Dr Tom Cromarty Editor Interests: Paediatric Emergency Medicine, Medical Engagement and Leadership, Simulation, Quality Improvement, Research Twitter: @Tomcromarty |
Welsh Research and Education Network
WREN BlogHot topics in research and medical education, in Wales and beyond
Dr Celyn Kenny Editor Interests: Neonates, Neurodevelopment, Sepsis, Media and Broadcasting Twitter: @Celynkenny |
Dr Rebecca Broomfield What is it? Why? TALK has been developed to give a framework to debriefing. The aim of the entire project is to promote a supportive culture of learning and patient safety in clinical settings. Reflection is a vital part of healthcare and the tool promotes guided reflection enabling teams to work together in order to improve and maintain patient safety, create a supportive workplace culture and increase efficiency. The project has some important values which also function to promote a positive workplace and enhance staff well being. Reflection is encouraged to be constructive, non judgemental, and can be initiated by any member of the team. It would be worth having a discussion within your workplace about debriefing. Do you debrief as a whole team? Is TALK a tool which could enhance the way your team work together? When getting started and initial discussion should take place in order to identify and agree potential situations which will prompt its use, focusing on positive events as well as negative. Once established then TALK can easily be adapted to different situations so don't let this initial discussion limit you! Training course I attended a workshop in order to facilitate using the TALK debriefing tool. I personally think that this tool is useful and needs to become embedded in the culture as much as the 'ABCD' algorithm for assessing a patient. It is initially a bit clunky to use, because it is unfamiliar but once practiced would easily facilitate difficult discussions. It could be argued that we already debrief and therefore why do we need a tool? There are several advantages which I can see:
For more information Follow @TALKdebriefing on twitter for up to date news
Visit www.talkdebrief.org
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Guest blog post by Dr Kimberley Hallam I’m an ST2 in paediatrics and unfortunately did not have the chance to attend the RCPCH conference last year. So, this year I was very excited when I realised, not only would I be able to attend for all 3 days, but it was also in Glasgow…a city which I love and where my twin sister lives. Getting up to Glasgow itself was challenging! I travelled up after work on the Wirral on Monday night. Soon after leaving, there was an announcement that there were trespassers on the line. Unfortunately, this meant I didn’t arrive at Glasgow Central Station until 00:45! Luckily, I was staying with my sister so didn’t have the hassle of a late night check in. DAY ONE Day one of the conference was entitled the ‘Science and Research’ day. Because of my late arrival to Glasgow, I didn’t attend the 8am ‘Personal Practice Sessions’, but started at 9am with a welcome from the (now ex-) President of the RCPCH, Neena Modi. During the course of the conference, she relinquished her presidential title to Russell Viner. She gave an eloquent opening talk which was followed by a presentation by the RCPCH & Us Network. This is a group of young people who work with the RCPCH to ensure that young people’s views are listened to in all matters within the RCPCH organisation. They spoke incredibly well and are clearly a group of passionate, intelligent young people who are forward thinking, keen to bring about change and ensure their voices are heard. Another highlight from the morning included a talk by Prof. David Archard regarding children and parental rights. He took examples from recent high profile cases and presented ethical considerations regarding parental rights. He focussed on a public slogan taken from the Charlie Gard Case: ‘My Child, My Choice.’ After a fascinating discussion, he concluded that ‘disagreements [between medical staff and parents] will continue and [will] probably proliferate. Parents’ feelings and views count but they are not decisive.’ He closed the session with the remark that ‘we live in a time of post-truth and populism.’ Next came an interesting presentation from Dr Cherry Alviani and was entitled ‘Sleep for your own health: A Pan-UK Survey on Paediatricians Experience of Sleep Around Shift Work.’ She talked about a survey she completed which showed a lot of trainees do not have training on how to manage sleep around night shifts and that many hospitals do not provide somewhere for trainees to sleep on night shift and/or do not support them doing so. Given lack of sleep affects judgement and clinical performance, these are important issues to address. As an aside, the BMJ have recently published a brilliant article which gives general advice on how to survive night shifts and which I have personally found quite useful: http://www.bmj.com/content/360/bmj.j5637.full After the plenary session, I attended a workshop entitled ‘Press, Politics and Paediatricians; Campaigning for Child Health Across the UK.’ This was an interactive workshop and even had some role play where members of the audience acted as news reporters and grilled (a pretend) Jeremy Corbyn and Jeremy Hunt. Suffice to say, this became a little heated! Overall, the session introduced the idea that it is our duty as paediatricians to be advocates for child health. This may include being politically active (e.g lobbying government) or may involve speaking out on behalf of paediatricians/children in the press. The RCPCH have opportunities for members to become involved in such work on their Press and Parliamentary Panels (they include free training). I’ve put this link here so you can have a wee look if you’re interested: https://www.rcpch.ac.uk/news/membership-benefit-month-media-and-parliamentary-training The last session of the day I went to was run by the British Association of Paediatricians of Indian Origin (BAPIO) and covered ‘Hot topics in paediatric subspecialties.’ They had a number of insightful and interesting talks including ‘When do you need a gut specialist?’, ‘Chronic cough: when is it a cause for concern?’ and ‘Changing landscapes in paediatric epilepsy.’ They also had talks from Neena Modi and Russell Viner (who got a bit of a kind-hearted grilling from the audience after his talk ‘Paediatric services: fit for the future’. I chose not to go to the meal out on the first night. Instead, I went to a fabulous place in Glasgow called Stravaigin with my sister and a Mersey trainee. It comes highly recommended! DAY 2 Day two of the conference was the ‘Global Child Health Day’ and, I have to admit, the day I was most looking forward to. It did not disappoint. The day kicked off at 8am with a session on how to include global health in your career which was delivered by a diverse group of trainees who all had experiences of working in global health during their training years. They introduced the variety of ways a trainee can take part in global health work. These include clinical work, teaching, quality improvement projects, research and public health. The session covered considerations such as the stage of training you should aim to do such work, what support you might receive and where you can do the work. They also talked about the courses you can go on to help prepare. For example, ETAT, CHILS, GIC and the Diploma of Tropical Medicine and Hygiene. I left this session feeling very inspired and excited about my potential future opportunities. Next up was the plenary with the first person to speak Prof Anthony Costello (Director of the Department of Maternal, Child and Adolescent Health, World Health Organisation). He gave a keynote speech on ‘Global governance for child health and sustainable development.’ As his title suggests, he came across as a very inspirational person. He questioned ‘is everything getting better?’ He stated that, globally, child mortality is improving rapidly and maternal mortality is improving but not to the same extent. As currently projected, low income countries will not catch up with higher income countries for a great number of years. Globally, we are still falling short in harder to reach areas and there are still basic health needs which are not being met. For example, lack of access to clean water and sanitation. Five key problems which act as a barrier to improving child health are as follows: 1. Fragmentation of global child health strategies undermines programming and limits impact 2. Child health goals will not be met without adequate funding and delivery to marginalised populations 3. Evidence is not systematically generated and integrated into policy and programs 4. Strategies are insufficiently tailored to country context, and tools need improved end-user design 5. Lack of accountability, clear targets and strong monitoring He then went on to describe five key areas for WHO and UNICEF to address. The next talk was regarding child refugee health and is something I have been interested in for a long time and passionate about since attending the Royal Society of Medicine’s study day ‘Child Refugee Health: Everyone’s Responsibility.’ Dr Marylyn Emedo presented data on ‘Adverse experiences of Unaccompanied Asylum Seeking children (UASC) and the impact on their emotional wellbeing and mental health needs.’ As a bit of background, there were 3290 unaccompanied asylum seeking children in the UK in 2016. Children from Afghanistan, Albania and Eritrea formed 48% of all UASC in 2016. Her study was a retrospective review of records of all UASC referred to a clinic run by a local authority in London between 1st January to 31st August, 2016. The study focussed on adverse experiences the children went through on their journey to the UK. It found that 51% of children experienced trauma on route to the UK including detention, beating, torture and sexual assault. All the children in the study were screened for mental health needs. Of these, 75% reported at least one symptom suggestive of PTSD, anxiety or depression and 43% accepted a referral to CAMHS. Her recommendations were for timely review in line with statutory guidelines and initiation of early support by mental health services. Next, the workshop I chose to attend was ‘What should RCPCH’s global health priorities be?’ This started with a talk outlining some stark facts: 98 of every 100 children who die <5 years, die in developing countries, mainly from avoidable/treatable causes. There has also been a shift of mortality from communicable to non-communicable diseases. There followed a discussion surround how to address these issues as we work towards the Sustainable Development Goals (SDPs) set by the UN (http://www.un.org/sustainabledevelopment/sustainable-development-goals/). There was participation from the audience and good engagement from the RCPCH. I was particularly happy to hear that the RCPCH are launching a global health professional development framework to run alongside paediatric training in order to engage trainees in global health work. I continued the global health theme by attending the International Child Health Group’s afternoon session. This took part in the main Clyde auditorium and was mainly delivered by people who had conducted projects related to international health. The first talk was delivered by Dr Jonson and was entitled ‘The validation of transcutaneous bilirubin as a method to monitor newborn jaundice in a low income country.’ She had recognised there were significant problems with babies developing kernicterus as a result of untreated jaundice in Haiti. Despite having a reasonably small data set, her study suggested that transcutaneous bilirubin monitoring was a safe way of measuring bilirubin in a low income country. The unit she was working on had a lower incidence of kernicterus following the trial. However, she suggested a larger data set would be required to fully validate her findings. Amongst the remainder of the afternoon talks, the one which stood out for me was given by Dr Christopher Hands and entitled ‘Delivering nurse-led emergency paediatric care in Sierra Leonean Hospitals: The effect on quality of care and mortality.’ This nurse-led care involved the introduction of triage systems, stream-lining the patient journey at the point of care and training nurses in ETAT. These basic interventions had resulted in a very impressive reduction in mortality. Anecdotally, nurses now recognised they had the skills to save the lives of individuals presenting with symptoms they previously thought they could do nothing for. For example, hypoglycaemia and seizures. Other talks included ‘Neonatal outcomes from FGM/cutting in the Gambia; results from a multicentre prospective study’, ‘The use of satellite clinics in W Uganda to remove barriers to seeking care’ and ‘Identification of the health burden for street children and service provision available in Kismu, Kenya, through Focus Group Discussions.’ At the end of the second day, I was exhausted. However, thanks to this day and the enthusiastic way in which the RCPCH approach global health, I now have a renewed determination to pursue a career in this area. DAY 3 Day three was entitled the ‘Health Services for Children day.’ The plenary in the auditorium started with a keynote speech from Prof. Jason Leitch, the National Clinical Director from Scottish Government. He was a very entertaining and enthusiastic speaker and it really was a pleasure to listen to him in his home city of Glasgow. He talked about the state of child health inequality in Scotland. He described how children living in Glasgow within a few miles of each other have a very different life expectancy (a phenomenon which is termed the ‘Glasgow Effect’). He then went on to talk about various local programmes which had been set up. For example, a programme in which fathers in prison are given intensive parenting classes and have their children visit the prison regularly. This even involved the inmates performing a play of the Gruffalo for the children and has the benefit of decreasing their chance of reoffending. There have also been programmes which involve intensive health visitor input. He ended with the following picture. After the plenary and a short refreshment break, it was time for the final workshop session. As I seemed to be developing a political interest as the conference went on, I decided to attend the session ‘Child Health Policy Development: Why, What and How?’ This started with a presentation regarding the RCPCH health policy strategic direction for 2018. This states that the RCPCH wants to achieve the following:
