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1.  Pain relief in children: how good are we? 
doi:10.1136/emj.2005.029751
PMCID: PMC2464393  PMID: 17057156
analgesia; emergency department; paediatrics
2.  Exploring the clinical utility of blood ketone levels in the emergency department assessment of paediatric patients 
Emergency Medicine Journal : EMJ  2006;23(10):783-787.
Background
Ketonuria (on standard urine testing) is a frequent finding in children presenting to emergency departments. With the advent of hand‐held ketone meters, blood ketone levels can now be rapidly quantified.
Hypothesis
Point of care testing (POCT) of blood ketone levels could provide clinically useful information on severity of illness in children and risk of hospital admission.
Methods
A prospective study using POCT of blood ketone levels in a convenience sample of children <13 years old, with a typical case mix of medical problems.
Findings
186 children were studied. The range of ketone levels varied widely among this study population depending on the presenting complaint. Higher levels were noted in those presenting with anorexia or vomiting and fever. The median ketone level of the total study population was 0.2 (range 0–6.0, interquartile range 0.1–0.9) mmol/l. Ketone levels correlated poorly with discharge destination and duration of admission. However, receiver–operator characteristics for ketones as a predictor of admission were comparable to Pediatric Risk of Admission scores (area under the curve 0.64 and 0.72, respectively) and may represent an independent risk factor for admission. A ketone level >1.2 mmol/l has a positive predictive value of 66.7% for admission. Ketone levels correlated well with decreased oral intake (R2 = 0.25; p<0.001).
Conclusions
A strong association was found between ketone levels, decreased oral intake and fever. Although ketone levels do not correlate well with more traditional markers of illness severity, they can help to predict the requirement for admission to hospital when interpreted in the context of the presenting illness. They may have applications in both the emergency department and primary care settings. Further prospective testing is required to validate these findings.
doi:10.1136/emj.2006.035758
PMCID: PMC2579600  PMID: 16988307
3.  Contact burns from hair straighteners: a new hazard in the home 
This series highlights a previously unreported hazard for children within the home, hair straightening irons. Thermal injury is a common reason for presentation at the emergency department. Contact burns from domestic irons and hair curling tongs are well documented in the literature. We have become aware of this new hazard in the home, which has resulted in several presentations to our department with deep partial thickness or full thickness burns.
doi:10.1136/emj.2005.027094
PMCID: PMC2464438  PMID: 16498145
burns; hair straighteners; children
4.  Streptococcus A in paediatric accident and emergency: are rapid streptococcal tests and clinical examination of any help? 
Background
Rapid streptococcal tests (RSTs) for streptococcal pharyngitis have made diagnosis at once simpler and more complicated. The American Academy of Pediatrics recommends that all RSTs be confirmed by a follow up throat culture unless local validation has proved the RST to be equally sensitive.
Aims
To evaluate (a) RST as a single diagnostic tool, compared with RST with or without throat culture; (b) clinical diagnosis and the relative contribution of different symptoms.
Methods
The study included 213 patients with clinical signs of pharyngitis. Throat swabs were analysed using Quickvue+ Strep A Test; negative RSTs were backed up by throat culture. Thirteen clinical features commonly associated with strep throat were analysed using backward stepwise logistic regression.
Results
Positive results (RST or throat culture) were obtained in 33 patients; RST correctly identified 21. Eleven samples were false negative on RST. At a strep throat prevalence of 15.9%, sensitivity of RST was 65.6% (95% CI 46.8% to 81.4%) and specificity 99.4% (96.7% to 99.9%). Sensitivity of clinical diagnosis alone was 57% (34% to 78%) and specificity 71% (61% to 80%). Clinically, only history of sore throat, rash, and pyrexia contributed to the diagnosis of strep throat (p<0.05).
Conclusion
The high specificity of RST facilitates early diagnosis of strep throat. However, the low sensitivity of RST does not support its use as a single diagnostic tool. The sensitivity in the present study is markedly different from that reported by the manufacturer. Clinical examination is of limited value in the diagnosis of strep throat. It is important to audit the performance of new diagnostic tests, previously validated in different settings.
doi:10.1136/emj.2004.022970
PMCID: PMC2564123  PMID: 16373800
pharyngitis; paediatrics; streptococcus; point‐of‐care systems
5.  Osteomyelitis in the well looking afebrile child 
BMJ : British Medical Journal  2002;324(7350):1380-1381.
