Miscarriage, stillbirth and congenital malformation in the offspring of UK veterans of the first Gulf war.

OBJECTIVES: To assess whether the offspring of UK veterans of the first Gulf war are at increased risk of fetal death or congenital malformation. METHOD: This was a retrospective reproductive cohort study of UK Gulf war veterans and a demographically similar comparison group who were in service at the time but were not deployed to the Gulf. Reproductive history was collected by means of a validated postal questionnaire between 1998 and 2001. RESULTS: In all, 27 959 pregnancies reported by men and 861 pregnancies reported by women were conceived after the first Gulf war and before November 1997. The risk of reported miscarriage was higher among pregnancies fathered by Gulf war veterans than by non-Gulf war veterans (OR = 1.4, 95% CI: 1.3, 1.5). Stillbirth risk was similar in both groups. Male Gulf war veterans reported a higher proportion of offspring with any type of malformation than the comparison cohort (OR = 1.5, 95% CI: 1.3, 1.7). Examination by type of malformation revealed some evidence for increased risk of malformations of the genital system, urinary system (renal and urinary tract), and 'other' defects of the digestive system, musculo-skeletal system, and non-chromosomal (non-syndrome) anomalies. These associations were weakened when analyses were restricted to clinically confirmed conditions. There was little or no evidence of increased risk for other structural malformations, specific syndromes, and chromosomal anomalies. Among female veterans, no effect of Gulf war service was found on the risk of miscarriage. The numbers of stillbirths and malformations reported by women were too small to allow meaningful analyses. CONCLUSION: We found no evidence for a link between paternal deployment to the Gulf war and increased risk of stillbirth, chromosomal malformations, or congenital syndromes. Associations were found between fathers' service in the Gulf war and increased risk of miscarriage and less well-defined malformations, but these findings need to be interpreted with caution as such outcomes are susceptible to recall bias. The finding of a possible relationship with renal anomalies requires further investigation. There was no evidence of an association between risk of miscarriage and mothers' service in the gulf

Do paediatric early warning scores relate to emergency department outcomes for children aged 0‐2 years brought in by ambulance?

Ambulance service policy requires paramedics in certain parts of the UK to transport children aged 0‐2 years to hospital, regardless of their presenting complaint. While there are a number of paediatric early warning scores (PEWS) that exist to detect deterioration in the hospitalised child, no study has considered the potential relationship between a PEWS recorded by the ambulance service and emergency department (ED) outcome. This study aims to evaluate and understand the potential utility of PEWS in an ambulance service setting

Establishing the research priorities of paediatric emergency medicine clinicians in the UK and Ireland

Objective: Paediatric Emergency Research in the UK and Ireland (PERUKI) is a collaborative clinical studies group established in August 2012. It consists of a network of 43 centres from England, Ireland, Northern Ireland, Scotland and Wales, and aims to improve the emergency care of children through the performance of robust collaborative multicentre research within emergency departments. A study was conducted regarding the research priorities of PERUKI, to establish the research agenda for paediatric emergency medicine in the UK and Ireland. Methods: A two-stage modified Delphi survey was conducted of PERUKI members via an online survey platform. Stage 1 allowed each member to submit up to 12 individual questions that they identified as priorities for future research. In stage 2, the shortlisted questions were each rated on a seven-point Likert scale of relative importance. Participants: Members of PERUKI, including clinical specialists, academics, trainees and research nurses. Results: Stage 1 surveys were submitted by 46/91 PERUKI members (51%). A total of 249 research questions were generated and, following the removal of duplicate questions and shortlisting, 60 questions were carried forward for stage 2 ranking. Stage 2 survey responses were submitted by 58/95 members (61%). For the 60 research questions that were rated, the mean score of 'relative degree of importance' was 4.70 (range 3.36-5.62, SD 0.55). After ranking, the top 10 research priorities included questions on biomarkers for serious bacterial illness, major trauma, intravenous bronchodilators for asthma and decision rules for fever with petechiae, head injury and atraumatic limp. Conclusions: Research priorities of PERUKI members have been identified. By sharing these results with clinicians, academics and funding bodies, future research efforts can be focused to the areas of greatest need

Can real-time feedback improve the simulated infant cardiopulmonary resuscitation performance of basic life support and lay rescuers?

