Does discharging asthma patients after one hour of treatment if clinically well affect emergency department length of stay.

AIM: Asthma is a major contributor to direct and indirect health-care costs and resource use. In May 2015, the Royal Children's Hospital (RCH) amended its clinical practice guideline for acute asthma management from discharging patients if the anticipated salbutamol requirement was every 3-4 h to discharging patients who were clinically well at 1 h after initial treatment. Our objective was to examine the impact of the new discharge recommendation on emergency department (ED) length of stay (LOS), rates of admission and representation. METHODS: We retrospectively audited the case notes of children presenting with mild or moderate asthma to the RCH ED over the equivalent 2-week periods in winter 2014 (pre-implementation of the new guideline) and 2015 (post-implementation). RESULTS: A total of 105 patients in 2014 and 92 patients in 2015 were included. In both years, all patients who initially presented with mild or moderate asthma either improved or stayed within the same severity classification at the 1-h assessment. For patients who were clinically well by the 1-h assessment, there was a significant reduction in admissions between 2014 and 2015 (40 vs. 10%, P = 0.001). There was also a reduction for these patients in median LOS from 3 h 13 min in 2014 to 2 h 31 min in 2015 (P = 0.03). In both years, all patients who were moderate at 1 h were admitted. There was no difference in the rate of representation or subsequent deterioration in those patients who were discharged at 1 h between the 2 years. CONCLUSION: Early discharge of patients who are clinically well 1 h after initial therapy may be associated with a reduction in LOS and admission rate without an apparent compromise in patient safety. Further evaluation of this intervention is required to determine whether this is a true causal relationship.

Pulmonary Mycobacterium abscessus complex in children with cystic fibrosis: A practical management guideline.

The treatment of Mycobacterium abscessus complex (MABSC) pulmonary infections is an emerging challenge in patients with cystic fibrosis (CF). Multidrug therapy for prolonged durations is required and carries the significant burden of drug-related toxicity, cost and selective pressure for multiresistant bacteria. International guidelines acknowledge that clinical and in vitro data to support treatment regimens are limited, particularly in children. As part of a collaboration between the infectious diseases and respiratory units at our institution, we have developed a modified treatment guideline that aims to balance the aims of MABSC eradication and slowing disease progression with minimising drug toxicity and resistance. The outcomes of this treatment approach will be monitored and reported. In this manuscript, we discuss the available evidence for treatment choices and present our treatment guideline for paediatric patients with CF and MABSC infection.

Impacts of forest harvesting on mobilization of Hg and MeHg in drained peatland forests on black schist or felsic bedrock.

Forest harvesting, especially when intensified harvesting method as whole-tree harvesting with stump lifting (WTHs) are used, may increase mercury (Hg) and methylmercury (MeHg) leaching to recipient water courses. The effect can be enhanced if the underlying bedrock and overburden soil contain Hg. The impact of stem-only harvesting (SOH) and WTHs on the concentrations of Hg and MeHg as well as several other variables in the ditch water was studied using a paired catchment approach in eight drained peatland-dominated catchments in Finland (2008-2012). Four of the catchments were on felsic bedrock and four on black schist bedrock containing heavy metals. Although both Hg and MeHg concentrations increased after harvesting in all treated sites according to the randomized intervention analyses (RIAs), there was only a weak indication of a harvest-induced mobilization of Hg and MeHg into the ditches. Furthermore, no clear differences between WTHs and SOH were found, although MeHg showed a nearly significant difference (p = 0.06) between the harvesting regimes. However, there was a clear bedrock effect, since the MeHg concentrations in the ditch water were higher at catchments on black schist than at those on felsic bedrock. The pH, suspended solid matter (SSM), dissolved organic carbon (DOC), and iron (Fe) concentrations increased after harvest while the sulfate (SO4-S) concentration decreased. The highest abundances of sulfate-reducing bacteria (SRB) were found on the sites with high MeHg concentrations. The biggest changes in ditch water concentrations occurred first 2 years after harvesting.

Paediatric infectious diseases: the last 50 years.

Many advances and challenges have occurred in the field of paediatric infectious diseases during the past 50 years. It is impossible to cover all of these in a short review, but a few highlights and lowlights will be covered. These include virtual disappearance of some infectious diseases, emergence of new ones, infections in the immunocompromised, antimicrobial resistance, development of new and improved antimicrobials, improved diagnostic tests and the Human Microbiome Project.

Managing childhood migraine.

BACKGROUND: Childhood migraines create a significant health burden and are probably under-diagnosed and treated. OBJECTIVES: The aim of this article is to offer a systematic approach to the management of migraine. DISCUSSION: A systematic approach to the presentation of migraines in children can help to alleviate parental and physician anxiety and allow for an accurate diagnosis. Treatment is multifactorial but pharmacological intervention should certainly play a role along with adjustment of environmental factors and addressing possible underlying psychosocial factors. Referral to a general practitioner (GP) with specialist interests, paediatrician, adolescent physician or neurologist may be appropriate. In extreme circumstances, referral to the emergency department is a reasonable option to allow aggressive abortive treatments, but ongoing management should be coordinated through the GP.

