A retrospective audit of adult and paediatric anaphylaxis management from two Australian metropolitan mixed emergency departments.

BACKGROUND: Anaphylaxis is a potentially life-threatening allergic reaction, with presentations to emergency departments (EDs) increasing across Australia. Understanding the features of those presenting with anaphylaxis and aspects related to its optimal clinical management across the admission, treatment and discharge settings is needed to minimise its impact. We aimed to evaluate the nature and management of presentations related to anaphylaxis across two Australian EDs. METHODS: Retrospective audit of paediatric and adult patients presenting to a community or tertiary level ED with anaphylaxis from 1 May 2018 to 30 April 2019. Data extracted from medical records included demographic characteristics, causative agents, clinical features, treatments administered across community, ambulance or ED settings, as well as post-discharge care arrangements including provision of Adrenaline Auto-Injector (AAI) and Allergy/Anaphylaxis Action Plan (AAP). RESULTS: A total of 369 (107 paediatric and 262 adult) ED presentations were identified. A total of 94 (36%) adult and 46 (43%) paediatric patients received pre-hospital adrenaline, with a further 91 (35%) adult and 29 (27%) paediatric patients receiving a dose of adrenaline in the ED. The most commonly administered treatment in ED were corticosteroids, given to 157 (60%) adult and 55 (51%) paediatric patients. Among those requiring an AAI for discharge, 123/210 (59%) adult and 57/91 (63%) of paediatric patients left hospital with an AAI. In contrast, among those requiring an allergy/anaphylaxis action plan (AAP) on discharge, 61/206 (30%) adult and 30/90 (33%) of paediatric patients left hospital with one. Factors associated with an increased likelihood of receiving AAI on discharge in paediatric and adult patients included receipt of any adrenaline, receipt of two or more doses of adrenaline, and longer duration of hospital stay. Adults presenting within business hours were more likely to be discharged with AAI, but no such difference was observed for paediatric patients. Similar findings were evident for provision of AAP on discharge. CONCLUSION: These findings demonstrate the need to improve assessment and treatment in the ED. In particular, the observed large variability in provision of AAI and AAP on discharge presents opportunities to explore strategies to improve awareness and provision of these critical components of post-discharge care.

Reality or wishful thinking: do bicycle helmets prevent facial injuries?

Standard bicycle helmets are designed to protect the cranial vault. Numerous studies have demonstrated the beneficial effect of standard bicycle helmets on craniocerebral trauma, but their protective effect on facial injuries remains unclear. Therefore, this study used data obtained by an accident research unit to investigate the protective effect of standard bicycle helmets on facial injuries. A total of 31,634 bicycle accidents were registered between 1999 and 2015; of these, 7004 met the study requirements. Demographic characteristics, technical information (relative collision speed, collision type, collision partner, helmet use), and clinical data (injury type) relating to these accidents were analyzed. Of all affected cyclists, 1005 (14.3%) had a facial injury (fracture and/or soft tissue injury). Bicycle helmets were worn in 11.8% of accidents. Of these, 75.4% involved males and 24.6% involved females. The bicycle helmet did not protect against facial injuries. Furthermore, sex and the type of collision partner were found to be risk factors for facial injuries. In the future, helmet designs should be modified to improve facial protection, and better education should be provided to the public regarding the benefits of bicycle helmets.

Implications of estimating road traffic serious injuries from hospital data.

To determine accurately the number of serious injuries at EU level and to compare serious injury rates between different countries it is essential to use a common definition. In January 2013, the High Level Group on Road Safety established the definition of serious injuries as patients with an injury level of MAIS3+(Maximum Abbreviated Injury Scale). Whatever the method used for estimating the number or serious injuries, at some point it is always necessary to use hospital records. The aim of this paper is to understand the implications for (1) in/exclusion criteria applied to case selection and (2) a methodological approach for converting ICD (International Classification of Diseases/Injuries) to MAIS codes, when estimating the number of road traffic serious injuries from hospital data. A descriptive analysis with hospital data from Spain and the Netherlands was carried out to examine the effect of certain choices concerning in- and exclusion criteria based on codes of the ICD9-CM and ICD10. The main parameters explored were: deaths before and after 30 days, readmissions, and external injury causes. Additionally, an analysis was done to explore the impact of using different conversion tools to derive MAIS3 + using data from Austria, Belgium, France, Germany, Netherlands, and Spain. Recommendations are given regarding the in/exclusion criteria and when there is incomplete data to ascertain a road injury, weighting factors could be used to correct data deviations and make more real estimations.