PMCID: PMC1123330  PMID: 12052811
6.  Sports related injuries in Scottish adolescents aged 11-15 
OBJECTIVES: To measure the age and sex distribution of self reported sports and leisure injuries in a 12 month retrospective recall period among a representative national sample of Scottish adolescents, and to examine the characteristics (gender, age, handedness, and level of sports participation) of sports related injuries in relation to injuries sustained during other activities. DESIGN/SETTING: Self completion questionnaire survey administered in schools during April- June 1994. SUBJECTS: 4710 pupils aged 11, 13, and 15 years drawn from a representative sample of 270 classes with returns from 224 classes (83% completion rate). RESULTS: 42.1% of the sample reported a medically attended injury. These were significantly more frequent among boys but there were no significant age differences in overall frequency of injury. Sport related injuries accounted for 32.2% of all medically attended injuries. As with all injuries, frequency was greater in boys than girls at all ages, and there are differences in the pattern of lesions in sports and nonsports injuries. Lower limb injuries were more frequent than upper limb injury in sports (57.6 v 23.9%), whereas there were no differences in non-sports injuries (31.5 v 31.3%). Age and handedness differences in sports injury rates were also identified. High sports participation was significantly associated with a higher risk of injury in general and sports related injury in particular. CONCLUSION: Age, gender, handedness, and level of sports participation have been shown to be implicated in differential risk of sports related injury. Reducing sports injury among adolescents should be a priority, but research into the injury profiles of different sports is needed before detailed injury prevention strategies can be developed. 



PMCID: PMC1756119  PMID: 9865398
7.  Just a pulled hamstring? 
Images
PMCID: PMC1343422  PMID: 10572829
10.  Toddler's fracture. 
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PMCID: PMC1342789  PMID: 8894877
11.  Rollerblading in children: the Edinburgh experience. 
OBJECTIVE: To determine the incidence and severity of injuries sustained by children who present to an accident and emergency (A&E) department following rollerblading accidents. DESIGN: A prospective case-control study. SETTING: The A&E department of a city centre paediatric teaching hospital. METHODS: Data were collected on a specially designed proforma on each child presenting with an injury sustained while rollerblading. The injury severity score was calculated for each patient and details were taken of the length of admission or outpatient follow up where appropriate. RESULTS: Seventy four children (37 male; 37 female) presented with injuries over a three month period. The age range was 6-13 years in both groups. Half the injuries occurred at weekends. Fractures (n = 37) and soft tissue injuries (n = 28) were the most prevalent; 89% of injuries involved the limbs. Sixty eight children (92%) required treatment in A&E. Four (3%) were admitted to hospital and required operative procedures under general anaesthetic. The injury severity score ranged from 1 to 9 with a mean of 2.8. The length of hospital stay for admissions was 1-3 days; 47 children required follow up in the outpatient department (1-3 visits). Average length of outpatient contact was 18 days. CONCLUSIONS: This study shows a greater incidence of rollerblading injuries than has been reported elsewhere. No figures are at present available for the United Kingdom as a whole.
PMCID: PMC1342775  PMID: 8894866
13.  An accident and emergency based child accident surveillance system: is it possible? 
OBJECTIVE--To evaluate the possibility of setting up a database on childhood accidents within an accident and emergency (A&E) department. DESIGN--A proforma detailing epidemiological details about the child and details of the injury was designed and tested for accuracy. It was completed in parallel with the existing case documentation. A retrospective sample was analysed after completion of the study to determine times when data collection was poorest. SETTING--Regional paediatric hospital (total catchment population c. 500,000). RESULTS--Of 13,958 patients in whom full information was available, 65% had all the information available on the forms. Areas of discrepancy in the remainder included (1) transposition of date and time of injury with date and time of attendance (73%), (2) wrong coding (11%), (3) illegible digits (6%), (4) inaccurate data entry to computer (6%). Form completion was worst between 1800 hours and midnight. CONCLUSIONS--Data collection is feasible in the A&E department and is a necessary step in effective child accident prevention. It should be done using real time entry onto computer systems. Additional audit staff must be employed to ensure data collection is as complete as possible as close to the time of the initial attendance as possible. Regular analysis of the findings is essential.
