Retaining dermatology patients in primary care through dialogue with secondary care providers: A service evaluation

BACKGROUND

There are long patient waiting lists for specialist care. A dermatology dialogue service between primary and secondary care (DDPS) was developed in eastern England. Primary care referrers uploaded patient images of skin conditions for review by and dialogue with consultant dermatologists in an attempt to retain patients in primary care rather than refer them to secondary care.

METHODS

Evaluation of service performance against specific targets, including reduction in secondary care waiting list growth over the period April 2021-March 2022 inclusive. Service activity was summarized in terms of speed of resolution, case numbers, and dispositions. Clinician and patient satisfaction were assessed using structured questionnaires. Actual numbers of new referrals were compared to projections based on historical data. Waiting list growth was compared to other specialties and other commissioning areas. Waiting times to initial treatment were monitored.

RESULTS

Over 3300 patients were enrolled and > 90% of dialogues were resolved within 36 hours. Clinician and patient satisfaction were high. Frequently asked questions and conditions were highlighted by dermatologists to design and deliver an educational event for primary care clinicians that was well received. Waiting list growth for dermatology patients in the commissioning area was smaller than for other major specialties, and generally smaller than growth for dermatology waiting lists commissioned by other NHS commissioners. There was no negative impact on the urgent priority (cancer pathway) waiting list.

CONCLUSION

The DDPS was satisfactory for clinicians and patients and coincided with lower growth in dermatology waiting lists than might otherwise have been expected.

Is Severe Neck Pain a Contraindication to Performing Laminoplasty in Patients With Cervical Spondylotic Myelopathy?

STUDY DESIGN

Retrospective review.

OBJECTIVE

The purpose of this study was to investigate the surgical outcomes in a cohort of patients with severe preoperative axial neck pain undergoing laminoplasty for cervical spondylotic myelopathy (CSM).

SUMMARY OF BACKGROUND DATA

No study has investigated whether patients with severe axial symptoms may achieve satisfactory neck pain and disability outcomes after laminoplasty.

METHODS

We performed a retrospective review of 91 patients undergoing C4-6 laminoplasty for CSM at a single academic institution between 2010 and 2021. Patient-reported outcome measures (PROMs), including Neck Disability Index (NDI), visual analog scale (VAS) Neck, and VAS Arm, were recorded preoperatively and at 6 months and 1 year postoperatively. Patients were stratified as having mild pain if VAS neck was 0-3, moderate pain if 4-6, and severe pain if 7-10. PROMs were then compared between subgroups at all the perioperative time points.

RESULTS

Both the moderate and severe neck pain subgroups demonstrated a substantial improvement in VAS neck from preoperative to 6 months postoperatively (-3.1±2.2 vs. -5.6±2.8, respectively; P <0.001), and these improvements were maintained at 1 year postoperatively. There was no difference in VAS neck between subgroups at either the 6-month or 1-year postoperative time points. Despite the substantially higher mean NDI in the moderate and severe neck pain subgroups preoperatively, there was no difference in NDI at 6 months or 1 year postoperatively ( P =0.99). There were no differences between subgroups in the degree of cord compression, severity of multifidus sarcopenia, sagittal alignment, or complications.

CONCLUSIONS

Patients with moderate and severe preoperative neck pain undergoing laminoplasty achieved equivalent PROMs at 6 months and 1 year as patients with mild preoperative neck pain. The results of this study highlight the multifactorial nature of neck pain in these patients and indicate that severe axial symptoms are not an absolute contraindication to performing laminoplasty in well-aligned patients with CSM.

1230 PALLIATIVE CARE MOVEMENT DISORDERS MULTIDISCIPLINARY MEETING

Introduction

It is well recognised that patients with Parkinson’s disease (PD) have significant symptom burden in advanced stages of their disease. Integration of movement disorder and palliative care services has been limited by concerns about resource and sustainability. We present our experience of establishing a movement disorders palliative care multidisciplinary meeting.

Method

In 2019 we established a multidisciplinary virtual bimonthly meeting between movement disorders and palliative care specialists. Referrals were accepted from movement disorder specialists, community Parkinson’s practitioners and palliative care specialists. Referring clinicians all actively applied primary palliative care approaches within their existing services. Aims of the meeting were to facilitate holistic management of complex needs, support advance care planning (ACP) and consider referral to specialist palliative care services.

Result

37 patients in total were discussed over a 2-year period (although the service was limited for a time due to COVID pressures). On average 3 new patients were discussed per meeting. Reasons for referral included motor and non-motor symptoms, support with ACP, medication advice, caregiver concerns and emotional distress. Meeting outcomes included medication adjustments, expediting reviews, hospice support, carer support, and referral to other services. Since the meetings started 23 (62%) patients have died. Of these, 30% died in hospital compared with the national average of 43.4%. The average between discussion at the meeting and death was 139 days. The meeting has generated education opportunities, triggered joint assessments and a professionals’ framework for the palliative management of patients with a movement disorder.

