Early senior decision-making in acute medicine: a critical review of health policy and implications for practice.

UK urgent care health policies advocate senior clinical decision-making at the point of referral into the system. The costs of employing senior clinicians in this role are substantial with little evidence of the value they bring over other strategies, particularly for patient outcomes. We sought to explore current remote and ambulatory emergency care decision-making in acute medical care in a large central healthcare system - NHS Scotland. We found that many sites use remote decision-making for some allocation decisions. However, involvement of clinical expertise varies, and available decision-aids are few. There is also variation in access to resources that facilitate non-admission. Research into the value that senior clinicians bring to this task over other strategies is required.

Investigation of a foodborne outbreak of Shigella sonnei in Ireland and Northern Ireland, December 2016: the benefits of cross-border collaboration and commercial sales data.

OBJECTIVES: To describe a cross-border foodborne outbreak of Shigella sonnei that occurred in Ireland and Northern Ireland (NI) in December 2016 whilst also highlighting the valuable roles of sales data and international collaboration in the investigation and control of this outbreak. STUDY DESIGN: A cross-border outbreak control team was established to investigate the outbreak. METHODS: Epidemiological, microbiological, and environmental investigations were undertaken. Traditional analytical epidemiological studies were not feasible in this investigation. The restaurant chain provided sales data, which allowed assessment of a possible increased risk of illness associated with exposure to a particular type of heated food product (product A). RESULTS: Confirmed cases demonstrated sole trimethoprim resistance: an atypical antibiogram for Shigella isolates in Ireland. Early communication and the sharing of information within the outbreak control team facilitated the early detection of the international dimension of this outbreak. A joint international alert using the European Centre for Disease Control's confidential Epidemic Intelligence Information System for Food- and Waterborne Diseases and Zoonoses (EPIS-FWD) did not reveal further cases outside of the island of Ireland. The outbreak investigation identified that nine of thirteen primary case individuals had consumed product A from one of multiple branches of a restaurant chain located throughout the island of Ireland. Product A was made specifically for this chain in a food production facility in NI. S. sonnei was not detected in food samples from the food production facility. Strong statistical associations were observed between visiting a branch of this restaurant chain between 5 and 9 December 2016 and eating product A and developing shigellosis. CONCLUSIONS: This outbreak investigation highlights the importance of international collaboration in the efficient identification of cross-border foodborne outbreaks and the value of using sales data as the analytical component of such studies.

Characteristics of respiratory outbreaks in care homes during four influenza seasons, 2011-2015.

BACKGROUND: Influenza and other respiratory infections can spread rapidly and cause severe morbidity and mortality in care home settings. AIM: This study describes the characteristics of respiratory outbreaks in care homes in Northern Ireland during a four-year period, and aims to identify factors that predict which respiratory outbreaks are more likely to be positively identified as influenza. METHODS: Epidemiological, virological, and clinical characteristics of outbreaks during the study period were described. Variables collected at notification were compared to identify predictors for an outbreak testing positive for influenza. t-Tests and χ2-tests were used to compare means and proportions respectively; significance level was set at 95%. FINDINGS: During the four seasons, 95 respiratory outbreaks were reported in care homes, 70 of which were confirmed as influenza. More than 1000 cases were reported, with 135 associated hospitalizations and 22 deaths. Vaccination uptake in residents was consistently high (mean: 86%); however, in staff it was poorly reported, and, when reported, consistently low (mean: 14%). Time to notification and number of cases at notification were both higher than expected according to national recommendations for reporting outbreaks. No clinically significant predictors of a positive influenza outbreak were identified. CONCLUSION: Respiratory outbreaks in care homes were associated with significant morbidity and mortality, despite high vaccination uptake. The absence of indicators at notification of an outbreak to accurately predict influenza infection highlights the need for prompt reporting and laboratory testing. Raising staff awareness, training in the management of respiratory outbreaks in accordance with national guidance, and improvement of staff vaccination uptake are recommended.

Outbreak of invasive pneumococcal disease at a Belfast shipyard in men exposed to welding fumes, Northern Ireland, April-May 2015: preliminary report.

