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PubMed1988

Paediatric manpower: towards the 21st century.

The British Paediatric Association (BPA) has carried out a national survey of paediatric medical manpower in the hospital and community child health services. The results of the survey relating to England and Wales are presented and compared with Department of Health and Social Security (DHSS) manpower statistics. On the basis of the survey findings and current trends in the pattern of paediatric care paediatric manpower requirements over the next 10 years are estimated.

Child↗

PubMed1992

Paediatric psychotherapy: a service in a general outpatient clinic.

The service of paediatric psychotherapy to a general paediatric outpatient clinic is described. Using techniques developed to suit paediatric patients a median of nine patients each clinic were treated. Referral symptoms resolved in a median time of four months after a median of seven sessions. This model for the management of paediatric patients with emotional and behavioural difficulties may allow an effective and efficient use of psychotherapy time.

Adolescent↗

PubMed1992

Prospective evaluation of the Paediatric Risk of Mortality (PRISM) score.

The performance of the admission day Paediatric Risk of Mortality (PRISM) score for outcome prediction was assessed prospectively in 270 consecutive admissions, aged 3 days to 18.6 years, to a paediatric intensive care unit. Using a cut off of r = 0.00 (expected mortality = 50%), the overall sensitivity (correct prediction of death) was 48% while specificity (correct prediction of survival) was 99%, comparable with the original validation data of the score in the USA. Outcome prediction was most accurate when the stay in the paediatric intensive care unit was between one and four days. Sensitivity was appreciably lower for operative patients (17%) compared with non-operative patients (71%) because of a failure to predict deaths after cardiac surgery. The sensitivity (41%) and specificity (99%) using five variables (systolic blood pressure, Glasgow coma scale, carbon dioxide tension, and serum bicarbonate and serum calcium concentrations) was similar to that using all 14 variables. Six variable ranges related differently with non-survival compared with the score. It is concluded that the performance of the PRISM score is institution independent and good for short stay patients. It underpredicts deaths after cardiac surgery. Only five variables may be needed for satisfactory outcome prediction. Some of the variables need reweighting for paediatric intensive care units in the UK.

Adolescent↗

PubMed1999

Can paediatric medical students devise a satisfactory standard of examination for their colleagues?

OBJECTIVES: To determine what standard paediatric medical students would set for examining their peers and how that would compare with the university standard. DESIGN: Single blinded computer marked examination with questionnaire. SETTING: University medical school. SUBJECTS: Medical students during their final paediatric attachment. INTERVENTIONS: Medical students asked to derive 10, five branch negatively marked multiple choice questions (MCQs) to a standard that would fail those without sufficient knowledge. Each 10 were then assessed by another student as to the degree of difficulty and the relevance to paediatrics. One year later student peers sat a mock MCQ examination derived from a random 40 questions (unaware that the mock MCQs had been derived by peers). MAIN OUTCOME MEASURES: Comparison of marks obtained in mock and final MCQ examinations; student perception of the standard in the two examinations assessed by questionnaire. RESULTS: 44 students derived 439 questions, of which 83% were considered an appropriate standard by a classmate. One year later 62 students sat the mock examination. Distribution of marks was better in the mock MCQ examination than the final MCQ examination. Students considered the mock questions to be a more appropriate standard (72% v 31%) and the topics more relevant (88% v 64%) to paediatric medical students. Questions were of a similar clarity in both examinations (73% v 78%). CONCLUSIONS: Students in this study were able to derive an examination of a satisfactory standard for their peers. Involvement of students in deriving examination standards may give them a better appreciation of how standards should be set and maintained.

Child↗

PubMed2000

Do presenters to paediatric meetings get their work published?

