Committee experiences of using formal consensus in healthcare guidelines: a longitudinal qualitative study

BACKGROUND

This feasibility study has the primary aim of capturing and comparing participant expectations and experiences of using a formal consensus method (FCM) and to explore whether these views change following participation within a guideline committee where FCM are used.

METHODS

Twelve healthcare committee members and associated technical team members participated in semi-structured qualitative interviews before and after using FCM during guideline committee meetings. Interviews also focused on past experiences and expectations of informal consensus methods.

RESULTS

Participants said formal consensus included a greater range of evidence. They described positive reactions and found it a useful way to encourage involvement by balancing group power dynamics. Group discussion time was identified as important to clarify ideas, supported by good group chairing. However, participants reported that undertaking FCM required additional resources and suggested targeting its use for low quality evidence, limited committee expertise, or where the evidence is controversial.

CONCLUSIONS

FCM is an acceptable alternative to informal consensus methods that has qualities specifically helpful to healthcare guidelines such as encouraging participation, inclusivity of a broad range of evidence, and managing group dynamics. More research is required to better understand when using formal consensus is most appropriate and effective.

Improving subacute management of post concussion symptoms: a pilot study of the Melbourne Paediatric Concussion Scale parent report

Aim:

To pilot a modification of the Post Concussion Symptom Inventory, the Melbourne Paediatric Concussion Scale (MPCS) and examine its clinical utility.

Materials & methods:

A total of 40 families of concussed children, aged 8–18 years, were recruited from the emergency department. Parent responses to the MPCS in the emergency department and 2-weeks post injury determined child symptomatic status. Association between MPCS symptom endorsement and symptomatic group status was examined.

Results:

All additional MPCS items were endorsed by at least 25% of the parents of symptomatic children at 2 weeks. MPCS items were classified into nine symptom domains, with most falling in mood, neurological, autonomic and vestibular domains.

Conclusion:

The additional items and domain classifications in the MPCS have the potential to improve subacute diagnostic precision, monitoring of clinical recovery and identification of appropriate interventions post pediatric concussion.

Protocol for a randomised clinical trial of multimodal postconcussion symptom treatment and recovery: the Concussion Essentials study

INTRODUCTION

While most children recover from a concussion shortly after injury, approximately 30% experience persistent postconcussive symptoms (pPCS) beyond 1-month postinjury. Existing research into the treatment of pPCS have evaluated unimodal approaches, despite evidence suggesting that pPCS likely represent an interaction across various symptom clusters. The primary aim of this study is to evaluate the effectiveness of a multimodal, symptom-tailored intervention to accelerate symptom recovery and increase the proportion of children with resolved symptoms at 3 months postconcussion.

METHODS AND ANALYSIS

In this open-label, assessor-blinded, randomised clinical trial, children with concussion aged 8-18 years will be recruited from The Royal Children's Hospital (The RCH) emergency department, or referred by a clinician, within 17 days of initial injury. Based on parent ratings of their child's PCS at ~10 days postinjury, symptomatic children (≥2 symptoms at least 1-point above those endorsed preinjury) will undergo a baseline assessment at 3 weeks postinjury and randomised into either Concussion Essentials (CE, n=108), a multimodal, interdisciplinary delivered, symptom-tailored treatment involving physiotherapy, psychology and education, or usual care (UC, n=108) study arms. CE participants will receive 1 hour of intervention each week, for up to 8 weeks or until pPCS resolve. A postprogramme assessment will be conducted at 3 months postinjury for all participants. Effectiveness of the CE intervention will be determined by the proportion of participants for whom pPCS have resolved at the postprogramme assessment (primary outcome) relative to the UC group. Secondary outcome analyses will examine whether children receiving CE are more likely to demonstrate resolution of pPCS, earlier return to normal activity, higher quality of life and a lower rate of utilisation of health services, compared with the UC group.

ETHICS AND DISSEMINATION

Ethics were approved by The RCH Human Research Ethics Committee (HREC: 37100). Parent, and for mature minors, participant consent, will be obtained prior to commencement of the trial. Study results will be disseminated at international conferences and international peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12617000418370; pre-results.

Australian and New Zealand Guideline for Mild to Moderate Head Injuries in Children

OBJECTIVE

Children frequently present with head injuries to acute care settings. Although international paediatric clinical practice guidelines for head injuries exist, they do not address all considerations related to triage, imaging, observation versus admission, transfer, discharge and follow-up of mild to moderate head injuries relevant to the Australian and New Zealand context. The Paediatric Research in Emergency Departments International Collaborative (PREDICT) set out to develop an evidence-based, locally applicable, practical clinical guideline for the care of children with mild to moderate head injuries presenting to acute care settings.

METHODS

A multidisciplinary Guideline Working Group (GWG) developed 33 questions in three key areas - triage, imaging and discharge of children with mild to moderate head injuries presenting to acute care settings. We identified existing high-quality guidelines and from these guidelines recommendations were mapped to clinical questions. Updated literature searches were undertaken, and key new evidence identified. Recommendations were created through either adoption, adaptation or development of de novo recommendations. The guideline was revised after a period of public consultation.

RESULTS

The GWG developed 71 recommendations (evidence-informed = 35, consensus-based = 17, practice points = 19), relevant to the Australian and New Zealand setting. The guideline is presented as three documents: (i) a detailed Full Guideline summarising the evidence underlying each recommendation; (ii) a Guideline Summary; and (iii) a clinical Algorithm: Imaging and Observation Decision-making for Children with Head Injuries.

CONCLUSIONS

The PREDICT Australian and New Zealand Guideline for Mild to Moderate Head Injuries in Children provides high-level evidence and practical guidance for front line clinicians.

