Langerhans cells (LCs) subserve an important antigen-presenting function in the skin immune system. They bear CD4 receptors, which make them potential targets for infection with the human immunodeficiency virus (HIV-1). The observation of reduced numbers of LCs in the skin of patients with the acquired immunodeficiency syndrome (AIDS), and the association of severe psoriasis with HIV-1 infection, raise interesting questions regarding the role of LCs in the skin of HIV-1-positive psoriatic patients. In this study, LCs were quantified in the lesional and non-lesional skin of seven HIV-1-positive psoriatic patients, and the results were compared with age-, sex- and site-matched HIV-1-negative psoriatic patients. The number of LCs was determined by staining skin sections with S-100 polyclonal antibody, using the three-step avidin-biotin immunoperoxidase method. The S-100-positive cells above the basal layer were quantified in two ways: cells/mm2 of epidermal area, and cells/mm of length of basement membrane. HIV-1-positive psoriatic patients showed a reduction in the number of epidermal LCs compared with HIV-1-negative psoriatic patients using both methods of quantification, in both lesional and non-lesional skin (P < 0.05, Mann-Whitney test). In addition, a reduction in the number of LCs in lesional compared with non-lesional skin was observed in both HIV-1-positive and -negative patients when LCs were quantified per mm2 of epidermal area (P < 0.05, Wilcoxon test).(ABSTRACT TRUNCATED AT 250 WORDS)
AIMTo determine if ketamine sedation is a safe and cost effective way of treating displaced paediatric radial and ulna fractures in the emergency department.METHODSFollowing an agreed interdepartmental protocol, fractures of the radius and ulna (moderately to severely displaced) in children between the age of 2 and 16 years old, presenting within a specified 4 mo period, were manipulated in our paediatric emergency department. Verbal and written consent was obtained prior to procedural sedation to ensure parents were informed and satisfied to have ketamine. A single attempt at manipulation was performed. Pre and post manipulation radiographs were requested and assessed to ensure adequacy of reduction. Parental satisfaction surveys were collected after the procedure to assess the perceived quality of treatment. After closed reduction and cast immobilisation, patients were then followed-up in the paediatric outpatient fracture clinic and functional outcomes measured prospectively. A cost analysis compared to more formal manipulation under a general anaesthetic was also undertaken.RESULTSDuring the 4 mo period of study, 10 closed, moderate to severely displaced fractures were identified and treated in the paediatric emergency department using our ketamine sedation protocol. These included fractures of the growth plate (3), fractures of both radius and ulna (6) and a single isolated proximal radius fracture. The mean time from administration of ketamine until completion of the moulded plaster was 20 min. The mean time interval from sedation to full recovery was 74 min. We had no cases of unacceptable fracture reduction and no patients required any further manipulation, either in fracture clinic or under a more formal general anaesthetic. There were no serious adverse events in relation to the use of ketamine. Parents, patients and clinicians reported extremely favourable outcomes using this technique. Furthermore, compared to using a manipulation under general anaesthesia, each case performed under ketamine sedation was associated with a saving of £1470, the overall study saving being £14700.CONCLUSIONKetamine procedural sedation in the paediatric population is a safe and cost effective method for the treatment of displaced fractures of the radius and ulna, with high parent satisfaction rates.
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Aims: As Paediatric Emergency Departments (PED) become busier the number of children requiring painful procedures continues to increase. We aimed to evaluate a locally developed paediatric procedural sedations (PPS) service using ketamine for safety, efficiency and efficacy in the context of the national 4 hour operational target which is due to be revised this year in the UK Methods: We enrolled consecutive patients over 12 months suitable for PPS ketamine and collected data for demographics, time to patient identification, time to ketamine administration, procedural duration and time to recovery. We also documented procedure outcome, adverse events, consent, ketamine dosage and baseline physiological observationsResults: From May 2017 to May 2018 ketamine PPS was performed on 36 patients with a mean age of 7 years (range 1.8 to 14.6 years). The most common procedure performed was manipulation of forearm fractures (n=21, 58%), followed by facial laceration repair (n=10, 28%). Total intravenous Ketamine dosages were; 1mg/kg (n=23, 64%) 1.5mg/kg (n=10, 28%) and 2mg/kg (n=3, 8%). Average time to referral to surgical speciality was 33 minutes which improved from 40 minutes (pre Sept) to 27 minutes (post Sept). Average time to ketamine administration was 168 minutes, improved from 185 minutes (pre Sept) to 155 minutes (post Sept). The average time taken to complete procedures, all under 20 minutes, also decreased from 19 minutes (pre Sept) to 10 minutes (post Sept) averaging 15 minutes overall. The recovery time was similar throughout the study period. The overall average length of stay (LOS) was 284 minutes, improved from 297 minutes (pre Sept) to 274 minutes (post Sept) figure 3. 20 (55%) of the 36 patients breached the 4 hour target. 10 (28%) patients were admitted, 9 for further neurovascular observations and only 1 where the outcome of a procedure was unsatisfactory. There were no seminal untoward incidents in our study. Vomiting occurred in 4, there was 1 drug error and one patient required brief airway manoeuvres for decreased oxygen saturations Conclusion:We have confirmed PPS ketamine service to be safe and further demonstrated good outcomes in procedures carried out. Despite improved efficiency in the study period the average LOS still falls outside the 4 hour target and a revision would be welcomed to reduce anxiety related to breaches in this group and encourage more uptake of PPS ketamine nationally
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