Alcohol and acute traumatic brain injury in the emergency department.

OBJECTIVE: There is limited research from Australasian EDs describing the demographic make-up, injury severity and impact of alcohol in patients requiring computed tomography (CT) for suspected traumatic brain injury (TBI). The present study aims to review the frequency and presenting patterns of patients who consume alcohol prior to presenting with suspected TBI. METHODS: Retrospective observational study of patients referred for head CT to exclude TBI from a major referral centre and regional ED in New Zealand, between 1 September 2018 and 31 August 2019. Comparison groups were defined as 'alcohol involved' or 'no alcohol involved'. RESULTS: 97/425 (22.8% [95% CI 18.3-27.4]) of included TBI presentations involved alcohol. 73/97 (75.3% [95% CI 58.6-93.5]) were male and 41/97 (42.3% [95% CI 29.3-55.2]) were aged 18-30 years. The alcohol group were more likely to report assault as the injury mechanism (19.6% [95% CI 10.8-28.4] vs 5.2% [95% CI 2.7-7.7], P < 0.05) and have Glasgow Coma Scale scores reflecting more moderate (13.5% [95% CI 5.9-21.1] vs 3.5% [95% CI 1.5-5.6]) and severe (5.6% [95% CI 0.7-10.5] vs 3.2% [95% CI 1.2-5.2] TBI. Presentation times post-injury were delayed compared to the no alcohol group (3.4 h [interquartile range 1.9-14.8] vs 2.8 h [interquartile range 1.8-6.6], P < 0.05). CONCLUSION: One quarter of patients with suspected TBI had consumed alcohol prior to their injury. Predominantly, those affected were young males who reported higher rates of assault; however, alcohol use was recorded in all age groups and sex. Alcohol-affected patients presented later, potentially delaying time to diagnosis. The present study supports the call for public health interventions that aim to reduce alcohol misuse.

Prescribers aware: a cross-sectional study from New Zealand emergency departments on the substances used in intentional self-poisoning and their sources.

INTRODUCTION Intentional self-poisoning or self-harm through poisoning, is a common cause of presentations to emergency departments (EDs). National datasets do not allow identification of the substances most commonly used in hospital-treated intentional self-poisoning in New Zealand, nor do they capture sources of these substances. AIM To investigate the specific substances used in intentional self-poisoning and the sources from which they are obtained. METHODS In this cross-sectional study, information about the demographics and presentation particulars of intentional self-poisoning patients aged ≥16 years, presenting to three public EDs, as well as the substances they used in the self-poisoning event and the sources of these agents, were collected prospectively. RESULTS A total of 102 patients were recruited from the potentially eligible 1137 intentional self-poisoning patients presenting to the three EDs during the study period. Seventy per cent used their own prescription medications and 24% used medicines they purchased themselves. Paracetamol and ethanol were most commonly encountered substances. Patients presented a median of 1.9h after exposure (interquartile range 1.0-3.3h), 62% self-referred, 60% presented to the ED in the evening or at night and 66% were triaged into Australasian Triage Scale 3 (to be seen within 30min). Two-thirds were referred to emergency psychiatric services. DISCUSSION Collecting specific substance information, such as from this study, can assist in planning specific activities to prevent intentional self-poisoning. As most people used their prescribed medicines, the findings can inform and assist doctors in their prescribing practices when they manage patients at risk of self-poisoning.

A descriptive study of intentional self-poisoning from New Zealand national registry data.

OBJECTIVE: Understanding which population groups intentionally poison themselves by overdose and which substances are used are key to developing prevention efforts for such injuries. This paper uses Ministry of Health (MOH) data to explore the demographic characteristics of those who intentionally self-poison and the substances used, identifies limitations of existing data collections and makes recommendations for the future. METHODS: MOH mortality data from 2000 to 2012, and public hospital presentation data from 2000-2014 of cases of intentional self-poisoning (ISP), and poisoning of undetermined intent (UDP), were examined. RESULTS: Men were more at risk of fatal intentional poisonings, while young women and people from deprived areas were predominant in hospital presentations for ISP and UDP. While ICD-10 categories were available, there was limited information in the majority of MOH data about specific substances used in the poisonings. CONCLUSIONS: The current format of MOH data indicates that developing interventions to help young people and those living in deprived areas may be useful. Finding specific solutions is challenging when only limited nationwide substance-specific poisoning information is available. Implications for public health: Including specific substances in national data collections is important for addressing the public health challenge of intentional overdose morbidity and mortality.

