Teachers' perspectives on the barriers to healthy lifestyle behaviors among adolescent girls of disadvantaged backgrounds in Ireland: A qualitative study.

Though adolescence is a particularly sensitive period regarding the development of long-lasting health-related attitudes and behaviors, little research has examined the factors which influence their engagement in such behaviors. Adolescent females are particularly sensitive to suffer from overweight and obesity. It is also a time that can impact the health patterns of future generations due to the influence of preconception maternal factors on the health of their offspring. Furthermore, much research has identified a strong socioeconomic gradient in obesity in Ireland, with individuals from low socioeconomic backgrounds being particularly likely to develop unhealthy habits. The current study aimed to develop an understanding of the factors which influence the health-related behaviors of adolescent girls of low-socioeconomic status in Ireland, an underrepresented yet particularly sensitive cohort. Semi-structured interviews were conducted with nine teachers from disadvantaged schools in Dublin and were examined using a thematic analytic approach. Nine themes were identified: lack of interest and knowledge, lack of self-confidence, the dual role of modern technology, behaviors of significant others, need for good role models, availability of convenience foods, inadequate existing approaches and initiatives, lack of resources to promote a healthy lifestyle, and living difficulties at home and in the community. Findings suggested ways for intervening at personal, interpersonal, organizational and community levels. In conclusion, a range of practical changes are required in the home, school, and community environments in order to improve the health of these individuals, and ultimately to improve the health of future generations.

Delayed Infant Subaponeurotic (Subgaleal) Fluid Collections: A Case Series of 11 Infants.

BACKGROUND: Although subgaleal hemorrhage can present very soon after delivery with catastrophic consequences, subaponeurotic or subgaleal fluid collections are rare and clinically distinct causes of infant scalp swelling that present weeks to months after birth. Their exact etiology remains uncertain; however, they are frequently associated with instrumental and traumatic delivery. AIM & METHODS: To characterize 11 subaponeurotic fluid collections that presented to the Temple Street Children's University Hospital Emergency Department (TSCUHED) from July 2013 to July 2015 by a retrospective chart review. CASE REPORT: Eleven infants were identified with delayed subaponeurotic fluid collections. Of note, all infants were either successful vacuum delivery or failed vacuum delivery with subsequent forceps delivery or emergency caesarean section. All infants were otherwise well at presentation, and resolution of the scalp swelling occurred within weeks to months. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This condition follows a benign course and conservative management is the treatment of choice.

An Evaluation of the Accuracy and Necessity of Fracture Clinic Referrals in a Busy Pediatric Emergency Department.

OBJECTIVES: Injuries account for approximately 18% of all pediatric emergency department presentations. Of these, a significant amount will have fractures that will require orthopedic management usually in the orthopedic fracture clinic. Our aim was to assess the accuracy and necessity of fracture clinic referrals from our emergency department and to suggest an approach that might safely reduce the referral numbers. METHODS: All fracture clinic referrals from Temple Street Emergency Department in August 2013 were retrospectively audited. RESULTS: There were 339 fracture clinic referrals in August 2013. Of these, 213 (63%) had fractures as reported by a consultant radiologist. One hundred twenty-six (37%) had no fracture confirmed, and of these, 24 (19%) had no fracture seen in the emergency department but were referred as clinically fractured. Thirty-three (10%) of the 339 were buckle fractures of the wrist. There were 21 (6.2%) finger injuries referred. Of ankle injuries referred to fracture clinic (n = 43), 14 (33%) were confirmed Salter-Harris 1 or 2 or avulsion fractures of the lateral malleolus and 16 (37%) were suspected Salter-Harris 1 or 2 fractures of the lateral malleolus. CONCLUSIONS: Through education and policy change such as the establishment of an Advanced Nurse Practioner (ANP)-led clinic or a virtual clinic within our emergency department, we could safely and efficiently reduce orthopedic fracture clinic referrals by more than 30%.

