Evaluation of mild periorbital cellulitis and home-based therapy in children-EPOCH study: A prospective single centre cohort study.

BACKGROUND: Paediatric periorbital cellulitis is a common eye condition and warrants prompt management for the prevention of complications. International consensus on the approach to optimal management of children with mild periorbital cellulitis including ambulatory management is lacking. We aimed to prospectively investigate the safety and effectiveness of ambulatory management of children with mild periorbital cellulitis. METHODS: Over a 23-month period, we prospectively enrolled 70 children aged between 2 and 16 years who presented to the emergency department with mild periorbital cellulitis. Demographic and clinical data were collected. Eligible children were commenced on oral antibiotics and were discharged home with close outpatient ambulatory care and ophthalmology follow up. We used descriptive statistics for data presentation. RESULTS: Of the 70 children with mild periorbital cellulitis, 30 (43%) had unknown aetiology. Sixty-five (92%) children received a structured ambulatory follow up. Five children (7%) received inpatient parenteral antibiotics for worsening of local symptoms within 24 h of initial presentation. One child developed orbital cellulitis at follow up. There was no mortality or significant morbidity noted in this group and none of the children needed surgical intervention. CONCLUSIONS: Ambulatory care for children with mild periorbital cellulitis is an effective and safe management strategy. This might prevent hospitalisation, reduce the burden on hospital bed occupancy and promote patient care in the community.

Trial of life: Well infants presenting more than 24 h after head injury with a scalp haematoma: A 10-year review.

AIM: To review the investigation, patterns of injury and short-term outcomes of infants younger than 12 months of age who presented more than 24 h after head injury with an isolated scalp haematoma. METHODS: A retrospective chart review of infants who presented with a head injury to the emergency department of a major paediatric hospital between 2006 and 2016. Patients were included if they presented more than 24 h after the injury, were clinically well and had a documented scalp haematoma. Charts were abstracted using a standardised instrument to yield patient characteristics, mechanism of injury, imaging performed, identified injuries and patient outcome. RESULTS: A total of 2433 records were reviewed, with 157 included in the study. The mean age was 7.5 months (standard deviation 2.6). Of the patients, 14 had a documented palpable skull fracture; 43 patients had a skull X-ray reported as a fracture; 13 patients had cranial ultrasounds with 3 reported as having a fracture; 124 patients had computed tomography head imaging, with 112 demonstrating a fracture; and 52 patients had acute intracranial abnormalities. There were nine unplanned representations (5.7%). No patients required any neurosurgical intervention. CONCLUSIONS: Infants presenting after 24 h with isolated scalp haematomas had good short-term outcomes despite a high prevalence of underlying injury on imaging. Expectant management, rather than imaging, may be a valid approach in this patient population. However, some of these injuries may have been the result of inflicted injury, and all of these patients require a robust assessment regardless of the decision to use a computed tomography scan.

Bell's palsy in children: Current treatment patterns in Australia and New Zealand. A PREDICT study.

AIM: The aetiology and clinical course of Bell's palsy may be different in paediatric and adult patients. There is no randomised placebo controlled trial (RCT) to show effectiveness of prednisolone for Bell's palsy in children. The aim of the study was to assess current practice in paediatric Bell's palsy in Australia and New Zealand Emergency Departments (ED) and determine the feasibility of conducting a multicentre RCT within the Paediatric Research in Emergency Departments International Collaborative (PREDICT). METHODS: A retrospective analysis of ED medical records of children less than 18 years diagnosed with Bell's palsy between 1 January, 2012 and 31 December, 2013 was performed. Potential participants were identified from ED information systems using Bell's palsy related search terms. Repeat presentations during the same illness were excluded but relapses were not. Data on presentation, diagnosis and management were entered into an online data base (REDCap). RESULTS: Three hundred and twenty-three presentations were included from 14 PREDICT sites. Mean age at presentation was 9.0 (SD 5.0) years with 184 (57.0%) females. Most (238, 73.7%) presented to ED within 72 h of symptoms, 168 (52.0%) had seen a doctor prior. In ED, 218 (67.5%) were treated with steroids. Prednisolone was usually prescribed for 9 days at around 1 mg/kg/day, with tapering in 35.7%. CONCLUSION: Treatment of Bell's palsy in children presenting to Australasian EDs is varied. Prednisolone is commonly used in Australasian EDs, despite lack of high-level paediatric evidence. The study findings confirm the feasibility of an RCT of prednisolone for Bell's palsy in children.

Improving the quality of care for children with wheeze: The use of electronic asthma action plans and electronic pre-school wheeze action plans.

AIM: To measure the long-term improvement in the documented provision of an asthma action plan (AAP) to children with asthma and wheeze discharged from the Emergency Department following the introduction of the electronic AAP (eAAP) and to determine the need for an electronic pre-school wheeze action plan in our population. METHODS: A retrospective case note review, from July 2014 to June 2015, of all patients over 12 months old discharged from the Emergency Department or Emergency Medical Unit, with a discharge diagnosis of either asthma or wheeze. The primary outcome was the documentation of an AAP, either recorded electronically as an eAAP or a report of an AAP as part of the patient medical record. RESULTS: Two thousand three hundred and forty-two patients were included in the study, 926 with asthma and 1416 with wheeze. The median age was 3.3 years (interquartile range (IQR) 3.5, range 1-15.9 years). The median age of the children with asthma was 5.3 years (IQR 4.6) and of the children with wheeze was 2.5 years (IQR 2.0).Overall, 1683 (71.9%) children had a documented AAP, with a significant difference between those with a discharge diagnosis of asthma (85.9%) compared with wheeze (62.9%), P < 0.001. These results justified the design of the electronic pre-school wheeze action plan. CONCLUSIONS: The integration of an eAAP into the Emergency Department has resulted in a sustained improvement in the documented provision of an AAP to children with a discharge diagnosis of asthma. Children with a discharge diagnosis of wheeze are significantly less likely to receive an action plan.

