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Papers by Mike South

Research paper thumbnail of Nasogastric hydration versus intravenous hydration for infants with bronchiolitis: a randomised trial

The Lancet. Respiratory Medicine, 2013

Bronchiolitis is the most common lower respiratory tract infection in infants and the leading cau... more Bronchiolitis is the most common lower respiratory tract infection in infants and the leading cause of hospital admission. Hydration is a mainstay of treatment, but insufficient evidence exists to guide clinical practice. We aimed to assess whether intravenous hydration or nasogastric hydration is better for treatment of infants. In this multicentre, open, randomised trial, we enrolled infants aged 2-12 months admitted to hospitals in Australia and New Zealand with a clinical diagnosis of bronchiolitis during three bronchiolitis seasons (April 1-Oct 31, in 2009, 2010, and 2011). We randomly allocated infants to nasogastric hydration or intravenous hydration by use of a computer-generated sequence and opaque sealed envelopes, with three randomly assigned block sizes and stratified by hospital site and age group (2-<6 months vs 6-12 months). The primary outcome was length of hospital stay, assessed in all randomly assigned infants. Secondary outcomes included rates of intensive-care unit admission, adverse events, and success of insertion. This trial is registered with the Australian and New Zealand clinical trials registry, ACTRN12605000033640. Mean length of stay for 381 infants assigned nasogastric hydration was 86·6 h (SD 58·9) compared with 82·2 h (58·8) for 378 infants assigned intravenous hydration (absolute difference 4·5 h [95% CI -3·9 to 12·9]; p=0·30). Rates of admission to intensive-care units, need for ventilatory support, and adverse events did not differ between groups. At randomisation, seven infants assigned nasogastric hydration were switched to intravenous hydration and 56 infants assigned intravenous hydration were switched to nasogastric hydration because the study-assigned method was unable to be inserted. For those infants who had data available for successful insertion, 275 (85%) of 323 infants in the nasogastric hydration group and 165 (56%) of 294 infants in the intravenous hydration group required only one attempt for successful insertion. Intravenous hydration and nasogastric hydration are appropriate means to hydrate infants with bronchiolitis. Nasogastric insertion might require fewer attempts and have a higher success rate of insertion than intravenous hydration. Australian National Health and Medical Research Council, Samuel Nissen Charitable Foundation (Perpetual), Murdoch Children's Research Institute, Victorian Government.

Research paper thumbnail of 140 mmol/L of sodium versus 77 mmol/L of sodium in maintenance intravenous fluid therapy for children in hospital (PIMS): a randomised controlled double-blind trial

Lancet, Jan 28, 2014

Use of hypotonic intravenous fluid to maintain hydration in children in hospital has been associa... more Use of hypotonic intravenous fluid to maintain hydration in children in hospital has been associated with hyponatraemia, leading to neurological morbidity and mortality. We aimed to assess whether use of fluid solutions with a higher sodium concentration reduced the risk of hyponatraemia compared with use of hypotonic solutions. We did a randomised controlled double-blind trial of children admitted to The Royal Children's Hospital (Melbourne, VIC, Australia) who needed intravenous maintenance hydration for 6 h or longer. With an online randomisation system that used unequal block sizes, we randomly assigned patients (1:1) to receive either isotonic intravenous fluid containing 140 mmol/L of sodium (Na140) or hypotonic fluid containing 77 mmol/L of sodium (Na77) for 72 h or until their intravenous fluid rate decreased to lower than 50% of the standard maintenance rate. We stratified assignment by baseline sodium concentrations. Study investigators, treating clinicians, nurses, an...

Research paper thumbnail of A prospective randomised trial comparing nasogastric with intravenous hydration in children with bronchiolitis (protocol) The comparative rehydration in bronchiolitis study (CRIB)

BMC Pediatrics, 2010

A prospective randomised trial comparing nasogastric with intravenous hydration in children with ... more A prospective randomised trial comparing nasogastric with intravenous hydration in children with bronchiolitis (protocol) The comparative rehydration in bronchiolitis study (CRIB) Abstract Background: Bronchiolitis is the most common reason for admission of infants to hospital in developed countries. Fluid replacement therapy is required in about 30% of children admitted with bronchiolitis. There are currently two techniques of fluid replacement therapy that are used with the same frequency-intravenous (IV) or nasogastric (NG).

