Trends in Management of Simple Febrile Seizures at US Children's Hospitals.

OBJECTIVE: We sought to measure trends in evaluation and management of children with simple febrile seizures (SFSs) before and after the American Academy of Pediatrics updated guidelines published in 2011. METHODS: In this retrospective, cross-sectional analysis, we used the Pediatric Health Information System database comprising 49 tertiary care pediatric hospitals in the United States from 2005 to 2019. We included children aged 6 to 60 months with an emergency department visit for first SFS identified using codes from the International Classification of Diseases, Ninth Revision, and International Classification of Diseases 10th Revision. RESULTS: We identified 142 121 children (median age 21 months, 42.4% female) with an emergency department visit for SFS. A total of 49 668 (35.0%) children presented before and 92 453 (65.1%) after the guideline. The rate of lumbar puncture for all ages declined from 11.6% (95% confidence interval [CI], 10.8% to 12.4%) in 2005 to 0.6% (95% CI, 0.5% to 0.8%) in 2019 (P < .001). Similar reductions were noted in rates of head computed tomography (10.6% to 1.6%; P < .001), complete blood cell count (38.8% to 10.9%; P < .001), hospital admission (19.2% to 5.2%; P < .001), and mean costs ($1523 to $601; P < .001). Reductions in all outcomes began before, and continued after, the publication of the American Academy of Pediatrics guideline. There was no significant change in delayed diagnosis of bacterial meningitis (preperiod 2 of 49 668 [0.0040%; 95% CI, 0.00049% to 0.015%], postperiod 3 of 92 453 [0.0032%; 95% CI, 0.00066% to 0.0094%]; P = .99). CONCLUSIONS: Diagnostic testing, hospital admission, and costs decreased over the study period, without a concomitant increase in delayed diagnosis of bacterial meningitis. These data suggest most children with SFSs can be safely managed without lumber puncture or other diagnostic testing.

Intrathecal Immunoglobulin M Synthesis is an Independent Biomarker for Higher Disease Activity and Severity in Multiple Sclerosis.

OBJECTIVE: We aimed to determine in relapsing multiple sclerosis (MS) whether intrathecal synthesis of immunoglobulin (Ig) M and IgG is associated with outcomes reflecting inflammatory activity and chronic worsening. METHODS: We compared cerebrospinal fluid analysis, clinical and magnetic resonance imaging data, and serum neurofilament light chain (sNfL) levels at baseline and follow-up in 530 patients with relapsing MS. Patients were categorized by the presence of oligoclonal IgG bands (OCGB) and intrathecal synthesis of IgG and IgM (intrathecal fraction [IF]: IgGIF and IgMIF ). Relationships with the time to first relapse, sNfL concentrations, T2-weighted (T2w) lesions, MS Severity Score (MSSS), and time to initiation of high-efficacy therapy were analyzed in covariate-adjusted statistical models. RESULTS: By categorical analysis, in patients with IgMIF the median time to first relapse was 28 months shorter and MSSS on average higher by 1.11 steps compared with patients without intrathecal immunoglobulin synthesis. Moreover, patients with IgMIF had higher sNfL concentrations, more new/enlarging T2w lesions, and higher total T2w lesion counts (all p ≤ 0.01). These associations were absent or equally smaller in patients who were positive for only OCGB or OCGB/IgGIF . Furthermore, quantitative analyses revealed that in patients with IgMIF ≥ median, the time to first relapse and to initiation of high-efficacy therapy was shorter by 32 and by 203 months, respectively (both p < 0.01), in comparison to patients with IgMIF < median. Dose-dependent associations were also found for IgMIF but not for IgGIF with magnetic resonance imaging-defined disease activity and sNfL. INTERPRETATION: This large study supports the value of intrathecal IgM synthesis as an independent biomarker of disease activity and severity in relapsing MS. ANN NEUROL 2021;90:477-489.

Lumbar and ventricular CSF concentrations of extracellular matrix proteins before and after shunt surgery in idiopathic normal pressure hydrocephalus.

