247 BENCHMARKING STROKE SERVICES TO INFORM A QUALITY IMPROVEMENT INIAITIVE

Background

Stroke is a leading cause of death and disability in Ireland. Continuous audit and quality improvement is essential in the delivery of stroke care where the evidence basis is constantly changing. This helps to ensure the delivery of high quality stroke care and compliance with evidenced based guidelines. We aimed to assess stroke care at an Irish university teaching hospital.

Methods

Patients with a HIPE discharge diagnosis of Cerebral Infarction or Cerebral Haemorrhage (1st January-31st December 2019) were identified through both the HIPE database and the institutional Stroke Portal. Data was benchmarked against national (Irish National Audit of Stroke 2019) and international (6th SSNAP Annual Report; American Heart Association, 2013) practice and used to inform a quality improvement strategy.

Results

419 patients were included (56.6% male, median 57 years). 75.9% were aged 65 years or older. We compared favourably with Irish National Audit of Stoke national indicators on the following: thrombolysis rates-10%; median door to needle time-60 mins; stroke unit admissions- 78.5%; median duration of symptoms- 3 hours 6 minutes; swallow assessment- 81.1%; in-patient mortality- 10.5%; rates of institutionalisation- 3.8%. Areas identified for improvement were: thrombectomy rates- 1.9%; median length of stay- 12 days; door to imaging time- median 104 minutes; mood screening- 11.5%.

Conclusion

International and national data is a useful benchmark against which local hospitals can assess the quality of their service. By completing this quality improvement initiative we identified areas to target resources in our centre, including mood screening, swallow screening, thrombectomy rates, length of stay and time to neuroimaging. An ongoing quality improvement process using ‘PDSA’ methodology is being carried out with an annual audit to monitor progress.

Investigating the effect of germanium on the structure of SiO2-ZnO-CaO-SrO-P2O5 glasses and the subsequent influence on glass polyalkenoate cement formation, solubility and bioactivity

A series of germanium (Ge)-containing glasses were synthesized based on a starting glass composition of SiO₂-ZnO-CaO-SrO-P₂O₅. Additions of GeO₂ (6 and 12 mol%) were incorporated at the expense of SiO_2, which retained the amorphous character, and each glass was processed to present similar particle size and surface area. Glass characterization using x-ray photoelectron spectroscopy (XPS) and magic angle spinning nuclear magnetic resonance (MAS-NMR) determined that the addition of GeO₂ increased the fraction of lower Q-speciation and subsequently the concentration of non-bridging oxygens (NBO). Glass Polyalkenoate Cements (GPC) were formulated from each glass with 40, 50 and 60 wt% PAA, and presented time dependent solubility profiles (1, 10, 100, 1000 h) for the release of Si⁴⁺ (4-140 mg/l), Ca²⁺ (1-8 mg/l), Zn²⁺ (<6 mg/l), Sr²⁺ (2-37 mg/l), PO₄^3- (2-43 mg/l) and Ge⁴⁺ (20-911 mg/l) and attained pH values close to 7.5 after 1000 h. Ge-GPCs containing 40 wt% polyacrylic acid (PAA) presented appropriate working time (T_w) and setting times (T_s), and the corresponding compressive strengths ranged from (14-30 MPa). The Ge-GPCs (40, 50 wt%) presented a linear increase (R²-0.99) with respect to time. Simulated Body Fluid (SBF) testing resulted in the Ge-GPCs encouraging the precipitation of crystalline hydroxyapatite on the GPC surface, more evidently after 100 and 1000 h incubation.

A Case Report of Progressive Brown Syndrome?

Aim:

To report an unusual case of progressive Brown syndrome and the successful surgical treatment.

Methods:

A 42-year-old male with a documented 14-year history of progressive Brown syndrome is presented. To improve diplopia symptoms an ipsilateral superior oblique (SO) 7 mm silicone tendon spacer and a contralateral 3 mm superior rectus (SR) recession were performed.

