Anesthesia

 Anaesthesia

Intra‐operative analgesia with remifentanil vs. dexmedetomidine: a systematic review and meta‐analysis with trial sequential analysis

SummaryIntra‐operative remifentanil is associated with increased postoperative analgesic requirements and opioid consumption. Dexmedetomidine has characteristics suggesting it may substitute for intra‐operative remifentanil during general anaesthesia, but existing literature has reported conflicting results. We undertook this meta‐analysis to investigate whether general anaesthesia including dexmedetomidine would result in less postoperative pain than general anaesthesia including remifentanil....

Anaesthesia

Fri Apr 05, 2019 14:45

Managing obstetric haemorrhage: is it time for a more personalised approach?

Anaesthesia

Fri Apr 05, 2019 14:38

Four years' experience of a ROTEM®‐guided algorithm for treatment of coagulopathy in obstetric haemorrhage

SummaryWe report four years of observational data from a large UK hospital and tertiary referral unit, following the introduction of a rotational thromboelastometry‐guided algorithm for treatment of coagulopathy in major obstetric haemorrhage. Fibrinogen concentrate was used to treat acquired hypofibrinogenaemia as defined by a FibTEM A5 value of < 7 mm, or 7–12 mm with ongoing or high risk of haemorrhage. Of 32,647 deliveries over 4 years, 893 (2.7%) women had an estimated blood loss...

Anaesthesia

Fri Apr 05, 2019 14:34

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 BMC Anesthesiology - Latest Articles

Cardioprotective effect of remote ischemic preconditioning with postconditioning on donor hearts in patients undergoing heart transplantation: a single-center, double-blind, randomized controlled trial

The cardioprotective effect of remote ischemic preconditioning (RIPC) in cardiovascular surgery is controversial. This study investigated whether RIPC combined with remote ischemic postconditioning (RIPostC) r...

BMC Anesthesiology - Latest Articles

Sat Apr 06, 2019 03:00

Outcomes in video laryngoscopy studies from 2007 to 2017: systematic review and analysis of primary and secondary endpoints for a core set of outcomes in video laryngoscopy research

Airway management is crucial and, probably, even the most important key competence in anaesthesiology, which directly influences patient safety and outcome. However, high-quality research is rarely published a...

BMC Anesthesiology - Latest Articles

Thu Apr 04, 2019 03:00

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 Indian Journal of Anaesthesia : 2014 - 58(6)

Labour epidural analgesia in Hypertrophic Obstructive Cardiomyopathy

Ranjith K Sivakumar, Sakthirajan Panneerselvam, Subashree Das, Priya RudingwaIndian Journal of Anaesthesia 2019 63(4):321-323

Indian Journal of Anaesthesia : 2014 - 58(6)

Thu Apr 04, 2019 00:00

Radiological evaluation of airway – What an anaesthesiologist needs to know!

Kinshuki Jain, Nishkarsh Gupta, Mukesh Yadav, Sanjay Thulkar, Sushma BhatnagarIndian Journal of Anaesthesia 2019 63(4):257-264 Airway management forms the foundation of any anaesthetic management. However, unanticipated difficult airway (DA) and its sequelae continue to dread any anaesthesiologist. In spite of development of various clinical parameters to judge DA, no single parameter has proved to be accurate in predicting it. Radiological evaluation may help assess the aspects of patient's airway...

Indian Journal of Anaesthesia : 2014 - 58(6)

Thu Apr 04, 2019 00:00

Anaesthetic management of an infant with tracheomalacia scheduled for computed tomography angiography: A challenge

Manpreet Kaur, Sana Y HussainIndian Journal of Anaesthesia 2019 63(4):312-315 Tracheomalacia is characterised by collapse of the tracheal wall with respiration. Computed tomography angiography (CTA) can be utilised for evaluation of airway abnormalities but providing sedation/anaesthesia for CTA in such a case carries the risk of airway catastrophe. We describe the anaesthetic management of an infant who had tracheomalacia with >90% collapse in lower two third of the intrathoracic trachea as...

Indian Journal of Anaesthesia : 2014 - 58(6)

Thu Apr 04, 2019 00:00

The subcostal nerve as the target for nerve stimulator guided transverse abdominis plane blocks – A feasibility study

Prasanna Vadhanan, Mohammed Hussain, Revathy PrakashIndian Journal of Anaesthesia 2019 63(4):265-269 Background and Aims: Transverse Abdominis Plane (TAP) block was originally described as a landmark-based technique. Peripheral nerve stimulator (PNS) guided blocks are still widely performed, where ultrasound is unavailable. Methods: Cadaveric dissections were performed which showed the subcostal nerve following a predictable course at the lateral abdominal wall in the TAP. The subcostal nerve was...

Indian Journal of Anaesthesia : 2014 - 58(6)

Thu Apr 04, 2019 00:00

Giant internal jugular vein

Michiel J Bos, Andre A J Van ZundertIndian Journal of Anaesthesia 2019 63(4):329-330

Indian Journal of Anaesthesia : 2014 - 58(6)

Thu Apr 04, 2019 00:00

Reliability of the thyromental height test for prediction of difficult visualisation of the larynx: A prospective external validation

Shizuha Yabuki, Satoka Iwaoka, Mamoru Murakami, Hiroko MiuraIndian Journal of Anaesthesia 2019 63(4):270-276 Background and Aims: Thyromental height (TMH) has been reported to be useful for prediction of difficult visualisation of the larynx (DVL), defined as Cormack--Lehane (C&L) grade III or IV. The aim of this study was to compare the diagnostic accuracy of the TMH test for DVL with that of other clinically used tests in Japanese patients. Methods: Six hundred and nine surgical patients...

