Working Towards Holistic Scar Assessment and Improved Shared Decision Making in Global Burn Care

Cutaneous burn scars impact various aspects of life. Scar treatment is mainly evaluated on scar characteristics. Consensus is needed on which other outcomes to capture, ensuring they are relevant to patients, clinicians, and researchers. The aim of this study was to identify, discuss and analyze outcomes related to cutaneous burn scarring, incorporating the voice of patients and views of healthcare professionals. For this, a Delphi process consisting of two survey rounds and a consensus meeting was initiated. Burn scar-related outcomes were identified from an existing comprehensive list of 100 outcomes by an international panel of patients, healthcare professionals and researchers. Fifty-nine outcomes were identified from the Delphi process as related to scarring (≥60% votes). Outcomes less impactful in relation to scar outcomes included psychosocial issues, sense of normality, understanding of treatment, costs and systemic issues. To represent a holistic assessment of outcomes related to cutaneous burn scarring, this Delphi process established a battery of outcomes currently included in scar quality assessment tools, and an expanded set of less frequently considered outcomes. Future work in this area must include the patient voice from developing countries. This is essential to identify globally applicable outcomes related to scarring.

Extravasation injury management for neonates and children: A systematic review and aggregated case series

BACKGROUND

Pediatric extravasation injuries are significant healthcare-associated injuries, with sometimes significant sequelae. Evidence-based guidance on management is necessary to prevent permanent injury.

PURPOSE

A systematic review of the literature, including aggregated case series, investigating extravasation injury management of hospitalized pediatric patients.

DATA SOURCES

PubMed, Cummulative Index to Nursing and Allied Health Literature (CINAHL), and Excerpta Medica database (EMBASE) were searched on December 13, 2021.

STUDY SELECTION

Primary research investigating extravasation injury management of hospitalized pediatric patients (to 18 years), published from 2010 onwards and in English, independently screened by two authors, with arbitration from a third author.

DATA EXTRACTION

Data regarding the study, patient (age, primary diagnosis), extravasation (site, presentation, outcome), and treatment (first aid, wound management) were extracted by two authors, with arbitration from a third author.

DATA SYNTHESIS

From an initial 1769 articles, 27 studies were included with extractable case data reported in 18 studies, resulting in 33 cases. No clinical trials were identified, instead, studies were primarily case studies (52%) of neonates (67%), with varied extravasation symptoms. Studies had good selection and ascertainment, but few met the causality and reporting requirements for quality assessments. Signs and symptoms varied, with scarring (45%) and necrosis (30%) commonly described. Diverse treatments were categorized into first aid, medical, surgical, and dressings.

CONCLUSIONS

Despite infiltration and extravasation injuries being common within pediatric healthcare, management interventions are under-researched, with low-quality studies and no consensus on treatments or outcomes.

Systematic literature review of topical local anaesthesia or analgesia to donor site wounds

BACKGROUND

Topical local analgesic and anaesthetic agents have been used both pre- and immediately post-harvest on split-thickness skin graft (STSG) donor site wounds (DSW). There is no systematic review of their effectiveness in providing post-harvest analgesia, or of the possible toxic effects of systemic absorption. This study is designed to address the question of which agent, if any, is favoured over the others and whether there are any safety data regarding their use.

METHODS

Systematic literature review of randomised controlled trials of topical agents applied to STSG DSWs, with a view to providing analgesia. Studies identified via search of Cochrane and EBSCO databases. No restrictions on language or publication year. Primary outcomes: pain at the time of (awake) STSG, and post-harvest pain (up to first dressing change). Secondary outcome was serum medication levels relative to published data on toxic doses. Cochrane risk of bias assessment tool utilised in assessment of included studies. At least 2 reviewers screened and reviewed included studies. A narrative review is presented.

RESULTS

There were 11 studies meeting inclusion criteria. Overall methodological quality and patient numbers were low. Topical eutectic mixture of lidocaine and prilocaine pre-harvest affords good local anaesthesia in awake STSG harvesting. Topical bupivacaine (5 studies) or lidocaine (1 study) gave significantly better post-harvest anaesthesia/analgesia than placebo. Topical morphine performs no better than placebo. Topical local anaesthetic agents at reported doses were all well below toxic serum levels.

CONCLUSIONS

Topical local anaesthetics (lidocaine or bupivacaine) provide good analgesia, both during and after STSG harvest, at well below toxic serum levels, but there are no good data determining the best local anaesthetic agent to use. There is no evidence morphine performs better than placebo.

Changes in cancer incidence and survival among Aboriginal and Torres Strait Islander children in Australia, 1997-2016

BACKGROUND

This study reports cancer incidence and survival among Aboriginal and Torres Strait Islander children and other Australian children, and assesses changes over time.

PROCEDURE

Data were from the population-based Australian Childhood Cancer Registry. The study comprised children aged under 15 diagnosed between 1997 and 2016 and with mortality follow-up until 31 December 2017. Incidence trends were analysed using JoinPoint regression. Five-year cancer-specific survival was calculated using the semi-complete approach with survival comparisons made using multivariable flexible parametric models.

