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Table S1. Details of individual patients and treatments. (PDF 403 kb)

Table S2. Dosing regimes. (PDF 279 kb)

Aims We aimed to assess the utilisation of attendances to a paediatric ambulatory unit (PAU) in North West London and to understand parental reasons for attending the service, and where they would go if it was closed. Methods We prospectively surveyed 95 parents attending the PAU from 18/09/15–23/10/15. A general paediatric registrar or consultant retrospectively reviewed each case to give a clinical perspective as to whether the service was utilised appropriately. Results The most common presentations were upper respiratory tract infection, fracture/suspected fracture, head injury or facial injury, viral-induced wheeze, urinary tract infection, tonsillitis, prolonged jaundice, and hand-foot-and-mouth disease and chickenpox. Parental reasons for attending were not being able to get a general practitioner (GP) appointment (21.7%), the condition was thought to be too serious for the GP to manage or wanting specialist input (14.1%), referral by GP/midwife/nurse/health visitor (27.2%), wanting to avoid visiting the emergency department (17.4%), and other (19.5%). Following review of the cases, up to 50% of the presentations could have been appropriately managed in the community setting by the GP. For the remaining cases, 25% were deemed most suitable for management by a hospital review (including rapid referral), 20% by A+E. and 5% by midwife. In contrast, almost 50% of parents reported they would attend A+E if the PAU was not available, and less than 15% would attend the GP practice. Conclusion Senior paediatric clinicians felt that one in two PAU attendances could have been managed in General Practice. However, there was a significant discrepancy the views of paediatricans and parents in where their child is best managed. 41% of parents attended as they were referred by a community health professional or felt the condition was too serious for the GP to manage. Important in addressing this mismatch will be improving parental confidence in their GP through improved integration of primary and secondary care services.

This overview has been supported by a review of the literature referring to the management of community-acquired pneumonia (in preparation). Difficulties diagnosing bacterial pneumonia include identifying the pathogens and the validation of radiographic signs suggesting bacterial or mycoplasmal infection. The World Health Organisation (WHO) has published guidelines for diagnosis which seem to be as relevant for developed as developing countries. The main diagnostic features are tachypnoea, fever greater than 38.5 degrees C and chest recession without wheeze. Radiographic features lag behind clinical findings and provide little additional help when antibiotic treatment is considered but are crucial in the proper management of complications.

Pleural empyema is a collection of pus between the lungs and the chest wall. There is debate about treatment options with the advent of both fibrinolytic enzymes to facilitate tube drainage and less invasive video-assisted thoracoscopic surgery (VATS).To determine which was more effective: surgical (using thoracoscopy or thoracotomy) or non-surgical techniques (thoracocentesis, chest tube drainage); and to establish whether there was an optimum time for intervention.In this updated review we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2005) MEDLINE (January 2002 to July Week 4, 2005) and EMBASE (January 2001 to 3rd Quarter 2005). Bibliographies, reference lists of identified studies and review articles were handsearched. Personal communication with authors is ongoing. There were no language restrictions.Randomised controlled trials (RCTs) of surgical techniques versus non-surgical approaches for treatment of pus in the pleural cavity in children and adults but not neonates. Studies of empyema associated with tuberculosis or malignancy were excluded.Trial quality was assessed using Jadad criteria (Jadad 1996). Authors were contacted for missing information. The primary outcomes were death or resolution of the empyema. Secondary outcomes addressed the length of time chest tubes were required, pain, hospital stay and any complications.Only one small randomised study was identified. Some methodological quality considerations cast doubt on the validity of the study with regard to patient selection, unclear allocation concealment and outcome assessor blinding and it scored 'B' overall (Jadad score 3). When compared with chest tube drainage combined with streptokinase, video-assisted thoracoscopic surgery (VATS) had a significantly higher primary treatment success and patients spent less time in hospital. Each treatment group suffered one mortality. The latest search revealed no further published randomised studies but communication with authors revealed two ongoing studies comparing conventional chest tube drainage plus antibiotics with and without fibrinolytics with video-assisted thorascopic surgery (VATS). A small unpublished study is awaiting assessment that compared chest tube drainage and antibiotics with thoracoscopy or thoracotomy plus antibiotics.It seems that for large, loculated pleural empyemas VATS is superior to chest tube drainage in terms of duration of chest tubes in situ and length of hospital stay. However, there are questions about validity in the one study which met the inclusion criteria and the study has too few participants to draw conclusions. There are risks of complications (associated with all treatments) which may not be apparent with small numbers. Larger studies are needed.

