Comparison of presentations to the emergency department during the COVID-19 pandemic (COPED-C).

BACKGROUND: Concerns have been raised that patients requiring emergency care may not have accessed healthcare services during coronavirus disease 2019 (COVID-19) lockdown. METHODS: This case control study aimed to understand changes in characteristics and diagnosis of patients attending a large UK Emergency Department (ED) during the first wave of the COVID-19 pandemic (March-May 2020) compared with equivalent weeks in 2019. RESULTS: We found a 50.7% drop in first attendances to the ED in 2020. Likelihood of attendance and admission decreased for paediatric patients and increased for patients ≥ 46 years, and for men. Likelihood of admission increased for all Black ethnic groups and for patients from the most deprived index of multiple deprivation quintiles. This shift to an older, male, more deprived patient population with greater representation of ethnic minority groups was amplified in the 'Infections' diagnostic category. CONCLUSIONS: COVID-19 has dramatically impacted ED usage. Our analysis contributes to local resource planning and understanding of changes in healthcare-seeking behaviour during the pandemic. Future research to identify positive behaviour changes could help sustain a reduction in non-urgent visits in the longer term.

Cryptic Species Account for the Seemingly Idiosyncratic Secondary Metabolism of Sarcophyton glaucum Specimens Collected in Palau.

Sarcophyton glaucum is one of the most abundant and chemically studied soft corals with over 100 natural products reported in the literature, primarily cembrane diterpenoids. Yet, wide variation in the chemistry observed from S. glaucum over the past 50 years has led to its reputation as a capricious producer of bioactive metabolites. Recent molecular phylogenetic analysis revealed that S. glaucum is not a single species but a complex of at least seven genetically distinct species not distinguishable using traditional taxonomic criteria. We hypothesized that perceived intraspecific chemical variation observed in S. glaucum was actually due to differences between cryptic species (interspecific variation). To test this hypothesis, we collected Sarcophyton samples in Palau, performed molecular phylogenetic analysis, and prepared chemical profiles of sample extracts using gas chromatography-flame ionization detection. Both unsupervised (principal component analysis) and supervised (linear discriminant analysis) statistical analyses of these profiles revealed a strong relationship between cryptic species membership and chemical profiles. Liquid chromatography with tandem mass spectrometry-based analysis using feature-based molecular networking permitted identification of the chemical drivers of this difference between clades, including cembranoid diterpenes (2R,11R,12R)-isosarcophytoxide (5), (2S,11R,12R)-isosarcophytoxide (6), and isosarcophine (7). Our results suggest that early chemical studies of Sarcophyton may have unknowingly conflated different cryptic species of S. glaucum, leading to apparently idiosyncratic chemical variation.

Electrocatalytic and photocatalytic hydrogen production from acidic and neutral-pH aqueous solutions using iron phosphide nanoparticles.

Nanostructured transition-metal phosphides have recently emerged as Earth-abundant alternatives to platinum for catalyzing the hydrogen-evolution reaction (HER), which is central to several clean energy technologies because it produces molecular hydrogen through the electrochemical reduction of water. Iron-based catalysts are very attractive targets because iron is the most abundant and least expensive transition metal. We report herein that iron phosphide (FeP), synthesized as nanoparticles having a uniform, hollow morphology, exhibits among the highest HER activities reported to date in both acidic and neutral-pH aqueous solutions. As an electrocatalyst operating at a current density of -10 mA cm(-2), FeP nanoparticles deposited at a mass loading of ∼1 mg cm(-2) on Ti substrates exhibited overpotentials of -50 mV in 0.50 M H2SO4 and -102 mV in 1.0 M phosphate buffered saline. The FeP nanoparticles supported sustained hydrogen production with essentially quantitative faradaic yields for extended time periods under galvanostatic control. Under UV illumination in both acidic and neutral-pH solutions, FeP nanoparticles deposited on TiO2 produced H2 at rates and amounts that begin to approach those of Pt/TiO2. FeP therefore is a highly Earth-abundant material for efficiently facilitating the HER both electrocatalytically and photocatalytically.

Electrocatalytic hydrogen evolution using amorphous tungsten phosphide nanoparticles.

Amorphous tungsten phosphide (WP), which has been synthesized as colloidal nanoparticles with an average diameter of 3 nm, has been identified as a new electrocatalyst for the hydrogen-evolution reaction (HER) in acidic aqueous solutions. WP/Ti electrodes produced current densities of -10 mA cm(-2) and -20 mA cm(-2) at overpotentials of only -120 mV and -140 mV, respectively, in 0.50 M H2SO4(aq).

