1219 INFORMAL CAREGIVERS OF PEOPLE WITH PARKINSONISM IN THE PRIME-UK CROSS-SECTIONAL STUDY

Introduction

Many people with parkinsonism require care as the disease progresses with much provided unpaid by family and friends. Caring for someone can have a negative impact on physical and psychosocial wellbeing. Caregiver burden can impact ability to continue this role, which can precipitate hospitalisation or institutionalisation of the recipient.

Methods

In this single-site study, primary, informal caregivers, defined as those providing any care or support, were enrolled alongside the person with parkinsonism or individually. Self-reported questionnaires included the 22-item Zarit Burden Interview (ZBI), which can range from 0-88, with higher scores representing greater burden. Linear regression was used to explore the association between recipient characteristics/need and caregiver burden.

Results

Of 1,032 eligible patients approached, 813 participants indicated whether they had an informal caregiver (708) or not (105). 376 caregivers consented (53.1%), of whom 321 have returned questionnaires, with patient data available for 296. The median age of caregivers was 73.0 (range 27.0- 91.1 years), 237 (73.8%) female. 274 (85.4%) were the spouse/partner of the patient. 215 (67.0%) were the sole caregiver. The median time per week spent caring was 21 hours (interquartile range 7, 41 hours). 18 (5.6%) of caregivers provided 24-hour care daily and 113 (35.2%) had provided support for over 5 years. Median ZBI score was 17, (interquartile range 7-29). The care recipient’s duration of parkinsonism was associated with higher burden score (0.38 increase per year of parkinsonism; 95% CI 0.07, 0.69; p value 0.015), as was the time per week spent caring (0.16 increase for each additional hour; 95% CI 0.11, 0.20; p value <0.0001).

Conclusions

Many informal caregivers in this study were the sole caregiver and many were themselves older adults. Burden increased with increasing duration of parkinsonism and as time spent caring increased. This highlights the ongoing need to improve support for this group.

Moving From 'Best Interests' to 'Will and Preference': A Study of Doctors' Level of Knowledge Relating to the Assisted Decision-Making (Capacity) Act 2015

Aims Irish decision-making capacity legislation is due to fundamentally change from 2022, with the commencement of the Assisted Decision-Making (Capacity) Act 2015, removing 'best interests' decision-making and replacing it with a 'will and preference' basis. This study aimed to investigate awareness amongst doctors regarding this Act, and specific knowledge relating to capacity assessment and advanced healthcare directives. Methods The study utilised a cross-sectional anonymised self-report questionnaire within a second tier hospital located in a rural part of Ireland. Results Only 2% of doctors had received any formal training on the Act, 25% were unsure of their role and 45% were unsure of a patient's role in decision-making. 37% believed that best interests was retained in decision-making. 50% were unaware of their obligations in assessing capacity, 23% were unable to assess capacity correctly and 47% were unsure of any consultative obligations in decision-making. 90% were unaware of what constituted a valid Advanced Healthcare Directive. Conclusion Further training is urgently required if the Act is to be successfully implemented in 2022.

A randomized, double-blind, placebo-controlled trial of intravenous alpha-1 antitrypsin for acute respiratory distress syndrome secondary to COVID-19

Background

Patients with severe coronavirus disease 2019 (COVID-19) develop a febrile pro-inflammatory cytokinemia with accelerated progression to acute respiratory distress syndrome (ARDS). Here we report the results of a phase 2, multicenter, randomized, double-blind, placebo-controlled trial of intravenous (IV) plasma-purified alpha-1 antitrypsin (AAT) for moderate to severe ARDS secondary to COVID-19 (EudraCT 2020-001391-15).

Methods

Patients (n = 36) were randomized to receive weekly placebo, weekly AAT (Prolastin, Grifols, S.A.; 120 mg/kg), or AAT once followed by weekly placebo. The primary endpoint was the change in plasma interleukin (IL)-6 concentration at 1 week. In addition to assessing safety and tolerability, changes in plasma levels of IL-1β, IL-8, IL-10, and soluble tumor necrosis factor receptor 1 (sTNFR1) and clinical outcomes were assessed as secondary endpoints.