Background Performing high-quality chest compressions during cardiopulmonary resuscitation (CPR) requires achieving of a target depth, release force, rate and duty cycle. Objective This study evaluates whether ‘real time’ feedback could improve infant CPR performance in basic life support-trained (BLS) and lay rescuers. It also investigates whether delivering rescue breaths hinders performing high-quality chest compressions. Also, this study reports raw data from the two methods used to calculate duty cycle performance. Methodology BLS (n=28) and lay (n=38) rescuers were randomly allocated to respective ‘feedback’ or ‘no-feedback’ groups, to perform two-thumb chest compressions on an instrumented infant manikin. Chest compression performance was then investigated across three compression algorithms (compression only; five rescue breaths then compression only; five rescue breaths then 15:2 compressions). Two different routes to calculate duty cycle were also investigated, due to conflicting instruction in the literature. Results No-feedback BLS and lay groups demonstrated 60% and >25% of all chest compressions, across all three algorithms. Performing rescue breaths did not impede chest compression quality. Conclusions A feedback system has great potential to improve infant CPR performance, especially in cohorts that have an underlying understanding of the technique. The addition of rescue breaths—a potential distraction—did not negatively influence chest compression quality. Duty cycle performance depended on the calculation method, meaning there is an urgent requirement to agree a single measure

Paediatric traumatic cardiac arrest: A Delphi study to establish consensus on definition and management

Aims Paediatric traumatic cardiac arrest (TCA) is associated with low survival and poor outcomes. The mechanisms that underlie TCA are different from medical cardiac arrest; the approach to treatment of TCA may therefore also need to differ to optimise outcomes. The aim of this study was to explore the opinion of subject matter experts regarding the diagnosis and treatment of paediatric TCA, and to reach consensus on how best to manage this group of patients.Methods An online Delphi study was conducted over three rounds, with the aim of achieving consensus (defined as 70% agreement) on statements related to the diagnosis and management of paediatric TCA. Participants were invited from paediatric and adult emergency medicine, paediatric anaesthetics, paediatric ICU and paediatric surgery, as well as Paediatric Major Trauma Centre leads and representatives from the Resuscitation Council UK. Statements were informed by literature reviews and were based on elements of APLS resuscitation algorithms as well as some concepts used in the management of adult TCA; they ranged from confirmation of cardiac arrest to the indications for thoracotomy.Results 73 experts completed all three rounds between June and November 2016. Consensus was reached on 14 statements regarding the diagnosis and management of paediatric TCA; oxygenation and ventilatory support, along with rapid volume replacement with warmed blood, improve survival. The duration of cardiac arrestand the lack of a response to intervention, along with cardiac standstill on ultrasound, help to guide the decision to terminate resuscitation.Conclusion This study has given a consensus-based framework to guide protocol development in the management of paediatric TCA, though further work is required in other key areas including its acceptability to clinicians

Emergency care provided to refugee children in Europe: RefuNET: A cross-sectional survey study

Background Refugee children and young people have complex healthcare needs. However, issues related to acute healthcare provision for refugee children across Europe remain unexplored. This study aimed to describe the urgent and emergency healthcare needs of refugee children in Europe, and to identify obstacles to providing this care.Methods An online cross-sectional survey was distributed to European healthcare professionals via research networks between 1 February and 1 October 2017 addressing health issues of children and young people age

Pathways to care for critically ill or injured children: A cohort study from first presentation to healthcare services through to admission to intensive care or death

Purpose Critically ill or injured children require prompt identification, rapid referral and quality emergency management. We undertook a study to evaluate the care pathway of critically ill or injured children to identify preventable failures in the care provided. METHODS: A year-long cohort study of critically ill and injured children was performed in Cape Town, South Africa, from first presentation to healthcare services until paediatric intensive care unit (PICU) admission or emergency department death, using expert panel review of medical records and caregiver interview. Main outcomes were expert assessment of overall quality of care; avoidability of severity of illness and PICU admission or death and the identification of modifiable factors. RESULTS: The study enrolled 282 children, 252 emergency PICU admissions, and 30 deaths. Global quality of care was graded good in 10% of cases, with half having at least one major impact modifiable factor. Key modifiable factors related to access to care and identification of the critically ill, assessment of severity, inadequate resuscitation, and delays in decision making and referral. Children were transferred with median time from first presentation to PICU admission of 12.3 hours. There was potentially avoidable severity of illness in 185 (74%) of children, and death prior to PICU admission was avoidable in 17/30 (56.7%) of children. CONCLUSIONS: The study presents a novel methodology, examining quality of care across an entire system, and highlighting the complexity of the pathway and the modifiable events amenable to interventions, that could reduce mortality and morbidity, and optimize utilization of scarce critical care resources; as well as demonstrating the importance of continuity and quality of care