Pleural empyema is a collection of pus between the lungs and the chest wall. Approximately 50% of cases complicate pneumonia. There are a variety of treatment options ranging from intravenous antibiotics alone to open thoracotomy and debridement, depending in part on the stage of the empyema and the severity. The condition changes with time, becoming loculated and more difficult to drain. There is much debate about the most appropriate therapy particularly with the advent of new treatments such as fibrinolytic enzymes (e.g. streptokinase, urokinase) and video-assisted thoracoscopic surgery (VATS).To determine which is more effective for the management of empyema: surgical (e.g. thoracoscopy, thoracotomy) or non-surgical techniques (e.g. thoracocentesis, chest tube drainage) and to establish whether there is an optimum time for intervention.The Cochrane Controlled Trials Register and DARE database were searched in addition to the Cochrane Acute Respiratory Infections Group's own register of trials. A specialised topic search with no language restrictions was used to search MEDLINE and EMBASE using Silverplatter. Bibliographies and the reference lists of identified studies and review articles were handsearched. Personal communication with authors and experts in the field is ongoing.Randomised controlled trials (RCTs) of surgical techniques versus non-surgical approaches for treatment of pus in the pleural cavity in children and adults but not neonates. Studies of empyema associated with tuberculosis or malignancy were excluded.Trial quality was assessed using Jadad criteria as recommended by the ARI group (Jadad 1996). The primary outcomes were death or resolution of the empyema. Secondary outcomes addressed length of time chest tubes were required, pain, hospital stay and any complications.Only one small randomised study was identified which met the inclusion criteria. It was conducted in a university thoracic surgery department. There were some methodological quality considerations which cast some doubt on validity ( patient selection, unclear allocation concealment and outcome assessor blinding) and it scored 'B' overall (Jadad score 3). The main results of the study were that when compared with chest tube drainage combined with streptokinase, the video-assisted thoracoscopic surgery (VATS) group had a significantly higher primary treatment success and spent less time in hospital. Each group suffered one mortality.It would appear that for large, loculated pleural empyemas VATS is superior to chest tube drainage with streptokinase in terms of duration of chest tubes and hospital stay. However there are questions about validity and the study is also too small to draw conclusions. There are risks of complications (associated with all treatments) which may not apparent with small numbers. VATS is performed under general anaesthetic and one lung ventilation. Fibrinolytics are also associated with side effects. Further larger multicentre studies need to be conducted.

The relative significance of factors which cause pH to decrease during fermentation has been investigated, using eleven yeast strains. Organic acid excretion and absorption of basic amino acids both have substantial effects: solution of carbon dioxide and absorption of primary phosphate contribute to a small extent. Buffering capacity, over the pH range 4 to 5, increases slightly during fermentation. Approximately 30% of the increase in hydrogen ion concentration cannot be attributed to known causes; direct excretion of hydrogen ions may be responsible. Fermentation with yeast propagated in semi-aerobic conditions rather than in fermentors gives beers of lower pH and increased organic acid content, but the latter factor is not in itself sufficient to account for the pH difference.

The acid content of a range of ales and lagers has been measured for some organic acids related to the Krebs cycle, and found to vary widely. Acetate, pyruvate, lactate, succinate, pyroglutamate, malate and citrate were present in all cases and α-ketoglutarate was usually detected. α-Hydroxyglutarate was recognized in a number of beers. The effect of the acids on the pH of beer is assessed. The strain of yeast which is used markedly influences the levels of all acids except pyroglutamate and the conditions of yeast propagation have a substantial influence on the extent of acid accumulation. During the fermentation of wort and synthetic media the extent of organic acid excretion is proportional to the extent of fermentation, but the nature of the acids which are excreted varies during the fermentation period. In synthetic media, nitrogen source is shown to have a substantial effect on the accumulation of organic acid. Pyruvate and acetate levels vary inversely towards the end of fermentation, suggesting that yeast converts pyruvate to acetate.

Excretion of pyruvate takes place during the yeast-growth phase of fermentation, and, in batch fermentation, the extent of its accumulation varies directly with the extent of growth. Pyruvate excretion is not related to the content of pyruvate decarboxylase in the cells and is not influenced by the addition of thiamine or alanine to the wort; the pH of the wort exerts a slight influence on pyruvate excretion. Pyruvate may be metabolized by yeast towards the end of fermentation and during conditioning, so that the quantity present in beer is influenced by the extent and timing of yeast separation. The addition of sodium pyruvate to beer alters beer flavour by affecting the ‘mouth feel’ aspect of flavour; the minimum quantity required to do this varies in different beers over a range of 50–400 mg/litre.

A case of skin depigmentation associated with intravenous anaesthetic induction agents is described. The differential diagnosis is briefly discussed.