Alcohol-related emergency department presentations and hospital admissions around the time of minimum unit pricing in Ireland.

BACKGROUND: Minimum unit pricing (MUP) was recently introduced in Ireland to reduce alcohol-related harms. The size of the impact of alcohol on hospital emergency departments (EDs) in Ireland is poorly understood due to inconsistent alcohol screening and documentation. AIMS: We sought to systematically characterise the volume, timing, and nature of alcohol-related presentations and admissions to a busy urban ED in Dublin, Ireland. METHOD: Patients presenting to the ED were assessed by a dedicated clinician during selected time periods before (Nov-Dec 2021) and after (Feb-Apr 2022) the introduction of MUP. A total of 725 interviews were conducted over 168 h in the ED. FINDINGS: Alcohol consumption was a factor in 19.4% of ED presentations and in 17.3% of hospital admissions across the entire study period. A reduction in overall alcohol-related ED presentations was noted in the period following MUP, although it is not possible to conclude a direct effect. CONCLUSION: Alcohol-related harm places a significant strain on EDs and hospitals, and the impact of MUP on hospital burden in Ireland merits further evaluation. Effective measures at local and population levels are urgently required to address this burden.

Self-reported beta-lactam allergy in government and private hospitals in Cape Town, South Africa.

BACKGROUND: Up to a quarter of inpatients in high-income countries (HICs) self-report beta-lactam allergy (BLA), which if incorrect,increases the use of alternative antibiotics, worsening individual health outcomes and driving bacterial resistance. In HICs, up to 95% ofself-reported BLAs are incorrect. The epidemiology of BLA in low- and middle-income African countries is unknown. OBJECTIVES: To describe the epidemiology and de-labelling outcomes of self-reported BLA in hospitalised South African (SA) patients. METHODS: Point-prevalence surveys were conducted at seven hospitals (adult, paediatric, government and privately funded, district andtertiary level) in Cape Town, SA, between April 2019 and June 2021. Ward prescription records and in-person interviews were conductedto identify and risk-stratify BLA patients using the validated PEN-FAST tool. De-labelling was attempted at the tertiary allergy clinic atGroote Schuur Hospital. RESULTS: A total of 1 486 hospital inpatients were surveyed (1 166 adults and 320 children). Only 48 patients (3.2%) self-reported a BLA,with a higher rate in private than in government-funded hospitals (6.3% v. 2.8%; p=0.014). Using the PEN-FAST tool, only 10.4% (n=5/48)of self-reported BLA patients were classified as high risk for true penicillin hypersensitivity. Antibiotics were prescribed to 70.8% (n=34/48)of self-reported BLA patients, with 64.7% (n=22/34) receiving a beta-lactam. Despite three attempts to contact patients for de-labelling atthe allergy clinic, only 3/36 underwent in vivo testing, with no positive results, and 1 patient proceeded to a negative oral challenge. CONCLUSION: Unlike HICs, self-reported BLA is low among inpatients in SA. The majority of those who self-reported BLA were low risk fortype 1 hypersensitivity, but outpatient de-labelling efforts were largely unsuccessful.

Transmural electrophysiological heterogeneities in action potential duration increase the upper limit of vulnerability.

Transmural dispersion in action potential duration (APD) has been shown to contribute to arrhythmia induction in the heart. However, its role in termination of lethal arrhythmias by defibrillation shocks has never been examined. The goal of this study is to investigate how transmural dispersion in APD affects cardiac vulnerability to electric shocks, in an attempt to better understand the mechanisms behind defibrillation failure. This study used a three- dimensional, geometrically accurate finite element bidomain rabbit ventricular model. Transmural heterogeneities in ionic currents were incorporated based on experimental data to generate the transmural APD profile recorded in adult rabbits during pacing. Results show that the incorporation of transmural APD heterogeneities in the model causes an increase in the upper limit of vulnerability from 26.7 V/cm in the homogeneous APD ventricles to 30.5 V/cm in the ventricles with heterogeneous transmural APD profile. Examination of shock-end virtual electrode polarisation and postshock electrical activity reveals that the higher ULV in the heterogeneous model is caused by increased dispersion in postshock repolarisation within the LV wall, which increases the likelihood of the establishment of intramural re-entrant circuits.

Sinogenic intracranial complications.

