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Introduction Headache is one of the main reasons for neurological consultation. Day care hospitals help reduce the costs of admitting patients to hospital. The headache unit in Vall d’Hebron hospital has started day care. Objective To evaluate the first six months of activity of a Headache Day Hospital (HDH). Method This is a descriptive cross-sectional study. All patients that were attended at the HDH between March and September 2019 were included. Demographic variables, headache diagnosis, reason for admission and type of treatment administered were recorded. Patients completed a patient satisfaction survey and the Patient Global Impression of Improvement scale. Data was collected on an anonymized database. Statistical analyses were performed. Results We included 71 patients: 66.7% female, with a mean age of 48.4 (±11.3) years. The most frequent diagnosis was migraine (76.7%). The main reasons for admission were for intravenous treatment (51%). The overall satisfaction score relative to the care received was 9.1 out of 10. Conclusions After the first six months of HDH functioning, we observe that the majority of patients admitted are diagnosed with migraine and, they are mostly admitted for intravenous treatment. Patients treated at HDHs report a high degree of satisfaction.

ObjectiveThis research aims to examine the effect of playing games with toys made of medical materials in children with cancer on pain that occurs during intravenous (IV) treatment.MethodsThe randomized controlled clinical trial was conducted between May 2016 and February 2018. The study sample comprised 110 children (experimental group 55; control group 55), determined using power analysis from the study population. The data were collected by the researcher, using face-to-face interview techniques, the Information Form, and Wong–Baker FACES Pain Rating Scale (WBS).ResultsThe pre- and post-test pain mean scores of patients in the experimental group were 2.27 ± 0.91 and 0.43 ± 0.66, respectively (p = 0.0001). The pre- and post-test pain mean scores of patients in the control group were 1.72 ± 0.82 and 3.34 ± 0.77, respectively (p = 0.0001).Significance of resultsThe experience of playing with toys made from materials used for invasive procedures relieves pain the during IV treatment.

Introduction Central venous access devices (CVAD) are used to facilitate intravenous treatment with coagulation factor concentrates (CFCs) in haemophilia A (HA). Guidelines for perioperative CFC replacement therapy are based on single centre experiences, and the length of replacement therapy varies. Aim The aim of this study was to evaluate whether haemostasis coverage under four days is as effective and safe as a longer period of haemostatic coverage. Methods We identified patients with severe HA without inhibitors or major bleeds within one month of the surgery who received their first CVAD. We compared the CFC consumption and bleeds between children with ≤4 and those who received 5-7 perioperative treatment days including the day of surgery. Bleeds were recorded up to 4 days after the end of perioperative haemostatic coverage. Results In total, 144 children met the eligibility criteria and were included in the study cohort: 34 had received haemostatic coverage for ≤4 days, while 110 had received 5-7 days of haemostatic coverage. One bleed related to the surgery occurred in both groups. Conclusion Overall, the bleeding complications were rare. Haemostatic coverage with CFCs under ≤4 days with elective CVAD insertions was as effective as coverage for ≥5 days.

Because previous randomized clinical trials have failed to show any benefits of renal artery stenting (RAS), clinicians have been confused regarding the optimal management of patients with atherosclerotic renal artery stenosis (ARAS). Here, we report a notable case with ARAS whose clinical course could help clinicians identify patients suitable for RAS. A 66-year-old woman with ARAS and some parameter abnormalities on renal duplex ultrasound was admitted to our hospital with severe hypertension (>250 mmHg). After the initiation of antihypertensive intravenous treatment, the patient manifested acute worsening of renal function over 6 days and required dialysis. Because renal failure continued to deteriorate over more than 4 weeks, we performed stenting to the severe ostial stenosis of the right renal artery. As a result, the patient achieved dramatic improvement in renal function and successful withdrawal from dialysis and has maintained stable control of blood pressure without additional events for more than 2 years since discharge. This case suggests that careful analysis of the patient's profile, such as history of rapidly deteriorating renal failure, presence of bilateral ARAS, or a solitary functional kidney, in addition to various parameters of renal duplex ultrasound, may help predict the efficacy of RAS in patients with ARAS.

A 49- year old immunocompetent male presented with a right flank abscess and was found to have disseminated cryptococcal disease. Treatment was initiated with a one-week intravenous regime of amphotericin B and flucytosine based on recent trial data that this is as effective, and less toxic, than the standard two weeks. After completion of intravenous treatment he was discharged with oral anti-fungals and is making a good recovery with ongoing follow up.