Nitrogen, phosphorus, carbon, and suspended solids loads from forest clear-cutting and site preparation: long-term paired catchment studies from eastern Finland.

The long-term impacts of current forest management methods on surface water quality in Fennoscandia are largely unexplored. We studied the long-term effects of clear-cutting and site preparation on runoff and the export of total nitrogen (total N), total organic nitrogen (TON), ammonium (NH(4)-N), nitrate (NO(3)-N), total phosphorus (total P), phosphate (PO(4)-P), total organic carbon, and suspended solids (SS) in three paired-catchments in Eastern Finland. Clear-cutting and soil preparation were carried out on 34 % (C34), 11 % (C11), and 8 % (C8) of the area of the treated catchments and wide buffer zones were left along the streams. Clear-cutting and soil preparation increased annual runoff and total N, TON, NO(3)-N, PO(4)-P, and SS loads, except for SS, only in C34. Runoff increased by 16 % and the annual exports of total N, TON, NO(3)-N, and PO(4)-P by 18, 12, 270, and 12 %, respectively, during the 14-year period after clear-cutting. SS export increased by 291 % in C34, 134 % in C11, and 16 % in C8 during the 14, 6, and 11-year periods after clear-cutting. In the C11 catchment, NO(3)-N export decreased by 12 %. The results indicate that while current forest management practices can increase the export of N, P and SS from boreal catchments for many years (>10 years), the increases are only significant when the area of clear cutting exceeds 30 % of catchment area.

Long-term changes in acidity and DOC in throughfall and soil water in Finnish forests.

The main objective of this study was to examine if any detectable trends in dissolved organic carbon (DOC), sulphate (SO4-S) concentrations and acid neutralizing capacity (ANC) in throughfall (TF) and soil water (SW) could be found during 1990-2010 and to relate them to recent changes in decreased acid deposition. The study was conducted in seven boreal coniferous forest sites: four of which are managed and three unmanaged forests sites. Generally, temporal trend showed a significant decrease in SO4-S concentrations in bulk precipitation (BP), TF and SW. At some of the sites, there was an increasing tendency in BP and TF in the DOC concentrations. This feature coincides with decreasing SO4-S concentration, indicating that SO4-S may be an important driver of DOC release from the canopy. However, a slightly increased temperature, larger senescing needle mass and consequently increased decaying activity in the canopy may partly explain the increasing trend in DOC. In SW, no consistent DOC trend was seen. At some sites, the decreased base cation concentrations mostly account for the decrease in the ANC values in SW and TF.

Are we there yet? Travel vaccinations for Australian children.

BACKGROUND: Australians travel overseas frequently and general practitioners (GPs) are often asked to provide detailed advice on travel vaccinations for children. Planning a safe and effective vaccination schedule is dependent on the context: where and when the family is travelling, the individual child's medical needs and past vaccination history, and if they are visiting family and friends. OBJECTIVE: In this paper we provide an overview of the issues to consider when vaccinating Australian children for overseas travel. We also list the suite of common travel vaccinations and discuss some clinical scenarios that are likely to present in Australian general practice. DISCUSSION: Australians love to travel overseas and, increasingly, GPs are asked by patients to provide detailed advice on travel vaccinations for their children. Decisions regarding vaccinations for travelling children can be complex and the advice often differs from that provided for adults. Children differ from adults in their vulnerability to illnesses and side effects of medications. These differences, as well as their status regarding routine childhood vaccinations, all need to be taken into account. As with adults, it is important to consider the location and duration of travel and time until departure. The age of the child is also important and there may be a case for accelerating the routine childhood vaccinations in some children. The aim of this paper is to provide a clear and simple outline of the vaccination recommendations for children travelling overseas from Australia.

Paediatric travel medicine: vaccines and medications.

The paediatric aspects of travel medicine can be complex, and individual advice is often required. Nonetheless, children are much more likely to acquire common infections than exotic tropical diseases whilst travelling. Important exceptions are malaria and tuberculosis, which are more frequent and severe in children. Overall, travellers' diarrhoea is the most common illness affecting travellers. This review discusses vaccines and medications that may be indicated for children who are travelling overseas. It focuses on immunizations that are given as part of the routine schedule, as well as those that are more specific to travel. Malaria and travellers' diarrhoea are also discussed.

Risk factors for Cryptococcus gattii infection, British Columbia, Canada.

