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.

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.

Linkages between soil carbon, soil fertility and nitrogen fixation in Acacia senegal plantations of varying age in Sudan.

BACKGROUND: Over the last decades sub-Saharan Africa has experienced severe land degradation and food security challenges linked to loss of soil fertility and soil organic matter (SOM), recurrent drought and increasing population. Although primary production in drylands is strictly limited by water availability, nutrient deficiencies, particularly of nitrogen (N) and phosphorus (P), are also considered limiting factors for plant growth. It is known that SOM (often measured as soil organic carbon (SOC)) is a key indicator of soil fertility, therefore, management practices that increase SOM contents, such as increasing tree cover, can be expected to improve soil fertility. The objectives of this study were to investigate the effect of Acacia senegal (Senegalia senegal) trees on soil nitrogen, phosphorus and potassium (K) in relation to SOC, the potential of A. senegal for N2 fixation, and to identify possible N and P ecosystem limitations. METHODS: Soil nutrient (total N, P, K and available P and exchangeable K) concentrations and stocks were determined for the 0-10, 10-20,20-30 and 30-50 cm layers of A. senegal plantations of varying age (ranging from 7 to 24-years-old) and adjacent grasslands (reference) at two sites in semi-arid areas of Sudan. At both sites, three plots were established in each grassland and plantation. The potential of A. senegal for N2 fixation in relation to plantations age was assessed using δ15N isotopic abundances and nutrient limitations assessed using C:N:P stoichiometry. RESULTS: Soil concentrations of all studied nutrients were relatively low but were significantly and directly correlated to SOC concentrations. SOC and nutrient concentrations were the highest in the topsoil (0-10 cm) and increased with plantations age. Acacia foliage δ15N values were >6‰ and varied little with plantations age. Soil C:N and C:P ratios did not differ between grassland and plantations and only 0-10 cm layer N:P ratios showed significant differences between grassland and plantations. DISCUSSION: The results indicated that soil fertility in the Sahel region is strongly related to SOM contents and therefore highlighting the importance of trees in the landscape. The higher mineral nutrient concentrations in the topsoil of the plantations may be an indication of 'nutrient uplift' by the deeper roots. The high foliar δ15N values indicated that N2 fixation was not an important contributor to soil N contents in the plantations. The accretion of soil N cannot be explained by deposition but may be related to inputs of excreted N brought into the area annually by grazing and browsing animals. The soil C:N:P stoichiometry indicated that the plantations may be limited by P and the grasslands limited by N.

The location of Australian Buruli ulcer lesions-Implications for unravelling disease transmission.

BACKGROUND: Buruli ulcer (BU), caused by Mycobacterium ulcerans, is increasing in incidence in Victoria, Australia. To improve understanding of disease transmission, we aimed to map the location of BU lesions on the human body. METHODS: Using notification data and clinical records review, we conducted a retrospective observational study of patients diagnosed with BU in Victoria from 1998-2015. We created electronic density maps of lesion locations using spatial analysis software and compared lesion distribution by age, gender, presence of multiple lesions and month of infection. FINDINGS: We examined 579 patients with 649 lesions; 32 (5.5%) patients had multiple lesions. Lesions were predominantly located on lower (70.0%) and upper (27.1%) limbs, and showed a non-random distribution with strong predilection for the ankles, elbows and calves. When stratified by gender, upper limb lesions were more common (OR 1·97, 95% CI 1·38-2·82, p<0·001) while lower limb lesions were less common in men than in women (OR 0·48, 95% CI 0·34-0·68, p<0·001). Patients aged ≥ 65 years (OR 3·13, 95% CI 1·52-6·43, p = 0·001) and those with a lesion on the ankle (OR 2·49, 95% CI 1·14-5·43, p = 0·02) were more likely to have multiple lesions. Most infections (71.3%) were likely acquired in the warmer 6 months of the year. INTERPRETATION: Comparison with published work in Cameroon, Africa, showed similar lesion distribution and suggests the mode of M. ulcerans transmission may be the same across the globe. Our findings also aid clinical diagnosis and provide quantitative background information for further research investigating disease transmission.

Antibiotic duration and timing of the switch from intravenous to oral route for bacterial infections in children: systematic review and guidelines.

