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1.  Facilitators and barriers to screening for child abuse in the emergency department 
BMC Pediatrics  2012;12:167.
Background
To identify facilitators of, and barriers to, screening for child abuse in emergency departments (ED) through interviews with ED staff, members of the hospital Board, and related experts.
Methods
This qualitative study is based on semi-structured interviews with 27 professionals from seven Dutch hospitals (i.e. seven pediatricians, two surgeons, six ED nurses, six ED managers and six hospital Board members). The resulting list of facilitators/barriers was subsequently discussed with five experts in child abuse and one implementation expert. The results are ordered using the Child Abuse Framework of the Dutch Health Care Inspectorate that legally requires screening for child abuse.
Results
Lack of knowledge of child abuse, communication with parents in the case of suspected abuse, and lack of time for development of policy and cases are barriers for ED staff to screen for child abuse. For Board members, lack of means and time, and a high turnover of ED staff are impediments to improving their child abuse policy. Screening can be promoted by training ED staff to better recognize child abuse, improving communication skills, appointing an attendant specifically for child abuse, explicit support of the screening policy by management, and by national implementation of an approved protocol and validated screening instrument.
Conclusions
ED staff are motivated to work according to the Dutch Health Care Inspectorate requirements but experiences many barriers, particularly communication with parents of children suspected of being abused. Introduction of a national child abuse protocol can improve screening on child abuse at EDs.
doi:10.1186/1471-2431-12-167
PMCID: PMC3502173  PMID: 23092228
Child abuse; Emergency department; Screening; Qualitative study
2.  School Playground Surfacing and Arm Fractures in Children: A Cluster Randomized Trial Comparing Sand to Wood Chip Surfaces 
PLoS Medicine  2009;6(12):e1000195.
In a randomized trial of elementary schools in Toronto, Andrew Howard and colleagues show that granitic sand playground surfaces reduce the risk of arm fractures from playground falls when compared with wood fiber surfaces.
Background
The risk of playground injuries, especially fractures, is prevalent in children, and can result in emergency room treatment and hospital admissions. Fall height and surface area are major determinants of playground fall injury risk. The primary objective was to determine if there was a difference in playground upper extremity fracture rates in school playgrounds with wood fibre surfacing versus granite sand surfacing. Secondary objectives were to determine if there were differences in overall playground injury rates or in head injury rates in school playgrounds with wood fibre surfacing compared to school playgrounds with granite sand surfacing.
Methods and Findings
The cluster randomized trial comprised 37 elementary schools in the Toronto District School Board in Toronto, Canada with a total of 15,074 students. Each school received qualified funding for installation of new playground equipment and surfacing. The risk of arm fracture from playground falls onto granitic sand versus onto engineered wood fibre surfaces was compared, with an outcome measure of estimated arm fracture rate per 100,000 student-months. Schools were randomly assigned by computer generated list to receive either a granitic sand or an engineered wood fibre playground surface (Fibar), and were not blinded. Schools were visited to ascertain details of the playground and surface actually installed and to observe the exposure to play and to periodically monitor the depth of the surfacing material. Injury data, including details of circumstance and diagnosis, were collected at each school by a prospective surveillance system with confirmation of injury details through a validated telephone interview with parents and also through collection (with consent) of medical reports regarding treated injuries. All schools were recruited together at the beginning of the trial, which is now closed after 2.5 years of injury data collection. Compliant schools included 12 schools randomized to Fibar that installed Fibar and seven schools randomized to sand that installed sand. Noncompliant schools were added to the analysis to complete a cohort type analysis by treatment received (two schools that were randomized to Fibar but installed sand and seven schools that were randomized to sand but installed Fibar). Among compliant schools, an arm fracture rate of 1.9 (95% confidence interval [CI] 0.04–6.9) per 100,000 student-months was observed for falls into sand, compared with an arm fracture rate of 9.4 (95% CI 3.7–21.4) for falls onto Fibar surfaces (p≤0.04905). Among all schools, the arm fracture rate was 4.5 (95% CI 0.26–15.9) per 100,000 student-months for falls into sand compared with 12.9 (95% CI 5.1–30.1) for falls onto Fibar surfaces. No serious head injuries and no fatalities were observed in either group.
Conclusions
Granitic sand playground surfaces reduce the risk of arm fractures from playground falls when compared with engineered wood fibre surfaces. Upgrading playground surfacing standards to reflect this information will prevent arm fractures.
Trial Registration
Current Controlled Trials ISRCTN02647424
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Playgrounds and outdoor play equipment provide children with a place to let steam off, play creatively, socialize, and learn new skills. And, in a world where childhood obesity is a burgeoning problem, playgrounds provide a place where children can be encouraged to exercise. But playgrounds are not without hazards. Even in well-maintained and well-run facilities, children can hurt themselves by falling off climbing frames, monkey bars, and other equipment or by falling from standing height during playground games such as tag. In the US alone, more than 200,000 children are treated in emergency departments for injuries sustained in playgrounds every year and about 6,400 children are admitted to hospitals because of playground injuries, most of which are bone fractures (broken bones). In fact, playground injuries in the US are more severe and have a higher hospital admission rate than any other sort of child injury except those involving vehicles.
Why Was This Study Done?
Children who fall off playground equipment are nearly four times as likely to break a bone (often in an arm) as children who fall from standing height. To reduce the number of fractures that occur in playgrounds, some governments have limited the height of playground equipment. Some have also set standards for the type of surfaces installed in playgrounds and for the depth of sand or engineered wood fiber in loose fill surfaces. These standards are based on laboratory tests in which headforms (artificial heads) are dropped onto surfaces. However, these tests provide no information about the ability of different surfaces to prevent broken arms and other specific injuries in the real world. In this cluster randomized trial (a study in which groups of people are randomly assigned to receive different interventions), the researchers compare the rates of arm fractures in elementary (primary) school playgrounds in Toronto (Canada) that have wood fiber surfacing with the rates in playgrounds that have granite sand surfacing.
What Did the Researchers Do and Find?
The researchers randomly assigned 37 elementary schools that had qualified for school board funding for replacement playground equipment to receive either wood fiber (19 schools) or granite sand surfacing (18 schools) in their playgrounds. 19 of the schools complied with their randomization (12 installed fiber and seven installed sand); two schools installed sand although they were randomized to install fiber and seven schools installed fiber instead of sand. The researchers evaluated the playgrounds and their surfaces several times during the 2.5-year study and collected data on how playground injuries happened and types of injuries from the schools, parents, and medical reports. Among the schools that complied with randomization, falls from height into sand resulted in 1.9 arm fractures per 100,000 student-months whereas falls into fiber resulted in 9.4 arm fractures per 100,000 student-months. Arm fracture rates and other injury rates were also higher for falls from height into fiber than into sand when all the schools that had installed new surfaces were considered. However, the rates of arm fracture and other injuries that did not involve a fall from height did not vary between surfaces.
What Do These Findings Mean?
The accuracy of these findings is limited by the small number of arm fractures that occurred during the trial—only 20 children who fell into fiber and two who fell into sand broke an arm. The accuracy of the findings may also be limited by the failure of many schools to comply with randomization although the researchers found no obvious differences between the schools that did and did not comply with randomization that might have affected the trial's outcome. However, even with these limitations, the findings of this real-world study indicate that granitic sand surfaces substantially reduce the risk of arm fractures and other injuries caused by falls from playground equipment when compared with wood fiber surfaces. Thus, because falls from playground equipment are more likely to cause a fracture than falls from standing height, if playground surfacing standards are adjusted to reflect the findings of this study (that is, if sand surfaces are recommended in preference to wood fiber surfaces), many arm fractures in children should be prevented.
Additional Information
Please access these Web sites via the online version of this summary at ttp://dx.doi.org/10.1371/journal.pmed.1000195.
Safe Kids Canada provides information about playground safety and other aspects of childhood safety (in English and French)
Safe Kids Worldwide is a global network of organizations whose mission is to prevent accidental childhood injury (in English and Spanish)
The Nemours Foundation, a nonprofit organization for child health, provides information for parents on playground safety
The Royal Society for the Prevention of Accidents provides information on the safety of indoor and outdoor play areas
The US Centers for Disease Control and Prevention provides fact sheets on playground injuries
The US Consumer Product Safety Commission also has information on playground safety, including resources designed for children such as The Further Adventures of Kidd Safety and Little Big Kids, a booklet on play safety written by children for children
doi:10.1371/journal.pmed.1000195
PMCID: PMC2784292  PMID: 20016688
3.  Screening for Occult Abdominal Trauma in Children with Suspected Physical Abuse 
Pediatrics  2009;124(6):1595.
Background
Abusive abdominal trauma may be difficult to diagnose, and even serious abdominal injury may be missed. Screening for occult abdominal trauma (OAT) has been recommended by child abuse experts. However, it is unclear how often screening occurs, and what factors are associated with screening.
Objectives
(1) To determine the prevalence of OAT in a sample of children with suspected physical abuse. (2) To assess the frequency of OAT screening. (3) To assess factors associated with screening.
Patients and Methods
Charts of children evaluated for abusive injury were identified via a search of hospital discharge codes. Identified charts were reviewed to determine whether OAT screening occurred. Data were collected regarding results of screening tests, abusive injuries identified, family demographics, and characteristics of the emergency department visit.
Results
Screening occurred in 51 of 244 eligible children (20%). Positive screens were identified in 41% of those screened, and 9% of the total sample. 5% of children aged 12–23 months had OAT identified by imaging studies. Screening occurred more often in children presenting with probable abusive head trauma [OR=20.4, 95% CI (3.6–114.6), p<0..01] compared to those presenting with other injuries. Subspecialty consultation from the Child Protection Team [OR=8.5, 95% CI (3.5–20.7), p<0.01] and other subspecialists [OR=24.3, 95% CI (7.1–83.3), p<0.01] also increased the likelihood that OAT screening would occur.
Conclusions
Our findings support OAT screening with liver and pancreatic enzymes for physically abused children. This study also supports the importance of subspecialty input, especially that of a Child Protection Team. Although many identified injuries may not require treatment, their role in confirming, or demonstrating increased severity of maltreatment can play a critical role in protecting children.
doi:10.1542/peds.2009-0904
PMCID: PMC2813699  PMID: 19933726
Child abuse; abdominal trauma; screening
4.  A Novel Brief Therapy for Patients Who Attempt Suicide: A 24-months Follow-Up Randomized Controlled Study of the Attempted Suicide Short Intervention Program (ASSIP) 
PLoS Medicine  2016;13(3):e1001968.
Background
Attempted suicide is the main risk factor for suicide and repeated suicide attempts. However, the evidence for follow-up treatments reducing suicidal behavior in these patients is limited. The objective of the present study was to evaluate the efficacy of the Attempted Suicide Short Intervention Program (ASSIP) in reducing suicidal behavior. ASSIP is a novel brief therapy based on a patient-centered model of suicidal behavior, with an emphasis on early therapeutic alliance.
Methods and Findings
Patients who had recently attempted suicide were randomly allocated to treatment as usual (n = 60) or treatment as usual plus ASSIP (n = 60). ASSIP participants received three therapy sessions followed by regular contact through personalized letters over 24 months. Participants considered to be at high risk of suicide were included, 63% were diagnosed with an affective disorder, and 50% had a history of prior suicide attempts. Clinical exclusion criteria were habitual self-harm, serious cognitive impairment, and psychotic disorder. Study participants completed a set of psychosocial and clinical questionnaires every 6 months over a 24-month follow-up period.
The study represents a real-world clinical setting at an outpatient clinic of a university hospital of psychiatry. The primary outcome measure was repeat suicide attempts during the 24-month follow-up period. Secondary outcome measures were suicidal ideation, depression, and health-care utilization. Furthermore, effects of prior suicide attempts, depression at baseline, diagnosis, and therapeutic alliance on outcome were investigated.
During the 24-month follow-up period, five repeat suicide attempts were recorded in the ASSIP group and 41 attempts in the control group. The rates of participants reattempting suicide at least once were 8.3% (n = 5) and 26.7% (n = 16). ASSIP was associated with an approximately 80% reduced risk of participants making at least one repeat suicide attempt (Wald χ21 = 13.1, 95% CI 12.4–13.7, p < 0.001). ASSIP participants spent 72% fewer days in the hospital during follow-up (ASSIP: 29 d; control group: 105 d; W = 94.5, p = 0.038). Higher scores of patient-rated therapeutic alliance in the ASSIP group were associated with a lower rate of repeat suicide attempts. Prior suicide attempts, depression, and a diagnosis of personality disorder at baseline did not significantly affect outcome. Participants with a diagnosis of borderline personality disorder (n = 20) had more previous suicide attempts and a higher number of reattempts.
Key study limitations were missing data and dropout rates. Although both were generally low, they increased during follow-up. At 24 months, the group difference in dropout rate was significant: ASSIP, 7% (n = 4); control, 22% (n = 13). A further limitation is that we do not have detailed information of the co-active follow-up treatment apart from participant self-reports every 6 months on the setting and the duration of the co-active treatment.
Conclusions
ASSIP, a manual-based brief therapy for patients who have recently attempted suicide, administered in addition to the usual clinical treatment, was efficacious in reducing suicidal behavior in a real-world clinical setting. ASSIP fulfills the need for an easy-to-administer low-cost intervention. Large pragmatic trials will be needed to conclusively establish the efficacy of ASSIP and replicate our findings in other clinical settings.
Trial registration
ClinicalTrials.gov NCT02505373
In a randomized controlled trial, Konrad Michel and colleagues test the efficacy of a manual-based therapy intended to prevent repeat suicide attempts.
Editors' Summary
Background
Suicide is a serious public health problem. Over 800,000 people worldwide die by suicide every year. In the US, one suicide death occurs approximately every 12 minutes. While the causes of suicide are complex, the goals of suicide prevention are simple—reduce factors that increase risk, and increase factors that promote resilience or coping. Factors that increase suicide risk include family history of suicide, family history of child abuse, previous suicide attempts, history of mental disorders (particularly depression), history of alcohol and substance abuse, and access to lethal means. Factors that are protective against suicide include effective clinical care for mental, physical, and substance abuse disorders; connectedness to family and community; and problem solving and conflict resolution skills. A previous suicide attempt is the main risk factor for repeat attempts and for completed suicide. Fifteen to 25 percent of people who attempt suicide make another attempt, and five to ten percent eventually die by suicide.
Why Was This Study Done?
A number of suicide prevention treatments have been developed. Most of them involve therapy sessions and personal follow-up. While some of them have been shown to work in clinical trials—often with participants who have made a previous suicide attempt—few interventions have proven to be effective consistently in different settings. For this study, the researchers developed a treatment called Attempted Suicide Short Intervention Program (ASSIP) composed of three therapy sessions shortly after the suicide attempt and follow-up over two years with personalized mailed letters. They wanted the therapy part to be short, in order to provide a treatment that would allow a psychiatric service to cope with the large number of patients seen in the emergency department after a suicide attempt. The therapeutic elements of the treatment emphasized building an early therapeutic alliance, which would then serve as a basis (“anchoring”) for long-term outreach contact through regular letters. The therapy sessions and letters follow a detailed script, which the researchers developed into a manual that includes a step-by-step description of the highly structured treatment, checklists, handouts, and standardized letters for use by health professionals in various clinical settings. This study was done to test whether ASSIP can reduce suicidal behavior in addition to routine treatment.
What Did the Researchers Do and Find?
The researchers carried out a randomized clinical trial testing ASSIP in people who had attempted suicide (the majority by intentional overdosing) and been admitted to the emergency department of the Bern University General Hospital in Switzerland. Participants were randomly assigned to two groups. The treatment group received ASSIP in addition to treatment as usual (inpatient, day patient, and outpatient care as deemed appropriate by the hospital clinicians); the control group received a single structured assessment interview plus treatment as usual. The study objective was to evaluate—with follow-up questionnaires and health-care data—whether ASSIP can reduce the rate of repeated suicide attempt in the 24 months after a suicide attempt. The researchers also compared suicidal ideation (i.e., whether and how often participants had suicidal thoughts), levels of depression, and how often people were hospitalized between the two groups.
A total of 120 patients who had recently attempted suicide were randomly allocated to treatment as usual or treatment as usual plus ASSIP. The 60 ASSIP participants received three therapy sessions followed by regular contact over 24 months. During the first therapy session, the patient was prompted to tell the story of how he or she had reached the point of attempting suicide. Narrative interviewing is a key element of ASSIP’s patient-centered collaborative approach. The first session was videotaped, and parts were watched and discussed by patient and therapist during the second session, to recreate the experience of psychological pain and analyze how stress developed into suicidal action. During the final session, therapist and patient developed a list of long-term goals, warning signs, and safety strategies. These were printed and given to the patient in a credit-card-sized folded leaflet along with a list of telephone help numbers. Patients were told to carry both items at all times and to use them in the event of an emotional crisis. Over the subsequent two years, patients received six letters from their therapist reminding them of the risk of future suicidal crises and the importance of the collaboratively developed safety strategies.
During the 24 months of follow-up, one death by suicide occurred in each group, five repeat suicide attempts were recorded in the ASSIP group, and 41 repeat suicide attempts were recorded in the control group. ASSIP was associated with an approximately 80% reduced risk of repeat suicide attempt. In addition, ASSIP participants spent 72% fewer days in the hospital during follow-up. There was no difference in patient-reported suicidal ideation or in levels of depression.
What Do these Findings Mean?
The results show that ASSIP, administered in addition to the usual clinical treatment, was able to reduce suicidal behavior over 24 months in patients who had recently attempted suicide. The addition of ASSIP to usual treatment directly or its effect on repeat attempts might also reduce health care costs. The absence of effects on suicidal thoughts and depression is consistent with ASSIP’s objective to help people cope with crises as opposed to eliminating them. The study’s findings in a real-world clinical setting (a university hospital in the Swiss capital) are promising. They justify further testing in large clinical trials and diverse settings to answer conclusively whether and where ASSIP can reduce repeat suicide attempts, prevent deaths from suicide, and reduce health-care costs.
Additional Information
This list of resources contains links that can be accessed when viewing the PDF on a device or via the online version of the article at http://dx.doi.org/10.1371/journal.pmed.1001968.
National Action Alliance for Suicide Prevention has information on research prioritization for suicide prevention
There is also a supplemental issue of the American Journal of Preventive Medicine focused on research about suicide prevention
More information about suicide is available from ZEROSuicide http://zerosuicide.sprc.org/ and the Suicide Prevention Resource Center http://www.sprc.org/
The US Centers for Disease Control and Prevention has information on suicide
The UK Mental Health Foundation also has information on suicide
The page “About Suicide” from the American Foundation for Suicide Prevention has information on warning signs, risk factors, and statistics
The US National Suicide Prevention Lifeline offers help and information
The Bern University Hospital of Psychiatry has a page describing ASSIP for patients (in German)
The Finnish Association for Mental Health has a page describing ASSIP (in English)
doi:10.1371/journal.pmed.1001968
PMCID: PMC4773217  PMID: 26930055
5.  Observational study of suspected maltreatment in Italian paediatric emergency departments 
Archives of Disease in Childhood  2005;90(4):406-410.
Aims: To evaluate how often children seen in paediatric accident & emergency (A&E) departments were suspected of abuse or neglect, and to explore some of the correlates of suspected child maltreatment.
Methods: Multicentre, cross-sectional study of 15 randomised census days during a six month period. Trained research assistants working with local paediatric staff completed a purpose made anonymised checklist covering sociodemographic and medical information. A six point suspicion index was used to rate compatibility with child maltreatment based on the occurrence of observable harm. Statistical analysis was carried out on the basis that a score of 4 or more was suspicious of child maltreatment. Nineteen hospitals provided standardised paediatric A&E consultation data on 0–14 year olds presenting between 10 am and 10 pm.
Results: Of 10 175 assessed children, 204 aroused suspicion of child maltreatment (95% CI 163 to 214 per 10 000). In a logistic regression model of suspected maltreatment statistically significant associations were found with socioeconomic disadvantage, children living in single parent families, and developmental delay. There was no correlation with pre-school age, male gender, foreign origin, or living in urban areas.
