Peritoneal fluid analysis in equine post-partum emergencies admitted to a referral hospital: A retrospective study of 110 cases.

BACKGROUND: Peritoneal fluid analysis has both diagnostic and prognostic value in colic but is little reported in the post-partum mare. Multiple conditions may present similarly in this period, and peritoneal fluid findings may aid a prompt diagnosis. OBJECTIVES: To describe the peritoneal fluid findings and their association with diagnosis in mares presenting to a single referral hospital for treatment of post-partum emergencies. STUDY DESIGN: A retrospective clinical study. METHODS: Clinical records of 110 Thoroughbred mares were reviewed. Details of peritoneal fluid analysis from samples obtained at admission were recorded, in addition to history, physical examination, presenting clinicopathological data. Cases were classified by their primary diagnosis into groups of gastrointestinal tract (GIT), urogenital trauma (UGT) and post parturient haemorrhage (PPH). Univariable analysis was performed to compare findings between groups, using one-way ANOVA and post hoc Tukey/Kruskal-Wallis, as appropriate. A multinomial logistic regression was performed for variables significant in the univariable analysis. RESULTS: When separated into their diagnostic categories, 33/110 (30%) mares were classified as GIT, 55/110 (50%) UGT and 22/110 (20%) PPH. Peritoneal fluid packed cell volume (PCV), nucleated cell count (WBCC) and cytological findings were significantly different between diagnostic categories. The likelihood of diagnosis of PPH increased with an increase in peritoneal fluid PCV, the absence of degenerate neutrophils on peritoneal fluid cytology and a decrease in the peritoneal fluid WBCC. Overall survival to discharge was 55%. MAIN LIMITATIONS: The study is referral hospital-based and retrospective in nature. Missing data reduced the power of analysis for several variables. CONCLUSIONS: Peritoneal fluid analysis may guide diagnosis in post-partum emergencies, but no one factor is uniformly diagnostic. Mares with PPH presented with a non-septic peritonitis with higher peritoneal PCV.

Bleb reconstruction using donor scleral patch graft for late bleb leak and hypotony.

PURPOSE: Bleb dysfunction may occur as a late complication following glaucoma filtration surgery. Over-filtering, thinning and cystic blebs can lead to hypotony, leak and corneal dellen. We report our surgical management and outcomes of this specific entity using donor scleral patch grafts. METHODS: This is a 10-year non-comparative, retrospective interventional case series. Bleb reconstruction involved excision of encysted conjunctiva and sclera to identify the original fistula. A functioning donor scleral patch graft was sited over this with fixed and releasable sutures and the conjunctiva advanced. Intraocular pressure, visual acuity and post-operative issues were assessed. RESULTS: A total of 18 eyes of 17 patients with mean age 65 years (standard deviation 13.5) were included. Trabeculectomy was the primary procedure in 72% (n = 13) and deep sclerectomy in 28% (n = 5). Bleb leak accounted for 61% (n = 11), hypotony 33% (n = 6) and corneal dellen 6% (n = 1). Mean pre-operative intraocular pressure was 7 mm Hg (standard deviation 4.6) which increased to 18.5 mm Hg (standard deviation 12) at day 1 (p < 0.001), 11.8 mm Hg (standard deviation 4.6) at 3 months (p < 0.05), 12.1 mm Hg (standard deviation 4.2) at 1 year (p < 0.01) which was maintained at 12.1 mm Hg (standard deviation 5.3) at last follow-up (p < 0.001). Post-operative interventions included bleb needling, re-suturing, suture removal, further glaucoma management, bleb leak and cataract surgery. Visual acuity also improved post-operatively and was maintained. CONCLUSION: Reconstruction of the filtering bleb architecture with donor sclera results in improved intraocular pressure while maintaining visual acuity. Post-operative care is required to support the restored bleb function. Our findings support the use of scleral patch graft as an effective and safe method for the long-term management of hypotony and bleb leak as a late complication of glaucoma filtration surgery.

Sociodemographic variables as predictors of adverse outcome in SARS-CoV-2 infection: an Irish hospital experience.