Conclusions

We present the experience of an MDT embedded within an early integrated palliative care service for movement disorders. The MDT has strengthened partnership working and findings suggest that alongside active primary palliative care, specialist palliative care for PD can be sustainable and resource efficient in a UK setting.

630 Hailey-Hailey Disease: A Rare Presentation in the Hypopharnyx

Background

Hailey-Hailey disease or familial benign pemphigus is a rare genetic blistering skin disease due to mutation of the ATP2C1 gene inherited in autosomal dominant fashion. Prevalence is around 1 in 50,000 and positive family history is observed in 75% of cases. Patients typically present with well-demarcated painful erosive and yellow-crusted rash in the skin folds, following a relapsing-remitting pattern. There are very limited known cases of extra-dermatological presentation of this disease.

Case

64-year-old gentleman presented with dysphagia, hoarseness, sore throat, dry cough, and intermittent haemoptysis. Initial flexible nasendoscopy showed mild erythema of epiglottis and false cords, post-cricoid oedema and very mild Reinke's oedema. He was treated as acid reflux with omeprazole but to little effect. Endoscopy 4 months later showed similar findings hence biopsy of the hypopharynx was taken. The sample demonstrated intraepithelial clefting, suspicious of intraepithelial vesiculobullous disorder particularly pemphigus vulgaris.

Looking into this gentleman's medical history, it was found that he is under the care of dermatology for Hailey-Hailey disease, which he was diagnosed 30 years ago. He also has a strong family history of this condition. Based on the biopsy findings and patient profile, it was concluded that this gentleman has a hypopharyngeal manifestation of Hailey-Hailey disease.

Discussion

Hailey-Hailey disease is traditionally described as a dermatological condition. This gentleman is one of the rare few cases of non-dermatological manifestation of this disease.

A systematic scoping review of early interventions for parents of deaf infants

Background

Over 90% of the 50,000 deaf children in the UK have hearing parents, many of whom were not expecting a deaf child and may require specialist support. Deaf children can experience poorer long-term outcomes than hearing children across a range of domains. After early detection by the Universal Newborn Hearing Screening Programme, parents in the UK receive support from Qualified Teachers of the Deaf and audiologists but resources are tight and intervention support can vary by locality. There are challenges faced due to a lack of clarity around what specific parenting support interventions are most helpful.

Methods

The aim of this research was to complete a systematic scoping review of the evidence to identify early support interventions for parents of deaf infants. From 5577 identified records, 54 met inclusion criteria. Two reviewers screened papers through three rounds before completing data extraction and quality assessment.

Results

Identified parent support interventions included both group and individual sessions in various settings (including online). They were led by a range of professionals and targeted various outcomes. Internationally there were only five randomised controlled trials. Other designs included non-randomised comparison groups, pre / post and other designs e.g. longitudinal, qualitative and case studies. Quality assessment showed few high quality studies with most having some concerns over risk of bias.

Conclusion

Interventions commonly focused on infant language and communication followed by parental knowledge and skills; parent wellbeing and empowerment; and parent/child relationship. There were no interventions that focused specifically on parent support to understand or nurture child socio-emotional development despite this being a well-established area of poor outcome for deaf children. There were few UK studies and research generally was not of high quality. Many studies were not recent and so not in the context of recent healthcare advances. Further research in this area is urgently needed to help develop evidence based early interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-021-02893-9.

1068 Cranial Fasciitis of the Temporal Bone

We present the case of a child with a rare benign tumour of the temporal bone.

A nine-month-old girl was referred to her local paediatric hospital with a painless right-sided, post-auricular swelling increasing in size in the preceding two months. On examination there was a 2x2cm mass overlying the temporal bone posterior to the right ear. The mass was firm, immobile, non-tender and well circumscribed. Ultrasound demonstrated a 1.9cm subcuticular mass with evidence of intracranial extension through the suture. Vascular flow and hyperechoic foci were demonstrated within the lesion. The local paediatric team requested magnetic resonance imaging (MRI) and computed tomography (CT) of temporal bone prior to referral to tertiary care centre. Imaging displayed a 2cm expansile lesion of the temporal bone with cortical loss and effacement of underlying dural venous sinus. The patient proceeded to incisional biopsy for tissue diagnosis which was suggestive of cranial fasciitis. Following discussion at the regional multidisciplinary meeting, she underwent surgical excision of the tumour in a joint Neurosurgery/Otology case. The tumour was fully resected macroscopically, with the normal surrounding bone and mastoid air cells preserved. Final histopathology showed a highly cellular lesion composed of spindle cells arranged in fascicles, with areas of myxoid background and confirmed the tumour to be cranial fasciitis. The child has made a good recovery and will be kept under close clinical follow-up. This case demonstrates a rare benign tumour of the temporal bone that may present to an otolaryngologist and the importance of tissue diagnosis, imaging and multidisciplinary management.

