Dental procedures in children with or without intellectual disability and autism spectrum disorder in a hospital setting

BACKGROUND

This population-based cohort study investigated dental procedures in the hospital setting in Western Australian children with or without intellectual disability (ID) and/or autism spectrum disorder (ASD) aged up to 18 years. Considering previously reported disparities in dental disease between Indigenous and non-Indigenous Australian children, this study also investigated the effect of Indigenous status on dental procedures.

METHODS

Data on Western Australian live births from 1983 to 2010 from the Midwives Notification System were linked to the Intellectual Disability Exploring Answers database and the Hospital Morbidity Data collection. Primary admissions for relevant dental diagnoses were identified, and treatment procedures for dental hospitalization were investigated. Descriptive statistics and Pearson's chi-squared test of independence were used for analysis.

RESULTS

Overall, 76 065 episodes of dental hospitalization were recorded. Amongst children with ID and/or ASD, Indigenous children experienced more extractions and fewer restorations (68.7% and 16.2%) compared to non-Indigenous children (51.5% and 25.9%). After 6 years, extraction occurred less often in children with ID and/or ASD than in those without, where most surgical dental extractions were in the age group of 13-18 years.

CONCLUSIONS

This study indicates a need for further improvements in access to dental services and the quality of care provided in hospitals for children with ID/ASD. There is also concern that more vulnerable Indigenous and all disadvantaged children are receiving an inadequate level of dental services resulting in more emergency dental hospitalization and invasive treatment.

Confidence of Irish dermatologists in caring for patients with skin of colour

To assess Irish dermatologists' confidence with dermatology in patients with skin of colour (SOC), an online survey was distributed to all members of the Irish Association of Dermatology (IAD) by email. Half (50%) of respondents were 'not confident' or 'not at all confident' in diagnosing skin conditions and one-third (33.9%) were 'not confident' or 'not at all confident' in managing skin conditions in patients with SOC. Irish dermatologists have low confidence with skin pathology in SOC, and specific training could reduce this disparity.

Bare necessities? The utility of full skin examination in the COVID-19 era

Full skin examination (FSE) may improve the detection of malignant melanoma (MM). The objective of this study was to assess the safety of targeted lesion examination (TLE) compared with FSE in our Pigmented Lesion Clinic (PLC). Patients attending the PLC were randomized in a 2 : 1 ratio to FSE (intervention) or TLE (standard care). Demographic details and risk factors were documented, and the time taken to perform FSE and TLE was noted. Of 763 participants, 520 were assigned to FSE and 243 were assigned to TLE. On average, FSE took 4.02 min and TLE took 30 s to perform. Of the 520 participants assigned to FSE, 37 (7.1%) had incidental findings, of whom 12 patients (2.3%) had additional lesions biopsied. No additional melanomas were detected that would have been missed by use of the standard protocol. This study suggests that in low-risk patients referred to a PLC with a lesion of concern, the possibility of missing incidental cutaneous malignancies using lesion-directed examination is low.

Adult North Star Network (ANSN): Consensus Guideline For The Standard Of Care Of Adults With Duchenne Muscular Dystrophy

There are growing numbers of adults with Duchenne Muscular Dystrophy living well into their fourth decade. These patients have complex medical needs that to date have not been addressed in the International standards of care. We sought to create a consensus based standard of care through a series of multi-disciplinary workshops with specialists from a wide range of clinical areas: Neurology, Cardiology, Respiratory Medicine, Gastroenterology, Endocrinology, Palliative Care Medicine, Rehabilitation, Renal, Anaesthetics and Clinical Psychology. Detailed reports of evidence reviewed and the consensus building process were produced following each workshop and condensed into this final document which was approved by all members of the Adult North Star Network including service users. The aim of this document is to provide a framework to improve clinical services and multi-disciplinary care for adults living with Duchenne Muscular Dystrophy.

A re-evaluation of teenage sunbed use following the introduction of banning legislation for under 18-year-olds

Background

There is little information on the effectiveness of introducing age restriction legislation alone to reduce the rate of sunbed usage by teenagers. Prior to the Public Health (Sunbed) Act of 2014 prohibiting the use of sunbeds in under 18-year-olds in Ireland we reported the rate of sunbed use at 7.5%.

Objectives

The aim of the study was to compare the rate of sunbed usage among Irish teenagers before and after the introduction of banning legislation to determine if it had the desired effect of reducing its rate of use.