BACKGROUND: Research presented to a scientific meeting is inaccessible to clinicians, unless it is also published in a cited journal. AIMS: To assess the publication rate of studies presented to two UK national paediatric meetings: the Paediatric Research Society (PRS) and the British Paediatric Association (BPA). METHODS: A Medline search in December 1999 for the first authors of all plenary abstracts presented in 1996. If not found, authors contacted by postal questionnaire. RESULTS: Information was obtained on 88/89 presentations. Twenty five of 48 PRS and 31 of 40 BPA studies were published in Medline listed journals. The major reason for non-publication was that they had not been submitted (PRS 15/48, BPA 6/40). Some authors were still hoping to do so (PRS 7, BPA 2). Other reasons were: publication in other forms (theses, book chapters, non-Medline journals) (PRS 5, BPA 2), or still being reviewed (PRS 3, BPA 1). Ten of 11 randomised, controlled trials were published, but only 20 of 37 observational studies were submitted and published. CONCLUSION: Presenters to paediatric meetings need help in submitting and publishing their work.

Child↗

PubMed2001

Identifying futility in a paediatric critical care setting: a prospective observational study.

AIMS: To determine the extent of futile care provided to critically ill children admitted to a paediatric intensive care setting. METHODS: Prospective evaluation of consecutive admissions to a 20 bedded multidisciplinary paediatric intensive care unit of a North London teaching hospital over a nine month period. Three previously defined criteria for futility were used: (1) imminent demise futility (those with a mortality risk greater than 90% using the Paediatric Risk of Mortality (PRISM II) score); (2) lethal condition futility (those with conditions incompatible with long term survival); and (3) qualitative futility (those with unacceptable quality of life and high morbidity). RESULTS: A total of 662 children accounting for 3409 patient bed days were studied. Thirty four patients fulfilled at least one of the criteria for futility, and used a total of 104 bed days (3%). Only 33 (0.9%) bed days were used by patients with mortality risk greater than 90%, 60 (1.8%) by patients with poor long term prognosis, and 16 (0.5%) by those with poor quality of life. Nineteen of 34 patients died; withdrawal of treatment was the mode of death in 15 (79%). CONCLUSIONS: Cost containment initiatives focusing on futility in the paediatric intensive care unit setting are unlikely to be successful as only relatively small amounts of resources were used in providing futile care. Paediatricians are recognising futility early and may have taken ethically appropriate measures to limit care that is futile.

Child↗

PubMed2003

Epidemiology of paediatric renal stone disease in the UK.

BACKGROUND: The previous epidemiological study of paediatric nephrolithiasis in Britain was conducted more than 30 years ago. AIMS: To examine the presenting features, predisposing factors, and treatment strategies used in paediatric stones presenting to a British centre over the past five years. METHODS: A total of 121 children presented with a urinary tract renal stone, to one adult and one paediatric centre, over a five year period (1997-2001). All children were reviewed in a dedicated stone clinic and had a full infective and metabolic stone investigative work up. Treatment was assessed by retrospective hospital note review. RESULTS: A metabolic abnormality was found in 44% of children, 30% were classified as infective, and 26% idiopathic. Bilateral stones on presentation occurred in 26% of the metabolic group compared to 12% in the infective/idiopathic group (odds ratio 2.7, 95% CI 1.03 to 7.02). Coexisting urinary tract infection was common (49%) in the metabolic group. Surgically, minimally invasive techniques (lithotripsy, percutaneous nephrolithotomy, and endoscopy) were used in 68% of patients. CONCLUSIONS: There has been a shift in the epidemiology of paediatric renal stone disease in the UK over the past 30 years. Underlying metabolic causes are now the most common but can be masked by coexisting urinary tract infection. Treatment has progressed, especially surgically, with sophisticated minimally invasive techniques now employed. All children with renal stones should have a metabolic screen.

Adolescent↗

PubMed2005

The indications and outcome of paediatric corneal transplantation in New Zealand: 1991-2003.

