Integration of a respiratory function monitor into newborn positive pressure ventilation training; development of a standardised training intervention.

Objective: One in twenty newborns require resuscitation with positive pressure ventilation (PPV) at birth. Newborn face mask ventilation is often poorly performed. To address this, the potential role of respiratory function monitors (RFM) in newborn resuscitation training has been highlighted. The objective of this study was to develop a standardised training intervention on newborn PPV using an RFM with a simple visual display to identify and correct suboptimal ventilations. Methods: We adapted the framework from a simulation development guideline to create a hands-on intervention on newborn PPV using an RFM with simple visual feedback (Monivent NeoTraining). We enrolled a group of healthcare professionals to a manikin-based pilot study as part of this process, conducting a series of teaching sessions to refine the intervention. Suggested changes were gathered from participants and instructors. Our main objective was to develop a standardised, reproducible training intervention. Results: A standardised training intervention on newborn PPV was systematically developed. Twenty-six healthcare professionals working in tertiary neonatal care participated in a pilot study, consisting of eight training sessions. Each iteration of the intervention was informed by the previous session. Instructions for the delivery of teaching were standardised and a training algorithm was developed. Conclusion: RFM's have been shown to be effective tools in research settings, addressing poor technique and face mask leak. They are not routinely used in newborn resuscitation training. To address this, we developed a standardised training intervention on newborn PPV using an RFM with simple visual feedback.

Voluntary and involuntary admissions with schizoaffective disorder: do they differ from schizophrenia?

OBJECTIVES: Schizoaffective disorder and schizophrenia are common presentations to psychiatry services. Research to date has focussed on hypothesised biological differences between these two disorders. Little is known about possible variations in admission patterns. Our study compared demographic and clinical features of patients admitted voluntarily and involuntarily with diagnoses of schizoaffective disorder or schizophrenia to three psychiatry admission units in Ireland. METHODS: We studied all admissions to three acute psychiatry units in Ireland for periods between 1 January 2008 and 31 December 2018. We recorded demographic and clinical variables for all admissions. Voluntary and involuntary admissions of patients with schizoaffective disorder were compared to those with schizophrenia. RESULTS: We studied 5581 admissions to the study units for varying periods between January 2008 and December 2018, covering a total of 1 976 154 person-years across the 3 catchment areas. The 3 study areas had 218.8, 145.5 and 411.2 admissions per 100 000 person-years, respectively. Of the 5581 admissions over the study periods, schizoaffective disorder accounted for 5% (n = 260) and schizophrenia for 17% (n = 949). Admissions with schizoaffective disorder were significantly more likely to be female and older, and less likely to have involuntary admission status, compared to those with schizophrenia. As first admissions were not distinguished from re-admissions in this dataset, these findings merit further study. CONCLUSIONS: Admissions with a schizoaffective disorder differ significantly from those with schizophrenia, being, in particular, less likely to be involuntary admissions. This suggests that psychotic symptoms might be a stronger driver of involuntary psychiatry admission than affective symptoms.

Prospective observational study investigating the predictive validity of the STarT Back tool and the clinical effectiveness of stratified care in an emergency department setting.

PURPOSE: To determine the predictive validity of the STarT Back tool (SBT) undertaken at baseline and 6 weeks to classify Emergency Department (ED) patients with LBP into groups at low, medium or high risk of persistent disability at 3 months. A secondary aim was to evaluate the clinical effectiveness of pragmatic risk-matched treatment in an ED cohort at 3 months. METHODS: A prospective observational multi-centre study took place in the physiotherapy services linked to the ED in four teaching hospitals in Dublin, Ireland. Patients were stratified into low, medium and high-risk groups at their baseline assessment. Participants received stratified care, where the content of their treatment was matched to their risk profile. Outcomes completed at baseline and 3 months included pain and disability. Linear regression analyses assessed if baseline or 6-week SBT score were predictive of disability at 3 months. Changes in the primary outcome of disability were dichotomised into those who achieved/ did not achieve a 30% improvement in their RMDQ at 6 weeks and 3 months. RESULTS: The study enrolled 118 patients with a primary complaint of LBP ± leg pain with 67 (56.7%) completing their 6-week and 3-month follow-up. Baseline RMDQ and being in medium or high risk SBT group at 6 weeks were predictive of persistent disability at 3 months. A total of 54 (80.6%) participants reported a > 30% improvement at 3 months. CONCLUSION: Disability at baseline and SBT administered at 6 weeks more accurately predicted disability at 3 months than SBT at baseline in an ED population.

Diagnostic Limitations in Congenital Zika Virus Infection.