Care versus convenience: Examining paracetamol overdose in New Zealand and harm reduction strategies through sale and supply.

AIM: To examine statistics on paracetamol overdose in New Zealand and investigate options to reduce paracetamol overdose rates, through supply reduction strategies. METHOD: Data was gathered from the Ministry of Health's National Minimum Dataset and Wellington Hospital Emergency Department attendances. Twenty articles on supply reduction strategies were sourced through article database searches. A survey on paracetamol availability from online pharmacies within New Zealand was conducted by searching for New Zealand online pharmacies through Google. RESULTS: A five-year audit of data (2007-2012) from the Wellington Hospital Emergency Department revealed that paracetamol was the most common medication used for overdose (23%). National data on aminophenol derivatives accounted for 22.4% of poisonings in New Zealand's public hospitals. An online search found that 25 out of 27 online pharmacies sold packets containing 50 grams of paracetamol. However, the literature supported restricting packets to the minimum threshold for an acute exposure (10 g). CONCLUSION: Paracetamol poisoning is the most common form of drug overdose in many developed countries. Tightening restrictions on the quantity of paracetamol sold per packet, in all outlets in New Zealand, may be an effective strategy to reduce overdose rates. This includes online pharmacies where large quantities of paracetamol per packet are available for sale.

Haptic fMRI: using classification to quantify task-correlated noise during goal-directed reaching motions.

Neuroimaging artifacts in haptic functional magnetic resonance imaging (Haptic fMRI) experiments have the potential to induce spurious fMRI activation where there is none, or to make neural activation measurements appear correlated across brain regions when they are actually not. Here, we demonstrate that performing three-dimensional goal-directed reaching motions while operating Haptic fMRI Interface (HFI) does not create confounding motion artifacts. To test for artifacts, we simultaneously scanned a subject's brain with a customized soft phantom placed a few centimeters away from the subject's left motor cortex. The phantom captured task-related motion and haptic noise, but did not contain associated neural activation measurements. We quantified the task-related information present in fMRI measurements taken from the brain and the phantom by using a linear max-margin classifier to predict whether raw time series data could differentiate between motion planning or reaching. fMRI measurements in the phantom were uninformative (2σ, 45-73%; chance=50%), while those in primary motor, visual, and somatosensory cortex accurately classified task-conditions (2σ, 90-96%). We also localized artifacts due to the haptic interface alone by scanning a stand-alone fBIRN phantom, while an operator performed haptic tasks outside the scanner's bore with the interface at the same location. The stand-alone phantom had lower temporal noise and had similar mean classification but a tighter distribution (bootstrap Gaussian fit) than the brain phantom. Our results suggest that any fMRI measurement artifacts for Haptic fMRI reaching experiments are dominated by actual neural responses.

Ytterbium-catalyzed conjugate allylation of alkylidene malonates.

Alkylidene malonates undergo efficient conjugate allylation upon treatment with allylstannanes or allylsilanes under the action of ytterbium catalysis.

ExHALED study: prevalence of smoking and harm levels in an emergency department cohort.

OBJECTIVE: To determine the prevalence of smoking among ED patients compared with the general New Zealand (NZ) smoking prevalence. Secondary outcomes were to determine smokers' level of nicotine dependence, readiness to quit and engagement with primary health care. METHODS: This was a prospective, cross-sectional prevalence study of ED patients seen consecutively over 6 days in Wellington Hospital, Wellington South, NZ. Medically stable patients > or = 18 years were asked about their smoking habits by a closed-question survey. RESULTS: Five hundred and twenty-eight patients comprised the study group. The ED smoking prevalence was 33.1% and higher than the general NZ smoking prevalence of 20.7%. Of those who smoked, 26.3% were 'moderately' to 'very highly' dependent on nicotine (Fagerstrom Test for Nicotine Dependence, FTND score > or = 5). Of those who smoked, 74.9% stated they wanted to quit, 42.9% wanted to quit within the next month and 60.6% wanted an ED quit smoking pack. There were 13.6% of ED patients not registered with a general practitioner; of this, 61.1% were current smokers and 70.5% wanted to quit smoking. CONCLUSIONS: The prevalence rates of smoking are higher among patients attending Wellington Hospital ED than the general NZ population and the majority would like to quit smoking. One in four ED smokers have a high FTND score and are considered nicotine-dependent. Many patients who were not registered with a general practitioner smoked, and the majority wanted to quit. Finally, there is significant interest from ED patients in receiving quit smoking packs from the ED.

