Risk factors for SARS-CoV-2 infection in healthcare workers following an identified nosocomial COVID-19 exposure during waves 1-3 of the pandemic in Ireland.

Healthcare workers (HCWs) have increased exposure and subsequent risk of infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). This case-control study was conducted to investigate the contemporaneous risks associated with confirmed SARS-CoV-2 infection amongst HCWs following in-work exposure to a confirmed coronavirus disease-2019 (COVID-19) case. We assessed the influence of demographic (age, sex, nationality, high risk co-morbidities and vaccination status) and work-related factors (job role, exposure location, contact type, personal protective equipment (PPE) use) on infection risk following nosocomial SARS-CoV-2 exposure. All contact tracing records within the hospital site during waves 1-3 of the COVID-19 pandemic in Ireland were screened to identify exposure events, cases and controls. In total, 285 cases and 1526 controls were enrolled, as a result of 1811 in-work exposure events with 745 index cases. We demonstrate that male sex, Eastern European nationality, exposure location, PPE use and vaccination status all impact the likelihood of SARS-CoV-2 infection following nosocomial SARS-CoV-2 exposure. The findings draw attention to the need for continuing emphasis on PPE use and its persisting benefit in the era of COVID-19 vaccinations. We suggest that non-work-related factors may influence infection risk seen in certain ethnic groups and that infection risk in high-risk HCW roles (e.g. nursing) may be the result of repeated exposures rather than risks inherent to a single event.

The epidemiology of assault-related hospital in-patient admissions and ED attendances.

The aim of this study was to describe the epidemiology and impact of serious assault warranting in-patient care over six years and its impact on ED attendances in a large teaching hospital in Dublin over 2 years. There were 16,079 emergency assault-related inpatient hospital discharges reducing from 60.1 per 100,000 population in 2005 to 50.6 per 100,000 population in 2010. The median length of stay was 1 day (1-466) representing 49,870 bed days. The majority were young males (13,921, 86.6%; median age 26 years). Overall crime figures showed a similar reduction. However, knife crimes did not reduce over this period. Data on ED attendances confirmed the age and gender profile and also showed an increase at weekends. Alcohol misuse was recorded in 2,292/16079 (14%) of in-patient cases and 242/2484 (10%) in ED attendances. An inter-sectoral preventative approach specifically targeting knife crime is required to reduce this burden on health services.

Estimating the effect of mastitis on the profitability of Irish dairy farms.

The objective of this paper was to estimate the effect of the costs of mastitis on the profitability of Irish dairy farms as indicated by various ranges of bulk milk somatic cell count (BMSCC). Data were collected from 4 sources and included milk production losses, cases treated, and on-farm practices around mastitis management. The Moorepark Dairy Systems Model, which simulates dairying systems inside the farm gate, was used to carry out the analysis. The cost components of mastitis that affect farm profitability and that were included in the model were milk losses, culling, diagnostic testing, treatment, veterinary attention, discarded milk, and penalties. Farms were grouped by 5 BMSCC thresholds of ≤ 100,000, 100,001-200,000, 200,001-300,000, 300,001-400,000, and > 400,000 cells/mL. The ≤ 100,000 cells/mL threshold was taken as the baseline and the other 4 thresholds were compared relative to this baseline. For a 40-ha farm, the analysis found that as BMSCC increased, milk receipts decreased from €148,843 at a BMSCC <100,000 cells/mL to €138,573 at a BMSCC > 400,000 cells/mL. In addition, as BMSCC increased, livestock receipts increased by 17%, from €43,304 at a BMSCC <100,000 cells/mL to €50,519 at a BMSCC > 400,000 cells/mL. This reflected the higher replacement rates as BMSCC increased and the associated cull cow value. Total farm receipts decreased from €192,147 at the baseline (< 100,000 cells/mL) to €189,091 at a BMSCC > 400,000 cells/mL. Total farm costs increased as BMSCC increased, reflecting treatment, veterinary, diagnostic testing, and replacement heifer costs. At the baseline, total farm costs were €161,085, increasing to €177,343 at a BMSCC > 400,000 cells/mL. Net farm profit decreased as BMSCC increased, from €31,252/yr at the baseline to €11,748/yr at a BMSCC > 400,000 cells/mL. This analysis highlights the impact that mastitis has on the profitability of Irish dairy farms. The analysis presented here can be used to develop a "cost of mastitis" tool for use on Irish dairy farms to motivate farmers to acknowledge the scale of the problem, realize the value of improving mastitis control, and implement effective mastitis control practices.

Development and application of a processing model for the Irish dairy industry.

