Severe DRESS with myocarditis secondary to naproxen/esomeprazole.

A man in his 60s presented with a widespread erythematous rash and associated chills, paraesthesia and haematuria. He had recently commenced naproxen/esomeprazole. Blood tests showed hypereosinophilia (0.73×109/L) and moderate acute kidney injury. Histology revealed parakeratosis, mild spongiosis with eosinophils. He developed acute coronary syndrome with rapid atrial fibrillation. Coronary angiogram was non-obstructive. Cardiac MRI (CMR) revealed acute myocarditis secondary to Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS). Naproxen/esomeprazole was discontinued, and he was supported with oral corticosteroids. A repeat CMR 3 months later showed resolution of myocarditis. Naproxen/esomeprazole is not a common offending drug. DRESS is a rare drug-induced hypersensitivity reaction with a mortality rate of 10%. The objective of this case report is to highlight the significant but rare cardiac complications that can ensue from DRESS, which warrant prompt recognition and withdrawal of the causative drug.

Leadership: briefing and debriefing in the operating room.

Steelman (2014) stated that the concept of briefing and debriefing used in operating theatres derived from the airline industry in the 1970s. There had been a series of devastating air crashes and the airline industry had come under severe public scrutiny. Investigations identified that, while the crews operating these aircrafts were very skilled and knowledgeable, they lacked competence in their ability to perform as part of a team.

The red zone.

This simple quality initiative won the best innovation in clinical practice at the recent CEO healthcare awards gala event in the North West of Ireland. It demonstrated how a simple collaborative idea led to improving the quality and safety of care in the operating room. As practitioners we have a huge contribution to make in providing quality and safe care to our patients. It is crucial that we share knowledge and have our input recognised.

The shocking stocking audit: an audit on the use of thromboembolic deterrent stockings (TEDS) for patients having surgery at Sligo regional hospital.

A concurrent audit was conducted over a four week period to determine if patients coming for surgery and wearing thromboembolic deterrent stockings (TEDS) adhered to local policy and recommended guidelines. Data was collected on 30 surgical procedures. The audit highlighted failings in the application of TEDS, identifying poor compliance with correct measurement, application and documentation. It also recognised poor communication between care givers and surgical patients regarding TEDS use. There needs to be an increased awareness about local policy, national and international guidelines regarding the use of TEDS for patients having surgery.

Stress among nurses working in an acute hospital in Ireland.

Stress among nurses leads to absenteeism, reduced efficiency, long-term health problems and a decrease in the quality of patient care delivered. A quantitative cross-sectional study was conducted. The study's aim was to identify perceived stressors and influencing factors among nurses working in the critical and non-critical care practice areas. A convenience sample of 200 nurses were invited to complete the Bianchi Stress Questionnaire. Information was collected on demographics and daily nursing practice. Findings indicated that perceived stressors were similar in both groups. The most severe stressors included redeployment to work in other areas and staffing levels. Results from this study suggest that age, job title, professional experience and formal post-registration qualifications had no influence on stress perception. These results will increase awareness of nurses' occupational stress in Ireland.

Specialist medication review does not benefit short-term outcomes and net costs in continuing-care patients.

OBJECTIVES: to evaluate specialist geriatric input and medication review in patients in high-dependency continuing care. DESIGN: prospective, randomised, controlled trial. SETTING: two residential continuing care hospitals. PARTICIPANTS: two hundred and twenty-five permanent patients. INTERVENTION: patients were randomised to either specialist geriatric input or regular input. The specialist group had a medical assessment by a geriatrician and medication review by a multidisciplinary expert panel. Regular input consisted of review as required by a medical officer attached to each ward. Reassessment occurred after 6 months. RESULTS: one hundred and ten patients were randomised to specialist input and 115 to regular input. These were comparable for age, gender, dependency levels and cognition. After 6 months, the total number of medications per patient per day fell from 11.64 to 11.09 in the specialist group (P = 0.0364) and increased from 11.07 to 11.5 in the regular group (P = 0.094). There was no significant difference in mortality or frequency of acute hospital transfers (11 versus 6 in the specialist versus regular group, P = 0.213). CONCLUSION: specialist geriatric assessment and medication review in hospital continuing care resulted in a reduction in medication use, but at a significant cost. No benefits in hard clinical outcomes were demonstrated. However, qualitative benefits and lower costs may become evident over longer periods.

What is the optimal duration of tilt testing for the assessment of patients with suspected postural tachycardia syndrome?

AIMS: The aim of this study is to define the optimal duration of tilt testing for the assessment of patients with suspected postural tachycardia syndrome (POTS). METHODS AND RESULTS: This was a case-control study. Cases were identified retrospectively from a database of patients referred with orthostatic intolerance (OI). All met the diagnostic criteria for POTS. Controls were enrolled prospectively. All subjects underwent tilting to 70 degrees for 40 min if tolerated. Continuous monitoring was provided by a Finometer. Analysis of responses to tilting was performed on 28 cases and 28 controls. The mean age in the case group was 23.6 and in the control group was 26.2. The majority was female in both groups (cases = 4F:3M, controls = 2F:1M). All cases met the criteria for POTS within 7 min of orthostasis. No controls demonstrated a sustained tachycardia. The prevalence of vasovagal syncope (VVS) was 36% in cases vs. 7% in controls (P = 0.02) and 25% in the remaining patients (n = 233) on the OI database (P = 0.259). CONCLUSION: A 10 min tilt will diagnose POTS in the majority of patients. It will not, however, be sufficient to identify the overlap that exists between POTS and VVS. The optimal duration of tilt testing in patients suspected of POTS is 40 min.

Impaired endothelial nitric oxide bioavailability: a common link between aging, hypertension, and atherogenesis?

Endothelial-derived nitric oxide (NO) is responsible for maintaining continuous vasodilator tone and for regulating local perfusion and systemic blood pressure. It also has significant antiproliferative effects on vascular smooth muscle and platelet anti-aggregatory effects. Impaired endothelial-dependent (NO mediated) vasorelaxation is observed in most animal and human models of healthy aging. It also occurs in age-associated conditions such as atherosclerosis and hypertension. Such "endotheliopathy" increases vascular risk in older adults. Studies have indicated that pharmacotherapeutic intervention with angiotensin-converting enzyme inhibitors and 3-hydroxy-3-methyl-glutaryl coenzyme-A reductase inhibitors may improve NO-mediated vasomotor function. This review, evaluates the association between impaired endothelial NO bioavailability, accelerated vascular aging, and the age-associated conditions hypertension and atherogenesis. This is important, because pharmacotherapy aimed at improving endothelial NO bioavailability could modify age-related vascular disease and transform age into a potentially modifiable vascular risk factor, at least in a subpopulation of older adults.

Near death and neurocardiogenic syncope.

We report the case of an 18-year-old female who presented as an out-of-hospital ventricular fibrillation cardiac arrest. She required ICD insertion and recovered without deficit. Following recurrent syncopal episodes we diagnosed the co-existence of Neurocardiogenic syncope.