Unremitting pro-inflammatory T-cell phenotypes, and macrophage activity, following paediatric burn injury.

Objectives: The aim of this study was to characterise the dynamic immune profile of paediatric burn patients for up to 18 months post-burn. Methods: Flow cytometry was used to measure 25 cell markers, chemokines and cytokines which reflected both pro-inflammatory and anti-inflammatory immune profiles. Peripheral blood mononuclear cells from 6 paediatric burn patients who had returned for repeated burn and scar treatments for > 4 timepoints within 12 months post-burn were compared to four age-matched healthy controls. Results: While overall proportions of T cells, NK cells and macrophages remained relatively constant, over time percentages of these immune cells differentiated into effector and proinflammatory cell phenotypes including Th17 and activated γδ T cells. Circulating proportions of γδ T cells increased their expression of pro-inflammatory mediators throughout the burn recovery, with a 3-6 fold increase of IL-17 at 1-3 weeks, and NFκß 9-18 months post-burn. T-regulatory cell plasticity was also observed, and Treg phenotype proportions changed from systemically reduced skin-homing T-regs (CCR4+) and increased inflammatory (CCR6+) at 1-month post-burn, to double-positive cell types (CCR4+CCR6+) elevated in circulation for 18 months post-burn. Furthermore, Tregs were observed to proportionally express less IL-10 but increased TNF-α over 18 months. Conclusion: Overall, these results indicate the circulating percentages of immune cells do not increase or decrease over time post-burn, instead they become highly specialised, inflammatory and skin-homing. In this patient population, these changes persisted for at least 18 months post-burn, this 'immune distraction' may limit the ability of immune cells to prioritise other threats post-burn, such as respiratory infections.

Reduction of Urinary Tract Infection in Pediatric Surgical Patients Using NSQIP-P and Quality Improvement Methodology.

BACKGROUND: Hospital-acquired urinary tract infections (UTIs) have a detrimental effect on patients, families, and hospital resources. The Sydney Children's Hospital Network (SCHN) participates in the NSQIP-Pediatric (NSQIP-P) to monitor postoperative complications. NSQIP-P data revealed that the median UTI rate at SCHN was 1.75% in 2019, 3.5 times higher than the NSQIP-P target rate of 0.5%. Over three quarters of the NSQIP-P identified patients with UTI also had a urinary catheterization performed intraoperatively. A quality improvement project was conducted between mid-2018 and 2021 to minimize catheter-associated UTIs (CAUTIs) at SCHN. STUDY DESIGN: NSQIP-P samples include pediatric (younger than 18 years) surgical patients from an 8-day cycle operative log. NSQIP-P data are statistically analyzed by the American College of Surgeons and provide biannual internationally benchmarked reports. The project used clinical redesign methodology with a 6-phase process for quality improvement projects. RESULTS: The objectives of the project were to reduce urinary catheter duration of use, educate parents or carers, and improve catheter care and insertion technique by health staff. The duration of a urinary catheter in situ reduced from a median of 4.5 to 3 days from 2017 to 2021. The median NSQIP-P UTI rate at SCHN was reduced by 47.4% from 1.75% in 2019 to 0.9% in 2022. CONCLUSIONS: A multifactorial approach in quality improvement has been shown to be an effective strategy to reduce UTI rates at SCHN, and patient outcomes were improved within a 3-year timeframe. Although this project has reduced UTI rates at SCHN, there remain opportunities for further improvement.

Laryngotracheal stenosis post mechanical ventilation in paediatric burns patients.