Research paper thumbnail of Surfactant abnormalities in infants with severe viral bronchiolitis

Archives of Disease in Childhood, Aug 1, 1996

To determine whether abnormalities of pulmonary surfactant occur in infants with acute viral bron... more To determine whether abnormalities of pulmonary surfactant occur in infants with acute viral bronchiolitis, surfactant indices were measured in lung lavage fluid from 12 infants with severe bronchiolitis and eight infants without lung disease. Compared with controls, the bronchiolitis group showed deficiency of surfactant protein A (1.02 v 14.4 igiml) and disaturated phosphatidylcholine (35 v 1060 Itg/ ml) which resolved as the disease improved. Surfactant functional activity was also impaired (minimum surface tension 22 v 17 mN/m). These findings indicate that surfactant abnormalities occur in bronchiolitis, and may represent one of the pathophysiological mechanisms causing airway obstruction. (Arch Dis Child 1996;75:133-136)

Research paper thumbnail of Implementation of evidence based guidelines for paediatric asthma management in a teaching hospital

Archives of Disease in Childhood, Jul 1, 2004

Aims: To evaluate a systematic approach to the development and implementation of evidence based a... more Aims: To evaluate a systematic approach to the development and implementation of evidence based asthma management guidelines. Methods: Comparative study of children (2-18 years) with acute asthma; a control cohort (cohort 1) was recruited before implementation of the guidelines and two cohorts were recruited after implementation (cohorts 2 and 3). Results: There was no difference in the proportion of patients who reattended in the six months following initial presentation for cohort 1 (21.5%), cohort 2 (27.8%), or cohort 3 (25.4%) and no difference in readmission rates (11.4%, 11.3%, 11.0% respectively). There was no difference in measures of asthma morbidity between the cohorts at 3 and 6 months across three domains: interval symptoms, exercise limitation, and bronchodilator use. Of those who did not have a management plan before presentation, one was provided to 46.9% of cohort 1, 74.8% of cohort 2, and 81.1% of cohort 3. There was no difference comparing cohort 2 or cohort 3 with cohort 1 regarding quality of life for either the subjects or their parents. Conclusions: Implementation of our evidence based guidelines was associated with the improved provision of asthma management plans, but there was no effect on reattendance or readmission to hospital, asthma morbidity, or quality of life. Future efforts to improve asthma management should target specific components of asthma care.

Research paper thumbnail of Exogenous Surfactant Therapy In Guinea Pigs With Acute Viral Bronchiolitis(AVB) ♦ 1944

Pediatric Research, 1998

Pulmonary surfactant is both deficient and dysfunctional in human infants with AVB (Arch Dis Chil... more Pulmonary surfactant is both deficient and dysfunctional in human infants with AVB (Arch Dis Child 75: 133, 1996). We therefore studied the effects of surfactant therapy in the guinea pig model of AVB, testing the hypothesis that surfactant administration would lead to an ...

Research paper thumbnail of Surfactant Abnormalities in Meconium Aspiration Syndrome and Neonatal Pneumonia. 1963

Pediatric Research, 1996

In neonates with meconium aspiration syndrome (MAS) and pneumonia, there is increasing evidence t... more In neonates with meconium aspiration syndrome (MAS) and pneumonia, there is increasing evidence that abnormalities of pulmonary surfactant contribute to lung dysfunction. We examined surfactant status in ventilated neonates with MAS (n= 9) and bacterial ...

Research paper thumbnail of Changes in Alveolar Surfactant Composition After Conversion from High Frequency Oscillation (Hfov) to Conventional Mechanical Ventilation (CV).† 1962

Pediatric Research, 1996

One of the putative advantages of HFOV is that, in contrast to CV, it facilitates expansion of al... more One of the putative advantages of HFOV is that, in contrast to CV, it facilitates expansion of alveoli without increasing surfactant turnover. There are, however, few available data examining the surfactant status in infants ventilated with HFOV, and none focusing on the ...

Research paper thumbnail of Clinical and Microbiologic Features Associated With Novel Swine-Origin Influenza A Pandemic 2009 (H1N1) Virus in Children

The Pediatric Infectious Disease Journal, 2010

Research paper thumbnail of Does the use of volumetric bladder ultrasound improve the success rate of suprapubic aspiration of urine?

Pediatric Emergency Care, 2002

To determine whether a volumetric bladder scanner can improve the success rate of suprapubic aspi... more To determine whether a volumetric bladder scanner can improve the success rate of suprapubic aspiration and whether there is an optimal volume of urine required in the bladder before suprapubic aspiration should be attempted. Two-phase prospective study. The emergency department of a tertiary children's hospital. Children younger than 2 years who required an uncontaminated urine specimen for microscopy and culture. In phase one, all patients had an ultrasound followed by suprapubic aspiration. In phase two, patients were randomized to either ultrasound or no ultrasound. In phase one, 37 subjects had ultrasound measurement prior to attempting suprapubic aspiration; 28 of 31 (90%) had successful suprapubic aspiration when a minimum volume of 10 mL was detected on ultrasound and no 0-mL readings were encountered. In phase two, the overall success rate of obtaining urine with the aid of the bladder scanner was 31 of 39 subjects (79%), compared with 16 of 36 subjects (44%) without ultrasound. Ultrasound was also useful in deferring an attempt when less than 10 mL of urine was noted on the scan. The volumetric bladder scanner is a rapid, safe, and accurate device that, in this study, greatly improved the success rate of suprapubic aspiration in small children. It also helped to avoid time delays or multiple blind attempts at suprapubic aspiration by predicting volumes at which suprapubic aspiration should or should not be attempted.

