What impact did a Paediatric Early Warning system have on emergency admissions to the paediatric intensive care unit? An observational cohort study.

UNLABELLED: The ideology underpinning Paediatric Early Warning systems (PEWs) is that earlier recognition of deteriorating in-patients would improve clinical outcomes. OBJECTIVE: To explore how the introduction of PEWs at a tertiary children's hospital affects emergency admissions to the Paediatric Intensive Care Unit (PICU) and the impact on service delivery. To compare 'in-house' emergency admissions to PICU with 'external' admissions transferred from District General Hospitals (without PEWs). METHOD: A before-and-after observational study August 2005-July 2006 (pre), August 2006-July 2007 (post) implementation of PEWs at the tertiary children's hospital. RESULTS: The median Paediatric Index of Mortality (PIM2) reduced; 0.44 vs 0.60 (p<0.001). Fewer admissions required invasive ventilation 62.7% vs 75.2% (p=0.015) for a shorter median duration; four to two days. The median length of PICU stay reduced; five to three days (p=0.002). There was a non-significant reduction in mortality (p=0.47). There was no comparable improvement in outcome seen in external emergency admissions to PICU. A 39% reduction in emergency admission total beds days reduced cancellation of major elective surgical cases and refusal of external PICU referrals. CONCLUSIONS: Following introduction of PEWs at a tertiary children's hospital PIM2 was reduced, patients required less PICU interventions and had a shorter length of stay. PICU service delivery improved.

Repair of acute rupture of the Achilles tendon: a new technique using polyester tape without external splintage.

INTRODUCTION: A new method of treating acute rupture of the Achilles tendon using polyester tape is reported. This requires no postoperative splintage, allows earlier mobilisation and prompt return to work and sport. PATIENTS AND METHODS: Thirty patients were reviewed prospectively and at a mean of 3 years from surgery. RESULTS: The average time of return to work, full weight-bearing and to driving was 40 days, 45 days and 49 days, respectively. The average time for return to sport was 122 days. Three patients required further surgery, two for infected wounds and one for scar release. There was one sural nerve injury. Twenty-two patients regained a normal range of ankle and subtalar movement, with the mean power of plantar flexion 84% of the opposite side. Of the 22 patients who played sport, 14 were still performing at the same or a higher level. There were no re-ruptures over this period. CONCLUSIONS: The technique is straightforward and avoids splintage. It also conveys other short- and long-term advantages over more established methods.

Chronic rupture of tendo Achillis. Long-term results of operative management using polyester tape.

We report the long-term results of the surgical treatment of chronic rupture of tendo Achillis using polyester tape. This requires minimal postoperative splintage and allows early mobilisation and a prompt return to work and sport. We reviewed 16 patients (10 women and 6 men) at a mean period of three years after surgery. The median time from injury to operation was 16.8 months (3.9 months to 13 years), and the median age of the patients was 52 years (27 to 78). The median time to full weight-bearing was 40 days and the median time for return to sport was 18 weeks (5.4 to 32). One patient required further surgery and one had numbness along the distribution of the sural nerve. After surgery only two patients had increased dorsiflexion of the ankle compared with the uninjured side. There were no cases of rerupture. We recommend this technique for the treatment of chronic rupture of tendo Achillis.

The perceived learning needs of paediatric intensive care nurses caring for children requiring haemofiltration.

This paper reports on a small exploratory phenomenological study to describe the lived experiences of paediatric intensive care nurses, who extended their roles to care for critically ill children requiring continuous veno-venous haemofiltration. In describing and understanding this learning experience, an insight into the educational and support needs of these nurses is offered. From the insight shared, five main themes were identified. These included the overwhelming need to be a competent practitioner, which was perceived within the context of knowledge for effective practice and technical dexterity.While generalizability of findings is not intended, the findings could be of value to other intensive care settings to guide the identification and implementation of strategies to meet the needs of nurses undertaking similar roles.

