Morbidity and mortality meetings at Australian major trauma centres: A proof of concept study

Background

Morbidity and mortality meetings are held at all Australian major trauma centres and provide a forum to identify problems and improve practices. Meetings should focus on addressing factors in the system to prevent similar errors occurring, rather than individual culpability. This paper describes current meeting practices and assesses the use of a systems approach.

Methods

This proof of concept study used a convenience sample of four Australian major trauma centres. Trauma leaders at each centre were surveyed regarding morbidity and mortality meeting practices. The use of a systems approach was measured by assessing practices against the London Protocol for Systems Analysis of Clinical Incidents. Meeting participants were also surveyed regarding perceptions of the objectives and effectiveness of meetings.

Results

This study found variable utilisation of a systems approach. Cases are not routinely analysed for contributing system factors and effective processes are not always used to correct problems that are identified. Meeting practices also vary between centres in terms of frequency, case selection criteria and use of audit filters. Participants generally view quality improvement as the most important objective of meetings.

Conclusion

Morbidity and mortality meeting practices vary between Australian major trauma centres and a systems approach has not been fully adopted.

Loss of idealism or realistic optimism? A cross-sectional analysis of dental hygiene students' and registered dental hygienists' professional identity perceptions

OBJECTIVES

The dental hygiene profession in the U.S. is in the process of establishing a direct access model of care and contributing to the creation of the profession of a dental therapist. The objectives were to analyse the professional role perceptions of dental hygiene students and registered dental hygienists in these times of change. Specifically, it was explored whether dental hygiene students' current professional identities differ (i) from their expected future identities, and (ii) from dental hygienists' current and (iii) past identities.

METHODS

Survey data were collected from 215 dental hygiene students concerning their present and future role perceptions, and from 352 registered dental hygienists concerning their present and past professional identity perceptions.

RESULTS

Students' future professional identity perceptions were even more positive than their very positive current perceptions of their professional role components. Students' current perceptions of professional pride, professional ambition, work ethic and patient relations were more positive than dental hygienists' current perceptions of these professional role components. A comparison of students' current perceptions with dental hygienists' current and retrospective descriptions showed that students were more positive than dental hygienists in each case.

CONCLUSIONS

The fact that dental hygienists had less positive role perceptions than dental hygiene students might lead to the conclusion that a loss of idealism occurs over the course of a professional lifespan. However, dental hygienists actually improved their role perceptions over time and students' future descriptions were more positive than their current descriptions, supporting the interpretation that realistic optimism dominates professional role perceptions in these times of change.

Can subsyndromal manifestations of major depression be identified in children at risk?

OBJECTIVE

Children of parents with major depression are at significantly increased risk for developing major depression themselves; however, not all children at genetic risk will develop major depressive disorder (MDD). We investigated the utility of subsyndromal scores on the Child Behavior Checklist (CBCL) Anxiety/Depression scale in identifying children at the highest risk for pediatric MDD from among the pool of children of parents with MDD or bipolar disorder.

METHOD

The sample was derived from two previously conducted longitudinal case-control family studies of psychiatrically and pediatrically referred youth and their families. For this study, probands were stratified based on the presence or absence of a parental mood disorder.

RESULTS

Subsyndromal scores on the CBCL Anxiety/Depression scale significantly separated the children at high risk for pediatric MDD from those at low risk in a variety of functional areas, including social and academic functioning. Additionally, children at genetic risk without elevated CBCL Anxiety/Depression scale scores were largely indistinguishable from controls.

CONCLUSION

These results suggest that the CBCL Anxiety/Depression scale can help identify children at highest risk for pediatric MDD. If implemented clinically, this scale would cost-effectively screen children and identify those most in need of early intervention resources to impede the progression of depression.