Long term intravenous antibiotic therapy is required for the treatment of selected infections. Outpatient parenteral antibiotic therapy (OPAT) allows patients who require intravenous treatment to be treated outside of the hospital with equal efficacy and safety as in-hospital; prolonged intravenous antibiotic therapy is required for the treatment of selected infections. OPAT is particularly beneficial for patients. Staying at home and resuming everyday life lead to significantly higher patient satisfaction and quality of life. Furthermore, the risk of nosocomial infections can be reduced, especially through multi-resistant pathogens. Outpatient prescriptions shorten the inpatient length of stay and costs can be saved. Additionally the reception capacities of hospitals will be increased.

Elderly patients hospitalized in acute care service very often have a weakened venous tissue which, in the case of medium-term intravenous treatment, leads to multiple painful punctures. In order to alleviate this major inconvenience, within the framework of a cooperation protocol, a catheter team was trained in the ultrasound-guided insertion of the appropriate catheter for the management of geriatric patients.

Acute otitis media, acute bacterial rhinosinusitis, and community-acquired pneumonia are major drivers of pediatric antibiotic consumption. With many available options and the added challenges of navigating antibiotic allergies and de-escalating from intravenous treatment for children requiring hospitalization, prescribing for these relatively simple infections can be a source of confusion and error. The purpose of this article is to evaluate the pharmacokinetic and pharmacodynamic properties of antibiotics commonly prescribed for these disease states, and to specifically compare antipneumococcal activity between oral beta-lactams.

Enzyme replacement therapy (ERT) with recombinant α‐galactosidase A (r‐αGAL A) for the treatment of Fabry disease has been available for over 15 years. Long‐term treatment may slow down disease progression, but cardiac, renal, and cerebral complications still develop in most patients. In addition, lifelong intravenous treatment is burdensome. Therefore, several new treatment approaches have been explored over the past decade. Chaperone therapy (Migalastat; 1‐deoxygalactonojirimycin) is the only other currently approved therapy for Fabry disease. This oral small molecule aims to improve enzyme activity of mutated α‐galactosidase A and can only be used in patients with specific mutations. Treatments currently under evaluation in (pre)clinical trials are second generation enzyme replacement therapies (Pegunigalsidase‐alfa, Moss‐aGal), substrate reduction therapies (Venglustat and Lucerastat), mRNA‐ and gene‐based therapy. This review summarises the knowledge on currently available and potential future options for the treatment of Fabry disease.

To evaluate the sensitivity of the Securetec DrugWipe 6 S Ketamine device in detecting salivary ketamine, we administered three fixed, increasing sub-anaesthetic doses of intravenous ketamine solut...

BACKGROUND: The use of peripheral venous catheters is hampered by short dwell time and central venous catheters are often preferred for medium- to long-time intravenous treatment. Ultrasound techniques allow for easy catheter insertion into the major veins of the upper arm. A new generation of midline catheters, Powerglide Pro, utilises a one-hand Seldinger technique and can be inserted by one single operator without assistance. This study aimed to evaluate the clinical performance of the Powerglide Pro midline catheter.METHODS: Consecutively inserted midline catheters were followed in a prospective, observational quality control study. Endpoints were dwell time, the incidence of premature catheter removal, causes of catheter removal and the dwell time and incidence rates of predefined subgroups representing potential effect modifiers.RESULTS: 100 midline catheters, of which 98 were accessible to follow-up, were inserted in 70 patients. Median dwell time was eight days and 60 catheters were removed before the indication for intravenous therapy had ceased. The overall incidence for premature catheter removal was 71.8/1000 days and no significant effects of subgroups (sex, body mass index, catheter reinsertions, significant comorbidity, anticoagulant therapy, irritant infusions) were identified for either dwell time or the incidence rate for premature midline catheter removal. The most frequent reasons for premature catheter removal were pain during infusion, clotted catheter or signs of infection.CONCLUSION: The median dwell time of the midline catheters was 8 days with substantial variation whereas the incidence for premature catheter removal was 71.8/1000 catheter days. The majority of midline catheters were removed prematurely.

