bs_bs_banner
Letters to the Editor
Table 1
Deaths over the preceding weekend (n = 5)
Age
Presumptive diagnosis
1 day 1 day 2 weeks 6 months 9 months
800 g Dubowitz estimated 32-week gestation Twin I 800 g Dubowitz estimated 32-week gestation Twin II Neonatal sepsis Septic shock Meningitis
(12.9%) had human immunodeficiency virus (HIV), seven were confirmed and six suspected (including two whose mothers were known to be HIV positive). There were 36 cases of tuberculosis (TB), of which 32 were confirmed, including pulmonary (n = 17), meningitis (n = 10), miliary (n = 3), Pott’s disease (n = 1) and abdominal (n = 1). Seven children (6.9%) had malignancy, including nephroblastoma (n = 2), leukaemia, Burkitt’s lymphoma, neuroblastoma, retinoblastoma and astrocytoma. Almost every inpatient had failure to thrive – most >2 SDs below mean weight. However, only two had Kwashiorkor. There were two children with rheumatic heart disease and another two with idiopathic dilated cardiomyopathy. There were also children with: Type 1 diabetes mellitus, presumed pyloric stenosis, a tracheostomy and a shunt blockage. The cancer ward was being renovated and patients could not access the limited chemotherapy available. The new computed tomography scanner has improved diagnostic abilities, but is often not operational (e.g. this ward round). Pathology services are severely limited and no results are available overnight, including cerebrospinal fluid Gram staining. The team reviews all the deaths over the preceding day/ weekend. Over this weekend, 3/5 deaths were neonates, one was 6 months and the other 9 months old. Bacterial sepsis accounted for 3/5 deaths (see Table 1). As expected, most PNG patients had bacterial diagnoses, and one in three had TB. However, quite concerning, 1 in 8 inpatient children had HIV and 1 in 14 had malignancy (no cases of either were reported in Dili).1 The good news is that this year was unprecedented for successful completion of the MMed and DCH, with some of the highest calibre and most committed candidates. So, despite the disease burden, there is progress in PNG’s capacity – notwithstanding the root causes often being beyond the health sector. Dr Hasantha Gunasekera1 Professor Nakapi Tefuarani2 Dr Cornelia Kilalang3 Dr James Amini4 Dr Kone Sobi3 Dr Jason Vuvu3 Professor Trevor Duke5 1 General Medicine, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia and 2Professor of Child Health, School of Medicine and Health Sciences, University of Papua New Guinea, 3 Paediatrician, 4Chief Paediatrician, Paediatric Department, Port Moresby General Hospital, and 5Adjunct Professor of Child Health, School of Medicine, University of Papua New Guinea, Port Moresby, Papua New Guinea
Reference 1 Bucens IK, Reid A, Barreto AC, Dwivedi V, Counahan M. Three years of paediatric morbidity and mortality at the national hospital in Dili, East Timor. J. Paediatr. Child Health 2013; 49: 1004–9.
Dear Editor, AUDIT OF TETANUS IMMUNIZATION STATUS IN PAEDIATRIC BURN PATIENTS Tetanus is a rare and potentially life-threatening medical condition caused by contamination of a wound with the bacteria Clostridium tetani, which is preventable by prior vaccination. A burn wound is potentially a tetanus-prone wound and tetanus prophylaxis is recommended by the Australian and New Zealand Burn Association1. At the Women’s and Children’s Hospital (WCH) Burns patients are asked about their tetanus immunization status, however often patients and their families cannot remember whether they have had a recent tetanus immunization and exactly when it was. Instead they often state that their child is ‘up-to-date’ with their immunizations. In Australia, patients under 7 years have their immunization history recorded on the Australian Childhood Immunisation Register (ACIR), which can be accessed by medical staff. As tetanus prophylaxis is a requirement for all patients who suffer a burn injury, it is an area that needs to be audited. This will also determine if the current method of assessing a patient’s tetanus status by asking if their immunizations are ‘up-to-date’ is adequate or whether it needs to be more thoroughly investigated. An audit of tetanus immunization status was conducted at the WCH for the 5-year period from January 2007 to December 2011. All burns inpatients under 7 years were included. The ACIR was used to retrieve their immunization dates. This was compared to the date of their burn injury to determine whether their tetanus immunization status was ‘up-to-date’ at the time. In cases where patients were not ‘up-to-date’, the medical records were reviewed to determine if this had been identified and addressed. Three hundred sixty patients were included. Of these, 25 (6.9%) were found to be not ‘up-to-date’ with their tetanus immunizations according to the ACIR. On reviewing the individual medical records, 10 patients had not been identified as