Methods

In a cross-sectional survey, students from the same schools as in our previous study completed an anonymous, written questionnaire pertaining to sunbed usage.

Results

In total, 783 questionnaires, from 13 schools across Ireland, were completed. The rate of sunbed use in the current study was 7.2%, compared to 7.5% in the pre-ban study, (P = 0.76). A higher rate of sunbed use was observed in Dublin schools and female public students.

Conclusion

Our study suggests that legislation alone is ineffective at reducing sunbed usage in a teenage population. A multifaceted approach is required that includes enforcement of the legislation together with targeted public education and awareness campaigns using all aspects of the media.

Survival of children and adolescents with intellectual disability following gastrostomy insertion

BACKGROUND

Positive health outcomes have been observed following gastrostomy insertion in children with intellectual disability, which is being increasingly used at younger ages to improve nutritional intake. This study investigated the effect of gastrostomy insertion on survival of children with severe intellectual disability.

METHODS

We used linked disability and health data of children and adolescents who were born in Western Australia between 1983 and 2009 to compare survival of individuals with severe intellectual disability by exposure to gastrostomy status. For those born in 2000-2009, we employed propensity score matching to adjust for confounding by indication. Effect of gastrostomy insertion on survival was compared by pertinent health and sociodemographic risk factors.

RESULTS

Compared with children born in the 1980s-1990s, probability of survival following first gastrostomy insertion for those born in 2000-2009 was higher (2 years: 94% vs. 83%). Mortality risk was higher in cases than that in their matched controls (hazard ratio 2.9, 95% confidence interval 1.1, 7.3). The relative risk of mortality (gastrostomy vs. non-gastrostomy) may have differed by sex, birthweight and time at first gastrostomy insertion. Respiratory conditions were a common immediate or underlying cause of death among all children, particularly among those undergoing gastrostomy insertion.

CONCLUSIONS

Whilst gastrostomy insertion was associated with lower survival rates than children without gastrostomy, survival improved with time, and gastrostomy afforded some protection for the more vulnerable groups, and earlier use appears beneficial to survival. Specific clinical data that may be used to prioritise the need for gastrostomy insertion may be responsible for the survival differences observed.

Work-related ill-health: Republic of Ireland, Northern Ireland, Great Britain 2005-2012

BACKGROUND

Data on work-related ill-health (WRIH) in the Republic of Ireland is inconsistent.

AIMS

To compare the incidence of WRIH in the Republic of Ireland (ROI), Northern Ireland (NI) and Great Britain (GB) reported by clinical specialists in skin and respiratory medicine and by specialist occupational physicians (OPs).

METHODS

Analysis of data reported to three surveillance schemes in The Health and Occupation Research (THOR) network in ROI and corresponding UK schemes.

RESULTS

Contact dermatitis was the most frequently reported skin disease in the three areas. Asthma was the most frequently-reported respiratory disease in the ROI, while asbestos-related cases predominate in GB and NI. Mental health disorders, followed by musculoskeletal disorders were reported most frequently by OPs. Annual average incidence rates for skin disease were 2 per 100000 employed (95% confidence interval [CI] 1.9-2.8) in the ROI and 7 per 100000 for GB (95% CI 4.8-9.4). Unadjusted incidence rates for respiratory disease were 1 (95% CI 0.3-1) and 8 (95% CI 6.1-10.7) per 100000 in the ROI and GB, respectively; adjusted for reporter non-response, these figures increased to 15 (95% CI 11.3-19.6) and 32 (95% CI 28.4-35.6) per 100000 respectively.

CONCLUSIONS

This is the first paper to include THOR data on WRIH from the ROI, NI and GB. Consistent and dedicated data collection in the ROI via the THOR schemes is viable and important in the light of a deficit of occupational ill-health data. Sustained efforts to improve participation are underway.

Functioning and post-school transition outcomes for young people with Down syndrome

AIM

To investigate the relationship between functioning and post-school day occupation for young adults with Down syndrome.

METHODS

Families of young people with Down syndrome (n = 269) aged 15-30 years in 2009 were recruited from the population-based Down syndrome 'Needs Opinion Wishes' database in Western Australia. Questionnaires were mailed to participating families and involved two parts, young person characteristics and family functioning; 203 were returned (75%). Of those families who returned questionnaires, 164 (80.8%) of their young adults had left school. Participation in post-school day occupations was the main outcome and included; open employment, training, sheltered employment or alternatives to employment (ATE).

