Incorporating Cone-Beam CT Into the Diagnostic Algorithm for Suspected Radiocarpal Fractures: A New Standard of Care?

OBJECTIVE. The purpose of this study was to assess the result of adding cone-beam CT to the standard imaging algorithm for patients with suspected radiographically occult traumatic radiocarpal fractures. SUBJECTS AND METHODS. A prospective review was performed on all patients who had cone-beam CT investigation of acute wrist pain after normal initial radiographs. Patients with no identified fractures were clinically reassessed and referred for MRI if concern for a fracture persisted. RESULTS. In all, 117 patients were assessed; 50.4% had fractures identified with a total of 67 radiographically occult fractures. One fracture was identified on MRI that was not seen on cone-beam CT. Cone-beam CT had sensitivity of 98.3% (95% CI, 91.1-100%), specificity of 100% (95% CI, 93.7-100%), positive predictive value of 100%, and negative predictive value of 98.3% (95% CI, 89.1-100%). Accuracy was 99.1% (95% CI, 95.3-100%). CONCLUSION. Incorporating cone-beam CT into routine clinical practice as part of a standardized diagnostic algorithm yielded a 50% fracture detection rate in patients with negative wrist radiographs but ongoing clinical concern for radiocarpal fracture. Cone-beam CT provides more diagnostic information than radiographs at a lower radiation dose than conventional MDCT. Given the poor accuracy of radiographs for acute radiocarpal fractures and the high fracture prevalence in this cohort, we feel that cone-beam CT should be regarded as the new standard of care in the investigation of these patients.

Clinical effects of cannabis compared to synthetic cannabinoid receptor agonists (SCRAs): a retrospective cohort study of presentations with acute toxicity to European hospitals between 2013 and 2020.

INTRODUCTION: Cannabis is the most common recreational drug worldwide and synthetic cannabinoid receptor agonists are currently the largest group of new psychoactive substances. The aim of this study was to compare the clinical features and outcomes of lone acute cannabis toxicity with lone acute synthetic cannabinoid receptor agonist toxicity in a large series of presentations to European emergency departments between 2013-2020. METHODS: Self-reported drug exposure, clinical, and outcome data were extracted from the European Drug Emergencies Network Plus which is a surveillance network that records data on drug-related emergency department presentations to 36 centres in 24 European countries. Cannabis exposure was considered the control in all analyses. To compare the lone cannabis and lone synthetic cannabinoid receptor agonist groups, univariate analysis using chi squared testing was used for categorical variables and non-parametric Mann-Whitney U- testing for continuous variables. Statistical significance was defined as a P value of <0.05. RESULTS: Between 2013-2020 there were 54,314 drug related presentations of which 2,657 were lone cannabis exposures and 503 lone synthetic cannabinoid receptor agonist exposures. Synthetic cannabinoid receptor agonist presentations had statistically significantly higher rates of drowsiness, coma, agitation, seizures and bradycardia at the time of presentation. Cannabis presentations were significantly more likely to have palpitations, chest pain, hypertension, tachycardia, anxiety, vomiting and headache. DISCUSSION: Emergency department presentations involving lone synthetic cannabinoid receptor agonist exposures were more likely to have neuropsychiatric features and be admitted to a psychiatric ward, and lone cannabis exposures were more likely to have cardiovascular features. Previous studies have shown variability in the acute toxicity of synthetic cannabinoid receptor agonists compared with cannabis but there is little comparative data available on lone exposures. There is limited direct comparison in the current literature between lone synthetic cannabinoid receptor agonist and lone cannabis exposure, with only two previous poison centre series and two clinical series. Whilst this study is limited by self-report being used to identify the drug(s) involved in the presentations, previous studies have demonstrated that self-report is reliable in emergency department presentations with acute drug toxicity. CONCLUSION: This study directly compares presentations with acute drug toxicity related to the lone use of cannabis or synthetic cannabinoid receptor agonists. It supports previous findings of increased neuropsychiatric toxicity from synthetic cannabinoid receptor agonists compared to cannabis and provides further data on cardiovascular toxicity in lone cannabis use.

Who needs a shot ... a review of tetanus immunity in the West of Ireland.

