Association of a protein phosphatase 1 activity with the human factor C1 (HCF) complex.

We have screened a human cDNA expression library with a digoxygenin-labelled protein phosphatase 1 (PP1) probe to identify novel PP1 interacting proteins. Eleven cDNA clones were isolated, which included genes encoding two previously characterised and six novel PP1 binding proteins. Three of the cDNAs encoded a protein called host cell factor (HCF), which is an essential component of the cellular complex required for the transcription of the herpes simplex virus (HSV) immediate-early (IE) genes. We demonstrate that HCF and PP1 exist as a complex in nuclear extracts and that this complex is distinct from the form of HCF that associates with HSV VP16. The data suggest novel roles for HCF and PP1, which may be relevant to their functions in transcription and cell cycle progression.

Cervical spinal injury in children's community rugby football.

OBJECTIVE: To examine the characteristics of cervical spinal injury (CSI) in school aged children injured in community based rugby football who presented to the emergency department for assessment. METHODS: This is a retrospective descriptive case series study reviewing the medical records of all children younger than 15 years of age who presented to the emergency department at the Children's Hospital at Westmead, Sydney, Australia for assessment of injury to the cervical spine between 2000 and 2003. RESULTS: There were 125 children with CSI; most (97%) were boys of mean age 12.7 years. Injuries occurred throughout the season, with an unexpected peak in June. Neck pain was the main presenting complaint (98%). Neurological symptoms were reported in 43%, half having concussion. Hyperextension of the neck accounted for a third of all cases and was usually the result of a spear tackle. Appropriate treatment of the cervical spine on the field of play before transport to hospital was inconsistently performed. Half of the players with CSI suffered secondary injuries, consisting of concussive head injury, faciomaxillary injury, eye injury, or limb fracture. Admission to hospital was common, with all children admitted undergoing further radiological assessment. Two minor fractures were reported and no permanent neurological disability. Overall, no adverse events were reported and the clinical outcome was good. CONCLUSION: CSI in children playing rugby football is rarely catastrophic although often associated with other injuries. Continued efforts are needed to educate players and referees to prevent injury.

Concussive head injury in children and adolescents related to sports and other leisure physical activities.

OBJECTIVE: To compare the characteristics of children and adolescents with concussive head injury (CHI) sustained during organised sports or other leisure physical activity. METHODS: This was a case series study reviewing the medical records retrospectively over a four year period of children 6-16 years presenting to the emergency department with a CHI after participating in sport and/or recreation activity. RESULTS: There were 592 cases of sport and recreation related concussion over the study period (2000-2003). Most of the patients (n = 424, 71.6%) were male, with half (n = 304, 51.4%) being older than 10 years of age. A total of 152 (25.7%) cases of CHI were related to playing sports. Most cases (71.2%) were mild concussion. The cause of injury was a fall (n = 322, 54.4%) or a collision. Nearly a quarter of the children (n = 143, 24.2%) were admitted to hospital, with imaging performed in 134 (22.7%). Most children were treated appropriately and no adverse events were reported. CONCLUSIONS: A severe CHI in a child is six times more likely to have resulted from organised sport than from other leisure physical activities. Outcomes for CHI in children is excellent, although their management places a considerable burden on emergency services. The need for activity restriction and the benefits of this in reducing long term cognitive effects of CHI are uncertain.

PPP1R6, a novel member of the family of glycogen-targetting subunits of protein phosphatase 1.

A complementary DNA encoding a novel human protein phosphatase 1 (PP1) glycogen-targetting subunit of molecular mass 33 kDa has been sequenced. PPP1R6 is 31% identical to the glycogen-targetting subunit (G(L)) of PP1 from rat liver, 28% identical to the N-terminal region of the glycogen-targetting subunit (G(M)) from human skeletal muscle and 27% identical to glycogen-targetting subunit PPP1R5. Unlike human PPP1R5 and its murine homologue PTG, whose mRNAs are most abundant in skeletal muscle, heart and liver, PPP1R6 is present at similar levels in a wide variety of tissues. The PPP1R6 is associated with glycogen in muscle but is not subject to the same modes of covalent and allosteric regulation as G(M) and G(L).

