Paediatric Head Injury and Traumatic Brain Injury.

Aim To determine prevalence of head injury presenting to paediatric emergency departments (PEDs) and characterise by demographics, triage category, disposition neuroimaging or re-attendance. Methods Presentations in 2014 and 2015, with diagnoses of head injury, intracranial bleed, skull fracture including single or re-attendances within 28 days post head injury to all national PEDs, were analysed. Demographics, triage score, imaging rate, admission, mechanisms and representation rate were recorded. Results Head injury was diagnosed in 13,392 of 224,860 (5.9%), median (IQR) age 3.9 (1.4 - 8.3) years. Regionally 3% of children <5 years attend each year. The total admitted/transferred was 10.8% (n=1460). Neuroimaging rate was 4.3% (n= 570). Falls predominated. Sport accounted for 12.2%. Conclusion One in twenty children PED presentations are head injury, over half in preschool children. A sizeable number were symptomatic reflected by admission, transfer, imaging or re-attendance. Observational management was favoured over imaging reflected in the higher admission versus imaging rate.

Paediatric Early Warning Trigger--A Cry for Help.

In paediatrics, it is crucial to ensure that the child who is clinically deteriorating is rapidly recognised and treated. We implemented a Paediatric Early Warning Trigger (PEWT) in our unit to improve recognition of these patients. Our trigger was a series of physiological measurements with a PEWT call if any result was outside the accepted range. We retrospectively compared 12 months prior to the introduction of the trigger (January to December 2009) to the three years post the introduction of the trigger (January 2010 to December 2012). We compared the time from deterioration to involvement of senior staff during the two time periods. We also examined the rates of crash calls and PICU transfers in the two periods. We found that the time from deterioration to senior clinician involvement reduced from 312 minutes to 166 minutes and the rate of transfers to PICU among the triage category 1 & 2 patients reduced from 1:50 in 2009 to 1:129, 1:118 and 1:131 during the three years of the trial. The rate of cardiac arrest among this group reduced from 1:100 in 2009 to 1:129, 1:216 and 1:542 during the three years of the trial. This study demonstrates the effectiveness of a Paediatric Early Warning Trigger in an Irish setting. We have been able to maximise senior clinician input into our sickest children in a more timely fashion

The compliance to acute asthma management protocols in paediatric emergency department.

Asthma guidelines should be followed closely to ensure improvement and consistency of outcome. In order to measure compliance with local acute asthma protocols, we reviewed notes of children presenting to our ED with acute asthma. We noted clinical assessment of severity of asthma exacerbation, compared management of cases with local protocols, noted time to first nebulisation, discharge advice and follow up plans. Retrospectively, 6 patients had life-threatening, 70 had severe and 64 had mild-to-moderate exacerbation. We observed inconsistent documentation of clinical signs including, respiratory effort 6 (100%), 62 (89%), 39 (61%), mental status 3 (50%), 46 (65%), 47 (73%) and speech 1 (16.7%), 19 (27%), 7 (11%) in life threatening, severe and mild-to-moderate groups respectively. Bronchodilator therapy was delayed in life-threatening 3 (50%) and severe cases 63 (90%). While discharge advice was documented in 54% patients, no written asthma action plans were given. This study demonstrated necessity of protocol-adherence in areas of clinical assessment, management and follow up.

Modes of death in neonatal intensive care units.

With the ever-increasing availability of aggressive medical treatment and technical support, neonatologists are offered an increasing ability to prolong life. While "end-of-life" decisions within NICUs have been studied internationally, there is limited data available for Ireland. Through the auspices of the Irish Faculty of Paediatrics 2002 Neonatal Mortality Ouestionnaire, decisions made around the time of death in Irish Neonatal Intensive Care Units were examined. The overall response rate to the questionnaire was 96% (n=25). One hundred and eighty seven deaths were reported for 2002. Information pertaining to the mode of death was available in 53% of cases. Seventy seven percent of those paediatricians who answered this question, reported either withdrawing or withholding treatment in babies thought to have a hopeless outcome, with the greatest proportion of these deaths occurring in premature infants (n=30) and babies with congenital defects (n=40).

Complications associated with the bacille Calmette-Guérin vaccination in Ireland.

INTRODUCTION: BCG vaccination is currently recommended for all newborns in Ireland except where specifically contraindicated. This paper describes a marked increase in the number of referrals of patients with localised complications after vaccination to two Dublin paediatric hospitals. This increase coincided with the introduction of a new strain of BCG vaccine METHODS: A population surveillance study was undertaken to determine the frequency and spectrum of complications associated with the new strain of BCG vaccine introduced in Ireland. Patients were identified though review of the infectious disease service case records and microbiology laboratory culture reports for the two year period from August 2002 to July 2004. Prospectively gathered data were supplemented by retrospective chart review. All infants who had inoculation site abscesses, suppurative adenopathy, or non-suppurative adenopathy with nodes > or =2 cm were included. RESULTS: Fifty eight patients presented a median of 13 weeks post-inoculation: 32 with suppurative adenitis, 17 with inoculation site abscess, three with both inoculation site abscess and suppurative adenitis, and six with non-suppurative adenopathy. The overall complication rate was estimated at 1/931 vaccinees with 1/1543 developing suppurative adenitis. Twenty six infants required surgery. DISCUSSION: This series illustrates the role of hospitals in sentinel surveillance and highlights the importance of having a well functioning and responsive system of adverse event reporting. These events raise a serious question as to the suitability of this vaccine strain for use in a national immunisation programme in a country where the prevalence of tuberculous disease is 10.4/100,000.