The effect of the COVID-19 pandemic on non-elective otolaryngology admissions and a positive change in clinical practice

As the COVID-19 pandemic progressed across the UK and Northern Ireland in March 2020, our otolaryngology department began to make preparations and changes in practice to accommodate for potentially large numbers of patients with COVID-19 related respiratory illness in the hospital. We retrospectively reviewed the number of non-elective admissions to our department between the months of January and May in 2019 and 2020. A significant reduction in admissions of up to 94% during the months of the pandemic was observed. Our practice shifted to manage patients with epistaxis and peritonsillar abscess on an outpatient basis, and while prospectively collecting data on this, we did not observe any significant adverse events. We view this as a positive learning point and change in our practice as a result of the COVID-19 pandemic.

Change in a clinical measure of cervical movement sense following four weeks of kinematic training

BACKGROUND

Training targeted towards improving cervical movement accuracy is an effective strategy in the management of neck pain. Relatively complex measures have been validated to measure this in research although a simple clinical measure using a head mounted laser tracing a standardised pattern has been shown to be reliable. It is not known if this method demonstrate clinically meaningful change to training.

OBJECTIVE

To assess change responsiveness of the clinical cervical movement sense (CCMS) test following home kinematic training (KT).

STUDY DESIGN

Pre-post treatment observational study.

METHODS

The CCMS measure was assessed in 56 patients with chronic neck pain (41 intervention, 15 control) at baseline and 4 weeks post intervention by blinded assessors. Task completion time and error number were assessed reviewing video of the performances. Change pre-post intervention was compared between groups.

RESULTS

There was a significantly greater mean improvement in the intervention (-9.2 ± 9.3) seconds) for completion time and combined time and error (-13.3 ± 16) compared to the control group for time (-2.0 ± 9.8) and combined time and error (-1.8 ± 14) with moderate to high effect sizes (Cohen's d 0.76). There was a non-significant trend for decreased number of errors in the intervention (-4.1 ± 9.0) compared to control group (0.2 ± 8.3).

CONCLUSION

Completion time of the CCMS test appears to be able to demonstrate meaningful change following four weeks of KT. This further supports its clinical utility as a measure of cervical movement accuracy and provides direction for future clinical use.

A Tasmanian devil breeding program to support wild recovery

Tasmanian devils are threatened in the wild by devil facial tumour disease: a transmissible cancer with a high fatality rate. In response, the Save the Tasmanian Devil Program (STDP) established an 'insurance population' to enable the preservation of genetic diversity and natural behaviours of devils. This breeding program includes a range of institutions and facilities, from zoo-based intensive enclosures to larger, more natural environments, and a strategic approach has been required to capture and maintain genetic diversity, natural behaviours and to ensure reproductive success. Laboratory-based research, particularly genetics, in tandem with adaptive management has helped the STDP reach its goals, and has directly contributed to the conservation of the species in the wild. Here we review this work and show that the Tasmanian devil breeding program is a powerful example of how genetic research can be used to understand and improve reproductive success in a threatened species.

Autism Spectrum Social Stories In Schools Trial 2 (ASSSIST2): study protocol for a randomised controlled trial analysing clinical and cost-effectiveness of Social Stories™ in primary schools

Background

Interventions designed to support children with a diagnosis of Autism Spectrum Conditions (ASC) can be time consuming, needing involvement of outside experts. Social Stories™ are a highly personalised intervention aiming to give children with ASC social information or describing an otherwise difficult situation or skill. This can be delivered daily by staff in education settings. Studies examining Social Story™ use have yielded mostly positive results but have largely been single case studies with a lack of randomised controlled trials (RCTs). Despite this numerous schools are utilising Social Stories™, and a fully powered RCT is timely.

Methods

A multi-site pragmatic cluster RCT comparing care as usual with Social Stories™ and care as usual. This study will recruit 278 participants (aged 4–11) with a clinical diagnosis of ASC, currently attending primary school in the North of England. Approximately 278 school based staff will be recruited to provide school based information about participating children with approximately 140 recruited to deliver the intervention. The study will be cluster randomised by school. Potential participants will be screened for eligibility prior to giving informed consent. Follow up data will be collected at 6 weeks and 6 months post randomisation and will assess changes in participants’ social responsiveness, goal based outcomes, social and emotional health. The primary outcome measure is the Social Responsiveness Scale Second Edition (SRS-2) completed by school based staff at 6 months. Approvals have been obtained from the University of York’s Research Governance Committee, Research Ethics Committee and the Health Research Authority. Study results will be submitted for publication in peer-reviewed journals and disseminated to participating families, educational staff, local authority representatives, community groups and Patient and Participant Involvement representatives. Suggestions will be made to NICE about treatment evidence dependent on findings.

