Outcomes of Patients with a pH<7.0 Presenting to the Emergency Department (OPpHED Study).

Objectives The aim of this study was to assess the mortality and predictive factors in patients presenting with a pH<7.0 to the emergency department (ED). Methods A retrospective study of patients presenting to the ED of University Hospital Galway with a pH<7.0 from January 2014 to December 2017 was performed. A pH<7.0 on arrival to the ED from either an arterial or venous sample as measured by the blood gas analyser machine were assessed for inclusion. Results A total of 130 patients presented to ED over a 4-year period, with a mean age of 58 ±20 years. Eighty-one (63%) patients of the total cohort were male. In terms of aetiology of presentation, 66 (51%) cases were from cardiac arrest (CA), while the remaining 64 (49%) cases were non-cardiac arrest (NCA) related. Twenty-eight-day mortality was 69.5% overall, with significant mortality in the CA group (89%) compared to the NCA group (48%) (p<0.00). A modified early warning score (MEWS) (odds ratio [OR] 1.37, 95% CI: 1.18-1.59) and PCO2 ([OR] 1.35, 95% CI: 1.08-1.68.) were predictive of mortality. Conclusion In patients presenting to the ED with a pH of <7.0 the overall mortality was 69.5%, with survival more likely in NCA aetiologies. Mortality was associated with higher pCO2 and MEWS.

A Case of Paget-Schroetter Syndrome in a Young Male After Lifting Weights

Paget-Schroetter Syndrome (PSS) or effort thrombosis of the axillary-subclavian venous axis is a rare disease affecting healthy young adults which requires a high index of suspicion to diagnose. Management often requires not only anticoagulation but also thrombolysis with first rib resection to prevent recurrence and complications. We present a case of a 31-year-old male who presented to our emergency department with pain and swelling of his left upper limb. He was diagnosed with PSS and underwent; anticoagulation, catheter directed thrombolysis and planned for first rib resection.

Presentations and Preceding factors of Drug Overdose amongst adolescents admitted in a Paediatric Regional Hospital.

Suicide is the third most common cause of death among adolescents globally, and poisoning is the leading method of attempted suicide. Survival after self-poisoning or drug overdose (OD) is common, providing an opportunity for secondary prevention. The aim of this study was to highlight pattern of presentations and preceding factors of OD in an adolescent population. We retrospectively evaluated the data of 85 adolescents presenting to a large regional hospital with OD over a 3-year period. The female-to-male ratio was 4.3:1. The median age of adolescents was 15.83 (range: 11.32 ­ 16.98) years. History of deliberate self-harm (DSH) was documented in 44.7%. Twenty-eight (33%) patients had been under the care of the CAMHS prior to index admission. Acetaminophen was the commonest drug used. Depression was the most common cause of mental illness in the study group. Substance abuse and conduct disorder were significantly commoner in males (p<0.05). Self-poisoning including OD in adolescence is a strong predictor of suicide; understanding the probable triggers can be significant in establishing appropriate prevention strategies.

Introduction of an Oral Fluid Challenge Protocol in the Management of Children with Acute Gastroenteritis: A Regional Hospital Experience.

Oral rehydration therapy (ORT) remains the ideal first line therapy for acute gastroenteritis (AGE). Our aim was to assess the impact of introducing an Oral Fluid Challenge (OFC) protocol on outcomes such as intravenous fluid use and documentation in our institution. A single centre study with data collected retrospectively pre-implementation (April 2015) of the OFC protocol and post implementation (April 2016). Consecutive sampling of the first 55 patients presenting with GE like symptoms and underwent OFC were recruited. One hundred and ten patients were included in this study with 55 patients per cycle. The rates of IVF use decreased from 22% (12) in cycle one to 18% (10) in cycle two. There was an improvement in documentation by 26% (14) for level of dehydration and 52% (31) for OFC volume from cycle one to two. Overall, the addition of the OFC protocol to the management of patients with uncomplicated AGE would help streamline and improve care.

Management of Paediatric Buckle (Torus) Wrist Fractures in Irish Emergency Departments: A National Survey

Buckle fractures are the most common wrist fractures reported in the paediatric age group. National Institute for Clinical Excellence (NICE) recommends using a non-rigid immobilisation with no follow up for these patients and appropriate discharge advice. A telephone survey was conducted to assess the variation in practice in Irish hospitals regarding the mpediatrianagement of buckle fractures. Twenty eight centres that manage paediatric patients with trauma were contacted. This survey demonstrates that over 70% (>20) of centres in Ireland are managing buckle fractures using the traditional approach of backslab cast and follow-up in fracture clinic. Despite relevant research and NICE guideline recommendations, there is a slow adoption of current evidence among Irish hospitals which points to a need for a national consensus on management of buckle fractures.

