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Background Point-of-care-tests (POCTs) have been advocated to optimise care in patients with infections but their actual use varies. This study aimed to estimate the variability in the adoption of current POCTs by paediatricians across Europe, and to explore the determinants of variability. Methods and findings A cross-sectional survey was conducted of hospital and primary care paediatricians, recruited through professional networks. Questions focused on the availability and use of currently available POCTs. Data were analysed descriptively and using Median Odds Ratio (MOR) to measure variation between countries. Multilevel regression modelling using changes in the area under the receiver operating characteristic curve of models were used to assess the contribution of individual or workplace versus country level factors, to the observed variation. The commonest POCT was urine dipsticks (UD) which were available to >80% of primary care and hospital paediatricians in 68% (13/19) and 79% (23/29) countries, respectively. Availability of all POCTs varied between countries. In primary care, the country (MOR) varied from 1.61 (95%CI: 1.04–2.58) for lactate to 7.28 (95%CI: 3.04–24.35) for UD. In hospitals, the country MOR varied from 1.37 (95%CI:1.04–1.80) for lactate to 11.93 (95%CI:3.35–72.23) for UD. Most paediatricians in primary care (69%, 795/1154) and hospital (81%, 962/1188) would use a diagnostic test in the case scenario of an infant with undifferentiated fever. Multilevel regression modelling showed that the country of work was more important in predicting both the availability and use of POCTs than individual or workplace characteristics. Conclusion There is substantial variability in the adoption of POCTs for the management of acute infections in children across Europe. To inform future implementation of both existing and innovative tests, further research is needed to understand what drives the variation between countries, the needs of frontline clinicians, and the role of diagnostic tests in the management of acute childhood infections.

In the European Union (EU), the delivery of health services is a national responsibility but there are concerted actions between member states to protect public health. Approval of pharmaceutical products is the responsibility of the European Medicines Agency, while authorising the placing on the market of medical devices is decentralised to independent ‘conformity assessment’ organisations called notified bodies. The first legal basis for an EU system of evaluating medical devices and approving their market access was the Medical Device Directive, from the 1990s. Uncertainties about clinical evidence requirements, among other reasons, led to the EU Medical Device Regulation (2017/745) that has applied since May 2021. It provides general principles for clinical investigations but few methodological details – which challenges responsible authorities to set appropriate balances between regulation and innovation, pre- and post-market studies, and clinical trials and real-world evidence. Scientific experts should advise on methods and standards for assessing and approving new high-risk devices, and safety, efficacy, and transparency of evidence should be paramount. The European Commission recently awarded a Horizon 2020 grant to a consortium led by the European Society of Cardiology and the European Federation of National Associations of Orthopaedics and Traumatology, that will review methodologies of clinical investigations, advise on study designs, and develop recommendations for aggregating clinical data from registries and other real-world sources. The CORE–MD project (Coordinating Research and Evidence for Medical Devices) will run until March 2024. Here, we describe how it may contribute to the development of regulatory science in Europe. Cite this article: EFORT Open Rev 2021;6:839-849. DOI: 10.1302/2058-5241.6.210081

Between 2015 and 2017, an estimated 200,000 to 400,000 children were seeking asylum each year in EU/EEA countries. As access to high-quality health care is important, we collected and compared current recommendations across Europe for a consensus recommendation on medical care for migrant (asylum-seeking and refugee) children. Existing recommendations were collected from published literature and identified through national representatives from paediatric societies of 31 EU/EEA countries through the European Academy of Paediatrics (EAP). Recommendations were systematically extracted and collected in a database. Those mentioned in at least one recommendation were evaluated for inclusion, and evidence on recommendations was specifically identified in literature searches focused on recent evidence from Europe. For eight EU/EEA countries, a national recommendation was identified. Growth and development, vision and hearing impairment, skin and dental problems, immunisations, anaemia, micronutrient deficiency, helminths, hepatitis B and C, human immunodeficiency virus, malaria, schistosomiasis, syphilis, tuberculosis, mental health disorder and sexual health were most frequently mentioned and therefore selected for inclusion in the recommendation. Conclusion: The current document includes general recommendations on ethical standards, use of interpreters and specific recommendations for prevention or early detection of communicable and non-communicable diseases. It may serve as a tool to ensure the fundamental right that migrant children in Europe receive a comprehensive, patient-centred health care.

