Growing Old in the Emergency Department.

The research team were concerned that older patients requiring emergency admission seemed to wait longer for a hospital bed, and as such were disproportionately affected by Emergency Department overcrowding. To investigate this theory and explore any changes over time, a ten year dataset (2005-2014 inclusive) was extracted from the information systems at Beaumont Hospital, Dublin. This research examines the changing age profile of ED patients, identifies the relationship between age and the total time spent in the Emergency Department (Patient Experience Time (PET)), and examines the public belief that EDs are busiest in winter when reports of overcrowding and elderly patients waiting on trolleys get most media attention. The results highlight that the ED is busy all year round (but for different seasonal reasons) and point to an overdue need to plan for the current and future healthcare of older patients within and beyond acute hospitals.

Cr[Formula: see text]AlN and the search for the highest temperature superconductor in the M[Formula: see text]AX family.

We have developed a high-throughput computational method to predict the superconducting transition temperature in stable hexagonal M[Formula: see text]AX phases, and applied it to all the known possible choices for M (M: Sc, Ti, V, Cr, Mn, Fe, Y, Zr, Nb, Mo, Lu, Hf and Ta). We combine this with the best candidates for A (A: Al, Cu, Ge and Sn ) and X (X: C and N) from our previous work, and predict T[Formula: see text] for 60 M[Formula: see text]AX-phase materials, 53 of which have never been studied before. From all of these, we identify Cr[Formula: see text]AlN as the best candidate for the highest T[Formula: see text], and confirm its high T[Formula: see text] with more detailed density functional theory electron-phonon coupling calculations. Our detailed calculations predict [Formula: see text] = 14.8 K for Cr[Formula: see text]AlN, which is significantly higher than any [Formula: see text] value known or predicted for any material in the M[Formula: see text]AX family to date.

Prediction of phonon-mediated superconductivity in new Ti-based M[Formula: see text]AX phases.

A high-throughput computational method is used to predict 39 new superconductors in the Ti-based M[Formula: see text]AX phases, and the best candidates are then studied in more detail using density functional theory electron-phonon coupling calculations. The detailed calculations agree with the simple predictions, and Ti[Formula: see text]AlX (X: B, C and N) materials are predicted to have higher values of [Formula: see text] than any currently known hexagonal M[Formula: see text]AX phases. The electronic states at the Fermi level are dominated by the Ti 3d states. The choice of X (X: B, C and N) has a significant impact on the electronic density of states but not on the phonon characteristics. The electron-phonon coupling parameter for Ti[Formula: see text]AlX (X: B, C and N) was determined to be 0.685, 0.743 and 0.775 with a predicted [Formula: see text] of 7.8 K, 10.8 K and 13.0 K, respectively.

Pilot translational study of dietary vitamin C supplementation in Barrett's esophagus.

The transcription factor Nuclear factor kappa B (NF-kappaB) is central to the regulation of genes encoding for mediators of inflammation and carcinogenesis. In the esophagus, NF-kappaB is progressively activated from inflammation to Barrett's metaplasia and adenocarcinoma. Vitamin C, an antioxidant, can inhibit NF-kappaB in in vitro models, and the aim of this study was to prospectively assess the effect of supplemental vitamin C on NF-kappaB and associated cytokines in patients with Barrett's esophagus. Twenty-five patients with long-segment Barrett's and specialized intestinal metaplasia received dietary vitamin C (1000 mg/day) orally for four weeks, and had pre- and post-vitamin C endoscopic biopsies. NF-kappaB activity (activated p50 and p65 subunits) of nuclear extracts was assessed using the Active Motif NF-kappaB assay, and cytokines and growth factors were measured using the Evidence Investigator biochip array. NF-kappaB and related pro-inflammatory cytokines and growth factors (IL-8, VEGF, IL-10) were activated in all Barrett's tissue pre-treatment. Down-regulation in activated NF-kappaB and cytokines was observed in 8/25 (35%) patients. Dietary vitamin C supplementation may down-regulate pro-inflammatory markers in a subset of Barrett's patients. Further studies with larger numbers of endpoints will be needed to further evaluate this effect.

Health-related quality of life assessment at presentation may predict complications and early relapse in patients with localized cancer of the esophagus.