1. To prioritise the health needs of infants, children and young people 2. To prevent ill health and promote health and wellbeing 3. To ensure continuous improvement in the quality of healthcare services 4. To reduce child health inequalities They plan to achieve these aims in the following way: 1. Developing robust, evidence-based policy 2. Prioritisation and horizon scanning 3. Understanding the environment we work in 4. Influencing the right decision makers, at the right time 5. Having a tailored approach so the right messages reach decision makers across the UK After the presentation, there was a discussion with audience participation and engagement from the new president. We discussed why and how the RCPCH develops policy, its impact and the role of paediatricians in influencing decision makers. We concluded that, as paediatricians, we have a duty to advocate on behalf of children and young people and part of that involves lobbying to push child health up the political agenda. Following the workshop and lunch, I decided to start the first part of the afternoon with the ‘Children’s Ethics and Law Special Interest Group’ (CHELSIG). After an introduction to CHELSIG, there was a presentation ‘Children’s rights, UK healthcare and Brexit: Could things get worse for young people?’ This session discussed the UN rights of the child, including Article 16 (the views of the child), Article 24 (health and health services) and Article 16 (young people have the right to a private life). According to a study completed by the NIHR, 57% of children felt they were not involved or only involved a little in their care. This session encouraged paediatricians to involve children in decisions about their care and consider facilitating groups where children and young people can provide input into the running of paediatric services. The next session was called ‘Moral distress, trauma and burnout in staff in relation to changes in PICU outcomes, challenging cases and media involvement in disagreements about end of life care.’ This session was led by Gillian Coleville who had studied the impact of the above in Great Ormond Street staff following the Charlie Gard case. The staff highlighted their main sources of distress are being accused of not caring, public condemnation without the right to reply, fears for their own safety, witnessing a child’s suffering, protracted legal proceedings, impact on other families and constant changes to care plan. 15% of staff had features of clinically significant post-traumatic stress syndrome. I was quite surprised at how high this was and also found it distressing to hear how the case had impacted upon their private lives. The final session I went to on day 3 was one run by the Association of Paediatric Emergency Medicine. This was an afternoon focussing on the Manchester Arena bombing on 22nd May, 2017. We heard from Allan Courdwell, Head of Group Emergency Planning with the Northern Care Alliance who talked us through what happened on the day and how the trust managed the major incident. This was followed by an insightful talk by Fiona Murphy MBE, Associate Director of Nursing who covered the bereavement response after the bombing. She gave a moving description of how the bereavement officers supported those who suffered the death of a loved one. Her commitment to providing dignified support to the families was exceptional. She described various ways in which she co-ordinated and delivered the bereavement support. This included putting families up in a hotel together, having 24-hour access to a bereavement officer and finding out information regarding the victims so they could, for example, play their favourite music when families were viewing their bodies. She also arranged for the families to visit the arena (when safe to do so) where they had lit a candle where each of the victims was found so the families could further understand and come to terms with what had happened. This talk moved me and many others to tears and I was so overwhelmed by the dedication she and her team showed to support the families in the aftermath of the bombings. So, that concluded my first attendance at an RCPCH conference and I really enjoyed the experience. It was great to see how proactive the college came across in providing advocacy for children and addressing global child health. It was also fabulous to catch up with old friends and be inspired by projects which other paediatric trainees are undertaking throughout the country. I’ll definitely aim to go again next year! Guest Post by Dr Emily Clark The Sustainable Development Goals, launched in 2015, are ambitious. For example: "By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births” This is a tough challenge we have set ourselves. Current global neonatal mortality (NMR) stands at 19/1000 live births, with under-5 mortality (U5M) at 41/1000 live births. In Madagascar, the NMR is 19/1000 live births, and the U5M 46/1000 live births (1). Note that these figures are all averages, which hides variation between regions, between rich and poor, between the educated and the illiterate (Hans Rosling has an excellent talk on this). I worked in a remote coastal region of southwest Madagascar, where there are no local data available for neonatal or child mortality as many births, and deaths, are not registered. I imagine that the statistics here would be worse than the average as communities are subject to the inverse care law: the paradox that those with the greatest need for health care have the least access. However, in terms of mortality rates, we have come a long way already. At the start of the Millennium Development Goals (MDGs) in 1990, the global NMR was 37/1000 live births (40/1000 in Madagascar), and the U5M was 93/1000 live births (160/1000 in Madagascar) (1). The Millennium Development Goals report states: “The dramatic decline in preventable child deaths over the past quarter of a century is one of the most significant achievements in human history” So what works, and what do we need to do? We know that most childhood illnesses are managed at home. This is memorably described in the case of malaria as the “ears of the hippo” – where only the minority of children are seen in a health facility. ‘‘The Ears of the Hippopotamus’’ where malaria patients are managed . . . and die. (2) How do we get children from home to the hospital? And how do we do so within a timely manner? The three delays model was devised in 1994 by Thaddeus and Maine (3). It states that the delay in a sick person receiving appropriate medical care can be broken down as follows: 1. The delay in recognition that medical help is required 2. The delay in arriving at a location where appropriate medical help can be given 3. The delay in receiving appropriate help at this location Rather than making the sick travel to the health centre, bringing health workers into the communities has demonstrated a reduction in childhood mortality. This initiative, known as Integrated Case Community Management (ICCM), targets the top causes of childhood deaths: diarrhoea, malaria, and pneumonia. If implemented globally, early treatment in the community of pneumonia in under-fives could reduce mortality by more than two-thirds. Similarly, community-based treatment of malaria could halve malaria-related mortality. Three-quarters of deaths from diarrhoea could be prevented by administration of oral rehydration solution (4). ICCM also promotes identification and treatment of malnutrition, which is observed in one-third to one-half of childhood deaths. I volunteered with Blue Ventures, a marine conservation NGO, working in remote coastal southwest Madagascar. I worked with their community health team, Safidy, which means “choice” in Malagasy. Here, it is all too easy to understand how receiving timely and appropriate medical intervention was a challenge. Health literacy was poor, transport infrastructure was sparse (relying on zebu carts, fishing pirogues, and ad hoc cars and lorries). The roads were sandy tracks, and driving to the city takes 7 hours to cover the 200km on a good day – and that was in a 4x4. Sadly, this is unaffordable to most. Poverty underlies life here. There is no money available for medicines, transport; many can simply not afford not to work for a day. As part of the Safidy programme, each village in the Blue Ventures service area has one agent communautaire (AC). These ACs, already respected women within their communities, were invited by the ICCM programme to an intensive eight-day residential training course. The training was centred around the use of a fiche, a paper-based form containing a series of questions which guide the ACs through key symptoms to aid diagnosis, and the “danger signs” of serious illness. These danger signs should prompt immediate treatment, as specified by the fiche, and referral to a health centre. The fiche guides ACs in providing safety net advice and follow up arrangements. The ACs also educate communities regarding public health measures, such as promotion of exclusive breastfeeding, and immunisations. ACs are provided with key items of equipment, such as rapid diagnostic tests for malaria, a measuring strip for mid-upper arm circumference for assessment of malnutrition, and a one-minute timer for measuring respiratory rate. Essential medicines are also provided, including oral rehydration solution and zinc, antibiotics for pneumonia, and anti-malarials. When a child falls ill, it is easy for the family to ask the AC within their own village for advice. The AC is able to assess and triage the child, and decide, using the fiche, what treatment is required. For example, a child presenting with a cough may well have pneumonia; the AC should then check for fever, and measure the respiratory rate. If the respiratory rate is raised, this should prompt antibiotic treatment and referral to a health centre. If there are no danger signs present, then the AC can provide a course of antibiotics and appropriate follow up advice. All the ACs are literate, however, they have had very limited education at school. Yet, these women perform the same job that we do, as a multi-disciplinary team, in the Children’s Assessment Unit. They are simply phenomenal. It is a lot to learn, and so, together with a local ICCM trainer, the Safidy team arranged for two study days for the newly-trained ACs. The focus was on role play rather than theory. Many of the ACs had brought their children along to the training and so they made for excellent “patients”, and so we witnessed some Oscar-worthy performances! Each AC received feedback on their performance: what went well, what could be improved next time. The ACs will now spend time working under direct supervision from nurses and midwives at local health facilities, before being approved to work independently within their communities. We hope that the success of ICCM in other countries can be replicated in this little corner of Madagascar. One AC measures a young actor’s respiratory rate using a specially-designed timer A trainer demonstrates assessment for pedal oedema; a danger sign that should prompt referral to a health centre Further reading For more reading on the Sustainable Development Goals: http://www.un.org/sustainabledevelopment/sustainable-development-goals/ The WHO have produced a report on the evidence for ICCM, available here: http://www.who.int/maternal_child_adolescent/documents/iccm_service_access/en/ To see data being brought to life, I would advise watching Hans Rosling – starting here: https://www.ted.com/talks/hans_rosling_shows_the_best_stats_you_ve_ever_seen ICCM complements the WHO programme Integrated Management of Childhood Illness (IMCI) which aims to improve the quality of care available to patients at health facilities. A recent Multi-Country Evaluation has demonstrated that quality of care is improved, resulting in a reduced childhood mortality. It has demonstrated cost-effectiveness, as earlier and correct treatment saves money. http://www.who.int/maternal_child_adolescent/topics/child/imci/en/ For more information regarding Blue Ventures’ community health programme, Safidy: https://blueventures.org/conservation/community-health/ References:
(1) All data from the World Bank, http://www.worldbank.org/ Accessed 20.03.2018 (2) The Intolerable Burden of Malaria: A New Look at the Numbers: Supplement to Volume 64(1) of the American Journal of Tropical Medicine and Hygiene. Breman JG, Egan A, Keusch GT, editors. Northbrook (IL): American Society of Tropical Medicine and Hygiene; 2001 Jan. (3) Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med. 1994 Apr;38(8):1091–110. http://dx.doi.org/10.1016/0277-9536(94)90226-7 pmid: 8042057 (4) WHO/UNICEF JOINT STATEMENT Integrated Community Case Management (iCCM). United Nations Children’s Fund. 2012 Guest blog by Dr Jemma Wright I was delighted to attend the first day of the RCPCH annual conference this year and here is a brief summary of my day. The day started early with a personal practice session about the new PROGRESS curriculum. Hopefully you are all aware of this new curriculum as it is going to be introduced this August. The session was an introduction to the new curriculum and it does seem like the college is trying to make it easier to engage with the new, much shorter curriculum. There is lots of information available on www.rcpch.ac.uk/progress including details of the mandatory 'key capabilities' we need to achieve and 'illustrations'/examples of how to evidence this on Kaizen. The main tip was to engage with this curriculum early as you can start producing evidence on your eportfolio now so it is already there to link to the new curriculum when it becomes live on 1st August 2018. The overall theme of the conference was ‘Children First – Ethics, Morality and Advocacy in Childhood’ and the main plenary had a strong theme on ethics.