A processing-sector model was developed that simulates (i) milk collection, (ii) standardization, and (iii) product manufacture. The model estimates the product yield, net milk value, and component values of milk based on milk quantity, composition, product portfolio, and product values. Product specifications of cheese, butter, skim and whole milk powders, liquid milk, and casein are met through milk separation followed by reconstitution in appropriate proportions. Excess cream or skim milk are used in other product manufacture. Volume-related costs, including milk collection, standardization, and processing costs, and product-related costs, including processing costs per tonne, packaging, storage, distribution, and marketing, are quantified. Operating costs, incurred irrespective of milk received and processing activities, are included in the model on a fixed-rate basis. The net milk value is estimated as sale value less total costs. The component values of fat and protein were estimated from net milk value using the marginal rate of technical substitution. Two product portfolio scenarios were examined: scenario 1 was representative of the Irish product mix in 2000, in which 27, 39, 13, and 21% of the milk pool was processed into cheese (€ 3,291.33/t), butter (€ 2,766.33/t), whole milk powder (€ 2,453.33/t), and skim milk powder (€ 2,017.00/t), respectively, and scenario 2 was representative of the 2008 product mix, in which 43, 30, 14, and 13% was processed into cheese, butter, whole milk powder, and skim milk powder, respectively, and sold at the same market prices. Within both scenarios 3 milk compositions were considered, which were representative of (i) typical Irish Holstein-Friesian, (ii) Jersey, and (iii) the New Zealand strain of Holstein-Friesian, each of which had differing milk constituents. The effect each milk composition had on product yield, processing costs, total revenue, component values of milk, and the net value of milk was examined. The value per liter of milk in scenario 1 was 24.8, 30.8, and 27.4 cents for Irish Holstein-Friesian, Jersey, and New Zealand strain of Holstein-Friesian milk, respectively. In scenario 2 the value per liter of milk was 26.1, 32.6, and 28.9 cents for Irish Holstein-Friesian, Jersey, and New Zealand strain of Holstein-Friesian milk, respectively.

Resource utilisation for syncope presenting to an acute hospital Emergency Department.

BACKGROUND: Syncope is a common clinical problem accounting for up to 6% of hospital admissions. Little is known about resource utilisation for patients admitted for syncope management in Ireland. AIM: To determine the utilisation of resources for patients admitted for syncope management. METHODS: Single centre observational case series of consecutive adult patients presenting to an acute hospital Emergency Department with syncope over a 5-month period. RESULTS: Two-hundred and fourteen of 18,898 patients (1.1%) had a syncopal episode, 110 (51.4%) of whom were admitted. Mean length of stay was 6.9 days. Sixty-four of these admissions were deemed unnecessary by retrospective review when compared to ESC guidelines. Eighty-five (77.3%) admitted patients had cardiac investigations and 56 (51%) had brain imaging performed. CONCLUSIONS: Syncope places a large demand on overstretched hospital resources. Most cases can be managed safely as an outpatient and to facilitate this, hospitals should develop outpatient Syncope Management Units.

Toma de decisiones clínicas en Medicina de Urgencias y Emergencias / Clinical decision making in emergency medicine

Se revisan los mecanismos en los que se basa la toma de decisiones en Medicina de Urgencias y Emergencias. Esta toma de decisiones, lejos de basarse en el principio de acción-reacción, se rige por procesos cognitivos que desarrollan estrategias y habilidades complejas y que permiten su ejecución correcta. En estos procesos cognitivos influyen factores relacionados con el profesional, con el propio servicio de urgencias y con los pacientes. Como resultado, se definen dos modelos generales de razonamiento clínico. El “sistema 1” es instintivo y alimentado por el reconocimiento. Se adquiere con el tiempo a través de la experiencia. El “sistema 2” es sistemático y analítico. Es más fiable que el primero y menos propenso al error, aunque más largo en el tiempo de aprender y más caro. La combinación de ambos sistemas de pensamiento es usualmente lo más efectivo para afrontar la mayoría de las situaciones clínicas. A lo largo de este artículo se describen los aspectos clave en la toma de decisiones, cuyo objetivo último es minimizar el riesgo de error en la práctica de la Medicina de Urgencias (AU)

This review of the bases for decision making in emergency medicine argues that the process involves more than a simple an action-reaction sequence. Instead, decisions are governed by cognitive processes that favor the development of strategies and complex skills that enable the physician to act appropriately. Influential factors include physician-related attributes as well as emergency service- and patient-related ones. Two models of clinical reasoning are defined. In the first system, reasoning is instinctive, driven by pattern recognition. The ability to make decisions with this system is acquired over time, through experience. In the second system, decision making is systematic and analytical. More reliable than the first system, this second one is less prone to error, although it takes longer to learn and is more costly. The most effective way to cope with most clinical situations is usually to combine these 2 cognitive approaches. This review describes key aspects of decision making processes that aim to minimize the risk of making mistakes in emergency medical practice (AU)

Caveats in the management and diagnosis of cerebellar infarct and vertebral artery dissection.

