A qualitative study exploring the challenges for a national police force as first responders to children and young people presenting with mental health crises: perspectives of emergency department professionals.

INTRODUCTION: The difficulties in accessing Child and Adolescent Mental Health Services (CAMHS) and the lack of out-of-hours and crises services have resulted in Ireland's national police force, An Garda Síochána (GS), becoming increasingly involved as first responders to children and young people (CYP) who are experiencing potential mental health crises. AIMS: To outline challenges faced by members of GS and emergency department (ED) professionals in such cases. METHOD: Qualitative study design with semi-structured interviews conducted with a convenience sample of medical and mental health professionals (n = 11) from a paediatric ED who are frequently involved with the interface between GS and CYP experiencing potential mental health crises. Thematic analysis was conducted on transcribed interviews using the software package MaxQDA to systematically organise and code transcriptions. RESULTS: Participants highlighted a lack of appropriate clinical settings within the ED for CYP who attend with a mental health crisis through GS. Whilst participants described positive rapport between GS and ED staff, interactions between GS and patients were identified as challenging. Knowledge gaps amongst members of GS in Mental Health Act (MHA) legislation and restraint were also identified as contributory stressors for GS and emergency department professionals. CONCLUSION: The increased prevalence of CYP mental health issues and psychosocial stressors in conjunction with difficulty in accessing CAMHS means that challenges faced by GS as first responders are likely to continue. Research is needed to quantify the adverse personal impacts on GS along with the potential negative impact on youth. Access to emergency mental health review for youth is essential to optimise the experience of both groups.

Electrical Cardiometry during transition and short-term outcome in very preterm infants: a prospective observational study.

The purpose of this study is to evaluate the association of Electrical Cardiometry (EC)-derived cardiac output indexed to weight (CO) and its changes during the first 48 h in relation to adverse short-term outcome in very preterm infants. In this prospective observational study of preterm infants < 32 weeks gestational age (GA), the combined adverse outcome was defined as mortality or abnormal cranial ultrasound (any grade intracranial hemorrhage (ICH) or periventricular leukomalacia) within the first 2 weeks postnatally. Logistic regression models were used to investigate the association between median CO and outcome and mixed-effects models for the time trajectory of CO. In the absence of device-specific thresholds for low or high CO, no thresholds were used in our analysis. Fifty-three infants (median (IQR) GA 29.0 (25.4-30.6) weeks, birthweight 1020 (745-1505) g) were included in the analysis. Median CO was 241 (197-275) mL/kg/min for the adverse outcome and 198 (175-227) mL/kg/min for normal outcome (odds ratio (OR) (95% confidence interval (95% CI)), 1.01 (1.00 to 1.03); p = 0.028). After adjustment for GA, the difference was not significant (adjusted OR (95% CI), 1.01 (0.99 to 1.02); p = 0.373). CO trajectory did not differ by outcome (p = 0.352). A post hoc analysis revealed an association between CO time trajectory and ICH ≥ grade 2.          Conclusions: EC-derived CO estimates within 48 h postnatally were not independently associated with brain injury (any grade) or mortality in the first 14 days of life. CO time trajectory was found to be associated with ICH ≥ grade 2. What is Known: • Bioreactance-derived cardiac output indexed to bodyweight (CO) in the transitional period has been associated with adverse short-term outcome in preterm infants. What is New: • Electrical Cardiometry (EC)-derived CO measurements in very preterm infants during the transitional period are not independently associated with adverse outcome (death or ultrasound detected brain damage) within 2 weeks postnatally. • In the first 48 h EC-derived CO increases over time and is higher in extremely preterm infants compared to very preterm and differs from previously reported bioreactance-derived CO values.

Surgical treatment of canine urethral prolapse via urethropexy or resection and anastomosis.

