Bystander rescue and cute thermal injury teaching: training and ethical implications.

The clinical outcome after thermal injury depends significantly on bystander action at the scene of the initial burn. Bystander action may save life, by rescue or by extinguishing flames; or by reducing medical complications which lead to death from respiratory injury or from secondary infection. Best-practice first aid may reduce the need for skin grafting; and can modify the rate and quality of healing. However, before first aid can begin, rescue and control of the incident site is crucial to the outcome of thermal injury. Bystanders are faced with an inescapable decision whether to attempt a rescue (or not), and the decision to choose the best method for the extinguishment of flames. This is the "rescue phase", currently a relatively neglected theme. In 1981, the St. John Ambulance Association introduced the primacy of "D" for "Danger" in the pedagogic first aid mnemonic, now in its current form of DRSABCD. Most secondary threats to the victim and risks to the rescuer come from high-energy sources [such as flames], and most involve a repetition of the primary incident. Current doctrine teaches four elements of how best to act in the rescue phase of a casually suffering from thermal injury. These imperatives are: (a) Assess for danger (b) Use protection if a rescue is undertaken; (c) Train in techniques for extinguishing the flames of the burning casualty; and (d) Train in the methods of physical retrieval to a safe place - where the standard dictates of DRSABCD can continue.

Herbert French (1875-1951) and his differential diagnosis a "work of reference unique in medical literature".

In 1912, the Guy's Hospital Assistant Physician, Dr Herbert French FRCP, published a magnum opus, An Index of Differential Diagnosis of Main Symptoms by Various Authors. This pioneering work was to formalise the paradigm of a six-chain sequence which underpins best-practice clinical medicine today. That chain comprises: taking a history, examination, compiling a differential diagnosis, tests and investigations, and formulating a diagnosis. Herbert French coined the term "differential diagnosis"; and formalised the earlier developments of Thomas Sydenham (1624 - 1689), Hermann Boerhaave (1668 - 1738) and later(1892), those of Sir William Osler in his The Principles and Practice of Medicine. French placed differential diagnosis formally as the pivot of the sequence of Oslerian medicine which distinguishes modern Western medicine from other healthcare systems. Herbert French was the Goulstonian Lecturer of the Royal College of Physicians (1907), a doctor-soldier in World War I and one of the Royal Physicians to H. M. Household. A prolific writer in the medical press, French updated and personally edited the first six editions of his Differential Diagnosis. The thirteenth edition (1996) was described as a work which "had no parallel" .This work, today in its sixteenth edition, remains "a reference unique in medical literature".

Normal Percentiles for Respiratory Rate in Children-Reference Ranges Determined from an Optical Sensor.

(1) Background: Increased respiratory rates (RRs) are described in several medical conditions, including pneumonia, bronchiolitis and asthma. There is variable methodology on how centiles for RR are derived in healthy children. Available age percentiles for RR have been generated using methods that have the potential themselves to alter the rate. (2) Methods: An optical respiratory sensor was used to measure RR. This technique enabled recording in awake children without the artefact of the observer's presence on the subject's RR. A cross-sectional sample of healthy children was obtained from maternity wards, childcare centres and schools in Brisbane, Queensland, Australia. (3) Results: RRs were observed in 560 awake and 103 sleeping children of which data from 320 awake and 94 sleeping children were used to develop centile charts for children from birth to 13 years of age. RR is higher when children are awake compared to asleep. There were significant differences between awake and sleeping RR in young children. The awake median RR was 59.3 at birth and 25.4 at 3 years of age. In comparison, the median sleeping RR was 41.4 at birth and 22.0 at 3 years. (4) Conclusions: The centile charts will assist in determining abnormal RRs in children and will contribute to further systematic reviews related to this important vital sign. This is particularly in relation to the data on children aged from 0 to 3 years, where data are presented on both the awake and sleeping state. Many studies in the literature fail to acknowledge the impact of sleep state in young children on RR.