Indian Journal of Anaesthesia : 2014 - 58(6)

Thu Apr 04, 2019 00:00

Continuous spinal anaesthesia for caesarean section in a patient with peripartum cardiomyopathy

Teena Bansal, Rajmala Jaiswal, Manju Bala, Deepika SeelwalIndian Journal of Anaesthesia 2019 63(4):317-319

Indian Journal of Anaesthesia : 2014 - 58(6)

Thu Apr 04, 2019 00:00

Correlation between bispectral index, end-tidal anaesthetic gas concentration and difference in inspired–end-tidal oxygen concentration as measures of anaesthetic depth in paediatric patients posted for short surgical procedures

Raylene Dias, Nandini Dave, Barkha Agrawal, Aarti BagheleIndian Journal of Anaesthesia 2019 63(4):277-283 Background and Aims: Measurement of end-tidal anaesthetic gas concentrations (ETAG) is currently a pragmatic indicator for monitoring anaesthetic depth. We aimed to assess the performance of ETAG for sevoflurane (ETAG-sevo) with bispectral index (BIS) and difference between inspired and end-tidal oxygen concentration (Fi−Et)O2% in measuring anaesthetic depth in toddlers and preschool children....

Indian Journal of Anaesthesia : 2014 - 58(6)

Thu Apr 04, 2019 00:00

Paediatric King Vision® videolaryngoscope in a case of infantile oral mass: A useful alternative to fiberoptic bronchoscope as a first choice in paediatric difficult airway

Gnanasekaran Srinivasan, Ranjith Kumar Sivakumar, Prasanna Bidkar, Dristi SharmaIndian Journal of Anaesthesia 2019 63(4):325-327

Indian Journal of Anaesthesia : 2014 - 58(6)

Thu Apr 04, 2019 00:00

Evaluation of performance of C-MAC® video laryngoscope Miller blade size zero for endotracheal intubation in preterm and ex-preterm infants: A retrospective analysis

Renu Sinha, Kanil Ranjith Kumar, Ram Kumar Kalaiyarasan, Puneet Khanna, Bikash Ranjan Ray, Ravinder Kumar Pandey, Jyotsna Punj, Vanlal DarlongIndian Journal of Anaesthesia 2019 63(4):284-288 Background and Aims: The preterm and ex-preterm babies form a separate group among the paediatric population with unique airway anatomy. The utility of C-MAC® Video laryngoscope (VL) for routine intubation of preterm babies has not been evaluated. The purpose of this study is to report the performance of C-MAC®...

Indian Journal of Anaesthesia : 2014 - 58(6)

Thu Apr 04, 2019 00:00

The subcostal nerve as the target for nerve stimulator–guided transversus abdominis plane blocks - Commentary

Sumitra G BakshiIndian Journal of Anaesthesia 2019 63(4):255-256

Indian Journal of Anaesthesia : 2014 - 58(6)

Thu Apr 04, 2019 00:00

Comparing the efficacy of aprepitant and ondansetron for the prevention of postoperative nausea and vomiting (PONV): A double blinded, randomised control trial in patients undergoing breast and thyroid surgeries

Salome Jeyabalan, Suma Mary Thampi, Reka Karuppusami, Kunder SamuelIndian Journal of Anaesthesia 2019 63(4):289-294 Background and Aims: Aprepitant, a Neurokinin-1 receptor antagonist, has been evaluated in abdominal and neurosurgeries, but its effect is less clear in breast and thyroid surgeries, which are also known to be high risk for post-operative nausea and vomiting (PONV). This study was done to compare the antiemetic efficacy of ondansetron and aprepitant in women undergoing mastectomy...

Indian Journal of Anaesthesia : 2014 - 58(6)

Thu Apr 04, 2019 00:00

Occurrence of Cardio-respiratory reflex during ophthalmic artery embolisation in the neurointervention radiology suite

Ketan K Kataria, Rajeev Chauhan, Summit Dev Bloria, Ankur LuthraIndian Journal of Anaesthesia 2019 63(4):316-317

Indian Journal of Anaesthesia : 2014 - 58(6)

Thu Apr 04, 2019 00:00

Comparison of Full Outline of UnResponsiveness (FOUR) score and the conventional scores in predicting outcome in aneurysmal subarachnoid haemorrhage patients

Rajeeb Kumar Mishra, Charu Mahajan, Indu Kapoor, Hemanshu Prabhakar, Parmod Kumar BithalIndian Journal of Anaesthesia 2019 63(4):295-299 Background and Aims: Full Outline of UnResponsiveness (FOUR) score is a more comprehensive score used to assess eye response, motor response, brainstem reflexes, and respiration that was introduced to overcome the drawbacks of Glasgow coma scale (GCS) score. Our aim was to assess which score best predicts mortality and poor outcome in aneurysmal subarachnoid haemorrhage...

Indian Journal of Anaesthesia : 2014 - 58(6)

Thu Apr 04, 2019 00:00

Foreign body obstructing fresh gas flow through disposable breathing circuit

Kavitha Lakshman, Jean Hannah Philip, HM Ravikiran, Namrata RanganathIndian Journal of Anaesthesia 2019 63(4):319-321

Indian Journal of Anaesthesia : 2014 - 58(6)

Thu Apr 04, 2019 00:00

Assessment of predisposing factors in myofascial pain syndrome and the analgesic effect of trigger point injections - A primary therapeutic interventional clinical trial

S Parthasarathy, Siyam Sundar, Gayatri MishraIndian Journal of Anaesthesia 2019 63(4):300-303 Background and Aims: Myofascial pain syndrome (MPS) is a common cause of chronic musculoskeletal pain, characterised by myofascial trigger points (TPs). TP injection is an established technique for management of MPS. In this study, we analysed the efficacy of myofascial TP injection of lignocaine and the influencing biomechanical factors on MPS. Methods: After obtaining ethical committee approval, we included...

Indian Journal of Anaesthesia : 2014 - 58(6)

Thu Apr 04, 2019 00:00

Awake fiberoptic intubation with double lumen tube for severe predicted difficult airways: Could it be feasible with a rigid fiberoptic stylet?

Stefano Falcetta, Massimiliano Sorbello, Ida Di Giacinto, Abele DonatiIndian Journal of Anaesthesia 2019 63(4):323-325

Indian Journal of Anaesthesia : 2014 - 58(6)

Thu Apr 04, 2019 00:00

Magnesium sulphate optimises surgical field without attenuation of the stapaedius reflex in paediatric cochlear implant surgery

Wahba Z Bakhet, Hassan A Wahba, Lobna M El Fiky, Hossam DebisIndian Journal of Anaesthesia 2019 63(4):304-309 Background and Aims: The anaesthesia technique for paediatric cochlear implantation should be modified to achieve an optimised surgical field and allow neuromonitoring. Total intravenous anaesthesia (TIVA) provides good surgical condition without affecting intraoperative electrical stapaedial reflex threshold (ESRT). Though magnesium sulphate (MgSO4) is a cheap, readily available drug for...