Reverse shoulder replacement after resection of the proximal humerus for bone tumours.

We investigated the functional outcome in patients who underwent reverse shoulder replacement (RSR) after removal of a tumour of the proximal humerus. A total of 16 patients (ten women and six men) underwent this procedure between 1998 and 2011 in our hospital. Five patients died and one was lost to follow-up. Ten patients were available for review at a mean follow-up of 46 months (12 to 136). Eight patients had a primary and two patients a secondary bone tumour. At final follow up the mean range of active movement was: abduction 78° (30° to 150°); flexion 98° (45° to 180°); external rotation 32° (10° to 60°); internal rotation 51° (10° to 80°). The mean Musculoskeletal Tumor Society score was 77% (60% to 90%) and the mean Toronto Extremity Salvage Score was 70% (30% to 91%). Two patients had a superficial infection and one had a deep infection and underwent a two-stage revision procedure. In two patients there was loosening of the RSR; one dislocated twice. All patients had some degree of atrophy or pseudo-atrophy of the deltoid muscle. Use of a RSR in patients with a tumour of the proximal humerus gives acceptable results.

Skin prick testing and peanut-specific IgE can predict peanut challenge outcomes in preschoolchildren with peanut sensitization.

BACKGROUND: The rise in peanut allergy is a source of considerable burden in the community. A growing number of preschoolchildren have been identified as peanut sensitized in the course of investigation of other allergic conditions. Although many have never knowingly ingested peanuts and their clinical reactivity is not known, it has been common practice to place these children on avoidance diets for many years. OBJECTIVE: To determine the utility of skin prick tests (SPT) and fluorescent-enzyme immunoassays (FEIA) for identifying either peanut allergy or tolerance in preschoolchildren with peanut sensitization. METHODS: Forty-nine preschoolchildren (<5 years of age) with peanut sensitization (SPT ≥ 2 mm or peanut-specific IgE ≥ 0.35 kU/L) but unknown clinical reactivity had graded open peanut challenges reaching a total of 11 g. A positive challenge was defined as an objective IgE-mediated reaction during challenge or the 2-h observation. RESULTS: Forty-nine percent (24/49) of children had positive challenges. An SPT of >7 mm on the day of challenge predicted a positive challenge with a sensitivity of 83% and a negative predictive value (NPV) of 84%. An FEIA of >2.0 kU/L showed a sensitivity of 79% and an NPV of 80%. Predicting challenge outcome from a combination of SPT and FEIA (SPT >7 and/or FEIA >2 is positive) increased sensitivity to 96% and NPV to 95%. CONCLUSION AND CLINICAL RELEVANCE: At least half of preschoolchildren with peanut sensitization and no antecedent history of peanut ingestion can tolerate peanuts. A SPT<7 mm and FEIA<2 kU/L identify children most likely to tolerate peanut, with only a 5% likelihood of failing an oral challenge. This study assists clinicians considering challenges in very young peanut-sensitized children.

The clinical outcomes of mosaicplasty in the treatment of osteochondritis dissecans of the distal humeral capitellum of young athletes.