This is the first documented case of an infant with congenital Zika virus infection (ZVI) born in Ireland. A term infant was delivered with an antenatal diagnosis of severe microcephaly. First trimester bloods confirmed maternal ZVI and although the infant did not have Zika virus RNA or Zika-specific IgM in her blood or urine, she had multiple clinical features of congenital ZVI and Zika virus RNA was present in the placenta.

Involuntary psychiatric admission based on risk rather than need for treatment: report from the Dublin Involuntary Admission Study (DIAS).

Aims Involuntary psychiatric admission in Ireland is based on the presence of mental disorder plus serious risk to self/others and/or need for treatment. This study aimed to examine differences between use of risk and treatment criteria, about which very little is known. Methods We studied 2,940 admissions, of which 423 (14.4%) were involuntary, at three adult psychiatry units covering a population of 552,019 people in Dublin, Ireland. Results Involuntary patients were more likely than voluntary patients to be male, unmarried and have schizophrenia or a related disorder. Involuntary admission based on the 'risk criterion' (rather than the 'treatment criterion' or both) was associated with a shorter period as an involuntary patient for patients with diagnoses other than schizophrenia. Conclusion If inpatient units are intended as treatment centres rather than risk management units, the balance between considerations of risk and treatment requires careful re-examination in the setting of involuntary psychiatric care.

Who can decide? Prevalence of mental incapacity for treatment decisions in medical and surgical hospital inpatients in Ireland.

BACKGROUND: The prevalence of mental incapacity for treatment decisions among medical and surgical hospital inpatients is poorly understood or not known in many countries, including Ireland. AIM: To assess the prevalence of mental incapacity in hospital inpatients in Ireland. DESIGN: Cross-sectional observational study of mental incapacity for treatment decisions. METHODS: We assessed mental capacity in 300 randomly selected hospital inpatients in 2 general hospitals in Dublin (urban) and Portlaoise (rural), in Ireland, using the MacArthur Competence Assessment Tool for Treatment (MacCAT-T). RESULTS: Mean MacCAT-T score was 14.80 (SD: 8.40) out of a possible maximum of 20 (with a higher score indicating greater mental capacity). Over one quarter of participants (27.7%; n = 83) lacked the mental capacity for treatment decisions; 1.7% (n = 5) had partial capacity and 70.7% (n = 212) had full capacity. Scores for each of the four sub-scales of the MacCAT-T were generally consistent across the four key areas of understanding, appreciation, reasoning and expressing a choice. CONCLUSIONS: Mental incapacity for treatment decisions is common in medical and surgical hospital inpatients in Ireland. This issue both merits and requires greater attention in clinical practice, research and legislation.

Severe thrombocytopenia and patterns of bleeding in neonates: results from a prospective observational study and implications for use of platelet transfusions.

OBJECTIVE: To describe patterns of clinical bleeding in neonates with severe thrombocytopenia (ST and platelet count <60 × 10(9) L(-1)), and to investigate the factors related to bleeding. STUDY DESIGN: Seven tertiary-level neonatal units enrolled neonates (n = 169) with ST. Data were collected prospectively on all clinically apparent haemorrhages. Relationships between bleeding, platelet count and baseline characteristics were explored through regression analysis. RESULTS: Bleeding was recorded in most neonates with ST (138/169; 82%), including 123 neonates with minor bleeding and 15 neonates with major bleeding. The most common sites of minor bleeding were from the renal tract (haematuria 40%), endotracheal tube (21%), nasogastric tube (10%) and skin (15%). Gestational age <34 weeks, development of ST within 10 days of birth and necrotizing enterocolitis were the strongest predictors for an increased number of bleeding events. For neonates with ST, a lower platelet count was not a strong predictor of increased bleeding. CONCLUSIONS: The majority of neonates with ST bleed, although most episodes are minor. These findings establish the importance of clinical factors for bleeding risk, rather than minimum platelet count. Further studies should assess the clinical significance of different types of minor bleed for neonatal outcomes, the predictive value of minor bleeding for major bleeding and the role of platelet transfusions in preventing bleeding.

Two-year outcomes from very low birthweight infants in a geographically defined population across 10 years, 1993-2002: comparing 1993-1997 with 1998-2002.

