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Why did you do this work?A proportion of children with complex neurodisability have life-limiting conditions with significant risk of respiratory deterioration requiring intensive care treatment. Advance care plans (ACP) provide the opportunity for patients, families and healthcare professionals to consider the priorities of care for the child in the event of a clinical deterioration. The aim of this project was to identify this cohort of children with complex neurodisability that have required intensive care therapy for respiratory deterioration and whether advance care plans are in place and accessible.What did you do?Patients with complex neurodisability admitted to PICU at a tertiary paediatric hospital under the paediatric respiratory team from October 2023-May 2024 were identified retrospectively. Data was gathered from the patients’ healthcare records including: age, diagnosis, respiratory cause of deterioration, whether an ACP was recorded, and the outcome following PICU admission. Furthermore, the healthcare trust introduced a new electronic patient record system (EPIC) in June 2024 and data from the ACP section of this record was gathered for each patient.What did you find?13 patients were identified with mean age 8.8 years. Underlying diagnoses included: cerebral palsy, Angelman syndrome, spina bifida, holoprosencephaly, acquired brain injury, neurogenetic disorders and mitochondrial disease. 92% (12/13) had an infective respiratory deterioration prompting PICU admission. 62% (8/13) required intubation. 38% (5/13) had been admitted to PICU on at least 5 previous occasions (range 0–10 admissions). 46% (6/13) had an ACP listed on their legacy electronic healthcare record; none were accessible on EPIC. Of those with an ACP 67% (4/6) included full resuscitation; 33% (2/6) had an identified ceiling of care. At the time of writing, 15% (2/13) have required further admission to PICU with one child deceased.What does it mean?The results suggest a need to collaborate with stakeholders including: PICU, neurodisability, respiratory, palliative care and community paediatric teams as to how planning for ACPs can be facilitated and implemented in this cohort of children. There is also clear need for existing ACPs to be transferred onto the new electronic patient record system (EPIC) which has since been completed. Due consideration should be given to highlight this issue to other trusts in the region prior to the planned migration to the EPIC system.

Why did you do this work?People with Trisomy 21 have an increased susceptibility to infection, particularly respiratory infection, characterised by increased frequency, severity and prolonged course of disease. Vaccination is one of the most effective public health interventions and particularly important in clinically vulnerable conditions including Trisomy 21. The aim of this project was to determine the vaccination coverage in children <18 years with Trisomy 21 attending community paediatric clinics across our healthcare trust.What did you do?Children aged <18 years (in October 2024) with Trisomy 21 attending community paediatric clinics across our healthcare trust were identified retrospectively using phlebotomy clinic lists over the previous 12 months and the trust’s electronic database (PARIS). Vaccination records for this cohort were obtained from the regional Child Health department. Data was gathered including: age, preschool vaccination history, childhood flu vaccination history for the 2023/24 flu season (in children >2 years). The vaccination coverage in children with Trisomy 21 was compared with current vaccination coverage across Northern Ireland (NI) in the Public Health Agency’s (PHA) Annual Surveillance Report1 and Annual Immunisation Reports.2 What did you find?97 patients were identified with a median age of 7 years (range 1–17 years). Of these 68% were school age (currently >5 years) and 32% were preschool age (currently <5 years) in the 2023/24 flu season. In the school age group, 100% of patients had partially completed their preschool vaccinations with 88% having fully completed. The table 1 below shows a breakdown of preschool vaccination coverage:Abstract 8145 Table 1Preschool vaccination coverage in children (>5 years) with trisomy 21 compared with NI coverage Vaccination Trisomy 21 All Children MMR1 98.4% 93.3% MMR2 92.0% 85.6% DTaP/IPV/Hib/Hep B 98.0% 94.8% DTAP/IPV Booster 93.9% 86.2% The uptake of the childhood flu vaccination by age group in the 2023/24 season is shown in the table 2 below:Abstract 8145 Table 2Childhood flu vaccination uptake in children with trisomy 21 compared with NI uptake Age Group Trisomy 21 All Children Preschool (2–4 years) 6.0% 32.9% Age 4–11 years 33.0% 68.6% Year 8–12 20.0% 56.5% What does it mean?The preschool vaccination coverage in children with Trisomy 21 is above the regional figures. The childhood flu vaccination uptake in children with Trisomy 21 is however markedly lower than the regional uptake, especially in the preschool age group. Now that this discrepancy has been highlighted, the community paediatric team can focus on developing interventions to improve the flu vaccination uptake in this patient cohort for the 2024/25 flu season.ReferencesPublic Health Agency. Annual Surveillance Report. Accessed via URL: https://www.publichealth.hscni.net/directorates/public-health/health-protection/surveillance-data/respiratory-infections/seasonal-1#vaccinationPublic Health Agency. Annual Immunisation Report: Northern Ireland vaccination coverage at 5 years of age. Accessed via URL: https://www.publichealth.hscni.net/directorate-public-health/health-protection/vaccination-coverage

