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Bacterial resistance or tolerance to antibiotics is costly to patients and healthcare providers. With the impact of antibiotic resistance forecast to grow, alternative antimicrobial approaches are needed to help treat patients with antibiotic refractory infections and reduce reliance upon existing antibiotics. There is renewed interest in bacteriophage (phage) therapy as a promising antimicrobial strategy. We therefore performed the first multi-specialty survey about phage therapy and the first such survey among clinicians in the United Kingdom. An anonymous 10-question survey of clinicians from medical and surgical specialties in two Scottish Health Boards was performed. The 90 respondents spanned 26 specialties and were predominantly consultants (73.3%). The respondents were concerned about antibiotic resistance in their clinical practice; 83 respondents estimated having seen 711 patients in the last 12 months whose infections were refractory to antibiotics (delaying or preventing resolution). Over half (58.8%) of the respondents had previously heard of phage therapy. Staphylococci, Pseudomonas and E . coli were identified as the highest cross-specialty priorities for the development of phage therapy. Together, 77 respondents estimated seeing 300 patients in the last 12 months for whom phage therapy may have been appropriate (an average of 3.9 patients per clinician). Most respondents (71.1%, n = 90) were already willing to consider using phage therapy in appropriate cases. Additional comments from the respondents affirmed the potential utility of phage therapy and highlighted a need for more information. The results of this survey demonstrate substantial demand for and willingness to use phage therapy in appropriate cases, both from individual clinicians and across specialties. Demand from a wide range of specialties illustrates the broad clinical utility of phage therapy and potential scope of impact. Widening access to phage therapy could deliver substantial clinical and financial benefits for patients and health authorities alike.

Bacteriophage (phage) therapy is a promising alternative antimicrobial approach which has the potential to transform the way we treat bacterial infections. Phage therapy is currently being used on a compassionate basis in multiple countries. Therefore, if a patient has an antibiotic refractory infection, they may expect their clinician to consider and access phage therapy with the hope of improvement. The expectations of clinicians may be similar and may also include expectations around data collection. However, there are multiple biological and practical barriers to fulfilling patient and clinician expectations. While it is possible to access phage therapy, the path to acquisition is not straightforward and expectations therefore need to be managed appropriately to avoid raising false hope and undermining confidence in phage therapy. Phage scientists have an important contribution to make in educating clinicians and the broader public about phage therapy. However, it is clinicians that are responsible for managing the expectations of their patients and this relies on clear communication about the barriers and limitations.

ObjectivesTo determine the indirect consequences of the COVID-19 pandemic on paediatric healthcare utilisation and severe disease at a national level following lockdown on 23 March 2020.DesignNational retrospective cohort study.SettingEmergency childhood primary and secondary care providers across Scotland; two national paediatric intensive care units (PICUs); statutory death records.Participants273 455 unscheduled primary care attendances; 462 437 emergency department attendances; 54 076 emergency hospital admissions; 413 PICU unplanned emergency admissions requiring invasive mechanical ventilation; and 415 deaths during the lockdown study period and equivalent dates in previous years.Main outcome measuresRates of emergency care consultations, attendances and admissions; clinical severity scores on presentation to PICU; rates and causes of childhood death. For all data sets, rates during the lockdown period were compared with mean or aggregated rates for the equivalent dates in 2016–2019.ResultsThe rates of emergency presentations to primary and secondary care fell during lockdown in comparison to previous years. Emergency PICU admissions for children requiring invasive mechanical ventilation also fell as a proportion of cases for the entire population, with an OR of 0.52 for likelihood of admission during lockdown (95% CI 0.37 to 0.73), compared with the equivalent period in previous years. Clinical severity scores did not suggest children were presenting with more advanced disease. The greatest reduction in PICU admissions was for diseases of the respiratory system; those for injury, poisoning or other external causes were equivalent to previous years. Mortality during lockdown did not change significantly compared with 2016–2019.ConclusionsNational lockdown led to a reduction in paediatric emergency care utilisation, without associated evidence of severe harm.