The Development of Nociceptive Network Activity in the Somatosensory Cortex of Freely Moving Rat Pups

Cortical perception of noxious stimulation is an essential component of pain experience but it is not known how cortical nociceptive activity emerges during brain development. Here we use continuous telemetric electrocorticogram (ECoG) recording from the primary somatosensory cortex (S1) of awake active rat pups to map functional nociceptive processing in the developing brain over the first 4 weeks of life. Cross-sectional and longitudinal recordings show that baseline S1 ECoG energy increases steadily with age, with a distinctive beta component replaced by a distinctive theta component in week 3. Event-related potentials were evoked by brief noxious hindpaw skin stimulation at all ages tested, confirming the presence of functional nociceptive spinothalamic inputs in S1. However, hindpaw incision, which increases pain sensitivity at all ages, did not increase S1 ECoG energy until week 3. A significant increase in gamma (20–50 Hz) energy occurred in the presence of skin incision at week 3 accompanied by a longer-lasting increase in theta (4–8 Hz) energy at week 4. Continuous ECoG recording demonstrates specific postnatal functional stages in the maturation of S1 cortical nociception. Somatosensory cortical coding of an ongoing pain “state” in awake rat pups becomes apparent between 2 and 4 weeks of age.

What do we really know about newborn infant pain?

NEW FINDINGS

What is the topic of this review? Pain in infancy. What advances does it highlight? New neurophysiological research on pain processing in the human infant brain. Increased awareness of pain in the newborn has led to the development of numerous assessment tools for use in neonatal intensive care units. Here, I argue that we still know too little about the neurophysiological basis for infant pain to interpret data from clinical observational measures. With increased understanding of how the neural activity and CNS connections that underlie pain behaviour and perception develop in the newborn will come better measurement and treatment of their pain. This review focuses upon two interconnected nociceptive circuits, the spinal cord dorsal horn and the somatosensory cortex in the brain, to highlight what we know and what we do not know about infant pain. The effectiveness of oral sucrose, widely used in clinical practice to relieve infant pain, is discussed as a specific example of what we do not know. This 'hot topic review' highlights the importance of new laboratory-based neurophysiological research for the treatment of newborn infant pain.

Broken Home or Drug using Peers: “Significant Relations”?

This study reports the results of a comparative survey with representative samples of 3,386 school attending youths, most of whom were 15 years of age and residing in five European cities. We found significant but low correlations between the type of family structure (intact family, model family, dual career houshold, single mother) and five forms of deviant behavior (tobacco smoking, cannabis use, delinquency, general drug use and a composite risk behavior scale). These correlations will be displaced by very high correlations with the level of drug using friends/peers. A number of differences were found between the youth from different cities in relation to these concerns. Results indicate differences among the cities in terms of the youths' relationships with drug use/deviance/risky behavior and family structure, gender role, and peer group behavior. This suggests that the cultural meanings associated with family, gender role, peer group, and risk behavior influence deviant outcomes.

Encoding of mechanical nociception differs in the adult and infant brain

Newborn human infants display robust pain behaviour and specific cortical activity following noxious skin stimulation, but it is not known whether brain processing of nociceptive information differs in infants and adults. Imaging studies have emphasised the overlap between infant and adult brain connectome architecture, but electrophysiological analysis of infant brain nociceptive networks can provide further understanding of the functional postnatal development of pain perception. Here we hypothesise that the human infant brain encodes noxious information with different neuronal patterns compared to adults. To test this we compared EEG responses to the same time-locked noxious skin lance in infants aged 0–19 days (n = 18, clinically required) and adults aged 23–48 years (n = 21). Time-frequency analysis revealed that while some features of adult nociceptive network activity are present in infants at longer latencies, including beta-gamma oscillations, infants display a distinct, long latency, noxious evoked 18-fold energy increase in the fast delta band (2–4 Hz) that is absent in adults. The differences in activity between infants and adults have a widespread topographic distribution across the brain. These data support our hypothesis and indicate important postnatal changes in the encoding of mechanical pain in the human brain.

