Starship Children's Hospital Research Articles

Should paediatric tonsillar asymmetry be an indication for tonsillectomy? A single centre experience.

Paediatric tonsillar lymphoma (TL) is a rare diagnosis. Historically, the presence of clinical features such as tonsillar asymmetry, grossly abnormal tonsil appearance and cervical lymphadenopathy raise concern for this diagnosis. Tonsillar asymmetry is considered to be the most concerning clinical feature; however, asymmetry is often apparent due to differences in depth or shape of tonsillar fossa and tonsillar pillars, rather than a true difference in volume. There is debate whether a tonsillectomy is required in all cases of tonsil asymmetry to exclude lymphoma, and what clinical features should raise concern. The aim of this study was to establish whether the presence of clinical asymmetry can be deemed a reliable marker for genuine tonsil size discrepancies. We also sought to evaluate the clinical and examination characteristics that are concerning for lymphoma. Retrospective review of clinical records for paediatric tonsil specimens sent for histological evaluation between 1 January 2012 and 1 January 2023 driven by a clinical suspicion of lymphoma at Starship Children's Hospital, New Zealand. Patient demographics and clinical data were recorded. A comparison was made between tonsil size asymmetry on clinical examination (Brodsky criteria) and tonsil volume difference based on dimensions given in pathology reports. One hundred and forty-three patients had tonsillectomies between 2012 and 2022 at Starship Children's Hospital due to concern for lymphoma. Of these, three were positive for lymphoma. Presence of pain and abnormal tonsil appearance were predictors for lymphoma (p<0.02). Interrater reliability agreement between clinical size difference and tonsil volume was poor, Kappa= -0.13 p<0.05. Clinical size difference is a poor predictor for true tonsil volume difference. We advise that assessment of tonsil size should be performed in conjunction with the examination of gross visual abnormalities and lymphadenopathy to guide clinical decision making.

Group A Streptococcus Primary Peritonitis in Children, New Zealand.

Group A Streptococcus (GAS) primary peritonitis is a rare cause of pediatric acute abdomen (sudden onset of severe abdominal pain); only 26 pediatric cases have been reported in the English language literature since 1980. We discuss 20 additional cases of pediatric primary peritonitis caused by GAS among patients at Starship Children's Hospital, Auckland, New Zealand, during 2010-2022. We compare identified cases of GAS primary peritonitis to cases described in the existing pediatric literature. As rates of rates of invasive GAS increase globally, clinicians should be aware of this cause of unexplained pediatric acute abdomen.

The incidence of juvenile onset recurrent respiratory papillomatosis at Starship Children's Hospital before and after a national HPV vaccination programme: a retrospective review.

To review and compare the incidence of juvenile onset recurrent respiratory papillomatosis (JRRP) at Starship Children's Hospital (SSH) before and after the introduction of a national HPV vaccination programme. Patients treated for JRRP at SSH were identified retrospectively using ICD-10 code D14.1 over a 14-year period. The incidence of JRRP in the 10-year period prior to the introduction of HPV vaccination (1 September 1998 to 31 August 2008) was compared with the incidence after its introduction. A second comparison was made between the pre-vaccination incidence with the incidence over the most recent 6 years when the vaccination became more widely available. All New Zealand hospital ORL departments that referred children with JRRP to SSH exclusively were included. SSH manages about half of the New Zealand paediatric population with JRRP. The incidence of JRRP before the introduction of the HPV vaccination programme was 0.21 per 100,000 per year in children 14 years of age and younger. This remained stable between 2008 and 2022 (0.23 vs 0.21 per 100,000 per year). The mean incidence in the later post-vaccination period was 0.15 per 100,000 per year based on small numbers. The mean incidence of JRRP before and after the introduction of HPV has remained unchanged in children treated at SSH. More recently, a reduction in incidence has been noted, although this is based on small numbers. The low HPV vaccination rate (≤70%) may explain why a significant reduction in the incidence of JRRP seen overseas has not been observed in New Zealand. Ongoing surveillance and a national study would provide more insight into the true incidence and evolving trends.

Boldly going… Introducing conflict management training to Starship Children's Hospital.

