Paediatric hospital admissions for psychiatric and psychosocial reasons during the first year of the COVID-19 pandemic

Increases in youth psychiatric presentations to out-patient and emergency department settings during COVID-19 have been reported. This study, using data from five hospitals in Ireland, examines changes in the number and type of paediatric admissions during COVID-19 (March 2020 - February 2021) compared to the previous two years. ICD-10 classification was used to establish admissions with mental, behavioural, neuro-developmental disorders and psychosocial reasons (MBN-PS). Overall hospital admissions fell by 25.3%, while MBN-PS fell by only 2.6%, mostly during an initial lockdown. Admissions for MBN-PS increased in July-August (9.2%), increased further in September-December (28.3%), returning to pre-COVID-19 levels in January-February 2021. Significant increases were observed among youths with anorexia nervosa (47.8%), other eating disorders (42.9%), and admissions for anxiety (29.6%), with these effects relating to females only. Although admissions for self-harm increased (3%) and rates of ASD admissions reduced (17%), these were not statistically significant. The disproportionate increase in admissions for MBN-PS compared to medical admissions suggests an adverse effect of COVID-19 on youth mental health, for females in particular, and supports previous reports of a pandemic specific increase in eating psychopathology. Combined community and acute service delivery and capacity planning are urgently needed given the prior underfunding of services pre-pandemic.

Surgery of the femur in HIV positive patients: a retrospective review from 2005 to 2011

BACKGROUND

There are an estimated 6,900 people with HIV living in Ireland. There is a significant prevalence of femoral osteonecrosis and risk factors for osteoporotic fractures. With this potential, increasing surgical workload, it is important to assess surgical demand and audit outcomes.

METHODS

The hospital's electronic records were examined. Between January 2005 and August 2011, 17 femoral surgeries were identified in seven patients. Patient records were retrospectively reviewed.

RESULTS

Elective operations undertaken were eight hip replacements and one nail dynamisation. Eight emergency operations were undertaken: two DHS, one plating, one nailing, one revision nailing, two incision and drainages and one biopsy. All procedures were carried out using appropriate safety guidelines. Indications for surgery included femoral head osteonecrosis (n = 7), osteomyelitis (n = 3), proximal femoral fracture (n = 2), femoral shaft non-union (n = 1), dynamisation of a nail (n = 1), osteoarthritis (n = 1), fractured femur (n = 1), and revision nailing (n = 1). For two procedures the patient was not on highly active anti-retroviral treatment. All elective patients had CD4 counts greater than 200 pre-operatively. Six patients had undetectable viral loads. Of the eight emergency procedures, four procedures had no preoperative immune status recorded. Complications recorded were three non-unions, one nail fracture, one lesser trochanter fracture and recurrence of osteomyelitis. No surgical site infections were recorded.

CONCLUSIONS

Complications were not related to immune status. The rate of surgical site infection in both elective and emergency procedures was low. The elective surgery patients can safely receive orthopaedic treatment in their regional orthopaedic unit. Due to the high non-infectious complication rates recorded in the emergency group, transfer to a tertiary facility with infectious disease expertise is advised.

Use of lean principals to improve flow of patients with fractured neck of femur--the HOPE study

We describe the implementation of a care pathway for patients with fractured neck of femur (NOF) using Lean and Six Sigma principles. After introduction of the Lean pathway, 32 patients out a total of 86 (37%) with fractured NOF were admitted to the Trauma Ward within 4 hours of presentation to the hospital; prior to implementation this was 16 patients out of a total of 59 (27%). Post-Lean an earlier mean theatre start time of 8.40am was achieved, resulting in a 38 minute increase in daily theatre time. An additional 52 patients (12%) received surgery within 24 hours of admission, resulting in 1 night length of stay reduction. Lean methodology proved an effective method to guide change resulting in an improved journey for the patient and significant workflow gains.

Difficult airway equipment in departments of emergency medicine in Ireland: results of a national survey

BACKGROUND AND OBJECTIVE

Adverse effects associated with difficult airway management can be catastrophic and include death, brain injury and myocardial injury. Closed-malpractice claims have shown prolonged and persistent attempts at endotracheal intubation to be the most common situation leading to disastrous respiratory events. To date, there has been no evaluation of the types of difficult airway equipment currently available in Irish departments of emergency medicine. The objective of this survey was to identify the difficult airway equipment available in Irish departments of emergency medicine.

METHODS

Departments of emergency medicine in the Republic of Ireland with at least one dedicated Emergency Medicine consultant were surveyed via telephone.

RESULTS

All of the departments contacted held at least one alternative device on site for both ventilation and intubation. The most common alternative ventilation device was the laryngeal mask airway (89%). The most common alternative intubating device was the surgical airway device (100%).

CONCLUSIONS

Irish departments of emergency medicine compare well with those in the UK and USA, when surveyed concerning difficult airway equipment. However, we believe that this situation could be further improved by training inexperienced healthcare providers in the use of the laryngeal mask airway and intubating laryngeal mask airway, by placing greater emphasis on the ready availability of capnography and by the increased use of portable difficult airway storage units.

