Management of traumatic dental injuries: a survey of paediatric emergency department health professionals

OBJECTIVE

To assess paediatric emergency department (PED) health professionals' confidence, experience and awareness in managing traumatic dental injuries (TDIs).

DESIGN

A cross-sectional online survey.

SETTING

PED at Alder Hey Children's Hospital and Birmingham Children's Hospital.

RESULTS

94 ED health professionals responded. One-third of responders (n=26) encounter children with dental trauma daily or weekly. TDI teaching during undergraduate training was received by 13% (n=12) of responders, and 32% (n=30) had never received training. Responders thought they would benefit from online resources and regular teaching on paediatric TDIs, in addition to an easy-to-use decision-making tool to signpost families.ED health professionals' confidence in giving advice to families following a TDI, and in recognising types of TDIs, was notably low; -79 and -76 Net Promotor Score, respectively.Responders' awareness of how to recognise and manage TDIs was varied. Majority were aware of the need to attempt to reimplant an avulsed permanent tooth, and the need to refer a child presenting with a complex permanent tooth injury to the oncall dentist. However, very few responders commented on the importance of follow-up. Responders also raised concerns about the lack of dental services to treat TDIs in children.

CONCLUSIONS

There is a need to enhance dental trauma teaching for all ED health professionals who encounter TDIs to increase their confidence and enable them to triage and advise patients appropriately. Additionally, increased signposting for families to the appropriate service could in turn improve outcomes and experience for children who experience a TDI.

Diagnosing acute bone and joint infection in children

Acute bone and joint infections in children are serious, and misdiagnosis can threaten limb and life. Most young children who present acutely with pain, limping, and/or loss of function have transient synovitis, which will resolve spontaneously within a few days. A minority will have a bone or joint infection. Clinicians are faced with a diagnostic challenge: children with transient synovitis can safely be sent home, but children with bone and joint infection require urgent treatment to avoid complications. Clinicians often respond to this challenge by using a series of rudimentary decision support tools, based on clinical, haematological, and biochemical parameters, to differentiate childhood osteoarticular infection from other diagnoses. However, these tools were developed without methodological expertise in diagnostic accuracy and do not consider the importance of imaging (ultrasound scan and MRI). There is wide variation in clinical practice with regard to the indications, choice, sequence, and timing of imaging. This variation is most likely due to the lack of evidence concerning the role of imaging in acute bone and joint infection in children. We describe the first steps of a large UK multicentre study, funded by the National Institute for Health Research, which seeks to integrate definitively the role of imaging into a decision support tool, developed with the assistance of individuals with expertise in the development of clinical prediction tools.

Pain management in children and young adults with minor injury in emergency departments in the UK and Ireland: a PERUKI service evaluation

BACKGROUND

Management of acute pain should commence at the earliest opportunity, as it has many short-term and long-term consequences. A research priority of Paediatric Emergency Research in the UK and Ireland (PERUKI) was to examine paediatric pain practices.

OBJECTIVE

To describe the outcomes for paediatric pain management of minor injuries presenting to emergency departments (EDs) across PERUKI.

METHODS

A retrospective service evaluation was performed over a 7-day period in late 2016/early 2017 across PERUKI sites, and analysis performed using an adapted Donabedian framework. Patients under 16 years presenting with minor trauma were eligible, and data were collected on prehospital management, pain assessment, analgesia administered and injury diagnosed.

RESULTS

Thirty-one sites submitted data on 3888 patients. There were 111 missed cases (missed rate 3.6%). The most common injuries were sprains, lacerations, contusions/abrasions and fractures. Documentation of receiving analgesia before arrival in ED occurred in 21% of patients (n=818). A pain assessment was documented in 57.5% of patients (n=2235) during their ED visit, and 3.5% of patients had their pain reassessed (n=138). Of the patients who presented in severe pain (pain score 7-10 or rated severe), 11% were reassessed. Site variability of initial pain assessment ranged from 1.4% to 100% (median 62%). The characteristics of the top quartile performing centres against the bottom quartile performing centres based on completion rate of initial pain scores were identified.