Results:

The surgical procedure was successful in reducing the primary position deviation (preoperative 30ΔLHoT 7ΔLXT; one month post surgery 3ΔLHo; one year post surgery 7-8ΔLHo 1-2ΔE) and eliminating the abnormal head posture (AHP). Diplopia was only reported on elevation and depression following surgery.

Conclusion:

This case of Brown syndrome is unusual as it was progressive and had a documented history over a number of years prior to surgery. Surgical treatment of Brown syndrome is rarely required, but in this case was successful in improving the patient’s diplopia and AHP.

Investigating the Effect of Glass Ion Release on the Cytocompatibility, Antibacterial Eflcacy and Antioxidant Activity of Y2O3 / CeO2 doped SiO2-SrO-Na2O glasses

The effect on ion release and cytocompatibility of Yttrium (Y) and Cerium (Ce) are investigated when substituted for Sodium (Na) in a 0.52SiO2-0.24SrO-0.24-Na2OMOglass series (where MO= Y2O3or CeO2). Glass leaching was evaluated through pH measurements and Inductive Coupled Plasma-Optical Emission Spectrometry (ICP-OES) analysiswhere the extract pH increased during incubation (11.2 - 12.5). Ion release of Silicon (Si), Na and Strontium (Sr) from the Con glass was at higher than that of glasses containing Y or Ce, and reached a limit after 1 day. Ion release from Y and Ce containing glasses reached a maximum of 1800 μg/mL, 1800 μg/mL, and 10 μg/mL for Si, Na, and Sr, respectively. Release of Y and Cewas below the ICP- OES detection limit <0.1 μg/mL. Cell viability of both L929 fibroblasts and MC3T3 osteoblasts decreased for Con, LY, and LCe extracts; HY extracts did not significantly decrease cell viability while YCe and HCe saw concentrationdependent viability decrease (20%, 33% extract concentrations). Bacterial studies saw Con and LCe eliminating >75% of bacteria at a 9% extract concentration. Antioxidant capacity (mechanism for neuroprotection) was evaluated using the ABTS assay. All glasses had inherent radical oxygen species (ROS) scavenging capability with Con reaching 9.5 mMTE.

A rising incidence and poorer male outcomes characterise early onset paediatric inflammatory bowel disease

BACKGROUND

The incidence of paediatric inflammatory bowel disease diagnosed before age 10 years is reportedly increasing, but national data are limited.

AIM

To characterise the epidemiology, phenotype and clinical outcomes of children diagnosed with inflammatory bowel disease before age 10 years, and compare with data from children diagnosed aged 10-16 years.

METHODS

A review of all Irish cases of early onset inflammatory bowel disease (diagnosis <10 years, EO-IBD) presenting between January 2000 and December 2014 was undertaken and compared to a cohort of later onset paediatric inflammatory bowel disease patients (diagnosis between 10 and 16 years, LO-IBD). Diagnostic investigations, phenotype, treatments, and long-term clinical and surgical outcomes were analysed.

RESULTS

One hundred and ninety children (99 male) with EO-IBD were identified; 92 (48%) CD, 77 (41%) UC and 21 (11%) IBDU. The incidence of EO-IBD increased by 0.6 per 100 000 per year (0.8-3.2 per 100 000 per year), with a significant increase in UC by 0.06 per 100 000 per year (P=.02). Males with CD had more upper GI disease (L4a; 48% vs 21%; P=.007), more extensive disease distribution (L3±L4; 31% vs 11%; P=.05) and more severe disease activity at presentation (52% vs 31%; P=.05) than females. Fewer patients with early onset than later onset Crohn's disease had ileocolonic disease (L3; 10% vs 20%; P<.001). More relapses were observed in the first year post-diagnosis in early onset than later onset IBD (1.02 vs 0.5 mean relapses; P<.001).

