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ObjectiveAs paediatric and adolescent gynaecology (PAG) falls within the remit of paediatrics and gynaecology, training in both specialties is underdeveloped. There is a paucity of research investigating trainee knowledge of PAG, while postgraduate paediatric training demonstrates little focus in the field. Compounding this, a finite number of PAG specialists means clinical training is limited. We hypothesize that knowledge deficits exist among paediatric and GP trainees and that this has future implications for increased morbidity in girls.Design, Setting and ParticipantsA structured questionnaire assessing PAG was distributed to forty paediatric and GP trainees in October 2019 in a tertiary paediatric hospital.Results60% (24) incorrectly identified vulvovaginitis as candidal infection. 80% (32) were unable to identify labial adhesions. 62% (25) were unable to define menorrhagia. 100% (9) of GP trainees said they would prescribe the OCP compared with 51% (16) of paediatric trainees. 52% (21) did not consider STI screening when appropriate. 75% (30) believed genital warts invariably warrant referral to child sexual assault clinic. 70% (28) could not identify female genital mutilation. 60% (24) did not consider imperforate hymen as a cause of primary amenorrhoea. 67% (27) misdiagnosed lichen sclerosis.ConclusionsA knowledge deficit among trainees was evident in relation to PAG conditions. Misdiagnosis and delayed treatment could lead to considerable increased morbidity for girls and we postulate that a key intervention which may prove effective in improving trainee competency in PAG lies in the introduction of a structured training curriculum for all clinicians involved in PAG practice.

Background Gonadoblastoma (GB) is a rare tumour of the gonads presenting in childhood or adolescence. It is a lesion composed of a mixture of germ cells at different stages of maturation, with low malignant potential. It is associated with disorders of sex development, most commonly Turner mosaic syndrome with Y chromosome material (TMSY), and 46XY gonadal dysgenesis (GD). Little is known about the natural history and incidence, however prophylactic gonadectomy is recommended. Objectives To determine the incidence and clinical features of GB presenting in childhood in the Irish Republic (RoI) from 1999–2018 inclusive. Methods A retrospective review of children and adolescents with a diagnosis of GB was undertaken using the records of the National Cancer Registry Ireland (NCRI) and the Departments of Endocrinology, Pathology and Surgery at the main children’s hospitals. Results Fifteen cases of gonadoblastoma were identified, all except one phenotypically female. Fourteen patients had prophylactic gonadectomy and one presented with an ovarian mass and raised tumour markers. Eight had TMSY (age at gonadectomy 2 weeks – 14 years). Seven were phenotypically female and one was male. Seven cases of 46 XY GD (all female phenotype) were diagnosed with gonadoblastoma with an age range of 4 months – 15 years at time of surgery. Four of these were unilateral. In the remaining three cases, one patient had bilateral gonadoblastoma, one had unilateral dysgerminoma and contralateral gonadoblastoma and the third had bilateral dysgerminoma with features of gonadoblastoma. Conclusions This is the first reported population incidence rate of GB in children with a 20 year incidence of gonadoblastoma in the Republic of Ireland of 1/100,000 live births. The data supports the recommendation for elective gonadectomy in high risk conditions. Due to the wide age range in presentations, however, the timing of gonadectomy should be individualised, based on underlying diagnosis and following multidisciplinary team discussion. The true rate of malignant transformation in early onset GB remains to be studied.

BackgroundWhen intubating newborns, clinicians aim to position the endotracheal tube (ETT) tip in the midtrachea. The depth to which ETTs should be inserted is often estimated using the infant’s weight. ETTs are frequently incorrectly positioned in newborns, most often inserted too far. Using the vocal cord guide (a mark at the distal end of the ETT) to guide insertion depth has been recommended.ObjectiveTo determine whether estimating ETT insertion depth using the vocal cord guide rather than weight results in more correctly positioned ETT tips.DesignSingle-centre randomised controlled trial.SettingLevel III neonatal intensive care unit (NICU) at a university maternity hospital (National Maternity Hospital, Dublin, Ireland).PatientsNewborn infants without congenital anomalies intubated in the NICU.InterventionsParticipants were randomised to have ETT insertion depth estimated using weight [insertion depth (cm) = weight (kg) +6] or vocal cord guide.Main outcome measureCorrect ETT position, that is, tip between the upper border of the first thoracic vertebra (T1) and the lower border of the second thoracic vertebra (T2) on a chest X-ray as determined by one paediatric radiologist masked to group assignment.Results136 participants were randomised. The proportion of correctly positioned ETTs was similar in both groups (weight 30/69 (44%) vs vocal cord guide 27/67 (40%), p=0.731). Most incorrectly positioned ETT (69/79, 87%) were too low.ConclusionEstimating ETT insertion depth using the vocal cord guide did not result in more correctly positioned ETT tips.Trial registration numberISRCTN39654846.