The prevention of child drowning: the causal factors and social determinants impacting fatalities in portable pools.

ISSUE ADDRESSED: There is a scarcity of research into portable pool drowning and its prevention. This total population study examines fatal drowning among children under five in portable pools in Australia. METHODS: All child drowning deaths in portable pools for the period 1 July 2002 to 30 June 2018 were identified. A portable pool was defined as any structure used for swimming and wading which, when emptied, can be moved. RESULTS: Twenty-three children (aged 0-17 years) drowned in portable pools. The drowning rate for children less than 5 years of age was 0.09 per 100 000 population. The peak age of death was 12-23 months (RR = 2.99; CI: 1.09-8.23), with the majority (n = 20 deaths) aged 16-31 months. Ninety per cent followed a fall into water. None were supervised. Children commonly resided in areas classified as socially and economically disadvantaged (85%; n = 17). Drowning rates in very remote areas were 15 times greater (RR = 15.41; CI: 0.03-7579.65) than city children. Eleven (55%) drowning deaths occurred in pools with a depth >300 mm, of which 10 (91%) were known to be unfenced. CONCLUSIONS: Social determinants impact child drowning in portables pools, which can occur quickly and in just 150 mm of water. Active supervision and a regulation-compliant barrier are effective prevention stratagems, factors which were absent from the deaths in this study. SO WHAT?: Portable pool drowning disproportionately impacts those aged 16-31 months who reside in very remote areas and areas classified as having high socio-economic disadvantage. Education for these groups on fencing and supervision of children must be provided.

Safety and efficacy of co-careldopa as an add-on therapy to occupational and physical therapy in patients after stroke (DARS): a randomised, double-blind, placebo-controlled trial.

BACKGROUND: Dopamine is a key modulator of striatal function and learning and might improve motor recovery after stroke. Previous small trials of dopamine agonists after stroke provide equivocal evidence of effectiveness on improving motor recovery. We aimed to assess the safety and efficacy of co-careldopa plus routine occupational and physical therapy during early rehabilitation after stroke. METHODS: This double-blind, multicentre, randomised controlled trial of co-careldopa versus placebo in addition to routine NHS occupational and physical therapy was done at 51 UK NHS acute inpatient stroke rehabilitation services. We recruited patients with new or recurrent clinically diagnosed ischaemic or haemorrhagic (excluding subarachnoid haemorrhage) stroke 5-42 days before randomisation, who were unable to walk 10 m or more, had a score of less than 7 points on the Rivermead Mobility Index, were expected to need rehabilitation, and were able to access rehabilitation after discharge from hospital. Participants were assigned (1:1) using stratified random blocks to receive 6 weeks of oral co-careldopa or matched placebo in addition to routine NHS physiotherapy and occupational therapy. The initial two doses of co-careldopa were 62·5 mg (50 mg of levodopa and 12·5 mg of carbidopa) and the remaining doses were 125 mg (100 mg of levodopa and 25 mg of carbidopa). Participants were required to take a single oral tablet 45-60 min before physiotherapy or occupational therapy session. The primary outcome was ability to walk independently, defined as a Rivermead Mobility Index score of 7 or more, at 8 weeks. Primary and safety analyses were done in the intention-to-treat population. The trial is registered on the ISRCTN registry, number ISRCTN99643613. FINDINGS: Between May 30, 2011, and March 28, 2014, of 1574 patients found eligible, 593 (mean age 68·5 years) were randomly assigned to either the co-careldopa group (n=308) or to the placebo group (n=285), on an average 18 days after stroke onset. Primary outcome data were available for all 593 patients. We found no evidence that the ability to walk independently improved with co-careldopa (125 [41%] of 308 patients) compared with placebo (127 [45%] of 285 patients; odds ratio 0·78 [95% CI 0·53-1·15]) at 8 weeks. Mortality at 12 months did not differ between the two groups (22 [7%] vs 17 [6%]). Serious adverse events were largely similar between groups. Vomiting during therapy sessions, after taking the study drug, was the most frequent adverse event and was more frequent in the co-careldopa group than the placebo group (19 [6·2%] vs 9 [3·2%]). INTERPRETATION: Co-careldopa in addition to routine occupational and physical therapy does not seem to improve walking after stroke. Further research might identify subgroups of patients with stroke who could benefit from dopaminergic therapy at different doses or times after stroke with more intensive motor therapy. FUNDING: Medical Research Council.