Nurse administered relative analgesia using high concentration nitrous oxide to facilitate minor procedures in children in an emergency department.

AIMS: To describe the experience of using high concentration nitrous oxide (N(2)O) relative analgesia administered by nursing staff in children undergoing minor procedures in the emergency department (ED) and to demonstrate its safety. METHOD: Data were collected over a 12 month period for all procedures in the ED performed under nurse administered N(2)O sedation. All children greater than 12 months of age requiring a minor procedure who had no contraindication to the use of N(2)O were considered for sedation by this method. The primary outcome measure was the incidence of a major complication namely respiratory distress or hypoxia during the procedure. Secondary outcome measures were minor complications and the maximum concentration of N(2)O used. RESULTS: Data were collected for a total of 224 episodes of nurse administered N(2)O sedation over a 12 month period. In 73.2% of children no complications were recorded. One major complication was recorded (respiratory distress) and the most common minor complication was mask intolerance in 17%. The mean maximum concentration of N(2)O used was 60.2%. CONCLUSIONS: N(2)O is a safe analgesic in children over the age of 1 year undergoing painful or stressful procedures in the ED. It may safely be administered in concentrations of up to 70% by nursing staff after appropriate training.

Near fatal envenomation from the funnel-web spider in an infant.

Children with significant envenomation require early first aid, resuscitation, and the administration of antivenom at the earliest possible time to survive. The case of a nine-month-old infant with life-threatening massive envenomation from the Sydney funnel-web spider (Atrax robustus) is presented. The infant was administered life-saving first aid (pressure immobilization bandage) and resuscitation measures prior to and during the administration of funnel-web-specific antivenom. The infant was discharged two days after the initial envenomation, without sequelae from the envenomation or antivenom. The survival of this infant is attributed to the immediate use of first aid, together with aggressive supportive measures and the administration of repeated doses of specific antivenom.

A short stay or 23-hour ward in a general and academic children's hospital: are they effective?

OBJECTIVE: We evaluated the usefulness of a short stay or 23-hour ward in a pediatric unit of a large teaching hospital, Westmead Hospital, and an academic Children's hospital, The New Children's Hospital, to determine if they are a useful addition to the emergency service. METHODS: This is a descriptive comparison of prospectively collected data on all children admitted to the short stay ward at Westmead Hospital (WH) during 1994 and the short stay ward at the New Children's Hospital (NCH) during 1997-98. These hospitals service an identical demographic area with the latter (NCH) a tertiary referral center. The following outcome measures were used: length of stay, appropriateness of stay, rate of admission to an in-hospital bed, and rate of unscheduled visits within 72 hours of discharge. Adverse events were reported and patient follow-up was attempted at 48 hours after discharge in all cases. RESULTS: The short stay ward accounted for 10.3% (Westmead Hospital) and 14.7% (New Children's Hospital) of admissions, with 56% medical in nature, 30% surgical, and the remainder procedural or psychological. Admission patterns were similar, with asthma, gastroenteritis, convulsion, pneumonia, and simple surgical conditions accounting for most short stay ward admissions. The short stay ward increased hospital efficiency with an average length of stay of 17.5 hours (Westmead Hospital) compared to 20.5 hours (New Children's Hospital). The users of the short stay ward were children of young age less than 2 years, with stay greater than 23 hours reported in only 1% of all admissions to the short stay ward. The rate of patient admission to an in-hospital bed was low, (4% [Westmead Hospital] compared to 6% [New Children's Hospital]), with the number of unscheduled visits within 72 hours of short stay ward discharge less than 1%. There were no adverse events reported at either short stay ward, with parental satisfaction high. The short stay ward was developed through reallocation of resources from within the hospital to the short stay ward. This resulted in estimated savings of $1/2 million (Westmead Hospital) to $2.3 million (New Children's Hospital) to the hospital, due to more efficient bed usage. CONCLUSION: This data demonstrates the robust nature of the short stay ward. At these two very different institutions we have shown improved bed efficient and patient care in a cost-effective way. We have also reported on greater parental satisfaction and early return of the child with their family to the community.