Blood supply of the Achilles tendon.

The Achilles tendon is one of the most common sites of injury and rupture as a result of overuse. Evidence suggests that the pathogenesis of rupture could involve the pattern of its blood supply. With use of angiographic and histological techniques, the blood supply of the Achilles tendon was investigated in 12 human cadaveric specimens. Angiography confirmed Mayer's 1916 finding that the blood supply to the tendon is from three areas: the musculotendinous and osseotendinous junctions and the paratenon, with the posterior tibial artery providing the major contribution. However, qualitative and quantitative histological analyses in this study showed that the Achilles tendon has a poor blood supply throughout its length, as determined by the small number of blood vessels per cross-sectional area, which do not in general vary significantly along its length. In light of these findings, it is suggested that poor vascularity may prevent adequate tissue repair following trauma, leading to further weakening of the tendon.

Hematocolpos. An unusual cause of sciatica in an adolescent girl.

STUDY DESIGN: A case report. OBJECTIVE: To document the occurrence of hematocolpos causing sciatica and leg weakness in an adolescent girl. SUMMARY OF BACKGROUND DATA: Low back pain resulting from hematocolpos has been reported previously but not associated with symptoms of sciatica or neurologic weakness. METHODS: The authors were involved in the care of this patient, and all medical records, radiologic investigations, and related literature were reviewed. RESULTS: After being checked for longstanding symptoms of sciatica and leg weakness, the patient underwent a computed tomographic examination of lumbar spine, which showed a large collection in the pelvis consistent with hematocolpos. Surgical drainage of the collection was associated with complete resolution of her symptoms. CONCLUSIONS: Awareness of hematocolpos as a possible cause for sciatica and neurologic symptoms in the lower limbs may lead to earlier diagnosis and, therefore, reduced morbidity in the investigation of the adolescent girl.

Predictive relationships for sidestream smoke cigarette yields.

Relationships have been sought for smoking machine generated sidestream smoke yields of cigarettes for particulate matter (water and nicotine free) (PMWNF) and nicotine. Comparisons have been made with the corresponding mainstream smoke yields, other readily measurable factors in machine smoking and with the physical characteristics of cigarettes. The sidestream smoke yields have been found to be related to the puff count during machine smoking multiplied by the cross-sectional area of a cigarette or to the total weight of cigarette tobacco burnt during machine smoking. For the brands retailed in the U.K. these relationships permit calculation of the sidestream smoke contributions of PMWNF and nicotine to environmental tobacco smoke. From the data used to derive these relationships, and based on 31 cigarette brands representing 71% of cigarette sales in the U.K., the sales weighted sidestream PMWNF yield is 27.1 mg/cigarette and that for nicotine is 5.12 mg/cigarette.

Reconstruction of the anterior talofibular ligament for the treatment of the unstable ankle.

Chronic instability of the ankle is frequently due to disruption of the fibres of the anterior talofibular ligament and the anterolateral capsule. This allows momentary subluxations at the ankle joint; the talus tilts into an abnormal varus position and rotates forwards and inwards about a vertical axis which passes through the medial malleolus. The use of a free tendon graft to reconstruct the anterior talofibular ligament restores the stability of the ankle without restricting movement at the subtalar level.

Assessment and resection of carcinoma at the gastroesophageal junction.

In a five year retrospective study of 70 patients, the roentgenologic and surgical assessments of carcinoma at the gastroesophageal junction have been compared to the histologic findings of the resected specimens. Although the lesion was demonstrated roentgenologically in all patients, no reliable indication of its limits could be obtained, and spread was seriously underestimated by both preoperative barium studies and direct examination at operation. It is suggested that the lack of roentgenologic evidence may have encouraged an inadequate surgical approach and, thus, contributed to incomplete resection and the high immediate mortality. There is, at present, no satisfactory method by which spread can be defined, either before or at operation, and neither the preoperative barium studies nor his operative assessment should influence the surgeon to limit the resection.