Findings

Treatment with IV AAT resulted in decreased inflammation and was safe and well tolerated. The study met its primary endpoint, with decreased circulating IL-6 concentrations at 1 week in the treatment group. This was in contrast to the placebo group, where IL-6 was increased. Similarly, plasma sTNFR1 was substantially decreased in the treatment group while remaining unchanged in patients receiving placebo. IV AAT did not definitively reduce levels of IL-1β, IL-8, and IL-10. No difference in mortality or ventilator-free days was observed between groups, although a trend toward decreased time on ventilator was observed in AAT-treated patients.

Conclusions

In patients with COVID-19 and moderate to severe ARDS, treatment with IV AAT was safe, feasible, and biochemically efficacious. The data support progression to a phase 3 trial and prompt further investigation of AAT as an anti-inflammatory therapeutic.

Funding

ECSA-2020-009; Elaine Galwey Research Bursary.

631 Designing an Oral and Maxillofacial Trauma Assessment Proforma for Dental Core Trainees in Northern Ireland

Aim

The dental core training (DCT) scheme is an optional postgraduate training pathway for dental graduates who have completed their foundation training and wish to undergo further specialist training. The majority of posts available in Northern Ireland (NI) are within oral and maxillofacial surgery (OMFS) units and include on-call commitment. Dental core trainees (DCTs) are expected to examine and assess OMFS trauma patients and often have limited experience of this prior to post commencement. This project outlines the development of an OMFS trauma assessment proforma designed for DCTs working in NI.

Method

An initial OMFS trauma proforma was designed alongside senior staff. This was introduced to 6 DCTs and 2 trust SHOs within a tertiary OMFS unit. 34 proformas were recorded within month 1, following which a feedback survey was completed by the 8 trainees. A revised proforma was redistributed and 33 recorded over month 2, followed by a repeat feedback survey.

Results

The revised proforma was found to be successful amongst trainees within the unit to act as an aid memoir and provide systematic structure to trauma examination. 100% of trainees recorded the revised proforma as useful. As a result, the proforma was introduced as part of the national induction programme for new DCTs commencing training posts in NI.

Conclusions

Progressing from general practice dentistry to the role of an OMFS DCT can be a challenging transition for many trainees. The proforma aids to guide junior clinicians in how to structure and record oral and maxillofacial trauma whilst ensuring thorough and comprehensive examination.

A randomised, double-blind, placebo-controlled, pilot trial of intravenous plasma purified alpha-1 antitrypsin for SARS-CoV-2-induced Acute Respiratory Distress Syndrome: a structured summary of a study protocol for a randomised, controlled trial

OBJECTIVES

The primary objective is to demonstrate that, in patients with PCR-confirmed SARS-CoV-2 resulting in Acute Respiratory Distress Syndrome (ARDS), administration of 120mg/kg of body weight of intravenous Prolastin®(plasma-purified alpha-1 antitrypsin) reduces circulating plasma levels of interleukin-6 (IL-6). Secondary objectives are to determine the effects of intravenous Prolastin® on important clinical outcomes including the incidence of adverse events (AEs) and serious adverse events (SAEs).

TRIAL DESIGN

Phase 2, randomised, double-blind, placebo-controlled, pilot trial.

PARTICIPANTS

The study will be conducted in Intensive Care Units in hospitals across Ireland. Patients with a laboratory-confirmed diagnosis of SARS-CoV-2-infection, moderate to severe ARDS (meeting Berlin criteria for a diagnosis of ARDS with a PaO₂/FiO₂ ratio <200 mmHg), >18 years of age and requiring invasive or non-invasive mechanical ventilation. All individuals meeting any of the following exclusion criteria at baseline or during screening will be excluded from study participation: more than 96 hours has elapsed from onset of ARDS; age < 18 years; known to be pregnant or breastfeeding; participation in a clinical trial of an investigational medicinal product (other than antibiotics or antivirals) within 30 days; major trauma in the prior 5 days; presence of any active malignancy (other than nonmelanoma skin cancer) which required treatment within the last year; WHO Class III or IV pulmonary hypertension; pulmonary embolism prior to hospital admission within past 3 months; currently receiving extracorporeal life support (ECLS); chronic kidney disease receiving dialysis; severe chronic liver disease with Child-Pugh score > 12; DNAR (Do Not Attempt Resuscitation) order in place; treatment withdrawal imminent within 24 hours; Prisoners; non-English speaking patients or those who do not adequately understand verbal or written information unless an interpreter is available; IgA deficiency.