CONCLUSION

Pain assessment was documented in under 60% of children with minor injury, re-assessment of pain was almost completely absent, data and outcomes were missing in a substantial volume of patients, indicating that pain management and the associated outcomes have not been adequately addressed and prioritised within existing network structures and processes.

784 The landscape of paediatric procedural sedation in UK & Irish emergency departments; a PERUKI study

Aims/Objectives/Background

Approximately 250,000 children undergo paediatric procedural sedation (PPS) in UK and Irish emergency departments (ED) annually. In comparison to other countries, PPS practice in our setting has not been described. We therefore aimed to evaluate PPS practice in UK and Irish EDs.

Methods/Design

Online survey distributed through Paediatric Emergency Research in the UK and Ireland (PERUKI) during June 2020. One respondent per ED completed the survey, including questions on indications, agents, staffing and governance. Results are presented using descriptive statistics.

Results/Conclusions

61/72 (85%) sites responded, of which PPS was performed in 50 (82.0%). Intravenous ketamine was the most common agent (43/50; 86%), followed by fixed concentration nitrous oxide (FCNO, 35/50; 70%), and variable concentration nitrous oxide (VCNO, 13/50; 26%). PPS was mostly performed a few times a week (17/50; 34%) or daily (9/50; 18%). The most frequent indications were wound closure (31/50; 62%), orthopaedic reduction (28/61; 56%) and foreign body removal (17/61; 34%). Required sedationist seniority was highest for propofol and ketamine/es-ketamine (requiring consultant, registrar, or ANP), whilst FCNO was widely delivered by nurses and SHOs. Most sites had a guideline (43/61; 70.5%), documentation proforma (39/61; 63.9%) and equipment (36/61; 59.0%) and patient checklists (41/50; 82%). Explicit discharge criteria were required for ketamine/es-ketamine (40/45; 88.9%), midazolam (9/10; 90%), propofol (7/10; 70%) and VCNO (9/13; 69.2%). Databases existed in 24/61 (39.3%).

We have demonstrated wide PPS use, but non-standardised practice, with only two-thirds of sites using a PPS guideline and standardised proforma. This leads to potential issues of risk and variability, highlighting a need for a UK and Ireland sedation package to standardise PPS practice and data collection, informed by international guidance and evidence. We propose development of a prospective ED sedation registry to facilitate data collection to support research within this area.

Traumatic and non-traumatic dental presentations to the paediatric emergency departments of two UK children's hospitals: A multi-centre evaluation

BACKGROUND

Dental attendances to paediatric emergency departments (PEDs) represent suboptimal use of resources of an unknown scale.

AIM

To evaluate dental attendances at two PEDs in the UK and compare traumatic dental injury (TDI) and non-traumatic dental conditions (NTDCs).

DESIGN

Retrospective data were collected for a 12-month period including demographics, attendance pattern, assessment, and management. Maxillofacial conditions were excluded, and attendances were grouped as TDI and NTDC.

RESULTS

Of 667 attendances, 35.1% (n = 234) were TDI and 64.9% (n = 433) NTDC. Nineteen children reattended. Proportionately, more TDI attenders were male, White British, of lower mean age, and resided in less deprived areas than NTDCs. Over half (52.3%, n = 339) of attendees resided in the 10% most deprived UK areas. Saturday and Monday were modal attendance days; attendance peaked in summer. Over half (56.4%, n = 376) attended out of hours. A majority (74.8%, n = 499) self-referred and half accessed no other service prior to PED attendance. No PED dental input was received for 38.7% (n = 258), and dental treatment was received for 12.4% (n = 83). Antibiotics were provided for 42.1% (n = 281), and 15.4% (n = 103) were admitted.

CONCLUSION

Dental abscesses and toothache accounted for half of attendances, many of these children may be managed in primary care. Improved signposting to alternative dental services for non-urgent conditions may better allocate resources to those with urgent need.

Structures of paediatric pain management: a PERUKI service evaluation study

BACKGROUND

Pain is very common in childhood emergency department (ED) attendances, but is under-recognised and undertreated. Sequential national paediatric analgesia audits demonstrate suboptimal outcomes in several domains. The Donabedian framework examines the structures, processes and outcomes to evaluate quality of care. To date there has been no network-level exploration of structures supporting analgesic practices or attempts to address failure to attain national standards.

