Jane Cocks: Communicating quality at DFTB17

Cite this article as:
Team DFTB. Jane Cocks: Communicating quality at DFTB17, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.15572

Jane Cocks is a leading expert in neonatal and paediatric retrieval and has literally wrote the book (well, a chapter anyway). As former clinical director of SAAS Medstar kids she talks about the importance of key performance indicators and metrics in paediatric retrieval. We all like to that we are amazing at everything we do, but we do fail sometimes.

How do we know if we any good?

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DFTB go to PEMFest18

Cite this article as:
Barnes, K. DFTB go to PEMFest18, Don't Forget the Bubbles, 2018. Available at:
https://dontforgetthebubbles.com/pemfest18/

Maybe you recognise the drill ……. you are tired, your frontline NHS job is tough,  there is a list of jobs as long as your arm at home, you still need to book transport to attend this conference, and you’re not sure if work will provide any study funding. But you decide to go for it. You’re pretty sure there’ll be someone to sit with – but too late now. Within five minutes of arriving you are infected – the space has a buzz, the crowd has a buzz and there is great coffee and little mini muffins (an army marches on its stomach), and it only gets better from there.

Casey Parker: Terror Australis at DFTB17

Cite this article as:
Team DFTB. Casey Parker: Terror Australis at DFTB17, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.15518

Who is Casey Parker? If you googled the name prior to the inaugural SMACC in Sydney you would have thought that she was one of Panama’s leading adult stars. But now, when not playing a minor role in Grey’s Anatomy, he is a true generalist, working in Broome in Western Australia.

He’s part rural anaesthetist, part general practitioner, part educationalist and the other quarter of him is made up of an ultrasound machine. He writes at Broomedocs.com  and also presents a podcast that is not just for rural generalists and ultrasound tragics.

This talk though is something else altogether.

You can listen to this talk as you walk to work on any device that supports podcasts.

And you can watch the talk below.

Casey writes from the heart about this case and the importance of practicing medicine from the heart.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. Please embrace the spirit of FOAMed and spread the word.

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Scarlet fever

Cite this article as:
Tessa Davis. Scarlet fever, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.15511

The start of 2018 has seen UK hospitals receiving an alert from Public Health England about the rise in cases of suspected scarlet fever. What is the extent of the problem and how good are we at actually diagnosing scarlet fever?

DFTB go to the Academy

Cite this article as:
Leo, G. DFTB go to the Academy, Don't Forget the Bubbles, 2018. Available at:
https://dontforgetthebubbles.com/dftb-go-academy/

Attending a first-time conference is a bit like watching a softball match as a much talked-about rising ‘star’ batter comes onto the field to face-off against a seasoned pitcher. Will they strike a home run or will they simply get struck out? Most want the batter to do well and may even expect it – but there is the sense of anticipation and uncertainty in the air until that moment in time when the bat and ball connect and the latter goes flying.

The Academy of Child and Adolescent Health held its official launch on the 1-2nd of March at the Royal Children’s Hospital in Melbourne and Henry and Grace were lucky enough to be able to attend. The ACAH is a non-profit organisation founded with the purpose of “promoting the health and well-being of every newborn, child and adolescent in order that they may reach their maximum potential”. This concept grew out from a RACP focus group though the ACAH is open to all health professionals. The conference focused on key issues related to child and adolescent health. It also explored the ways that the ACAH may be able to make a difference in the areas of education, policy making and advocacy.

Day 1:

Keynote

One of the highlights of the ACAH morning session was the keynote by Kim Oates. He discussed some of the key areas he thought the ACAH might address in the future including indigenous and refugee healthcare, domestic violence (and child maltreatment), patient safety, parenting support and culture in healthcare.

ACAH board and strategic directions

Of particular note during the morning session, the entire board came to the front and introduced themselves and fielded questions about the ACAH and their involvement to date. In the afternoon there was also a review of the strategic planning day which involved multiple paediatric subspecialty groups discussing some of the steps the ACAH might make to become a central hub that strengthens and utilises the skills and resources in these other organisations in addition to producing its own material.