INTERVENTION AND COMPARATOR

Intervention: Either a once weekly intravenous infusion of Prolastin® at 120mg/kg of body weight for 4 weeks or a single dose of Prolastin® at 120mg/kg of body weight intravenously followed by once weekly intravenous infusion of an equal volume of 0.9% sodium chloride for a further 3 weeks. Comparator (placebo): An equal volume of 0.9% sodium chloride intravenously once per week for four weeks.

MAIN OUTCOMES

The primary effectiveness outcome measure is the change in plasma concentration of IL-6 at 7 days as measured by ELISA. Secondary outcomes include: safety and tolerability of Prolastin® in the respective groups (as defined by the number of SAEs and AEs); PaO₂/FiO₂ ratio; respiratory compliance; sequential organ failure assessment (SOFA) score; mortality; time on ventilator in days; plasma concentration of alpha-1 antitrypsin (AAT) as measured by nephelometry; plasma concentrations of interleukin-1β (IL-1β), interleukin-8 (IL-8), interleukin-10 (IL-10), soluble TNF receptor 1 (sTNFR1, a surrogate marker for TNF-α) as measured by ELISA; development of shock; acute kidney injury; need for renal replacement therapy; clinical relapse, as defined by the need for readmission to the ICU or a marked decline in PaO₂/FiO₂ or development of shock or mortality following a period of sustained clinical improvement; secondary bacterial pneumonia as defined by the combination of radiographic findings and sputum/airway secretion microscopy and culture.

RANDOMISATION

Following informed consent/assent patients will be randomised. The randomisation lists will be prepared by the study statistician and given to the unblinded trial personnel. However, the statistician will not be exposed to how the planned treatment will be allocated to the treatment codes. Randomisation will be conducted in a 1:1:1 ratio, stratified by site and age.

BLINDING (MASKING)

The investigator, treating physician, other members of the site research team and patients will be blinded to treatment allocation. The clinical trial pharmacy personnel and research nurses will be unblinded to facilitate intervention and placebo preparation. The unblinded individuals will keep the treatment information confidential. The infusion bag will be masked at the time of preparation and will be administered via a masked infusion set to maintain blinding.

NUMBERS TO BE RANDOMISED (SAMPLE SIZE)

A total of 36 patients will be recruited and randomised in a 1:1:1 ratio to each of the trial arms.

TRIAL STATUS

In March 2020, version 1.0 of the trial protocol was submitted to the local research ethics committee (REC), Health Research Consent Declaration Committee (HRCDC) and the Health Products regulatory Authority (HPRA). REC approval was granted on April 1^st 2020, HPRA approval was granted on April 24^th 2020 and the HRCDC provided a conditional declaration on April 17^th 2020. In July 2020 a substantial amendment (version 2.0) was submitted to the REC, HRCDC and HPRA. Protocol changes in this amendment included: the addition of trial sites; extending the duration of the trial to 12 months from 3 months; removal of inclusion criteria requiring the need for vasopressors; amendment of randomisation schedule to stratify by age only and not BMI and sex; correction of grammatical error in relation to infusion duration; to allow for inclusion of subjects who may have been enrolled in a clinical trial involving either antibiotics or anti-virals in the past 30 days; to allow for inclusion of subjects who may be currently enrolled in a clinical trial involving either antibiotics or anti-virals; to remove the need for exclusion based on alpha-1 antitrypsin phenotype; removal of mandatory isoelectric focusing of plasma to confirm Pi*MM status at screening; removal of need for mandatory echocardiogram at screening; amendment on procedures around plasma analysis to reflect that this will be conducted at the central site laboratory (as trial is multi-site and no longer single site); wording amended to reflect that interim analysis of cytokine levels taken at 7 days may be conducted. HRCDC approved version 2.0 on September 14th 2020, and HPRA approved on October 22nd 2020. REC approved the substantial amendment on November 23^rd. In November 2020, version 3.0 of the trial protocol was submitted to the REC and HPRA. The rationale for this amendment was to allow for patients with moderate to severe ARDS from SARS-CoV-2 with non-invasive ventilation. HPRA approved this amendment on December 1st 2020 and the REC approved the amendment on December 8th 2020. Patient recruitment commenced in April 2020 and the last patient will be recruited to the trial in April 2021. The last visit of the last patient is anticipated to occur in April 2021. At time of writing, patient recruitment is now complete, however follow-up patient visits and data collection are ongoing.