CONCLUSIONS

EO-IBD is increasing in incidence. Males have more extensive and severe disease phenotypes, and younger patients have higher relapse rates than older children. Further research to explain these findings is warranted.

Investigating the influence of Na+ and Sr2+ on the structure and solubility of SiO2-TiO2-CaO-Na2O/SrO bioactive glass

This study was conducted to determine the influence that network modifiers, sodium (Na+) and strontium (Sr2+), have on the solubility of a SiO2-TiO2-CaO-Na2O/SrO bioactive glass. Glass characterization determined each composition had a similar structure, i.e. bridging to non-bridging oxygen ratio determined by X-ray photoelectron spectroscopy. Magic angle spinning nuclear magnetic resonance (MAS-NMR) confirmed structural similarities as each glass presented spectral shifts between -84 and -85 ppm. Differential thermal analysis and hardness testing revealed higher glass transition temperatures (Tg 591-760 °C) and hardness values (2.4-6.1 GPa) for the Sr2+ containing glasses. Additionally the Sr2+ (~250 mg/L) containing glasses displayed much lower ion release rates than the Na+ (~1,200 mg/L) containing glass analogues. With the reduction in ion release there was an associated reduction in solution pH. Cytotoxicity and cell adhesion studies were conducted using MC3T3 Osteoblasts. Each glass did not significantly reduce cell numbers and osteoblasts were found to adhere to each glass surface.

Investigating the surface reactivity of SiO2-TiO2-CaO-Na2O/SrO bioceramics as a function of structure and incubation time in simulated body fluid

This study focuses on evaluating the biocompatibility of a SiO2-TiO2-CaO-Na2O/SrO glass and glass-ceramic series. Glass and ceramic samples were synthesized and characterized using X-ray diffraction. Each material was subject to maturation in simulated body fluid over 1, 7 and 30 days to describe any changes in surface morphology. Calcium phosphate (CaP) deposition was observed predominantly on the Na(+) containing amorphous and crystalline materials, with plate-like morphology. The precipitated surface layer was also observed to crystallize with respect to maturation, which was most evident in the amorphous Na(+) containing glasses, Ly-N and Ly-C. The addition of Sr(2+) greatly reduced the solubility of all samples, with limited CaP precipitation on the amorphous samples and no deposition on the crystalline materials. The morphology of the samples was also different, presenting irregular plate-like structures (Ly-N), needle-like deposits (Ly-C) and globular-like structures (Ly-S). Cell culture analysis presented a significant increase in cell viability with the Na(+) materials, 134%, while the Sr(2+) containing glasses, 60-80% and ceramics, 60-85% presented a general reduction in cell viability, however these reductions were not significant.

Degradable borate glass polyalkenoate cements

Glass polyalkenoate cements (GPCs) containing aluminum-free borate glasses having the general composition Ag2O-Na2O-CaO-SrO-ZnO-TiO2-B2O3 were evaluated in this work. An initial screening study of sixteen compositions was used to identify regions of glass formation and cement compositions with promising rheological properties. The results of the screening study were used to develop four model borate glass compositions for further study. A second round of rheological experiments was used to identify a preferred GPC formulation for each model glass composition. The model borate glasses containing higher levels of TiO2 (7.5 mol %) tended to have longer working times and shorter setting times. Dissolution behavior of the four model GPC formulations was evaluated by measuring ion release profiles as a function of time. All four GPC formulations showed evidence of incongruent dissolution behavior when considering the relative release profiles of sodium and boron, although the exact dissolution profile of the glass was presumably obscured by the polymeric cement matrix. Compression testing was undertaken to evaluate cement strength over time during immersion in water. The cements containing the borate glass with 7.5 mol % TiO2 had the highest initial compressive strength, ranging between 20 and 30 MPa. No beneficial aging effect was observed-instead, the strength of all four model GPC formulations was found to degrade with time.