The first keynote speech was about “Putting the Child First” and was an extremely topical philosophical exploration of the interaction between best interests and parental rights. There has been some significant media attention in the last year on multiple cases of disagreement between the medical teams and the parents. He alluded to these cases including the common protest of ‘my child, my choice’, and put a spin on this statement by highlighting that a parent does not necessary have the right to choose anything for their child – his example being that parents have the right to choose what to feed their child but they cannot choose to feed them poison. Overall it was an interesting discussion concluding that the child must always come first. This was followed by three project presentations: The first was on the impact of austerity on families with disabled children across Europe. The conclusion of the project survey was that cuts since 2008 have resulted in worsening quality and access of services to disabled children with a significant negative impact on families in the UK, especially those in severe poverty. The second was about delays in seeking legal judgements in cases of withdrawal of care, collecting data of 15 cases across the England over the last 5 years. They recommended considering alternative methods to avoid these delays such as mediation/dispute resolution, which have high success rates in avoiding litigation, and tend to have higher satisfaction rates. The last project was about a UK survey on paediatricians experience of sleep education. It was found that around 75% of paediatric trainees have not received any teaching on sleep during their training. Interestingly they recommended that we should all be taking a 15 min nap during our night shifts to reduce fatigue and that this should be supported by our workplaces. For more information, they have recently published articles in ADC and BMJ to promote more awareness about how to approach sleep during shift work. The plenary concluded with Professor Neena Modi talking about “Children in the 21st century’ focussing on the historical progression of a child’s role in society from possession, to protection, to partnership. She also talked about the increasing importance of non-communicable diseases in children especially childhood obesity and the interaction between child health and adult health. There is a whole section about these issues in the State of Child Health section on the RCPCH website. Next up, I chose to go to a workshop about navigating academic training pathways. As a non-academic trainee, it was interesting to hear that the college is keen to support paediatricians interested in developing an academic element to their job. I found out about a research funding opportunities database on the RCPCH website (https://www.rcpch.ac.uk/research_funding_opportunities) and the new academic toolkit (http://apatoolkit.eastface.co.uk). After lunch, I headed to the BPAIIG speciality group session. We had a presentation from an epidemiologist at PHE taking about paediatric antimicrobial resistance followed by a talk by a paediatric ID consultant about balancing antimicrobial stewardship since the new NICE sepsis guidelines. The key learning point when prescribing antibiotics was to be mindful of antibiotic resistance and always ‘Start Smart then Focus‘. There was a good representation from Wales in this session. I was asked to present my project about the epidemiology/microbiology of candidaemia over the last 15 years at Alder Hey Children’s Hospital followed by an excellent presentation by a Cardiff medical student looking at the risk of laceration when using an adrenaline auto-injector. There were also two further presentations about the impact of PCV on pneumococcal meningitis rates and two cases of INF a/b receptor 2 deficiency associated with immunodeficiency. Finally there were two further talks by paediatric ID consultants about the use of biomarkers to guide length of antibiotic course and the novel use of old antibiotics or new antibiotic combinations to treat multi-resistant bacteria. Excitingly there is a new national trial entitled BATCH (biomarker guided duration of antibiotic treatment in children hospitalised with confirmed or suspected bacterial infection), which is being coordinated by the Centre for Trials Research in Cardiff and may guide further developments in this area. Overall I had an excellent thought provoking day and enjoyed the excuse to visit Glasgow, my old FY2 home. The regular visitors to the site will have noticed an extra tab at the top of the page. The Welsh Paediatric Simulation Group (WPSG) provides paediatric simulation training throughout Wales covering a wide range of topics. Because WREN is linked to WPSG through education provision we thought it would be beneficial to have a one stop shop for access to educational opportunities so nobody misses out. The aim is that we will publish the dates of courses and contact details to book them on the WREN website as well as providing access to all the precourse reading materials. It’s a work in progress so please bear with us while we update this over the coming months. Also let us know what would be most useful to see on these pages and we can edit them to make they are adding value and making things a little bit easier. Welcome to the WREN pages WPSG Scheduled courses Course PRUDIC Study Day Date 2nd March 2018 Venue Bridgend Princess of Wales Hospital (Paediatrics) Contact Dr Dana Beasley Consultant Paediatrician Dana.Beasley@wales.nhs.uk Course Paediatric Trauma Course Date 18th May 2018 Venue Cardiff University Hospital of Wales Contact Dr Hannah Murch via Liz Williams Elizabeth.Williams34@wales.nhs.uk Course Step up to Registrar/Shift Leader Date 21st May 2018 Venue Cardiff University Hospital of Wales Contact Dr Sally Richards Associate Specialist Sally.richards2@wales.nhs.uk Course Safeguarding Date June 2018 Venue Bridgend Princess of Wales Hospital (Paediatrics) Contact Dr. Emily Payne Community GRID trainee Emily.payne@wales.nhs.uk Course Paediatrics 2 Date 2nd July 2018 Venue Cardiff University Hospital of Wales Contact Dr Sally Richards Associate Specialist Sally.richards2@wales.nhs.uk Course Step up to Registrar/Shift Leader Date 10th September 2018 Venue Cardiff University Hospital of Wales Contact Dr Sally Richards Associate Specialist Sally.richards2@wales.nhs.uk Course Paediatrics 1 Date 31st October 2018 Venue Merthyr Tydfil Prince Charles Hospital Contact Dr David Deekollu Consultant Paediatrician david.deekollu@wales.nhs.uk As more course dates become available we will update the WPSG page of the WREN website
‘Eculizumab in Shiga-Toxin producing E. Coli Haemolytic Uraemic Syndrome: A Randomised, Double-Blind, Placebo-Controlled Trial’ This is a trial currently recruiting on the Paediatric Nephrology Unit at UHW Aim of trial: To assess whether Eculizumab reduces the severity of Shiga-toxin producing Ecoli Haemolytic Uraemic Syndrome (STEC HUS) in children and young people Background:
What is Eculizumab?
