Multidisciplinary guidelines for the management of paediatric tracheostomy emergencies.

Temporary and permanent tracheostomies are required in children to manage actual or anticipated long-term ventilatory support, to aid secretion management or to manage fixed upper airway obstruction. Tracheostomies may be required from the first few moments of life, with the majority performed in children < 4 years of age. Although similarities with adult tracheostomies are apparent, there are key differences when managing the routine and emergency care of children with tracheostomies. The National Tracheostomy Safety Project identified the need for structured guidelines to aid multidisciplinary clinical decision making during paediatric tracheostomy emergencies. These guidelines describe the development of a bespoke emergency management algorithm and supporting resources. Our aim is to reduce the frequency, nature and severity of paediatric tracheostomy emergencies through preparation and education of staff, parents, carers and patients.

Controversies in the management of deep neck space infection in children: an evidence-based review.

BACKGROUND: Deep neck space infection (DNSI) is defined as infection in the potential spaces and fascial planes of the neck. Early recognition of DNSI can be challenging due to the complex head and neck anatomy; hence, a high index of suspicion is required to prevent a delay in diagnosis and appropriate management. OBJECTIVE OF REVIEW: There remains a lack of consensus on the management of paediatric DNSI with many advocating a more aggressive approach with immediate surgical drainage, while others favour a more conservative approach with medical management in the first instance. The current literature on the management of paediatric DNSI is reviewed. TYPE OF REVIEW AND SEARCH STRATEGY: A literature review performed in November 2015 searched PubMed using the terms 'deep neck space', 'infection', 'paediatric', 'pediatric', 'children', 'imaging', 'conservative', 'antibiotic' and 'surgery'. Articles not in the English language were excluded. RESULTS: (i) Clinical presentation: Management of a compromised airway is the priority. Clinical history and examination enables the identification of the primary source of infection and presence of complications. (ii) Investigations: Laboratory and microbiological investigations should be appropriately targeted, and CT imaging is the modality utilised in most cases. The presence of specific complications may warrant other imaging modalities. (iii) Antibiotics: An evidence-based antibiotic regime is proposed. (iv) Conservative treatment: In children lacking indications for surgical intervention, a trial 48 h of intravenous antibiotics (IV Abx) should be commenced. v) Surgical intervention: Indications include signs of airway compromise, presence of complications, no clinical improvement after 48 h of IV Abx, abscess >2.2 cm on CT imaging, age <4 years and ITU admission. CONCLUSIONS: An appreciation of head and neck anatomy is vital to understanding disease pathology and potential complications of DNSI, which may be life threatening. Both conservative and surgical approaches are viable treatment options and may compliment each other. Current evidence suggests that clinical management should be targeted towards the individual patient as factors such as age of the child may influence the balance of a conservative versus a surgical approach.

The involvement of parents in healthcare decisions where adult children are at risk of lacking decision-making capacity: a qualitative study of treatment decisions in epilepsy.

BACKGROUND: Patients with intellectual disabilities (ID) receive health care by proxy. It is family members and/or paid support staff who must recognise health problems, communicate with clinicians, and report the benefits, if any, of a particular treatment. At the same time international and national statutes protect and promote the right of people with disabilities to access the highest attainable standards of health on the basis of free and informed consent. METHODS: To consider the role of parent-proxies in the management of epilepsy in adult children with ID who are at risk of lacking capacity to make decisions about their health care we interviewed 21 mothers. FINDINGS: These mothers are not pursuing changes in treatment that might improve their son or daughter's epilepsy, nor are they willing to countenance changes in treatment. Clinicians concerned to build and sustain therapeutic alliances with these mothers, our evidence suggests, may well avoid going against their wishes. DISCUSSION: Our research highlights the interactional contingencies of a hitherto neglected three-way clinical relationship comprising parent-proxy, an adult at risk of lacking decision-making capacity, and a treating clinician. This is a relationship, our findings suggest, where little importance is attached to either patient consent, or involvement in treatment decisions.

12 minute consultation: An evidence-based approach to the management of a child with speech and language delay.

BACKGROUND: Speech and language delay is a common developmental disorder. Persistent delay may lead to adverse effects on literacy, educational achievement and psychosocial development. Affected children are commonly referred to the otolaryngologist; hence, a structured management approach is required to facilitate diagnosis and allow for early intervention and improved outcomes. METHODS: A literature search was performed on 05 November 2012 using the MEDLINE, EMBASE and Cochrane databases with the search terms paediatric, children, speech, language, delay, disorder, investigation and management. Relevant references from selected articles were reviewed after reading the abstract. RESULTS: Speech and language delay may be primary, meaning there is no associated comorbidity to account for the delay, or secondary, where it can be attributed to another condition or syndrome. Secondary causes include hearing loss and syndromes such as Down syndrome amongst many others. Speech and language therapy has been shown to be effective for primary disorders. If the delay is found to be secondary in nature, onward referral to an appropriate healthcare professional is required. CONCLUSIONS: The outpatient consultation for a child with speech and language delay should consist of a structured history and examination with the aim of identifying whether the delay is primary or secondary in nature. Relevant targeted investigations should lead to a correct diagnosis of the delay and enable appropriate treatment. This often requires a multidisciplinary approach and always requires full cooperation from the child's parents.