Conclusions: Child maltreatment based on immediate scoring of suspicion, focused on observable harm, occurred in 2% of a representative sample of paediatric emergency consultations in Italy. This was more common if there were associated social and developmental vulnerabilities. True prevalence of child maltreatment in emergency departments remains elusive because of changing definitions and forensic validation problems.
doi:10.1136/adc.2003.040790
PMCID: PMC1720360  PMID: 15781934
6.  Internet-Based Device-Assisted Remote Monitoring of Cardiovascular Implantable Electronic Devices 
Executive Summary
Objective
The objective of this Medical Advisory Secretariat (MAS) report was to conduct a systematic review of the available published evidence on the safety, effectiveness, and cost-effectiveness of Internet-based device-assisted remote monitoring systems (RMSs) for therapeutic cardiac implantable electronic devices (CIEDs) such as pacemakers (PMs), implantable cardioverter-defibrillators (ICDs), and cardiac resynchronization therapy (CRT) devices. The MAS evidence-based review was performed to support public financing decisions.
Clinical Need: Condition and Target Population
Sudden cardiac death (SCD) is a major cause of fatalities in developed countries. In the United States almost half a million people die of SCD annually, resulting in more deaths than stroke, lung cancer, breast cancer, and AIDS combined. In Canada each year more than 40,000 people die from a cardiovascular related cause; approximately half of these deaths are attributable to SCD.
Most cases of SCD occur in the general population typically in those without a known history of heart disease. Most SCDs are caused by cardiac arrhythmia, an abnormal heart rhythm caused by malfunctions of the heart’s electrical system. Up to half of patients with significant heart failure (HF) also have advanced conduction abnormalities.
Cardiac arrhythmias are managed by a variety of drugs, ablative procedures, and therapeutic CIEDs. The range of CIEDs includes pacemakers (PMs), implantable cardioverter-defibrillators (ICDs), and cardiac resynchronization therapy (CRT) devices. Bradycardia is the main indication for PMs and individuals at high risk for SCD are often treated by ICDs.
Heart failure (HF) is also a significant health problem and is the most frequent cause of hospitalization in those over 65 years of age. Patients with moderate to severe HF may also have cardiac arrhythmias, although the cause may be related more to heart pump or haemodynamic failure. The presence of HF, however, increases the risk of SCD five-fold, regardless of aetiology. Patients with HF who remain highly symptomatic despite optimal drug therapy are sometimes also treated with CRT devices.
With an increasing prevalence of age-related conditions such as chronic HF and the expanding indications for ICD therapy, the rate of ICD placement has been dramatically increasing. The appropriate indications for ICD placement, as well as the rate of ICD placement, are increasingly an issue. In the United States, after the introduction of expanded coverage of ICDs, a national ICD registry was created in 2005 to track these devices. A recent survey based on this national ICD registry reported that 22.5% (25,145) of patients had received a non-evidence based ICD and that these patients experienced significantly higher in-hospital mortality and post-procedural complications.
In addition to the increased ICD device placement and the upfront device costs, there is the need for lifelong follow-up or surveillance, placing a significant burden on patients and device clinics. In 2007, over 1.6 million CIEDs were implanted in Europe and the United States, which translates to over 5.5 million patient encounters per year if the recommended follow-up practices are considered. A safe and effective RMS could potentially improve the efficiency of long-term follow-up of patients and their CIEDs.
Technology
In addition to being therapeutic devices, CIEDs have extensive diagnostic abilities. All CIEDs can be interrogated and reprogrammed during an in-clinic visit using an inductive programming wand. Remote monitoring would allow patients to transmit information recorded in their devices from the comfort of their own homes. Currently most ICD devices also have the potential to be remotely monitored. Remote monitoring (RM) can be used to check system integrity, to alert on arrhythmic episodes, and to potentially replace in-clinic follow-ups and manage disease remotely. They do not currently have the capability of being reprogrammed remotely, although this feature is being tested in pilot settings.
Every RMS is specifically designed by a manufacturer for their cardiac implant devices. For Internet-based device-assisted RMSs, this customization includes details such as web application, multiplatform sensors, custom algorithms, programming information, and types and methods of alerting patients and/or physicians. The addition of peripherals for monitoring weight and pressure or communicating with patients through the onsite communicators also varies by manufacturer. Internet-based device-assisted RMSs for CIEDs are intended to function as a surveillance system rather than an emergency system.
Health care providers therefore need to learn each application, and as more than one application may be used at one site, multiple applications may need to be reviewed for alarms. All RMSs deliver system integrity alerting; however, some systems seem to be better geared to fast arrhythmic alerting, whereas other systems appear to be more intended for remote follow-up or supplemental remote disease management. The different RMSs may therefore have different impacts on workflow organization because of their varying frequency of interrogation and methods of alerts. The integration of these proprietary RM web-based registry systems with hospital-based electronic health record systems has so far not been commonly implemented.
Currently there are 2 general types of RMSs: those that transmit device diagnostic information automatically and without patient assistance to secure Internet-based registry systems, and those that require patient assistance to transmit information. Both systems employ the use of preprogrammed alerts that are either transmitted automatically or at regular scheduled intervals to patients and/or physicians.
The current web applications, programming, and registry systems differ greatly between the manufacturers of transmitting cardiac devices. In Canada there are currently 4 manufacturers—Medtronic Inc., Biotronik, Boston Scientific Corp., and St Jude Medical Inc.—which have regulatory approval for remote transmitting CIEDs. Remote monitoring systems are proprietary to the manufacturer of the implant device. An RMS for one device will not work with another device, and the RMS may not work with all versions of the manufacturer’s devices.
All Internet-based device-assisted RMSs have common components. The implanted device is equipped with a micro-antenna that communicates with a small external device (at bedside or wearable) commonly known as the transmitter. Transmitters are able to interrogate programmed parameters and diagnostic data stored in the patients’ implant device. The information transfer to the communicator can occur at preset time intervals with the participation of the patient (waving a wand over the device) or it can be sent automatically (wirelessly) without their participation. The encrypted data are then uploaded to an Internet-based database on a secure central server. The data processing facilities at the central database, depending on the clinical urgency, can trigger an alert for the physician(s) that can be sent via email, fax, text message, or phone. The details are also posted on the secure website for viewing by the physician (or their delegate) at their convenience.
Research Questions
The research directions and specific research questions for this evidence review were as follows:
To identify the Internet-based device-assisted RMSs available for follow-up of patients with therapeutic CIEDs such as PMs, ICDs, and CRT devices.
To identify the potential risks, operational issues, or organizational issues related to Internet-based device-assisted RM for CIEDs.
To evaluate the safety, acceptability, and effectiveness of Internet-based device-assisted RMSs for CIEDs such as PMs, ICDs, and CRT devices.
To evaluate the safety, effectiveness, and cost-effectiveness of Internet-based device-assisted RMSs for CIEDs compared to usual outpatient in-office monitoring strategies.
To evaluate the resource implications or budget impact of RMSs for CIEDs in Ontario, Canada.
Research Methods
Literature Search
The review included a systematic review of published scientific literature and consultations with experts and manufacturers of all 4 approved RMSs for CIEDs in Canada. Information on CIED cardiac implant clinics was also obtained from Provincial Programs, a division within the Ministry of Health and Long-Term Care with a mandate for cardiac implant specialty care. Various administrative databases and registries were used to outline the current clinical follow-up burden of CIEDs in Ontario. The provincial population-based ICD database developed and maintained by the Institute for Clinical Evaluative Sciences (ICES) was used to review the current follow-up practices with Ontario patients implanted with ICD devices.
Search Strategy
A literature search was performed on September 21, 2010 using OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, the Cumulative Index to Nursing & Allied Health Literature (CINAHL), the Cochrane Library, and the International Agency for Health Technology Assessment (INAHTA) for studies published from 1950 to September 2010. Search alerts were generated and reviewed for additional relevant literature until December 31, 2010. Abstracts were reviewed by a single reviewer and, for those studies meeting the eligibility criteria full-text articles were obtained. Reference lists were also examined for any additional relevant studies not identified through the search.
Inclusion Criteria
published between 1950 and September 2010;
English language full-reports and human studies;
original reports including clinical evaluations of Internet-based device-assisted RMSs for CIEDs in clinical settings;
reports including standardized measurements on outcome events such as technical success, safety, effectiveness, cost, measures of health care utilization, morbidity, mortality, quality of life or patient satisfaction;
randomized controlled trials (RCTs), systematic reviews and meta-analyses, cohort and controlled clinical studies.
Exclusion Criteria
non-systematic reviews, letters, comments and editorials;
reports not involving standardized outcome events;
clinical reports not involving Internet-based device assisted RM systems for CIEDs in clinical settings;
reports involving studies testing or validating algorithms without RM;
studies with small samples (<10 subjects).
Outcomes of Interest
The outcomes of interest included: technical outcomes, emergency department visits, complications, major adverse events, symptoms, hospital admissions, clinic visits (scheduled and/or unscheduled), survival, morbidity (disease progression, stroke, etc.), patient satisfaction, and quality of life.
Summary of Findings
The MAS evidence review was performed to review available evidence on Internet-based device-assisted RMSs for CIEDs published until September 2010. The search identified 6 systematic reviews, 7 randomized controlled trials, and 19 reports for 16 cohort studies—3 of these being registry-based and 4 being multi-centered. The evidence is summarized in the 3 sections that follow.
1. Effectiveness of Remote Monitoring Systems of CIEDs for Cardiac Arrhythmia and Device Functioning
In total, 15 reports on 13 cohort studies involving investigations with 4 different RMSs for CIEDs in cardiology implant clinic groups were identified in the review. The 4 RMSs were: Care Link Network® (Medtronic Inc,, Minneapolis, MN, USA); Home Monitoring® (Biotronic, Berlin, Germany); House Call 11® (St Jude Medical Inc., St Pauls, MN, USA); and a manufacturer-independent RMS. Eight of these reports were with the Home Monitoring® RMS (12,949 patients), 3 were with the Care Link® RMS (167 patients), 1 was with the House Call 11® RMS (124 patients), and 1 was with a manufacturer-independent RMS (44 patients). All of the studies, except for 2 in the United States, (1 with Home Monitoring® and 1 with House Call 11®), were performed in European countries.
The RMSs in the studies were evaluated with different cardiac implant device populations: ICDs only (6 studies), ICD and CRT devices (3 studies), PM and ICD and CRT devices (4 studies), and PMs only (2 studies). The patient populations were predominately male (range, 52%–87%) in all studies, with mean ages ranging from 58 to 76 years. One study population was unique in that RMSs were evaluated for ICDs implanted solely for primary prevention in young patients (mean age, 44 years) with Brugada syndrome, which carries an inherited increased genetic risk for sudden heart attack in young adults.
Most of the cohort studies reported on the feasibility of RMSs in clinical settings with limited follow-up. In the short follow-up periods of the studies, the majority of the events were related to detection of medical events rather than system configuration or device abnormalities. The results of the studies are summarized below:
The interrogation of devices on the web platform, both for continuous and scheduled transmissions, was significantly quicker with remote follow-up, both for nurses and physicians.
In a case-control study focusing on a Brugada population–based registry with patients followed-up remotely, there were significantly fewer outpatient visits and greater detection of inappropriate shocks. One death occurred in the control group not followed remotely and post-mortem analysis indicated early signs of lead failure prior to the event.
Two studies examined the role of RMSs in following ICD leads under regulatory advisory in a European clinical setting and noted:
– Fewer inappropriate shocks were administered in the RM group.
– Urgent in-office interrogations and surgical revisions were performed within 12 days of remote alerts.
– No signs of lead fracture were detected at in-office follow-up; all were detected at remote follow-up.
Only 1 study reported evaluating quality of life in patients followed up remotely at 3 and 6 months; no values were reported.
Patient satisfaction was evaluated in 5 cohort studies, all in short term follow-up: 1 for the Home Monitoring® RMS, 3 for the Care Link® RMS, and 1 for the House Call 11® RMS.
– Patients reported receiving a sense of security from the transmitter, a good relationship with nurses and physicians, positive implications for their health, and satisfaction with RM and organization of services.
– Although patients reported that the system was easy to implement and required less than 10 minutes to transmit information, a variable proportion of patients (range, 9% 39%) reported that they needed the assistance of a caregiver for their transmission.
– The majority of patients would recommend RM to other ICD patients.
– Patients with hearing or other physical or mental conditions hindering the use of the system were excluded from studies, but the frequency of this was not reported.
Physician satisfaction was evaluated in 3 studies, all with the Care Link® RMS:
– Physicians reported an ease of use and high satisfaction with a generally short-term use of the RMS.
– Physicians reported being able to address the problems in unscheduled patient transmissions or physician initiated transmissions remotely, and were able to handle the majority of the troubleshooting calls remotely.
– Both nurses and physicians reported a high level of satisfaction with the web registry system.
2. Effectiveness of Remote Monitoring Systems in Heart Failure Patients for Cardiac Arrhythmia and Heart Failure Episodes
Remote follow-up of HF patients implanted with ICD or CRT devices, generally managed in specialized HF clinics, was evaluated in 3 cohort studies: 1 involved the Home Monitoring® RMS and 2 involved the Care Link® RMS. In these RMSs, in addition to the standard diagnostic features, the cardiac devices continuously assess other variables such as patient activity, mean heart rate, and heart rate variability. Intra-thoracic impedance, a proxy measure for lung fluid overload, was also measured in the Care Link® studies. The overall diagnostic performance of these measures cannot be evaluated, as the information was not reported for patients who did not experience intra-thoracic impedance threshold crossings or did not undergo interventions. The trial results involved descriptive information on transmissions and alerts in patients experiencing high morbidity and hospitalization in the short study periods.
3. Comparative Effectiveness of Remote Monitoring Systems for CIEDs
Seven RCTs were identified evaluating RMSs for CIEDs: 2 were for PMs (1276 patients) and 5 were for ICD/CRT devices (3733 patients). Studies performed in the clinical setting in the United States involved both the Care Link® RMS and the Home Monitoring® RMS, whereas all studies performed in European countries involved only the Home Monitoring® RMS.
3A. Randomized Controlled Trials of Remote Monitoring Systems for Pacemakers
Two trials, both multicenter RCTs, were conducted in different countries with different RMSs and study objectives. The PREFER trial was a large trial (897 patients) performed in the United States examining the ability of Care Link®, an Internet-based remote PM interrogation system, to detect clinically actionable events (CAEs) sooner than the current in-office follow-up supplemented with transtelephonic monitoring transmissions, a limited form of remote device interrogation. The trial results are summarized below:
In the 375-day mean follow-up, 382 patients were identified with at least 1 CAE—111 patients in the control arm and 271 in the remote arm.
The event rate detected per patient for every type of CAE, except for loss of atrial capture, was higher in the remote arm than the control arm.
The median time to first detection of CAEs (4.9 vs. 6.3 months) was significantly shorter in the RMS group compared to the control group (P < 0.0001).
Additionally, only 2% (3/190) of the CAEs in the control arm were detected during a transtelephonic monitoring transmission (the rest were detected at in-office follow-ups), whereas 66% (446/676) of the CAEs were detected during remote interrogation.
The second study, the OEDIPE trial, was a smaller trial (379 patients) performed in France evaluating the ability of the Home Monitoring® RMS to shorten PM post-operative hospitalization while preserving the safety of conventional management of longer hospital stays.
Implementation and operationalization of the RMS was reported to be successful in 91% (346/379) of the patients and represented 8144 transmissions.
In the RM group 6.5% of patients failed to send messages (10 due to improper use of the transmitter, 2 with unmanageable stress). Of the 172 patients transmitting, 108 patients sent a total of 167 warnings during the trial, with a greater proportion of warnings being attributed to medical rather than technical causes.
Forty percent had no warning message transmission and among these, 6 patients experienced a major adverse event and 1 patient experienced a non-major adverse event. Of the 6 patients having a major adverse event, 5 contacted their physician.
The mean medical reaction time was faster in the RM group (6.5 ± 7.6 days vs. 11.4 ± 11.6 days).
The mean duration of hospitalization was significantly shorter (P < 0.001) for the RM group than the control group (3.2 ± 3.2 days vs. 4.8 ± 3.7 days).
Quality of life estimates by the SF-36 questionnaire were similar for the 2 groups at 1-month follow-up.
3B. Randomized Controlled Trials Evaluating Remote Monitoring Systems for ICD or CRT Devices
The 5 studies evaluating the impact of RMSs with ICD/CRT devices were conducted in the United States and in European countries and involved 2 RMSs—Care Link® and Home Monitoring ®. The objectives of the trials varied and 3 of the trials were smaller pilot investigations.
The first of the smaller studies (151 patients) evaluated patient satisfaction, achievement of patient outcomes, and the cost-effectiveness of the Care Link® RMS compared to quarterly in-office device interrogations with 1-year follow-up.
Individual outcomes such as hospitalizations, emergency department visits, and unscheduled clinic visits were not significantly different between the study groups.
Except for a significantly higher detection of atrial fibrillation in the RM group, data on ICD detection and therapy were similar in the study groups.
Health-related quality of life evaluated by the EuroQoL at 6-month or 12-month follow-up was not different between study groups.
Patients were more satisfied with their ICD care in the clinic follow-up group than in the remote follow-up group at 6-month follow-up, but were equally satisfied at 12- month follow-up.
The second small pilot trial (20 patients) examined the impact of RM follow-up with the House Call 11® system on work schedules and cost savings in patients randomized to 2 study arms varying in the degree of remote follow-up.
The total time including device interrogation, transmission time, data analysis, and physician time required was significantly shorter for the RM follow-up group.
The in-clinic waiting time was eliminated for patients in the RM follow-up group.
The physician talk time was significantly reduced in the RM follow-up group (P < 0.05).
The time for the actual device interrogation did not differ in the study groups.
The third small trial (115 patients) examined the impact of RM with the Home Monitoring® system compared to scheduled trimonthly in-clinic visits on the number of unplanned visits, total costs, health-related quality of life (SF-36), and overall mortality.
There was a 63.2% reduction in in-office visits in the RM group.
Hospitalizations or overall mortality (values not stated) were not significantly different between the study groups.
Patient-induced visits were higher in the RM group than the in-clinic follow-up group.
The TRUST Trial
The TRUST trial was a large multicenter RCT conducted at 102 centers in the United States involving the Home Monitoring® RMS for ICD devices for 1450 patients. The primary objectives of the trial were to determine if remote follow-up could be safely substituted for in-office clinic follow-up (3 in-office visits replaced) and still enable earlier physician detection of clinically actionable events.
Adherence to the protocol follow-up schedule was significantly higher in the RM group than the in-office follow-up group (93.5% vs. 88.7%, P < 0.001).
Actionability of trimonthly scheduled checks was low (6.6%) in both study groups. Overall, actionable causes were reprogramming (76.2%), medication changes (24.8%), and lead/system revisions (4%), and these were not different between the 2 study groups.
The overall mean number of in-clinic and hospital visits was significantly lower in the RM group than the in-office follow-up group (2.1 per patient-year vs. 3.8 per patient-year, P < 0.001), representing a 45% visit reduction at 12 months.
The median time from onset of first arrhythmia to physician evaluation was significantly shorter (P < 0.001) in the RM group than in the in-office follow-up group for all arrhythmias (1 day vs. 35.5 days).
The median time to detect clinically asymptomatic arrhythmia events—atrial fibrillation (AF), ventricular fibrillation (VF), ventricular tachycardia (VT), and supra-ventricular tachycardia (SVT)—was also significantly shorter (P < 0.001) in the RM group compared to the in-office follow-up group (1 day vs. 41.5 days) and was significantly quicker for each of the clinical arrhythmia events—AF (5.5 days vs. 40 days), VT (1 day vs. 28 days), VF (1 day vs. 36 days), and SVT (2 days vs. 39 days).
System-related problems occurred infrequently in both groups—in 1.5% of patients (14/908) in the RM group and in 0.7% of patients (3/432) in the in-office follow-up group.
The overall adverse event rate over 12 months was not significantly different between the 2 groups and individual adverse events were also not significantly different between the RM group and the in-office follow-up group: death (3.4% vs. 4.9%), stroke (0.3% vs. 1.2%), and surgical intervention (6.6% vs. 4.9%), respectively.
The 12-month cumulative survival was 96.4% (95% confidence interval [CI], 95.5%–97.6%) in the RM group and 94.2% (95% confidence interval [CI], 91.8%–96.6%) in the in-office follow-up group, and was not significantly different between the 2 groups (P = 0.174).