Research paper thumbnail of Early markers of major adverse events in children after cardiac operations☆, ☆☆, ★, ★★, ♢, ♢♢

The Journal of Thoracic and Cardiovascular Surgery, 1997

The purpose of this study was to determine the physiologic variables that predict major adverse e... more The purpose of this study was to determine the physiologic variables that predict major adverse events in children in the intensive care unit after cardiac operations. A cohort observational study was conducted. At the time of admission to the intensive care unit and 4, 8, 12, and 24 hours later the following variables were recorded: mean arterial pressure, heart rate, cardiac index, oxygen delivery, mixed venous oxygen saturation, base deficit, blood lactate, gastric intramucosal pH, carbon dioxide difference (the difference between arterial carbon dioxide tension and gastric intraluminal carbon dioxide tension), and toe-core temperature gradient. Major adverse events were prospectively identified as cardiac arrest, need for emergency chest opening, development of multiple organ failure, and death. Ninety children were included in the study; 12 had major adverse events and there were 4 deaths. Blood lactate level, mean arterial pressure, and duration of cardiopulmonary bypass were the only significant, independent predictors of major adverse events when measured at the time of admission to the intensive care unit. The odds ratio (95% confidence intervals) for major adverse events if a lactate level was greater than 4.5 mmol/L was 5.1 (1.2 to 21.1), for admission hypotension 2.3 (0.5 to 9.8), and for a cardiopulmonary bypass time greater than 150 minutes 13.7 (3.3 to 57.2). Four hours after admission lactate and carbon dioxide difference, and 8 hours after admission lactate and base deficit, were independently significant predictors. The odds ratios for major adverse events if the blood lactate level was greater than 4 mmol/L at 4 and 8 hours were 8.3 (1.8 to 38.4) and 9.3 (1.9 to 44.3), respectively. At no time in the first 24 hours were cardiac output, oxygen delivery, mixed venous oxygen saturation, toe-core temperature gradient, or heart rate significant predictors of major adverse events. In the context of our current treatment strategies, the duration of cardiopulmonary bypass and blood lactate level, measured in the early postoperative period, were the best predictors of impending major adverse events.

Research paper thumbnail of Spontaneous arterial thrombosis in children

The Journal of Pediatrics, 1999

Research paper thumbnail of Evidence against a synergistic effect of desmopressin with conditioning in the treatment of nocturnal enuresis

The Journal of Pediatrics, 2004

Objective To test the hypothesis that desmopressin facilitates acquisition of continence, we aime... more Objective To test the hypothesis that desmopressin facilitates acquisition of continence, we aimed to establish whether, in children with nocturnal enuresis who are desmopressin nonresponders, adjunct desmopressin increases the rate of sustained continence after treatment with a conditioning alarm.

Research paper thumbnail of Surfactant and surfactant inhibitors in meconium aspiration syndrome

The Journal of Pediatrics, 2001

Research paper thumbnail of Blood aspiration syndrome as a cause of respiratory distress in the newborn infant

The Journal of Pediatrics, 2003

Early-onset respiratory distress and a radiographic appearance of an aspiration syndrome occurred... more Early-onset respiratory distress and a radiographic appearance of an aspiration syndrome occurred in three neonates who had not passed meconium before delivery. In each case there was evidence of inhalation of blood, associated with very high plasma protein concentration in lung fluid. Blood aspiration syndrome is a distinct diagnostic entity that can result in significant respiratory distress in the neonate.

Research paper thumbnail of Updating asthma management: The process of change

Journal of Pediatric Health Care, 2001

A strategic approach to changing clinical practice that is managed by a multidisciplinary team is... more A strategic approach to changing clinical practice that is managed by a multidisciplinary team is an effective way of implementing new treatment methods or approaches to patient care. The Royal Children's Hospital, Melbourne, Australia, a tertiary pediatric hospital, instituted new Asthma Delivery Device Guidelines in recognition of current evidence that described the benefits of treating acute pediatric asthma with pressurized metered dose inhalers and spacer devices. The working group that coordinated the project attributes the successful change in practice to a multifaceted, multidisciplinary approach, a significant planning stage, initial and ongoing intensive staff and patient/parent education, and accessibility of information.

