The relationship between parental adverse childhood experiences and the health, well-being and development outcomes of their children: a systematic review

OBJECTIVES

A growing body of research is emerging regarding the relationship between parental adverse childhood experiences (ACEs) and negative health, well-being and developmental outcomes in their children. This systematic review seeks to understand the relationship between parental ACEs and the health, well-being and developmental outcomes of their children and whether the relationships differ according to the number and type of parental ACEs.

STUDY DESIGN

Systematic review.

METHOD

The review includes articles published between 2000 and 2021 from studies using quantitative longitudinal methods and multivariate analysis to investigate the relationship between parental ACEs and their offspring's outcomes. Relevant studies were identified through a systematic search of five databases and findings synthesised using a narrative synthesis. This review was registered on PROSPERO (CRD42021274068).

RESULTS

Nineteen studies met the inclusion criteria and were included in the review. This resulted in a combined population sample of 124,043 parents and 128,400 children. Diversity in measurement of parental ACE exposure and in the type of ACEs measured within the studies precluded a meta-analysis. Offspring of parents exposed to ACEs had a higher risk of a range of negative health, well-being and developmental outcomes. This relationship differs according to the number and type of parental ACEs, with a positive relationship observed between the number of parental ACEs and the risk of negative health, well-being and development outcomes in their children.

CONCLUSIONS

These findings indicate that screening for parental ACEs by health visitors, midwives and other health or social care staff may identify an at-risk population of infants, children and adolescents and improve child outcomes.

Secondary survey in paediatric trauma

The purpose of a secondary survey is to identify the non-life-threatening injuries that are not a priority in the primary survey, but if missed could have long-term impacts for the patient. This article provides a structured approach of the head-to-toe examination required for the secondary survey. We follow the journey of a 9-year-old boy, Peter, who was involved in an accident-electric scooter versus car. After resuscitation and primary survey, you have been asked to carry out the secondary survey. This is a guide of the steps to follow in order to carry out a comprehensive examination to ensure nothing is missed. It highlights the importance of good communication and documentation.

Mid‐Arm Point in PAEDiatrics (MAPPAED): An effective procedural aid for safe pleural decompression in trauma

OBJECTIVE

Life-threatening thoracic trauma requires emergency pleural decompression and thoracostomy and chest drain insertion are core trauma procedures. Reliably determining a safe site for pleural decompression in children can be challenging. We assessed whether the Mid-Arm Point (MAP) technique, a procedural aid proposed for use with injured adults, would also identify a safe site for pleural decompression in children.

METHODS

Children (0-18 years) attending four EDs were prospectively recruited. The MAP technique was performed, and chest wall skin marked bilaterally at the level of the MAP; no pleural decompression was performed. Radio-opaque markers were placed over the MAP-determined skin marks and corresponding intercostal space (ICS) reported using chest X-ray.

RESULTS

A total of 392 children participated, and 712 markers sited using the MAP technique were analysed. Eighty-three percentage of markers were sited within the 'safe zone' for pleural decompression (4th to 6th ICSs). When sited outside the 'safe zone', MAP-determined markers were typically too caudal. However, if the site for pleural decompression was transposed one ICS cranially in children ≥4 years, the MAP technique performance improved significantly with 91% within the 'safe zone'.

CONCLUSIONS

The MAP technique reliably determines a safe site for pleural decompression in children, albeit with an age-based adjustment, the Mid-Arm Point in PAEDiatrics (MAPPAED) rule: 'in children aged ≥4 years, use the MAP and go up one ICS to hit the safe zone. In children <4 years, use the MAP.' When together with this rule, the MAP technique will identify a site within the 'safe zone' in 9 out of 10 children.

Parental Perceptions Regarding the Impact of Housing on Child Health

Introduction Childhood poverty has life-long adverse impacts. We aimed to assess perceptions of parents of a cohort of children attending a paediatric emergency department regarding the impact of their housing on their child and family Methods From 01/11/2020 - 08/01/2021 a cross-sectional study was performed in a paediatric emergency department in Dublin Results Of 312 parents who completed a questionnaire, 4.5% (n = 14) reported themselves to be homeless. Homeless children were less likely to be registered with general practitioners (78.6% vs. 97.5%, p = .009) or be fully vaccinated (71.4% vs. 92.4%, p = .024). Homeless parents were more likely to feel unsafe at home (35.7% vs. 3.4%, p &lt;.001), and to report that their housing negatively impacted their child's education (58.3% vs 10.7%, p &lt;.001), physical health (45.5% vs 11.7, p = .007), and mental health (61.5% vs 12.6%, p &lt;.001). Ten percent of non-homeless parents were concerned about losing their home. A lack of landlord permission to install child safety measures in the home was reported by 28% of all parents. Conclusion Homeless parents were more likely to report that their living situation negatively impacted their child's play, development, education, safety, and health.