Child concussion recognition and recovery: a community delivered, evidenced-based solution

Pediatric concussion is a growing health concern. Concussion is generally poorly understood within the community. Many parents are unaware of the signs and varying symptoms of concussion. Despite the existence of concussion management and return to play guidelines, few parents are aware of how to manage their child’s recovery and return to activities. Digital health technology can improve the way this information is communicated to the community. A multidisciplinary team of pediatric concussion researchers and clinicians translated evidence-based, gold-standard guidelines and tools into a smartphone application with recognition and recovery components. HeadCheck is a community facing digital health application developed in Australia (not associated with HeadCheck Health) for management of concussion in children aged 5–18 years. The application consists of (I) a sideline concussion check and (II) symptom monitoring and symptom-targeted psychoeducation to assist the parent manage their child’s safe return to school, exercise and sport. The application was tested with target end users as part of the development process. HeadCheck provides an accessible platform for disseminating best practice evidence. It provides feedback to help recognize a concussion and symptoms of more serious injuries and assists parents guide their child’s recovery.

Professionalism of physicians at a major teaching hospital during the Fukushima nuclear disaster

It poses a serious problem if physicians leave a hospital without having a replacement or without permission. A huge earthquake followed by a devastating tsunami seriously damaged the Fukushima-Daiichi nuclear power plant. This disaster overwhelmed a major teaching hospital in the local area and many hospital employees, including some resident physicians, left the premises. Since the threat of severe radiation exposure poses a potentially greater lifetime risk to younger individuals, letting the young resident physicians leave the hospital was not only allowed, it was actually recommended by many attending physicians and hospital administrators. The hospital administrator was required to make the difficult decision of whether to make all efforts to provide the highest level of medical care, including keeping all of the physicians on the premises, or to evacuate the resident physicians in order to preserve their health and their potential future contributions to healthcare. Consideration and compassion needed to be provided to all people, regardless of the reason they wanted to leave. From an ethical perspective, the roles of performance under these complex circumstances should be understood and embraced by us as individuals, professionals, supervisors and society as a whole.

Outpatient versus inpatient IV antibiotic management for pediatric oncology patients with low risk febrile neutropenia: a randomised trial

BACKGROUND

Febrile neutropenia (FN) is a frequent, serious complication of intensive pediatric chemotherapy regimens. The aim of this trial was to compare quality of life (QOL) between inpatient and outpatient intravenous antibiotic management of children and adolescents with low risk febrile neutropenia (LRFN).

PROCEDURE

In this randomised non-blinded trial, patients between 1 and 21 years old, receiving low/moderate intensity chemotherapy were pre-consented and, on presentation to emergency (ED) with FN satisfying low risk criteria, randomised to either outpatient or inpatient care with intravenous cefepime 50 mg/kg (12 hourly). All patients continued antibiotics for at least 48 hours, until afebrile for 24 hours and demonstrating a rising absolute neutrophil count ≥200/mm(3). Several domains of QOL were examined by daily questionnaire.

RESULTS

Eighty-one patients presented to ED with 159 episodes of fever. Thirty-seven FN presentations involving 27 patients were randomised to inpatient (18) and outpatient (19) management. Combined QOL mean scores for parents were higher for the outpatient group and scores for three specific parent variables (keeping up with household tasks/time spent with partner/time spent with other children) were higher among outpatients. There was no difference in parent confidence/satisfaction in care between groups. Patients scored better in the outpatient group overall and for sleep and appetite. The mean length of fever was equivalent between groups and there were no serious adverse events attributable to cefepime or outpatient care.

CONCLUSION

Outpatient cefepime management of LRFN provided significant benefit to parents and patients across several QOL domains and appeared both feasible and safe.

Mutations in the T (brachyury) gene cause a novel syndrome consisting of sacral agenesis, abnormal ossification of the vertebral bodies and a persistent notochordal canal

BACKGROUND

The T gene (brachyury gene) is the founding member of the T-box family of transcription factors and is vital for the formation and differentiation of the mesoderm and the axial development of all vertebrates.

RESULTS

We report here on four patients from three consanguineous families exhibiting sacral agenesis, a persistent notochordal canal and abnormal ossification of the vertebral bodies, and the identification and characterisation of their underlying genetic defect. Given the consanguineous nature and the similarity of the phenotypes between the three families, we performed homozygosity mapping and identified a common 4.1 Mb homozygous region on chromosome 6q27, containing T, brachyury homologue (mouse) or T. Sequencing of T in the affected individuals led to the identification of a homozygous missense mutation, p.H171R, in the highly conserved T-box. The homozygous mutation results in diminished DNA binding, increased cell growth, and interferes with the normal expression of genes involved in ossification, notochord maintenance and axial mesoderm development.

CONCLUSIONS

We have identified a shared homozygous mutation in three families in T and linked it to a novel syndrome consisting of sacral agenesis, a persistent notochordal canal and abnormal ossification of the vertebral bodies. We suggest that screening for the ossification of the vertebrae is warranted in patients with sacral agenesis to evaluate the possible causal involvement of T.

Acquisition of high quality DNA for massive parallel sequencing by in vivo chromatin immunoprecipitation

ChIP-seq is rapidly becoming a routine technique for the determination of the genome wide association of DNA binding proteins and histone modifications. Here we provide a protocol for the isolation, purification, and immunoprecipitation of DNA fragments associated with a target transcription factor of interest. Although the method makes use of adult mouse hearts, it can, with relative ease, be adapted for the in vivo ChIP isolation of DNA from other cell and tissue sources with the intention of massive parallel sequencing.

Prospective audit of patients with haemophilia: bleeding episodes and management

BACKGROUND

Haemophilia is a congenital bleeding disorder that requires replacement of factor VIII (haemophilia A) or factor IX (haemophilia B) via intravenous infusions. Children can either be treated with prophylactic treatment to prevent bleeding or be managed with on-demand therapy and treat specific bleeding episodes.

AIMS

The aim of this paper was to prospectively follow a cohort of haemophilia patients to determine the incidence of bleeding, re-bleeding, re-treatment and adjunct management over a period of 5 months.

METHODS

Sixty-six boys with haemophilia were followed. Age range was 10 months to 19 years; 70% of patients had severe haemophilia and 38 (58%) of all patients were on prophylaxis.

RESULTS

Twenty-nine patients experienced at least one episode of bleeding during study period which included 70 home bleeding episodes and 20 emergency department (ED) presentations. Secondary treatments occurred in 38% of all bleeding episodes. The incidence of re-bleeds occurring within 3 weeks of the initial bleeding episode was 11%.

