Early senior decision-making in acute medicine: a critical review of health policy and implications for practice.

UK urgent care health policies advocate senior clinical decision-making at the point of referral into the system. The costs of employing senior clinicians in this role are substantial with little evidence of the value they bring over other strategies, particularly for patient outcomes. We sought to explore current remote and ambulatory emergency care decision-making in acute medical care in a large central healthcare system - NHS Scotland. We found that many sites use remote decision-making for some allocation decisions. However, involvement of clinical expertise varies, and available decision-aids are few. There is also variation in access to resources that facilitate non-admission. Research into the value that senior clinicians bring to this task over other strategies is required.

Investigation of a foodborne outbreak of Shigella sonnei in Ireland and Northern Ireland, December 2016: the benefits of cross-border collaboration and commercial sales data.

OBJECTIVES: To describe a cross-border foodborne outbreak of Shigella sonnei that occurred in Ireland and Northern Ireland (NI) in December 2016 whilst also highlighting the valuable roles of sales data and international collaboration in the investigation and control of this outbreak. STUDY DESIGN: A cross-border outbreak control team was established to investigate the outbreak. METHODS: Epidemiological, microbiological, and environmental investigations were undertaken. Traditional analytical epidemiological studies were not feasible in this investigation. The restaurant chain provided sales data, which allowed assessment of a possible increased risk of illness associated with exposure to a particular type of heated food product (product A). RESULTS: Confirmed cases demonstrated sole trimethoprim resistance: an atypical antibiogram for Shigella isolates in Ireland. Early communication and the sharing of information within the outbreak control team facilitated the early detection of the international dimension of this outbreak. A joint international alert using the European Centre for Disease Control's confidential Epidemic Intelligence Information System for Food- and Waterborne Diseases and Zoonoses (EPIS-FWD) did not reveal further cases outside of the island of Ireland. The outbreak investigation identified that nine of thirteen primary case individuals had consumed product A from one of multiple branches of a restaurant chain located throughout the island of Ireland. Product A was made specifically for this chain in a food production facility in NI. S. sonnei was not detected in food samples from the food production facility. Strong statistical associations were observed between visiting a branch of this restaurant chain between 5 and 9 December 2016 and eating product A and developing shigellosis. CONCLUSIONS: This outbreak investigation highlights the importance of international collaboration in the efficient identification of cross-border foodborne outbreaks and the value of using sales data as the analytical component of such studies.

Outbreak of invasive pneumococcal disease at a Belfast shipyard in men exposed to welding fumes, Northern Ireland, April-May 2015: preliminary report.

We report an outbreak of four confirmed cases of invasive pneumococcal disease (IPD) in individuals occupationally exposed to welding fumes, at a Belfast shipyard (Northern Ireland). All cases were hospitalised. A high-risk sub-group of 679 workers has been targeted for antibiotic prophylaxis and pneumococcal vaccination. Physicians and public health institutions outside Northern Ireland should be alert to individuals presenting with pneumonia or IPD and recent links to the shipyard, to facilitate early assessment and treatment.

Increase in scarlet fever notifications in the United Kingdom, 2013/2014.

Increases in scarlet fever above usual seasonal levels are currently being seen across the United Kingdom. Medical practitioners have been alerted to the exceptional increase in incidence. Given the potential for this to signal a population increase in invasive group A streptococcal disease, close monitoring of invasive disease is essential.

Salmonella enterica serovar Agona European outbreak associated with a food company.

We investigated an international outbreak of Salmonella Agona with a distinct PFGE pattern associated with an Irish Food company (company X) producing pre-cooked meat products sold in various food outlet chains in Europe. The outbreak was first detected in Ireland. We undertook national and international case-finding, food traceback and microbiological investigation of human, food and environmental samples. We undertook a matched case-control study on Irish cases. In total, 163 cases in seven European countries were laboratory-confirmed. Consumption of food from food outlet chains supplied by company X was significantly associated with being a confirmed case (mOR 18·3, 95% CI 2·2-149·2) in the case-control study. The outbreak strain was isolated from the company's pre-cooked meat products and production premises. Sufficient evidence was gathered to infer the vehicles of infection and sources of the outbreak and to justify the control measures taken, which were plant closure and food recall.

Hepatitis A outbreak predominantly affecting men who have sex with men in Northern Ireland, October 2008 to July 2009.