Acute intestinal failure (AIF) is defined as an inability to tolerate 80% of nutritional requirements delivered enterally for a minimum of 48 h. In surgical patients it commonly relates to abdominal sepsis, intestinal obstruction, or ileus. The prevalence of AIF in surgical units in Ireland has not previously been studied. We retrospectively audited the general surgical and ICU departments in St James’s Hospital over a 3-month period to identify patients with AIF and followed their management and outcomes focusing on the need for artificial nutrition and surgical intervention. Fifty-four surgical patients (11.4% of surgical emergency admissions) were diagnosed with AIF over the 3-month period. Of these, 30 (55.6%) required nutritional support; 26 (48.2%) had surgical ± radiological intervention and 6 (11.1%) had radiological intervention alone. Abdominal sepsis was present in 17 (31.5%) patients, a group that required significantly longer parenteral (14.6 vs. 6.7 days, p 0.029) and enteral (13.9 vs. 2.2 days, p 0.005) nutrition than AIF patients without abdominal sepsis. AIF also took longer to resolve in (5.8 vs. 4.2 days, p 0.024) in sepsis versus nonsepsis patients. The majority of patients (n = 43, 80%) were referred to clinical nutrition teams early after having symptoms for 3.77 days (range 1–21) and 72% had complete nutritional assessment clearly documented. AIF is common, and can often be treated conservatively. Early linkage with nutrition services is recommended. Early diagnosis of abdominal sepsis is important as this cohort of patients can be particularly difficult to manage.

Introduction Although children with painful sickle cell crises (PSCC) frequently present to the Emergency Department (ED), pain in sickle cell disease is often under-recognised, under-treated and treatment may be delayed. We aimed to evaluate pain assessment and management in children presenting to the ED with PSCC. Methods A 12-month prospective descriptive study of acute pain management of PSCC at an urban tertiary paediatric ED. Pain was assessed by the triage nurse or physician using a validated age appropriate pain scale (Faces, Legs, Activity, Cry, Consolability (FLACC) Scale; Manchester Pain Ruler). Results There were 96 presentations in 66 patients with PSCC (Table 1). Nineteen (19.7%) patients recieved no pre-hospital analgesia. Conclusion PSCC pain is under-treated, under-monitored and adequate treatment of pain is delayed in our ED. Patients with severe pain appear at highest risk for treatment guideline violation. This is predominantly related to lack of opiate administration. An educational intervention, with/without the inclusion of an easily administered, fast-onset and short-acting opiate e.g. intranasal fentanyl, may decrease the time from ED arrival to effective pain relief.

Objectives To understand and classify causal factors linked to medication errors and to define opportunities for systematic changes to improve the safety of prescription medication use. Design, Setting, and Participants All recipients of liver, kidney, and/or pancreas allografts followed up by an academic medical center and encountered in the acute care facility, outpatient clinic, or by telephone during 12 months (April 1, 2004, through March 31, 2005). Errors were sought by specific review of the expected and actual medication lists. Main Outcome Measure Proportion of medication errors in each of 5 classifications developed through iterative revision. Definitions included failure to provide a correct prescription (prescription error); deliver a prescribed medication to the patient (delivery error); possess enough medication for a 24-hour or greater supply (availability error); accurately use an available, prescribed medication (patient error); and identify the type, dosage, or frequency of a medication (reporting error). Results We identified 149 errors in 93 patients who were prescribed a mean of 10.9 medications each. Adverse events were associated with 48 errors (32%), including hospitalization (17 patients) or outpatient invasive procedure (3 patients) in 13%. Nine episodes of rejection and 6 failed allografts were identified. The most common error type was patient error in 83 errors (56%) with prescription errors in 20 errors (13%), delivery errors in 20 errors (13%), availability errors in 15 errors (10%), and reporting errors in 12 errors (8%). Root cause analysis identified the patient as the cause in 101 errors (68%) while pharmacies and other sectors of the health care team caused 41 errors (27%). Finances were linked to 7 errors (5%). Error frequency was estimated during 4 weeks of outpatient visits at 15 of 219 visits. Conclusions Outpatient medication errors are abundant, often occult, and associated with significant adverse events in a complex transplant population. The health care system is associated with nearly one third of errors.