SUMMARY: Health-related quality of life (HR-QOL) assessment in esophageal cancer is increasingly performed. However, the association of baseline HR-QOL in predicting outcome is unclear. This study aimed to assess the impact of HR-QOL scores at diagnosis with major morbidity, mortality, failure to progress to surgery, recurrence within 1 year, and survival in patients with localized esophageal cancer. The European Organization for Research and Treatment of Cancer's quality of life questionnaire was completed at diagnosis. Univariate and multivariate logistic regression were used to investigate the relationship between baseline HR-QOL and outcomes adjusting for confounding variables. A total of 185 patients with localized esophageal cancer were included, 89 undergoing multimodal therapy and 96 surgery alone. Global QOL scores were significantly associated with in-hospital mortality (P = 0.020) but not with major morbidity (P = 0.709) or 1-year survival (P = 0.247). Symptoms of fatigue and dyspnea at baseline were significantly (P < 0.05) associated with major morbidity, in-hospital mortality, and survival in univariate analysis. After adjusting for known confounding variables in multivariate analysis, only worse dyspnea score remained predictive of in-hospital mortality and a worse fatigue score remained predictive of 1-year survival. HR-QOL was of no benefit in predicting survival in multivariate analysis that identified pathological nodal status as the most significant factor. HR-QOL questionnaires may be helpful in preoperative assessment of risk. It is possible that patients with unrecognized micrometastatic disease at the time of surgery may report worse systemic symptoms at diagnosis, in particular fatigue and dyspnea, and these and global QOL scores may also identify poorer reserves that may increase in-hospital morbidity and mortality postoperatively.

The Rossetti-Nissen fundoplication--effective in managing gastro-oesophageal reflux disease.

BACKGROUND: The report herein details a prospective audit of a unit's eight-year experience of the Rossetti-Nissen fundoplication using a predominantly laparoscopic technique, selective hiatal repair, no bougie and a standardised protocol of pre- and post-operative functional endoscopic and symptom assessment. METHODS: Three hundred and seventy-eight patients underwent the Rossetti-Nissen fundoplication. All patients had documented data on endoscopy, health related quality of life (HR-QoL), surgical details and complications pre-operatively and at six months post-operatively. Repeat physiological testing was performed at six months. RESULTS: At a median follow-up of six (range 3-13) months there was improved symptom scoring and HR-QoL after fundoplication with an 89% patient satisfaction rate. Ninety-five patients (25%) reported some early dysphagia, and 91 of these reported the outcome of surgery to be excellent or good. Thirty-eight patients (10%) had recurrent heartburn and 28 (7%) were back on medication at six months post-operatively. At follow-up pH study at a median of six months, 89% of patients had normalised acid reflux scores. CONCLUSIONS: Rossetti-Nissen fundoplication, with no use of an oesophageal bougie and no division of short gastric vessels, is an effective procedure giving 89% patient satisfaction and significant improvement in QoL parameters and physiological measurements.

Seeing baby: women's experience of prenatal ultrasound examination and unexpected fetal diagnosis.

OBJECTIVE: Although prenatal ultrasound (US) is a common clinical undertaking today, little information is available about women's experience of the procedure from the perspective of women themselves. The objective of this study was to explore women's experience of undergoing a routine prenatal US examination associated with an unexpected fetal diagnosis. STUDY DESIGN: Qualitative methods were used to explore the prenatal US experience of 13 women. Five women were given unexpected news of multiple pregnancy and eight women were given unexpected news of congenital fetal abnormality. One in-depth audio-taped interview was conducted with each woman. Content analysis of interview data identified themes common to women's experience of US. RESULTS: Identified themes of women's experience of routine prenatal US examination associated with an unexpected fetal diagnosis are: experiencing the setting, sensing information, feeling connected/disconnected, the power of the image, and communication rules. CONCLUSIONS: Women's experience of prenatal US examination is influenced by physical and environmental factors and by the behaviors of the US examiner. Behaviors of the examiner contribute to a woman's labeling of the US experience as positive or negative. Women identify being objectified by the examination and experience poor communication patterns after a fetal US diagnosis. Women's description of the US screen image as a baby suggests it is a powerful influence on subsequent clinical and ethical decision-making about the pregnancy.

Serial assessment of ductus arteriosus hemodynamics in hyaline membrane disease.

OBJECTIVES: To assess the efficacy of Doppler echocardiography (DE) in the quantification of patent ductus arteriosus (PDA) shunt volume and to correlate PDA shunt volume with clinical outcome in infants with hyaline membrane disease. METHODS: Ninety-eight DE studies were performed in 30 preterm ventilated infants with hyaline membrane disease within the first 24 hours of age and then at 48-hour intervals to a maximum of three studies while ventilated with a final study after extubation. Right and left ventricular outputs (QRV and QLV, respectively) and PDA flow were calculated using cross-sectional area and flow velocity integrals. Left atrial-to-aortic root diameter measurements were also taken. Clinical outcomes were correlated with the shunt fraction (QLV/QRV). RESULTS: QLV/QRV demonstrated a linear relationship with the left atrial-to-aortic root diameter ratio (n = 92; r = .79). In the absence of a PDA (n = 33 studies), QRV versus QLV demonstrated a linear relationship (r = .88). In the presence of a PDA (n = 64 studies) the mean QLV (334 +/- 133 ml/kg per minute) was significantly greater than the mean QRV (237 +/- 84 ml/kg per minute). There was a linear relationship between QLV-QRV (PDA shunt volume) and PDA flow (n = 60; r = .84). In studies with exclusive left-to-right shunting at the PDA (n = 48), the mean QLV-QRV (112 +/- 83 ml/kg per minute) was significantly higher than in those with bidirectional shunting (n = 16; mean QLV-QRV = 50 +/- 27 ml/kg per minute). Two infants with severe intraventricular hemorrhage (IVH grade 3) and two infants with periventricular leukomalacia (PVL) had significantly higher QLV/QRV (2.09 +/- 0.36 and 1.67 +/- 0.02 respectively) than those with no IVH (n = 6; QLV/QRV = 1.31 +/- 0.18) or those with IVH grades 1 and 2 (n = 8; QLV/QRV = 1.48 +/- 0.27). There was no difference in QLV/QRV in infants with or without bronchopulmonary dysplasia and retinopathy of prematurity. Necrotizing enterocolitis did not develop in any of the 30 infants. CONCLUSION: PDA shunt volume can be quantified by DE. Larger studies are needed to correlate clinical outcome with QLV/QRV.