AIM: To evaluate patient characteristics, indications, surgical details, and outcome of paediatric keratoplasty in New Zealand. METHODS: As part of a prospective longitudinal study, paediatric keratoplasty data collected by the New Zealand National Eye Bank (NZNEB) was analysed for the 13 year period 1991-2003. RESULTS: During the study period the NZNEB supplied 2547 corneas for keratoplasty, of which 65 (3%) were used for paediatric patients (14 years or younger). The 65 keratoplasties were performed in 58 eyes of 52 patients (66% male, 34% female, mean age 10.6 years, SD 4.3 years). Indications were classified into three groups: congenital (16%, n = 9), acquired non-traumatic (74%, n = 43), and acquired traumatic (10%, n = 6). Peters' anomaly (7% of total), keratoconus (67%), and penetrating trauma (8%) were the most common indications in each group, respectively. 82% of keratoplasties with known outcome survived (clear graft) 1 year postoperatively, 16% failed, and one patient died. Keratoplasty for congenital indications had a lower 1 year survival rate (78%) compared to acquired non-traumatic (85%) and traumatic (100%) indications, although the difference was not statistically significant (p = 0.65). 38% of patients with known outcome had a 1 year postoperative best corrected Snellen visual acuity (BCSVA) of 6/9 or better, and 60% had a BCSVA of 6/18 or better. Visual outcome was significantly better for acquired compared to congenital indications (p = 0.03). CONCLUSION: Analysis of the NZNEB database provided valuable information in relation to paediatric keratoplasty in New Zealand. In particular, this study highlighted an unusually high prevalence of keratoconus as an indication for keratoplasty. In addition, a high 1 year survival rate and good visual outcome were identified, especially in cases of keratoplasty for acquired conditions.

Adolescent↗

PubMed2006

Retinoscopic (refractive) estimation of axial length in paediatric aphakia: a comparison with ultrasonic measurement.

AIM: To compare paediatric axial length values estimated from the aphakic refraction alone with axial length values measured by ultrasound. METHODS: Retrospective institutional medical record review of paediatric aphakic patients 12 years of age and younger with documented ultrasonic axial length and objective refraction (retinoscopy) within 3 months of each other. An estimate of axial length was made from the aphakic refraction alone (with an assumed average keratometry value of 44 dioptres) for all patients. RESULTS: 149 eyes of 102 paediatric aphakic patients were identified. The ultrasonic axial length values (mean 22.47 mm, SD 1.69, 95% confidence interval (CI) 0.27) and estimated axial length values (mean 22.41 mm, SD 1.53, 95% CI 0.25) had an average difference of 0.05 mm (SD 1.04, 95% CI 0.17) and were not significantly different (p = 0.56) by the two tailed paired t test. A histogram of the differences that did exist between the two values resembled a normal distribution. The nine eyes with the largest differences between the two values had either low hyperopic aphakic refractions or abnormal average keratometry values. CONCLUSIONS: There was no significant difference between the two groups of axial length values, and the distribution of differences that did exist seemed random. The greatest differences between the two values occurred in longer (less hyperopic) eyes and in eyes with abnormally steep or flat keratometry. Estimation of axial length from the aphakic refraction alone seems to be a useful technique in the average paediatric eye, especially if biometry is unavailable.

Adolescent↗

PubMed2003

The Armenian Eye Care Project: surgical outcomes of complicated paediatric glaucoma.

AIM: To review surgical results of the Armenian Eye Care Project's (AECP) efforts in paediatric glaucoma and to identify additional morbidity associated with its initial itinerant nature. METHODS: A non-randomised, retrospective historical cohort study of complicated paediatric glaucoma surgeries was performed by the AECP at the Republican Eye Hospital. 38 eyes of 34 paediatric patients underwent mitomycin C trabeculectomies (MMCT) (n = 20) or Ahmed glaucoma valve (AGV) placements (n = 18) for complicated paediatric glaucomas. The median age was 12.5 years with a range of 6-17 years. Three clinical groups were represented: congenital glaucoma, Frank Kamenetsky syndrome (a glaucoma associated with uveitis), and Rieger's syndrome. RESULTS: Preoperative and postoperative intraocular pressures were similar for the two groups (MMCT v AGV = 30 v 32 mm Hg and 13.5 v 14.8 mm Hg, respectively; p>0.05, t test). The AGV group was twice as likely to use medications postoperatively (44% v 23%; p<0.05, t test). The MMCT group was more likely to have a three line drop in visual acuity than the AGV group (28% v 12%; p<0.05, t test). The decreased visual acuity found postoperatively was most commonly secondary to cataract formation. CONCLUSION: Total success rates were similar in the two surgical treatment groups. These compared favourably with success rates reported for non-itinerant surgery. Postoperative complications worsened by the itinerant nature of the project were few and represented 5% of the total surgical interventions. Ultimately, the installation of fellowship trained specialists is the most effective approach to minimising this problem and is recommended by the AECP as a strategy for developing and recovering countries.