CONCLUSIONS

Further study focusing on optimising treatment regimes for patients with haemophilia presenting with bleeding episodes is necessary.

Parental disciplinary practices following acquired brain injury in children

PURPOSE

This study describes the disciplinary practices of parents following acquired brain injury (ABI) of their child and examines the relationship between disciplinary use, family-parental adversities and children's behavioural sequelae.

METHOD

Participants were 48 parent respondents of children between 3-12 years with mild, moderate and severe ABI. Parents provided demographic information and completed questionnaires investigating disciplinary strategy use, parental-family functioning and child behaviour.

RESULTS

Over-reactive and lax disciplinary strategies were endorsed most by parents. Dysfunctional levels of disciplinary use were associated with children who displayed more behaviour problems, parents with elevated distress and families experiencing more dysfunction and social adversity.

CONCLUSION

Dysfunctional parenting practices, if not ameliorated, could exacerbate problematic child behaviour following ABI, as well as parent and family difficulties. Parental assessment may be useful as a method of screening for parental factors that put children at risk for ongoing behaviour problems and families for ongoing stress.

Sox4 mediates Tbx3 transcriptional regulation of the gap junction protein Cx43

Tbx3, a T-box transcription factor, regulates key steps in development of the heart and other organ systems. Here, we identify Sox4 as an interacting partner of Tbx3. Pull-down and nuclear retention assays verify this interaction and in situ hybridization reveals Tbx3 and Sox4 to co-localize extensively in the embryo including the atrioventricular and outflow tract cushion mesenchyme and a small area of interventricular myocardium. Tbx3, SOX4, and SOX2 ChIP data, identify a region in intron 1 of Gja1 bound by all tree proteins and subsequent ChIP experiments verify that this sequence is bound, in vivo, in the developing heart. In a luciferase reporter assay, this element displays a synergistic antagonistic response to co-transfection of Tbx3 and Sox4 and in vivo, in zebrafish, drives expression of a reporter in the heart, confirming its function as a cardiac enhancer. Mechanistically, we postulate that Sox4 is a mediator of Tbx3 transcriptional activity.

High-concentration nitrous oxide for procedural sedation in children: adverse events and depth of sedation

OBJECTIVE

Nitrous oxide is an attractive agent for procedural sedation and analgesia in the emergency department; however, there are limited safety data for high-concentration continuous-flow nitrous oxide (50%-70%) and its use in young children. We set out to characterize the depth of sedation and incidence of adverse events associated with various concentrations of nitrous oxide used in a pediatric emergency department.

METHODS

This was a prospective observational study of nitrous oxide use for procedural sedation and analgesia in a tertiary children's hospital emergency department. Nitrous oxide concentration, adverse events, and sedation depth were recorded. Adverse events were categorized as mild or serious. Sedation depth was recorded on a sedation scale from 0 to 6.

RESULTS

A total of 762 patients who were aged 1 to 17 years received nitrous oxide during the 2-year study period. A total of 548 (72%) received nitrous oxide 70%, and 101 (13%) received nitrous oxide 50%. Moderate or deep sedation with scores of < or = 2 occurred in 3% of patients who had received nitrous oxide 70% and no patients who had received nitrous oxide 50%. Mean sedation scores were 4.4 at nitrous oxide 70% and 4.6 at nitrous oxide 50%. Sixty-three (8.3%) patients sustained 70 mild and self-resolving adverse events, most of which were vomiting (5.7%); 2 (0.2%) patients had serious adverse events. There was no significant difference in adverse events rates between nitrous oxide 70% (8.4%) and nitrous oxide 50% (9.9%). There was no significant difference in the percentage of deep sedation when children who were < or = 3 years of age (2.9%) were compared with older children (2.8%).

CONCLUSIONS

In this largest prospective emergency department series, high-concentration continuous-flow nitrous oxide (70%) was found to be a safe agent for procedural sedation and analgesia when embedded in a comprehensive sedation program. Nitrous oxide also seems safe in children aged 1 to 3 years.

Topical lignocaine for pain relief in acute otitis media: results of a double-blind placebo-controlled randomised trial

OBJECTIVE

Acute otitis media (AOM) is common in children, yet the optimal management of ear pain associated with AOM has not been well studied. We set out to determine the efficacy of topical aqueous 2% lignocaine eardrops compared with a placebo (saline) for pain relief of AOM in children.

DESIGN

Double-blind, randomised, placebo-controlled trial.

SETTING

Tertiary children's hospital emergency department.

PATIENTS AND INTERVENTIONS

Children aged between 3 and 17 years with earache and AOM without evidence of perforation were eligible. Patients were randomised to receive either 2% lignocaine or saline eardrops (placebo).

MAIN OUTCOME MEASURES

Pain scores were measured before and after ear-drop administration. Patient and physician-interpreted pain scores were measured by using the Bieri faces pain scale and visual analogue scale at 10, 20 and 30 minutes. The primary outcome measure was reduction in patient-measured pain scores by 50% from the baseline. Secondary outcome measures were reduction in patient-measured pain scores by 25% or by at least two points. Telephone follow-up occurred after 1 day and 1 week. Analysis was by intention to treat.

RESULTS

63 children (31 were treated with lignocaine, 32 with placebo) aged 3 to 12 years were enrolled. The groups were demographically and clinically similar, with similar proportions having received analgesia in the preceding 4 hours. Children receiving lignocaine showed significantly lower patient-measured pain scores with a reduction by 50% from baseline at 10 minutes (RR 2.06, 95% CI 1.03-4.11, p = 0.03) and 30 minutes (RR 1.44, 95% CI 1.07-1.93, p = 0.009) but not at 20 minutes (RR 1.35 95% CI 0.88-2.06). The response to lignocaine treatment showed significantly lower patient-measured pain scores for 25% reduction at all time points and for two-point reduction at 10 minutes and favoured lignocaine at 20 minutes and 30 minutes without reaching statistical significance. There were no serious adverse events during the 30 minute follow-up period.

CONCLUSION

This study suggests that topical aqueous 2% lignocaine eardrops provide rapid relief for many young children presenting with ear pain attributed to AOM. The concurrent use of simple oral analgesia is a likely contributor to effective management of this painful childhood condition.