Discussion

This study addresses a much used but currently under researched intervention and results will inform school based support for primary school children with a diagnosis of ASC.

Trial registration

The trial is registered on the ISRCTN registry (registration number: ISRCTN11634810). The trial was retrospectively registered on 23rd April 2019.

Ice therapy: cool, current and complicated

This is the fourth Capsule review article provided by the WSAVA Global Pain Council and which discusses the use of ice or cold therapy as a non-pharmacologic modality for pain control in small animal practice. The physiological effects of cold therapy on tissues, receptors and ion channels are discussed; as well as indications, recommendations for, and limitations of use.

Effects of epigenetic pathway inhibitors on corticotroph tumour AtT20 cells

Medical treatments for corticotrophinomas are limited, and we therefore investigated the effects of epigenetic modulators, a new class of anti-tumour drugs, on the murine adrenocorticotropic hormone (ACTH)-secreting corticotrophinoma cell line AtT20. We found that AtT20 cells express members of the bromo and extra-terminal (BET) protein family, which bind acetylated histones, and therefore, studied the anti-proliferative and pro-apoptotic effects of two BET inhibitors, referred to as (+)-JQ1 (JQ1) and PFI-1, using CellTiter Blue and Caspase Glo assays, respectively. JQ1 and PFI-1 significantly decreased proliferation by 95% (P < 0.0005) and 43% (P < 0.0005), respectively, but only JQ1 significantly increased apoptosis by >50-fold (P < 0.0005), when compared to untreated control cells. The anti-proliferative effects of JQ1 and PFI-1 remained for 96 h after removal of the respective compound. JQ1, but not PFI-1, affected the cell cycle, as assessed by propidium iodide staining and flow cytometry, and resulted in a higher number of AtT20 cells in the sub G1 phase. RNA-sequence analysis, which was confirmed by qRT-PCR and Western blot analyses, revealed that JQ1 treatment significantly altered expression of genes involved in apoptosis, such as NFκB, and the somatostatin receptor 2 (SSTR2) anti-proliferative signalling pathway, including SSTR2. JQ1 treatment also significantly reduced transcription and protein expression of the ACTH precursor pro-opiomelanocortin (POMC) and ACTH secretion by AtT20 cells. Thus, JQ1 treatment has anti-proliferative and pro-apoptotic effects on AtT20 cells and reduces ACTH secretion, thereby indicating that BET inhibition may provide a novel approach for treatment of corticotrophinomas.

Gunshot Wounds to the Hip: Doomed to Failure?

The purpose is to evaluate hip fractures due to gunshot wounds (GSW) to the hip, which are treated surgically, and the complications. Patients who sustained a low velocity GSW with fracture to the femoral head/neck and intertrochanteric/peritrochantric region at three Level 1 Trauma Centers were eligible. There were 69 patients (63 males-91%), with an average age of 29 (18-60). Nine patients had orthopaedic surgical site infections. There were 6 nonunions, 4 patients with hardware failure, 2 cases of avascular necrosis (AVN), 3 patients with post traumatic arthritis (PTA) and 20 patients with heterotopic ossification (HO). There was no significant difference found regarding fracture site or type of fixation with regards to complications. This represents the largest study of surgically treated GSW to the hip. Of patients studied, 61% sustained additional GSW. These injuries are not benign; the main complications being infection and heterotopic ossification. (Journal of Surgical Orthopaedic Advances 29(3):135-140, 2020).

Intraperitoneal and incisional analgesia in small animals: simple, cost-effective techniques

The World Small Animal Veterinary Association Global Pain Council (WSAVA-GPC) has recently published its first "capsule review" by Monteiro et al. These are short articles that present a brief assessment of the scientific evidence and practical recommendations on important, and sometimes controversial, subjects in pain management. The capsules will be published regularly in the Journal of Small Animal Practice, the official journal of the WSAVA. This second article discusses the use of intraperitoneal and incisional analgesia in small animal practice, including their limitations and recommendations by the authors.

Quality assurance of rifampicin-containing fixed-drug combinations in South Africa: dosing implications

SETTING:

Rifampicin (RMP) drives treatment response in drug-susceptible tuberculosis. Low RMP concentrations increase the risk of poor outcomes, and drug quality needs to be excluded as a contributor to low RMP exposure.

OBJECTIVES AND DESIGN:

We performed an open-label, three-way cross-over study of three licensed RMP-containing formulations widely used in South Africa to evaluate the bioavailability of RMP in a two-drug fixed-dose combination tablet (2FDC) and a four-drug FDC (4FDC) against a single-drug reference. RMP dosed at 600 mg was administered 2 weeks apart in random sequence. Plasma RMP concentrations were measured pre-dose and 1, 2, 3, 4, 6, 8 and 12 h post-dose. The area under the concentration-time curve (AUC_0–12) of the FDCs was compared to the single drug reference. Simulations were used to predict the impact of our findings.