Fatal asthma or anaphylaxis?

The incidence of anaphylaxis is under-reported. Children with asthma are frequently atopic and prone to allergic reactions. Parents and clinicians may attribute wheeze of rapid onset to acute severe asthma, rather than recognising an anaphylactic event. Two cases of fatal anaphylaxis are reported who were initially diagnosed as acute severe asthma, and responded poorly to bronchodilator treatment. Survivors of "acute asphyxic asthma" should be screened for reactions to common allergens that provoke anaphylactic reactions. Even if no provoking factor is identified, the asthma management plan of children who survive an episode of acute asphyxic asthma should include intramuscular adrenaline (epinephrine) in addition to conventional bronchodilators.

Short stay facilities: the future of efficient paediatric emergency services.

Many children admitted to hospital can stay for 24 hours or less. Short stay facilities offer such children rapid stabilisation and early discharge with considerable financial saving. A 12 month study was completed in which data were collected from the children's emergency annex (CEA) at Westmead Hospital in Sydney's western suburbs. This university based teaching hospital provides care for a large paediatric population as well as three other district hospitals with limited children's bed capacity. From April 1994 to April 1995, 1300 children were admitted and entered into a database of general and hospital-specific information. Critical incident monitoring was undertaken and follow up with review within 24-72 hours for all children. The CEA increased hospital efficiency significantly by reducing bed days, with a saving of over $500,000 to the department. The average length of stay was 17.5 hours, and 58% of users were children of 2 years and under. Only 3% remained beyond 24 hours, and another 4% were admitted to inpatient beds for continued management of the primarily diagnosed condition. No critical incident was reported during this 12 month period. Short stay facilities are efficient and cost-effective for children with acute illness who can be rapidly stabilised with early discharge without critical incident. Children 12 months and under are particularly suited to this type of facility. Short stay facilities should be used to augment efficiency within children's emergency services which have high turnover and limited bed capacity.

Evaluation of a protocol for selective empiric treatment of fever without localising signs.

A protocol for management of young febrile children at risk for bacteraemia has been used at Westmead Hospital, a university based hospital in the western Sydney region, since early 1994. Implementation of the protocol was retrospectively evaluated for the 12 month period 1 June 1994 to 31 May 1995, using the emergency department log book as the primary data source. Altogether 498 children, aged from 3 months to 3 years, with a fever > or = 39.5 degrees C were identified over this period, of whom 291 were admitted to hospital because of evidence of sepsis or identified focal infection and 207 children without focal infection were observed in the short stay annexe of the emergency department. Fifty children, considered at high risk of bacteraemia because of a total white cell count > or = 20 x 10(9)/1 received empiric antibiotic treatment with ceftriaxone, of whom 19 subsequently had proved bacteraemia and another 10 had focal infection identified during observation in the short stay annexe. Bacteraemia was due to Streptococcus pneumoniae in 16 cases and Haemophilus influenzae type b in three. No adverse events occurred at follow up. Use of a management protocol and selection on higher white cell count criterion than previously recommended by US centres resulted in restriction of empiric antibiotic treatment to a small proportion of young febrile children presenting to a busy emergency department of whom 38% were bacteraemic.

Controlling seizures in the prehospital setting: diazepam or midazolam?