Prospective study of 101 patients with suspected drink spiking.

OBJECTIVE: To evaluate cases of suspected drink spiking presenting to the ED by the prospective collection of standardized relevant historical, clinical and laboratory data. METHODS: A prospective observational study of 101 patients presenting to metropolitan hospital ED with suspected drink spiking within the previous 12 h. Clinical history, including details surrounding the alleged drink spiking incident, and examination. Blood ethanol concentration measurement, together with the analysis of urine and blood samples for illicit and sedative drugs. RESULTS: Of the 97 alleged drink spiking cases included, there were only 9 plausible cases. We did not identify a single case where a sedative drug was likely to have been illegally placed in a drink in a pub or nightclub. Illicit drugs were detected in 28% of the study group. Ethanol was commonly detected, with the mean number of standard drinks consumed being 7.7 +/- 3.9 SD, and the median blood ethanol concentration at the time of presentation was 0.096% (96 mg/dL). At follow-up there were no major sequelae and no police prosecutions. Thirty five per cent of patients still believed that they had been a victim of drink spiking irrespective of the results. CONCLUSION: Our study did not reflect the current public perception of drink spiking. Drink spiking with sedative or illicit drugs appears to be rare. If drink spiking does occur, ethanol appears to be the most common agent used. Of greater concern was the frequency of illicit drug use and excessive ethanol consumption within the study population, making it difficult to determine whether a person had truly had a drink spiked.

Cricoid pressure: assessment of performance and effect of training in emergency department staff.

OBJECTIVES: (i) To evaluate the theoretical knowledge and practical skills of ED staff regarding the technique of cricoid pressure; (ii) to assess the efficacy of two methods of cricoid pressure training. METHODS: Theoretical knowledge of participants was assessed by a pretraining questionnaire, and practical ability was assessed using a Flinders Meditech cricoid pressure trainer. Participants then received a brief period of theoretical instruction, and were allocated to two training groups. Group A received further training with the pressure trainer. Group B was provided with reading material. Practical ability was assessed again immediately and then 4-6 weeks later. RESULTS: Seventy subjects were recruited. A total of 53% could identify the position of the cricoid cartilage, and 16% could identify the pressure required. The percentage achieving a correct position at baseline, immediately after training and after 4-6 weeks was 47%, 97% and 70% respectively in group A, compared with 61%, 86% and 74% respectively in group B, a non-significant difference between groups. The percentage achieving correct pressure at baseline, immediately after training and 4-6 weeks later was 38%, 88% and 67% respectively in group A, compared with 30%, 33% and 51% respectively in group B. The between-group difference was significant only immediately following training (P < 0.0001). CONCLUSION: Theoretical knowledge and technique regarding cricoid pressure was poor among our ED staff. Both methods of training appeared to improve performance. The biofeedback group was more likely to apply correct pressure immediately after training. The effects of training diminished rapidly with time.

Death by oral ingestion of iodine.

We report the clinical and toxicological features of a case of fatal iodine ingestion, and summarize the physiology, clinical characteristics and management of iodine ingestion. Physicians are likely to have little experience in managing such patients, particularly with the advent of less toxic preparations, and therefore need ready access to management guidelines. This case also highlights the potential for substances to retain their toxicity over long periods of time.

Carbon resource sharing and rhizome expansion of Phalaris aquatica plants in grazed pastures.

The patterns of carbon (C) resource sharing and new rhizome development in phalaris (Phalaris aquatica L. cv. Australian) were examined in grazed pastures in western Victoria. The seasonal pattern of new rhizome growth was similar under the four grazing systems tested. New rhizome production was infrequent but concentrated in winter. The phalaris plants maintained more than 1600 kg DW ha-1 of non-assimilating material beneath the soil surface (0-5 cm). Gaseous 14C was fed into plants in the field to determine if these below ground structures continued to be supported by the C assimilating tillers. The results indicated that the primary tiller does provide C to support the growth of secondary and tertiary tillers derived from its axillary buds. There was some evidence that C was exported from the fed tiller to non-assimilating plant structures. The old reproductive tiller bases (from which the assimilating tillers originate) received some C support, suggesting that this was maintained because it had deep roots attached. C export to older plant parts declined, which may lead to plant fragmentation.