Introduction of the low risk ankle rule to a paediatric emergency department.

INTRODUCTION: Ankle injuries are a common presentation to the paediatric emergency department (PED), accounting for approximately 2% of presentations.1 X-rays are ordered for 85-95% of patients but only 12% of x-rays reveal a fracture. Clinical prediction rules, such as The Low Risk Ankle Rule (LRAR) exist to help clinicians safely reduce the frequency of radiography in these injuries. The LRAR has been shown to reduce imaging by up to 60% without missing any clinically significant fractures. We sought to introduce The LRAR into our department and study its outcomes on our practice. AIMS: To introduce the LRAR into our department and study its effects on our radiography rate and length of stay (LOS). METHODS: An audit of x-ray rates in ankle injuries in 2016 was performed to determine our department's baseline rate of radiography and LOS. We then conducted education sessions and created x-ray ordering prompts to encourage clinicians to use the LRAR. We introduced the LRAR, with a pilot period initially, and gathered data prospectively. RESULTS: 969 patients presented in with an ankle injury in 2016, 90.7% of these patients had an x-ray. The median LOS was 109 min. 92 patients presented during  the LRAR implementation period with an ankle injury. Nine patients had exclusion criteria from using the LRAR and the attending physician did not use the LRAR in four patients. Of the remaining 79 patients, 49 had a LRAR positive exam. Only one of these patients went on to have an x-ray, which was normal. The 30 patients with a LRAR negative exam all had an x-ray. Overall, our x-ray rate during the study period was 40/92 (43.4%), a reduction of 47.3%. The average LOS during the study was 101 min. No clinically significant fractures were missed. CONCLUSION: The LRAR can safely and effectively reduce the rate of radiography in ankle injuries, without missing any clinically significant fractures.

Opportunity Costs in Paediatric Training: The Specialist Registrars Experience.

In the training process, there is a tension between the work life and home life of trainees. This study explored both the personal impact and the opportunity costs of training from the Specialist Paediatric Registrar (SPR) perspective. The survey explored 1) career progression, 2) perceived functional effectiveness at work, 3) psychological impact of hospital based training, and 4) the personal and social cost of training. Fifty-three (71%) SPRs responded of whom 47 (89%)were married or in long term relationships. Seventy-five percent of trainees had a definite career plan with 86% intending to undertake fellowship training. Seventy percent believed they were efficient time managers but 53% had difficulty in making time for academic pursuits and fifty percent experienced negative feelings, which lingered after work and interfered with their relationships at home. Seventy-four percent stated training was undertaken at significant personal cost with only 21% achieving a very satisfactory work/life balance. To address these difficulties trainee wellbeing should be addressed at the Basic Specialist Training (BST) level and the career path clearly explained outlining the challenges that are likely to be encountered.

Poor compliance with child safety restraint use while travelling.

Road traffic accidents are a leading cause of death of children. It is the law that all children should be appropriately secured when traveling in vehicles. The aim of this study was to evaluate parental conformity with these regulations and to test if advice given at a Paediatric outpatient clinic could improve compliance. Two groups were assigned, an intervention group (parents given an information leaflet and a clear explanation about appropriate restraints for their children) and a non-intervention group (received no information). They were contacted again after 2 months and asked regarding compliance. A total of 394 children from 186 families were initially given the questionnaire. Nearly one third of children (29.2%) were not using any restraint while travelling rising to 35.3% on follow up. This study concluded that once off parental education made negligible difference to an already inconsistent and haphazard approach to compliance with safety regulations.

Optical coherence tomography: a potential tool for unsupervised prediction of treatment response for Port-Wine Stains.

BACKGROUND: Treatment of Port-Wine Stains (PWS) suffers from the absence of a reliable real-time tool for monitoring a clinical endpoint. Response to treatment varies substantially according to blood vessel geometry. Even though optical coherence tomography (OCT) has been identified as a modality with potential to suit this need, it has not been introduced as a standard clinical monitoring tool. One reason could be that - although OCT acquires data in real-time - gigabyte data transfer, processing and communication to a clinician may impede the implementation as a clinical tool. OBJECTIVES: We investigate whether an automated algorithm can address this problem. METHODS: Based on our understanding of pulsed dye laser treatment, we present the implementation of an unsupervised, real-time classification algorithm which uses principal components data reduction and linear discriminant analysis. We evaluate the algorithm using 96 synthesized test images and 7 clinical images. RESULTS: The synthesized images are classified correctly in 99.8%. The clinical images are classified correctly in 71.4%. CONCLUSIONS: Principal components-fed linear discriminant analysis (PC-fed LDA) may be a valuable method to classify clinical images. Larger sampling numbers are required for a better training model. These results justify undertaking a study involving more patients and show that disease can be described as a function of available treatment options.

Laser depilation and hygiene: preventing recurrent pilonidal sinus disease.

BACKGROUND: Pilonidal sinus disease of the natal cleft is a painful and debilitating condition which often recurs despite multiple surgical undertakings. We describe the long pulsed alexandrite laser for hair depilation and the role of personal hygiene, which is often overlooked when treating this disease, as an adjunct to preventing recurrent pilonidal sinus disease. METHODS: A review of 14 patients who underwent laser hair depilation in the natal cleft following pilonidal sinus surgery. The majority of patients had recurrent disease and had undergone numerous surgical procedures (range 1-5, mean 2.07) All patients were given advice regarding meticulous personal hygiene at the time of consultation. RESULTS: 12 patients received the full course of treatment (three treatments, 6-weekly) followed by 'top-up' treatments as required (mean number of treatments 3.9). None of the patients developed recurrent disease at 1-year follow up and, to date, none have required further surgery. CONCLUSION: Laser hair depilation is a useful adjunct in preventing the recurrence of pilonidal sinus disease and should be offered routinely to all patients. This coupled with patient education regarding personal hygiene reduces the risk of developing recurrent pilonidal sinus disease.