Mycobacterium avium complex pulmonary disease: characteristics and treatment in an Irish patient cohort

The prevalence of Mycobacterium avium complex (MAC) pulmonary disease is increasing globally. However, reliable national and international data relating to its epidemiology and management is lacking. During the period 2003-2014, MAC was isolated from the pulmonary samples of 75 patients at the Irish Mycobacteria Reference Laboratory (IMRL). Most patients (42, 56%) had underlying pulmonary disease, and 37 (49%) had clinical/radiographic characteristics consistent with MAC pulmonary disease. However, only 18 patients (24%) fulfilled internationally accepted criteria for diagnosis/treatment of this disease. Treatment was started in 13 (72%) of these cases, which is similar to internationally published treatment rates. The diagnosis of significant MAC pulmonary disease can be difficult, and treatment is not always warranted even when diagnostic criteria are met.

Energetic Geodesic Acoustic Modes Associated with Two-Stream-like Instabilities in Tokamak Plasmas

An unstable branch of the energetic geodesic acoustic mode (EGAM) is found using fluid theory with fast ions characterized by their narrow width in energy distribution and collective transit along field lines. This mode, with a frequency much lower than the thermal GAM frequency ω_{GAM}, is now confirmed as a new type of unstable EGAM: a reactive instability similar to the two-stream instability. The mode can have a very small fast ion density threshold when the fast ion transit frequency is smaller than ω_{GAM}, consistent with the onset of the mode right after the turn-on of the beam in DIII-D experiments. The transition of this reactive EGAM to the velocity gradient driven EGAM is also discussed.

Mapping Cortical Responses to Somatosensory Stimuli in Human Infants with Simultaneous Near-Infrared Spectroscopy and Event-Related Potential Recording

Near-infrared spectroscopy (NIRS) and electroencephalography (EEG) have recently provided fundamental new information about how the newborn brain processes innocuous and noxious somatosensory information. However, results derived independently from these two techniques are not entirely consistent, raising questions about the relationship between hemodynamic and electrophysiological responses in the study of touch and pain processing in the newborn. To address this, we have recorded NIRS and EEG responses simultaneously for the first time in the human infant following noxious (time-locked clinically required heel lances) and innocuous tactile cutaneous stimulation in 30 newborn infants. The results show that both techniques can be used to record quantifiable and distinct innocuous and noxious evoked activity at a group level in the newborn cortex. Noxious stimulation elicits a peak hemodynamic response that is 10-fold larger than that elicited by an innocuous stimulus (HbO2: 2.0 vs 0.3 µM) and a distinct nociceptive-specific N3P3 waveform in electrophysiological recordings. However, a novel single-trial analysis revealed that hemodynamic and electrophysiological responses do not always co-occur at an individual level, although when they do (64% of noxious test occasions), they are significantly correlated in magnitude. These data show that, while hemodynamic and electrophysiological touch and pain brain activity in newborn infants are comparable in group analyses, important individual differences remain. These data indicate that integrated and multimodal brain monitoring is required to understand central touch and pain processing in the newborn.

Enabling dual cellular destinations of polymeric nanoparticles for treatment following partial injury to the central nervous system

Following neurotrauma, oxidative stress is spread via the astrocytic syncytium and is associated with increased aquaporin 4 (AQP4), inflammatory cell infiltration, loss of neurons and glia and functional deficits. Herein we evaluate multimodal polymeric nanoparticles functionalized with an antibody to an extracellular epitope of AQP4, for targeted delivery of an anti-oxidant as a therapeutic strategy following partial optic nerve transection. Using fluorescence microscopy, spectrophotometry, correlative nanoscale secondary ion mass spectrometry (NanoSIMS) and transmission electron microscopy, in vitro and in vivo, we demonstrate that functionalized nanoparticles are coated with serum proteins such as albumin and enter both macrophages and astrocytes when administered to the site of a partial optic nerve transection in rat. Antibody functionalized nanoparticles synthesized to deliver the antioxidant resveratrol are effective in reducing oxidative damage to DNA, AQP4 immunoreactivity and preserving visual function. Non-functionalized nanoparticles evade macrophages more effectively and are found more diffusely, including in astrocytes, however they do not preserve the optic nerve from oxidative damage or functional loss following injury. Our study highlights the need to comprehensively investigate nanoparticle location, interactions and effects, both in vitro and in vivo, in order to fully understand functional outcomes.

