Outcomes following intensive day rehabilitation for young people in Western Australia.

OBJECTIVE: Intensive rehabilitation aims to improve and maintain functioning in young people who experience disability due to illness or injury. Day rehabilitation may have advantages for families and healthcare systems over inpatient models of rehabilitation. METHODS: This study evaluated the goals and outcomes of a cohort of young people in Western Australia who attended a specialist intensive day rehabilitation programme ("iRehab") at Perth Children's Hospital. Analysis of the iRehab service database was performed. Rehabilitation goals and outcomes were recorded as per the Canadian Occupational Performance Measure (COPM), Children's Functional Independence Measure (WeeFIM), and Goal Attainment Scale (GAS). RESULTS: There were 586 iRehab admissions between August 11, 2011, and December 31, 2018. Admissions were divided by diagnosis: Cerebral Palsy (228, 38.5%), Acquired Brain Injury (125, 21.3%), Spinal Cord Disorders (91, 15.5%), and Other (141, 24.2%). Mean COPM Performance increased by 2.78 points from admission to discharge (95% CI 2.58 to 2.98, p < 0.001). Mean COPM Satisfaction was 3.29 points higher at discharge than admission (95% CI 3.07 to 3.51, p < 0.001). Mean total WeeFIM score improved by 6.51 points between admission and discharge (95% CI 5.56 to 7.45, p < 0.001), and by 3.33 additional points by six months post discharge (95% CI 2.14 to 4.53, p < 0.001). Mean GAS T-scores increased by 27.85 (95% CI 26.73 to 28.97, p < 0.001) from admission to discharge, and by 29.64 (95% CI 28.26 to 31.02, p < 0.001) from admission to six months post discharge, representing improvement consistent with team expectations. CONCLUSION: This study describes a model by which intensive rehabilitation can be delivered in a day rehabilitation setting. A diverse population of young people who experienced disability achieved significant improvements in occupational performance, independence, and goal attainment after accessing intensive day rehabilitation. Improvements were measured in all diagnostic subgroups and were maintained six months after discharge.

Listening and spoken language outcomes after 5 years of cochlear implant use for children born preterm and at term.

AIM: To compare listening and spoken language outcomes after cochlear implantation for children born preterm and at term, and to examine patterns associated with additional disabilities or gestational age. METHOD: Children were included if they underwent cochlear implantation in 2013 or 2014 and had complete 5-year follow-up data available. An analysis of assessment data recorded annually was conducted, including outcomes as measured by the Category of Auditory Performance (CAP), the Speech Intelligibility Rating, Second Edition (SIR 2) scale, and the British Picture Vocabulary Scales, Third Edition (BPVS-3). Analyses were conducted to measure the impact of preterm birth and of additional causes of disability on these outcomes. RESULTS: Eighty-two children (39 males, 43 females; median corrected age at first cochlear implantation 28.5mo [interquartile range 16.3-48.5]) were included in the study. Children who underwent cochlear implantation experienced significant improvements as measured by the CAP, SIR 2, and BPVS-3. Comparable improvements were seen in the groups born at term and preterm. Children with additional disabilities experienced significant improvement in all measures but performed less well than children without additional disabilities. INTERPRETATION: Infants born preterm benefit from cochlear implantation to a degree comparable to their peers born at term. Additional disabilities may limit improvements in speech intelligibility, listening performance, and receptive vocabulary. Children with additional disabilities, nonetheless, derived significant benefit from cochlear implantation; additional benefits of cochlear implantation for this subgroup may go unmeasured by the outcome tools used in this study.

Narcolepsy in children and young people in Ireland: 2006-2017.

AIM: To describe the population of young people in Ireland diagnosed with narcolepsy with regards to vaccine exposure, symptomatology, investigation results and experience of medical treatment. METHOD: Retrospective review of medical records at the single tertiary referral centre for young people with narcolepsy in Ireland. RESULTS: Sixty-seven patients were diagnosed with narcolepsy between July 2006 and July 2017. Sixty-one (91%) of these developed symptoms after receiving the Pandemrix vaccine. The population was largely homogeneous with low hypocretin (87.5%), HLA DQB1∗0602 positivity (95%) and unremarkable findings on MRI Brain (100%). 77.6% experienced cataplexy; we also measured high levels of obesity, school non-attendance and psychosocial complexity. Symptoms often continued despite treatment, with multiple medications prescribed in 76.1% of patients. Prescription of sodium oxybate was associated with a significant reduction in BMI standard deviation scores at 6 months, with improved IOTF obesity scores seen at 36 month follow-up. CONCLUSIONS: This paper describes the experience of narcolepsy in children and young people in Ireland from 2006 - 2017 at the national tertiary referral centre. Narcolepsy in children and young people in Ireland carries a significant burden of illness, with impact on participation in education as well as physical and mental health. Symptoms can be refractory to medical treatment. Referral to tertiary centres for prompt treatment and multidisciplinary input is essential.

