Audit of PPI Prescribing Practices: A Risk to Patient Safety?

Aim Proton pump inhibitors (PPIs) are frequently prescribed to surgical patients (50-60%) to prevent gastrointestinal bleeding. However, most surgical patients are at low risk of significant bleeds. The aim of this audit was to identify inappropriate PPI prescribing, if any, in a cohort of surgical inpatients. Methods This was a prospective analysis completed over a 4 month period. Data was collected via review of clinical notes and drug charts. The audit standard was the consensus guideline on indications for PPI use issued by Scarpignato et al (2016). Results In total 89 patients were included (n = 89). 73% were on PPI therapy. 30% had a documented indication for therapy which was concordant with recommendations. However, the majority of PPI prescriptions (70%) were inappropriate. Conclusion PPIs are frequently prescribed to surgical patients without an appropriate indication. Indiscriminate use of these drugs has implications in the form of costs and potential complications.

Magnetic Stent Removal in a Nurse Led Clinic; a Nine Month Experience.

Ureteric stents are frequently inserted post endourological procedures. However, subsequent endoscopic stent removal requires a second procedure for the patient and the availability of necessary resources. Longer duration of indwelling stents can lead to increased risk of symptoms and complications. The use of magnetic stents removed with a magnetic retrieval device (BlackStar©), offers an alternative which obviates the need for cystoscopy. We assessed the outcomes for this novel method of stent removal in our institution. A retrospective analysis was performed of all patients undergoing magnetic stent insertion and subsequent removal in a nurse-led clinic over a nine-month period. Patients were followed up with a prospective validated Ureteral Stent Symptoms Questionnaire (USSQ)3. A cost analysis was also performed. In total, 59 patients were treated using magnetic stents. The complication rate was low (6.7%). The median duration of indwelling stent was 5.8 days (range 1-11 days). Patients reported haematuria and lower urinary tract symptoms but >90% experienced no functional impairment with minimal days of employment lost (mean 0.75 days). All patients reported satisfaction with nurse-led stent removal and 97% were happy to have stents removed via this method in the future. The total financial savings were estimated at €47,790 over this period. Nurse-led removal of magnetic stents is safe and well tolerated by patients and enables expedient stent removal. It also provides a significant cost benefit and frees up valuable endoscopic resources.

Supporting Youth Participation in Health and Climate Justice Through Advocacy Training Comment on "Between Rhetoric and Reality: Learnings From Youth Participation in the Adolescent and Youth Health Policy in South Africa".

This paper responds to lessons from the Adolescent and Youth Health Policy (AYHP) process in South Africa by drawing comparisons with youth participation within the climate justice movement. Relationship building is essential to successful youth participation in health policy and climate change as it creates intergenerational learning and cross-cultural engagement. At the same time, both sets of youth also deal with compounding challenges due to contemporary and historical legacies of colonialism and inequality. Yet, tokenism challenges the participatory process as adults profess to value youth perspectives, yet recommendations by youth often do not get incorporated into policies or plans. For organizations and agencies trying to build youth's capacity, organizations and agencies should look to programs that train youth in advocacy. These programs help build youth's confidence, increase their optimism for change, and give youth a sense of ownership.

Detailed analysis of in-hospital transmission of SARS-CoV-2 using whole genome sequencing.

BACKGROUND: Hospital transmission of SARS-CoV-2 has proved difficult to control, with healthcare-associated infections troublesome throughout. AIM: To understand factors contributing to hospital transmission of infections, which is necessary for containing spread. METHODS: An outbreak of 56 staff and patient cases of COVID-19 over a 31-day period in a tertiary referral unit is presented, with at least a further 29 cases identified outside of the unit and the hospital by whole genome sequencing (WGS). FINDINGS: Transmission is documented from staff to staff, staff to patients, and patients to staff, showing disruption of a tertiary referral service, despite implementation of nationally recommended control measures, superior ventilation, and use of personal protective equipment. There was extensive spread from the index case, despite this patient spending only 10 h bed bound on the ward in strict cubicle isolation and with an initial single target low level (CT = 32) polymerase chain reaction test. CONCLUSION: This investigation highlights how effectively and rapidly SARS-CoV-2 can spread in certain circumstances. It raises questions about infection control measures in place at the time and calls into question the premise that transmissibility can be reliably detected by using lower sensitivity rapid antigen lateral flow tests. We also highlight the value of early intervention in reducing impact as well as the value of WGS in understanding outbreaks.