Attitudes and Knowledge of Healthcare Professionals Regarding Organ Donation. A Survey of the Saolta University Health Care Group.

Organ donation saves lives and healthcare professionals (HCPs) play a vital role in that process. Therefore, the purpose of this study was to assess the attitudes and level of knowledge of HCPs regarding organ donation. An online anonymous self-administered questionnaire containing 40 questions on organ donation using google forms was created. The survey was distributed to HCPs working in the Saolta University Health Care Group. A hundred and thirty-nine responses were received giving a response rate of 11.8%. HCPs willingness to donate their organs was at 93% compared to 97% willing to receive a transplant. More HCPs understood or had knowledge of the term donation after brain death (64%) than donation after circulatory death (49%). HCPs working in intensive care knew more about the management of brain dead donors than other specialties (p<0.0001). Over 60% of HCPs when asked either disagreed or strongly disagreed with the adequacy of training in organ donation and transplant. Overall, HCPs surveyed had positive attitudes towards organ donation but there was a lack of knowledge particularly among non-intensive care professionals. This study highlights the need to increase awareness along with implementation of educational programmes among HCPs regarding organ donation and transplant.

The Effect of Surgical Weight Loss on Cognition in Individuals with Class II/III Obesity.

BACKGROUND: Obesity is a global epidemic and is associated with cognitive impairment and dementia. It remains unknown whether weight loss interventions, such as bariatric surgery, can mitigate cognitive impairment. OBJECTIVES: We aimed to determine the effect of surgical weight loss on cognition in individuals with class II/III obesity. DESIGN: We performed a prospective cohort study of participants who underwent bariatric surgery. At baseline and two years following surgery, participants completed metabolic risk factor and neuropsychological assessments. SETTING: Participants were enrolled from an academic suburban bariatric surgery clinic. PARTICIPANTS: There were 113 participants who completed baseline assessments and 87 completed two-year follow-up assessments (66 in-person and 21 virtual) after bariatric surgery. The mean (SD) age was 46.8 (12.5) years and 64 (73.6%) were female. INTERVENTION: Bariatric surgery. There were 77 (88.5%) participants that underwent sleeve gastrectomy and 10 (11.5%) that underwent gastric bypass surgery. MEASUREMENTS: Cognition was assessed using the NIH toolbox cognitive battery (NIHTB-CB) and the Rey Auditory Verbal Learning Test (AVLT). The primary outcome was the change in NIHTB-CB fluid composite score before and after surgery. RESULTS: The primary outcome, NIHTB-CB composite score, was stable following bariatric surgery (-0.4 (13.9), p=0.81,n=66). Among secondary outcomes, the NIHTB-CB dimensional card sorting test (executive function assessment), improved (+6.5 (19.9),p=0.01,n=66) while the Rey AVLT delayed recall test (memory assessment) declined (-0.24 (0.83),p=0.01,n=87) following surgery. Improvements to metabolic risk factors and diabetes complications were not associated with improvements to NIHTB-CB composite score. The other 4 NIHTB-CB subtests and Rey AVLT assessments of auditory learning and recognition were stable at follow-up. CONCLUSIONS: Following bariatric surgery, the age-adjusted composite cognitive outcome did not change, but an executive subtest score improved. These results suggest that bariatric surgery may mitigate the natural history of cognitive decline in individuals with obesity, which is expected to be faster than normal aging, but confirmatory randomized controlled trials are needed. The decline in delayed recall also warrants further studies to determine potential differential effects on cognitive subtests.

Left ventricular mass and systolic function in human immunodeficiency virus-infected patients after weight loss.

Transthoracic echocardiography was performed on 27 patients with human immunodificiency virus after weight loss and in 20 lean controls. Left ventricular mass index was significantly higher and left ventricular fractional shortening was significantly lower in patients with human immunodificiency virus after weight loss than in lean, normal controls.

[Neutralization of the hemorrhagic effect induced by Bothrops asper (Serpentes: Viperidae) venom with tropical plant extracts]. / Neutralización del efecto hemorrágico inducido por veneno de Bothrops asper (Serpentes: Viperidae) por extractos de plantas tropicales.