INTRODUCTION: The duration of endotracheal intubation is thought to be the most important factor in the development of acquired laryngotracheal stenosis (LTS); however, there is a paucity of studies examining the incidence of LTS in the paediatric burn population. The aim of this study was to determine the incidence of LTS in paediatric burns patients requiring mechanical ventilation to develop guidelines for consideration of a tracheostomy. METHODS: A retrospective review of all children treated at The Children's Hospital at Westmead (CHW) Burns Unit (BU) from December 2009 to December 2019 who required intubation for their burn injury. RESULTS: During the 10-year study period 115 patients required endotracheal intubation after having sustained a burn injury. Of these 11 were excluded. The mean age was 6.2 years (0-16), with the majority of patients being male (65%). The average TBSA was 18.5% with a range of 0.1-70%. Flame was the most common mechanism of burn (n = 59). Burns to the head and/or neck were the most common indication for intubation with the mean duration of intubation 6.1 days (range 0-40). Tracheostomies were performed on two patients (1.9%). LTS was found in two patients (1.9%). CONCLUSION: LTS in the paediatric burn population post mechanical ventilation appears to be a rare event. Endotracheal intubation can safely be used as the route of airway access in paediatric burns patients. Based on our experience, a definitive recommendation on the timing of tracheostomy in the paediatric burn patient cannot be made.

Predictors of 12 month functional outcomes and length of stay of severely injured children in NSW, Australia. A longitudinal multi-centre study.

BACKGROUND: The majority of paediatric injury outcomes studies focus on mortality rather than the impact on long-term quality of life, health care use and other health-related outcomes. This study sought to determine predictors of 12-month functional and psychosocial outcomes for children sustaining major injury in NSW. METHODS: The study included all children < 16 years requiring intensive care or an injury severity score (ISS) ≥ 9 treated in NSW at a paediatric trauma centre (PTC). Children were identified through the three PTCs and NSW Trauma Registry. The paediatric Quality of Life Inventory (PedsQL) and EuroQol five-dimensional EQ-5D-Y were used to measure HRQoL post-injury, completed via parent/carer proxy recruited through NSW PTCs. RESULTS: There were 510 children treated at the three NSW PTCs during the 15-month study period. The mean (SD) age was 6.7 (6.0) years, with a median NISS (New Injury Severity Score) of 11 (IQR: 9-18). Regression analysis showed worse psychosocial health at twelve months was associated with hospital length of stay (LoS) and number of body regions injured (F2,65 = 5.85, p = 0.005). Physical outcome was associated with LoS and intensive care unit (ICU) admission (F2,66 = 13.48, p < 0.001). Hospital LoS was significantly associated with NISS and head injury (F2,398 = 51.5, p < 0.001). CONCLUSION: Hospital length of stay and polytrauma are independent factors that negatively influence psychological and physical outcomes of children with major injuries. Early intervention to enable emotional well-being, discharge home and long-term follow up such as dedicated family support and rehabilitation at home could reduce preventable poor outcomes.

Pathways and factors that influence time to definitive trauma care for injured children in New South Wales, Australia.

BACKGROUND: Timely definitive paediatric trauma care influences patient and parental physical and emotional outcomes. New South Wales (NSW) covers a large geographical area with all three NSW paediatric trauma centres (PTC) located in two approximated major cities, meaning it is inevitable that some injured children receive initial treatment locally and then require transfer. Little is known about the factors that then impact timely arrival of injured children to definitive care. METHODS: This included children admitted between July 2015 and September 2016, <16 years with an injury severity (ISS) ≥9; or requiring intensive care admission; or deceased following injury. Children were identified through the three PTCs, NSW Trauma Registry and NSW Medical Retrieval Registry. RESULTS: There were 593 children admitted following injury and 46% required transfer to a PTC. There was no significant difference in age, ISS, ICU admission or head injury (AIS >2) between transferred and directly transported cohorts. There were significant differences in mechanism of injury between the two groups (χ2(9) = 45.9, p < 0.001). The median (IQR) time to book a transfer from arrival at the referring facility, was 146.5 (86-238) minutes. Time from injury to arrival at the PTC more than doubled for children transferred, with significant and unwarranted variability between transporting agencies resulting in unwarranted delays to surgical intervention. For example, time spent at the referring facility by Aeromedical Retrieval Service was less than half that of the Newborn & paediatric Emergency Transport Service [53 (IQR:47-61) vs 115 (84-155) minutes (p <0.001)]. CONCLUSION: Clinicians caring for paediatric trauma patients in facilities outside trauma centres require the capability and opportunity to identify and notify early those requiring transfer for ongoing management. The provision of a streamlined referral and transfer process for all paediatric trauma patients requiring treatment in NSW PTCs would reduce the burden on the referring facility, reduce variation amongst transport providers and improve time to definitive care.