Fifteen-minute consultation: A guide to the paediatric primary survey

It's 21:00 and you receive a stand-by call from the local ambulance service. Peter, a 9-year-old boy, was riding an electric scooter and has collided with a car. He has reduced consciousness, signs of shock and is hypoxic. How will you prepare your team? What are the possible injuries? Who will perform the primary survey? Injury is the leading cause of morbidity and mortality in the paediatric population accounting for approximately half of all attendances to paediatric emergency departments in the UK and Ireland. Major trauma can be distressing for patients, parents and physicians. Managing major trauma is challenging and it is vital to have a clear and organised approach. In this 15-minute guide we describe a structured approach to the primary survey that includes how to prepare before the child's arrival, the suggested roles of team members and the key components of the primary survey. We discuss life-threatening injuries, the life-saving bundle and the principles of resuscitation, and the role of imaging in the initial assessment of the injured child.

Emergency department utilisation by homeless children in Dublin, Ireland: a retrospective review

INTRODUCTION

Despite increasing prevalence, European family homelessness remains under-researched.

METHODS

A retrospective review was performed of homeless children attending a paediatric emergency department in Dublin, Ireland, from 1 January 2017 to 31 December 2020. Comparison was made with a random cohort of 1500 non-homeless paediatric attendances in 2019. Homelessness was defined using the European Typology of Homelessness and Housing Exclusion, including those with addresses of no fixed abode, government homeless accommodation and certain residential settings. The objectives were to compare presentations between homeless and non-homeless children. We were interested in determining differences regarding demographics, healthcare utilisation, clinical presentation and outcomes.

RESULTS

Of 197 437 attendances 3138 (1.59%) were homeless. Compared with the non homeless, homeless children were less likely to be ethnically Irish (37.4% vs 74.6%, p<0.001) or have been born in Ireland (82.3% vs 96.2%, p<0.001). Irish Travellers (3% vs 0.8%), Roma (22.5% vs 2.4%) and black (21.1% vs 4.2%) ethnicities were over-represented (p<0.001) in the homeless cohort.Homeless children were younger (age <12 months: 26% vs 16%; p<0.001), less likely to be fully vaccinated (73.6% vs 81.9%, p<0.001) and have registered general practitioners (89.7% vs 95.8%, p<0.001). They were more likely to represent within 2 weeks (15.9% vs 10.5%, p<0.001), and use ambulance transportation (13.2% vs 6.7%, p<0.001). Homeless children had lower acuity presentations (triage category 4-5: 47.2% vs 40.7%, p<0.001) and fewer admissions (5.9% vs 8.4%, p<0.001) than non-homeless children.

DISCUSSION

Infants, Irish Travellers, Roma and black ethnicities were over-represented in homeless presentations. Homeless children had increased reliance on emergency services for primary healthcare needs.

Paediatric major trauma in the setting of the Irish trauma network

BACKGROUND

The construction of a new tertiary children's hospital and reconfiguration of its two satellite centres will become the Irish epicentre for all paediatric care including paediatric trauma. Ireland is also currently establishing a national trauma network although further planning of how to manage paediatric trauma in the context of this system is required. This research defines the unknown epidemiology of paediatric major trauma in Ireland to assist strategic planning of a future paediatric major trauma network.

METHODS

Data from 1068 paediatric trauma cases was extracted from a longitudinal series of annual cross-sectional studies collected by the Trauma Audit and Research Network (TARN). All paediatric patients between the ages of 0-16 suffering AIS ≥2 injuries in Ireland between 2014-2018 were included. Demographics, injury patterns, hospital care processes and outcomes were analysed.

RESULTS

Children were most commonly injured at home (45.1%) or in public places/roads (40.1%). The most frequent mechanisms of trauma were falls <2 m (36.8%) followed by RTAs (24.3%). Limb injuries followed by head injuries were the most often injured body parts. The proportion of head injuries in those aged <1 year is double that of any other age group. Only 21% of patients present directly to a children's hospital and 46% require transfer. Consultant-led emergency care is currently delivered to 41.5% of paediatric major trauma patients, there were 555 (48.2%) patients who required operative intervention and 22.8% who required critical care admission. A significant number of children in Ireland aged 1-5 years die from asphyxia/drowning. The overall mortality rate was 3.8% and was significantly associated with the presence of head injuries (p < 0.001).

CONCLUSION

Paediatric Trauma represents a significant childhood burden of mortality and morbidity in Ireland. There are currently several sub-optimal elements of paediatric trauma service delivery that will benefit from the establishment of a trauma network. This research will help guide prevention strategy, policy-making and workforce planning during the establishment of an Irish paediatric trauma network and will act as a benchmark for future comparison studies after the network is implemented.