Enduring biographic heritage - Medical numismatics.

The most enduring archive of medical biography is that composed of coins and medals. More than 20,000 commemorative and tribute medals comprise the domain of medical numismatics. Several thousand of these portray individual doctors whose lives and work are thus recorded in gold, silver, bronze and the alloys of medallic art. Such enduring records range from the names and images of the most famous and significant of doctors in international perspective, to those held in local or parochial esteem by their peers. The medical numismatic archive includes medals and coins which portray the gods of medicine; founders of the profession such as Hippocrates and Galen; and those who have been held in local esteem, all such that the record of their service to medicine might not be forgotten.

Unintentional fatal child drowning in the bath: A 12-year Australian review (2002-2014).

AIM: To establish the prevalence of unintentional fatal drowning in baths involving children <18 years in Australia and to identify causal factors to underpin prevention. METHODS: We report a total population study of all childhood (0-17 years) unintentional drowning fatalities in baths (bathtubs, spa baths and showers) in Australia between 1 July 2002 and 30 June 2014. Demographic, forensic and aetiological data (including co-bathing, use of bath aids, supervision and enactment of cardiopulmonary resuscitation) were documented for each victim. RESULTS: Seventy-eight children were identified; two thirds (66.7%) were under 2 years old, of which 43.6% were aged less than 1 year (1.0/100 000/annum) and 23.1% 1-2 years (0.27/100 000/annum). Nine older children (10-17 years) also drowned. Common causes included: infants and children unable to hold their head out of water while unsupervised and associated pre-existing medical conditions, including epilepsy. All children who drowned were left without adult supervision. No child drowned in a bath with water deeper than 40 cm (M = 19.4 cm). Custodian-reported 'time left unsupervised' ranged from 30 s to 60 min. Children with pre-existing medical conditions were, on average, older (9.9 years; confidence interval: 7.9-11.9) and left unsupervised for longer (M = 15.4 min; confidence interval: 3.8-27.1) than those without. CONCLUSIONS: On average, 6.5 children drown every year in baths in Australia. Children aged younger than 1 year are most affected, with both genders equally represented. Infants and toddlers left unsupervised, false confidence in the preventive role of bath aids, unrealistic expectations in the supervisory capabilities of co-bathing children and epilepsy remain threats to children in the bath.

Drowning fatalities in childhood: the role of pre-existing medical conditions.

OBJECTIVES: This study is an analysis of the contribution of pre-existing medical conditions to unintentional fatal child (0-14 years) drowning and a of critique prevention stratagems, with an exploration of issues of equity in recreation. DESIGN: This study is a total population, cross-sectional audit of all demographic, forensic and on-site situational details surrounding unintentional fatal drowning of children 0-14 years in Australia for the period of 1 July 2002 to 30 June 2012. Data were sourced from the National (Australia) Coronial Information System. Age-specific disease patterns in the general population were obtained from the Australian Institute of Health and Welfare. RESULTS: Four hundred and sixty-eight children drowned during the study period. Fifty-three (11.3%) had a pre-existing medical condition, of whom 19 suffered from epilepsy, 13 from autism and 5 with non-specific intellectual disabilities. Epilepsy is a risk factor in childhood drowning deaths, with a prevalence of 4.1% of drowning fatalities, compared with 0.7%-1.7% among the general 0-14 years population (relative risk: 2.4-5.8). Epilepsy was deemed to be contributory in 16 of 19 cases (84.2% of epilepsy cases) with a median age of 8 years. Asthma and intellectual disabilities were under-represented in the drowning cohort. CONCLUSION: Except for epilepsy, this research has indicated that the risks of drowning while undertaking aquatic activities are not increased in children with pre-existing medical conditions. Children with pre-existing medical conditions can enjoy aquatic activities when appropriately supervised.