Radiotherapy for optic nerve sheath meningioma: a case for earlier intervention?

AIMS: To assess tumour control, visual outcomes and toxicity after radiotherapy for all patients with optic nerve sheath meningiomas (ONSM) treated by a single radiation oncologist at a single institution over a 15 year period. To explore potential predictors of outcomes. MATERIALS AND METHODS: All patients underwent ophthalmological and radiological assessments before radiotherapy. These were repeated at regular intervals after treatment. A retrospective analysis of clinical, dosimetric and radiological data was carried out. Patients with useful vision before radiotherapy were divided into two groups - those with maintained or improved vision and those with a deterioration in vision. The groups were compared using the Mann-Whitney U-test with regard to eight potential predictors of outcome. RESULTS: Seventeen patients with 18 ONSM were treated with fractionated radiotherapy (46.8-55.8 Gy in 26-31 fractions). No evaluable tumours grew after treatment: control rate 100% (95% confidence interval 82-100%). Using the most common definition of visual function described in the literature, vision was maintained or improved in 89% (95% confidence interval 67-97%) of cases. In those with useful vision before treatment (13 evaluable eyes), visual acuity was maintained or improved in eight (62%, 95% confidence interval 36-82%). There was a suggestion that the time from the onset of symptoms to radiotherapy may influence outcome. Those with stable or better visual acuity after radiotherapy had been observed for a shorter time compared with those who had worse visual acuity (median of 18 months versus 62 months). Acute and late toxicity from radiotherapy was manageable. CONCLUSION: Radiotherapy is an extremely effective modality in arresting the growth of ONSM. A longer time from symptom onset to the start of radiotherapy may predict for poorer outcomes.

Primary anorectal melanoma: an update.

The anorectum is a rare anatomic location for primary melanoma. Mucosal melanoma is a distinct biological and clinical entity from the more common cutaneous melanoma. It portrays worse prognosis than cutaneous melanoma, with distant metastases being the overwhelming cause of morbidity and mortality. Surgery is the treatment of choice, but significant controversy exists over the extent of surgical resection. We present an update on the state of the art of anorectal mucosal melanoma. To illustrate the multimodality approach to anorectal melanoma, we present a typical patient.

Development and maturation in the nereidid polychaetes Platynereis dumerilii and Nereis succinea exposed to xenoestrogens.

Few studies link biochemical, cellular and whole animal effects of toxic compounds with growth and reproductive output on invertebrate model organisms. Thus, we explore the effects of xenoestrogens on nereid worms. Larvae of Platynereis dumerilii exposed to estradiol (E(2)) ethynylestradiol (EE(2)) and nonyplhenol (NP) observing the effects on growth, primordial germ cell (PGC) proliferation and maturation. In addition, a single exposure study was performed with a 50 days latency period on adult worms of Nereis succinea. Since reduced glutathione (GSH) is required in detoxification of NP and is the precursor of the spawning pheromone nereithione (CSSG) in N. succinea, we analysed how the estrogenic chemical NP affects GSH concentrations. PGC were not affected by exposure to E(2) and EE(2) from 24hpf to 6 days. Chronic exposure of P. dumerilii with NP over the full life cycle did not influence segment proliferation. Mature females that developed, even at high concentrations, were able to spawn and successful fertilization occurred. However, at high NP levels no P. dumerilii males matured. A significant decline of GSH can be seen in N. succinea males upon treatment with NP, but not in females, indicating that females stabilize GSH levels even in stress situations. This study shows some results that link the foundation to causally integrate toxic exposure to xenoestrogens with development, growth and reproductive outputs in nereidid polychaetes.

Validation of lamellar body counts using three hematology analyzers.

The lamellar body count (LBC) represents an alternative method to the TDx-FLM II (Abbott Laboratories, Abbott Park, IL), which is planned to be discontinued, for assessing fetal lung maturity. Our objective was to validate the LBC on 3 hematology analyzers (Coulter LH 750 and Coulter Ac.T diff2, Beckman Coulter, Brea, CA; and Sysmex XE-2100, Sysmex, Mundelein, IL) to serve as a template for other laboratories attempting to perform in-house validation. Intra-assay and interassay coefficients of variation ranged from 1.7% to 21.8% and 1.9% to 7.1%, respectively, and all analyzers demonstrated excellent linearity. Whole blood and meconium were shown to interfere with LBCs, and specimens with these contaminants should be tested using phosphatidyl glycerol. With a TDx-FLM II cutoff of 55 mg/g or more and an LBC cutoff of 50,000/microL or more for maturity, concordance between the TDx-FLM II and the LBC on all instruments was poor (<80% in all cases). Concordance between hematology analyzers was excellent (>or=94%). When laboratories are performing in-house validations, they should not correlate LBC with TDx-FLM II results without outcome data. Correlation with another validated LBC method is preferred.