Debriefing immediately after intubation in a children's emergency department is feasible and contributes to measurable improvements in patient safety

OBJECTIVE

In 2013, our intubations highlighted a safety gap - only 49% achieved first-pass success without hypoxia or hypotension. NAP4 recommended debriefing after intubation, but limited published methods existed. Primary aim is to implement a feasible process for immediate debriefing and feedback for emergency airway management. Secondary aims are to contribute to reduced frequency of adverse intubation-related events and implement qualitative improvements in patient safety through team reflection and feedback.

METHODS

A component of a prospective quality improvement (QI) study over 4 years in the ED of the Royal Children's Hospital, Melbourne, Australia. Debrief and feedback after intubation was one of seven study interventions. Targeted staff training and involvement of departmental leaders occurred. A post-intervention cohort was audited in 2016. Analysis included the Team Emergency Assessment Measure.

RESULTS

Immediate post-event debriefing occurred in 39 (85%) of 46 intubations. Debriefing was short (median duration 5 min, interquartile range [IQR] 5-10) and soon after (median time 20 min, IQR 5-60). Commonest location was the resuscitation room (92%), led by the team leader (97%). Commonest barrier preventing immediate debriefing was excessive workload. Two QI process measures were assessed during debriefing (adequate resuscitation, airway plan) and case summaries distributed for 100% of intubations. Performance outcomes included contribution to 78% first-pass success without hypoxia or hypotension. Team reflection prompted changes to environment (signage, stickers), training (skill drills), teamwork and process (communication, clinical event debriefing).

CONCLUSION

Structured and targeted debriefing after intubating children in the ED is feasible and contributes to measurable and qualitative improvements in patient safety.

Pneumomediastinum in a child with severe COVID-19

The current global pandemic of the novel coronavirus SARS-CoV2 is a threat to the health and lives of millions of people worldwide. The latest statistics from the World Health Organisation show that there have been 6,515,796 confirmed cases worldwide with 387,298 confirmed deaths (last update 5 June 2020, 10:41 CEST). The majority of critically unwell patients with SARS-CoV2 are adults and the radiological findings associated with them are consistent throughout the literature. However, the reported paediatric cases are few, and as such, there is a limited body of evidence available. More international data is needed, not only on the clinical presentation, but also the radiological findings, so that health-care providers are better able to understand and diagnose this pandemic disease. We describe a case of a previously healthy 9-year-old female who presented to the Emergency Department with symptoms suggestive of raised intracranial pressure. Her CT revealed a medulloblastoma and post-operatively she tested positive for SARS-CoV2. She had a rapid deterioration in her clinical condition and required admission to the intensive care unit (ICU). We provide the supporting radiology along her clinical course in order to demonstrate important insights into this disease in children, including the unusual pnemomediastinum complications which occurred as part of her clinical course. This case is the first reported of its kind.

Finger thoracostomy in patients with chest trauma performed by paramedics on a helicopter emergency medical service

OBJECTIVE

To determine the frequency of finger thoracostomy performed by intensive care flight paramedics after the introduction of a training programme in this procedure and complications of the procedure that were diagnosed after hospital arrival.

METHODS

This was a retrospective cohort study of adult and paediatric trauma patients undergoing finger thoracostomy performed by paramedics on a helicopter emergency medical service between June 2015 and May 2018. Hospital data were obtained through a manual search of the medical records at each of the three receiving major trauma services. Additional data were sourced from the Victorian State Trauma Registry.

RESULTS

The final analysis included 103 cases, of which 73.8% underwent bilateral procedures with a total of 179 finger thoracostomies performed. The mean age of patients was 42.8 (standard deviation 21.4) years and 73.8% were male. Motor vehicle collision was the most common mechanism of injury accounting for 54.4% of cases. The median Injury Severity Score was 41 (interquartile range 29-54). There were 30 patients who died pre-hospital, with most (n = 25) having finger thoracostomy performed in the setting of a traumatic cardiac arrest. A supine chest X-ray was performed prior to intercostal catheter insertion in 38 of 73 patients arriving at hospital; of these, none demonstrated a tension pneumothorax. There were three cases of potential complications related to the finger thoracostomy.

CONCLUSION

Finger thoracostomy was frequently performed by intensive care flight paramedics. It was associated with a low rate of major complications and given the deficiencies of needle thoracostomy, should be the preferred approach for chest decompression.