TRIAL REGISTRATION

EudraCT 2020-001391-15 (Registered 31 Mar 2020).

FULL PROTOCOL

The full protocol (version 3.0 23.11.2020) is attached as an additional file accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol. The study protocol has been reported in accordance with the Standard Protocol Items: Recommendations for Clinical Interventional Trials (SPIRIT) guidelines (Additional file 2).

Hospital outbreak of linezolid-resistant and vancomycin-resistant ST80 Enterococcus faecium harbouring an optrA-encoding conjugative plasmid investigated by whole-genome sequencing

BACKGROUND

Linezolid is an antibiotic used to treat infections caused by multi-drug-resistant Gram-positive bacteria. Linezolid resistance in enterococci has been reported with increasing frequency, with a recent rise in resistance encoded by optrA, poxtA or cfr.

AIM

To investigate a hospital outbreak of linezolid- and vancomycin-resistant Enterococcus faecium (LVREfm) using whole-genome sequencing (WGS).

METHODS

Thirty-nine VREfm from patient screening (19 isolates, 17 patients) and environmental sites (20 isolates) recovered in October 2019 were investigated. Isolates were screened using polymerase chain reaction for optrA, poxtA and cfr, and underwent Illumina MiSeq WGS. Isolate relatedness was assessed using E. faecium core genome multi-locus sequence typing (cgMLST). One LVREfm underwent MinION long-read WGS (Oxford Nanopore Technologies) and hybrid assembly with MiSeq short-read sequences to resolve an optrA-encoding plasmid.

FINDINGS

Twenty isolates (51.3%) were LVREfm and optrA-positive, including the LVREfm from the index patient. A closely related cluster of 28 sequence type (ST) 80 isolates was identified by cgMLST, including all 20 LVREfm and eight linezolid-susceptible VREfm, with an average allelic difference of two (range 0-10), indicating an outbreak. Nineteen (95%) LVREfm harboured a 56,684-bp conjugative plasmid (pEfmO_03). The remaining LVREfm exhibited 44.1% sequence coverage to pEfmO_03. The presence of pEfmO_03 in LVREfm and the close relatedness of the outbreak cluster isolates indicated the spread of a single strain. The outbreak was terminated by enhanced infection prevention and control (IPC) and environmental cleaning measures, ceasing ward admissions and ward-dedicated staff.

CONCLUSION

WGS was central in investigating an outbreak of ST80 LVREfm. The rapid implementation of enhanced IPC measures terminated the outbreak.

A neutron camera system for MAST

A prototype neutron camera has been developed and installed at MAST as part of a feasibility study for a multichord neutron camera system with the aim to measure the spatial and time resolved 2.45 MeV neutron emissivity profile. Liquid scintillators coupled to a fast digitizer are used for neutron/gamma ray digital pulse shape discrimination. The preliminary results obtained clearly show the capability of this diagnostic to measure neutron emissivity profiles with sufficient time resolution to study the effect of fast ion loss and redistribution due to magnetohydrodynamic activity. A minimum time resolution of 2 ms has been achieved with a modest 1.5 MW of neutral beam injection heating with a measured neutron count rate of a few 100 kHz.