The first new treatment for sickle cell disease in 20 years is to become available for patients in England under a managed access agreement, although the National Institute for Health and Care Excellence (NICE) has not yet recommended its routine use in the NHS.1 Crizanlizumab is an intravenous treatment recommended as an option for preventing recurrent sickle cell crisis in people aged 16 or over. It can be taken on its own or alongside hydroxycarbamide. Amanda Pritchard, NHS chief executive, said the drug …

BACKGROUND: Hypothyroid crisis, or myxoedema coma, is a rare condition with high mortality and must be treated promptly. Even though it may be unfavourable, most guidelines only focus on intravenous drug administration due to lack of data on oral treatment. METHODS/RESULTS: The course of oral treatment in two patients admitted in our hospital is described. Patients were treated with levothyroxine 1.3 μg/kg and liothyronine 25 μg twice daily, followed after 1 week with only levothyroxine 1.3 μg/kg daily. Oral treatment was successful in both patients without complications or side-effects. CONCLUSIONS: Oral substitution is an appropriate alternative to intravenous substitution, which has potential disadvantages and is associated with higher mortality. LEARNING POINTS: Hypothyroid crisis or myxoedema coma is a rare condition with a high mortality rate, so early diagnosis and prompt treatment are necessary. High-dose intravenous treatment is associated with higher mortality, so oral substitution may be an acceptable approach, especially as intravenous medicines are not widely available.

Background Famotidine is sometimes administered as a continuous rate infusion (CRI) to treat gastrointestinal ulceration in critically ill dogs. However, clinical studies have not evaluated the efficacy of a famotidine CRI in dogs. Hypothesis/Objectives To evaluate the efficacy of famotidine at raising intragastric pH when it is administered as a CRI in dogs. We hypothesized that CRI treatment with famotidine would meet clinical goals for raising intragastric pH ≥3 and 4. Animals Nine healthy Beagle dogs. Methods Randomized 2‐way crossover. All dogs received 1.0 mg/kg IV q12h famotidine or CRI famotidine at 1.0 mg/kg IV loading dose and 8.0 mg/kg/d for 3 consecutive days. Beginning on day 0 of treatment, intragastric pH monitoring was used to continuously record intragastric pH. Mean percentage times (MPTs) for which intragastric pH was ≥3 and ≥4 were compared between groups using analysis of variance. Results There was a statistically significant difference (P

The use of guidelines in infectious diseases is of unquestionable value, especially in non-common conditions, like chronic bone and joint infections. However, in a significant number of these infections it is difficult to apply one-size-fits-all treatment strategies, as they will be conditioned by multiple factors, mainly the quality of surgical debridement and residual infection. A basic knowledge of the different phases of the infection and the potential role of antimicrobials at each of these phases will help to make a sensible treatment plan for these particular infections. The initial antimicrobial treatment is usually delivered intravenously but a definitive antimicrobial plan must answer some important questions. The first question is related to the duration of intravenous treatment and appropriateness of switching to oral antimicrobials. Given the limitation on bone penetration of most antimicrobials and the subsequent risk of development of resistance in the presence of suboptimal antimicrobial concentrations, combination therapy is a potential solution, using agents able to perform effectively in the bone, where bacteria usually grow at extremely low rates, limiting the target exposure to some of the most common antimicrobials, which need bacteria actively replicating to inactivate them. A final question is the duration of antimicrobial treatment, which despite the existence of well-defined treatment periods in most of the guidelines, is extremely influenced by the surgical treatment and its capacity to achieve eradication of the infection. In this article we will clarify the above questions.

Context Microbial resistance to antibiotics is increasing while antimicrobials are limited. Responsible use is necessary. Objective Describe the present acquisitions of antimicrobial stewardship programmes (ASPs) in general and in urology. Evidence synthesis Well-designed ASPs have an impact on reducing treatment duration, shortening intravenous treatment in favour of oral targeted therapy, and reducing the total antibiotic prescription. Moreover, the hospital length of stay can potentially be reduced without hazard for the patient. Conclusions It is recommended to set up an ASP for education and feedback as standard in urological practice. The exact design of the ASP should be tailored to regional prerequisites.