not being ‘up-to-date’, six had been identified but were not subsequently given a vaccination, three had not been immunized due to parental objections and two had been identified and given the tetanus vaccination and immunoglobulin. Four patients had no record of tetanus immunization status either in the medical records or the ACIR. Our vaccination rate of 93.1% was higher than the national average of 91%2 for similarly aged children. However, the 16 patients that had not been identified or were identified but not given a vaccination, indicate that our practice could be improved. In consultation with the Infectious Diseases team, it was recommended that burns patients at risk of tetanus should have their immunization status investigated by reviewing the
Journal of Paediatrics and Child Health 50 (2014) 494–496 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
495
Letters to the Editor
child’s ‘blue book’ or checking the ACIR. If a patient is found to be inadequately immunized, then the immunization nurse will arrange a catch-up schedule. This will help to ensure that all burns patients are protected against the risk of developing tetanus and improve the standard of care at the WCH. Dr Nicholas S Solanki Dr Sarah Middleton Ms Linda Quinn Mr Anthony Sparnon Burns Service, Department of Surgery Women’s and Children’s Hospital North Adelaide, South Australia Australia
References 1 Australian Technical Advisory Group on Immunisation. The Australian Immunisation Handbook, 10th edn. Canberra: Australian Government Department of Health, 2013. Available from:: http://www.health.gov .au/internet/immunise/publishing.nsf/Content/Handbook10 -home [accessed June 2013]. Part 4.19. 2 Australian Childhood Immunisation Register Statistics. Available from: http://www.medicareaustralia.gov.au/provider/patients/ acir/statistics.jsp [accessed April 2013].
questions about our options and responsibilities when patients write about doctors on social media, particularly negative feedback written without the doctor’s prior knowledge or consent. Institutions may have a public relations unit for assistance, but private practitioners are much more isolated. Much of the discussion about social media focuses heavily on the risks. I think it is worth asking though, is social media so different to a better MRI machine or a new ventilator? It is all just technology, helpful and unhelpful only to the extent that it helps us achieve our goals. In an essay in which she reviews the movie The Social Network and a book by Jaron Lanier called You are not a Gadget: a manifesto, Zadie Smith, author of White Teeth, raises the point that all software (and therefore all online interaction) is constrained by the limitations of the programmer. Users are often unaware of this; barely anyone notices that Facebook is all in blue because Mark Zuckerberg is red–green colour blind.2 Clinicians are very familiar with balancing usefulness and risk with new interventions for the benefit of our patients yet have generally seemed uncomfortable adopting online services the same way we would a new asthma medication (with some exceptions). A 2013 review of the use of social media use by 935 Australian hospitals demonstrated that few public hospitals use social media to actively engage patients and commented that even simple online services are lacking; for example, few hospitals have a campus map easily accessible on their website.3 In our discussions about the risks of social media, we may be missing the many opportunities (and even perhaps obligations) for health services and clinicians to help patients as well.
Dear Editor, Dr Chris Elliot General Paediatrican St George Hospital Kogarah, New South Wales Australia
SOCIAL MEDIA IN MEDICINE Your editorial addresses the important point of patient privacy.1 The widespread adoption of social media also raises other relevant issues: the privacy of health professionals ourselves, the risks and benefits of accessing our patient’s own social media and the possibility of new obligations. When patients’ reflections on their own health are publically available online, some might argue that reading them can help clinicians better understand that patient’s circumstances. Others, myself included, could contend that circumventing one-on-one communication with our patients in this way risks corrupting the doctor–patient relationship. There are still many unanswered
References 1 Isaacs D. Social media and communication. J. Paed. Child Health 2014; 50: 421–2. 2 Smith Z. Generation Why? New York Review of Books 2010. Available from: http://www.nybooks.com/articles/archives/2010/nov/25/ generation-why/?pagination=false [accessed January 2014]. 3 Cadogan M. Aussie hospital social media 2012. Life Fast Lane 2012. Available from: http://lifeinthefastlane.com/aussie-hospital-social -media-2012/ [accessed January 2014].
Conflict of interest: None declared.