Conflict between health professionals and whānau (families) in paediatric hospitals is common and leads to significant distress for families and staff. The likelihood of challenges and conflict around communication and critical medical decision-making is increased where there are cultural and social complexities. Training staff to recognise and manage conflict as early as possible improves patient/whānau outcomes and staff well-being. This article describes an ongoing collaboration between Starship Children's Hospital in Auckland New Zealand (NZ) and the UK Medical Mediation Foundation (MMF) focused on educating staff in the early recognition and management of conflict using mediation skills. An evidence-based training programme and structured ongoing supervision of a small group of champions has enabled this training to be embedded into Starship clinical practice. The collaboration has included careful consideration of the New Zealand setting, ensuring that the content of the programme specifically addresses our unique cultural and social context. Mediation skills are an important step in ensuring that our patients and whānau feel heard, acknowledged, and respected, and contribute to the Starship Child Health's strategic priority of eliminating inequity and addressing institutional bias.

Utility of data linkage for orthopaedic service planning in the paediatric population with cerebral palsy at Starship Children's Hospital.

To determine the accuracy of orthopaedic surgical procedure coding (ICD-10-AM/ACHI/ACS) for children with cerebral palsy (CP) at Starship Children's Hospital, use data linkage with the New Zealand Cerebral Palsy Register (NZCPR) to obtain demographic and clinical information for children with CP requiring orthopaedic surgical services in the Auckland District Health Board catchment area, and to determine if trends in the clinical and demographic data are useful for future service planning for children with CP. Surgical admission data for children with CP aged 0-18 years at the time of their first procedure were extracted from Auckland District Health Board records for 2013-2018, and information on demographics and Gross Motor Function Classification System level were obtained from the NZCPR. The ICD-10-AM/ACHI/ACS codes for surgery/intervention were matched with the operation notes in the electronic health records using NHI numbers and assessed for accuracy. During the study period, 261 paediatric patients with CP underwent orthopaedic procedures, which could be grouped broadly into five categories (spine, upper limb, lower limb, Botulinum-A toxin injection only, and other) with a coding accuracy of 95%. Clinical and demographic data could be obtained from the NZCPR for 232 (88.9%) of the 261 patients. Using orthopaedic surgical procedure codes, we could identify broad categories of procedures received by children with CP and the demographic and clinical characteristics of these children, which will assist with service planning and identify trends in care delivery.

The learning curve of BiZact™ tonsillectomy

ObjectiveTo evaluate the learning curve of BiZact™ tonsillectomy amongst trainees and fellows as a further technical skill. MethodsProspective audit of consecutive BiZact™ tonsillectomies undertaken by a trainee and fellow at Starship Children's Hospital. Primary outcomes measured were operative time from gag open to gag closed, readmission and post tonsillectomy bleed rates. Secondary outcomes included need for bipolar rescue dissection, bipolar haemostasis including site and side, tonsil size (Brodsky grade 1–4) and depth (shallow or deep). Operative time was plotted against number of procedures performed and moving averages was used to investigate the learning curve. Generalised linear model was applied to examine the association between operation time and tonsil depth. ResultsMean operative time for the trainee and fellow was similar (07 min 34 s versus 07min and 37 s). We observed a trend of decreased operative time over number of procedures performed by the trainee but the learning curve was short. The fellow's initial time was lower than the trainee's and remained similar over time. No bipolar rescue dissection was required. Additional bipolar haemostasis was required 95% of the time, but the majority involved the superior pole only (87.5%, p = 0.0001). The overall operative time for shallow tonsils was shorter than for deep tonsils (06 min 31 s versus 08 min 09 s, p = 0.0066). A learning curve was evident for both shallow and deep tonsils for both surgeons combined but was steeper for deep. There were no primary bleeds and the secondary haemorrhage rate was 5.8% (3/51 cases) with no returns to theatre. ConclusionThis is the first study to investigate the BiZact™ tonsillectomy learning curve. BiZact™ tonsillectomy is safe and easy to learn. We observed a clear trend of shallow tonsils being quicker to remove than deep tonsils using this technique. The secondary bleed rate of 5.8% is comparable to the previously published Starship rate of 4.7% for all tonsillectomies performed over a 10 year period. Moving averages is a useful method to assess operative learning curves during training and beyond.

Neuropsychological assessment of paediatric brain tumour survivors: Factors associated with assessment.