RESULTS

Aboriginal and Torres Strait Islander children accounted for 506 of 13,299 eligible cases (3.8%). Incidence rates for Aboriginal and Torres Strait Islander children across the study period increased by 2.3% annually (95% confidence interval [CI]: +0.6% to +4.0%) and for other Australian children increased by 0.6% annually (95% CI: +0.3% to +0.9%; p = .05). Nonetheless, cancer incidence was consistently lower for Aboriginal and Torres Strait Islander children, with an incidence rate ratio of 0.73 (95% CI: 0.62-0.85; p < .01) between 2012 and 2016. Survival for Aboriginal and Torres Strait Islander children with solid tumours was 70.6% (95% CI: 62.5%-77.3%) and for other Australian children was 83.5% (95% CI: 82.3%-84.7%; p < .01), with indications of this difference diminishing in recent years.

CONCLUSIONS

Improvements in identification, particularly in urban areas, most likely accounts for the greater increase in cancer incidence rates among Aboriginal and Torres Strait Islander children. Examination of data on stage at diagnosis and treatment may provide important insights into survival for children with solid tumours.

Improving peripheral venous cannula insertion in children: a mixed methods study to develop the DIVA key

OBJECTIVE

To develop and validate a difficult intravenous access risk assessment and escalation pathway, to increase first time intravenous insertion success in paediatrics.

METHODS

Mixed methods underpinned by literature and co-production principles. Iterative development of the instrument was informed through semi-structured interviews and stakeholder workshops. The instrument includes a risk assessment, inserter skill self-assessment, and escalation pathways. Reproducibility, reliability, and acceptability were evaluated in a prospective cohort study at a quaternary paediatric hospital in Australia.

RESULTS

Interview data (three parents, nine clinicians) uncovered two themes: i) Recognition of children with DIVA and subsequent escalation is ad hoc and problematic; and ii) Resources and training impact inserter confidence and ability. Three workshops were delivered at monthly intervals (February-April 2020) involving 21 stakeholders culminating in the co-production of the "DIVA Key". The DIVA Key was evaluated between May-December 2020 in 78 children; 156 clinicians. Seventy-eight paired assessments were undertaken with substantial agreement (concordance range = 81.5 to 83.0%) between the assessors. Interrater reliability of the DIVA risk assessment was moderate (kappa = 0.71, 95% CI 0.63-0.80). The DIVA Key predicted multiple insertion attempts for red (high risk) DIVA classification (relative risk ratio 5.7, 95% CI 1.2-27.1; reference low risk). Consumer and clinician satisfaction with DIVA Key was high (median (IQR) = 10 [8-10]; 8 [8-10 respectively).

CONCLUSION

The DIVA Key is a straightforward, reliable instrument with inbuilt escalation pathway to support the identification of children with difficult intravenous access.

The morbidity associated with paediatric burn wound escharotomies

INTRODUCTION

An escharotomy is an effective surgical procedure for the rapid decompression of a constricting and unyielding eschar, to permit restoration of blood flow. However, an escharotomy is also a full-thickness incision, which adds additional scarring to the burn injury area. The cosmetic and functional morbidity of escharotomy scarring in children is poorly characterised.

METHODS

Children who required a burn wound escharotomy at the Queensland Children's Hospital (QCH) between May 2011 and May 2020 were included. Demographics of these children were described. In addition, the number of operations for revision of escharotomy scars was recorded as an indicator of functional or cosmetic concern.

RESULTS

A total of 19 patients required an escharotomy after a burn injury. Children with 1% to 96% TBSA burns required an escharotomy, with a median of 28% (IQR 10-39%) TBSA. Two patients (81% and 96% TBSA) died. Seventy-one percent (12/17) of survivors had operative revisions of their escharotomy scars. The median time from burn to first scar intervention was 35 weeks (IQR 19-70 weeks).

CONCLUSION

There is substantial morbidity associated with escharotomies in children. Further investigation of the current methods of decompression after burn injury, and the long-term morbidity of escharotomy, is required.

Massive, benign, cystic ovarian tumors: A technical modification for minimally invasive resection

The majority of large, cystic ovarian tumors presenting in children are benign and amenable to ovarian sparing surgery (OSS). Laparoscopy is impractical in these cases and when attempted has been associated with a high rate of intraperitoneal fluid spill. We present a modified technique for controlled cyst decompression that allows delivery of the ovary through minilaparotomy and subsequent OSS. Criteria that must be met for the procedure to be undertaken are discussed.

Surgeon's practices and beliefs in Australia and New Zealand regarding the donor site wound for paediatric skin grafts

AIM

Children's burns care in Australasia is performed by paediatric surgeons and by plastic surgeons. The aim was to determine practices regarding the donor site wound (DSW), and to explore any differences by training scheme or nature of unit (paediatric vs. mixed).

METHODS

Online survey of Australasian burns surgeons.

RESULTS

Forty surgeons responded. 23/40 paediatric surgeons, 23/40 worked in a stand-alone children's burns unit. All used powered dermatomes. Alginates were the most common DSW dressing. Idealised dressings favour patient factors over cost. Plastic, and mixed-practice, surgeons use a broader range of dermatome settings in children >1 year. Mixed practice surgeons use thicker settings. All surgeons see pain as a common DSW problem. Paediatric surgeons recognise itch as a problem.

CONCLUSIONS

While there are differences related to training scheme and the mix of patients being treated, there is a broader commonality of practice.

Penile nerve block predicts higher revision surgery rate following distal hypospadias repair when compared with caudal epidural block: A consecutive cohort study

INTRODUCTION

Recent literature has suggested caudal epidural blocks (CEB) may increase revision surgery rates following hypospadias repair. We sought to investigate this using a large, multi-surgeon series.

