Safeguarding essentials in modern-day paediatrics: inflicted injuries, body maps and section 47 investigations.

The second case in the Safeguarding Essentials in Modern-day Paediatrics series, this article focuses on inflicted injuries, body maps and child protection investigations (CPIs). Using the scenario of a 6-year-old presenting to the emergency department having 'fallen off a swing', this article focuses on key considerations for history taking and examination in cases where you suspect injuries may have been inflicted, and how to discuss raising these suspicions with the family, as well as the importance of accurate body map completion. Also covered are CPIs, giving consideration to the legal framework surrounding these, and relevant useful resources and guidance are provided for dealing with the challenging circumstances that arise when physical abuse is first suspected.

Acute Safeguarding Essentials in Modern-day Paediatrics: Sexual Relationships, Consent and Confidentiality.

As the third case in the acute safeguarding essentials in modern-day paediatrics series, this article focuses on sexual relationships, consent and confidentiality. Using the scenario of a 15-year-old girl presenting to the emergency department with a positive pregnancy test, it begins with a guide to taking a psychosocial history in young people followed by discussion about some of the legality surrounding sexual relationships in adolescents, issues around consent and considerations for confidentiality in this age group.

Acute safeguarding essentials in modern-day paediatrics: neglect, unsupervised minors and modern slavery.

As part of a case-series exploring acute safeguarding essentials in modern day paediatrics, this article focusses on themes of neglect, unsupervised minors and modern slavery. Considerations around initial management, relevant legislation and useful resources, and available to all professionals involved in safeguarding children.

Acute safeguarding essentials in modern-day paediatrics.

This case series addresses the complexities of child safeguarding in modern-day paediatrics, exploring common themes and key pieces of legislation, while emphasising the centrality of the child's welfare in decision-making at all times. It discusses the evolving nature of child protection, including the importance of a multiagency approach and the rising impact of the internet and social media on child welfare, necessitating awareness of online risks and the development of mitigation strategies. Each article presents a case vignette, prompts for consideration, discussions on specific safeguarding concerns, practical considerations, and relevant legislation. Key learning points are emphasised, with links to additional freely available online resources. Ultimately, the series aims to equip paediatric professionals with the necessary tools and techniques to manage safeguarding cases and prioritise the well-being of children and young people.

Distinct Interaction Mechanism of RNA Polymerase and ResD at Proximal and Distal Subsites for Transcription Activation of Nitrite Reductase in Bacillus subtilis.

The ResD-ResE signal transduction system plays a pivotal role in anaerobic nitrate respiration in Bacillus subtilis. The nasD operon encoding nitrite reductase is essential for nitrate respiration and is tightly controlled by the ResD response regulator. To understand the mechanism of ResD-dependent transcription activation of the nasD operon, we explored ResD-RNA polymerase (RNAP), ResD-DNA, and RNAP-DNA interactions required for nasD transcription. Full transcriptional activation requires the upstream promoter region where five molecules of ResD bind. The distal ResD-binding subsite at -87 to -84 partially overlaps a sequence similar to the consensus distal subsite of the upstream (UP) element with which the Escherichia coli C-terminal domain of the α subunit (αCTD) of RNAP interacts to stimulate transcription. We propose that interaction between αCTD and ResD at the promoter-distal site is essential for stimulating nasD transcription. Although nasD has an extended -10 promoter, it lacks a reasonable -35 element. Genetic analysis and structural simulations predicted that the absence of the -35 element might be compensated by interactions between σA and αCTD and between αCTD and ResD at the promoter-proximal ResD-binding subsite. Thus, our work suggested that ResD participates in nasD transcription activation by binding to two αCTD subunits at the proximal and distal promoter sites, representing a unique configuration for transcription activation. IMPORTANCE A significant number of ResD-controlled genes have been identified, and transcription regulatory pathways in which ResD participates have emerged. Nevertheless, the mechanism of how ResD activates transcription of different genes in a nucleotide sequence-specific manner has been less explored. This study suggested that among the five ResD-binding subsites in the promoter of the nasD operon, the promoter-proximal and -distal ResD-binding subsites play important roles in nasD activation by adapting different modes of protein-protein and protein-DNA interactions. The finding of a new type of protein-promoter architecture provides insight into the understanding of transcription activation mechanisms controlled by transcription factors, including the ubiquitous response regulators of two-component regulatory systems, particularly in Gram-positive bacteria.

Safeguarding children and young people requiring kidney replacement therapy: challenges and potential opportunities.

Kidney replacement therapy (KRT) makes considerable physical and psychological demands on children, young people and their families. The impact can be wide-ranging, affecting education, employment, mental health, finances and relationships for both child and caregiver. It is vitally important for those working with these families to recognise the psychosocial challenges they face and to know the range of interventions available. This article explores the psychosocial impact of KRT, considering opportunities to minimise risk and optimise outcomes for children, young people and their families.

Fifteen-minute consultation: The toddler's fracture.