Before viability: a geographically based outcome study of infants weighing 500 grams or less at birth.

OBJECTIVE: The primary objective of this study was to determine the likelihood of long-term survival and avoidance of disabilities in a geographically based population of infants born at 20 weeks gestation or more and weighing 500 g or less at birth. STUDY DESIGN: This was a 12-year historical cohort follow-up study of all infants born in this gestational age and birth weight category in the Province of Alberta, Canada, between 1983 and 1994. Data were collected from certificates of live births or stillbirths, death certificates, hospital records, and longitudinal multidisciplinary follow-up examinations. RESULTS: One thousand one hundred ninety-three infants were of 20 weeks gestation or more, weighed 500 g or less, and were born between 1983 and 1994. Eight hundred eleven (68.0%) were stillborn and 382 (32.0%) were born alive. Among the latter, neonatal intensive care was provided in 113 (29.6%) and withheld in 269 (70.4%). The infants receiving intensive care were of heavier birth weight, later gestational age, higher antenatal risk scores, were more likely to be born in a level III center, to have received antenatal steroids, and to have been delivered by cesarean section. Of the infants receiving intensive care, 95 (84. 1%) died and 18 (15.9%) were discharged alive, but 5 of these died after discharge because of respiratory complications. The infants discharged alive had later gestational age, were more likely to be small for gestational age, singletons, treated with antenatal steroids, and to have been delivered by cesarean section. Maternal indications were described in the majority of cesarean sections done for live-born infants. The 13 infants who were long-term survivors were followed at ages 12 and 36 months adjusted age. Four had no serious disabilities, 4 had one disability (cerebral palsy or mental retardation), and 5 had multiple disabilities (cerebral palsy plus mental retardation with blindness in 2 cases and deafness in 1 case). CONCLUSION: The majority of infants born at gestational age 20 weeks or more weighing <500 g were stillborn. Among live births, neonatal intensive care was withheld in 70% and initiated in 30%. Of the latter, 11% survived to 36 months of age, and of these, 4 infants (31%), most of whom are small for gestational age, female infants, avoided major disabilities but 9 (69%) had one or more major disabilities. Survivors are prone to rehospitalizations early in life, slow growth, feeding problems, and minor visual difficulties; rates of learning-related and behavioral problems at school age are not yet known. Implications. Parents and caregivers faced with the impending delivery of an infant in this gestational age/birth weight category should understand that survival without multiple major disabilities is possible but rare. They should be made aware of local population-based results and not just isolated reports.

Cyclopia and congenital cytomegalovirus infection.

We describe the first documented association of congenital cytomegalovirus (CMV) infection and cyclopia. A previous report has suggested that any infant with congenital ocular defects should be investigated for CMV infection [Frenkel et al, 1980]. Our case underlines this suggestion and questions a teratogenic role for CMV in cyclopiaholoprosencephaly. More documented cases may help clarify the relationship of transplacental CMV infection to the holoprosencephaly developmental field defect, including cyclopia.

Isolated chylopericardium after repair of coarctation of the aorta.

A case of chylopericardium developing in a neonate after subclavian flap repair of a preductal coarctation of the aorta is reported and a review of the literature is presented.

Myocardial vagal stimulation impairs lower esophageal sphincter function.