Indian Journal of Anaesthesia : 2014 - 58(6)

Thu Apr 04, 2019 00:00

Ultrasound-guided left brachiocephalic vein cannulation: Where to puncture the vein?

Amarjeet Kumar, Chandni Sinha, Ajeet Kumar, Neeraj Kumar, Jitendra K SinghIndian Journal of Anaesthesia 2019 63(4):327-328

Indian Journal of Anaesthesia : 2014 - 58(6)

Thu Apr 04, 2019 00:00

A new indication of erector spinae plane block for perioperative analgesia is total hip replacement surgery – A case report

Swati Singh, Rahul Ranjan, Dusu LalinIndian Journal of Anaesthesia 2019 63(4):310-311 A new indication of ultrasound – guided Erector spinae plane block for perioperative analgesia is orthopaedic surgery. We report here the use of this paraspinal block in the case of a 68-yr-old female with multiple systemic disorder for total hip replacement surgery.

Indian Journal of Anaesthesia : 2014 - 58(6)

Thu Apr 04, 2019 00:00

Unilateral giant internal jugular vein – In response

Venkata Ganesh, B Naveen Naik, Kamal KajalIndian Journal of Anaesthesia 2019 63(4):331-332

Indian Journal of Anaesthesia : 2014 - 58(6)

Thu Apr 04, 2019 00:00

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 Journal of Neurosurgical Anesthesiology - Published Ahead-of-Print

Journal Club

No abstract available

Journal of Neurosurgical Anesthesiology - Published Ahead-of-Print

Wed Apr 03, 2019 03:00

Effects of Vasopressors on Cerebral Circulation and Oxygenation: A Narrative Review of Pharmacodynamics in Health and Traumatic Brain Injury

The clinical use of vasoactive drugs aims to improve hemodynamic variables and thereby maintain or restore adequate perfusion and oxygenation in accordance with metabolic demands. A main focus in the management of patients with brain pathology during surgery and neurointensive care is restoring and/or maintaining adequate cerebral perfusion pressure in order to ensure cerebral blood flow in accordance with metabolic demands. One commonly used clinical strategy is the administration of vasoactive...

Journal of Neurosurgical Anesthesiology - Published Ahead-of-Print

Wed Apr 03, 2019 03:00

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 Journal of Neurosurgical Anesthesiology - Published Ahead-of-Print

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 Latest Results for Journal of Anesthesia

Sleep science in anesthesiology

Latest Results for Journal of Anesthesia

Sat Apr 06, 2019 03:00

Three versus five lumbar PVB injections for herniorrhaphy

Latest Results for Journal of Anesthesia

Fri Apr 05, 2019 03:00

Response to letter to the editor

Latest Results for Journal of Anesthesia

Fri Apr 05, 2019 03:00

Dexmedetomidine and clinical outcomes of non-cardiac surgery

Latest Results for Journal of Anesthesia

Thu Apr 04, 2019 03:00

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Aesthetic Plastic Surgery

 British Association of Plastic Surgeons

Quantifying the burden of litigation in UK plastic surgery: A national survey

Publication date: Available online 4 April 2019Source: Journal of Plastic, Reconstructive & Aesthetic SurgeryAuthor(s): Shakeel Rahman, Lilli Cooper, David Thomson, Mark Soldin

British Association of Plastic Surgeons

Fri Apr 05, 2019 16:14

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 Journal of Plastic, Reconstructive & Aesthetic Surgery

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 Latest Results for Aesthetic Plastic Surgery

Facial Contouring by Using Dermal Fillers and Botulinum Toxin A: A Practical Approach

Abstract Background The perception of an attractive face is largely subjective. The purpose of this paper is to provide an insight and a practical approach to facial contouring management with hyaluronic acid (HA) implants and botulinum toxin A. Methods This study is presenting the clinical experience of the authors regarding facial contouring. After a careful...

Latest Results for Aesthetic Plastic Surgery

Fri Apr 05, 2019 03:00

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Archives of Disease in Childhood

Highlights from this issue In Kipling's seminal novel 'Kim', the central premise (literal and metaphorical) is the wresting for power in fin de (19th) siècle South Asia. This attritional confrontation became popularly known as the Great Game and, though ostensibly a children's book, is really more complex. At its core, it is an examination of conflict at multiple levels, part of course of the 'human condition'. The book, is as apposite now as it was in the Bombay and Kabul of Kipling's youth and the theme underpins several of this month's broad ranging papers Disaster preparedness Though one might debate the relative contributions to the change, no one would refute the fact that, as starkly highlighted by the global terrorism index, the world is becoming less stable. Though human beings may always have had this propensity, technological changes have altered the means of expressing this phenotype on both a personal and national scale....

Conflict, candour and reflection There are many challenges to practising medicine well, not least keeping up to date with medical advances, implementing them within the time and financial restraints of ever expanding healthcare and avoiding over or under treatment while keeping the patient safe and avoiding criticism or complaints. In essence, considering the 'whole patient' and managing them using our knowledge, skills and experience which no longer equates to just the medical facts with increased recognition that skills like 'openness', 'listening', 'transparency' and enhanced communication are partly acquired by experience but can also be facilitated by training, mentoring and working in a positive and supportive environment. Multiple new areas of thinking have emerged as priorities—conflict resolution training, the duty of candour, learning from excellence, the need to reflect and active consideration of well being for ourselves, our patients and their families. These concepts need to be embraced as they will help facilitate us...