Use of adrenaline to manage suspected anaphylaxis following COVID-19 vaccination: An Australian retrospective cohort study.

BACKGROUND: The rate of anaphylaxis following COVID-19 vaccinations is estimated to be 2-11 cases per million doses administered. However, adrenaline is occasionally used in individuals who are later diagnosed with immunisation stress-related responses, as their initial presenting signs and symptoms can appear similar to that of anaphylaxis. This study aims to describe the clinical profile of individuals who had received adrenaline following a COVID-19 vaccine and their subsequent revaccination outcomes. METHODS: We examined notifications of cases who had received adrenaline following a COVID-19 vaccine in New South Wales, Australia. The cases were classified into Brighton Collaboration Case Definition (BCCD) for anaphylaxis, their clinical presentation, management and subsequent revaccination outcomes were compared. RESULTS: From 22 February 2021 to 30 September 2021, there were 222 cases where adrenaline was administered. Of these, 32 (14 %) fulfilled Level 1 BCCD, 59 (27%) Level 2, 2 (1%) Level 3, 97 (44%) Level 4 and 32 (14 %) Level 5. The most commonly reported symptoms were sensation of throat closure (n = 116, 52%), difficulty breathing (n = 82, 37%) and nausea (n = 55, 25 %). Of the 176 (79%) individuals who proceeded to further vaccination, 89 (51%) received the same vaccine formulation and only 14 (8%) experienced another allergic adverse event with 9 (5%) receiving adrenaline. CONCLUSION: Less than one in five individuals who received adrenaline met Level 1 BCCD criteria for anaphylaxis. Many reactions that were treated with adrenaline had little to no diagnostic certainty of anaphylaxis and in such cases repeat vaccination had a high likelihood of being tolerated. Increased awareness and education on objective signs and symptoms of anaphylaxis is required to ensure appropriate use of adrenaline.

Exploring the use of virtual reality to manage distress in adolescent patients in emergency departments: A feasibility study.

OBJECTIVE: The present study aimed to explore the feasibility and potential benefits of deploying virtual reality (VR) for adolescents in the ED. METHODS: This multi-centre study was undertaken in paediatric and adult EDs in two university teaching hospitals. Twenty-six participants who had voluntarily attended the ED received the VR intervention. Pre- and post-measures assessing changes in state anxiety, stress and affect, and physical biomarkers were obtained. RESULTS: The use of VR intervention was associated with significant reductions in distress (Short State Stress Questionnaire - Distress Subscale; t = 4.55, P < 0.001) and negative affect (the International Positive and Negative Affect Scale - Short Form version; t = 4.99, P < 0.001). Most participants chose 'Netflix' as their content of choice. The technology was well received by the participants with subjective reports indicating that receiving VR intervention was 'insanely cool', 'takes you away from what's actually happening' and some participants felt 'privileged to get this experience in a hospital'. CONCLUSIONS: VR technology can effectively be used in EDs to assist adolescents and young adults better manage their distress and take steps towards activating more self-control mechanisms that will in turn allow for more meaningful engagements to be established with health clinicians. This technology has broad implications for reducing distress in adolescents in a variety of clinical contexts.

Factors predictive for computed tomography use and abnormality in paediatric head injuries in Australia and New Zealand.

OBJECTIVES: To investigate patient-level factors predictive for computed tomography of the brain (CTB) use and abnormality in head injured children in Australia and New Zealand. METHODS: Retrospective data from tertiary, urban/suburban and regional/rural EDs including factors predictive for CTB use and abnormality. RESULTS: Of 3072 children at 31 EDs, 212 (6.9%) had a CTB scan, of which 66 (31%) were abnormal. Increasing age, serious mechanisms of injury and decreasing Glasgow Coma Score were predictive for ordering CTB. Decreasing age was predictive for CTB abnormalities. Other factors were not. CONCLUSION: Patient-level drivers of CTB use in children in Australia and New Zealand are consistent with international data.

A complex mosaic of enteroviruses shapes community-acquired hand, foot and mouth disease transmission and evolution within a single hospital.

Human enteroviruses (EV) pose a major risk to public health. This is especially so in the Asia-Pacific region where increasing numbers of hand, foot and mouth disease (HFMD) cases and large outbreaks of severe neurological disease associated with EV-A71 have occurred. Despite their importance, key aspects of the emergence, epidemiology and evolution of EVs remain unclear, and most studies of EV evolution have focused on a limited number of genes. Here, we describe the genomic-scale evolution of EV-A viruses sampled from pediatric patients with mild disease attending a single hospital in western Sydney, Australia, over an 18-month period. This analysis revealed the presence of eight viral serotypes-Coxsackievirus (CV) A2, A4, A5, A6, A8, A10, A16 and EV-A71-with up to four different serotypes circulating in any 1 month. Despite an absence of large-scale outbreaks, high levels of geographical and temporal mixing of serotypes were identified. Phylogenetic analysis revealed that multiple strains of the same serotype were present in the community, and that this diversity was shaped by multiple introductions into the Sydney population, with only a single lineage of CV-A6 exhibiting in situ transmission over the entire study period. Genomic-scale analyses also revealed the presence of novel and historical EV recombinants. Notably, our analysis revealed no association between viral phylogeny, including serotype, and patient age, sex, nor disease severity (for uncomplicated disease). This study emphasizes the contribution of EV-A viruses other than EV-A71 to mild EV disease including HFMD in Australia and highlights the need for greater surveillance of these viruses to improve strategies for outbreak preparedness and vaccine design.