Is adjunctive balloon postdilatation necessary after coronary stent deployment? Final results from the POSTIT trial

Early-generation balloon-expandable stents required postdilatation with noncompliant balloons at high pressure to optimize stent deployment. The need for adjunctive balloon postdilatation with modern stent delivery systems is unknown. Patients undergoing elective stenting were randomized to Boston Scientific NIR, Guidant Tri-Star/Tetra, and Medtronic AVE S670 stents. The primary endpoint was optimum stent deployment defined as a minimal stent diameter (MSD) >/= 90% of the average reference lumen diameter assessed by intravascular ultrasound (IVUS) performed immediately following stent deployment. If, by operator assessment, the primary endpoint was not achieved with the stent delivery system, adjunctive postdilatation with noncompliant balloons was performed. Of 256 patients with IVUS studies adequate for core laboratory analysis, only 29% achieved optimum stent deployment with the stent delivery system. None of the baseline clinical or angiographic variables predicted optimum stent deployment. Of the procedural variables, the type of stent and nominal stent size were not predictors, but higher deployment pressures were associated with a higher frequency of optimum stent deployment (< 12 atm 14% vs. >/= 12 atm 36%; P = 0.007). The inability to achieve optimum stent deployment was not due to undersizing the stent delivery balloon, but rather to an inability of the stent delivery balloon to expand fully the stent to nominal size. In patients who underwent postdilatation, the frequency of achieving optimum stent deployment increased from 21% to 42%, minimal stent area increased from 6.6 +/- 2.2 to 7.8 +/- 2.3 mm(2), and MSD increased from 2.6 +/- 0.5 to 2.8 +/- 0.4 mm. These data stress the continued need for adjunctive balloon postdilatation with modern stent delivery systems. Cathet Cardiovasc Intervent 2003;59:184-192.

Brachytherapy for refractory coronary artery restenosis

A 76-year-old female patient complained of progressive episodes of chest and left arm pain and numbness, accompanied by a burning sensation in the left breast. The symptoms were nitroglycerine-responsive and consistent with her prior angina. Cardiac history included an initial percutaneous coronary intervention and 4 subsequent occurrences of restenosis in a stented area of the left anterior descending (LAD) coronary artery. Following a fifth restenosis of the LAD, the Novoste Beta-Cath Brachytherapy System was employed following balloon dilatation of the persistent recurrence. At 10 months post-brachytherapy, angiography revealed a patent LAD with no evidence of in-stent restenosis.

Efficacy of postdeployment balloon dilatation for current generation stents as assessed by intravascular ultrasound

Adjunctive balloon dilatation strategy has been shown to improve optimal stent deployment. As improvements in current stent designs evolve, less adjunctive balloon dilatation may be needed. However, few data currently exist to support this practice. We evaluated 88 native coronary lesions treated with single stent implantation (Nir, Tristar or S670). Serial intravascular ultrasound was performed after successful stent deployment and again after adjunctive balloon dilatation. To investigate further the precise expansion characteristics of the stents, serial volumetric intravascular ultrasound analyses were performed in 40 patients with automated pullback. After adjunctive balloon dilatation, minimal stent area increased significantly, from 6.4 +/- 2.1 to 7.4 +/- 2.2 mm(2) (p <0.001). Volumetric analysis showed a corresponding increase in stent volume index (6.6 +/- 1.8 to 7.5 +/- 2.0 mm(3)/mm, p <0.001). In the analysis of cross sections at 0.5-mm axial intervals, the percentage of cross sections, where stent area was > or =80% of the average reference lumen area, increased from 51% to 78% (p <0.001). Similarly, the percentage of cross sections, where stent area was > or =90% of the average reference lumen area, increased from 29% to 56% (p <0.001) with postdilatation. Postdeployment high- pressure balloon dilatation improved minimal stent area and volumetric expansion throughout the stented segment.

Clinical and angiographic outcome in the laser angioplasty for restenotic stents (LARS) multicenter registry

In-stent restenosis (ISR), when treated with balloon angioplasty (PTCA) alone, has an angiographic recurrence rate of 30%-85%. Ablating the hypertrophic neointimal tissue prior to PTCA is an attractive alternative, yet the late outcomes of such treatment have not been fully determined. This multicenter case control study assessed the angiographic and clinical outcomes of 157 consecutive procedures in 146 patients with ISR at nine institutions treated with either PTCA alone (n = 64) or excimer laser assisted coronary angioplasty (ELCA, n = 93)) for ISR. Demographics were similar except more unstable angina at presentation in ELCA-treated patients (74.5% vs. 63.5%; P = 0.141). Lesions selected for ELCA were longer (16.8 +/- 11.2 mm vs. 11.2 +/- 8.6 mm; P < 0.001), more complex (ACC/AHA type C: 35.1% vs. 13.6%; P < 0.001), and with compromised antegrade flow (TIMI flow < 3: 18.9% vs. 4.5%; P = 0.008) compared to PTCA-treated patients. ELCA-treated patients had similar rate of procedural success [93 (98.9% vs. 62 (98.4%); P = 1.0] and major clinical complications [1 (1.1%) vs. 1 (1.6%); P = 1.0]. At 30 days, repeat target site coronary intervention was lower in ELCA-treated patients (1.1% vs. 6.4% in PTCA-treated patients; P = 0.158), but not significantly so. At 1 year, ELCA-treated patients had similar rate of major cardiac events (39.1% vs. 45.2%; P = 0.456) and target lesion revascularization (30.0% vs. 32.3%; P = 0.646). These data suggest that ELCA in patients with complex in-stent restenosis is as safe and effective as balloon angioplasty alone. Despite higher lesion complexity in ELCA-treated patients, no increase in event rates was observed. Future studies should evaluate the relative benefit of ELCA over PTCA alone for the prevention of symptom recurrence specifically in patients with complex in-stent restenosis.