We report an outbreak of four confirmed cases of invasive pneumococcal disease (IPD) in individuals occupationally exposed to welding fumes, at a Belfast shipyard (Northern Ireland). All cases were hospitalised. A high-risk sub-group of 679 workers has been targeted for antibiotic prophylaxis and pneumococcal vaccination. Physicians and public health institutions outside Northern Ireland should be alert to individuals presenting with pneumonia or IPD and recent links to the shipyard, to facilitate early assessment and treatment.

Increase in scarlet fever notifications in the United Kingdom, 2013/2014.

Increases in scarlet fever above usual seasonal levels are currently being seen across the United Kingdom. Medical practitioners have been alerted to the exceptional increase in incidence. Given the potential for this to signal a population increase in invasive group A streptococcal disease, close monitoring of invasive disease is essential.

Hepatitis A outbreak predominantly affecting men who have sex with men in Northern Ireland, October 2008 to July 2009.

We describe an outbreak of hepatitis A which evolved in Northern Ireland between October 2008 and July 2009, against a background of large concurrent hepatitis A outbreaks in various parts of Europe. Thirty-eight cases were defined as outbreak cases using a stratified case definition; 36 were males with a median age of 29 years and of the 28 males whose sexual orientation was known, 26 were men who have sex with men(MSM). Detailed descriptive epidemiology data collected through standardised questionnaires, together with sequencing of a 289 bp fragment of the VP1/2PA region of the virus, significantly aided the understanding of the spread of the outbreak when non-MSM cases occurred. The sequence of the outbreak strain, genotype IA, was indistinguishable from that involved in a large outbreak in the Czech Republic. Although seeded in a generally susceptible Northern Ireland population, the outbreak remained mostly contained in MSM, showing this sub-population to be the most vulnerable despite ongoing hepatitis A vaccination programmes in genito-urinary medicine clinics.

Salmonella enterica serovar Agona European outbreak associated with a food company.

We investigated an international outbreak of Salmonella Agona with a distinct PFGE pattern associated with an Irish Food company (company X) producing pre-cooked meat products sold in various food outlet chains in Europe. The outbreak was first detected in Ireland. We undertook national and international case-finding, food traceback and microbiological investigation of human, food and environmental samples. We undertook a matched case-control study on Irish cases. In total, 163 cases in seven European countries were laboratory-confirmed. Consumption of food from food outlet chains supplied by company X was significantly associated with being a confirmed case (mOR 18·3, 95% CI 2·2-149·2) in the case-control study. The outbreak strain was isolated from the company's pre-cooked meat products and production premises. Sufficient evidence was gathered to infer the vehicles of infection and sources of the outbreak and to justify the control measures taken, which were plant closure and food recall.

Spotlight on measles 2010: ongoing measles outbreak in Northern Ireland following an imported case, September-October 2010.

We report an ongoing outbreak of measles with five laboratory-confirmed and four epidemiologically linked cases in Northern Ireland as at 26 October 2010. The index case was an unvaccinated non-Northern Ireland resident with subsequent genotyping suggesting that infection originated in the usual country of residence of this case. Confirmed cases include one patient with a history of two measles-mumps-rubella vaccine doses.

Anthracenone ABA analogue as a potential photoaffinity reagent for ABA-binding proteins.

An anthracenone analogue of abscisic acid (ABA) was synthesized as a potential photoaffinity reagent and tested for biological activity. Reaction between 10,10'-dimethoxy-9-anthrone with two equivalents of the lithiated dianion of cis-3-methylpent-2-en-4-yn-1-ol afforded an acetylenic alcohol key intermediate. Subsequent reduction of the triple bond, functional group manipulation of the side chain alcohol and deprotection of the dimethoxy protected anthrone provided anthracenone ABA analogue 7 as a potential photoaffinity reagent for ABA-binding proteins. The effect of natural ABA and the potential photoaffinity anthracenone ABA 7 on corn cell growth was determined at various concentrations. The results show that anthracenone ABA 7 is perceived as ABA-like, although producing less inhibition than ABA itself. For example, 7 at 33 microM produces approximately the same inhibition as ABA at 10 microM.

