The impact of a contaminated city water supply on an emergency department.

In March 2007 Galway City and County's water supply was officially contaminated by cryptosporidiosis. The medical and nursing staff at the city's only Emergency Department had noted a rise in an atypical form of gastroenteritis in the preceding months. A retrospective audit of 11,723 charts from January 1st 2007 to 22nd March (day after contamination was confirmed) was performed to identify these patients. The number of potential gastroenteritis cases was 185 (incidence 1.6%), with a peak five weeks before the outbreak was confirmed. Half the patients were aged between 20 and 34. Pain (80%), nausea or vomiting (74%) and diarrhoea (66.5%) were the most frequent symptoms. The mean duration of symptoms at presentation was 2 days. Stool samples were sent for nine patients and four of these were tested for Cryptosporidium. Over a quarter (28.6%) of patients were admitted and almost three-quarters (69.7% +/- 7%) had a residential address in the affected area. Difficulty exists in the early identification of new outbreaks and many of the affected patients are not detected using routine surveillance or current capture methods.

Medical students in the emergency department: how do patients view participation in clinical teaching?

A survey was carried out in the Emergency Department (ED) of a single urban Irish teaching hospital to determine patients' acceptability towards medical students and their attitudes towards participating in clinical teaching. We analysed 145 patient replies and found 45 (31%) patients with previous ED medical student contact. Amongst these, 23/45 (51%) did not have verbal consent before being seen, 8/45 (18%) experienced pressure to participate but overall 35/45 (78%) felt their experience was a positive one. When patients who did not have previous contact with medical students were included in the analysis, receptiveness to student examination and procedures remained high [119 (82%) and 102 (70%) respectively] despite almost none of the patients recalled reading information about participating in medical teaching. Up to 52% patients would vary their consent depending on the severity of their clinical complaint but the majority, 104 (81%) patients were satisfied that involving medical students would not alter their clinical care.

Prehospital trauma management: a national study of paramedic activities.

OBJECTIVES: The benefits of prehospital trauma management remain controversial. This study aimed to compare the processes of care and outcomes of trauma patients treated by paramedics, who are trained in advanced prehospital trauma care, with those treated by ambulance technicians. METHODS: A six year prospective study was conducted of adult trauma patients attended to by the Scottish Ambulance Service and subsequently admitted to hospital. Prehospital times, interventions, triage, and outcomes were compared between patients treated by paramedics and those treated by technicians. RESULTS: Paramedics attended more severely injured patients (16.5% versus 13.9%, p<0.001); they attended a higher proportion of patients with penetrating trauma (6.6% versus 5.7%, p = 0.014) and had longer prehospital times. Patients managed by paramedics were more likely to be taken to the intensive care unit, operating theatre or mortuary, (11.2% versus 7.8%, p<0.001) and had higher crude mortality rates (5.3% versus 4.5%, p = 0.07). However, no difference in mortality between the two groups was noted when corrected for age, Glasgow coma score and injury severity score. CONCLUSIONS: This large scale national study shows that paramedics show good triage skills and clinical judgement when managing trauma patients. However, the value of the individual interventions they perform could not be ascertained. Further controlled trials are necessary to determine the true benefits of advanced prehospital trauma life support.

The Football World Cup 2002--analysis of related attendances to an Irish Emergency Department.

Throughout the Football World Cup Finals of 2002, 47 patients attended the Emergency department with a variety of conditions related to the event. The majority were minor trauma victims such as assaults or falls and in over half the presentations alcohol was a factor. Thirty-eight of these patients attended within 24 hours of an Ireland match. The overall impact on the Emergency Department was limited. Introduction Ireland's participation in the Football World Cup Finals of 2002 led to intense media coverage and huge public interest. The Finals were held in South Korea and Japan. Many travelled to watch the Irish team but the vast majority of supporters had to be content with watching the televised coverage of the event. To illustrate this, on Irish terrestrial television alone, an estimated 1,714,000 people watched the televised Ireland v Spain match. This represents 53% of the population of Ireland.