We describe an outbreak of hepatitis A which evolved in Northern Ireland between October 2008 and July 2009, against a background of large concurrent hepatitis A outbreaks in various parts of Europe. Thirty-eight cases were defined as outbreak cases using a stratified case definition; 36 were males with a median age of 29 years and of the 28 males whose sexual orientation was known, 26 were men who have sex with men(MSM). Detailed descriptive epidemiology data collected through standardised questionnaires, together with sequencing of a 289 bp fragment of the VP1/2PA region of the virus, significantly aided the understanding of the spread of the outbreak when non-MSM cases occurred. The sequence of the outbreak strain, genotype IA, was indistinguishable from that involved in a large outbreak in the Czech Republic. Although seeded in a generally susceptible Northern Ireland population, the outbreak remained mostly contained in MSM, showing this sub-population to be the most vulnerable despite ongoing hepatitis A vaccination programmes in genito-urinary medicine clinics.

Spotlight on measles 2010: ongoing measles outbreak in Northern Ireland following an imported case, September-October 2010.

We report an ongoing outbreak of measles with five laboratory-confirmed and four epidemiologically linked cases in Northern Ireland as at 26 October 2010. The index case was an unvaccinated non-Northern Ireland resident with subsequent genotyping suggesting that infection originated in the usual country of residence of this case. Confirmed cases include one patient with a history of two measles-mumps-rubella vaccine doses.

Characteristics of respiratory outbreaks in care homes during four influenza seasons, 2011-2015.

BACKGROUND: Influenza and other respiratory infections can spread rapidly and cause severe morbidity and mortality in care home settings. AIM: This study describes the characteristics of respiratory outbreaks in care homes in Northern Ireland during a four-year period, and aims to identify factors that predict which respiratory outbreaks are more likely to be positively identified as influenza. METHODS: Epidemiological, virological, and clinical characteristics of outbreaks during the study period were described. Variables collected at notification were compared to identify predictors for an outbreak testing positive for influenza. t-Tests and χ2-tests were used to compare means and proportions respectively; significance level was set at 95%. FINDINGS: During the four seasons, 95 respiratory outbreaks were reported in care homes, 70 of which were confirmed as influenza. More than 1000 cases were reported, with 135 associated hospitalizations and 22 deaths. Vaccination uptake in residents was consistently high (mean: 86%); however, in staff it was poorly reported, and, when reported, consistently low (mean: 14%). Time to notification and number of cases at notification were both higher than expected according to national recommendations for reporting outbreaks. No clinically significant predictors of a positive influenza outbreak were identified. CONCLUSION: Respiratory outbreaks in care homes were associated with significant morbidity and mortality, despite high vaccination uptake. The absence of indicators at notification of an outbreak to accurately predict influenza infection highlights the need for prompt reporting and laboratory testing. Raising staff awareness, training in the management of respiratory outbreaks in accordance with national guidance, and improvement of staff vaccination uptake are recommended.

Effect of food on blood hydralazine levels and response in hypertension.

A study with a nonspecific hydralazine assay reported that food increased hydralazine concentrations in plasma. We used a specific HPLC hydralazine assay to determine the effect of food on hydralazine blood levels and hemodynamic responses after oral hydralazine. Six subjects with uncomplicated essential hypertension were given 1 mg/kg hydralazine solution orally on two occasions at least 3 days apart. On 1 study day subjects fasted and on the other they were given a standard meal 45 min before hydralazine. Mean arterial pressure and heart rate were monitored for 2 hr before and for 4 hr after hydralazine and frequent venous blood samples were drawn for hydralazine assay. Hepatic blood flow was estimated by determination of indocyanine green clearance before food, after food, and 30 min after hydralazine. Peak blood hydralazine concentrations fell in all (46.2% +/- 11.5%; means +/- SE) and areas under the blood hydralazine concentration/time curves fell (45.7% +/- 9.5%) after food. This could not be explained by changes in liver blood flow. Food-related reductions in blood levels of hydralazine were associated with reduced vasodepressor effects (41.5% +/- 5.6%). It is possible that food increases intravascular conversion of hydralazine to hydralazine pyruvic acid hydrazone. The reduction in vasodepressor response suggests that patients with hypertension should take hydralazine at a fixed time in relation to meals.

Effect of oral dose size on hydralazine kinetics and vasodepressor response.