BACKGROUND: Coronary artery disease and gastroesophageal reflux disease frequently coexist, but a direct pathophysiologic link has not been established. METHODS: This study examines the effect of myocardial vagal receptor stimulation on lower esophageal sphincter (LES) tone in eight adult mongrel dogs, each acting as its own control. Pharmacologic stimulation was carried out by the application of 1 cm gauze patches soaked in nicotine (200 micrograms/ml) to the epicardium. Epicardial vagal receptors were stimulated mechanically by digital friction. RESULTS: Pharmacologic stimulation produced a rapid fall in LES tone from a mean (SEM) of 12.6 (1.5) to 8.6 (0.9) sphinctometer units (p = 0.007). Mechanical stimulation also produced a rapid fall from 12.0 (1.5) sphinctometer units to 6.8 (0.7) (p = 0.007). Both were associated with a drop in mean arterial blood pressure and heart rate. Sham patches soaked in sterile water produced no effects. CONCLUSIONS: These data suggest a direct vagal reflex linking the myocardium and the LES that may explain the high incidence of gastroesophageal reflux in patients with heart disease.

Mechanisms of columnar metaplasia and squamous regeneration in experimental Barrett's esophagus.

BACKGROUND: This study examined the effect of the lower esophageal milieu on the healing of a mucosal defect. METHODS: With a canine model a mucosal defect was created in the lower esophagus, and acid reflux was promoted by a cardioplasty and pentagastrin injection in 10 animals. At 3 months the regenerated mucosa was excised and underwent histologic examination. Six of these animals underwent an antireflux procedure, had their acid secretion suppressed, and were followed up for a further 3 months, at which time they were killed and the entire esophagus underwent histologic examination. RESULTS: When reflux was stimulated, healing of the mucosal defect was by columnar epithelium alone in seven of 10 animals. After reflux control in six animals healing was again by columnar epithelium, but in all six cases islands of squamous epithelium occurred. Histologic examination showed both types of regenerating epithelium to be in continuity with the ducts of the esophageal glands, lined in their proximal two thirds by columnar and in their distal one third by squamous cells. CONCLUSIONS: It is suggested that the type of regenerating epithelium is determined by the depth of injury to mucosa or gland ducts. If both cell types survive, a mixed pattern of regeneration may occur, but columnar repair will usually predominate because of its more rapid turnover. If the squamous cells of the mucosa and ducts are destroyed, however, repair will be by columnar epithelium alone.

Early motor development of breech- and cephalic-presenting infants.

OBJECTIVE: This study was conducted to determine whether breech-presenting infants have a different pattern of early neuromotor development than cephalic-presenting infants--regardless of mode of delivery-thus explaining both the failure to assume cephalic version at the end of gestation and the higher rates of childhood motor impairments associated with breech presentation. METHODS: Ninety morphologically normal, term, breech-presenting singletons with birthweights greater than 2,500 g were paired with a similar cephalic-presenting infant, matched for gender and mode of delivery (n = 180; 100 delivered abdominally and 80 delivered vaginally). Data on neurological status (Neurological Assessment of the Preterm and Full-term Newborn Infant) and motor performance (Alberta Infant Motor Scale, Peabody Developmental Motor Scales, and age of walking) were collected prospectively over the first 18 months of life. This study was designed with a power of .80 to detect a "medium" effect size for motor development using the Alberta Infant Motor Scale. The data were analyzed using analysis of variance techniques. RESULTS: Breech-presenting infants had minor transient differences compared with cephalic-presenting infants. First, they had more open popliteal angles at birth (P < .001). Second, they had significantly lower motor scores at 6 weeks than the normative sample (P < .001). At 18 months, three infants were diagnosed with neurological problems, all of whom were delivered electively in the cesarean-breech group. CONCLUSION: As a group, breech-presenting infants do not have a persistent, inherently different pattern of motor development than cephalic-presenting infants. Mode of delivery did not explain the excess neuromotor impairment detected in the subgroup of breech infants.

Neonatal spinal cord syndrome associated with hypoplastic aortic arch and anemia.

Spinal cord syndrome is a rare postoperative complication in neonates. We describe a case occurring after surgical treatment of a hypoplastic aortic arch in the presence of anemia.

Assessment of a cardiovascular education program.

A single education program for teaching principles of the Prudent Diet was assessed for its effectiveness in producing compliance to dietary recommendations. The study population consisted of 50 free-living adults between the ages of 20 and 75. Each adult was a member of a club or organization that had requested to view the program via a local chapter of the AHA. A pretest/post-test format was used for the study. Individuals completed a questionnaire prior to viewing the program and again eight weeks after viewing the program. The questionnaire was designed to measure attitudes, knowledge, and compliance to recommendations. Demographic data regarding age, sex, and exposure to heart disease were also obtained. Results indicated that the study population changed their beliefs about their perceived susceptibility to CHD, becoming more concerned after viewing the program. Attitudes toward diet and CHD became slightly more positive but not significantly so. An overall gain in knowledge occurred that was highly significant. The study group consumed skim milk, lean meats, and broiled meats more often after viewing the program. In addition, they reported trimming all visible fat from meat before preparation and/or consumption. It was concluded that this education program has potential for producing an attitude change and knowledge acquisition and for motivating positive changes in dietary habits toward the recommendations of the Prudent Diet.