Research paper thumbnail of The salivagram in severe cerebral palsy and able-bodied adults

Journal of Paediatrics and Child Health, 2009

To test the hypothesis that the salivagram is frequently positive in those at high risk of aspira... more To test the hypothesis that the salivagram is frequently positive in those at high risk of aspiration but negative in individuals at low risk of aspiration lung disease. Methods: We studied 63 individuals with spastic quadriparetic cerebral palsy (CP), aged 14 months to 16 years (31 females and 32 males), and 20 able-bodied young adult volunteers, aged 19-29 years (17 female and three males) using the salivagram. Twenty millilitres of 99mTc-sulphur colloid in saline was instilled into the pharynx of each subject over 1 h. Aspiration was characterised by the appearance of activity in either lung field. Results: Aspiration was demonstrated by salivagram in 56% of children with CP (95% confidence interval 43% to 68%), compared to 0% of young adults (97.5% one-sided confidence interval 0% to 17%). The difference in frequency is highly significant (P < 0.0006).

Research paper thumbnail of Intended management of children with acute idiopathic thrombocytopenic purpura: A national survey

Journal of Paediatrics and Child Health, 2005

Objective: In Australia acute idiopathic thrombocytopenic purpura (ITP) is mainly treated by paed... more Objective: In Australia acute idiopathic thrombocytopenic purpura (ITP) is mainly treated by paediatricians (either general paediatricians or paediatric haematologists/oncologists). A survey was conducted to gauge the current practice of treating children with acute ITP in Australia. Methods: All practising Australian paediatricians registered by the Royal Australasian College of Physicians were surveyed regarding their intended management of children with acute ITP. The questionnaire, adapted from a study of paediatric haematologists/oncologists in North America, presented four clinical scenarios of children with acute ITP with a platelet count of 3000 × 10 9 /L, with and without mucosal bleeding (wet and dry purpura, respectively). Questionnaires were returned by mail or filled in online at a dedicated webpage. Results: Five hundred and sixty-three of 1097 (51%) paediatricians responded to the survey. Data from 140 who had treated at least one child with ITP in the previous 12 months were analysed. Respondents indicated that children with acute ITP are usually or always hospitalised (58-92%) and that 48% would be given active treatment, even with dry purpura. Various regimens of i.v. immunoglobulin or corticosteroids are used when treatment is administered. In comparing Australian and North American management of acute ITP there were many similarities, although Australian paediatricians were less likely to arrange a bone marrow aspirate if corticosteroids were prescribed. Conclusions: There is great variation in the intended management of children with acute ITP in Australia. Previously published management recommendations regarding investigation and treatment have had little impact on intended practice. Prospective studies are required to evaluate hypotheses so as to produce evidence-based recommendations for treatment of patients with acute ITP.

Research paper thumbnail of What research questions matter to Australian paediatricians? National Delphi Study

Journal of Paediatrics and Child Health, 2009

The newly formed Australian Paediatric Research Network (APRN) aims to facilitate general paediat... more The newly formed Australian Paediatric Research Network (APRN) aims to facilitate general paediatricians' participation in research in secondary care settings. This (its first) project aimed to identify Australian paediatricians' top research priorities and preferred research designs. Methods: All Australian general paediatricians were invited into a national Delphi process survey. In Stage 1, they were asked 'Thinking about your clinical practice, what are the most important research questions which need addressing?'. Using qualitative methods, a 'top 20' list of the most common, feasible research questions was generated. In Stage 2, respondents prioritised these 'top 20' research questions in terms of perceived importance to their practice, and rated their interest in participating in various types of research. Results: A total of 685 (68%) of 1006 paediatricians completed the baseline survey, with 209 paediatricians contributing 430 Stage 1 research questions. Of these, 128 (30%) had not been addressed in the literature and were researchable in the secondary care outpatient setting. The top five questions ranked in Stage 2 by 348 paediatricians were obesity management (two questions), long-term ADHD educational outcomes, autism spectrum outcomes, and prophylactic antibiotics in preventing urinary tract infections. Paediatricians were willing to participate in research designs, including longitudinal research (75%) and randomised trials (64%). Conclusions: Australian paediatricians are interested in research, and their ideas can provide direction for APRN and potentially other networks in Australia. Many of the questions generated could not be easily answered by traditional biomedical and clinical research methods, highlighting the potential benefit of practice-based research networks.