OBJECTIVES: The objective was to report and compare the complications and recurrence rates of urethral prolapse in dogs when treated with urethropexy, resection and anastomosis or a combined surgical technique. STUDY DESIGN: Retrospective study. MATERIALS AND METHODS: A total of 86 dogs were identified from the medical records of 10 veterinary referral hospitals from February 2012 and October 2022. Dogs were included if they underwent surgery for a urethral prolapse at first presentation. Complications were classified as minor or major based on the necessity of further surgical intervention. Complications leading to death were also considered major complications. RESULTS: Seventy-nine dogs were included, urethropexy (n=44), resection and anastomosis (n=27) and a combined surgical technique (n=8). Minor complications were identified in 41 of 79 dogs (51.9%): urethropexy 19 of 44 (43.2%), resection and anastomosis 18 of 27 (66.6%) and a combined surgical technique four of eight (50%). Major complications occurred in 23 dogs (29.1%), of which 21 were recurrence (26.6%). Recurrence occurred in 17 of 44 dogs following a urethropexy (38.6%), three of 27 dogs following resection and anastomosis (11.1%) and one of eight dogs treated with a combined surgical technique (12.5%). Recurrence of a urethral prolapse was significantly more likely following urethropexy in comparison to resection and anastomosis. CLINICAL SIGNIFICANCE: Resection and anastomosis was associated with a lower recurrence rate in comparison to urethropexy for the surgical treatment of urethral prolapse. Based on these results, we concluded that resection and anastomosis may be preferable to urethropexy for treatment of urethral prolapse at first presentation. Urethropexy, and resection and anastomosis combined surgical technique was associated with low recurrence rate; however, further studies will be needed to clarify if it provides any benefit over resection and anastomosis.

ATP1A3 related disease manifesting as rapid onset dystonia-parkinsonism with prominent myoclonus and exaggerated startle.

We report ATP1A3-associated rapid-onset dystonia-parkinsonism with an atypical presentation including myoclonus and exaggerated startle in four patients. Their prominence over parkinsonism prompted consideration of a syndromic diagnosis of myoclonus dystonia. ATP1α3 dysfunction in GABAergic neurons could explain these examination findings. The spectrum of ATP1A3-associated movement disorders includes myoclonus-dystonia.

A true congenital pancreatic cyst in a dog.

BACKGROUND: True congenital pancreatic cysts are a rare pathological process reported within feline and human literature. To date there has been no documented case of a true congenital cyst affecting a canine patient. The objective of this case report is to document the clinical findings, diagnostic investigations, surgical treatment, histopathological diagnosis and long-term outcome of a dog with a true pancreatic cyst. CASE PRESENTATION: A 5-month-old crossbreed dog was presented with a six-week history of abdominal pain, apparent bilateral pelvic limb weakness, reluctance to walk and intermittent vomiting and diarrhoea. An abdominal ultrasound examination performed by the dog's primary care veterinarian identified a large intra-abdominal structure of unclear origin. A computed tomographic examination identified a large ovoid structure measuring 156 mm in length, 95 mm in height and 89 mm in width and apparently originating from the left limb of the pancreas. An exploratory coeliotomy was performed and a partial pancreatectomy was performed to allow complete removal of the cystic structure. Histopathological analysis of sections of the wall of the large fluid-filled cyst identified a thick fibromuscular wall lined by a well regimented hyperplastic tall columnar epithelium with basally located round to ovoid nuclei featuring fine chromatin stippling and abundant apically located and surface mucin, concurrent with a true congenital pancreatic cyst. A long-term follow-up of twenty-nine months identified no clinical signs of recurrence. CONCLUSION: A partial pancreatectomy and en bloc excision of a true pancreatic cyst provided an excellent long-term outcome in a dog.

Location-specific reflex epilepsy: a novel reflex epilepsy phenotype.

Reflex epilepsies are rare syndromes where seizures are triggered by particular stimuli or activities that may be motor, sensory or cognitive in nature. Triggers are diverse, may be extrinsic or intrinsic in nature and heterogeneous phenotypes have been described over the years. We give an account of a case of location-specific reflex epilepsy which we suggest is a novel reflex epilepsy phenotype relating to higher cortical function (HCF), and review the literature in relation to features of HCF reflex epilepsies described to date.

The Impact of the New State Body for Transplantation on Lung Transplantation Waiting List Mortality.

Introduction Organ Donation Transplant Ireland (ODTI) was established in 2014 to provide leadership and governance of the transplant programme in Ireland. We aim to establish if the implementation of ODTI translates into a decrease in waiting list mortality. Methods A retrospective analysis of all patients listed for lung transplantation on the Irish Heart and Lung Transplant Programme, between January 2011 and December 2016, was performed. We compared mortality on the waiting list before and after the establishment of ODTI. Results During the study period, a total of 259 patients were on the lung transplant list. Sixty percent of patients underwent lung transplantation. Following establishment of ODTI, there was a statistically significant reduction of waiting list mortality from 46% in the era prior to ODTI to 33% after ODTI formation (p=0.02). Conclusion This study demonstrates the establishment of the governing body ODTI reduced mortality on the lung transplant waiting list.