Evaluation of Safety and Cost-Effectiveness of the Low Risk Ankle Rule in One of Europe's Busiest Pediatric Emergency Departments.

OBJECTIVES: Low Risk Ankle Rule (LRAR) has 100% sensitivity for identifying clinically important pediatric ankle fractures (high-risk injuries) and has the potential to safely reduce imaging by approximately 60%. This study investigates the safety and cost-effectiveness of this rule in our institution. METHODS: All patients triaged during July and August 2013 with an "ankle injury" had a retrospective clinical notes and radiology report review. Data were recorded using Excel and tests of significance, χ test. RESULTS: One hundred twenty-one patients were included. Of these, 65 were female and 56 were male (no significant difference in sex, P = 0.41). Mean age was 9.95 years. Seventy-eight (64%) had LRAR positive examinations. Of these, 77 (98.7%) had an x-ray and 12 (15%) had fractures. Of those with fractures, none had high-risk injuries.Eighteen (100%) of the doctors in our ED felt that a clinical decision rule would be of use within the department. Only 8 (44%) had heard of the LRAR, and of these, only 4 (50%) would be confident to implement the LRAR. Forty-four (88%) of parents felt that an x-ray is required in the diagnosis of ankle injuries in children, and 41 (82%) would want to know whether their child had an ankle sprain or a low-risk fracture even if the management was not different. CONCLUSIONS: By implementing the LRAR in our institution, we could reduce ankle x-rays by 64%. This would offer a significant reduction in radiation exposure to a radiosensitive population. Estimated costs of an ankle x-ray and interpretation are Euro 47 ($65), thus with more than 800 carried out per year in The Children's University Hospital, a potential annual saving is Euro 25,000 ($34,500).

Medium term outcome in Bell's palsy in children.

OBJECTIVE: Bell's palsy is a non-life threatening disorder with important functional and psychosocial effects. While recent research has shown significant benefit from treatment with steroids in adults, there have been no conclusive studies demonstrating benefit in children. This study set out to explore the medium term resolution of symptoms in Bell's palsy presenting to the emergency department (ED). PATIENTS AND METHODS: This was a retrospective cohort study of children attending an Irish paediatric ED with a diagnosis of Bell's palsy. Patients were identified via the ED database. The primary outcome measure was resolution at follow-up call (6-18 months after presentation). Secondary outcome measures were ED treatment, imaging and time to resolution of symptoms. RESULTS: There were 48 presentations, involving 45 patients. Left and right-sided palsies were equally represented. Of these, 16 (33%) received prednisolone. MRI was performed in five cases (10%), four were normal and one did not change management. In follow-up telephone contact, of 35 presentations, 28 (80%, 95% CI 63% to 91%) had complete resolution, six (17%, 95% CI 7% to 34%) partial resolution to variable degrees and one patient showed no improvement. Of the 13 patients who had received prednisolone, nine (69%, 95% CI 39% to 91%) had complete resolution; of the 22 patients who were not treated with prednisolone 19 (86%, 95% CI 65% to 97%) had complete resolution (p=0.22). CONCLUSIONS: The majority of children with Bell's palsy have complete resolution of the facial weakness. Steroid use is highly variable and warrants a placebo controlled randomised trial.

Qualitative analysis of the cognitive triad in a sample of the general population in response to the COVID-19 pandemic.