RESULTS:

Twenty healthy volunteers (median age 22.8 years, body mass index 24.2 kg/m²) completed the study. The AUC_0–12 of the 4FDC/reference (geometric mean ratio [GMR] 78%, 90%CI 69–89) indicated an average 20% reduction in RMP bioavailability in the 4FDC. The 2FDC/reference (GMR 104%, 90%CI 97–111) was bioequivalent. Simulations suggested dose adjustments to compensate for the poor bioavailability of RMP with the 4FDC, and revised weight-band doses to prevent systematic underdosing of low-weight patients.

CONCLUSION:

Post-marketing surveillance of in vivo bioavailability of RMP and improved weight band-based dosing are recommended.

Long-term use of non-steroidal anti-inflammatory drugs in cats with chronic kidney disease: from controversy to optimism

This is the first of a series of capsule reviews published by the World Small Animal Veterinary Association - Global Pain Council (WSAVA-GPC). Each of these short articles provides a brisk assessment of the scientific evidence in specific aspects of pain management, including analgesic techniques, recommendations and controversies surrounding their use. In this first capsule review, the scientific evidence available on the long-term use of non-steroidal anti-inflammatory drugs in cats with concomitant chronic pain and chronic kidney disease is discussed.

'I can't tell my child they are dying'. Helping parents have conversations with their child

This paper explores the challenges of resolving conflicting feelings around talking with a child about their terminal prognosis. When children are left out of such conversations it is usually done with good intent, with a parent wishing to protect their child from anxiety or loss of hope. There is however growing evidence that sensitive, timely, age appropriate information from those with whom children have a good relationship is helpful both for the child and their family. There is no evidence that involving children in sensitive and timely discussions creates significant problems, rather that withholding information may lead to confusion, frustration, distress and anger. The authors discuss ways in which families can be supported to have these significant conversations with their children.

Epigenetic pathway inhibitors represent potential drugs for treating pancreatic and bronchial neuroendocrine tumors

Cancer is associated with alterations in epigenetic mechanisms such as histone modifications and methylation of DNA, and inhibitors targeting epigenetic mechanisms represent a novel class of anti-cancer drugs. Neuroendocrine tumors (NETs) of the pancreas (PNETs) and bronchus (BNETs), which may have 5-year survivals of <50% and as low as 5%, respectively, represent targets for such drugs, as >40% of PNETs and ~35% of BNETs have mutations of the multiple endocrine neoplasia type 1 (MEN1) gene, which encodes menin that modifies histones by interacting with histone methyltransferases. We assessed 9 inhibitors of epigenetic pathways, for their effects on proliferation, by CellTiter Blue assay, and apoptosis, by CaspaseGlo assay, using 1 PNET and 2 BNET cell lines. Two inhibitors, referred to as (+)-JQ1 (JQ1) and PFI-1, targeting the bromo and extra terminal (BET) protein family which bind acetylated histone residues, were most effective in decreasing proliferation (by 40-85%, P<0.001) and increasing apoptosis (by 2-3.6 fold, P<0.001) in all 3 NET cell lines. The anti-proliferative effects of JQ1 and PFI-1 remained present for at least 48 hours after removal of the compound. JQ1, but not PFI-1, had cell cycle effects, assessed by propidium iodide staining and flow cytometry, resulting in increased and decreased proportions of NET cells in G1, and S and G2 phases, respectively. RNA Sequencing analysis revealed that these JQ1 effects were associated with increased histone 2B expression, and likely mediated through altered activity of bromodomain-containing (Brd) proteins. Assessment of JQ1 in vivo, using a pancreatic beta cell-specific conditional Men1 knockout mouse model that develops PNETs, revealed that JQ1 significantly reduced proliferation (by ~50%, P<0.0005), assessed by bromodeoxyuridine incorporation, and increased apoptosis (by ~3 fold, P<0.0005), assessed by terminal deoxynucleotidyl transferase dUTP nick end labelling, of PNETs. Thus, our studies demonstrate that BET protein inhibitors may provide new treatments for NETs.

Family Perceptions and Provision of Analgesia for Acutely Painful Conditions in Children: A Multi-Centred Prospective Survey

BACKGROUND: More than two-thirds of children who present to the emergency department (ED) complain of pain. It is well known that children’s pain is poorly managed in the ED compared to their adult counterparts. With respect to analgesic administration in the ED, discrepancies exist between physician self-report and institutional audit. Patient refusal of analgesia is a likely explanation. There is good evidence that misconceptions and fears about analgesia in children are common among caregivers and may contribute to withholding pain medication. To date, no study has surveyed caregivers presenting the the ED to assess frequency of analgesic administration and reasons for withholding analgesia. We hypothesize that there will be a significant proportion of care-givers and patients that refuse pain medication in the ED. We also hypothesize that there will be a wide range of reasons for refusal. The insight we gain from this study will help nurses, clinical educators, and physicians provide the appropriate information to parents in an effort to target misconceptions and allay fears.