Primary Research Objective: To determine whether the severity of STEC HUS is less in those given Ecu compared with those given placebo, in children aged 6m-18 years -Clinical Severity Score assigned at day 60 Secondary Objectives: i)To assess the safety of Ecu in STEC HUS ii)To determine whether the incidence of CKD following STEC HUS is less in those receiving Ecu compared with those receiving placebo iii)To evaluate the cost-effectiveness of administration of Ecu in STEC HUS from the perspective of the NHS Inclusion Criteria
- MAHA - Thrombocytopaenia - AKI
Exclusion Criteria
Active arm: Standard therapy + 1st dose Ecu Day 1, & 2nd dose Ecu Day 8 Control arm: Standard therapy + 1st dose placebo Day 1, & 2nd dose placebo Day 8 NB: The trial contains an internal pilot phase of 18m (12m recruitment, 6m follow-up), the purpose of which is to determine whether the substantive trial will continue. For further information please contact: Jennifer Muller, Paediatric Research Specialist Nurse (CYARU) Jennifer.muller@wales.nhs.uk Annabel Greenwood
Paediatric ST3 Wellbeing and Resilience In the Wales Deanery Paediatric trainees change rotation in September and March so this seemed a good opportunity to have an article about a current hot topic within medicine, wellbeing. The GMC have noted a rise in foundation doctors citing burnout as their reason for taking an F3 year or time out before applying to specialty training, what can we do about this as a profession? . We deal with life and death situations, we lack sleep through shift work, make large volumes of decisions and balance work life with time away from our families. All of these conditions can lead to increased levels of stress, depression and anxiety. With winter pressures and the ever growing demands on juniors combined with the widely discussed Dr Bawa-Garba case, we need to find ways protect our own mental health and our colleagues, supporting ourselves to manage our work-life balance. What can we focus on? Sleep No article on wellbeing should neglect the important role of sleep to maintaining a positive status quo. And no mention of sleep would be complete without mentioning the work being done by Dr Michael Farquhar. I was planning on providing a summary of his advice in this blog post however I feel the whole article published in Archives is valuable, really easy to read and very short. So rather than provide a truncated summary I direct you to the reference below and encourage you to take a few minutes to read this. Sleep matters, and we are only just scratching the surface of this topic. Farquhar M Fifteen-minute consultation: problems in the healthy paediatrician—managing the effects of shift work on your health Archives of Disease in Childhood - Education and Practice 2017;102:127-132. Exercise Personally this is my main go to wellbeing option. I run. It's not fast, I don't do it to come first, and I don't look pretty doing it, but running 3 times a week enables me to keep on top of everything. Now I accept running is not for everybody, although I would encourage anybody to try it and there are plenty of coach to 5km programs that are freely available to download, exercise is achievable. Pick an exercise which is sustainable and you enjoy. Fit it into your routine and prioritise it. You don't need to run marathons but get your body moving or make it a social event. Meet up with friends, or making new ones. Mindfulness What is mindfulness? Professor Mark Williams, former director of the Oxford Mindfulness Centre, says that mindfulness means knowing directly what is going on inside and outside ourselves, moment by moment. I personally use the Headspace App (@Headspace) to practice mindfulness but there are plenty of other options available. There are plenty of free blog posts on mindfulness on the Headspace website that cover a wide variety of topics. They also have links to published journal articles on the benefits of mindful practice. Action for happiness is a good twitter feed to follow if you are interested. @actionhappiness They have been producing a calendar for each month with daily ideas to improve wellbeing and their focus for March is Mindfulness. Mindfulness doesn't have to be meditation however, it can simply be taking the time to give yourself some space, take notice of your surroundings and stop being so busy. It can mean going to a certain place, taking time to listen to your favorite music or read a book. As with all these suggestions - make them work for you. Support Remember you are not alone. Ask for help. This seems like a simple statement of fact but sometimes it can be hard to remember that you are not a silo. We work in teams, especially in Paediatrics. There will always be somebody around to talk to, to give you support and to bounce ideas off of. If you don't know who these people are for you then go and find them! I have needed to call on my support network recently and without fail they stepped up to the plate. During this time, I also called on my friends outside of medicine. Find your network, what makes you able to bounce back from set backs and be the best you can. Places to look https://www.yougotthiswellness.com/ You Got This is the UK's first programme designed to promote Wellness and support the wellbeing of staff working in emergency medicine. However, don't feel that you have to be an emergency medical trainee in order to access this. It is a fantastic resource and worth checking in with. See them on Twitter as well @yougotthiswell
Locally in Cardiff and Vale The Child Health Psychology team run drop in Mindfulness sessions for staff on alternate Tuesdays 13:00-13:30 in Seminar room B, Noah's Ark Hospital. The March sessions are on 6th March and 20th March. Any other good resources which you think would benefit other readers of this post, feel free to comment below. Dr Rebecca Broomfield
After the huge success of last year’s St David’s Day Conference, I was very much looking forward to this year’s event, and Abby Parish and her team once again certainly did not disappoint! Nestled in the heart of Wales’ vibrant capital city, a stone’s throw away from the iconic sites of Cardiff Castle and the Millenium Stadium, Park Inn provided a classy, yet relaxed setting for an exciting day of learning ahead. Greeted with a lovely warm beverage and a selection of delicious pastries on arrival, there followed an opportunity to catch-up with paediatric colleagues both old and new before the opening lecture of the day. The programme itself was particularly attractive this year, focusing on Ethics as the principal theme. On a personal note, I felt my knowledge of Ethics in Paediatrics was somewhat lacking, with minimal educational opportunities available previously to explore this complex but fascinating topic. I therefore jumped at the opportunity to attend this year’s St David’s Day Conference to broaden my knowledge and experiences. The introductory lecture was provided by the President of the RCPCH, Professor Neena Modi. This fascinating lecture on the ethical issues in neonatal research emphasised the importance of the positive relationship between parents/patients and the medical profession, to enhance understanding about science and research methodology, whilst simultaneously strengthening trust between both parties. Professor Modi also discussed the concepts of ‘opt-out’ consent and mention of a possible ‘inclusion benefit’ in order to improve recruitment and efficiency of Randomised Controlled Trials. The next lecture was one of three of the day by Dr Richard Hain, Consultant and all-Wales Clinical Lead in Paediatric Palliative Medicine. His ‘Introduction to Parental Authority’ talk gave an excellent insight into the difficulties often faced concerning parents’ influence on treatment and care decisions. He talked about the concept of “best interest,” discussing the differences between objective and subjective interests, and their importance in helping parents choose ‘the path of least regret’ with regards to treatment decisions. Before morning coffee there was a case presentation session led by Wales Neonatal GRID Trainees Kate Burke and Zoe Howard. Their experiences of the management of three different babies born with Trisomy 18 highlighted the variability of genetic diagnoses, the postnatal role of perinatal palliative care, and the central role of the parents. The final session of the morning featured a lecture on prenatal screening and the associated ethical dilemmas, by Professor Angus Clarke, Clinical Geneticist in Wales. He discussed the goals of antenatal screening programmes, particularly focusing on the permission of informed reproductive decisions, conveying ‘reproductive autonomy,’ whilst considering the balance of health economic assessments. Dr Hain brought the morning session to a close with his lecture on ‘the value of a short life, who decides?’ This was an extremely thought-provoking session discussing the rights of the fetus, and the value of a child, particularly focusing on the views of the parents and that of the law. The afternoon session, entitled ‘Costly care – because you’re worth it,’ focussed on the legal aspects of a number of ethical dilemmas, including reference to the relevant articles of the European Convention on Human Rights. The legal concepts were presented by Dr Rim Al-Samsam, Consultant in Paediatric Critical Care Medicine, who has a special interest in law in the context of healthcare. Dr Richard Hain then chaired an open session alongside Dr Al-Samsam, encouraging audience participation to discuss potential treatment dilemmas faced in a hypothetical case. Following an incredibly profound and inspiring day, the CEO of the RCPCH hosted an interactive ‘road-show’ to discuss some of the topical issues faced by the RCPCH and their potential plans to improve them. Also discussed was the exciting new RCPCH curriculum, due to be launched over the coming weeks. If you are yet to attend a St David’s Day Conference I could not recommend it more. I very much look forward to next year’s instalment already! Annabel Greenwood
Paediatric ST3 3rd-5th January 2018, Siwan Lloyd I had the pleasure of being able to attend the British Paediatric Neurology Association Annual Conference this year held at King’s College London. Despite a horrendous viral illness over the festive season which left me with significant post-viral fatigue, I managed to catch my early train to London on the 3rd of January (and had the pleasure of travelling first class in view of my tardiness in buying the ticket resulting in the first class ticket being cheaper!). Loaded up with free coffee and biscuits from the first class carriage, I arrived in London just in time for the first session. The venue was great, close to Waterloo Bridge, and there were beautiful views of the city to be seen in the evenings when crossing the bridge to attend the social events. The conference had a packed programme full of interesting talks, clinical practice sessions, e-posters and symposia. One of the highlights included the opening talk by Dr. Charlie Fairhurst who discussed the creation of the NICE guideline for Cerebral Palsy in under 25’s in which he emphasised the importance of treating pain first and foremost because if a child is in pain, there is no point in complex interventions to improve their mobility/social interaction because the pain will hinder the child’s participation. Patients with Cerebral Palsy are particularly at risk of pain from numerous sources (e.g. orthopaedic/muscular problems, GI dysmotility, pressure sores, dystonia etc. in addition to the usual causes of pain that anybody can experience). I felt that the talk also provided a very important reminder of the need for holistic and multi-disciplinary care. There were multiple presentations throughout the conference on current research ongoing in neurological disorders (including neuro-inflammation in psychiatric disorders, antibodies in neuro-inflammatory and demyelinating disorders, neurogenetics etc.) which really made me appreciate the rate at which our understanding of neurological disorders is advancing. There were also sessions on Neuroimaging including advances in fetal neuro-imaging (talk given by Prof. Mary Rutherford) and advances in PET scanning particularly in guiding epilepsy surgery. On the first day, I attended a workshop on Childhood Sleep Disorders run by the tertiary sleep service at Evelina Children’s Hospital, which involved learning about methods of sleep assessment (including polysomnography, actigraphy and sleep diaries). Pharmacological therapy including melatonin and clonidine (for fragmented sleep) were discussed. We also discussed potential contributors to sleep fragmentation (e.g. pain, seizures, obstructive sleep apnoea) and also discussed basic sleep hygiene advice and psychological interventions to help with behavioural insomnia. On day 2, I attended a workshop session on early epileptic encephalopathies and the emergence of underlying diagnoses related to epilepsy gene panels where the indications for genetic testing were discussed. We also discussed when a referral to a clinical genetics service is indicated and the common genetic mutations now being identified on epilepsy panels (SCN1a, SCN8a, SCN2a, KCNQ2, PRRT2 etc). On the third day, I attended a workshop on movement disorder emergencies including how to manage status dystonicus. This was something I had never come across in clinical practice and therefore was a very useful session highlighting the management including pain relief, dystonia medications, checking CK, strict fluid management. The session also discussed common mutations causing dystonia (including DYT 1, PANK2, RRT1, TOR1A) and also discussed surgical management options including deep brain stimulation and pallidectomy. This year’s conference used an app instead of the usual printed programme. The app allowed you to formulate your own personal programme and came with alerts to indicate which talks were about to start. During talks, you could also write notes on the app which were then linked to the talk. At the end of the conference you could then download all of your notes. There was also an option to ‘chat’ with other attendees during the talks (though I didn’t use this feature as I felt I didn’t have anything very intelligent to say as many of the topics were completely new to me!). During the conference, I presented my poster on head injuries sustained following infant falls on the postnatal ward. The poster outlined the findings of a case series of infant falls in UHW between January 2015-September 2017. We found a high incidence of injury on CT imaging in these infants and therefore we propose a lower threshold for CT imaging in this group. We also found significant variation in monitoring, investigation and follow-up of these patients highlights a need for guideline development in this area. I am now planning to expand this project to a multi-centre WREN project collecting data from other units across Wales to gain more insight in to the scale of this problem and how cases are managed elsewhere across Wales. I was very pleased to see that two other Wales Deanery Trainees also had posters to display at the conference. Anne-Marie Proctor with her poster on Improving EEG investigations: Child’s Play? This poster presented how extension of a child-centred approach to EEG (including play therapy and flexibly timed investigations) to a second site in ABMU improved EEG success rates. Qumrun Nahar also presented her poster on the delivery of Botulinum Toxin Injection for Children with Spasticity: a Service Evaluation Project in Pembrokeshire, West Wales which showcased the service model of Botulinum Injections delivered in a rural DGH. This year’s conference displayed all of the posters as e-posters which meant that poster presenters were given a 3 minute slot to present their poster as part of a powerpoint presentation in a designated room. All presenters had 2 minutes to present and 1 minute for questions. Numerous poster presentations were running in parallel. The positive side of this was having an allocated time session to present your poster, and then you were free to listen to the other posters being presented with no obligation to stay standing next to your poster. The down-side was that because of the parallel sessions it was easy to miss out on seeing another poster that took your interest. For example, unfortunately I couldn’t attend both Anne-Marie and Qumrun’s poster presentations and was very sad to have to miss out on seeing one completely. There were also some posters which I felt could have generated much more than three minutes’ discussion and it was a shame to be limited to that timescale (some of the presenters struggled to describe their poster in any sort of detail in only 2 minutes!). It was an interesting and innovative way to display posters and it will be interesting to see if the idea is taken up at other conferences.