BACKGROUND: The purpose of this study was to evaluate the clinical outcomes of mosaicplasty in the treatment of osteochondritis dissecans of the distal humeral capitellum. MATERIALS AND METHODS: Between 2003 and 2007, 10 patients (6 female and 4 male patients), with a mean age at surgery of 18 years (range, 13 to 27 years), with advanced lesions of capitellar osteochondritis dissecans underwent mosaicplasties. The surgical technique involves transplanting small-sized cylindrical osteochondral grafts from the lateral periphery of the femoral condyle at the level of the patellofemoral joint to the defect of the capitellum. At a mean follow-up of 30 months, all elbows were assessed with the Mayo Elbow Performance Score and a modified functional elbow score (Constant). RESULTS: Postoperative radiographs and control magnetic resonance imaging/computed tomography images showed incorporation of the subchondral cortex in all patients. All but 2 patients were completely pain free after surgery. Of the patients, 8 (80%) had no reduction in range of motion. By use of the Mayo Elbow Performance Score, the injured elbow had a preoperative mean score of 71 points (range, 55 to 85 points) and increased significantly to a mean score of 93.5 points (range, 85 to 100 points) postoperatively (P = .0005, paired t test). The nonoperative elbows had a mean score of 100 points, whereas the operated elbows had a mean score of 93.5 points. The functional elbow score showed a mean difference of 7.5 points between the operated and nonoperative elbows. No infection or neurologic deficit developed after surgery in any case. CONCLUSIONS: Autologous osteochondral mosaicplasty for advanced lesions of capitellar osteochondritis dissecans can provide satisfactory clinical and radiographic results.

Practical prebiotics, probiotics and synbiotics for allergists: how useful are they?

With the advent of the hygiene hypothesis, probiotics have provided an avenue of hope in curbing the allergic epidemic. The initial enthusiasm has been tempered by recognition of the inherent complexities of this approach. This review examines the current clinical evidence and practical issues in using probiotics and related products, for the prevention and treatment of allergic disease. So far, probiotics have shown more promise, albeit limited, in the primary prevention of allergic disease rather than in the treatment of established disease. These effects have largely been limited to the prevention of early childhood conditions such as eczema, with no consistent effects on other allergic outcomes. There is emerging evidence that clinical effects may be strain specific, but again these findings have been inconsistent. While there have been several meta-analyses to examine probiotics in both the prevention and the treatment of allergic disease, these have been hampered by significant heterogeneity between studies, including wide variations in the strains used, the methods and timing of administration and the age and assessment of allergic outcomes. In any case, these have also become outdated by a series of new studies published in the last year. Although it is not yet clear exactly how the growing number of new studies will modify the results of meta-analyses, it is likely that these will add yet further heterogeneity that will continue to make interpretation of pooled data difficult. At this stage, the effects of prebiotics, synbiotics and postbiotics are even less clear. Thus, while there is little doubt that microbiota modulate immune development and can prevent the allergic phenotype, the optimal way of achieving this is far from clear. Given the current level of evidence, it is not appropriate to recommend prebiotics/probiotics/synbiotics or postbiotics as a part of standard therapy or for the prevention of any allergic conditions. Further studies are needed to address the growing speculation that supplementation with a single probiotic strain may be oversimplistic and that approaches that have a more global effect on colonization may be warranted.

Swimmers' painful shoulder arthroscopic findings and return rate to sports.

Shoulder pain is the most common musculo-skeletal complaint in competitive swimmers. It remains one of the shoulder pain syndromes in overhead athletes where no golden standard of treatment exists. Eighteen competitive swimmers who all had undergone shoulder arthroscopy for therapy-resistant shoulder pain were retrospectively evaluated with respect to operative findings and ability to return to their sport after the operation. The most common finding at arthroscopy was labral pathology in 11 (61%) and subacromial impingement in five shoulders (28%). Operative procedures included debridement in 11 swimmers, partial release of the coraco-acromial ligament in four, and bursectomy in four. Sixteen (89%) responded to the follow-up evaluation. Nine swimmers (56%) were able to compete at preinjury level after 4 (2-9) months. Findings at arthroscopy suggest that the term "Swimmer's shoulder" covers a variety of pathologies including labral wearing and subacromial impingement. Arthroscopic debridement of labral tears or bursectomy in swimmers with shoulder pain has a low success rate with regard to return to sport. Further understanding and investigation of this syndromes complex pathophysiology is needed.

Revision of failed total elbow arthroplasty with use of a linked implant.