Orbital metastasis: clinical features, management and outcome.

PURPOSE: To review the clinical features, treatment, outcome and survival of metastatic tumors of the orbit. MATERIALS AND METHODS: Retrospective, non-comparative, chart review of 80 patients with orbital metastasis treated in four tertiary orbital centres in Australia. RESULTS: The study included 80 patients of which, 44 were male with a mean age of 60 years. Orbital involvement commonly presented late in a multisystemic disease; however, the orbit was the first presentation in 15% of the cases. Diplopia (48%), pain (42%), and visual loss (30%) were the commonest symptoms at presentation; whereas proptosis (63%), strabismus (62%), and visual loss (41%) were the most frequent clinical signs. Computed tomography commonly showed a solid enhancing mass (42 cases) located within the orbital fat (43%), or enlarging an extraocular muscle (28%). Breast carcinoma (29%), melanoma (20%), and prostatic cancer (13%) were the most frequent histological types. Treatment was often multi-disciplinary and modalities included radiotherapy, chemotherapy, hormone therapy, surgery, and immunotherapy. Survival was limited to 1.5 years after diagnosis independent of the histological type, with 29% of patients alive after 17 months follow-up. CONCLUSIONS: A high index of suspicion and appropriate intervention with histological diagnosis can help in the management and quality of life in patients with metastatic orbital disease. Overall survival is limited and we encountered statistical limitations proving differences in the survival based on the sub-type of primary tumour involved. Metastatic orbital melanoma presented a higher incidence when compared with previous studies, probably due to the increase frequency of skin found in the Australian population.

Safety and efficacy of daptomycin in the treatment of osteomyelitis: results from the CORE Registry.

Antibiotic safety is a major determinant in osteomyelitis therapy. Limited data is available describing the long-term safety and efficacy of daptomycin. the safety population was drawn from CORE 2005 and 2006, a retrospective, observational, multicenter study. Clinically evaluable patients received >3 days of daptomycin appropriately adjusted for renal function. three hundred twenty-seven patients were evaluated for safety; 188 (57%) >or=6 mg/kg, 139 (43%) <6 mg/kg. Thirty-one (10%) patients experienced adverse events possibly related to daptomycin and the incidence was similar regardless of dose. No difference was observed in the rate of creatine phosphokinase elevations by dose. A trend toward higher improved rates was noted in patients receiving a final dose of >or=6mg/kg (96% vs. 90%, P=0.08). Daptomycin appeared well-tolerated at doses of 6 mg per kg or greater which were associated with greater clinical improvement. These results require verification via a prospective clinical trial.

The visual fields: an interdisciplinary history II. neurosurgeons and quantitative perimetry.

When operations for brain tumours became possible, exact charting of visual field defects assumed great importance in diagnosis and in monitoring post-operative progress. This process, known as quantitative perimetry, was energetically practised and taught by Harvey Cushing and by many of his pupils. The advent of non-invasive methods of imaging the brain and the rise of neuro-ophthalmology as an independent discipline were associated with a decline in neurosurgical commitment to quantitative perimetry, but it remains an important branch of the clinical neurosciences.

The visual fields: an interdisciplinary history I. The evolution of knowledge.

A subjective study of a hemianopic field defect was reported to the London Royal Society in 1824. The German ophthalmologist Albrecht von Graefe devised a means of mapping field defects, which evolved into quantitative perimetry as an exact method of localizing lesions in the visual pathways. Knowledge of these pathways increased during the nineteenth century; final identification of the visual cortex in the occipital lobe was achieved by Japanese and British ophthalmologists and neurologists on the basis of wartime studies of field defects due to cerebral missile wounds.

Neuro-ophthalmic manifestations of intracranial cavernous hemangiomas.