The current epidemiology of SIDS in Ireland

This paper examines some epidemiological factors associated with SIDS to give a general profile of SIDS cases occurring in Ireland between the years 1993 to 1997. There has been a dramatic decrease in the incidence of the Sudden Infant Death Syndrome (SIDS) in the Republic of Ireland in the last decade from an average rate of 2.2/1000 live-births in the 1980s to 0.8/1000 live-births in the years 1993-1997, a decrease of 100 deaths a year. The fall in the SIDS rate has been seen in many countries and is felt to be associated with Reduce The Risks (RTR) of SIDS campaigns and the avoidance of the prone sleeping position. The use of the prone sleep position averaged at 6% of children being put prone in the years 1993-1997 but the prone position has progressively decreased from 13% of children being put prone in 1994 to only 2% in 1997. The profile of the Irish SIDS cases is similar to that of SIDS cases in other countries following similar RTR campaigns with a male predominance, the characteristic clustering of deaths in the first six months of life and the majority of cases (75%) occuring in the night sleep period. The loss of the seasonal variation of the time of death is also shown and factors such as lower socio-economic status, unemployment and medical card eligibility were seen in higher proportions in SIDS families than in the general population. A high percentage of SIDS mothers smoked (73%). Higher smoking rates were seen among younger and single mothers and smoking rates were inversely related to educational level and socioeconomic grouping. An urgent question that needs to be addressed is how socioeconomic disadvantage increases the SIDS risk and what factors influence socioeconomically disadvantaged families to adopt life style and parenting practices such as smoking that influence their children's health.

Bombesin-like peptide and receptors in lung injury models: diverse gene expression, similar function

We previously demonstrated that bombesin-like peptide (BLP) mediates lung injury in premature infants with bronchopulmonary dysplasia (BPD). We now investigate gene expression and function of BLP (gastrin-releasing peptide, GRP) and BLP-receptors (GRP-R and BRS-3) in lung from two baboon BPD models. In the "interrupted gestation model," only GRP mRNA was up-regulated. In the "hyperoxic model," GRP-R mRNA was up-regulated. In lung explants from O2-treated animals, all BPD animals responded to 1nM bombesin, whereas non-BPD animals did not; the opposite effect was observed with a BLP blocking antibody. Cumulatively, these observations suggest that novel BLPs and/or BLP receptors are likely to be implicated in the pathogenesis of BPD.

Personal exposure to particles in Banská Bystrica, Slovakia

Epidemiological studies have associated adverse health impacts with ambient concentrations of particulate matter (PM), though these studies have been limited in their characterization of personal exposure to PM. An exposure study of healthy nonsmoking adults and children was conducted in Banska Bystrica, Slovakia, to characterize the range of personal exposures to air pollutants and to determine the influence of occupation, season, residence location, and outdoor and indoor concentrations on personal exposures. Twenty-four-hour personal, at-home indoor, and ambient measurements of PM10, PM2.5, sulfate (SO4(2-)) and nicotine were obtained for 18 office workers, 16 industrial workers, and 15 high school students in winter and summer. Results showed that outdoor levels of pollutants were modest, with clear seasonal differences: outdoor PM10 summer/winter mean = 35/45 microg/m3; PM2.5 summer/winter mean = 22/32 microg/m3. SO4(2-) levels were low (4-7 microg/m3) and relatively uniform across the different sample types (personal, indoor, outdoor), areas, and occupational groups. This suggests that SO4(2-) may be a useful marker for combustion mode particles of ambient origin, although the relationship between personal exposures and ambient SO4(2-) levels was more complex than observed in North American settings. During winter especially, the central city area showed higher concentrations than the suburban location for outdoor, personal, and indoor measures of PM10, PM2.5, and to a lesser extent for SO4(2-), suggesting the importance of local sources. For PM2.5 and PM10, ratios consistent with expectations were found among exposure indices for all three subject groups (personal>indoor>outdoor), and between work type (industrial>students>office workers). The ratio of PM2.5 personal to indoor exposures ranged from 1.0 to 3.9 and of personal to outdoor exposures from 1.6 to 4.2. The ratio of PM10 personal to indoor exposures ranged from 1.1 to 2.9 and the ratio of personal to outdoor exposures from 2.1 to 4.1. For a combined group of office workers and students, personal PM10/PM2.5 levels were predicted by statistically significant multivariate models incorporating indoor (for PM2.5) or outdoor (for PM10) PM levels, and nicotine exposure (for PM10). Small but significant fractions of the overall variability, 15% for PM2.5 and 17% for PM10, were explained by these models. The results indicate that central site monitors underpredict actual human exposures to PM2.5 and PM10. Personal exposure to SO4(2-) was found to be predicted by outdoor or indoor SO4(2-) levels with 23-71% of the overall variability explained by these predictors. We conclude that personal exposure measurements and additional demographic and daily activity data are crucial for accurate evaluation of exposure to particles in this setting.