Two hundred and nineteen patients, with intracranial complications of sinusitis, are presented. Sinusitis is still a life-threatening condition and if neglected, or mismanaged, can lead to intracranial complications that result in a high mortality and morbidity. Twenty-two patients had meningitis, 127 subdural empyema, 38 brain abscess, 15 combined brain abscess and subdural empyema and 17 extradural empyema. The diagnosis of intracranial abscess and sinusitis was made with the aid of a CT scan, and that of meningitis on cerebrospinal fluid microscopy, chemistry and culture. The most frequent presenting signs were fever (68 per cent) and headache (54 per cent). The most common localizing neurological sign was hemiparesis (35.5 per cent). Orbital inflammation was present in 41.5 per cent of patients. Treatment entailed immediate, appropriate, intravenous antibiotic therapy and prompt surgery, performed within 12 hours of admission. In patients with meningitis, the surgery entailed surgery of the sinus disease only. In patients with subdural empyema, brain abscess and extradural empyema, evacuation of the primary source of infection by the radical frontoethmoidectomy approach, immediately after drainage of the intracranial collection of pus, was carried out. There were 35 deaths (16 per cent). The highest mortality rate was recorded in patients with meningitis (45 per cent) followed by brain abscess (19 per cent) and subdural empyema (11 per cent). Despite advances in medicine, i.e. antibiotics and CT scan for early and accurate diagnosis, the mortality from sinogenic intracranial complications has remained significant. This can only be eliminated through education.(ABSTRACT TRUNCATED AT 250 WORDS)

Schwannoma of the posterior pharyngeal wall.

Schwannoma of the posterior pharyngeal wall, in a 36-year-old male patient is presented demonstrating the asymptomatic nature of the tumour (which is peculiar to schwannomas). The tumour gradually increased in size, destroyed the body of the third cervical vertebra but remained asymptomatic. The patient only presented to hospital when the tumour obstructed the airway, because of its large size.

Radical mastoidectomy: its place in otitic intracranial complications.

Standard recommended treatment for patients with intracranial complications from otitis media, has been radical mastoidectomy, whether cholesteatoma is present or not. This was established in the pre-antibiotic era to improve survival. Over a six-year period, from January 1985 to December 1990, 268 patients were admitted with intracranial and extracranial complications of otitis media. The prospective treatment consisted of antibiotics and surgery. Surgery entailed mastoidectomy and drainage of intracranial collections of pus in all patients. However, prospectively in these patients the ear pathology and not the complication dictated the type of mastoidectomy performed. Cortical mastoidectomy was performed in non-cholesteatomatous ears and radical mastoidectomy in cholesteatomatous ears. Recurrence of intracranial complications occurred in only four patients (two per cent), a temporal lobe cerebritis in the non-cholesteatomatous ear group, and, a temporal lobe abscess, posterior fossa abscess and subdural empyema in the cholesteatomatous ear group. The temporal lobe cerebritis settled on intravenous antibiotics whilst the temporal lobe abscess, posterior fossa abscess and subdural empyema required redrainage. In none of these was the ear surgery revised. There were 15 deaths (eight per cent), all occurring in patients with intracranial complications, 12 associated with brain abscess, two with subdural empyema and one with meningitis. Eight were from the non-cholesteatomatous group and seven from the cholesteatomatous group. The mortality was directly related to the patients consciousness level on admission and not to the type of ear pathology. It can therefore be concluded that radical mastoidectomy is unwarranted in the non-cholesteatomatous ear, even with an otogenic intracranial complication.

Tuberculosis of the parotid gland: clinically indistinguishable from a neoplasm.

Tuberculosis of the parotid gland may be clinically indistinguishable from a neoplasm. This poses a problem with regard to management, because the treatment of tuberculosis is medical, whilst that of the majority of tumours is surgical. If radical surgery with resection of a branch or branches of the facial nerve is embarked upon in a patient with tuberculosis, without prior histological diagnosis, unnecessary permanent disability will result. Two cases of tuberculosis of the parotid gland are reported, demonstrating the clinical similarity of tuberculosis to a parotid neoplasm and the absolute need for histological diagnosis before embarking on surgery that will require resection of the branches of the facial nerve. The conclusion is that although tuberculosis of the parotid gland is rare, it still exists and must be thought of as one of the differential diagnoses of a parotid tumour. This must be kept in mind, especially when the decision to sacrifice branches of the facial nerve is indicated, in order to get a tumour-free margin on an excisional biopsy. If the suspicion of tuberculosis is high, a therapeutic trial of antituberculous chemotherapy, for one week, can be diagnostic.