OBJECTIVES: Our objectives were to characterize the degree of care-giver and patient provision of analgesia prior to arrival, refusal of analgesia in the ED, and reasons behind their decision-making process. We hope to identify specific misconceptions, attitudes, or beliefs that impair the optimal provision of analgesia to children in the ED.

DESIGN/METHODS: A novel survey was designed by a focus group using an iterative approach and implemented over a 16-week period across two Canadian tertiary care paediatric EDs. We included a consecutive sample of caregivers of children aged 4-17 years with an acutely painful condition (headache, abdominal pain, injury, otitis, pharyngitis). Caregivers were asked to answer questions covering five domains: (i) demographics, (ii) analgesia prior to arrival (iii) analgesia offered in the ED and reasons for refusal, (iv) perceptions of analgesia, and (v) caregiver satisfaction at discharge. Children were asked to rate their pain on arrival and at discharge. The primary outcome was the frequency of caregiver provision of analgesia prior to arrival and the proportion of caregivers who accept the offer of analgesia offered in the ED.

RESULTS: Three hundred forty-four caregivers completed the survey. The majority were female (269/339, 79%), aged 36 years or older (256/340, 75%) with a post-secondary education (237/336, 71%). Most (309/339, 91%) reported being able to “tell when their child was in pain”. All respondents rated their child’s maximal pain related to the presenting condition as at least a 6/10. With regards to the primary outcome, 229/338 (68%) of caregivers reported that they did not treat their child’s pain prior to arrival in the ED. Of those who did treat their child’s pain, ibuprofen was the most commonly used analgesic (77/112, 69%). The most common reasons for withholding analgesia was a lack of time (80/210, 38%), fear of masking seriousness of child’s condition (49/210, 23%), fear of masking signs and symptoms (48/210, 23%), and a lack of analgesia at home (47/210, 22%). Analgesia was offered to 186/344 (45%) of children in the ED and the majority of caregivers 157/186 (84%) accepted the offer. The most common reason for not accepting analgesia in the ED was child refusal (15/20, 75%). Most, 231/338 (68%) of caregivers felt that their child’s pain was managed well in the ED.

CONCLUSION: This survey of caregiver perceptions surrounding analgesia for children with acutely painful conditions presenting to the pae-diatric ED suggests that most do not treat their child’s pain prior to arrival, despite high levels of pain. Misconceptions surrounding analgesia prior to arrival are common. Despite this, most caregivers accepted analgesia in the ED. Our results suggest that educational strategies should be directed at caregiver awareness of the impact of pain on children and the need for prompt analgesic therapy, even when an ED visit is planned.

Hallucinations and illusions in migraine in children and the Alice in Wonderland Syndrome

DESIGN

A prospective observational study over 1 year.

SETTING

A District General Hospital, and Child and Adolescent Mental Health Department.

PATIENTS

Children aged 8-18 years living in the catchment area of a district hospital service with any type of unexplained hallucinations or illusions associated with or without an established diagnosis of migraine.

RESULTS

The study identified nine children with a combination of migraine and a variety of hallucinations and illusions, including illusions of size, time, colour, body shape, movement and visual and auditory hallucination. An average of 10 symptoms (range 7-15) were reported.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

None.

CONCLUSIONS

It is important to recognise these symptoms to enable appropriate history taking and diagnosis. These symptoms are common and currently seem to go unrecognised and may pose diagnostic difficulties if onset is before typical migraine headaches occur.

THE LEPIDOPTERA OF BERMUDA: THEIR FOOD PLANTS, BIOGEOGRAPHY, AND MEANS OF DISPERSAL

The 183 species of Lepidoptera recorded from Bermuda are discussed with respect to their world distribution, origin, long-range dispersal capability, host plants, nomenclature, and the circumstances of their occurrence in Bermuda; most are illustrated. Fifty-nine species are reported from Bermuda for the first time; Oenobotys invinacealis Ferguson (Pyralidae) and Tetanolita mynesalis inaequalis Ferguson (Noctuidae) are described as new. Four new genus–species combinations and four new synonymies are proposed.The Bermuda islands have a distressed fauna dominated by introduced pest species and migrants from the North American mainland and Caribbean Region. About 125 of the 183 recorded species are thought to be established residents; the remainder are assumed to be vagrants. Of approximately 50 resident species identified as probably indigenous, 11 species and three subspecies are endemic, and one of these, Semiothisa ochrifascia (Warren), is believed extinct.All Bermudian Lepidoptera are of American origin except the few introduced Old World species that are nearly cosmopolitan. Like Norfolk Island, Australia, Bermuda has a supersaturated lepidopterous fauna — more recorded species than its land area might support, which can be explained only by a high incidence of migrants and transients. This migratory component is explained relative to long-range movements of the same or congeneric species elsewhere; and hypotheses are proposed concerning the natural history of long-range dispersal in eastern North America and the ability of these moths to reach Bermuda. From a list of 113 species of Lepidoptera identified as frequent south–north migrants on the mainland, 76 are recorded from Bermuda. These include 38 of the 40 best-known cutworm moths of the eastern United States. It is argued that such moths reach Bermuda repeatedly without man's assistance and must regularly travel similar distances in North America.