OBJECTIVE

To benchmark current variation in assessment and management of childhood pain at network level.

METHODS

Online survey distributed between December 2016 and January 2017 exploring health system structures including pain score tools, pain assessment/protocols, training, practice guidelines and analgesic agent usage. We explored structures, processes and outcomes to identify interventions, and their potential effectiveness and feasibility.

RESULTS

In total 95% (38/40 sites) responded, including 25 tertiary (66%) and 13 secondary hospitals (34%), with a total annual paediatric ED census of 1 225 000 (range 11 500-65 000). Availability of analgesics varied included topical wound anaesthesia in 29/38 sites (76%), oral diclofenac sodium in 22/38 sites (58%) and tramadol in 16/38 sites (42%). Pain assessment was mandatory in initial assessment in 34/38 sites (89%), and 18/38 sites had a policy on frequency of pain assessment (47%). Local guidance aligned with national guidance in 21/38 sites (55%). There was no staff training at induction/orientation in 14/38 sites (37%) and no mandatory competencies in pain management in 23/38 sites (61%). Play specialist services were available in 21/38 sites (55%).

CONCLUSION

Despite national guidance and recommendations from multiple audits, there are substantial variations in structures relating to pain assessment and management across sites. The lack of uniformity is a likely root cause for the persistent suboptimal practices identified by serial national audits. A whole system and person-centred approach to improving pain outcomes by utilising effective interventions seeks to improve paediatric pain outcomes.

Not just little adults: preparing a children's emergency department for COVID-19

COVID-19 presented unique challenges in preparing our stand-alone children's emergency department for the pandemic and has demonstrated well the paediatric adage, 'children aren't little adults'.

COVID-19: A UK Children's Hospital Experience

OBJECTIVES

Reports from China relating to coronavirus disease (COVID-19) in children indicate a milder disease course compared with adults. Although a few pediatric COVID-19 reports from other parts of the world exist, there are none from the United Kingdom. We describe the clinical characteristics of children with COVID-19 admitted to a specialist children's hospital in United Kingdom.

METHODS

Retrospective case-series of inpatients with a positive polymerase chain reaction test for severe acute respiratory syndrome coronavirus 2, during a 6-week period from March 14 to April 24, 2020.

RESULTS

Forty-five children tested positive for severe acute respiratory syndrome coronavirus 2 during the study period. Median (interquartile range) age was 3.5 (0.7-12) years, and 31 (69%) were male. Children with comorbidities constituted 64% (29 of 45) of the study population, including 44% (20 of 45) who were considered "extremely vulnerable." Fever (67%) and cough (55%) were the most common symptoms. High C-reactive protein (>10 mg/L) was observed in 68% (19 of 28). Lymphopenia (<1.2 × 10⁹/L) was observed in 23% (9 of 40) of children, but it was related to coexisting medical conditions in 6 children. Nine children required supplemental oxygen, two of whom received high-flow nasal cannula oxygen; one needed noninvasive ventilation and one child required invasive mechanical ventilation. Median length of stay of children with an admission outcome (n = 42, 93%) was 3 (2-7) days. There were no COVID-19-related deaths.

CONCLUSIONS

COVID-19 had a relatively mild course of illness in majority of the hospitalized children that included a subgroup of vulnerable children with significant comorbidities. Confirmation of this in larger nationwide studies of children is required.

Inhaled methoxyflurane (Penthrox®) versus placebo for injury-associated analgesia in children-the MAGPIE trial (MEOF-002): study protocol for a randomised controlled trial

Background

Pain from injuries is one of the commonest symptoms in children attending emergency departments (EDs), and this is often inadequately treated in both the pre-hospital and ED settings, in part due to challenges of continual assessment and availability of easily administered analgesic options. Pain practices are therefore a key research priority, including within the field of paediatric emergency medicine. Methoxyflurane, delivered via a self-administered Penthrox® inhaler, belongs to the fluorinated hydrocarbon group of volatile anaesthetics and is unique among the group in having analgesic properties at low doses. Despite over 30 years of clinical acute analgesia use, and a large volume of evidence supporting its safety and efficacy, there is a paucity of randomised controlled trial data for Penthrox®.