Emergency analgesia in the paediatric population. Part I: current practice and perspectives.

Children frequently present to the accident and emergency (A&E) department in pain. Most presentations are acute, but children with pain of longer duration also present. Children also often undergo painful procedures in A&E in the process of diagnosis or treatment. These papers review recent literature to examine factors involved in the provision of emergency analgesia in the paediatric population. This will include a discussion of current practice and make recommendations for future management of children's pain and anxiety in the A&E department. Part I: Current practice and perspectives. Part II: Pharmacological methods of paediatric analgesia. Part III: Non-pharmacological methods of pain control and anxiolysis. Part IV: Paediatric sedation in accident and emergency.

Cytomegalovirus (CMV)-specific CD4+ T lymphocyte immune function in long-term survivors of AIDS-related CMV end-organ disease who are receiving potent antiretroviral therapy.

To better understand the relation of cytomegalovirus (CMV)-specific CD4+ T lymphocyte immunity and clinical outcome in AIDS-related CMV end-organ disease, 2 patient groups were prospectively studied: patients recently diagnosed with active CMV end-organ disease and survivors of CMV retinitis who had responded to highly active antiretroviral therapy and had quiescent retinitis when anti-CMV therapy was discontinued. Most patients with active CMV disease had negative CMV-specific CD4+ T lymphocyte responses at diagnosis, as measured by lymphoproliferation (7/7) or cytokine flow cytometry (3/5) assays. In contrast, all 10 subjects with quiescent retinitis and >150 absolute CD4+ T lymphocytes/microL whose anti-CMV therapy was discontinued during 6 months of follow-up had positive CMV-specific immune responses at least once by each assay. However, 6 of these 10 subjects also had negative CMV-specific immune responses > or =1 time. Such patients may be at risk for future CMV disease progression and should be closely monitored.

Thoracic and thoracoabdominal aortic aneurysm repair using cardiopulmonary bypass, profound hypothermia, and circulatory arrest via left side of the chest incision.

PURPOSE: Although some authors advocate hypothermic circulatory arrest for spinal cord protection in descending thoracic and thoracoabdominal repair, this method has been associated with high morbidity and mortality rates in other studies. The safety and effectiveness of this surgical adjunct were evaluated. METHODS: Between February 1991 and April 1997, 409 patients underwent thoracic or thoracoabdominal aortic repair. Because of an inability to gain proximal aortic control because of anatomic or technical difficulty, hypothermic circulatory arrest was used in 21 patients (4.9%). Thirteen patients were men, 8 were women, and the median age was 57 (range, 21 to 81 years). Four patients (19%) had Marfan's syndrome, and 1 had aortitis. Seven patients (33%) had aortic dissection (4 chronic type A, 2 chronic type B, 1 acute B), and 1 had aortic laceration. All but 6 patients had hypertension. Fifteen patients (73%) were operated on for repair of the distal arch and descending thoracic aorta, 4 (19%) for repair of the distal arch and thoracoabdominal aorta, and 2 for repair of either the thoracoabdominal or descending thoracic aorta alone. Surgery for 9 patients (43%) also included bypass grafts to the subclavian or innominate arteries. Six operations (29%) were urgent. RESULTS: The overall 30-day mortality rate was 29% (6 of 21 patients). Among urgent patients, the mortality rate was 50% (3 of 6 patients) versus 20% (3 of 15) for elective patients. Of the remaining 15 patients, renal failure occurred in 1 (7%) and heart failure in 2 (13%). Ten patients (67%) had pulmonary complications. Encephalopathy occurred in 5 patients (33%) and stroke in 2 (13%), and spinal cord neurologic deficit developed in 2 (13%). The median recovery was 28 days (range, 10 to 157 days). CONCLUSION: Hypothermic circulatory arrest did not reduce the incidence of deaths and morbidity to a rate comparable with our conventional methods. We recommend the judicious application of this method in rare instances when proximal control is not feasible or catastrophic intraoperative bleeding leave the surgeon with no other option.

