Service and support needs following pediatric brain injury: perspectives of children with mild traumatic brain injury and their parents.

OBJECTIVE: To provide a qualitative examination of the service and support needs of children who have had a mild traumatic brain injury (mTBI), and their parents, in order to improve clinical services. METHODS: Semi-structured interviews were conducted with 9 children (8-12 years; M = 10.6 years, SD = 0.8) and their parents (n = 9) 29-55 days (M = 34 days; SD = 9.3) after presenting to an Australian Paediatric Emergency Department (PED) for mTBI. Children's post-concussive symptoms (PCS) were additionally measured using the Post-Concussive Symptom Inventory (PCSI). Audio recordings were transcribed, and a thematic analysis was conducted. RESULTS: Post-injury needs were reflected in four main themes: Communication; Family Burden; Continuity of Care; and Social and Community Support. These themes reflected children's and parents' needs for information, emotional/social/community support, and follow-up care. Both the children's and parents' needs, and the extent to which they were met, appeared to be related to the severity and duration of the child's PCS. CONCLUSIONS: Dedicated pediatric mTBI follow-up services that build on family's resources and meet their individual needs for information, emotional support, and referral may assist in optimizing post-injury outcomes.

A young man with hyperimmunoglobulin-E syndrome and IgA and IgG deficiencies.

Hyperimmunoglobulin E syndrome (HIES) with recurrent infection is a rare primary immunodeficiency characterized by the clinical triad of recurrent staphylococcal abscesses, cyst-forming pneumonia and an elevated serum immunoglobulin (Ig)E level. We report an 18-year-old man with recurrent chest infections, skin infections and dermatitis. On examination, he had the characteristic facies of HIES: high arched palate, webbing between his thumb and index finger bilaterally, and extensive scarring from multiple staphylococcal skin abscesses. He had an elevated IgE level of 14 300 kU/L. IgA and IgG deficiencies were also identified, which are rare associations of this syndrome and complicated the patient's treatment. The coexistence of HIES, IgA and IgG deficiencies has, to our knowledge, not been reported previously in the literature.

Asthma in emergency departments: combined adult and paediatric versus paediatric only centres.

OBJECTIVE: To compare the management of paediatric patients with mild or moderate asthma in paediatric-only emergency departments (POEDs) to treatment in a mixed adult-child emergency departments (mixed EDs). METHODS: Prospective, observational study conducted in 36 Australian emergency departments (EDs) for 2 weeks in 2001. Children aged 1-15 years with acute asthma classified as mild or moderate severity. Details of demography, severity assessment, and type of treatment facility, treatment and disposition were collected. Analysis used descriptive statistics, comparison of proportions by chi2, and multiple logistic regression. RESULTS: Two-hundred and nine children were treated at POEDs and 257 at mixed EDs. The groups had similar severity. Spacers to deliver beta-agonists were used more frequently in POEDs (67.5% vs 24.2%; P < 0.01). Children treated at POEDs with a mild attack were more likely to be admitted (20.6% vs 9.5%; P < 0.02) and given salbutamol (82.8% vs 71.9%; P = 0.03). For children with moderate asthma, oral steroid prescription on hospital discharge was more common for those treated in a mixed ED (81.0% vs 95.7%; P = 0.01). Ipratropium bromide (IB) was widely used at both types of ED but more commonly used in mixed EDs (41.7% vs 54.9%; P < 0.01). There were no differences in length-of-stay, representation rate within one month and oral steroid use for attack. Less than 2/3 of children with mild asthma attacks received steroid treatment in the ED. CONCLUSION: Treatment was similar between the two types of ED. IB was overused in mild asthma and oral steroids were underused in moderate asthma, by both ED types. Spacers were under-utilized in mixed EDs.

Normal Ca2+ extrusion by the Ca2+ pump of intact red blood cells exposed to high glucose concentrations.

