START CARE: a protocol for a randomised controlled trial of step-wise budesonide-formoterol reliever-based treatment in children.

Background: Asthma is the most common chronic childhood respiratory condition globally. Inhaled corticosteroid (ICS)-formoterol reliever-based regimens reduce the risk of asthma exacerbations compared with conventional short-acting ß2-agonist (SABA) reliever-based regimens in adults and adolescents. The current limited evidence for anti-inflammatory reliever therapy in children means it is unknown whether these findings are also applicable to children. High-quality randomised controlled trials (RCTs) are needed. Objective: The study aim is to determine the efficacy and safety of budesonide-formoterol reliever alone or maintenance and reliever therapy (MART) compared with standard therapy: budesonide or budesonide-formoterol maintenance, both with terbutaline reliever, in children aged 5 to 11 years with mild, moderate and severe asthma. Methods: A 52-week, multicentre, open-label, parallel group, phase III, two-sided superiority RCT will recruit 400 children aged 5 to 11 years with asthma. Participants will be randomised 1:1 to either budesonide-formoterol 100/6 µg Turbuhaler reliever alone or MART; or budesonide or budesonide-formoterol Turbuhaler maintenance, with terbutaline Turbuhaler reliever. The primary outcome is moderate and severe asthma exacerbations as rate per participant per year. Secondary outcomes are asthma control, lung function, exhaled nitric oxide and treatment step change. Assessment of Turbuhaler technique and cost-effectiveness analysis are also planned. Conclusion: This will be the first RCT to compare the efficacy and safety of a step-wise budesonide-formoterol reliever alone or MART regimen with conventional inhaled ICS or ICS-long-acting ß-agonist maintenance plus SABA reliever in children. The results will provide a much-needed evidence base for the treatment of asthma in children.

A Low Impact Approach to Infected Pancreatic Necrosis: Review of a Case Series.

BACKGROUND: Infected pancreatic necrosis develops in approximately one third of patients with necrotizing pancreatitis and can lead to significant morbidity and mortality rates. Historically, open necrosectomy has been the mainstay of management for these patients but is in itself a morbid procedure. In recent times, minimally invasive techniques have evolved to allow a less invasive approach to these patients. Percutaneous catheter drainage of infected pancreatic necrosis is a technique that has been demonstrated to be potentially useful in the treatment of this group of patients. PATIENTS AND METHODS: The aim of this study was to review outcomes and define the technique of percutaneous catheter drainage in patients with infected pancreatic necrosis. All patients with infected pancreatic necrosis were exclusively treated with percutaneous drainage over the study period. Acute Physiology and Chronic Health Evaluation (APACHE) II score, number and size of drains, drainage technique and drain management, hospital and intensive care unit (ICU) stay, nutritional requirements, and morbidity and mortality data were evaluated for the patient group. Computed tomography (CT) scans were used to assess the progression of the disease process and the effectiveness of the treatment. RESULTS: There were nine patients with infected pancreatic necrosis in this case series between 2007 and 2012, all of whom were treated with percutaneous catheter drainage alone. The median APACHE II score in the patient group was 11, with a median stay in the ICU of 3 d and median hospital stay of 41 d. On average, nine CT scans were performed per patient during the hospital admission. A median of three drains were inserted per patient, and in the course of the study, it was evident that the larger drain size was the most effective. In eight of the nine patients in the group, complications developed that were both directly and indirectly related to the pancreatitis, but were effectively managed. There were no deaths. CONCLUSION: Percutaneous catheter drainage as a stand-alone intervention is an alternative strategy for infected pancreatic necrosis and can be used with acceptable morbidity and mortality rates in this challenging group of patients.

Respiratory hygiene practices by the public during the 2009 influenza pandemic: an observational study.

AIMS: To describe the public use of respiratory hygiene behaviours during the 2009 influenza pandemic and to test the feasibility of an observational method. METHODS: Respiratory behaviour was systematically observed at three public settings during August 2009 in the capital city of New Zealand (Wellington). Data on each coughing or sneezing event were collected. RESULTS: A total of 384 respiratory events were observed, at a rate of 0·8 cough/sneeze per observed-person-hour. Around a quarter of respiratory events (27·3%) were uncovered, and there was infrequent use of the responses recommended by health authorities (i.e., covering with a tissue or handkerchief at 3·4% and covering with elbow or arm at 1·3%). Respiratory event rates were higher in all settings that were 'high flow' (for people movement) compared to 'low flow' settings. Uncovered events were more common among people at the hospital entrance versus the hospital café [risk ratio (RR) = 7·8, 95% confidence interval (CI): 1·1-52·6] and when a person was located within 1 m of others (RR = 1·5, 95% CI: 1·1-1·9). Observing respiratory hygiene was found to be feasible in all of the selected public locations. There was good agreement between observing pairs about whether or not respiratory events occurred (inter-observer correlation = 0·81) and for uncovered versus covered events (total Cohen's kappa score = 0·70). CONCLUSIONS: It was feasible to document respiratory hygiene behaviour in public urban settings during a influenza pandemic. Respiratory hygiene advice was not being adequately followed by this population towards the end of the first wave of the pandemic.

Outcomes from out-of-hospital cardiac arrest in the Wellington region of New Zealand. Does use of the Fire Service make a difference?

AIMS: Survival from community cardiac arrest in the Wellington region was analysed and compared with similar data reported nationally and internationally. In particular, the impact of a dual fire and ambulance service response was studied. METHOD: A retrospective comparative study was undertaken of out-of-hospital cardiac arrests in the Wellington region between 1 July 2007 and 31 December 2009. Data was collected from Wellington Free Ambulance and hospital records in accordance with the Utstein template. The New Zealand Fire Service provided details of firefighter attendance and timings. The primary outcome measure was survival to hospital discharge. RESULTS: Overall survival to hospital discharge was 11% (37/339) whilst survival from initial ventricular fibrillation or tachycardia (VF/VT) was 21% (34/161). Initial VF/VT was more common in witnessed than unwitnessed arrests (57% v. 35%, p=0.001) and this mirrored survival in these groups (15% vs 6%, p=0.01). Survival to hospital discharge was also associated with younger age and shorter emergency service response time. Bystanders attempted CPR in 55% and the fire service in 50% but neither intervention influenced outcome. Although, when activated, the fire service arrived on average 1-2 minutes ahead of the ambulance, the dual response did not influence survival to hospital admission or discharge. CONCLUSION: Survival from out-of-hospital cardiac arrest in Wellington is similar to that of other New Zealand cities and better than that reported from several large centres overseas. The combined fire and ambulance response was not shown to have any beneficial impact on survival over and above that achieved by the ambulance service alone. System changes are proposed to try and improve survival from community cardiac arrest in Wellington.