Background and objectiveCardiorespiratory polygraphy (CRP) is the predominant technology used to diagnose obstructive sleep apnoea (OSA) in tertiary centres in the UK. Nocturnal pulse oximetry (NPO) is, however, cheaper and more accessible. This study evaluated the ability of NPO indices to predict OSA in typically developing (TD) children.MethodsIndices from simultaneous NPO and CRP recordings were compared in TD children (aged 1–16 years) referred to evaluate OSA in three tertiary centres. OSA was defined as an obstructive apnoea–hypopnoea index (OAHI) ≥1 event/hour. Receiver operating characteristic curves assessed the diagnostic accuracy of NPO indices including ODI3 (3% Oxygen Desaturation Index, ODI4 (4% Oxygen Desaturation Index), delta 12 s index and minimum oxygen saturation. Two-by-two tables were generated to determine the sensitivities and specificities of whole number cut-off values for predicting OAHIs ≥1, 5 and 10 events/hour.ResultsRecordings from 322 TD children, 197 male (61.2%), median age 4.9 years (range 1.1–15.6), were reviewed. OAHI was ≥1/hour in 144 (44.7%), ≥5/hour in 61 (18.9%) and ≥10/hour in 28 (8.7%) cases. ODI3 and ODI4 had the best diagnostic accuracy. ODI3 ≥7/hour and ODI4 ≥4/hour predicted OSA in TD children with sensitivities/specificities of 57.6%/85.4% and 46.2%/91.6%, respectively. ODI3 ≥8/hour was the best predictor of OAHI ≥5/hour (sensitivity 82.0%, specificity 84.3%).ConclusionRaised ODI3 and ODI4 predict OSA in TD children with high specificity but variable sensitivity. NPO may be an alternative to diagnose moderate-severe OSA if access to CRP is limited. Low sensitivities to detect mild OSA mean that confirmatory CRP is needed if NPO is normal.

[...]a 3.5 mm plain Portex endotracheal tube taped at a depth of 3 cm at the cords (9 cm at the lips) was used to ventilate the patient in PICU.

IntroductionAccurate evaluation of respiratory rate and pattern is important in health and disease; however, it can be challenging in children and babies due to small size and poor tolerability of existing monitoring equipment. This protocol outlines a study evaluating the feasibility of collecting respiratory data using a chest-worn accelerometer-based motion sensor in paediatric patients at risk of apnoea, respiratory failure and sudden death.Methods and analysisThis is an observational feasibility study over a 2-year period. The biosensor is an accelerometer worn on an ECG electrode during standard care at the Royal Hospital for Children, Glasgow. We aim to recruit three groups of patients (75 patients to each group): (1) Children attending for overnight cardiorespiratory polygraphy (0 to ≤16 years), (2) neonatal inpatients (from 30 weeks gestation) and (3) children attending for video telemetry at the epilepsy monitoring unit (0 to ≤16 years). Measurements will include (1) chest and/or abdominal wall motion measured by the worn biosensors; (2) standard clinical monitoring data will be collected to support biosensor data interpretation and (3) acceptability will be measured by a feedback questionnaire completed by patients and their parents/guardians.Ethics and disseminationThis study protocol was reviewed and approved by Yorkshire and The Humber-Leeds East Research Ethics Committee, approval number 314 696. This study involves human participants; written informed consent and assent, when appropriate, will be obtained from participants (or their parent/legal guardian/next of kin) to participate in the study. The study will be carried out in accordance with the World Medical Association Declaration of Helsinki (1964) standard reporting. Study findings will be reported clearly and transparently with relevant stakeholders including researchers, practitioners and publicly available databases. Results from this study will be presented at national and international conferences and reported in peer-reviewed publications.Trial registration numberNCT06292299 pre-results stage.

Using routine clinical records, microbiology laboratory reports, procedure lists for chest drain insertion, and a list of hospital admissions provided by Public Health Scotland, we identified community acquired pleural empyema cases requiring chest drain insertion from Jan 1 to Dec 27, 2022, at the three tertiary centres doing this procedure in Scotland (Glasgow, Edinburgh, and Aberdeen). A clear single cause for the rise in iGAS cases reported here, and seen across the UK, has not yet been identified.5 Given the low number of cases of GAS empyema, and iGAS more generally, seen in from March 23, 2020, to Sept 1, 2022 (with only one GAS case isolated from a sterile site in children aged <15 years in 2021; appendix p 3), it is possible that a waning in immunity might have a role.5 Another contributing factor might be an increase in viral respiratory tract infections after the easing of physical distancing restrictions. [...]it is possible that changes in the S pyogenes genome could have made GAS more transmissible or virulent;5,7 we found that most cases in our series were associated with emm type 1·0. TCW is principal investigator for the BronchStart project, which is funded by the Respiratory Syncytial Virus Consortium in Europe (RESCEU), with data collection supported by the UK National Institute for Health Research.