Levels of hydralazine in blood are log-linearly related to its vasodepressor effect. We examined the effect of oral dose size on the proportion of hydralazine that reaches systemic circulation. Nine subjects with hypertension were given hydralazine in oral doses in the therapeutic range. Blood hydralazine levels, effective liver blood flow, blood pressure, and heart rate were measured. As the hydralazine dose increased, the ratios of the AUC of hydralazine to hydralazine dose and of peak blood hydralazine concentration to hydralazine dose increased, indicating an increase in the proportion of the dose in blood. Liver blood flow tended to increase (maximum 40%) as dose increased above 0.5 mg/kg. Vasodepressor response and degree of tachycardia increased disproportionately with increasing hydralazine dose. There were strong log-linear relationships between peak hydralazine levels and both vasodepressor response and tachycardia that did not change with increasing hydralazine dose. Thus blood hydralazine and vasodepressor response increase disproportionately with increasing hydralazine doses in hypertension.

Anthracenone ABA analogue as a potential photoaffinity reagent for ABA-binding proteins.

An anthracenone analogue of abscisic acid (ABA) was synthesized as a potential photoaffinity reagent and tested for biological activity. Reaction between 10,10'-dimethoxy-9-anthrone with two equivalents of the lithiated dianion of cis-3-methylpent-2-en-4-yn-1-ol afforded an acetylenic alcohol key intermediate. Subsequent reduction of the triple bond, functional group manipulation of the side chain alcohol and deprotection of the dimethoxy protected anthrone provided anthracenone ABA analogue 7 as a potential photoaffinity reagent for ABA-binding proteins. The effect of natural ABA and the potential photoaffinity anthracenone ABA 7 on corn cell growth was determined at various concentrations. The results show that anthracenone ABA 7 is perceived as ABA-like, although producing less inhibition than ABA itself. For example, 7 at 33 microM produces approximately the same inhibition as ABA at 10 microM.

Computer-assisted instruction in mixed dentition analysis.

A computer-assisted instruction (CAI) tutorial in the basics of mixed dentition analysis was developed and evaluated as a substitute for a one-hour lecture segment on the same topic. The instructional effectiveness of the program was evaluated using an experimental CAI-lecture group design. A posttest included in the final examination for the course served to compare learning outcomes of 24 students instructed via the computer with 28 students instructed by the traditional lecture method. The results of this investigation revealed that: the CAI group performed significantly better on the posttest than did the lecture group, there was no significant correlation between posttest scores and the time used to view the program for students in the computer groups, and student attitude toward the use of this CAI program was favorable.

The results of coronary arteriography in young men after myocardial infarction in north-east Scotland.

The case records of 50 consecutive male patients aged 40 years or under who were investigated by selective coronary arteriography after myocardial infarction were reviewed. Fourteen patients had normal coronary vessels and 36 patients had significant occlusive disease. Eighteen were considered to be in need of surgical treatment. The features of myocardial infarction on the ECG were less marked in the group of patients with normal coronary arteriograms. Many of these patients were asymptomatic and had complete resolution of the ECG changes. As well as having normal coronary arteries, many also had normal left ventricular angiograms. Cigarette smoking was very common in the whole group, 86 per cent of patients being moderately heavy cigarette smokers. Five of the 14 patients in the 'non-occlusive' group were non-smokers and only two of the 36 patients in the 'occlusive' group were non-smokers (P less than 0.01). The fasting serum cholesterol was significantly lower in the 'non-occlusive' group than in the 'occlusive' group. There was no significant difference between the two groups regarding blood pressure, family history of ischaemic heart disease, obesity or alcohol consumption. There was, however, a high incidence of heavy alcohol consumption amongst patients who subsequently required coronary artery surgery. Many of the patients in the 'non-occlusive' group were considered to have had smaller, more localised myocardial infarctions and a lesser degree of coronary disease which may not be detected by coronary arteriography. Others, with more widespread cardiac damage, could be explained on the basis of thrombosis and subsequent recanalisation.

Long-term prognosis after resuscitation from primary ventricular fibrillation complicating acute transmural myocardial infarction in the north east of Scotland.