Lokomaika'i (inner health) in a remarkable hospital.

Seven years ago, The Queen's Medical Center in Honolulu, Hawaii embarked on a journey of rediscovery, one that would explore the past, present and future of the health care environment. In an effort to provide the best care and services to the people of Hawaii, Queen's embraces a philosophy of care that incorporates the physical, emotional, social and spiritual needs of its patients.

The Queen's Medical Center Honolulu, Hawaii.

The Queen's Medical Center created and almost fully realized a vision of professional nursing practice. This vision was mission-driven and philosophically oriented in that our Hawaiian heritage and commitment to a patient-centered focus dictated the direction taken. Utilizing the nursing process, we listened to our patients in identifying the nursing model to best meet their needs: primary nursing. In order to achieve that, the nurse at the bedside had to be empowered to make decisions directly impacting patient care. We further committed to treating the whole patient and considering complementary therapies. We have established an evaluation baseline and are committed to a process that will carry us into the year 2000.

The effects of time and dose on the relative beta 1- and beta 2-adrenoceptor antagonism of betaxolol and atenolol.

1. Six normal subjects were given single oral doses of betaxolol 10 mg (B10), 40 mg (B40), 80 mg (B80); atenolol 50 mg (A50), 200 mg (A200); or placebo (PL). Measurements of beta 1-adrenoceptor blockade (reduction of exercise heart rate) and of beta 2-adrenoceptor blockade (attenuation of isoprenaline responses) were made at baseline, and at 2, 4, 6, 8 and 24 h after drug ingestion. 2. Mean values for Cmax and tmax were as follows: B10 (33 ng ml-1, 3.7 h), B40 (84 ng ml-1, 4.0 h), B80 (179 ng ml-1, 3.7 h); A50 (261 ng ml-1, 2.7 h), A200 (1369 ng ml-1, 2.0 h). 3. Reduction of exercise heart rate (EHR) occurred in dose-dependent fashion up to a ceiling at B40 (as % reduction c.f. placebo, at peak and 24 h): B10 16.2 to 10.2%, B40 27.1 to 16.2%, B80 27.0 to 18.7%; A50 20.9 to 9.1%, A200 28.8 to 15.8%. There were also dose-related increases in beta 2-adrenoceptor antagonism (IT100 dose ratios, at peak and 24 h): B10 2.1 to 1.2, B40 4.7 to 2.6, B80 6.0 to 4.7; A50 2.0 to 1.2, A200 4.7 to 1.8. There were similar trends for attenuation of heart rate and DBP responses to isoprenaline. 4. Ratios of beta 1:beta 2-adrenoceptor antagonism were calculated (as % reduction EHR divided by IT100 dose ratio); to provide an index of beta 1-adrenoceptor selectivity at peak and 24 h: B10 7.7 to 8.5, B40 5.8 to 6.2, B80 4.5 to 4.0; A50 10.5 to 7.6, A200 6.1 to 8.8.(ABSTRACT TRUNCATED AT 250 WORDS)

A dose-ranging study to evaluate the beta 1-adrenoceptor selectivity of bisoprolol.