Nerve injury and neuropathic pain - A question of age

The effects of peripheral nerve injury on somatosensory processing and pain are highly dependent upon the age at which the damage occurs. Adult nerve injury rapidly triggers neuropathic pain, but this is not so if the same nerve injury is performed in animals below postnatal day (P) 28, consistent with observations in paediatric patients. However, longitudinal studies show that pain hypersensitivity emerges later in life, when the animal reaches adolescence, an observation that could be of clinical importance. Here we discuss the evidence that the central consequences of nerve damage are critically determined by the status of neuroimmune regulation at different ages. In the first postnatal weeks, when spinal somatosensory circuits are undergoing synaptic reorganisation, the ‘default’ neuroimmune response is skewed in an anti-inflammatory direction, suppressing the excitation of dorsal horn neurons and preventing the onset of neuropathic pain. As animals grow up and the central nervous system matures, the neuroimmune profile shifts in a pro-inflammatory direction, unmasking a ‘latent’ pain response to an earlier nerve injury. The data predicts that nerve injury in infancy and childhood could go unnoticed at the time, but emerge as clinically ‘unexplained’ or ‘functional’ pain in adolescence.

Large and prolonged food-borne multistate hepatitis A outbreak in Europe associated with consumption of frozen berries, 2013 to 2014

In May 2013, Italy declared a national outbreak of hepatitis A, which also affected several foreign tourists who had recently visited the country. Molecular investigations identified some cases as infected with an identical strain of hepatitis A virus subgenotype IA. After additional European Union/European Economic Area (EU/EEA) countries reported locally acquired and travel-related cases associated with the same outbreak, an international outbreak investigation team was convened, a European outbreak case definition was issued and harmonisation of the national epidemiological and microbiological investigations was encouraged. From January 2013 to August 2014, 1,589 hepatitis A cases were reported associated with the multistate outbreak; 1,102 (70%) of the cases were hospitalised for a median time of six days; two related deaths were reported. Epidemiological and microbiological investigations implicated mixed frozen berries as the vehicle of infection of the outbreak. In order to control the spread of the outbreak, suspected or contaminated food batches were recalled, the public was recommended to heat-treat berries, and post-exposure prophylaxis of contacts was performed. The outbreak highlighted how large food-borne hepatitis A outbreaks may affect the increasingly susceptible EU/EEA general population and how, with the growing international food trade, frozen berries are a potential high-risk food.

Lead optimization attrition analysis (LOAA): a novel and general methodology for medicinal chemistry

Herein, we report a novel and general method, lead optimization attrition analysis (LOAA), to benchmark two distinct small-molecule lead series using a relatively unbiased, simple technique and commercially available software. We illustrate this approach with data collected during lead optimization of two independent oncology programs as a case study. Easily generated graphics and attrition curves enabled us to calibrate progress and support go/no go decisions on each program. We believe that this data-driven technique could be used broadly by medicinal chemists and management to guide strategic decisions during drug discovery.

Functional magnetic resonance imaging can be used to explore tactile and nociceptive processing in the infant brain

Aim

Despite the importance of neonatal skin stimulation, little is known about activation of the newborn human infant brain by sensory stimulation of the skin. We carried out functional magnetic resonance imaging (fMRI) to assess the feasibility of measuring brain activation to a range of mechanical stimuli applied to the skin of neonatal infants.

Methods

We studied 19 term infants with a mean age of 13 days. Brain activation was measured in response to brushing, von Frey hair (vFh) punctate stimulation and, in one case, nontissue damaging pinprick stimulation of the plantar surface of the foot. Initial whole brain analysis was followed by region of interest analysis of specific brain areas.

Results

Distinct patterns of functional brain activation were evoked by brush and vFh punctate stimulation, which were reduced, but still present, under chloral hydrate sedation. Brain activation increased with increasing stimulus intensity. The feasibility of using pinprick stimulation in fMRI studies was established in one unsedated healthy full-term infant.

Conclusion

Distinct brain activity patterns can be measured in response to different modalities and intensities of skin sensory stimulation in term infants. This indicates the potential for fMRI studies in exploring tactile and nociceptive processing in the infant brain.