INTRODUCTION: Our hospital found itself at the epicentre of the Irish COVID-19 pandemic. We describe the organisational challenges faced in managing the surge and identified risk factors for mortality and ICU admission among hospitalised SARS-CoV-2-infected patients. METHODS: All hospitalised SARS-CoV-2 patients diagnosed between March 13 and May 1, 2020, were included. Demographic, referral, deprivation, ethnicity and clinical data were recorded. Multivariable regression, including age-adjusted hazard ratios (HR (95% CI), was used to explore risk factors associated with adverse outcomes. RESULTS: Of 257 inpatients, 174 were discharged (68%) and 39 died (15%) in hospital. Two hundred three (79%) patients presented from the community, 34 (13%) from care homes and 20 (8%) were existing inpatients. Forty-five percent of community patients were of a non-Irish White or Black, Asian or minority ethnic (BAME) population, including 34 Roma (13%) compared to 3% of care home and 5% of existing inpatients, (p < 0.001). Twenty-two patients were healthcare workers (9%). Of 31 patients (12%) requiring ICU admission, 18 were discharged (58%) and 7 died (23%). Being overweight/obese HR (95% CI) 3.09 (1.32, 7.23), p = 0.009; a care home resident 2.68 (1.24, 5.6), p = 0.012; socioeconomically deprived 1.05 (1.01, 1.09), p = 0.012; and older 1.04 (1.01, 1.06), p = 0.002 were significantly associated with death. Non-Irish White or BAME were not significantly associated with death 1.31 (0.28, 6.22), p = 0.63 but were significantly associated with ICU admission 4.38 (1.38, 14.2), p = 0.014 as was being overweight/obese 2.37 (1.37, 6.83), p = 0.01. CONCLUSION: The COVID-19 pandemic posed unprecedented organisational issues for our hospital resulting in the greatest surge in ICU capacity above baseline of any Irish hospital. Being overweight/obese, a care home resident, socioeconomically deprived and older were significantly associated with death, while ethnicity and being overweight/obese were significantly associated with ICU admission.

Use of a digital delirium pathway and quality improvement to improve delirium detection in the emergency department and outcomes in an acute hospital.

BACKGROUND: delirium is a common condition associated with hospital admission. Detection and diagnosis is important to identify the underlying precipitating cause and implement effective management and treatment. Quality improvement (QI) methodology has been applied in limited publications. There are even fewer publications of the role of development of the electronic health record (EHR) to enhance implementation. METHODS: we used QI methodology to improve delirium detection in the emergency department (ED). Plan Do Study Act (PDSA) cycles could be broadly categorised into technology, training and education and leadership. As part of the technology PDSA an electronic delirium pathway was developed as part of an NHS England digital systems improvement initiative (NHS England Global Digital Exemplar). The electronic pathway incorporated the 4AT screening tool, the Confusion Assessment Method, the TIME delirium management bundle, investigation order sets and automated coding of delirium as a health issue. RESULTS: development of the EHR combined with education initiatives had benefit in terms of the number of people assessed for delirium on admission to the ED and the total number of people diagnosed with delirium across the organisation. The implementation of a delirium pathway as part of the EHR improved the use of 4AT in those 65 years and over from baseline of 3% completion in October 2017 to 43% in January 2018. CONCLUSION: we showed that enhancement of the digital record can improve delirium assessment and diagnosis. Furthermore, the implementation of a delirium pathway is enhanced by staff education.

The difference in intraocular pressure readings between 3 applanation tonometers is independent of central corneal thickness, in glaucomatous and nonglaucomatous eyes.

PURPOSE: To look at tonometry differences between 3 tonometers and to correlate this difference with central corneal thickness (CCT) in glaucomatous and nonglaucomatous eyes. METHODS: A total of 145 patients were recruited (39 with glaucoma). Intraocular pressure (IOP) was carried out using the Tonosafe (TS), Tono-Pen XL (TP), and Goldmann applanation tonometer (GAT). CCT was also performed using a digital pachymeter. RESULTS: The TS underestimated IOP when compared with the GAT by a mean (±SD) of 1.03±2.14 mm Hg (P<0.001). The TP when compared to the GAT overestimated IOP by a mean (±SD) of +1.09±6.38 mm Hg (P=0.071). We found only 31% of TP readings to be within ±2 mm Hg of the GAT readings and only 60% to be within ±4 mm Hg of the GAT readings. Correlation was poor (F=0.247) between the GAT and TP with the coefficient of determination being 0.061. The difference in IOP was independent of CCT and a diagnosis of glaucoma. CONCLUSIONS: The TS, when compared with the GAT, underestimates IOP with a tendency for this to increase in the higher range of IOP readings. The TP is poorly correlated with the GAT.