A dose-ranging study was performed to compare the beta 1-adrenoceptor selectivity of bisoprolol with that of atenolol and nadolol. Seven normal subjects (mean age 26 y) were given single oral doses of bisoprolol 5 mg (B5), 10 mg (B10), 20 mg (B20); atenolol 50 mg (A50), 100 mg (A100); nadolol 40 mg (N40); and placebo (PL), in a single blind randomised cross-over design. Beta 2-adrenoceptor responses were assessed by attenuation of finger tremor and cardiovascular responses to graded isoprenaline infusions. Dose-response curves were constructed, and doses of isoprenaline required to increase finger tremor by 100% (IT100), heart rate by 25 beats/min (IH25), SBP by 25 mmHg (IS25), cardiac output by 35% (IC35), and decrease DBP by 10 mmHg (ID10), after each treatment were calculated. These indices were compared with placebo response and expressed as dose-ratios. Exercise heart rate (EHR) was used to assess beta 1-adrenoceptor blockade. There were dose-related increases in plasma concentrations of bisoprolol and atenolol. Reduction of EHR was significantly less with B5 (16.8%) in comparison with all other treatments: B10 21.9%, B20 23.1%; A50 22.5%, A100 22.6%; N40 22.9%. There were small but significant reductions in isoprenaline-induced tachycardia with bisoprolol and atenolol, although mean dose-ratios were considerably less in comparison with N40 (IH25 dose-ratios): B5 2.55, B10 3.18, B20 3.93, A50 2.91, A100 4.89, N40 17.23. There were similar patterns for the other isoprenaline responses. These results show that conventional doses of bisoprolol (10 mg) and atenolol (50 mg) produced equal antagonism of beta 1 and beta 2-adrenoceptors, and therefore possess equal degrees of beta 1-adrenoceptor selectivity.(ABSTRACT TRUNCATED AT 250 WORDS)

The effects of chronic dosing on the beta 1 and beta 2-adrenoceptor antagonism of betaxolol and atenolol.

Six normal subjects were given once daily treatment for 15 days with placebo (PL), betaxolol 10 mg (B10), 40 mg (B40); atenolol 100 mg (A 100); and nadolol 40 mg (N40). Measurements of beta 1-adrenoceptorblockade (reduction of exercise heart rate) and of beta 2-adrenoceptor-blockade (attenuation of isoprenaline induced finger tremor) were made after the first, eighth and fifteenth doses of each drug. Plasma concentrations showed dose related increases between 10 mg and 40 mg doses of betaxolol, and there was significant drug accumulation at steady state compared with after single dosing. The reduction in exercise heart rate (EHR) with B10 was less in comparison with all other treatments. There were no significant differences in effects between single and chronic-dosing for any of the treatments (% reduction EHR compared with placebo, on days 1 and 15): B10 (18.2, 19.0), B40 (28.6, 26.5); A100 (22.7, 23.1); N40 (26.6, 23.8). Dose-ratios for attenuation of isoprenaline-induced finger tremor (IT100) were significantly greater with B40 compared with B10 or A100 (no dose-ratio for finger tremor could be calculated for N40). There were no differences between single and chronic-dosing (IT100 dose-ratios on days 1 and 15): B10 (3.0, 2.5), B40 (4.4, 5.3); A100 (3.0, 3.0). The attenuation of isoprenaline-induced chronotropic response (IH25) by N40 was significantly greater in comparison with all other treatments. IH25 dose-ratios (on days 1 and 15) were as follows: B10 (2.8, 3.6), B40 (5.1, 5.8); A100 (3.6, 3.6); N40 (19.0, 17.4).(ABSTRACT TRUNCATED AT 250 WORDS)

Cellular fatty acid composition of Oerskovia species, CDC Coryneform groups A-3, A-4, A-5, Corynebacterium aquaticum, Listeria denitrificans and Brevibacterium acetylicum.

Twenty four strains representing eight species of gram positive yellow-pigmented rods (Oerskovia turbata, Oerskovia xanthineolytica, CDC Coryneform groups A-3, A-4, A-5, Listeria denitrificans, Corynebacterium aquaticum and Brevibacterium acetylicum) were divided into two major groups based on the relative amounts of 12 methyltetradecanoate (15:0a) obtained by capillary gas liquid chromatography. O. turbata, O. xanthineolytica, CDC groups A-3 and A-4, L. denitrificans and C. aquaticum were placed in the first group due to the presence of a higher percentage (29-47%) of 15:0a, than CDC group A-5 and B. acetylicum. The latter contained 2-6% of this fatty acid, and were placed in the second group. All species in the two groups except C. aquaticum and CDC group A-4, were further separated from each other based on the qualitative and quantitative differences in their fatty acid compositions. In addition, the eight strains of CDC group A-5 revealed four different patterns and were further divided into four subgroups. This study supports the importance of the composition of cellular fatty acids in differentiating some closely related organisms.