RESULTS

Young adults were reported as participating in open employment (n = 42), training (n = 17), sheltered employment (n = 64) or ATE (n = 41) post-school. Those who reported better functioning in self-care, community and communication skills were more likely to be in open employment and/or attending Technical and Further Education compared with those attending sheltered employment and/or ATE after adjusting for age, gender and rural/metropolitan regions. Current health as measured by visits to a general practitioner (GP) and hospitalizations revealed a weak relationship with post-school day occupations, with increasing likelihood of participating in open employment or training with increasing hospitalizations and GP visits.

CONCLUSIONS

Our analysis shows that functioning in activities of daily living was related to post-school day occupation. Current health status and behaviour were found to have a weak relationship with post-school day occupation adjusting for functioning in the final model.

Factors associated with staffing provision and medical equipment acquisition in Irish general practice

GPs form an integral part of Irish primary care provision. However, current information concerning general practice structure, staffing and development in Ireland is quite limited. This report provides a profile of General Practice in Ireland in 2010 drawing on a national survey of practices using a standardised questionnaire. On average, there are 2.7 GPs per practice, although one in four practices remains single-handed. The majority of practices employ nursing 485 (80.7%) and clerical 549 (91.3%) support. A high proportion of practices have the following items of equipment: ECG machine 496 (82.5%), 24 hour blood pressure monitor 481 (80.1%), spirometer 383 (63.8%), cryotherapy equipment 505 (84%), minor surgery equipment 453 (74.3%) and foetal monitor 484 (80.5%). Using chi-square analysis, we find statistically significant positive relationships between nursing support and possession of each of the six items of medical equipment (chi2 = 81.57, p < 0.01; chi2 = 105.4, p < 0.01; 2 = 38.5, p < 0.01; chi2 = 16.6, p < 0.01; chi2 = 39.5, p < 0.01; = 19.5, p < 0.01) and between practice size and possession of each item of medical equipment (chi2 = 26.3, p < 0.01; chi2 = 45, p < 0.01; chi2 = 16.5, p < 0.01; chi2 = 44.4, p < 0.01; chi2 = 13.8, p < 0.01; chi2 = 14.7, p < 0.01).

Family functioning in families with a child with Down syndrome: a mixed methods approach

BACKGROUND

This study aimed to explore the factors that predict functioning in families with a child with Down syndrome using a mixed methods design. The quantitative component examined the effect of maladaptive and autism-spectrum behaviours on the functioning of the family while the qualitative component explored the impact of having a child with Down syndrome on family holidays, family activities and general family functioning.

METHODS

Participants in this study were 224 primary caregivers of children with Down syndrome aged 4-25 years (57.1% male; 42.9% female) currently residing in Western Australia (74.0% in metropolitan Perth and 26.0% in rural Western Australia).

RESULTS

Maladaptive and autism-spectrum behaviour were associated with poorer family functioning. Mean total scores on the measures of family functioning and marital adjustment were comparable to that of families of typically developing children. Consistent with the quantitative findings, normality was the most common theme to emerge in the qualitative data. Child problem behaviours were also identified by parents/carers as having a negative impact on the family.

CONCLUSIONS

This study has implications for the development of programs to support families with a child with Down syndrome and may dispel some of the myths surrounding the impact of intellectual disability on the family.

'Idiopathic' intestinal failure--the importance of identifying and treating primary psychopathology

BACKGROUND

Gastrointestinal neuromuscular disorders (GINMD) are an important cause of intestinal failure (IF). We present six cases of IF in whom a diagnosis of GINMD was initially suspected, but in whom psychopathology was discovered to be the primary etiology.

METHODS

(i) Six consecutive cases referred to our unit with IF, initially presumed to be due to GINMD, were selected. Informed consent was obtained from all patients. Case notes were reviewed for salient clinical information. (ii) A literature search was performed to ascertain the epidemiology of psychopathology in IF and the current evidence for the management of severe functional GI disorders with a multidisciplinary psychiatric approach.