OBJECTIVE: To determine which is the most effective and safe treatment for controlling seizures in children out-of-hospital: diazepam or midazolam. METHODS: A retrospective review of the medical records of children presenting to the Emergency Department of the Children's Hospital at Westmead (CHW-ED) with seizures requiring treatment in the field by paramedics was carried out over a 4-year period (April 1996 to March 2000). In New South Wales, children with seizures in the prehospital setting received 0.5 mg/kg per rectum (p.r.) or 0.1 mg/kg i.v. diazepam until March 1998 and from March 1997 onwards they received 0.15 mg/kg i.m. or 0.1 mg/kg i.v. midazolam. The main outcome measured was cessation of seizure in the prehospital setting. Secondary outcomes were time taken to initiate treatment and the frequency of cardiorespiratory compromise. RESULTS: Over the 4-year period, 2566 children presented to CHW-ED with a seizure; 107 children were eligible for entry into the present study. Of these 107 patients, 62 received diazepam and 45 received midazolam. Thirty-one (50.0%) in the diazepam group and 15 (33.3%) in the midazolam group were febrile seizures. Both groups were similar in terms of demographics and seizure type. A comparison of diazepam with midazolam showed that both drugs were effective in stopping seizures within 5 min of drug administration (37.1% cf. 51.1%). Fewer patients in the midazolam group suffered apnoea (20.0% cf. 29.0%; P < 0.05). CONCLUSION: Midazolam controls seizures as effectively as diazepam in the prehospital setting. Furthermore, midazolam potentially reduces respiratory depression and time to treatment.

Clinical pathway using rapid rehydration for children with gastroenteritis.

OBJECTIVE: To determine in the Emergency Department (ED) the efficacy of a clinical pathway using rapid rehydration for children moderately dehydrated as a result of acute gastroenteritis. METHODS: This was a prospective study using historical controls, set in the ED of the Children's Hospital at Westmead, NSW, Australia. Subjects were aged from 6 months to 16 years presenting with vomiting and diarrhoea for <48 h who were mildly or moderately dehydrated. The intervention was a clinical pathway involving rapid rehydration using N/2 saline + 2.5% dextrose intravenously at 20 mL/kg per h for 2 h, or Gastrolyte R (Aventis Pharma, Lane Cove, NSW, Australia) via nasogastric tube at the same rate. There were 145 children in the prospective intervention group and 170 in the historical control group. The outcome measures were admission rate, percentage of patients discharged from the ED in 8 h or less, rate of re-presentations within 48 h requiring admission, and rate of procedures with intravenous cannula or nasogastric tube. RESULTS: In the moderately dehydrated children, significant reductions were observed in the admission rate and the number discharged in 8 h or less in the intervention group compared with the control group, with no significant difference in the rate of re-presentation and the rate of procedures. In the moderately dehydrated children in the intervention group, the admission rate was 29 of 52 (55.8%) compared with the controls 26 of 27 (96.3%) (P < 0.001) and the number discharged in 8 h or less was 23 of 52 (44.2%) compared with 1 of 27 (3.7%) in the controls (P < 0.01). CONCLUSION: The clinical pathway utilizing rapid rehydration in children moderately dehydrated from gastroenteritis is effective in reducing admission rates and lengths of stay in the ED.

The benefits of using clinical pathways for managing acute paediatric illness in an emergency department.

The aim of this study was to provide an evaluation of the overall effectiveness of using a number of clinical pathways in treating common acute paediatric conditions in an emergency department. This was a before and after study conducted on the effectiveness of three clinical pathways (gastroenteritis, asthma, and croup) in the emergency department of the Children's Hospital at Westmead, conducted over two separate yearly periods January to December 1996 and January to December 1999 representing before and after the introduction of clinical pathways in the emergency department. The main outcomes of the effectiveness of the pathways, namely admission to an in-patient bed, length of hospital stay and re-presentation after discharge from the ED were compared. Other outcomes of interest such as parental satisfaction and patient waiting times were also presented. Any deviation from a key clinical pathway process was reported. A total of 2854 children were managed by a clinical pathway compared to 2680 children managed before clinical pathways were introduced. The admission rate was reduced by threefold (9.1% compared to 23.6%) with a twofold reduction in length of hospital stay (32.7 h compared to 17.5 h). In 3.6% of children using a clinical pathway an unscheduled medical visit or re-presentation to the emergency department occurred after discharge, compared to 4.9% before the use of clinical pathways. No adverse events were reported in these children. In 76 cases deviation from a clinical pathway process was reported. High parental satisfaction was reported for clinical pathways throughout the study. Clinical pathways in this emergency department allowed rapid stabilisation of children, reducing admission rate, with a shortened length of hospital stay and few patients re-presenting after discharge and were well accepted by parents.

