Application of the 2007 NICE guidelines in the management of paediatric minor head injuries in a UK emergency department.

BACKGROUND: The National Institute for Health and Clinical Excellence (NICE) published guidelines containing clear criteria for CT scanning of children with head injury in 2007. The aim of this study was to quantify the effects of adherence to these guidelines on the number of head scans requested. METHOD: A retrospective case note review was carried out of all patients under the age of 16 years presenting to the emergency department with head injury in 2007. The number of CT head scans actually performed was recorded, and the number that would have been requested using the hospital guidelines and the 2007 NICE guidelines was calculated. RESULTS: 25 (6.7%) of the 394 patients included in our study had head CT scans. 47 (12.7%) children would have been scanned had the hospital guidelines been rigidly followed and 74 (19.7%) children would have had head CT scans if the 2007 NICE guidelines had been adhered to. CONCLUSION: Considerably fewer children with head injury had CT scans in 2007 than would have been indicated by the hospital guidelines or 2007 NICE guidelines.

Things that go bump ... bump ... bump: an analysis of injuries from falling down stairs in children based at Sheffield Children's Hospital.

BACKGROUND: Falls down stairs are a common presentation to the paediatric emergency department. The pattern of injury associated with this mechanism of injury has not been described for the UK population. A retrospective analysis of attendances to the Emergency Department of Sheffield Children's Hospital was carried out. RESULTS: Overall 90% (216/239) of patients sustained one or more injuries; 69% (165/239) sustained minor head and facial injuries; 12% (29/239) sustained minor soft tissue injuries of other regions; 10% (23/239) had limb fractures, of which 60% (14/23) were of the upper limb (nine clavicle fractures, one supracondylar fracture of the elbow and four wrist fractures) and 40% (9/23) were of the lower limb (four femoral fractures and five tibial fractures). Two per cent (5/239) had skull fractures (all were in the group of children dropped while being carried on the stairs). Injuries to more than one body part occurred in only 3% (8/239) of cases. DISCUSSION: The results suggest that children who fall down the stairs are mainly toddlers and in general sustain only minor injuries, the commonest being a minor head injury. Severe truncal and extremity injuries or injuries involving multiple body regions should provoke further questioning looking for evidence of non-accidental injury. There is no correlation between the number of stairs fallen down and the likelihood or severity of injury. CONCLUSION: Infants who fall down stairs with their carer or are dropped while being carried down stairs require an especially close evaluation.

A change in practice from epidural to intrathecal morphine analgesia for hepato-pancreato-biliary surgery.

BACKGROUND: This study was designed to audit the change of anesthetic practice from thoracic epidural analgesia (TEA) to intrathecal morphine (ITM) combined with patient-controlled analgesia (PCA) for hepato-pancreato-biliary (HPB) surgery. METHODS: All patients who underwent major HPB surgery and received TEA or ITM from March 2005 to March 2008 were identified. Patients who received PCA alone were used for comparison. Data were retrospectively collected and analyzed for success of TEA, perioperative intravenous fluid (IVF) volume administered, hypotension, complications, and hospital stay. RESULTS: During the study period, 51 (32%) patients received TEA, 79 (49%) received ITM plus PCA opiate, and 31 (19%) received PCA alone. The incidence of postoperative hypotension was significantly higher in those who received TEA compared with those who received ITM (21/51 (41%) vs. 7/79 (9%), P < 0.001). The median (range) perioperative IVF administration was higher in the TEA group compared with the ITM group for both the first 24 h (6 (3-11) liters vs. 5 (3-11) liters, P < 0.05) and in total (15.5 (5-48.5) liters vs. 9 (3-70) liters, P < 0.001). Respiratory complications occurred in five (10%) of the TEA group compared with one (1%) in the ITM group (P < 0.05). The median (range) hospital stay was longer in the TEA group compared with the ITM group (9 (3-36) days vs. 7 (3-55) days, P < 0.01). CONCLUSIONS: In a resource-limited setting, ITM, compared with TEA, is associated with a reduced incidence of postoperative hypotension, reduced IVF requirements, shorter hospital stay, and lowers the incidence of respiratory complication.

Limited role for SREBP-1c in defective glucose-induced insulin secretion from Zucker diabetic fatty rat islets: a functional and gene profiling analysis.

Accumulation of intracellular lipid may contribute to defective insulin secretion in type 2 diabetes. Although Zucker diabetic fatty (ZDF; fa/fa) rat islets are fat-laden and overexpress the lipogenic master gene, sterol regulatory element binding protein 1c (SREBP-1c), the contribution of SREBP-1c to the secretory defects observed in this model remains unclear. Here we compare the gene expression profile of lean control (fa/+) and ZDF rat islets in the absence or presence of dominant-negative SREBP-1c (SREBP-1c DN). ZDF islets displayed elevated basal insulin secretion at 3 mmol/l glucose but a severely depressed response to 17 mmol/l glucose. While SREBP-1c DN reduced basal insulin secretion from ZDF islets, glucose-stimulated insulin secretion was not improved. Of 57 genes differentially regulated in ZDF islets and implicated in glucose metabolism, vesicle trafficking, ion fluxes, and/or exocytosis, 21 were upregulated and 5 were suppressed by SREBP-1c DN. Genes underrepresented in ZDF islets were either unaffected (Glut-2, Kir6.2, Rab3), stimulated (voltage-dependent Ca(2+) channel subunit alpha1D, CPT2, SUR2, rab9, syt13), or inhibited (syntaxin 7, secretogranin-2) by SREBP-1c inhibition. Correspondingly, SREBP-1c DN largely corrected decreases in the expression of the transcription factors Pdx-1 and MafA but did not affect the abnormalities in Pax6, Arx, hepatic nuclear factor-1alpha (HNF1alpha), HNF3beta/Forkhead box-a2 (Foxa2), inducible cyclic AMP early repressor (ICER), or transcription factor 7-like 2 (TCF7L2) expression observed in ZDF islets. We conclude that upregulation of SREBP-1c and mild increases in triglyceride content do not explain defective glucose-stimulated insulin secretion from ZDF rats. However, overexpression of SREBP-1c may contribute to enhanced basal insulin secretion in this model.