AIM: To determine the prevalence and nature of disability at 2 years of age in infants born from 1993 to 2002 with a birth weight of <1500 g. METHODS: A prospective cohort analysis of all eight neonatal units in East Anglia, UK using a single database. Local paediatricians assessed children at 2 years of age using the Health Status Questionnaire. Data were analysed using SPSS v 9 and MSAccess 97. RESULTS: 97% of the 1850 survivors were assessed at 2 years. 21% had mild disability, 10.8% moderate and 8.6% severe. There was no evidence of an increased rate of disability despite survival rates increasing from 75% in 1993 to 89% in 2002. There was an increased trend in survival of infants of <28 weeks' gestation from 17% to 21% (p=0.08), and the overall rate of moderate to severe disability decreased significantly from 35% to 28% (p<0.01). There was a decreasing trend in the number of infants with cerebral palsy (6% vs 4%). There was also a decrease in the numbers of infants with blindness, hydrocephalus or a hearing impairment. Follow-up rates decreased from 99% to 94.5%. Analysis of those lost to follow-up revealed they were of higher gestation and birth weight. CONCLUSION: There was no evidence of an increased rate of disability despite improved survival rates over the two time periods. The rate of blindness decreased, probably reflecting earlier treatment of retinopathy of prematurity. This study demonstrates that although follow-up remains a challenge, rates of over 90% are achievable.

Do current retinopathy of prematurity screening guidelines miss the early development of pre-threshold type 1 ROP in small for gestational age neonates?

PURPOSE: To investigate whether current UK retinopathy of prematurity (ROP) screening guidelines miss the early development of pre-threshold type 1 ROP in some neonates born small for gestational age (SGA) and consider if the guidelines should be changed. METHODS: Data were collected on neonates of < or =31 completed weeks gestation and/or birth weight (BW) < or =1500 g born over a 37-month period. Babies who did not complete the screening programme in Cambridge and those with other ocular abnormalities were excluded. We compared the time course of ROP progression and the development of the early treatment for ROP pre-threshold ROP in relation to the gestational age and the BW of the babies. RESULTS: A total of 105 neonates were included, 11 (10.5%) were born SGA (less than 9th centile of predicted BW). Of these 11, 2 (18.2%) had pre-threshold ROP at their first screen (median post-natal age (PNA) 6.5 weeks, median postmenstrual age (PMA) 33.5 weeks). No other neonate in this group developed pre-threshold ROP.Of the 94 other neonates, none had pre-threshold ROP at first screen (median PNA 7.1 weeks). Pre-threshold ROP developed in 12 (12.8%) of these babies between 8 and 12 (median 11.5) post-natal weeks, at a PMA of 33-38 (median 35.5) weeks. CONCLUSION: Current UK ROP screening guidelines recommend first screening at 6-7 post-natal weeks. Our study suggests that pre-threshold type 1 ROP can develop before this especially in SGA babies. We suggest that screening should either start at 4 post-natal weeks in such babies, or be based on PMA rather than PNA, to allow timely laser therapy.

A dose response study of inhaled nitric oxide in hypoxic respiratory failure in preterm infants.

BACKGROUND: Inhaled nitric oxide (iNO) is used widely in newborn infants with hypoxic respiratory failure, despite the known and theoretical toxicity of iNO, and a relative lack of information about appropriate doses. AIM: To determine whether a dose-response relationship existed for iNO in preterm infants. DESIGN: A four-period, four-dose, cross-over design was used with iNO given for 15 min in a randomised sequence in concentrations of 5, 10, 20 and 40 parts per million (ppm), with a minimum 5 min wash-out period. Data on ventilatory, blood gas and other physiological measurements were recorded before and at the end of each period. The relationship of clinical response with iNO dose and period was analysed using multivariate regression. SUBJECTS: Infants with gestational age < 34 weeks and < 28 days postnatal age with hypoxic respiratory failure were recruited. OUTCOME MEASURE: A clinically significant dose-response was defined as a rise in the post-ductal arterial oxygen tension (PaO(2)) of at least 3 kPa. RESULTS: Thirteen infants were recruited. At trial entry, ten were < 3 days of age; 11 were being treated with high frequency oscillatory ventilation; median (inter-quartile range) gestational age 27 (25-29) weeks; birthweight 983 (765-1120) g; oxygenation index 27.1 (21.8-28.8). Six infants (46%) showed a clinically significant response. After adjusting for period and patient effect, no evidence for an overall dose effect was identified (likelihood ratio test, p=0.34). CONCLUSION: No evidence of a dose-response relationship with iNO was found in this study of very preterm infants with respiratory failure.

A family with autosomal dominant hypocalcaemia with hypercalciuria (ADHH): mutational analysis, phenotypic variability and treatment challenges.