We studied retrospectively the results of revision arthroplasty of the elbow using a linked Coonrad-Morrey implant in 23 patients (24 elbows) after a mean follow-up period of 55 months. According to the Mayo Elbow Performance Score, 19 elbows were satisfactory, nine were excellent and ten good. The median total score had improved from 35 points (20 to 75) before the primary arthroplasty to 85 points (40 to 100) at the latest follow-up. There was a marked relief of pain, but the range of movement showed no overall improvement. Two patients had a second revision because of infection and two for aseptic loosening. The estimated five-year survival rate of the prosthesis was 83.1% (95% confidence interval 61.1 to 93.3). Revision elbow arthroplasty using the Coonrad-Morrey implant provided satisfactory results but with complications occurring in 13 cases.

[Quality control of audiologic results in a university phoniatric/pediatric institution. An example of expert assessment of occupational noise induced hearing loss]. / Qualitätskontrolle audiologischer Befunde einer universitären phoniatrisch/pädaudiologischen Einrichtung. Am Beispiel der Begutachtung der beruflichen Lärmschwerhörigkeit.

AIM: An investigation was made to reveal whether suspicion of occupational hearing loss can be satisfactorily determined by an otolaryngologist or workplace audiological measurement. These were compared with a formal audiometrical assessment at a university clinic. METHODS AND RESULTS: A retrospective study was made of 95 cases of noise induced hearing loss. A total of 78 individuals were investigated by an otolaryngologist and 70 by workplace audiometry. Using workplace audiometry, 27% of the tests showed a reduction in working capacity of at least 20%. In only five of these was a specialist opinion sought within a year. In 50%, this took longer than 5 years. A comparison of audiometric data from expert opinion revealed that there was conformity in only 47% with workplace audiometry and 48% with otolaryngologist testing. In some cases (27% workplace and 33% ENT practice), the measured hearing loss and calculation of disability exceeded that determined by the experts. CONCLUSIONS: The results of workplace audiometry demonstrated that hearing loss was frequently reported only after the workers had received a disability of at least 20%. Possible reasons for discrepancies in audiological testing might be the exaggeration of hearing loss by the worker, insufficient recovery time after noise exposure, or inexperienced audiologists. Our data show that audiometric testing in workplace audiometry, as well as in ENT practice, often reveal a higher disability rating compared to formal audiological (university) assessment, even if these discrepancies do not reach statistical significance.

[Myoclonus of the middle ear. A rare, differential diagnosis for objective tinnitus]. / Myolonus des Mittelohrs. Eine seltene Differenzialdiagnose bei objecktivem Tinnitus.

UNLABELLED: PRESENT STATE OF KNOWLEDGE: Myoclonus of the musculature of the soft palate, as well as middle ear myoclonus resulting from abnormal contraction of the stapedius and/or tensor tympani muscles, are two of the rarer causes in the differential diagnose of objective tinnitus. AIM: Here we describe a childhood case. To our knowledge, no case has previously been described in a child. METHODS AND RESULTS: Our patient isa six year old girl with a bilateral 40 dB sensorineural hearing loss and a high frequency objective tinnitus. The methods of clinical investigation, possible differential diagnoses and therapeutic options are discussed. CONCLUSION: Both intracerebral changes and systemic disorders have been described in some adult patients with palatal myoclonus. Whereas these cases are unlikely to respond to therapy, there is the chance that in some patients with objective tinnitus middle ear myoclonus may be the cause. This should be excluded by appropriate otoneurological investigations.

[Myoclonus of the middle ear : A rare, differential diagnose for objective tinnitus]. / Myoklonus des Mittelohrs : Eine seltene Differenzialdiagnose bei objektivem Tinnitus.