INTRODUCTION: Tetanus is a rare disease but, in the era of widespread vaccination, largely a preventable one. Immunization programmes in childhood are felt to offer lifelong immunity but it is known that with increased age immunity wanes. We sought to assess immunity in a sample of patients presenting for conditions unrelated to injury to the emergency department covering an area in the West of Ireland. METHODS: A convenience sample of 216 patients, who presented to the emergency department for complaints unrelated to injury, requiring blood tests for their management was obtained. Using the Protetanus QuickStick® all samples were analysed. RESULTS: No statistical difference between men and women in terms of tetanus immunity (p=0.94) but significant reduction in immunity with increasing age (p<0.001). Those non-immune tended to be older with mean age of 66 years compared to mean age of 46 year for immune. Using logarithmic regression analysis an increase in age of 10 years was associated with 50% reduction in immunity. DISCUSSION: National guidelines should incorporate this data and explicitly advocate the use of booster doses of tetanus toxoid outside of the normal vaccination programme especially in the elderly.

Variation of drugs involved in acute drug toxicity presentations based on age and sex: an epidemiological approach based on European emergency departments.

OBJECTIVE: To analyse the relative percentage of acute recreational drug toxicity emergency department (ED) presentations involving the main drug groups according to age and sex and investigate different patterns based on sex and age strata. METHODS: We analysed all patients with acute recreational drug toxicity included by the Euro-DEN Plus dataset (22 EDs in 14 European countries) between October 2013 and December 2016 (39 months). Drugs were grouped as: opioids, cocaine, cannabis, amphetamines, gamma-hydroxybutyrate (GHB), hallucinogens, new psychoactive substances (NPS), benzodiazepines and ketamine. Descriptive data by age and sex are presented and compared among age/sex categories and among drug families. RESULTS: Of 17,371 patients were included during the 39-month period, 17,198 (99.0%) had taken at least one of the investigated drugs (median age: 31 years; 23.9% female; ethanol co-ingestion recorded in 41.5%, unknown in 31.2%; multiple drug use in 37.9%). Opioids (in 31.4% of patients) and amphetamines (23.3%) were the most frequently involved and hallucinogens (1.9%) and ketamine (1.7%) the least. Overall, female patients were younger than males, both in the whole cohort (median age 29 vs. 32 years; p < 0.001) and in all drug groups except benzodiazepines (median age 36 vs. 36 years; p = 0.83). The relative proportion of each drug group was different at every age strata and some patterns could be clearly described: cannabis, NPS and hallucinogens were the most common in patients <20 years; amphetamines, ketamine and cocaine in the 20- to 39-year group; GHB/GBL in the 30- to 39-year group; and opioids and benzodiazepines in patients ≥40 years. Ethanol and other drug co-ingestion was more frequent at middle-ages, and multidrug co-ingestion was more common in females than males. CONCLUSION: Differences in the drugs involved in acute drug toxicity presentations according to age and sex may be relevant for developing drug-prevention and education programs for some particular subgroups of the population based on the increased risk of adverse events in specific sex and/or age strata.

Prevalence and predictors of oral to intravenous antibiotic switch among adult emergency department patients with acute bacterial skin and skin structure infections: a pilot, prospective cohort study.

OBJECTIVE: To determine the prevalence and predictors of oral to intravenous antibiotic switch among adult emergency department (ED) patients with acute bacterial skin and skin structure infections (ABSSSIs). DESIGN: Multicentre, pilot cohort study. SETTING: Three urban EDs in Dublin, Ireland. PARTICIPANTS: Consecutive ED patients aged >16 years old with ABSSSIs between March 2015 and September 2016. INTERVENTION: Oral flucloxacillin 500 mg-1 g four times a day (alternative in penicillin allergy). PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was to determine the prevalence and predictors of oral to intravenous antibiotic switch. Secondary outcomes were to determine the prevalence and predictors of receiving an extended course of oral antibiotic treatment and measurement of interobserver reliability for clinical predictors at enrolment. RESULTS: Overall, 159 patients were enrolled of which eight were lost to follow-up and five were excluded. The majority of patients were male (65.1%) and <50 years of age (58.2%). Oral to intravenous antibiotic switch occurred in 13 patients (8.9%; 95% CI 4.8% to 14.7%). Increased lesion size (OR 1.74; 95% CI 1.09 to 2.79), white cell count (OR 1.32; 95% CI 1.05 to 1.67), athlete's foot (OR 8.00; 95% CI 2.31 to 27.71) and fungal nail infections (OR 7.25; 95% CI 1.99 to 26.35) were associated with oral to intravenous antibiotic switch. 24.8% (95% CI 18.1% to 33.0%) of patients received an extended course of oral antibiotic treatment. CONCLUSION: The prevalence of oral to intravenous antibiotic switch in this pilot study is 8.9% (95% CI 4.8% to 14.7%). We identify the predictors of oral to intravenous switch worthy of future investigation. TRIAL REGISTRATION NUMBER: NCT02230813.