BACKGROUND: Idiopathic normal pressure hydrocephalus (iNPH) is a reversible CNS disease characterized by disturbed cerebrospinal fluid (CSF) dynamics. Changes in the extracellular matrix (ECM) composition might be involved in the pathophysiology of iNPH. The aim of this study was to explore possible differences between lumbar and ventricular CSF concentrations of the ECM markers brevican and neurocan, matrix metalloproteinases (MMPs) and tissue inhibitor of metalloproteinase-1 (TIMP-1) and their relation to clinical symptoms in iNPH patients before and after shunt surgery. METHODS: Paired lumbar and ventricular CSF was collected from 31 iNPH patients, before and four months after shunt surgery. CSF was analysed for concentrations of tryptic peptides originating from brevican and neurocan using a mass spectrometry-based panel, and for MMP-1, -2, -9, -10 and TIMP-1 using fluorescent or electrochemiluminescent immunoassays. RESULTS: Brevican and neurocan peptide levels were not influenced by CSF origin, but MMP-1, -2, -10 and TIMP-1 were increased (p ≤ 0.0005), and MMP-9 decreased (p ≤ 0.0003) in lumbar CSF compared with ventricular CSF. There was a general trend of ECM proteins to increase following shunt surgery. Ventricular TIMP-1 was inversely correlated with overall symptoms (rho = - 0.62, p < 0.0001). CSF concentrations of the majority of brevican and neurocan peptides were increased in iNPH patients with a history of cardiovascular disease (p ≤ 0.001, AUC = 0.84-0.94) compared with those without. CONCLUSION: Levels of the CNS-specific proteins brevican and neurocan did not differ between the lumbar and ventricular CSF, whereas the increase of several CNS-unspecific MMPs and TIMP-1 in lumbar CSF suggests contribution from peripheral tissues. The increase of ECM proteins in CSF following shunt surgery could indicate disturbed ECM dynamics in iNPH that are restored by restitution of CSF dynamics.

National Trends in Lumbar Puncture from 2010 to 2018: A Shift Reversal from the Emergency Department to the Hospital Setting for Radiologists and Advanced Practice Providers.

BACKGROUND AND PURPOSE: Prior research has shown substantial shifts in procedure shares between specialty groups providing lumbar punctures. Our aim was to analyze national trends in lumbar punctures among the Medicare population from 2010 to 2018. MATERIALS AND METHODS: Medicare Part B Physician/Supplier Procedure Summary Master Files from 2010 to 2018 were analyzed for all Current Procedural Terminology, Version 4 codes related to lumbar punctures (62270 and 62272). Lumbar puncture procedure volume and utilization rates were assessed and stratified by place of service and specialty background of the providers. RESULTS: From 2010 to 2018, the overall number of lumbar puncture procedures essentially has not changed (92,579 versus 92,533). Radiologists hold the largest and an increasing procedure share of diagnostic and overall lumbar punctures (overall share, 45.7% in 2010 [n = 42,296] versus 52.3% in 2018 [n = 48,414]). Advanced practice providers have increased their procedure share (3.7% in 2010 [n = 3388] versus 8.4% in 2018 [n = 7785], + 129.8% procedure volume). Emergency medicine physicians and neurologists have a decreasing procedure share (21.8% versus 15.3% and 12.5% versus 8.8%, respectively). The inpatient hospital setting remains the largest place of service for lumbar punctures, recording a 5.3% increase in procedure share. The emergency department lumbar puncture volume has declined, with a 7.4% decrease in the overall procedure share. Similarly, the hospital outpatient department procedure volume has increased (+4%), while the private office volume has decreased (-1.7%). CONCLUSIONS: During the past decade, lumbar puncture procedures among the Medicare population have remained stable, with a shift in procedure volume from the emergency department and private offices to the hospital setting, which has mainly affected radiologists and advanced practice providers.

Declines in the Number of Lumbar Punctures Performed at United States Children's Hospitals, 2009-2019.