Family presence during resuscitation in paediatric and neonatal cardiac arrest: A systematic review

Context: Parent/family presence at pediatric resuscitations has been slow to become consistent practice in hospital settings and has not been universally implemented. A systematic review of the literature on family presence during pediatric and neonatal resuscitation has not been previously conducted. Objective: To conduct a systematic review of the published evidence related to family presence during pediatric and neonatal resuscitation. Data sources: Six major bibliographic databases was undertaken with defined search terms and including literature up to June 14, 2020. Study selection: 3200 titles were retrieved in the initial search; 36 ultimately included for review. Data extraction: Data was double extracted independently by two reviewers and confirmed with the review team. All eligible studies were either survey or interview-based and as such we turned to narrative systematic review methodology. Results: The authors identified two key sets of findings: first, parents/family members want to be offered the option to be present for their child\u27s resuscitation. Secondly, health care provider attitudes varied widely (ranging from 15% to \u3e85%), however, support for family presence increased with previous experience and level of seniority. Limitations: English language only; lack of randomized control trials; quality of the publications. Conclusions: Parents wish to be offered the opportunity to be present but opinions and perspectives on the family presence vary greatly among health care providers. This topic urgently needs high quality, comparative research to measure the actual impact of family presence on patient, family and staff outcomes. PROSPERO registration number: CRD42020140363

Cardiopulmonary resuscitation in low-resource settings: a statement by the International Liaison Committee on Resuscitation, supported by the AFEM, EUSEM, IFEM, and IFRC.

Most recommendations on cardiopulmonary resuscitation were developed from the perspective of high-resource settings with the aim of applying them in these settings. These so-called international guidelines are often not applicable in low-resource settings. Organisations including the International Liaison Committee on Resuscitation (ILCOR) have not sufficiently addressed this problem. We formed a collaborative group of experts from various settings including low-income, middle-income, and high-income countries, and conducted a prospective, multiphase consensus process to formulate this ILCOR Task Force statement. We highlight the discrepancy between current cardiopulmonary resuscitation guidelines and their applicability in low-resource settings. Successful existing initiatives such as the Helping Babies Breathe programme and the WHO Emergency Care Systems Framework are acknowledged. The concept of the chainmail of survival as an adaptive approach towards a framework of resuscitation, the potential enablers of and barriers to this framework, and gaps in the knowledge are discussed, focusing on low-resource settings. Action points are proposed, which might be expanded into future recommendations and suggestions, addressing a large diversity of addressees from caregivers to stakeholders. This statement serves as a stepping-stone to developing a truly global approach to guide resuscitation care and science, including in health-care systems worldwide

Linked randomised controlled trials of face-to-face and electronic brief intervention methods to prevent alcohol related harm in young people aged 14–17 years presenting to Emergency Departments (SIPS junior)

Background: Alcohol is a major global threat to public health. Although the main burden of chronic alcohol-related disease is in adults, its foundations often lie in adolescence. Alcohol consumption and related harm increase steeply from the age of 12 until 20 years. Several trials focusing upon young people have reported significant positive effects of brief interventions on a range of alcohol consumption outcomes. A recent review of reviews also suggests that electronic brief interventions (eBIs) using internet and smartphone technologies may markedly reduce alcohol consumption compared with minimal or no intervention controls. Interventions that target non-drinking youth are known to delay the onset of drinking behaviours. Web based alcohol interventions for adolescents also demonstrate significantly greater reductions in consumption and harm among ‘high-risk’ drinkers; however changes in risk status at follow-up for non-drinkers or low-risk drinkers have not been assessed in controlled trials of brief alcohol interventions