Cortical activity evoked by inoculation needle prick in infants up to one-year old

Inoculation is one of the first and most common experiences of procedural pain in infancy. However, little is known about how needle puncture pain is processed by the central nervous system in children. In this study, we describe for the first time the event-related activity in the infant brain during routine inoculation using electroencephalography. Fifteen healthy term-born infants aged 1 to 2 months (n = 12) or 12 months (n = 5) were studied in an outpatient clinic. Pain behavior was scored using the Modified Behavioral Pain Scale. A distinct inoculation event-related vertex potential, consisting of 2 late negative-positive complexes, was observable in single trials after needle contact with the skin. The amplitude of both negative-positive components was significantly greater in the 12-month group. Both inoculation event-related potential amplitude and behavioral pain scores increased with age but the 2 measures were not correlated with each other. These components are the first recordings of brain activity in response to real-life needle pain in infants up to a year old. They provide new evidence of postnatal nociceptive processing and, combined with more traditional behavioral pain scores, offer a potentially more sensitive measure for testing the efficacy of analgesic protocols in this age group.

A procedural check list for pleural decompression and intercostal catheter insertion for adult major trauma

BACKGROUND

Intercostal catheter (ICC) insertion is the standard pleural decompression and drainage technique for blunt and penetrating traumatic injury. Potentially high complication rates are associated with the procedure, with the literature quoting over 20% in some cases (1-4). Empyema in particular is a serious complication. Risk adverse industries such as the airline industry and military services regularly employ checklists to standardise performance and decrease human errors. The use of checklists in medical practice is exemplified by introduction of the WHO Surgical Safety checklist.

METHODS

The Alfred Hospital in Melbourne, Australia is an Adult Level 1 Trauma Centre. In August 2009 The Alfred Trauma Service introduced an evidence-based checklist system for the insertion of ICCs, combined with standardised formal training for resident medical staff, in an attempt to minimise the incidence of ICC related empyema.

RESULTS

Between January 2003 and July 2009 the incidence of empyema was 1.44% (29 in 2009 insertions). This decreased to 0.57% between August 2009 and December 2011 (6 in 1060 insertions) when the measures described above were introduced [p=0.038 Fisher's exact test, 2-tailed].

CONCLUSION

Quality control checklists - such as the ICC checklist described - are a sensible and functional means to standardise practice, to decrease procedural error and to reduce complication rates during trauma resuscitation.

Structural requirements for anti-oxidant activity of calix[n]arenes and their associated anti-bacterial activity

Treatment of neural cells with calix[n]arenes featuring sulphonate moieties and linked to Ag nanoparticles results in reduced reactive species. For Gram+ bacteria there is an inverse correlation between anti-bacterial activity and ROS reduction whereas for Gram- bacteria only calix[6]arenes bearing O-alkyl sulphonate functions act as ROS inhibitors and anti-bacterial agents.

Outbreak of hepatitis A infection associated with the consumption of frozen berries, Ireland, 2013--linked to an international outbreak

In May 2013, a European alert was issued regarding a hepatitis A virus (HAV) outbreak in Italy. In June 2013, HAV subgenotype IA with an identical sequence was identified in Ireland in three cases who had not travelled to Italy. The investigation consisted of descriptive epidemiology, a case-control study, microbiological testing of human and food specimens, molecular typing of positive specimens and food traceback. We identified 21 outbreak cases (14 confirmed primary cases) with symptom onset between 31 January and 11 October 2013. For the case-control study, we recruited 11 confirmed primary cases and 42 matched controls. Cases were more likely than controls to have eaten berry cheesecake (matched odds ratio (mOR): 12; 95% confidence interval (CI): 1.3-114), whole frozen berries (mOR: 9.5; 95% CI: 1.0-89), yoghurt containing frozen berries (mOR: 6.6, 95% CI: 1.2-37) or raw celery (mOR: 4; 95% CI: 1.2-16). Among cases, 91% had consumed at least one of four products containing frozen berries (mOR: 12; 95% CI: 1.5-94). Sixteen food samples tested were all negative for HAV. As products containing frozen berries were implicated in the outbreak, the public were advised to heat-treat frozen berries before consumption.