OBJECTIVE: To evaluate trends in lumbar puncture (LP) performance among US children's hospitals to assess how these trends may impact pediatric resident trainee exposure to LP. STUDY DESIGN: We quantified LPs for emergency department (ED) and inpatient encounters at 29 US children's hospitals from 2009 to 2019. LP was defined by either a LP procedure code or cerebrospinal fluid culture billing code. Temporal trends and hospital variation in LP were assessed using logistic regression analysis. RESULTS: A total of 215 030 LPs were performed during the study period (0.8% of all encounters). Twenty six thousand and five hundred twenty three and 16 696 LPs were performed in the 2009 and 2018 academic years, respectively (overall 37.1% reduction, per-year OR, 0.935; 95% CI, 0.922-0.948; P < .001), and the rate of LP decreased from 10.9 per 1000 hospital encounters to 6.0 per 1000 hospital encounters over the same period. CONCLUSIONS: LP rates have declined across US children's hospitals over the past decade, potentially resulting in reduced clinical exposure for pediatric resident trainees. Improved procedural simulation during residency may augment the clinical experience.

Factors Associated with Lumbar Puncture Participation in Alzheimer's Disease Research.

BACKGROUND: Cerebrospinal fluid (CSF) provides insight into the spectrum of Alzheimer's disease (AD) pathology. While lumbar punctures (LPs) for CSF collection are generally considered safe procedures, many participants remain hesitant to participate in research involving LPs. OBJECTIVE: To explore factors associated with participant willingness to undergo a research LP at baseline and follow-up research study visit. METHODS: We analyzed data from 700 participants with varying cognition (unimpaired, mild cognitive impairment, and dementia) in the Wisconsin Alzheimer's Disease Research Center. We evaluated the relationship of demographic variables (age, sex, race, ethnicity, and years of education) and clinical variables (waist-to-hip ratio, body mass index, AD parental history, cognitive diagnosis) on decision to undergo baseline LP1. We evaluated the relationship of prior LP1 experience (procedure success and adverse events) with the decision to undergo follow-up LP2. The strongest predictors were incorporated into regression models. RESULTS: Over half of eligible participants opted into both baseline and follow-up LP. Participants who underwent LP1 had higher mean education than those who declined (p = 0.020). White participants were more likely to choose to undergo LP1 (p < 0.001); 33% of African American participants opted in compared to 65% of white participants. Controlling for age, education, and AD parental history, race was the only significant predictor for LP1 participation. Controlling for LP1 mild adverse events, successful LP1 predicted LP2 participation. CONCLUSION: Race was the most important predictor of baseline LP participation, and successful prior LP was the most important predictor of follow-up LP participation.

Risk of Postdural Puncture Headache in Adolescents and Adults.

BACKGROUND: Spinal anesthesia is known to have numerous benefits, including reductions in nausea and opioid consumption; however, postdural puncture headache (PDPH) remains a significant risk associated with this technique. The literature specifically examining this complication in adolescents is scarce. Our primary objective was therefore (1) to estimate the incidence of PDPH with a 27G pencil-point needle in patients between the ages of 12 and 19 undergoing ambulatory lower extremity procedures and (2) to compare it to the incidence in adults aged 20-45 years. METHODS: After institutional review board (IRB) approval, patients aged 12-45 years undergoing ambulatory lower extremity surgery were approached. Patients undergoing the procedure under combined spinal-epidural (CSE) or spinal anesthesia with a 27G pencil-point needle were eligible for enrollment. Patients were consented before surgery and received a survey via e-mail on postoperative day (POD) 4 inquiring about the presence of a headache. Each headache was described by the participant and assessed for severity, time of onset, duration, location, and whether it was of a postural nature. All patients reporting a postural headache were contacted by a physician author to confirm a diagnosis of PDPH using the International Headache Society diagnostic criteria. RESULTS: A total of 656 patients were included in the analysis. Overall, 3.4% of patients developed PDPH. The percentage developing PDPH was 4.9% (3.0-7.8) among those aged 12-19 years and 1.8% (0.8-3.9) in the 20- to 45-year-old group. After adjusting for covariates, the age group between 12 and 19 years was associated with an almost 3-fold increase in the odds (2.8 [95% confidence interval {CI}, 1.1-7.3]) for the development of PDPH compared to that in the 20-45 age group. One patient in the adult group required an epidural blood patch. CONCLUSIONS: The overall incidence for the development of PDPH in ambulatory patients <45 years of age is low. However, the odds for developing PDPH is significantly higher in teenagers compared to those aged 20-45 years. This increase was not associated with an increase in the need for an epidural blood patch. Providers may incorporate these data in their consent process and have a higher index of suspicion for PDPH in teenagers who report headaches after neuraxial anesthesia.