Autosomal dominant hypocalcaemia with hypercalciuria (ADHH) is an intriguing syndrome, in which activating mutations of the calcium sensing receptor (CaSR) have recently been recognised. We describe a kindred with seven affected individuals across three generations, including patients affected in the first decade of life. Age at diagnosis varied from birth to 50 years. Affected members had hypocalcaemia (1.53-1.85 mmol/l), hypercalciuria, low but detectable parathyroid hormone (PTH) and hypomagnesaemia. Four of seven affected individuals were symptomatic (seizures, abdominal pains and paraesthesias), unrelated to severity of hypocalcaemia. Additional complications include nephrocalcinosis (n = 3) and basal ganglia calcification, identified by CT scanning in all five individuals. Symptomatic individuals were treated with calcium and calcitriol to reduce the risk of hypocalcaemic seizures. DNA sequence analysis, identified a mutation in exon 3, codon 129 (TGC-->TAC) of the CaSR gene of seven affected family members, resulting in loss of a conserved cysteine residue, potentially disrupting CaSR receptor dimerisation. Thus, a novel mutation was identified in this family, who demonstrate variability of ADHH phenotype and also illustrate the complexities of clinical management. Optimal management of ADHH is difficult and we recommend judicious treatment to avoid an increased risk of nephrocalcinosis.

The role of matrix metalloproteinases -9 and -2 in development of neonatal chronic lung disease.

AIM: Matrix metalloproteinases (MMPs) -9 and -2 degrade type-IV collagen, a major constituent of lung basement membrane, and may have a role in the pathogenesis of neonatal chronic lung disease (CLD). We determined factors influencing MMP levels in neonatal bronchoalveolar lavage (BAL) fluid to establish whether an imbalance between MMP and its inhibitor could be implicated in CLD. METHODS: We measured MMP-9 and -2 and tissue inhibitor of metalloproteinase-1 (TIMP-1) levels in 316 BAL fluid samples from 121 babies of gestational ages 23 to 42 wk over the first 14 d of life to determine effects of gestation and postnatal age. Median MMP-9, -2, TIMP-1 and MMP-9/TIMP-1 ratio in BAL were further studied in a subgroup of 85 babies <33 wk gestation to determine their ability to predict CLD and to establish effects of antenatal corticosteroid therapy (ANCS). RESULTS: MMP-9, -2 and TIMP levels did not vary with postnatal age over the first week. Median MMP-9 levels and MMP-9/TIMP-1 ratio increased with decreasing gestation in preterm babies. The MMP-9/TIMP-1 ratio was higher in babies who developed CLD, implying a proteinase/antiproteinase imbalance, but this association disappeared when controlled for gestational age. ANCS had no effect on BAL fluid MMP or TIMP levels. CONCLUSION: MMPs may have a role in the development of lung injury and fibrosis, but estimating their levels in the first week of life does not help with prediction of CLD.

Chorioamnionitis increases matrix metalloproteinase-8 concentrations in bronchoalveolar lavage fluid from preterm babies.

OBJECTIVE: To determine the effects of chorioamnionitis and antenatal corticosteroids on matrix metalloproteinase-8 (MMP-8) concentrations in bronchoalveolar lavage (BAL) fluid from preterm babies in the first week of life. DESIGN: Prospective observational study. SETTING: Regional neonatal intensive care unit. PATIENTS: Thirty five ventilated preterm babies < 33 weeks gestation, seven of whom were born after chorioamnionitis, which was diagnosed histologically as the presence of inflammatory cells in the chorioamnionic plate. METHODS: MMP-8 was measured by enzyme linked immunosorbent assay (ELISA) in 90 serial BAL samples taken during the first six postnatal days. The median MMP-8 concentration for each baby was calculated. RESULTS: Median MMP-8 concentrations were higher in the chorioamnionitis group than in those without (43 v 5 ng/ml). Partial or complete courses of antenatal corticosteroids had no effect on MMP-8 concentrations. CONCLUSIONS: Higher concentrations of MMP-8 are found in BAL fluid from preterm babies from pregnancies complicated by chorioamnionitis. This type I collagenase may contribute to the lung injury that occurs in some babies with respiratory distress syndrome.

Screening of lower back pain, low back pain clinic. The clinical experience.

Acute low back pain is a common complaint with high prevalence in society. Orthopaedic and specialist spinal services may be overwhelmed by large numbers of patients with low back pain who do not require investigation or surgical intervention. This phenomenon has led to the establishment of back pain screening clinics as a system of triage for those with acute low back pain. In March 2001, a back pain screening clinic was established in the Adelaide and Meath Hospitals incorporating the National Children's hospital. Six hundred and sixty-five patients were seen in the first year of this clinic. Of these, only ninety-six required referral to the orthopaedic spinal clinic. Just twenty-nine of these patients required surgical intervention. The introduction of this service resulted in a reduction in the waiting periods for the specialised spine clinic. We conclude that back pain screening clinics result in a clinical and economical improvement in the care of those suffering from acute low back pain. This is achieved by the systematic and efficient assessment, treatment and referral of patients afflicted with acute low back pain.