Emergency department management of severely injured children in New South Wales.

OBJECTIVE: Presentations to EDs for major paediatric injury are considerably lower than for adults. International studies report lower levels of critical intervention, including intubation, required in injured children. A New South Wales study demonstrated an adverse event rate of 7.6% in children with major injury. Little is known about the care and interventions received by children presenting to Australian EDs with major injury. METHODS: The ED care of injured children <16 years who ultimately received definitive care at a New South Wales Paediatric Trauma Centre between July 2015 and September 2016, and had an Injury Severity Score ≥9, required intensive care admission or died were included. RESULTS: There were 491 injured children who received treatment at 64 EDs, half (49.4%, n = 243) were treated initially in a Paediatric Trauma Centre. One third (32.8%) sustained an Injury Severity Score >12, more than half (n = 251, 51.1%) of children were classified as a triage category 1 or 2, and 38.3% received trauma team activation. Critical intervention was infrequent. Intubation was documented in 9.2% (n = 45), needle thoracostomy and activation of massive transfusion protocol in two (0.4%) and eight (1.6%) had intraosseous access established. Only a small proportion (14.7%, n = 63) had two or more observations outside the normal range. CONCLUSION: A small proportion of children arriving in the ED post-major trauma have deranged clinical observations and receive critical interventions. The limited exposure in the management of trauma in paediatric patients requires measures to ensure clinicians have adequate training, skills and confidence to manage these clinical presentations in all EDs.

Acticoat versus biobrane: a retrospective review on the treatment of paediatric mid-dermal torso burns.

OBJECTIVES: Scalds involving toddlers commonly involve the torso and are frequently mid-dermal in depth. Initial management of a mid-dermal burn is conservative, progressing to grafting if healing has not been achieved in 10-14 days. Historically BiobraneTM (UDL Laboratories, Inc., Sugar Land, TX) is thought to have more favourable clinical outcomes compared to Acticoat TM (Smith and Nephew, St. Petersburg, Fl, USA). The Burns Unit at The Children's Hospital at Westmead (CHW) uses both dressings on a regular basis, providing the opportunity to compare the results of the dressings in a cohort of patients with mid-dermal torso burns. METHOD: A retrospective review was undertaken of all paediatric mid-dermal torso burns admitted to CHW between 2015 and 2017. The primary outcomes analysed were: time to complete healing and the need for grafting. Secondary outcomes included: operating theatre time, clinic visits, length of stay in hospital and positive wound swab colonisation. RESULTS: 78 children met the study criteria, 64 (82%) in the Acticoat group and 14 (18%) in the Biobrane group. 36 out of 78 children (56%) in the Acticoat group had their burns spontaneously healed without the need of skin graft surgery, compared with 10 out of 14 children (71%) in the Biobrane group. The days to complete healing were quicker in the Acticoat group (13 days) compared to the Biobrane group (17 days), although this was not statistically significant (P = 0.3). Overall patients managed with the Biobrane dressing required more operative sessions under general anaesthesia, a longer hospital stay, more clinic visits and a higher number of positive wound swab colonisation with heavy growth compared to the Acticoat group. CONCLUSION: This study suggests that the use of the Biobrane dressing does not significantly improve the clinical outcomes of mid-dermal torso burns in children compared to the Acticoat dressing. Acticoat reduced healing time, decreased the requirements for a general anaesthesia, reduced inpatient hospital stay and risk of infection.

Assessment and management of minor burns in children.

BACKGROUND: Approximately 1% of the Australian and New Zealand population seeks medical assistance for a burn injury each year, and many patients presenting with burns are children. Minor burns that do not meet referral criteria can be managed by the family general practitioner (GP). If there are any concerns about the injury or progress of the burn wound healing, GPs are encouraged to contact their local burns service for advice. OBJECTIVE: The aim of this article is to provide primary healthcare clinicians with a summary of the acute management of minor burns in children. DISCUSSION: Effective first aid for burns will minimise burn progression and alleviate pain. Appropriate wound care will promote optimal healing and potentiate favourable outcomes. Although a minor burn may not meet initial referral criteria for transfer to a specialised burn centre, GPs are encouraged to refer if there are any concerns in relation to wound healing, pain management or scarring, or if consultative advice regarding management is required.