Simultaneous recordings of ocular microtremor and microsaccades with a piezoelectric sensor and a video-oculography system.

Our eyes are in continuous motion. Even when we attempt to fix our gaze, we produce so called "fixational eye movements", which include microsaccades, drift, and ocular microtremor (OMT). Microsaccades, the largest and fastest type of fixational eye movement, shift the retinal image from several dozen to several hundred photoreceptors and have equivalent physical characteristics to saccades, only on a smaller scale (Martinez-Conde, Otero-Millan & Macknik, 2013). OMT occurs simultaneously with drift and is the smallest of the fixational eye movements (∼1 photoreceptor width, >0.5 arcmin), with dominant frequencies ranging from 70 Hz to 103 Hz (Martinez-Conde, Macknik & Hubel, 2004). Due to OMT's small amplitude and high frequency, the most accurate and stringent way to record it is the piezoelectric transduction method. Thus, OMT studies are far rarer than those focusing on microsaccades or drift. Here we conducted simultaneous recordings of OMT and microsaccades with a piezoelectric device and a commercial infrared video tracking system. We set out to determine whether OMT could help to restore perceptually faded targets during attempted fixation, and we also wondered whether the piezoelectric sensor could affect the characteristics of microsaccades. Our results showed that microsaccades, but not OMT, counteracted perceptual fading. We moreover found that the piezoelectric sensor affected microsaccades in a complex way, and that the oculomotor system adjusted to the stress brought on by the sensor by adjusting the magnitudes of microsaccades.

Are boys and girls that different? An analysis of traumatic brain injury in children.

INTRODUCTION: The Phillips Report on traumatic brain injury (TBI) in Ireland found that injury was more frequent in men and that gender differences were present in childhood. This study determined when gender differences emerge and examined the effect of gender on the mechanism of injury, injury type and severity and outcome. METHODS: A national prospective, observational study was conducted over a 2-year period. All patients under 17 years of age referred to a neurosurgical service following TBI were included. Data on patient demographics, events surrounding injury, injury type and severity, patient management and outcome were collected from 'on-call' logbooks and neurosurgical admissions records. RESULTS: 342 patients were included. Falls were the leading cause of injury for both sexes. Boys' injuries tended to involve greater energy transfer and involved more risk-prone behaviour resulting in a higher rate of other (non-brain) injury and a higher mortality rate. Intentional injury occurred only in boys. While injury severity was similar for boys and girls, significant gender differences in injury type were present; extradural haematomas were significantly higher in boys (p=0.014) and subdural haematomas were significantly higher in girls (p=0.011). Mortality was 1.8% for girls and 4.3% for boys. CONCLUSIONS: Falls were responsible for most TBI, the home is the most common place of injury and non-operable TBI was common. These findings relate to all children. Significant gender differences exist from infancy. Boys sustained injuries associated with a greater energy transfer, were less likely to use protective devices and more likely to be injured deliberately. This results in a different pattern of injury, higher levels of associated injury and a higher mortality rate.

The NEXUS criteria: do they stand the test of time?

The National Emergency X-ray Utilisation Study (NEXUS) criteria and the Canadian cervical spine rules are validated clinical decision-making tools used to facilitate selective cervical spine (C-spine) radiography. The NEXUS criteria are frequently used, as the Canadian cervical spine rules have been noted to be difficult to learn, remember and implement. We present a series of significant C-spine injury in three elderly patients who would not have warranted C-spine imaging using the NEXUS criteria. Each patient was mobile and fully orientated after the injury. There was no midline tenderness, neurological deficit, distracting injury or alcohol/drug involvement. Plain film imaging was initially performed as each patient had a reduced range of movement. Significant odontoid peg injury was confirmed on subsequent computed tomography/MRI imaging for all patients. Despite previous validation studies of the NEXUS criteria in the elderly population, we would urge caution in using the NEXUS criteria alone in determining radiography of the C-spine in the elderly.

Malarial cases presenting to a European urban Emergency Department.