The CONNECT Trial
The CONNECT trial, another major multicenter RCT, involved the Care Link® RMS for ICD/CRT devices in a15-month follow-up study of 1,997 patients at 133 sites in the United States. The primary objective of the trial was to determine whether automatically transmitted physician alerts decreased the time from the occurrence of clinically relevant events to medical decisions. The trial results are summarized below:
Of the 575 clinical alerts sent in the study, 246 did not trigger an automatic physician alert. Transmission failures were related to technical issues such as the alert not being programmed or not being reset, and/or a variety of patient factors such as not being at home and the monitor not being plugged in or set up.
The overall mean time from the clinically relevant event to the clinical decision was significantly shorter (P < 0.001) by 17.4 days in the remote follow-up group (4.6 days for 172 patients) than the in-office follow-up group (22 days for 145 patients).
– The median time to a clinical decision was shorter in the remote follow-up group than in the in-office follow-up group for an AT/AF burden greater than or equal to 12 hours (3 days vs. 24 days) and a fast VF rate greater than or equal to 120 beats per minute (4 days vs. 23 days).
Although infrequent, similar low numbers of events involving low battery and VF detection/therapy turned off were noted in both groups. More alerts, however, were noted for out-of-range lead impedance in the RM group (18 vs. 6 patients), and the time to detect these critical events was significantly shorter in the RM group (same day vs. 17 days).
Total in-office clinic visits were reduced by 38% from 6.27 visits per patient-year in the in-office follow-up group to 3.29 visits per patient-year in the remote follow-up group.
Health care utilization visits (N = 6,227) that included cardiovascular-related hospitalization, emergency department visits, and unscheduled clinic visits were not significantly higher in the remote follow-up group.
The overall mean length of hospitalization was significantly shorter (P = 0.002) for those in the remote follow-up group (3.3 days vs. 4.0 days) and was shorter both for patients with ICD (3.0 days vs. 3.6 days) and CRT (3.8 days vs. 4.7 days) implants.
The mortality rate between the study arms was not significantly different between the follow-up groups for the ICDs (P = 0.31) or the CRT devices with defribillator (P = 0.46).
Conclusions
There is limited clinical trial information on the effectiveness of RMSs for PMs. However, for RMSs for ICD devices, multiple cohort studies and 2 large multicenter RCTs demonstrated feasibility and significant reductions in in-office clinic follow-ups with RMSs in the first year post implantation. The detection rates of clinically significant events (and asymptomatic events) were higher, and the time to a clinical decision for these events was significantly shorter, in the remote follow-up groups than in the in-office follow-up groups. The earlier detection of clinical events in the remote follow-up groups, however, was not associated with lower morbidity or mortality rates in the 1-year follow-up. The substitution of almost all the first year in-office clinic follow-ups with RM was also not associated with an increased health care utilization such as emergency department visits or hospitalizations.
The follow-up in the trials was generally short-term, up to 1 year, and was a more limited assessment of potential longer term device/lead integrity complications or issues. None of the studies compared the different RMSs, particularly the different RMSs involving patient-scheduled transmissions or automatic transmissions. Patients’ acceptance of and satisfaction with RM were reported to be high, but the impact of RM on patients’ health-related quality of life, particularly the psychological aspects, was not evaluated thoroughly. Patients who are not technologically competent, having hearing or other physical/mental impairments, were identified as potentially disadvantaged with remote surveillance. Cohort studies consistently identified subgroups of patients who preferred in-office follow-up. The evaluation of costs and workflow impact to the health care system were evaluated in European or American clinical settings, and only in a limited way.
Internet-based device-assisted RMSs involve a new approach to monitoring patients, their disease progression, and their CIEDs. Remote monitoring also has the potential to improve the current postmarket surveillance systems of evolving CIEDs and their ongoing hardware and software modifications. At this point, however, there is insufficient information to evaluate the overall impact to the health care system, although the time saving and convenience to patients and physicians associated with a substitution of in-office follow-up by RM is more certain. The broader issues surrounding infrastructure, impacts on existing clinical care systems, and regulatory concerns need to be considered for the implementation of Internet-based RMSs in jurisdictions involving different clinical practices.
PMCID: PMC3377571  PMID: 23074419
7.  Detection of the awareness rate of abuse in pediatric patients admitted to emergency medicine department with injury 
Objective
It was aimed to investigate whether neglected and abused pediatric patients are properly recognized and reported by emergency physicians in the emergency department (ED).
Methods
This prospective study was conducted on patients between 0 and 6 years of age presenting with trauma to ED. Patients were examined again by an emergency medicine specialist independent from the physician who did the first intervention during clinical follow-up phase after notification of patients presenting with trauma to emergency physician. Asked radiological examinations and clinical follow-up were performed. The suspected abuse evaluation form, consisting 12 items, which was formed by considering the forms used in previous studies was used to examine the awareness of physicians in cases of abuse suspicion.
Results
A total of 126 patients were included in our study. 54% of cases (n = 68) were male and mean age was determined to be 31.3 ± 18.9 months. It was found that no judicial records were written to 35.7% (n = 45) of our patients and that 11.1% (n = 5) of these patients were hospitalized. In 51.1% (n = 23) of patients without judicial records, multiple suspected abuse findings were identified. According to evaluation of first physician, it was found that 75.9% (n = 41) of discharged patients had no judicial records and was not considered as neglect and abuse.
Conclusion
We conclude that detection rates of abuse can be increased by developing child abuse screening forms and ensuring the continuity of the necessary training programs.
doi:10.1016/j.tjem.2016.06.001
PMCID: PMC5103051  PMID: 27857986
Neglect; Abuse; Pediatric
8.  4th Pediatric Allergy and Asthma Meeting (PAAM) 
Yavuz, S. Tolga | Koc, Ozan | Gungor, Ali | Gok, Faysal | Hawley, Jessica | O’Brien, Christopher | Thomas, Matthew | Brodlie, Malcolm | Michaelis, Louise | Mota, Inês | Gaspar, Ângela | Piedade, Susana | Sampaio, Graça | Dias, José Geraldo | Paiva, Miguel | Morais-Almeida, Mário | Madureira, Cristina | Lopes, Tânia | Lopes, Susana | Almeida, Filipa | Sequeira, Alexandra | Carvalho, Fernanda | Oliveira, José | Gay-Crosier, Fabienne | Nenciu, Ioana-Valentina | Nita, Andreia Florina | Ulmeanu, Alexandru | Oraseanu, Dumitru | Zapucioiu, Carmen | Machinena, Adrianna | Sánchez, Olga Domínguez | Lozano, Montserrat Alvaro | Feijoo, Rosa Jiménez | Blasco, Jaime Lozano | Gibert, Mònica Piquer | Muñoz, Mª Teresa Giner | da Costa, Marcia Dias | Martín, Ana Maria Plaza | Yilmaz, Ebru Arik | Cavkaytar, Özlem | Buyuktiryaki, Betul | Soyer, Ozge | Sackesen, Cansin | Netting, Merryn | El-Merhibi, Adaweyah | Gold, Michael | Quinn, Patrick | Penttila, Irmeli | Makrides, Maria | Giavi, Stavroula | Muraro, Antonella | Lauener, Roger | Mercenier, Annick | Bersuch, Eugen | Montagner, Isabella M. | Passioti, Maria | Celegato, Nicolò | Summermatter, Selina | Nutten, Sophie | Bourdeau, Tristan | Vissers, Yvonne M. | Papadopoulos, Nikolaos G. | van der Kleij, Hanneke | Warmenhoven, Hans | van Ree, Ronald | Pieters, Raymond | Opstelten, Dirk Jan | van Schijndel, Hans | Smit, Joost | Fitzsimons, Roisin | Timms, Victoria | Du Toit, George | Kaya, Guven | Gulec, Mustafa | Saldir, Mehmet | Sener, Osman | Hassan, Nagwa | Shaaban, Hala | El-Hariri, Hazem | Mahfouz, Ahmed Kamel Inas E. | Gabor, Papp | Gabor, Biro | Csaba, Kovacs | Chawes, Bo | Bønnelykke, Klaus | Stokholm, Jakob | Heickendorff, Lene | Brix, Susanne | Rasmussen, Morten | Bisgaard, Hans | Hallas, Henrik Wegener | Arianto, Lambang | Pincus, Maike | Keil, Thomas | Reich, Andreas | Wahn, Ulrich | Lau, Susanne | Grabenhenrich, Linus | Fagerstedt, Sara | Hesla, Helena Marell | Johansson, Emelie | Rosenlund, Helen | Mie, Axel | Scheynius, Annika | Alm, Johan | Esparza-Gordillo, Jorge | Matanovic, Anja | Marenholz, Ingo | Bauerfeind, Anja | Rohde, Klaus | Nemat, Katja | Lee-Kirsch, Min-Ae | Nordenskjöld, Magnus | Winge, Marten C.G. | Krüger, Renate | Beyer, Kirsten | Kalb, Birgit | Niggemann, Bodo | Hübner, Norbert | Cordell, Heather J. | Bradley, Maria | Lee, Young-Ae | Gough, Hannah | Schramm, Dirk | Beschorner, John | Schuster, Antje | Bauer, Carl-Peter | Forster, Johannes | Zepp, Fred | Bergmann, Renate | Bergmann, Karl | Garcia, Filipe Benito | Santos, Natacha | Pité, Helena | Papadopoulou, Athina | Mermiri, Despina | Xatziagorou, Elpida | Tsanakas, Ioannis | Lampidi, Stavroula | Priftis, Kostas | Fuertes, Elaine | Markevych, Iana | Bowatte, Gayan | Gruzieva, Olena | Gehring, Ulrike | Becker, Allan | Berdel, Dietrich | Brauer, Michael | Carlsten, Chris | Hoffmann, Barbara | Kozyrskyj, Anita | Lodge, Caroline | Pershagen, Göran | Wijga, Alet | Joachim, Heinrich | Zivkovic, Zorica | Djuric-Filipovic, Ivana | Jocić-Stevanovic, Jasmina | Zivanovic, Snežana | Taka, Styliani | Kokkinou, Dimitra | Papakonstantinou, Aliki | Stefanopoulou, Panagiota | Georgountzou, Anastasia | Maggina, Paraskevi | Stamataki, Sofia | Papaevanggelou, Vassiliki | Andreakos, Evangelos | Gibert, Monica Piquer | Spera, Adriana Machinena | Deliu, Matea | Belgrave, Danielle | Simpson, Angela | Custovic, Adnan | Marques, João Gaspar | Carreiro-Martins, Pedro | Belo, Joana | Serranho, Sara | Peralta, Isabel | Neuparth, Nuno | Leiria-Pinto, Paula | Vazquez-Ortiz, Marta | Pascal, Mariona | Plaza, Ana Maria | Juan, Manel | Paparo, Lorella | Nocerino, Rita | Aitoro, Rosita | Langella, Ilaria | Amoroso, Antonio | Amoroso, Alessia | Di Scala, Carmen | Berni Canani, Roberto | Maity, Santanu | Rotiroti, Giuseppina | Gandhi, Minal | Jonsson, Karin | Ljung, Annika | Hesselmar, Bill | Adlerbert, Ingegerd | Brekke, Hilde | Johansen, Susanne | Wold, Agnes | Sandberg, Ann-Sofie | Nordlund, Björn | Lundholm, Cecilia | Ullemar, Villhelmina | van Hage, Marianne | Örtqvist, Anne | Almqvist, Catarina | Selby, Anna | Grimshaw, Kate | Clausen, Michael | Dubakiene, Ruta | Fiocchi, Alessandro | Kowalski, Marek | Papadopoulos, Nikos | Reche, Marta | Sigurdardottir, Sigurveig | Sprikkleman, Aline | Xepapadaki, Paraskevi | Mills, Clare | Roberts, Graham | Neto, Herberto Jose Chong | Wandalsen, Gustavo Falbo | Bianca, Ana Carolina Dela | Aranda, Carolina | Rosário, Nelson Augusto | Solé, Dirceu | Mallol, Javier | Marcos, Luis García | Banic, Ivana | Rijavec, Matija | Plavec, Davor | Korosec, Peter | Turkalj, Mirjana | Bozicevic, Alen | De Mieri, Maria | Hamburger, Matthias | Holley, Simone | Morris, Ruth | Mitchell, Frances | Knibb, Rebecca | Latter, Susan | Liossi, Christina | Hassan, Mostafa M. M. | Barman, Malin | Sandin, Anna | Posa, Daniela | Perna, Serena | Hoffmann, Ute | Chen, Kuan-Wei | Resch, Yvonne | Vrtala, Susanne | Valenta, Rudolf | Matricardi, Paolo Maria | Tsilochristou, Olympia | Rohrbach, Alexander | Cappella, Antonio | Hofmaier, Stephanie | Hatzler, Laura | D’Amelio, Raffaele | Björkander, Sophia | Johansson, Maria A. | Lasaviciute, Gintare | Sverremark-Ekström, Eva | Rüschendorf, Franz | Strachan, David P. | Spycher, Ben D. | Baurecht, Hansjörg | Margaritte-Jeannin, Patricia | Sääf, Annika | Kerkhof, Marjan | Ege, Markus | Baltic, Svetlana | Matheson, Melanie C. | Li, Jin | Michel, Sven | Ang, Wei Q. | McArdle, Wendy | Arnold, Andreas | Homuth, Georg | Demenais, Florence | Bouzigon, Emmanuelle | Söderhäll, Cilla | de Jongste, Johan C. | Postma, Dirkje S. | Braun-Fahrländer, Charlotte | Horak, Elisabeth | Ogorodova, Ludmila M. | Puzyrev, Valery P. | Bragina, Elena Yu | Hudson, Thomas J. | Morin, Charles | Duffy, David L. | Marks, Guy B. | Robertson, Colin F. | Montgomery, Grant W. | Musk, Bill | Thompson, Philip J. | Martin, Nicholas G. | James, Alan | Sleiman, Patrick | Toskala, Elina | Rodriguez, Elke | Fölster-Holst, Regina | Franke, Andre | Lieb, Wolfgang | Gieger, Christian | Heinzmann, Andrea | Rietschel, Ernst | Cichon, Sven | Nöthen, Markus M. | Pennell, Craig E. | Sly, Peter D. | Schmidt, Carsten O. | Schneider, Valentin | Heinig, Matthias | Holt, Patrick G. | Kabesch, Michael | Weidinger, Stefan | Hakonarson, Hakon | Ferreira, Manuel AR | Laprise, Catherine | Freidin, Maxim B | Genuneit, Jon | Koppelman, Gerard H | Melén, Erik | Dizier, Marie-Hélène | John Henderson, A. | Lee, Young Ae | González-Delgado, Purificacion | Caparrós, Esther | Clemente, Fernando | Cueva, Begoña | Moreno, Victoria M. | Carretero, Jose Luis | Fernández, Javier | Swan, Kate | Gopi, Mudiyur | Smith, Tim | Ramesh, Edara | Sadasivam, Arun | Arêde, Cristina | Borrego, Luís Miguel | Pires, Graça | Santa-Marta, Cristina | Brand, Stephanie | Stein, Karina | Heine, Holger | Kauth, Marion | Rolfsjord, Leif Bjarte | Bakkeheim, Egil | Skjerven, Håvard Ove | Carlsen, Kai-Håkon | Hunderi, Jon Olav | Berents, Teresa Løvold | Mowinckel, Petter | Lødrup Carlsen, Karin C. | Munzel, Ullrich | Berger, William | Valiente, Román | Vozmediano, Valvanera | Lukas, John C. | Rodríguez, Mónica | Guarnaccia, Sebastiano | Vitale, Luigi | Pluda, Ada | D’Agata, Emanuele | Colombo, Denise | Felici, Stefano | Gretter, Valeria | Facchetti, Susanna | Pecorelli, Gaia | Quecchia, Cristina | Guibas, George | Spandou, Evangelia | Megremis, Spyridon | West, Peter | Papadopoulos, Nikolaos | Rufo, João Cavaleiro | Madureira, Joana | Paciência, Inês | Aguiar, Lívia | Padrão, Patrícia | Pinto, Mariana | Delgado, Luís | Moreira, Pedro | Teixeira, João Paulo | Fernandes, Eduardo Oliveira | Moreira, André | Dominguez, Adriana Izquierdo | Valero, Antonio | Mullol, Joaquim | Del Cuvillo, Alfonso | Montoro, Javier | Jauregui, Ignacio | Bartra, Joan | Davila, Ignacio | Ferrer, Marta | Sastre, Joaquin | Martins, Catarina | Lima, Jorge | Leandro, Maria José | Nunes, Glória | Branco, Jorge Cunha | Trindade, Hélder | Borrego, Luis Miguel | Conkar, Secil | Kilic, Mehtap | Aygun, Canan | Sancak, Recep | Tagalaki, Eleni | Banos, Lambros | Vlachou, Anna | Giannoula, Fotini | Pavlakou, Marina | Kryoni, Maria | Makris, Kostas | Lazova, Snezhina | Petrova, Guergana | Miteva, Dimitrinka | Perenovska, Penka | Klyucharova, Aliya | Skorohodkina, Olesya | Koumaki, Dimitra | Manousaki, Alkisti | Agrapidi, Maria | Iatridou, Lida | Eruk, Omima | Myridakis, Konstantinos | Manousakis, Emmanouil | Koumaki, Vasiliki | Dimou, Maria | Ingemansson, Maria | Hedlin, Gunilla | Pastor, Nitida | de Boissieu, Delphine | Vanderhoof, Jon | Moore, Nancy | Maditz, Kaitlin | Mehdi, Adeli | Elhassan, Shaza | Beck, Carolin | Al-Hammadi, Ahmed | Maris, Ioana | O’Sullivan, Ronan | Hourihane, Jonathan | Raptis, George | DunnGalvin, Audrey | Greenhawt, Matthew | Venter, Carina | O’Regan, Evelyn | Cronin, Duncan | O’Reilly, Anna | Abdelaziz, Foued | Khelifi-Touhami, Dounia | Selim, Nihad | Khelifi-Touhami, Tahar | Merida, Pablo | Plaza, Ana Mª | Castellanos, Juan Heber | Lozano, Jaime | Dominguez, Olga | Piquer, Monica | Jimenez, Rosa | Giner, Mª Teresa | Kakleas, Konstantinos | Joishy, Manohar | Maskele, Wendmu | Jenkins, Huw R. | Escarrer, Mercedes | Madroñero, Agustín | Guerra, Maria Teresa | Julia, Juan Carlos | Cerda, Juan Carlos | Contreras, Javier | Tauler, Eulalia | Vidorreta, Maria Jesus | Rojo, Ana | Del Valle, Silvia | Flynn, Niamh | Foley, Gary | Harmon, Carol | Fitzsimons, John | Baynova, Krasimira | Del Robledo, Ávila Maria | Marina, Labella | Cortes, Aaron | Sciaraffia, Alicia | Castillo, Angela | Juel-Berg, Nanna | Hansen, Kirsten Skamstrup | Poulsen, Lars Kærgaard | Lazar, Adina | Aguiar, Rita | Lopes, Anabela | Paes, Maria J. | Santos, Amélia S. | Pereira-Barbosa, M. A. | Eke Gungor, Hatice | Uytun, Salih | Sahiner, Umit Murat | Altuner Torun, Yasemin | Zivanovic, Mirjana | Atanasković-Marković, Marina | Vesel, Tina | Nahtigal, Mihaela | Obermayer-Temlin, Andreja | Križnik, Eva Šoster | Maslar, Mirjana | Bizjak, Ruben | Tomšič-Matic, Marjeta | Posega-Devetak, Sonja | Skerbinjek-Kavalar, Maja | Predalič, Mateja | Avčin, Tadej | Pouessel, Guillaume | Beaudouin, Etienne | Moneret-Vautrin, Anne M. | Deschildre, Antoine | Viñas, Marta | Borja, Bartolomé | Hernández, Nora | Castillo, Mª José | Izquierdo, Adriana | Ibero, Marcel | Kocabas, Can Naci | Heming, Camille | Garrett, Emily | Blackstock, Adam | Chodhari, Rahul | Belohlavkova, Simona | Kopelentova, Eliska | Visek, Petr | Setinova, Ivana | Svarcova, Ivana | Sjölander, Sigrid | Nilsson, Nora | Berthold, Malin | Ekoff, Helena | Borres, Magnus | Nilsson, Caroline | González Domínguez, Loreto | Muñoz Archidona, Cristina | Moreira Jorge, Ana | Quevedo Teruel, Sergio | Bracamonte Bermejo, Teresa | Castillo Fernández, Miriam | Pineda de la Losa, Fernando | Echeverría Zudaire, Luis Ángel | Vrani, Olga | Mavroudi, Antigone | Fotoulaki, Maria | Emporiadou, Maria | Spiroglou, Kleomenis | Xinias, Ioannis | Sadreddini, Helyeh A. | Warnes, Mia | Traves, Donna | Kostić, Gordana | Filipovic, Đorđe | Sittisomwong, Sawapon | Sittisomwong, Siripong | Podolec, Zygmunt | Hartel, Marcin | Panek, Daria | Podolec-Rubiś, Magdalena | Banasik, Tomasz | Abbasi, Elham | Moghtaderi, Mozhgan | Sanneerappa, Phani | Deliu, Alina | Kutty, Moosa | Ramesh, Nagabathula | Sherkat, Roya | Sabri, Mohammad Reza | Dehghan, Bahar | Bigdelian, Hamid | Raeesi, Nahid | Afshar, Mino | Rahimi, Hamid | Klein, Christoph | Al-Jebouri, Mohemid | Svitich, Oxana A. | Zubacheva, Daria O. | Potemkin, Dmitrii A. | Gankovskaya, Ludmila V. | Zverev, Vitalii V. | OB Doyle, Elaine | Gallagher, Paul | Dewlett, Sherine | Man, Kin | Pocock, James | Gerrardhughes, Anna | Wasilewska, Jolanta | Kaczmarski, Maciej | Lebensztejn, Dariusz | Thuraisingham, Chandramani | Sinniah, Davendralingam | Chen, Yue | Mei, Xiaomei | Ozdogan, Sebnem | Karadeniz, Pinar | Ayyildiz-Emecen, Durdugul | Oncul, Ummuhan | Sari, Gizem | Cavdar, Sabanur | Farzan, Niloufar | Vijverberg, Susanne J. | Palmer, Colin J. | Tantisira, Kelan G. | Maitland-van der Zee, Anke-Hilse | Yavuzyilmaz, Fatma | Urganci, Nafiye | Usta, Merve | Hoxha, Mehmet | Basho, Maksim | Wandalsen, Gustavo F. | Monteiro, Fernanda | Lame, Blerta | Mesonjesi, Eris | Sherri, Arjeta | Ibranji, Alkerta | Gjati, Laert | Loloci, Gjustina | Bardhi, Ardii | Moghtaderi, Behnam | Farjadian, Shirin | Eghtedari, Dorna | Olaya, Manuela | Del Mar Vasquez, Laura | Ramirez, Luis Fernando | Serrano, Carlos Daniel | Usta Guc, Belgin | Asilsoy, Suna | Ozer, Fulya | Shopova, Sylvia | Papochieva, Vera | Loekmanwidjaja, Jessica | Mallozi, Márcia | Ratner, Paul | Soteres, Daniel | Novák, Zoltán | Yáñez, Anahí | Ildikó, Kiss | Kuna, Piotr | Tortajada, Miguel | Valiente, Román | Feuerhahn, Julia | Blome, Christine | Hadler, Meike | Karagiannis, Efstrathios | Langenbruch, Anna | Augustin, Matthias | Roux, Michel | Kakudo, Shinji | Zeldin, Robert K. | Sokolova, Anna | Silva, Tiago Milheiro | Zivanovic, Snezana S. | Cvetkovic, Vesna | Nikolic, Ivana | Zivanovic, Sonja J. | Saranac, Ljiljana | Nesterenko, Zoia | Radic, Snezana | Milenkovic, Branislava | Smiljanic, Spomenka | Micic-Stanijevic, Milka | Calovic, Olivera | Hofbauer, Anne Marie Bro | Agertoft, Lone | Everson, Lucy | Kearney, Jessica | Coppel, Jonny | Braithwaite, Simon | Christiansen, Elisabeth S. | Kjaer, Henrik Fomsgaard | Eller, Esben | Mørtz, Charlotte G. | Halken, Susanne | Román India, Cristina | Jiménez Jiménez, Juana | Echeverría Zudaire, Luis | O’Connor, Cathal | Kanti, Varvara | Lünnemann, Lena | Malise, Günther | Ludriksone, Laine | Stroux, Andrea | Henrich, Wolfgang | Abu-Dakn, Michael | Blume-Peytavi, Ulrike | Garcia Bartels, Natalie | Schario, Marianne | Stanley, Thorsten | Brandenbarg, Nicolien | Boardman, Alia | McGreevy, Gary | Rodger, Emily | Knight, Katherine | Taylor, Trisha | Scanlan, Gemma | Christoph, Grüber | van Stuivenberg, Margriet | Mosca, Fabio | Moro, Guido | Chirico, Gaetano | Braegger, Christian P. | Riedler, Joseph | Yavuz, Yalcin | Boehm, Günther | Arasi, Stefania | Crisafulli, Giuseppe | Caminiti, Lucia | Porcaro, Federica | Pajno, Giovanni Battista | Tanaka, Akane | Togawa, Yaei | Oida, Kumiko | Kambe, Naotomo | Arkwright, Peter | Amagai, Yosuke | Shimojo, Naoki | Sato, Yasunori | Mochizuki, Hiroyuki | Jang, Hyosun | Ishizaka, Saori | Matsuda, Hiroshi | Barlianto, Wisnu | Olivianto, Ery | Chandra Kusuma, H. M. S. | Mollica, Mariapia | Trinchese, Giovanna | Alfano, Elena | Amato, Francesco | Pirozzi, Claudio | Calignano, Antonio | Meli, Rosaria | Rossberg, Siri | Gerhold, Kerstin | Zimmermann, Kurt | Zaino, Mohammad | Geske, Thomas | Hamelmann, Eckard | Bogovic, Sarah | van den Berg, Jochem | Janssen, Chantal | Claver, Angela | Martin-Muñoz, Mª Flor | Martorell, C. | Belver, M. T. | Alonso Lebrero, E. | Zapatero, L. | Fuentes, V. | Piqué, M. | Plaza, A. | Muñoz, C. | Blasco, Cristina | Villa, B. | Gómez, C. | Nevot, S. | García, J. M. | Echeverria, L. | DeWitt, Brenda | Holloway, Judith | Hodge, Donald | Ludman, Sian | Jafari-Mamaghani, Merhdad | Ebling, Rosemary | Fox, Adam T. | Lack, Gideon | Lovén Björkman, Sofia | Ballardini, Natalia | Basu, Supriyo | Hallet, Jenny | Srinivas, Jyothi | Stringer, Hazel | Jay, Nicola | Fonseca, Paula | Vieira, Clara | Mastrorilli, Carla | Caffarelli, Carlo | Asero, Riccardo | Tripodi, Salvatore | Dondi, Arianna | Ricci, Gianpaolo | Povesi Dascola, Carlotta | Calamelli, Elisabetta | Cipriani, Francesca | Di Rienzo Businco, Andrea | Bianchi, Annamaria | Candelotti, Paolo | Frediani, Tullio | Verga, Carmen | Korovessi, Paraskevi | Tiliakou, Skevi | Tavoulari, Evaggelia | Moraiti, Kalliopi-Maria | Tee, Wan Jean | Deiratany, Samir | Seedhoo, Raymond | McNamara, Roisin | Okafor, Ike | Khaleva, Ekaterina | Novic, Gennady | Bychkova, Natalia | Abd Al-Aziz, Amany | Fatouh, Amany | Motawie, Ayat | Bostany, Eman El | Ibrahim, Amr | Andonova, Sylvia | Savov, Alexey | Zoto, Maria | Kyriakakou, Marialena | Vassilopoulou, Mariza | Balaska, Athina | Kostaridou, Stavroula | Wartna, Jorien | Bohnen, Arthur M. | Elshout, Gijs | Pols, David H. J. | Bindels, Patrick J. E. | Seys, Sven F. | Dilissen, Ellen | Van der Eycken, Sarah | Schelpe, An-Sofie | Marijsse, Gudrun | Troosters, Thierry | Vanbelle, Vincent | Aertgeerts, Sven | Ceuppens, Jan L. | Dupont, Lieven J. | Peers, Koen | Bullens, Dominique M. | Lokas, Sandra Bulat | Zivkovic, Jelena | Nogalo, Boro | Kobal, Iva Mrkic | Oliveira, Georgeta | Pike, Katharine | Melo, Alda | Amélia, Tomás | Cidrais Rodrigues, José Carlos | Serrano, Cristina | Lopes dos Santos, José Manuel | Lopes, Carla | Schauer, Uwe | Bergmann, Karl-Christian | Moral, Luis | Toral, Teresa | Marco, Nuria | Avilés, Beléns García | Fuentes, Mª Jesús | Garde, Jesús | Montahud, Cristina | Perona, Javier | Forniés, Mª José | Arroabarren, Esozia | Anda, Marta | Sanz, Maria Luisa | Lizaso, Maria Teresa | Arregui, Candida | May, Sara | Hartz, Martha | Joshi, Avni | Park, Miguel A. | Posega Devetak, Sonja | Koren Jeverica, Anja | Castro, Leonor | Gouveia, Carolina | Marques, Ana Carvalho | Cabral, Antonio Jorge | Amaral, Luis | Carolino, Fabrícia | Castro, Eunice | Passos, Madalena | Cernadas, Josefina R. | Amaral, Luís | Dias de Castro, Eunice | Pineda, Fernando | Gomes, Armanda | Brough, Helen | Röhmel, Jobst | Schwarz, Carsten | Mehl, Anne | Stock, Philippe | Staab, Doris | Seib, Christine | Critchlow, Anita | Barber, Alyson | Delavalle, Belen | Garriga, Teresa | Vilá, Blanca | Astolfi, Annalisa | Di Chiara, Costanza | Neri, Iria | Patrizi, Annalisa | Neskorodova, Katerina | Kudryavtseva, Asya | Alvarez, Jorge | Palacios, Miriam | Martinez-Merino, Marta | Vaquero, Ibone
Clinical and Translational Allergy  2016;6(Suppl 1):1-60.
Table of contents
WORKSHOP 4: Challenging clinical scenarios (CS01–CS06)
CS01 Bullous lesions in two children: solitary mastocytoma
S. Tolga Yavuz, Ozan Koc, Ali Gungor, Faysal Gok
CS02 Multi-System Allergy (MSA) of cystic fibrosis: our institutional experience
Jessica Hawley, Christopher O’Brien, Matthew Thomas, Malcolm Brodlie, Louise Michaelis
CS03 Cold urticaria in pediatric age: an invisible cause for severe reactions
Inês Mota, Ângela Gaspar, Susana Piedade, Graça Sampaio, José Geraldo Dias, Miguel Paiva, Mário Morais-Almeida
CS04 Angioedema with C1 inhibitor deficiency in a girl: a challenge diagnosis
Cristina Madureira, Tânia Lopes, Susana Lopes, Filipa Almeida, Alexandra Sequeira, Fernanda Carvalho, José Oliveira
CS05 A child with unusual multiple organ allergy disease: what is the primer?
Fabienne Gay-Crosier
CS06 A case of uncontrolled asthma in a 6-year-old patient
Ioana-Valentina Nenciu, Andreia Florina Nita, Alexandru Ulmeanu, Dumitru Oraseanu, Carmen Zapucioiu
ORAL ABSTRACT SESSION 1: Food allergy (OP01–OP06)
OP01 Food protein-induced enterocolitis syndrome: oral food challenge outcomes for tolerance evaluation in a Pediatric Hospital
Adrianna Machinena, Olga Domínguez Sánchez, Montserrat Alvaro Lozano, Rosa Jimenez Feijoo, Jaime Lozano Blasco, Mònica Piquer Gibert, Mª Teresa Giner Muñoz, Marcia Dias da Costa, Ana Maria Plaza Martín
OP02 Characteristics of infants with food protein-induced enterocolitis syndrome and allergic proctocolitis
Ebru Arik Yilmaz, Özlem Cavkaytar, Betul Buyuktiryaki, Ozge Soyer, Cansin Sackesen
OP03 The clinical and immunological outcomes after consumption of baked egg by 1–5 year old egg allergic children: results of a randomised controlled trial
MerrynNetting, Adaweyah El-Merhibi, Michael Gold, PatrickQuinn, IrmeliPenttila, Maria Makrides
OP04 Oral immunotherapy for treatment of egg allergy using low allergenic, hydrolysed egg
Stavroula Giavi, Antonella Muraro, Roger Lauener, Annick Mercenier, Eugen Bersuch, Isabella M. Montagner, Maria Passioti, Nicolò Celegato, Selina Summermatter, Sophie Nutten, Tristan Bourdeau, Yvonne M. Vissers, Nikolaos G. Papadopoulos
OP05 Chemical modification of a peanut extract results in an increased safety profile while maintaining efficacy
Hanneke van der Kleij, Hans Warmenhoven, Ronald van Ree, Raymond Pieters, Dirk Jan Opstelten, Hans van Schijndel, Joost Smit
OP06 Administration of the yellow fever vaccine in egg allergic children
Roisin Fitzsimons, Victoria Timms, George Du Toit
ORAL ABSTRACT SESSION 2: Asthma (OP07–OP12)
OP07 Previous exacerbation is the most important risk factor for future exacerbations in school-age children with asthma
S. Tolga Yavuz, Guven Kaya, Mustafa Gulec, Mehmet Saldir, Osman Sener, Faysal Gok
OP08 Comparative study of degree of severity and laboratory changes between asthmatic children using different acupuncture modalities
Nagwa Hassan, Hala Shaaban, Hazem El-Hariri, Ahmed Kamel Inas E. Mahfouz
OP09 The concentration of exhaled carbon monoxide in asthmatic children with different controlled stadium
Papp Gabor, Biro Gabor, Kovacs Csaba
OP10 Effect of vitamin D3 supplementation during pregnancy on risk of persistent wheeze in the offspring: a randomised clinical trial
Bo Chawes, Klaus Bønnelykke, Jakob Stokholm, Lene Heickendorff, Susanne Brix, Morten Rasmussen, Hans Bisgaard
OP11 Lung function development in childhood
Henrik Wegener Hallas, Bo Chawes, Lambang Arianto, Hans Bisgaard
OP12 Is the effect of maternal and paternal asthma different in female and male children before puberty?
Maike Pincus, Thomas Keil, Andreas Reich, Ulrich Wahn, Susanne Lau, Linus Grabenhenrich
ORAL ABSTRACT SESSION 3: Epidemiology—genetics (OP13–OP18)
OP13 Lifestyle is associated with incidence and category of allergen sensitisation: the ALADDIN birth cohort
Sara Fagerstedt, Helena Marell Hesla, Emelie Johansson, Helen Rosenlund, Axel Mie, Annika Scheynius, Johan Alm
OP15 Maternal filaggrin mutations increase the risk of atopic dermatitis in children: an effect independent of mutation inheritance
Jorge Esparza-Gordillo, Anja Matanovic, Ingo Marenholz, Anja Bauerfeind, Klaus Rohde, Katja Nemat, Min-Ae Lee-Kirsch, Magnus Nordenskjöld, Marten C. G. Winge, Thomas Keil, Renate Krüger, Susanne Lau, Kirsten Beyer, Birgit Kalb, Bodo Niggemann, Norbert Hübner, Heather J. Cordell, Maria Bradley, Young-Ae Lee
OP16 Allergic multimorbidity of asthma, rhinitis and eczema in the first 2 decades of the German MAS birth cohort
Thomas Keil, Hannah Gough, Linus Grabenhenrich, Dirk Schramm, Andreas Reich, John Beschorner, Antje Schuster, Carl-Peter Bauer, Johannes Forster, Fred Zepp, Young-Ae Lee, Renate Bergmann, Karl Bergmann, Ulrich Wahn, Susanne Lau
OP17 Childhood anaphylaxis: a growing concern
Filipe Benito Garcia, Inês Mota, Susana Piedade, Ângela Gaspar, Natacha Santos, Helena Pité, Mário Morais-Almeida
OP18 Indoor exposure to molds and dampness in infancy and its association to persistent atopic dermatitis in school age. Results from the Greek ISAAC II study
Athina Papadopoulou, Despina Mermiri, Elpida Xatziagorou, Ioannis Tsanakas, Stavroula Lampidi, Kostas Priftis
ORAL ABSTRACT SESSION 4: Pediatric rhinitis—immunotherapy (OP19–OP24)
OP19 Associations between residential greenness and childhood allergic rhinitis and aeroallergen sensitisation in seven birth cohorts
Elaine Fuertes, Iana Markevych, Gayan Bowatte, Olena Gruzieva, Ulrike Gehring, Allan Becker, Dietrich Berdel, Michael Brauer, Chris Carlsten, Barbara Hoffmann, Anita Kozyrskyj, Caroline Lodge, Göran Pershagen, Alet Wijga, Heinrich Joachim
OP20 Full symptom control in pediatric patients with allergic rhinitis and asthma: results of a 2-year sublingual allergen immunotherapy study
Zorica Zivkovic, Ivana Djuric-Filipovic, Jasmina Jocić-Stevanovic, Snežana Zivanovic
OP21 Nasal epithelium of different ages of atopic subjects present increased levels of oxidative stress and increased cell cytotoxicity upon rhinovirus infection
Styliani Taka, Dimitra Kokkinou, Aliki Papakonstantinou, Panagiota Stefanopoulou, Anastasia Georgountzou, Paraskevi Maggina, Sofia Stamataki, Vassiliki Papaevanggelou, Evangelos Andreakos, Nikolaos G. Papadopoulos
OP22 Cluster subcutaneous immunotherapy schedule: tolerability profile in children
Monica Piquer Gibert, Montserrat Alvaro Lozano, Jaime Lozano Blasco, Olga Domínguez Sánchez, Rosa Jiménez Feijoo, Marcia Dias da Costa, Mª Teresa Giner Muñoz, Adriana Machinena Spera, Ana Maria Plaza Martín
OP23 Rhinitis as a risk factor for asthma severity in 11-year old children: population-based cohort study
Matea Deliu, Danielle Belgrave, Angela Simpson, Adnan Custovic
OP24 The Global Lung Function Initiative equations in airway obstruction evaluation of asthmatic children
João Gaspar Marques, Pedro Carreiro-Martins, Joana Belo, Sara Serranho, Isabel Peralta, Nuno Neuparth, Paula Leiria-Pinto
POSTER DISCUSSION SESSION 1: Food allergy (PD01–PD05)
PD01 Allergen-specific humoral and cellular responses in children who fail egg oral immunotherapy due to allergic reactions
Marta Vazquez-Ortiz, Mariona Pascal, Ana Maria Plaza, Manel Juan
PD02 FoxP3 epigenetic features in children with cow milk allergy
Lorella Paparo, Rita Nocerino, Rosita Aitoro, Ilaria Langella, Antonio Amoroso, Alessia Amoroso, Carmen Di Scala, Roberto Berni Canani
PD04 Combined milk and egg allergy in early childhood: let them eat cake?
Santanu Maity, Giuseppina Rotiroti, Minal Gandhi
PD05 Introduction of complementary foods in relation to allergy and gut microbiota in farm and non-farm children
Karin Jonsson, Annika Ljung, Bill Hesselmar, Ingegerd Adlerbert, Hilde Brekke, Susanne Johansen, Agnes Wold, Ann-Sofie Sandberg
POSTER DISCUSSION SESSION 2: Asthma and wheeze (PD06–PD16)
PD06 The association between asthma and exhaled nitric oxide is influenced by genetics and sensitisation
Björn Nordlund, Cecilia Lundholm, Villhelmina Ullemar, Marianne van Hage, Anne Örtqvist, Catarina Almqvist
PD09 Prevalence patterns of infant wheeze across Europe
Anna Selby, Kate Grimshaw, Thomas Keil, Linus Grabenhenrich, Michael Clausen, Ruta Dubakiene, Alessandro Fiocchi, Marek Kowalski, Nikos Papadopoulos, Marta Reche, Sigurveig Sigurdardottir, Aline Sprikkleman, Paraskevi Xepapadaki, Clare Mills, Kirsten Beyer, Graham Roberts
PD10 Epidemiologic changes in recurrent wheezing infants
Herberto Jose Chong Neto, Gustavo Falbo Wandalsen, Ana Carolina Dela Bianca, Carolina Aranda, Nelson Augusto Rosário, Dirceu Solé, Javier Mallol, Luis García Marcos
PD13 A single nucleotide polymorphism in the GLCCI1 gene is associated with response to asthma treatment in children
IvanaBanic, Matija Rijavec, Davor Plavec, Peter Korosec, Mirjana Turkalj
PD14 Pollen induced asthma: Could small molecules in pollen exacerbate the protein-mediated allergic response?