Hammurabi's Code: A primary datum in the conjoined professions of medicine and law.

The history of our current law dates from Palaeolithic times. The first written laws were codified by the rulers of Mesopotamian kingdoms, from the beginning of the second millennium B.C.E. This history, and those of the medico-legal specialties in particular, trace their origins to Hammurabi's Code. Hammurabi (ruled 1792-1750 B.C.E.) was the sixth King of the First Dynasty of ancient Babylon, today an archaeological site in modern-day Iraq. Hammurabi's Laws (c.1760 B.C.E.), inscribed on at least one diorite stele, were set up in public places in Babylon, towards the end of the King's 43-year reign. Comprising almost 300 specific laws, with judicial punishment for transgressions, Hammurabi's Code reflects his role both as a guardian of the vulnerable and as a protector of the weak and powerless. Just as medical papyri from ancient Egypt (e.g. the Edwin Smith papyrus c.1600 B.C.E.) are regarded as the origins of western medicine, so Hammurabi is the pioneer of "medical" laws as these have evolved to their sophisticated state today.

Medical memorials of the Heroic Age of Antarctic exploration.

The Heroic Age of Antarctic exploration spanned the period from 1895 to 1922. Medical men who took part in the expeditions of that period made significant contributions to the expeditions in medical treatment of expedition members, geographical discovery and science and, as a result of such contributions, many had geographical features named after them. A recent paper listed five doctors from the Heroic Age who were so honoured. We now add biographical précises of a further 17 personnel, including two medical students who have geographical features named after them.

A pioneer of Australian paediatrics: Dr Henry Edward Brown (1858-1931).

The emergence of paediatrics as a specialty in Australian medicine dates from the last two decades of the 19th century. Among the pioneers of pre-Federation paediatrics, we include Dr Henry Edward Brown (1858-1931), an Irish-born physician and surgeon who became the first paediatrician to practise in the northern half of the Australian continent. In 1885, he was appointed as the medical superintendent of the Rockhampton Children's Hospital, itself a pioneer institution in the care of sick and injured children. Dr H.E. Brown also served as medical officer of health concurrently in three Queensland shires. He was a leader in the literary and sporting life of the busy port town of Rockhampton and a scholar and significant philanthropist in the domain of French literature. His life was and remains an exemplar of a class of pre-Federation paediatricians who established the ethos of clinical and societal service, which remains as a core feature of the speciality discipline of paediatrics in the 21st century.

Professor Tyndale John Rendle-Short (1919-2010), British and Australian paediatrician: A life in two domains.

Professor Tyndale John Rendle-Short (1919-2010), a British and Australian paediatrician, lived a professional life of considerable influence in two domains - academic paediatrics and fundamentalist theology. A Cambridge medical graduate (1943) and doctor-soldier, he was appointed as the Foundation Professor of Child Health at the University of Queensland (1961). In Australia, he was a pioneer in three paediatric developments ('rooming-in' for mothers in hospitals, autism research and cystic fibrosis). His A Synopsis of Children's Diseases was published in six editions, was translated into three languages and was used as a standard paediatric textbook on four Continents. Distinct from this clinical domain, as a passionate anti-Darwinist his fundamentalist theology was that variously self-described as 'theistic evolution' (believing in 'progressive Creationism') and later that of 'six-literal day young-earth Creation'. He established and was the Foundation Chairman of the Creation Science Foundation (UK) and was World Chairman of the US-based Creation Ministries International. This biography is a record of this perhaps paradoxical and unique life.

Two medieval doctors: Gilbertus Anglicus (c1180-c1250) and John of Gaddesden (1280-1361).