Paediatric brain tumour survivors are at increased risk of neurocognitive deficits that affect their education. The aim of this study was to assess the proportion of brain tumour survivors who historically received a neuropsychological assessment and examine the demographic and treatment-related variables associated with neuropsychological assessment. A further aim was to determine the number and treatment profile of brain tumour survivors who would benefit from neuropsychological assessment. Data from the New Zealand Children's Cancer Registry including treatments received, was used to identify children treated for a brain tumour at Starship Children's Hospital between January 2009 and December 2015. Clinical records were examined for evidence of a neuropsychological assessment in the form of a written report. Logistic regression models were used to determine factors associated with receipt of an assessment. Of the 132 brain tumour survivors, 37 (28.0%) had evidence of a neuropsychological assessment in their clinical records. In adjusted analysis, children who were treated with all three of surgery, chemotherapy and radiotherapy (n=38) were more likely to have had an assessment (odds ratio: 12.90; 95% confidence interval: 4.76-34.93) than children who had either no treatment, chemotherapy alone, surgery alone or chemotherapy and surgery (n=73). Treatment with radiotherapy alone or with either chemotherapy or surgery (n=21) was not significantly associated with receipt of assessment (odds ratio=2.40; 95% confidence interval: 0.69-8.37). It is important to identify the number of children who might benefit from neuropsychological assessment to inform prioritisation within existing resource and plan for additional resource if required. With a focus on reducing late effects, it is imperative that neuropsychological assessment is an integral component of a paediatric brain tumour programme.

Transitioning from paediatric to adult services with cystic fibrosis or bronchiectasis: What is the impact on engagement and health outcomes?

To determine whether the transfer of young people with cystic fibrosis (CF) or bronchiectasis from paediatric to adult services is associated with changes in service engagement and/or health outcomes. Young people aged ≥15 years of age with CF or bronchiectasis who transferred from the Auckland-based paediatric service (Starship Children's Hospital) to one of three Auckland-based District Health Boards between 2005 and 2012 were identified and included if they had 3 years care both pre-transfer and post-transfer care. Transfer preparation, service engagement (clinics scheduled, clinics attended) and health outcomes (lung function, hospitalisations) were collected per annum. Fifty-seven young people transferred in this period with 46 meeting inclusion criteria (CF n = 20, bronchiectasis n = 26). The CF group had better transfer documentation, were transferred at an older age (11 months older P < 0.0001 95%CI: 6.7 months, 14.7 months), were 20 times more likely to attend clinics (P < 0.0001, 95%CI: 7.8, 66.1) and had 3-4 more clinics scheduled pre-transfer (P < 0.0001, 95%CI: 3.4, 4.9) and post-transfer (P < 0.0001, 95%CI: 2.4, 3.8) despite having less severe respiratory disease as measured by FEV1 for each year (P < 0.01, 95%CI: 0.34, 1.22). The transfer of young people with CF to adult services did not affect health engagement or outcomes, in contrast to those with bronchiectasis. Use of a formalised transfer process, more clinic appointments offered and greater resources for CF may be responsible for this difference. Comprehensive transition with purposeful, planned movement and developmentally appropriate care is a key goal.

A008 The Starship Cardiac Care Screening Program: A Two-year Pilot Program Screening Perceived Quality of Life and Psychosocial Outcomes for Children Diagnosed With Congenital Heart Disease (CHD)

With advances in cardiac care and increased survival, research has shifted focus to quality of life. Nearly 50% of CHD children report reduced quality of life with associated developmental, learning, emotional and behavioural challenges. Early diagnosis/intervention, including the implementation of screening programs, improve cardiac prognosis and perceived quality of life resulting in improved long- term functioning. Screening programs have proven difficult to establish in New Zealand. To address this and obtain information about the outcomes of Kiwi children with CHD, the Cardiac Care program was established at Starship Children's Hospital. The screening pilot program began in 2017 and recruited 189 CHD outpatients (2-17 years). Patient-parent pairs completed the Peds-QL Cardiac Module measuring cardiac specific health-related quality of life, developmental and psychosocial outcomes. The screening ran from February 2017-February 2019. Diagnostic categories were biventricular repair (60%), Fontan palliation (31%) and unrepaired CHD (9%). 76% of all diagnostic groups reported concerns in the areas of physical, emotional and academic development with 52% reporting peer difficulties. Lower overall Peds-QL scores were reported in the Fontan palliation group and those with increased medical intervention/hospitalisation. 7.5% of the unrepaired CHD group reported anxiety/worry. Overall, children with CHD and their parents perceived a lower quality of life with reduced psychosocial functioning and developmental difficulties. Children with more severe CHD reported worse physical and psychosocial quality of life.