A rise in cases with a new hyperinflammatory disease in children has been reported in Europe and in the Unites States of America, named the Paediatric Inflammatory Multisystem Syndrome – temporally associated with SARS-CoV-2 (PIMS-TS). There appears to be a wide spectrum of signs and symptoms with varying degrees of severity, including a toxic shock like presentation with hypovolaemia and shock, and a Kawasaki-like presentation with involvement of the coronary arteries. Most of these children have evidence of a previous infection with SARS-CoV-2, or a history of significant exposure, but not all. Limited data exist on the incidence of PIMS-TS, but it remains a rare condition. Early recognition and escalation of care is important to prevent the development of serious sequelae, such as coronary artery aneurysms. Clinicians assessing febrile children in primary and secondary care should include PIMS-TS in their differential diagnoses. In children fulfilling the case definition, additional investigations should be undertaken to look for evidence of inflammation and multiorgan involvement. Suspected cases should be discussed with experts in paediatric infectious diseases at an early stage, and advice should be sought from critical care in more severe cases early. There is limited consensus on treatment; but most children have been treated with immunoglobulins or steroids, and with early consideration of biologicals such anti-TNF and anti-IL1 agents. Treatment should ideally be within the context of controlled treatment trials. Clinicians are encouraged to document and share their cases using research registries.

Background Despite the fact that vaccines save 2–3 million lives worldwide every year, a percentage of children are not getting appropriately vaccinated, thus leading to disease outbreaks. One of the major reasons of low vaccine uptake in Europe is vaccine hesitancy, contributing to the recent measles outbreaks. Monitoring of vaccine hesitancy is valuable in early identification of vaccine concerns. Methods We performed an eighteen country European survey on parents’ attitudes and behaviors regarding their children’s immunization. Parents having at least one child 1–4 years old were mostly recruited by primary care paediatricians to reply to a web-based questionnaire. The questionnaire was developed by the European Academy of Paediatrics Research in Ambulatory Setting Network steering committee, based on similar surveys. An individual level hesitancy score was constructed using the answers to 21 questions, and correlations of the score with socio-demographic characteristics and types of providers were explored. To assess inter country differences, a country level self -reported confidence was defined. Results Fifty six percent and 24% of 5736 respondents defined themselves as “not at all hesitant”, and “somewhat hesitant”, respectively. Parents who consulted general practitioners were more hesitant than parents who consulted pediatricians (p < 0.05). Consultation with homeopathists was associated with the highest reported hesitancy (p < 0.05). Vaccine confidence was highest in Portugal and Cyprus, and lowest in Bulgaria and Poland. Conclusion The majority of parents in Europe believe in the importance of childhood vaccination. However, significant lack of confidence was found in certain European countries, highlighting the need for continuous monitoring, awareness and response plans. The possible influence of different types of healthcare providers on parental decisions demonstrated for the first time in our survey, calls for further research. Monitoring and continuous medical education efforts aimed mostly at those professionals who might not be likely to recommend vaccination are suggested.

Antimicrobial stewardship (AMS) aims to optimise treatment, minimise the risk of adverse effects and reduce health care costs. In addition, it is recognised as a key component to stop the current spread of antimicrobial resistance in Europe. Educational programmes are particularly important for the successful implementation of AMS. Training should start during medical school, continue during clinical training and be reinforced throughout postgraduate training. National core curricula for paediatric training should include passive and active training of competencies needed for AMS and future paediatricians should be skilled in taking leadership roles in AMS initiatives. Other core members of the paediatric AMS team should also receive training focused on the unique medical needs of the paediatric patient. Conclusion: Ideally, all communities, hospitals and health regions in Europe should have AMS that serve all patient types, including children. We all have the responsibility to ensure that existing antibiotics remain effective. What is Known:• Antimicrobial stewardship (AMS) is a key component to stop the current spread of antimicrobial resistance • Educational programmes are particularly important for the successful implementation of AMS What is New: • All medical doctors in Europe who will be undertaking significant practice in child health should master the competencies needed to prescribe antibiotics to children rationally as described in the European Academy of Paediatrics (EAP) Curriculum for Common Trunk Training in Paediatrics • Interdisciplinary approaches of education need to be developed, as all hospitals and health regions in Europe ideally should have AMS programmes that serve all patient types, including children

