Children and adolescents on intensive insulin therapy maintain postprandial glycaemic control without precise carbohydrate counting

Aims Carbohydrate (CHO) quantification is used to adjust pre‐meal insulin in intensive insulin regimens. However, the precision in CHO quantification required to maintain postprandial glycaemic control is unknown. We determined the effect of a ±10‐g variation in CHO amount, with an individually calculated insulin dose for 60 g CHO, on postprandial glycaemic control. Methods Thirty‐one children and adolescents (age range 9.5–16.8 years), 17 using continuous subcutaneous insulin infusion (CSII) and 14 using multiple daily injections (MDI), participated. Each subject consumed test lunches of equal macronutrient content, differing only in carbohydrate quantity (50, 60, 70 g CHO), in random order on three consecutive days. For each participant, the insulin dose was the same for each meal, based on their usual insulin : CHO ratio for 60 g CHO. Activity was standardized. Continuous glucose monitoring was used. Results The CSII and MDI subjects demonstrated no difference in postprandial blood glucose levels (BGLs) for comparable carbohydrate loads (P > 0.05). The 10‐g variations in CHO quantity resulted in no differences in BGLs or area under the glucose curves for 2.5 h (P > 0.05). Hypoglycaemic episodes were not significantly different (P = 0.32). The 70‐g meal produced higher glucose excursions after 2.5 h, with a maximum difference of 1.9 mmol/l at 3 h (P = 0.01), but the BGLs remained within international postprandial targets. Conclusions In patients using intensive insulin therapy, an individually calculated insulin dose for 60 g of carbohydrate maintains postprandial BGLs for meals containing between 50 and 70 g of carbohydrate. A single mealtime insulin dose will cover a range in carbohydrate amounts without deterioration in postprandial control.     

How do clinical features help identify paediatric patients with fractures following blunt wrist trauma?

Objective

Wrist injuries are a common presentation to the emergency department (ED). There are no validated decision rules to help clinicians evaluate paediatric wrist trauma. This study aimed to identify which clinical features are diagnostically useful in deciding the need for a wrist radiograph, and then to develop a clinical decision rule.

Methods

This prospective cohort study was carried out in the ED of Sheffield Children''s Hospital. Eligible patients were recruited if presenting within 72 hours following blunt wrist trauma. A standardised data collection form was completed for all patients. The outcome measure was the presence or absence of a fracture. Univariate analysis was performed with the χ² test. Associated variables (p<0.2) were entered into a multivariate model. Classification and regression tree (CART) analysis was used to derive the clinical decision rule.

Results

In total, 227 patients were recruited and 106 children were diagnosed with fractures (47%). Of 10 clinical features analysed, six were found by univariate analysis to be associated with a fracture. CART analysis identified the presence of radial tenderness, focal swelling, or an abnormal supination/pronation as the best discriminatory features. Cross fold validation of this decision rule had a sensitivity of 99.1% (95% confidence interval 94.8% to 100%) and a specificity of 24.0% (17.2% to 32.3%). The radiography rate would be 87%.

Conclusions

Radial tenderness, focal swelling, and abnormal supination/pronation are associated with wrist fractures in children. The clinical decision rule derived from these features had a high sensitivity, but low specificity, and would not substantially alter our current radiography rate. The potential for a clinical decision rule for paediatric wrist trauma appears limited.     

Validation of the Paediatric Triage Tape

Introduction

The Paediatric Triage Tape (PTT) is an easy to use major incident primary triage tool, based upon a modification of the Triage Sieve. The purpose of this study was to prospectively validate the PTT for use in paediatric major incidents.

Methods

A database of children presenting the Trauma Unit of the Red Cross Children''s Hospital, Cape Town, was developed over a nine month period. Each child was triaged using the PTT, and had an Injury Severity Score (ISS) calculated. Additionally, the New Injury Severity Score (NISS) was calculated, and the presence of interventions that may occur to the children (“Garner criteria”) was documented. The sensitivity, specificity, overtriage, and undertriage rates were calculated.

Results

3461 children were entered into the database. For identifying children with an ISS of over 15, the PTT had a sensitivity of 37.8%, specificity of 98.6%, overtriage rate of 38.8%, and an undertriage rate of 3.5%. Against the NISS and Garner criteria, the results were comparable.