INTRODUCTION: Malaria accounts for approximately 225 million infections and 781 000 deaths annually worldwide. Malaria should be considered in the Emergency Department as an important cause of illness in returning travellers. We were interested in evaluating the malarial caseload presenting to an urban inner city Emergency Department in terms of the nature and severity of clinical presentations. METHODS: A retrospective study of all cases of malaria presenting to our Emergency Department from 1 January 2004 to the 31 December 2010 was conducted. Information about patient demographics, areas in which malaria was contracted, clinical course, treatment and complications was recorded from chart reviews. RESULTS: Fifty-six cases of malaria were diagnosed in the period studied. The majority of patients had falciparum malaria (80%), were originally from West or Central Africa (75%), were mainly from Nigeria (48%), and were visiting friends and relatives in their country of origin. A total of 79% had not taken appropriate antimalarial chemoprophylaxis. A total of 7% were classified as severe malaria according to the WHO criteria. There was one death. CONCLUSION: Malarial cases occurred predominantly in immigrants who were returning to endemic areas to visit friends and relatives in their country of origin. The majority of patients did not undergo antimalarial prophylaxis. Severe malaria is a medical emergency requiring urgent recognition and appropriate antimicrobial and critical care therapy. Improving public awareness and healthcare promotion regarding risks of travel-related malaria may help to improve compliance with prophylaxis and preventative measures, and thereby reduce the prevalence of malarial infection in this group.

Prehospital medication administration: a randomised study comparing intranasal and intravenous routes.

Introduction. Opioid overdose is an ever-increasing problem globally. Recent studies have demonstrated that intranasal (IN) naloxone is a safe and effective alternative to traditional routes of naloxone administration for reversal of opioid overdose. Aims. This randomised controlled trial aimed to compare the time taken to deliver intranasal medication with that of intravenous (IV) medication by advanced paramedic trainees. Methods. 18 advanced paramedic trainees administered either an IN or IV medication to a mannequin model in a classroom-based setting. The time taken for medication delivery was compared. End-user satisfaction was assessed using a 5-point questionnaire regarding ease of use and safety for both routes. Results. The mean time taken for the IN and IV group was 87.1 seconds and 178.2 seconds respectively. The difference in mean time taken was 91.1 seconds (95% confidence interval 55.2 seconds to 126.9 seconds, P ≤ 0.0001). 89% of advanced paramedic trainees reported that the IN route was easier and safer to use than the IV route. Conclusion. This study demonstrates that, amongst advanced paramedic trainees, the IN route of medication administration is significantly faster, better accepted and perceived to be safer than using the IV route. Thus, IN medication administration could be considered more frequently when administering emergency medications in a pre-hospital setting.

Are we prepared for a growing population? Morbid obesity and its implications in Irish emergency departments.

Two percent of the Irish population is morbidly obese with this figure expected to rise significantly. This survey aimed to establish the present logistical capacity of Irish emergency departments (EDs) to adequately cater for the bariatric patients. A telephone survey was carried out of 37 health service executive EDs over a 5-day period in October 2008. Questions were posed to the departmental lead nurse regarding facilities (Supplemental digital content 1). No ED had adequate facilities. Two of 37 units questioned had on-site hoists designed to lift patients of more than 170 kg. Four departments had rapid access to mattresses within the hospital and three of these four had access to beds and trolleys for weighing patients. Two percent of the Irish population is morbidly obese with this figure expected to rise significantly to more than 150 kg. One department had access to commodes, chairs, wheelchairs and trolleys from inpatient services. All departments had extra-wide blood pressure cuffs and 12 had a difficult airways trolley. Necessary infrastructure and equipment for bariatric patients is deficient in the majority of Irish EDs.

Junior doctors and undergraduate teaching: the influence of gender on the provision of medical education.

