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The Ottawa Ankle Rules (OAR) are a clinical decision tool used to minimize unnecessary radiographs in ankle and foot injuries. The OAR are a reliable tool to exclude fractures in children over 5 years of age when applied by physicians. Limited data support its use by other health care workers in children. Our objective was to determine the accuracy of the OAR when applied by non-physician providers (NPP).
Children aged 5 to 17 years presenting with an acute ankle or foot injury were enrolled. Phase 1 captured baseline data on x-ray use in 106 patients. NPPs were then educated on the usage of the OAR and completed an OAR learning module. In phase 2, NPPs applied the OAR to 184 included patients.
The sensitivity of the foot rule, as applied by NPP’s, was 100% (56-100% CI) and the specificity was 17% (9-29% CI) for clinically significant fractures. The sensitivity of the ankle portion of the rule, as applied by NPP’s, was 88% (47-99 CI) and the specificity was 31% (23-40% CI) for clinically significant fractures. The only clinically significant fracture missed by NPP’s was detected on physician assessment. Inter-observer agreement was κ=0.24 for the ankle rule and κ=0.49 for the foot rule.
The sensitivity of the OAR when applied by NPP’s was very good. More training and practice using the OAR would likely improve NPP’s inter-observer reliability. Our data suggest the OAR may be a useful tool for NPP’s to apply prior to physician assessment.
Gingivostomatitis is a common, painful pediatric presentation, and yet, few studies are available to guide management. We aimed to describe pediatric emergency physicians’ current practice patterns, with respect to analgesic use in children with acute gingivostomatitis, in order to inform future studies.
A national survey was conducted at all 15 national academic pediatric centres.
Electronic surveys were distributed to pediatric emergency physicians using a modified Dillman protocol; non-respondents received paper surveys via post. Data were collected regarding demographic characteristics, clinical behaviour, factors that may influence practice, and future directions.
Response rate was 74% (150/202). Most physicians (72%) preferred the combination of acetaminophen and ibuprofen to either agent alone (ibuprofen 19%, acetaminophen 7%). The preferred second-line analgesics were oral morphine (48%, 72/150) and compounded topical formulas (42%, 64/150). The most commonly cited compounded agent was Benadryl plus Maalox (23%, 35/150). Clinical experience with a medication had the greatest influence on practice pattern, with 52% (78/149) strongly agreeing. The most commonly cited barrier to adequate analgesia was difficulty in the administration of topical or oral medication to children.
As with many other painful conditions, the combination of acetaminophen and ibuprofen was preferred, followed by either agent alone. Oral morphine and topical compounded agents were also frequently prescribed. Regardless of patient age, physicians preferred oral morphine as a second-line agent to treat pain from severe gingivostomatitis. Future research will focus on determining which analgesic and route (oral or topical) is the most effective and best-tolerated choice.
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