Objectives‘Sleeping beauties’, i.e. publications that are not cited for a long while, present interesting findings in science. This study analysed the citation trends of sleeping beauties in paediatric research.MethodsThe study used bibliometric software to analyse the papers citing sleeping beauties in paediatric research, to understand the context in which paediatric sleeping beauties were finally cited and the impact of these sleeping beauties on paediatric research.ResultsTwo paediatric sleeping beauties, addressing medical homes and the transition from paediatric to adult health care, respectively, awakened in response to organizational needs. Both presented novel concepts of paediatric service organization that became important because of an increased need for optimization of services.ConclusionAll sleeping beauties bring new knowledge that becomes important only after several years. Paediatric sleeping beauties exhibited unique characteristics; however, their presence in paediatric research shows that knowledge acquisition in paediatrics resembles that in other disciplines.

Vitamin D is synthesized in human skin upon sun exposure and is also a nutrient. It regulates calcium and phosphate metabolism and is essential for the maintenance of bone health. Vitamin D supplementation during infancy, in order to prevent rickets, is universally accepted. Many human cell types carry vitamin D receptor, this being a drive for conducting studies on the possible association between vitamin D status and other diseases. Studies have affirmed that a considerable number of healthy European children may be vitamin D deficient, especially in high-risk groups (darker pigmented skin, living in areas with reduced sun exposure and other disorders). However, the definition of deficiency is unclear due to inter assay differences and due to a lack of consensus as to what is an "adequate" 25(OH)D level. Therefore, there is no justification for routine screening for vitamin D deficiency in healthy children. An evaluation of vitamin D status is justified in children belonging to high-risk groups. All infants up to 1 year of age should receive an oral supplementation of 400 IU/day of vitamin D. Beyond this age, seasonal variation of sunlight should be taken into account when considering a national policy of supplementation or fortification.

The European Academy of Paediatrics (EAP) is the paediatric section of the European Union of Medical Specialists (UEMS). The UEMS is responsible for the supervision and approval of training programmes in paediatrics and in its subspecialties. This implies also that EAP has the responsibility to address the training of all professionals working with children, to ensure that their paediatric competences and skills are adequate when dealing with children. The EAP has developed syllabi for paediatricians that provide standards of practice, and criteria for the assessment of competencies in trainees and training centres across Europe. The EAP recommends that all health care professionals working with children should have an officially approved training in child health in addition to formal qualifications in their own field. Moreover, the existing paediatric workforce must maintain their knowledge and skills with relevant continuous professional development and medical education in child health. Conclusion: There is a need to reassess the training of all health care professionals caring for children, ensuring that it supports new models of integrated and multidisciplinary care and focuses on the needs of the child and the family. A standardised, competency-based minimum paediatric training programme/curriculum should be part in the specialty curriculums.

ObjectiveTo describe current practice among European paediatricians regarding diagnosis and management of urinary tract infections in children aged 1–36 months and to compare these practices with recently published guidelines.DesignWeb-based large scale survey evaluating knowledge of, attitudes towards and the methods for diagnosing, treating and managing urinary tract infections in children.SettingPrimary and secondary care practices in Europe.Sample1129 paediatricians.ResultsA diagnosis of urinary tract infection is considered by 62% of the respondents in children aged 1–36 months with unexplained fever. The preferred method of urine collection is use of a bag (53% for infants ConclusionsManagement of febrile urinary tract infections remains controversial and heterogeneous in Europe. Simple, short, practical and easy-to-remember guidelines and educational strategies to ensure their implementation should be developed.