KEY RESULTS

(i)All six cases required multidisciplinary psychiatric management in a specialized psychiatric unit that included the use of antidepressants, antipsychotics, mood stabilizers, and Electroconvulsive therapy in addition to nutritional support via enteral or parenteral routes. (ii) The evidence base for the treatment of severe FGIDs is sparse.

CONCLUSIONS & INFERENCES

There is a need for additional reporting of such cases and further research. Our experience would suggest that a delay in the involvement of a specialist liaison psychiatrist has the potential to be life threatening in such cases. This may be more likely with greater severity, where the apparent predominance of 'physical' symptoms generates reluctance in both patient and physician to consider a psychiatric etiology and also appears to occur due to a lengthier investigative process than existed previously. We therefore propose that the provision of a specialist psychiatric assessment for all patients presenting with IF is indicated at the point of initial clinical contact, based upon the substantial clinical benefit it has the potential to confer upon a significant minority. This process need not delay investigation, which can continue as indicated in parallel, but can be life-saving.

New records of Batrachochytrium dendrobatidis in Chilean frogs

We used molecular techniques to examine 11 species of frogs in 6 localities in southern Chile to ascertain the incidence of the chytrid fungus Batrachochytrium dendrobatidis (Bd). We detected the fungus in 2 localities (Coñaripe and Raúl Marín Balmaceda) in 3 species: Batrachyla leptopus, Pleurodema thaul and Rhinoderma darwinii. Our findings expand the list of Bd hosts to include B. leptopus and P. thaul and extend the spatial distribution in Chile to include the southernmost Bd record at Raúl Marín Balmaceda.

Batrachochytrium dendrobatidis in Darwin's frog Rhinoderma spp. in Chile

The presence of the chytrid fungus Batrachochytrium dendrobatidis in Chile was evaluated in 2 endangered frog species of the genus Rhinoderma. Specimens from a captive rearing facility, wild populations and preserved collection material were analyzed using histological and molecular techniques. The fungus was identified in the rearing facility and in wild populations, but not in the archived frogs. This study confirms, for first time, the presence of chytridiomycosis in Rhinoderma darwinii in Chile.

Cost-effectiveness of employing a total parenteral nutrition surveillance nurse for the prevention of catheter-related bloodstream infections

The cost of catheter-related bloodstream infection (CRBSI) is substantial in terms of morbidity, mortality and financial resources. Total parenteral nutrition (TPN) is a recognised risk factor for CRBSI. In 1997, an intravenous nutrition nurse was promoted to TPN surveillance clinical nurse manager (CNM) and quarterly infection audit meetings were introduced to monitor trends in CRBSI. Data were prospectively collected over a 15-year period using specific TPN records in a 535-bed tertiary acute university hospital. A total of 20 439 CVC-days and 307 CRBSIs were recorded. Mean number of infections before, and after, the introduction of a dedicated TPN surveillance CNM were compared. Mean CRBSI per 1000 catheter-days+/-SD was 20.5+/-6.34 prior to 1997 and 14.64+/-7.81 after 1997, representing a mean reduction of 5.84 CRBSIs per 1000 catheter-days (95% CI: -4.92 to 16.60; P=0.05). Mean number of CRBSIs per year+/-SD was 28.3+/-4.93 prior to 1997 and 18.5+/-7.37 after 1997, representing a mean decrease of 9.8 infections per year (95% CI: 0.01 to 19.66; P<0.05). The savings made by preventing 9.8 infections per year were calculated from data on bed-days obtained from the hospital finance office. The cost in hospital days saved per annum was euro135,000. Introduction of a TPN surveillance CNM saved the hospital at least euro78,300 per annum and led to a significant decrease in CRBSIs in TPN patients.

IDEA (Intellectual Disability Exploring Answers): A population-based database for intellectual disability in Western Australia

Despite the demands it places on individuals, families and the community, intellectual disability (ID) is a neglected area of public health. Accurate estimates of prevalence are sparse and range from 0.5 to 3.0%. The cause of the condition is unknown in at least 50% of cases. This paper describes the Intellectual Disability Exploring Answers (IDEA) database set up in Western Australia to provide an infrastructure for research and to facilitate the planning of service provision for people with ID. Since 1953 a database for ID has been maintained in Western Australia, a state with a population of 1.95 million in an area of 2.52 million km2. The current IDEA database aims to obtain ongoing population-based ascertainment of ID from providers of clinical and educational services, with the potential for linkage to a network of other state databases. The average prevalence of ID for children born in Western Australia over the years 1983-1996 was 15.2 per 1000 live births, with 50% ascertained only through the education system. During this time period 60% of cases were male. Of children with an ID born in Western Australia in 1980-1999 and surviving to 1 year, 30.1% had a birth defect, and the prevalence ratio of birth defects in this group compared to the population with no birth defects was 6.5 (CI 6.3-6.8).