What does practice development (PD) offer mental health-care contexts? A comparative case study of PD methods and outcomes

Practice development (PD) in mental health nursing has been progressing over the last decade; however, the level and impact of PD activity in the field of mental health remains poorly understood outside localized project impact. More specific reporting and comparative analysis of PD outcomes will improve this situation. In response, this paper presents three case scenarios from work taking place in Australia and New Zealand, as working examples of how PD methodologies have been applied within mental health practice settings. Using a comparative framework that captures the contributing assumptions, practices, processes and conditions imperative to effective PD work within a mental health-care context, three case vignettes are reviewed. The critical question driving this paper is 'what mental health-care services does PD offer in terms of transformational change approaches and the promotion of effective workplace cultures?' Conditions considered necessary for successful PD initiatives within mental health contexts are explored such as how PD converges and diverges with mental health-related theories, plus where and how PD activity best integrates with the specific elements associated with mental health-care provision. The findings are further reviewed in line with reports of PD outcomes from other fields of health care.

The consequences of pain in early life: injury-induced plasticity in developing pain pathways

Pain in infancy influences pain reactivity in later life, but how and why this occurs is poorly understood. Here we review the evidence for developmental plasticity of nociceptive pathways in animal models and discuss the peripheral and central mechanisms that underlie this plasticity. Adults who have experienced neonatal injury display increased pain and injury-induced hyperalgesia in the affected region but mild injury can also induce widespread baseline hyposensitivity across the rest of the body surface, suggesting the involvement of several underlying mechanisms, depending upon the type of early life experience. Peripheral nerve sprouting and dorsal horn central sensitization, disinhibition and neuroimmune priming are discussed in relation to the increased pain and hyperalgesia, while altered descending pain control systems driven, in part, by changes in the stress/HPA axis are discussed in relation to the widespread hypoalgesia. Finally, it is proposed that the endocannabinoid system deserves further attention in the search for mechanisms underlying injury-induced changes in pain processing in infants and children.

Staff support for the Health Service Executive (HSE) global health programme

The Global Health programme (GHP) within the Health Service Executive (HSE) aims to improve health in developing countries by creating partnerships between Irish and developing world healthcare institutions. To ascertain the level of interest among HSE staff for the GHP a web-based survey was conducted. 1,028 responses were received. Medical professionals, 202 (27.7%) composed the largest category of respondents. The majority, 503 (69.3%) of respondents wished to actively participate in the GHP. 237 (23.1%) staff had previous experience of working in the developing world. This survey highlighted a number of themes respondents considered important for successful partnerships including: reciprocal staff exchange, joint scientific research, the avoidance of "brain drain" and utilising the Internet to link institutions. Less than 1% (2/203) of comments expressed a negative view of the GHP.

Two cases of methaemoglobinaemia secondary to amyl nitrate use

We wish to report two cases of methaemoglobinaemia secondary to amyl nitrate use. A 55-year-old male presented with saturations in the mid 80s despite FiO2 of 1.0 and GCS 10 and a 22-year-old female who presented with fluctuating GCS and a slate grey colour. Both were found to have high levels of metheamoglobinaemia on ABG, were treated with methylene blue and made excellent recoveries. These cases illustrate the risk of methaemoglobinaemia secondary to amyl nitrate. Appropriate and prompt management can lead to very good outcomes.