T-box factors determine cardiac design

The heart of higher vertebrates is a structurally complicated multi-chambered pump that contracts synchronously. For its proper function a number of distinct integrated components have to be generated, including force-generating compartments, unidirectional valves, septa and a system in charge of the initiation and coordinated propagation of the depolarizing impulse over the heart. Not surprisingly, a large number of regulating factors are involved in these processes that act in complex and intertwined pathways to regulate the activity of target genes responsible for morphogenesis and function. The finding that mutations in T-box transcription factor-encoding genes in humans lead to congenital heart defects has focused attention on the importance of this family of regulators in heart development. Functional and genetic analyses in a variety of divergent species has demonstrated the critical roles of multiple T-box factor gene family members, including Tbx11, −2, −3, −5, −18 and −20, in the patterning, recruitment, specification, differentiation and growth processes underlying formation and integration of the heart components. Insight into the roles of T-box factors in these processes will enhance our understanding of heart formation and the underlying molecular regulatory pathways.

A pilot study of inhaled methoxyflurane for procedural analgesia in children

BACKGROUND

Methoxyflurane (MF), a potent volatile anesthetic, can be used as an analgesic in subanesthetic concentrations. In Australia, MF is extensively used in children and adults as an analgesic in the prehospital setting via a hand-held inhaler device. We conducted a pilot study to explore its use as a patient controlled analgesic for painful procedures in children in the emergency department (ED).

METHODS

This is a prospective observational case series of children aged 5 years and older requiring procedural analgesia for brief painful procedures. Pain scores, depth of sedation, adverse events and patient, parent and staff satisfaction were assessed as well as consumption of MF measured.

RESULTS

Fourteen patients (aged 6-13 years) received MF mainly for extremity injuries. Amount of MF consumed ranged from 0.36 to 3.06 g per patient inhaled over 4-25 min. There were no serious adverse events. No patient was deeply sedated. Five patients had mild brief self-resolving adverse events including agitation, euphoria, blurry vision, dizziness and cough. Four patients with fractures with initial high pain scores (> or =6) received MF for bridging analgesia with large drops in pain scores. Four patients who required fracture reductions with initial low scores did not achieve adequate analgesia. The remaining six patients had painful procedures undertaken with satisfactory analgesia.

CONCLUSIONS

On the basis of this small pilot study of MF use in children in the ED, this agent appears to be a powerful analgesic. MF seems most useful as a self-titrated bridging analgesic agent in patients after extremity trauma. It appears less useful as a procedural agent when patients are unable to anticipate and achieve a sufficient level of analgesia before painful stimulus infliction. Pre- and intraprocedure coaching is an important aspect of its use especially if initial pain scores are low.

Respiratory syncytial virus infection and recurrent wheeze/asthma in children under five years: an epidemiological survey

AIM

To determine the rates of respiratory syncytial virus (RSV) infection in children under 5 years of age with recurrent wheeze or asthma and compare their clinical presentation, course and outcome with asthmatic children of the same age who did not have RSV.

METHODS

Children were recruited prospectively from the emergency department of the Royal Children's Hospital, Melbourne during peak RSV season in 1998. Information was collected regarding past and current asthma presentations, a nasopharyngeal asprirate was taken for viral isolation and all children were reviewed by telephone 1 week following presentation.

RESULTS

73 children were included with a median age of 28 months. RSV was isolated from 33 (45%) of children, one child had adenovirus and in the remainder no virus was isolated. Children less than 12 months were more likely to have RSV (70%). RSV-positive children had a longer duration of illness prior to hospital presentation than RSV-negative children but were not more likely to be admitted or to have a longer duration of ongoing symptoms.

CONCLUSION

A high rate of RSV infection was demonstrated in young children with recurrent wheeze or asthma during the RSV season. This information has important implications for the control of nosocomial infection with RSV (i.e. isolation of patients) and in targeting another group to be included for RSV vaccine development.

Efficacy of particle-based DNA delivery for vaccination of sheep against FMDV

As an alternative strategy to classical inactivated viral vaccine against FMDV, naked DNA vaccine is attractive because of safety, flexibility and low cost. However DNA vaccination is usually poorly efficient in target species. Indeed we found that naked DNA plasmids encoding for P1-2A3C3D and GM-CSF proteins did not induce any detectable immunity against FMDV in sheep. Interestingly, we demonstrate herein that formulations of DNA on poly(D,L-lactide-co-glycolide) (PLG) or in lipofectin triggered divergent types of immune responses: PLG stimulated a T cell response and could elicit significant neutralising antibody titers, whereas lipofectin generated even higher antibody titers but no significant T cell response. The DNA/PLG regimen used in five sheep protected against clinical symptoms and viraemia and prevented the carrier state in four of them. Thus formulated DNA can be remarkably efficient against FMDV in a ruminant species that is usually refractory to DNA vaccination.

Risk factors for intussusception in infants in Vietnam and Australia: adenovirus implicated, but not rotavirus

OBJECTIVE

This study aimed to investigate risk factors for the development of intussusception in infants in a developing country with a suspected high incidence and in a developed country with a low incidence.

STUDY DESIGN

A prospective case-control study of infants <2 years of age with idiopathic intussusception confirmed by air enema or surgery was conducted at the National Hospital of Paediatrics (NHP), Vietnam (n = 533) and the Royal Children's Hospital (RCH), Australia (n = 51). Diagnosis was validated in a subset (84% NHP; 67% RCH) by an independent blinded radiologist. Risk factor assessment was performed using a standardized questionnaire. Stool specimens were assayed for bacterial, viral, and parasitic agents.

RESULTS

The incidence of intussusception in Vietnam was 302/100,000 in infants <1 year of age (95% CI: 258-352), substantially higher than in Australia (71/100,000). A strong association with adenovirus infection was observed at both sites (cases positive at NHP: 34%, OR 8.2; cases positive at RCH: 40%, OR 44). No association was identified between intussusception and rotavirus, other enteric pathogens, oral polio vaccine, feeding practices, or living conditions.