Point-of-Care Ultrasound echocardiography diagnosis of an atrial myxoma in a child presenting with stroke

We describe a case of paediatric stroke secondary to atrial myxoma, diagnosed in the Emergency Department by Point-of-Care echocardiography. A previously fit and healthy teenage male presented to our paediatric emergency department following a collapse with loss of consciousness. He had suffered a stroke, and had facial paralysis and hemiplegia. His cardiac examination revealed a 3/6 ejection systolic murmur. Whilst his CT was being reported, he had a Point-of-Care echocardiogram in the resuscitation room which showed a very large mass arising from the left atrium and occupying >50% of the chamber. A piece of the myxoma had detached and caused the stroke. The patient was rapidly transferred to a cardiac intensive care unit and underwent emergency surgery the same day. His tumour was successfully completely resected, and he has only a mild residual hemiplegia. Cardiac myxoma should be considered in any child who presents with unexplained acute stroke and a cardiac murmur. Point-of-Care Ultrasound echocardiography in the Paediatric Emergency Department can be used to make a life-saving diagnosis, enabling early surgical management and preventing lifelong complications in children.

Thoracostomy in children with severe trauma: An overview of the paediatric experience in Victoria, Australia

OBJECTIVE

Thoracic trauma is a leading cause of paediatric trauma deaths. Traumatic cardiac arrest, tension pneumothorax and massive haemothorax are life-threatening conditions requiring emergency and definitive pleural decompression. In adults, thoracostomy is increasingly preferred over needle thoracocentesis for emergency pleural decompression. The present study reports on the early experience of thoracostomy in children, to inform debate regarding the best approach for emergency pleural compression in paediatric trauma.

METHODS

Retrospective review of Ambulance Victoria and The Royal Children's Hospital Melbourne, Trauma Registry between August 2016 and February 2019 to identify children undergoing thoracostomy for trauma, either pre-hospital or in the ED.

RESULTS

Fourteen children aged 1.2-15 years underwent 23 thoracostomy procedures over the 31 month period. The majority of patients sustained transport-related injuries, and underwent thoracostomies for the primary indications of hypoxia and hypotension. Two children were in traumatic cardiac arrest. Ten children underwent needle thoracocentesis prior to thoracostomy, but all required thoracostomy to achieve the necessary definitive decompression. All patients were severely injured with multiple-associated serious injuries and median Injury Severity Score 35.5 (17-75), three of whom died from their injuries. Thoracostomy in our cohort had a low complication rate.

CONCLUSION

In severely injured children, thoracostomy is an effective and reliable method to achieve emergency pleural decompression, including in the young child. The technical challenges presented by children are real, but can be addressed by training to support a low complication rate. We recommend thoracostomy over needle thoracocentesis as the first-line intervention in children with traumatic cardiac arrest, tension pneumothorax and massive haemothorax. [Correction added on 23 September 2019 after first online publication: in the second sentence of the conclusion, the words "under review process" were mistakenly added and have been removed.].

Rule of 4's: Safe and effective pleural decompression and chest drain insertion in severely injured children

The intersecting scenarios of multi-trauma, thoracic injury and traumatic cardiac arrest present some of the most demanding moments in paediatric trauma. For these reasons, decision support through teamwork, checklists, technology and guidelines are central to ensuring quality paediatric trauma care. The 'Rule of 4's' is a simple aide-memoire, which guides clinicians of all grades, expertise and distractedness in a reliable approach to injured children who require safe and effective emergency pleural decompression and timely insertion of a chest drain. The Rule of 4's enables these important therapeutic goals to be met through: (i) four steps in a 'good plan'; (ii) fourth (or fifth) intercostal space as the basis for siting a 'good hole'; (iii) 4× uncuffed endotracheal tube size (4× [age/4 + 4]) to guide selection of a 'good tube'; and (iv) 4 cm mark for a 'good stop' to ensure the drain is in far enough but not too far.

Abstract P3-12-24: Tumor-secreted predictive biomarkers of response to radiotherapy in breast cancer

Background:In breast cancer (BC), radiotherapy (RT) is used adjuvantly to prevent recurrence and also in the palliative setting. Clinical signs of RT response are often not apparent for several weeks post-treatment and we currently lack tools to predict or monitor tumor response to RT early during treatment. The aim was to identify tumor-secreted biomarkers whose release reflects response to RT, which could be monitored during treatment in the blood or intratumorally by an implantable biosensor, currently under development within the Implantable Microsystems for Personalised Anti-Cancer Therapy (IMPACT) program.

Methods: A series of experiments assessed the effect of different radiation doses (2-10Gy) on 3 human BC cell lines – MDA-MB-231 (ER-), MCF-7 (ER+) and HBL-100 (ER-) –, 1 canine breast cancer and 2 sheep lung cancer lines. Culture media was collected from each dose experiment at a range of post-radiation time-points (1-24 hours). Proteins were isolated from collected media for secretome mass spectrometry (MS) analysis. A subset of treatment/time conditions were repeated in the same BC cell lines and radioresistant (RR) derivatives from which RNA was extracted and analysed using Lexogen QuantSeq for whole-genome transcriptomics.In-lab candidate biomarker validation was carried out using immuhistochemistry (IHC), immunofluorescence (IF) and western blotting (WB) using validated antibodies. Levels of candidate biomarkers were also assessed in normal and untreated BC tissues using IHC. ELISA-based methods are currently under investigation for detection of the lead candidate biomarkers in the blood of large animal cancer models treated with RT.