The selectivity of rostroventral medulla descending control of spinal sensory inputs shifts postnatally from A fibre to C fibre evoked activity

Brainstem descending control is crucial in maintaining the balance of excitation and inhibition in spinal sensory networks. In the adult, descending inhibition of spinal dorsal horn circuits arising from the brainstem rostroventral medial medulla (RVM) is targeted to neurons with a strong nociceptive C fibre input. Before the fourth postnatal week, the RVM exerts a net facilitation of spinal networks but it is not known if this is targeted to specific dorsal horn neuronal inputs. As the maturation from descending facilitation to inhibition occurs only after C fibre central synaptic maturation is complete, we hypothesized that RVM facilitation in young animals is targeted to A fibre afferent inputs. To test this, the RVM was stimulated while recording dorsal horn neuronal activity in vivo under isoflurane anaesthesia at postnatal day (P) 21 and P40 (adult). Electrical thresholds for A and C fibre evoked activity, spike counts and wind-up characteristics at baseline and during RVM stimulation (10–100 µA, 10 Hz) were compared. In adults, RVM stimulation selectively increased the threshold for C fibre evoked activity while at P21, it selectively decreased the threshold for A fibre evoked activity and these effects were correlated to the wind-up characteristics of the neuron. Thus, the postnatal shift in RVM control of dorsal horn circuits is not only directional but also modality specific, from facilitation of A fibre input in the young animal to inhibition of nociceptive C input in the adult, with additional contextual factors. The descending control of spinal sensory networks serves very different functions in young and adult animals.

Serum lipase for assessment of pancreatic trauma

PURPOSE

Pancreatic enzymes are routinely measured during reception of trauma patients to assess for pancreatic injury despite conflicting evidence on their utility. The aim of this study was to investigate the utility of routine initial serum lipase measurement for the diagnosis of acute pancreatic trauma.

MATERIALS AND METHODS

Lipase measurements were introduced as part of the trauma pathology panel and requested on all patients who presented to an adult major trauma service and met trauma call-out criteria. Clinical records of these patients were extracted from the trauma registry and retrospectively reviewed. The performance of an initial serum lipase level measured on presentation to detect pancreatic trauma was determined.

RESULTS

There were 2,580 patients included in the study, with 17 patients diagnosed with pancreatic trauma. An elevated lipase was recorded in 390 patients. Statistically significant associations were observed for elevated lipase in patients with pancreatic trauma, head injury, acute alcohol ingestion and massive blood transfusion. As a test for pancreatic trauma, an abnormal serum lipase result had a specificity of 85.3 % (95 % CI 83.8-86.6), sensitivity of 76.5 % (95 % CI 49.8-92.2), positive predictive value of 3.3 % (95 % CI 1.8-5.8) and negative predictive value of 99.8 % (95 % CI 99.4-99.9). Higher cut-offs of serum lipase did not result in better performance.

CONCLUSIONS

A normal serum lipase result can be a useful adjunct to exclude pancreatic injury. A positive lipase result, regardless of the cut-off used, was not reliably associated with pancreatic trauma, and should not be used to guide further assessment.

Postnatal temporal, spatial and modality tuning of nociceptive cutaneous flexion reflexes in human infants

Cutaneous flexion reflexes are amongst the first behavioural responses to develop and are essential for the protection and survival of the newborn organism. Despite this, there has been no detailed, quantitative study of their maturation in human neonates. Here we use surface electromyographic (EMG) recording of biceps femoris activity in preterm (<37 weeks gestation, GA) and term (≥ 37 weeks GA) human infants, less than 14 days old, in response to tactile, punctate and clinically required skin-breaking lance stimulation of the heel. We show that all infants display a robust and long duration flexion reflex (>4 seconds) to a single noxious skin lance which decreases significantly with gestational age. This reflex is not restricted to the stimulated limb: heel lance evokes equal ipsilateral and contralateral reflexes in preterm and term infants. We further show that infant flexion withdrawal reflexes are not always nociceptive specific: in 29% of preterm infants, tactile stimulation evokes EMG activity that is indistinguishable from noxious stimulation. In 40% of term infants, tactile responses are also present but significantly smaller than nociceptive reflexes. Infant flexion reflexes are also evoked by application of calibrated punctate von Frey hairs (vFh), 0.8-17.2 g, to the heel. Von Frey hair thresholds increase significantly with gestational age and the magnitude of vFh evoked reflexes are significantly greater in preterm than term infants. Furthermore flexion reflexes in both groups are sensitized by repeated vFh stimulation. Thus human infant flexion reflexes differ in temporal, modality and spatial characteristics from those in adults. Reflex magnitude and tactile sensitivity decreases and nociceptive specificity and spatial organisation increases with gestational age. Strong, relatively non-specific, reflex sensitivity in early life may be important for driving postnatal activity dependent maturation of targeted spinal cord sensory circuits.