Case report of an arteriovenous graft for renal dialysis, with multiple complications treated successfully over 5 years.

INTRODUCTION: Arteriovenous grafts (AVG) is a good alternative when native arteriovenous fistula (AVF) is not possible. However, complications are higher and close surveillance is required for successful salvage intervention. PRESENTATION OF CASE: We present the case of a 35 year old man with a history of a successful Brachio-Axillary AVG performed in his right arm in 2012. He had a background of multiple previous failed attempts of a native AVF formation. He presented in 2014 with symptoms consistent with AVF stenosis. He underwent a successful fistuloplasty and 2 stent insertion. In June 2015 he presented again with re-stenosis and successful fistuloplasty was performed with balloon dilatation. In October 2015 he presented with AVF thrombosis. This was treated with fistuloplasty and thrombolysis. He presented again in August 2016 with a recurrent thrombosis in his AVG and this was again treated with a successful fistuloplasty and thrombolysis on two separate occasions. He then presented in September 2016 with re-stenosis. This was treated with fistuloplasty and 2 stent insertion. He underwent a successful renal transplant during this time and presented again with a sinus discharge in February 2019 when the plan was made for subtotal graft excision. CONCLUSION: Incidence of complications is higher when a graft is used over a native AVF. However, close surveillance and prompt intervention can lead to multiple successful salvage procedures thus prolonging the lifespan of the graft. As in our case we were able to prolong the lifespan of the AVG with multiple successful interventions.

'Khatatonia' - cathinone-induced hypertensive encephalopathy.

Khat consumption is an under-recognised cause of hypertensive encephalopathy and intraparenchymal brain haemorrhage. We report the radiological findings of extensive periventricular, subcortical and brain stem white matter pathology of a patient who had consumed excessive amounts of Khat. The Khat plant contains cathinone, an amphetamine-like alkaloid which has been associated with chronic hypertensive end-organ damage, but is seldom considered a cause of cerebrovascular events in northern Europe.

The effects of licence disqualification on drink-drivers: Is it the same for everyone?

Drink-driving remains a major road safety concern that creates a significant social burden. Licence disqualification continues to play a key role in drink driving deterrence and sanctions together with police enforcement to address the problem in most motorised countries. However, on-going questions remain regarding the differing effect of licence disqualification periods between first time and repeat offenders, and between other sub-groups of offenders. As a result, this study aimed to determine whether: (a) differences exist in re-offence rates of convicted drink-drivers between: the period between committing the drink-driving offence and licence disqualification (pre-licence disqualification), during the period of licence disqualification, and after being re-licensed (post-licence restoration); and (b) differential effects of offence rates are evident based on Blood Alcohol Content (BAC), gender, age, repeat offender status and crash involvement at the time of offence. The sample consisted of 29,204 drink-driving offenders detected in Victoria, Australia between 1 January 1996 and 30 September 2002. The analysis indicated that licence disqualifications were effective as drink-driving offenders had a significantly lower rate of offending (both drink-driving and other traffic offences) during licence disqualifications compared to pre-licence disqualification and post-licence restoration periods. The influence of licence disqualification appeared to extend beyond the disqualification period, as offence rates were lower during post-licence restoration than during pre-licence disqualification. Interestingly, the highest rate of offending (both for drink-driving and other traffic offences) was during the pre-licence disqualification period, which suggests offenders are particularly vulnerable to drink and drive while waiting to be sanctioned. A consistent pattern of results was evident across genders and age groups. Additionally, those who were involved in a crash at the same time as their index offence had lower offence rates (compared to those who were not involved in a crash) for all periods, although for general traffic offences, the offence rate was highest in the post-licence restoration period for those who had a crash at index offence. This indicates that being involved in a crash may deter these offenders, at least in the short-term. The implications of the results for managing both first time and repeat offenders are discussed.

Giant desmoid tumour of the thorax following latissimus dorsi and implant breast reconstruction: case report and review of the literature.

The case of a giant thoracic desmoid tumour in a 44-year-old woman, who presented two years following a breast reconstruction with a latissimus dorsi (LD) flap and implant, is reported. Clinical findings included a rapidly growing, painless mass. Computed tomography (CT) suggested skin and intercostal soft tissue invasion. The tumour was resected en bloc with the LD muscle, implant capsule and underlying rib segments. The resultant thoracic and abdominal wall defects were reconstructed with Dualmesh® and polypropylene meshes respectively. There was no evidence of recurrence at thirty-six months follow-up.