I was absolutely exhausted at the end of the three days, but know that I have learnt a great deal that will improve my interaction with children with neurological disorders, their families and the wider MDT. You can download the BPNA app which has further information on upcoming BPNA courses and events. And if you have an interest in Paediatric Neurology I would thoroughly recommend attending the BPNA conference next year. And if anybody is interested in getting involved in the upcoming WREN project looking at Head Injuries in Neonates on the Postnatal Ward please get in touch at siwanlloyd@doctors.org.uk! Rebecca Broomfield With a busy family and work life my pile of “must read” journal articles grows larger and larger month by month. However, when the article below popped up on my twitter feed during January it was so relevant to what I do currently every shift and there are a significant number of differing views and options it immediately jumped to the top of the list! (And I actually read it!) The topic of whether to give steroids or not to give steroid when a preschool child presents with wheeze is one which causes huge debate and which I frequently question my own management on. A previous paper published by Panickar et al in 2009 changed our practise and guidelines, despite having questions about the applicability of the study. However, the paper outlined below suggests that we still have more to think about. Oral Prednisolone in preschool children with virus-associated wheeze: a prospective, randomised, double-blind, placebo-controlled trial. S.J. Foster, M N Cooper, S Oosterhof, M L Borland The Lancet Respiratory Medicine 2018 January 17 https://doi.org/10.1016/S2213-2600(18)30008-0 Study Aim To assess the efficacy of oral prednisolone in children presenting to a paediatric emergency department with suspected viral wheeze. The study was originally a non-inferiority trial designed to test the hypothesis that a placebo is non-inferior to prednisolone, the authors added in a superiority analysis, testing the hypothesis that prednisolone was superior to placebo. The secondary hypothesis was added after the data had been collected but prior to data analysis. Participants Eligible patients were between 2- 6 years of age who presented to the paediatric emergency department in Princess Margaret Hospital, Perth, Australia and had a clinical diagnosis of wheeze combined with symptoms of a viral upper respiratory tract infection. Patients were excluded with: Oxygen saturations <92% in air, a silent chest, shock or sepsis, previous PICU admission with wheeze, prematurity, other cardio-respiratory disease, likely alternative diagnosis for wheeze, steroid treatment within the preceding 14 days, allergy to prednisolone or previous study recruitment. The eligibility criteria were suitable for the objective and looked at a population of children who regularly present with viral wheeze. The authors have excluded the bronchiolitis age group of children by excluding children under 2. This is important because they respond to different management. Design There were 3727 patients assessed for eligibility. After exclusions 312 were put into the placebo arm and 312 into the prednisolone arm. Following withdrawals 300 were included for analysis in the placebo group and 305 for the prednisolone group. Prior to data collection the authors calculated a sample size in order to ensure significant results. This was calculated on the original aim of non-inferiority. The study was a randomised double blind trial. Once eligible the participants were randomly assigned on a 1:1 basis to receive either 1mg/kg once daily of prednisolone or placebo. The placebo was formulated by the hospital and matched the prednisolone for volume, concentration, colour, smell and taste. The drugs were in matching bottles and randomisation was appropriate. The blinding for parents, patients, doctors, the research team and biostatician was kept until the statistical analysis was completed. The initial drug dose was administered by a nurse but for the following 2 days were given by the parents at home. The severity of the wheeze was assessed prior to treatment using a calculated pulmonary score. The family completed a questionnaire about home management and previous symptoms and a viral swab was taken from each participant. Each patient was managed with bronchodilators in line with the hospital policy. If the patient who was included in the study was admitted to the ward, and the admitting doctor felt that the patient should receive steroids, then these were given. 23 patients in the placebo group were given steroids in these circumstances. These patients were included in the intention to treat arm and the continuation of the study drug, alongside the prescribed prednisolone was at the discretion of the patient and their parents. They were included in the analysis and if anything would have made it more difficult to demonstrate a statistical significance between the groups. A pulmonary symptom scoring system was used for each patient to group wheeze severities together for analysis which enabled comparisons between groups, and to assess whether initial symptom severity was responsible for patient outcomes. All staff were competent in its use, however, this has score not been validated in children less than 5 years old. Outcomes This paper only comments on some of the data collected during the trial, the remaining data on long term outcomes will be presented in further manuscripts. The initial dual primary outcomes were length of stay in the emergency department and the total length of stay within the hospital. Secondary outcomes (within the first 7 days after hospital discharge) included: reattendance, readmission, salbutamol usage and residual symptoms after discharge. During the data collection it was felt the initial primary outcome; length of stay within the emergency department, was not reflective of the clinical condition as it was dependent on many non clinical factors. The study therefore only looked at an outcome of total length of stay in hospital until the participant was fit for discharge. This change was clearly outlined by the authors and appropriate for the aim of the study. Analysis The study groups were well balanced and the authors found no significant differences between groups in: baseline demographics; pulmonary score at presentation; personal or family history of atopy; use of salbutamol before attendance to the department. Categorical variables were analysed using a χ2 test or fishers exact test and continuous variables were compared using Students t test. Therefore a previously identified risk factor of personal or family history of atopy did not affect the outcomes in this study. Linear regression is the main analysis used to see if outcomes differ for the 2 groups. The authors conclude:
Subgroup analyses:
Secondary outcomes assessed were around representation post discharge. 26 patients re-attended (15 from prednisolone arm and 13 from the placebo arm). 3 patients from the prednisolone group and 2 patients from the placebo group were then prescribed steroids. One patient, from the prednisolone group needed admission to PICU. The statistical analysis of the reattenders (secondary outcomes) was not made clear within the article. Discussion The authors discuss their results in regards to the Panickar 2009 paper; they postulate that the study design could go some way to explaining the different outcome. The authors outline that they have tried to address some of the identified limitations found in the 2009 paper. These include the exclusion of children under 2 years old, thus reducing the likelihood for inclusion of patients with bronchiolitis. They urge some caution within their subgroup analysis conclusions as the sample size was smaller than the sample size used for calculating the general conclusion, also the patients were not randomly allocated to the arms based on the severity of symptoms or the use of salbutamol prior to attendance. This presentation is something we see daily in the emergency department and children’s assessment unit. It is an area for which I don’t feel that we have fully understood all the physiology behind the presentations. There are most likely many phenotypes of childhood wheeze. More research is definitely needed in order to assess the need for steroids and how to select the patients who would benefit from them. I look forward to reading further papers on the more long term conclusions of this trial. I think that I will still continue to judge the need for steroids on a patient by patient basis. Questioning with each patient whether they should or should not receive steroids. (And we’ve not even touched on Dexamethasone vs. Prednisolone!) It would be great to hear your views on this topic, I encourage you to comment on the blog or tweet me. (@RCBroomfield) Have a lovely February Rebecca The previous paper referenced can be found at: Panickar J, Lakhanpaul M, Lambert PC, Kenia P, Stephenson T, Smyth A, Grigg J. Oral Prednisolone for preschool children with acute virus induced wheezing, New England Journal of Medicine. 2009 Jan 22;360(4);329-38 By Katherine Burke (Neonatal GRID Trainee, Wales Deanery; Welsh Clinical Academic Trainee) katherine.burke@gmail.com Twitter: @DrKNeely Following on from the presentation at the WREN Autumn Study Day 2017, here's the 30-second guide to the best resources to use to get involved in research and get funding! Being ‘Involved’ in Research: https://www.rcpch.ac.uk/improving-child-health/research-and-surveillance/research-opportunities/get-involved-research/get-in http://www.peruki.org/ Lists projects which are ongoing. https://www.rcpch.ac.uk/bpsu/bursary Fantastic opportunity to design and carry out a project in partnership with the British Paediatric Surveillance Unit. Potential Sources of Funding for PhD For projects which are already ’set up’ i.e. designed and funded, see www.findaphd.com https://www.rcpch.ac.uk/research_funding_opportunities The RCPCH curate a list of funding opportunities – you need to be logged in with your college account but it is really comprehensive, and great for ‘specifics’ i.e. funding streams and opportunities related to particular conditions. https://wellcome.ac.uk/funding Wellcome provide grants for people undertaking particular projects. If you have an idea and a supervisor in mind, there are multiple streams under which you can apply i.e. Biomedical Sciences, Medical Humanities (for society/ethics projects) or International Development. https://www.mrc.ac.uk/funding/how-we-fund-research/ Similar to Wellcome. https://www.sparks.org.uk/ https://www.action.org.uk/our-research/apply-research-grant/apply-project-grant Dedicated to funding Paediatric Research. Again, need a project idea and a sponsor and supervisor in place. Disease specific opportunities….. (NOT comprehensive, just some examples!) https://www.kidneyresearchuk.org/research/paediatric-research-applications http://christopherssmile.org.uk/research/ https://www.childrenwithcancer.org.uk/research/for-researchers/funding-opportunities/ https://www.epilepsyresearch.org.uk/research-scientists/apply-for-funding/ Writing a ‘Research Proposal’
When developing a project idea, a good place to start is by carrying out a ‘literature review’ outlining the current status of knowledge for a particular area or field. If you contact the library at UHW, there is regular training available on ‘how to do….’ literature searches, among other useful things. https://www.nbt.nhs.uk/sites/default/files/attachments/How_to_write_a_research_proposal.pdf By Annabel Greenwood The Neonatal Unit at UHW are currently participating in the ‘Optimist-A Trial’ and I thought this would be the perfect platform to raise awareness and explain briefly about the trial…
What is it? An international multicentre randomised controlled trial of surfactant administration whilst on CPAP, in preterm infants 25-28/40 gestation. Research Question Does administration of exogenous surfactant using a minimally-invasive technique improve outcome in preterm infants treated with continuous positive airway pressure (CPAP)? Why is it important? Premature babies ( ≤28 weeks gestation) with significant surfactant deficiency on CPAP have historically required intubation for the administration of surfactant therapy, with subsequent increased associated risk of death, bronchopulmonary dysplasia (BPD) and other morbidities. In an attempt to address this problem, minimally-invasive surfactant therapy (MIST) techniques have been developed whereby exogenous surfactant is administered via an instillation catheter, inserted briefly into the trachea under direct laryngoscopy, whilst on CPAP. Eligibility Criteria
Randomisation Eligible infants will be randomly allocated to receive exogenous surfactant via MIST, or continue on CPAP. Intervention
Primary Outcome
Any further queries? Contact Rachel Hayward Neonatal SpR at UHW, for any further information (Rachel.hayward@doctor.org.uk) Wednesday 29th November 2017 Summary Newsletter and Projects Information By Chris Course The Welsh Research and Eduction Network (WREN) Autumn Study Day took place at the Princess of Wales Hospital, Bridgend on 29th November 2017. We had a really good turnout with lots of trainees keen to learn more about research, aided by the morning educational sessions (see further information below). Following this, there were updates on the current WREN project portfolio, with completed projects on audiology follow-up after meningitis being presented by Fiona Astill, and Siwan Lloyd presenting her work on the referral process for developmental delay. Qumrun Nahar presented her preliminary work on the use of botox for spasticity in Pembrokeshire, with plans to expand the project to other health boards in Wales. Full details of the project results will be published on our website shortly. With one large-scale project still ongoing, and two more planned for the start of 2018, there’s still lots going on within the network to get involved with!