Steroid allergy in patients with inflammatory bowel disease

BACKGROUND

Contact allergy to a steroid enema leading to worsening of inflammatory bowel disease (IBD) has recently been reported. This study was designed to look for evidence of steroid allergy in patients with IBD.

OBJECTIVES

To look for the presence of steroid allergy in general, and steroid enema allergy in particular, in a cohort of IBD patients prepared to attend for patch testing.

METHODS

Patients with IBD in two gastroenterology units at Dublin and Cork were asked to take part in the study. Those who agreed to take part were tested to the British Contact Dermatitis Society standard and steroid batteries. Patients with positive tests to steroids were subsequently asked to attend for intradermal testing with prednisolone, and patch testing to the two commercially available steroid enemas in Ireland and an extended battery of steroids. Reactions were read at days 2 and 4.

RESULTS

In total, 44 patients from the two units were patch tested. Four patients had positive patch tests to one or more steroids in these batteries: budesonide (n = 2), triamcinolone acetonide (n = 1), tixocortol pivalate (n = 1) and prednisolone (n = 1). Of these, three underwent further testing. All three had positive reactions to intradermal prednisolone and one had a positive test to steroid enema.

CONCLUSIONS

Four (9%) of our patients were found to have steroid allergy. This has important implications for the local and systemic treatment of their IBD.

Photopatch testing of 1155 patients: results of the U.K. multicentre photopatch study group

BACKGROUND

Photoallergic contact dermatitis can be difficult to diagnose if not appropriately investigated. Currently, the most common U.K. photoallergens appear to be sunscreen chemicals. The investigation of choice is photopatch testing (PPT), which is probably underused. In part, this is due to differences in methodology and results interpretation.

OBJECTIVES

To conduct PPT using a group of sunscreen chemicals, defined indications and a standardized methodology including interpretation and relevance of reactions in patients attending for investigation at 17 centres across the U.K., Ireland and the Netherlands.

METHODS

Patients (n = 1155) who fulfilled the inclusion criteria were investigated with PPT using sunscreen chemicals in addition to suspected topical products. Readings were taken at 24, 48 and 72 h following standardized ultraviolet A irradiation (5 J cm(-2)). The clinical relevance of any reaction was recorded.

RESULTS

Of the 1155, 130 had allergic reactions (11.3%). Of these, 51 had photoallergy (PA) (4.4%), 64 had contact allergy (CA) (5.5%), and 15 patients had combined PA and CA (1.3%). Multiple PA was seen in some. The most common photoallergen was benzophenone-3 (27 reactions; 21%). Most reactions (60%) were clinically relevant. The most common indication for testing in patients found to have PA was a history of reacting to a sunscreen (41%). The other 59% had an exposed-site dermatitis/skin problem or a photodermatosis. Some centres (n = 8) performed readings after the standard 48-h reading, and an extra 32 PA and 22 CA reactions were detected, which were not evident at 48 h. A new photoallergen (octyl triazone) was detected in two patients.

CONCLUSIONS

Sunscreen PA and CA are probably equally uncommon. Most reactions, of both reaction types, were relevant clinically. A large proportion of patients (59%) found to have PA was unaware of reacting to a sunscreen chemical, suggesting that PA should be considered as an explanation in any exposed-site dermatitis. Although this study focused on reactions at 48 h postirradiation, readings performed up to 96 h, while inconvenient, add value by detecting additional relevant responses. A previously unknown photoallergen was found, highlighting the need for awareness of novel photoallergens in the marketplace. A standardized PPT method not only encourages more use of this investigation, but also facilitates comparison of results between centres and so will improve our understanding of PA.

Ethnic variations in the management of patients with acute stroke

BACKGROUND

There is increasing interest in the management of stroke in ethnic minorities but few studies have considered this issue. This study investigated if differences in acute stroke management exist between a white European and Bangladeshi populations living in London, England.