Research paper thumbnail of Evidence to support current use of nebulised epinephrine in croup to achieve immediate clinical improvement

Journal of Paediatrics and Child Health, 2012

Evidence to support current use of nebulised epinephrine in croup to achieve immediate clinical i... more Evidence to support current use of nebulised epinephrine in croup to achieve immediate clinical improvement

Research paper thumbnail of Nasogastric hydration versus intravenous hydration for infants with bronchiolitis: a randomised trial

The Lancet. Respiratory Medicine, 2013

Bronchiolitis is the most common lower respiratory tract infection in infants and the leading cau... more Bronchiolitis is the most common lower respiratory tract infection in infants and the leading cause of hospital admission. Hydration is a mainstay of treatment, but insufficient evidence exists to guide clinical practice. We aimed to assess whether intravenous hydration or nasogastric hydration is better for treatment of infants. In this multicentre, open, randomised trial, we enrolled infants aged 2-12 months admitted to hospitals in Australia and New Zealand with a clinical diagnosis of bronchiolitis during three bronchiolitis seasons (April 1-Oct 31, in 2009, 2010, and 2011). We randomly allocated infants to nasogastric hydration or intravenous hydration by use of a computer-generated sequence and opaque sealed envelopes, with three randomly assigned block sizes and stratified by hospital site and age group (2-&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;6 months vs 6-12 months). The primary outcome was length of hospital stay, assessed in all randomly assigned infants. Secondary outcomes included rates of intensive-care unit admission, adverse events, and success of insertion. This trial is registered with the Australian and New Zealand clinical trials registry, ACTRN12605000033640. Mean length of stay for 381 infants assigned nasogastric hydration was 86·6 h (SD 58·9) compared with 82·2 h (58·8) for 378 infants assigned intravenous hydration (absolute difference 4·5 h [95% CI -3·9 to 12·9]; p=0·30). Rates of admission to intensive-care units, need for ventilatory support, and adverse events did not differ between groups. At randomisation, seven infants assigned nasogastric hydration were switched to intravenous hydration and 56 infants assigned intravenous hydration were switched to nasogastric hydration because the study-assigned method was unable to be inserted. For those infants who had data available for successful insertion, 275 (85%) of 323 infants in the nasogastric hydration group and 165 (56%) of 294 infants in the intravenous hydration group required only one attempt for successful insertion. Intravenous hydration and nasogastric hydration are appropriate means to hydrate infants with bronchiolitis. Nasogastric insertion might require fewer attempts and have a higher success rate of insertion than intravenous hydration. Australian National Health and Medical Research Council, Samuel Nissen Charitable Foundation (Perpetual), Murdoch Children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s Research Institute, Victorian Government.

Research paper thumbnail of 140 mmol/L of sodium versus 77 mmol/L of sodium in maintenance intravenous fluid therapy for children in hospital (PIMS): a randomised controlled double-blind trial

Lancet, Jan 28, 2014

Use of hypotonic intravenous fluid to maintain hydration in children in hospital has been associa... more Use of hypotonic intravenous fluid to maintain hydration in children in hospital has been associated with hyponatraemia, leading to neurological morbidity and mortality. We aimed to assess whether use of fluid solutions with a higher sodium concentration reduced the risk of hyponatraemia compared with use of hypotonic solutions. We did a randomised controlled double-blind trial of children admitted to The Royal Children's Hospital (Melbourne, VIC, Australia) who needed intravenous maintenance hydration for 6 h or longer. With an online randomisation system that used unequal block sizes, we randomly assigned patients (1:1) to receive either isotonic intravenous fluid containing 140 mmol/L of sodium (Na140) or hypotonic fluid containing 77 mmol/L of sodium (Na77) for 72 h or until their intravenous fluid rate decreased to lower than 50% of the standard maintenance rate. We stratified assignment by baseline sodium concentrations. Study investigators, treating clinicians, nurses, an...

Research paper thumbnail of A prospective randomised trial comparing nasogastric with intravenous hydration in children with bronchiolitis (protocol) The comparative rehydration in bronchiolitis study (CRIB)

BMC Pediatrics, 2010

A prospective randomised trial comparing nasogastric with intravenous hydration in children with ... more A prospective randomised trial comparing nasogastric with intravenous hydration in children with bronchiolitis (protocol) The comparative rehydration in bronchiolitis study (CRIB) Abstract Background: Bronchiolitis is the most common reason for admission of infants to hospital in developed countries. Fluid replacement therapy is required in about 30% of children admitted with bronchiolitis. There are currently two techniques of fluid replacement therapy that are used with the same frequency-intravenous (IV) or nasogastric (NG).