Results: Biomarker discovery using the MS data revealed 4 promising candidates: EIF3G, SEC24C, YBX3 and TK1. These are released from BC and animal cancer cells sensitive to radiation in a dose-dependent manner 24 hours after treatment. Analysis of the transcriptomic data showed an 8-fold higher expression of the genes encoding the 4 candidates in the radio-sensitive parental cell lines compared to the RR cell lines. IF and WB confirmed lower intracellular expression of the 4 proteins in RR cells compared to the parental lines. WB of collected culture media confirmed release of each of the 4 candidates 24 hours after a 2Gy dose of radiation in only the parental lines. GAPDH was not found in these media samples, demonstrating that protein release was not due to cell lysis.

Conclusions:

· We have identified 4 promising biomarkers which are released from cancer cells sensitive to RT and not released from RR derivatives.

· All 4 candidates are released 24 hours after a 2Gy radiation dose, which fits with the current clinical dosing schedule where radiation is administered at 24 hour intervals. Ongoing work will elucidate if these biomarkers can be reliably detected in blood or intratumorally using implantable biosensors.

· There are currently no validated predictive tools to monitor RT response during treatment. If successfully validated, these biomarkers could have a clinical role in personalising RT dosing schedules and durations for solid tumors in the neoadjuvant and palliative setting, thus optimising treatment and preventing the administration of ineffective RT and its associated side effects.

Citation Format: Meehan J, Gray M, Turnbull AK, Martinez-Perez C, Bonello M, Ward C, Langdon SP, McLaughlin S, MacLennan M, Dixon JM, Wills J, Quinn N, Finich AJ, von Kriegsheim A, Cameron D, Kunkler IH, Murray A, Argyle D. Tumor-secreted predictive biomarkers of response to radiotherapy in breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-12-24.

Abstract P4-08-02: Understanding the mechanisms of action underlying the role of IL6ST, a key biomarker for prediction of response to endocrine therapy

Introduction: IL6ST is regarded as a putative ER target gene. Recently it has been recognised as a key biomarker for prediction of response to endocrine therapy (ET), having been included as the primary biomarker in our EA2Clin test and as an ER-signalling gene in the EndoPredict test. In both tests higher IL6ST expression is associated with a better response to ET and better prognosis. Despite its importance as a biomarker, little is known about its functional role in breast cancer (BC).

Methods: Pre- and on-treatment (at 14-days and at surgery) samples were collected from 102 post-menopausal women with ER+ BC, treated with 3-6 months of neoadjuvant ET. RNA was extracted for whole-genome expression analysis. From a subset with available fresh frozen tissue (28 patients, 83 samples) protein was extracted and proteome analysis using mass spectrometry is currently underway – results available for SABCS 2017. Immunohistochemistry was performed on FFPE tissue microarrays (TMAs) comprising pre-treatment samples from 102 patients. Cytoplasmic/membrane staining was scored using a graduated scale (0-3+) and nuclear staining was graded using an Immunoscore.

Results: IL6ST exists in membrane-bound and soluble forms of varying size. The full-length membrane bound molecule comprises 8 domains: 6 extracellular, 1 transmembrane and 1 cytoplasmic. In the EA2Clin test, pre-treatment BC tissues are stained for IL6ST with an antibody specific for a region spanning the transmembrane and cytoplasmic domains. TMAs were stained for IL6ST with both this and a second antibody binding the extracellular part, detecting both full-length and most soluble isoforms. Levels of both were correlated (R=0.82, P&lt;0.0001).

IL6ST is known to mediate the action of cytokines including IL6, OSM and LIF via downstream regulation of pathways such as JAK/STAT. TMAs were stained for antibodies against IL6ST, OSM, IL6, total STAT3, pSTAT3 (Tyr705) and pSTAT3 (Ser727). IL6ST was scored as low (0/1+) or high (2+/3+). There was a positive association between levels of IL6ST and IL6 (P=0.02) and total STAT3 (P=0.003). There was no association between IL6ST and OSM or either pSTAT3.