Alen Bozicevic, Maria De Mieri, Matthias Hamburger
PD15 A qualitative study to understand how we can empower teenagers to better self-manage their asthma
Simone Holley, Ruth Morris, Frances Mitchell, Rebecca Knibb, Susan Latter, Christina Liossi, Graham Roberts
PD16 Polymorphism of endothelial nitric oxide synthase (eNOS) gene among Egyptian children with bronchial asthma
Mostafa M. M. Hassan
POSTER DISCUSSION SESSION 3: Mechanisms—Epidemiology (PD17–PD21)
PD17 Pregnancy outcomes in relation to development of allergy in a Swedish birth cohort
Malin Barman, Anna Sandin, Agnes Wold, Ann-Sofie Sandberg
PD18 Evolution of the IgE response to house dust mite molecules in childhood
Daniela Posa, Serena Perna, Carl-Peter Bauer, Ute Hoffmann, Johannes Forster, Fred Zepp, Antje Schuster, Ulrich Wahn, Thomas Keil, Susanne Lau, Kuan-Wei Chen, Yvonne Resch, Susanne Vrtala, Rudolf Valenta, Paolo Maria Matricardi
PD19 Antibody recognition of nsLTP-molecules as antigens but not as allergens in the German-MAS birth cohort
Olympia Tsilochristou, Alexander Rohrbach, Antonio Cappella, Stephanie Hofmaier, Laura Hatzler, Carl-Peter Bauer, Ute Hoffmann, Johannes Forster, Fred Zepp, Antje Schuster, RaffaeleD’Amelio, Ulrich Wahn, Thomas Keil, Susanne Lau, Paolo Maria Matricardi
PD20 Early life colonization with Lactobacilli and Staphylococcus aureus oppositely associates with the maturation and activation of FOXP3+ CD4 T-cells
Sophia Björkander, Maria A. Johansson, Gintare Lasaviciute, Eva Sverremark-Ekström
PD21 Genome-wide meta-analysis identifies 7 susceptibility loci involved in the atopic march
Ingo Marenholz, Jorge Esparza-Gordillo, Franz Rüschendorf, Anja Bauerfeind, David P. Strachan, Ben D. Spycher, Hansjörg Baurecht, Patricia Margaritte-Jeannin, Annika Sääf, Marjan Kerkhof, Markus Ege, Svetlana Baltic, Melanie C Matheson, Jin Li, Sven Michel, Wei Q. Ang, Wendy McArdle, Andreas Arnold, Georg Homuth, Florence Demenais, Emmanuelle Bouzigon, Cilla Söderhäll, Göran Pershagen, Johan C. de Jongste, Dirkje S Postma, Charlotte Braun-Fahrländer, Elisabeth Horak, Ludmila M. Ogorodova, Valery P. Puzyrev, Elena Yu Bragina, Thomas J Hudson, Charles Morin, David L Duffy, Guy B Marks, Colin F Robertson, Grant W Montgomery, Bill Musk, Philip J Thompson, Nicholas G. Martin, Alan James, Patrick Sleiman, Elina Toskala, Elke Rodriguez, Regina Fölster-Holst, Andre Franke, Wolfgang Lieb, Christian Gieger, Andrea Heinzmann, Ernst Rietschel, Thomas Keil, Sven Cichon, Markus M Nöthen, Craig E Pennell, Peter D Sly, Carsten O Schmidt, Anja Matanovic, Valentin Schneider, Matthias Heinig, Norbert Hübner, Patrick G. Holt, Susanne Lau, Michael Kabesch, Stefan Weidinger, Hakon Hakonarson, Manuel AR Ferreira, Catherine Laprise, Maxim B. Freidin, Jon Genuneit, Gerard H Koppelman, Erik Melén, Marie-Hélène Dizier, A. John Henderson, Young Ae Lee
POSTER DISCUSSION SESSION 4: Food allergy—Anaphylaxis (PD22–PD26)
PD22 Atopy patch test in food protein induced enterocolitis caused by solid food
Purificacion González-Delgado, Esther Caparrós, Fernando Clemente, Begoña Cueva, Victoria M. Moreno, Jose Luis Carretero, Javier Fernández
PD23 Watermelon allergy: a novel presentation
Kate Swan, George Du Toit
PD24 A pilot study evaluating the usefulness of a guideline template for managing milk allergy in primary care
Mudiyur Gopi, Tim Smith, Edara Ramesh, Arun Sadasivam
PD26 Efficacy and safety of cow’s milk oral immunotherapy protocol
Inês Mota, Filipe Benito Garcia, Susana Piedade, Angela Gaspar, Graça Sampaio, Cristina Arêde, Luís Miguel Borrego, Graça Pires, Cristina Santa-Marta, Mário Morais-Almeida
POSTER DISCUSSION SESSION 5: Prevention and treatment—Allergy (PD27–PD36)
PD27 Allergy-protection by the lactic acid bacterium Lactococcus lactis G121: mode-of-action as revealed in a murine model of experimental allergy
Stephanie Brand, Karina Stein, Holger Heine, Marion Kauth
PD29 The relationship between quality of life and morning salivary cortisol after acute bronchiolitis in infancy
Leif Bjarte Rolfsjord, Egil Bakkeheim, Johan Alm, Håvard Ove Skjerven, Kai-Håkon Carlsen, Jon Olav Hunderi, Teresa Løvold Berents, Petter Mowinckel, Karin C. Lødrup Carlsen
PD30 Randomised trial of the efficacy of MP29-02* compared with fluticasone propionate nasal spray in children aged ≥6 years to <12 years with allergic rhinitis
Ulrich Wahn, Ullrich Munzel, William Berger
PD31 10 mg of oral bilastine in 2 to 11 years old children has similar exposure to the adult therapeutic dose (20 mg)
Ulrich Wahn, Román Valiente, Valvanera Vozmediano, John C. Lukas, Mónica Rodríguez
PD33 Daily symptoms, nocturnal symptoms, activity limitations and reliever therapies during the three steps of IOEASMA programme: a comparison
Sebastiano Guarnaccia, Luigi Vitale, Ada Pluda, Emanuele D’Agata, Denise Colombo, Stefano Felici, Valeria Gretter, Susanna Facchetti, Gaia Pecorelli, Cristina Quecchia
PD34 Sensitisation to an inert aeroallergen in weaning rats and longstanding disease, in a sensitisation-tolerant and easily tolerisable rodent strain
George Guibas, Evangelia Spandou, Spyridon Megremis, Peter West, Nikolaos Papadopoulos
PD35 Bacterial and fungi exposure in school and allergic sensitisation in children
João Cavaleiro Rufo, Joana Madureira, Inês Paciência, Lívia Aguiar, Patrícia Padrão, Mariana Pinto, Luís Delgado, Pedro Moreira, João Paulo Teixeira, Eduardo Oliveira Fernandes, André Moreira
PD36 Comparative study of allergy rhinitis between two populations: children vs. adults
Adriana Izquierdo Dominguez, Antonio Valero, Joaquim Mullol, Alfonso Del Cuvillo, Javier Montoro, Ignacio Jauregui, Joan Bartra, Ignacio Davila, Marta Ferrer, Joaquin Sastre
POSTER VIEWING SESSION 1: Inflammation—Genetics—Immunology—Dermatology (PP01–PP09)
PP01 Immune profile in late pregnancy: immunological markers in atopic asthmaticwomen as risk factors for atopy in the progeny
Catarina Martins, Jorge Lima, Maria José Leandro, Glória Nunes, Jorge Cunha Branco, Hélder Trindade, Luis Miguel Borrego
PP02 The impact of neonatal sepsis on development of allergic diseases
Secil Conkar, Mehtap Kilic, Canan Aygun, Recep Sancak
PP03 Clinical overview of selective IgE deficiency in childhood
Athina Papadopoulou, Eleni Tagalaki, Lambros Banos, Anna Vlachou, Fotini Giannoula, Despina Mermiri
PP04 Inverse relationship between serum 25(ΟΗ) vitamin D3 and total IgE in children and adolescence
Athina Papadopoulou, Stavroula Lampidi, Marina Pavlakou, Maria Kryoni, Kostas Makris
PP05
PP06
PP07 Asthma control questionnaire and specific IgE in children
Snezhina Lazova, Guergana Petrova, Dimitrinka Miteva, Penka Perenovska
PP08 Features of chronic urticaria of adolescents
Aliya Klyucharova, Olesya Skorohodkina
PP09 Cutaneous mastocytosis in children: a clinical analysis of 8 cases in Greece
Dimitra Koumaki, Alkisti Manousaki, Maria Agrapidi, Lida Iatridou, Omima Eruk, Konstantinos Myridakis, Emmanouil Manousakis, Vasiliki Koumaki
POSTER VIEWING SESSION 2: Food allergy—Anaphylaxis (PP10–PP47)
PP10 Prognostic factors in egg allergy
Maria Dimou, Maria Ingemansson, Gunilla Hedlin
PP11 Evaluation of the efficacy of an amino acid-based formula in infants who are intolerant to extensively hydrolysed protein formula
Nitida Pastor, Delphine de Boissieu, Jon Vanderhoof, Nancy Moore, Kaitlin Maditz
PP12 Anaphylaxis and epinephrine auto-injector use: a survey of pediatric trainees
Adeli Mehdi, Shaza Elhassan, Carolin Beck, Ahmed Al-Hammadi
PP13 Anaphylaxis in children: acute management in the Emergency Department
Ioana Maris, Ronan O’Sullivan, Jonathan Hourihane,
PP14 Understanding Cumbrian schools preparedness in managing children at risk of anaphylaxis in order to provide training and support which will create healthy and safe environments for children with allergies
George Raptis, Louise Michaelis
PP15 A new valid and reliable parent and child questionnaire to measure the impact of food protein enterocolitis syndrome on children: the FPIES Quality of Life Questionnaire (FPIESQL), Parent and Child Short Form
Audrey DunnGalvin, Matthew Greenhawt, Carina Venter, Jonathan Hourihane
PP16 An in-depth case study investigation of the experiences of teenagers and young adults in growing up and living with food allergy with emphasis on coping, management and risk, support, and social and self-identity
Evelyn O’Regan, Duncan Cronin, Jonathan Hourihane, Anna O’Reilly, Audrey DunnGalvin
PP17 Cow’s milk protein allergy in Constantine. A retrospective study of 62 cases between 1996 and 2013
Foued Abdelaziz, Dounia Khelifi-Touhami, Nihad Selim, Tahar Khelifi-Touhami
PP18
PP19 Cow’s milk and egg oral immunotherapy in children older than 5 years
Pablo Merida, Ana Mª Plaza, Juan Heber Castellanos, Adrianna Machinena, Montserrat Alvaro Lozano, Jaime Lozano, Olga Dominguez, Monica Piquer, Rosa Jimenez, Mª Teresa Giner
PP20 Professionals’ awareness of management of Cow’s Milk Protein Allergy (CMPA) in North Wales Hospitals
Konstantinos Kakleas, Manohar Joishy, Wendmu Maskele, Huw R. Jenkins
PP21
PP22 Anaphylaxis: the great unknown for teachers. Presentation of a protocol for schools
Mercedes Escarrer, Agustín Madroñero, Maria Teresa Guerra, Juan Carlos Julia, Juan Carlos Cerda, Javier Contreras, Eulalia Tauler, Maria Jesus Vidorreta, Ana Rojo, Silvia Del Valle
PP23 Challenges facing children with food allergies and their parents in out of school activity sectors
Niamh Flynn
PP24 A review of food challenges at a Regional Irish Centre
Gary Foley, Carol Harmon, John Fitzsimons
PP25 The use of epinephrine in infants with anaphylaxis
Krasimira Baynova, Ávila Maria Del Robledo, Labella Marina
PP26
PP27
PP28 Mother’s psychological state predicts the expression of symptoms in food allergic children
Aaron Cortes, Alicia Sciaraffia, Angela Castillo
PP29 The correlation between sIgE towards tree nuts and birch pollen in a Danish Pediatric Allergy Clinic
Nanna Juel-Berg, Kirsten Skamstrup Hansen, Lars Kærgaard Poulsen
PP30 Food allergy in children: evaluation of parents’ use of online social media
Andreia Florina Nita, Ioana Valentina Nenciu, Adina Lazar, Dumitru Oraseanu
PP31 The impact of food allergy on quality of life: FAQLQ questionnaire
Rita Aguiar, Anabela Lopes, Maria J. Paes, Amélia S. Santos, M. A. Pereira-Barbosa
PP32 An unexpected cause of anaphylaxis: potato
Hatice Eke Gungor, Salih Uytun, Umit Murat Sahiner, Yasemin Altuner Torun
PP33 Is it clinical phenotype of allergic diseases determined by sensitisation to food?
Mirjana Zivanovic, Marina Atanasković-Marković
PP34
PP35 Prescribing adrenaline auto-injectors in children in 2014: the data from regional pediatricians
Tina Vesel, Mihaela Nahtigal, Andreja Obermayer-Temlin, Eva Šoster Križnik, Mirjana Maslar, Ruben Bizjak, Marjeta Tomšič-Matic, Sonja Posega-Devetak, Maja Skerbinjek-Kavalar, Mateja Predalič, Tadej Avčin
PP36 Who should have an adrenaline autoinjector? Adherence to the European and French guidelines among 121 allergists from the Allergy Vigilance Network
Guillaume Pouessel, Etienne Beaudouin, Anne M. Moneret-Vautrin, Antoine Deschildre, Allergy Vigilance Network
PP37 Anaphylaxis by Anacardium Occidentale
Marta Viñas, Bartolomé Borja, Nora Hernández, Mª José Castillo, Adriana Izquierdo, Marcel Ibero
PP38 Anaphylaxis with honey in a child
S. Tolga Yavuz, Ali Gungor, Betul Buyuktiryaki, Ozan Koc, Can Naci Kocabas, Faysal Gok
PP39 Evaluation of courses adopted to children on prevention, recognition and management of anaphylaxis
Tina Vesel, Mihaela Nahtigal
PP40 Symptomatic dust mites and shrimp allergy: three pediatric case reports
Filipa Almeida, Susana Lopes, Cristina Madureira, Tânia Lopes, Fernanda Carvalho
PP41 Poor identification rates of nuts by high risk individuals: a call for improved education and support for families
Camille Heming, Emily Garrett, Adam Blackstock, Santanu Maity, Rahul Chodhari
PP42 DAFALL: database of food allergies in the Czech Republic
Simona Belohlavkova, Eliska Kopelentova, Petr Visek, Ivana Setinova, Ivana Svarcova
PP43 Serological cross-reactivity between grass and wheat is not only caused by profilins and CCDs
Sigrid Sjölander, Nora Nilsson, Malin Berthold, Helena Ekoff, Gunilla Hedlin, Magnus Borres, Caroline Nilsson
PP44 Oil body associated proteins in children with nuts allergy. Allergens to consider in IgE-mediated nuts allergy
Loreto González Domínguez, Cristina Muñoz Archidona, Ana Moreira Jorge, Sergio Quevedo Teruel, Teresa Bracamonte Bermejo, Miriam Castillo Fernández, Fernando Pineda de la Losa, Luis Ángel Echeverría Zudaire
PP45
PP46 Protective effect of helicobacter pylori infection against food allergy in children
Olga Vrani, Antigone Mavroudi, Maria Fotoulaki, Maria Emporiadou, Kleomenis Spiroglou, Ioannis Xinias
PP47 Anaphylaxis pathway: A road tryp-tase to success?
Helyeh A. Sadreddini, Mia Warnes, Donna Traves
POSTER VIEWING SESSION 3: Miscellaneous (PP48–PP58)
PP48 Surveillance study on safety of SLIT in pediatric population
Ivana Djuric-Filipovic, Zorica Zivkovic, Snežana Zivanovic, Gordana Kostić, Đorđe Filipovic
PP49 Efficacy and safety of mixed mite subcutaneous immunotherapy among allergic rhinitis patients in the Northeastern Thailand
Sawapon Sittisomwong, Siripong Sittisomwong
PP50 Effect of inhaled beclomethasone or placebo on brain stem activity in a patient chronically treated with steroids: preliminary report
Zygmunt Podolec, Marcin Hartel, Daria Panek, Magdalena Podolec-Rubiś, Tomasz Banasik
PP51 Sensitisation to aeroallergens in patients with allergic rhinitis, asthma and atopic dermatitis in Shiraz, Southwestern Iran
Elham Abbasi, Mozhgan Moghtaderi
PP52 Referring a child for allergy test: how appropriate are we?
Phani Sanneerappa, Alina Deliu, Moosa Kutty, Nagabathula Ramesh
PP53 EBV lymphoproliferative disease and cardiac lymphoma in a STK4 deficient patient
Roya Sherkat, Mohammad Reza Sabri, Bahar Dehghan, Hamid Bigdelian, Nahid Raeesi, Mino Afshar, Hamid Rahimi, Christoph Klein
PP54 A case study: the effect of massive honeybees attack on various body parameters atopic girl including allergy
Mohemid Al-Jebouri
PP55 The role of TLR9, NLRP3 and proIL-1β in activation of antiviral innate immunity
Oxana A. Svitich, Daria O. Zubacheva, Dmitrii A. Potemkin, Ludmila V. Gankovskaya, Vitalii V. Zverev
PP56 Overnight pulse oximetry, as a screening tool to diagnose obstructive sleep apnoea. How effective is it?
Phani Sanneerappa, Elaine OB Doyle, Paul Gallagher, Nagabathula Ramesh
PP57 The presentation and management of acute urticaria and allergic reactions in children in a multi-ethnic, inner city Emergency Department (ED)
Sherine Dewlett, Kin Man, Minal Gandhi, James Pocock, Anna Gerrardhughes
PP58 Food allergens responsible for delayed-type sensitisation in atopy patch test in children diagnosed with autism spectrum disorder
Jolanta Wasilewska, Maciej Kaczmarski, Dariusz Lebensztejn
POSTER VIEWING SESSION 4: Asthma—Rhinitis (PP59–PP87)
PP59 Systematic review of incense as a trigger factor for asthma
Chandramani Thuraisingham, Davendralingam Sinniah
PP60 Increased risks of mood and anxiety disorders in children with asthma
Yue Chen, Xiaomei Mei
PP61
PP62 Asthma Control Test (ACT) and Pediatric Asthma Quality of Life Questionnaire (PAQLQ) association in children
Sebnem Ozdogan, Pinar Karadeniz, Durdugul Ayyildiz-Emecen, Ummuhan Oncul
PP63 Seasonal and gender variations in vitamin D levels in children with asthma and its association with pulmonary function tests
Sebnem Ozdogan, Gizem Sari, Sabanur Cavdar
PP64 Defining treatment response in childhood asthma: rationale and design of the Pharmacogenomics in the Childhood Asthma (PiCA) consortium
Niloufar Farzan, Susanne J. Vijverberg, Colin J. Palmer, Kelan G. Tantisira, Anke-Hilseon Maitland-van der Zee behalf of the PiCA consortium
PP65 Prevalence of asthma and allergic disease in patients with inflammatory disease compared to celiac disease
Fatma Yavuzyilmaz, Sebnem Ozdogan, Nafiye Urganci, Merve Usta
PP66 A severe case with cystic fibrosis (CF) asthma
Mehmet Hoxha, Maksim Basho
PP67 Severe asthma exacerbation complicated with pneumothorax in a child with uncontrolled asthma due to poor treatment compliance
Ioana Valentina Nenciu, Andreia Florina Nita, Adina Lazar, Alexandru Ulmeanu, Carmen Zapucioiu, Dumitru Oraseanu
PP68 Evaluation of the Pediatric Quality of Life inventory (PedsQL) asthma module among low income asthmatic children and adolescents in Sao Paolo, Brazil
Gustavo F. Wandalsen, Fernanda Monteiro, Dirceu Solé
PP69 Early initiation of specific immunotherapy in asthma patients leads to higher benefits
Blerta Lame, Eris Mesonjesi, Arjeta Sherri
PP70 Treatment resistant asthma and rhinosinusitis with recurrent pulmonary infections. Is it primary ciliary dyskinesia?