Emergencies related to recreational drug abuse in Spain compared to emergencies attended in 3 European areas. / Comparación de las urgencias atendidas por drogas de abuso en dos servicios de urgencias españoles con las atendidas en tres áreas europeas distintas.

OBJECTIVES: To analyze epidemiologic, clinical, and care characteristics in cases in which patients came to 2 Spanish emergency departments (EDs) with symptoms caused by recreational drug abuse. To compare the characteristics with those reported for other areas of Europe. MATERIAL AND METHODS: Secondary analysis of the registry of the European Drug Emergencies Network (Euro-DEN Plus), which collects cases in 14 European countries and 20 EDs. The registry included all patients attending EDs with symptoms of recreational drug abuse (excepting cases involving alcohol alone) over a period of 39 consecutive months (October 2013 to December 2016). We compared the cases from the 2 Spanish EDs (in Barcelona and Palma de Mallorca) to those from the 5 EDs in Ireland and the UK, 6 in northern Europe, and 7 in central Europe. RESULTS: A total of 17 104 patients' cases were included: Spain, 1186; UK and Ireland, 6653; northern Europe, 6097; and central Europe, 3168. Spain saw more emergencies related to cocaine (48.4%) and fewer related to opioids (12.4%) than the other areas. The Spanish patients were younger (32.2 years) on average than those in northern Europe and older than those in the UK and Ireland and central Europe. Fewer patients were women in Spain (21.9%) than in northern or central Europe. Fewer arrived in ambulances in Spain (70.0%) than in the UK and Ireland or northern Europe. The Spanish EDs recorded the temperature and respiratory frequency of fewer patients (29.8% and 30.3%, respectively). Clinical signs differed between geographical areas attributable to differences in drug-use patterns. In Spain, naloxone was used by fewer patients (9.6%) than in the UK and Ireland and northern Europe, and flumazenil was used by more patients (5.6%) than in other areas. Spain saw lower percentages of admissions (4.6%) and patients who left without an ED discharge (6.2%) in comparison with other areas. Mortality rates in the Spanish EDs (0.4%) and after discharge from them (0.7%) were higher than in northern Europe. CONCLUSION: The characteristics of emergencies related to recreational drug abuse registered by the Spanish EDs were differed from those registered in other parts of Europe due to different patterns of drug use. We also detected differences between the Spanish and other European EDs with respect to examinations or tests performed, treatment given, and discharge disposition.

OBJETIVO: Analizar algunas características epidemiológicas, clínicas y asistenciales de los pacientes atendidos por sintomatología directamente derivada del consumo de drogas de abuso en dos servicios de urgencias hospitalarios (SUH) españoles y compararlas con las observadas en otras regiones de Europa. METODO: Análisis secundario del Registro Euro-DEN Plus (14 países europeos, 20 SUH) que incluyó todos los pacientes atendidos por sintomatología derivada del consumo de drogas (excepto etanol aislado) durante 39 meses consecutivos (octubre 2013 a diciembre 2016). Se comparan los casos de los 2 centros españoles (Barcelona, Palma) con los de 5 centros de Reino Unido e Irlanda (Islas Británicas ­IB­), 6 del Norte de Europa (NE) y 7 de Europa Central (EC). RESULTADOS: Se recogieron 17.104 pacientes: España 1.186, IB 6.653, NE 6.097 y EC 3.168. En España hubo más urgencias por cocaína (48,4%) y menos por opiáceos (12,4%) que en el resto de zonas; los pacientes eran más jóvenes (32,2 años) que en NE y mayores que en IB y EC; menos frecuentemente mujeres (21,9%) que en NE y EC; llegaron menos frecuentemente en ambulancia (70,0%) que en IB y NE; y en el SUH se registró escasamente la temperatura (29,8%) y frecuencia respiratoria (30,3%). Las manifestaciones clínicas difirieron entre zonas por la distinta prevalencia de cada tipo de droga. Naloxona (9,6%) se utilizó menos que en IB y NE, y flumazenilo (5,6%) más que en las otras zonas, y los porcentajes de ingresos (4,6%) y fugas del SUH (6,2%) fueron los menores de todas las regiones analizadas. La mortalidad, en urgencias (0,4%) y global (0,7%), fue significativamente superior que en NE. CONCLUSIONES: Las características de las urgencias generadas por drogas de abuso son diferentes en España respecto a otras zonas europeas, debido a un diferente patrón de consumo. Su manejo en el SUH, en términos de exploraciones realizadas, tratamientos empleados y disposición tras la asistencia también son diferentes.