Adolescent↗

PubMed1990

"Short report" staffing in practice: five years' experience of a consultant based service in obstetrics and neonatal paediatrics.

Recent government plans include the concept of a core of doctors of intermediate grade providing 24 hour emergency cover in hospital departments. Hinchingbrooke Hospital has, since its opening in 1983, been run on a two tier basis, with consultants and a part time senior registrar supported only by senior house officers in their first post, usually on general practice vocational training schemes. With a planned rate of around 2000 deliveries per year all high risk obstetric and neonatal paediatric procedures, including ventilation of very small babies, have been carried out within the hospital. A study of the first five complete years of operation of the obstetric and paediatric departments showed that the perinatal mortality rate was low (hospital rate 4.7/1000 in 9149 deliveries during 1984-8 v district rate 5.1/1000 during 1986-8), and patient satisfaction seemed to be high. In a separate prospective study of out of hours work performed by consultants in paediatrics (four weeks) and obstetrics (20 days) three consultants in paediatrics spent 71 hours working out of hours; for the obstetricians, of the 56 request for advice and 38 interventions, only five and six respectively occurred between midnight and 9 am. Although successful at this hospital, the two tier system would be expensive under the Royal College of Obstetricians' guidelines of one consultant to a maximum of 500 deliveries. An equal mixture of two tier and three tier systems might be the best solution for patient care and training of junior doctors.

Consultants↗

PubMed2004

Prospective observational study on the incidence of medication errors during simulated resuscitation in a paediatric emergency department.

OBJECTIVES: To characterise the incidence and nature of medication errors during paediatric resuscitations. DESIGN: A prospective observational study of simulated emergencies. SETTING: Emergency department of a tertiary paediatric hospital. PARTICIPANTS: Teams that included a clinician who commonly leads "real" resuscitations, at least two assisting physicians, and two or three paediatric nurses. INTERVENTIONS: The teams conducted eight mock resuscitations, including ordering medications. Exercises were videotaped and drugs ordered and administered during the resuscitation were recorded. Syringes and drugs prepared during the resuscitation were collected and analysed for concentrations and actual amounts. MAIN OUTCOME MEASURES: Number and type of drug errors. RESULTS: Participants gave 125 orders for medications. In 21 (17%) of the orders the exact dose was not specified. Nine dosing errors occurred during the ordering phase. Of these errors, five were intercepted before the drug reached the patient. Four 10-fold errors were identified. In nine (16%) out of 58 syringes analysed, measured drug concentrations showed a deviation of at least 20% from the ordered dose. A large deviation (at least 50%) from the expected dose was found in four (7%) cases. CONCLUSIONS: Medication errors commonly occur during all stages of paediatric resuscitation. Many errors could be detected only by analysing syringe content, suggesting that such errors may be a major source of morbidity and mortality in resuscitated children.

Child↗

PubMed2005

A feasibility study of signed consent for the collection of patient identifiable information for a national paediatric clinical audit database.

OBJECTIVES: To investigate the feasibility of obtaining signed consent for submission of patient identifiable data to a national clinical audit database and to identify factors influencing the consent process and its success. DESIGN: Feasibility study. SETTING: Seven paediatric intensive care units in England. PARTICIPANTS: Parents/guardians of patients, or patients aged 12-16 years old, approached consecutively over three months for signed consent for submission of patient identifiable data to the national clinical audit database the Paediatric Intensive Care Audit Network (PICANet). MAIN OUTCOME MEASURES: The numbers and proportions of admissions for which signed consent was given, refused, or not obtained (form not returned or form partially completed but not signed), by age, sex, level of deprivation, ethnicity (South Asian or not), paediatric index of mortality score, length of hospital stay (days in paediatric intensive care). RESULTS: One unit did not start and one did not fully implement the protocol, so analysis excluded these two units. Consent was obtained for 182 of 422 admissions (43%) (range by unit 9% to 84%). Most (101/182; 55%) consents were taken by staff nurses. One refusal (0.2%) was received. Consent rates were significantly better for children who were more severely ill on admission and for hospital stays of six days or more, and significantly poorer for children aged 10-14 years. Long hospital stays and children aged 10-14 years remained significant in a stepwise regression model of the factors that were significant in the univariate model. CONCLUSION: Systematically obtaining individual signed consent for sharing patient identifiable information with an externally located clinical audit database is difficult. Obtaining such consent is unlikely to be successful unless additional resources are specifically allocated to training, staff time, and administrative support.