Organic extracts representing 48 species included in 30 families of Costa Rican tropical plants were evaluated for their ability to neutralize hemorrhagic activity induced by the venom of the snake Bothrops asper. A bioassay in mice was used, based on intradermal injection of either venom or venom-extract mixtures followed by the measurement of hemorrhagic areas. Total inhibition of hemorrhage was observed with the ethanolic, ethyl acetate and aqueous extracts of Bursera simaruba, Clusia torresii, C. palmana, Croton draco, Persea americana, Phoebe brenesii, Pimenta dioica, Sapindus saponaria, Smilax cuculmeca and Virola koschnyi. Chemical analysis of these extracts identified catequines, flavones, anthocyanines and condensated tannins, which may be responsible for the inhibitory effect observed, probably owing to the chelation of the zinc required for the catalytic activity of venom's hemorrhagic metalloproteinases.

Estimation of genetic variability in locally grown pulses (Cajans cajan (L.) Millsp and Vigna unguiculata (L.) Walp): a panacea for sourcing superior genotypes.

The negligence of breeders and farmers to explore and exploit landraces of pulses is worrisome and urgent measures needed to be set in motion to forestall major future crisis, taking into cognizance the high adaptability and nutritive values accredited to them. This study focused on the estimation of genetic variability and heritability of desirable morphological characters in Fiofio (Cajans cajan) and Olaudi and Akidi (Vigna unguiculata) with the aim of conservation. Three landraces of pulses were sown using randomized complete block design. The field experiment was carried out at the University of Calabar Experimental Farm, University of Calabar, Calabar, during 2008-2010 growing season. Phenotypic and genotypic variances and coefficients of variation and genetic advance were estimated on yield and yield-related traits. The results showed that there were considerable variations among the pulses for the traits studied. The result revealed high genetic variability in the number of leaf per plant, leaf area, number of flowers per plant, number of pods per plant and number of seeds per plant. It also showed that genetic variability in pod length and 100-seed weight was low. Heritability estimates obtained in the result were very high though the magnitude of genetic variability in the yield and yield-related traits was not proportional to the heritability estimates. The traits studied also show high genetic advance. These explicitly showed that there are sufficient genetic variations to warrant conservation and improvement in these extinction-threatened pulses studied.

Effect of different dosage and administration schedules of folic acid on blood folate levels in a population of Honduran women of reproductive age.

BACKGROUND: Observational studies and clinical trials have shown conclusive evidence that periconceptional folic acid supplementation prevents up to 70 % of neural tube defects (NTD). The Honduran government wanted to implement a supplementation programme of folic acid but needed to assess the relative effects of two dosages of folic acid. OBJECTIVE: To determine the effect of two dosages of folic acid on blood folate levels in Honduran female factory workers aged 18 to 49 years. DESIGN: This was a randomized, double-blind control supplementation trial conducted in Choloma, Honduras. A total of 140 eligible women were randomly assigned to two dosage groups and followed up for 12 weeks. One group received a daily dosage of 1 mg folic acid and the other a once weekly dosage of 5 mg. Serum folate and red blood cell folate levels were determined by radioassay at baseline, 6 weeks and 12 weeks. RESULTS: Serum folate levels increased from 6.3 (se 0.2) to 14.9 (se 0.6) ng/ml (P < 0.0001) in women assigned to the 1 mg/d group and from 6.9 (se 0.3) to 10.1 (se 0.4) ng/ml (P < 0.0001) in those assigned to the 5 mg/week group. Red blood cell folate concentrations also increased significantly in both groups, albeit more slowly. Educational level, age and BMI were not associated with the changes in serum and red blood cell folate levels during the supplementation period. However, a differential effect on serum folate levels by dosage group and time was observed. CONCLUSIONS: Although both folate supplementation regimens increased serum and red blood cell folate levels significantly among the women studied, blood folate levels that are considered to be protective of NTD were reached faster with the daily dosage of 1 mg folic acid.

Amniotic fluid embolism.

Amniotic fluid embolism is a rare occurrence, with no single pathognomonic clinical or laboratory finding. Diagnosis is based on clinical presentation and supportive laboratory values. We describe the case of a 17-year-old nulliparous woman at 27 weeks' gestation who had uterine bleeding, hematuria, hemoptysis, hypotension, dyspnea, and hypoxemia within 30 minutes of vaginal delivery. Laboratory values revealed diffuse intravascular coagulation. Chest films were consistent with adult respiratory distress syndrome. Pulmonary artery catheterization revealed moderately increased pulmonary capillary wedge pressure. Supportive measures, including oxygenation, fluid resuscitation, and plasma, were administered. Central hemodynamic monitoring and inotropic support were necessary. Our patient recovered uneventfully and 6 weeks later was living an unrestricted life-style.