Comparison of a SiO₂-CaO-ZnO-SrO glass polyalkenoate cement to commercial dental materials: ion release, biocompatibility and antibacterial properties

Ion Release and biocompatibility of a CaO-SrO-ZnO-SiO₂ (BT 101) based glass polyalkenoate cement (GPC) was compared against commercial GPCs, Fuji IX and Ketac Molar. The radiopacity (R) was similar for each material, 2.0-2.8. Ion release was evaluated on each material over 1, 7, 30 and 90 days. BT 101 release included Ca (23 mg/L), Sr (23 mg/L) Zn (13 mg/L), Si (203 mg/L). Fuji IX release includes Ca (0.7 mg/L), Al (3 mg/L) Si (26 mg/L), Na (60 mg/L) and P (0.5 mg/L) while Ketac Molar release includes Ca (1 mg/L), Al (0.6 mg/L) Si (23 mg/L), Na (76 mg/L) and P (0.7 mg/L). Simulated body fluid trials revealed CaP surface precipitation on BT 101. No evidence of precipitation was found on Fuji IX or Ketac Molar. Cytotoxicity testing found similar cell viability values for each material (~60 %, P = 1.000). Antibacterial testing determined a reduced CFU count with BT 101 (2.5 × 10³) when compared to the control bacteria (2.4 × 10⁴), Fuji IX (1.5 × 10⁴) and Ketac Molar (1.2 × 10⁴).

Fabrication of CaO-NaO-SiO(2)/TiO (2) scaffolds for surgical applications

A series of titanium (Ti) based glasses were formulated (0.62 SiO(2)-0.14 Na(2)O-0.24 CaO, with 0.05 mol% TiO(2) substitutions for SiO(2)) to develop glass/ceramic scaffolds for bone augmentation. Glasses were initially characterised using X-ray diffraction (XRD) and particle size analysis, where the starting materials were amorphous with 4.5 μm particles. Hot stage microscopy and high temperature XRD were used to determine the sintering temperature (~700 °C) and any crystalline phases present in this region (Na(2)Ca(3)Si(6)O(16), combeite and quartz). Hardness testing revealed that the Ti-free control (ScC-2.4 GPa) had a significantly lower hardness than the Ti-containing materials (Sc1 and Sc2 ~6.6 GPa). Optical microscopy determined pore sizes ranging from 544 to 955 μm. X-ray microtomography calculated porosity from 87 to 93 % and surface area measurements ranging from 2.5 to 3.3 SA/mm(3). Cytotoxicity testing (using mesenchymal stem cells) revealed that all materials encouraged cell proliferation, particularly the higher Ti-containing scaffolds over 24-72 h.

Gallium containing glass polyalkenoate anti-cancerous bone cements: glass characterization and physical properties

A gallium (Ga) glass series (0.48SiO(2)-0.40ZnO-0.12CaO, with 0.08 mol% substitution for ZnO) was developed to formulate a Ga-containing Glass Polyalkenoate Cement (GPC) series. Network connectivity (NC) and X-ray Photoelectron Spectroscopy (XPS) was employed to investigate the role of Ga(3+) in the glass, where it is assumed to act as a network modifier. Ga-GPC series was formulated with E9 and E11 polyacrylic acid (PAA) at 50, 55 and 60 wt% additions. E11 working times (T(w)) ranged from 68 to 96 s (Lcon.) and 106 s for the Ga-GPCs (LGa-1 and LGa-2). Setting times (T(s)) ranged from 104 to 226 s (Lcon.) and 211 s for LGa-1 and LGa-2. Compression (σc) and biaxial flexural (σf) testing were conducted where Lcon. increased from 62 to 68 MPa, LGa-1 from 14 to 42 MPa and LGa-2 from 20 to 47 MPa in σc over 1-30 days. σf testing revealed that Lcon. increased from 29 to 42 MPa, LGa-1 from 7 to 32 MPa and LGa-2 from 12 to 36 MPa over 1-30 days.