Concentrations of antimony in infants dying from SIDS and infants dying from other causes

OBJECTIVES

Raised concentrations of antimony have been found in infants dying of sudden infant death syndrome (SIDS). The presumed source of this antimony is toxic gases generated from fire retardants that are present in cot mattresses. The aim of this study was to determine the role of antimony in SIDS.

DESIGN

Samples of liver, brain, serum, and urine were collected from all patients dying from SIDS and a group of aged matched control infants who had died of other causes.

SETTING

Nationwide study in Ireland.

SUBJECTS

52 infants dying from SIDS and 19 control infants aged > 7 days and < 1 year.

RESULTS

The median concentration of antimony in the liver and brain of infants dying of SIDS was < 1 ng/g, with no difference detected between the infants dying from SIDS and the control infants. The range of antimony in the serum of infants dying of SIDS was 0.09-0.71 microg/litre (median, 0.26). Although no difference was found between infants dying from SIDS and control infants, SIDS infants were found to have higher concentrations when compared with healthy infants in the 1st year of life, probably as a result of release of antimony into serum after death. Urine antimony concentrations in infants dying from SIDS were < 3.91 ng/mg (corrected for creatinine) and similar to values found both in control infants and healthy infants.

CONCLUSION

There is no evidence to support a causal role for antimony in SIDS.

Sudden infant death syndrome--are parents getting the message?

BACKGROUND

Factors that place an infant at increased risk of sudden infant death include the prone sleep position, overheating and parental smoking, while practices such as bottle-feeding, co-sleeping and the use of pacifiers remain controversial. Major publicity campaigns have been undertaken, which have included the distribution of printed material and extensive media coverage.

AIMS

To examine if Irish parents follow the currently recommended childcare guidelines to reduce the risk of sudden infant death and to examine factors that may have impact on their acceptance.

METHODS

A random selection of 197 infants from the Birth Register of the Eastern Health Board. Parents were interviewed and a semi-structured survey questionnaire was completed.

RESULTS

Forty one per cent of infants are still placed on their side to sleep, an inherently unstable position. First time parents are more likely to place their infants on their backs. Over 60% of infants are exposed to one or more adults smoking in the home despite parental knowledge of its association with sudden infant death syndrome (SIDS). Sixty eight per cent of infants are overwrapped at night and parental understanding of what constitutes overwrapping is poor. Thirteen per cent of infants regularly co-sleep with their parents and 20% of these parents smoke. Pacifier use is common.

CONCLUSION

Future programmes should target first time parents, should provide clear information regarding appropriate infant thermal environment, and should ensure regular updating of medical personnel so that they can instruct families on best current practice. Smoking remains a significant health issue with an impact on sudden infant death.

Ability of the digene hybrid capture II test to identify Chlamydia trachomatis and Neisseria gonorrhoeae in cervical specimens