CSF volume provocation maneuvers during lumbar puncture as a possible predictive tool for diagnosing spontaneous intracranial hypotension.

OBJECTIVES: Spontaneous intracranial hypotension (SIH) is a pathologic state of low CSF volume caused by a CSF to venous fistula or CSF leak. It is diagnosed based on symptoms, imaging, and CSF pressure but is often a diagnostic challenge because no single test is highly sensitive. Physician-induced changes in CSF volume may result in changes in patient symptoms, as has been shown with idiopathic intracranial hypertension (IIH). The purpose of this study is to determine the sensitivity of CSF volume provocation maneuvers in the diagnosis of SIH. PATIENTS AND METHODS: We reviewed consecutive patients that underwent lumbar puncture from January 2015 to January 2017. Patients were included if they met ICHD3 criteria for SIH and CSF volume provocation maneuvers were performed. Cases were considered concordant if there was improvement of symptoms with addition of CSF. RESULTS: 1084 patients underwent 2250 CT-guided lumbar punctures from January 2015 to January 2017. 92 patients with SIH were identified and 62 of these patients underwent CSF volume provocation maneuvers. 58% (36/62) had concordant lumbar puncture encounters with symptom improvement upon addition of artificial CSF. CONCLUSION: CSF volume provocation maneuvers demonstrate 58% sensitivity for identifying patients with SIH, better than those reported for CSF opening pressure and myelography. A positive symptomatic response to CSF volume provocation maneuvers was independent of the other objective tests used for SIH and may aid in the often-challenging diagnostic workup of these patients. Future prospective case-controlled studies are needed.

Cognitive and upper limb symptom changes from a tap test in Idiopathic Normal Pressure Hydrocephalus.

OBJECTIVES: To determine which cognitive and upper limb assessments can identify change in patients undergoing a Cerebrospinal fluid (CSF) tap test (TT) diagnosed with idiopathic Normal Pressure Hydrocephalus (iNPH). PATIENTS AND METHODS: Prospective observational study of 74 iNPH patients undergoing a CSF TT for consideration of a ventricular peritoneal shunt. Patients who were offered surgical intervention were classified as responders. Patients were assessed with a battery of cognitive and upper limb assessments prior to and following a CSF TT. The Timed up and go cognition (TUG-C), Montreal Cognitive assessment (MoCA) and 9-hole peg test were utilised. RESULTS: 40 patients were classified responders. Significant differences were identified for responders for the MoCA (0.62 points) and TUG-C (-6.02 s). Only the executive function and orientation sub scores of the MoCA showed significant changes for responders. The 9 hole peg test mean change of 4.33 s for responders was not significant. Non-responder change scores for the MoCA (0.22 points), TUG-C (0.3 s) and 9 hole peg test (2.58 s) were not significant. CONCLUSION: The TUG-C has the potential to identify change in patients resulting from a CSF TT. While statistically significant change was found for the MoCA, a mean change of less than 1 point on this scale is unlikely to be clinically relevant. Similarly, the 9 hole peg test cannot be endorsed as an assessment tool for identifying changed performance in iNPH.

The use of cerebrospinal fluid in biomarker studies.

Cerebrospinal fluid (CSF) is an extremely useful matrix for biomarker research for several purposes, such as diagnosis, prognosis, monitoring, and identification of prominent leads in pathways of neurologic diseases. Such biomarkers can be identified based on a priori hypotheses around prominent protein changes, but also by applying -omics technologies. Proteomics is widely used, but metabolomics and transcriptomics are rapidly revealing their potential for CSF studies. The basis of such studies is the availability of high-quality biobanks. Furthermore, profound knowledge and consequent optimization of all aspects in biomarker development are needed. Here we discuss current knowledge and recently developed protocols for successful biomarker studies, from collection of CSF by lumbar puncture, processing, and biobanking protocols, preanalytic confounding factors, and cost-efficient development and validation of assays for implementation into clinical practice or research.

Endolymphatic hydrops in idiopathic intracranial hypertension: prevalence and clinical outcome after lumbar puncture. Preliminary data.