Hospitalised burns in children up to 16 years old: A 10-year population-based study in Australia.

AIM: Globally, burns remain a significant public health issue that disproportionately affect young children. The current study examines the 10-year epidemiological profile of burn hospitalisations, hospital treatment cost and health outcomes by age group for children ≤16 years in Australia. METHODS: National, population-based, linked hospital and mortality data from 1 July 2002 to 30 June 2012 were used to identify burn-related hospitalisations. Age-standardised hospitalisation rates and hospital treatment costs were estimated. RESULTS: There were 25 098 children aged ≤16 years hospitalised after sustaining a burn. The age-standardised hospitalisation rate was 54.4 per 100 000 (95% confidence interval (CI): 53.7-55.1). Children aged 1-5 years had the highest burn hospitalisation rate (105.6 per 100 000; 95% CI: 103.8-107.3). The burn hospitalisation rate of infants <1 year declined by 3.1% per annum (95% CI: -4.84, -1.37, P < 0.001). Contact with heat and other substances, hot drinks, food, fats and cooking oils was the most common burn mechanism, and the home was the most common place of occurrence for children ≤10 years. Exposure to the ignition of highly flammable material was the most common burn mechanism for children aged 11-16 years. There were 7260 hospital readmissions within 28 days and 11 deaths within 30 days of the index burn hospitalisation. Total hospital treatment costs were estimated at $168 million. CONCLUSIONS: Childhood burns continue to account for a large proportion of hospitalised morbidity. To assist in reducing burn hospitalisations, the development, implementation and resourcing of national multi-sectorial childhood injury prevention is needed in Australia.

Biobrane™ versus acticoat™ for the treatment of mid-dermal pediatric burns: a prospective randomized controlled pilot study.

OBJECTIVES: The management of pediatric mid-dermal burns is challenging. Anecdotal evidence suggests Biobrane™ (UDL Laboratories, Inc., Sugar Land, TX) may expedite epithelization, reducing the requirement for skin grafting. Our standard management for burns of this depth is Acticoat™ (Smith and Nephew, St. Petersburg, Fl, USA). No publications are known to compare Biobrane™ to Acticoat™ for treatment of mid-dermal burns. METHODS: A prospective, randomised controlled pilot study was conducted, comparing Biobrane™ to Acticoat™ for mid-dermal burns affecting ≥ 1% Total Body Surface Area (TBSA) in children. Mid-dermal burns were confirmed using Laser Doppler Imaging within 48 hours of injury. Participants were randomized to Biobrane™ with an Acticoat™ overlay or Acticoat™ alone. RESULTS: 10 participants were in each group. Median age and TBSA were similar; 2.0 (Biobrane™) and 1.5 years (Acticoat™), 8% (Biobrane™) and 8.5% TBSA (Acticoat™). Use of Biobrane™ had higher infection rates (6 children versus 1) (P = 0.057) and more positive wound swabs, although not significant (7 children versus 4) (P = 0.37). Healing time was shorter in the Biobrane™ group, this was not significant (19 days versus 26.5 days, P = 0.18). Median dressing changes were similar (5 versus 5.5) (P = 0.56). Skin grafting requirement was greater in the Acticoat™ group (7 versus 4 children, P = 0.37) and similar in % TBSA (1.75% TBSA). CONCLUSION: This pilot study suggests that the use of Biobrane™ for mid-dermal burns in children may be associated with increased risk of infection but appears to decrease the time to healing and therefore the need for skin grafting compared to Acticoat™ alone.

A population-based comparison of the post-operative outcomes of open and laparoscopic appendicectomy in children.