Cluster headache: Horton's cephalalgia revisited.

BACKGROUND: Cluster headache (CH), though not fully characterized until this century, is a relatively common primary headache disorder. METHODS: We reviewed pertinent literature on CH and related cephalalgias. RESULTS: We found that CH typically occurs in middle-aged men and has a characteristic cyclic temporal pattern. During the cluster cycle, CH paroxysms last from 15 to 180 minutes and are manifested by excruciating periorbital or upper facial pain. Associated autonomic symptoms such as lacrimation, rhinorrhea, conjunctival injection, and Horner's syndrome are common in CH. Its pathophysiology is not entirely understood, though it may include a complex cascade of autonomic, immunologic, and vascular phenomena. CONCLUSIONS: Although its pathophysiology is still not completely understood, we present the most recent evidence regarding the underlying anatomic and biochemical basis for CH. We also present an update on the modern management of CH, including the appropriate use of standard and novel abortive and prophylactic agents, as well as more invasive treatment.

Biatrial myxoma resembling an interatrial clot in transit on echocardiogram.

A 47-year-old man had an embolic stroke. Transesophageal echocardiography showed biatrial, elongated, mobile masses that appeared interconnected via a patent foramen ovale. Echocardiography did not distinguish between an interatrial clot in transit and an atypical biatrial myxoma. Surgical resection and subsequent histopathologic examination identified the mass as a biatrial myxoma. This case identifies a limitation of echocardiography in the diagnosis of cardiac myxoma.

Evaluación de la posible adulteración de mieles de abeja comerciales de origen costarricense al compararlas con mieles artesanales provenientes de apiarios específicos / Evaluation of the potential adulteration of commercial honey distributed in Costa Rica compared with artesanian honey samples coming from specific apiaries

Honey is the principal apiculture product, produced by Apis mellifera bee. This, as any other food product, has to accomplish certain quality standards, including physicochemical, organoleptic and microbiological properties. Within these parameters, different measures are considered as adulteration indicators, including hydroxymethylfurfural and diastase enzyme activity which are associated to overheating, and the sucrose, glucose and fructose content. In this study, a determination of previous parameters, additional to glucose, fructose and fructose/glucose index was performed to 35 artisan samples, obtained directly from beekeeper, previously characterized as having good productive practices and 25 commercial samples. Same time, the results obtained were compared and interpreted, in order to determine the kind of adulteration present in the honey sample. The 89% of artesian samples accomplished the parameters established by the Codex Alimentarius for HMF content, diastase activity, sucrose and simple sugars content. Nevertheless, only 20% (5) of the commercial samples accomplished the international and national normative. 24% of these samples presented succrose addition, 32% overheating or inverted sugar syrup addition, and 24% were adulterated with inverted sugar syrup.

La miel es el principal producto de la apicultura, generado por la abeja Apis mellifera. Éste, como cualquier producto alimenticio, debe cumplir con ciertas normas de calidad, propiedades fisicoquímicas, organolépticas y microbiológicas. Entre estos parámetros se encuentran el contenido de hidroximetilfurfural (HMF), indicador de adulteración, sobrecalentamiento y envejecimiento de la miel, la actividad de la enzima diastasa, indicador de sobrecalentamiento, y la determinación de contenido de sacarosa y azúcares simples, indicadores de adulteración. En el presente estudio, se procedió a determinar los anteriores parámetros, además del contenido de glucosa, fructosa e índice fructosa/glucosa a 35 muestras de mieles artesanales obtenidas directamente del apicultor, previamente catalogado como productor con buenas prácticas y 25 de mieles distribuidas en expendios. A su vez, se compararon los resultados poblacionales obtenidos y se les interpretó, con el objetivo de determinar el tipo de alteración que presentara la miel. Se determinó que 89% de las mieles control cumplieron con los parámetros establecidos por el Codex Alimentarius para su contenido de HMF, actividad de diastasa, contenido de sacarosa y de fructosa y glucosa. Contrario, sólo el 20% (5) de las mieles comerciales logró cumplir los estándares internacionales y la normativa nacional. Se destaca que un 24% de las muestra comerciales presentan adición de sacarosa y glucosa, 32% sobrecalentamiento o adulteración con sirope de azúcar invertido, y 24% adición de jarabe de azúcar invertido.