Stuart Howell

BackgroundThis first epidemiological study of paediatric out-of-hospital cardiac arrest (pOHCA) across Australia and New Zealand explores the incidence, patient and event characteristics, both overall and by developmental age groups, and examines factors associated with outcomes.MethodsAll pOHCAs (aged <18 years) attended by emergency medical services (EMS) in Australia and New Zealand from 2017 to 2023 were included. Crude incidence rates (per 100,000 person-years) were calculated for EMS-attended and EMS-treated cases. Logistic regression models were used to identify associations between patient and arrest characteristics and survival (event and 30-day/hospital discharge).ResultsEMS attended 4,779 cases and treated 3,139 (65.7%). Incidence rates for EMS-attended and EMS-treated cases were 10.1 and 6.6, respectively; with a bimodal age distribution peaking in infants (65.4) and adolescents (11.4). Most EMS-attended cases were unwitnessed (66.9%), of medical origin (60.1%), had initial non-shockable rhythms (91.1%), occurred in private residences (74.3%), and received bystander cardiopulmonary resuscitation (62.7%). Few (1.6%) received bystander defibrillation. Arrest characteristics varied widely between age groups. Survival to 30-days/hospital discharge in EMS-treated cases was 10.0% (highest in late childhood [15.4%] and lowest in infants [7.9%]). Multivariable analysis identified that increasing age was positively associated with event survival, whilst bystander-witnessed arrest, initial shockable rhythm, arrest aetiology, and EMS response time were significant predictors of short and long-term survival.ConclusionThe incidence, patient characteristics, and survival outcomes of pOHCA in our region differ significantly by age groups. Age- and context-specific prevention and resuscitation strategies are essential for reducing the burden and improving survival outcomes.

Aim: This study aims to explore regional variation and identify regions within Australia with high incidence of out-of-hospital cardiac arrest (OHCA) and low rates of bystander cardiopulmonary resuscitation (CPR). Method: Adult OHCAs of presumed medical aetiology occurring across Australia between 2017 and 2019 were mapped onto local government areas (LGA) using the location of arrest coordinates. Bayesian spatial models were applied to provide “smoothed” estimates of OHCA incidence and bystander CPR rates (for bystander-witnessed OHCAs) for each LGA. For each state and territory, high-risk LGAs were defined as those with an incidence rate greater than the state or territory’s 75^th percentile and a bystander CPR rate less than the state or territory’s 25^th percentile. Results: A total of 62,579 OHCA cases attended by emergency medical services across 543 LGAs nationwide were included in the study. Nationally, the OHCA incidence rate across LGA ranged from 58.5 to 198.3 persons per 100,000, while bystander CPR rates ranged from 45% to 75%. We identified 60 high-risk LGAs, which were predominantly located in the state of New South Wales. Within each region, high-risk LGAs were typically located in regional and remote areas of the country, except for four metropolitan areas–two in Adelaide and two in Perth. Conclusions: We have identified high-risk LGAs, characterised by high incidence and low bystander CPR rates, which are predominantly in regional and remote areas of Australia. Strategies for reducing OHCA and improving bystander response may be best targeted at these regions.

Background Distraction therapies are widely used to manage pain and anxiety in paediatric emergency departments (ED). Paediatric patients also comprise up to 13% of some ambulance services workloads¹ yet only a single study exists outlining the ad-hoc use of paramedic-initiated distraction therapy.² Building rapport with frightened, unwell children is challenging for paramedics, but is essential to facilitate rapid assessment and care.^1,3.This review aims to identify effective ED distraction techniques potentially suitable for use in paediatric patients in the prehospital setting. Method Databases and grey literature sources including Ovid Medline, EMBASE and CINAHL and Google Scholar were searched from their beginning to October 2021. English language interventional or observational studies were included if they reported on distraction techniques suitable for use in the prehospital setting, paediatric ED presentations, and pain and/or anxiety. Results Of the 4,054 records screened, 27 met the eligibility criteria. Twenty randomised trials and seven interventional studies involved children aged three months to 18 years. Distraction techniques were digital, non-digital and environmental adaptations and included virtual-reality, cartoons, music, vibration devices, bubble-blowing and ambient lighting. Ten studies reported significant reductions in self-reported pain and seven for self-reported anxiety. Some reported reduced pharmacological administration and improved patient cooperation, and parent and/or healthcare provider satisfaction when using distraction. Studies were highly heterogeneous with 17 distractors and 21 pain and/or anxiety measurement tools used. Conclusion A range of effective distraction techniques exist in paediatric EDs that may be suitable for the prehospital setting to manage pain and/or anxiety and improve patient outcomes. References Fowler J, Beovich B, Williams B. Improving paramedic confidence with paediatric patients: a scoping review. Australasian Journal of Paramedicine 2017;15(1). Preston C and Bray L. Developing understanding and awareness of children’s distress, distraction techniques and holding. Journal of Paramedic Practice 2015;7(3):122–130. Cushman JT, Fairbanks RJ, O’Gara KG, et al. Ambulance personnel perceptions of near misses and adverse events in pediatric patients. Prehosp Emerg Care 2010;14:477–84. Conflict of interest None. Funding AU$4000 in funding has been provided by the Australia and New Zealand College of Paramedicine, and AU$11,000 in funding was provided through a Monash University Advancing Womens Research Success Grant for this program of research. Dr Eastwood, Dr Howell and Professor Cameron are supported by the National Health and Medical Research Council (NHMRC) Prehospital Emergency Care Centre for Research Excellence (PEC-ANZ; #1116453).