In many European countries, paediatric junior staff has no formal training in adolescent medicine and is ill-equipped to deal with issues and health problems such as substance use, unprotected sex, eating disorders and transition to adult care. This position paper of the European Academy of Paediatrics proposes a set of competency-based training goals and objectives as well as pedagogic approaches that are expected to improve the capacity of paediatricians to meet the needs of this important segment of the paediatric population. The content has been developed from available publications and training programmes and mostly covers the generic aspects of adolescent healthcare, such as how to communicate effectively, how to review and address lifestyles, how to perform a respectful and relevant physical examination, how to address common problems of adolescents and how to support adolescents in coping with a chronic condition. Conclusion: The European Academy of Paediatrics urges national bodies, paediatric associations and paediatric teaching departments to adopt these training objectives and put them into practice, so that paediatricians will be better prepared in the future to meet the challenge of delivering appropriate and effective healthcare to adolescents.

Antibiotics are the most commonly prescribed medicines for acutely unwell children worldwide [1]. Many of these antibiotic prescriptions are issued in a primary care setting [2–4]. Despite this, a robust evidence base for agent selection in primary care is lacking for many childhood indications, including community-acquired pneumonia (CAP). In an era of increasing antibiotic resistance, with optimal antibiotic use being paramount to preserve this precious resource, trials involving ambulatory patients representative of those seen in primary care are needed to address this gap., Survey of EAPRASnet and @PREPARE_EUROPE members reveals heterogeneity of antibiotic choice for childhood pneumonia http://ow.ly/4mIS2P

Aim: Young children are the highest receivers of antibiotics in the European Union, with the majority of antibiotics given for children with minor upper respiratory infections (URIs). The study aims to examine paediatricians’ reported views influencing community antibiotic prescribing. Methods: European primary care paediatricians and participants of the European Academy of Paediatrics Research in Ambulatory Setting Network were asked to complete a Web-based survey on knowledge, attitudes and practice of antibiotic prescribing for URIs. Results: The survey was completed by 685 respondents from 21 countries, 397 network participants (response rate 65%) and 288 paediatricians. Overall, 43.5% of respondents overestimated the risks associated with not prescribing antibiotics and the clinical benefit of antibiotics in otitis media and tonsillitis (strong believers in the benefits of antibiotics phenotype). Strong believers are also more likely to be high prescribers of antibiotics. Paediatricians from a low or medium European Surveillance of Antimicrobial Consumption country category prescribe less antibiotics than those from a higher category. Conclusion: There is a clear need for an educational intervention focused on European primary care paediatricians based on the risk-benefit analysis associated with the antibiotic prescribing for minor URIs, to reduce inappropriate prescribing.

The European Academy of Paediatrics (EAP) is gravely concerned about the human papillomavirus (HPV) vaccination crisis in Japan and particularly about the negative position taken by governmental authorities. Given that the HPV vaccine is both safe and effective, there is no recognizable reason to date to withhold this lifesaving and cost effective public health measure from a population. Therefore, the EAP strongly encourages the Japanese health authorities to actively support HPV vaccination for the future health of their children and adolescents.

The eradication of smallpox and the elimination of several other infectious diseases from much of the world has provided convincing evidence that vaccines are among the most effective interventions for promoting health. The current scepticism about immunisation among members of the new US administration carries a risk of decreasing immunisation rates also in Europe. While only a small minority of the population are strongly anti-vaccine, their public activities have significantly influenced an uncertainty among the general population about both the safety of and the necessity for vaccination. Therefore, the EAP calls for greater publically available, scientifically supported information on vaccination, particularly targeted at health care providers, for the further development of electronically based immunisation information systems (IIS). We further call on all European countries to work together both in legislative and public health arenas in order to increase vaccination coverage among the paediatric population. In the interest of children and their parents, the EAP expresses its strong support for childhood immunisation and recommended vaccination schedules. We are prepared to work with governments and media and share the extensive evidence demonstrating the effectiveness and safety of vaccines.