ObjectivesEarly pulse oximetry screening (POS) identifies babies with congenital heart disease (CHD) and other pathologies that without early detection could lead to postnatal collapse.1 POS is intended for well, asymptomatic babies and should ideally be performed at 4–12 hours of life. Routine POS was introduced on Newborn and Infant Physical Examination (NIPE) checks in Royal Jubilee Maternity Hospital Belfast in August 2022.MethodsSnapshot audits were conducted on all of the postnatal wards to monitor adherence to the routine POS guideline. It was noted that there was an initial suboptimal completion of POS and further education sessions were provided to staff involved in NIPE checks. In addition, a new format of NIPE documentation was introduced with POS specified. A further snapshot audit was conducted after the implementation of these changes in May-July 2023. Data was collected including: SpO2 recordings at POS, age at POS, record keeping and the management of abnormal POS.ResultsInitial audit findings in October 2022 and December 2022 showed 60% (56/94) and 74% (76/103) of babies respectively had routine POS as part of NIPE checks. The re- audit in July 2023 following education sessions and changes to the NIPE documentation showed 96% (49/51) of babies had routine POS, with some postnatal wards achieving 100% compliance. Of these babies, 29% had POS in the first 24 hours of life, and 80% within first 48 hours of life. 2 babies were admitted to NNU with low SpO2 recordings and required further investigations including Chest X-Ray and echocardiogram; both were subsequently diagnosed with transitional circulation. No babies were diagnosed with critical CHD.ConclusionThere has been significant improvement in compliance with routine POS as part of NIPE checks with staff training and the new documentation format. Although there have been no cases of critical CHD detected on POS to date, the screening test is now fully implemented with almost all babies (96%) receiving POS in our unit. Furthermore, most babies (80%) have their NIPE check completed within the first 48 hours of life.ReferenceSingh A, et al. The impact of routine predischarge pulse oximetry screening in a regional neonatal unit. Arch Dis Child Foetal Neonatal Ed. 2014;99:F253-F253.

ObjectivesRespiratory illness is the leading cause of mortality in children with cerebral palsy (CP). A consensus statement published by Gibson et al identified 9 risk factors for respiratory disease in CP predisposing to increased 5 year risk of hospital admission with associated morbidity and healthcare burden.1 The aim of this project was to evaluate the number and demographics of children in Southern Trust with CP and identify their respiratory risk factors.MethodsCase records were identified from the Cerebral Palsy Register and Child Development Clinic. The specified inclusion criteria were as follows: age <18 years, resident in Southern Trust, diagnosis of CP.The Cerebral Palsy Register provided data regarding GMFCS classification, previous seizures, swallow difficulties and drooling. The patients’ electronic healthcare records were reviewed to determine respiratory hospital admissions over the previous 12 months, antibiotic use for respiratory infections, current seizures, diagnosis and treatment of reflux, frequent snoring and paediatric review within preceding 18 months.ResultsA total of 114 patients were identified. The GMFCS classification of the patients were as follows: Level 1 (23%), Level 2 (30%), Level 3 (14%), Level 4 (14%), Level 5 (19%). 70% of patients received a paediatric review over the preceding 18 months; all GMFCS Level 5 children were reviewed. 7% had a respiratory hospital admission over past 12 months; all were, or predicted to be, GMFCS Level 5 and comparatively younger (18% <6year, 5% 6–12year, 5% 12–18year).25% of patients had swallow difficulties; of whom 94% were GMFCS Level 4 or 5. 28% drooling issues; of which 78% were GMFCS were Level 4/5. 17% of patients had seizures in preceding 12 months. 9% had frequent respiratory symptoms; all were GMFCS Level 4/5. 9% had received at least 2 antibiotics for chest infections over the preceding 12 months; 90% were GMFCS Level 4/5. 23% of children had reflux; 84% were GMFCS Level 4/5. 5% of children snored frequently; 90% were GMFCS Level 4/5.ConclusionThere are many predisposing risk factors for respiratory hospital admission that can be challenging to recall in the outpatient setting. Children with GMFCS 4/5 have concomitant respiratory risk factors. Children <6 years appear to have greater risk of respiratory hospital admission. The findings suggest the introduction of a respiratory checklist for children with GMFCS 4/5 could ensure the modifiable risk factors are identified, optimised and prompt timely referral to a respiratory specialist.ReferenceGibson N, Blackmore AM, Chang AB, Cooper MS, Jaffe A, Kong WR, Langdon K, Moshovis L, Pavleski K, Wilson AC. Prevention and management of respiratory disease in young people with cerebral palsy: consensus statement. Dev Med Child Neurol. 2021 Feb;63(2):172–182. doi: 10.1111/dmcn.14640. Epub 2020 Aug 9. PMID: 32803795; PMCID: PMC7818421.