Methods

This is an international multi-centre randomised, double-blind, placebo-controlled phase III trial assessing the efficacy and safety of methoxyflurane delivered via the Penthrox® inhaler for the management of moderate to severe acute traumatic pain in children and young people aged 6–17 years. Following written informed consent, eligible participants are randomised to self-administer either inhaled methoxyflurane (maximum dose of 2 × 3 ml) or normal saline placebo (maximum dose 2 × 5 ml). Patients, treating clinicians and research nurses are blinded to the treatment. The primary outcome is the change in pain intensity at 15 min after the commencement of treatment, as measured by the Visual Analogue Scale (VAS) or the Wong-Baker FACES® Pain Rating scale, with the latter converted to VAS values. Secondary outcome measures include the number and proportion of responders who achieve a 30% reduction in VAS score compared to baseline, rescue medication requested, time and number of inhalations to first pain relief, global medication performance assessment by the patient, clinician and research nurse, and evaluation of adverse events experienced during treatment and during the subsequent 14 ± 2 days. The primary analysis will be by intention to treat. The total sample size is 110 randomised and treated patients per treatment arm.

Discussion

The Methoxyflurane AnalGesia for Paediatric InjuriEs (MAGPIE) trial will provide efficacy and safety data for methoxyflurane administered via the Penthrox® inhaler, in children and adolescents who present to EDs with moderate to severe injury-related pain.

Trial registration

EudraCT, 2016–004290-41. Registered on 11 April 2017.

ClinicalTrials.gov, NCT03215056. Registered on 12 July 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3511-4) contains supplementary material, which is available to authorized users.

Hanging and near hanging in children: injury patterns and a clinical approach to early management

Near hanging refers to survival following suspension by the neck. This is a devastating injury which can lead to mortality or serious long-term morbidity. Children and young people present to emergency departments following accidental or deliberate near hanging. This article describes the patterns of injury, the initial management and important prognostic factors.

Low-dose methoxyflurane analgesia in adolescent patients with moderate-to-severe trauma pain: a subgroup analysis of the STOP! study

Introduction

The undertreatment of acute pain presents a significant challenge in the Emergency Department. This post hoc subgroup analysis of a previously reported randomized controlled UK study reports the efficacy and safety of low-dose methoxyflurane analgesia in treating adolescent patients with moderate-to-severe trauma pain.

Patients and methods

Three hundred patients (96 in the adolescent subgroup) aged ≥12 years requiring analgesia for acute trauma pain (pain score of 4-7 on the Numerical Rating Scale) at triage were randomized 1:1 to methoxyflurane (up to 6 mL) or placebo (normal saline), both administered using a Penthrox^® inhaler. The patient could request rescue medication (paracetamol/opioids) at any time. The primary endpoint was the change from baseline in visual analog scale (VAS) pain intensity.

Results

Mean VAS pain score for the adolescent subgroup at baseline was ~ 61 mm. Adjusted mean change in VAS pain intensity from baseline to 5, 10, 15, and 20 minutes was -24.5, -28.1, -31.6, and -31.7 mm for methoxyflurane and -14.6, -18.8, -19.2, and -23.7 mm for placebo, with a statistically significant treatment effect in favor of methoxyflurane overall across all four time points (-9.9 mm; 95% CI: -17.4, -2.4 mm; P=0.0104). Median time to first pain relief was significantly shorter with methoxyflurane (1 minute) than placebo (3 minutes, P<0.0001). Pain relief was reported within 1-10 inhalations in 95.7% of methoxyflurane-treated patients and 64.6% of placebo-treated patients. Rescue medication was requested by two (4.3%) methoxyflurane-treated patients and three (6.3%) placebo-treated patients. Over 95% of patients, physicians, and nurses rated methoxyflurane treatment as "Excellent", "Very Good" or "Good" compared with between 64% and 68% for placebo. The incidence of adverse events was higher with methoxyflurane (51%) than placebo (42%), mostly comprising mild/transient dizziness and headache.