CONCLUSIONS

The incidence of intussusception in infants was markedly higher in Vietnam than in Australia. A strong association between adenovirus infection and intussusception was identified at both sites suggesting that adenovirus may play a role in the etiology of intussusception.

Validation of clinical case definition of acute intussusception in infants in Viet Nam and Australia

OBJECTIVE

To test the sensitivity and specificity of a clinical case definition of acute intussusception in infants to assist health-care workers in settings where diagnostic facilities are not available.

METHODS

Prospective studies were conducted at a major paediatric hospital in Viet Nam (the National Hospital of Pediatrics, Hanoi) from November 2002 to December 2003 and in Australia (the Royal Children's Hospital, Melbourne) from March 2002 to March 2004 using a clinical case definition of intussusception. Diagnosis of intussusception was confirmed by air enema or surgery and validated in a subset of participants by an independent clinician who was blinded to the participant's status. Sensitivity of the definition was evaluated in 584 infants aged<2 years with suspected intussusception (533 infants in Hanoi; 51 in Melbourne). Specificity was evaluated in 638 infants aged<2 years presenting with clinical features consistent with intussusception but for whom another diagnosis was established (234 infants in Hanoi; 404 in Melbourne).

FINDINGS

In both locations the definition used was sensitive (96% sensitivity in Hanoi; 98% in Melbourne) and specific (95% specificity in Hanoi; 87% in Melbourne) for intussusception among infants with sufficient data to allow classification (449/533 in Hanoi; 50/51 in Melbourne). Reanalysis of patients with missing data suggests that modifying minor criteria would increase the applicability of the definition while maintaining good sensitivity (96-97%) and specificity (83-89%).

CONCLUSION

The clinical case definition was sensitive and specific for the diagnosis of acute intussusception in infants in both a developing country and a developed country but minor modifications would enable it to be used more widely.

Non-urgent presentations to a paediatric emergency department: parental behaviours, expectations and outcomes

OBJECTIVES

To identify factors that influence the attendance of children with non-urgent medical problems to a tertiary paediatric ED and to define parental expectations of the hospital visit.

METHODS

A questionnaire administered to a convenience sample of 200 parents/carers who attended the paediatric ED and whose children were categorized as having non-urgent problems that had been present for at least 4 weeks. Subsequent outpatient attendances were then analysed retrospectively.

RESULTS

Most patients had visited a general practitioner but remained unhappy with the outcome of the consultation. The hospital was expected to provide immediate diagnosis and initiate appropriate treatment by the vast majority of parent. Only four patients required admission.

CONCLUSIONS

The expectations of parents who attend the paediatric ED with children who have non-urgent chronic complaints are high. Rapid access to outpatient clinics might provide an acceptable alternative for these patients, and free valuable ED resources.

Preprocedural fasting state and adverse events in children receiving nitrous oxide for procedural sedation and analgesia

STUDY OBJECTIVE

Established fasting guidelines for analgesia and sedation are difficult to follow in the emergency department (ED), and the association between preprocedural fasting and adverse events has been questioned. We characterize the fasting status of patients receiving procedural sedation and analgesia with nitrous oxide (N2O) in a pediatric ED and assess the relationship between fasting status and adverse events.

METHODS

A prospective case series was conducted in a children's hospital ED over an 8-month period. Patients receiving N2O for procedural sedation and analgesia were enrolled and followed up by telephone call. Preprocedural fasting state and adverse events, as well as N2O concentration, adjunctive drugs, and deepest level of sedation, were recorded. Adverse events were analyzed in relation to fasting status.

RESULTS

Two hundred twenty children who underwent procedural sedation and analgesia with N2O were enrolled. Fasting status was obtained in 218 patients (99.1%). Of these, 155 (71.1%; 95% confidence interval [CI], 64.5%-77.0%) did not meet fasting guidelines for solids There were no serious adverse events and no episodes of aspiration (1-sided 97.5% CI, 0%-1.7%). While in the ED, 46 minor adverse events occurred in 37 patients (16.8%; 95% CI, 12.1%-22.4%). Emesis occurred in 15 patients (7%), including 4 (6.3%; 95% CI, 1.8%-15.5%) of 63 patients who met and in 11 (7.1%; 95% CI, 3.6%-12.3%) of 155 patients who did not meet fasting guidelines for solids. There was no significant difference in median fasting duration between patients with and without emesis.

CONCLUSION

Seventy-one percent of patients undergoing ED procedural sedation and analgesia with N2O did not meet established fasting guidelines. In this series, there was no association between preprocedural fasting and emesis. There were no serious adverse events.

Advanced Training in Pediatric Emergency Medicine in the United States, Canada, United Kingdom, and Australia: An International Comparison and Resources Guide

Pediatric emergency medicine is an important subspecialty of pediatrics and emergency medicine. It is a well-established subspecialty in some countries and less well developed or evolving in others. We set out to develop a resource guide and document the current status of pediatric emergency medicine training across 4 countries (United States, Canada, United Kingdom, and Australia). This article also aims to provide a starting point for pediatric or emergency physicians charged with the development of pediatric emergency medicine training programs in countries without such programs.

Factors associated with adverse outcomes in children with diabetic ketoacidosis-related cerebral edema

OBJECTIVE

To investigate the relation between outcomes of children with diabetic ketoacidosis (DKA)-related cerebral edema and baseline clinical features and therapeutic interventions for treatment of cerebral edema.

STUDY DESIGN

All children </=18 years old with DKA and cerebral edema (n = 61) were retrospectively identified from 10 pediatric centers between 1982 and 1997. Demographic, biochemical, and therapeutic data were collected. Ordinal logistic regression analysis was used to identify factors associated with the clinical outcome (death or persistent vegetative state; mild to moderate neurological disability; or normal) after adjusting for known risk factors for the development of cerebral edema as well as the degree of neurologic depression at the time of diagnosis of cerebral edema.

RESULTS

Seventeen (28%) children died or survived in a vegetative state; 8 (13%) survived with mild to moderate neurologic disabilities; and 36 (59%) survived without sequelae. Factors associated with poor outcomes included greater neurologic depression at the time of diagnosis of cerebral edema, a high initial serum urea nitrogen concentration, and intubation with hyperventilation to a PCO (2) <22 mm Hg.