Idiopathic intracranial hypertension is characterized by raised intracranial pressure (ICP) without any underlying pathology, presenting with (IIH) or without papilledema (IIHWOP). Headache, often on daily basis, is the most frequent symptom. Among audiovestibular symptoms, tinnitus and dizziness are commonly reported, while vertigo and hearing impairment are infrequent reports. Endolymphatic hydrops (ELH) is the typical histopathologic feature of Ménière disease, a condition featured by episodes of vertigo, dizziness, fluctuating hearing loss, tinnitus, and aural fullness. Evidences suggest that ICP is transmitted to inner ear. The aim of this study is to investigate the prevalence of ELH symptoms in IIH/IIHWOP and the relationship between the raised ICP and ELH. The prevalence of chronic headache and of ELH symptoms was investigated in a consecutive series of IIH/IIHWOP patients, and a standard audiometry with hearing threshold measurement (pure-tone average-PTA) was performed. Differences in chronic headache and ELH symptoms prevalence and changes of PTA threshold were calculated after ICP normalization by lumbar puncture (LP). Thirty-one patients (17 with IIH and 14 with IIHWOP) were included. Before LP, chronic headache was present in 93.5%. The percentages of patients reporting tinnitus, dizziness, vertigo, and aural fullness were 67.7, 77.4, 22.6, and 61.3%, respectively. Headache frequency as well as ELH symptoms and PTA significantly improved after LP. The improvement of PTA and of ELH symptoms observed after LP in this series of IIH/IIHWOP patients indicates that a raised ICP, a condition known to be involved in the progression and refractoriness of migraine pain, has also a role in ELH. We propose that intracranial hypertension may represent the shared pathogenetic step explaining the large epidemiological comorbidity between migraine and vestibular symptoms, at present conceptualized as "vestibular migraine."

Factors associated with the onset and persistence of post-lumbar puncture headache.

IMPORTANCE: This study assesses factors associated with the most common adverse event following lumbar puncture. OBJECTIVE: To identify factors associated with the risk, onset, and persistence of post-dural puncture headache (PDPH). DESIGN, SETTING, AND PARTICIPANTS: We performed univariate and multivariable analyses of 338 lumbar punctures in the Dominantly Inherited Alzheimer Network observational study using linear mixed models, adjusting for participant-level and family-level random effects. MAIN OUTCOMES AND MEASURES: We directly evaluated associations of 3 post-lumbar puncture outcomes (immediate postprocedural headache, PDPH at 24-hour follow-up, and PDPH receiving a therapeutic blood patch) with participant age and sex, positioning, collection method, needle size, needle insertion site, and cerebrospinal fluid (CSF) volume collected. RESULTS: The incidence of adverse events included 73 immediate postprocedural headaches (21.6%), 59 PDPHs at 24-hour follow-up (17.5%), and 15 PDPHs receiving a therapeutic blood patch (4.4%). Greater volume of CSF collected was associated with increased risk of immediate postprocedural headache, largely owing to a nonlinear increase in risk on collection of volumes above 30 mL (odds ratio, 3.73 for >30 mL and 0.98 for <17 mL). In contrast, collection of higher volumes showed a protective effect in decreasing rates of PDPH at 24-hour follow-up and rates of PDPH receiving a therapeutic blood patch (odds ratio, 0.35 per 10 mL). Although differences in needle size did not reach statistical significance, no participant in the 24G needle group received a therapeutic blood patch compared to 8 of 253 for the larger 22G needles. CONCLUSIONS AND RELEVANCE: Factors that acutely lower CSF pressure (eg, seated positioning or extracting very high volumes of CSF) may be associated with transient post-lumbar puncture headache, without increasing rates of persistent PDPH or therapeutic blood patch. Collection of up to 30 mL of CSF appears to be well tolerated and safe.

Complications of spinal fluid drainage in thoracic and thoracoabdominal aortic aneurysm surgery in 724 patients treated from 1987 to 2013.