The Digene Hybrid Capture II (HCII CT/GC) test is a combination test designed to detect Chlamydia trachomatis and Neisseria gonorrhoeae in a single specimen. It is a nucleic acid hybridization test which uses signal amplification to increase sensitivity. We compared its performance to that of culture on cervical specimens from 1,370 women. Direct fluorescent-antibody assay was used to resolve discrepant results for C. trachomatis. Samples were collected with a proprietary cervical brush or with endocervical swabs. The HCII CT/GC test proved to be sensitive and specific in detecting these organisms. Compared to N. gonorrhoeae culture, it had a sensitivity of 93% (87/94) and a specificity of 98.5% (1,244/1,263). Compared to C. trachomatis culture, the sensitivity was 97.7% (129/132) and specificity was 98.2% (1,216/1,238). Testing of some specimens with discrepant results by PCR suggested that the test would actually prove to be even more specific if it were compared to a nucleic acid amplification test (NAAT). The sensitivity of C. trachomatis culture was somewhat less, at 88.6% (117/132). The endocervical brush appeared to be better than Dacron swabs for collecting specimens. The HCII CT/GC test offers an attractive format that allows simultaneous detection of C. trachomatis and N. gonorrhoeae with a single specimen. An initial positive result is followed by repeat tests with probes to identify chlamydiae or gonococci. This test is more sensitive than C. trachomatis culture and is at least as sensitive as culture for gonococci. It deserves further evaluation and comparison with NAATs and may well offer an attractive alternative for diagnosis and screening of these infections.

A national model of care service for professionals dealing with sudden infant death

Sudden Infant Death Syndrome (SIDS) is any death occurring in an infant or young child which is unexpected by history and in which a thorough post mortem examination fails to demonstrate an adequate cause of death. The National Sudden Infant Death Register collects information on all sudden unexpected deaths in infants and young children occurring in Ireland. In this study, a comparison was made between parent's experience of professional services in the aftermath of their child's death both before and after the implementation of a National Model of Care for professionals in 1995. In addition, a random sample of 105 professionals were surveyed about their knowledge of the Model of Care services. Results were grouped according to the parental experience of the emergency services, the hospital services, the community services and the bereavement support services offered to parents. Prior to the implementation of the Model of Care Service (MOC) (1992-1994), 14 per cent of families stated that they did not find the Gardai helpful. After the Model of Care, only 7 per cent of parents expressed such dissatisfaction. Prior to the MOC, only 3 per cent of Gardai provided families with an information booklet on sudden infant death but afterwards, 23 per cent of Gardai did so. After the MOC families were more likely to have been given the opportunity to hold their infant, were given more privacy and were offered more keepsakes of their infant. Only 46 per cent of families were offered momentos of their baby prior to the MOC as compared to 84 per cent after the implementation of the MOC. They were also more likely to perceive the ancillary services such as the Gardai in a more positive light, where 22 per cent of Gardai offered the family the ISIDA support booklet compared to a previous 3 per cent. Over 50 per cent of parents were provided with a special room in the hospital following the MOC as opposed to a previous 48 per cent. Twenty-one per cent of parents prior to the MOC described the conditions in the hospital as awful, poor or fair, however 31 per cent of parents stated this after the MOC. While there have been improvements in certain areas, there still remains considerable variation in the quality of service provided to all parents. Specifically, we need to address the fact that 16 per cent of parents still report a difficulty in obtaining post-mortem information. Almost 40 per cent said they had little input into how their child was dressed or laid out at this highly emotive time. Over one-third of parents stated they were concerned about how few of their primary health providers, namely general practitioners and public health nurses called to visit them in the aftermath of this tragic event.

High attenuation gyri CT in postasphyxial encephalopathy

Two term infants suffering severe asphyxial events were found to have diffusely high attenuation of the cortical gyri on CT scanning within 12 days. The findings are consistent with haemorrhagic necrosis or microcalcification. This feature has rarely been described in the literature. The evolution of the CT appearance, the possible neuropathological findings and the relationship with hypoxic-ischaemic encephalopathy are discussed.

Antimony in blood and urine of infants

AIM

To establish a reference range for antimony in the serum and urine of infants in the first year of life.

METHODS

100 infants were selected randomly from the population. Each infant had a single blood and urine sample taken. Antimony was assayed using inductively coupled plasma mass spectrometry.

RESULTS

The reference range for antimony in the serum of infants in the first year of life was established as 0.09-0.25 microgram/l. The upper 95% centile for urinary antimony, corrected for creatinine, in the same population was 2.6 ng/mg creatinine. There was a very weak correlation between the serum and urine concentrations.

CONCLUSIONS

This study confirms the presence of low concentrations of antimony in the serum and urine of healthy infants.