BACKGROUND: International experience has demonstrated that the medical profession is becoming less dominated by men. This "feminization of medicine" has been a topic of much debate in the medical literature. As the gender ratio in the profession changes, it is likely that a greater proportion of undergraduate education will be provided by women. Whether this shift away from the male-dominated provision of medical education will have an effect on undergraduate education is unknown. PURPOSE: The aim of this research was to clarify whether there are differences between the attitudes and practices of male and female junior doctors regarding the practice of undergraduate teaching. METHOD: A survey methodology among a cohort of nonconsultant hospital doctors in a major Irish teaching hospital was utilized. The overall response rate was 93%. The cohort held a positive attitude toward teaching undergraduates, and the majority were actively engaged in this activity. Doctors of both genders expressed a willingness to undertake teacher training. RESULTS: There were no significant differences between the genders regarding the self-reported quantity of teaching provided to undergraduates. Male doctors perceived themselves as more confident educators when compared to female doctors, but this is likely to reflect cohort demographics in which a greater proportion of male doctors were more senior. CONCLUSIONS: This study demonstrates that male and female doctors have similar attitudes toward, and practices in, voluntary undergraduate teaching. As a result, any gender shift in medicine is unlikely to result in a significant change in junior doctors' attitudes toward undergraduate medical education.

Treating pain in the emergency department.

The objective of this audit was to evaluate the impact of brief educational intervention on prompt recognition and treatment of pain in the emergency department. The audit was performed on all patients in the emergency department with pain presenting over a 24-h period on three occasions: preintervention, 1-week postintervention and at 4 months. In 151 patients, pain severity scores were mild (24%), moderate (42%), severe (16%) and unknown (18%). Pain score documentation at triage improved from 72 to 94% during the audit (P = 0.01). There was no significant difference in the number of patients treated within 20 min for severe pain (P = 0.076) and within 60 min for moderate pain (P = 0.796) between audits. The likelihood of receiving analgesia within 20 min increased with the patients' pain category (relative risk: 1.8 95% confidence interval: 1.4-2.3). Documentation of pain assessment and the use of pain scores at triage improved after a brief educational intervention but there was no measurable impact on treatment times.

Compact portable ocular microtremor sensor: design, development and calibration.

Ocular microtremor (OMT) is a physiological high-frequency (up to 150 Hz) low-amplitude (25-2500 nm peak-to-peak) involuntary motion of the human eye. Recent studies suggest a number of clinical applications for OMT that include monitoring the depth of anesthesia of a patient in surgery, prediction of outcome in coma, and diagnosis of brain stem death. Clinical OMT investigations to date have used mechanical piezoelectric probes or piezoelectric strain gauges that have many drawbacks which arise from the fact that the probe is in contact with the eye. We describe the design of a compact noncontact sensing device to measure OMT that addresses some of the above drawbacks. We evaluate the system performance using a calibrated piezoelectric vibrator that simulates OMT signals under conditions that can occur in practice, i.e., wet eye conditions. We also test the device at low light levels well within the eye safety range.

End-of-life care in the intensive care unit: the Irish Ethicus data.

OBJECTIVE: To study the frequency, rationale and process for withholding (WH) and withdrawing (WD) life-sustaining therapies in intensive care patients in Ireland. DESIGN: Prospective, observational study, comprising a subset of the European Ethicus Study. SETTING AND PARTICIPANTS: 122 patients who died or who had life-sustaining therapies limited in the ICU of a university hospital, 1 September 1999 to 30 June 2000. OUTCOME MEASURES AND RESULTS: An end-of-life (EOL) treatment decision was made for 85/122 patients (69%). Forty-five (36%) had therapy withheld, 40 (33%) had it withdrawn, 26 (21%) had unsuccessful cardiopulmonary resuscitation, and 11 (10%) suffered brain death. The median time from ICU admission to death was 4.0 days for WH patients and 2.9 days for WD patients (range, 10 minutes to 123 days). The discussion to limit therapy was initiated by the ICU doctor in 50 cases (59%), and involved families in 66 cases (78%). Families initiated 9% of EOL discussions. Nursing staff were involved in 98% of decisions. No patients were mentally competent, but their wishes were known in 28% of cases. The primary reason for limiting life-sustaining therapy was that the patient was unresponsive to maximum therapy (68% of patients). An EOL decision was made every 55 hours during "office hours" and every 120 hours during "on-call" working hours. Withholding was more frequent than withdrawing during "on call" periods. DISCUSSION: The frequency of withdrawal or withholding of therapy in this Irish ICU is in line with current international practice. The time to EOL decision-making is variable and relatively short compared with that in the United States, but similar to that in Europe. Clinicians are the primary initiators of the EOL decision in Ireland, with little patient involvement. Family members are more likely to initiate an EOL decision than in Europe. EOL decisions were usually made during "routine" working hours after significant consultation with all groups.