Supervised gene expression analysis comparing pre-treatment samples with high and low IL6ST levels revealed increased levels of STAT3-regulated genes: cell cycle (CEBPD, CDKN1B), apoptosis (NFIL3, ATF3, BCL2), extracellular matrix remodelling (ADM, SEPRINE1-3) and interferon signalling (IFIT1, IFI44, IFI27). Unsupervised gene enrichment analysis revealed increased expression of genes involved with JAK/STAT, PI3K, mTOR and ERBB1 signalling in tumours expressing higher IL6ST levels. Lower levels were associated with increased energy generation, cellular metabolism and epithelial-mesenchymal transition.

Conclusions:

• This is the first matched whole-genome and mass spectrometry proteome analysis of sequential ET-treated BC patients

• IL6ST predicts response to ET – it is used in2 independent assays

• Levels of full-length IL6ST appear to be the most important for ET response prediction

• IL6ST may have an active role in BC cells, mediating signalling of cytokines such as IL6 through the JAK/STAT pathway and subsequent downstream transcriptional regulation.

Citation Format: Turnbull AK, Fernando A, Martinez-Perez C, Finch AJ, von Kriegsheim A, Wills J, Quinn N, Selli C, Mosley D, Langdon SP, Sims AH, Dixon JM. Understanding the mechanisms of action underlying the role of IL6ST, a key biomarker for prediction of response to endocrine therapy [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-08-02.

A quality improvement initiative to increase the safety of pediatric emergency airway management

BACKGROUND

Emergency airway management is commonly associated with life-threatening hypoxia and hypotension which may be preventable.

AIMS

The aim of this quality improvement study was to reduce the frequency of intubation-related hypoxia and hypotension.

METHODS

This prospective quality improvement study was conducted over 4 years in the Emergency Department of The Royal Children's Hospital, Melbourne, Australia. A preintervention cohort highlighted safety gaps and was used to design study interventions, including an emergency airway algorithm, standardized airway equipment, a preintubation checklist and equipment template, endtidal carbon dioxide monitoring, postintubation team debriefing, and multidisciplinary team training. Following implementation, a postintervention cohort was used to monitor the impact of study interventions on clinical process and patient outcome. Process measures were as follows: use of a preintubation checklist, verbalization of an airway plan, adequate resuscitation prior to intubation, induction agent dose titration, use of apneic oxygenation, and use of endtidal carbon dioxide to confirm endotracheal tube position. The primary outcome measure was first pass success rate without hypoxia or hypotension. Potential harms from study interventions were monitored.

RESULTS

Forty-six intubations were included over one calendar year in the postintervention cohort (compared to 71 in the preintervention cohort). Overall clinical uptake of the 6 processes measures was 85%. First pass success rate without hypoxia or hypotension was 78% in the postintervention cohort compared with 49% in the preintervention cohort (absolute risk reduction: 29.0%; 95% confidence interval 12.3%-45.6%, number needed to treat: 3.5). No significant harms from study interventions were identified.

CONCLUSION

Quality improvement initiatives targeting emergency airway management may be successfully implemented in the emergency department and are associated with a reduction in adverse intubation-related events.

Dynamic platelet function on von Willebrand factor is different in preterm neonates and full-term neonates: changes in neonatal platelet function

Essentials It is unclear if platelet function differs between preterm and full-term neonates. Platelet behavior was characterized using a flow-based assay on von Willebrand Factor (VWF). Preterms had increased platelet interaction with VWF and glycoprotein Ibα expression. Platelets from preterm neonates behave differently on VWF compared to full-term neonates.

SUMMARY

Background Very low birth weight (VLBW) preterm neonates have an increased risk of hemorrhage-related morbidity and mortality as compared with their full-term counterparts. It is unclear whether platelet function differs between preterm and full-term neonates. This is partly because of the large volumes of blood required to perform standard platelet function tests, and the difficulty in obtaining such samples in neonates. Objectives This study was designed to characterize platelet behavior in neonates with a physiologic flow-based assay that quantifies platelet function in microliter volumes of blood under arterial shear. Methods Blood from VLBW preterm neonates of ≤ 32 weeks' gestation (n = 15) and full-term neonates (n = 13) was perfused under arterial shear over surface-immobilized von Willebrand factor (VWF). Platelet behavior was recorded by digital-image microscopy and analyzed. Surface expression of platelet glycoprotein (GP) Ibα and GPIIIa of VLBW preterm and full-term neonates was also measured. Results VLBW preterm neonates had increased numbers of platelets interacting with VWF, and increased GPIbα expression on the platelet surface. Despite the increased numbers of VWF interactions as reflected by flow-driven platelet translocation along the protein surface, no significant differences were observed in the numbers of platelets that adhered in a stationary fashion to VWF. Platelets from VLBW preterm neonates and those from full-term neonates behaved differently on VWF. Conclusions These differences in platelet function may contribute to the higher incidence of bleeding observed in VLBW preterm neonatal populations, or may represent a compensatory mechanism to counteract this risk of bleeding.