The modular nature of histone deacetylase HDAC4 confers phosphorylation-dependent intracellular trafficking.

In C2C12 myoblasts, endogenous histone deacetylase HDAC4 shuttles between cytoplasmic and nuclear compartments, supporting the hypothesis that its subcellular localization is dynamically regulated. However, upon differentiation, this dynamic equilibrium is disturbed and we find that HDAC4 accumulates in the nuclei of myotubes, suggesting a positive role of nuclear HDAC4 in muscle differentiation. Consistent with the notion of regulation of HDAC4 intracellular trafficking, we reveal that HDAC4 contains a modular structure consisting of a C-terminal autonomous nuclear export domain, which, in conjunction with an internal regulatory domain responsive to calcium/calmodulin-dependent protein kinase IV (CaMKIV), determines its subcellular localization. CaMKIV phosphorylates HDAC4 in vitro and promotes its nuclear-cytoplasmic shuttling in vivo. However, although 14-3-3 binding of HDAC4 has been proposed to be important for its cytoplasmic retention, we find this interaction to be independent of CaMKIV. Rather, the HDAC4.14-3-3 complex exists in the nucleus and is required to confer CaMKIV responsiveness. Our results suggest that the subcellular localization of HDAC4 is regulated by sequential phosphorylation events. The first event is catalyzed by a yet to be identified protein kinase that promotes 14-3-3 binding, and the second event, involving protein kinases such as CaMKIV, leads to efficient nuclear export of the HDAC4.14-3-3 complex.

Conserved regions of the Drosophila erect wing protein contribute both positively and negatively to transcriptional activity.

Genetic studies of the Drosophila erect wing (ewg) gene have revealed that ewg has an essential function in the embryonic nervous system and is required for the specification of certain muscle cells. We have found that EWG is a site-specific transcriptional activator, and we report here that evolutionarily conserved regions of EWG contribute both positively and negatively to transcriptional activity. Using gel mobility shift assays, we have shown that an EWG dimer binds specifically to DNA. In transfection assays, EWG activated expression of a reporter gene bearing specific binding sites. Analysis of deletion mutants and fusions of EWG to the Gal4 DNA binding domain has identified a transcriptional activation domain in the C terminus of EWG. Deletion analysis also revealed a novel inhibitory region in the N terminus of EWG. Strikingly, both the activation domain and the inhibitory region are conserved in EWG homologs including human nuclear respiratory factor 1 (NRF-1) and the sea urchin P3A2 protein. The strong conservation of elements that determine transcriptional activity suggests that the EWG, NRF-1, and P3A2 family of proteins shares common mechanisms of action and has maintained common functions across evolution.

Transpiration efficiency of three Mediterranean annual pasture species and wheat.

Attempts to improve water use efficiency in regions with Mediterranean climates generally focus on increasing plant transpiration relative to evaporation from the soil and increasing transpiration efficiency. Our aim was to determine if transpiration efficiency differs among key species occurring in annual pastures in southern Australia. Two glasshouse experiments were conducted with three key pasture species, subterranean clover (Trifolium subterraneum L.), capeweed [Arctotheca calendula (L.) Levyns] and annual ryegrass (Lolium rigidum Gaudin), and wheat (Triticum aestivum L.). Transpiration efficiency was assessed at the levels of␣whole-plant biomass and water use (W), leaf gas exchange measurements of the ratio of CO2 assimilation to leaf conductance to water vapour (A/g), and carbon isotope discrimination (Δ) in leaf tissue. In addition, Δ was measured on shoots of the three pasture species growing together in the field. In the glasshouse studies, annual ryegrass had a consistently higher transpiration efficiency than subterranean clover or capeweed by all methods of measurement. Subterranean clover and capeweed had similar transpiration efficiencies by all three methods of measurement. Wheat had W values similar to ryegrass but A/g and Δ values similar to subterranean clover or capeweed. The high W of annual ryegrass seems to be related to a conservative leaf gas exchange behaviour, with lower assimilation and conductance but higher A/g than for the other species. In contrast to the glasshouse results, the three pasture species had similar Δ values when growing together in mixed-species swards in the field. Reasons for these differing responses between glasshouse and field-grown plants are discussed in terms of the implications for improving the transpiration efficiency of mixed-species annual pasture communities in the field.