Learning to forget: continual prediction with LSTM

Long short-term memory (LSTM; Hochreiter & Schmidhuber, 1997) can solve numerous tasks not solvable by previous learning algorithms for recurrent neural networks (RNNs). We identify a weakness of LSTM networks processing continual input streams that are not a priori segmented into subsequences with explicitly marked ends at which the network's internal state could be reset. Without resets, the state may grow indefinitely and eventually cause the network to break down. Our remedy is a novel, adaptive "forget gate" that enables an LSTM cell to learn to reset itself at appropriate times, thus releasing internal resources. We review illustrative benchmark problems on which standard LSTM outperforms other RNN algorithms. All algorithms (including LSTM) fail to solve continual versions of these problems. LSTM with forget gates, however, easily solves them, and in an elegant way.

Effectiveness of mask ventilation performed by hospital doctors in an Irish tertiary referral teaching hospital

The objective of this study was to assess the effectiveness of mask ventilation performed by 112 doctors with clinical responsibilities at a tertiary referral teaching hospital. Participant doctors were asked to perform mask ventilation for three minutes on a Resusci Anne mannequin using a facemask and a two litre self inflating bag. The tidal volumes generated were quantified using a Laerdal skillmeter computer as grades 0-5, corresponding to 0, 334, 434, 561, 673 and > 800 ml respectively. The effectiveness of mask ventilation (i.e. the proportion of ventilation attempts which achieved a volume delivery of > 434 mls) was greater for anaesthetists [78.0 (29.5)%] than for non anaesthetists [54.6 (40.0)%] (P = 0.012). Doctors who had attended one or more resuscitation courses where no more effective at mask ventilation than their colleagues who had not undertaken such courses. It is likely that first responders to in-hospital cardiac arrests are commonly unable to perform adequate mask ventilation.

Some lengthening factors in English speech combine additively at most rates

The known lengthening effects of phrase-final position and of contrastive emphasis have been predicted by Klatt to combine superadditively. In a new experiment, texts elicited at a wide range of speaking rates were measured and the separate and combined effects of these lengthening factors were found to combine approximately additively at all rates studied. The proportion of lengthening attributable to each factor was found to be relatively invariant except at the fastest speaking rates, where lengthening was eventually eliminated. The results support the interpretation of absolute speaking rate as an inessential variable for characterizing speech at a range of moderate rates.

Six month outcome and determinants of adverse clinical events after successful excimer laser coronary angioplasty. ELCA A.I.S. Multicenter Registry

OBJECTIVE

To describe the six month outcome and predictors of adverse clinical events following successful excimer laser coronary angioplasty (ELCA).

DESIGN

Retrospective analysis of comprehensive data collected at time of initial procedure and during planned follow-up intervals.

SETTING

There were 35 participating institutions throughout the United States.

PATIENTS

The study population was comprised of 3,069 patients who had successful ELCA and completed follow-up at 6 months, representing 91% of eligible cases. Forty percent had prior balloon angioplasty and 34% had prior bypass surgery.

MEASUREMENTS

Patient symptomatology was assessed by Canadian Cardiovascular Society functional (CCSF) class. Interim adverse clinical events [death, Q wave myocardial infarction (QMI), repeat intervention, bypass surgery, and a composite end-point] were tracked. Twenty-six pre-ELCA clinical, angiographic and procedural variables were evaluated to assess their ability to predict outcome.

RESULTS

At 6 months, there was 2.8% mortality, 2.5% incidence of QMI, and 28.7% required either repeat intervention or bypass surgery. Overall, 69.2% of patients had no adverse event. In this cohort, the pre-ELCA CCSF class grade was 2.7 +/- 1.2, but at 6 months, it was 0.7 +/- 1.1 (p < 0.001). The multivariate predictors of the composite end point were gender, stenosis location, and rest and unstable angina.

CONCLUSIONS

There is an excellent 6 month outcome after successful ELCA in this selected population with complex coronary artery disease. The majority of patients without interim events enjoy significant alleviation of symptoms. The predictors of adverse events are clinical rather than angiographic.