The toddler's fracture is a distinct entity among tibial shaft fractures. It is defined as a minimally displaced or undisplaced spiral fracture, usually affecting the distal shaft of the tibia, with an intact fibula. They are often difficult to diagnose due to the absence of witnessed trauma and because initial radiographs may appear normal. Moreover, the presenting complaint (a non-weight bearing child) has a wide differential diagnosis. A detailed history and examination, together with additional imaging and other investigations, is crucial to diagnose a toddler's fracture. Analgesia and immobilisation are the mainstays of treatment, with follow-up in fracture clinic recommended. Inflicted injury (Note: this article will use the term inflicted injury which is also called non-accidental injury. In the field of safeguarding, there is a move away from using the term 'non-accidental injury' due to misinterpretation of the term as being less serious than 'abusive injury' and that in child protection reports the term can be easily misread or mistyped as 'accidental' injury) should always be considered when red flags for child abuse are present. In this article, we aim to cover the differential diagnoses for toddler's fracture including indicators that might suggest an inflicted injury.

Improving rates of appropriate skeletal survey use in a district general paediatric emergency department.

Improving rates of appropriate skeletal survey use in a district general paediatric emergency department.

Fifteen-minute consultation: Recognising and addressing rude, undermining and bullying behaviour.

We set ourselves very high standards at work and when there is a sense that somehow we have failed, we are left feeling disappointed and frustrated. We all set very high standards for ourselves. When those feelings are exacerbated by the embarrassment of a public dressing down, especially if there isn't an opportunity to explain just how difficult the situation had been, we are left feeling angry and let down. Most of us learn how a bully behaves in the playground or at nursery school-and yet, when it happens as an adult at work we often fail to realise what is happening. Harassment or undermining behaviour can be more challenging to identify because it isn't always obvious and can happen without colleagues being aware. Sometimes, it isn't even apparent to those who experience it, until an event means the problem becomes overwhelming. In fact, many people who experience undermining at work perceive the problem as their own and this can have a far more insidious impact on well-being, professional performance and mental health.

Accurate diagnosis of CHD by Paediatricians with Expertise in Cardiology.

Introduction Paediatricians with Expertise in Cardiology assess children with a full history, examination, and often perform an echocardiogram. A minority are then referred to an outreach clinic run jointly with a visiting paediatric cardiologist. The accuracy of the echocardiography diagnosis made by the Paediatrician with Expertise in Cardiology is unknown. Materials and methods We conducted a retrospective review of clinic letters for children seen in the outreach clinic for the first time between March, 2004 and March, 2011. Children with CHD diagnosed antenatally or elsewhere were excluded. We recorded the echocardiography diagnosis made by the paediatric cardiologist and previously by the Paediatrician with Expertise in Cardiology. RESULTS: The Paediatrician with Expertise in Cardiology referred 317/3145 (10%) children seen in the local cardiac clinics to the outreach clinic over this period, and among them 296 were eligible for inclusion. Their median age was 1.5 years (range 1 month-15.1 years). For 244 (82%) children, there was complete diagnostic agreement between the Paediatrician with Expertise in Cardiology and the paediatric cardiologist. For 29 (10%) children, the main diagnosis was identical with additional findings made by the paediatric cardiologist. The abnormality had resolved in 17 (6%) cases by the time of clinic attendance. In six (2%) patients, the paediatric cardiologist made a different diagnosis. In total, 138 (47%) patients underwent a surgical or catheter intervention. Discussion Paediatricians with Expertise in Cardiology can make accurate diagnoses of CHD in children referred to their clinics. This can allow effective triage of children attending the outreach clinic, making best use of limited specialist resources.

Managing outpatient consultations: from referral to discharge.

Although a great deal of paediatric consultations are not urgent, doctors in training spend so much time providing service for acute conditions that they spend little time focusing on outpatient work before they become a consultant. Engaging clinicians in the managerial aspects of providing clinical care is a key to improving outcomes, and this article addresses these aspects of the outpatient consultation from referral to discharge. We aim to provide doctors in training with a tool to use during their training and their first few years as a consultant, to think about how outpatient work is organised and how it can be improved to maximise patient experience. The non-urgent consultation varies across the world; this article is aimed to be relevant to an international audience.

Learning the hard way: 10 lessons for developing undergraduate curricula.

The present study outlines key learning points derived from 2 years spent developing a national undergraduate curriculum for child health. Findings are sourced from analyses of a series of semi-structured musings by beleaguered educationalists and may serve to reassure others engaged in developing undergraduate curricula that it is possible to survive the process and even to produce something quite good. The authors' best advice is to do it, but don't say we didn't warn you.

Fifteen-minute consultation: problems in the healthy child-toilet training.

Toilet training is a process that all healthy children go through. It is one of the developmental milestones for which parents most often seek medical help. Despite this, many paediatricians feel unconfident managing children presenting with a toilet training problem. We address some common questions arising when assessing and managing such a child, including identifying rare but important diagnoses not to miss.