The European Academy of Paediatrics (EAP) is gravely concerned about the human papillomavirus (HPV) vaccination crisis in Japan and particularly about the negative position taken by governmental authorities. Given that the HPV vaccine is both safe and effective, there is no recognizable reason to date to withhold this lifesaving and cost effective public health measure from a population. Therefore, the EAP strongly encourages the Japanese health authorities to actively support HPV vaccination for the future health of their children and adolescents.

From the Strategic Pediatric Alliance, Padova, Italy; European Confederation of Primary Care Pediatricians–Conf ed eration Europ eenne de P ediatrie Ambulatoire, Lyon, France; Strategic Pediatric Alliance, Secretariat, Great West House, Great West Road, Brentford, United Kingdom; European Paediatric Association–Union of National European Paediatric Societies and Associations, Berlin, Germany; Department of Pediatrics, University of Foggia, Foggia, Italy; European Academy of Paediatrics–European Union of Medical Specialists, Brussels, Belgium; Clinica Pediatrica, Universita’ degli Studi, Udine, Italy; Maccabi Health Services, Tel Aviv, Israel; European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine, London, United Kingdom; and Children’s Hospital, Hannover Medical School, Hannover, Germany E P A ising indebtedness has refocused the debate around European healthcare reform to focus on costsaving. Will reforms enable Europe’s healthcare systems to tackle the challenges of demographic and epidemiologic changes, rising demand for healthcare, and an increasing focus on quality improvement? Or will the pressures to deliver more for less inevitably drive costcutting, more rationing, and risk declines in quality and access of care? How can we reshape the debate on European health care reform to encourage a new vision of health? These and other key questions were raised and debated at a recent forum convened by The Economist Conferences in Geneva in March 2011. The alarming conclusions later published by The Economist in a report entitled, “The Future of Health Care in Europe,” paint a very bleak picture (Figure). The pressure on European healthcare systems is likely to have a differentially greater effect on vulnerable groups such as children. Yet children feature very little in a forum like The Economist Conferences and in general health systems debates throughout Europe. European health care systems need to adapt to ongoing financial pressures, while at the same time evolving better to suit changing health care needs of children as chronic conditions become increasingly dominant problems. For example, in response to current global economic pressures, many countries are considering changing from a pediatriciandelivered primary care system to a general practitioner model as a cost-cutting exercise, rather than in response to evidence about quality. Different possible “extreme scenarios” have been described in response to the likelihood that substantial changes in health care will unfold for European healthcare in the next 20 years. Three of these scenarios include: (1) European nations joining forces to create a single panEuropean healthcare system; (2) preventive medicine taking precedence over acute care for sick patients; and (3) European healthcare systems focusing on vulnerable members of society. The first scenario we judge to be unlikely, given the diversity of primary care systems for children in Europe. The second scenario focuses on prevention, already an integral part of a pediatrician’s principal function. The third possibility should include the elderly patients and the very young as the most vulnerable members of society. Unfortunately, children and their unique needs are all too often forgotten in wider health systems discussion and policy planning.

Young children are the highest receivers of antibiotics in the European Union, with the majority of antibiotics given for children with minor upper respiratory infections (URIs). The study aims to examine paediatricians' reported views influencing community antibiotic prescribing.European primary care paediatricians and participants of the European Academy of Paediatrics Research in Ambulatory Setting Network were asked to complete a Web-based survey on knowledge, attitudes and practice of antibiotic prescribing for URIs.The survey was completed by 685 respondents from 21 countries, 397 network participants (response rate 65%) and 288 paediatricians. Overall, 43.5% of respondents overestimated the risks associated with not prescribing antibiotics and the clinical benefit of antibiotics in otitis media and tonsillitis (strong believers in the benefits of antibiotics phenotype). Strong believers are also more likely to be high prescribers of antibiotics. Paediatricians from a low or medium European Surveillance of Antimicrobial Consumption country category prescribe less antibiotics than those from a higher category.There is a clear need for an educational intervention focused on European primary care paediatricians based on the risk-benefit analysis associated with the antibiotic prescribing for minor URIs, to reduce inappropriate prescribing.