To determine whether particular environmental, medical, or behavioral risk factors existed among Cryptcoccus gattii-infected persons compared with the general population, we conducted a sex-matched case-control study on a subset of case-patients in British Columbia (1999-2001). Exposures and underlying medical conditions among all case-patients (1999-2007) were also compared with results of provincial population-based surveys and studies. In case-control analyses, oral steroids (matched odds ratio [MOR] 8.11, 95% confidence interval [CI] 1.74-37.80), pneumonia (MOR 2.71, 95% CI 1.05-6.98), and other lung conditions (MOR 3.21, 95% CI 1.08-9.52) were associated with infection. In population comparisons, case-patients were more likely to be ≥50 years of age (p<0.001), current smokers (p<0.001), infected with HIV (p<0.001), or have a history of invasive cancer (p<0.001). Although C. gattii is commonly believed to infect persons with apparently healthy immune systems, several immunosuppressive and pulmonary conditions seem to be risk factors.

Management of severe asthma in children.

BACKGROUND: Asthma is the most common chronic disease of childhood and the leading cause of childhood morbidity from chronic disease. When uncontrolled, asthma can place significant limits on daily life, and is sometimes fatal. OBJECTIVE: This article describes the initial assessment and management of status asthmaticus in children. DISCUSSION: Status asthmaticus is a medical emergency in which asthma symptoms are refractory to initial bronchodilator therapy. Patients may report chest tightness, rapidly progressive shortness of breath, dry cough and wheezing. Typically, patients present a few days after the onset of a viral respiratory illness, following exposure to potent allergens or irritants, or after exercise in a cold environment, however, they can also present with sudden onset of symptoms with an unknown trigger. Early recognition and initiation of therapy is vital in preventing severe complications such as respiratory failure. Aggressive treatment with beta-agonists, anticholinergics and corticosteroids remains the gold standard for this condition.

Meningococcal sepsis.

BACKGROUND: Meningococcal disease remains a significant illness with an overall mortality of around 8%. The majority of deaths occur in the first 24 hours, before the commencement of specialist care. Missing a diagnosis of meningococcal disease is a fear among health care practitioners. OBJECTIVE: This article presents a guide to identifying the salient features of meningococcal sepsis and initial management strategies in the primary care setting. DISCUSSION: Initial presentation is often nonspecific and therefore it is important to have a high index of suspicion in children presenting with fever, lethargy, myalgia, vomiting and headache. These children should be monitored and reviewed carefully. If a nonblanching rash develops, immediate treatment, liaison with a paediatric intensive care unit and urgent hospital transfer is required. Initial management involves assessment and regular review of airway, breathing and circulation. Antibiotics (preferably intravenous cephalosporin) should be administered before hospital transfer.

Assessment of the unwell child.

BACKGROUND: Children present to general practitioners with a wide range of problems, but most of the time they are not particularly unwell. Children with a more serious illness often compensate very well initially, so there is a risk that their illness will be overlooked or underestimated. OBJECTIVE: To outline the early recognition and management of children who are seriously ill. DISCUSSION: The initial assessment of an unwell child includes the paediatric assessment triangle: appearance, breathing and circulation to skin; primary survey that focuses on basic life support, patient assessment and immediate management; secondary survey with a detailed history of the event and physical examination; and ongoing assessment. Medical practitioners and their clinic staff must be prepared to undertake initial emergency management of a seriously ill child, and they must have the equipment and supplies available to carry out that management effectively.

Croup - assessment and management.

BACKGROUND: Croup is a common childhood disease characterised by sudden onset of a distinctive barking cough that is usually accompanied by stridor, hoarse voice, and respiratory distress resulting from upper airway obstruction. The introduction of steroids in the treatment of croup has seen a significant reduction in hospital admissions and improved outcomes for children. OBJECTIVE: This article discusses the key aspects of diagnosing croup and the evidence supporting the different treatment strategies. DISCUSSION: The assessment of airway, breathing and circulation, focusing on airway, is paramount in treating croup. However, it is important to take care not to cause the child undue distress. In mild to moderate croup, give prednisolone 1.0 mg/kg and review in 1 hour. In severe or life threatening croup, give 4 mL of adrenaline 1:1000 (undiluted) via nebuliser and send immediately to hospital via ambulance.

Minor head injuries in children - an approach to management.

BACKGROUND: Traumatic head injury is a common occurrence in the paediatric population, with the majority of patients sustaining only mild head injury. OBJECTIVE: This article outlines the management of mild head injuries in children. DISCUSSION: A careful history including time of injury, the mechanism of injury, and any loss of consciousness or seizure activity; a thorough examination including a Glascow Coma Scale (GCS) score; and observation should be appropriate for most patients. Only a small number of injuries require further examination/imaging with computerised tomography. Indicators for transfer to hospital include GCS equal to or less than 12, focal neurological deficit, clinical evidence of skull fracture, loss of consciousness for more than 30 seconds, ataxia, amnesia, abnormal drowsiness, persistent headache, seizure following initial normal behaviour or recurrent vomiting. Postconcussive symptoms frequently occur after minor head injuries and parents and other family members should be aware of what symptoms to expect, and possible duration. Regular follow up until all symptoms have resolved is mandatory, with clear guidelines for stepwise resumption of physical activity.

Back to school: Safe for children with underlying medical conditions.

As schools reopen as a result of low community transmission rates of COVID-19, parents and teachers will have understandable concerns about the risks to students and staff.