Sweet syndrome revealing systemic lupus erythematosus

Sweet Syndrome is an acute inflammatory skin eruption which is rare in children. We report a case of childhood Systemic Lupus Erythematosus (SLE) that presented with Sweet syndrome. This case is a unique presentation of a common disorder which provides a new facet for the differential diagnosis of SLE in children. It is also the first paediatric case to be reported in a Caucasian child.

Influence of extraction technique on the anti-oxidative potential of hawthorn (Crataegus monogyna) extracts in bovine muscle homogenates

Six extracts were prepared from hawthorn (Crataegus monogyna) leaves and flowers (HLF) and berries (HB) using solid-liquid [traditional (T) (HLFT, HBT), sonicated (S) (HLFS, HBS)] and supercritical fluid (C) extraction (HLFC, HBC) techniques. The antioxidant activities of HLF and HB extracts were characterised using in vitro antioxidant assays (TPC, DPPH, FRAP) and in 25% bovine muscle (longissimus lumborum) homogenates (lipid oxidation (TBARS), oxymyoglobin (% of total myoglobin)) after 24h storage at 4°C. Hawthorn extracts exhibited varying degrees of antioxidant potency. In vitro and muscle homogenate (TBARS) antioxidant activity followed the order: HLFS>HLFT and HBT>HBS. In supercritical fluid extracts, HLFC>HBC (in vitro antioxidant activity) and HLFC≈HBC (TBARS). All extracts (except HBS) reduced oxymyoglobin oxidation. The HLFS extract had the highest antioxidant activity in all test systems. Supercritical fluid extraction (SFE) exhibited potential as a technique for the manufacture of functional ingredients (antioxidants) from hawthorn for use in muscle foods.

Contact with a nurse practitioner: a short-term evaluation study in Parkinson's disease and dystonia

Forty patients with Parkinson's disease and 24 patients with dystonia took part in a study aiming to assess the value of access to and contact with a nurse practitioner over a 6 month period. Patients in each group were randomly allocated to "intervention" or "control" groups, which were matched on important variables. All patients completed a set of questionnaires relating to psychosocial function at two time points separated by 6 months. In the intervening period, those allocated to the "intervention" group received two home visits and five telephone calls from the nurse practitioner. This contact was not provided to the "control" group. The nurse practitioner had a major impact on the provision of information and the facilitation of referral to other health-care agencies. The results of an independent assessment indicated that the patients in the "intervention" programme had found access to and contact with a nurse practitioner of great value. In contrast, the results of the questionnaire assessment did not reveal any statistically significant change in psychosocial functioning from the first to the second assessment for either the "intervention" or "control" groups. The lack of change in the questionnaire measures is discussed in terms of possible sampling bias and the duration of intervention and follow-up. Recommendations are made for future studies, and for the possible provision of clinical services.

Samuel Alexander Kinnier Wilson. Wilson's disease, Queen Square and neurology

This historical article describes the life and work of the British physician Samuel Alexander Kinnier Wilson (1878-1937), who was one of the world's greatest neurologists of the first half of the 20th century. Early in his career, Wilson spent one year in Paris in 1903 where he learned from Pierre-Marie at Bicêtre Hospital. He subsequently retained uninterrupted links with French neurology. He also visited in Leipzig the German anatomist Paul Flechsig. In 1904, Wilson returned to London, where he worked for the rest of his life at the National Hospital for the Paralysed and Epileptic (later the National Hospital for Nervous Diseases, and today the National Hospital for Neurology and Neurosurgery) in Queen Square, and also at Kings' College Hospital. He wrote on 'the old motor system and the new', on disorders of motility and muscle tone, on the epilepsies, on aphasia, apraxia, tics, and pathologic laughing and crying, and most importantly on Wilson's disease. The other objective of our paper is to commemorate the centenary of Wilson's most important work published in 1912 in Brain, and also in Revue Neurologique, on an illness newly recognized and characterized by him entitled "Progressive lenticular degeneration, a familial nervous disease associated with liver cirrhosis". He analyzed 12 clinical cases, four of whom he followed himself, but also four cases previously published by others and a further two that he considered in retrospect had the same disease as he was describing. The pathological profile combined necrotic damage in the lenticular nuclei of the brain and hepatic cirrhosis. This major original work is summarized and discussed in the present paper. Wilson not only delineated what was later called hepato-lenticular degeneration and Wilson's disease, but also introduced for the first time the terms extrapyramidal syndrome and extrapyramidal system, stressing the role of the basal ganglia in motility. The present historical work emphasizes the special contributions made by Wilson to the study of movement disorders, including akinesia and bradykinesia in Parkinson's disease, and their relation to basal ganglia pathology.

Pyloric stenosis--do males and females present differently?