An electronic survey assessing primary care pediatricians' estimations and practices regarding parents' vaccination refusal was sent to 395 members of the European Academy of Pediatrics Research in Ambulatory Setting network, with a response rate of 87%. Of respondents who vaccinate in the clinic, 93% estimated the total vaccine refusal rate as

Background Although it is known that differences in paediatric primary care (PPC) are found throughout Europe, little information exists as to where, how and who delivers this care. The aim of this study was to collect information on the current existing situation of PPC in Europe. Methods A survey, in the form of a questionnaire, was distributed to the primary or secondary care delegates of 31 European countries asking for information concerning their primary paediatric care system, demographic data, professionals involved in primary care and details of their training. All of them were active paediatricians with a broad knowledge on how PPC is organised in their countries. Results Responses were received from 29 countries. Twelve countries (41%) have a family doctor/general practitioner (GP/FD) system, seven (24%) a paediatrician-based system and 10 (35%) a combined system. The total number of paediatricians in the 29 countries is 82 078 with 33 195 (40.4%) working in primary care. In only 15 countries (51.7%), paediatric age at the primary care level is defined as 0–18 years. Training in paediatrics is 5 years or more in 20 of the 29 countries. In nine countries, training is less than 5 years. The median training time of GPs/FDs in paediatrics is 4 months (IQR 3–6), with some countries having no formal paediatric training at all. The care of adolescents and involvement in school health programmes is undertaken by different health professionals (school doctors, GPs/FDs, nurses and paediatricians) depending on the country. Conclusions Systems and organisations of PPC in Europe are heterogeneous. The same is true for paediatric training, school healthcare involvement and adolescent care. More research is needed to study specific healthcare indicators in order to evaluate the efficacy of different systems of PPC.

Objective To evaluate differences in child health care service delivery in Europe based on comparisons across health care systems active in European nations. Study design A survey involved experts in child health care of 40 national pediatric societies belonging both to European Union and non-European Union member countries. The study investigated which type of health care provider cared for children in 3 different age groups and the pediatric training and education of this workforce. Results In 24 of 36 countries 70%-100% of children (0-5 years) were cared for by primary care pediatricians. In 12 of 36 of countries, general practitioners (GPs) provided health care to more than 60% of young children. The median percentage of children receiving primary health care by pediatricians was 80% in age group 0-5 years, 50% in age group 6-11, and 25% in children >11 years of age. Postgraduate training in pediatrics ranged from 2 to 6 years. A special primary pediatric care track during general training was offered in 52% of the countries. One-quarter (9/40) of the countries reported a steady state of the numbers of pediatricians, and in one-quarter (11/40) the number of pediatricians was increasing; one-half (20/40) of the countries reported a decreasing number of pediatricians, mostly in those where public health was changing from pediatric to GP systems for primary care. Conclusions An assessment on the variations in workforce and pediatric training systems is needed in all European nations, using the best possible evidence to determine the ideal skill mix between pediatricians and GPs.

This article reviews how Italian National Health Service (NHS) pediatricians have tried to fulfill the obligations of modern primary care providers in a managed care environment, with special reference to the experience of the Veneto region in Italy and compares this situation with the present changes of the health system in the United States. Italian NHS primary care pediatricians work independently in their offices, providing acute and chronic patients to all children 0 to 14 years old: NHS primary care physicians, including 7000 pediatricians, contract directly with the government for the care of patients through a capitated reimbursement system. Twenty-nine independent associations of community pediatricians have been formed with the primary goal to pursue research and education in primary care pediatrics, in addition to traditional care. Several multicenter collaborative research studies at the national level have been organized and four university residency programs are training their residents in community-based pediatricians’ offices also, giving priority to activities specific to ambulatory practice and follow the suggestion of an Italian work group on ambulatory pediatric training. The NHS has allowed the Italian pediatrician to focus on patient care and education rather than business. Computerization has been applied to the practice of medicine through the development of electronic medical records, particularly in the Veneto region. This technology allows combining effective clinical care with outcome researches and facilitates continuing medical education and residents’ training programs. Italian primary care NHS pediatricians have tried to identify and address patient’s needs as well as the needs of a primary care provider in a managed care system. Recent and possible future modifications in the health system in the United States and in Italy need to be examined to learn from similarities and differences. primary care, network research, managed care, national health care, education.