496
Journal of Paediatrics and Child Health 50 (2014) 494–496 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
Letters to the Editor
Table 1
Deaths over the preceding weekend (n = 5)
Age
Presumptive diagnosis
1 day 1 day 2 weeks 6 months 9 months
800 g Dubowitz estimated 32-week gestation Twin I 800 g Dubowitz estimated 32-week gestation Twin II Neonatal sepsis Septic shock Meningitis
(12.9%) had human immunodeficiency virus (HIV), seven were confirmed and six suspected (including two whose mothers were known to be HIV positive). There were 36 cases of tuberculosis (TB), of which 32 were confirmed, including pulmonary (n = 17), meningitis (n = 10), miliary (n = 3), Pott’s disease (n = 1) and abdominal (n = 1). Seven children (6.9%) had malignancy, including nephroblastoma (n = 2), leukaemia, Burkitt’s lymphoma, neuroblastoma, retinoblastoma and astrocytoma. Almost every inpatient had failure to thrive – most >2 SDs below mean weight. However, only two had Kwashiorkor. There were two children with rheumatic heart disease and another two with idiopathic dilated cardiomyopathy. There were also children with: Type 1 diabetes mellitus, presumed pyloric stenosis, a tracheostomy and a shunt blockage. The cancer ward was being renovated and patients could not access the limited chemotherapy available. The new computed tomography scanner has improved diagnostic abilities, but is often not operational (e.g. this ward round). Pathology services are severely limited and no results are available overnight, including cerebrospinal fluid Gram staining. The team reviews all the deaths over the preceding day/ weekend. Over this weekend, 3/5 deaths were neonates, one was 6 months and the other 9 months old. Bacterial sepsis accounted for 3/5 deaths (see Table 1). As expected, most PNG patients had bacterial diagnoses, and one in three had TB. However, quite concerning, 1 in 8 inpatient children had HIV and 1 in 14 had malignancy (no cases of either were reported in Dili).1 The good news is that this year was unprecedented for successful completion of the MMed and DCH, with some of the highest calibre and most committed candidates. So, despite the disease burden, there is progress in PNG’s capacity – notwithstanding the root causes often being beyond the health sector. Dr Hasantha Gunasekera1 Professor Nakapi Tefuarani2 Dr Cornelia Kilalang3 Dr James Amini4 Dr Kone Sobi3 Dr Jason Vuvu3 Professor Trevor Duke5 1 General Medicine, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia and 2Professor of Child Health, School of Medicine and Health Sciences, University of Papua New Guinea, 3 Paediatrician, 4Chief Paediatrician, Paediatric Department, Port Moresby General Hospital, and 5Adjunct Professor of Child Health, School of Medicine, University of Papua New Guinea, Port Moresby, Papua New Guinea
Reference 1 Bucens IK, Reid A, Barreto AC, Dwivedi V, Counahan M. Three years of paediatric morbidity and mortality at the national hospital in Dili, East Timor. J. Paediatr. Child Health 2013; 49: 1004–9.
Dear Editor, AUDIT OF TETANUS IMMUNIZATION STATUS IN PAEDIATRIC BURN PATIENTS Tetanus is a rare and potentially life-threatening medical condition caused by contamination of a wound with the bacteria Clostridium tetani, which is preventable by prior vaccination. A burn wound is potentially a tetanus-prone wound and tetanus prophylaxis is recommended by the Australian and New Zealand Burn Association1. At the Women’s and Children’s Hospital (WCH) Burns patients are asked about their tetanus immunization status, however often patients and their families cannot remember whether they have had a recent tetanus immunization and exactly when it was. Instead they often state that their child is ‘up-to-date’ with their immunizations. In Australia, patients under 7 years have their immunization history recorded on the Australian Childhood Immunisation Register (ACIR), which can be accessed by medical staff. As tetanus prophylaxis is a requirement for all patients who suffer a burn injury, it is an area that needs to be audited. This will also determine if the current method of assessing a patient’s tetanus status by asking if their immunizations are ‘up-to-date’ is adequate or whether it needs to be more thoroughly investigated. An audit of tetanus immunization status was conducted at the WCH for the 5-year period from January 2007 to December 2011. All burns inpatients under 7 years were included. The ACIR was used to retrieve their immunization dates. This was compared to the date of their burn injury to determine whether their tetanus immunization status was ‘up-to-date’ at the time. In cases where patients were not ‘up-to-date’, the medical records were reviewed to determine if this had been identified and addressed. Three hundred sixty patients were included. Of these, 25 (6.9%) were found to be not ‘up-to-date’ with their tetanus immunizations according to the ACIR. On reviewing the individual medical records, 10 patients had not been identified as not being ‘up-to-date’, six had been identified but were not subsequently given a vaccination, three had not been immunized due to parental objections and two had been identified and given the tetanus vaccination and immunoglobulin. Four patients had no record of tetanus immunization status either in the medical records or the ACIR. Our vaccination rate of 93.1% was higher than the national average of 91%2 for similarly aged children. However, the 16 patients that had not been identified or were identified but not given a vaccination, indicate that our practice could be improved. In consultation with the Infectious Diseases team, it was recommended that burns patients at risk of tetanus should have their immunization status investigated by reviewing the
Journal of Paediatrics and Child Health 50 (2014) 494–496 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
495
Letters to the Editor
child’s ‘blue book’ or checking the ACIR. If a patient is found to be inadequately immunized, then the immunization nurse will arrange a catch-up schedule. This will help to ensure that all burns patients are protected against the risk of developing tetanus and improve the standard of care at the WCH. Dr Nicholas S Solanki Dr Sarah Middleton Ms Linda Quinn Mr Anthony Sparnon Burns Service, Department of Surgery Women’s and Children’s Hospital North Adelaide, South Australia Australia
References 1 Australian Technical Advisory Group on Immunisation. The Australian Immunisation Handbook, 10th edn. Canberra: Australian Government Department of Health, 2013. Available from:: http://www.health.gov .au/internet/immunise/publishing.nsf/Content/Handbook10 -home [accessed June 2013]. Part 4.19. 2 Australian Childhood Immunisation Register Statistics. Available from: http://www.medicareaustralia.gov.au/provider/patients/ acir/statistics.jsp [accessed April 2013].
questions about our options and responsibilities when patients write about doctors on social media, particularly negative feedback written without the doctor’s prior knowledge or consent. Institutions may have a public relations unit for assistance, but private practitioners are much more isolated. Much of the discussion about social media focuses heavily on the risks. I think it is worth asking though, is social media so different to a better MRI machine or a new ventilator? It is all just technology, helpful and unhelpful only to the extent that it helps us achieve our goals. In an essay in which she reviews the movie The Social Network and a book by Jaron Lanier called You are not a Gadget: a manifesto, Zadie Smith, author of White Teeth, raises the point that all software (and therefore all online interaction) is constrained by the limitations of the programmer. Users are often unaware of this; barely anyone notices that Facebook is all in blue because Mark Zuckerberg is red–green colour blind.2 Clinicians are very familiar with balancing usefulness and risk with new interventions for the benefit of our patients yet have generally seemed uncomfortable adopting online services the same way we would a new asthma medication (with some exceptions). A 2013 review of the use of social media use by 935 Australian hospitals demonstrated that few public hospitals use social media to actively engage patients and commented that even simple online services are lacking; for example, few hospitals have a campus map easily accessible on their website.3 In our discussions about the risks of social media, we may be missing the many opportunities (and even perhaps obligations) for health services and clinicians to help patients as well.
Dear Editor, Dr Chris Elliot General Paediatrican St George Hospital Kogarah, New South Wales Australia
SOCIAL MEDIA IN MEDICINE Your editorial addresses the important point of patient privacy.1 The widespread adoption of social media also raises other relevant issues: the privacy of health professionals ourselves, the risks and benefits of accessing our patient’s own social media and the possibility of new obligations. When patients’ reflections on their own health are publically available online, some might argue that reading them can help clinicians better understand that patient’s circumstances. Others, myself included, could contend that circumventing one-on-one communication with our patients in this way risks corrupting the doctor–patient relationship. There are still many unanswered
References 1 Isaacs D. Social media and communication. J. Paed. Child Health 2014; 50: 421–2. 2 Smith Z. Generation Why? New York Review of Books 2010. Available from: http://www.nybooks.com/articles/archives/2010/nov/25/ generation-why/?pagination=false [accessed January 2014]. 3 Cadogan M. Aussie hospital social media 2012. Life Fast Lane 2012. Available from: http://lifeinthefastlane.com/aussie-hospital-social -media-2012/ [accessed January 2014].
Conflict of interest: None declared.
496
Journal of Paediatrics and Child Health 50 (2014) 494–496 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