Randomised trial of intravenous salbutamol in early management of acute severe asthma in children.

BACKGROUND: The mainstay of treatment for acute asthma in children is nebulised beta 2-adrenergic agents such as salbutamol, given with corticosteroids. However, penetration of the drug to the small airways is impeded by obstruction so intravenous salbutamol may be more effective. We assessed the use of intravenous salbutamol in the management of children with acute severe asthma in a double-blind randomised study. METHODS: Children who presented to the Emergency Department of Westmead Hospital, Sydney, Australia with asthma were assessed with a clinical assessment scale, and those with severe acute asthma were given nebulised salbutamol at a dose of 2.5 mg (age < or = 2 years) or 5.0 mg (age > 2 years), made up to 4 mL with saline. Children who did not improve were eligible to enter phase one of the study. In this phase (0 h-2 h) treatment was by a standard protocol: nebulised salbutamol at the above dose: 4 L/min or 6 L/min continuous oxygen until oxygen saturation reached 93% in room air for at least 30 min; a bolus of intravenous hydrocortisone 5 mg/kg given over 3 min; and then 15 micrograms/kg intravenous salbutamol or saline, depending on randomised allocation. In phase two (2 h-24 h) the children were given nebulised salbutamol continuously then at 30 min, 1 h, 2 h, 3 h, and 4 h, according to need. All children were transferred to the ward once they were ready to start hourly nebulisation. All patients were followed up until discharge. The primary endpoints were recovery time (no longer requiring inhaled salbutamol) and persistent moderate to severe asthma 2 h after randomisation. Analyses were by intention-to-treat although no withdrawals occurred. FINDINGS: The recovery time (time to cessation of nebulised salbutamol every 30 min) was 4 h in the 14 children allocated intravenous salbutamol compared with 11.5 h for the 15 children in the control group. 2 (14%) of the intravenous salbutamol group compared with 8 (53%) of the control group needed oxygen to maintain oxygen saturation at 93% room air. The intravenous salbutamol group were ready for discharge from the emergency department 9.7 h earlier than the control group. No clinically significant side-effects were found in either group. INTERPRETATION: Addition of a 10 min infusion of salbutamol in the early treatment of children with acute severe asthma has the potential to curtail the clinical progression of asthma, reduce demand placed on hospital resources, and improve the quality of health care provided to the acutely sick child with asthma.

The level of the glycogen targetting regulatory subunit R5 of protein phosphatase 1 is decreased in the livers of insulin-dependent diabetic rats and starved rats.

Hepatic glycogen synthesis is impaired in insulin-dependent diabetic rats owing to defective activation of glycogen synthase by glycogen-bound protein phosphatase 1 (PP1). The identification of three glycogen-targetting subunits in liver, G(L), R5/PTG and R6, which form complexes with the catalytic subunit of PP1 (PP1c), raises the question of whether some or all of these PP1c complexes are subject to regulation by insulin. In liver lysates of control rats, R5 and R6 complexes with PP1c were found to contribute significantly (16 and 21% respectively) to the phosphorylase phosphatase activity associated with the glycogen-targetting subunits, G(L)-PP1c accounting for the remainder (63%). In liver lysates of insulin-dependent diabetic and of starved rats, the phosphorylase phosphatase activities of the R5 and G(L) complexes with PP1c were shown by specific immunoadsorption assays to be substantially decreased, and the levels of R5 and G(L) were shown by immunoblotting to be much lower than those in control extracts. The phosphorylase phosphatase activity of R6-PP1c and the concentration of R6 protein were unaffected by these treatments. Insulin administration to diabetic rats restored the levels of R5 and G(L) and their associated activities. The regulation of R5 protein levels by insulin was shown to correspond to changes in the level of the mRNA, as has been found for G(L). The in vitro glycogen synthase phosphatase/phosphorylase phosphatase activity ratio of R5-PP1c was lower than that of G(L)-PP1c, suggesting that R5-PP1c may function as a hepatic phosphorylase phosphatase, whereas G(L)-PP1c may be the major hepatic glycogen synthase phosphatase. In hepatic lysates, more than half the R6 was present in the glycogen-free supernatant, suggesting that R6 may have lower affinity for glycogen than R5 and G(L)