Biographies of medieval English doctors are uncommon and fragmentary. The two best-known English medieval physicians were Gilbertus Anglicus and John of Gaddesden. This paper brings together the known details of their lives, compiled from extant biographies and from internal references in their texts. The primary records of their writings exist in handwritten texts and thereafter in incunabula from the time of the invention of printing in 1476. The record of the lives of these two medieval physicians can be expanded, as here, by the general perspective of the life and times in which they lived. Gilbertus Anglicus, an often-quoted physician-teacher at Montpellier, wrote a seven-folio Compendium medicinae in 1271. He described pioneering procedures used later in the emergent disciplines of anaesthetics, cosmetic medicine and travel medicine. Gilbertus' texts, used extensively in European medical schools, passed in handwritten copies from student to student and eventually were printed in 1510. John of Gaddesden, an Oxford graduate in Arts, Medicine and Theology, wrote Rosa Anglica, published circa 1314. Its detailed text is an exemplar of the mixture of received Hippocratic and Galenic lore compounded by medieval astronomy and religious injunction, which mixture was the essence of medieval medicine. The writings of both these medieval English physicians formed part of the core curriculum that underpinned the practice of medicine for the next 400 years.

Bernard de Gordon (fl. 1270-1330): medieval physician and teacher.

The Montpellier physician Bernard de Gordon flourished in the late Middle Ages in the era when university education first evolved in the training of European physicians. Fragmentary details of his life and medical influence are known from seven books, particularly his extensive (163 chapters) text Lilium Medicine and from Chaucer's reference to him in the Canterbury Tales. Chaucer lists Bernard de Gordon as one whose writings were part of the core curriculum of the best-trained European doctors of medieval Europe. Bernard de Gordon was one of that small group of medieval physicians who reverently followed Galenic lore which had endured for a thousand years yet who began to challenge its details and to experiment clinically with new methods of treatment. In his writings, Bernard de Gordon made the first reference to spectacles and to the hernial truss. His writings also contained detailed desiderata for the ethical best practice of medicine of his day, extending the principles of both Hippocrates and Haly ibn Abbas. Unlike many of the surviving writings of other medieval medical teachers, his texts have within them a tone of humility and acknowledged fallibility. Bernard de Gordon holds a small but significant place in the evolving pre-Renaissance chronology of medical professionalism.

Australian orchids and the doctors they commemorate.

Botanical taxonomy is a repository of medical biographical information. Such botanical memorials include the names of some indigenous orchids of Australia. By searching reference texts and journals relating to Australian botany and Australian orchidology, as well as Australian and international medical and botanical biographical texts, I identified 30 orchids indigenous to Australia whose names commemorate doctors and other medical professionals. Of these, 24 have names that commemorate a total of 16 doctors who worked in Australia. The doctors and orchids I identified include: doctor-soldiers Richard Sanders Rogers (1862-1942), after whom the Rogers' Greenhood (Pterostylis rogersii) is named, and Robert Brown (1773-1858), after whom the Purple Enamel Orchid (Elythranthera brunonis) is named; navy surgeon Archibald Menzies (1754-1842), after whom the Hare Orchid (Leptoceras menziesii) is named; radiologist Hugo Flecker (1884-1957) after whom the Slender Sphinx Orchid (Cestichis fleckeri) is named; and general medical practitioner Hereward Leighton Kesteven (1881-1964), after whom the Kesteven's Orchid (Dendrobium kestevenii) is named. Biographic references in scientific names of plants comprise a select but important library of Australian medical history. Such botanical taxonomy commemorates, in an enduring manner, clinicians who have contributed to biology outside clinical practice.

Novel and recurrent germline and somatic mutations in a cohort of 67 patients from 48 families with Brooke-Spiegler syndrome including the phenotypic variant of multiple familial trichoepitheliomas and correlation with the histopathologic findings in 379 biopsy specimens.