Randomised trial of estimating oral endotracheal tube insertion depth in newborns using weight or vocal cord guide.

BACKGROUND: When intubating newborns, clinicians aim to position the endotracheal tube (ETT) tip in the midtrachea. The depth to which ETTs should be inserted is often estimated using the infant's weight. ETTs are frequently incorrectly positioned in newborns, most often inserted too far. Using the vocal cord guide (a mark at the distal end of the ETT) to guide insertion depth has been recommended. OBJECTIVE: To determine whether estimating ETT insertion depth using the vocal cord guide rather than weight results in more correctly positioned ETT tips. DESIGN: Single-centre randomised controlled trial. SETTING: Level III neonatal intensive care unit (NICU) at a university maternity hospital (National Maternity Hospital, Dublin, Ireland). PATIENTS: Newborn infants without congenital anomalies intubated in the NICU. INTERVENTIONS: Participants were randomised to have ETT insertion depth estimated using weight [insertion depth (cm) = weight (kg) +6] or vocal cord guide. MAIN OUTCOME MEASURE: Correct ETT position, that is, tip between the upper border of the first thoracic vertebra (T1) and the lower border of the second thoracic vertebra (T2) on a chest X-ray as determined by one paediatric radiologist masked to group assignment. RESULTS: 136 participants were randomised. The proportion of correctly positioned ETTs was similar in both groups (weight 30/69 (44%) vs vocal cord guide 27/67 (40%), p=0.731). Most incorrectly positioned ETT (69/79, 87%) were too low. CONCLUSION: Estimating ETT insertion depth using the vocal cord guide did not result in more correctly positioned ETT tips. TRIAL REGISTRATION NUMBER: ISRCTN39654846.

Perspectives on Erving Goffman's "Asylums" fifty years on.

Erving Goffman's "Asylums" is a key text in the development of contemporary, community-orientated mental health practice. It has survived as a trenchant critique of the asylum as total institution, and its publication in 1961 in book form marked a further stage in the discrediting of the asylum model of mental health care. In this paper, some responses from a range of disciplines to this text, 50 years on, are presented. A consultant psychiatrist with a special interest in cultural psychiatry and mental health legislation, two collaborating psychotherapists in adult and forensic mental health, a philosopher, and a recent medical graduate, present their varying responses to the text. The editors present these with the hope of encouraging further dialogue and debate from service users, carers, clinicians, and academics and researchers across a range of disciplines.

A disjointed effort: paediatric musculoskeletal examination.

BACKGROUND: Musculoskeletal (MSK) symptoms are a frequent cause of emergency department attendance for children, and while most often indicative of benign or self-limiting disease, such symptoms can occasionally be the first presentation of serious illness such as leukaemia or juvenile idiopathic arthritis. MSK examination, however, is often not included as part of the routine paediatric examination. The authors aimed to evaluate how often and how thoroughly MSK examination was performed during admissions to the paediatric ward and to compare it with the examination of other symptoms in relation to the presenting complaint and eventual diagnosis. RESULTS: Medical records for 100 consecutive patients were reviewed. A poster campaign to increase awareness was then commenced along with oral and written presentations to staff regarding MSK examination. A further 100 consecutive patients were then reviewed. Only 9% of children in the initial group had routine MSK examination, rising to 32% in the second group. Where performed, MSK examination was often incomplete. Frequent errors included only examining the reported site of injury and only examining a single limb or single joint when limpness/stiffness was the presenting complaint. Non-limb joints were very rarely examined. CONCLUSIONS: MSK examination is not performed routinely during paediatric admissions in contrast to the examination of other symptoms regardless of the presenting complaint. This may need to be addressed by local audit and increased undergraduate teaching.