The use of electronic reporting to aid surveillance of ADRs in children: a proof of concept study.

OBJECTIVE: To investigate: (1) the feasibility of establishing active paediatric surveillance for adverse drug reactions (ADRs), (2) whether electronic reporting is effective and (3) whether such a system could complement the Medicines and Healthcare products Regulatory Agency (MHRA) yellow card system. DESIGN: Between January 2006 and February 2007 ADRs in children under 16 were reported each month by consultant paediatricians and paediatric pharmacists in Scotland. For 8 months respondents received a postal card, after which half were selected to report electronically via an email card for a further 6 months and half continued with the postal card. Reports of paediatric ADRs severe enough to warrant hospital admission or to delay discharge of hospitalised patients or resulting from an outpatient prescription were followed up. A postal questionnaire evaluated the system at the end of the study. RESULTS: Following a 2-month lead-in period, 83% of the cards were returned over the year, 84% by paediatricians and 82% by pharmacists. With electronic reporting the response rate was 80%. Eighty-seven confirmed reports of a drug being associated with one or more adverse reactions were reported in 67 children. Only eight children were also identified through the MHRA yellow card system. Respondents indicated continuing willingness to contribute to an active (preferably electronic) reporting system. CONCLUSIONS: Active paediatric ADR surveillance is feasible; electronic reporting is effective and data collected are different to, but could complement, those collected by the MHRA yellow card.

Choking on pins, needles and a blowdart: aspiration of sharp, metallic foreign bodies secondary to careless behavior in seven adolescents.

OBJECTIVE: To review the demographics, pathophysiology and management of aspiration of sharp, metallic foreign bodies; to review prevention strategies. DESIGN: Case series and review of the related literature (1932-2006). SETTING: Tertiary care pediatric hospital. PATIENTS: All patients presenting to BC Children's Hospital with aspiration of sharp, metallic foreign bodies since 1998. RESULTS: The seven patients ranged in age from 11 to 15 years (mean 13 years). The two boys had been playing with other boys at the time of aspiration. One aspirated a thumbtack and one aspirated a homemade blowdart (which traveled from his carina to his subglottis with coughing). Three of the five girls had been holding thumbtacks or a darting pin between their lips while putting up posters or sewing. The other two girls, who aspirated thumbtacks, refused to provide a history. One was treated successfully 6 days after the aspiration. The other girl withheld the history for over a year, presented with hemoptysis and eventually required thoractomy and right main bronchotomy to remove the tack. All of the other patients were diagnosed and successfully treated by rigid bronchoscopy within 24h. (Two patients initially had a failed attempt at foreign body removal by flexible bronchoscopy at another hospital.) This is the second largest series of aspiration of sharp, metallic foreign bodies since at least 1966. Adolescents are still aspirating sharp, metallic foreign bodies because of the same behaviors described by Jackson and Jackson in 1932. Education about choking hazards is needed for this age group. CONCLUSIONS: Aspiration of a sharp, metallic foreign body is a serious injury which is best treated by rigid bronchoscopy. These injuries potentially could be prevented through education.

Pediatric aerodigestive foreign body injuries are complications related to timeliness of diagnosis.

Foreign body (FB) injury from aspiration or ingestion is a common pediatric health problem. Diagnosis relies on clinical judgment plus medical history, physical examination, and radiographic evaluation. A multi-institutional review of 1269 FB events revealed that 85% were correctly diagnosed following a single physician encounter. However, 15% of the children had an elusive diagnosis (>1 week), despite previous evaluation. Delays in diagnosis were seven times more likely to occur in aspirations than in ingestions. Secondary injuries (e.g., pneumonia and atelectasis) occurred in 13% of airway FBs but in only 1.7% of esophageal FBs. Plain radiographs were used in 82% of children, and special studies (e.g., fluoroscopy) in only 7%. We conclude that diagnosis of FB injury in children is frequently achieved at the initial evaluation but that continued surveillance by follow-up visits to health care facilities from parents and other caretakers is important, to reduce pulmonary injuries.

Subglottic hemangioma: a practical approach.

A specific entity known as a subglottic hemangioma may present in a six to 12-week-old baby with gradual onset of a two-way stridor. A cough may be present. The voice and feeding may be normal, until severe airway obstruction occurs. A barium swallow with fluoroscopy should be performed by a radiologist or technician experienced with babies to rule out other lesions such as a vascular ring. Direct examination is then performed using a 3.0 mm Storz-Hopkins bronchoscope under general anesthetic as a method of choice. Other methods are discussed. Ideal treatment is probably best undertaken in a large center, using a carbon dioxide laser through a subglottiscope again under general anesthesia with the child breathing spontaneously. Airway support may be necessary at any stage. Alternative treatments are discussed.