PRESENT STATE OF KNOWLEDGE: Myoclonus of the musculature of the soft palate, as well as middle ear myoclonus resulting from abnormal contraction of the stapedius and/or tensor tympani muscles, are two of the rarer causes in the differential diagnose of objective tinnitus. AIM: Here we describe a childhood case. To our knowledge, no case has previously been described in a child. METHODS AND RESULTS: Our patient is a six year old girl with a bilateral 40 dB sensorineural hearing loss and a high frequency objective tinnitus. The methods of clinical investigation, possible differential diagnoses and therapeutic options are discussed. CONCLUSION: Both intracerebral changes and systemic disorders have been described in some adult patients with palatal myoclonus. Whereas these cases are unlikely to respond to therapy, there is the chance that in some patients with objective tinnitus middle ear myoclonus may be the cause. This should be excluded by appropriate otoneurological investigations.

The role of CD44 during CD40 ligand-induced dendritic cell clustering and maturation.

The interaction between CD40 on dendritic cells (DC) and its ligand CD154 has been recognized to be an important feature in the maturation of DC. Here, we were interested in the role of CD44 a surface receptor shown to mediate cell-cell adhesion and binding to Hyaluronic acid (HA). Western blot analysis of human DC stimulated for 3-12 h with CD154 revealed the rapid induction of the 85 kDa standard form of CD44 and an increased HA-binding affinity. Time-lapse video-imaging microscopy of human DC co-cultured on CD154-transfected murine fibroblasts showed that the CD44 up-regulation coincided with the rapid induction of homotypic DC clustering, which did not occur on empty vector-transfected fibroblasts. In this system, addition of anti-CD44s mAbs abrogated DC-cluster formation, thereby inhibiting further maturation, as shown by a reduced TNF-alpha production and inhibition of CD154-induced MHC class II up-regulation. However, co-incubation with HA-degrading enzymes induced no changes in the CD154-mediated DC clustering and maturation.

[Phoniatric aspects in microsurgical removal of benign vocal cord changes]. / Phoniatrische Aspekte bei der mikrochirurgischen Abtragung gutartiger Stimmlippenveränderungen.

INTRODUCTION: Microsurgery of benign vocal cord lesions is usually done to improve, to restore or to preserve patients' voice. Solid anatomical and physiological knowledge concerning the voice are basic requirements of any surgeon operating in this field. PREOPERATIVE DIAGNOSTICS AND DOCUMENTATION: The significance of patients' history as well as phoniatric investigation, laryngoscopic and stroboscopic findings and their proper documentation are presented. INDICATIONS: The surgical procedure must be part of an extensive therapeutical concept that also takes into consideration drug therapy as well as voice therapy procedures to improve voice quality. POSTOPERATIVE REGIMEN: The care for the patient's voice usually goes beyond surgery. To gain the best possible postoperative results, several steps are necessary in addition to surgical procedures. These steps will be pointed out.

[Value of acoustic speech analysis for prognostic assessment of stuttering in children. Partial results of a prospective longitudinal study]. / Die Aussagekraft einer akustischen Sprachanalyse für die prognostische Einschätzung des kindlichen Stotterns. Teilergebnisse einer prospektiven Längsschnittstudie.

UNLABELLED: PRESENT STATE OF KNOWLEDGE: There are currently no known acoustic parameters by which stuttering children can be appraised which will predict their subsequent speech fluency. AIM: To explain the significance of factors which perpetuate stuttering by using computer-based speech analysis of fluent speech for a 1 1/2 year period and to relate acoustic analysis with clinical measurements of stuttering. Special attention was given to motor-oral and/or linguistic deficits. METHOD AND RESULTS: A prospective study of 58 pre-school children who stutter. Correlations were sought between acoustic variables in the severity and course of the stuttering with the influence of motor-oral and linguistic disturbances. 19 age-matched, normal-speaking children served as controls. A subdivision of the study group into different subgroups with particular motor-oral and/or linguistic problems showed that children whose stuttering coincides with a delayed speech development have a distinctly better prognosis for early remission. In most of these children the stuttering remitted to such a degree as the deficits causing the stuttering could be reappraised, which means simultaneous improvement of the linguistic competence. CONCLUSION: It was apparent that remission rate was much higher in those children who showed linguistic disturbances at the same time with stuttering. Within the stuttering group, subgroups showed a few correlations in several acoustic parameters, but these could not, as yet, be shown to give any prognostic markers in the routine diagnosis of children who stutter. If a child shows any danger-signs of acquiring stuttering on a more permanent basis, a careful diagnosis is necessary in order to find the individually underlying factors before any therapeutical procedure.