Early MRI, available 24 h a day and at weekends, will make a timely diagnosis in cases of cerebellar infarct and a normal initial CT scan does not exclude it. In many emergency departments MRI is not as routinely available out of hours as CT. It is important to appreciate the varied symptomatology and signs of cerebellar infarcts in order to avoid misdiagnosis or delayed diagnosis and to remember that, apart from requiring treatment with anticoagulation for the cerebellar infarct itself, the complications of cerebellar infarct may require surgical intervention. Vertebral artery dissection as a cause of cerebellar infarct may require anticoagulation or endovascular therapy.

Validation of the use of the ROSIER stroke recognition instrument in an Irish emergency department.

BACKGROUND: A study was performed to determine the utility of the 8-point recognition of stroke in the emergency room (ROSIER) instrument as a diagnostic tool in a large Irish emergency department. METHODS: Fifty patients had ROSIER scores completed by doctors. Diagnoses achieved using the score were compared with discharge diagnoses. Relations between ROSIER score, impairment and length of stay were assessed. RESULTS: Forty-seven patients (94%) had a ROSIER Score > or =1 indicating a stroke, 44 (94%) of these had stroke confirmed on investigation. Two patients with stroke were missed and three were wrongly identified. Positive predictive value for the ROSIER was 94%. ROSIER correlated with Scandinavian neurological stroke score. (r = -0.414, p = 0.003) and was associated with increasing length of stay in survivors (p = 0.16, one-way ANOVA. F = 3.116, df = 6). CONCLUSION: The ROSIER is a suitable and useful adjunct in the assessment of stroke patients in Ireland.

Intravenous magnesium is ineffective in adult asthma, a randomized trial.

Intravenous magnesium sulphate (MgSO4) has been tried in the emergency department treatment of asthma since the mid-1980s, but published reports vary as to its efficacy. The literature suggests that it may be effective in the more severely ill asthmatic. We evaluated i.v. MgSO4 in adult asthmatics having a moderate to severe exacerbation. The study was performed in a convenience sample of adult asthmatics between the ages of 18 and 55 presenting to the emergency department with a peak expiratory flow (PEF) of < 100 l/min or < 25% of predicted flow. Patients received either 2.0 grams of MgSO4 or placebo in a randomized, double-blind fashion. All patients received inhaled bronchodilators and i.v. steroids. Outcome variables were: improvement in PEF, subjective respiratory distress as measured by the Borg dyspnoea scale (BDS) and hospital admission. The first visits of 42 patients presenting with acute asthma exacerbations were evaluated, 18 receiving MgSO4 and 24 receiving placebo. The t = 60 peak flow in the MgSO4 group was 174 l/min versus 212 l/min in placebo, p = 0.04. Controlling for age, heart rate, initial PEF and initial BDS in ordinal logistic regression, the t = 60 Borg scale of subjective dyspnoea had an odds ratio of 1.54 in favour of more dyspnoea in MgSO4 (95% C.I., 0.36-6.67; p = 0.56). Five of 18 patients (28%) receiving MgSO4 were admitted compared with 5 of 24 (21%) receiving placebo (p = 0.72). In moderately severe adult asthmatics, 2.0 grams of MgSO4 i.v. resulted in less improvement in peak expiratory flow compared with placebo. MgSO4 did not appear to decrease subjective dyspnoea or the hospital admission rate. This evidence does not support the use of MgSO4 in the treatment of acute asthma.

How we did it: the development of a specialist registrar training programme by the Mersey Accident and Emergency Trainees' Association.

Over the last three years the accident and emergency trainees in Merseyside have developed a self directed training programme which now consists of twice monthly meetings. This has been achieved through a process of evolution, shaped by the core curriculum, and supervised by the region's consultants with the support of the postgraduate dean. The meetings have proved both popular and valuable. The development and format of the scheme is presented in the hope of stimulating others to work together to improve the training of specialist registrars.

Occult gunshot injury of the temporal bone.

Increasing firearms violence has produced much public disquiet in recent months and Liverpool has seen a particularly well publicized spate of shootings. This is a case report of an initially occult intracranial injury which illustrates the unpredictable nature of missile trauma and the importance of computerised tomography in all cases of gunshot injury to the head.