Conclusion

This subgroup analysis shows that low-dose inhaled methoxyflurane is a rapid-acting and effective analgesic in adolescent patients presenting with moderate-to-severe trauma pain.

Trial registration

Clinicaltrials.gov identifier: NCT01420159, EudraCT number: 2011-000338-12.

Efficacy and safety of inhaled low-dose methoxyflurane for acute paediatric pain: A systematic review

Introduction

Undertreatment of acute, moderate-to-severe pain in children is common, due in part to barriers to the use of opioids. Low-dose methoxyflurane is an inhaled, non-opioid analgesic widely used in Australia and recently approved in Europe for the emergency relief of acute moderate-to-severe trauma pain in adults.

Methods

Using an integrative review framework, we conducted a literature analysis to examine the potential utility of methoxyflurane in children with acute pain. EMBASE®, MEDLINE® and PubMed were searched (criteria included ‘methoxyflurane’ ‘child*’ or ‘adolescent’ or ‘pediatr*’ or ‘paediatr*’) from January 2000 to October 2017, along with internet-based sources to identify relevant grey literature (no predefined search criteria). A series of investigative questions were developed regarding the safety and efficacy of methoxyflurane in this setting and addressed using evidence collated from the identified studies.

Results

Of 366 results from the literature searches, 6 clinical trials and observational studies were identified which explored the safety and/or efficacy of inhaled methoxyflurane in individuals < 18 years in either a clinical trial or observational study. All six studies concluded that methoxyflurane provides effective and rapid analgesia for paediatric acute moderate-to-severe pain. Methoxyflurane was well tolerated and associated with good levels of patient/healthcare provider satisfaction in this setting.

Conclusions

While large-scale studies are needed to better inform treatment approaches for paediatric use, inhaled methoxyflurane has potential to provide easy to administer, needle-free analgesia with a rapid onset and good safety profile.

Fifteen minute consultation: a structured approach to the recognition and management of concussion in children and adolescents

Concussion is a disturbance in brain function caused by a direct or indirect force, which is transmitted to the head. The incidence of concussion is rising, and poor recognition of symptoms, with inappropriate management strategies, increases the risk of long-term cognitive and neuropsychiatric complications. We address some common questions that arise when assessing and managing patients with suspected concussion.

A qualitative study of the barriers to procedural sedation practices in paediatric emergency medicine in the UK and Ireland

INTRODUCTION

There is extensive literature on paediatric procedural sedation (PPS) and its clinical applications in emergency departments (EDs). While numerous guidance and policy documents exist from international bodies, there remains a lack of uniformity and consistency of PPS practices within EDs. PPS is now gaining traction in the UK and Ireland and this study aimed to describe existing PPS practices and identify any challenges to training and provision of ED-based PPS.

METHODS

A qualitative approach was employed to capture data through a focus group interview. Nine consultants in emergency medicine (EM) participated, varying in years of experience, clinical settings (mixed adult and paediatric ED or paediatric only) and geographical location (UK and Ireland). The focus group was audio-recorded, transcribed verbatim and analysed using Attride-Stirling's framework for thematic network analysis.

RESULTS

The global theme 'The Future of PPS in EM-A UK and Ireland Perspective' emerged from the following three organising themes: (1) training and education of ED staff; (2) current realities of PPS in EDs and (3) PPS and the wider hospital community. The main findings were (1) there is variability in ED PPS practice throughout the UK and Ireland; (2) lack of formal PPS training for trainees is a barrier to its implementation as a standard treatment and (3) there is a lack of recognition of PPS at a College level as a specialised EM skill.

CONCLUSIONS

Establishment of PPS as a standard treatment option in the emergency setting will require implementation of robust training into general and paediatric EM training. This should be supported and enhanced through national and international collaboration in EM-led PPS research and audit.