Renal transplantation outcomes following heart and heart-lung transplantation.

BACKGROUND: Chronic kidney disease is a frequent complication following heart and combined heart-lung transplantation. The aim of this study was to analyse the outcome of a subsequent renal transplant in heart, lung and heart-lung transplantation recipients. METHODS: All heart, lung and heart-lung transplant recipients who received a subsequent renal transplant over a 27-year period in a national heart and lung transplant centre were included in this study. RESULTS: A total of 18 patients who had previously undergone heart (n = 6), lung (n = 7) and heart-lung (n = 5) transplantation received a renal transplant. The mean duration to development of end-stage kidney disease (ESKD) was 115 ± 45.9 months. The most common contributor to ESKD was calcineurin inhibitor nephrotoxicity. The 5-year patient survival and graft survival rates were 91.7 and 85.6%, respectively. The median creatinine level at the most recent follow-up was 123 µmol/L, IQR 90.8-147.5. CONCLUSIONS: The overall outcome of renal transplantation following previous non-renal solid organ transplantation is excellent considering the medical complexity and co-morbidities of this patient population. Renal transplantation represents an important treatment option for ESKD in non-renal solid organ transplant recipients.

University Hospital Waterford: 5-year experience of cutaneous melanoma.

INTRODUCTION: The incidence of cutaneous melanoma (CM) continues to rise in Ireland. Despite significant advances in melanoma molecular therapy, surgery remains the mainstay of treatment for CM. The University Hospital Waterford (UHW) prospectively maintained CM registry was established in 2010. AIM: To summarize 5-year experience (2010-2015) of primary CM presenting to UHW. METHODS: Data were retrospectively obtained from a central electronic pathology and radiology repository augmented by HIPE data and theatre logs. Data collected included patient demographics and clinico-pathological characteristics, specimen number, size, anatomical location, melanoma subtype, Breslow thickness, Clark's level, ulceration, and mitosis. RESULTS: 592 CMs were managed in UHW during the study period. Overall, females comprised the majority of cases with mean age at presentation 60.78 ± 18.29 years. The most commonly affected anatomical location was the lower limb (26.7%) followed by the back (15.1%), upper limb (15.07%), and face (14.40%). Superficial spreading and lentigo maligna were the most common histological subtype accounting for 19.8 and 20%, respectively. Overall, the mean Breslow depth was 2.4 ± 3.7 mm with corresponding Clark's Level III. Sentinel lymph node positivity was 39/103 (37.89%) most commonly located in the axilla (53.8%) and groin (30.7%). CONCLUSION: There has been a steady increase in the number of cutaneous melanoma presentations over the past 5-years to the South East Cancer Centre. Patients are managed best by prompt surgical excision and multidisciplinary management. Our results are in keeping with international standards and work continues in determining overall 5-year survival and recurrence rates.

Epidemiological, clinical and genetic aspects of adult onset isolated focal dystonia in Ireland.

BACKGROUND: Adult onset idiopathic isolated focal dystonia presents with a number of phenotypes. Reported prevalence rates vary considerably; well-characterized cohorts are important to our understanding of this disorder. AIM: To perform a nationwide epidemiological study of adult onset idiopathic isolated focal dystonia in the Republic of Ireland. METHODS: Patients with adult onset idiopathic isolated focal dystonia were recruited from multiple sources. Diagnosis was based on assessment by a neurologist with an expertise in movement disorders. When consent was obtained, a number of clinical features including family history were assessed. RESULTS: On the prevalence date there were 592 individuals in Ireland with adult onset idiopathic isolated focal dystonia, a point prevalence of 17.8 per 100 000 (95% confidence interval 16.4-19.2). Phenotype numbers were cervical dystonia 410 (69.2%), blepharospasm 102 (17.2%), focal hand dystonia 39 (6.6%), spasmodic dysphonia 18 (3.0%), musician's dystonia 17 (2.9%) and oromandibular dystonia six (1.0%). Sixty-two (16.5%) of 375 consenting index cases had a relative with clinically confirmed adult onset idiopathic isolated focal dystonia (18 multiplex and 24 duplex families). Marked variations in the proportions of patients with tremor, segmental spread, sensory tricks, pain and psychiatric symptoms by phenotype were documented. CONCLUSIONS: The prevalence of adult onset idiopathic isolated focal dystonia in Ireland is higher than that recorded in many similar service-based epidemiological studies but is still likely to be an underestimate. The low proportion of individuals with blepharospasm may reflect reduced environmental exposure to sunlight in Ireland. This study will serve as a resource for international comparative studies of environmental and genetic factors in the pathogenesis of the disorder.