Research paper thumbnail of Surfactant abnormalities in infants with severe viral bronchiolitis

Archives of Disease in Childhood, Aug 1, 1996

To determine whether abnormalities of pulmonary surfactant occur in infants with acute viral bron... more To determine whether abnormalities of pulmonary surfactant occur in infants with acute viral bronchiolitis, surfactant indices were measured in lung lavage fluid from 12 infants with severe bronchiolitis and eight infants without lung disease. Compared with controls, the bronchiolitis group showed deficiency of surfactant protein A (1.02 v 14.4 igiml) and disaturated phosphatidylcholine (35 v 1060 Itg/ ml) which resolved as the disease improved. Surfactant functional activity was also impaired (minimum surface tension 22 v 17 mN/m). These findings indicate that surfactant abnormalities occur in bronchiolitis, and may represent one of the pathophysiological mechanisms causing airway obstruction. (Arch Dis Child 1996;75:133-136)

Research paper thumbnail of Implementation of evidence based guidelines for paediatric asthma management in a teaching hospital

Archives of Disease in Childhood, Jul 1, 2004

Aims: To evaluate a systematic approach to the development and implementation of evidence based a... more Aims: To evaluate a systematic approach to the development and implementation of evidence based asthma management guidelines. Methods: Comparative study of children (2-18 years) with acute asthma; a control cohort (cohort 1) was recruited before implementation of the guidelines and two cohorts were recruited after implementation (cohorts 2 and 3). Results: There was no difference in the proportion of patients who reattended in the six months following initial presentation for cohort 1 (21.5%), cohort 2 (27.8%), or cohort 3 (25.4%) and no difference in readmission rates (11.4%, 11.3%, 11.0% respectively). There was no difference in measures of asthma morbidity between the cohorts at 3 and 6 months across three domains: interval symptoms, exercise limitation, and bronchodilator use. Of those who did not have a management plan before presentation, one was provided to 46.9% of cohort 1, 74.8% of cohort 2, and 81.1% of cohort 3. There was no difference comparing cohort 2 or cohort 3 with cohort 1 regarding quality of life for either the subjects or their parents. Conclusions: Implementation of our evidence based guidelines was associated with the improved provision of asthma management plans, but there was no effect on reattendance or readmission to hospital, asthma morbidity, or quality of life. Future efforts to improve asthma management should target specific components of asthma care.

Research paper thumbnail of Exogenous Surfactant Therapy In Guinea Pigs With Acute Viral Bronchiolitis(AVB) ♦ 1944

Pediatric Research, 1998

Pulmonary surfactant is both deficient and dysfunctional in human infants with AVB (Arch Dis Chil... more Pulmonary surfactant is both deficient and dysfunctional in human infants with AVB (Arch Dis Child 75: 133, 1996). We therefore studied the effects of surfactant therapy in the guinea pig model of AVB, testing the hypothesis that surfactant administration would lead to an ...

Research paper thumbnail of Surfactant Abnormalities in Meconium Aspiration Syndrome and Neonatal Pneumonia. 1963

Pediatric Research, 1996

In neonates with meconium aspiration syndrome (MAS) and pneumonia, there is increasing evidence t... more In neonates with meconium aspiration syndrome (MAS) and pneumonia, there is increasing evidence that abnormalities of pulmonary surfactant contribute to lung dysfunction. We examined surfactant status in ventilated neonates with MAS (n= 9) and bacterial ...

Research paper thumbnail of Changes in Alveolar Surfactant Composition After Conversion from High Frequency Oscillation (Hfov) to Conventional Mechanical Ventilation (CV).† 1962

Pediatric Research, 1996

One of the putative advantages of HFOV is that, in contrast to CV, it facilitates expansion of al... more One of the putative advantages of HFOV is that, in contrast to CV, it facilitates expansion of alveoli without increasing surfactant turnover. There are, however, few available data examining the surfactant status in infants ventilated with HFOV, and none focusing on the ...

Research paper thumbnail of Clinical and Microbiologic Features Associated With Novel Swine-Origin Influenza A Pandemic 2009 (H1N1) Virus in Children

The Pediatric Infectious Disease Journal, 2010

Research paper thumbnail of Does the use of volumetric bladder ultrasound improve the success rate of suprapubic aspiration of urine?

Pediatric Emergency Care, 2002

To determine whether a volumetric bladder scanner can improve the success rate of suprapubic aspi... more To determine whether a volumetric bladder scanner can improve the success rate of suprapubic aspiration and whether there is an optimal volume of urine required in the bladder before suprapubic aspiration should be attempted. Two-phase prospective study. The emergency department of a tertiary children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s hospital. Children younger than 2 years who required an uncontaminated urine specimen for microscopy and culture. In phase one, all patients had an ultrasound followed by suprapubic aspiration. In phase two, patients were randomized to either ultrasound or no ultrasound. In phase one, 37 subjects had ultrasound measurement prior to attempting suprapubic aspiration; 28 of 31 (90%) had successful suprapubic aspiration when a minimum volume of 10 mL was detected on ultrasound and no 0-mL readings were encountered. In phase two, the overall success rate of obtaining urine with the aid of the bladder scanner was 31 of 39 subjects (79%), compared with 16 of 36 subjects (44%) without ultrasound. Ultrasound was also useful in deferring an attempt when less than 10 mL of urine was noted on the scan. The volumetric bladder scanner is a rapid, safe, and accurate device that, in this study, greatly improved the success rate of suprapubic aspiration in small children. It also helped to avoid time delays or multiple blind attempts at suprapubic aspiration by predicting volumes at which suprapubic aspiration should or should not be attempted.