Orbital complications of ethmoiditis: B.C. Children's Hospital experience, 1982-89.

Orbital complications of ethmoiditis primarily affect children. Infection proceeds through contiguous spread to the orbit. We undertook a retrospective analysis of all children admitted to British Columbia Children's Hospital in Vancouver with a diagnosis of periorbital and orbital cellulitis due to ethmoiditis between 1982 and 1989. The majority of children presented with periorbital cellulitis, which resolved with aggressive parenteral antibiotic therapy. Five children (17%) progressed to subperiosteal abscess formation as documented by CT scan and required external ethmoidectomy as a drainage procedure. We conclude that early hospitalization and aggressive parenteral antibiotics are effective in resolving periorbital cellulitis. Surgical drainage is indicated when subperiosteal abscess is documented by CT scan. In our series, there were no cases of permanent visual deficit resulting from complications of ethmoiditis.

Tissue-space emphysema, tissue necrosis, and infection following use of compressed air during pulp therapy: case report.

The intraoperative development of tissue-space emphysema in a child undergoing restorative treatment under general anesthesia is presented. Emphysema development seems to be concomitant with the use of compressed air around patent root canals, complicated by tissue destruction due to movement of canal irrigants/medicaments into the periapical tissues and by secondary infection. Several recommendations for the prevention of tissue-space emphysema are presented including the use of a rubber dam, judicious use of compressed air, and maintenance of canal irrigants and medicaments within the root canal. Treatment recommendations vary from palliative care with follow up in cases of facial emphysema to immediate medical attention in cases of pharyngeal or mediastinal emphysema.

Daycare tonsillectomy and/or adenoidectomy at the British Columbia Children's Hospital.

The fact that tonsillectomy (T), or tonsillectomy with adenoidectomy (T & A) or adenoidectomy (A) can be performed safely in selected children on a daycare or outpatient basis is well proven. This article illustrates the approach that the British Columbia Children's Hospital (B.C.C.H.) took to confirm that the procedures were safe locally. A pilot project was started in June of 1984 to perform daycare adenoidectomies only, using two full-time pediatric otolaryngologists. When this proved successful, other otolaryngologists were encouraged to use the program. In June of 1988, a second pilot project was started for daycare tonsillectomies (or tonsillectomy and adenoidectomy). Criteria were established for patient selection, preparation, anesthesia, post-anesthetic recovery (PAR), Daycare Unit (DCU) nursing, and discharge. Follow-up information was obtained. Daycare tonsillectomy with or without adenoidectomy and daycare adenoidectomy are now routine procedures at B.C.C.H.

Tourette syndrome and otolaryngology.

Tourette syndrome (TS) is the most complex tic disorder and presents primarily in the pediatric population between the ages of two and 15. The otolaryngologist may be consulted to see such a patient because of head and neck or facial tics or more often because of phonic or vocal tics such as throat-clearing, sniffing, coughing or abnormal noises. As this disorder has not appeared in the otolaryngologic literature we undertook a retrospective chart review (N = 72) and follow-up questionnaire related to the otolaryngologic aspects of this disorder.

Management of hemangiomas of the head and neck in children.

Hemangiomas occur in approximately 1% of Caucasian children, and the head and neck is a common site of presentation. Lesions in this region may cause morbidity and occasionally mortality by virtue of complications such as ulceration, infection, hemorrhage, hemodynamic change, aerodigestive tract obstruction and disfigurement. The majority of hemangiomas regress spontaneously. Those with impending complications may require treatment with several modalities. Embolization, surgery, laser therapy, cryotherapy and medical therapy with steroids and antifibrinolytic agents may be used in selected situations. Radiotherapy is now rarely favored due to potential induction of late malignancies. The natural history of these lesions is discussed along with the treatment modalities available and indications for use. Several representative cases are presented.

Sinusitis in children.

Sixty-eight children with the primary diagnosis of sinusitis have been admitted to the B.C. Children's Hospital since its opening in 1982 until July of 1986. Sinusitis in children under six years differs in presentation and course from sinusitis in older children. Children under six years seem to respond well to antibiotics while some children over six need surgery. Underlying diseases were present in half the cases and should be searched for in children who present with recurrent sinusitis.

Comparative efficacies of erythromycin-sulfisoxazole and cefaclor in acute otitis media: a double blind randomized trial.