Additionally, the new WREN Blog (www.wrenpaediatrics.com/blog) was launched last month, and is being edited by Rebecca Broomfield and Annabel Greenwood. They will be publishing on the first of each month on a range topics, including conference reports, critical appraisal and current research happening in Wales now. They are looking for contributors too, so if you have something to share or a topic you’d love to write about, please get in touch. Details of the WREN projects and their project leads, with contact details, are below. We will be disseminating these projects amongst the units, but if you would like to get involved in any of the projects in WREN’s current portfolio, please contact the project leads (details below). If you have an idea for a project you would like to develop with WREN’s help, please contact either myself or Siwan Lloyd via our website or using the details at the top of this newsletter. The next WREN study day is planned for May 2018 (confirmed date to follow), and we hope that you will be able to join us for another stimulating and thought-provoking study day, building on from the success of the last! Education The morning educational sessions were focussed on the importance of good research practice, with Health and Care Research Wales coming to give an update on Good Clinical Practice (GCP) for paediatrics. The added complexities of research for the paediatric population were highlighted, as well as the robust nature of research methodology to ensure valid results. The workshop received excellent feedback, and all attendees received a certificate for their portfolios. This was followed by Kate Burke and David Gallagher coming to share their experiences of taking time out from clinical training to undertake a PhD. The highs and the lows of their journeys were illuminating, and their varied experiences of the opportunities on offer, like experiencing a European neonatal units way of working, plus the ability to develop new lab skills, demonstrated the gains to be had. The realities of thesis writing were made plain though, so there’s always a flip-side! Thanks to our our speakers for an excellent morning educational session. Ongoing Projects: Project Title: ‘Antibiotic use on the post-natal wards.’ Project Lead: Zoe Howard, ST5 Royal Glamorgan zoe.howard@doctors.org.uk (and Annabel Greenwood ST3, UHW greenwoodan@hotmail.co.uk and Chris Course, ST4 UHW) Description: NICE guidance on the management of suspected early-onset neonatal sepsis has existed for several years, however management appears to vary across units throughout Wales. A prospective audit of infants started on antibiotics for suspected sepsis post-delivery is underway for units across Wales. A comparison of local unit guidelines across Wales is also a part of this project. This project has so far completed 4 months of data collection, and is planning on completing a further two months before starting data analysis. So far data on more than 200 infants has been gathered. Upcoming Projects: Project Title: ‘Head injuries on the postnatal wards’ Project Lead: Siwan Lloyd, ST3 Noah's Ark Children's Hospital for Wales siwanlloyd@doctors.org.uk Description: A pilot study at UHW has demonstrated that infants being accidentally dropped on the postnatal ward is not an uncommon occurrence, however their management and level of investigation following injury was very variable. Following on from this, an all Wales study is planned to determine the incidence, risk factors and management used, with the aim of producing a best practice guideline for these infants and their parents. Project Title: ‘Re-audit of the Management of Respiratory Distress Syndrome in Preterm Infants’ Project Lead: Chris Course, ST4 Noah's Ark Children's Hospital for Wales chriscourse@doctors.org.uk Description: Following the initial audit in 2014/2015 by WREN, a Wales Neonatal Network guideline was introduced for the Management of RDS in Preterm Infants in June 2016. The re-audit is planned to commence in March 2018 and will run for six months to assess how the new national guideline has affected patient care. Association for Simulated Practise in Healthcare (ASPiH), 6th – 8th November 2017, Telford International Centre By Rebecca Broomfield As a part of my Clinical Leadership Fellow year I am focusing on the evaluation of simulation as a teaching technique, attempting to relate this to improved patient safety and improved patient outcomes. Anybody who knows me knows that I love a simulated scenario as a teaching session, it’s not everybody’s cup of tea but it really fantastic opportunity to learn. I therefore jumped at the chance to attend the ASPiH conference. I started by attending a pre-conference workshop session based on Evaluation of Simulation. I was actually unaware that pre-conference workshops happened. A lot of big conferences have a day prior to the main event which they run focus groups or workshops that people can attend to be taught and explore ideas with like minded others. My workshop covered a lot of educational theory behind simulation and how you can use this to evaluate your simulation sessions. Key learning points included the fact that a poor evaluation undermines the development of new approaches. The evaluation itself is “a systematic acquisition and assessment of info to provide useful feedback about some [object]”, therefore while evaluation of the session is often an afterthought and a quick Likert score which nobody reads or bothers to fill in correctly, it really should be an important part of the structure of the simulation session. We also discussed how to structure your evaluation and a way to form a measurable outcome. The actual conference kicked off on the Tuesday morning. There were key note sessions delivered at different points in the day and there were split sessions with a choice of what to attend between these. The keynotes were all interesting a relevant to current trends in simulation. Cherrie Evan’s talk on delivering simulation based education in Africa was an eye opener and inspiring to see how correctly administered simulation can really make a significant difference in patient safety and improve outcomes. Her work was through an organisation called Jhpiego and focuses on the safety of a mother and newborn at delivery. Dr Gabriel Reedy delivered a session on the educational theory behind education, which is particularly relevant to my project. All the keynotes can be found at: http://www.youtube.com/playlist?list=PLzm6Ad9XIwxmnblhwSbEcjceDNpUFW1iu - I’d also recommend watching Dr Al Ross’ talk on Resilience within healthcare if like me you’ve become a bit disillusioned with the term resilience and its meaning. In between the keynotes there was so much going on, it was almost overwhelming. Sessions ran throughout the day with presentations about many different aspects of simulation from setting up in-situ simulations with an emergency department, evaluation of simulation sessions and development of simulations focusing on wellbeing and resilience. The sponsors were around with lots of new technology and we got to play with all the new simulation models. There is a particularly interesting baby and child model which is amazingly lifelike and provokes significant emotion (I automatically checked the veins on this model immediately after picking it up!) I also got to observe a session using a interactive tent to have a projected environment in which to run a simulation. The situation that I observed was a building site with an injured builder. The walls were displaying images of a new housing estate and there were building site noises being played throughout. The tent feeds into the educational theory of distributed cognition suggesting that we need to be investing cognitive power into the technology as well as the people.
ASPiH is working hard to provide a standardised quality simulation teaching nationwide and as such they have developed their standards documents which can be found here: http://aspih.org.uk/standards-framework-for-sbe/. These outline the standard expectations for running a good simulation education program. It is looking into developing an accreditation system in order to promote good quality simulation. We know that simulation teaching is good, we now need to prove it and regulate its delivery in order to standardise experiences. I am even more excited about simulation teaching and its huge potential since attending this conference. I tweeted throughout the days including sketchnotes of some of the sessions I attended, if you are interested in these they are on my twitter feed for the conference dates. I am planning on attending the Paediatric specific International Pediatric Simulation Society (IPSS) conference during May in Amsterdam, if anybody fancies joining me you’d be welcome. If you want more information on ASPiH then visit their website here: http://aspih.org.uk/ As a Paediatrician I think we play a vitally important role in Public Health, we have the ability to make a significant difference with every contact we have with children and young people, therefore I was excited to attend the Public Health Wales Conference in October. It provided an opportunity to keep up to date with all aspects of Public Health as well as focus in on paediatric specific topics, such as adverse childhood events, the venue was fantastic and with Michael Sheen making a keynote presentation what was not to love?! The start to day 1 was nothing short of inspirational, a montage of pictures detailing the history of Public Health in Wales and significant events in history, such as devolving power over health, was accompanied by a harp and a flashmob choir popping up in the audience culminating in a local school choir taking to the stage, it was breath taking. After an impressive start the audience heard from Rebecca Evans, Minister for Social Services and Public health, who updated us on the progress which Wales had made within Public health. The next speaker Dr Christoph Hamelmann, Head of the World Health Organisation Europe office for Investment in Health and Development, spread the net wider and discussed more global issues and reiterated the importance in looking beyond your own borders in Public Health spheres. I was pleased to learn that the ‘Well being of future generations act” really is leading the way within the WHO. We wrapped up before lunch with a keynote on Climate change, followed by a discussion panel exploring air pollution and how we can build a sustainable future. The afternoon sessions on day one were split into ‘Spotlight sessions’ there were many of these going on at the same time and the topics which you could choose from were diverse. I attended one entitled “Mindfulness for wellbeing: Evidence and Practise” The science behind mindfulness was discussed briefly, demonstrating the activation of the pre-frontal cortex when being mindful. Children who are naturally high in mindfulness react less strongly and have better emotional regulation. It was interesting to see demonstrated that by using mindfulness techniques with school aged children you can shift them into individuals with high mindfulness. After the training these children had a significant decrease in the intensity of their reactions to angry faces. Mindfulness has an enormous potential for development within education, as within other areas, but it important that the training is ongoing and children learn to use it within everyday life. Mindfulness, growth mindset and metacognition are surrounding feature of the new curriculum being developed in Wales and has the opportunity to vastly improve the outcomes in mental health for this generation of children. My spotlight session was fantastic, but I had significant spotlight session envy as a college attended a Lego workshop based on driving improvement through the value chain and got to use LEGO to demonstrate visually resilience and improvements – she got to play with LEGO and call it work! (on a side note you can train to deliver LEGO sessions and this could be your job!)