Research paper thumbnail of Early markers of major adverse events in children after cardiac operations☆, ☆☆, ★, ★★, ♢, ♢♢

The Journal of Thoracic and Cardiovascular Surgery, 1997

The purpose of this study was to determine the physiologic variables that predict major adverse e... more The purpose of this study was to determine the physiologic variables that predict major adverse events in children in the intensive care unit after cardiac operations. A cohort observational study was conducted. At the time of admission to the intensive care unit and 4, 8, 12, and 24 hours later the following variables were recorded: mean arterial pressure, heart rate, cardiac index, oxygen delivery, mixed venous oxygen saturation, base deficit, blood lactate, gastric intramucosal pH, carbon dioxide difference (the difference between arterial carbon dioxide tension and gastric intraluminal carbon dioxide tension), and toe-core temperature gradient. Major adverse events were prospectively identified as cardiac arrest, need for emergency chest opening, development of multiple organ failure, and death. Ninety children were included in the study; 12 had major adverse events and there were 4 deaths. Blood lactate level, mean arterial pressure, and duration of cardiopulmonary bypass were the only significant, independent predictors of major adverse events when measured at the time of admission to the intensive care unit. The odds ratio (95% confidence intervals) for major adverse events if a lactate level was greater than 4.5 mmol/L was 5.1 (1.2 to 21.1), for admission hypotension 2.3 (0.5 to 9.8), and for a cardiopulmonary bypass time greater than 150 minutes 13.7 (3.3 to 57.2). Four hours after admission lactate and carbon dioxide difference, and 8 hours after admission lactate and base deficit, were independently significant predictors. The odds ratios for major adverse events if the blood lactate level was greater than 4 mmol/L at 4 and 8 hours were 8.3 (1.8 to 38.4) and 9.3 (1.9 to 44.3), respectively. At no time in the first 24 hours were cardiac output, oxygen delivery, mixed venous oxygen saturation, toe-core temperature gradient, or heart rate significant predictors of major adverse events. In the context of our current treatment strategies, the duration of cardiopulmonary bypass and blood lactate level, measured in the early postoperative period, were the best predictors of impending major adverse events.

Research paper thumbnail of Spontaneous arterial thrombosis in children

The Journal of Pediatrics, 1999

Research paper thumbnail of Evidence against a synergistic effect of desmopressin with conditioning in the treatment of nocturnal enuresis

The Journal of Pediatrics, 2004

Objective To test the hypothesis that desmopressin facilitates acquisition of continence, we aime... more Objective To test the hypothesis that desmopressin facilitates acquisition of continence, we aimed to establish whether, in children with nocturnal enuresis who are desmopressin nonresponders, adjunct desmopressin increases the rate of sustained continence after treatment with a conditioning alarm.

Research paper thumbnail of Surfactant and surfactant inhibitors in meconium aspiration syndrome

The Journal of Pediatrics, 2001

Research paper thumbnail of Blood aspiration syndrome as a cause of respiratory distress in the newborn infant

The Journal of Pediatrics, 2003

Early-onset respiratory distress and a radiographic appearance of an aspiration syndrome occurred... more Early-onset respiratory distress and a radiographic appearance of an aspiration syndrome occurred in three neonates who had not passed meconium before delivery. In each case there was evidence of inhalation of blood, associated with very high plasma protein concentration in lung fluid. Blood aspiration syndrome is a distinct diagnostic entity that can result in significant respiratory distress in the neonate.

Research paper thumbnail of Updating asthma management: The process of change

Journal of Pediatric Health Care, 2001

A strategic approach to changing clinical practice that is managed by a multidisciplinary team is... more A strategic approach to changing clinical practice that is managed by a multidisciplinary team is an effective way of implementing new treatment methods or approaches to patient care. The Royal Children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s Hospital, Melbourne, Australia, a tertiary pediatric hospital, instituted new Asthma Delivery Device Guidelines in recognition of current evidence that described the benefits of treating acute pediatric asthma with pressurized metered dose inhalers and spacer devices. The working group that coordinated the project attributes the successful change in practice to a multifaceted, multidisciplinary approach, a significant planning stage, initial and ongoing intensive staff and patient/parent education, and accessibility of information.