CONCLUSIONS

After adjusting for potential confounding variables and the degree of neurologic compromise at the initiation of therapy, intubation with hyperventilation is associated with adverse outcomes of DKA-related cerebral edema. Greater neurologic depression at the time of diagnosis of cerebral edema and a higher initial serum urea nitrogen concentration are also associated with poor outcome.

Aspects of emergency vaccination against foot-and-mouth disease

Emergency vaccination is one of several measures which may be deployed to control outbreaks of foot-and-mouth disease. It can be a valuable adjunct to the application of the essential zoosanitary controls which must include rapid diagnosis, tracing, movement control and disinfection and which may also include slaughter of infected and in-contact animals and their safe disposal. Criteria which determine the successful application of emergency vaccination include access to vaccine(s) that (i) contain virus strain(s) of sufficient antigenic relatedness to the outbreak strain(s) (ii) are of the required type of vaccine formulation (iii) have acceptable innocuity and potency (iv) have appropriate availability, including quantity and immediacy of supply and (v) meet considerations of cost. Contingency planning should include provision for emergency vaccination and must address the complex decisions of not only when, where, and how to apply vaccine but also its economic consequences. Computer modelling may be a useful aid to cost benefit and decision support systems in this context. Planning must be detailed and regularly reviewed and should ensure, (i) that the legal and financial aspects are catered for (ii) that any contractual supply agreements are in place (iii) that information is collected and its currency maintained on the species, numbers and whereabouts of susceptible livestock (iv) that vaccination teams are formed and trained (v) that the vaccine cold chain is established and maintained (vi) that supplies of vaccination equipment are held in readiness and (vii) that briefing materials are available to inform the various stakeholders on relevant aspects of emergency vaccination. Knowledge concerning the characteristics and performance of emergency vaccines is summarised and areas identified for further research.

Does the use of volumetric bladder ultrasound improve the success rate of suprapubic aspiration of urine?

OBJECTIVE

To determine whether a volumetric bladder scanner can improve the success rate of suprapubic aspiration and whether there is an optimal volume of urine required in the bladder before suprapubic aspiration should be attempted.

DESIGN

Two-phase prospective study.

SETTING

The emergency department of a tertiary children's hospital.

SUBJECTS

Children younger than 2 years who required an uncontaminated urine specimen for microscopy and culture.

METHODS

In phase one, all patients had an ultrasound followed by suprapubic aspiration. In phase two, patients were randomized to either ultrasound or no ultrasound.

RESULTS

In phase one, 37 subjects had ultrasound measurement prior to attempting suprapubic aspiration; 28 of 31 (90%) had successful suprapubic aspiration when a minimum volume of 10 mL was detected on ultrasound and no 0-mL readings were encountered. In phase two, the overall success rate of obtaining urine with the aid of the bladder scanner was 31 of 39 subjects (79%), compared with 16 of 36 subjects (44%) without ultrasound. Ultrasound was also useful in deferring an attempt when less than 10 mL of urine was noted on the scan.

CONCLUSIONS

The volumetric bladder scanner is a rapid, safe, and accurate device that, in this study, greatly improved the success rate of suprapubic aspiration in small children. It also helped to avoid time delays or multiple blind attempts at suprapubic aspiration by predicting volumes at which suprapubic aspiration should or should not be attempted.

Evaluation of the THINK FIRST For KIDS injury prevention curriculum for primary students

THINK FIRST is a national non-profit organization whose mission is to educate young people about the prevention of brain and spinal cord injuries. This paper describes a study conducted by THINK FIRST of Oregon on one of its injury prevention curricula, THINK FIRST for KIDS.

A randomized clinical trial: should the child with transient synovitis of the hip be treated with nonsteroidal anti-inflammatory drugs?

STUDY OBJECTIVES

The diagnosis of transient synovitis of the hip ("irritable hip") is made frequently in the pediatric emergency department. We hypothesized that an anti-inflammatory agent (ibuprofen syrup) would shorten the duration of symptoms.

METHODS

Patients who were clinically diagnosed with transient synovitis of the hip in the ED between July 1997 and July 1998 were randomized in a double-blind, placebo-controlled trial to receive either ibuprofen syrup (10 mg/kg 3 times a day for 5 days) or placebo. There were stringent exclusion criteria, and patients were only included if there was a low index of suspicion of more serious pathology. All patients had a hip ultrasonography performed at enrollment and at day 7. Symptoms were monitored by the use of a parental diary and clinical review.

RESULTS

Forty patients were initially enrolled, but 4 patients were subsequently excluded, leaving 17 patients in the ibuprofen group and 19 in the placebo group. Although symptoms resolved in more than 80% (30 of 36) of patients in both groups by 7 days, the median duration of symptoms was shorter in the ibuprofen group (2 days compared with 4.5 days in the placebo group; P =.05 on Wilcoxon-Breslow test). The medication was well tolerated, with only minor gastrointestinal side effects being reported by 6 patients (4 ibuprofen and 2 placebo).

CONCLUSION

In this small study, ibuprofen shortened the duration of symptoms in children with a clinical diagnosis of transient synovitis of the hip.

Are methods used to estimate weight in children accurate?

OBJECTIVE

The exact weight of a child undergoing resuscitation is usually not known. Several methods to estimate a child's weight have been proposed. We evaluated six of these methods to determine their accuracy and clinical usefulness across a range of weights and ages.

METHOD

Children attending a tertiary paediatric emergency department on 30 non-consecutive days were weighed, a length or height was obtained and an estimation of body habitus (slim, average or heavy) made by a single investigator, Karen Black (KB). All children less than 145 cm were also measured using the Broselow tape. Six methods of weight estimation were employed and the calculated weight compared to the true weight. The weight estimation methods evaluated were the advanced paediatric life support (APLS) method, Broselow tape, devised weight estimation method (DWEM), Oakley table, Traub-Johnson and the Traub-Kichen methods.

