Paediatric Psychiatry Admissions to Critical Care.

Aims Children and adolescents may require admission to PICU to manage significant episodes of psychiatric or behavioural disorders. The primary aim was to determine the number of paediatric psychiatry patients requiring PICU admission and the indications for admission. Methods Our patient information system was used to identify patients admitted with a psychiatric presentation. Results Fifteen patients were admitted during the study period. Ten (66%) patients were admitted at a weekend and 12 (80%) were admitted after 5pm. The admitting diagnosis was self-harm in 7 (46%), psychosis in five (33%) and an eating disorder in three (20%) patients. Conclusion The number of patients requiring PICU admission was small but represents a significant challenge to staff and resources. There is a need to establish a governance structure and pathway of care for these patients.

Introduction of the low risk ankle rule to a paediatric emergency department.

INTRODUCTION: Ankle injuries are a common presentation to the paediatric emergency department (PED), accounting for approximately 2% of presentations.1 X-rays are ordered for 85-95% of patients but only 12% of x-rays reveal a fracture. Clinical prediction rules, such as The Low Risk Ankle Rule (LRAR) exist to help clinicians safely reduce the frequency of radiography in these injuries. The LRAR has been shown to reduce imaging by up to 60% without missing any clinically significant fractures. We sought to introduce The LRAR into our department and study its outcomes on our practice. AIMS: To introduce the LRAR into our department and study its effects on our radiography rate and length of stay (LOS). METHODS: An audit of x-ray rates in ankle injuries in 2016 was performed to determine our department's baseline rate of radiography and LOS. We then conducted education sessions and created x-ray ordering prompts to encourage clinicians to use the LRAR. We introduced the LRAR, with a pilot period initially, and gathered data prospectively. RESULTS: 969 patients presented in with an ankle injury in 2016, 90.7% of these patients had an x-ray. The median LOS was 109 min. 92 patients presented during  the LRAR implementation period with an ankle injury. Nine patients had exclusion criteria from using the LRAR and the attending physician did not use the LRAR in four patients. Of the remaining 79 patients, 49 had a LRAR positive exam. Only one of these patients went on to have an x-ray, which was normal. The 30 patients with a LRAR negative exam all had an x-ray. Overall, our x-ray rate during the study period was 40/92 (43.4%), a reduction of 47.3%. The average LOS during the study was 101 min. No clinically significant fractures were missed. CONCLUSION: The LRAR can safely and effectively reduce the rate of radiography in ankle injuries, without missing any clinically significant fractures.

Acute sixth nerve palsy in a young man, beware of the 'red herring'.

BACKGROUND: Cranial nerve palsies has several etiologies including vascular insufficiency, neoplasm, trauma and inflammation. Isolated sixth nerve palsy is an extremely rare presenting feature of leukemia. AIM: We describe an unusual ocular presentation of a bilateral progressive sixth nerve palsy in a young male with a preceding head injury. CONCLUSION: Acquired sixth nerve palsies in young adults may be due to trauma but in the absence of a definitive history other systemic processes must be outruled. We describe a case of bilateral sixth nerve palsy in a patient with ALL with no obvious CNS involvement. Potential etiological mechanisms are discussed.

The impact of available anti-glaucoma therapy on the volume and age profile of patients undergoing glaucoma filtration surgery.

PURPOSE: To investigate whether new classes of glaucoma medication have influenced glaucoma filtration surgery over a 20-year period in the southeast region of Ireland. METHODS: All patients undergoing glaucoma filtration surgery between January 1986 and December 2005 in Waterford Regional Hospital were identified. The following data were recorded for each patient: age; sex; and type of filtration procedure. RESULTS: Over the 20-year study period two consultant ophthalmic surgeons performed a total of 760 glaucoma filtration procedures on patients aged over 20 years. The annual average number of glaucoma surgeries declined steadily, defined by availability of different topical anti-glaucoma medications, from an average of 23.75 surgeries per surgeon per year in the subperiod 1986-1995, to 21 in 1996, 20 in 1997, and 12.69 surgeries per surgeon per year in 1998-2005, these differences being statistically significant (general linear model, P<0.001). The age profile of patients did not change significantly over the course of the study period. CONCLUSIONS: The volume of patients requiring glaucoma filtration surgery under the care of two consultant ophthalmic surgeons decreased over the 20-year study period, an era in which three classes of anti-glaucoma medications were made available. However, an increase in the age profile of patients undergoing glaucoma filtration surgery during the same period was not observed. Further study is required to resolve whether introduction of the new topical anti-glaucoma medications has led to a real reduction in the demand for glaucoma filtration surgery, or has just led to the deferral of such a demand.

Age and sex profile of patients having cataract surgery between 1986 and 2003.