OBJECTIVE: To study complications from spinal fluid drainage in open thoracic/thoracoabdominal and thoracic endovascular aortic aneurysm repairs to define risks of spinal fluid drainage. DESIGN: Retrospective, prospectively maintained, institutionally approved database. SETTING: Single institution university center. PARTICIPANTS: 724 patients treated from 1987 to 2013 INTERVENTIONS: The authors drained spinal fluid to a pressure≤6 mmHg during thoracic aortic occlusion/reperfusion in open and ≤8 mmHg after stent deployment in endovascular procedures. Low pressure was maintained until leg strength was documented. If bloody fluid appeared, drainage was stopped. Head computed tomography (CT) and, if indicated, spine CT and magnetic resonance imaging (MRI) were performed for bloody spinal fluid or neurologic deficit. MEASUREMENTS AND MAIN RESULTS: Spinal fluid drainage was studied for bloody fluid, CT/MRI-identified intracranial and spinal bleeding, neurologic deficit, and death. Seventy-three patients (10.1%) had bloody fluid; 38 (5.2%) had intracranial blood on CT. One patient had spinal epidural hematoma. Higher volume of fluid drained and higher central venous pressure during proximal clamping were associated with intracranial blood. Most patients with intracranial blood were asymptomatic. Six patients had neurologic deficits: of the 6, 3 died (0.4%), 1 (0.1%) had permanent hemiparesis, and 2 recovered. Three of the six deficits were delayed, associated with heparin anticoagulation. CONCLUSIONS: 10% of patients had bloody spinal fluid; half of these had intracranial bleeding, which was almost always asymptomatic. In these patients, immediately stopping drainage and correcting coagulopathy may decrease the risk of serious complications. Neurologic deficit from spinal fluid drainage is uncommon (0.8%), but has high morbidity and mortality.

Trends in lumbar puncture over 2 decades: a dramatic shift to radiology.

OBJECTIVE: The purpose of this study is to evaluate national trends in lumbar puncture (LP) procedures and the relative roles of specialty groups providing this service. MATERIALS AND METHODS: Aggregated claims data for LPs were extracted from Medicare Physician Supplier Procedure Summary master files annually from 1991 through 2011. LP procedure volumes by specialty group and place of service were studied. RESULTS: Between 1991 and 2011, the overall numbers of LP procedures increased, with a slight increase in diagnostic LP procedures (90,460 vs 90,785) and a marked increase in therapeutic LP procedures (2868 vs 6461) in Medicare fee-for-service beneficiaries. Although radiologists performed 11.3% (n = 10,533) of all LP procedures in 1991, they performed 46.6% (n = 45,338) in 2011. For diagnostic LPs, radiology (11.4% [n = 10,272] in 1991 and 48.0% [n = 43,601] in 2011) now exceeds emergency medicine, neurosciences, and all others as the dominant provider group. For therapeutic LP procedures, radiology now performs the second greatest number of LP procedures (9.0% [n = 261] in 1991 and 26.9% [n = 1737] in 2011). Although volumes remain small (< 10% of all procedures), midlevel practitioners have experienced over 100-fold growth for most services. The inpatient hospital setting remains the dominant site of service (71,385 in 1991 vs 44,817 in 2011: -37%), followed by procedures performed in the emergency department (297 in 1991 vs 26,117 in 2011: 8794%). CONCLUSION: Over the last 2 decades, LP procedures on Medicare beneficiaries have increased, with radiology now the dominant overall provider. Although this trend may have relatively negative financial implications for radiology practices in current fee-for-service payment models, it has the potential to cement radiology's more central position through direct involvement in patient care in emerging accountable care organizations.

¿Se realiza correctamente la punción lumbar en pediatría? Revisión de las recomendaciones actuales y análisis de la realidad / Do paediatricians perform lumbar puncture correctly? Review of recommendations and analysis the technique in Spain