Spacer compliance after discharge following a mild to moderate asthma attack.

AIM: To assess MDIS usage in patients discharged from a children's hospital emergency department following a mild to moderate asthma attack. METHODS: Prospective observational study of 73 consecutive patients presenting to a children's hospital emergency department with a mild to moderate asthma attack. Demographic data, whether asthma literature/written MDIS instructions were provided, and who provided MDIS instructions (either a discharge coordinator or other emergency department staff) were noted. Parents of patients were telephoned after the first week following discharge and questioned about patient improvement, MDIS use/reasons for not using MDIS, and unscheduled presentations to their local doctor or hospital. RESULTS: Following discharge, 50/73 (68.5%) patients used MDIS exclusively (compliers), while 23/73 used nebulisers some or all of the time (non-compliers). There was no difference in patient improvement or unscheduled presentations between compliers and non-compliers. Most non-compliers 14/23 (60.9%) changed because of parental preference; ease of nocturnal nebuliser use was a possible factor. Compliance was associated with the age of the patient, spacer usage at hospital, the size of device used at hospital, and whether an information fact sheet was given. CONCLUSIONS: Most children discharged from the emergency department following a mild to moderate asthma attack continue MDIS use exclusively in the first week. MDIS compliance may be associated with knowledge, experience, and ease of spacer usage. The study shows that education for parents is crucial for MDIS compliance.

Paediatric walk-out patients: characteristics and outcomes.

OBJECTIVE: To investigate the characteristics and outcomes of patients who walked out from a tertiary children's hospital emergency department (ED) without seeing a medical officer. METHODS: A prospective study of patients who walked-out from the ED of a children's hospital, without seeing a medical officer. Information collected at triage included demographics, presenting problems, time of arrival, time of departure and reason for leaving. Charts were reviewed and those at high risk of serious illness or adverse outcome were contacted by telephone within 24 h. Further information collected during follow up included outcome, such as adverse events and admission to hospital. Data were analysed by comparing the walk-out and non-walk-out groups with regard to demographic variables, presenting problems and outcomes. RESULTS: Over a 29 week period, 1037 (5.5%) patients walked out from the ED of the hospital without seeing a medical officer. Comparisons between the walk-out and non-walk-out patients indicated no differences in terms of demographics. However, significant differences were found between the triage categories, presenting problems and arrival time. Of these, 829 (79.9%) were followed up by telephone. This revealed the predominant presenting problem was non-urgent and infectious in nature and no adverse events occurred. The admission rate for walk-out patients (1.5%) was significantly lower in comparison with the non-walk-out group (6.9%; odds ratio 0.2; 95% confidence interval 0.1-0.3). Walk-out patients who were eventually hospitalized had a shorter mean length of stay than non-walk-out patients (20.4 vs 34.8 h, respectively; t = 17.78, P < 0.0001). CONCLUSIONS: Medical resources are limited and, therefore, some extended waiting in the ED is necessary. Paediatric patients who walk-out of the ED without seeing a medical officer have simple illnesses that resolve without medical intervention or adverse events.

Interplay between insulin and nutrients in the regulation of translation factors.