Quality of life after extremely preterm birth Gire et al examine the quality of life (QoL) of French primary school-age children born extremely preterm (EP), without disabilities.1 EP birth is usually defined as birth <28 completed weeks' pregnancy, and accounts for <1% of all births, and about 5% of all preterm births. Most children born preterm are moderate to late preterm. However, children born EP have been followed up in international cohort studies for many years, and are well recognised as being at high risk of mortality, morbidity and adverse long-term neurodevelopmental and metabolic outcomes. As these children grow into adulthood, a rich body of literature is emerging, describing their self-reported and observer-reported QoL: an important adjunct to the medical and psychological outcome measures that are deemed important by clinicians and researchers. Gire et al report that this cross-sectional multicentre study from five level III neonatal hospitals includes 20% of children born EP in France. Importantly, both...

Research beyond the hospital walls Introduction Reading widely is not only good for children. Although 'publish or perish' has tended to replace 'read or be dull' in academic life, reading beyond the clinical literature gives us grown-ups a better understanding of children's lives and histories as well as our own. This article provides pointers to the kinds of work with something important to say about children's well-being beyond hospital or clinical settings. The more we understand—as medical education reminds us—that bodies are not just a bunch of organs and that medicine is only one of many determinants of good child health, the more fun it can be to see what we might learn from people on whose shoulders we stand, whatever their discipline. Earlier articles in this series discuss the imperative to build on what we know and to ask the kinds of questions that children, parents and healthcare professionals would like to...

Maternal immunisation in pregnancy to protect newborn infants Although maternal tetanus immunisation has been effectively implemented for many years in the developing world,1 there has been a renewed global interest in maternal immunisation programmes over the past several years.2–5 This has been driven partly by the severity of the 2009 H1N1 influenza pandemic in pregnant women and the safety provided by the widespread maternal immunisation programme implemented in response to the pandemic.6 7 It has also been increasingly appreciated that maternal immunisations are an excellent way to provide protection to young infants before their own primary immunisation series would begin. There are several reasons that immunising pregnant women is an attractive vaccination strategy. First, by immunising the pregnant woman there is the potential to prevent the targeted infection in both the pregnant woman and her infant. This approach is often referred to as a 'two-fer' with...

A call to action: attention to paediatric-specific disaster preparedness Natural and man-made disasters have been increasing worldwide. Six hundred natural disasters were documented worldwide in 2016 compared with 200 in 1980.1 The Global Terrorism Index score (which reflects the relative impact of terrorism incidents annually) increased ninefold from 2000 to 2015.2 With this increasing frequency of mass-casualty events globally, hospitals and their healthcare professionals (HCPs) must be ready to receive and manage a large influx of patients. Additionally, these institutions and front-line healthcare workers must be prepared to care for disaster victims of all ages, including the paediatric population, regardless of the hospitals' typical intake patterns. In order to be best prepared, many countries across the world have developed healthcare-related disaster plans. Similar to other countries, France has developed the Organisation de la Réponse du Système de Santé en Situations Sanitaires Exceptionnelles plan to guide the management of mass casualties. However, this specific plan lacks...

Disaster preparedness in French paediatric hospitals 2 years after terrorist attacks of 2015 Objective We aimed to determine paediatric hospital preparedness for a mass casualty disaster involving children in both prehospital and hospital settings. The study findings will serve to generate recommendations, guidelines and training objectives. Design and setting The AMAVI-PED study is a cross-sectional survey. An electronic questionnaire was sent to French physicians with key roles in specialised paediatric acute care. Results In total, 81% (26 of 32) of French University Hospitals were represented in the study. A disaster plan AMAVI with a specific paediatric emphasis was established in all the paediatric centres. In case of a mass casualty event, paediatric victims would be initially admitted to the paediatric emergency department for most centres (n=21; 75%). Paediatric anaesthesiologists, paediatric surgeons and paediatric radiologists were in-house in 20 (71%), 5 (18%) and 12 (43%) centres, respectively. Twenty-three (82%) hospitals had a paediatric specialised mobile intensive care unit and seven (25%) of these could provide a prehospital emergency response. Didactic teaching and simulation exercises were implemented in 20 (71%) and 22 (79%) centres, respectively. Overall, physician participants rated the level of readiness of their hospital as 6 (IQR: 5–7) on a 10-point readiness scale. Conclusion Paediatric preparedness is very heterogeneous between the centres. Based on the study findings, we suggest that a national programme must be defined and guidelines generated.

Reducing healthcare conflict: outcomes from using the conflict management framework Objective To test a new conflict management framework (CMF) to help staff identify and de-escalate conflict between staff and patients/families. Design Before/after study that reports staff quality of life, frequency/severity of conflicts and qualitative interviews on using the framework. Data were collected from May 2017 to September 2017. Setting A paediatric oncology department day-patient and 23-bed inpatient ward. Intervention A two-stage CMF used by staff during daily handovers to identify and then manage conflict cases with families. Results Staff found the CMFto be helpful in identifying and de-escalating conflicts. The number of conflicts reported decreased by 64% from baseline to follow-up. Communication regarding conflict identification improved. Reports of staff burn-out decreased between the two time-points (n=55 at baseline, n=31 at follow-up; p=0.001). Scores on compassion and secondary traumatic stress did not change. Conclusions The CMF substantially reduces the incidence of conflicts and is an acceptable approach for staff. Continued use of the framework would require it to be fully integrated into the working of the ward, which would need to include senior medical buy-in. Further refinements to the framework have been made and will be tested in four UK sites in 2018/2019.

Quality of life of extremely preterm school-age children without major handicap: a cross-sectional observational study Objective To determine the quality of life (QoL) of school-aged children who were born <28+0 weeks of gestation and who have no resultant major disabilities. Design, setting and patients A cross-sectional multicentre study of extremely preterm (EPT) infants born <28+0 weeks, discharged alive and free from severe impairments (cerebral palsy, autism, major cognitive disabilities). Two generic, self-evaluation and hetero-evaluation (by parent) QoL measurement questionnaires (Kidscreen 10/VSP-A) were used and then compared with French population reference. Main outcome measures Clinical examination, an assessment of cognitive functions and QoL between 7 and 10 years of age. Results 40 (7.5%) severely disabled children were excluded. Among those 471 eligible, the lost to follow-up group (169 (36%)) paralleled those 302 (64%) included in the study. The mean gestational age was 26.2 (±0.8), birth weight was 879 (±181) g and the mean age was 8.4 (±0.87) years. 48% of participants had minor or moderate cognitive disabilities based on their Full-Scale Index Quotient. Working memory, attention and mental flexibility scored as low-average. Except for family relationships, the EPT QoL VSP-A and Kidscreen 10 assessment were significantly lower based on the children's and parent's perspectives. Children reported the most significant QoL decline as (1) friends' relationships, (2) self-esteem and (3) leisure, while parents indicated (1) psychological well-being, (2) schoolwork and (3) vitality. Conclusion The QoL of a school-age EPT child without severe impairment was lower relative to a reference population from both the parents' and child's points of view. This evaluation should help to better understand the long-term outcomes and to provide better support for them and their families. Trial registration number NCT01675726, pre-results.

