommended vaccinations, whether vaccination schedules are completed and which factors influence serologic immunity. We performed a cross sectional ELISA - quantification of specific antibodies in 46 patients after pediatric thoracic Tx. Findings were correlated to vaccination history, age at Tx, clinical course and immunosuppressive regimen. We found protective antibody levels against diphtheria in 74% of patients, against tetanus in 22%, against Haemophilus influenzae type b in 30% and against Streptococcus pneumoniae in 59%. Antibody concentrations against live attenuated vaccines were significantly lower in children transplanted in the first 2 years of life. Antibodies were absent for measles in 55% of late - and 81% of early transplanted children, for mumps in 66%/94%, for rubella in 30%/56% and for Varicella in 34%/63%. We found significant correlation of low antibody concentrations and age at Tx. Patients without protective antibody concentrations had significantly longer use of steroids. Vaccination schedules were incomplete or delayed in the majority of patients associated with more days in hospital pre-Tx. Our study shows that closer adherence to pretransplantation vaccination schedules and also post-transplantation monitoring of antibody levels are required in transplant patients.