How I do it: intracapsular coblation tonsillectomy.

BACKGROUND: There has been increased interest in the adoption of an intracapsular tonsillectomy technique in the UK in recent years. The adoption of any newer surgical technique inevitably is accompanied by an educational need. OBJECTIVES: This paper aims to outline the equipment preparation and surgical steps for intracapsular coblation tonsillectomy, including recognition of the tonsillar capsule. The paper also discusses how to avoid and deal with common complications and technical difficulties.

Susceptibility of Rice to Oebalus pugnax (F.) (Hemiptera: Pentatomidae) Feeding at Different Levels of Grain Maturity and Impacts on Insecticide Termination.

The stages of rice, Oryza sativa L. (Poales: Poaceae), grain maturity that are most susceptible to rice stink bug, Oebalus pugnax (F.), damage have been identified; however, the stage at which they are no longer capable of causing appreciable damage during grain maturity is unclear. The objective of this study was to determine the susceptibility of rice to rice stink bug feeding at different levels of grain maturity and determine an insecticide termination timing. Rice stink bug damage was examined using five levels of grain maturity described as percent of kernels reaching mature straw coloration referred to as hard dough (20, 40, 60, 80, and 100%) across a range of infestation levels using single panicle sleeve cages and large cages. Hybrid and conventional cultivar rice panicles at 20, 40, and 60% hard dough were found to be susceptible to indirect yield loss, as two rice stink bugs per panicle resulted in over 7% peck. In large cage trials, 25 rice stink bugs caused 0.7-1% peck to hybrid and conventional rice plots at 20% hard dough. Much less damage was observed once rice reached 60% hard dough, where peck averages only reached 0.4%. Decreased damage at 60% hard dough was validated using uncaged trials where 0.4% additional peck was observed in unsprayed plots. These data indicate that rice in the early stages of hard dough is susceptible to large levels of indirect yield loss, but unless significant densities of rice stink bug are present at 60% hard dough, no more sampling or applications are necessary.

How is epilepsy treated in people with a learning disability? A retrospective observational study of 183 individuals.

Epilepsy in those with learning disability (LD) is currently managed by various health agencies with no obvious criteria for selecting particular care pathways and limited evidence-based descriptions of optimal treatment. The aim of this study was to examine relationships between management strategies and clinical outcomes in a community-based cohort of individuals with epilepsy and LD. The results may inform epilepsy management directly and contribute to an evidence base to support development of formal clinical trials. An attempt was made to recruit all individuals with epilepsy and LD known to community LD health services in one geographic area. However, those with profound LD were under-represented in the final sample. Information relating to the epilepsy, the severity of the LD, comorbidities and epilepsy management were obtained retrospectively both from the clinical notes and from interviews with carers and clinicians. We recruited 183 individuals of whom 33% had no reported seizures in the previous three months whilst 12% recorded more than 20 seizures per month. 73 individuals were receiving monotherapy, 66 were treated with two AEDs and 42 were prescribed three or more AEDs at the time of the study. In those taking monotherapy, there was no difference in the mean monthly seizure frequency between groups taking different AEDs. Similarly, for those prescribed two AEDS, no particular combination was associated with significantly lower seizure frequency. One third of the sample was receiving epilepsy management from hospital neurology services but no criteria determining choice of treatment pathway were identified. The findings suggest that more research needs to be carried out to identify both optimal care pathways and AED strategies.

Radio opacity of various ENT foreign bodies in sheep's neck preparation.

We conducted an experimental study to evaluate the radio densities of different ENT foreign bodies. Various ENT foreign bodies were placed in the oesophagus of a sheep's neck preparation. An X-ray lateral view of the neck was taken, following the soft tissue neck protocol. Foreign bodies were grouped depending upon their radio densities and pixel value. The visibility of different materials on plain radiographs depends on their ability to absorb X-rays, and their inherent radio density and relation between it and the tissue in which they are embedded.

Grommet insertion: a novel technique.

We describe a new technique for inserting grommets which is both easy to master and provides better visualization of the tympanic membrane. This is particularly helpful in patients with narrow ear canals.

Evaluating characteristics of community riparian awareness program interactions.

As part of its mandate to evaluate and monitor program delivery, the Alberta Riparian Habitat Management Society (Cows and Fish) has commissioned independent evaluations to examine the effectiveness and applicability of the community-based riparian awareness and management program. The society's aim is to improve the understanding of landscape function, to better enable landowners and managers to make management decisions. The staff interaction evaluation examined staff ability to deliver certain valued characteristics, and identified whether the program and staff increased awareness and management action. Respondents rated staff highly on all characteristics. Landowners that participated in riparian health programming as part of community/watershed groups were 19% more likely to have learned new information and 21% more likely to implement management change than those that were not part of a group. Repeat interactions are critical to learning new information and influencing management. All those with frequent interactions had learned new information, compared to only 70% of those with very little interaction. A diverse array of interactions led respondents to alter their management, indicating the need for a wide variety of extension tools and activities. The results strongly support the need for a community-based approach in resource management and awareness activities, which enables repeat, ongoing and diverse interactions with extension staff.