This paper explored cognitive responses to the COVID-19 pandemic in those selfreporting depressive symptoms during a period of realistic health, economic and social threat. Negative cognitions are a key therapy target for evidence-based psychological interventions. A cross-sectional survey was conducted with a convenience sample from the general population between December 2020 and February 2021. Adult respondents (n = 555) completed open text-box questions which provided prompts of the cognitive triad: "I am…/I am not…"; "Other people are…/Other people are not…"; "The world is…". These qualitative data were analysed using reflexive thematic analysis. Thematic responses were compared between people who self-reported moderate depressive symptoms (n = 223) and those who did not (n = 332). Fourteen independent themes were identified. Those self-reporting depressive symptoms described significantly fewer positive cognitions across all three aspects of the cognitive triad, X2 = 60.40 p < 0.01;  X2 = 10.51 p < 0.05; X2 = 12.22 p < 0.01. Those self-reporting depressive symptoms also reported more self-referent negative cognitions. These data highlighted that an absence of positive cognitions differentiated the two groups more greatly than negative cognitions. These data have implications for the cognitive targets in psychological therapies in realistic high-stress situations. This paper explored cognitive responses to the COVID-19 pandemic in those selfreporting depressive symptoms during a period of realistic health, economic and social threat. Negative cognitions are a key therapy target for evidence-based psychological interventions. A cross-sectional survey was conducted with a convenience sample from the general population between December 2020 and February 2021. Adult respondents (n = 555) completed open text-box questions which provided prompts of the cognitive triad: "I am…/I am not…"; "Other people are…/Other people are not…"; "The world is…". These qualitative data were analysed using reflexive thematic analysis. Thematic responses were compared between people who self-reported moderate depressive symptoms (n = 223) and those who did not (n = 332). Fourteen independent themes were identified. Those self-reporting depressive symptoms described significantly fewer positive cognitions across all three aspects of the cognitive triad, X2 = 60.40 p < 0.01;  X2 = 10.51 p < 0.05; X2 = 12.22 p < 0.01. Those self-reporting depressive symptoms also reported more self-referent negative cognitions. These data highlighted that an absence of positive cognitions differentiated the two groups more greatly than negative cognitions. These data have implications for the cognitive targets in psychological therapies in realistic high-stress situations.

National rotavirus vaccination programme implementation and gastroenteritis presentations: the paediatric emergency medicine perspective.

BACKGROUND: Throughout the developed world, the introduction of rotavirus vaccination has led to reductions in the incidence and severity of acute gastroenteritis (AGE) in young children and consequently to reductions in paediatric emergency department (PED) attendances with AGE. Rotavirus vaccination was added to the Irish National Immunisation Schedule in November 2016. AIMS: To assess the impact of vaccine introduction on citywide PED attendances and hospital admissions with all-cause AGE during rotavirus season. METHODS: In an observational study, a retrospective search was performed of electronic records in three independent PEDs in Dublin. Weekly presentations and admissions with AGE in the first 30 weeks (gastroenteritis season) of the years 2012-2018 were counted and stratified by age. RESULTS: Median weekly presentations in 2017-2018, 126 (interquartile range (IQR) 103-165) were significantly lower than in 2012-2016, 160 (IQR 128-214) (p < 0.001). A reduction in presentations was seen across the three hospitals and in those aged less than 5 years. In one PED, median admissions in 2017-2018 were 10 (IQR 7-13) in comparison with nine (IQR 7-13) in 2012-2016, (p = 0.463). The emergency department AGE presentations to hospital ward admission rate was 6.7:1. CONCLUSION: A reduction in PED presentations with AGE is demonstrated post-rotavirus vaccine introduction into the Irish National Immunisation Schedule. No significant change in paediatric hospital admissions was demonstrated.

An audit of discharge summaries from secondary to primary care.

BACKGROUND: Health is information-intensive. Reliable health care depends on access to this information in a timely and accurate manner. A standardised data set for clinical discharge summaries is essential to optimise the care the patient receives, particularly at discharge. The Irish Health Information and Quality Authority (HIQA) have recently developed a national standard for patient discharge summaries. AIMS: Our aim was to assess the current quality of discharge summaries being received, determine the main areas of concern and establish the areas to improve patient safety. METHODS: We studied 60 discharge summaries received at 3 general practices in the Mid-West of Ireland. We used HIQA "National Standard for Patient Discharge Summary" 2013 as our audit standard. RESULTS: Mandatory fields including Surname, Forename and date of birth were present in 100%, missing in 0%. The patient's address was missing in 7% (n = 4). Gender was missing in 82% (n = 50). Source of referral was missing in 52% (n = 32). No method of admission was documented in 70% (n = 43). Whilst principal diagnosis was documented in 100% (n = 60), no co-morbidities were documented in 28% (n = 17). No medication was documented in 30% (n = 18), and there was no documentation of medication changed in 39% (n = 24). Details of the person completing the discharge summary were incomplete as follows: 85% (n = 52) had no specialty documentation, 36% (n = 22) had no registration number and 38% (n = 23) had no contact number. CONCLUSIONS: This audit shows deficits in adhering to HIQA standards. These must be addressed as a matter of urgency.