Introducción: La punción lumbar (PL) es una técnica ampliamente utilizada en pediatría. La realización adecuada de la técnica puede evitar la mayoría de las complicaciones asociadas. Objetivo: Evaluar si en España los pediatras y los residentes de pediatría siguen las recomendaciones de la técnica de la PL. Material y métodos: Estudio transversal basado en un cuestionario escrito distribuido por correo electrónico a través de la Sociedad Española de Urgencias Pediátricas, que recogía datos epidemiológicos y preguntas de respuesta múltiple sobre la realización de la PL. Resultados: Se analizaron 206 cuestionarios, 143 (69,5%) respondidos por pediatras y 63 (30,5%) por residentes de pediatría. Hacen la PL sin los padres presentes 128 médicos (62,1%), aplican sedoanalgesia 198 (96,1%); 84 (42%) sólo analgesia local. Colocan al paciente sentado 108 (53,7%). La mayoría utiliza aguja tipo Quincke (126; 62,7%), orienta bien el trocar al hacer la punción 22 (36,1%) residentes y 21 pediatras (15,1%), diferencia estadísticamente significativa (p=0,001). En los neonatos, 63 (46%) pediatras y 19 (30,2%) residentes usan aguja sin fiador tipo «palomilla», diferencia también significativa (p=0,035). Reintroducen el estilete para redirigir el trocar 190 (92,2%) encuestados y para extraerlo 186 (93%). Recomiendan reposo tras la PL 195 (94,7%) médicos. Conclusiones: La mayoría de los pediatras orientan mal el trocar cuando hacen una PL y siguen utilizando aguja tipo «palomilla» en los neonatos a pesar de que está desaconsejado. Los residentes de pediatría y los pediatras con menor experiencia siguen las recomendaciones con mayor frecuencia(AU)

Introduction: Lumbar puncture (LP) is a commonly performed procedure in paediatrics. Performing this technique properly can avoid the most common associated complications. Objective: To assess whether paediatricians and paediatric residents in Spain follow current recommendations for the LP technique. Material and methods: A cross-sectional study was conducted by sending a questionnaire by mail through the Spanish Society of Paediatric Emergencies, collecting demographic information and responses to multiple choice questions about LP technique. Results: A total of 206 questionnaires were analysed, of which 143 (69.5%) were answered by paediatricians, and 63 (30.5%) by paediatric residents. The majority (128; 62.1%) of physicians did not allow parents to be present during LP, 198 (96.1%) routinely use analgesia and sedation; 84 (42%) only used local anaesthesia. The majority of respondents used standard Quincke needles (126; 62.7%). The bevel was correctly positioned when puncturing the dura mater by 22 residents (36.1%) and 21 paediatricians (15.1%), a variation that was statistically significant (P=.001). For neonatal lumbar punctures, 63 paediatricians (46%) and 19 paediatric residents used a butterfly needle which did not contain a stylet, and this difference was also statistically significant (P=.035). Of those surveyed, 190 (92.2%) re-inserted the stylet when re-orientating the needle, and 186 (93%) re-oriented this when removing it. The recommendation of bed rest was made by 195 (94.7%) physicians. Conclusions: The majority of paediatricians orient the bevel wrongly when inserting the needle during LP, and still use "butterfly" needles in newborns, despite warnings to the contrary. Paediatric residents and less experienced paediatricians follow the recommendations more frequently(AU)

Adjustment of cerebrospinal fluid protein for red blood cells in neonates and young infants.

OBJECTIVE: To determine the relationship between cerebrospinal fluid (CSF) red blood cell (RBC) count and CSF protein in neonates and young infants undergoing lumbar puncture. DESIGN: Cross-sectional study. SETTING: Urban tertiary care children's hospital. PATIENTS: Infants 56 days of age and younger who had a lumbar puncture in the emergency department between January 1, 2005 and July 31, 2009 were eligible for inclusion. Infants with missing laboratory data, exceedingly high CSF red blood cell counts, or conditions known to elevate CSF protein were excluded. MEASUREMENTS: Linear regression was used to determine the association between CSF RBC and CSF protein. RESULTS: Of 1986 infants, 56 days of age or younger, who underwent lumbar puncture in the emergency department during the study period, 1241 (62.5%) met inclusion criteria. The median age was 34 days (interquartile range: 19-46 days); 45% of patients were male. The median CSF RBC count was 40 cells/mm(3) (interquartile range: 2-1080 cells/mm(3)); 11.8% of patients had a CSF RBC >10,000 cells/mm(3). CSF protein increased by 1.9 mg/dL (95% confidence interval: 1.7-2.1 mg/dL) per 1000 CSF RBCs for all included patients. Restricting analysis to patients without pleocytosis yielded comparable results, as did subanalyses by age and delivery type. CONCLUSIONS: We found that CSF protein concentrations increased by approximately 2 mg/dL for every 1000 CSF RBCs. These data may assist clinicians in interpreting CSF protein concentrations in infants 56 days of age and younger in the context of traumatic lumbar punctures.