The approach to an isolated close anterior margin in breast conserving surgery.

INTRODUCTION: Although close radial margins after breast-conserving surgery routinely undergo re-excision, appropriate management of patients with close anterior margins remains a topic of controversy. An increasing body of literature suggests that re-excision of close anterior margins yields low rates of residual malignancy and may only be necessary in selected patients. The aim of this study was to examine the management of close anterior margins after breast conserving surgery in a single institution and to analyse the rate of residual disease in re-excised anterior margins. METHODS: All patients having breast conserving surgery at St Vincent's University Hospital from January 2008 to December 2012 were reviewed retrospectively. Data collected included patient demographics, tumour characteristics, margin positivity, re-excision rates and definitive histology of the re-excision specimens. A close margin was defined as les than 2 mm. RESULTS: A total of 930 patients were included with an average age of 65 years (range 29-94 years). Of these, 121 (13%) had a close anterior margin. Further re-excison of the anterior margin was carried out in 37 patients (30.6%) and a further 16 (13.2%) proceeded to mastectomy. Residual disease was found in 18.5% (7/36) of those who underwent re-excision and 7/16 (43.75%) of those who underwent mastectomy. Overall, 11.57% (14/121) of patients with close anterior margins were subsequently found to have residual disease. CONCLUSION: The low yield of residual disease in re-excised anterior margins specimens supports the concept that routine re-excision of close anterior margins is not necessary. Further research is required to definitively assess its influence on the risk of local recurrence.

Rates of bluetongue virus transmission between Culicoides sonorensis and sheep.

Two experiments were undertaken to estimate the transmission rates of bluetongue virus (BTV) serotype 1 between a biting midge vector, Culicoides sonorensis (Wirth & Jones) (Ceratopogonidae), and a natural host, sheep. In an experiment to measure the transmission rate from vector to host (V-->H), six batches of one, five and 20 intrathoracically infected midges were fed on a total of 18 bluetongue (BT)-naïve sheep. The sheep were then monitored for 21 days for clinical signs of BT, viraemia and antibody response. All sheep fed on by five or 20 midges and five of six sheep fed on by just one midge showed signs of BT, were viraemic and developed antibody. The sixth sheep fed on by a single infected midge did not show signs of BT or have detectable viraemia; it did, however, develop a weak antibody response. A bite from a single infected midge is therefore able to transmit BTV to naïve sheep with 80-100% efficiency. Sheep fed upon by larger numbers of infected midges took less time to reach maximum viraemia and developed stronger antibody responses. Sheep exposed to greater amounts of BTV in feeding midges developed a higher level of viraemia and stronger antibody responses. In a second experiment to measure the transmission rate from host to vector (H-->V), batches of up to 500 uninfected female C. sonorensis fed every 1-2 days on two experimentally infected sheep during the course of infection. Of 3929 engorged midges that were individually titrated after surviving the extrinsic incubation period, only 23 (0.6%) were infected with BTV. Viraemia in the sheep extended for up to 19 days post-inoculation. No infected midges, however, were detected from 14 days post-infection.

X-ray structure of human relaxin at 1.5 A. Comparison to insulin and implications for receptor binding determinants.

The X-ray crystal structure of relaxin at 1.5 A resolution is reported for the physiologically active form of the human hormone. Relaxin is a small, two-chain polypeptide that is a member of the protein hormone family that also includes insulin and the insulin-like growth factors IGF-I and IGF-II. These hormones have biologically diverse activities but are structurally similar, sharing a distinctive pattern of cysteine and glycine residues. The predicted structural homology of relaxin to insulin is confirmed by this structural analysis; however, there are significant differences in the terminal regions of the b-chain. Although relaxin, like insulin, crystallizes as a dimer, the orientation of the molecules in the respective dimers is completely different. The region of the relaxin molecule proposed to be involved in receptor binding is part of the dimer interface, suggesting that some of the other residues contained in the dimer contact surface might be receptor binding determinants as well. The proposed receptor binding determinants for insulin likewise include residues at its dimer interface. However, because the dimer contacts of relaxin and insulin are quite different, it appears that these two structurally related hormones have evolved somewhat dissimilar mechanisms for receptor binding.