Air pollution and autism It's clear that genetics plays a major role in the aetiology of autistic spectrum disorder (ASD), but the genuine increase in prevalence over recent decades suggests that environmental factors are also responsible. If ASD is considered to be a neurodevelopmental disorder, rather than a social construct, then antenatal influences during early brain development may be important. Potential prenatal causes suggested thus far are many and varied, including paracetamol (Archivist Oct 2016 doi.org/10.1136/archdischild-2016–3 11 708), antidepressant drugs (Archivist March 2016 doi.org/10.1136/archdischild-2016–3 10 462), ultrasound (Archivist Sept 2018 doi.org/10.1136/archdischild-2018–3 15 816), season of conception (Lucina Dec 2016 doi.org/10.1136/archdischild-2016–3 12 102), and obesity, among many others. Several studies have hinted at a link with maternal air pollution exposure, but these have been inconsistent or inconclusive. ASD definitions have been imprecise, exposure indicators not sufficiently localised, and types of pollution lumped together. Importantly, confounding factors need to be accounted for, as families with the highest psychosocial risks for autism may tend...

Highlights from this issue In Kipling's seminal novel 'Kim', the central premise (literal and metaphorical) is the wresting for power in fin de (19th) siècle South Asia. This attritional confrontation became popularly known as the Great Game and, though ostensibly a children's book, is really more complex. At its core, it is an examination of conflict at multiple levels, part of course of the 'human condition'. The book, is as apposite now as it was in the Bombay and Kabul of Kipling's youth and the theme underpins several of this month's broad ranging papers Disaster preparedness Though one might debate the relative contributions to the change, no one would refute the fact that, as starkly highlighted by the global terrorism index, the world is becoming less stable. Though human beings may always have had this propensity, technological changes have altered the means of expressing this phenotype on both a personal and national scale....

Conflict, candour and reflection There are many challenges to practising medicine well, not least keeping up to date with medical advances, implementing them within the time and financial restraints of ever expanding healthcare and avoiding over or under treatment while keeping the patient safe and avoiding criticism or complaints. In essence, considering the 'whole patient' and managing them using our knowledge, skills and experience which no longer equates to just the medical facts with increased recognition that skills like 'openness', 'listening', 'transparency' and enhanced communication are partly acquired by experience but can also be facilitated by training, mentoring and working in a positive and supportive environment. Multiple new areas of thinking have emerged as priorities—conflict resolution training, the duty of candour, learning from excellence, the need to reflect and active consideration of well being for ourselves, our patients and their families. These concepts need to be embraced as they will help facilitate us...

Quality of life after extremely preterm birth Gire et al examine the quality of life (QoL) of French primary school-age children born extremely preterm (EP), without disabilities.1 EP birth is usually defined as birth <28 completed weeks' pregnancy, and accounts for <1% of all births, and about 5% of all preterm births. Most children born preterm are moderate to late preterm. However, children born EP have been followed up in international cohort studies for many years, and are well recognised as being at high risk of mortality, morbidity and adverse long-term neurodevelopmental and metabolic outcomes. As these children grow into adulthood, a rich body of literature is emerging, describing their self-reported and observer-reported QoL: an important adjunct to the medical and psychological outcome measures that are deemed important by clinicians and researchers. Gire et al report that this cross-sectional multicentre study from five level III neonatal hospitals includes 20% of children born EP in France. Importantly, both...

Research beyond the hospital walls Introduction Reading widely is not only good for children. Although 'publish or perish' has tended to replace 'read or be dull' in academic life, reading beyond the clinical literature gives us grown-ups a better understanding of children's lives and histories as well as our own. This article provides pointers to the kinds of work with something important to say about children's well-being beyond hospital or clinical settings. The more we understand—as medical education reminds us—that bodies are not just a bunch of organs and that medicine is only one of many determinants of good child health, the more fun it can be to see what we might learn from people on whose shoulders we stand, whatever their discipline. Earlier articles in this series discuss the imperative to build on what we know and to ask the kinds of questions that children, parents and healthcare professionals would like to...

Maternal immunisation in pregnancy to protect newborn infants Although maternal tetanus immunisation has been effectively implemented for many years in the developing world,1 there has been a renewed global interest in maternal immunisation programmes over the past several years.2–5 This has been driven partly by the severity of the 2009 H1N1 influenza pandemic in pregnant women and the safety provided by the widespread maternal immunisation programme implemented in response to the pandemic.6 7 It has also been increasingly appreciated that maternal immunisations are an excellent way to provide protection to young infants before their own primary immunisation series would begin. There are several reasons that immunising pregnant women is an attractive vaccination strategy. First, by immunising the pregnant woman there is the potential to prevent the targeted infection in both the pregnant woman and her infant. This approach is often referred to as a 'two-fer' with...

A call to action: attention to paediatric-specific disaster preparedness Natural and man-made disasters have been increasing worldwide. Six hundred natural disasters were documented worldwide in 2016 compared with 200 in 1980.1 The Global Terrorism Index score (which reflects the relative impact of terrorism incidents annually) increased ninefold from 2000 to 2015.2 With this increasing frequency of mass-casualty events globally, hospitals and their healthcare professionals (HCPs) must be ready to receive and manage a large influx of patients. Additionally, these institutions and front-line healthcare workers must be prepared to care for disaster victims of all ages, including the paediatric population, regardless of the hospitals' typical intake patterns. In order to be best prepared, many countries across the world have developed healthcare-related disaster plans. Similar to other countries, France has developed the Organisation de la Réponse du Système de Santé en Situations Sanitaires Exceptionnelles plan to guide the management of mass casualties. However, this specific plan lacks...