OBJECTIVE

The primary objective of this study was to identify the impact of CEB or penile nerve blocks (PNB) on revision surgery rates following distal hypospadias repair at our centre.

STUDY DESIGN

A prospectively maintained database of consecutive patients undergoing primary hypospadias repairs under the supervision of 8 different paediatric surgeons at our centre between January 2015 and December 2018 was queried for the following potential risk factors: Age at surgery, American Society of Anaesthesiologist's (ASA) grade, hypospadias type, type of surgery, CEB or PNB, and training level of primary surgeon. Revision surgery was defined as reoperation for fistulas, dehiscence, strictures or meatal stenosis. Univariate and Multivariate analysis was performed using logistic regression.

RESULTS

188 patients underwent primary distal hypospadias repair over the study time period. Patients were aged between 7 months and 15 years of age. Median age at surgery was 14 months. Revision surgery was performed for 31 patients (16.5%). Indications were urethrocutaneous fistula (n = 17, 9.0%), meatal stenosis or stricture (n = 9, 4.8%) and glans dehiscence (n = 5, 2.7%). 114 (60.6%) received a penile block and 74 (39.4%) a caudal block. On univariate analysis, PNB (HR 2.55 95% CI 1.04-6.27, p = 0.04) was statistically significant for revision surgery. This association remained significant on multivariate analysis (HR 2.74 95% CI 1.09-6.92, p = 0.03). All other prognostic factors examined were not statistically significant for revision surgery.

DISCUSSION

Our findings suggest PNB are associated with higher revision surgery rates following distal hypospadias repair. This contrasts with the findings of other authors.

CONCLUSION

Our study is the first to demonstrate an association between PNB and higher revision surgery rates following distal hypospadias repair.

Incidence and outcomes of neuroblastoma in Australian children: A population-based study (1983-2015)

AIM

Neuroblastoma predominantly affects younger children and exhibits heterogeneous behaviour. This study describes incidence and outcomes for neuroblastoma using national population-based data from the Australian Childhood Cancer Registry.

METHODS

Deidentified data for all children (0-14 years) diagnosed with neuroblastoma and ganglioneuroblastoma from 1983 to 2015 were extracted. Cause-specific (CSS) and event-free survival were estimated using the cohort method. Adjusted hazard ratios were calculated using a multivariable flexible parametric survival model. Other outcomes investigated included recurrence and second primary malignancies (SPMs).

RESULTS

The study cohort comprised 1269 patients. Age-standardised incidence rates remained steady across the study period at approximately 9.5 per million children per year. The proportion of patients with metastatic disease at diagnosis decreased from 63% in 1983-1995 to 42% by 2006-2015 (P < 0.001). CSS and event-free survival both improved significantly over time and reached 75% (95% confidence interval (CI) = 71-79%) and 71% (95% CI = 66-75%) at 5 years post-diagnosis, respectively, for children diagnosed between 2004 and 2013. Of patients achieving full remission, 28% relapsed with subsequent 5-year CSS of only 20%. Although SPMs were rare, neuroblastoma survivors carried a fivefold increased risk compared to cancer rates in the general population (standardised incidence ratio = 5.18, 95% CI = 3.01-8.91), with 7 of the 13 patients (54%) who were diagnosed with an SPM dying within 5 years.

CONCLUSIONS

CSS for childhood neuroblastoma has improved substantially over time in Australia, but still remains lower than for most other types of childhood cancer. SPMs are uncommon and carry a better prognosis than relapse of the primary tumour.

The Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics: miniMAGIC

OBJECTIVES

Vascular access device decision-making for pediatric patients remains a complex, highly variable process. To date, evidence-based criteria to inform these choices do not exist. The objective of the Michigan Appropriateness Guide for Intravenous Catheters in pediatrics (miniMAGIC) was to provide guidance on device selection, device characteristics, and insertion technique for clinicians, balancing and contextualizing evidence with current practice through a multidisciplinary panel of experts.

METHODS

The RAND Corporation and University of California, Los Angeles Appropriateness Method was used to develop miniMAGIC, which included the following sequential phases: definition of scope and key terms, information synthesis and literature review, expert multidisciplinary panel selection and engagement, case scenario development, and appropriateness ratings by an expert panel via 2 rounds.

RESULTS

The appropriateness of the selection, characteristics, and insertion technique of intravenous catheters commonly used in pediatric health care across age populations (neonates, infants, children, and adolescents), settings, diagnoses, clinical indications, insertion locations, and vessel visualization devices and techniques was defined. Core concepts including vessel preservation, insertion and postinsertion harm minimization (eg, infection, thrombosis), undisrupted treatment provision, and inclusion of patient preferences were emphasized.

CONCLUSIONS

In this study, we provide evidence-based criteria for intravenous catheter selection (from umbilical catheters to totally implanted venous devices) in pediatric patients across a range of clinical indications. miniMAGIC also highlights core vascular access practices in need of collaborative research and innovation.

Renal tumours in Australian children: 30 years of incidence, outcome and second primary malignancy data from the Australian Childhood Cancer Registry

AIM

This paper describes the incidence and outcomes of childhood renal malignancies in Australia using national population-based data from the Australian Childhood Cancer Registry.