BackgroundOur District General Hospital increased the upper age limit for paediatric admissions from 14 years to 16 years in 2019-possibly among the last to do so in the United Kingdom.ObjectivesTo identify the clinical profile of young persons aged 14 years and over admitted to a paediatric unit in a District General Hospital over a 1–year period.To identify training and service provision gaps around care of 14–16 year olds admitted under the paediatric medical teamMethodsClinical features of patients aged 14 years and above admitted under the paediatric medical team between May 2019 and May 2020 were recorded in a pre designed proforma.A survey sent to Health Care Professionals working in the Paediatric inpatient facility was analysedA telephone survey of experience of 17 randomly selected service users was analysed.An educational package consisting of simulation, lectures, videos and a resource pack related to adolescent health was created, disseminated and feedback analysed.Results93 young persons aged 14–16y were admitted medically over 1 year with an average of 8 admissions per month.27 were male and 66 were female.The average length of stay was 2.4 days65 had a medical diagnosis and 28 a psychosocial diagnosisCommonest medical diagnosis was acute infections (18 out of 65)Commonest psychosocial diagnosis was deliberate self-harm (20 out of 28)Logistic issues included managing intoxicated patient or offender on the paediatric ward and interdisciplinary communicationHCP felt the biggest challenges were gaps in knowledge around management of substance abuse, intentional overdose and mental health presentations.They reported interface issues with adult and tertiary services especially when a young person between 14–16 years required Paediatric Intensive Care or specialist advice.Everyone welcomed training sessions on mental health presentations, substance abuse and suggested topics such as consent and adolescent gynecologyWe conducted 17 phone interviews, which involved either a parent, or both a parent and an adolescent.A prevailing theme was the praise and appreciation they expressed about the services provided on the ward. This included staff expertise and attitude.The facilities were frequently highlighted as being excellent Respondents also expressed their preference to stay on a children’s ward rather than an adult ward.Only a few respondents expressed dissatisfaction with their child’s stay in the paediatric ward. Feedback from the training sessions, videos and resource pack has been positive. ConclusionsThere were around 8 paediatric medical admissions per month in the 14–16 year age group with over two thirds having medical diagnoses and under a third with psychosocial diagnosesHCP perceived management of substance abuse and psychological presentations most challenging and reported logistic challenges when seeking tertiary or specialist input for this age group.Families were extremely satisfied by staff expertise, staff attitude, ward facilities and expressed a preference to stay on the paediatric rather than adult ward.The training package has received positive feedbackWe identified a need for an adolescent lead team and mental health liaison worker on the ward.

The Ashmolean was thrilled to see James Hall's piece on Titian's Triumph of Love, which the museum has just acquired (\"Love conquers all\", 11 July).

1. Wildfires are increasing in both frequency and intensity in many ecosystems, with climate change models predicting further escalations in fire-prone environments. Set against this background is the global decline of amphibians, with up to 40% of species facing extinction from multiple additive threats. Despite these disturbing figures, it is currently unclear how increasing fire frequency may impact the long-term persistence of frog populations. 2. Following a severe wildfire in south-eastern Australia in 2009, field surveys indicated healthy tree frog populations. However, the 2009 fire had significant impacts on genetic diversity, including increased levels of inbreeding and declines in effective population size. 3. Using stochastic population modelling under a range of fire-frequency scenarios, we demonstrate that amphibian populations in fire-prone environments may be increasingly vulnerable to extinction, particularly where rates of immigration are low. 4. Synthesis and applications. This study of amphibian population genetics before and after a major wildfire emphasizes the importance of integrating both ecological and genetic data into population models. This will help managers make more appropriate conservation decisions regarding fire management of natural environments, especially those containing threatened populations. Priorities for agencies involved in planning controlled burns should consider carefully the timing of controlled burns, along with maintaining habitat connectivity.

Impact of AIDS from the perspective of the humanities and social sciences; US, chiefly. Includes discussion on the role and responsibilities of government in managing the epidemic.