Disaster preparedness in French paediatric hospitals 2 years after terrorist attacks of 2015 Objective We aimed to determine paediatric hospital preparedness for a mass casualty disaster involving children in both prehospital and hospital settings. The study findings will serve to generate recommendations, guidelines and training objectives. Design and setting The AMAVI-PED study is a cross-sectional survey. An electronic questionnaire was sent to French physicians with key roles in specialised paediatric acute care. Results In total, 81% (26 of 32) of French University Hospitals were represented in the study. A disaster plan AMAVI with a specific paediatric emphasis was established in all the paediatric centres. In case of a mass casualty event, paediatric victims would be initially admitted to the paediatric emergency department for most centres (n=21; 75%). Paediatric anaesthesiologists, paediatric surgeons and paediatric radiologists were in-house in 20 (71%), 5 (18%) and 12 (43%) centres, respectively. Twenty-three (82%) hospitals had a paediatric specialised mobile intensive care unit and seven (25%) of these could provide a prehospital emergency response. Didactic teaching and simulation exercises were implemented in 20 (71%) and 22 (79%) centres, respectively. Overall, physician participants rated the level of readiness of their hospital as 6 (IQR: 5–7) on a 10-point readiness scale. Conclusion Paediatric preparedness is very heterogeneous between the centres. Based on the study findings, we suggest that a national programme must be defined and guidelines generated.

Reducing healthcare conflict: outcomes from using the conflict management framework Objective To test a new conflict management framework (CMF) to help staff identify and de-escalate conflict between staff and patients/families. Design Before/after study that reports staff quality of life, frequency/severity of conflicts and qualitative interviews on using the framework. Data were collected from May 2017 to September 2017. Setting A paediatric oncology department day-patient and 23-bed inpatient ward. Intervention A two-stage CMF used by staff during daily handovers to identify and then manage conflict cases with families. Results Staff found the CMFto be helpful in identifying and de-escalating conflicts. The number of conflicts reported decreased by 64% from baseline to follow-up. Communication regarding conflict identification improved. Reports of staff burn-out decreased between the two time-points (n=55 at baseline, n=31 at follow-up; p=0.001). Scores on compassion and secondary traumatic stress did not change. Conclusions The CMF substantially reduces the incidence of conflicts and is an acceptable approach for staff. Continued use of the framework would require it to be fully integrated into the working of the ward, which would need to include senior medical buy-in. Further refinements to the framework have been made and will be tested in four UK sites in 2018/2019.

Quality of life of extremely preterm school-age children without major handicap: a cross-sectional observational study Objective To determine the quality of life (QoL) of school-aged children who were born <28+0 weeks of gestation and who have no resultant major disabilities. Design, setting and patients A cross-sectional multicentre study of extremely preterm (EPT) infants born <28+0 weeks, discharged alive and free from severe impairments (cerebral palsy, autism, major cognitive disabilities). Two generic, self-evaluation and hetero-evaluation (by parent) QoL measurement questionnaires (Kidscreen 10/VSP-A) were used and then compared with French population reference. Main outcome measures Clinical examination, an assessment of cognitive functions and QoL between 7 and 10 years of age. Results 40 (7.5%) severely disabled children were excluded. Among those 471 eligible, the lost to follow-up group (169 (36%)) paralleled those 302 (64%) included in the study. The mean gestational age was 26.2 (±0.8), birth weight was 879 (±181) g and the mean age was 8.4 (±0.87) years. 48% of participants had minor or moderate cognitive disabilities based on their Full-Scale Index Quotient. Working memory, attention and mental flexibility scored as low-average. Except for family relationships, the EPT QoL VSP-A and Kidscreen 10 assessment were significantly lower based on the children's and parent's perspectives. Children reported the most significant QoL decline as (1) friends' relationships, (2) self-esteem and (3) leisure, while parents indicated (1) psychological well-being, (2) schoolwork and (3) vitality. Conclusion The QoL of a school-age EPT child without severe impairment was lower relative to a reference population from both the parents' and child's points of view. This evaluation should help to better understand the long-term outcomes and to provide better support for them and their families. Trial registration number NCT01675726, pre-results.

Air pollution and autism It's clear that genetics plays a major role in the aetiology of autistic spectrum disorder (ASD), but the genuine increase in prevalence over recent decades suggests that environmental factors are also responsible. If ASD is considered to be a neurodevelopmental disorder, rather than a social construct, then antenatal influences during early brain development may be important. Potential prenatal causes suggested thus far are many and varied, including paracetamol (Archivist Oct 2016 doi.org/10.1136/archdischild-2016–3 11 708), antidepressant drugs (Archivist March 2016 doi.org/10.1136/archdischild-2016–3 10 462), ultrasound (Archivist Sept 2018 doi.org/10.1136/archdischild-2018–3 15 816), season of conception (Lucina Dec 2016 doi.org/10.1136/archdischild-2016–3 12 102), and obesity, among many others. Several studies have hinted at a link with maternal air pollution exposure, but these have been inconsistent or inconclusive. ASD definitions have been imprecise, exposure indicators not sufficiently localised, and types of pollution lumped together. Importantly, confounding factors need to be accounted for, as families with the highest psychosocial risks for autism may tend...

Highlights from the literature I am honoured to take over the role of Lucina; Goddess of Childbirth World-wide estimate of Suicidal ideation in 13-17 year olds An estimate of the prevalence of suicidal ideation, suicide planning, and suicide attempts using data from Global School-based Student Health Survey of schoolchildren aged 13 to 17 years has highlighted some important geographical variation. [Uddin R et al. Lancet (Adolescent and Child Health) DOI:https://doi.org/10.1016/S2352-4642(18)30403-6]. This is a large population-based study of 229, 129 adolescents (mean age 14·6 [SD 1·18] years), from 59 low-income and middle-income countries across six WHO regions collected between 2003 and 2015. Meta-analysis with random effects was used to focus on age based and gender based estimates. The overall prevalence of suicidal ideation was 16·9% (95% CI 15·0–18·8), suicide planning was 17·0% (14·8–19·2), and suicide attempts was 17·0% (14·7–19·3) in the 12 months preceding survey completion. The African region had the highest prevalence of suicidal...