Few studies are available to inform duration of intravenous antibiotics for children and when it is safe and appropriate to switch to oral antibiotics. We have systematically reviewed antibiotic duration and timing of intravenous to oral switch for 36 paediatric infectious diseases and developed evidence-graded recommendations on the basis of the review, guidelines, and expert consensus. We searched databases and obtained information from references identified and relevant guidelines. All eligible studies were assessed for quality. 4090 articles were identified and 170 studies were included. Evidence relating antibiotic duration to outcomes in children for some infections was supported by meta-analyses or randomised controlled trials; in other infections data were from retrospective series only. Criteria for intravenous to oral switch commonly included defervescence and clinical improvement with or without improvement in laboratory markers. Evidence suggests that intravenous to oral switch can occur earlier than previously recommended for some infections. We have synthesised recommendations for antibiotic duration and intravenous to oral switch to support clinical decision making and prospective research.

Diagnostic Yield of Timing Blood Culture Collection Relative to Fever.

BACKGROUND: Conventional practice involves obtaining a blood culture during or immediately after a fever to increase diagnostic yield. There are no data to support this practice in children. METHODS: Retrospective single-center case-control study of children (0-18 years) who had blood cultures performed as part of routine care. Cases had an a priori defined pathogen isolated from blood culture (n = 410) and were age-matched with contemporaneous controls with a sterile blood culture (n = 410). The predictive value of fever (before and after blood culture), C-reactive protein and hematologic indices were analyzed by multivariate regression and area under the receiver operating characteristic curves (AUCs) in neonatal, general pediatric and pediatric oncology patients. RESULTS: One thousand one hundred seventy-two (6.7%) of 17,607 blood cultures were positive, of which 410 (35%) cultured pathogen(s). Three hundred and twenty four (79%) cases and 275 (67.1%) controls had a fever (≥37.5°C) during the 12 hours pre- or post-collection. Fever 2-6 hours before a blood culture was neither sensitive nor specific for predicting bacteremia in neonatal or pediatric patients and marginally predictive in oncology patients (AUC 0.59-0.63). Cultures obtained 2-6 hours before fever were nonpredictive in neonates (AUC 0.56-0.59), marginally predictive in pediatric patients (AUC 0.64-0.67) and moderately predictive in oncology patients (AUC 0.70). C-reactive protein was marginally predictive in neonates (AUC 0.60). Hematologic indices were nonpredictive in all groups. CONCLUSIONS: Fever before obtaining blood culture was neither sensitive nor specific for culture positivity; timing of pediatric blood cultures relative to fever is unimportant. Bacteremia precedes a fever, but this is of limited clinical applicability.

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.

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.

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.

Determination of low methylmercury concentrations in peat soil samples by isotope dilution GC-ICP-MS using distillation and solvent extraction methods.

Most often, only total mercury concentrations in soil samples are determined in environmental studies. However, the determination of extremely toxic methylmercury (MeHg) in addition to the total mercury is critical to understand the biogeochemistry of mercury in the environment. In this study, N2-assisted distillation and acidic KBr/CuSO4 solvent extraction methods were applied to isolate MeHg from wet peat soil samples collected from boreal forest catchments. Determination of MeHg was performed using a purge and trap GC-ICP-MS technique with a species-specific isotope dilution quantification. Distillation is known to be more prone to artificial MeHg formation compared to solvent extraction which may result in the erroneous MeHg results, especially with samples containing high amounts of inorganic mercury. However, methylation of inorganic mercury during the distillation step had no effect on the reliability of the final MeHg results when natural peat soil samples were distilled. MeHg concentrations determined in peat soil samples after distillation were compared to those determined after the solvent extraction method. MeHg concentrations in peat soil samples varied from 0.8 to 18 µg kg(-1) (dry weight) and the results obtained with the two different methods did not differ significantly (p=0.05). The distillation method with an isotope dilution GC-ICP-MS was shown to be a reliable method for the determination of low MeHg concentrations in unpolluted soil samples. Furthermore, the distillation method is solvent-free and less time-consuming and labor-intensive when compared to the solvent extraction method.

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.

Formal infectious diseases consultations at a tertiary pediatric hospital: a 14-year review.

We analyzed the formal consultations seen by the infectious diseases service over a 14-year period at one of the largest pediatric hospitals in Australia. We highlight the increasing demand for pediatric infectious diseases expertise and the reasons for which consultations are sought. Our findings will help in planning and resource allocation in an era of increasingly complex patients.