Workload and short-term outcome of babies weighing 2,500 grams or more at birth admitted to the paediatric unit of the Rotunda Hospital.

BACKGROUND: Audit is important in ensuring adequate use of resources and maintaining optimum standards of care. Most of the emphasis in neonatal audit is focused on very low birth weight infants. However, term and near-term infants account for a significant proportion of the workload in neonatal units and warrant regular audit. In addition, audit of these infants may be useful as a marker of the organisation of the perinatal service. METHODS: A retrospective audit was performed of all infants with birth weights greater than or equal to 2,500 grams admitted to the neonatal department in the first week of life over a two-year period, examining mode of delivery, level of care, duration of stay, diagnosis and short-term outcome. RESULTS: Eight hundred and seventy infants were admitted greater than or equal to 2,500 grams birth weight, 54% of all neonatal admissions, during the study period. Six hundred and eighty seven of these infants were admitted in the first week of life and were included in the study; this was 5.8% of infants born with a birth weight 2500 grams or more. Infants born by caesarean section were twice as likely to require admission (9.8%) compared with infants born by vaginal delivery (4.5%). The median length of stay was 3 days (3 hours to 45 days). One hundred and six (15.4%) infants required level 1 or level 2 care. One hundred and eleven infants received normal care, only. Most of these infants were admitted for maternal or social reasons. Other common reasons for admission were jaundice, respiratory disease, neonatal abstinence syndrome and congenital abnormality. Forty-one infants required transfer to another hospital, most commonly for surgical or cardiac conditions. Six infants died after admission. However, only one normally formed infant delivered in our hospital died prior to discharge or transfer. One infant was born at home and four infants who had a lethal congenital abnormality are known to have died following transfer. CONCLUSION: Term and near-term infants account for a significant proportion of neonatal admissions and deserve regular audit. Many admissions are potentially avoidable. Survival for infants weighing 2,500 grams or greater is excellent. Only one normally formed infant died following admission during the study period. The number of "social" admissions of "well" infants highlighted by this study reflects poorly on the services available for well infant whose mothers are unable to care for them for whatever reason. We recommend regular audit of these infants in order to ensure efficient use of neonatal resources and to ensure optimum levels of neonatal intensive care.

Running in the family: A rare diagnosis of familial papillary thyroid cancer.

INTRODUCTION: Whilst inherited medullary thyroid cancer has been extensively reported, familial non-medullary thyroid cancer is a rare and less well described clinical entity. Familial forms of the disease demonstrate more aggressive features than sporadic non-medullary thyroid cancer. PRESENTATION OF CASE: A 54 year old lady was referred with globus on a background of a longstanding goitre. Three first degree relatives had a history of non-medullary thyroid carcinoma. Investigations revealed a papillary thyroid carcinoma and the patient proceeded to total thyroidectomy and ipsilateral Level VI neck dissection, followed by adjuvant radioiodine ablation. DISCUSSION: Familial papillary thyroid carcinoma syndrome is defined as three or more first degree relatives diagnosed with the disease in the absence of other known associated syndromes. It is often associated with the presence of benign thyroid disorders, and is characterised by the early onset of multi-focal bilateral locally advanced tumours. CONCLUSION: Familial papillary thyroid cancer is a rare clinical entity but should be considered where ≥3 first degree relatives are diagnosed with non-medullary thyroid cancer. It is necessary to exclude other familial tumour syndromes to make the diagnosis. It demonstrates more aggressive features with higher rates of local recurrence than its sporadic counterpart, and therefore mandates more aggressive management than might otherwise be indicated. Screening of first degree relatives should be considered. SUMMARY: The case of a 54 year old female diagnosed with familial non-medullary thyroid carcinoma is reported.