Effect of amiloride on contractility of rat cardiac muscle exposed to chronic hypercapnia and acute acidosis.

Papillary muscle preparations from rats with normal arterial oxygen and carbon dioxide tensions and from rats which had been maintained with normal oxygen tension but with hypercapnia for 28 days (FICO2 = 5%) were subjected to acute hypercapnia with or without amiloride, a competitive inhibitor of the Na+/H+ pump. Acclimatisation to hypercapnia reduced the slope of the line relating log tension against the extracellular pH from 0.96(SEM0.06) to 0.71(0.07) (p less than 0.02). Amiloride increased the slope in unacclimatised muscle to 1.39(0.09), p less than 0.001 and in muscles acclimatised to hypercapnia to 1.03(0.13), p less than 0.05. The slope in acclimatised muscles was significantly less steep than in unacclimatised muscle (p less than 0.05). The sarcolemmal Na+H+ exchanger is important in the protection of rat cardiac muscle against acute respiratory acidosis.

The effect of noradrenaline on the ability of rat papillary muscle to resist an acute respiratory acidosis.

We have studied the effect of an increase in extracellular calcium and of noradrenaline on the ability of rat right ventricular papillary muscle in vitro to resist an acute fall in extracellular pH (pHe) produced by a rise in superfusate PCO2. We found a steep linear relationship, slope 0.86(SEM 0.06), r = 0.94, between a plot of logarithmic change in tension against pHe for control muscles (superfusate containing 1.8 mmol.litre-1 calcium). An increase in extracellular calcium (3.6 mmol.litre-1) increased absolute tension but did not alter the slope significantly. Increasing concentrations of noradrenaline (6.3 x 10(-8) to 6.3 x 10(-6) M) progressively reduced the slope of the tension/pHe plot from 0.82(0.05) to 0.35(0.07), p less than 0.001. Noradrenaline improved the ability of rat papillary muscle to resist an acute acidosis by a mechanism independent of changes in calcium concentration.

Increased resistance to acute respiratory acidosis in isolated cardiac muscle following chronic hypoxia-induced hypertrophy.

OBJECTIVES: Hypertrophied myocardium is more sensitive to ischaemic dysfunction and damage. The objective of this study was to determine the effect of respiratory acidosis on cardiac muscle function following hypoxia-induced right ventricular hypertrophy, and to ascertain the role of Na(+)-H+ antiporter, which is known to be associated with cell growth. METHODS: Wistar rats were maintained at 10% O2 for 1 or 4 weeks. Experiments were performed on right ventricular papillary muscles stimulated at 1 Hz, and developed tension was recorded. The effect of respiratory acidosis was examined by equilibrating the perfusing solution with increasing levels of CO2, and the role of the Na(+)-H+ antiporter was determined by preincubation with the inhibitor 5-(N,N-hexamethylene) amiloride (HMA). Data were analysed by comparison of the slope of the semi-log plot of normalised tension against pH. RESULTS: Right ventricular hypertrophy was apparent after both 1 and 4 weeks of hypoxia. Respiratory acidosis reduced developed force in preparations from all groups, but the relationship between log tension and pH in the 4-week hypoxia group was less steep than in controls (4-week hypoxia 0.736 (0.057); control 0.947 (0.067); P < 0.01). In the 1-week hypoxia group however the relationship was steeper (1.243 (0.090); P < 0.01). HMA increased the slope in all groups, and under these conditions the control and 4-week hypoxia groups were not significantly different (control 1.134 (0.080); 4-week hypoxic 1.083 (0.087); P > 0.05). CONCLUSIONS: The increased resistance to respiratory acidosis of hypertrophied cardiac muscle following 4 weeks of hypoxia was abolished by HMA. This implies that it is related to increased activity of the Na(+)-H+ antiporter. The mechanism underlying the decreased resistance to acidosis following 1 week of hypoxia is unclear, but is unlikely to involve the Na(+)-H+ antiporter.

Single-dose etoposide in combination with vincristine and doxorubicin in the treatment of small-cell lung cancer (SCLC).

From July 1980, 104 consecutive patients with previously untreated small-cell lung cancer (SCLC) received vincristine 1.4 mg/m2, doxorubicin (Adriamycin) 40 mg/m2, and Etoposide (VePesid) 300 mg/m2 intravenously (as a single infusion) every 3 weeks. The overall response rate (complete response plus partial response) was 58%. In 47 patients with limited disease the response rate was 66% with 21/47 (45%) complete responders. Treatment was delivered on an outpatient basis. Toxicity was mild, and in 455 rapid infusions of etoposide, there have been no adverse reactions.