METHODS

De-identified data for children (0-14 years) diagnosed with renal malignancies from 1983 to 2015 inclusive were extracted. Cause-specific (CSS) and event-free survival up to 20 years from diagnosis were estimated using the cohort method. Adjusted excess mortality hazard ratios were calculated using a multivariable flexible parametric survival model. Details relating to second primary malignancies (SPMs) were also examined.

RESULTS

There were 1046 children diagnosed with renal malignancies in Australia between 1983 and 2015 (91% nephroblastoma), generating an annual age-standardised incidence rate of 8 per million children, which remained constant over the study period. CSS was 89% (95% confidence interval = 87-91%) and 88% (86-90%) at 5 and 20 years, respectively, and 5-year event-free survival was 82% (80-84%). Five-year CSS did not change over the study period and was highest for nephroblastoma (91%). Of the 94% of patients achieving remission, 15% relapsed and subsequent 5-year CSS was 49% (40%-58%). Eleven children were diagnosed with SPM (standardised incidence ratio = 2.9, 95% confidence interval = 1.6-5.3, P < 0.001), and five of them (45%) died within 5 years of the second diagnosis.

CONCLUSIONS

Children treated for renal malignancies in Australia have excellent long-term survival, which is unchanged since 1983. SPMs are uncommon following treatment for childhood renal cancer but carry a poor prognosis. Relapse carries a similarly poor prognosis to SPM but is more common. These data are comparable to registry outcomes in similarly developed nations.

Development of a paediatric central venous access device database: A retrospective cohort study of practice evolution and risk factors for device failure

AIM

To describe practice evolution, complications and risk factors for multiple insertion attempts and device failure in paediatric central venous access devices (CVADs).

METHODS

A paediatric retrospective cohort study using prospectively collected data from CVAD database 2012-2014. Data included were patient (i.e. age, condition), insertion (i.e. indication, device, technique) and removal (complications, dwell). Descriptive statistics and incidence rates were calculated per calendar year and compared. Risk factors for multiple insertion attempts and failure were explored with logistic regression and cox regression, respectively.

RESULTS

A total of 1308 CVADs were observed over 273 467 catheter-days in 863 patients. Multiple insertion attempts remained static (14%) and significantly associated with non-haematological oncology (odds ratio 2.19; 95% confidence interval (CI) 1.08-4.43), respiratory (3.71; 1.10-12.5), gastroenterology (4.18; 1.66-10.5) and other (difficult intravenous access) (2.74; 1.27-5.92). CVAD failure decreased from 35% (2012) to 25% (2014), incidence rate from 1.50 (95% CI 1.25-1.80) to 1.28 (1.06-1.54) per 1000 catheter-days. Peripherally inserted CVAD failure was significantly associated with lower body weight (per kilogram decrease, hazard ratio (HR) 1.02; 95% CI 1.00-1.03), cephalic vein (1.62; 1.05-2.62), difficult access (1.92; 1.02-3.73), sub-optimal tip placement (1.69; 1.06-2.69) and gastroenterology diagnosis (2.27; 1.05-4.90). Centrally placed CVAD failure was significantly associated with younger age (per year, HR 1.04; 95% CI 1.00-1.07), tunnelled device (3.38; 2.41-4.73) and gastroenterology diagnosis (1.70; 1.06-2.73).

CONCLUSIONS

While advancement in CVAD practices improved overall CVAD insertion and failure outcomes, further improvements and innovation are necessary to ensure improved vessel health and preservation for children requiring CVAD.

Creating Consumer-Generated Health Data: Interviews and a Pilot Trial Exploring How and Why Patients Engage

Background

Consumer-generated health data (CGHD) are any clinically relevant data collected by patients or their carers (consumers) that may improve health care outcomes. Like patient experience measures, these data reflect the consumer perspective and is part of a patient-centric agenda. The use of CGHD is believed to enhance diagnosis, patient engagement, and thus foster an improved therapeutic partnership with health care providers.

Objective

The aim of this study was to further identify how these data were used by consumers and how it influences engagement via a validated framework. In addition, carer data has not been explored for the purpose of engagement.

Methods

Study 1 used interviews with CGHD-experienced patients, carers, and doctors to understand attitudes about data collection and use, developing an ontological framework. Study 2 was a pilot trial with carers (parents) of children undergoing laparoscopic appendectomy. For 10 days carers generated and emailed surgical site photographs to a tertiary children’s hospital. Subsequently, carers were interviewed about the engagement framework. In total, 60 interviews were analyzed using theme and content analysis.

Results

This study validates a framework anchored in engagement literature, which categorizes CGHD engagement outcomes into 4 domains: physiological, cognitive, emotional, and behavioral. CGHD use is complex, interconnected, and can be organized into 10 themes within these 4 domains.

Conclusions

CGHD can instigate an ecosystem of engagement and provide clinicians with an enhanced therapeutic relationship through an extended view into the patient’s world. In addition to clinical diagnosis and efficient use of health care resources, data offer another tool to manage consumers service experience, especially the emotions associated with the health care journey. Collection and use of data increases consumers sense of reassurance, improves communication with providers, and promotes greater personal responsibility, indicating an empowering consumer process. Finally, it can also improve confidence and satisfaction in the service.