Alkerta Ibranji, Laert Gjati, Gjustina Loloci, Ardii Bardhi
PP71 The comparison of sensitisation to animal allergens in children- and adult- onset patients with asthma
Behnam Moghtaderi, Shirin Farjadian, Dorna Eghtedari
PP72 Characterisation of children less than five years with wheezing episodes in Cali, Colombia
Manuela Olaya, Laura Del Mar Vasquez, Luis Fernando Ramirez, Carlos Daniel Serrano
PP73 Evaluation of the patients with recurrent croup
Belgin Usta Guc, Suna Asilsoy, Fulya Ozer
PP74 Obesity in adolescence compromising the asthma control
Guergana Petrova, Sylvia Shopova, Vera Papochieva, Snezhina Lazova, Dimitrinka Miteva, Penka Perenovska
PP75 Sleep behavior in children with persistent allergic rhinitis
Gustavo F. Wandalsen, Jessica Loekmanwidjaja, Márcia Mallozi, Dirceu Solé
PP76 Randomised trial of the safety of MP29-02* compared with fluticasone propionate nasal spray in children aged ≥4 years to <12 years with allergic rhinitis
William Berger, Ulrich Wahn, Paul Ratner, Daniel Soteres
PP77 Safety and tolerability evaluation of bilastine 10 mg in children from 2 to 11 years of age with allergic rhinoconjunctivitis or urticaria
Zoltán Novák, Anahí Yáñez, Kiss Ildikó, Piotr Kuna, Miguel Tortajada, Román Valiente, the Bilastine Pediatric Safety Study Group
PP78 Sensitisation to Alternaria alternata: Is it a risk factor for severe rhinitis?
Susana Lopes, Filipa Almeida, Tânia Lopes, Cristina Madureira, José Oliveira, Fernanda Carvalho
PP79 Validation of the Patient Benefit Index (PBI) for the assessment of patient-related outcomes in allergic rhinitis in children
Julia Feuerhahn, Christine Blome, Meike Hadler, Efstrathios Karagiannis, Anna Langenbruch, Matthias Augustin
PP80 Efficacy of sublingual tablet of house dust mite allergen extracts in adolescents with house dust mite-associated allergic rhinitis
Michel Roux, Shinji Kakudo, Efstrathios Karagiannis, Robert K. Zeldin
PP81 Lung function improvement in a child treated with omalizumab for bronchial asthma
Anna Sokolova, Tiago Milheiro Silva
PP82 How to treat a child suffering from asthma, allergic rhinitis, allergy to peanuts and diabetes at the same time?
Snezana S. Zivanovic, Vesna Cvetkovic, Ivana Nikolic, Sonja J. Zivanovic
PP83 Nitric oxide in exhaled air in the relationship of the degree of sensitisation to aeroallergens
Snezana S. Zivanovic, Ljiljana Saranac, Ivana Nikolic, Sonja J. Zivanovic, Zorica Zivkovic
PP84 Clinical basis of diagnostic errors in pediatric asthma
Zoia Nesterenko
PP85
PP86 Childhood asthma control in Serbia and organised Asthma Educational Intervention (AEI)
Snezana Radic, Branislava Milenkovic, Spomenka Smiljanic, Milka Micic-Stanijevic, Olivera Calovic
PP87 Experience from a group of adolescents with severe allergic asthma treated with Omalizumab
Anne Marie Bro Hofbauer, Lone Agertoft
THEMATIC POSTER SESSION 1: Prevention and Treatment—Epidemiology (TP01–TP18)
TP01 A cost effective primary school asthma education program: pilot study from inner London schools
Lucy Everson, Jessica Kearney, Jonny Coppel, Simon Braithwaite, Rahul Chodhari
TP02 The prevalence of allergic diseases among 14–15 years old adolescents in two Danish birth cohorts 14 years apart
Elisabeth S. Christiansen, Henrik Fomsgaard Kjaer, Esben Eller, Charlotte G. Mørtz, Susanne Halken
TP03 Does pattern of sensitisation to phleum pratense change with age? Is it different in children with allergic rhinitis or asthma?
Cristina Román India, Ana Moreira Jorge, Loreto González Domínguez, Cristina Muñoz Archidona, Sergio Quevedo Teruel, Teresa Bracamonte Bermejo, Juana Jiménez Jiménez, Luis Echeverría Zudaire
TP04 Practicalities of prevention of peanut allergy: modelling a national response to LEAP
Cathal O’Connor, Jonathan Hourihane
TP05 Comparison of the influence of sunflower seed oil and skin care lotion on the skin barrier function of newborns: a randomised controlled trial
Varvara Kanti, Lena Lünnemann, Günther Malise, Laine Ludriksone, Andrea Stroux, Wolfgang Henrich, Michael Abu-Dakn, Ulrike Blume-Peytavi, Natalie Garcia Bartels
TP06 The effect of daily skin care on skin barrier properties in infants with dry skin and risk for atopic dermatitis
Varvara Kanti, Lena Lünnemann, Laine Ludriksone, Marianne Schario, Andrea Stroux, Ulrike Blume-Peytavi, Natalie Garcia Bartels
TP07 Change in sum total aeroallergen skin prick test wheal diameters at 6 months predicts which children will respond to subcutaneous immunotherapy by three years
Thorsten Stanley, Nicolien Brandenbarg
TP08 Are mobile apps regarding adrenaline auto-injectors accessed by adolescents for support and education in the community?
Alia Boardman, Gary McGreevy, Emily Rodger, Katherine Knight, Victoria Timms, Trisha Taylor, Gemma Scanlan, Roisin Fitzsimons
TP09
TP10 Prevention of early atopic dermatitis among low-atopy-risk infants by immunoactive prebiotics is not sustained after the first year of life
Grüber Christoph, Ulrich Wahn, Margriet van Stuivenberg, Fabio Mosca, Guido Moro, Gaetano Chirico, Christian P. Braegger, Joseph Riedler, Yalcin Yavuz, Günther Boehm
TP11
TP12
TP13 Treatment with Omalizumab in a 16-year-old Caucasian girl with refractory solar urticaria
Stefania Arasi, Giuseppe Crisafulli, Lucia Caminiti, Federica Porcaro, Giovanni Battista Pajno
TP14 Ultra-pure soft water ameliorates skin conditions of adult and child patients with atopic dermatitis
Akane Tanaka, Yaei Togawa, Kumiko Oida, Naotomo Kambe, Peter Arkwright, Yosuke Amagai, Naoki Shimojo, Yasunori Sato, Hiroyuki Mochizuki, Hyosun Jang, Saori Ishizaka, Hiroshi Matsuda
TP15 Potential adjuvant effect of immunomodulator to improve specific immunotherapy in asthmatic child
Wisnu Barlianto, Ery Olivianto, H. M. S. Chandra Kusuma
TP16 How can Component Resolved Diagnosis (CRD) influence in Specific Immunotherapy (SIT) prescription, in a Spanish children population
Ana Moreira Jorge, Cristina Román India, Loreto González Domínguez, Cristina Muñoz Archidona, Juana Jiménez Jiménez, Teresa Bracamonte Bermejo, Sergio Quevedo Teruel, Luis Echeverría Zudaire
TP17 Mitochondrial dysfunction in food allergy: effects of L. rhamnosus GG in a mice model of peanut allergy
Rosita Aitoro, Mariapia Mollica, Roberto Berni Canani, Giovanna Trinchese, Elena Alfano, Antonio Amoroso, Lorella Paparo, Francesco Amato, Claudio Pirozzi, Antonio Calignano, Rosaria Meli
TP18 Prediction of atopic diseases in childhood: elevated blood eosinophils in infancy in a high risk birth cohort
Siri Rossberg, Kerstin Gerhold, Kurt Zimmermann, Mohammad Zaino, Thomas Geske, Eckard Hamelmann, Susanne Lau
THEMATIC POSTER SESSION 2: Food allergy—Anaphylaxis (TP19–TP38)
TP19
TP20
TP21 Double-blind provocation tests in non-IgE mediated cow’s milk allergy and the occurrence of placebo reactions
Sarah Bogovic, Jochem van den Berg, Chantal Janssen
TP22 Gradual introduction of baked egg (BE) in egg allergic patients under 2 years old
Angela Claver
TP23 Randomised controlled trial of SOTI with raw hen’s egg in children with persistent egg allergy I: safety and efficacy of daily vs. weekly protocols of induction
Mª Flor Martin-Muñoz, C. Martorell, M. T. Belver, E. Alonso Lebrero, L. Zapatero, V. Fuentes, M. Piqué, A. Plaza, C. Muñoz, A. Martorell, Cristina Blasco, B. Villa, C. Gómez, S. Nevot, J. M. García, L. Echeverria
TP24 Randomised controlled trial of SOTI with raw hen’s egg in children with persistent egg allergy II: a randomised controlled trial to study a safer, more effective and easy to perform maintenance (daily vs. every two days) pattern of egg SOTI
Mª Flor Martin-Muñoz, C. Martorell, M. T. Belver, E. Alonso Lebrero, L. Zapatero, V. Fuentes, M. Piqué, A. Plaza, C. Muñoz, A. Martorell, Cristina Blasco, B. Villa, C. Gómez, S. Nevot, J. M. García, L. Echeverria
TP25 Determining the safety of baked egg home reintroduction for children with mild egg allergy
Brenda DeWitt, Judith Holloway, Donald Hodge
TP26 Demographics, investigations and patterns of sensitisation in children with oral allergy syndrome in a London Teaching Hospital
Sian Ludman, Merhdad Jafari-Mamaghani, Rosemary Ebling, Adam T. Fox, Gideon Lack, George Du Toit
TP27 Airborne peanut challenge in children: allergic reactions are rare
Sofia Lovén Björkman, Caroline Nilsson, Natalia Ballardini
TP28 The nutty question on Pediatric Wards: to be or “nut” to be?
Supriyo Basu, Jenny Hallet, Jyothi Srinivas
TP29
TP30
TP31 Allergy education in nursery schools
Hazel Stringer, Nicola Jay
TP32 Food allergy in the first year of life
Tânia Lopes, Cristina Madureira, Filipa Almeida, Susana Lopes, Paula Fonseca, Clara Vieira, Fernanda Carvalho
TP33 Prevalence and geographic distribution of oral allergy syndrome in Italian children: a multicenter study
Carla Mastrorilli, Carlo Caffarelli, Riccardo Asero, Salvatore Tripodi, Arianna Dondi, Gianpaolo Ricci, Carlotta Povesi Dascola, Elisabetta Calamelli, Francesca Cipriani, Andrea Di Rienzo Businco, Annamaria Bianchi, Paolo Candelotti, Tullio Frediani, Carmen Verga, Paolo Maria Matricardi
TP34 Are common standardised allergen extracts used in skin test enough in the diagnosis of nuts allergy?
Cristina Muñoz Archidona, Loreto González Domínguez, Ana Moreira Jorge, Sergio Quevedo Teruel, Teresa Bracamonte Bermejo, Miriam Castillo Fernández, Fernando Pineda de la Losa, Luis Ángel Echeverría Zudaire
TP35 Evaluation of IgE sensitisation in children with allergic proctocolitis and its relationship to atopic dermatitis
Despina Mermiri, Paraskevi Korovessi, Skevi Tiliakou, Evaggelia Tavoulari, Kalliopi-Maria Moraiti, Fotini Giannoula, Athina Papadopoulou
TP36 Food allergy in children: are we managing them appropriately in the Emergency Department?
Wan Jean Tee, Samir Deiratany, Raymond Seedhoo, Roisin McNamara, Ike Okafor
TP37 Importance of oil body associated allergenic proteins in nuts suspected allergy children
Loreto González Domínguez, Ana Moreira Jorge, Cristina Muñoz Archidona, Teresa Bracamonte Bermejo, Sergio Quevedo Teruel, Fernando Pineda de la Losa, Miriam Castillo Fernández, Luis Ángel Echeverría Zudaire
TP38 Practical application of basophil activation test in children with food allergy
Ekaterina Khaleva, Gennady Novic, Natalia Bychkova
THEMATIC POSTER SESSION 3: Asthma (TP39–TP57)
TP39 Effect of corticosteroid therapy upon serum magnesium level in chronic asthmatic children
Amany Abd Al-Aziz, Amany Fatouh, Ayat Motawie, Eman El Bostany, Amr Ibrahim
TP40 ADAM33 in Bulgarian children with asthma
Guergana Petrova, Dimitrinka Miteva, Snezhina Lazova, Penka Perenovska, Sylvia Andonova, Alexey Savov
TP41
TP42 The impact of vitamin D serum levels in asthma and allergic rhinitis
Maria Zoto, Marialena Kyriakakou, Paraskevi Xepapadaki, Nikolaos G. Papadopoulos
TP43 Life-threatening, first reported, paradoxical bronchospasm after nebulised Salbutamol in a 10 year old child
Paraskevi Korovessi, Mariza Vassilopoulou, Athina Balaska, Lambros Banos, Stavroula Kostaridou, Despina Mermiri
TP44
TP45 Asthma symptoms in children with treatment for allergic rhinoconjunctivitis
Jorien Wartna, Arthur M. Bohnen, Gijs Elshout, David H. J. Pols, Patrick J. E. Bindels
Erasmus MC, Rotterdam, The Netherlands
TP46 Atopy increased the risk of developing exercise-induced bronchoconstriction in young athletes
Sven F. Seys; Ellen Dilissen, Sarah Van der Eycken, An-Sofie Schelpe, Gudrun Marijsse, Thierry Troosters, Vincent Vanbelle, Sven Aertgeerts, Jan L. Ceuppens, Lieven J. Dupont, Koen Peers, Dominique M. Bullens
TP47 The effect of higher BMI on risk for asthma and treatment outcome in overweight and obese children
Ivana Banic, Sandra Bulat Lokas, Jelena Zivkovic, Boro Nogalo, Iva Mrkic Kobal, Davor Plavec, Mirjana Turkalj
TP48
TP49
TP50
TP51
TP52 The impact of a multidisciplinary project intended to change the culture of nebulisers towards pressurised metered dose inhalers
Georgeta Oliveira, Katharine Pike, Alda Melo, Tomás Amélia, José Carlos Cidrais Rodrigues, Cristina Serrano, José Manuel Lopes dos Santos, Carla Lopes
TP53
TP54
TP55
TP56 Increased asthma control in patients with severe persistent allergic asthma after 12 month of nightly temperature controlled laminar airflow (TLA)
Eckard Hamelmann, Uwe Schauer, Karl-Christian Bergmann
TP57
THEMATIC POSTER SESSION 4: Drug allergy—Dermatology (TP58–TP77)
TP58 Should we proceed directly to provocation challenges to diagnose drug allergy? Our experience says yes
Luis Moral, Teresa Toral, Nuria Marco, Beléns García Avilés, Mª Jesús Fuentes, Jesús Garde, Cristina Montahud, Javier Perona, Mª José Forniés
TP59 Anaphylaxis to 13-valent pneumococcal vaccine
Esozia Arroabarren, Marta Anda, Maria Luisa Sanz, Maria Teresa Lizaso, Candida Arregui
TP60 Intrapartum antibiotic exposure for treatment of group B streptococcus was not associated with the development of penicillin allergy in children
Sara May, Martha Hartz, Avni Joshi, Miguel A. Park
TP61 Evaluation of suspected drug hypersensitivity reactions in 169 children referred to the General Hospital
Sonja Posega Devetak, Tina Vesel, Anja Koren Jeverica, Tadej Avčin
TP62 Drug provocation testing: experience of a tertiary hospital
Leonor Castro, Carolina Gouveia, Ana Carvalho Marques, Antonio Jorge Cabral
TP63 Perioperative anaphylaxis: a growing concern in pediatric population
Luis Amaral, Fabrícia Carolino, Eunice Castro, Madalena Passos, Josefina R. Cernadas
TP64 Raising awareness of hypersensitivity to non-steroidal anti-inflammatory drugs in the pediatric age
Fabrícia Carolino, Luís Amaral, Eunice Dias de Castro, Josefina R. Cernadas
TP65 Perioperative anaphylaxis in young children: how to confirm the suspicion
Josefina R. Cernadas, Fabrícia Carolino, Luís Amaral, Fernando Pineda, Armanda Gomes
TP66 A case study of a child suspected to be penicillin allergic-digging deeper
Katherine Knight, Roisin Fitzsimons, Helen Brough
TP67 Prevalence, characteristics and risk factors of hypersensitivity reactions to antibiotics in patients with cystic fibrosis
Jobst Röhmel, Carsten Schwarz, Anne Mehl, Philippe Stock, Doris Staab
TP68 Antibiotic drug hypersensitivity in cystic fibrosis: A pilot study using cellular allergy tests for diagnostics
Jobst Röhmel, Carsten Schwarz, Christine Seib, Doris Staab, Philippe Stock
TP69 Oral antibiotics challenges in children
Anita Critchlow, Alyson Barber, Nicola Jay
TP70 Hypersensitivity reaction to vancomycin: a new successful desensitization protocol
Belen Delavalle, Teresa Garriga, Blanca Vilá, Cristina Blasco
TP71
TP72 Clinical phenotypes according to FLG gene loss of function mutations in children with atopic dermatitis
Francesca Cipriani, Annalisa Astolfi, Costanza Di Chiara, Elisabetta Calamelli, Iria Neri, Annalisa Patrizi, Gianpaolo Ricci
TP73
TP74 Urticaria in children: clinical and epidemiological features
Katerina Neskorodova, Asya Kudryavtseva
TP75
TP76 Acute urticaria at the Pediatrics Emergency Department: is it allergy?
Esozia Arroabarren, Jorge Alvarez, Marta Anda, Miriam Palacios, Marta Martinez-Merino, Ibone Vaquero
TP77
doi:10.1186/s13601-016-0117-8
PMCID: PMC5123301
9.  Child protection procedures in emergency departments 
Emergency Medicine Journal : EMJ  2007;24(12):831-835.
Background
Emergency departments (EDs) may be the first point at which children who have been subject to abuse or neglect come into contact with professionals who are able to act for their protection. In order to ascertain current procedures for identifying and managing child abuse, we conducted a survey of EDs in England and Northern Ireland.
Methods
Questionnaires were sent to the lead professionals in a random sample of 81 EDs in England and 20 in Northern Ireland. Departments were asked to provide copies of their procedures for child protection. These were analysed qualitatively using a structured template.
Results
A total of 74 questionnaires were returned. 91.3% of departments had written protocols for child protection. Of these, 27 provided copies of their protocols for analysis. Factors judged to improve the practical usefulness of protocols included: those that were brief; were specific to the department; incorporated both medical and nursing management; included relevant contact details; included a single page flow chart which could be accessed separately. 25/71 (35.2%) departments reported that they used a checklist to highlight concerns. The most common factors on the checklists included an inconsistent history or one which did not match the examination; frequent attendances; delay in presentation; or concerns about the child's appearance or behaviour, or the parent–child interaction.
Conclusions
There is a lack of consistency in the approach to identifying and responding to child abuse in EDs. Drawing on the results of this survey, we are able to suggest good practice guidelines for the management of suspected child abuse in EDs. Minimum standards could improve management and facilitate clinical audit and relevant training.
doi:10.1136/emj.2007.051011
PMCID: PMC2658353  PMID: 18029514
10.  Value of systematic detection of physical child abuse at emergency rooms: a cross-sectional diagnostic accuracy study 
BMJ Open  2016;6(3):e010788.
Objectives
The aim of our diagnostic accuracy study Child Abuse Inventory at Emergency Rooms (CHAIN-ER) was to establish whether a widely used checklist accurately detects or excludes physical abuse among children presenting to ERs with physical injury.
Design
A large multicentre study with a 6-month follow-up.
Setting
4 ERs in The Netherlands.
Participants
4290 children aged 0–7 years attending the ER because of physical injury. All children were systematically tested with an easy-to-use child abuse checklist (index test). A national expert panel (reference standard) retrospectively assessed all children with positive screens and a 15% random sample of the children with negative screens for physical abuse, using additional information, namely, an injury history taken by a paediatrician, information provided by the general practitioner, youth doctor and social services by structured questionnaires, and 6-month follow-up information.
Main outcome measure
Physical child abuse.
Secondary outcome measure
Injury due to neglect and need for help.
Results
4253/4290 (99%) parents agreed to follow-up. At a prevalence of 0.07% (3/4253) for inflicted injury by expert panel decision, the positive predictive value of the checklist was 0.03 (95% CI 0.006 to 0.085), and the negative predictive value 1.0 (0.994 to 1.0). There was 100% (93 to 100) agreement about inflicted injury in children, with positive screens between the expert panel and child abuse experts.