The ATPase activity of the plasma membrane Ca2+ pump (PMCA) has been reported to be inhibited by exposure of red blood cell (RBC) PMCA preparations to high glucose concentrations. It has been claimed that this effect could have potential pathophysiological relevance in diabetes. To ascertain whether high glucose levels also affect PMCA transport function in intact RBCs, Ca2+ extrusion by the Ca2+-saturated pump [PMCA maximal velocity (V(max))] was measured in human and rat RBCs exposed to high glucose in vivo or in vitro. Preincubation of normal human RBCs in 30-100 mM glucose for up to 6 h had no effect on PMCA V(max). The mean V(max) of RBCs from 15 diabetic subjects of 12.9 +/- 0.7 mmol. 340 g Hb(-1). h(-1) was not significantly different from that of controls (14.3 +/- 0.5 mmol. 340 g Hb(-1). h(-1)). Similarly, the PMCA V(max) of RBCs from 11 streptozotocin-diabetic rats was not affected by plasma glucose levels more than three times normal for 6-8 wk. Thus exposure to high glucose concentrations does not affect the ability of intact RBCs to extrude Ca2+.

Refinement and evaluation of a model of Mg2+ buffering in human red cells.

The total Mg2+ content of human red cells ([Mg]T,i) is partitioned between free and bound forms. The main cytoplasmic Mg2+ buffers are ATP and 2,3 bisphosphoglycerate. Haemoglobin binds free ATP and bisphosphoglycerate, preferentially in the deoxygenated state. Thus, the free ionized Mg2+ concentration ([Mg2+]i) oscillates with the oxy-deoxy condition of the cells. The binding reactions are also modulated by the pH changes that accompany the oxygenation-deoxygenation transitions. The complex interactions between Mg2+, its ligands and Hb can be encoded in a set of equilibrium equations representing all the known binding reactions of the system. To develop a comprehensive understanding of the Mg2+ homeostasis of intact red cells it is necessary to correct and refine the equations and parameters of the model by systematic comparisons between model predictions and measured cytoplasmic Mg2+ buffering curves under a variety of experimental conditions. Earlier models largely underestimated total Mg2+ binding in intact cells. We carried out experiments in which [Mg]T,i and [Mg2+]i were controlled over a wide range ([Mg]T,i between 0.1 and 23 mM) by the use of the ionophore A23187, under diverse metabolic conditions, and the results were used to interpret the adjustments required for good model fits. By the inclusion of low-affinity Mg2+ binding to ATP and bisphosphoglycerate, and also binding of Mg2+ to haemoglobin (four ions per tetramer) with an apparent dissociation constant of 45 mM we were able to realistically model, for the first time, all the experimentally observed changes in [Mg2+]i in human red cells under diverse metabolic conditions.

Repeated dose inhaled budesonide versus placebo in the treatment of croup.

OBJECTIVE: To investigate the efficacy and tolerance of 12-hourly dosing with 2 mg 4 mL-1 of inhaled budesonide versus placebo in patients admitted to hospital with moderate/severe croup. METHOD: Eighty-two children hospitalised with croup received either 2 mg 4 mL-1 of budesonide or placebo 12 hourly (maximum four doses) via Ventstream nebuliser in a randomised, double-blind manner. Croup scores were performed at 0, 2, 6, 12, 24, 36 and 48 h from initial nebulisation whilst the patient remained hospitalised. Follow-up assessments were made 1 and 3 days after discharge. RESULTS: Improvement was observed in the budesonide group over the 12-h dosing interval when compared to placebo (P = 0.04). Time to attain a significant clinical improvement was superior in the budesonide group (P = 0.01). Three days after discharge seven of 32 placebo-treated patients and one of 34 budesonide-treated patients had sought further medical follow-up (P = 0.02). CONCLUSION: Twelve-hourly dosing with inhaled budesonide significantly improved symptoms of croup as well as decreased relapse rates when compared with placebo.

Emergency management skills of South Australian paediatric trainees.

OBJECTIVE: This article describes a theoretical and practical assessment of the emergency management skills of South Australian paediatric trainees. The aim was to identify strengths and weaknesses so as to optimally orientate future training in this area, and to provide a baseline that could be used to assess effectiveness of future interventions. METHODOLOGY: Thirty-four paediatric trainee medical officers responsible for after hours emergency care in Adelaide were asked to anonymously complete a 24 question theory assessment based on recognized emergency management training programmes, and to perform a mock clinical resuscitation. Response rate was 90% for the theoretical section and 69% for the practical. RESULTS: The average trainee was found to be deficient in one quarter to one third of the theoretical precepts, and required an average of 2 min to establish effective bag-valve-mask ventilation with an infant manikin. CONCLUSIONS: There is a range of theoretical and practical resuscitation deficits that may currently hinder effective emergency management by paediatric trainees.