Day 1 ended with a chaired Brexit Debate. The views from the panel were interesting and the uncertainty regarding the exit plans are already causing problems for Public Health initiatives within Wales. The panel presented reasoning that it doesn’t matter what side you were on when voting took place, we need to overcome this and work together to move forward. Wales have already done some of the ground work with how to respond. Brexit is currently overwhelming all of UK politics and other important issues are being neglected because of this focus. But on the other side of the coin, and attempting to be a glass half full type of person, Brexit is a huge opportunity to have ‘No more excuses’ and reduce inequalities. We need to change our mindset on Brexit, accept that it is currently happening and focus on the positives which we can derive from it. Day 2 started by hearing from Dr Frank Atherton who is Chief Medical Officer for Wales and a person I will never get bored of hearing speak. He attended WPS last Autumn and delivered an engaging Keynote there, and as a Welsh Clinical Leadership Fellow we have been in the privileged position to meet him on several occasions. He presented that we should celebrate our Public Health successes (Hepatitis C, Future generations act, reduction in smoking rates) but also recognise that we still have a long way to go. Inequalities still exist and are widening. Moving forward we need to focus on prevention with improved outcomes and ensure sustainability. But because a long term view is not easy to fit into political cycles it is hard to engage managers with this viewpoint. Dr Atherton concluded that we are on the right track and need to continue to engage the public and sustain ongoing developments in Prudent Health Care. Dr Chrissie Pickin followed on from Frank Atherton and presented an engaging talk entitled “Understanding people’s choices and how to influence them”. She started by noting that Health issues are complex and for every complex problem there is a straightforward, easy to implement, wrong solution. Providing education is an obvious solution because the assumption is that people would not deliberately harm themselves but a knowledge gap is rarely the reason behind the behaviour. She gave some top tips to influence people’s choices.
Having learnt about how to influence people’s choices it was fitting that the next speaker, Richard Chataway delivered a talk on Social Marketing and Communication Science. Because we have a better understanding of what drives behaviour change as well as advances in technology social marketing has significantly changed. Richard Chataway presented, amongst other topics, a public health initiate undertaken in Australia, his team wanted to reduce smoking rates. When quitting smoking the motivation is there, the knowledge is there but people need support. He launched My Quit Buddy, an app which provided daily progress tracking, distraction techniques and motivational messages. This was an incredibly successful campaign and the app has had wide uptake. He also explored the use of technology within research into changing behaviours. With the introduction in artificial intelligence it is possible to pre-test communications such as an advertising campaign, to understand it people will find it motivating at a subconscious level this can remove the test and learn element of marketing which will make it more effective, quicker. He again reiterated that in order to find a solution it is important to understand the behaviour and design a solution around it. A panel discussion followed this. After a short break, there were more ‘Spotlight sessions’ with lunch in the middle. There were again many topics to choose from. I attended “Tackling Adverse Childhood Experiences” It is known that if a young person experiences 4 events they are 15x more likely to commit violence, 14x more likely to experience violence and 20x more likely to be in prison than the general population. We need to break the generational cycle and make a social movement for change looking at the root causes and take a psychological approach to tackle these. The impact of breaking the generational cycle is huge, 47% of adults have experience 1 adverse event. The second of my ‘spotlight sessions’, after lunch was “The good, the bad and the social: Two sides of social media” Social media is more addictive than smoking or alcohol, 10 million photos are uploaded to Facebook every hour. It can be both positive and negative the challenge comes with harnessing the positives while mitigating the negatives. Instagram is cited as the most negative with associations to negative body image as well as anxiety and cyber bullying. There was a lot of discussion about where the responsibility lies for managing social media for children and young people. It was felt that this was not just the responsibility of parents, social media itself needs to take some responsibility. The conference closed with Michael Sheen discussing “Building on our cultural strengths: Supporting communities.” As expected Michael Sheen was an engaging and well informed speaker. His message began with the understanding the if you want different outcomes you have to fundamentally change what you do. He outlines inequality as a significant problem, the less you have the more you have to pay for it. If we want families to drive themselves up socially then we need to look at the weight of debt which they have. We have a benefit within Wales as we have a strong community spirit and have held onto our identity and language. As a Public Health team we need to support our communities to be as healthy and sustainable as possible, we need to provide space where communities can come together and shift the power into the grass roots. His concluding statement is worth recognition and highlights a positive to finish a highly engaging conference. “One who has health has hope, and one who has hope, has everything” (Originally a proverb I think!) Once again, I tweeted through the conference and these can be found on my twitter feed from these dates. Public Health is an important topic which is extremely relevant within Paediatrics and the selection of work presented during this conference leaves me in no doubt that Wales really is leading the way. Leaders in Healthcare Conference 30th October – 1st November 2017, ACC Liverpool By Rebecca Broomfield I am currently taking a year out from the Paediatric training program and doing a Clinical Leadership Fellows placement through the Wales deanery. As a part of this year we come under the umbrella of the Faculty of Medical Leadership and Management (FMLM), it was under this disguise we managed to sneak ourselves into the FMLM’s annual conference "Leaders in Healthcare". I went to this conference with an initially pessimistic outlook. I truly believed that a lot of the information provided would be over my head, in a language that I didn’t understand, from managers who were slightly out of touch. I am humble enough to eat my own thoughts and I would thoroughly recommend everybody tries to attend an FMLM conference at some point in their career, indulge me and read on to discover why! As per conference structure, which I am becoming more and more familiar with, Day 1 began with a welcome – another choir, (starting to think this is a new trend .... perhaps someone could do a study?) followed by a Key note speaker. Seriously, this was an impressive start. We heard from Nicky Moffat in a keynote entitled “Leadership is everyone’s business” Nicky Moffat has a background in the military and spoke about the importance of not buying in people for leadership roles but investing in people and growing them up from within. She voiced an important message of inclusion; that every person has a role to play, as a leader your role is to value these differences and figure out how to make them work. You do not have to be able to do everything, but you do have a responsibility to those who you lead to dedicate time to your own personal development. You set the tone, so make sure that you lead your way. She was inspirational to listen to and it was particularly interesting to hear from somebody whose career was outside of medicine but was experienced in a structured, high-pressured environment. After a brief pause for coffee, we split into smaller group sessions. I went for a workshop entitled “Joy in work”. It was run by Henry Stewart, a man who introduced himself as “Chief happiness officer”, which I love, who wouldn’t want that to be their job title??! He runs the Happy company, which has been listed as one of the 20 best workplaces in the UK for five successive years (www.happy.co.uk). Henry Stewart has also written “The Happy Manifesto” a book that has made it onto my Christmas wish list (along with many others from this conference alone.) The company motto is “Don’t tell when you can ask” He has identified that people work better when they are challenged and given freedom. As a manager we should be enabling people to innovate, and rather than focusing on weaknesses we should develop our strengths. Mistakes should be celebrated and, within the boundaries of clear principles and targets, team members should be given freedom and ownership of projects. The style of the session was relaxed, he actively encouraged participation, and provided a significantly different perspective on workplace than my experience of the NHS. Lunch provided an opportunity to network with other conference attendees. There was a wide range of people present, many with backgrounds in significant leadership positions within the NHS. My after lunch session focused on collaboration across barriers and introduced me to the concept of Compassionate Leadership, which will be a blog post for the future. I didn’t want to stick to hearing from people with leadership roles within the NHS, so I headed to a second afternoon session delivered by Carrie Thomas, who herself is an ST4 in emergency medicine, but was delivering a session on how we can learn lessons from elite sport. She directed the audience to focus on the daily standards, looking at the processes rather than focusing on the outcome. She advised learning from excellence, managing what you are able to control and utilising visualisation to drive you forwards. Remember that you are a team and it is vitally important to work together, not only should you commiserate together but you should celebrate the wins. Day 1 ended with an incredibly passionate and moving talk from Gulwali Passarlay (his book “The Lightless Sky” has also made it onto my wish list!). Guwali started with a thank you and a reminder not to forget the little things you do as clinicians daily as they are the important things. He spoke about his incredible journey as a child refugee travelling alone from Afghanistan across 12 countries, to end up in Britain, go to university and carry the Olympic torch in 2012. It served as an acute reminder of our privileges. His story was about overcoming adversity and never giving up. He reminded his audience that having an experience was one thing, but how you used that experience was another; you have a choice. At the start of day 2 Dr Bruce Keogh, hopefully an man who needs no introduction, delivered the opening keynote. He started by stating that we do not want to loose our NHS by mistake and received a standing ovation at the end of his talk. He outlined the history of the NHS and spoke about innovation. I’m not entirely sure that I agreed with some of what he said, but that is probably best left out of this blog for fear of entering a political minefield that I am unable to control or step back from. He did make a very valid point however, stating that people do not fear change, they fear loss. I will be taking this forward as a part of this year, and my future career. An important role as a leader is to engage people, bring them with us, inspire them to innovate and together we will be able to make a difference. As per day 1, day 2 then broke into smaller group sessions. I attended a resilience workshop. This started by recommending everybody watch ‘Inside Out’, which already had me engaged and listening. The workshop ran through 4 stages of coping and looked at each of these. They explained that resilience found ways to bypass stages, and therefore you progress through these stages quicker, or even skip some stages when faced with conflict or a challenging situation. The focus on the ability to define the problem, which would enable you to employ the correct solution. For example, it is important to be direct in complex situations. Building resilience is based on 4 key pillars; confidence, social support, purposefulness and adaptability. They encouraged assessing your own resilience, a tool to do this can be found here; www.robertsoncooper.com/iresilience/ and focusing on one weakness to improve. It was an interesting session, and do now go and watch ‘Inside Out’! After lunch I focused on 'Changing Culture'. Culture is important within a workplace because it impacts the mood and atmosphere which in turn affects performance. Leadership is about gestures and choices which we make all of the time and these influence the culture within our teams. Culture itself cannot be managed, it is a behaviour pattern which becomes established and over time this is reinforced and amplified by visible artefacts. Changing culture is what we are ultimately trying to achieve with our quality improvement projects. Small gestures can create tipping points which is known as the butterfly effect. Within culture change, the leader is in charge but not in control, this is complexity thinking which involves non linear relationships which cannot be predicted. However, machine thinking is the predominant discourse in the NHS; the NHS can be managed and the leader has complete control. The down sides to machine thinking is that everything falls to the leader, participants and team members are passive which leads to significant amount of stress and pressure. A switch from machine thinking to complexity thinking will change the culture. It is hard but as clinical leaders we should be brave! Make that change, a small shift can have a much wider impact. All of us are leaders and we need to recognise this. The final small group session I attended was on coaching – I am exploring this more on a personal level and will during, the course of the year, write a blog solely focused on this theme.