Long‐term effect of methotrexate for childhood atopic dermatitis

To evaluate methotrexate (MTX) for paediatric atopic dermatitis (AD) while on and post-treatment. Medical records of children prescribed MTX for AD between 2011 and 2016 at Starship Children's Hospital, Auckland, New Zealand, were reviewed for demographics, dose and duration of MTX and hospitalisations for AD. In the follow-up by telephone in 2017, parents of the patients reported response on MTX, AD relapses and use of additional systemic treatment and completed a patient-oriented eczema measure (POEM). Forty-three patients aged 2-16 years were included. Four (9%) had previous systemic treatment, and 14 (33%) were hospitalised (28 admissions). MTX was given at median dose of 0.33 mg/kg (interquartile range (IQR) 0.26-0.40) for a median of 17 months (IQR 7.5-20). After initiating MTX, only six (14%) were hospitalised (nine admissions). Thirty (70%) parents of patients were followed up for a median of 29 months (IQR 14-45) after discontinuing MTX. Five (17%) reported 'no change', 2 (7%) 'slightly better' and 23 (77%) 'a lot better' AD on MTX. Of the 25 who responded to MTX, AD relapsed in 10 (40%) at a median of 24 months post-MTX; only four (16%) restarted MTX. Median POEM at follow-up was 6 (IQR 1-17). Eleven (37%) were clear (POEM 0-2), 11 (37%) had mild to moderate AD (POEM 3-16), and 8 (27%) had severe AD (POEM ≥17). Although a natural resolution cannot be excluded, MTX for severe AD was effective and well tolerated. Improvement was reported by 83%, and AD hospitalisation reduced by half. At a median of 2 years after discontinuing MTX, one third were clear, and one third had mild to moderate AD, suggesting persistence of benefit post-MTX.

Surgical treatment of otitis media with effusion in Maori children.

This study aimed to compare the incidence and outcomes of Maori and non-Maori children with otitis media with effusion who underwent myringotomy plus ventilation tube insertion (MVTI). De-identified extraction of Auckland District Health Board (ADHB) morbidity records belonging to all children who underwent an MVTI procedure between January 1996 and June 2016 at Starship Children's Hospital was performed. Demographic, procedural and outcome data were analysed. A total of 11 941 children aged less than 10 years underwent at least one MVTI procedure in the Auckland region from January 1996 to June 2016. Of those, 2387 (20%) were Maori and 9554 (80%) were non-Maori. There was no difference in gender, age, length of stay, 30-day readmissions or complications between Maori and non-Maori at index or subsequent surgeries. Maori were not more likely than non-Maori to require subsequent MVTI (P = 0.13). There was no difference between Maori and non-Maori rates of having MVTI alone (P = 0.11) or MVTI with adenoidectomy ± tonsillectomy (P = 0.61). Some epidemiological evidence suggests that Maori have a higher incidence of middle ear disease in the community. However, this study indicates that there is no difference in the post-operative course between Maori and non-Maori children.

Comparing audiological outcomes between the Bonebridge and bone conduction hearing aid on a hard test band: Our experience in children with atresia and microtia

IntroductionTo compare the audiological results of Bone Conduction Hearing Aid (BCHA) on hard test band and Bonebridge (BB) implant among children with microtia and atresia. MethodsThis is a retrospective review of patients with microtia and atresia who underwent BB implant insertion from September 2014 to February 2017 in Starship Children's Hospital. Preoperative audiological testing using a powered BCHA (Oticon Medical Ponto Pro Power) on a hard test band was used to compare post-operative hearing assessments with the BB. ResultsTen microtia and atresia patients were treated with a BB of whom three were treated bilaterally The children were aged between 5 and 15 and all had moderate to moderately severe conductive hearing loss. For each ear tested and subsequently implanted, BB aided speech scores were equivalent to that obtained by a BCHA. The mean improvement of speech reception threshold level between unaided and BB was statistically significant (p > 0.0001). Subjective questionnaire data indicated that BB implanted patients were performing within the norms of overall listening, both in quiet and in noise. Aided Speech In Noise (SIN) testing values were found to range from 0.8–6.5 for BCHA and 0.2–1.2 for BB and the difference was not statistically significant with a p value of 0.143. ConclusionIn audiologic assessments BB performs comparably to BCHA among children with microtia and atresia.