Measurement of the distribution of anion exchange function in normal human red cells.

1. The aim of the present work was to investigate cell-to-cell variation in anion exchange turnover in normal human red cells. Red cells permeabilized to protons and K+ dehydrate extremely rapidly by processes that are rate-limited by the induced K+ permeability or by anion exchange turnover. Conditions were designed to render dehydration rate-limited by anion exchange turnover. Cell-to-cell variation in anion exchange function could then be measured from the distribution of delay times required for dehydrating cells to attain resistance to haemolysis in a selected hypotonic medium. 2. Red cells were suspended at 10% haematocrit in a low-K+ solution and, after a brief preincubation with 20 microM SITS at 4 degrees C, were warmed to 24 degrees C, and the protonophore CCCP was added (20 microM) followed 2 min later by valinomycin (60 microM). Delay times for cells to become resistant to lysis were measured from the instant of valinomycin addition by sampling suspension aliquots into thirty volumes of 35 mM NaCl. After centrifugation the per cent lysis was estimated by measuring the haemoglobin concentration in the supernatant. Typical median delay times with this standardized method were 4-5 min. 3. The statistical parameters of the delay time distributions report the population spread in the transport function that was limiting to dehydration. In the absence of SITS and CCCP, dehydration was limited by the diffusional Cl- permeability (PCl). Delay time distributions for PCl- and anion exchange-limited dehydration were measured in red cells from three normal donors. For both distributions, the coefficients of variation ranged between 13.0 and 15.2%, indicating a high degree of uniformity in PCl and anion exchange function among individual red cells.

Goitre causing acute respiratory arrest.

A patient reported symptoms of upper airway obstruction for 4 years. His symptoms worsened with a viral upper respiratory infection and he suffered acute respiratory arrest. He was resuscitated and a large goitre with intrathoracic extension which was compressing the trachea was resected. The mechanisms of upper airway compromise by goitre are discussed. The symptoms of the effect of goitre on the airway are reviewed.

Topical anaesthesia for minor lacerations: MAC versus TAC.

OBJECTIVE: To determine whether a solution of bupivacaine Marcain [Astra]), adrenaline and cocaine (MAC) is as safe and effective as tetracaine, adrenaline and cocaine (TAC) as topical anaesthesia for wound suturing. DESIGN: Double-blind, randomised, prospective trial. SETTING: Emergency departments of two tertiary referral hospitals (one specialising in paediatric care) in Adelaide, South Australia, between February 1992 and April 1994. PARTICIPANTS: 181 patients, aged six or older, with simple dermal lacerations less than 5mm deep, not involving mucous membranes or areas with end-arterial blood supply. INTERVENTIONS: Patients received a weight-adjusted dose of either MAC or TAC. OUTCOME MEASURES: Needle-prick testing of wound for pain before suturing, pain ratings by patients and physicians during suturing, signs and symptoms of cocaine toxicity, wound complications and patient preference for topical anaesthesia. RESULTS: Topical anaesthesia was adequate for suturing in 73% of patients (83% or those with head wounds and 56% of those with extremity wounds). MAC and TAC did not differ significantly in efficacy overall or by wound location. Pain ratings from patients treated with MAC and TAC were comparable, as was patients acceptance of topical anesthesia (77%, MAC; 81%, TAC) and the incidence of adverse effects (4% infection rate overall). CONCLUSIONS: Topical anesthesia is a safe and effective means of anaesthetising selected lacerations for suturing. As we found no significant differences in either the efficacy or safety of the two solutions, we believe that MAC can be substituted for the less readily available TAC whenever expedient.

Distribution of chloride permeabilities in normal human red cells.