Establishing the research priorities of paediatric emergency medicine clinicians in the UK and Ireland

OBJECTIVE

Paediatric Emergency Research in the UK and Ireland (PERUKI) is a collaborative clinical studies group established in August 2012. It consists of a network of 43 centres from England, Ireland, Northern Ireland, Scotland and Wales, and aims to improve the emergency care of children through the performance of robust collaborative multicentre research within emergency departments. A study was conducted regarding the research priorities of PERUKI, to establish the research agenda for paediatric emergency medicine in the UK and Ireland.

METHODS

A two-stage modified Delphi survey was conducted of PERUKI members via an online survey platform. Stage 1 allowed each member to submit up to 12 individual questions that they identified as priorities for future research. In stage 2, the shortlisted questions were each rated on a seven-point Likert scale of relative importance.

PARTICIPANTS

Members of PERUKI, including clinical specialists, academics, trainees and research nurses.

RESULTS

Stage 1 surveys were submitted by 46/91 PERUKI members (51%). A total of 249 research questions were generated and, following the removal of duplicate questions and shortlisting, 60 questions were carried forward for stage 2 ranking. Stage 2 survey responses were submitted by 58/95 members (61%). For the 60 research questions that were rated, the mean score of 'relative degree of importance' was 4.70 (range 3.36-5.62, SD 0.55). After ranking, the top 10 research priorities included questions on biomarkers for serious bacterial illness, major trauma, intravenous bronchodilators for asthma and decision rules for fever with petechiae, head injury and atraumatic limp.

CONCLUSIONS

Research priorities of PERUKI members have been identified. By sharing these results with clinicians, academics and funding bodies, future research efforts can be focused to the areas of greatest need.

Variation in treatment of acute childhood wheeze in emergency departments of the United Kingdom and Ireland: an international survey of clinician practice

OBJECTIVE

National clinical guidelines for childhood wheeze exist, yet despite being one of the most common reasons for childhood emergency department (ED) attendance, significant variation in practice occurs in other settings. We, therefore, evaluated practice variations of ED clinicians in the UK and Ireland.

DESIGN

Two-stage survey undertaken in March 2013. Stage one examined department practice and stage two assessed ED consultant practice in acute childhood wheeze. Questions interrogated pharmacological and other management strategies, including inhaled and intravenous therapies.

SETTING AND PARTICIPANTS

Member departments of Paediatric Emergency Research in the United Kingdom and Ireland and ED consultants treating children with acute wheeze.

RESULTS

30 EDs and 183 (81%) clinicians responded. 29 (97%) EDs had wheeze guidelines and 12 (40%) had care pathways. Variation existed between clinicians in dose, timing and frequency of inhaled bronchodilators across severities. When escalating to intravenous bronchodilators, 99 (54%) preferred salbutamol first line, 52 (28%) magnesium sulfate (MgSO4) and 27 (15%) aminophylline. 87 (48%) administered intravenous bronchodilators sequentially and 30 (16%) concurrently, with others basing approach on case severity. 146 (80%) continued inhaled therapy after commencing intravenous bronchodilators. Of 170 who used intravenous salbutamol, 146 (86%) gave rapid boluses, 21 (12%) a longer loading dose and 164 (97%) an ongoing infusion, each with a range of doses and durations. Of 173 who used intravenous MgSO4, all used a bolus only. 41 (24%) used non-invasive ventilation.

CONCLUSIONS

Significant variation in ED consultant management of childhood wheeze exists despite the presence of national guidance. This reflects the lack of evidence in key areas of childhood wheeze and emphasises the need for further robust multicentre research studies.

STOP!: a randomised, double-blind, placebo-controlled study of the efficacy and safety of methoxyflurane for the treatment of acute pain

Objective

To evaluate the short-term efficacy and safety of methoxyflurane for the treatment of acute pain in patients presenting to an emergency department (ED) with minor trauma.

Methods

STOP! was a randomised, double-blind, multicentre, placebo-controlled study conducted at six sites in the UK. A total of 300 patients, 90 of whom were adolescent patients (age 12–17 years), were randomised 150:150 to receive either methoxyflurane via a Penthrox inhaler or placebo. The primary end point of the study was the change in pain intensity as measured using the visual analogue scale (VAS) from baseline to 5, 10, 15 and 20 min after the start of study drug inhalation. Patients were supplied with one inhaler containing 3 mL methoxyflurane or 5 mL placebo after enrolment and initial assessments. Age group (adolescent/adult) and baseline VAS score were controlled for in the statistical analyses.