BioWeld® Tube and surgical glue for experimental sutureless venous microanastomosis

Background

The medial wall of mammalian veins is generally thin and fragile compared with the thick muscle seen in arteries. This makes venous microanastomoses time consuming and challenging. This study aimed to determine the feasibility and effectiveness of using the BioWeld® Tube in conjunction with a surgical glue (butyl-2-cyanoacrylate) in performing sutureless venous microanastomoses.

Methods

The feasibility and effectiveness of microvascular anastomoses in a rabbit jugular vein model were investigated in six animals, using the BioWeld® Tube in conjunction with butyl-2-cyanoacrylate surgical glue. Patency and tissue repair mechanisms at the anastomotic site were assessed 1 week after the procedure.

Results

All anastomoses remained patent at 1 week. Muscle necrosis occurred only in areas where the tissue was subject to the fold-and-bond procedure.

Conclusion

The study showed the feasibility and short-term effectiveness of the BioWeld® Tube in facilitating venous anastomoses.

Artery of percheron infarction: imaging patterns and clinical spectrum

BACKGROUND AND PURPOSE

Occlusion of the AOP results in a characteristic pattern of ischemia: bilateral paramedian thalamus with or without midbrain involvement. Although the classic imaging findings are often recognized, only a few small case series and isolated cases of AOP infarction have been reported. The purpose of this study was to characterize the complete imaging spectrum of AOP infarction on the basis of a large series of cases obtained from multiple institutions.

MATERIALS AND METHODS

Imaging and clinical data of 37 patients with AOP infarction from 2000 to 2009 were reviewed retrospectively. The primary imaging criterion for inclusion was an abnormal signal intensity on MR imaging and/or hypoattenuation on CT involving distinct arterial zones of the bilateral paramedian thalami with or without rostral midbrain involvement. Patients were excluded if there was a neoplastic, infectious, or inflammatory etiology.

RESULTS

We identified 4 ischemic patterns of AOP infarction: 1) bilateral paramedian thalamic with midbrain (43%), 2) bilateral paramedian thalamic without midbrain (38%), 3) bilateral paramedian thalamic with anterior thalamus and midbrain (14%), and 4) bilateral paramedian thalamic with anterior thalamus without midbrain (5%). A previously unreported finding (the "V" sign) on FLAIR and DWI sequences was identified in 67% of cases of AOP infarction with midbrain involvement and supports the diagnosis when present.

CONCLUSIONS

The 4 distinct patterns of ischemia identified in our large case series, along with the midbrain V sign, should improve recognition of AOP infarction and assist with the neurologic evaluation and management of patients with thalamic strokes.

Are there more bowel symptoms in children with autism compared to normal children and children with other developmental and neurological disorders?: A case control study

There is considerable controversy as to whether there is an association between bowel disorders and autism. Using a bowel symptom questionnaire we compared 51 children with autism spectrum disorder with control groups of 35 children from special school and 112 from mainstream school. There was a significant difference in the reporting of certain bowel symptoms (constipation, diarrhoea, flatulence) and food faddiness between the autism group and the mainstream school control group. There was no significant difference between the autism group and children in the special schools except for faddiness, which is an autism specific symptom and not a bowel symptom. This study confirms previously reported findings of an increase in bowel symptoms in children with autism. It would appear, however, that this is not specifically associated with autism as bowel symptoms were reported in similar frequency to a comparison group of children with other developmental and neurological disorders.

Clinical dilemmas in children with life-limiting illnesses: decision making and the law

Decision making about interventions for children and young people with life-limiting illnesses is fraught with difficulties but faced regularly by staff in children's hospices and paediatric wards. The perspectives of the child, various family members and professionals may all be different. The process of discussion and negotiation and the mechanism by which a decision is arrived at is complex. Various laws have recently changed in the UK that have an impact on this process. This article discusses several clinical scenarios to better understand these decisions and the effects of changes in the law. It also discusses how multidisciplinary teams in children's hospices (and other supportive clinical systems) can best support young people and families with and without recourse to the law.

The role of evaluation in the development of a service for children with life-limiting conditions in the community

BACKGROUND

Much of the care for children and young people with life-limiting conditions is now delivered in the home and new services have developed to support families in this setting. It is essential to monitor and evaluate whether these services are meeting the needs of families.

