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Background and aims

Within a tertiary level paediatric cardiology unit, in a United Kingdom hospital, the current practice was for referrals to be informally documented and discussed with the consultant cardiologist and the referring team. There was no formal structure for information collection and documentation of plan to referring team was variable. This clinical governance project aimed to develop a new referral proforma and assess effectiveness.

Methods

The first audit cycle (FAC) reviewed the information from the current referral system. Data was collected over 42 days (Monday to Friday, 9am to 5pm, excluding bank holidays). A structured referral proforma was developed. Relevant staff received training in appropriate usage. A second audit cycle (SAC) was completed over 42 days. Statistical analysis was undertaken using Chi Square Tests.

Results

A similar number of referrals were received (FAC n=135, SAC n=131). Within the SAC group there were significant increases in referrals with a plan documented (p<0.00001, 91.6% vs 42.0%) and with plans communicated to the referring team (p<0.00001, 77.1% vs 3.7%). Referral aetiology showed roughly similar frequencies of different causes over both audit periods. Comparing the graded referral urgency between referrer and receiver matched in urgency on a majority of cases (50/57, 87.7%).

Discussion

The new referral proforma demonstrates significantly improved data documentation and communication of plan. The urgency matching provides confidence to make changes to referral process to direct patients to outpatient services.

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BACKGROUND: In Mongolia, despite government measures to implement supplementation and improve food security, malnutrition and micronutrient deficiencies persist. Thus, we assessed the micronutrients deficiencies and the nutritional status of children in two schools in the steppes of the most affected region. It was performed to propose appropriate actions at school level, relying on a compulsory school enrolment with, due to the Mongolian way of life, almost half of the children housed in boarding schools.

METHODS: This descriptive observational study was conducted among schoolchildren between 2 and 18 years old of the Khangaï region and included a complete questioning and a thorough clinical examination, involving standard anthropometric values adapted to age and micronutrients deficiencies signs.

RESULTS: Altogether, 899 children were included. In children under 5 years old, 6% were stunted, 3% underweight and 4% wasted, without severity criteria. In children over 5 years old, 6.2% were stunted, 2.3% underweight, 2.2% thinness with 1.5% of them presenting severe characteristics. Obesity concerned 8% and 16% of them, respectively. Clinical signs of vitamin D deficiency were founded in 5.9% of the children, vitamin B9 or B12 deficiency’s signs in 2.7% and iron deficiency’s signs in 3.4%. Iron deficiency prevalence was the only data with a significant difference between schools (p<0,001).

CONCLUSION: Besides micronutrient deficiencies and stunting persistence, the Mongolian diet, based on dairy products and meat, also lead to increased obesity. Thus, growing selected vegetables in already existing school fields would give access to better nutrition, would improve food safety and global nutrition status.

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Introduction: Discriminating viral from bacterial lower respiratory tract infections (LRTI) in children is challenging, commonly resulting in antibiotic overuse. The Feverkidstool, a validated clinical prediction model including clinical symptoms and C-reactive protein, safely reduced antibiotics in children at low-risk for bacterial LRTI in a multicentre trial at Emergency Departments (EDs) in the Netherlands. We simulated the impact of the Feverkidstool on antibiotic prescriptions compared to real-life prescriptions in children with suspected LRTI at European EDs.

Methods: This study is embedded in MOFICHE (Management and Outcome of Febrile children in Europe), an observational study of febrile children <18 years presenting to 12 EDs in 8 European countries. We included children with respiratory symptoms and excluded upper respiratory tract infections. Using the Feverkidstool, we calculated individual risks for bacterial LRTI and modelled the withholding of antibiotics in children at low risk (≤10%) for varying rates of usage and compliance to the treatment advice. We compared antibiotic prescription rates between real-life and simulations.

Results: Of 6346 children, 5438 (85.7%) were at low risk for bacterial LRTI and in real-life 2195 (34.6%) received antibiotics. Assuming full usage and compliance, the Feverkidstool reduced antibiotic prescription to 12.0% (pooled risk difference: 24.4[95%CI:20.7-28.0]). Simulating usage of 40-100% with 90% compliance resulted in absolute reductions ranging 6.3%-16.3%. Antibiotic prescriptions were reduced in each ED, whilst large reductions were observed in EDs with high real-life prescription rates and >90% low-risk patients.

Conclusion: Implementation of the Feverkidstool could safely reduce antibiotic prescriptions in children with suspected LRTI in European EDs.

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Background: Infants with Down Syndrome (DS) undergoing surgical correction of congenital heart disease (CHD) may exhibit altered loading conditions and myocardial performance during the peri-operative period. This may result in higher morbidity.

We aimed to characterise the impact of DS on myocardial performance in infants with CHD over the peri-operative period in comparison with genetically normal controls, matched for cardiac lesion.

Methods: Infants with DS and non-DS with AVSD and VSD were prospectively recruited to undergo three echocardiograms (pre-operatively, post-operatively and pre-discharge). Left (LV) and right (RV) ventricular function were measured using deformation analysis to derive LV global longitudinal strain (LV GLS) and RV free wall longitudinal strain (RV FwLS) including LV end systolic wall stress (ESWS) and RV systolic pressure (RVSp). Demographics, clinical characteristics and morbidity were compared.

Results: 34 DS compared with 17 controls. LVGLS was significantly higher in the DS group at echo 1 and 3. LVGLS decreased in both groups post-operative with neither recovering to pre-operative values pre-discharge. RV FwLS decreased in both groups post-operative with better recovery at discharge in controls. DS demonstrated lower ESWS and higher RVSp throughout study. Post-operatively only DS developed chylothorax, higher vasoactive inotropic scores, longer duration of inotropic support and duration of PICU stay.

Conclusion: Infants with DS and CHD demonstrated increased LVGLS and lower ESWS peri-operatively with lower recovery in RV function and higher RVSp pre-discharge, also exhibit an increase disease burden post-operatively. This may reflect the autonomic dysfunction described in infants with DS, although this requires further evaluation.