Cortical activity evoked by an acute painful tissue-damaging stimulus in healthy adult volunteers

Everyday painful experiences are usually single events accompanied by tissue damage, and yet most experimental studies of cutaneous nociceptive processing in the brain use repeated laser, thermal, or electrical stimulations that do not damage the skin. In this study the nociceptive activity in the brain evoked by tissue-damaging skin lance was analyzed with electroencephalography (EEG) in 20 healthy adult volunteers (13 men and 7 women) aged 21-40 yr. Time-frequency analysis of the evoked activity revealed a distinct late event-related vertex potential (lance event-related potential, LERP) at 100-300 ms consisting of a phase-locked energy increase between 1 and 20 Hz (delta-beta bands). A pairwise comparison between lance and sham control stimulation also revealed a period of ultralate stronger desynchronization after lance in the delta band (1-5 Hz). Skin application of mustard oil before lancing, which sensitizes a subpopulation of nociceptors expressing the cation channel TRPA1, did not affect the ultralate desynchronization but reduced the phase-locked energy increase in delta and beta bands, suggesting a central interaction between different modalities of nociceptive inputs. Verbal descriptor screening of individual pain experience revealed that lance pain is predominantly due to Aδ fiber activation, but when individuals describe lances as C fiber mediated, an ultralate delta band event-related desynchronization occurs in the brain-evoked activity. We conclude that pain evoked by acute tissue damage is associated with distinct Aδ and C fiber-mediated patterns of synchronization and desynchronization of EEG oscillations in the brain.

Use of a geographic information system to map cases of measles in real-time during an outbreak in Dublin, Ireland, 2011

In 2011, there was a large measles outbreak in Dublin. Nationally 285 cases were notified to the end of December 2011, and 250 (88%) were located in the Dublin region. After the first case was notified in week 6, numbers gradually increased, with 25 notified in June and a peak of 53 cases in August. Following public health intervention including a measles-mumps-rubella (MMR) vaccination campaign, no cases were reported in the Dublin region in December 2011. Most cases (82%) were children aged between 6 months and 14 years, and 46 cases (18%) were under 12 months-old. This is the first outbreak in Dublin to utilise a geographic information system for plotting measles cases on a digital map in real time. This approach, in combination with the analysis of case notifications, assisted the department of public health in demonstrating the extent of the outbreak. The digital mapping documented the evolution of two distinct clusters of 87 (35%) cases. These measles cases were infected with genotype D4-Manchester recently associated with large outbreaks across Europe. The two clusters occurred in socio-economically disadvantaged areas and were attributable to inadequate measles vaccination coverage due in part to the interruption of a school-based MMR2 vaccination programme.

A role for NT-3 in the hyperinnervation of neonatally wounded skin

Neurotrophin-3 (NT-3) is a target-derived neurotrophic factor that regulates sensory neuronal survival and growth. Here we report that NT-3 plays a critical permissive role in cutaneous sensory nerve sprouting that contributes to pain and sensitivity following skin wounding in young animals. Sensory terminal sprouting in neonatally wounded dermis and epidermis is accompanied by increased NT-3 transcription, NT-3 protein levels, and NT-3 protein release 3-7 days post skin injury in newborn rats and mice. Functional blockade of NT-3 activity with specific antibodies greatly reduces sensory neurite outgrowth induced by wounded skin, but not by naïve skin, in dorsal root ganglion/skin co-cultures. The requirement for NT-3 for sensory terminal sprouting in vivo is confirmed by the absence of wound-induced hyperinnervation in heterozygous transgenic mice (NT-3(+/-)lacZ). We conclude that upregulation of NT-3 in neonatally wounded skin is a critical factor mediating the sensory nerve sprouting that underlies hypersensitivity and pain following skin injury.