Source: Wiendels NJ, van der Geest MCM, Neven AK, et al. Chronic daily headache in children and adolescents. Headache. 2005;45:678-683. A retrospective review of medical records of 79 children and adolescents younger than age 16 years with headache more than 15 days a month is reported from Leiden University Medical Center, the Netherlands. Chronic daily headache (CDH) occurred in 57 (72%) patients for more than 6 months. Headache duration was more than 4 hours a day in 60% of the cases. Analgesics were used by 60 children (76%), with daily use in 13 (16%). Frequent school absenteeism and sleeping problems were reported in one-third of patients. Twenty-eight patients (35%) could be classified according to the International Headache Criteria: 17 (22%) had chronic tension-type headaches, 5 (6%) had chronic migraine, 6 (8%) had medication overuse headache, 15 (19%) did not fit any category, and 36 (46%) presented insufficient data for classification. Withdrawal of all analgesic medication is recommended in CDH management.
Sources: (1) Manasse HR. Conscientious objection and the pharmacist. Science. 2005;308:1558-1559. (2) Charo RA. The celestial fire of conscience -refusing to deliver medical care. N Engl J Med. 2005;352:2471-2473. Dr. Mears has disclosed no financial relationships relevant to this commentary.at
Source:Han YY, Carcillo JA, Dragotta MA, et al. Early reversal of pediatric-neonatal septic shock by community physicians is associated with improved outcome. Pediatrics. 2003;112:793-799. T imely resuscitation of infants and children with septic shock appears to improve outcome. 1 The American College of Critical Care Medicine (ACCM) has recently published guidelines for the hemodynamic management of neonatal and pediatric septic shock that emphasize early and aggressive fluid therapy and use of vasoactive infusions. 2 A retrospective review from the University of Pittsburgh, Pa, sought to determine if early reversal of septic shock by community physicians would improve survival, and if outcome was influenced by providing treatment consistent with the ACCM guidelines.The authors report the management and outcome of 91 infants and children (average age 22 months, range 1-131) who were transported to a pediatric tertiary care center after presentation to a community hospital with septic shock. Patients were included if they had signs of sepsis with decreased perfusion, with or without hypotension. Reversal of shock was defined as improvement in capillary refill time to less than 3 seconds and correction of hypotension, if present. Overall mortality was 26%. Shock reversal in response to therapy occurred in 26% of patients prior to arrival of the pediatric transport team (median response time, 75 minutes), and resulted in a survival rate of 96%. Thirty percent of the patients received treatment that was consistent with the ACCM guidelines, which was associated with a 92% survival. For each hour that the patient remained in shock, the odds of mortality, adjusted for PRISM (Pediatric Risk for Mortality) score, more than doubled.While patients whose shock was reversed prior to transport had improved survival, the study does not support the hypothesis that improved outcome was the result of the community physicians' management. Survivors received less fluid resuscitation than nonsurvivors (median 20 mL/kg versus 32.9 mL/kg) and were significantly less likely to receive vasoactive infusions (25% versus 42%) or to be intubated (38% versus 73%). These results suggest that severity of illness at presentation is the most important factor in determining outcome, and those patients who improved in response to fluid therapy, with or without vasoactive infusions, were more likely to survive than those whose shock was unresponsive to these measures. The overall mortality rate of 26% is higher than the reported mortality rate from severe sepsis in pediatric patients, which is approximately 10%. 3 This may indicate that non-survivors experienced a delay in presentation, recognition of shock, or transfer to the tertiary care center. Furthermore, the authors do not state whether PRISM scores reflected pre-or post-resuscitation status; therefore, adjustment of mortality rates for severity of illness may only indicate that non-survivors were more severely ill. The observation that survival was increased when patients received resu...
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