Brooke-Spiegler syndrome (BSS) is a rare, inherited, autosomal dominant disorder characterized by development of multiple adnexal cutaneous neoplasms including spiradenoma, cylindroma, spiradenocylindroma, and trichoepithelioma. The syndrome of multiple familial trichoepitheliomas (MFT) is considered a phenotypic variant of BSS in which patients present with trichoepitheliomas only. We studied germline and somatic mutations of the CYLD gene by direct sequencing in patients with BSS (n = 49) and MFT (n = 18) using peripheral blood and 90 samples of frozen or formalin-fixed paraffin-embedded tumor tissue selected from 379 available histology specimens. Germline CYLD mutations were found in 51 patients (76%) from 36 families (75%). Germline CYLD mutations were found in 43 of the 49 patients with BSS (88%) but in only 8 of 18 MFT cohort (44%). Twenty-one frameshift, 15 nonsense, 3 missense, and 4 splice site mutations were found in patients with BSS, whereas 1 frameshift, 5 nonsense, and 2 splice site mutations were identified in the MFT cohort. Five novel mutations were identified including 4 frameshift mutations (c.1027dupA/p.T343NfsX7, c.2155dupA/p.M719NfsX5, c.2288_2289delTT/p.F763X, and c.2641delG/p.D881TfsX32) and 1 nonsense mutation (c.2713C>T/p. Q905X). Of the 76 tumors from 32 patients with a germline CYLD mutation, 12 were spiradenomas, 15 spiradenocylindromas, 26 cylindromas, 15 trichoepitheliomas, and 7 were other tumor types. Somatic mutations were detected in 67 specimens of these 76 tumors (88%). Of the 67 somatic mutations, 21 (31%) represented a sequence alteration and 46 (69%) showed loss of heterozygosity. In the remaining 9 cases (12%), the somatic changes remained unknown. A germline CYLD mutation was not detected in 14 tumor samples from 8 patients. In these 14 tumors, somatic mutations were identified in 6 samples (43%), all consisting of sequence alterations (1 sample showed 2 different sequence alterations). In the remaining 8 samples (53%), neither germline nor somatic mutations were found in the lesional tissue. Our study increases the catalog of known CYLD mutations in patients with BSS/MFT to 86 and documents the variability of somatic mutations that may occur in them. We confirm the absence of firm genotype-phenotype correlations and the existence of a subset of patients with BSS/MFT who lack a demonstrable germline CYLD mutation. Further studies are needed to explain the reasons for this phenomenon.

Community stroke rehabilitation helps patients return to work.

Around 150,000 people experience a stroke every year in the UK. Nearly one million people in England are living with the effects of a stroke; one third of whom are moderately to severely disabled. A quarter of stroke survivors are under the age of 65 meaning that many are in work and/or have responsibility for caring for children or elderly parents. With a comprehensive rehabilitation team, patients with more complex or severe disability can be rehabilitated in the community providing that the home environment can be suitably adapted. All patients will require regular review by their own doctor and some of these reviews will focus on standardised assessments of risk factors for stroke and implementation of appropriate secondary prevention. The GP has a role in identifying the emotional impact of stroke on the patient and the impact that the stroke has on relatives and carers. The core components of the community-based programme can be broadly defined as improving emotional wellbeing, communication, cognitive function and physical independence and supporting return to work. Antidepressants are effective in reducing emotional lability. Cognitive functions such as memory, attention, perception and planning are often affected by stroke. Assessment and treatment by the occupational therapy team and clinical psychologist can reduce the impact of these impairments. Speech and language therapy is instrumental in facilitating recovery as is training carers in supportive communication and providing aphasia-friendly information. NICE recommends that patients receive 45 minutes of each relevant therapy five times a week. Each therapy needs to be provided at an intensity that will produce a functional change. Most patients will be able to drive again if there is no significant visual field loss or uncontrolled epilepsy. Graded return to work programmes are more successful as people are gradually accustomed to the workplace.