Prospective randomised controlled trial of Algisite™ M, Cuticerin™, and Sorbact® as donor site dressings in paediatric split-thickness skin grafts

BACKGROUND

This is a parallel three-arm prospective randomised controlled trial (RCT) comparing Algisite™ M, Cuticerin™, and Sorbact® as donor site dressings in paediatric split-thickness skin grafts (STSG). All three were in current use within the Pegg Leditschke Children's Burn centre (PLCBC), the largest paediatric burns centre in Queensland, Australia. Our objective was to find the best performing dressing, following on from previous trials designed to rationalise dressings for the burn wound itself.

METHODS

All children for STSG, with thigh donor sites, were considered for enrolment in the trial. Primary outcome measures were days to re-epithelialisation, and pain. Secondary measures were cost, itch, and scarring at 3 and 6 months. Patients and parents were blinded to group assignment. Blinding of assessors was possible with the dressing in situ, with partial blinding following first dressing change. Blinded photographic assessments of re-epithelialisation were used. Scar assessment was blinded. Covariates for analysis were sex, age, and graft thickness (as measured from a central biopsy).

RESULTS

There were 101 patients randomised to the Algisite™ M (33), Cuticerin™ (32), and Sorbact® (36) arms between April 2015 and July 2016. All were analysed for time to re-epithelialisation. Pain scores were not available for all time points in all patients. There were no significant differences between the three arms regarding pain, or time to re-epithelialisation. There were no significant differences for the secondary outcomes of itch, scarring, or cost. Regression analyses demonstrated faster re-epithelialisation in younger patients and decreased donor site scarring at 3 and 6 months with thinner STSG. There were no adverse effects noted.

CONCLUSIONS

There are no data supporting a preference for one trial dressing over the others, in donor site wounds (DSW) in children. Thinner skin grafts lead to less donor site scarring in children. Younger patients have faster donor site wound healing.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Register (ACTRN12614000380695).Royal Children's Hospital Human Research Ethics Committee (HREC/14/QRCH/36).University of Queensland Medical Research Ethics Committee (#2014000447).

Intentional self-inflicted and peer-inflicted aerosol skin injuries called 'frosties': Cohort series and systematic literature review

BACKGROUND AND OBJECTIVES

'Frosties' are deliberate cold skin burns caused by an aerosol device. The aim of this article was to examine our own cohort, and those previously published, to identify the key features of patients presenting with frosties and inform appropriate early clinical interventions.

METHOD

We compared cases in our dataset that occurred between 1 January 2013 and 30 June 2017 with those reported in the literature, focusing on seven domains: sex, age at injury, days to presentation, first aid, depth of injury and outcome.

RESULTS

The median patient age was 13 years; 70.5% were female. Adequate first aid was not reported in any patient. Where recorded, the median time to presentation to a health service was six days. Where severity of injury was recorded, 13 of 37 cases (35.1%) were full thickness, and 10 patients received a split thickness skin graft. Two subgroups were identified: cluster injuries and psychological distress.

DISCUSSION

Cluster injuries occur as the result of a mutual 'test of courage'. Solo injuries may point to underlying psychological distress. Frosties frequently result in significant burn injuries and often require skin grafting. The severity of frosties is underappreciated and, as a consequence, treatment, through first aid or presentation to a health service, is delayed or absent. General practitioners should be familiar with the appearance of frosties in order to identify them in unrelated consultations.

Telehealth in paediatric surgery: Accuracy of clinical decisions made by videoconference

AIM

Telehealth is a useful method of providing specialist consultation to a geographically diverse population. Canadian studies of telehealth for paediatric surgery demonstrate good accuracy, but have low numbers of cryptorchid patients in their cohorts. Our aim was to confirm Canadian studies for our cohort and to assess accuracy regarding cryptorchidism.

METHODS

We conducted a cohort study of patients seen via paediatric surgical telehealth over a 12-month period, to determine accuracy of telediagnosis with respect to face-to-face diagnosis and plan.

RESULTS

A total of 183 children had 224 videoconferences, resulting in 74 surgical bookings. There was high diagnostic concordance, except for undescended testes. One discharged patient, and two patients booked for review, have subsequently required an orchidopexy (false negatives). Of 15 patients booked for surgery, three did not require an operation (false positives). Other patients had their procedures upgraded (from open to laparoscopic) or downgraded (from laparoscopic to open) due to inaccuracies in far-end assessment.

CONCLUSION

Telehealth for paediatric surgery is accurate for most conditions seen, but for cryptorchidism there are significant concerns.

The treatment of pyloric stenosis: Evolution in practice

Over the last hundred years, idiopathic hypertrophic pyloric stenosis has undergone an evolution in treatment, with subsequent improvements in outcome. Initially, it was treated by physicians with antispasmodics and various alternative feeding and resuscitation modalities. The evolution of surgical approaches led to a revolution in outcome, from almost certain death to complete cure. The progression of surgical and medical treatments is reviewed in this article until, ultimately, Ramstedt's pyloromyotomy is reached. This distilled operation has remained the gold-standard procedure for over a century.

Innovative dressing and securement of tunneled central venous access devices in pediatrics: a pilot randomized controlled trial

BACKGROUND

Central venous access device (CVAD) associated complications are a preventable source of patient harm, frequently resulting in morbidity and delays to vital treatment. Dressing and securement products are used to prevent infectious and mechanical complications, however current complication rates suggest customary practices are inadequate. The aim of this study was to evaluate the feasibility of launching a full-scale randomized controlled efficacy trial of innovative dressing and securement products for pediatric tunneled CVAD to prevent complication and failure.