Living with disability

The midday session featured a fantastic panel on navigating disability. One speaker who particularly impressed us with Jacki (Jax) Brown who spoke on how the way that disability affects and encompasses each individual uniquely. She also raised the importance of considering wheelchair accessibility of events, healthcare venues, work and public transport. Simply being labelled “Wheelchair Accessible” does not mean that a building is wheelchair friendly. Sometimes it might be a separate entrance around the garage which requires buzzer accessmaking the people using it feel excluded. Jax asked us to model inclusion and not ignore disability when we see it – but to respect people living with disabilities, remember that they have value and enable them to define for themselves who they are and what their identifies are. She also encouraged a move away from treating people with disabilities as passive receivers needing to ‘justify’ their needs, but rather to engage and work together with people with disabilities on the structure and social barriers that are causing problems for equity.

Asylum seekers, children in detention

The afternoon session was divided into a presentation from Megan Mitchell – the National Children’s Commissioner and a strategic planning session. This  encouraged delegates to add their thoughts regarding the future direction of the ACAH. Megan Mitchell’s talk focused on presenting the findings from the recent report into Asylum Seekers, Refugees and Human Rights. She pointed out that Australia has now been elected to the UN Human Rights council for the next three years and that this could be a critical time to uphold and support the human rights of asylum seekers, refugees and indigenous populations in Australia. After many years, Australia has finally committing to ratify OPCAT (Optional Protocol to the Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment). OPCAT should apply to all places of detention in Australia, including prisons, juvenile justice and mental health facilities, and immigration detention. Megan shared her experiences talking with children in Australia and offshore centres ias well as some of the terrible conditions children have been subjected to – conditions such as having hygiene products withheld for misbehaviour and placing children in prolonged isolation for up to 20 hours a day. These methods of discipline have been teaching children that the abuse of others, especially those less powerful, is normal. It is also likely to be traumatising already vulnerable children and adolescents.

Overall verdict after day 1:

Although the ACAH provided no ground-breaking change in terms of the experience compared with more traditional conference – we still enjoyed it. The talks were, for the most part, on-point. There was a good buzz and question time for every talk was filled without difficulty.

 

Day 2

If the first day of the conference is like the time a batter comes to the plate, the second day of a conference is the bottom half of the game. It’s all about finding and keeping the lead. It’s also a nice part of the game because there’s momentum to play off and you’re more familiar with and more invested in the delegates and topics as whole.

Human Digital Interface of Healthcare

This morning session opened with Gareth Baynam discussing digital diagnosis and the search for answers for children suffering from rare diseases. Kath Carmo discussed the value of telemedicine used by the NETS team in retrieval to help guide support and make decisions about transfers. She also explained the importance of retrieval of sick kids in having equitable access to healthcare. James Dromey’s talk was focused on future digital platforms and the way that healthcare can work with IT and tech companies to create new software and hardware to help with preventative medicine and provide education for both healthcare workers and families. He honed in on the importance of product development which doesn’t just ‘sound’ like a good idea – but which is user-centred and has both proof of concept and sustainability.

Advocacy & Global Health

The second session was an intriguing look into how the American Academy of Paediatrics, the UK RCPCH and the Paediatric Society of Australia and New Zealand have grown and developed their role in advocacy and global health. The importance of engaging members and using multiple different approaches in advocacy was stressed. Another element in the early afternoon session was a thoughtful speech from Dame Quentin Bryce who officially launched the ACAH and reaffirmed key areas in need of advocacy such as indigenous health, adolescent health, supporting research and the value in engaging whole families in care for children.

Safe Spaces for Children

The last session for the meeting was broad but interesting –  relating to the areas of social media, dealing with violence and providing a legal perspective on children and media. In particular, Donna Cross shared the interests of CoLabforKids and discussed the need to appreciate the nuances of managing screen time and social media. It is not enough to simply say that children should only have X amount of screen time; rather it is important to also look at the quality of the time and use. For example –  Is it watching movies in the car or is it with grandma reading an interactive online story book? The latter is much more likely to be beneficial to learning. On the topic of cyber-bullying and social media use – Donna made a great analogy to water safety. Swimming pools are both beneficial but dangerous. Children and adolescents need training, supervision, appropriate barriers and supports to safely enjoy and utilise them.