Adolescent↗

PubMed2005

A review of emergency equipment carried and procedures performed by UK front line paramedics on paediatric patients.

OBJECTIVES: In 1997 a review of paramedic practice upon adult patients in the UK found many inconsistencies and deficiencies in basic care. A follow up review in 2002 identified widespread improvement in provision of equipment and skills to provide basic and advanced life support.Paediatric care was not assessed in either review. The authors conducted this study to identify current standards of care in paediatric paramedic practice and areas of potential improvement. METHOD: A questionnaire designed to determine what equipment and skills were available to paramedics for the management of common or serious paediatric emergencies was sent to chief executives of the 32 NHS Ambulance Trusts in England and Wales. RESULTS: The trend of expanding and standardising practice among adult patients has not extended to paediatric practice despite national guidelines from the Joint Royal Colleges Ambulance Liaison Committee (JRCALC). Furthermore there are some serious failings in the provision of care and skills. Many Trusts have not adopted JRCALC guidelines for the management of life threatening paediatric emergencies such as asthma, meningitis, and fluid replacement in hypovolaemia. CONCLUSIONS: Ambulance Trusts not meeting standards set out in the JRCALC guidelines must address their areas of deficiency. Failure to do so endangers children's lives and leaves Trusts open to criticism.

Child↗

PubMed1996

Value and impact of necropsy in paediatric cardiology.

OBJECTIVE: To assess the current value of necropsy in paediatric cardiology and cardiothoracic surgery and determine its potential impact on clinical practice. DESIGN AND SETTING: Descriptive study of all paediatric cardiac deaths occurring over four years in a tertiary referral centre. Data were obtained from reviewing the hospital files, available necropsy records and specimens, and audit reports. PATIENTS: Paediatric patients with congenital or acquired heart disease, who died of a cardiac cause between January 1992 and July 1995. Inclusion criteria were that the diagnosis of heart disease was made before death, and that patients were managed thereafter medically and/or surgically at the referral centre. The value of necropsy was assessed according to its contribution in establishing the cause of death (confirmed, clarified, precise cause of death uncertain) and the anatomy (simple confirmation or additional information provided). For cases not submitted to necropsy the clinical information relating to the cause of death was assessed and the case assigned as cause of death firm, uncertain, or unknown. RESULTS: One hundred and six deaths were identified (61 males, age at death: one day to 20 years). Seventy occurred early (a month or less) after surgery and were graded as postoperative deaths. The rest were considered to be either medical or late surgical deaths. Necropsy was performed in 59 (55.6%). The precise cause of death was confirmed in 33 (55.9%), clarified in 22 (37.3%), and remained uncertain in four (7.8%). Additional information regarding the anatomy was found in eight (13.6%) cases. In five cases (8.5%) the necropsy detected findings which, if known before death, would probably have improved outcome. For the patients dying without a necropsy, the cause of death remained uncertain in 10 (21.3%) and unknown in seven (14.9%). In 36% of cases, therefore, a firm cause of death that might have been provided by a necropsy was missing. CONCLUSION: In paediatric cardiology necropsy continues to provide clinically relevant information at a high level. It remains vital for ensuring quality of medical care, in instigating improvements in future management, and increasing understanding of congenital heart disease. The procedure should therefore be sought actively in all cases.

Adolescent↗

PubMed2005

Light microscopic examination of scalp hair samples as an aid in the diagnosis of paediatric disorders: retrospective review of more than 300 cases from a single centre.