PURPOSE: To investigate the age and sex profile of patients having cataract surgery by 2 consulting ophthalmic surgeons over an 18-year period. SETTING: Waterford Regional Hospital, Waterford, Republic of Ireland. METHODS: Operating theater logbooks were reviewed, and all patients having cataract surgery between January 1986 and December 2003 in Waterford Regional Hospital were identified. The following data were recorded for each patient: age, sex, and type of cataract surgery. Patients having cataract surgery were categorized according to the date of the procedure as follows: Group 1: 1986-1991; Group 2: 1992-1997; Group 3: 1998-2003. RESULTS: Eight thousand two hundred fifty-seven patients who had cataract surgery during the study period were identified. The mean age of patients was 72.32 years +/- 12.21 (SD) and 74.89 +/- 11.03 years of men and women, respectively. The age profile of patients having cataract surgery was statistically comparable in Groups 1, 2, and 3 (mean age; Group 1: 72.33 +/- 13.03 years; Group 2: 73.72 +/- 11.78 years; Group 3: 74.57 +/- 10.69 years), indicating that the age profile of patients did not change significantly with the passage of time (analysis of variance, F<1). The proportion of women having cataract surgery rose significantly over the duration of the study period (1986-1991: 55.13%; 1992-1997: 57.68%; 1998-2003: 59.43% (chi-square test, P<.01)). CONCLUSIONS: The age profile of 8257 patients having cataract surgery did not change over the 18-year study period. A small but significant increase in the proportion of women having cataract surgery was noted in latter years. This data is useful to those involved in health care planning.

Changes in clinic vaccination coverage after institution of measurement and feedback in 4 states and 2 cities.

BACKGROUND: Since 1995, states and jurisdictions receiving federal immunization funds have been required to perform annual measurements of vaccination coverage in their public clinics, based on data from Georgia where clinic coverage increased after the institution of a measurement and feedback intervention. OBJECTIVE: To determine if clinic vaccination coverage improved in localities that used the Georgia intervention model. DESIGN: Retrospective examination of clinic vaccination coverage data. PARTICIPANTS: Children aged 19 to 35 months enrolled in clinics in localities that had applied the intervention for 4 years or longer. INTERVENTION: The Georgia intervention model: assessment of clinic vaccination coverage, feedback of the information to the clinic, incentives to clinics, and promotion of exchange of information among clinics (AFIX). MAIN OUTCOME MEASURE: Change in median clinic coverage rates, based on the primary (4-3-1) vaccine series, with comparison to results of the National Immunization Survey. RESULTS: Four states and 2 cities that had applied the AFIX intervention for 4 years or longer were identified. The number of clinic records reviewed annually was 4639 to 18000 in 73 to 116 clinics for states, and 714 to 5276 in 8 to 25 clinics for cities. Median clinic coverage rose in all localities: Missouri, 44% (1992) to 93% (1997); Louisiana, 61% (1992) to 83% (1997); Colorado, 55% (1993) to 75% (1997); Iowa, 71% (1994) to 89% (1997); Boston, Mass, 41% (1994) to 79% (1997); and Houston, Tex, 28% (1994) to 84% (1997). The increase in clinic coverage exceeded that of the general population in 5 localities and was identical in the sixth. The average annual coverage rise attributable to the intervention was +5 percentage points per year (Georgia, +6 per year). The average crude direct program cost was $49533 per locality per year. CONCLUSION: The Georgia intervention model (AFIX) can be reproduced elsewhere and is associated with improvements in clinic vaccination coverage.

Effect of a manager training program on sanitary conditions in restaurants.

OBJECTIVE: To evaluate the effectiveness of a food manager training and certification program in increasing compliance with restaurant sanitary codes. METHODS: Using routine sanitary inspection records, the authors compared pre- and post-training inspection scores for 94 restaurants falling into three groups: a "mandatory" group (managers' attendance was mandated for these restaurants); a "voluntary" group (managers attended the training voluntarily); and a control group (no staff attended the training program). RESULTS: Restaurants for which managers were mandated to attend a training and certification program demonstrated a significant improvement in inspection scores, an improvement that was sustained over a two-year follow-up period. The mean inspection scores for a control group did not change significantly over time. However, improvements were not noted in all areas of food safety. CONCLUSIONS: Food manager training and certification programs may be an effective way to improve the sanitary conditions of restaurants and reduce the spread of foodborne illnesses.

Use of acyclovir in herpetic ocular infection.

Acyclovir has veen shown to have potent antiviral activity against both herpes simplex and herpes zoster viruses, especially the former, with low cellular toxicity, preferentially affecting virally infective cells by inhibiting viral DNA synthesis [1,2]. In experimental herpes simplex corneal infection, acyclovir has been found to be effective [3,4] and in early clinical trials it has been found to be at least as good as idoxuridine [5-7]. Acyclovir has also been found to have antiviral activity against the herpes zoster virus in tissue culture [1] and to affect favorably the course of the disease in immunosuppressed patients [8]. This paper describes the use of acyclovir in patients with either herpes simplex or herpes zoster ocular infections. Topical acyclovir has been compared with adenine arabinoside in the treatment of herpes simplex corneal ulceration in a coded clinical trial. The use of acyclovir will also be described in patients with complicated herpes simplex eye disease. Our initial results with topical acyclovir in herpes zoster keratouveitis are also described.

Squash ball to eye ball: the likelihood of squash players incurring an eye injury.

The records of the 118 patients treated as Southampton Eye Hospital during 1978-9 for injuries incurred while playing squash, badminton, tennis, table tennis, cricket, and football show that for squash the main cause of eye injury was the player being hit by the ball. Severe eye injuries--those requiring treatment as an inpatient--were rare but much more frequent than such injuries in other sports. Less serious injuries--those requiring treatment as an outpatient--were also rare, with a frequency comparable with that of similar injuries in football and badminton. Squash players are most unlikely to incur an eye injury, but should this occur it has far-reaching consequences both in the short and the long term. Each individual player must weigh these chances and consequences against the possible inconvenience of using some form of eye protection.