Diagnosing sleep-disordered breathing in children with suspected sleep-disordered breathing Sleep questionnaires, combined sleep questionnaires and ‘protocol-driven’ clinical assessments, sleep video recordings and sleep audio recordings Children without comorbidities Recommendations The Sleep-Related Breathing Disorder scale of the Paediatric Sleep Questionnaire (SRBD-PSQ), with a cut-off of ≥0.33, or Obstructive Sleep Apnoea-18 item questionnaire (OSA-18), with a cut-off of ≥0.60, can be considered for diagnosing moderate-to-severe SDB in children of at least 2 years of age with no comorbidities. While pulse oximetry is non-discriminatory at all ages, particular caution is required in using oximetry to diagnose OSA in children under 2 years of age as children in this age group are predisposed to central sleep apnoea (CSA) (as a result of developmental immaturity) and oxygen desaturations cannot discriminate between obstructive and central events. If hypoventilation is suspected, please refer to the ‘Pulse oximetry and carbon dioxide (CO2) monitoring’ recommendations and GPPs below. The American Academy of Sleep Medicine (AASM) recommends scoring hypoventilation during sleep when >25% of the total sleep time, as measured by either the arterial PCO2 or surrogate (transcutaneous or end tidal which is more relevant in paediatrics), is spent with a PCO2 >50 mm Hg/6.7 kPa.3 Home monitoring (pulse oximetry or CRSS) Recommendation Home CRSS can be considered for diagnosing SDB in children without comorbidities where the patients and/or carers are deemed appropriate for implementing a home sleep study.

The search strategy is available for review in Online supplement appendix 12 of the full guideline.1 Critical appraisal and GRADE analysis of the evidence After an initial screening to determine relevance to the clinical questions, each paper was assessed to determine if it addressed: Following data extraction from the ‘accepted’ papers, evidence profiles were generated for each of the clinical questions and the quality of the evidence was assessed using the GRADE principles.5 Where GRADE analysis was not possible, but the evidence was deemed important enough to be included in the guideline, the evidence has been listed as (Ungraded), denoting that inclusion was reached by consensus of the Guideline Development Group (GDG). A definition of the GRADE scores is shown in table 1.Table 1 GRADE score definitions GRADE Definition High High confidence that the true effect is close to the estimated effect Moderate Moderate confidence that the true effect is close to the estimated effect Low Low confidence that the true effect is close to the estimated effect Very low Very low confidence that the true effect is close to the estimated effect Ungraded GRADE analysis not possible, but evidence deemed important GRADE, Grading of Recommendations, Assessment, Development and Evaluation. GRADE specifies two categories of strength for a recommendation as shown in table 2.Table 2 Explanation of the terminology used in BTS recommendations Strength Benefits and risks Implications Strong Recommended, so ‘offer’ Benefits appear to outweigh the risks (or vice versa) for the majority of the target group Most service users would want to, or should receive this intervention Conditional Suggested, so ‘consider’ Risks and benefits are more closely balanced, or there is more uncertainty in likely service users’ values and preferences Service users should be supported to arrive at a decision based on their values and preferences BTS, British Thoracic Society.

Background and objectiveCardiorespiratory polygraphy (CRP) is the predominant technology used to diagnose obstructive sleep apnoea (OSA) in tertiary centres in the UK. Nocturnal pulse oximetry (NPO) is cheaper and more accessible. This study evaluates NPO indices’ ability to predict OSA in children with Down syndrome (DS).Methods Indices from simultaneous NPO and CRP recordings were compared in children with DS (aged 2–16 years) referred to evaluate OSA in two tertiary centres across an 8-year period. Receiver operating characteristic curves assessed the diagnostic accuracy of NPO indices, including ODI3 (3% Oxygen Desaturation Index) and ODI4 (4% Oxygen Desaturation Index). Two-by-two tables determined the sensitivities and specificities of cut-off values for predicting OSA.Results387 children with DS were included with stand-alone NPO; 177 female (46.7%), median age 6.1 years (range 2.02–15.97). There were 265 children (68.5%) with Obstructive Apnoea–Hypopnoea Index (OAHI) ≥1/hour, 164 with OAHI ≥1<5/hour (42.4%), 51 with OAHI ≥5<10/hour (13.2%) and 50 with OAHI ≥10/hour (12.9%). ODI3 and ODI4 demonstrated the best predictive value for predicting OSA. An ODI3 ≥19/hour and an ODI4 ≥8/hour were associated with the highest combined sensitivity (59.2%/63.8%) and specificity (74.6%/71.3%), respectively.ConclusionRaised ODI3 and ODI4 predict moderate and severe OSA in children with DS with moderate specificity/sensitivity and have a low sensitivity for detecting mild OSA. The poor predictive performance of oximetry reflects the multifactorial nature of sleep disordered breathing in children with DS. We recommend oximetry is not used for diagnosis of OSA in DS and CRP/polysomnography should be used.