1. The rate of dehydration of K+ permeabilized red cells is influenced by their Cl- permeability (PCl). In instances of pathological K+ permeabilization, cell-to-cell differences in PCl may determine which red cells dehydrate most. The present study was designed to investigate whether PCl differed significantly among red cells from a single blood sample. 2. Previously available methods measure only the mean PCl of red cell populations. We describe a 'profile migration' method in which dilute red cell suspensions in low-K+ media were permeabilized to K+ with a high concentration of valinomycin, rendering PCl the main rate-limiting factor for cell dehydration. As the cells dehydrated, samples were processed to obtain full haemolysis curves at precise times. Variations in PCl among cells would have appeared as progressive changes in the profile of their haemolysis curves, as the curves migrated towards lower tonicities. 3. Red cells from five normal volunteers showed no change in profile of the migrating haemolysis curves, suggesting that their PCl distributions were fairly uniform. Quantitative analysis demonstrated that intercell variation in PCl was less than 7.5%. 4. Results obtained with this technique were analysed using the Lew-Bookchin red cell model. The calculated PCl was within the normal range described in earlier studies.

Effect of intracellular magnesium on calcium extrusion by the plasma membrane calcium pump of intact human red cells.

1. The effect of varying the concentration of intracellular magnesium on the Ca(2+)-saturated Ca(2+)-extrusion rate through the Ca2+ pump (phi max) was investigated in human red blood cells with the aid of the divalent cation ionophore A23187. The aim was to characterize the [Mg2+]i dependence of the Ca2+ pump in the intact cell. 2. The initial experimental protocol consisted of applying a high ionophore concentration to obtain rapid sequential Mg2+ and [45Ca]CaCl2 equilibration, prior to measuring phi max at constant internal [MgT]i by either the Co2+ block method or by ionophore removal. With this protocol, competition between Ca2+ and Mg2+ through the ionophore prevented Ca2+ equilibration at high [Mg2+]o. To provide rapid and comparable Ca2+ loads and maintain intracellular ATP within normal levels it was necessary to separate the Mg2+ and the Ca2+ loading-extrusion stages by an intermediate ionophore and external Mg2+ removal step, and to use different metabolic substrates during Mg2+ loading (glucose) and Ca2+ loading-extrusion (inosine) periods. 3. Intracellular Co2+ was found to sustain Ca2+ extrusion by the pump at subphysiological [Mg2+]i. Ionophore removal was therefore used to estimate the [Mg2+]i dependence of the pump at levels below [MgT]i (approximately 2 mmol (340 g Hb)-1), whereas both ionophore removal and Co2+ block were used for higher [MgT]i levels. 4. [Mg2+]i was computed from measured [MgT]i using known cytoplasmic Mg(2+)-buffering data. The phi max of the Ca2+ pump increased hyperbolically with [Mg2+]i. The Michaelis parameter (K 1/2) of activation was 0.12 +/- 0.04 mmol (1 cell water)-1 (mean +/- S.E.M.). Increasing [MgT]i and [Mg2+]i to 9 mmol (340 g Hb)-1 and 2.6 mmol (1 cell water)-1, respectively, failed to cause significant inhibition of the phi max of the Ca2+ pump. 5. The results suggest that within the physiological and pathophysiological range of [Mg2+]i, from 0.3 mmol (1 cell water)-1 in the oxygenated state to 1.2 mmol (1 cell water)-1 in the deoxygenated state, the Ca(2+)-saturated Ca2+ pump remains unaffected by [Mg2+]i at normal ATP levels.

Parent satisfaction with services in an emergency department located at a paediatric teaching hospital.

OBJECTIVE: To evaluate parents' satisfaction with the services provided in an emergency department located at a paediatric hospital. METHODOLOGY: A descriptive study in which the parents of children with non-life-threatening illnesses attending an emergency department completed a questionnaire describing their satisfaction with services in the department. RESULTS: The majority of parents were satisfied with the services provided. However, less satisfied parents reported having to wait significantly longer before receiving medical attention than satisfied parents. Consistent with this finding, 77% of less satisfied parents reported that staff did not attend to their children's needs quickly enough and 62% felt that there were insufficient staff available to provide help. Twenty-nine per cent of the less satisfied parents reported that they did not know what was required for the ongoing care of their children after their discharge from the emergency department. CONCLUSIONS: In order to address the concerns of less satisfied parents, emergency departments need to give careful attention to the maintenance of reasonable waiting times, the provision of adequate staffing, and the quality of staff-parent communication. Addressing these issues may improve the ongoing care of children after their discharge from emergency departments.

Generation of normal human red cell volume, hemoglobin content, and membrane area distributions by "birth" or regulation?