AIMS

To evaluate a new rural community palliative care service for children according to the perceptions of families and service providers, to make changes suggested by families and to re-evaluate 1 year later.

METHOD

In 2005, 2 years after the onset of the service, 24 families were sent postal questionnaires, including the Measure of Process of Care (MPOC-UK). Changes suggested by families were then implemented. In 2006, all of the families receiving care from the service (n=27) were given the option of completing the questionnaire independently or with the support of an impartial researcher. Two families also completed qualitative interviews about their experience of the service with an impartial researcher. In both years, the service providers, (n=12 and n=15, respectively) were asked to complete the Measure of Process of Care for Service Providers (MPOC-SP). The service providers were the clinicians providing direct care (paediatrician, community nurses, dietician, psychologist, occupational therapist, physiotherapist, and speech and language therapist).

RESULTS

Seven (29%) of families completed the survey in 2005. Families rated 'respectful and supportive care' as the highest domain in the MPOC-UK and 'providing general information' as the lowest. Particular emphasis was placed on improving provision of information during the following year. Fourteen (52%) families completed the survey in 2006. Scores increased across all domains in the second survey. The largest increase was 'providing general information'.

CONCLUSION

The results from both of the MPOC tools were extremely useful in helping providers to identify aspects of the service in need of improvement and hence implement valued changes.

Future innovations in anti-platelet therapies

Platelets have long been recognized to be of central importance in haemostasis, but their participation in pathological conditions such as thrombosis, atherosclerosis and inflammation is now also well established. The platelet has therefore become a key target in therapies to combat cardiovascular disease. Anti-platelet therapies are used widely, but current approaches lack efficacy in a proportion of patients, and are associated with side effects including problem bleeding. In the last decade, substantial progress has been made in understanding the regulation of platelet function, including the characterization of new ligands, platelet-specific receptors and cell signalling pathways. It is anticipated this progress will impact positively on the future innovations towards more effective and safer anti-platelet agents. In this review, the mechanisms of platelet regulation and current anti-platelet therapies are introduced, and strong, and some more speculative, potential candidate target molecules for future anti-platelet drug development are discussed.

National biosecurity approaches, plans and programmes in response to diseases in farmed aquatic animals: evolution, effectiveness and the way forward

The rapid increase in aquaculture production and trade, and increased attention to the negative effects of disease, are becoming stimuli for developing national biosecurity strategies for farmed fisheries, for which the World Organisation for Animal Health (OIE) Aquatic Animal Health Code and Manual of Diagnostic Tests for Aquatic Animals serve as an excellent framework. Using examples from a few countries and selected diseases, this paper provides a general overview of the development of approaches to implementing biosecurity strategies, including those emerging in the national legislation and regulations of some countries, and those being initiated by industries themselves. The determination of disease status in different epidemiological units (from a farm to a nation), appropriate approaches for preventing the introduction of disease and developing contingencies for disease control and eradication are also discussed. Important to the effectiveness of such strategies are provision of financial, personnel and other resources to implement them, including incentives such as indemnification or compensation in eradication programmes, and practical linkage to regulatory or government policy initiatives.

National aquatic animal health plans: the Australian experience

Following a major pilchard (Sardinops sagax) mortality event in 1995, Australia recognised the need for a national approach to aquatic animal health, particularly with respectto disease response. Cooperation between industry and government led to the development of AQUAPLAN, Australia's National Strategic Plan for Aquatic Animal Health. Under AQUAPLAN, institutional arrangements for the national technical response to aquatic animal health emergencies were developed based on existing arrangements for terrestrial animal health. The number and range of Australian Aquatic Veterinary Emergency Plan (AQUAVETPLAN) manuals are rising steadily; these are manuals that outline Australia's approach to national disease preparedness and propose the technical response and control strategies to be activated. Additional resources include standard diagnostic techniques and a disease field identification guide. Simulation exercises provide training to respond to aquatic emergency animal disease events. While resource issues and addressing governance remain priorities for the further implementation of AQUAPLAN, the highest priority is the development of a formal arrangement between governments and private sectors on the response to an aquatic emergency animal disease event.

Laser-assisted end-to-end BioWeld anastomosis in an ovine model

The BioWeld tube, an albumin-based exovascular stent, has been used for microsurgical anastomoses and compared to conventional sutures. The study presented investigated the potential of the BioWeld tube for vascular anastomosis in larger vessels. Laser-assisted BioWeld anastomoses were compared to conventional-sutured anatomoses of the carotid artery of Merino-x ewes. The BioWeld procedure resulted in 100% survival and 100% patency at 1 and 6 week post-operative periods, with no noticeable foreign body response. Sutured animals showed 100% survival and patency. The ischemic time for BioWeld anastomosis averaged 15 minutes compared with 10 minutes for sutures. This study indicates that the BioWeld tube is an easy to use anastomotic technique with equivalent success rates and comparable anastomotic times.