OBJECTIVE: To assess and compare the post-operative outcomes of open and laparoscopic appendicectomy in children. DESIGN: Record linkage analysis of administrative hospital (Admitted Patient Data Collection) and emergency department (Emergency Department Data Collection) data.Participants, setting: Children under 16 years of age who underwent an appendicectomy in a public or private hospital in New South Wales between January 2002 and December 2013. MAIN OUTCOME MEASURES: Association between type of appendicectomy and post-operative complications within 28 days of discharge, adjusted for patient characteristics and type of hospital. RESULTS: Of 23 961 children who underwent appendicectomy, 19 336 (81%) had uncomplicated appendicitis and 4625 (19%) had appendicitis complicated by abscess, perforation, or peritonitis. The proportion of laparoscopic appendicectomies increased from 11.8% in 2002 to 85.8% in 2013. In cases of uncomplicated appendicitis, laparoscopic appendicectomy was associated with more post-operative complications (mostly symptomatic re-admissions or emergency department presentations) than open appendicectomy (7.4% v 5.8%), but with a reduced risk of post-operative intestinal obstruction (adjusted odds ratio [aOR], 0.59; 95% CI, 0.36-0.97). For cases of complicated appendicitis, the risk of wound infections was lower for laparoscopic appendicectomy (aOR, 0.67; 95% CI, 0.50-0.90), but not the risks of intestinal obstruction (aOR, 0.97; 95% CI, 0.62-1.52) or intra-abdominal abscess (aOR, 1.06; 95% CI, 0.72-1.55). CONCLUSION: Post-appendicectomy outcomes were similar for most age groups and hospital types. Children with uncomplicated appendicitis have lower risk of post-operative bowel obstruction after laparoscopic appendicectomy than after open appendicectomy, but may be discharged before their post-operative symptoms have adequately resolved.

The impact of general anesthesia on child development and school performance: a population-based study.

BACKGROUND: There has been considerable interest in the possible adverse neurocognitive effects of exposure to general anesthesia and surgery in early childhood. AIMS: The aim of this data linkage study was to investigate developmental and school performance outcomes of children undergoing procedures requiring general anesthesia in early childhood. METHODS: We included children born in New South Wales, Australia of 37+ weeks' gestation without major congenital anomalies or neurodevelopmental disability with either a school entry developmental assessment in 2009, 2012, or Grade-3 school test results in 2008-2014. We compared children exposed to general anesthesia aged <48 months to those without any hospitalization. Children with only 1 hospitalization with general anesthesia and no other hospitalization were assessed separately. Outcomes included being classified developmentally high risk at school entry and scoring below national minimum standard in school numeracy and reading tests. RESULTS: Of 211 978 children included, 82 156 had developmental assessment and 153 025 had school test results, with 12 848 (15.7%) and 25 032 (16.4%) exposed to general anesthesia, respectively. Children exposed to general anesthesia had 17%, 34%, and 23% increased odds of being developmentally high risk (adjusted odds ratio [aOR]: 1.17; 95% CI: 1.07-1.29); or scoring below the national minimum standard in numeracy (aOR: 1.34; 95% CI: 1.21-1.48) and reading (aOR: 1.23; 95% CI: 1.12-1.36), respectively. Although the risk for being developmentally high risk and poor reading attenuated for children with only 1 hospitalization and exposure to general anesthesia, the association with poor numeracy results remained. CONCLUSION: Children exposed to general anesthesia before 4 years have poorer development at school entry and school performance. While the association among children with 1 hospitalization with 1 general anesthesia and no other hospitalization was attenuated, poor numeracy outcome remained. Further investigation of the specific effects of general anesthesia and the impact of the underlying health conditions that prompt the need for surgery or diagnostic procedures is required, particularly among children exposed to long duration of general anesthesia or with repeated hospitalizations.

Trauma hazards in children: An update for the busy clinician.