Using flow cytometry and osmotic lysis measurements, we document here the means and coefficients of variation of the following red cell (RBC) properties: hemoglobin (Hb) content, volume, Hb concentration, and relative lytic tonicity distributions in populations of normal human RBCs, before and after density fractionation. The distributions showed a pattern characterized by much larger coefficients of variation of the Hb content and volume distributions than of the Hb concentration and relative lytic tonicity distributions. From analysis of the factors that determine those RBC properties, the patterns were interpreted as reflecting previously unrecognized statistical proportionalities between cell osmolyte content, Hb content, and membrane area. The possible origin of these statistical links was analyzed by considering alternative models with and without the participation of regulatory processes during cell maturation. A model was shown to be feasible in which mature RBC variability with proportional volume, area, and Hb content arises solely from cell size variability at the last erythroid cell division.

Traumatic hemipelvectomy associated with contralateral hip dislocation: case report.

A case of a 28-year-old man surviving traumatic hemipelvectomy is presented. This patient is the first reported survivor in Australia of traumatic hemipelvectomy and one of few survivors reported in the world literature. Accurate and rapid early management including good resuscitation, rapid transport to the operating room and an aggressive team surgical approach all contributed to survival. Acute complications can be kept to a minimum by adhering to the approach of rapid resuscitation and early intervention by a team of surgeons. Associated dislocation of the contralateral hip with sciatic nerve damage and subsequent heterotopic calcification has not been previously reported and presents a significant obstacle to rehabilitation. Early attention to the psychological status of the patient and early involvement of rehabilitation specialists is advocated.

Factors influencing the presentation and care of elderly people in the emergency department.

OBJECTIVE: To provide Australian data from a community setting on the use of the Emergency Department by elderly persons. DESIGN: The paper describes three studies. Study 1 analyses patient admission patterns, and clinical data taken retrospectively from medical records for 1987. Studies 2 and 3 prospectively survey referral, transport, demographic profiles and clinical management practices in two patient samples taken during 1987 and 1988. SETTING: The Emergency Department of Sutherland Hospital, Sydney--a community based hospital of 374 beds. PATIENTS: In study 1, we assessed 4609 hospital admissions of patients aged 60 years or more using ICD-9-CM coding. In Studies 2 and 3, samples of 74 patients aged 65 years or more and 100 patients aged 70 years or more who presented to the Emergency Department were assessed consecutively and prospectively. INTERVENTIONS: No specific interventions outside of usual Emergency Department routines were undertaken except for collection of demographic data. MAIN OUTCOME MEASURES: Demographic characteristics, diagnostic categories, and referral, admissions and hospital separation data. RESULTS: In Study 1, of 4609 patients aged 60 years or more 3182 (69%) entered hospital via the Emergency Department. These 3182 represented 29% of total hospital admissions for that year. In Study 2 the male to female ratio was 32 to 42; the mean age was 78.16 years; 88% were pensioners; 20% had additional private insurance; 76% of women were widowed compared with 32% of men; 84% of the group lived in their own homes but, of these, 51% of women lived alone compared with 7.7% of men. The disease profile was that of acute organic disease in 97% of presentations. Ambulance transport to the Emergency Department was used by 65% of patients and Emergency Department facilities were used mostly during "working hours"; 64% of patients were admitted to hospital. The pre-hospital "activities of daily living" (ADL) functioning was assessed as being independent in 85%. In Study 3, the social and demographic profile was similar to Study 2. Fifty seven of the 100 patients used ambulance transport to the Emergency Department and this was initiated by a general practitioner in 13 instances. The general practitioner was the referring source in 28% of cases. Waiting times in the Emergency Department demonstrated a mean time from arrival to assessment by a medical officer of 30 minutes and a total time spent in the Emergency Department of 3 hours 4 minutes for those discharged home and 4 hours 24 minutes for those admitted. CONCLUSION: These studies demonstrate that the Emergency Department is a major area for care of the elderly and entry into the hospital system. Referral from a general practitioner and the use of ambulance transport from home to the Emergency Department are frequent pathways of care that may have important cost-benefit implications and deserve further study. The elderly in these studies appear to use the Emergency Department appropriately for acute medical/surgical need. The social profiles suggest that widowed women present a special case in terms of discharge plans for management.