Post-stroke lower limb spasticity (PSLLS) has a prevalence of 28–37%. PSLLS can cause difficulty in walking and reduce quality of life (QOL). Post stroke spasticity impairs the ability to intervene to improve walking ability. Botulinum Toxin A (BT) is an effective intervention for focal spasticity, but its use is currently restricted in many countries by their reimbursement system stating that the evidence for improvement in walking and quality of life (QOL) is not robust for treatment in the lower limb. This randomized control trial (RCT) will investigate the effectiveness of BT in modifying spasticity, and improving functioning (mobility, walking, activities of daily living (ADL’s) and QOL. A double-blind placebo-controlled trial injection will assess the effect of BT compared with a placebo (normal saline) in a sample of n = 94 patients. Following treatment of spasticity measured by Modified Ashworth Scale (MAS), the primary outcome of gait velocity will be measured by i) Gait Rite (Electronic Walkway); ii) walking by 2 Min Walk Test; iii) balance by Berg Balance Scale; mobility by iv) Timed Up and Go (TUG); v) lower limb function by ABILICO; vi) patient related goal by Goal Attainment Scale (GAS); vii) QOL by SF 12 (Rand version); viii) activities of daily living by the Functional Autonomy Measurement System (SMAF). There will be an associated health economic analysis. The study methodology is based on our systematic review 2026 studies, which concluded the evidence for improving mobility following use of BT to reduce spasticity was not robust. The results of this study could establish the use of BT in improving gait and lower limb function in PSLLS. This study could provide the evidence needed for reimbursement schemes to consider and changes to its funding policy for BT in PSLLS. The trial is registered with the Australia New Zealand Clinical Trails Registry (ANZCTR)- ANZCTRN12617001603303 . Registered 07/12/2017.

Mutations in proline‐rich transmembrane protein 2 (PRRT2) cause a range of episodic disorders that include paroxysmal kinesigenic dyskinesia and benign familial infantile epilepsy. Mutations are generally loss of function and include the c649dupC frameshifting mutation that is present in around 80% of affected individuals. To investigate how Prrt2 loss of function mutations causes disease, we performed a phenotypic investigation of a transgenic Prrt2 knockout (Prrt2 KO) mouse. We observed spontaneous paroxysmal episodes with behavioural features of both seizure and movement disorders, as well as unexplained deaths in KO and HET animals. KO mice showed spatial learning deficits in the Morris water maze, as well as gait abnormalities in the quantitative Digigait analysis; both of which may be representative of the more severe phenotypes experienced by homozygous patients. These findings extend the described phenotypes of Prrt2 mutant mice, further confirming their utility for in vivo investigation of the role of Prrt2 mutations in episodic diseases.

Importance: This study assesses the interobserver agreement on dacryocystography (DCG) and dacryoscintigraphy (DSG) findings.Background: There are no standard grading criteria to guide the interpretation of conventional DCG and DSG findings and therefore there may be a degree of subjectivity. This study evaluates the level of interobserver agreement in the interpretation of DCG and DSG findings.Design: A retrospective observational study at the Royal Adelaide Hospital.Participants: A total of 165 patients who presented with epiphora with 276 DCGs and 290 DSGs performed were included in this study.Methods: DCG and DSG images were obtained, anonymized, randomized and interpreted by three independent oculoplastic surgeons. Standard grading criteria were set for both DCG and DSG images. Data from all observers were analysed for interobserver agreement using Kappa (κ) statistics, generated using a variation of Cohen's kappa for multiple observers.Main Outcome Measures: Level of interobserver agreement (κ values) in the grading of DCG and DSG findings.Results: There was an overall moderate interobserver agreement for DCG findings (κ = 0.55), with the highest agreement on interpreting canalicular obstruction (κ = 0.80), followed by proximal nasolacrimal duct obstruction (κ = 0.67) and normal patency (κ = 0.63). There was an overall fair interobserver agreement for DSG findings (κ = 0.36), with the best being moderate agreement (κ = 0.42‐0.50) for interpreting pre‐sac delay and post‐sac proximal delay.Conclusions and Relevance: DCG offers good reliability in interpreting patent and obstructed systems. On the other hand, DSG has poor agreement and highlights some of the limitations in the ability to guide epiphora management.