METHODS

An external, pilot, four-group randomized controlled trial of standard care (bordered polyurethane dressing and suture), in comparison to integrated securement-dressing, suture-less securement device, and tissue adhesive was undertaken across two large, tertiary referral pediatric hospitals in Australia. Forty-eight pediatric participants with newly inserted tunneled CVADs were consecutively recruited. The primary outcome of study feasibility was established by elements of eligibility, recruitment, attrition, protocol adherence, missing data, parent and healthcare staff satisfaction and acceptability, and effect size estimates for CVAD failure (cessation of function prior to completion of treatment) and complication (associated bloodstream infection, thrombosis, breakage, dislodgement or occlusion). Dressing integrity, product costs and site complications were also examined.

RESULTS

Protocol feasibility was established. CVAD failure was: 17% (2/12) integrated securement-dressing; 8% (1/13) suture-less securement device; 0% tissue adhesive (0/12); and, 0% standard care (0/11). CVAD complications were: 15% (2/13) suture-less securement device (CVAD associated bloodstream infection, and occlusion and partial dislodgement); 8% (1/12) integrated securement-dressing (partial dislodgement); 0% tissue adhesive (0/12); and, 0% standard care (0/11). One CVAD-associated bloodstream infection occurred, within the suture-less securement device group. Overall satisfaction was highest in the integrated securement-dressing (mean 8.5/10; standard deviation 1.2). Improved dressing integrity was evident in the intervention arms, with the integrated securement-dressing associated with prolonged time to first dressing change (mean days 3.5).

CONCLUSIONS

Improving the security and dressing integrity of tunneled CVADs is likely to improve outcomes for pediatric patients. Further research is necessary to identify novel, effective CVAD securement to reduce complications, and provide reliable vascular access for children.

TRIAL REGISTRATION

ACTRN12614000280606 ; prospectively registered on 17/03/2014.

Paediatric urinary tract infections: Diagnosis and treatment

BACKGROUND

Urinary tract infections (UTIs) commonly occur in children. An estimated 8% of girls and 2% of boys will have at least one episode by seven years of age. Of these children, 12-30% will experience recurrence within one year. Australian hospital admission records indicate that paediatric UTIs represent 12% of all UTI hospital admissions.

OBJECTIVE

The aim of this article is to review the pathogenesis, clinical assessment and management of UTIs, and prevention strategies in children.

DISCUSSION

Clinically, paediatric UTI presentations are challenging because symptoms are vague and variable. Young infants may present with sepsis or fever and lack specific symptoms, whereas older children present with classical features such as dysuria, frequency and loin pain. Early diagnosis with appropriate urine specimen collection techniques, investigations and treatment is necessary for prevention of renal damage and recurrence. Effective, evidence-based investigations and treatment options are available, and physicians should feel confident in identifying and managing paediatric UTIs.

Starchy liquid burns do not have worse outcomes in children relative to hot beverage scalds

AIM

To characterise children presenting with hot beverage scalds versus scalds caused by starchy water.

METHODS

Retrospective survey of prospectively collected database of all children presenting over a two-year period.

RESULTS

There were 138 starch scalds and 262 hot beverage injuries. Children with hot beverage injuries were significantly younger (18.2 months; IQR 14.1, 27.8) than those suffering starch scald injuries (51.4 months; 18.7, 102.3; p<0.001). Perineal burns were more common in the starch group than the hot beverage scald group (10.9% vs. 2.4%, p<0.001). Chest/breast and abdominal burns were more common in the hot beverage group than the starch group (60.7% vs. 36.9%, p<0.001). Children under three years of age in both groups are significantly less likely to receive adequate first aid at the scene (p<0.001). There are no differences in the need for skin grafting or scar management when comparing hot beverage scalds and scalds caused by starchy liquids.

CONCLUSIONS

Scald injuries caused by starchy liquids do not appear to cause a more severe injury than hot beverage scalds. There is a different pattern of injury from starchy liquids in older children. Children under three years old are less likely to receive appropriate first aid at the scene.

Central venous Access device SeCurement And Dressing Effectiveness (CASCADE) in paediatrics: protocol for pilot randomised controlled trials

INTRODUCTION

Paediatric central venous access devices (CVADs) are associated with a 25% incidence of failure. Securement and dressing are strategies used to reduce failure and complication; however, innovative technologies have not been evaluated for their effectiveness across device types. The primary aim of this research is to evaluate the feasibility of launching a full-scale randomised controlled efficacy trial across three CVAD types regarding CVAD securement and dressing, using predefined feasibility criteria.

METHODS AND ANALYSIS

Three feasibility randomised, controlled trials are to be undertaken at the Royal Children's Hospital and the Lady Cilento Children's Hospital, Brisbane, Australia. CVAD securement and dressing interventions under examination compare current practice with sutureless securement devices, integrated securement dressings and tissue adhesive. In total, 328 paediatric patients requiring a peripherally inserted central catheter (n=100); non-tunnelled CVAD (n=180) and tunnelled CVAD (n=48) to be inserted will be recruited and randomly allocated to CVAD securement and dressing products. Primary outcomes will be study feasibility measured by eligibility, recruitment, retention, attrition, missing data, parent/staff satisfaction and effect size. CVAD failure and complication (catheter-associated bloodstream infection, local infection, venous thrombosis, occlusion, dislodgement and breakage) will be compared between groups.