Edinburgh's Hogmanay celebrations: beyond a major disaster.

OBJECTIVE: To assess the impact of Edinburgh's Hogmanay celebrations on the city's accident and emergency (A&E) service. METHODS: Retrospective analysis. RESULTS: A crowd estimated at more than 350,000 attended the celebrations. During the three day period between 00.01 h on 31 December and 23.59 h on 2 January, 1151 new patients presented to the A&E department and of these half arrived in the first 24 hours. Thirty six patients required emergency resuscitation and eight died in the department during the study period. CONCLUSIONS: The absolute number of patients presenting during the study period greatly exceeded most of the "major disasters" in contemporary UK experience. No deaths were directly attributable to the event, but the spectrum of patient pathologies, their severity and presentation is analogous to several recent major incidents. It is doubtful whether the Hogmanay celebrations are safe.

Transient vitreous inflammatory reactions associated with combination antiretroviral therapy in patients with AIDS and cytomegalovirus retinitis.

PURPOSE: To report the observation that a transient vitreous inflammatory reaction may develop in the eyes of patients with acquired immunodeficiency syndrome (AIDS), cytomegalovirus retinitis, and an increased CD4+ T-lymphocyte count during treatment with antiretroviral therapy including a protease inhibitor. METHODS: We reviewed the medical records of eight patients with AIDS and cytomegalovirus retinitis who developed vitreous inflammatory reactions greater than those usually seen with this disease. RESULTS: Vitreous inflammatory reactions obscured the view of the posterior pole in all patients. No iris nodules, synechiae, glaucoma, or cystoid macular edema were observed. Six patients had unilateral cytomegalovirus retinitis, and, in each, the inflammation occurred only in the eye with cytomegalovirus retinitis. The vitreous inflammatory reactions were associated with clinically inactive cytomegalovirus retinitis in six patients, with disease reactivation in one patient, and were present at diagnosis of active disease in one patient. Cytomegalovirus retinitis has not recurred in any of these patients since their episodes of vitreous inflammation. Vitreous inflammation developed in all eight patients after a substantial increase in CD4+ T-lymphocyte counts caused by combination antiretroviral therapy. Five patients had CD4+ T-lymphocyte counts of greater than 100 cells per microl at the time the vitreous inflammatory reaction developed. No other causes of uveitis were found. CONCLUSIONS: Patients with AIDS and cytomegalovirus retinitis may develop transient intraocular inflammation associated with combination antiretroviral therapy. We believe that this inflammation reflects an improved immune response against cytomegalovirus.

Cytomegalovirus retinitis after initiation of highly active antiretroviral therapy.

BACKGROUND: In previous natural history studies and clinical trials, AIDS-related cytomegalovirus (CMV) retinitis has occurred primarily in patients with absolute CD4 counts of 50 cells/microL or less (0.05 x 10(9)/L) at the time of diagnosis. METHODS: We report five patients identified from our clinical practices who were diagnosed with CMV retinitis while their CD4 counts were above 195 cells/microL. We also analysed, based on CD4 counts, 76 AIDS patients with newly diagnosed CMV retinitis whose CD4 lymphocyte enumerations were done in laboratories that maintained certification in a common external quality control programme. FINDINGS: 5-24 weeks before retinitis was diagnosed, all five patients had had absolute CD4 lymphocyte counts of less than 85 cells/microL, and 4-7 weeks before diagnosis, all five patients had started taking highly active antiretroviral treatment (HAART) regimens. Only one (4%) of 27 patients enrolled in the trial between July, 1995, and February, 1996, had an absolute CD4 count of more than 50 cells/microL, and none of 27 had an absolute CD4 count of more than 100/microL on entry to the trial. However, from March, 1996 (when indinavir and ritonavir were approved by the FDA for marketing in the USA), to August, 1996, 14 (29%) of 49 patients had CD4 counts of more than 50/microL and seven (14%) of 49 had a CD4 count of more than 100 cells/microL on entry. INTERPRETATION: These findings suggest that the early immunological effects of HAART may not provide sufficient protection to prevent CMV retinitis in patients who have very low CD4 counts when therapy is started. Clinicians should note that CMV retinitis may now occur in patients who have CD4 counts of more than 100 cells/microL.