Overall Impressions

The ACAH launch was relatively small but filled with many experienced and respected individuals. There was a keen sense of anticipation in the air and thoughtful debate around key issues of advocacy. There were a number of strong speakers but I particularly liked disability panel and thought it worked well. It was very good to see patient and family representation at the conference. The ACAH team also showed a willingness for transparency and utilising a grass-roots approach. This was seen through the opportunity for discussion during and between the conference about the ‘where to from here’ and brainstorming of opinions about areas for priority and methods that might be employed. The majority of delegates were paediatric consultants although a few GPs also attended. It would be good to see further diversity in the board, speakers and delegates across health professionals given the aim and goals of the ACAH. The conference validated, in my mind, both the great need and opportunity for an organisation like the ACAH and I found myself registering for membership by the end of it. Whilst they may have won the game, there are many more matches to come. It will be of the great interest to follow how the ACAH board and members make good on their intentions from this launch in the next few months.

For more on the ACAH or to join membership check out www.acah.org.au

 

What children wish we knew

Cite this article as:
Andrew Tagg. What children wish we knew, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.14759

This blog post is based on a talk I’m giving to a mixed group of adult and paediatric emergency physicians. I was asked to talk about something I thought both groups needed to know. I could have got stuck into the role of steroids in pre-school wheeze or antibiotics in otitis media but they can be rather dry topics to talk about over dinner. Instead I decided to focus on what children would want us to know…

Rachel Callander: Love, Life and Awesomeness at DFTB17

Cite this article as:
Team DFTB. Rachel Callander: Love, Life and Awesomeness at DFTB17, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.12698

This talk was recorded live at DFTB17 in Brisbane. Watch out for more talks from our inaugural conference in the lead up to DFTB18.. If you haven’t done so yet then book some time off for August and come to Melbourne for our next amazing conference. Check out www.dftb18.com for more details. You can also join Rachel and Mary Freer for a workshop on conversations around caring. See the website for more details.

The 14th Bubble Wrap

Cite this article as:
Grace Leo. The 14th Bubble Wrap, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.14609

With millions upon millions of journal articles being published every year it is impossible to keep up.  Every month we ask some of our friends from PERUKI (Paediatric Emergency Research in UK and Ireland) to point out something that has caught their eye.

Steroids for pre-school wheeze

Cite this article as:
Tessa Davis. Steroids for pre-school wheeze, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.14563

Wheeze must be one of the most common paediatric presentations to the emergency department and up till now most of us have been reassuring parents and sending them away without treatment. But should we be doing more?  A paper, released just last week, suggests that we could.

Kat Evans: Paediatrics in South Africa at DFTB17

Cite this article as:
Team DFTB. Kat Evans: Paediatrics in South Africa at DFTB17, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.14284

This talk was recorded live on the first day at DFTB17 in Brisbane. If you missed out on 2017 then why not book your leave for 2018 now. Tickets are on sale for the pre-conference workshops as well as the conference itself at www.dftb18.com.

Guanfacine

Cite this article as:
Mary Hardimon. Guanfacine, Don't Forget the Bubbles, 2017. Available at:
https://doi.org/10.31440/DFTB.13727

On 22nd August 2017, guanfacine hydrochloride (current sole brand name Intuniv) was accepted as a new chemical entity by the Therapeutic Goods Administration in Australia.1 Whilst new to Australia, guanfacine has been available within the United States of America and Europe since 20102 and 20153 respectively. The development of generic brands within these countries has seen increased uptake of this medication as an alternative to stimulant medications.

 

So what is it?

Guanfacine is an alpha 2 agonist. Unlike clonidine (which is non-selective and shows high affinity for all 3 subtypes of alpha 2 receptors – A, B and C), guanfacine has preferencial affinity for alpha 2A receptors. Stimulation of these receptors in the prefrontal cortex mimics noradreline/norepinephrine actions in this region, with current ADHD (Attention Deficit Hyperactivity Disorder) causal theories demonstrating noradrenergic dysfunction as underlying the cognitive and behavioural manifestations of ADHD.4

https://www.priory.com/psychiatry/clonidine.htm

 

Indications and Usage

Under current licensing in Australia, guanfacine is indicated for “the treatment of attention deficit hyperactivity disorder (ADHD) in children and adolescents 6-17 years old, as monotherapy (when stimulants or atomoxetine are not suitable, not tolerated or have been shown to be ineffective) or as adjunctive therapy to psychostimulants (where there has been a sub-optimal response to psychostimulants).”