METHODS

All stroke surviving patients discharged over a five year period in a major London teaching hospital based in an ethnically diverse area of inner city London were recruited. Cerebrovascular risk factors, their management, and investigation for acute stroke syndromes were recorded and comparison between white and Bangladeshi cohorts was made. Categorical data were analysed using Fisher's exact test.

RESULTS

Measurement of cholesterol concentrations are undertaken less often in those from a Bangladeshi background (25%) compared with white Europeans (76%) (p<0.0001). Statin therapy tends to be given less often to Bangladeshis. However, neuroimaging (p<0.05) and echocardiography (p<0.0001) is performed more often in Bangladeshis compared with white Europeans.

CONCLUSION

There are variations in the management of acute stroke because of ethnicity and these variations could have substantial consequences on secondary rates of cerebrovascular and cardiovascular disease. Whether the reasons for this disparity are attributable to inequity or iniquity of care need to be further investigated perhaps along with the development of ethnicity specific protocols. Overall the management of stroke and its risk factors in either racial group remains lamentable.

Clinical and electrophysiological differences between patients with arrhythmogenic right ventricular dysplasia and right ventricular outflow tract tachycardia

AIMS

Radiofrequency catheter ablation is considered first line treatment for symptomatic patients with right ventricular outflow tract tachycardia (RVOT). The role of ablation in arrhythmogenic right ventricular dysplasia (ARVD) is more limited. As such, differentiating between the two conditions is essential.

METHODS AND RESULTS

This study compared non-invasive findings, magnetic resonance images (MRI), invasive electrophysiological characteristics, results of ablation and long-term outcome in 50 consecutive patients with RVOT (33) or ARVD (17). Structural abnormalities were uniform in the ARVD group; in addition 18 (54%) of the RVOT tachycardia group had MRI abnormalities. At electrophysiological study the tachycardia in the ARVD group displayed features of re-entry in over 80%, but behaved with a triggered automatic basis in 97% with RVOT. Ablation was complete or partial success in 12 (71%) patients with ARVD and ventricular tachycardia (VT) recurred in eight (48%). In the RVOT patients, ablation was a complete success in 97% with recurrent VT in 6%. Long-term success in the RVOT patients was 95% in both patients with and without MRI abnormalities.

CONCLUSIONS

Electrophysiological characterization can differentiate ARVD from RVOT. The finding of abnormalities on MRI does not have any bearing on arrhythmia mechanism, acute or long-term success of RFA.

The phenotype of limb-girdle muscular dystrophy type 2I

BACKGROUND

Mutations in the fukutin-related protein gene FKRP cause limb-girdle muscular dystrophy (LGMD2I) as well as a form of congenital muscular dystrophy (MDC1C).

OBJECTIVE

To define the phenotype in LGMD2I.

METHODS

The authors assessed 16 patients from 14 families with FKRP gene mutations and LGMD and collected the results of mutation analysis, protein studies, and respiratory and cardiac investigations.

RESULTS

Thirteen patients, most with adult presentation, were homozygous for the common C826A mutation in FKRP. The three other cases were compound heterozygotes for C826A and two of them presented in childhood, with more progressive disease. The pattern of muscle involvement, frequently including calf hypertrophy, was similar to dystrophinopathy. Complications in patients with LGMD2I were common and sometimes out of proportion to the skeletal muscle involvement. Six patients had cardiac involvement, and 10 had respiratory impairment: five required nocturnal respiratory support. All patients had serum creatine kinase at least 5 to 70 times normal. The most consistent protein abnormality found on muscle biopsy was a reduction of laminin alpha2 immunolabeling, either on muscle sections or immunoblotting alone.

CONCLUSIONS

LGMD2I due to FKRP mutations appears to be a relatively common cause of LGMD, with respiratory and cardiac failure as prominent complications.

Detecting and reducing adverse events in an Australian rural base hospital emergency department using medical record screening and review

OBJECTIVE

To determine if retrospective medical record screening and clinical review followed by appropriate action can effectively and efficiently detect and reduce adverse events in an emergency department.

METHOD AND PARTICIPANTS

The medical records of 20 050 patients who attended the emergency department over a two year period were screened for adverse events using five general patient outcome criteria. Records that screened positive were reviewed by the hospital's clinical risk manager. If an adverse event was detected, the record was also reviewed by the director of emergency. For the first three months details of adverse events were recorded to determine a baseline adverse event rate, but no further action was taken. When an adverse event was found in the remaining 21 months, further analysis and recommendations for action to prevent a recurrence were made to relevant hospital staff.