Mechanical airway obstruction secondary to retropharyngeal haematoma.

Mechanical airway obstruction secondary to retropharyngeal haematoma is a life-threatening emergency and should be anticipated in all cervical spine injure patients regardless of the severity of trauma. Most retropharyngeal haematomas described in the literature have involved complicating factors such as anticoagulant therapy, tumour, aneurysm, infection or major cervical spine injury. Several authors have however described haematomas causing airway compromise with minor hyperextension injuries. We describe the case of a 19-year-old male who was involved in a motorcycle accident. He sustained an atlanto-occipital fracture-dislocation and a very large retropharyngeal haematoma which resulted in airway obstruction and a subsequent difficult intubation. We outline the normal anatomy of the retropharyngeal space, the pathogenesis of retropharyngeal haematomas, and outline techniques of intubation available.

Patient-induced power changes in rigid gas permeable contact lenses: a case report and literature review.

BACKGROUND: The tendency for rigid gas permeable contact lenses to suffer parameter changes is well known. The following case report identifies an infrequently reported instance of marked power change associated with inappropriate abrasive cleaning. METHODS: A patient presented to our clinic with contact lens-related decrease in vision that was determined to have been the result of a patient-induced lens power change. A review of the literature uncovered similar reported cases. Further evaluation revealed the existence of common etiological factors. RESULTS: Consideration of elements common to this particular case and the available literature allows for the construction of a profile of a patient at risk for this lens complication. These include prior history of PMMA wear, use of an abrasive cleaner, silicone-acrylate lenses, and digital cleaning. CONCLUSIONS: Contact lens patients may present with complaints of decreased vision that are secondary to a number of different causes. One potential problem identified in this report is that of lens power change induced by inappropriate patient cleaning. It is hoped that this will serve to alert other practitioners to patients who correspond to this profile.

Randomized phase I trial of two different combination foscarnet and ganciclovir chronic maintenance therapy regimens for AIDS patients with cytomegalovirus retinitis: AIDS clinical Trials Group Protocol 151.

AIDS patients with newly diagnosed cytomegalovirus (CMV) retinitis who had just completed a 14-day course of ganciclovir induction therapy were randomly assigned to an alternating or concurrent combination regimen of chronic ganciclovir-foscarnet therapy for CMV retinitis. Each regimen used lower weekly cumulative doses of each drug than standard monotherapy maintenance treatment regimens. Dose-limiting toxicity attributable to foscarnet occurred in only 2 (7%) of 29 evaluatable patients, and no patients experienced dose-limiting nephrotoxicity. Although absolute neutrophil counts < 500 cells/microL occurred in 11 (38%) of 29 patients, all who subsequently used adjunctive granulocyte colony-stimulating factor had severe neutropenia prevented. Severe toxicity of any type and neutropenia, in particular, occurred significantly more frequently in patients assigned to the concurrent treatment regimen. CMV was isolated from none of 21 patients who had urine cultured and from only 1 of 24 who had blood cultured while being treated during the study (median evaluation, 12 weeks). This suggests that combination therapy provides better in vivo antiviral activity in suppressing CMV replication than previously reported with monotherapy regimens.

Pharmacodynamic relationship of pharmacokinetic parameters of maintenance doses of foscarnet and clinical outcome of cytomegalovirus retinitis.

The pharmacodynamic relationship between a range of foscarnet exposure measurements obtained from studying nine patients receiving ongoing maintenance therapy for cytomegalovirus retinitis and a range of efficacy values (days to retinitis progression) obtained by independent examination of serial retinal photographs from the same nine patients was analyzed. In the resulting proportional hazards models, the foscarnet area under the concentration-time curve approached statistical significance (P = 0.11) as a predictor of decreased risk of retinitis progression.