SCID newborn screening in New Zealand

A testing platform for newborn screening (NBS) for severe combined immunodeficiency (SCID) by TREC quantitation from dried blood spot (DBS) was developed and validated for population-based screening by the NIH in 2005.1 Since 2008 NBS for SCID has been adopted by 49 screening programs in the United States.2 The Paediatric Immunology department, Starship Children's Hospital, made a submission to the Technical Advisory Group of the National Screening Unit (NSU) NZ in 2013 to have SCID added to NBS. A cost-utility study was undertaken in 2014 and addition of SCID NBS was approved by the National Screening Advisory Committee in 2015. Evaluation of the EnLite™ Neonatal TREC (Perkin Elmer) CE marked in-vitro diagnostic (IVD) assay, a multiplex endpoint PCR method (quantifying TREC DNA and a B-actin control), was undertaken by the newborn screening team at LabPlus. The assay performed to kit specifications, comparable with published data.3 Agreement was obtained for CDC proficiency samples and four confirmed SCID positive DBS were successfully identified. Over 3000 unique retrospective newborn DBS were run and allowed a TREC cut-off threshold to be determined and development of a SCID NBS testing algorithm. Pathways for confirmatory testing and clinical support were developed and SCID NBS will commence in NZ from December 2017.

Castillo Morales Appliance Therapy in the treatment of drooling children

ObjectiveTo evaluate the efficacy of Castillo Morales Appliance Therapy (CMAT) in reducing the severity and frequency of problematic drooling in children. MethodsA de-identified extraction of all hospital morbidity records belonging to patients with drooling who underwent treatment with CMAT was performed between June 22, 2000 and April 12, 2016. Data were obtained from Starship Children's Hospital clinical records department. Demographic, diagnostic, and procedural data were included. Severity and frequency of drooling was quantified using the Thomas-Stonell and Greenberg classification method. ResultsThere were fifty-three children less than 17 years of age who were treated with CMAT for the indication of problematic drooling between June 22, 2000 and April 12, 2016. 72% (n = 38) of patients had a reduction in the severity and frequency of drooling with CMAT. Mean follow up was 51 months. These patients did not require further treatment for drooling with botulinum toxin or surgery. Within this group, 63% (n = 24) of patients had significant improvement in drooling as per the Thomas-Stonell and Greenberg classification method (p = 0.024). ConclusionsChildren who underwent CMAT for drooling were less likely to require further treatment with botulinum toxin or surgery. This result suggests that the use of CMAT in children with problematic drooling confers benefit.

Pediatric Tibial Osteomyelitis.

Osteomyelitis shows a strong predilection for the tibia in the pediatric population and is a significant source of complications. The purpose of this article is to retrospectively review a large series of pediatric patients with tibial osteomyelitis. We compare our experience with that in the literature to determine any factors that may aid diagnosis and/or improve treatment outcomes. A 10-year retrospective review was performed of clinical records of all cases of pediatric tibial osteomyelitis managed at the 2 children's orthopaedic departments in the Auckland region. The Osteomyelitis Database was used to identify all cases between 1997 and 2007, at Starship Children's Hospital, and 1998 and 2008 at Middlemore's Kids First Hospital. One hundred ninety-one patients fulfilled the inclusion criteria, and had a review of clinical notes and relevant investigations. The average duration of symptoms before presentation to hospital was 5.7 days. Less than 40% of patients had a recent episode of trauma. Almost 60% of patients could not bear weight on admission. Over 40% of patients had a temperature above 38°C. Erythrocyte sedimentation rate was elevated in 78% and the C-reactive protein was elevated in 90% of patients. In total, 42% of blood cultures and almost 75% of tissue cultures were positive, with Staphylococcus aureus being the most commonly cultured organism. X-rays, bone scans, and magnetic resonance imaging were all used to aid the diagnosis. About 43% of patients had surgery. Treatment length was an average of 2 weeks 6 days of intravenous antibiotics followed by 3 weeks 2 days of oral treatment. Six postsurgical complications and 46 readmissions were noted: 25 for relapse, with the remainder due to social and antibiotic-associated complications. Although generally diagnosed on presentation, pediatric tibial osteomyelitis can require more sophisticated investigations and prolonged management. Treatment with intravenous and oral antibiotics and surgical debridement where indicated can lead to a good clinical outcome, although complications are often noted. Level IV-Prognostic study.