The Leaders in Healthcare conference closed with a keynote from Deborah Rowland: “How to lead mindful change” The most important message I will take from her session is that good leadership starts with knowing yourself. Invest in yourself as a leader, understand your strengths and weaknesses and recognise them without judgement. When you have spotted something you are able to change it, if you don’t look for it and recognise it, then you cannot. Her four key messages for developing your own leadership style were: Perceiving (tuning into the system), Noticing (staying present), Integrating (all aspects, including difficulty) and Choosing (respond, don’t react). To run through all of these points would take a blog post in it’s own right so instead I will direct you to her book, ‘Still Moving’ which is a challenging but useful read. In conclusion, despite my initial reservations, the Leaders in Healthcare conference was an extremely simulating and enjoyable two days. I never felt during sessions that voicing my opinion was not as valid as the opinion of somebody with significantly more leadership experience than myself. The conference has inspired me to continue to develop myself as a leader, and to first reflect on my own skills and weaknesses which will enable me to be better equipped to help guide the NHS through the challenging times ahead. I would encourage everybody to take a look at the FMLM website and available courses and opportunities www.fmlm.ac.uk
Once randomized, children will be followed up over a 28-day period, with telephone contact at 7, 14 and 21 days, and a face-to-face consultation at 28 days. Parents are also keeping a daily symptom diary to monitor their child’s progress, as well as filling in wellbeing questionnaires at the contact times. Pre- and post-treatment nasoparyngeal and saliva swabs are being taken to analyse bacterial resistance patterns.
CAP-IT is planned to be recruiting over the next two winters with a target cohort of around 2,500 children, so is still in its early phases. It’s one of the first major trials being run out of the new Children and Young People’s Research Unit, based at the Noah’s Ark Children’s Hospital for Wales. For anyone that is interested and wants to know more, or even get involved, please get in touch with WREN and we can point you in the right direction! Links to the protocol and website are included at the bottom of the article. So, hopefully in a few years, we may understand this common condition a little better, but more importantly, the best way to treat it and ensure that treatment will continue working for the generations to come. CAP-IT: Efficacy, safety and impact on antimicrobial resistance of duration and dose of amoxicillin treatment for young children with Community-Acquired Pneumonia (CAP): A randomized controlled trial. www.capitstudy.org.uk http://www.ctu.mrc.ac.uk/our_research/research_areas/other_conditions/studies/cap_it/ 9th November 2017, Royal Society of Medicine, London By Chris Course On 9th November, the Neonatal Society held their Autumn Meeting at the Royal Society of Medicine in London. The program included oral presentations of submitted abstracts as well as invited guest speakers. There were a variety of topics covered, from studies looking at postnatal dexamethasone use upregulating surfactant proteins in preterm lamb models, surgical outcomes of preterm infants with congenital diaphragmatic hernia over a twenty-year period, increasing demands on neonatal unit for management of hypoglycaemia and breastmilk exposure influencing preterm brain development. The Widdowson lecture was given by Professor Pierre Gressens of King’s College and concerned the genomics of preterm brain injury. To be honest, some of the technicalities of the science and molecular pathways went a bit over my head, but there seemed to be some promising preliminary results on upregulating pro-repair inflammatory pathways and suppressing the damaging and immunomodulatory pathways by using tiny engineered pieces of DNA to protect the preterm brain’s white matter. Might seem a bit removed from clinical practice now, and seemed to be still a way from trials in human subjects, but then again, in a decade who knows what we’ll be doing on the wards! The keynote lecture came from Professor Rebecca Reynolds of Edinburgh University, who gave a fascinating talk on maternal health determining offspring life-course outcome. She went through data showing that it had been identified in the 1960’s that areas with high infant mortality ratios at the turn of the last century, went on to become areas with high rates of cardiovascular deaths in later life. Over the years, various studies have been conducted looking at the fetal programming effects of raised cortisol (secondary to maternal stress) reprogramming the fetal hypothalamo-pituitary-adrenal axis, and raised BMI/poor maternal diet/lifestyle leading to impaired insulin sensitivity in the fetus. Cohorts have been followed-up which show these infants have higher rates of type 2 diabetes and poorer neurodevelopmental outcomes/behavioural problems. There’s also a cohort of mothers in Finland that’s been followed up based on the amount of liquorice they consume…. Might seem odd, but apparently, it’s a popular snack in Finland, but suppresses an enzyme in the placenta that prevents too much cortisol passing into the fetus. It really highlighted how what we do in early life, and even before conception, can affect us for the rest of our lives! It did however also make me aware that in our role as paediatricians/neonatologists we have an opportunity to change long-term health for the better too. For anyone who hasn’t been to the Royal Society of Medicine, it’s a suitably impressive venue (befitting the name really) just behind Oxford Street, which was perfect for a leisurely lunch and a spot of early Christmas shopping during the society’s business meeting. And the day was rounded off with a drinks reception – what’s not to love! The day really brought home how diverse the neonatal research world is, and how much work is going on to try and improve understanding of physiology, diseases and develop new treatments. The Neonatal Society hold three meetings a year. The Autumn and Spring meetings are one-day, held in London, are free to attend and don’t require prior registration. The Summer meeting changes location around the UK (and sometimes ventures into Europe), with next year’s being held in Dublin in June. Abstracts are invited to be submitted for all the meetings, and are a great opportunity to get projects presented at a high-quality, national meeting – good for the CV/portfolio! Additionally, once you have presented at a society meeting, you are eligible to apply for membership.
For more information, check out www.neonatalsociety.ac.uk St Brides Hotel, Saundersfoot, Friday 10th November 2017 Hosted by Glangwili General Hospital & Bronglais Hospital By Annabel Greenwood This Autumn’s WPS meeting took place in the absolutely stunning location of St Brides Hotel in the picturesque seaside town Saundersfoot. Nestled in the clifftop, overlooking the breath-taking rugged Welsh coastline, it provided the perfect backdrop for an invigorating day of presentations, discussions and networking. The day began with the invitation lecture from the esteemed Dr Trevor Brown, Consultant Paediatric Allergist at Ulster Hospital, on cow’s milk allergy (formerly cow’s milk protein allergy). Ever a diagnostic and management paradox for GPs and general paediatricians, this in-depth discussion covering IgE verus non-IgE mediated reactions, clinical presentation and potential management options was invaluable. The morning session presentations were abundant in variety and interest, including projects and audits from Cardiff University Medical Students, Welsh Paediatric trainees, and Consultants. Of highlight during this session was the fantastic prize-winning project presented by our very own WREN co-chair Dr Siwan Lloyd on head injury following infant falls on the postnatal ward – a case series. The variety in the approach to investigation and management of such patients was fascinating, especially given the high rate of CT head abnormalities of those imaged. The subsequent departmental guideline implemented at UHW will certainly help standardise care and provide more clarity and direction for management. Almost time for lunch, but of course not before the brilliant Guest Lecture from Detective Superintendent Anthony Griffiths, Head of Public Protection, Dyfed Powys Police – ‘Child Protection: The Challenges for Policy and Multi-Agency Working.’ This lecture provided an invaluable insight into the challenges often faced by the police in child protection cases. The videos and images used were extremely powerful and emphasized the great difficulties in tracking down offenders in today’s society, particularly given the huge smart phone and social media influence. After an action-packed morning of presentations and lectures it was time to refuel with a mouth-watering lunch overlooking the absolutely spectacular scenery. Coffee could be taken onto the balcony, and what a treat it was to catch up with friends and colleagues with the sound of the waves crashing onto the shore below. There was also the opportunity during this lunchbreak to visit the exhibitor stands, the main theme being cow’s milk allergy, in-keeping with the invitation lecture earlier in the day, and there were a variety of different formulas to sample at these stands (some of which far more palatable than others!!) The afternoon session was equally interesting and stimulating, including presentations inspiring and empowering trainees, highlighting the importance of blogging, social media and trainee-led initiatives to encourage learning and champion change. The final Guest Lecture of the day was provided by the highly-regarded Dr Julian Forton, Consultant in Paediatric Respiratory Medicine and Cystic Fibrosis, UHW, on ‘the new C21 Curriculum at Cardiff University School of Medicine.’ It was absolutely fascinating to learn how the curriculum and course structure has evolved since my days in medical school! The aim is for a more case-based, small group learning approach with early clinical exposure. The exam format was also an interesting change, whereby all years take the same end-of-year exam, with the focus being on demonstrating improvement and development each year. As the sun was setting at the end of a wonderful day, it was time for the evening entertainment in the form of the ‘celebrating trainee event’ followed by the formal evening dinner. This year the Best Trainee prize went to Dr Siwan Lloyd in South Wales (taking a clean sweep of prizes!) and to Dr Stacey Killick in the North. Best Educational Supervisor went to Dr Zoe Roberts…congratulations to all!
The day was wrapped up with a splendid evening of dinner and dancing (thank goodness for the spa to recover the next morning!) Once again, WPS has delivered an outstanding conference! It provides an excellent platform to showcase your work, and to become inspired by colleagues and friends. It also provides the opportunity to learn from lead professionals in their specialised field, and to celebrate the achievements of others. We certainly are lucky to have such a wonderful paediatric society in Wales! Now, who’s joining me for the Spring meeting?!.... Welcome to our new WREN Blog, we’re glad you found us!
As an initial post we thought we would introduce ourselves, outline what we are aiming to achieve, what you can expect from us and what we want from you. We are Welsh Paediatric Trainees with a passion for research and education. Annabel is an ST3 trainee currently based in Paediatric Nephrology at UHW. She has a keen interest in Neonatalogy and Acute Paediatrics, as well as engaging in teaching and QI. Rebecca is an ST5 trainee with an interest in Emergency Paediatrics. She is currently taking a year out of program to undertake a Clinical Leadership Fellowship. She has an interest in mindfulness and resilience, and lives at home with her husband and 2 young children in South Wales We have created this blog to provide a platform to encourage trainees across Wales to engage in research and education. WREN already provides an amazing opportunity to coordinate a number of fascinating multicentre projects, however we want to expand our horizons and encourage trainees to share their knowledge and experience with each other. We hope to use the blog to raise awareness of local clinical trials, provide information about research and educational events, and to reflect on exciting opportunities available. Furthermore, we want trainees to utilise this space for critical appraisals of interesting articles and hot-topic fact sheets within Paediatrics. We want to know about what you do when you are not doing clinical work…If you go to a conference or an interesting meeting, write up the important points and we can then share it with everyone and encourage people to make the most of the learning opportunities which are available. In conclusion we need your help to make this blog a success! If you’ve found something interesting then no doubt others will benefit too! We plan on updating the blog on the first of every month with new articles, so put a reminder in your calendar to check-in with us then! To whet your appetite, next month features a write-up of WPS (and the spa!) as well as information tabs on current clinical trials and an interesting journal article review. Look forward to seeing you again then! Annabel and Rebecca |
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