A dose-ranging study to evaluate the beta-adrenoceptor selectivity of single doses of betaxolol.

1. Six normal subjects were given single oral doses of betaxolol 10 mg (B10), 20 mg (B20), 40 mg (B40), 80 mg (B80), propranolol 40 mg (P40), or placebo (PL) in a single-blind randomised cross-over design. 2. beta 1-adrenoceptor blockade was assessed by reductions in exercise heart rate. Betaxolol produced dose-related reductions in exercise heart rate (beats min-1) up to a ceiling at B40, after which B80 showed a lesser effect: (158 +/- 8 PL, 128 +/- 3 B10, 123 +/- 2 B20, 116 +/- 4 B40, 136 +/- 10 B80, 135 +/- 4 P40). All doses of betaxolol (except B80) produced greater reductions compared with P40: (B10 P less than 0.001, B20 P less than 0.005, B40 P less than 0.001). 3. beta 2-adrenoceptor blockade was assessed by attenuation of finger tremor and cardiovascular responses to graded infusions of i.v. isoprenaline. Dose-response curves were constructed and the doses required to increase heart rate by 25 beats min-1, finger tremor by 200%, calf blood flow by 0.5 ml dl-1 min-1, and decrease diastolic blood pressure by 10 mm Hg, after each treatment were calculated. These were then compared with placebo responses and expressed as dose-ratios. 4. Dose-ratios for finger tremor showed significant attenuation by all doses of betaxolol (compared with PL): B10 1.5 +/- 0.18 (P less than 0.05), B20 2.62 +/- 0.45 (P less than 0.005), B40 2.55 +/- 0.33 (P less than 0.001), B80 2.48 +/- 0.48 (P less than 0.01); and by P40 6.49 +/- 1.12 (P less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of once daily atenolol, nitrendipine and their combination in mild to moderate essential hypertension.

1. The aim of the study was to compare the efficacy and the tolerability of treatment with atenolol (50-100 mg once daily), nitrendipine (20-40 mg once daily) and their combination (atenolol 50 mg + nitrendipine 20 mg) once daily in patients with mild to moderate essential hypertension. 2. The study was a randomised, double-blind, placebo controlled parallel groups design: blood pressures were measured at 'trough' effect (i.e. 24 h after dosing) to assess the adequacy of once-daily treatment. 3. Mean blood pressures (mm Hg) recorded on four occasions over 12 weeks of treatment were significantly lower both with atenolol (155/97 sitting: 155/104 standing) and with the combination of atenolol plus nitrendipine (153/96 sitting: 152/104 standing) than with placebo (169/108 sitting: 169/114 standing). Nitrendipine alone had no significant effect on blood pressure 24 h after dosing (165/104 sitting: 165/110 standing). 4. Withdrawals due to adverse effects were more common during treatment with nitrendipine: 7/32 of the patients experienced adverse effects attributable to intense systemic vasodilatation (e.g., flushing, erythema, headache). 2/37 patients taking atenolol were withdrawn: one because he developed a psoriatic rash and the other because of impaired peripheral circulation. Of the 35 patients taking combination treatment, two were withdrawn: one developed headaches and dyspnoea, and the other asthma. 5. The results suggest that once daily dosing with nitrendipine does not control blood pressure throughout the 24 h period in the majority of patients, and is associated with a considerable burden of adverse effects. Combination treatment was better tolerated but appeared to offer no advantages over atenolol alone in terms either of blood pressure control or adverse effects.

Rapid screening test for the diagnosis of rotavirus infection.

The early diagnosis of human rotavirus infection is essential for effective patient management and infection control. We report here a rapid, easy-to-perform, and inexpensive test for rotavirus detection. The viral RNA is extracted directly from the stools and electrophoresed on 1% agarose gels. Currently available immunoassays for routine diagnostic purposes are directed at the common group A-specific antigen. As reports become available on human gastroenteritis caused by the atypical or novel rotaviruses, this technique presents an added advantage in that it can detect both group A and non-group A rotaviruses.