Conclusion

The PTT has poor sensitivity at identifying immediate priority children by these criteria. Specificity (the ability to identify non‐T1 patients) is excellent, and the overtriage and undertriage rates are within the range deemed unavoidable by the American College of Surgeons.     

A double-blind comparative clinical trial of cephalexin and ampicillin in the treatment of childhood acute otitis media

Summary

Cephalexin and ampicillin were compared in a double-blind trial in the treatment of acute otitis media. Fifty-four children under the age of 12 years were treated with 50?mg./kg./24 hours of either ampicillin or cephalexin for at least 7 days. The results of the trial showed no significant differences in clinical response to either antibiotic, and indicate that cephalexin and ampicillin are equally effective in the treatment of childhood acute otitis media.     

Collaboration between occupational therapists and teachers: definitions, implementation and efficacy

Aim: The aim of this article is to present a critical review of available health and education literature to ascertain how collaboration is defined, what the barriers to collaboration are, how effective collaboration between occupational therapists and teachers is, and to determine implications for research and future practice in Australia. Methods: A comprehensive electronic search process was undertaken, identifying studies from health and education databases. Manual searching of reference lists was then conducted for retrieved articles. Studies were reviewed to determine quality and relevance to the review question. Results: Nine research articles were reviewed, which included six qualitative and three quantitative articles. An additional seven discussion papers and three literature reviews were also included. It is apparent that the available literature is predominantly written about USA and UK contexts, and empirical evidence is limited. Definitions of collaboration differ, and although professionals agree that it is important to collaborate, the evidence of effectiveness is scant. Conclusions: Although there is much anecdotal desire for collaboration, empirical evidence is limited, but positive. Professionals express desire for collaboration, but the implementation appears inconsistent, and poorly researched. The literature outlines factors, which support collaboration in practice including interactional, organisational and systemic factors. Using this model, strategies for successful collaboration can be formulated. Results indicate a need for research into appropriate models of practice for an Australian context, and particularly for states, where the health and education systems are not well integrated.     

Predicting the impact on workload with the application of inpatient clinical review criteria into a paediatric emergency department

Objective: Inpatient paediatric clinical observation charts that have predefined physiological criteria, which when reached might generate a mandatory medial review, are to be introduced into EDs in New South Wales. The present study estimated the increased workload of introducing these charts. Methods: The present study was carried out in the ED of The Children's Hospital at Westmead, Sydney, Australia. All patients admitted directly to the inpatient wards or to the Emergency Medical Unit for a 2 week period in April 2010 were included. The last set of clinical observations prior to the child being transferred out of the ED were recorded. These data were compared to the review criteria defined by the observation charts. The primary outcome was a possible activation of a review. Secondary outcomes were an attempt to quantify the extra time in the ED required before the review would be completed and the patient would be ready for transfer. Results: There were 1822 presentations. Two hundred and fifty‐three were admitted to the wards and 109 to the Emergency Medical Unit. There were 126 possible activations. Fifty‐seven (52%) of Emergency Medical Unit patients and 69 (28%) of ward patients met review criteria at the time of transfer. The review activations might have generated an extra 7060 min of additional workload. Conclusions: Individual units must decide where in the patient journey to introduce the charts for acute paediatric admissions based on the number of acute paediatric admissions and their severity as well as the availability and ability of staff to respond to calls.     

Hydroxycarbamide treatment in children with Sickle Cell Anaemia is associated with more intact white matter integrity: a quantitative MRI study

Sickle cell anaemia (SCA) is a devastating genetic blood disorder leading to chronic anaemia, impaired cerebrovascular dilatory capacity and cerebral infarctions. Our aim was to assess the relationship between microstructural properties of the white matter (WM) and both cerebrovascular reactivity (CVR) and cerebral blood flow, as well as the effects of hydroxycarbamide on these relationships. Our results demonstrate that mean CVR was increased in hydroxycarbamide-treated patients compared to untreated patients. Moreover, untreated SCA patients had increased skew and kurtosis of mean diffusivity histograms in the WM compared to hydroxycarbamide-treated patients and healthy age-matched controls, indicating disruption of WM integrity. Regression analysis of CVR and WM mean diffusivity (MD) revealed a significant linear relationship between CVR and MD histogram skew and kurtosis in healthy controls, but not in either of the two SCA groups. These findings suggest that patients treated with hydroxycarbamide possess white matter MD histogram parameters which more closely resemble those of healthy controls.