Intoxication by gamma hydroxybutyrate and related analogues: Clinical characteristics and comparison between pure intoxication and that combined with other substances of abuse.

OBJECTIVE: To study the profile of European gamma-hydroxybutyrate (GHB) and gammabutyrolactone (GBL) intoxication and analyse the differences in the clinical manifestations produced by intoxication by GHB/GBL alone and in combination with other substances of abuse. METHOD: We prospectively collected data on all the patients attended in the Emergency Departments (ED) of the centres participating in the Euro-DEN network over 12 months (October 2013 to September 2014) with a primary presenting complaint of drug intoxication (excluding ethanol alone) and registered the epidemiological and clinical data and outcomes. RESULTS: We included 710 cases (83% males, mean age 31 years), representing 12.6% of the total cases attended for drug intoxication. Of these, 73.5% arrived at the ED by ambulance, predominantly during weekend, and 71.7% consumed GHB/GBL in combination with other substances of abuse, the most frequent additional agents being ethanol (50%), amphetamine derivatives (36%), cocaine (12%) and cannabis (8%). Among 15 clinical features pre-defined in the project database, the 3 most frequently identified were altered behaviour (39%), reduced consciousness (34%) and anxiety (14%). The severity ranged from mild cases requiring no treatment (308 cases, 43.4%) to severe cases requiring admission to intensive care (103 cases, 14.6%) and mechanical ventilation (49 cases, 6.9%). No deaths were reported. In comparison with only GHB/GBL consumption, patients consuming GHB/GBL with co-intoxicants presented more vomiting (15% vs. 3%, p<0.001) and cardiovascular symptoms (5.3% vs. 1.5%, p<0.05), a greater need for treatment (59.8% vs. 48.3%, p<0.01) and a longer ED stay (11.3% vs. 3.6% patients with ED stay >12h, p<0.01). CONCLUSIONS: The profile of the typical GHB/GBL-intoxicated European is a young male, requiring care for altered behaviour and reduced level of consciousness, mainly during the weekend. The clinical features are more severe when GHB is consumed in combination with other substances of abuse.

Nurses', physicians' and radiographers' perceptions of the safety of a nurse prescribing of ionising radiation initiative: A cross-sectional survey.

BACKGROUND: A new initiative was introduced in Ireland following legislative changes that allowed nurses with special training to prescribe ionising radiation (X-ray) for the first time. A small number of studies on nurse prescribing of ionising radiation in other contexts have found it to be broadly as safe as ionising radiation prescribing by physicians. Sociological literature on perceptions of safety indicates that these tend to be shaped by the ideological position of the professional rather than based on objective evidence. OBJECTIVES: To describe, compare and analyse perceptions of the safety of a nurse prescribing of ionising radiation initiative across three occupational groups: nursing, radiography and medicine. DESIGN: A cross-sectional survey design. SETTINGS: Participants were drawn from a range of clinical settings in Ireland. PARTICIPANTS: Respondents were 167 health professionals comprised of 49 nurses, 91 radiographers, and 27 physicians out of a total of 300 who were invited to participate. Non-probability sampling was employed and the survey was targeted specifically at health professionals with a specific interest in, or involvement with, the development of the nurse prescribing of ionising radiation initiative in Ireland. METHODS: Comparisons of perspectives on the safety of nurse prescribing of ionising radiation across the three occupational groups captured by questionnaire were analysed using the Kruskal-Wallis H test. Pairwise post hoc tests were conducted using the Mann-Whitney U test. RESULTS: While the majority of respondents from all three groups perceived nurse prescribing of ionising radiation to be safe, the extent to which this view was held varied. A higher proportion of nurses was found to display confidence in the safety of nurse prescribing of ionising radiation compared to physicians and radiographers with differences between nurses' perceptions and those of the other two groups being statistically significant. CONCLUSION: That an occupational patterning emerged suggests that perceptions about safety and risk of nurse prescribing of ionising radiation are socially constructed according to the vantage point of the professional and may not reflect objective measures of safety. These findings need to be considered more broadly in the context of ideological barriers to expanding the role of nurses.