Importance of risk factor management in diabetic patients and reduction in Stage B heart failure.

BACKGROUND: A number of studies have demonstrated the presence of a diabetic cardiomyopathy, increasing the risk of heart failure development in this population. Improvements in present-day risk factor control may have modified the risk of diabetes-associated cardiomyopathy. AIM: We sought to determine the contemporary impact of diabetes mellitus (DM) on the prevalence of cardiomyopathy in at-risk patients with and without adjustment for risk factor control. DESIGN: A cross-sectional study in a population at risk for heart failure. METHODS: Those with diabetes were compared to those with other cardiovascular risk factors, unmatched, matched for age and gender and then matched for age, gender, body mass index, systolic blood pressure and low density lipoprotein cholesterol. RESULTS: In total, 1399 patients enrolled in the St Vincent's Screening to Prevent Heart Failure (STOP-HF) cohort were included. About 543 participants had an established history of DM. In the whole sample, Stage B heart failure (asymptomatic cardiomyopathy) was not found more frequently among the diabetic cohort compared to those without diabetes [113 (20.8%) vs. 154 (18.0%), P = 0.22], even when matched for age and gender. When controlling for these risk factors and risk factor control Stage B was found to be more prevalent in those with diabetes [88 (22.2%)] compared to those without diabetes [65 (16.4%), P = 0.048]. CONCLUSION: In this cohort of patients with established risk factors for Stage B heart failure superior risk factor management among the diabetic population appears to dilute the independent diabetic insult to left ventricular structure and function, underlining the importance and benefit of effective risk factor control in this population on cardiovascular outcomes.

Expression and activity of a gene encoding rat cytochrome c in the yeast Saccharomyces cerevisiae.

A rat-processed pseudogene, which encodes normal rat cytochrome c, has been expressed in the yeast, Saccharomyces cerevisiae. The translated region of the chromosomal CYC1+ locus, which encodes yeast iso-1-cytochrome c, was replaced by the translated region of the gene encoding rat cytochrome c (CYC1-RAT), thus preserving the proper CYC1 transcription initiation and termination signals. Although the levels of transcription of the normal CYC1+ gene and the CYC1-RAT gene in yeast were equivalent, rat cytochrome c was produced at approx. 40% of the level of iso-1-cytochrome c. In addition, the specific activity in vivo was estimated to be approx. 60% that of the yeast iso-1-cytochrome c. N-terminal processing of indigenous rat cytochrome c, in which the N-terminal methionine residue is cleaved and the penultimate glycine residue is acetylated, also occurred in yeast. Methionine cleavage was complete, while acetylation proceeded to only 70% completion. Lys-72 was trimethylated to 66% completion in the rat cytochrome c produced in yeast. The near normal expression (40%) and specific activity (60%) in vivo indicates that the 40% difference in amino acid sequence is not critical for mitochondrial import, heme attachment and interactions with redox partners.

Conditions not attributable to a mental disorder: an epidemiological study of family problems.

OBJECTIVE: The objective of this research was to identify and measure the differences among three groups of psychiatric outpatients: those with family problems but without mental disorders, those with both family problems and mental disorders, and those with a mental disorder but without family problems. DSM-III V code conditions (conditions not attributable to a mental disorder) other than family problems do occur, but family problems were chosen because of their importance. METHOD: All patients admitted to an outpatient psychiatric clinic during a 2-year period were studied (N = 382). Of these, 92 had V code conditions unrelated to family problems and were excluded. Data are presented on the remaining 290 patients. Sociodemographic variables, DSM-III diagnoses, source of referral, previous and subsequent use of outpatient services, and type of family problem were examined. Patients were from a low-income population and came from three ethnic groups (white, black, and Hispanic). RESULTS: Among whites, more men than women had family problems without mental disorders; among blacks, more women than men had family problems with and without mental disorders. Marital problems occurred most frequently in the group with family problems without mental disorders, and married subjects were more likely to have a V code condition. Professional referrals were more common than other referral sources in all three groups. However, family problems without mental disorders were more likely to occur among those who were referred by their families and had never had psychiatric treatment; patients with family problems and mental disorders were more likely to be self-referred and to have been previously treated; those with a mental disorder but without family problems were usually referred by professionals and almost always had been previously treated. There appeared to be underreporting of family problems among those with family problems and mental disorders and among black men with family problems with and without mental disorders. CONCLUSIONS: More research is needed on the patterns of use of outpatient psychiatric services by individuals with family problems and other V code conditions.