Conclusions
Rare cases of inflicted injury among preschool children presenting at ERs for injury are very likely captured by easy-to-use checklists, but at very high false-positive rates. Subsequent assessment by child abuse experts can be safely restricted to children with positive screens at very low risk of missing cases of inflicted injury. Because of the high false positive rate, we do advise careful prior consideration of cost-effectiveness and clinical and societal implications before de novo implementation.
doi:10.1136/bmjopen-2015-010788
PMCID: PMC4809108  PMID: 27006346
ACCIDENT & EMERGENCY MEDICINE; EPIDEMIOLOGY
11.  The Value of a Checklist for Child Abuse in Out-of-Hours Primary Care: To Screen or Not to Screen 
PLoS ONE  2017;12(1):e0165641.
Objectives
To assess the diagnostic value of the screening instrument SPUTOVAMO-R2 (checklist, 5 questions) for child abuse at Out-of-hours Primary Care locations (OPC), by comparing the test outcome with information from Child Protection Services (CPS). Secondary, to determine whether reducing the length of the checklist compromises diagnostic value.
Methods
All children (<18 years) attending one of the participating OPCs in the region of Utrecht, the Netherlands, in a year time, were included. The checklist is an obligatory field in the electronic patient file. CPS provided data on all checklist positives and a sample of 5500 checklist negatives (dataset). The checklist outcome was compared with a report to CPS in 10 months follow up after the OPC visit.
Results
The checklist was filled in for 50671 children; 108 (0.2%) checklists were positive. Within the dataset, 61 children were reported to CPS, with emotional neglect as the most frequent type of abuse (32.8%). The positive predictive value (PPV) of the checklist for child abuse was 8.3 (95% CI 3.9–15.2). The negative predictive value (NPV) was 99.1 (98.8–99.3), with 52 false negatives. When the length of the checklist was reduced to two questions closely related to the medical process (SPUTOVAMO-R3), the PPV was 9.1 (3.7–17.8) and the NPV 99.1 (98.7–99.3). These two questions are on the injury in relation to the history, and the interaction between child and parents.
Conclusions
The checklist SPUTOVAMO-R2 has a low detection rate of child abuse within the OPC setting, and a high false positive rate. Therefore, we recommend to use the shortened checklist only as a tool to increase the awareness of child abuse and not as a diagnostic instrument.
doi:10.1371/journal.pone.0165641
PMCID: PMC5207629  PMID: 28045904
12.  Introduction of HIV post-exposure prophylaxis for sexually abused children in Malawi 
Archives of Disease in Childhood  2005;90(12):1297-1299.
Aims: To improve the care of children who are victims of child sexual abuse (CSA) by routinely assessing eligibility for HIV post-exposure prophylaxis (PEP) and to investigate the feasibility, safety, and efficacy of such treatment started in a paediatric emergency department in Malawi.
Methods: Children presenting to the Queen Elizabeth Central Hospital, Blantyre between 1 January 2004 and 31 December 2004 with a history of alleged CSA were assessed for eligibility for HIV PEP and followed prospectively for six months.
Results: A total of 64 children presented with a history of alleged CSA in the 12 month period; 17 were offered PEP. The remainder were not offered PEP because of absence of physical signs of abuse (n = 20), delay in presentation beyond 72 hours from assault (n = 11), repeated sexual abuse in the preceding six months (n = 15), and HIV infection found on initial testing (n = 1). No family refused an HIV test. No side effects due to antiretroviral therapy were reported. Of the 17 children commenced on PEP, 11 returned for review after one month, seven returned at three months, and two of 15 returned at six months post-assault. None have seroconverted.
Conclusions: In a resource-poor setting with a high HIV prevalence, HIV PEP following CSA is acceptable, safe, and feasible. HIV PEP should be incorporated in to national guidelines in countries with a high community prevalence of HIV infection.
doi:10.1136/adc.2005.080432
PMCID: PMC1720206  PMID: 16174638
13.  Hospital Based Emergency Department Visits Attributed to Child Physical Abuse in United States: Predictors of In-Hospital Mortality 
PLoS ONE  2014;9(6):e100110.
Objectives
To describe nationally representative outcomes of physical abuse injuries in children necessitating Emergency Department (ED) visits in United States. The impact of various injuries on mortality is examined. We hypothesize that physical abuse resulting in intracranial injuries are associated with worse outcome.
Materials and Methods
We performed a retrospective analysis of the Nationwide Emergency Department Sample (NEDS), the largest all payer hospital based ED database, for the years 2008–2010. All ED visits and subsequent hospitalizations with a diagnosis of “Child physical abuse” (Battered baby or child syndrome) due to various injuries were identified using ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification) codes. In addition, we also examined the prevalence of sexual abuse in this cohort. A multivariable logistic regression model was used to examine the association between mortality and types of injuries after adjusting for a multitude of patient and hospital level factors.
Results
Of the 16897 ED visits that were attributed to child physical abuse, 5182 (30.7%) required hospitalization. Hospitalized children were younger than those released treated and released from the ED (1.9 years vs. 6.4 years). Male or female partner of the child’s parent/guardian accounted for >45% of perpetrators. Common injuries in hospitalized children include- any fractures (63.5%), intracranial injuries (32.3%) and crushing/internal injuries (9.1%). Death occurred in 246 patients (13 in ED and 233 following hospitalization). Amongst the 16897 ED visits, 1.3% also had sexual abuse. Multivariable analyses revealed each 1 year increase in age was associated with a lower odds of mortality (OR = 0.88, 95% CI = 0.81–0.96, p<0.0001). Females (OR = 2.39, 1.07–5.34, p = 0.03), those with intracranial injuries (OR = 65.24, 27.57–154.41, p<0.0001), or crushing/internal injury (OR = 4.98, 2.24–11.07, p<0.0001) had higher odds of mortality compared to their male counterparts.
Conclusions
In this large cohort of physically abused children, younger age, females and intracranial or crushing/internal injuries were independent predictors of mortality. Identification of high risk cohorts in the ED may enable strengthening of existing screening programs and optimization of outcomes.
doi:10.1371/journal.pone.0100110
PMCID: PMC4053408  PMID: 24919088
14.  Improving compliance with iron infusion therapy in the treatment of chronic anemia in haemodialysis patients with chronic kidney disease 
BMJ Quality Improvement Reports  2015;4(1):u204642.w2177.
This quality improvement project was conducted at the haemodialysis unit in the paediatric nephrology department at Noah's Ark Children's Hospital, Cardiff. Stakeholders involved were the medical and nursing staff at the haemodialysis unit, responsible for the care of children with chronic kidney disease CKD.
Anaemia is prevalent among children with CKD. Iron infusion is administered to such children with chronic anaemia. Children on haemodialysis attending the Children's Kidney Center receive iron infusion if they satisfy the criteria based on haemoglobin and serum ferritin values according to departmental guidelines. This involves measurement of c-reactive protein and serum ferritin prior to iron administration. High iron exposure is detrimental to end organ function and hence warrants regular monitoring in conjunction with CRP, another inflammatory marker. We suspect that some children may be receiving iron infusions despite being iron replete. Also, we may be over-investigating these children with anaemia.
We identified all children receiving iron infusion in the haemodialysis unit over a four week period. We retrospectively enquired blood investigations done, prior to and after iron infusion. Blood investigations lagged on pre and post infusion times.
We devised a checklist for nursing staff to follow, primarily looking at set times for measuring haemoglobin, serum ferritin, and CRP during the month (at the start of the first and third week of the month) and also tabulating the ferritin values that would trigger frequency of iron infusions. These were aimed to:
1. Prevent iron overloading in patients with chronic anemia
2. Regularise the checking of bloods in those receiving iron infusions
3. Empower the nursing staff to independently take decisions on iron infusion delivery.
The strategy for change encompassed multiple PDSA cycles.
Plan: empower decision making on iron infusion by haemodialysis nursing staff
Do: formulate a checklist for iron infusion based on the recommended set values of ferritin, CRP and haemoglobin
Study: analyse adherence to checklist in three months time
Act: make appropriate changes to workplace behaviour based on findings of the PDSA cycle
We analysed 13 patient episodes prior to the intervention and a total of 19 patient episodes after the improvement cycles. The checklist was improved based on feedback obtained after the first PDSA cycle. A second cycle showed that investigations done were optimised. The third cycle showed improved adherence and compliance with prevention of over-treatment with iron infusion. There was 100% adherence to the investigations done prior to infusion and complied well with the department guidelines. This meant that the required number of blood tests were done on a more regular basis and it did not exceed from those done previously.
Nursing behaviour with regard to initiation and maintenance of iron infusion became more independent. This empowered nursing decision making skills and consequently freed doctor-time. It also resulted in improving team morale and ultimately patient safety by mitigating human errors.
For any QI project, interventions should be carefully designed. Stakeholder buy-in and easy accessibility of the intervention improves sustainability. Multiple PDSA cycles and incorporating stakeholder feedback into the cycle are key to success.
doi:10.1136/bmjquality.u204642.w2177
PMCID: PMC4645701  PMID: 26734315
15.  Monitoring the Impact of Influenza by Age: Emergency Department Fever and Respiratory Complaint Surveillance in New York City 
PLoS Medicine  2007;4(8):e247.
Background
The importance of understanding age when estimating the impact of influenza on hospitalizations and deaths has been well described, yet existing surveillance systems have not made adequate use of age-specific data. Monitoring influenza-related morbidity using electronic health data may provide timely and detailed insight into the age-specific course, impact and epidemiology of seasonal drift and reassortment epidemic viruses. The purpose of this study was to evaluate the use of emergency department (ED) chief complaint data for measuring influenza-attributable morbidity by age and by predominant circulating virus.
Methods and Findings
We analyzed electronically reported ED fever and respiratory chief complaint and viral surveillance data in New York City (NYC) during the 2001–2002 through 2005–2006 influenza seasons, and inferred dominant circulating viruses from national surveillance reports. We estimated influenza-attributable impact as observed visits in excess of a model-predicted baseline during influenza periods, and epidemic timing by threshold and cross correlation. We found excess fever and respiratory ED visits occurred predominantly among school-aged children (8.5 excess ED visits per 1,000 children aged 5–17 y) with little or no impact on adults during the early-2002 B/Victoria-lineage epidemic; increased fever and respiratory ED visits among children younger than 5 y during respiratory syncytial virus-predominant periods preceding epidemic influenza; and excess ED visits across all ages during the 2003–2004 (9.2 excess visits per 1,000 population) and 2004–2005 (5.2 excess visits per 1,000 population) A/H3N2 Fujian-lineage epidemics, with the relative impact shifted within and between seasons from younger to older ages. During each influenza epidemic period in the study, ED visits were increased among school-aged children, and each epidemic peaked among school-aged children before other impacted age groups.
Conclusions
Influenza-related morbidity in NYC was highly age- and strain-specific. The impact of reemerging B/Victoria-lineage influenza was focused primarily on school-aged children born since the virus was last widespread in the US, while epidemic A/Fujian-lineage influenza affected all age groups, consistent with a novel antigenic variant. The correspondence between predominant circulating viruses and excess ED visits, hospitalizations, and deaths shows that excess fever and respiratory ED visits provide a reliable surrogate measure of incident influenza-attributable morbidity. The highly age-specific impact of influenza by subtype and strain suggests that greater age detail be incorporated into ongoing surveillance. Influenza morbidity surveillance using electronic data currently available in many jurisdictions can provide timely and representative information about the age-specific epidemiology of circulating influenza viruses.
Don Olson and colleagues report that influenza-related morbidity in NYC from 2001 to 2006 was highly age- and strain-specific and conclude that surveillance using electronic data can provide timely and representative information about the epidemiology of circulating influenza viruses.
Editors' Summary
Background.
Seasonal outbreaks (epidemics) of influenza (a viral infection of the nose, throat, and airways) send millions of people to their beds every winter. Most recover quickly, but flu epidemics often disrupt daily life and can cause many deaths. Seasonal epidemics occur because influenza viruses continually make small changes to the viral proteins (antigens) that the human immune system recognizes. Consequently, an immune response that combats influenza one year may provide partial or no protection the following year. Occasionally, an influenza virus with large antigenic changes emerges that triggers an influenza pandemic, or global epidemic. To help prepare for both seasonal epidemics and pandemics, public-health officials monitor influenza-related illness and death, investigate unusual outbreaks of respiratory diseases, and characterize circulating strains of the influenza virus. While traditional influenza-related illness surveillance systems rely on relatively slow voluntary clinician reporting of cases with influenza-like illness symptoms, some jurisdictions have also started to use “syndromic” surveillance systems. These use electronic health-related data rather than clinical impression to track illness in the community. For example, increased visits to emergency departments for fever or respiratory (breathing) problems can provide an early warning of an influenza outbreak.
Why Was This Study Done?
Rapid illness surveillance systems have been shown to detect flu outbreaks earlier than is possible through monitoring deaths from pneumonia or influenza. Increases in visits to emergency departments by children for fever or respiratory problems can provide an even earlier indicator. Researchers have not previously examined in detail how fever and respiratory problems by age group correlate with the predominant circulating respiratory viruses. Knowing details like this would help public-health officials detect and respond to influenza epidemics and pandemics. In this study, the researchers have used data collected between 2001 and 2006 in New York City emergency departments to investigate these aspects of syndromic surveillance for influenza.
What Did the Researchers Do and Find?
The researchers analyzed emergency department visits categorized broadly into a fever and respiratory syndrome (which provides an estimate of the total visits attributable to influenza) or more narrowly into an influenza-like illness syndrome (which specifically indicates fever with cough and/or sore throat) with laboratory-confirmed influenza surveillance data. They found that emergency department visits were highest during peak influenza periods, and that the affect on different age groups varied depending on the predominant circulating viruses. In early 2002, an epidemic reemergence of B/Victoria-lineage influenza viruses caused increased visits among school-aged children, while adult visits did not increase. By contrast, during the 2003–2004 season, when the predominant virus was an A/H3N2 Fujian-lineage influenza virus, excess visits occurred in all age groups, though the relative increase was greatest and earliest among school-aged children. During periods of documented respiratory syncytial virus (RSV) circulation, increases in fever and respiratory emergency department visits occurred in children under five years of age regardless of influenza circulation. Finally, the researchers found that excess visits to emergency departments for fever and respiratory symptoms preceded deaths from pneumonia or influenza by about two weeks.
What Do These Findings Mean?
These findings indicate that excess emergency department visits for fever and respiratory symptoms can provide a reliable and timely surrogate measure of illness due to influenza. They also provide new insights into how different influenza viruses affect people of different ages and how the timing and progression of each influenza season differs. These results, based on data collected over only five years in one city, might not be generalizable to other settings or years, warn the researchers. However, the present results strongly suggest that the routine monitoring of influenza might be improved by using electronic health-related data, such as emergency department visit data, and by examining it specifically by age group. Furthermore, by showing that school-aged children can be the first people to be affected by seasonal influenza, these results highlight the important role this age group plays in community-wide transmission of influenza, an observation that could influence the implementation of public-health strategies such as vaccination that aim to protect communities during influenza epidemics and pandemics.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0040247.
• US Centers for Disease Control and Prevention provides information on influenza for patients and health professionals and on influenza surveillance in the US (in English, Spanish, and several other languages)
• World Health Organization has a fact sheet on influenza and on global surveillance for influenza (in English, Spanish, French, Russian, Arabic, and Chinese)
• The MedlinePlus encyclopedia contains a page on flu (in English and Spanish)
• US National Institute of Allergy and Infectious Diseases has a feature called “focus on flu”
• A detailed report from the US Centers for Disease Control and Prevention titled “Framework for Evaluating Public Health Surveillance Systems for Early Detection of Outbreaks” includes a simple description of syndromic surveillance
• The International Society for Disease Surveillance has a collaborative syndromic surveillance public wiki
• The Anthropology of the Contemporary Research Collaboratory includes working papers and discussions by cultural anthropologists studying modern vital systems security and syndromic surveillance
doi:10.1371/journal.pmed.0040247
PMCID: PMC1939858  PMID: 17683196
16.  The Effectiveness of Community Action in Reducing Risky Alcohol Consumption and Harm: A Cluster Randomised Controlled Trial 
PLoS Medicine  2014;11(3):e1001617.
In a cluster randomized controlled trial, Anthony Shakeshaft and colleagues measure the effectiveness of a multi-component community-based intervention for reducing alcohol-related harm.
Background
The World Health Organization, governments, and communities agree that community action is likely to reduce risky alcohol consumption and harm. Despite this agreement, there is little rigorous evidence that community action is effective: of the six randomised trials of community action published to date, all were US-based and focused on young people (rather than the whole community), and their outcomes were limited to self-report or alcohol purchase attempts. The objective of this study was to conduct the first non-US randomised controlled trial (RCT) of community action to quantify the effectiveness of this approach in reducing risky alcohol consumption and harms measured using both self-report and routinely collected data.
Methods and Findings
We conducted a cluster RCT comprising 20 communities in Australia that had populations of 5,000–20,000, were at least 100 km from an urban centre (population ≥ 100,000), and were not involved in another community alcohol project. Communities were pair-matched, and one member of each pair was randomly allocated to the experimental group. Thirteen interventions were implemented in the experimental communities from 2005 to 2009: community engagement; general practitioner training in alcohol screening and brief intervention (SBI); feedback to key stakeholders; media campaign; workplace policies/practices training; school-based intervention; general practitioner feedback on their prescribing of alcohol medications; community pharmacy-based SBI; web-based SBI; Aboriginal Community Controlled Health Services support for SBI; Good Sports program for sports clubs; identifying and targeting high-risk weekends; and hospital emergency department–based SBI. Primary outcomes based on routinely collected data were alcohol-related crime, traffic crashes, and hospital inpatient admissions. Routinely collected data for the entire study period (2001–2009) were obtained in 2010. Secondary outcomes based on pre- and post-intervention surveys (n = 2,977 and 2,255, respectively) were the following: long-term risky drinking, short-term high-risk drinking, short-term risky drinking, weekly consumption, hazardous/harmful alcohol use, and experience of alcohol harm. At the 5% level of statistical significance, there was insufficient evidence to conclude that the interventions were effective in the experimental, relative to control, communities for alcohol-related crime, traffic crashes, and hospital inpatient admissions, and for rates of risky alcohol consumption and hazardous/harmful alcohol use. Although respondents in the experimental communities reported statistically significantly lower average weekly consumption (1.90 fewer standard drinks per week, 95% CI = −3.37 to −0.43, p = 0.01) and less alcohol-related verbal abuse (odds ratio = 0.58, 95% CI = 0.35 to 0.96, p = 0.04) post-intervention, the low survey response rates (40% and 24% for the pre- and post-intervention surveys, respectively) require conservative interpretation. The main limitations of this study are as follows: (1) that the study may have been under-powered to detect differences in routinely collected data outcomes as statistically significant, and (2) the low survey response rates.
Conclusions
This RCT provides little evidence that community action significantly reduces risky alcohol consumption and alcohol-related harms, other than potential reductions in self-reported average weekly consumption and experience of alcohol-related verbal abuse. Complementary legislative action may be required to more effectively reduce alcohol harms.
Trial registration
Australian New Zealand Clinical Trials Registry ACTRN12607000123448
Please see later in the article for the Editors' Summary
Editors' Summary
Background
People have consumed alcoholic beverages throughout history, but alcohol use is now an increasing global public health problem. According to the World Health Organization's 2010 Global Burden of Disease Study, alcohol use is the fifth leading risk factor (after high blood pressure and smoking) for disease and is responsible for 3.9% of the global disease burden. Alcohol use contributes to heart disease, liver disease, depression, some cancers, and many other health conditions. Alcohol also affects the well-being and health of people around those who drink, through alcohol-related crimes and road traffic crashes. The impact of alcohol use on disease and injury depends on the amount of alcohol consumed and the pattern of drinking. Most guidelines define long-term risky drinking as more than four drinks per day on average for men or more than two drinks per day for women (a “drink” is, roughly speaking, a can of beer or a small glass of wine), and short-term risky drinking (also called binge drinking) as seven or more drinks on a single occasion for men or five or more drinks on a single occasion for women. However, recent changes to the Australian guidelines acknowledge that a lower level of alcohol consumption is considered risky (with lifetime risky drinking defined as more than two drinks a day and binge drinking defined as more than four drinks on one occasion).
Why Was This Study Done?