Amaç : Kadınlarda postpartum demir eksikliği anemisi oldukça yaygındır. Çoğu kadın oral veya intravenöz (iv) demir ile ya da kan transfüzyonu ile tedavi edilir. Bu çalışmanın amacı, intravenöz ferrik karboksimaltozun postpartum anemisi olan kadınlarda ferröz sülfatla karşılaştırıldığında etkinliğini, güvenilirliğini ve tolere edilebilirliğini değerlendirmektir.Gereç ve Yöntemler: Çalışmamız postpartum 1.günde hemoglobin değeri 8 ile 10 g/dl arasında olan hastalardan, hastanede yatışı süresince iv demir tedavisi verilen ve taburculuk sonrası oral demir tedavisi alan hastaların dosyalarının incelenmesi ile oluşturuldu. 1.grubu oluşturan hastalar; postpartum 1.günde 15mg/kg den maksimum 1000 mg iv ferrik karboksimaltoz tedavisi alan (n:100), 2.grubu oluşturan hastalar ise postpartum taburculuk ile beraber oral ferroz sulfat (100 mg) / 2x1 den 6 hafta boyunca tedavisi düzenlenen hastalardı (n:100). Her iki grupta yer alan hastaların sistem üzerinden bilgileri ve tetkik sonuçları incelendi ve postpartum 1.gün, 14.gün ve 40.gün hemoglobin, hematokrit ve ferritin düzeyleri kaydedildi.Bulgular: Bu hastalardan 1. grubun yaş ortalaması 29.8, 2. grubun yaş ortalaması 29.0 olarak saptandı. Gruplar arasında gravida ve parite sayıları, doğum şekilleri ve tedavi öncesi bakılan hemoglobin (Hb) ve hematokrit (Htc) değerleri arasında fark yoktu. Tedavi sonrası 1. Gün bakılan Hb ve Htc değerleri iv demir tedavisi alan 1.grupta, oral demir tedavisi alan 2.gruba göre anlamlı derecede yüksekti (p

In this retrospective cohort study, selected patients with disseminated Staphylococcus aureus bacteremia, but without endovascular infection on echocardiography and 18F-FDG-PET/CT, were free of relapse after IV-oral switch. Mortality was low and similar to patients who received prolonged intravenous treatment. IV-oral switch was associated with a shorter length of hospital stay.

This report presents the case of a 13-year-old female patient with history of acute myeloid leukemia, who, after a bone marrow transplant, began to vomit and experienced rapidly progressive deterioration of consciousness, in addition to disseminated erythematous-violaceous macules, and some blisters with hemorrhagic content inside. Skin biopsy evidenced intravascular filamentous structures. A blood culture confirmed the presence of Fusarium oxysporum. Intravenous treatment with voriconazole was initiated. The patient evolved unfavorably with multiple necrotic skin lesions, ischemic brain lesions, and death.

Herpes zoster ophthalmicus usually presents with ocular manifestations, but neurological complications are much more infrequent. An 84-year-old woman with herpes zoster of the left first trigeminal branch developed herpetic keratouveitis in her left eye despite treatment with oral valaciclovir. Seven days later, a progressive and total left ophthalmoplegia appeared, requiring hospital admission and intravenous treatment with acyclovir and corticosteroids. The neuroimaging was suggestive of an orbital apex syndrome. The evolution of the ophthalmoplegia was favourable, with complete resolution at 5 months, but with decreased visual acuity due to the optic nerve involvement.

This case report describes a case of endogenous endophthalmitis in a 58 year old man upon a background of urosepsis and bronchitis. The patient was hospitalised at a department of internal medicine in another hospital. The day after admittance he was sent to our clinic for a consultation examination due to worsening of vision and pain in the left eye. The condition was diagnosed as endogenous endophthalmitis. Visual acuity at the first examination was hand movement in front of the eye. Intravitreal therapy was commenced with a combination of two antibiotics (ceftazidime 2 mg/ 0.1 ml and vancomycin 1 mg/0.1 ml) and an antimycotic agent (amphotericin B 10 μg/0.1 ml). Over the course of two weeks the patient received this antibiotic treatment intravitreally 3x in total. During the first application of antibiotics, material was sampled from the anterior chamber of the eye for a microbiological examination – the result was negative. The blood culture tested positive for staphylococcus aureus. Intravenous application of antibiotics (gentamicin 240 mg i.v. every 24 hours and amoxicillin with clavulanic acid 1.2 g i.v. every 8 hours) was set for two weeks, and then antibiotic treatment continued (ciprofloxacin 500 mg every 12 hours) and antimycotic therapy (itraconazole 100 mg every 12 hours) orally for 2 months. Four weeks after the beginning of therapy, visual acuity in the left eye was 20/100 and after two months 20/40. The study emphasises the advantage of multi-disciplinary co-operation.