ETHICS AND DISSEMINATION

Ethical approval to conduct the research has been obtained. All dissemination will be undertaken using the CONSORT Statement recommendations. Additionally, the results will be sent to the relevant organisations which lead CVAD focused clinical practice guidelines development.

TRIAL REGISTRATION NUMBERS

ACTRN12614001327673; ACTRN12615000977572; ACTRN12614000280606.

Primary Sternal Osteomyelitis With Extensive Mediastinal Abscess in a Neonate

Sternal osteomyelitis is extremely rare in neonates. We present the first report of a neonate with primary sternal osteomyelitis and an extensive mediastinal collection. Magnetic resonance imaging was used to delineate the extent of bony and soft tissue involvement. Serial ultrasound imaging proved useful for monitoring the response to treatment. The patient was successfully treated with antibiotics, surgical débridement, vacuum-assisted dressings, and delayed primary closure.

A review of paediatric telehealth for pre- and post-operative surgical patients

The Queensland Telepaediatric Service (QTS) was established in the year 2000 to deliver a broad range of paediatric specialist health services from the Royal Children's Hospital (RCH) in Brisbane, mainly via videoconference. During a 13-year study period, the QTS facilitated 18,949 video consultations, comprising Mental Health (42%), Medicine (30%), Surgery (21%) and Other (8%). We reviewed the surgical services provided through the QTS. There were 3880 video consultations with a paediatric surgeon. Most of these (91%) used fixed videoconferencing units, 8% were delivered via mobile units (robots) and 1% were delivered using Skype. Surgical consultations were provided by telehealth to 106 sites: 89% in Queensland and the rest to other states. The main surgical specialties were burns (50%), ear, nose and throat (19%), general surgery (21%), orthopaedics (9%) and vascular anomalies (2%). During a 12-month audit period, there were 224 teleconsultations in general surgery; the most common reason for referral was for undescended testes (17%). During the study period there was a significant growth in all surgical telehealth activity: linear regression showed an annual increase of 17 cases per year (P < 0.02). In the last four years of the study, there was a substantial growth in the general surgical component, although there was also a reduction in the burns component. Telehealth has potential for other specialist consultations which require periodic assessment and review.

Three donor site dressings in pediatric split-thickness skin grafts: study protocol for a randomised controlled trial

BACKGROUND

For children requiring split-thickness skin grafting for burn injury, the optimum donor site dressing is an ongoing subject of debate. The most common dressings in use, both regionally and worldwide, are calcium alginates. We will compare an alginate with two other dressings, all of which are in current use in the Pegg Leditschke Paediatric Burns Centre (PLPBC), to determine which dressing performs the best.

METHODS/DESIGN

This is a randomised, prospective single center parallel three-arm trial comparing three donor site wound (DSW) dressings: Algisite™ M, a calcium alginate dressing; Cuticerin™, a smooth acetate gauze impregnated with water-repellent ointment (petrolatum, paraffin and Eucerite®) and Sorbact®, a gauze mesh coated with a dialkylcarbamoyl chloride (DACC) and amorphous hydrogel. Primary outcomes are days to complete DSW healing, and pain. Previously validated measures will be used for all outcomes. Secondary outcomes are: itch; scar appearance at three, six and 12 months; ease of dressing application and removal and dressing costs and utility. Results will be analysed on an intention-to-treat basis. Donor site thickness will be measured with a small biopsy from the center of the graft, to document the depth of the DSW across the groups.

DISCUSSION

This study will provide comprehensive short- and long-term data on DSW dressings in pediatric split-thickness skin grafting. The best-performing dressing will become the preferred dressing for the PLPBC. We will provide rigorous data against which other dressings can be compared in future, recognising that alginates are the most common DSW dressing currently in use. Our study design replicates a real-world scenario in order to identify clinically significant differences between the three dressings.

TRIAL REGISTRATION

This trial was prospectively registered on 8 April 2014 with the Australia and New Zealand Clinical Trials Register (identifier: ACTRN12614000380695 ).

Theatre of paediatric surgery

In the 50 years since the first edition of this journal, operative paediatric surgery has undergone radical change. Many of the most common instruments are unchanged, both as a testament to their utility and in recognition of past surgeons remembered eponymously. Surrounding that basic core of instruments, theatre has changed radically as new tools and techniques have arisen. Surgeons have come down from their pedestals, recognising surgery as a team sport rather than a solo performance. More than half of the current paediatric surgical trainees are women, a higher proportion than in any other craft group of the Royal Australasian College of Surgeons. The appearance, and rapid development, of laparoscopy is to many observers the most notable change in surgery over the last 50 years. Placed in its context though, it is simply the most prominent example of a frameshift in surgical thinking. The patient as a whole is now the focus, rather than just the disease. Recent developments are as much about minimising harm to normal tissues as they are about extirpating pathology. As a surgical maxim, 'Primum non nocere' is even more in evidence in 2015 than it was in 1965.

Non-operative advances: what has happened in the last 50 years in paediatric surgery?