'Start smart': using front-line ownership to improve the quality of empiric antibiotic prescribing in a paediatric hospital.

Infection is the most frequent indication for non-scheduled admission to paediatric hospitals, leading to high levels of empiric antibiotic prescribing. Antibiotic prescribing in line with local guidelines, improves patient outcomes, reduces adverse drug events and helps to reduce the emergence of antimicrobial resistance. We undertook an improvement project at Temple Street Children's University Hospital targeting documentation of indication and compliance with empiric antibiotic prescribing guidelines among medical admissions via the emergency department (ED). Results of weekly audits of empiric antibiotic prescribing were fed back to prescribers. Front-line ownership techniques were used to empower prescribers to generate ideas for change, such as regular discussion of antibiotic prescribing issues at weekly clinical meetings, antibiotic 'spot quiz', updates to prescribing guidelines, improved access and promotion of a prescribing app, laminated guideline summary cards, and reminders and guideline summaries at a point of prescribing in ED. Documentation of indication and guideline compliance increased from a median of 30% in December 2014 to 100% in March 2015, and was sustained at 100% to September 2016, then 90% to December 2017. The intervention was associated with improvements in non-targeted indicators of prescribing quality, an overall reduction in antimicrobial consumption in the hospital, and a €105 000 reduction in annual antimicrobial acquisition costs. We found that a simple, paper-based, data collection system was effective, provided opportunities for a point-of-care interaction with prescribers, and facilitated weekly data feedback. We also found that using a pre-existing weekly clinical meeting to foster prescriber ownership of the data, allowing prescribers to identify possible tests of change, and exploiting the competitive nature of doctors, led to a rapid and sustained improvement in prescribing quality. Awareness of local prescribing processes and culture are essential to delivering improvements in antimicrobial stewardship.

The role of real-time PCR testing in the investigation of paediatric patients with community-onset osteomyelitis and septic arthritis.

BACKGROUND: Culture yield in osteomyelitis and septic arthritis is low, emphasising the role for molecular techniques. AIMS: The purpose of this study was to review the laboratory investigation of childhood osteomyelitis and septic arthritis. METHODS: A retrospective review was undertaken in an acute tertiary referral paediatric hospital from January 2010 to December 2016. Cases were only included if they had a positive culture or bacterial PCR result from a bone/joint specimen or blood culture, or had radiographic evidence of osteomyelitis. RESULTS: Seventy-eight patients met the case definition; 52 (66%) were male. The median age was 4.8 years. Blood cultures were positive in 16 of 56 cases (29%), with 11 deemed clinically significant (Staphylococcus aureus = 8, group A Streptococcus = 3). Thirty-seven of 78 (47%) bone/joint samples were positive by culture with S. aureus (n = 16), coagulase-negative Staphylococcus (n = 9) and group A Streptococcus (n = 4), being the most common organisms. Sixteen culture-negative samples were sent for bacterial PCR, and four were positive (Kingella kingae = 2, Streptococcus pneumoniae = 1, group A Streptococcus = 1). CONCLUSIONS: Sequential culture and PCR testing can improve the detection rate of causative organisms in paediatric bone and joint infections, particularly for fastidious microorganisms such as K. kingae. PCR testing can be reserved for cases where culture is negative after 48 h. These results have been used to develop a standardised diagnostic test panel for bone and joint infections at our institution.