Confused health and nutrition claims in food marketing to children could adversely affect food choice and increase risk of obesity Objectives To investigate the nutritional quality of foods marketed to children in the UK and to explore the use of health and nutrition claims. Design This cross-sectional study was carried out in a wide range of UK food retailers. Products marketed to children above the age of 1 year containing any of a range of child friendly themes (i.e. cartoons, toys and promotions), and terms suggesting a nutritious or healthy attribute such as 'one of 5-a-day', on product packaging were identified both in stores and online. Information on sugar, salt and fat content, as well as health and nutrition claims, was recorded. The Ofcom nutrient profiling model (NPM) was used to assess if products were healthy. Results Three hundred and thirty-two products, including breakfast cereals, fruit snacks, fruit-based drinks, dairy products and ready meals, were sampled. The use of cartoon characters (91.6%), nutrition claims (41.6%) and health claims (19.6%) was a common marketing technique. The one of 5-a-day claim was also common (41.6%), but 75.4% (103) of products which made this claim were made up of less than 80 g of fruit and vegetables. Sugar content (mean±SD per 100 g) was high in fruit snacks (48.4±16.2 g), cereal bars (28.9±7.5 g) and cereals (22.9±8.0 g). Overall, 41.0% of the products were classified as less healthy according to the Ofcom NPM. Conclusion A large proportion of products marketed to children through product packaging are less healthy, and claims used on product packaging are confusing. Uniform guidance would avoid confusion on nutritional quality of many popular foods.

Association between hypotension and serious illness in the emergency department: an observational study Background The value of routine blood pressure measurement in the emergency department (ED) is unclear. Objective To determine the association between hypotension in addition to tachycardia and the Shock Index for serious illness. Design Observational study. Setting University ED (2009–2016). Participants, methods and main outcomes Routine data collected from consecutive children <16 years. Using logistic regression, we assessed the association between hypotension (adjusted for tachycardia) and Shock Index (ratio heart rate/blood pressure [BP]) for serious illness. The predictive accuracy (sensitivity, specificity) for hypotension and Shock Index was determined for serious illness, defined as intensive care unit (ICU) and hospital admissions. Results We included 10 698 children with measured BP. According to three age-adjusted clinical cut-offs (Advanced Paediatric Life Support, Paediatric Advanced Life Support and Paediatric Early Warning Score), hypotension was significantly associated with ICU admission when adjusted for tachycardia (range OR 2.6–5.3). Hypotension showed low sensitivity (range 0.05–0.12) and high specificity (range 0.95–0.99) for ICU admission. Combining hypotension and tachycardia did not change the predictive value for ICU admission. Similar results were found for hospitalisation. Shock index was associated with serious illness. However, no specific cut-off value was identified in different age groups. Conclusions Hypotension, adjusted for tachycardia, is associated with serious illness, although its sensitivity is limited. Shock index showed an association with serious illness, but no acceptable cut-off value could be identified. Routine BP measurement in all children to detect hypotension has limited value in the ED. Future studies need to confirm which patients could benefit from BP measurement.

Acute ataxia in paediatric emergency departments: a multicentre Italian study Objectives To evaluate the causes and management of acute ataxia (AA) in the paediatric emergency setting and to identify clinical features predictive of an underlying clinically urgent neurological pathology (CUNP). Study design This is a retrospective medical chart analysis of children (1–18 years) attending to 11 paediatric emergency departments (EDs) for AA in an 8-year period. A logistic regression model was applied to identify clinical risk factors for CUNP. Results 509 patients (mean age 5.8 years) were included (0.021% of all ED attendances). The most common cause of AA was acute postinfectious cerebellar ataxia (APCA, 33.6%). Brain tumours were the second most common cause (11.2%), followed by migraine-related disorders (9%). Nine out of the 14 variables tested showed an OR >1. Among them, meningeal and focal neurological signs, hyporeflexia and ophthalmoplegia were significantly associated with a higher risk of CUNP (OR=3–7.7, p<0.05). Similarly, the odds of an underlying CUNP were increased by 51% by each day from onset of ataxia (OR=1.5, CI 1.1 to 1.2). Conversely, a history of varicella-zoster virus infection and vertigo resulted in a significantly lower risk of CUNP (OR=0.1 and OR=0.5, respectively; p<0.05). Conclusions The most frequent cause of AA is APCA, but CUNPs account for over a third of cases. Focal and meningeal signs, hyporeflexia and ophthalmoplegia, as well as longer duration of symptoms, are the most consistent 'red flags' of a severe underlying pathology. Other features with less robust association with CUNP, such as seizures or consciousness impairment, should be seriously taken into account during AA evaluation.

Longitudinal analysis of health disparities in childhood Objective Combatting disparities in health outcomes among children is a major public health concern. This study focuses on two questions: (1) To what extent does socioeconomic status (SES) contribute to disparities in health outcomes? and (2) To what extent can social inequalities in health outcomes be explained by differences in children's health behaviours? Design This study included 2-year follow-up data of 1259 children (4–12 years of age) who participated in the 'Healthy Primary School of the Future' project (ClinicalTrials.gov NCT02800616). SES was measured by maternal and paternal education and household income (adjusted for family size). Health outcomes were body mass index (BMI) z-score, health resource use, school absenteeism, health-related quality of life and psychosocial health, measured over 2 years of follow-up (2015–2017). Health behaviours included physical activity, and consumption of fruits, vegetables and sweetened beverages. Associations between SES and baseline health behaviours were examined, and mixed models for repeated measures were used to assess associations between SES and health outcomes over 2 years of follow-up. Results A high socioeconomic background was significantly associated with better health outcomes (all outcomes). For example, children with a low SES had higher BMI z-scores (beta coefficient: 0.42, 95% CI 0.22 to 0.62) and higher consumption healthcare costs (ratio of mean costs: 2.21, 95% CI 1.57 to 3.10). Effects of SES changed very little after controlling for health behaviours. Discussion Our findings strongly suggest that socioeconomic background has a pervasive impact on disparities in child health, but gives little support to the idea that social inequalities in child health can be tackled by means of lifestyle interventions.