The aim of this study is to determine the long-term prognosis of patients successfully resuscitated from primary ventricular fibrillation in the acute phase of transmural myocardial infarction and to identify predictors of mortality. Details of 75 consecutive patients between October 1971 and May 1981 were reviewed in October 1985. The cumulative survival rates at one year, two year, five year and 10 year were 84%, 77% 67% and 40.5% respectively with a median survival time of 8.7 years. Univariate and Cox survival analyses were used to determine predictors of mortality. Only the age of the patient at the time of infarction was found to be highly significant with a greatly increased mortality rate in the older age group (p less than 0.001). The sex, site of infarction (anterior or inferior) and time of entry in the study did not significantly influence long-term prognosis.

Lokomaika'i (inner health) in a remarkable hospital.

Seven years ago, The Queen's Medical Center in Honolulu, Hawaii embarked on a journey of rediscovery, one that would explore the past, present and future of the health care environment. In an effort to provide the best care and services to the people of Hawaii, Queen's embraces a philosophy of care that incorporates the physical, emotional, social and spiritual needs of its patients.

Age and blood pressure determine vasodepressor response to sodium nitroprusside.

Twenty-two patients, aged 33-72 years, with uncomplicated essential hypertension were given sequential incremental intravenous infusions of sodium nitroprusside, each of 10 min duration, to examine the determinants of the vasodepressor response. Changes in mean arterial pressure (delta MAP), heart rate (delta HR), and plasma norepinephrine (delta nc) were determined at the end of each infusion period. The slopes of the dose-response curves obtained were directly proportional to predrug blood pressure (p less than 0.0001) and inversely proportional to baroreflex sensitivity as measured by the slope of the delta HR vs. delta MAP relationship (p = 0.0007). Baroreflex sensitivity was in turn inversely proportional to, and approximately equally dependent on, predrug blood pressure and age (p = 0.0116). Thus, the slopes of the dose-response curves were determined by both predrug blood pressure and patient age. The relationship was such that predrug blood pressure accounted for approximately 75% of the variability in the slope of the dose-response curve, and age for only 25%. This suggests that the age-related reduction in baroreflex sensitivity is mechanistically different from the hypertension-related reduction and is of less importance in modifying homeostatic responses to vasodilation.

Differential hemodynamic and sympathoadrenal effects of sodium nitroprusside and hydralazine in hypertensive subjects.

The hemodynamic and sympathoadrenal effects of serial incremental doses of a mixed veno-arteriolar dilator (intravenous sodium nitroprusside 0.0125-0.50 micrograms/kg/min) and a pure arteriolar dilator (bolus injections of hydralazine, 0.05-0.3 mg/kg) were compared in 18 subjects with uncomplicated essential hypertension. Blood pressure was reduced to the same extent over approximately the same time with both drugs. Sodium nitroprusside produced significant reduction in cardiac output (9%) and stroke volume (16%) despite an 11% increase in heart rate. Total peripheral resistance did not change. In contrast, hydralazine produced a significant (39%) reduction in peripheral resistance with a compensatory increase in heart rate (19%), stroke volume (20%), and cardiac output (42%). The catecholamine responses to the drugs differed both quantitatively and qualitatively. Administration of both drugs was associated with gradual increases in plasma norepinephrine, but the levels were consistently 40% higher with sodium nitroprusside for the same fall in blood pressure. No consistent change in plasma epinephrine was found with sodium nitroprusside, whereas with hydralazine, the concentration increased gradually after the blood pressure had been reduced by 9 mm Hg. This threshold was independent of the starting blood pressure. These differences in catecholamine response could reflect different patterns of regional sympathetic activation by the low pressure mechanoreceptors (sodium nitroprusside) and by the arterial baroreceptors (hydralazine). Neither drug has an ideal hemodynamic profile, particularly in subjects with cardiac disease, but a balanced combination of the two may produce a favorable hemodynamic profile and optimal hypotensive effect, minimizing the need for large doses of sympathetic inhibitors.

Rapid screening test for the diagnosis of rotavirus infection.

The early diagnosis of human rotavirus infection is essential for effective patient management and infection control. We report here a rapid, easy-to-perform, and inexpensive test for rotavirus detection. The viral RNA is extracted directly from the stools and electrophoresed on 1% agarose gels. Currently available immunoassays for routine diagnostic purposes are directed at the common group A-specific antigen. As reports become available on human gastroenteritis caused by the atypical or novel rotaviruses, this technique presents an added advantage in that it can detect both group A and non-group A rotaviruses.