Research paper thumbnail of The salivagram in severe cerebral palsy and able-bodied adults

Journal of Paediatrics and Child Health, 2009

To test the hypothesis that the salivagram is frequently positive in those at high risk of aspira... more To test the hypothesis that the salivagram is frequently positive in those at high risk of aspiration but negative in individuals at low risk of aspiration lung disease. Methods: We studied 63 individuals with spastic quadriparetic cerebral palsy (CP), aged 14 months to 16 years (31 females and 32 males), and 20 able-bodied young adult volunteers, aged 19-29 years (17 female and three males) using the salivagram. Twenty millilitres of 99mTc-sulphur colloid in saline was instilled into the pharynx of each subject over 1 h. Aspiration was characterised by the appearance of activity in either lung field. Results: Aspiration was demonstrated by salivagram in 56% of children with CP (95% confidence interval 43% to 68%), compared to 0% of young adults (97.5% one-sided confidence interval 0% to 17%). The difference in frequency is highly significant (P < 0.0006).

Research paper thumbnail of Intended management of children with acute idiopathic thrombocytopenic purpura: A national survey

Journal of Paediatrics and Child Health, 2005

Objective: In Australia acute idiopathic thrombocytopenic purpura (ITP) is mainly treated by paed... more Objective: In Australia acute idiopathic thrombocytopenic purpura (ITP) is mainly treated by paediatricians (either general paediatricians or paediatric haematologists/oncologists). A survey was conducted to gauge the current practice of treating children with acute ITP in Australia. Methods: All practising Australian paediatricians registered by the Royal Australasian College of Physicians were surveyed regarding their intended management of children with acute ITP. The questionnaire, adapted from a study of paediatric haematologists/oncologists in North America, presented four clinical scenarios of children with acute ITP with a platelet count of 3000 × 10 9 /L, with and without mucosal bleeding (wet and dry purpura, respectively). Questionnaires were returned by mail or filled in online at a dedicated webpage. Results: Five hundred and sixty-three of 1097 (51%) paediatricians responded to the survey. Data from 140 who had treated at least one child with ITP in the previous 12 months were analysed. Respondents indicated that children with acute ITP are usually or always hospitalised (58-92%) and that 48% would be given active treatment, even with dry purpura. Various regimens of i.v. immunoglobulin or corticosteroids are used when treatment is administered. In comparing Australian and North American management of acute ITP there were many similarities, although Australian paediatricians were less likely to arrange a bone marrow aspirate if corticosteroids were prescribed. Conclusions: There is great variation in the intended management of children with acute ITP in Australia. Previously published management recommendations regarding investigation and treatment have had little impact on intended practice. Prospective studies are required to evaluate hypotheses so as to produce evidence-based recommendations for treatment of patients with acute ITP.

Research paper thumbnail of What research questions matter to Australian paediatricians? National Delphi Study

Journal of Paediatrics and Child Health, 2009

The newly formed Australian Paediatric Research Network (APRN) aims to facilitate general paediat... more The newly formed Australian Paediatric Research Network (APRN) aims to facilitate general paediatricians' participation in research in secondary care settings. This (its first) project aimed to identify Australian paediatricians' top research priorities and preferred research designs. Methods: All Australian general paediatricians were invited into a national Delphi process survey. In Stage 1, they were asked 'Thinking about your clinical practice, what are the most important research questions which need addressing?'. Using qualitative methods, a 'top 20' list of the most common, feasible research questions was generated. In Stage 2, respondents prioritised these 'top 20' research questions in terms of perceived importance to their practice, and rated their interest in participating in various types of research. Results: A total of 685 (68%) of 1006 paediatricians completed the baseline survey, with 209 paediatricians contributing 430 Stage 1 research questions. Of these, 128 (30%) had not been addressed in the literature and were researchable in the secondary care outpatient setting. The top five questions ranked in Stage 2 by 348 paediatricians were obesity management (two questions), long-term ADHD educational outcomes, autism spectrum outcomes, and prophylactic antibiotics in preventing urinary tract infections. Paediatricians were willing to participate in research designs, including longitudinal research (75%) and randomised trials (64%). Conclusions: Australian paediatricians are interested in research, and their ideas can provide direction for APRN and potentially other networks in Australia. Many of the questions generated could not be easily answered by traditional biomedical and clinical research methods, highlighting the potential benefit of practice-based research networks.

Research paper thumbnail of Evidence to support current use of nebulised epinephrine in croup to achieve immediate clinical improvement

Journal of Paediatrics and Child Health, 2012

Evidence to support current use of nebulised epinephrine in croup to achieve immediate clinical i... more Evidence to support current use of nebulised epinephrine in croup to achieve immediate clinical improvement