Pharmacological management of abnormal tone and movement in cerebral palsy Background The evidence base to guide the pharmacological management of tone and abnormal movements in cerebral palsy (CP) is limited, as is an understanding of routine clinical practice in the UK. We aimed to establish details of motor phenotype and current pharmacological management of a representative cohort across a network of UK tertiary centres. Methods Prospective multicentre review of specialist motor disorder clinics at nine UK centres, collecting data on clinical features and pharmacological management of children and young people (CYP) with CP over a single calendar month. Results Data were collected from 275 CYP with CP reviewed over the calendar month of October 2017. Isolated dystonia or spasticity was infrequently seen, with a mixed picture of dystonia and spasticity ± choreoathetosis identified in 194/275 (70.5%) of CYP. A comorbid diagnosis of epilepsy was present in 103/275 (37.4%). The most commonly used medications for abnormal tone/movement were baclofen, trihexyphenidyl, gabapentin, diazepam and clonidine. Medication use appeared to be influenced separately by the presence of dystonia or spasticity. Botulinum toxin use was common (62.2%). A smaller proportion of children (12.4%) had undergone a previous neurosurgical procedure for tone/movement management. Conclusions CYP with CP frequently present with a complex movement phenotype and comorbid epilepsy. They have multiple therapy, medical and surgical management regimens. Future trials of therapeutic, pharmacological or surgical interventions in this population must adequately encompass this complexity in order to be translatable to clinical practice.

Contained and controlled: a collaborative future Antimicrobial resistance continues to be a major global challenge. The recent Governmental publication from the Department of Health and Social Care in January 2019 reminds of this challenge and attempts to lay out an ambitious plan for the next 20 years; the UK 20-year vision for antimicrobial resistance. Department of Health and Social Care; 2019. https://www.gov.uk/government/publications/uk-20-year-vision-for-antimicrobial-resistance. They comment that "The vision and plan were developed across the government, its agencies and administrations in Scotland, Wales and Northern Ireland, with support from a range of stakeholders. It is supported by the 'UK 5 year action plan for antimicrobial resistance 2019 to 2024'. " It summarises the global issues of antimicrobial resistance (AMR). It challenges not only the medical professions but all stakeholders in public sector and private sector and the public themselves. It reminds us that in the UK that at least 20% of antibiotic prescribed in primary care are...

Can the rotavirus vaccination reduce the incidence of Type 1 diabetes? As the global epidemic of obesity and type two diabetes in children and adults continues to be a major challenge to public health, an intriguing possible 'off-target' effect of the rotavirus vaccine and association with a reduction in the incidence of Type 1 diabetes, has been reported in JAMA Paediatrics. An Australian study from a team in Melbourne, JAMA Pediatr 2019;173(3):280-282. doi: 10.1001/jamapediatrics.2018.4578) and is the first report of epidemiological evidence of this possible and fascinating association. Nearly 20 years ago it was recognised the rotavirus may have an effect on islet cells auto immunity (Diabetes 2000;49(8):1319–1324. doi:10.2337/diabetes.49.8.1319). Rotavirus vaccination was introduced in Australia in 2007. The team examined the incidence of type 1 diabetes, 8 years before the introduction of the vaccine and compared the incidence to the 8 years after introduction. They hypothesised that the rotavirus vaccination may reduce the incidence of the disease over time. National coverage of the vaccination...

Falling admissions to hospital with febrile seizures in the UK Objectives There was a reduction in febrile seizure admissions in Scotland after 2008. Our hypothesis was that a similar trend would be seen in other countries. Methods We obtained the number of febrile and non-febrile seizure admissions in England and Scotland 2000–2013 and the incidence of all seizure admissions 2000–2013 in European countries. We compared the incidence of admission for febrile seizure (Scotland and England) and all seizures (all countries) between 2000–2008 and 2009–2013. Results The incidence of febrile seizure admissions per 1000 children in 2009–2013 was lower than 2000–2008 in Scotland (0.79 vs 1.08, p=0.001) and England (0.92 vs 1.20, p<0.001). The incidence of all seizure admissions (but not non-febrile seizures) was lower in 2009–2013 compared with 2000–2008 in Scotland (1.84 vs 2.20, p=0.010) and England (2.71 vs 2.91, p=0.001). Across 12 European countries (including the UK), there was no difference in all seizure admissions after 2008. We explored the possibility that the fall was related to the introduction of routine pneumococcal vaccination in 2006 but there were insufficient data. Conclusion A fall in admissions for febrile (but not afebrile) seizures after 2008 in Scotland and England explains a fall in all emergency admissions for seizure. A fall in all seizure admissions has not occurred in other European countries, and more research is required to understand the different outcomes in the UK and non-UK countries.

Age-related gait standards for healthy children and young people: the GOS-ICH paediatric gait centiles Objective To develop paediatric gait standards in healthy children and young people. Methods This observational study aims to address the lack of population standards for gait measurements in children. Analysing gait in children affected by neurological or musculoskeletal conditions is an important component of paediatric assessment but is often confounded by developmental changes. The standards presented here do not require clinician expertise to interpret and offer an alternative to developmental tables of normalised gait data. Healthy children aged 1–19 years were recruited from community settings in London and Hertfordshire, UK. The GAITRite walkway was used to record measurements for each child for velocity, cadence, step length, base of support and stance, single and double support (as percentage of gait cycle). We fitted generalised linear additive models for location, scale and shape (gamlss). Results We constructed percentile charts for seven gait variables measured on 624 (321 males) contemporary healthy children using a gamlss package in R. A clinical application of gait standards was explored. Conclusion Age-related, gender-specific standards for seven gait variables were developed and are presented here. They have a familiar format and can be used clinically to aid diagnoses and to monitor change over time for both medical therapy and natural history of the condition. The clinical example demonstrates the potential of the Great Ormond Street Institute of Child Health Paediatric Gait Centiles to enable meaningful interpretation of change in an individual's performance and describes characteristic features of gait from a specific population throughout childhood.