BACKGROUND: Microscopic examination of scalp hair can provide important diagnostic information in a range of paediatric conditions. It is a non-invasive and cost effective investigation, which is not widely performed. AIMS: To examine retrospectively the value of hair examination by light microscopy, including polarising microscopy, in a specialist paediatric pathology department during a 15 year period (1989-2004) and to describe the morphological abnormalities indicative of specific paediatric conditions. METHODS: Three hundred and twenty two hair samples were submitted. Microscopic changes were analysed in the light of clinical information categorised as: (1) erythroderma, (2) neurological impairment, (3) immunological/haematological defect, (4) ectodermal dysplasia, (5) abnormal hair only, and (6) non-specific/absent clinical details. RESULTS: Abnormalities were evident in 49% of the samples. In 25%, the changes were compatible with specific diagnoses including Menkes disease, Netherton's syndrome, trichothiodystrophy, Griscelli and Chediak-Higashi syndromes, monilethrix, uncombable hair, and loose anagen syndromes. In respect of the clinical presentation groups noted above, diagnostic changes were seen in 41%, 32%, 33%, 0%, 29%, and 0%, respectively. CONCLUSIONS: Morphological light microscopic examination of scalp hair is an inexpensive, rapid, and non-invasive investigation, which can provide valuable diagnostic information in a range of paediatric conditions.

Adolescent↗

PubMed1995

Denominator estimation: approaches in the Hamburg paediatric sentinel network.

STUDY OBJECTIVE: The aims were to develop an estimator for the size of paediatric practices to be used as a denominator for purposes of comparison; to analyse the age structure of the patients attending paediatric practices and to check the necessity for an age specific denominator; and to validate the denominator information by other available data. DESIGN: This was an observational study. SETTING/PARTICIPANTS: A sentinel network was set up comprising 26 self selected paediatric practices. Weekly patient contacts in relation to age and sex were counted three times during the study period of two years. In addition, accounting data, including the total number of children treated in a given three month period (quarter), were available. MAIN RESULTS: Weekly patient contact counts were stable over time, not in terms of the absolute number of contacts but in the rank positions of the practices (rs = 0.86) and in their age structure. The age distribution of weekly patient contacts differed significantly between the practices. Cross validation of the weekly contact count by means of the quarterly accounting data resulted in a rank correlation of rs = 0.90. CONCLUSIONS: Sentinel networks with paediatric practices should use age specific denominator information. Weekly contact group, estimated by counts in a sample of weeks, is a stable and easily available denominator for sentinel practices in the context of the German health care system.

Age Distribution↗

PubMed1996

Spiral computed tomographic scanning of the chest with three dimensional imaging in the diagnosis and management of paediatric intrathoracic airway obstruction.

BACKGROUND: The usefulness of spiral computed tomographic (CT) scans of the chest with three dimensional imaging (3D-CT) of intrathoracic structures in the diagnosis and management of paediatric intrathoracic airway obstruction was assessed. METHODS: A retrospective review was made of five consecutive cases (age range six months to four years) admitted to the paediatric intensive care unit and paediatric radiology division of a tertiary care children's hospital with severe respiratory decompensation suspected of being caused by intrathoracic large airway obstruction. Under adequate sedation, the patients underwent high speed spiral CT scanning of the thorax. Non-ionic contrast solution was injected in two patients to demonstrate the anatomical relationship between the airway and the intrathoracic large vessels. Using computer software, three-dimensional images of intrathoracic structures were then reconstructed by the radiologist. RESULTS: In all five patients the imaging results were useful in directing the physician to the correct diagnosis and appropriate management. In one patient, who had undergone repair of tetralogy of Fallot with absent pulmonary valve, the 3D-CT image showed bilateral disruptions in the integrity of the tracheobronchial tree due to compression by a dilated pulmonary artery. This patient underwent pulmonary artery aneurysmorrhaphy and required continued home mechanical ventilation via tracheostomy. In three other patients with symptoms of lower airway obstruction the 3D-CT images showed significant stenosis in segments of the tracheobronchial tree in two of them, and subsequent bronchoscopy established a diagnosis of segmental bronchomalacia. These two patients required mechanical ventilation and distending pressure to relieve their bronchospasm. In another patient who had undergone surgical repair of intrathoracic tracheal stenosis three years prior to admission the 3D-CT scan ruled out restenosis as the reason for her acute respiratory decompensation. CONCLUSIONS: 3D-CT scanning is a useful additional diagnostic tool for intrathoracic airway obstruction in paediatric patients.

Bronchial Diseases↗