Atypical social cognitive processing in premotor Huntington's disease: a single case study.

BACKGROUND: We report the case of a 52-year-old male with pre-motor Huntington's disease (HD) who has undergone detailed clinical and neuropsychological examination. This patient's negative symptomatology and behavioural change are having a detrimental impact on his social, occupational and interpersonal life, in the absence of motor symptoms. METHODS: The patient has undergone repeat neuropsychological testing (T1 aged 50; T2 aged 52) with particular focus on executive function and social cognition on repeat testing. RESULTS: This case details a specific manifestation of HD relating to behavioural, psychiatric and social affective deficits. CONCLUSIONS: This case illustrates how social cognitive changes can occur in HD, months and even years prior to the onset of motor features and how such unrecognized deficits can have a deleterious impact on an individual's functional ability and lifestyle, before the disease is traditionally considered to have become manifest.

Links between serotonin reuptake inhibition during pregnancy and neurodevelopmental delay/spectrum disorders: A systematic review of epidemiological and physiological evidence.

OBJECTIVE: To investigate possible linkages between neurodevelopmental delay and neurodevelopmental spectrum disorders and exposure to medication with effects on serotonin reuptake inhibition during pregnancy. METHODS: We systematically reviewed the epidemiological literature for studies bearing on this relationship in children born with neurodevelopmental spectrum disorder and related conditions, as well as animal studies giving serotonin reuptake inhibitors to pregnant animals and in addition reviewed the literature for proposals as to possible mechanisms that might link effects on serotonin reuptake with cognitive changes post-partum.The epidemiological studies were analysed to produce Forest plots to illustrate possible relations. RESULTS: The odds ratio of Autistic Spectrum or related Disorders in children born to women taking serotonin reuptake inhibiting antidepressants during pregnancy in case control studies was 1.95 (95% C.I. 1.63, 2.34) and in prospective cohort studies was 1.96 (95% C.I. 1.33, 2.90). CONCLUSIONS: There appears to be a link between serotonin reuptake inhibition in pregnancy and developmental delay and spectrum disorders in infancy leading to cognitive difficulties in childhood. More work needs to be done to establish more precisely the nature of the difficulties and possible mechanisms through which this link might be mediated.

A Comparison of the Mallampati evaluation in neutral or extended cervical spine positions: a retrospective observational study of >80 000 patients.

BACKGROUND: The Mallampati examination is a standard component of an airway risk assessment. Existing evidence suggests that cervical spine extension improves the predictive power of the Mallampati examination for detecting difficult laryngoscopy and tracheal intubation, but a comparative effectiveness study has not been conducted. METHODS: The extended Mallampati examination (EMS) was introduced to the standard preoperative airway assessment, in addition to the standard Modified Mallampati examination (MMP). This study compared the accuracy of both Mallampati examinations on the prediction of difficult laryngoscopy, tracheal intubation, and bag mask ventilation. Univariate and adjusted analyses were performed. RESULTS: 80 801 patients with recorded MMP and EMS, and subsequent glottic view obtained during direct laryngoscopy, were examined. There was increased specificity (88.7% cf. 81.9%) but reduced sensitivity (33.3% cf. 45.7%) in the detection of difficult direct laryngoscopy with use of the EMS. The area under the receiver operating characteristic curve of each test performed in combination with other airway predictors for the models predicting difficult laryngoscopy was 0.740 (95% CI 0.731-0.753) for MMP and 0.739 (95% CI 0.729-0.752) for EMS. The area under the receiver operating characteristic curve of each test, performed in combination with other airway predictors for the models predicting difficult intubation was 0.699 (95% CI 0.688-0.711) for MMP and 0.695 (95% CI 0.683-0.707) for EMS. CONCLUSIONS: This retrospective observational study demonstrates that cervical extension improves the specificity but decreases sensitivity of Mallampati examination. The Mallampati evaluation should be performed with the cervical spine in the neutral position to maximize test sensitivity.