[Patella dislocation. Therapeutic principles and prevention of late complications]. / Patellaluksation. Behandlingsprincipper og forebyggelse af senkomplikationer.

In this review we have compared the different kinds of treatment of acute dislocation of the patella regarding the effects and the complications. The literature describes a variety of treatments and no standard treatment exists. Most studies are not randomised prospective studies and the follow-up period is often short. We conclude that there is a need for randomised, prospective studies with a large number of patients and with a long follow-up period in order to find the best kind of treatment. Treatment modalities for acute as well as recurrent dislocation are described in the general section of the review. In order to achieve the best results and decrease the number of complications it is necessary to have a clear diagnosis of APD and knowledge of predisposing factors.

[Acute and chronic patella dislocations. Therapeutic strategies in Danish orthopedic departments]. / Akutte og kroniske patellaluksationer. Behandlingsstrategier på danske ortopaedkirurgiske afdelinger.

BACKGROUND: In review of the literature there is no standard treatment of acute- as well as recurrent dislocation of the patella. Most investigations are retrospective or not randomised. Approximately 1500 patients/year with the diagnosis luxatio patellae are seen in Danish hospitals. METHODS: Using a questionnaire we wished to find out how these patients were treated in Danish orthopaedic departments. RESULTS: We found that there was no consensus on the treatment of patellar dislocation. CONCLUSION: We concluded that there is a need for prospective randomised studies involving a large number of patients, with a long follow up time.

[Medication-induced vocal cord paralysis as an uncommon cause of cord paralysis]. / Der medikamenteninduzierte Stimmlippenstillstand.Eine seltene Differentialdiagnose.

A case is reported of a 57-year-old man who was found to have a right vocal cord paralysis that most likely followed prolonged treatment with the anti-arrythmic medication Amiodaron-HCl (Cordarex). Phoniatric treatment was given for 5 1/2 months, during which time microlaryngoscopy and stroboscopy were performed. With the help of speech therapy, mobility of the paralyzed cord was seen to begin to return 3 1/2 months after discontinuing the Amiodaron-HCl. Full cord mobility has not returned to date.

[Intraabdominal hemangiopericytoma. Diagnosed during surgery for suspected acute appendicitis]. / Intraabdominalt haemangiopericytom. Diagnosticeret under operation på mistanke om appendicitis acuta.

A 39 year-old febrile man with lower abdominal pain and peritoneal reaction was operated on suspicion of acute appendicitis. During the past eighteen months he had been hospitalized twice due to similar symptoms, both times with spontaneous remission. The operative finding was a large multilobular vascular tumour which on pathological examination was a haemangiopericytoma, with no degree of malignancy. The tumour was removed in toto.

Functional and magnetic resonance imaging evaluation after single-tendon rotator cuff reconstruction.

The aim of this study was to investigate tendon integrity after surgical repair of single-tendon rotator cuff lesions. In 31 patients, 31 single-tendon repairs were evaluated. Thirty-one patients were available for clinical assessment and magnetic resonance imaging (MRI) at follow-up. A standard series of MR images was obtained for each. The results of functional assessment were scored according to the system of Constant. According to MRI evaluation, 21 (68%) patients had an intact or thinned rotator cuff and 10 (32%) had recurrence of a full-thickness cuff defect at follow-up. Patients with an intact or thinned rotator cuff had a median Constant score of 75.5 points; patients with a full-thickness cuff defect had a median score of 62 points. There was no correlation between tendon integrity on postoperative MR images and functional outcome. Patients with intact or thinned cuffs did not have significantly better functional results than patients with retorn cuffs. Because of the presence of metal artifacts and the difficulty in distinguishing postoperative scar tissue from partial tears or thinning, MRI is of minor diagnostic value in assessing the shoulder after cuff repair. However, full-thickness tears are readily diagnosed after operation with MRI.