A prospective double blind trial compared the fixed combination of erythromycin-sulfisoxazole (E/S) with cefaclor in the treatment of acute otitis media. One hundred nineteen children in six centers across Canada were studied. Diagnostic tympanocentesis of 134 ears yielded 135 bacterial isolates: Streptococcus pneumoniae (42%); Haemophilus influenzae (21%); Branhamella catarrhalis (10%); Streptococcus pyogenes (5%); and other bacteria (22%). Seventy-seven percent of strains of B. catarrhalis and 14% of strains of H. influenzae were beta-lactamase producers. E/S exhibited greater in vitro activity against H. influenzae and B. catarrhalis. Twenty-three patients had bacteriologically sterile middle ear fluid. The overall clinical outcome at Days 10 and 31 was identical in both treatment groups. Otoscopic findings improved more rapidly in the E/S group than in the cefaclor group at 10 and 31 days (P less than or equal to 0.04). In cases where pre-treatment middle ear fluid was negative on routine bacterial culture, complete cure at 10 days was observed in 75% of patients treated with E/S but only in 14% of those treated with cefaclor (P = 0.02). Side effects were infrequent and comparable between the test drugs. E/S is at least as effective as cefaclor in the management of acute otitis media and may be superior, particularly for cases not yielding bacteria on routine culture.

Tracheobronchial and esophageal foreign bodies in the pediatric population.

A foreign body lodged in the aerodigestive tract of a child often poses a difficult medical problem. Experience with the diagnosis and removal of these foreign bodies is presented in this retrospective review. The description by a witness of the actual ingestion frequently provided the key to diagnosis. Rigid endoscopy remains a safe technique for foreign body extraction with a low resultant morbidity and mortality. Organic matter comprises the majority of bronchial foreign bodies (70%) while coins are the predominant finding (80%) in the esophagus.

Stridor due to cricoarytenoid arthritis in pauciarticular onset juvenile rheumatoid arthritis.

A 2-year-old girl developed severe inspiratory and expiratory stridor 2 months after onset of pauciarticular juvenile rheumatoid arthritis (JRA). Direct laryngoscopy demonstrated that both vocal cords were immobile and approximated to each other in the midline secondary to arthritis of the cricoarytenoid joints. High dose corticosteroid therapy resulted in clinical and laryngoscopic improvement and tracheostomy was avoided. Cricoarytenoid arthritis can be a life threatening complication in JRA. Early institution of corticosteroids appears to be the treatment of choice.

Cancer of the nasopharynx in British Columbia.

The Chinese population in British Columbia has been increasing in recent years due to the migration of the Chinese from Southern China, which has tripled during the last decade. From 1939 to 1980, 296 cases of nasopharyngeal carcinoma (NPC) were seen at the Cancer Control Agency of British Columbia (CCABC). Of these, 167 (56%) were Chinese and 119 (40%) were Caucasians. The incidence of cancer of the nasopharynx in the Chinese born in China was 115 times greater than Caucasians before 1970 and 107 times greater in the 1970s. The incidence of NPC in the Caucasian population remained unchanged as did that of the North American-born Chinese (six times greater than that of the Caucasians) for the last 2 decades. The overall survival for all cases was 39% at 5 years and 28% at 10 years. The survival of cases was better in patients treated after 1970 (48% at 5 years and 36% at 10 years) than in patients treated before 1970 (34% at 5 years and 20% at 10 years). The survival was 50% at 5 years for all N0 cases but it was only 27% in patients with nodal metastasis. The survival of NPC was related essentially to initial staging, type and dose of irradiation, and pre-irradiation biopsy of neck metastasis. The survival was not significantly related to birth place, race, or histological grade.

Subglottic hemangiomas in infants.

Subglottic hemangioma, a lesion absent at birth and developing in the first few months of life, may present as an acute airway obstruction. Definitive diagnosis may be delayed or confused with other conditions. Recent experience with infants presenting with subglottic hemangioma lead to the proposal of delayed laser surgical intervention until age nine months, at which time natural involution begins. Five cases are reviewed to illustrate this contention.

The sleep apnea syndrome.

Four patients with sleep apnea syndrome were seen at the Vancouver General Hospital within the last three years and are discussed in this paper. The history of recognition of the syndrome, the types of apnea, and method of evaluation using polysomnographic techniques are reviewed, and methods of treatment are outlined.

Microbiology of recurrent and chronic otitis media with effusion.

A study was conducted of 274 children who had recurrent acute or chronic otitis media with effusion. Forty-five percent of the ears with effusion were found to contain bacteria, and 11% contained bacteria that were "probable pathogens" (S. pneumoniae, H. influenzae, and S. pyogenes). Bacteria were also found in 40% of the ears without effusions. The type of organism found did not vary with the age of the patient studied or the season of the year. The significance of these bacteria in the etiology of recurrent acute or chronic otitis media with effusion remains to be demonstrated.