Archives of Disease in Childhood最新文献

Objective: To determine whether National Health Service (NHS) 111 advice regarding paediatric patients given by clinically trained health advisors (CHAs) is, as previously found for adult patients, less risk-averse, more accurate and complied with more than that given by non-clinically trained health advisors (NHAs) DESIGN: Retrospective observational study using routinely collected, linked NHS urgent care data.

Setting: NHS 111 triaging services in Yorkshire and the Humber, 2014-2017.

Patients: Children (<16 years) who were the subject of a call to NHS 111.

Main outcome measures: The recommendation given, whether the patient attended the emergency department (ED) within 48 hours and if so whether the patient was admitted to hospital, or considered 'non-urgent'. Adjusted logistic regressions were used for analysis.

Results: 972 221 calls were analysed (26.5% CHA; 73.5% NHA). CHAs were more likely than NHAs to recommend guardian/self-care (OR 45, 95% CI 44 to 46), and less likely to recommend ambulance dispatch (OR 0.5; 95% CI 0.48 to 0.51), ED attendance (OR 0.79; 95% CI 0.77 to 0.8) or primary care (OR 0.163; 95% CI 0.161 to 0.165). Patients were less likely to attend ED following guardian/self-care recommendations from CHAs versus NHAs (OR=0.64; 95% CI 0.56 to 0.74), but no more likely to be admitted if they did attend (OR 1.2; 95% CI 0.8 to 1.8). Callers were more likely to terminate a call before receiving a formal recommendation from a CHA (OR 2.02; 95% CI 2.0 to 2.1). Call-terminators were less likely to attend ED (OR 0.128; 95% CI 0.12 to 0.13) and more likely to be considered non-urgent if attending ED (OR 1.23; 95% CI 1.2 to 1.3) if advised by a CHA.

Conclusions: Paediatric patient journeys suggest triage by CHAs is less risk-averse and more accurate. Patients are more likely to avoid attending ED if advised to by a CHA. Callers who terminate a call early may typically represent the 'worried well'. CHAs may better identify these patients and discourage them from attending ED in prerecommendation conversation. This has implications for the cost-benefit balance of NHS 111 staffing.

Objective: To establish the incidence of adrenal crisis (AC) in patients treated with supraphysiological glucocorticoid (GC) for nephrotic syndrome (NS) or juvenile idiopathic arthritis (JIA) and hence at risk of adrenal suppression (AS).

Design: Retrospective observational single centre study.

Setting: Great North Children's Hospital, Newcastle upon Tyne.

Patients: Children aged 1 month-<16 years, who received supraphysiological GC for NS or JIA within a defined period.

Main outcome measures: Monthly GC regimen and incidence of AC identified by reviewing: (1) clinic letters and emergency department attendance, (2) region wide electrolyte results, (3) clinical coding and (4) proactive discussion with respective clinical teams.

Results: 97 patients were included, totalling 2363 patient months of follow-up. During GC weaning, all NS and 15% of JIA patients were switched to an alternate day GC regimen. A total of 974 patient months were observed following discontinuation of GC and no episodes of AC were identified. An assessment of AC events in other published cohorts indicated that the low incidence is not simply a reflection of poor sensitivity linked to sample size.

Conclusions: This study suggests that supraphysiological GC administered for several weeks can potentially be weaned and stopped safely without formal biochemical assessment in patients with NS and JIA. Specialist teams provide families with rapid access to advice which supports safe practice. An alternate day weaning regimen following a modest period of daily supraphysiological GC may have reduced the likelihood of AS at critical times.

Objective: To determine if an age-appropriate intervention is more effective than treatment as usual (TAU) in reducing post-traumatic stress disorder (PTSD) symptoms in parents/guardians of children discharged from paediatric intensive care unit (PICU).

Design: A two-arm, parallel-group, single-centre randomised controlled trial.

Setting: PICU, St Mary's Hospital, London, UK.

Patients: Children admitted to the PICU between July 2021 and September 2022, with a length of stay >24 hours, and a corrected gestational age of >36 weeks at the time of PICU admission, up to <16 years of age. Parents/guardians were required to be >18 years old. We predefined subgroups of children as those <4 years and those ≥4 years.

Intervention: An age-appropriate educational booklet given at PICU discharge and a targeted telephone call at 6 weeks posthospital discharge.

Main outcomes and measures: Parental PTSD symptoms 6 months after PICU discharge, measured by the Impact of Events Scale-Revised (IES-R).

Results: 679 children were admitted to PICU, 212 were eligible for enrolment, 81 declined and 131 were included, of which 126 completed the study. 64 were randomised to TAU and 62 to intervention. 6-month questionnaires were returned by 60 families (36 from TAU group and 24 from intervention group (p=0.049)). There was no significant difference in IES-R scores between the TAU and intervention groups overall (IES-R score 37 vs 17 (p=0.132)). The ≥4-year intervention group had lower IES-R scores compared with TAU (13 in intervention vs 42 in TAU (p=0.008)). There was no difference in the <4-year group or in any secondary outcome.

Conclusions: This intervention was effective in reducing PTSD symptoms in parents of children ≥4 years after PICU discharge.

Trial registration number: NCT04635449.

Introduction: We aimed to establish the clinical characteristics of children and young people (CAYP) currently receiving deep brain stimulation (DBS) therapy for the management of movement disorders in the UK to better inform planning of future service provision.

Methods: Cross-sectional service evaluation of centres providing DBS for the management of movement disorders in childhood.

Results: A total of 139 CAYP were identified across three centres. Median age at surgery was 9.8 years (range 2.0-18.9 years), and median duration of DBS was 4.4 years (range from 1 week to 15.75 years). Modal Gross Motor Function Classification System level was V (n=66). The most common causes of movement disorder were dyskinetic cerebral palsy (69/139, 49.6%), dystonia due to mutations in the lysine methyltransferase 2B gene, aka DYT-KMT2B, (13/139, 9.4%) and dystonia due to mutations in the Torsin-1A gene, aka DYT-TOR1A, (9/139, 6.5%). A monogenetic cause of dystonia without evidence of central nervous system pathology on MRI was identified in 30 CAYP (21.6%). Clinically significant dystonia was present in all CAYP, with significant chorea in 47/139 (33.8%) and significant spasticity in only 13/139 (9.4%). No tone-reducing medications were currently used by 43/139 (30.9%) of CAYP. The remaining 96/139 CAYP were currently receiving 1-6 tone-reducing medications, most commonly gabapentin (n=58), clonidine (n=50) and a form of benzodiazepine (n=43). Despite care being provided by paediatric services, 37/139 (26.6%) of CAYP were >18 years of age.

Conclusions: CAYP currently receiving DBS therapy represent a heterogeneous population in terms of dystonia aetiology, functional level and additional pharmacological management. Only 102 CAYP<18 years of age are currently receiving DBS therapy in the UK, representing a small proportion of the population who could benefit from this intervention.