Silver coated bioactive glass particles for wound healing applications

Bioactive glass particles (0.42SiO(2)-0.15CaO-0.23Na(2)O-0.20ZnO) of varying size (<90 μm and 425-850 μm) were synthesized and coated with silver (Ag) to produce Ag coated particles (PAg). These were compared against the uncoated analogous particles (Pcon.). Surface area analysis determined that Ag coating of the glass particles resulted in increased the surface area from 2.90 to 9.12 m(2)/g (90 μm) and 1.09-7.71 m(2)/g (425-850 μm). Scanning electron microscopy determined that the Ag coating remained at the surface and there was little diffusion through the bulk. Antibacterial (Escherichia coli--13 mm and Staphylococcus epidermidis--12 mm) and antifungal testing (Candida albicans--7.7 mm) determined that small Ag-coated glass particles exhibited the largest inhibition zones compared to uncoated particles. pH analysis determined an overall higher pH consider in the smaller particles, where after 24 h the large uncoated and Ag coated particles were 8.27 and 8.74 respectively, while the smaller uncoated and Ag coated particles attained pH values of 9.63 and 9.35 respectively.

Does elevating silver content in zinc-based glass polyalkenoate cements increase their antibacterial efficacy against two common bacteria using the agar gel diffusion method?

The authors have previously shown that it is possible to incorporate silver into a soda-zinc-silicate glass and subsequently form a glass polyalkenoate cement from it. The objective of the research described herein is to determine if incremental increases in the silver content of these glass polyalkenoate cements will increase their antibacterial efficacy against gram-positive and gram-negative bacteria using the accepted spread plate method. Four glass polyalkenoate cements were formulated; three contained increasing amounts of silver incorporated into them (cements A, B, and C, containing 0.33 mol%, 0.66 mol%, and 0.99 mol% silver, respectively) and a fourth contained no silver, which acted as a control (control cement). The handling properties of the glass polyalkenoate cements were evaluated, where working times were around 2 min and setting times ranged from 1 h 17 min to 2 h 41 min. Inductively coupled plasma atomic emission spectroscopy was employed to determine silver ion release with cement maturation for up to 14 days. The majority of silver ions were released within the first 24 h, with up to 2 mg/L cumulative ion release recorded up to 14 days. The antibacterial properties of the coatings were evaluated against Staphylococcus aureus and Pseudomonas aeruginosa bacteria. The silver-glass polyalkenoate cements exhibited antibacterial effect against both bacterial strains. The maximum inhibition zones recorded against S. aureus was 14.8 mm (SD ± 1.11) and against P. aeruginosa was 20.6 mm (SD ± 0.81). Cement B had a greater antibacterial effect compared to cement A, however, cements B and C had comparable antibacterial effects after 14 days even though cement C contained 0.33 mol% more silver than B. This indicates that by increasing the silver content in these cements, the antibacterial efficacy increases to a point, but there is a threshold where further silver ion release does not increase the antibacterial effect.

Zinc and silver glass polyalkenoate cements: an evaluation of their antibacterial nature

A biofilm is an accumulation of micro-organisms and their extracellular products forming a structured community on a surface. Biofilm formation on medical devices has severe health consequences as bacteria growing in this lifestyle are tolerant to both host defence mechanisms and antibiotic therapies. However, silver and zinc ions inhibit the attachment and proliferation of immature biofilms. The objective of this study is to evaluate whether silver and zinc ions eluted from novel glass polyalkenoate cement (GPC) coatings have the ability to inhibit Methicillin-resistant Staphylococcus aureus (MRSA) in vivo. A silver and zinc-containing GPC coating was synthesised, deposited onto Ti6Al4V discs and placed in a specified amount of analytical water for 1, 7 and 30 days. The resulting elutes were collected and Atomic absorption spectroscopy was used to measure ion release. The elutes were injected into Galleria mellonella larvae infected with MRSA and the antibacterial properties of these elutes were evaluated in vivo. The majority of the zinc and silver ions were released within the first 24 h; this corresponded with the greatest degree of protection observed in infected larvae. Results were compared to a conventional in vitro model where identical elutes were incubated with MRSA on nutrient agar. These results were consistent with those observed in the larval model, demonstrating a reduction in bacterial viability when co-cultured with elutes for 2 h. This work confirms the promise of the Galleria mellonella as a model for the assessment of antimicrobial agents and demonstrates the capacity of novel silver and zinc-containing GPCs to retard the colonisation of MRSA.