SETTING

A rural base hospital in the Wimmera region of Victoria, Australia between October 1997 and September 1999.

RESULTS

Of all the patient attendances 573 (2.85%) were screened positive for one or more criteria. An adverse event was confirmed in 250 patient attendances (1.24% of all attendances). Of the adverse occurrences, 81 (32.4%) were determined to be of major severity and 169 (67.6%) of minor severity. Quality improvement activities, mostly changes to hospital policies and work processes, were implemented with the aim of preventing the recurrence of specific adverse patient events. Over two years the number of adverse events fell from 84 (3.26% of all patient attendances) in the pre-intervention quarter to 12 (0.48% of all patient attendances) in the final quarter (relative risk reduction 85.3% (95% CI, 62.7% to 100%)).

CONCLUSIONS

Adverse events in emergency departments can be efficiently detected and their rate reduced using retrospective medical record screening together with clinical review, analysis and action to prevent recurrences.

Guidelines for care of contact dermatitis

These guidelines for the management of contact dermatitis have been prepared for dermatologists on behalf of the British Association of Dermatologists. They present evidence-based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines, including details of relevant epidemiological aspects, diagnosis and investigation.

Nationwide study of haemolytic uraemic syndrome: clinical, microbiological, and epidemiological features

AIMS

To establish the incidence and aetiology of haemolytic uraemic syndrome (HUS) in Australia and compare clinical and microbial characteristics of sporadic and outbreak cases.

METHODS

National active surveillance through the Australian Paediatric Surveillance Unit with monthly case notification from paediatricians, July 1994 to June 1998. Children under 15 years presenting with microangiopathic haemolytic anaemia, thrombocytopenia, and acute renal impairment were identified.

RESULTS

Ninety eight cases were identified (incidence 0.64 per 10(5) children <15 years/annum and 1.35 per 10(5) children <5 years/annum). Eighty four were associated with diarrhoea (64 sporadic, 20 constituting an outbreak) and 14 were atypical. Shiga toxin producing Escherichia coli (STEC) O111:H- was the most common isolate in sporadic HUS and caused the outbreak. However O111:H- isolates from outbreak and sporadic cases differed in phage type and subtyping by DNA electrophoresis. STEC isolates from sporadic cases included O26:H-, O113:H21, O130:H11, OR:H9, O157:H-, ONT:H7, and ONT:H-. STEC O157:H7 was not isolated from any case. Only O111:H- isolates produced both Shiga toxins 1 and 2 and possessed genes encoding E coli attaching and effacing gene (intimin) and enterohemolysin. Outbreak cases had worse gastrointestinal and renal disease at presentation and more extrarenal complications.

CONCLUSIONS

Linking national surveillance with a specialised laboratory service allowed estimation of HUS incidence and provided information on its aetiology. In contrast to North America, Japan, and the British Isles, STEC O157:H7 is rare in Australia; however, non-O157:H7 STEC cause severe disease including outbreaks. Disease severity in outbreak cases may relate to yet unidentified virulence factors of the O111:H- strain isolated.

Detecting and reducing hospital adverse events: outcomes of the Wimmera clinical risk management program

OBJECTIVES

To determine if an integrated clinical risk management program that detects adverse patient events in a hospital, analyses their risk and takes action can alter the rate of adverse events.

DESIGN

Longitudinal survey of adverse patient events over eight years of progressive implementation of the risk management program.

PARTICIPANTS AND SETTING

49,834 inpatients (July 1991 to September 1999) and 20,050 emergency department patients (October 1997 to September 1999) at a rural base hospital in the Wimmera region of Victoria.

MAIN OUTCOME MEASURES

Rates of adverse events detected by medical record review and clinical incident and general practitioner reporting.

RESULTS

The annual rate of inpatient adverse events decreased between the first and eighth years of the study from 1.35% of all patient discharges (69 events) to 0.74% (49 events) (P<0.001). Absolute risk reduction was 0.61% (95% CI, 0.23%-0.99%), and relative risk reduction was 44.9% (95% CI, 16.9%-72.9%). The quarterly rate of emergency department adverse events decreased between the first and eighth quarters of monitoring from 3.26% of all attendances (84 events) to 0.48% (12 events) (P< 0.001). Absolute risk reduction was 2.78% (95% CI, 2.04%-3.52%), and relative risk reduction was 85.3% (95% CI, 62.7%-100%).