Experimental models for the investigation of female sexual function and dysfunction.

There have been limited anatomic and physiological investigations of the female sexual arousal response. A broader understanding of the physiologic mechanisms of female sexual arousal function is required to improve the management of women with sexual dysfunction. Three experimental test systems have been developed to understand better the biochemical and physiological mechanisms of female sexual arousal response. An in vivo animal model was developed to record physiological and hemodynamic changes in the clitoris and vagina following pelvic nerve stimulation and administration of vasoactive agents and physiological modulators. In vitro organ baths of clitoral and vaginal tissue were utilized to investigate mechanisms involved in the regulation of smooth muscle contractility. In addition, primary cell cultures of human and animal clitoral and vaginal smooth muscle cells were developed to investigate signal transduction pathways modulating smooth muscle tone. In vivo studies revealed hemodynamic changes in vagina and clitoris in response to pelvic nerve stimulation, vasodilators and physiological modulators. Organ bath studies have demonstrated that clitoral and vaginal smooth muscle tone is affected by non-adrenergic and non-cholinergic neurotransmitters, and the presence of functional alpha 1 and alpha 2 adrenergic receptors in these tissues has been established through biochemical studies. These changes are regulated by the tone of vascular and non-vascular smooth muscle in the vagina and clitoris. Primary cell culture studies have suggested that several physiological modulators such as vasoactive intestinal polypeptide (VIP), nitric oxide (NO), and prostaglandin E (PGE) regulate vaginal smooth muscle contractility. Data from experimental models have provided a preliminary understanding of the mechanisms of the female sexual arousal response.

A nutrition curriculum for health education: its effect on students' knowledge, attitude, and behavior.

The objective of the study was to determine the effect of nutrition instruction, using the curriculum guides, Nutrition In A Changing World, A Curriculum for Junior High Health, and A Curriculum for Senior High Health, on improving the nutrition knowledge, selected food/nutrition attitudes, and dietary behavior of students enrolled in secondary level health courses. Three groups of students were utilized including one experimental and two control groups at each level (junior high and senior high). The experimental group was pretested, taught the nutrition curriculum, and posttested. One control group was posttested only to measure the effect of the pretest on posttest performance. A second control group was pretested and posttested. Neither control group received nutrition instruction until after the study was completed. The three instruments used to collect data were a nutrition knowledge test, a food/nutrition attitude instrument, and a food frequency form. The results indicate that, at all grade levels, the experimental group had significantly improved knowledge scores. Little change in attitude scale scores was noted in grades seven and eight, while ninth grade experimental students scored significantly higher on the posttest for all attitude scales. Little improvement was seen in the posttest food frequency scores.

Acute myeloid leukaemia-A review of sixty-seven cases.

Sixty-seven consecutive patients with acute myeloid leukaemia (AML), who presented to the unit over a 5-year period, were reviewed. Remission rates, length of remission and duration of survival were studied. Twenty-seven patients (40.3%) achieved complete remission (CR). Eleven patients (16.4%) achieved a second CR. The median survival of patients who achieved a CR was 15 months. Median survival of patients who failed to go into remission was one month. Median duration of the first remission was 7 months. Three patients are still alive and in remission. These results are discussed in relation to those reported from other centres.

Cellular dysmaturity as a prognostic index in acute myeloid leukaemia.

The bone marrow and peripheral blood findings of 22 selected patients with acute myeloid leukaemia were studied. A correlation was detected between the incidence of attainment of complete remission and the balance of nucleo-cytoplasmic differentiation in the neutrophil series. The prognostic significance of this finding and its relevance to choice of therapy is discussed, as are the possible underlying causes for the phenomenon.