The starship children's hospital tonsillectomy: A further 10 years of experience

Tonsillectomy as a day-stay procedure remains controversial, although it is an established procedure in New Zealand. We reviewed our last 10 years' experience. A prospective audit was used to determine unplanned conversion from day-stay to overnight hospital admission rates and the incidence of postoperative complications. There were 5,400 tonsillectomies performed over the 10-year study period (January 2004-January 2015); 71% as outpatients. The unplanned conversion rate to overnight stay was 0.4%. The median age of day-stay patients was 6.5 years (range 13 months-15 years) compared with those admitted for overnight stay (5 years; range 8 months-15 years). The primary postoperative bleed rate was 0.5% (confidence interval [CI] 0.3%-0.7%), and the combined primary and secondary posttonsillectomy bleed rate was 4.3% (CI 3.8%-5.0%). The rate of patients returning with postoperative complications within 1 month of surgery was 6.3% (CI 5.6%-7.0%). Day-stay tonsillectomy in the pediatric population is safe when performed using the described guidelines in a facility with appropriate resources. 4. Laryngoscope, 126:E416-E420, 2016.

Pediatric Humeral Osteomyelitis.

Osteomyelitis is a common problem among the pediatric population. The humerus is the most commonly affected bone in the upper limb; however, there are relatively few series in the literature. This article retrospectively reviews a large number of cases of pediatric humeral osteomyelitis. We aim to further define the disease and its clinical course to aid in improved treatment. A 10-year retrospective review was performed of clinical records of pediatric humeral osteomyelitis at the 2 children's orthopaedic departments in the Auckland region. The Osteomyelitis Database was used to identify all cases between 1997 and 2007 at Starship Children's Hospital, and 1998 and 2008 at Middlemore's Kidz First Hospital. Forty-nine patients were identified. Sixty-one percent were male with an average age of 4.2 years. Maori and Pacific Islanders were overrepresented. Seventy-eight percent were not using the limb, 70% complained of pain. Only 55% were febrile. White cell count, erythrocyte sedimentation rate, and C-reactive protein raised in 73%, 74%, and 79% of cases, respectively. X-ray, bone scintigraphy, and particularly magnetic resonance imaging were useful in radiologic diagnosis. Blood and tissue cultures revealed Staphylococcus aureus as the most common organism; there were 2 cases of community-acquired methicillin-resistant S. aureus. The distal humerus was more commonly affected. Fifty-three percent required surgery. Antibiotic therapy averaged 2.7 weeks intravenous and 2.6 weeks of oral therapy. There were 7 cases with adjacent septic arthritis, which had higher inflammatory markers. Major complications included 2 multiorgan failure and 1 growth disturbance. Humeral osteomyelitis can be diagnosed with an appropriate history, clinical examination, and investigations. One should be aware of concurrent septic arthritis and be prepared to treat this urgently. Those children with septic arthritis were not using the limb and had higher inflammatory markers. Treatment with intravenous and oral antibiotics and surgical debridement/washout if indicated can lead to good clinical outcomes with minimal complications. Level IV-retrospective case series.

Pediatric Acute Hematogenous Osteomyelitis.

Osteomyelitis continues to be a significant problem among the New Zealand pediatric population. We present a large series of acute hematogenous osteomyelitis (AHO) cases, with the aim to identify any changing trends and guide successful management of the disease. A 10-year retrospective review was performed of clinical records of children with AHO at the 2 children's orthopaedic departments in the Auckland region. Cases were identified from Starship Children's Hospital between 1997 and 2007 and Middlemore's Kidz First Hospital between 1998 and 2008. A total of 813 cases of pediatric AHO were identified. The incidence was 1:4000, which was decreasing over the 10-year period. There was a male predominance and New Zealand (NZ) Maori and Pacific Islanders were overrepresented. The diagnosis was made clinically in 27%, radiographically in 66%, and surgically in 7%. The most common pathogen was Staphylococcus aureus and the incidence of methicillin-resistant S. aureus was low (2%). The average length of antibiotic treatment was 44 days and 44% required surgery. This produced a recurrence rate of only 7% and a 15% treatment-related complication rate. In the New Zealand population, the incidence of AHO remains high with NZ Maori and Pacific Islanders overrepresented. The predominant pathogen remains S. aureus and our population has a very low incidence of methicillin-resistant S. aureus; flucloxacillin remains a good choice for empiric treatment in our population. Our rate of relapse and subsequent chronic osteomyelitis is low. This could be explained by traditionally longer antibiotic courses; however, this may also lead to increased treatment-related complications. Through prompt and accurate diagnosis with the aid of laboratory and radiologic tests and effective treatment with appropriate antibiotics (guided by local pathogen sensitivities) and surgical treatment when indicated, AHO can be well managed with minimal severe complications. Level IV-retrospective case series.