Refocusing acute psychiatry, performance management, standards and accountability, a new context for mental health nursing

The term 'performance management' has an aversive 'managerial' aspect, is unappealing to many public sector staff and has an 'image problem'. Perhaps as a consequence, it has failed to make a significant impact on Irish public sector workers, notably mental health nurses. In this paper, performance management is introduced and examined within an Irish healthcare context and with reference to its use in other countries. Some of the challenges faced by Irish mental health nurses and the potential benefits of working within a performance managed workplace are discussed. The paper concludes that performance management is likely to increasingly affect nurses, either as active agents or as passive recipients of a change that is thrust on them. The authors anticipate that the performance management 'image problem' will give way to recognition that this is a fundamental change which has the potential to enable health services to change. This change will bring high standards of transparency, worker involvement in decision making, an explicit value base for health services and individual teams. It provides the potential for clear practice standards and high standards of transparency as well as worker welfare in all aspects, including supporting employment and career progression.

Antibacterial coatings for medical devices based on glass polyalkenoate cement chemistry

A biofilm is an accumulation of micro-organisms and their extracellular products forming a structured community on a surface. Biofilm formation on medical devices has severe health consequences as bacteria growing in this lifestyle are tolerant to both host defense mechanisms and antibiotic therapies. However, silver and zinc ions inhibit the attachment and proliferation of immature biofilms. The objective of this study is to evaluate whether it is possible to produce silver and zinc-containing glass polyalkenoate cement (GPC) coatings for medical devices that have antibacterial activity and which may therefore inhibit biofilm formation on a material surface. Two silver and zinc-containing GPC coatings (A and B) were synthesised and coated onto Ti6Al4V discs. Their handling properties were characterised and atomic absorption spectrometery was employed to determine zinc and silver ion release with coating maturation up to 30 days. The antibacterial properties of the coatings were also evaluated against Staphylococcus aureus and a clinical isolate of Pseudomonas aeruginosa using an agar diffusion assay method. The majority of the zinc and silver ions were released within the first 24 h; both coatings exhibited antibacterial effect against the two bacterial strains, but the effect was more intense for B which contained more silver and less zinc than A. Both coatings produced clear zones of inhibition with each of the two organisms tested. In this assay, Ps. aeruginosa was more sensitive than S. aureus. The diameters of these zones were reduced after the coating had been immersed in water for varying periods due to the resultant effect on ion release.

Music therapy in ICU

This paper provides an overview of the benefits of using music therapy in intensive care. Music therapy is described as a complementary therapy and can be used to complement more conventional and medically oriented treatments available to patients who are critically ill. The physiological and psychological effects of this intervention are discussed.

Interictal spike localisation with methohexitone: preoperative activation and surgical follow-up

Thirty-four patients with intractable temporal lobe epilepsy underwent preoperative and perioperative EEG activation with methohexitone sodium. Subsequently, all patients underwent anterior temporal lobectomy with deep structure preservation. Preoperative spike localisation with methohexitone was concordant with peroperative recording in most cases. Large doses of methohexitone were administered to two patients, rendering the EEG almost isoelectric. Areas of abnormal spiking activity were refractory to the effects of methohexitone, and recovery was marked by an increase in spike frequency. Postoperative clinical evaluation confirmed the specificity of methohexitone for abnormally epileptogenic tissue.