Background Polymyxin B once had to exit the market due to its toxicity. As antibacterial is widely used, the problem of drug-resistance, especially the gram-negative bacteria, has become a major threat to global health. Polymyxin B has reappeared as a last resort for the treatment of multidrug-resistant (MDR) and extensively drug-resistant (XDR) Gram-negative bacteria. With its return, the use of polymyxin B greatly increased over time in China. The aim of our study was to overview the actual clinical application of polymyxin B in patients with MDR and XDR Gram-negative bacteria in Peking Union Medical College Hospital (PUMCH), Moreover its usage characteristics were summarized in detail.Methods: All the patients hospitalized in Perking Union Medical College of Hospital (PUMCH) from August 2018 (available in PUMCH) to December 2019 who received polymyxin B were enrolled in the study. Patients’ basic information, previous medical history, antimicrobial susceptibility, the use of antimicrobials throughout the hospital stay, adverse reactions, and clinical outcomes were extracted and recorded for descriptive analysis.Results: A total of 84 hospitalized patients received polymyxin B intravenous injection. Most of the patients had underlying conditions such as hypertension, diabetes or in the states of immunosuppression, who had already received other antibiotic therapy, particularly carbapenems, β-lactam/β-lactamase inhibitor and tigecycline, prior to receiving polymyxin B. About 73.81% of the patients had mixed infections, with pneumonia being the most common. The leading pathogens were Acinetobacter baumannii (73.81%) followed by Pseudomonas aeruginosa (28.57%) and Klebsiella pneumonia (20.23). The microbiological clearance of the targeted bacteria after therapy was 17.88%. Clinical amelioration at the last day of polymyxin B therapy was observed in 52.38% of cases, while mortality was observed in 32.14%. Nephrotoxicity and neurotoxicity were observed in 5 and 1 cases respectively.Conclusion: Polymyxin B was used to fight against MDR and XDR Gram-negative bacterial infections under the conditions of previous treatment failure, changes of antimicrobial susceptibility, and drug intolerance in PUMCH. However, owing to lack of experience and widely recognized application criteria, the use of polymyxin B demanded more research to help achieve uniform standards and rules to guide the clinical application of polymyxin B, thus leading to better clinical outcomes.

Acute heart failure (AHF) is a life-threatening condition with a dramatic burden in terms of symptoms, morbidity and mortality. It is a specific syndrome requiring urgent, life-saving treatment. Multiple specific pathophysiologic mechanisms may be involved, including congestion, inflammation, and neurohormonal activation. This process eventually leads to symptoms, end-organ damage, and adverse outcomes. Clinical presentation varies, but it almost universally includes worsening of congestion associated with different degrees of hypoperfusion. Due to substantial early symptoms burden and high morbidity and mortality, patients with AHF require intensive monitoring and intravenous treatment. However, beyond variable improvement in congestion, none of the available intravenous therapies for AHF was shown to improve longer term outcomes. Although oral treatment with guideline-directed therapies for stable patients with HF and reduced ejection fraction (HFrEF) before discharge may fully prevent subsequent episodes, proof that this strategy may benefit patients is lacking. First, most patients with AHF have preserved EF (HFpEF) where no therapies have been shown to be effective. Second, all therapies developed for patients with HFrEF were tested for efficacy on outcomes in patients who were stable without recent AHF. Hence, the implementation of these chronic therapies during an AHF episode is untested. Third, the problem to better treat AHF patients in their early phase remains crucial with treatment strategies largely untested, yet. Further studies targeting AHF specific mechanisms, such as inflammation and end-organ damage, and finding effective intravenous drugs remain therefore warranted.

Oncology has been undergoing a profound transition in the last ten years with the increased usage in oral anti-cancer medication. Approximately 25% of all anti-cancer medication is now designed for oral use and this is likely to increase prospectively. These treatments are convenient for patients and are often preferred by them, yet there are similar safety and toxicity concerns as there are to intravenous treatment. Oral anti-cancer medications (OAMs) have the potential to alleviate capacity issues in cancer treating units as patients receive their treatment at home, however there remains a requirement for safe and efficient assessment and care. Consequently, the management of patients on OAMs is of paramount importance. The optimum setting, whether within primary or secondary care, in addition to the appropriate health care professional to carry out patient assessment and monitoring needs to be established. This paper presents a protocol for a scoping review which aims to systematically and comprehensively map the literature on the current management of adults receiving OAMs. The review will follow the published guidance to direct the various steps involved. The protocol will be guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) framework to ensure methodological and reporting quality. Independent full text review will be performed by two reviewers and any disagreements resolved through discussion with a third reviewer. The process will be iterative in nature. This scoping review will provide a narrative synthesis and map the literature on the management of individuals receiving OAMs. This work is an appropriate initial stage in presenting the literature to inform the subsequent steps in a multi-phased research study which aims to establish and analyse the safety and efficacy of an integrated care model for the management of patients receiving OAM in the community by an advanced practitioner.