An international national emergency airway registry for children: Comparison of tracheal intubation practices across international PICUs

An international national emergency airway registry for children: Comparisonof tracheal intubationpractices across international PICUs Jan hau Lee, Gabrielle Nuthall, Takanari Ikeyama, Osamu Saito, Yee hui Mok, Vinay M. Nadkarni, Akira Nishisaki KK Women's and Children's Hospital, Singapore Starship Children's Hospital, New Zealand Aichi Children's Health and Medical Center, Japan Tokyo Metropolitan Children's Medical Center, Japan The Children's Hospital of Philadelphia, USA Background/Purpose: Tracheal intubation (TI) is a common, lifesaving intervention in pediatric intensive care units (PICUs). There is heterogeneity in approaches to TI across PICUs. This variation may be more marked across different geographical regions and may lead to difference in safety outcomes. We hypothesized that there would be differences in the process of care and safety outcomes for TI across PICUs in 4 different geographical regions (Japan, New Zealand, Singapore, and North America). Methods: The multicenter TI safety database National Emergency Airway Registry for Children (NEAR4KIDS) expanded to include international PICUs since 2012. Currently, there are 3 international PICUs outside of North America. We analyzed data from the NEAR4KIDS database from 3 PICUs (1 in Japan, 1 in New Zealand, and 1 in Singapore) from January 2013 to September 2014 and compared against North America (25 ICUs). We included all initial TI courses performed in PICUs. Outcome measures included adverse tracheal intubation associated events (TIAEs) and severe TIAEs (eg, cardiac arrest, aspiration, esophageal intubation not immediately recognized). Univariate analysis was performed with χ test and Kruskal-Wallis test, with P b .05 taken as statistical difference. Results: We identified a total of 515 TIs across the 3 international PICUs. Median age of patients (years) was 0 (IQR, 0-2) in Japan, 0 (0-1) in New Zealand, and 1 (0-5) in Singapore, significantly different (P = .005). The most common TI indication was respiratory failure (74% in Japan, 62% in New Zealand, 68% in Singapore, P = .17), similar to TIs from North America (62%). Direct laryngoscopy was the most common TI method in both international and North America (96% vs 85%, P b .001). International PICUs used uncuffed tracheal tube more often (62% vs 7%, P b .001). Among the reported TIs, tube change was more common in international sites (36% vs 12%, P b .001). The occurrence of adverse TIAE was 20% in Japan, 14% in New Zealand, and 10% in Singapore, not different from North America (international 15% vs North America 16%, P= .64). The occurrence of severe TIAEswas 11% in Japan, 6% in New Zealand, and 2% in Singapore, not different fromNorth America (international 7% vs North America 6%, P = .73). Conclusions: NEAR4KIDS TI registry successfully captured similarities and differences in TI practice and outcomes across international PICUs. International sites used uncuffed tracheal tube more often and had higher proportionof tracheal tube change. Theoccurrenceof TIAEand severeTIAEs were similar between international and North American sites.

Physiotherapy management in eating disorders

The Paediatric Unit at Flinders Medical Centre in South Australia launched an Eating Disorder Program in February 2013. The presentation of an eating disorder patient varies among consumers, and treatment requires a sustained, flexible and multidisciplinary approach. Physiotherapy was asked to be involved in the multi-disciplinary team to deliver an inpatient exercise class to provide education on posture and provide a safe environment for healthy exercise. The class began and consisted of two half an hour sessions a week. To increase the knowledge of Physiotherapy management in Eating Disorders a study tour was undertaken to observe the role of physiotherapists at the leading children's hospitals. The hospitals visited include Westmead Children's Hospital, Princess Margaret Hospital and the Starship Children's Hospital in Auckland. On completion of the study tour it was identified that to progress Physiotherapy involvement with the Eating Disorder population we should incorporate an initial physiotherapy assessment when new patients are admitted, provide discharge information for exercise and an information sheet for parents for compulsive exercise. It was also identified that there were no guidelines for Physiotherapy Management in Eating Disorders and this would be beneficial to standardise the role of physiotherapy across Australia.