RESULTS

Four hundred and ninety-five children were included in the study. Children were evenly distributed among the weight groups of less than 10 kg, 10-25 kg, 25-40 kg and over 40 kg. The methods with the best overall performance were the devised weight estimation method and Broselow tape although the latter has a length limitation of 145 cm. The other methods performed well in the middle two weight groups but poorly outside these groups.

CONCLUSIONS

The most accurate methods of weight estimation in children are the Broselow tape and the devised weight estimation method. We recommend the use of either of these methods in emergency situations where direct weighing is not possible.

Comparison of two benzodiazepines used for sedation of children undergoing suturing of a laceration in an emergency department

OBJECTIVES

(1) To determine if oral diazepam (POD) is as effective in sedating children less than 6 years of age for laceration repair as oral midazolam (POM) or intranasal midazolam (INM); and (2) To determine if patients stayed longer in the department after sedation when given POD for sedation.

DESIGN/METHODS

Block-randomized, single-blind trial.

SETTING

Tertiary pediatric emergency department.

PARTICIPANTS

Patients 1 to 5 years old with a laceration requiring sutures were enrolled.

INTERVENTIONS

All patients had topical anesthetic applied to the wound and were randomly assigned to POD 0.5 mg/kg, POM 1.0 mg/kg, or INM 0.4 mg/kg for sedation.

RESULTS

One hundred twenty-nine patients were enrolled, 42 POD, 45 POM, and 42 INM. Each group was similar at baseline for age, heart rate, respiratory rate, blood pressure, oxygen saturation, previous laceration or sedation, anxiety score, and site of laceration. POM and POD were better tolerated than INM (P = 0.05 and 0.034), respectively. Time to sedation was significantly longer in POD (31.0 +/- 9 min) than INM (26.1 +/- 9 min) (P = 0.011) but there was no significant difference when comparing the other groups. However, this difference was not clinically significant. POD was significantly worse at sedating children compared with POM and INM on all four scores (ie, doctor, nurse, parent, and investigator), but INM and POM were equivalent. Total time in the department was no different between POM and INM or POM and POD, but was significantly different for POD (53.9 +/- 16 min) and INM (48 +/- 12 min); however, this difference was minimal. More patients were said to be drowsy at home in the POM group (51%) than the POD group (32%).

CONCLUSIONS

The oral route of delivery of POM and POD was better tolerated than INM. POM and INM were more effective at sedation than POD, but there was no clinical difference between any groups for time to sedation or time to discharge. More patients in the POM group had side effects after leaving the department. POD may be an alternative to POM, but a higher dose may be required, possibly with longer recovery times.

Paediatric sedation in emergency department: what is our practice?

OBJECTIVES

The aim of the present study was to document the use of sedation in paediatric patients in emergency departments within Australia and New Zealand.

METHODS

A questionnaire was sent to 54 emergency departments throughout Australia and New Zealand.

RESULTS

A total of 45 departments (83%) responded to the survey. Because the adult departments (n 5) reported few paediatric attendances, they were not included in the analysis. Thirty-nine of 40 departments (97.50%) reported using sedation in children. Midazolam was used most frequently (77%) for sedation. There was marked variation in the route of delivery and the dose of midazolam used. Ketamine was reported as the most efficacious agent used, but it was used only in 12% of cases. Formal guidelines existed in all paediatric departments but only in 58% of mixed departments, and formal discharge criteria were used in only 52% of all departments. The use of topical anaesthesia in wound closure was reported in only 3,000 of departments.

CONCLUSIONS

There exists wide variation in practice regarding the use of sedation in children in emergency departments throughout Australia and New Zealand. Thus, the development of adequate guidelines, including discharge instructions and the use of topical agents, will improve sedation for children.

Community ventures in rural health: the establishment of community health trusts in Southern New Zealand

During the 1990s, a shortage of funds and a competitive market for public sector health services created both threats and opportunities for rural health services in New Zealand. In three of the four regional funding areas, rural health services experienced increased levels of closure or privatisation. In the fourth area, the Southern Region, the initiative of the community and the response of the funder combined to produce an alternative response; the formation of community health trusts that allowed local communities to own their own health facilities and to contract to run the services. Through a survey of community trusts this research analyses the process of trust formation and assesses the critical success factors in the community (local leadership, local financial and other commitment, involvement of local professionals, learning from each other, local operational efficiency) which allowed the trusts to survive and thrive.

Recognition of peroxisomal targeting signal type 1 by the import receptor Pex5p

We have studied how Pex5p recognizes peroxisomal targeting signal type 1 (PTS1)-containing proteins. A randomly mutagenized pex5 library was screened in a two-hybrid setup for mutations that disrupted the interaction with the PTS1 protein Mdh3p or for suppressor mutations that could restore the interaction with Mdh3p containing a mutation in its PTS1. All mutations localized in the tetratricopeptide repeat (TPR) domain of Pex5p. The Pex5p TPR domain was modeled based on the crystal structure of a related TPR protein. Mapping of the mutations on this structural model revealed that some of the loss-of-interaction mutations consisted of substitutions in alpha-helices of TPRs with bulky amino acids, probably resulting in local misfolding and thereby indirectly preventing binding of PTS1 proteins. The other loss-of-interaction mutations and most suppressor mutations localized in short, exposed, intra-repeat loops of TPR2, TPR3, and TPR6, which are predicted to mediate direct interaction with PTS1 amino acids. Additional site-directed mutants at conserved positions in intra-repeat loops underscored the importance of the loops of TPR2 and TPR3 for PTS1 interaction. Based on the mutational analysis and the structural model, we put forward a model as to how PTS1 proteins are selected by Pex5p.

On a hiding to nothing? Assessing the corporate governance of hospital and health services in New Zealand 1993-1998

In New Zealand the governance of public sector hospital and health services has changed significantly over the past decade. For most of the century hospitals had been funded by central government grants but run by locally elected boards. In 1989 a reforming Labour government restructured health services along managerialist lines, including changing governance structures so that some area health board members were government appointments, with the balance elected by the community. More market oriented reform under a new National government abolished this arrangement and introduced (1993) a corporate approach to the management of hospitals and related services. The hospitals were established as limited liability companies under the Companies Act. This was an explicitly corporate model and, although there was some modification of arrangements following the election of a more politically moderate centre-right coalition government in 1996, the corporate model was largely retained. Although significant changes occurred again after the election of a Labour government in 1999, the corporate governance experience in New Zealand health services is one from which lessons can, nevertheless, be learnt. This paper examines aspects of the performance and process of corporate governance arrangements for public sector health services in New Zealand, 1993-1998.