To compare the visual outcomes of patients with acute retinal necrosis (ARN) treated initially with intravenous acyclovir vs oral valacyclovir therapy.Retrospective, comparative, interventional case series.Sixty-two patients (68 eyes) with ARN, treated at Moorfields Eye Hospital (United Kingdom) between 1992 and 2016, were identified through the hospital's electronic database. Exclusion criteria included insufficient patient records or follow-up (150 days). Fifty-six patients had unilateral ARN, while 6 had bilateral ARN. Patients who received intravenous acyclovir on diagnosis (n = 33) were compared with patients treated with oral valacyclovir (n = 29) across outcomes including best-corrected visual acuity, retinal detachment, severe vision loss, and other complications. The impact of adjunctive intravitreal antiviral and prophylactic barrier laser treatment was also assessed.Change in best-corrected visual acuity was not significantly different for eyes treated initially with intravenous therapy vs oral therapy over 5 years of follow-up data (P = .16). There was no difference in the rates of severe vision loss between the 2 groups (46% and 59%, respectively, P = .18), or of those eyes retaining good vision (28% vs 31%, respectively, P = .80). Retinal detachment occurred in 63% of cases and did not differ across treatment groups (62% vs 66%, respectively, P = .67). Barrier laser and intravitreal therapy had no effect on retinal detachment rate in either group.Oral valacyclovir is clinically equivalent to intravenous therapy in the management of ARN. Oral valacyclovir as an outpatient therapy-with or without intravitreal foscarnet-can therefore be considered as an acceptable alternative to inpatient therapy required for intravenous treatment.

This case report describes a 7-year-old male patient with painless unilateral visual impairment due to optic neuropathy confirmed by visual evoked potentials (VEP), which was found to be attributed to neuroborreliosis. The diagnosis was confirmed by applying both European (European Federation of Neurological Societies [EFNS]) and American (Centers for Disease Control and Prevention [CDC]) criteria. Following intravenous treatment with broad-spectrum antibiotics, his vision gradually improved. This case report adds to the scarce evidence for an association between optic neuropathies and neuroborreliosis. It illustrates that, although uncommon, the clinician should be aware of the possibility of Lyme disease in patients with unilateral visual impairment due to optic neuropathy. Recognition is especially important because visual acuity can return to normal after adequate treatment. We reviewed the differences in criteria by the European EFNS guidelines and the American CDC criteria for making the diagnosis.

Objective: The present study aimed to determine the pain experienced by children during intravenous bolus treatment and to identify what causes it. Method: In the first stage of the study, the first 40 observations were performed by two researchers. The study was continued by a single observer after the Kappa test was performed. In this study, 101 drug treatments were administered by intravenous bolus in patients aged between 1 month and 6 years. The pain experienced during treatment was assessed using pain scales according to the age group the patient was in. Results: Pain was observed in 63.4% ( n = 64) of the treatments. There was a significant relationship between the type of medication administered and pain experienced during drug administration. There was also a significant correlation between the age of the children and their pain experiences. Given the location of the catheter, there was no significant difference among the children who experienced pain during intravenous treatment. Conclusion: Intravenous drug therapy may cause pain in children. To minimize such pain, it is recommended to determine the drugs that cause pain during intravenous treatment and to develop application protocols to minimize pain caused by these drugs.

Childhood asthma is a common condition where there is no consensus on definition, no diagnostic test and no reliable test to monitor symptoms. Despite (or because of) these considerable clinical challenges, many national bodies produce guidelines for the diagnosis and management of childhood asthma. The British Thoracic Society and Scottish Intercollegiate Guidelines Network (BTS/SIGN) published their first asthma guideline in 1995 and have updated regularly, and most recently in 2016. The present article will (i) summarise changes in the BTS/SIGN asthma guideline between 1995 and 2014 and (ii) highlight what has changed between 2014 and 2016. The guideline has evolved considerably over 21 years, but the core principles for diagnosis and management have remained constant. The major changes to the 2016 guideline include (i) the initial trial of treatment should be with inhaled corticosteroids (ICS) (ii) there is new terminology for the dose of ICS (iii) there are new recommendations for the traditional “steps” 1 to 3 and (iv) the 5–12 and less than 5 year old stepwise algorithms in the 2014 guideline are now unified. For acute severe asthma, the first choice intravenous treatment is magnesium sulphate. Childhood asthma remains a clinical diagnosis where management is symptom-based and patient-focussed.