Cor triatriatum dexter is a rare cardiac malformation, usually diagnosed incidentally at operation or necropsy. We report the case of a 5-month-old infant, severely symptomatic, who underwent correction of a highly obstructive cor triatriatum dexter, with multiple anomalies of the systemic venous return and a large interatrial communication. This appears to be the first case of successful repair of this anomaly during infancy.

Lung perfusion was evaluated in 19 patients in whom a Fontan operation had been performed at a mean age of 3.7 years. First pass and equilibrium data were acquired during the lung particle perfusion scan 0.5 to 7.9 years (mean 3.7 years) following the Fontan procedure. Abnormalities of lung perfusion were documented in 8 patients. Minimal underperfusion of small areas of either right or left lung were noted in 4 patients, while the remaining 4 had evidence of major perfusion defects, involving both lungs. The perfusion defects were localized, in the majority of cases, on the side where a palliative procedure had been performed before the Fontan operation: it is of note that all our patients without palliative procedures did not show abnormalities in lung perfusion. Major abnormalities of lung perfusion seemed related to possible intimal thrombosis or emboli due to prolonged polycythemia or to pulmonary vessel distortion due to long-standing shunts.

Oral health is an essential component of children's general health. The aim of this study is to evaluate the training, knowledge, attitudes and practices of primary care paediatricians in oral health in Europe. Paediatricians were invited to complete a survey on the web. There was a 54.3% response rate. The oral health education of the responders was received mainly through continuing medical education and practical experience (51%) rather than in medical school or during paediatric residency training (33%). Twenty-four percent of the responders did not know that the first signs of caries were white spots on the surfaces of teeth. Although 98.8% of paediatricians check the oral health status of children, only 52% feel confident enough to identify dental caries. A large proportion of the paediatricians (43%) recommended a first dental visit for children above the age of 3 years and only 7% under 1 year of age.Paediatricians are familiar with some aspects of the oral health but are not confident in identifying the risk factors. The current postgraduate curriculum in Paediatrics should incorporate training on basic oral healthcare. In addition, continuous educational programmes are needed to keep the knowledge of the paediatrician up to date. What is Known: • Oral health is an essential component of general health that influences the functional, psychological and social dimensions of a child's well-being. • Paediatricians are the leading providers of primary healthcare for children. What is New: • Paediatricians are familiar with some aspects of the oral health of children but are not confident in identifying the risk factors responsible for oral disease. • The current postgraduate curriculum in Paediatrics should incorporate training on basic oral healthcare in children.

Significant abnormalities in cardiac hemodynamics at rest [1, 2], becoming more significant with exercise [3, 4], have been documented at cardiac catheterization in asymptomatic patients who had undergone a successful Fontan procedure. We report in this paper the results of an evaluation with radionuclide angiography of ventricular contraction at rest and during exercise in 20 patients in whom the Fontan procedure had been performed for various types of congenital heart defects. The diagnosis included tricuspid atresia in nine patients, transposition of the great arteries with hypoplastic right ventricle in two, and single ventricle in nine.

Ventricular contraction was evaluated in 18 patients studied at a mean of 2.6 years after Fontan repair. The diagnosis was tricuspid atresia in 9 patients and single ventricle in 9. Gated first-pass and gated equilibrium radionuclide ventriculography were performed at rest and during exercise. Abnormally low ventricular ejection fraction (EF) at rest was present in 8 of 18 patients by the gated equilibrium technique and 6 of 13 technically adequate gated first-pass studies. An abnormal response to exercise (failure of EF to increase less than or equal to 5% from rest to maximal exercise) was found in 10 of 16 patients by the gated equilibrium technique and in 8 of 12 by the gated first-pass technique. Only 2 patients by each radionuclide technique had both normal EF at rest and normal exercise response. Thus, this study confirms the frequent presence of abnormalities in ventricular contraction after the Fontan procedure at rest or during exercise or both despite absence of symptoms. Both EF response and the hemodynamic response during exercise were more abnormal in the presence of an atriopulmonary than an atrioventricular connection.