AIMS

In infants with pyloric stenosis we explored (a) if males develop symptoms and present to hospital earlier than females and (b) does any delay in presentation influence the severity of metabolic derangement.

METHOD

A retrospective casenote review of 99 infants who underwent pyloromyotomy (with confirmation of pyloric stenosis) over a two year period (Jan 2006-Dec 2007) in our hospital. The data collected included: sex, age at onset of symptoms, age at presentation to hospital and initial blood results.

RESULTS

The group comprised 84 males and 15 females. Symptoms developed at 26 (0-70) days in males and 35 (0-77) in females. (Mann-Whitney U=428, p=0.04 two tailed). Males presented to hospital at 34 (13-91) days, females at 45 (13-98) days (Mann-Whitney U=391, p=0.01 two tailed). The differences between males and females for (1) age at onset of symptoms and (2) age at presentation to hospital became more significant when weighted averages were calculated using SPSS (Statistical Package for Social Sciences). The lower weighted averages for male infants can be seen in the final table. Increasing duration of symptoms showed a positive correlation with fall in Chloride level. (Spearman's rho: rs= -0.2, p=0.049 two tailed). There was a positive correlation between duration of symptoms and bicarbonate level but this was not significant. (rs=0.06, p>0.05 two tailed). There was a positive correlation between duration of symptoms and pH, but this was not significant (rs=0.12, p>0.05 two tailed).

CONCLUSION

In our hospital, females with pyloric stenosis develop symptoms and present significantly later than males. This should be considered when assessing a female with vomiting outside the usual 20-40 day range.

The impact of a national mental health arts and film festival on stigma and recovery

OBJECTIVE

This study aims to evaluate the impact of a national mental health arts festival for the general public, encompassing a wide variety of art forms and themes.

METHOD

An evaluation was undertaken with 415 attendees from 20 different events, combining qualitative and quantitative approaches.

RESULTS

The findings demonstrate positive impact on the relationship between arts and mental health. Events increased positive attitudes, including positive representations of people's contributions, capabilities and potential to recover. They did not decrease negative attitudes. Intended behaviour change was modest and one film event increased audience perceptions of dangerousness.

CONCLUSION

The paper argues that the arts can change stigma by constructing shared meanings and engaging audiences on an emotional level. Carefully programmed, collaborative, community-based arts festivals should form an integral part of national programmes to address stigma and to promote mental health and wellbeing, alongside traditional social marketing and public education approaches.

Thoracolumbar spinal fixation for camptocormia in Parkinson's disease

A man with early non-fluctuating Parkinson's disease developed disabling camptocormia. The patient was treated with posterior thoracolumbar fixation, which subsequently had to be augmented with anterior interbody fusion. Although the patient ultimately achieved excellent sagittal correction, his postoperative course was complicated and prolonged. Therefore, although this case demonstrates that spinal fixation surgery can be successful, it should probably only be offered after subthalamic nucleus deep brain stimulation has been unsuccessful, or for well motivated patients who express a strong wish for this major reconstructive surgery.

Second consensus statement on the diagnosis of multiple system atrophy

BACKGROUND

A consensus conference on multiple system atrophy (MSA) in 1998 established criteria for diagnosis that have been accepted widely. Since then, clinical, laboratory, neuropathologic, and imaging studies have advanced the field, requiring a fresh evaluation of diagnostic criteria. We held a second consensus conference in 2007 and present the results here.

METHODS

Experts in the clinical, neuropathologic, and imaging aspects of MSA were invited to participate in a 2-day consensus conference. Participants were divided into five groups, consisting of specialists in the parkinsonian, cerebellar, autonomic, neuropathologic, and imaging aspects of the disorder. Each group independently wrote diagnostic criteria for its area of expertise in advance of the meeting. These criteria were discussed and reconciled during the meeting using consensus methodology.

RESULTS

The new criteria retain the diagnostic categories of MSA with predominant parkinsonism and MSA with predominant cerebellar ataxia to designate the predominant motor features and also retain the designations of definite, probable, and possible MSA. Definite MSA requires neuropathologic demonstration of CNS alpha-synuclein-positive glial cytoplasmic inclusions with neurodegenerative changes in striatonigral or olivopontocerebellar structures. Probable MSA requires a sporadic, progressive adult-onset disorder including rigorously defined autonomic failure and poorly levodopa-responsive parkinsonism or cerebellar ataxia. Possible MSA requires a sporadic, progressive adult-onset disease including parkinsonism or cerebellar ataxia and at least one feature suggesting autonomic dysfunction plus one other feature that may be a clinical or a neuroimaging abnormality.

CONCLUSIONS

These new criteria have simplified the previous criteria, have incorporated current knowledge, and are expected to enhance future assessments of the disease.