European journal of pediatrics
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Few episodes of suspected infection observed in paediatric intensive care are classifiable without ambiguity by a priori defined criteria. Most require additional expert judgement. Recently, we observed a high variability in antibiotic prescription rates, not explained by the patients' clinical data or underlying diseases. We hypothesised that the disagreement of experts in adjudication of episodes of suspected infection could be one of the potential causes for this variability. During a 5-month period, we included all patients of a 19-bed multidisciplinary, tertiary, neonatal and paediatric intensive care unit, in whom infection was clinically suspected and antibiotics were prescribed ( n=183). Three experts (two senior ICU physicians and a specialist in infectious diseases) were provided with all patient data, laboratory and microbiological findings. All experts classified episodes according to a priori defined criteria into: proven sepsis, probable sepsis (negative cultures), localised infection and no infection. Episodes of proven viral infection and incomplete data sets were excluded. Of the remaining 167 episodes, 48 were classifiable by a priori criteria ( n=28 proven sepsis, n= 20 no infection). The three experts only achieved limited agreement beyond chance in the remaining 119 episodes (kappa = 0.32, and kappa = 0.19 amongst the ICU physicians). The kappa is a measure of the degree of agreement beyond what would be expected by chance alone, with 0 indicating the chance result and 1 indicating perfect agreement. ⋯ agreement of specialists in hindsight adjudication of episodes of suspected infection is of questionable reliability.
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The original Jones criteria, first introduced in 1944, have been modified four times and updated-revised criteria were published in 1992. A variety of clinical manifestations, which may be the presenting signs and symptoms of acute rheumatic fever, are not included in the updated-revised Jones criteria. A retrospective study was conducted on all children previously diagnosed to have acute rheumatic fever between September 1998 and September 2002. Review was focused on clinical presentation; out of 60 medical records reviewed, 4 patients with unusual clinical presentation were recognised and are reported here to highlight the potential diagnostic problems of acute rheumatic fever. They presented with atypical articular involvement, silent carditis and low-grade fever in the presence some time of a positive family history for rheumatic fever. ⋯ a high index of suspicion and an awareness of the absence of early carditis are necessary to make the diagnosis of acute rheumatic fever.