PMCID: PMC1342652  PMID: 8653234
15.  Intussusception presenting to a paediatric accident and emergency department. 
In a retrospective study, 110 patients episodes with intussusception presenting to a paediatric accident and emergency (A&E) department were reviewed, with particular attention being paid to presenting symptoms, time to diagnosis, radiological investigation, management and outcome. Between 1983 and 1993 100 patients presented to this department with 110 episodes of intussusception. Delay in diagnosis of greater than 12 h from initial medical contact was associated with increased morbidity. Associated factors in delayed diagnosis were departure from the classical symptoms (pain, vomiting and blood per rectum) and the presence of diarrhoea. General practitioner (GP) referral was to the medical team (rather than the surgical team) in around 50% of cases. Irrespective of the specialty of the first hospital doctor to see the patient only 42% were diagnosed correctly within 3 h of admission. In this population diarrhoea is a common symptom of intussusception and should alert the clinician rather than reassure. Because of its many presentations and relative rarity, intussusception remains a difficult condition to diagnose.
Images
PMCID: PMC1342475  PMID: 8581242
17.  Post-traumatic transient cortical blindness in children: a report of four cases and a review of the literature. 
Four cases of transient cortical blindness following head injury in children are described. The theories regarding the pathophysiology of the condition are discussed and advice regarding management of such cases is given.
PMCID: PMC1342457  PMID: 7894813
18.  Monteggia fracture-dislocation in children. 
Monteggia fracture-dislocations are uncommon in childhood. Correct early diagnosis is essential to avoid elbow dysfunction and the necessity for open reduction of the radial head. This retrospective analysis of 220 forearm fractures in children shows that 50% of Monteggia fractures were misdiagnosed by accident and emergency (A&E) department senior house officers (SHOs) and 25% were misdiagnosed by senior radiologists. Instruction in correct clinical and radiological examination of the elbow joint in children to junior A&E doctors, with early review of suspicious cases by senior medical staff, may help to reduce the incidence of missed Monteggia fractures.
Images
PMCID: PMC1342431  PMID: 7804589
19.  Paediatric accident & emergency short-stay ward: a 1-year audit. 
Archives of Emergency Medicine  1993;10(3):181-186.
A short-stay ward attached to the accident and emergency (A&E) department has opened recently. The development of this ward is described together with its operation over a 1-year period. Head injuries were the commonest reason for admission. Only 7% of children stayed longer than anticipated or were considered inappropriate admissions.
PMCID: PMC1285985  PMID: 8216591
20.  Short-stay facilities in accident and emergency departments for children. 
Archives of Emergency Medicine  1993;10(3):177-180.
This paper assesses short stay ward facilities for children in the United Kingdom. The results of a postal questionnaire indicate that 50% of departments surveyed have a short-stay ward. Of these 25% admit small numbers of children. These are mainly children who have sustained trauma-related problems. The potential role of paediatric short-stay ward facilities is discussed.
PMCID: PMC1285984  PMID: 8216590
21.  Teaching of basic life support. 
PMCID: PMC1285901  PMID: 1449589
22.  Avulsion fracture of the straight and reflected heads of rectus femoris. 
Archives of Emergency Medicine  1992;9(3):310-313.
We present a rare case of avulsion fracture of the reflected head of rectus femoris. This occurred in a 13-year-old male footballer. Diagnosis was made with pelvic radiology and treatment was bed rest and analgesia.
Images
PMCID: PMC1285890  PMID: 1449579
25.  Clinical assessment and radiograph following blunt chest trauma. 
Archives of Emergency Medicine  1989;6(2):125-127.
This study was undertaken to assess the accuracy of clinical examination in predicting significant injury following blunt chest trauma and to determine whether more selective use of frontal chest radiography could be achieved.
PMCID: PMC1285580  PMID: 2742666

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