In 2010, the World Health Assembly endorsed a global strategy to reduce the harmful use of alcohol. This strategy emphasizes the importance of community action–a process in which a community defines its own needs and determines the actions that are required to meet these needs. Although community action is highly acceptable to community members, few studies have looked at the effectiveness of community action in reducing risky alcohol consumption and alcohol-related harm. Here, the researchers undertake a cluster randomized controlled trial (the Alcohol Action in Rural Communities [AARC] project) to quantify the effectiveness of community action in reducing risky alcohol consumption and harms in rural communities in Australia. A cluster randomized trial compares outcomes in clusters of people (here, communities) who receive alternative interventions assigned through the play of chance.
What Did the Researchers Do and Find?
The researchers pair-matched 20 rural Australian communities according to the proportion of their population that was Aboriginal (rates of alcohol-related harm are disproportionately higher among Aboriginal individuals than among non-Aboriginal individuals in Australia; they are also higher among young people and males, but the proportions of these two groups across communities was comparable). They randomly assigned one member of each pair to the experimental group and implemented 13 interventions in these communities by negotiating with key individuals in each community to define and implement each intervention. Examples of interventions included general practitioner training in screening for alcohol use disorders and in implementing a brief intervention, and a school-based interactive session designed to reduce alcohol harm among young people. The researchers quantified the effectiveness of the interventions using routinely collected data on alcohol-related crime and road traffic crashes, and on hospital inpatient admissions for alcohol dependence or abuse (which were expected to increase in the experimental group if the intervention was effective because of more people seeking or being referred for treatment). They also examined drinking habits and experiences of alcohol-related harm, such as verbal abuse, among community members using pre- and post-intervention surveys. After implementation of the interventions, the rates of alcohol-related crime, road traffic crashes, and hospital admissions, and of risky and hazardous/harmful alcohol consumption (measured using a validated tool called the Alcohol Use Disorders Identification Test) were not statistically significantly different in the experimental and control communities (a difference in outcomes that is not statistically significantly different can occur by chance). However, the reported average weekly consumption of alcohol was 20% lower in the experimental communities after the intervention than in the control communities (equivalent to 1.9 fewer standard drinks per week per respondent) and there was less alcohol-related verbal abuse post-intervention in the experimental communities than in the control communities.
What Do These Findings Mean?
These findings provide little evidence that community action reduced risky alcohol consumption and alcohol-related harms in rural Australian communities. Although there was some evidence of significant reductions in self-reported weekly alcohol consumption and in experiences of alcohol-related verbal abuse, these findings must be interpreted cautiously because they are based on surveys with very low response rates. A larger or differently designed study might provide statistically significant evidence for the effectiveness of community action in reducing risky alcohol consumption. However, given their findings, the researchers suggest that legislative approaches that are beyond the control of individual communities, such as alcohol taxation and restrictions on alcohol availability, may be required to effectively reduce alcohol harms. In other words, community action alone may not be the most effective way to reduce alcohol-related harm.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001617.
The World Health Organization provides detailed information about alcohol; its fact sheet on alcohol includes information about the global strategy to reduce the harmful use of alcohol; the Global Information System on Alcohol and Health provides further information about alcohol, including information on control policies around the world
The US National Institute on Alcohol Abuse and Alcoholism has information about alcohol and its effects on health
The US Centers for Disease Control and Prevention has a website on alcohol and public health that includes information on the health risks of excessive drinking
The UK National Health Service Choices website provides detailed information about drinking and alcohol, including information on the risks of drinking too much, tools for calculating alcohol consumption, and personal stories about alcohol use problems
MedlinePlus provides links to many other resources on alcohol
More information about the Alcohol Action in Rural Communities project is available
doi:10.1371/journal.pmed.1001617
PMCID: PMC3949675  PMID: 24618831
17.  Femur Fractures in the Pediatric Population: Abuse or Accidental Trauma? 
Background
Child abuse represents a serious threat to the health and well-being of the pediatric population. Orthopaedic specialists will often become involved when child abuse is suspected as a result of the presence of bony injury. Distinguishing abuse from accidental trauma can be difficult and is often based on clinical suspicion.
Questions/purposes
We sought to determine whether accidental femur fractures in pediatric patients younger than age 4 could be distinguished from child abuse using a combination of presumed risk factors from the history, physical examination findings, radiographic findings, and age.
Methods
We searched our institution’s SCAN (Suspected Child Abuse and Neglect) and trauma databases. We identified 70 patients in whom the etiology of their femur fracture was abuse and compared that group with 139 patients who had a femur fracture in whom accidental trauma was the etiology.
Results
A history suspicious for abuse, physical or radiographic evidence of prior injury, and age younger than 18 months were risk factors for abuse. Patients with no risk factors had a 4% chance, patients with one risk factor had a 29% chance, patients with two risk factors had an 87% chance, and patients with all three risk factors had a 92% chance of their femur fracture being a result of abuse.
Conclusions
Clinicians can use this predictive model to guide judgment and referral to social services when seeing femur fractures in very young children in the emergency room.
Level of Evidence
Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-010-1339-z
PMCID: PMC3032851  PMID: 20373153
18.  Femur Fractures in the Pediatric Population: Abuse or Accidental Trauma? 
Background
Child abuse represents a serious threat to the health and well-being of the pediatric population. Orthopaedic specialists will often become involved when child abuse is suspected as a result of the presence of bony injury. Distinguishing abuse from accidental trauma can be difficult and is often based on clinical suspicion.
Questions/purposes
We sought to determine whether accidental femur fractures in pediatric patients younger than age 4 could be distinguished from child abuse using a combination of presumed risk factors from the history, physical examination findings, radiographic findings, and age.
Methods
We searched our institution’s SCAN (Suspected Child Abuse and Neglect) and trauma databases. We identified 70 patients in whom the etiology of their femur fracture was abuse and compared that group with 139 patients who had a femur fracture in whom accidental trauma was the etiology.
Results
A history suspicious for abuse, physical or radiographic evidence of prior injury, and age younger than 18 months were risk factors for abuse. Patients with no risk factors had a 4% chance, patients with one risk factor had a 29% chance, patients with two risk factors had an 87% chance, and patients with all three risk factors had a 92% chance of their femur fracture being a result of abuse.
Conclusions
Clinicians can use this predictive model to guide judgment and referral to social services when seeing femur fractures in very young children in the emergency room.
Level of Evidence
Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-010-1339-z
PMCID: PMC3032851  PMID: 20373153
19.  Preventive health care, 2000 update: prevention of child maltreatment 
Objectives
To update the 1993 report from the Canadian Task Force on the Periodic Health Examination (now the Canadian Task Force on Preventive Health Care) by reviewing the evidence for the effectiveness of interventions aimed at preventing child maltreatment described in the scientific literature over the past 6 years.
Options
Screening: a variety of techniques including assessment of risk indicators. Prevention: programs including home visitation; comprehensive health care programs; parent education and support, combined services and programs aimed specifically at preventing sexual abuse.
Outcomes
Occurrence of one or more of the subcategories of physical abuse, sexual abuse, neglect and emotional abuse in childhood.
Evidence
MEDLINE, PSYCINFO, ERIC and several other databases were searched, experts were consulted, and published recommendations were reviewed. Original research articles and overviews that examined screening for or prevention of child maltreatment were included in the update. No meta-analysis was performed because the range of manoeuvres precluded comparability.
Benefits, harms and costs
Because of the high false-positive rates of screening tests for child maltreatment and the potential for mislabelling people as potential child abusers, the possible harms associated with these screening manoeuvres outweigh the benefits. Two randomized controlled trials showed a reduction in the incidence of childhood maltreatment or outcomes related to physical abuse and neglect among first-time disadvantaged mothers and their infants who received a program of home visitation by nurses in the perinatal period extending through infancy. It is expected that a reduction in incidence of child maltreatment and other outcomes will lead to substantial government savings. Evidence remains inconclusive on the effectiveness of a comprehensive health care program, a parent education and support program, or a combination of services in preventing child maltreatment. Education programs designed to teach children prevention strategies to avoid sexual abuse show increased knowledge and skills but not necessarily reduced abuse.
Values
The systematic review and critical appraisal of the evidence were conducted according to the evidence-based methodology of the Canadian Task Force on Preventive Health Care.
Recommendations
There is further evidence of fair quality to exclude screening procedures aimed at identifying individuals at risk of experiencing or committing child maltreatment (grade D recommendation). There is good evidence to continue recommending a program of home visitation for disadvantaged families during the perinatal period extending through infancy to prevent child abuse and neglect (grade A recommendation). The target group for this program is first-time mothers with one or more of the following characteristics: age less than 19 years, single parent status and low socioeconomic status. The strongest evidence is for an intensive program of home visitation delivered by nurses beginning prenatally and extending until the child's second birthday. There is insufficient evidence to recommend a comprehensive health care program (grade C recommendation), a parent education and support program (grade C recommendation) or a combination of home-based services (grade C recommendation) as a strategy for preventing child maltreatment, but these interventions may be recommended for other reasons. There is insufficient evidence to recommend education programs for the prevention of sexual abuse (grade C recommendation); whether such programs reduce the incidence of sexual abuse has not been established.
Validation
The members of the Canadian Task Force on Preventive Health Care reviewed the findings of this analysis through an iterative process. The task force sent the final review and recommendations to selected external expert reviewers, and their feedback was incorporated.
Sponsors
The Canadian Task Force on Preventive Health Care is funded through a partnership between the Provincial and Territorial Ministries of Health and Health Canada.
PMCID: PMC80412  PMID: 11192650
20.  Therapeutic Intervention and Parenting Style of Abusive Parents 
Background:
Victims of abuse comprise a significant proportion of all child psychiatric admissions, with an estimated 30% incidence of lifetime of physical and sexual abuse among child and adolescent outpatients, and as high as 55% among psychiatric inpatients.
Objectives:
The present study was conducted to examine the effects of therapeutic intervention and parent management training on parenting skill of abusive parents.
Patients and Methods:
The study population consisted of all children who were referred to Child Psychiatric and Pediatric Departments of Imam Hossein Hospital, Tehran, IR Iran diagnosed with child abuse. Children and their families were visited by a psychiatrist for psychiatric problems. Later, the necessary interventions were taken for the children. To study the effect of intervention, parents completed ‘Being a Parent and Parenting Scale’ before intervention, and then again, in the third and sixth months following the intervention. The interventions included 8 weekly parent management training sessions for all of the involved parents and additional pharmacologic and psychological interventions according to the subjects’ needs.
Results:
Participants included 73 children with the mean age of 6.9 ± 4.3 year, while the mean age of parents was 31.76 ± 6.52 year for the mothers and 38.07 ± 8.45 year for the fathers. General anxiety disorder (30.1%) and depression (27.4%) were the most common psychiatric disorders among mothers. In parenting scale, there were significant differences between the zero and third month in all subscales (P = 0.008), but there was no significant difference in verbosity and overreactivity after 6 months. Laxness showed significant changes over the period (P = 0.03). In viewing the ‘Being a Parent Scale’, there was no significant difference in satisfaction and competency subscales before and after the intervention.
Conclusions:
Therapeutic intervention and parent management training improves parenting skill of abusive parents, and this might lead to fewer incidents of abuse or neglect.
doi:10.5812/ijhrba.22156
PMCID: PMC4331661  PMID: 25741485
Child Abuse; Intervention Studies; Parenting; Parent-Child Relations
21.  Is early detection of abused children possible?: a systematic review of the diagnostic accuracy of the identification of abused children 
BMC Pediatrics  2013;13:202.
Background
Early detection of abused children could help decrease mortality and morbidity related to this major public health problem. Several authors have proposed tools to screen for child maltreatment. The aim of this systematic review was to examine the evidence on accuracy of tools proposed to identify abused children before their death and assess if any were adapted to screening.
Methods
We searched in PUBMED, PsycINFO, SCOPUS, FRANCIS and PASCAL for studies estimating diagnostic accuracy of tools identifying neglect, or physical, psychological or sexual abuse of children, published in English or French from 1961 to April 2012. We extracted selected information about study design, patient populations, assessment methods, and the accuracy parameters. Study quality was assessed using QUADAS criteria.
Results
A total of 2 280 articles were identified. Thirteen studies were selected, of which seven dealt with physical abuse, four with sexual abuse, one with emotional abuse, and one with any abuse and physical neglect. Study quality was low, even when not considering the lack of gold standard for detection of abused children. In 11 studies, instruments identified abused children only when they had clinical symptoms. Sensitivity of tests varied between 0.26 (95% confidence interval [0.17-0.36]) and 0.97 [0.84-1], and specificity between 0.51 [0.39-0.63] and 1 [0.95-1]. The sensitivity was greater than 90% only for three tests: the absence of scalp swelling to identify children victims of inflicted head injury; a decision tool to identify physically-abused children among those hospitalized in a Pediatric Intensive Care Unit; and a parental interview integrating twelve child symptoms to identify sexually-abused children. When the sensitivity was high, the specificity was always smaller than 90%.
Conclusions
In 2012, there is low-quality evidence on the accuracy of instruments for identifying abused children. Identified tools were not adapted to screening because of low sensitivity and late identification of abused children when they have already serious consequences of maltreatment. Development of valid screening instruments is a pre-requisite before considering screening programs.
doi:10.1186/1471-2431-13-202
PMCID: PMC4029314  PMID: 24314318
Child abuse; Child neglect; Systematic review; Diagnostic accuracy
22.  National audit of emergency department child protection procedures 
Emergency Medicine Journal : EMJ  2003;20(3):222-224.
Objective: To assess the compliance with national guidelines on child protection procedures and provision of paediatric services in major English emergency departments.
Background: Victims of child abuse may present to emergency departments, and successful detection and management depends on adequate child protection procedures being in place. Two official documents published in 1999 provide recommendations for child protection procedures and staffing arrangements in emergency departments, and these can be used as standards for audit.
Methods: Structured telephone questionnaire survey of English emergency departments receiving at least 18 000 child attenders per year.
Results: Many of the standards are being met. Areas for improvement include: better access to child protection registers with clearer indications for their use; improved communication with other professionals such as the school nurse; more formal training for medical and nursing staff in the identification of potential indicators of child abuse; and improved awareness of local named professionals with expertise in child protection. More consultants with training in paediatric emergency medicine and more registered children's nurses are needed.
Conclusion: Many nationally agreed recommendations are being met, but there is a need for improved training, increased numbers of specialised staff, and improved communication between professionals. There is considerable variation in practice between departments.
doi:10.1136/emj.20.3.222
PMCID: PMC1726076  PMID: 12748133
23.  Randomized Prospective Study to Evaluate Child Abuse Documentation in the Emergency Department 
Objectives
To determine whether an educational intervention for health care providers would result in improved documentation of cases of possible physical child abuse in children < 36 months old treated in the emergency department (ED) setting.
Methods
This study had a statewide group-randomized prospective trial design. Participating EDs were randomized to one of three intervention groups: no intervention, partial intervention, full intervention. Medical records for children < 36 months of age were abstracted before, during, and after the intervention periods for specific documentation elements. The main outcome measure was the change in documentation from baseline. Generalized estimating equations (GEEs) were used to test for intervention effect.
Results
One thousand five hundred and seventy-five charts from 14 hospitals EDs were abstracted. Hospital and demographic characteristics were similar across intervention groups. There were 922 (59%) injury visits and 653 (41%) non-injury visits. For each specific documentation element, a GEE model gave p values of > 0.2 in independent tests, indicating no evidence of significant change in documentation after the intervention. Even among the 26 charts in which the possibility of physical abuse was noted, documentation remained variable.
Conclusions
The educational interventions studied did not improve ED documentation of cases of possible physical child abuse. The need for improved health care provider education in child abuse identification and documentation remains. Future innovative educational studies to improve recognition of abuse are warranted.
doi:10.1111/j.1553-2712.2008.00346.x
PMCID: PMC4461201  PMID: 19154562
child abuse; emergency department; intervention
24.  Assessment of Unsuspected Exposure to Drugs of Abuse in Children from a Mediterranean City by Hair Testing 
Hair testing was used to investigate the prevalence of unsuspected exposure to drugs of abuse in a group of children presenting to an urban paediatric emergency department without suggestive signs or symptoms. Hair samples were obtained from 114 children between 24 months and 10 years of age attending the emergency room of Hospital del Mar in Barcelona, Spain. Hair samples from the accompanying parent were also collected. The samples were analyzed for the presence of opiates, cocaine, amphetamines, and cannabinoids by ultra-performance liquid chromatography-tandem mass spectrometry. Parental sociodemographics and possible drug of abuse history were recorded. Hair samples from twenty-three children (20.1%) were positive for cocaine (concentration range 0.15–3.81 ng/mg hair), those of thirteen children (11.4%) to cannabinoids (Δ9-THC concentration range 0.05–0.54 ng/mg hair), with four samples positive to codeine (0.1–0.25 ng/mg hair), one positive for 2.09 ng methadone per mg hair and one to 6-MAM (0.42 ng/mg hair) and morphine (0. 15 ng/mg hair) . In 69.5 and 69.2% of the positive cocaine and cannabinoids cases respectively, drugs was also found in the hair of accompanying parent. Parental sociodemographics were not associated with children exposure to drugs of abuse. However, the behavioural patterns with potential harmful effects for the child’s health (e.g., tobacco smoking, cannabis, benzodiazepines and/or antidepressants use) were significantly higher in the parents of exposed children. In the light of the obtained results (28% overall children exposure to drugs of abuse) and in agreement with 2009 unsuspected 23% cocaine exposure in pre-school children from the same hospital, we support general hair screening to disclose exposure to drugs of abuse in children from risky environments to provide the basis for specific social and health interventions.
doi:10.3390/ijerph110202288
PMCID: PMC3945599  PMID: 24566054
hair testing; drugs of abuse; children; unsuspected exposure
25.  Violence in the United States 
JAMA  2015;314(5):478-488.
IMPORTANCE
Interpersonal violence, which includes child abuse and neglect, youth violence, intimate partner violence, sexual violence, and elder abuse, affects millions of US residents each year. However, surveillance systems, programs, and policies to address violence often lack broad, cross-sector collaboration, and there is limited awareness of effective strategies to prevent violence.
OBJECTIVES
To describe the burden of interpersonal violence in the United States, explore challenges to violence prevention efforts and to identify prevention opportunities.
DATA SOURCES
We reviewed data from health and law enforcement surveillance systems including the National Vital Statistics System, the Federal Bureau of Investigation’s Uniform Crime Reports, the US Justice Department’s National Crime Victimization Survey, the National Survey of Children’s Exposure to Violence, the National Child Abuse and Neglect Data System, the National Intimate Partner and Sexual Violence Survey, the Youth Risk Behavior Surveillance System, and the National Electronic Injury Surveillance System—All Injury Program.
RESULTS
Homicide rates have decreased from a peak of 10.7 per 100 000 persons in 1980 to 5.1 per 100 000 in 2013. Aggravated assault rates have decreased from a peak of 442 per 100 000 in 1992 to 242 per 100 000 in 2012. Nevertheless, annually, there are more than 16 000 homicides and 1.6 million nonfatal assault injuries requiring treatment in emergency departments. More than 12 million adults experience intimate partner violence annually and more than 10 million children younger than 18 years experience some form of maltreatment from a caregiver, ranging from neglect to sexual abuse, but only a small percentage of these violent incidents are reported to law enforcement, health care clinicians, or child protective agencies. Moreover, exposure to violence increases vulnerability to a broad range of mental and physical health problems over the life course; for example, meta-analyses indicate that exposure to physical abuse in childhood is associated with a 54% increased odds of depressive disorder, a 78% increased odds of sexually transmitted illness or risky sexual behavior, and a 32% increased odds of obesity. Rates of violence vary by age, geographic location, sex, and race/ethnicity, and significant disparities exist. Homicide is the leading cause of death for non-Hispanic blacks from age 1 through 44 years, whereas it is the fifth most common cause of death among non-Hispanic whites in this age range. Additionally, efforts to understand, prevent, and respond to interpersonal violence have often neglected the degree to which many forms of violence are interconnected at the individual level, across relationships and communities, and even intergenerationally. The most effective violence prevention strategies include parent and family-focused programs, early childhood education, school-based programs, therapeutic or counseling interventions, and public policy. For example, a systematic review of early childhood home visitation programs found a 38.9% reduction in episodes of child maltreatment in intervention participants compared with control participants.
CONCLUSIONS AND RELEVANCE
Progress has been made in reducing US rates of interpersonal violence even though a significant burden remains. Multiple strategies exist to improve violence prevention efforts, and health care providers are an important part of this solution.
doi:10.1001/jama.2015.8371
PMCID: PMC4692168  PMID: 26241599

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