Protein synthesis in mammalian cells is regulated through alterations in the states of phosphorylation of eukaryotic initiation factors and elongation factors (eIFs and eEFs respectively) and of other regulatory proteins. This modulates their activities or their abilities to interact with one another. Insulin activates several of these proteins including the following: the guanine-nucleotide exchange factor eIF2B; the eIF4F complex, which (through eIF4E) interacts with the cap of the mRNA; p70 S6 kinase; and elongation factor eEF2, which mediates the translocation step of elongation. Control of the last three of these is linked to mTOR (mammalian target of rapamycin). In Chinese hamster ovary cells, regulation of all these proteins by insulin is modulated by the presence of amino acids and/or glucose in the medium. For example, p70 S6 kinase activity declines in the absence of amino acids and cannot be stimulated by insulin under this condition. The readdition of amino acids, especially leucine, restores activity and sensitivity to insulin. With eIF2B and eEF2, both amino acids and glucose must be provided for insulin to regulate their activities. In contrast, insulin-stimulation of the formation of eIF4F complexes requires glucose but not amino acids. Glucose metabolism is required for this permissive effect. Our recent studies have also identified the mechanism by which mTOR signalling regulates the phosphorylation of eEF2. eEF2 kinase is phosphorylated by p70 S6 kinase at Ser-366; this results in the inactivation of eEF2 kinase, especially at low (micromolar) Ca concentrations.

Effectiveness of a croup clinical pathway in the management of children with croup presenting to an emergency department.

OBJECTIVE: The aim of this study was to evaluate the safety and effectiveness of a clinical pathway for croup in an emergency department (ED). METHODOLOGY: This before-and-after intervention study on all consecutive children aged 6 months to 10 years who presented to our ED with moderate/severe croup was conducted over a 6-month period. Children with a clinical croup score (CSS) of 2 or more and resting stridor were considered eligible for entry into the study. Children were treated with either oral dexamethasone, or a combination of oral dexamethasone suspension and nebulized adrenaline. Children were clinically assessed, observed in the emergency short-stay ward and discharged or admitted according to the clinical pathway. The following outcomes were measured: admission rates, hospital re-presentation, length of stay, and adverse clinical events. Children in the post-intervention group were followed up by telephone within 48 h of discharge. RESULTS: There were 157 patients recruited in the pre-intervention group and 110 in the post-intervention group. Significant reductions were reported in the length of stay (18.9 h compared with 5.2 h), hospital admission (52.9% compared with 18.0%) and intensive care admission (10.2% compared with 0.0%) after the introduction of the croup clinical pathway. No children in the study experienced an adverse clinical event. Follow-up interviews of parents indicated that the new treatment strategy was well received. CONCLUSION: The use of the croup clinical pathway in the ED is safe and effective in guiding consistent management, resulting in reduced admission rates, earlier discharge home, and no reported adverse events.

Penetrating injuries in children: is there a message?

OBJECTIVES: To determine the frequency, management and outcome of penetrating trauma in children. METHODS: A retrospective review of penetrating injuries in children under 16 years of age admitted to the Children's Hospital at Westmead (CHW), and deaths reported to the New South Wales Paediatric Trauma Death (NPTD) Registry, from January 1988 to December 2000. Patient details, circumstances of trauma, injuries identified, management and outcome were recorded. RESULTS: Thirty-four children were admitted to the CHW with penetrating injuries during the 13-year period. This represented 0.2% of all trauma admissions, but 3% of those children with major trauma. The injury typically involved a male, school-age child that fell onto a sharp object or was assaulted with a knife or firearm by a parent or person known to them. Twenty-five children (75%) required operative intervention for their injuries and 14 survivors (42%) suffered long-term morbidity. Thirty children were reported to the NPTD Registry over the same interval, accounting for 2.3% of all trauma deaths in New South Wales. Of these, a significant minority was injured by falls from a mower or a tractor towing a machine with blades. CONCLUSIONS: Penetrating injuries are uncommon, but cause serious injury in children. There are two clear groups: (i) those dead at the scene or moribund on arrival, in whom prevention must be the main aim; and (ii) those with stable vital signs. Penetrating wounds should be explored in the operating theatre to exclude major injury. Young children should not ride on mowers or tractors.