Head injuries in infants and young children: the value of the Paediatric Coma Scale. Review of literature and report on a study.

The normal verbal and motor responses embodied in the standard Glasgow Coma Scale (GCS) are not achievable during the first few years of life. The recent literature contains numerous reports of attempts to devise scales of responses quantitating the conscious level in infants and young children, both for research purposes and as clinical guides; some of these scales incorporate items, e.g. brainstem reflexes, that are not included in the GCS. We have reported on a simple paediatric version of the GCS, which uses the standard scale with minor modifications in the verbal component, and sets realistic age-related normal responses. This has been tested prospectively in a series of 60 head-injured infants and children (age range 0-72 months). Of 6 cases recorded as comatose 6 h after injury, 4 have confirmed or suspected residual disabilities. Of 35 cases considered to be fully conscious at 6 h, 31 have made good recoveries and only 1 has suspected residual disabilities. The study suggests that the scale accords with the realities of neurological immaturity, and confirms that it can be used in routine paediatric practice. For comparative therapeutic trials, the conscious level in infants has limited value as an index of brain injury, and should be complemented by other indices, such as brainstem reflexes.

An epidemiological survey of dog bites presenting to the emergency department of a children's hospital.

German shepherds are the most popular registered breed of dog in South Australia, but are also the most hazardous to children, biting more often and more severely. A study of the victims of dog bites presenting to the Emergency Department of the Adelaide Children's Hospital over an 18 month period revealed that, although many breeds were involved, only German shepherds were implicated more frequently than their prevalence in the community. Attacks occurred most often in a domestic setting involving a friendly dog that was known to the victim. Boys were more often bitten than girls and children aged 1-6 years most commonly involved. Injuries to the face and scalp were frequent and the usual ones to require admission for suture under general anaesthetic. Some scarring was a common sequel and resulting fear of dogs remained with some children. Most attacks were reported to be unprovoked and a previous biting history on the part of the dog was uncommon. Parents who are contemplating obtaining a dog for a family pet should be made aware of these facts and advised regarding the biting hazards and possible prevention. The German shepherd situation especially should be brought to their attention.

Survival after trauma--experience at an acute-care general hospital.

OBJECTIVE: To assess the effectiveness of the management of acute traumatic illness at an acute-care general hospital. DESIGN: The study was conducted prospectively for the calendar year 1989. The Trauma Score (TS) and the revised Trauma Score (RTS) were calculated on arrival at hospital. These clinical indices were used, with the Injury Severity Score (ISS) and the age, to predict the probability of survival (Ps) and the probability of mortality. The predicted probabilities were compared with the probabilities of survival and mortality derived from a recognised baseline. SETTING: The Trauma Service of The Sutherland Hospital Caringbah, including the Emergency and Intensive Care Departments and the Departments of Surgery and Anaesthetics. PATIENTS: 74 patients of all ages who were brought to the Emergency Department because of acute traumatic illness with an ISS greater than 16. Only patients with signs of life on arrival were included in the study group. Data were complete in all 74 patients. RESULTS: There were 60 survivors and 14 deaths compared to figures predicted using data from the baseline group of 52.6 survivors and 21.4 deaths. There were no preventable deaths. There were five survivors whose probability of survival was less than 0.50. Three cases of late diagnosis were noted; the late diagnoses did not significantly affect the outcomes--they occurred because specialist assessment was delayed. CONCLUSIONS: It is possible, with few resources, to quantitatively and qualitatively assess the effectiveness of a trauma care service.

Red cells suspended in a phosphate-fortified additive: biochemical enhancement and longer storage.

When compared to our current storage regime, an additive solution, with 75 mM inorganic phosphate, improved certain biochemical and morphological parameters measured in suspensions of packed red cells throughout 49 days of liquid storage. In particular, the mean ATP level of 20 donations stored with the high phosphate additive was consistently and significantly higher than in standard (n = 6) suspensions. The increased amount of inorganic phosphate and the higher pH of the new additive stimulated ATP production and provided better pH buffering than the standard solution currently in use. Although survival study results indicated adequate 24h survivals for erythrocytes stored for 42 days with the new solution, after 49 days storage, the mean 24h survival of autologous erythrocytes was only 58 +/- 7% (n = 6).