The use of guanfacine “must be used as part of a comprehensive ADHD management programme, typically including psychological, educational and social measures.1

These stipulations encourage prescribers to manage ADHD within a bio-psycho-social context, understanding that in the vast majority of cases, the condition whilst caused by a neurotransmitter imbalance may be attenuated by psychological and social strategies.

Shire Australia (whom is licensed for its distribution) recommends its use in children and adolescents 6 – 17 years of age.6 There are very limited studies7 surrounding guanfacine use in children younger than 6 years and whilst efficacy has been suggested, caution would be suggested in making ADHD diagnoses particularly in toddler years due to a great variety in “normal” in this period.

 

Dosage and Administration

Guanfacine will be released in 1mg, 2mg, 3mg and 4mg modified release tablets with administration once per day orally. Tablets should not be crushed or dissolved. Guanfacine should not be taken with high fat meals as this significantly affects absorption.

The recommended initial dose is 1mg (when used as either monotherapy or co-administered with stimulants). Dose adjustments are recommended by no more than 1mg/week with a target dose range (or based on therapeutic effect should it occur prior to this dose) of 0.05 – 0.12mg/kg/day. Doses exceeding 4mg (co-administration) and 7mg (when used as monotherapy) have not been evaluated.8

 

Recommended target dose range for maintenance therapy when guanfacine is sole agent8

Weight Target dose range (0.05 – 0.12 mg/kg/day)
25.0-33.9 kg 2-3 mg/day
34.0-41.4 kg 2-4 mg/day
41.5-49.4 kg 3-5 mg/day
49.5-58.4 kg 3-6 mg/day
58.5-91.0 kg 4-7 mg/day
≥91.0 kg 5-7 mg/day

 

Adverse effects

The most common adverse effects9 include:

  • Somnolence
  • Sedation
  • Abdominal pain
  • Dizziness
  • Hypotension
  • Dry mouth
  • Constipation

In contrast to stimulant medication, weight gain (mean of 0.5kg) is seen in patients using guanfacine.

Less common (although clinically significant) side effects10 include:

  • Atrioventricular block
  • Asthenia and chest pain
  • Increased ALT
  • Convulsion
  • Increased urinary frequency
  • Hypertension
  • Pallor

 

Drug interactions

CYP3A4 inhibitors (such as ketoconazole) and CYP3A4 inducers (such as rifampin) may affect guanfacine blood levels and subsequent clinical response.10

 

Cost

Since being introduced onto the PBS 1st September 2018, the previously prohibitive costs are now more affordable for families (although still quite expensive without a health care card) – ~$40 regular PBS price ~$6 concession PBS price.

 

References

1 https://www.tga.gov.au/prescription-medicines-registration-new-chemical-entities-australia

2 https://www.drugs.com/newdrugs/shire-announces-fda-approval-once-daily-intuniv-guanfacine-extended-release-adhd-children-1599.html

3

4 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3676929/

5 https://stahlonline.cambridge.org/content/ep/images/85702c17_fig24.jpg

6 https://www.guildlink.com.au/gc/ws/zi/pi.cfm?product=zipintun10817

7 https://onlinelibrary.wiley.com/doi/10.1002/%28SICI%291097-0355%28199723%2918:3%3C300::AID-IMHJ6%3E3.0.CO;2-Q/abstract

8 https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf/pdf?OpenAgent&id=CP-2017-PI-02254-1&d=2017110516114622483

9 https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/022037lbl.pdf

10 https://pi.shirecontent.com/PI/PDFs/Intuniv_USA_ENG.pdf

Additional useful websites:

  1. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=b972af81-3a37-40be-9fe1-3ddf59852528
  2. https://pi.shirecontent.com/PI/PDFs/Intuniv_USA_ENG.pdf
  3. https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Pharmacy-Education-Materials/Downloads/stim-pediatric-factsheet11-14.pdf
  4. https://www.guildlink.com.au/gc/ws/zi/pi.cfm?product=zipintun10817