Trauma and injury continue to be common in children and remain an important cause of mortality and morbidity. Legislation mandating the use of helmets for all cyclists appears to have been effective in reducing the incidence and severity of head and facial injuries, with no clear evidence of a reduction in cycling usage or activity. Straddle injuries, whilst uncommon and generally minor, require careful clinical assessment as they may be associated with urethral trauma. Quad bikes remain highly dangerous with continuing reports of deaths in child riders due to their inherent lack of stability: a ban on their use by children would seem the most effective solution. The popularity of mobile devices and toys, coupled with the development of higher voltage, lithium button batteries have seen a surge in the number of cases and subsequent complications from ingestion. The problems seen in children following ingestion of high-powered, rare earth magnets in the late 1990s and 2000s has now receded due to legislation introduced in 2012. Inhaled, typically organic foreign bodies remain a diagnostic challenge with rigid bronchoscopy still the most effective diagnostic and therapeutic modality. Corrosive ingestion, now seen much less commonly, continues to be a potentially devastating injury when occurring as a result of caustic soda. Recent publicity concerning the problem of childhood drowning highlights the need for constant parental vigilance, the limitations of pool fencing and the importance of community cardiopulmonary resuscitation training, together with repeated education of the risk of rips when swimming in the sea.

Differences in survival outcome for severely injured paediatric trauma by type of trauma centre.

AIM: Whether treatment at paediatric trauma centres (PTCs) provides a survival advantage for injured children over treatment at adult trauma centres (ATCs) remains inconclusive. This study examines the association between trauma centre type and in-hospital mortality for severely injured paediatric trauma patients in New South Wales, Australia. METHODS: A retrospective examination of paediatric patient characteristics (aged ≤15 years), treatment and injury outcome was conducted using data from the New South Wales Trauma Registry for 2009-2014. Logistic regression was used to examine the association of in-hospital mortality and type of trauma centre. RESULTS: There were 1230 children who were severely injured (i.e. Injury Severity Score; ISS > 12) and 81.0% received definitive care at a PTC. Two-thirds were male, 37.8% were aged 11-15 years and falls represented 32.0% of the injuries. Almost half (48.9%) the injured children had an ISS between 16 and 24, 31.9% between 25 and 39 and 3.8% an ISS between 40 and 75. The mean and median hospital length of stay was 17.5 and 5 days, respectively. Fifty percent of children that received definitive care at a PTC were admitted to an ICU compared to 23.9% at a Level 1 ATC. There were 119 (9.7%) in-hospital deaths. Children aged ≤15 years who were treated at a Level 1 ATC had 6.1 times higher odds of not surviving their injuries than if treated at a PTC. CONCLUSION: Children who received definitive care at a PTC had a survival advantage compared to those treated at a Level 1 ATC. Prospectively examining the processes of care for severely injured children may assist in identification of quality and system changes required to ensure optimal trauma care within the health-care system.

The effect of ambient lighting on Laser Doppler Imaging of a standardized cutaneous injury model.

OBJECTIVE: The aim of this study was to investigate the potential confounding effects of four different types of ambient lighting on the results of Laser Doppler Imaging (LDI) of a standardized cutaneous injury model. METHODS: After applying a mechanical stimulus to the anterior forearm of a healthy volunteer and inducing a wheal and arteriolar flare (the Triple response), we used a Laser Doppler Line Scanner (LDLS) to image the forearm under four different types of ambient lighting: light-emitting-diode (LED), compact fluorescent lighting (CFL), halogen, daylight, and darkness as a control. A spectrometer was used to measure the intensity of light energy at 785 nm, the wavelength used by the scanner for measurement under each type of ambient lighting. RESULTS: Neither the LED nor CFL bulbs emitted detectable light energy at a wavelength of 785 nm. The color-based representation of arbitrary perfusion unit (APU) values of the Triple response measured by the scanner was similar between darkness, LED, and CFL light. Daylight emitted 2 mW at 785 nm, with a slight variation tending more towards lower APU values compared to darkness. Halogen lighting emitted 6 mW of light energy at 785 nm rendering the color-based representation impossible to interpret. CONCLUSIONS: Halogen lighting and daylight have the potential to confound results of LDI of cutaneous injuries whereas LED and CFL lighting did not. Any potential sources of daylight should be reduced and halogen lighting completely covered or turned off prior to wound imaging.

A novel device to create consistent deep dermal burns in a porcine model.