Results

A total of 149 patients received methoxyflurane, and 149 patients received placebo. Demographic and baseline characteristics were comparable between the groups. Methoxyflurane reduced pain severity significantly more than placebo (p<0.0001) at all time points tested, with the greatest estimated treatment effect of −18.5 mm (adjusted change from baseline) seen at 15 min after the start of treatment. Methoxyflurane was well tolerated, with the majority of adverse reactions being mild, transient and in line with anticipated pharmacological action.

Conclusion

The results of this study suggest that methoxyflurane administered via the Penthrox inhaler is an efficacious, safe, and rapidly acting analgesic.

Trial registration number:

NCT01420159.

The action of diaspirin cross-linked haemoglobin blood substitute on human arterial bypass conduits

BACKGROUND

Immediately available blood substitutes could transform medicine. In coronary artery surgery, vasoconstriction induced by some of these agents could have serious implications. We have examined some of the vasoactive effects of one of these blood substitute, diaspirin cross-linked haemoglobin (DCLHb), on isolated rings of human arterial conduits.

METHODS

Sections of human left internal mammary artery (LIMA) and radial artery (RA) were cut into 3-mm rings, mounted in individual organ baths containing aerated (95% O(2)/5% CO(2)) Krebs-Heinseleit solution at 37 degrees C and attached to isometric strain gauge for measurements of tension. All rings were tested for the presence of endothelium by addition of carbachol to rings pre-contracted with phenylephrine. The relative importance of nitric oxide (NO) in contraction mediated by the addition of DCLHb was studied.

RESULTS

Carbachol relaxed phenylephrine precontracted LIMA by 72.3+/-1.7% and RA by 97+/-0.7% confirming the presence of a functional endothelium. Sodium nitroprusside (SNP) caused complete relaxation of LIMA with an EC(50) value of 2.0+/-0.1x10(-8) M and RA with an EC(50) value of 1. 9+/-0.1x10(8) M. In the presence of DCLHb (10(-7) M), carbachol-induced relaxation was significantly reduced to 46.3+/-0. 7% (P<0.01) and the BC(50) value for SNP relaxation increased to 1. 2+/-0.1x10(-7) M (P<0.01). DCLHb caused rings to contract in the absence of phenylephrine with EC(50) values of 1.6+/-0.1x10(-7) M (LIMA) and 1.8+/-0.1x10(-7) M (RA). Presence of L-NAME (300 microM) caused no alteration in DCLHb-induced contraction.

CONCLUSION

In this study of isolated rings of human vessels, DCLHb causes a significant reduction in relaxation mediated by carbachol and SNP, which is likely to be due to its ability to bind NO. However, it is possible that other mechanisms might contribute to the vasoconstrictor effects of DCLHb and these might be amenable to anti-vasospastic strategies.

Lithium in a case of severe anorexia nervosa

Anorexia nervosa may sometimes be resistant to all forms of therapy, with cases running through a gamut of somatic and psychological treatments. One possible explanation for this may be that the illness is of heterogeneous aetiology (Kay and Leigh, 1938; King, 1963; Feighner et al, 1972), although others regard anorexia as a single condition that tends to breed true though having protean manifestations (Russell, 1970; Crisp et al, 1980). In most of the larger series of cases, a proportion have depressive symptoms both during the illness (Dally, 1969; Theander, 1970; Crisp et al, 1980) and some years later (Morgan and Russell, 1975; Hsu et al, 1979), and a family history of affective disorder is also commonly reported (Dally, 1969; Theander, 1970; Morgan and Russell, 1975). Cantwell et al (1977) have reviewed the complex relationship between depression and anorexia nervosa and have suggested that some of the remedies used in the treatment of depression merit further exploration in the management of anorexia nervosa. We report here a patient who was in hospital for over four years and in whose eventual improvement lithium may have played an important role.