PURPOSE: To describe the neuro-ophthalmic manifestations of patients with intracranial cavernous hemangiomas (cavernomas). METHODS: A retrospective review of all patients with intracranial cavernomas with neuroophthalmic manifestations who were treated at the Royal Adelaide Hospital in Australia between 1994 and 2004. RESULTS: There were nine patients (three men and six women), with a mean age of 39 years (range 22-61). There was one cerebellar lesion, two thalamic, four pontine, one midbrain/pontine, and one midbrain. Ophthalmic presentations included internuclear ophthalmoplegia (one patient), third cranial nerve (CN) palsy (one patient), fourth CN palsy (one patient), and sixth CN palsy (six patients). Three patients underwent extraocular muscle surgery, and six were treated medically or observed. In five patients the diplopia resolved, in three it was only mild, and in one patient no significant change was noted during the follow-up period. CONCLUSIONS: Diplopia is the main neuro-ophthalmic manifestation of intracranial cavernomas. Sixth CN palsy is the most common cause. Neurosurgical or conservative treatment leads to improvement in most cases, and later use of spectacles or extraocular muscle surgery may lead to further improvement.

Lipid-based amphotericin in pulmonary zygomycosis: safety and efficacy of high exposure in a renal allograft recipient.

Zygomycosis is associated with a high mortality in immunosuppressed patients. Treatment typically includes surgical resection and administration of intravenous amphotericin B. Success of treatment may require withdrawal of immunosuppression, with risk of graft loss. We report the successful treatment of invasive pulmonary zygomycosis, following initial surgical resection, using very high doses of lipid-based amphotericin B without withdrawal of immunosuppression. The patient received daily doses up to 10 mg/kg/day (51 g cumulatively) of lipid-based amphotericin B along with a brief course of intrapleural amphotericin. Despite immunosuppression not being withdrawn, the patient's kidney allograft function remained stable. We conclude that high doses of lipid-based amphotericin B can be safe and effective as part of the treatment regimen for pulmonary zygomycosis.

Neuro-ophthalmological sequelae of horse-related accidents.

PURPOSE: The aim of this study was to highlight the neuro-ophthalmological dangers associated with horse riding, and working around horses, and the importance of wearing adequate headgear to protect the rider from neuro-ophthalmic injuries. It raises the questions of whether the current laws regarding helmet use are satisfactory, and whether helmets currently used are of an adequate standard. METHODS: The records over a 20-year period of one neuro-ophthalmologist in Adelaide were reviewed producing 22 patients with neuro-ophthalmological sequelae of head injuries as a result of horse-related accidents. RESULTS: There were 22 patients (16 female, six male), one of whom was involved in three separate accidents, Of these, seven were professional riders and 15 amateur. In 20 of the 24 accidents, patients were either thrown or fell from the horse. Helmets were worn in 15 of the accidents. All the patients had closed head injuries of varying severity. The most common neuro-ophthalmological complication found was a fourth-nerve palsy in 11 patients. Five patients had a significant loss of vision and two of these were severe enough to warrant a blind pension. CONCLUSIONS: Horse riding and working around horses constitute an occupation or recreation with inherent dangers. Previous studies have shown that wearing of protective headgear reduces the risk and severity of head injuries, and helmet use should be vigorously promoted. The current laws and practices regarding helmet use are not uniform and seem to be inadequate. The current standard for equestrian safety helmets (AS/NZS 3838:1998) embodies improvements on earlier helmet standards and certainly increases the rider's chances of surviving a severe impact. Nevertheless, serious brain injuries have occurred in wearers of approved helmets, and further research is desirable to ensure the optimum degree of protection compatible with rider acceptance.

Visual field loss associated with vigabatrin: pathological correlations.

Pathological changes are reported in the anterior visual pathways of a 41 year old man with complex partial seizures treated with vigabatrin who developed bilateral visual field constriction. There was peripheral retinal atrophy with loss of ganglion cells and loss of nerve fibres in the optic nerves, chiasm, and tracts. No evidence of intramyelinic oedema was seen. These findings suggest that the primary site of injury lies within the ganglion cells in the retina. The degree of atrophy seen would suggest that the visual field loss is irreversible.

Ganglioglioma of the lateral ventricle presenting with blepharospasm - case report and review of the literature.

Gangliogliomas of the lateral ventricle are unusual tumours of the central nervous system. We report a 25-year-old female who presented with a 4-week history of generalized headaches associated with left-sided blepharospasm. Clinical examination revealed bilateral papilloedema but no focal neurological deficits. Computed tomography and magnetic resonance imaging demonstrated a large lesion within the left lateral ventricle. Gross total surgical resection of the lesion was performed through a para-sagittal, trans-callosal approach. Histopathological analysis revealed the diagnosis of ganglioglioma. The post-operative course was uneventful, with complete resolution of both the headaches and blepharospasm. The presentation with an ipsilateral blepharospasm has never previously been reported in the setting of a lateral ventricular tumour.