Risk factors for cerebral edema in children with diabetic ketoacidosis. The Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics

BACKGROUND

Cerebral edema is an uncommon but devastating complication of diabetic ketoacidosis in children. Risk factors for this complication have not been clearly defined.

METHODS

In this multicenter study, we identified 61 children who had been hospitalized for diabetic ketoacidosis within a 15-year period and in whom cerebral edema had developed. Two additional groups of children with diabetic ketoacidosis but without cerebral edema were also identified: 181 randomly selected children and 174 children matched to those in the cerebral-edema group with respect to age at presentation, onset of diabetes (established vs. newly diagnosed disease), initial serum glucose concentration, and initial venous pH. Using logistic regression we compared the three groups with respect to demographic characteristics and biochemical variables at presentation and compared the matched groups with respect to therapeutic interventions and changes in biochemical values during treatment.

RESULTS

A comparison of the children in the cerebral-edema group with those in the random control group showed that cerebral edema was significantly associated with lower initial partial pressures of arterial carbon dioxide (relative risk of cerebral edema for each decrease of 7.8 mm Hg [representing 1 SD], 3.4; 95 percent confidence interval, 1.9 to 6.3; P<0.001) and higher initial serum urea nitrogen concentrations (relative risk of cerebral edema for each increase of 9 mg per deciliter [3.2 mmol per liter] [representing 1 SD], 1.7; 95 percent confidence interval, 1.2 to 2.5; P=0.003). A comparison of the children with cerebral edema with those in the matched control group also showed that cerebral edema was associated with lower partial pressures of arterial carbon dioxide and higher serum urea nitrogen concentrations. Of the therapeutic variables, only treatment with bicarbonate was associated with cerebral edema, after adjustment for other covariates (relative risk, 4.2; 95 percent confidence interval, 1.5 to 12.1; P=0.008).

CONCLUSIONS

Children with diabetic ketoacidosis who have low partial pressures of arterial carbon dioxide and high serum urea nitrogen concentrations at presentation and who are treated with bicarbonate are at increased risk for cerebral edema.

The peroxisomal membrane protein Pex13p shows a novel mode of SH3 interaction

Src homology 3 (SH3) domains are small non-catalytic protein modules capable of mediating protein-protein interactions by binding to proline-X-X-proline (P-X-X-P) motifs. Here we demonstrate that the SH3 domain of the integral peroxisomal membrane protein Pex13p is able to bind two proteins, one of which, Pex5p, represents a novel non-P-X-X-P ligand. Using alanine scanning, two-hybrid and in vitro interaction analysis, we show that an alpha-helical element in Pex5p is necessary and sufficient for SH3 interaction. Sup pressor analysis using Pex5p mutants located in this alpha-helical element allowed the identification of a unique site of interaction for Pex5p on the Pex13p-SH3 domain that is distinct from the classical P-X-X-P binding pocket. On the basis of a structural model of the Pex13p-SH3 domain we show that this interaction probably takes place between the RT- and distal loops. Thus, the Pex13p-SH3-Pex5p interaction establishes a novel mode of SH3 interaction.

Saccharomyces cerevisiae PTS1 receptor Pex5p interacts with the SH3 domain of the peroxisomal membrane protein Pex13p in an unconventional, non-PXXP-related manner

A number of peroxisome-associated proteins have been described that are involved in the import of proteins into peroxisomes, among which is the receptor for peroxisomal targeting signal 1 (PTS1) proteins Pex5p, the integral membrane protein Pex13p, which contains an Src homology 3 (SH3) domain, and the peripheral membrane protein Pex14p. In the yeast Saccharomyces cerevisiae, both Pex5p and Pex14p are able to bind Pex13p via its SH3 domain. Pex14p contains the classical SH3 binding motif PXXP, whereas this sequence is absent in Pex5p. Mutation of the conserved tryptophan in the PXXP binding pocket of Pex13-SH3 abolished interaction with Pex14p, but did not affect interaction with Pex5p, suggesting that Pex14p is the classical SH3 domain ligand and that Pex5p binds the SH3 domain in an alternative way. To identify the SH3 binding site in Pex5p, we screened a randomly mutagenized PEX5 library for loss of interaction with Pex13-SH3. Such mutations were all located in a small region in the N-terminal half of Pex5p. One of the altered residues (F208) was part of the sequence W(204)XXQF(208), that is conserved between Pex5 proteins of different species. Site-directed mutagenesis of Trp204 confirmed the essential role of this motif in recognition of the SH3 domain. The Pex5p mutants could only partially restore PTS1-protein import in pex5Delta cells in vivo. In vitro binding studies showed that these Pex5p mutants failed to interact with Pex13-SH3 in the absence of Pex14p, but regained their ability to bind in the presence of Pex14p, suggesting the formation of a heterotrimeric complex consisting of Pex5p, Pex14p, and Pex13-SH3. In vivo, these Pex5p mutants, like wild-type Pex5p, were still found to be associated with peroxisomes. Taken together, this indicates that in the absence of Pex13-SH3 interaction, other protein(s) is able to bind Pex5p at the peroxisome; Pex14p is a likely candidate for this function.

Corporate governance of public health services: lessons from New Zealand for the state sector

New Zealand public hospitals and related services were grouped into 23 Crown Health Enterprises and registered as companies in 1993. Integral to this change was the introduction of corporate governance. New directors, largely from the business sector, were appointed to govern these organisations as efficient and effective businesses. This article presents the results of a survey of directors of New Zealand publicly-owned health provider organisations. Although directors thought they performed well in business systems development, they acknowledged their shortcomings in meeting government expectations in respect to financial performance and social responsibility. Changes in public health sector provider performance indicators have resulted in a mixed report card for the sector six years after corporate governance was instituted.