We conducted this study to evaluate a novel device to create a consistent and reproducible deep partial thickness burn in a porcine model. A thermostatically controlled, heated aluminium disc device was fashioned by the Biomedical Department of our institution. Contact burns were made on the flank of two Great White pigs by applying the device heated to 92°C at intervals of 5, 10, 15 and 20 seconds to four separate test areas area of skin. Biopsies for histological analysis of burn depth were taken on day 0 at 10 minutes post burn and on day 8. Biopsies taken at day 0 revealed superficial to mid-dermal burns, with minimal dermal edema and necrosis. Those from day 8 showed mid to deep dermal edema and necrosis in all four test areas following a 20 second contact duration burn. The new contact burn device was able to create a consistent deep dermal burn after 20 seconds of contact. We anticipate that this new device could be used to investigate the development of hypertrophic scarring in a porcine model.

Biobrane™ and skin staples: beware of necrotic ulceration.

Biobrane™ is a product used for temporary wound coverage post major paediatric burn wound debridement. We report two cases of necrotic ulceration associated with the use of Biobrane™ with skin staples. We suggest securing Biobrane™ with alternatives such as adhesive tapes and glue to prevent the occurrence of this adverse outcome.

Acute costs and predictors of higher treatment costs for major paediatric trauma in New South Wales, Australia.

AIMS: To describe the costs of acute trauma admissions for children aged ≤15 years in trauma centres; to identify predictors of higher treatment costs and quantify differences in actual and state-wide average cost in New South Wales (NSW), Australia. METHOD: Admitted trauma patient data provided by 12 trauma centres was linked with financial data for 2008-2009. Demographic, injury details and injury severity scores (ISS) were obtained from trauma registries. Individual patient costs, Australian Refined Diagnostic Related Groups (AR-DRG) and state-wide average costs were obtained. Actual costs incurred by each hospital were compared with state-wide AR-DRG average costs. Multivariate multiple linear regression identified predictors of cost. RESULTS: There were 3493 patients with a total cost of AUD$20.2 million. Falls (AUD$6.7 million) and road trauma (AUD$4.4 million) had the highest total expenditure. The reduction in cost between ISS < 9 compared to ISS 9-12 and ISS > 12 was significant (P < 0.0001). The median cost of injury increased with every additional body region injured (P < 0.0001). For each additional day spent in hospital, there was an increased cost of AUD$1898 and patients admitted to an intensive care unit (ICU) cost AUD$7358 more than patients not admitted to ICU. The total costs incurred by trauma centres were AUD$1.4 million above the NSW peer group average cost estimates. CONCLUSIONS: The high financial cost of paediatric patient treatment highlights the need to ensure prevention remains a priority in Australia. Hospitals tasked with providing trauma care should be appropriately funded and future funding models should consider trauma severity.

Early developmental outcome following surgery for oesophageal atresia.

AIM: To compare the developmental outcome of infants with oesophageal atresia with or without trachea-oesophageal fistula (OA/TOF) who underwent surgery in early infancy with healthy control infants in New South Wales, Australia. METHODS: Infants diagnosed with OA/TOF requiring surgical intervention were enrolled prospectively between 1 August 2006 and the 31 December 2008. Healthy control infants were enrolled in the same time period. The children underwent a developmental assessment at 1 year of age (corrected) using the Bayley Scales of Infant and Toddler Development (Version III). RESULTS: Of 34 infants with OA/TOF that were enrolled, 31 had developmental assessments. The majority (75%) were term infants (≥37 weeks gestation) with a mean birth weight of 2717 g. Fourteen infants (44%) had an associated birth defect and one infant with multiple associated anomalies subsequently died. Developmental assessments were also performed on 62 control infants matched for gestational age. Infants with OA/TOF had a mean score significantly lower on the expressive language subscale (P < 0.05) compared with the control infants. CONCLUSIONS: This study found a lower than expected developmental score for infants following surgery for OA/TOF in the expressive language subscale compared with the healthy control infants. These findings support concerns over the potential impact of OA/TOF and its effects on development. Further studies, including continuing developmental review to determine whether these differences persist and their functional importance, should be performed.