CONCLUSIONS

Adverse patient events can be detected, and their frequency reduced, using multiple detection methods and clinical improvement strategies as part of an integrated clinical risk management program.

The emotions in war: fear and the British and American military, 1914-45

In modern warfare, technological innovations are applied to terrifying effect. On the machine-dominated battlefields of the twentieth century, the ability of individuals to master their emotions is crucial to the whole martial enterprise. Fear has widely been recognized as the most fraught of all emotions: it may stimulate combatants to fight and it may cause them to flee. This article examines the proliferation of theories about the nature of this emotion within the British and American forces during the First and Second World Wars. The military recognized the impact of new technologies upon human physiology and psychology, elaborated ways of interpreting the particular threat posed by ‘fear’ in modern conflicts, and prescribed ways of disciplining the emotional lives of combatants.

Reducing medical errors: a practical guide

Healthcare delivery involves complex systems Preventable injuries occur more frequently than in other complex industries. Clinical risk management aims to reduce the probability of adverse patient events occurring. Adverse events can be detected by medical record review, clinical incident reporting and other methods. Events are analysed to determine latent and active errors and ranked in order of risk severity. Action is then planned and implemented to prevent the event from recurring. Effective actions include simplifying systems, standardising procedures, introducing constraints, using reminders and checklists, providing timely information, and small-group interactive education. Organisational factors that may increase the probability of successfully reducing medical errors in hospitals include the availability of adequate resources and education, the presence of clinical, executive and board of management quality champions, and quality improvement and risk management as key objectives in a hospital's strategic plan. Governments can aid the implementation of risk management programs by financially rewarding high quality care.

Latex allergy--implications for Irish patients and healthcare workers

A 34-year-old lady presented with an exacerbation of her atopic dermatitis. She also gave a history of angioedema during labour. Type I latex hypersensitivity was confirmed by serological and epicutaneous testing. Virtually unrecognised until the 1980s, latex hypersensitivity is now being reported more and more frequently, particularly in spina bifida patients, atopics and healthcare personnel. The importance of this problem for patients and healthcare personnel is discussed.

UTP-preferring P2 receptor mediates inhibition of sodium transport in porcine thyroid epithelial cells

1. The effects of adenosine 5'-triphosphate (ATP), uridine 5'-triphosphate (UTP) and analogues on forskolin-stimulated absorption of Na+ by porcine thyroid epithelial cells were analysed in cultures grown as confluent monolayers on permeable supports in Transwell Ussing chambers. 2. 85% of the forskolin (10 microM)-stimulated short-circuit current was inhibited by phenamil (1 microM), which is a selective antagonist for epithelial type Na+ channels. 3. Phenamil-sensitive current was inhibited in a dose dependent manner by nucleotides added to the apical compartment of Ussing chambers. In contrast, the phenamil-resistant current, previously shown to represent anion secretion, was unaffected by nucleotides. 4. The order of potency (with EC50 values given in microM) was UTP (0.08)>>ATP (6.3)=uridine 5'-diphosphate (UDP) (6. 6)>2methyl-thio-adenosine-5'-triphosphate (2MeSATP) (84.5)>adenosine 5'-diphosphate (ADP) (147.8)>alpha,beta-methylene ATP (>150)>>adenosine (>1000). 5. P2 receptors mediating inhibition of sodium absorption were present on the apical membrane of the cells since addition of UTP (1-1000 microM) to the basal compartment of the Ussing chambers had little effect while subsequent addition to the apical compartment produced a normal response. 6. Cibachron blue (Reactive blue 2) (1-100 microM), an antagonist at some P2 receptor subtypes, inhibited phenamil sensitive current in a dose dependent manner with half maximal inhibition occurring at 14.25 microM. 7. Suramin (100 microM), pyridoxalphosphate-6-azophenyl-2', 4'-disulphonic acid (PPADS) (100 microM) and pyridoxal 5'-phosphate (P5P) (100 microM) showed only slight competitive antagonism against the response to UTP. 8 These results indicate that a UTP-preferring P2 receptor located on the apical membrane of thyroid epithelial cells mediates inhibition of Na+ absorption.