Paediatric surgeons remain paediatric clinicians who have the unique skill set to treat children with surgical problems that may require operative intervention. Many of the advances in paediatric surgical care have occurred outside the operating theatre and have involved significant input from medical, nursing and allied health colleagues. The establishment of neonatal intensive care units, especially those focusing on the care of surgical infants, has greatly enhanced the survival rates and long-term outcomes of those infants with major congenital anomalies requiring surgical repair. Educational initiatives such as the advanced trauma life support and emergency management of severe burns courses have facilitated improved understanding and clinical care. Paediatric surgeons have led with the non-operative management of solid organ injury following blunt abdominal trauma. Nano-crystalline burn wound dressings have enabled a reduced frequency of painful dressing changes in addition to effective antimicrobial efficacy and enhanced burn wound healing. Burns care has evolved so that many children may now be treated almost exclusively in an ambulatory care setting or as day case-only patients, with novel technologies allowing accurate prediction of burn would outcome and planning of elective operative intervention to achieve burn wound closure.

Fetoscopic endoluminal tracheal occlusion (FETO) for congenital diaphragmatic hernia in Australia and New Zealand: are we willing, able, both or neither?

AIM

An estimated 140 pregnancies are diagnosed with congenital diaphragmatic hernia (CDH) in Australia and New Zealand each year, with these fetuses having a less than even chance of 1-year survival. Fetoscopic endoluminal tracheal occlusion (FETO) is a relatively new technique that offers a prenatal interventional strategy for selective cases of CDH. This is not routinely offered in Australia or New Zealand. The aim of this systematic review is to critically appraise controlled clinical trials investigating the role of FETO in moderate and severe isolated CDH and explore whether this treatment is justified within our region.

METHODS

A systematic literature search of multiple electronic databases was undertaken, with restrictions to human subjects and controlled clinical trials.

RESULTS

Nine relevant studies were identified. No current evidence was found in favour of FETO for moderate severity CDH. For severe CDH, the most recent evidence demonstrates significantly improved survival following FETO performed using contemporary percutaneous minimally invasive techniques. Optimum timing for balloon insertion, removal and occlusion duration remains conjectural. Substantial variation in survival rates observed among control groups highlights the impact of post-natal care in prenatally diagnosed CDH.

CONCLUSION

Until recently, evidence to support a role for FETO in prenatal CDH management was weak. Recently reported and ongoing controlled trials give cause for optimism, with improved FETO safety and increased survival reported for severe CDH cases. Should Australasia embrace FETO for selected CDH cases, a co-ordinated, evidence-informed service should be established under the guidance of experienced international partnerships.

Long-term review of sutureless ward reduction in neonates with gastroschisis in the neonatal unit

BACKGROUND

A sutureless ward reduction (SWR) protocol was implemented in the neonatal intensive care unit of a tertiary level hospital in 1999. Although the short-term outcomes associated with SWR have been documented, the long-term outcomes are unknown.

METHODS

Retrospective data were collected from the medical records of all neonates with gastroschisis from September 1999 to December 2010. Data on their growth and development and the prevalence of any health problems were collected.

RESULTS

Eighty-eight patients with gastroschisis were managed over an 11 year period. Forty-four of these patients received SWR, with 2 deaths in the neonatal period. In the 42 survivors, 35 patients were reviewed at a median age of 7 years and 10 months (range, 6-134 months; interquartile range, 37-124 months). One patient experienced failure to thrive and developmental delay, and later died of a medical complication. Thirty-two patients (91.4%) developed an umbilical hernia, only 2 of whom required umbilical herniotomy. Four patients (11.4%) developed small bowel obstruction, all within the first year.

CONCLUSION

Most patients with SWR exhibited normal growth with minimal bowel complications. Despite the high incidence of umbilical hernia, the majority resolved spontaneously and did not require subsequent herniotomy.

The role of steroids in children with multiple recurrences of intussusception

We describe the case of a boy who had 9 recurrences of intussusception, for which no pathological lesion at the leadpoint was identified. A contrast follow-through study revealed a follicular/nodular mucosal pattern, particularly prominent in the terminal ileum and caecum. Patients with multiple recurrences usually have an identifiable lesion at the leadpoint, but sometimes recurrences may be due to lymphoid hyperplasia, as presumed in our case. No further recurrences occurred after a two month tapering course of oral prednisolone.

Parent attitudes towards medical student attendance and interaction in the paediatric burns outpatient clinic

Medical student attendance in the Outpatient Department is not only essential for the teaching of paediatric burns, but is also important in the recruitment of promising individuals for the growth of our speciality. In 2008, 110 consecutive parents were asked to complete written surveys before the start of their clinic appointment. Only one parent per family could choose to complete the survey. The response rate was 100%. Parents from a diverse range of cultural, educational and socioeconomic were represented in this study. Eighteen parents (16.4%), 48 parents (46.3%) and 44 parents (40.0%) considered their child's burn to be severe, moderate and mild, respectively. One hundred and nine parents (99.1%) accepted the attendance of medical students. Forty-two parents (38.5%) preferred fewer than 3 students, 35 parents (32.1%) would be comfortable with 3-5 medical students and 32 parents (29.4%) could accept more than 6 medical students. One hundred and two parents (92.7%) would allow students to physically interact with their children and 108 parents (99.2%) would allow medical students to freely ask questions in burns clinic. Using logistic regression analysis, we found that high income earners would be comfortable with fewer medical students attending clinic than low income earners (p=0.007). Also, younger parents (p=0.002) and parents from families who made less than A$25,000 a year (p=0.009), believed that they could perceive 'a lot of benefit' from observing medical students being taught, whereas older parents and parents from higher income families responded more often with a perception of only 'some benefit'. This first study in a paediatric outpatient setting shows that parents are overwhelmingly prepared to have medical students involved in the care of their child.