Current use of the TORCH screen in the diagnosis of congenital infection

The aim of the study was to determine the number of congenital infections detected in Dublin with the current use of the TORCH screen. A review of all laboratory results was undertaken with subsequent review of relevant medical charts. A total of nine cases were documented in a 5-year period from January 1991 to December 1995. Six of these had already been suspected. There was a failure to follow up 47% of positive screens. TORCH screening in Ireland has an unacceptably low yield, and in the opinion of the authors should be abolished.

A profile of attenders at the A&E Department of the Children's Hospital, Temple Street, Dublin

The Department of Health state that the prime function of the A&E department is to provide for the reception and initial management of every variety of medical emergency, provided that the condition could not be treated by the General Practitioner. The A&E department in the Children's Hospital, Temple Street, Dublin receives an average of 55,000 visits annually. The study profiled attenders according to their: socioeconomic status; reasons for attendance; appropriateness of attendance; and outcome of attendance. Attenders parents were more likely to be unemployed (22%), single (26%) and GMS card holders (52%) than national average figures. Families who attended out of hours (i.e. after 5pm) and/or who were self-referred did not differ socio-economically from other attenders. 74% of all attenders were self-referred and the self-referred group were more likely to attend after 5pm. 54% of attenders had attended the department more than once in the previous twelve months. 37% of all attendance were due to accidents. Casualty doctors assessed that 39% of all attendance did not require hospital services. However, the percentage of 'GP referred' and 'self-referred' groups deemed to require hospital services were comparable (47% v 38%). Furthermore, only 19% of GP referrals were admitted. These figures suggest that a large number of children who attend the A&E department should be attending a medical paediatric out patient unit, rather than an A&E department.

Determination of antimony in urine, blood and serum and in liver and lung tissues of infants by inductively coupled plasma mass spectrometry

Methods are presented for the determination by ICP-MS of antimony in body fluids and tissues of infants. Urine, serum and whole blood specimens are prepared for analysis by simply diluting 200 microliters sample volumes (1 + 14) with water and adding indium as internal standard. Liver and lung tissues are digested using 16 M HNO3 either in open quartz vessels at 150 degrees C or in sealed vessels with microwave heating. The acid digests are diluted with water and indium is added as internal standard for ICP-MS measurements. All analyses were subjected to stringent internal quality control protocols. Accuracy was assessed by recoveries, repeated analyses and by analysis of NIST SRMs 1577a Bovine Liver and 1566a Oyster Tissue. Precisions of analyses were better than 5-10% in the ranges 0.1-0.3 microgram l-1 for urine, serum and blood; and at 7-25 ng g-1 in tissues. Detection limits were 0.7 ng g-1 in liver, 0.8 ng g-1 in lung, and 0.01 microgram l-1 in urine, serum and blood. The need to employ validated procedures for specimen collection and to give considerable attention to pre-analytical factors in order to avoid adventitious contamination with antimony is demonstrated.

The Marshall-Smith syndrome: a review of the laryngeal complications

The Marshall-Smith syndrome is characterised by a triad of facial dysmorphism, failure to thrive and accelerated osseous maturation. We report a further case of this rare syndrome with the unusual but previously reported complication of laryngeal hypoplasia and review the associated laryngeal anomalies that have been reported to date.

CONCLUSION

Severe airway obstruction due to congenital anomalies must be excluded in any dysmorphic child presenting with respiratory distress at birth. Rapid airway assessment will enable early and appropriate intervention and may be important when deciding on the long-term plan for the infant.

Single road traffic deaths--accident or suicide?

Many authors have suggested that some deaths resulting from road traffic accidents are in fact suicide. The purpose of this study was to examine the circumstances of single road traffic deaths in County Mayo, Ireland, over the 15-year period from 1978 to 1992 inclusive. Using the information available from the coroners' files, evidence was sought to support the hypothesis that some accidental deaths may have been disguised suicides. The authors could find no conclusive evidence to suggest that this hypothesis was true. However, there was suspicion of suicide in six (4.5%) of the 134 fatalities examined. Interesting data regarding gender differences, seasonality, time of accident, and the consumption of alcohol were found.

Human papillomavirus testing by hybrid capture appears to be useful in triaging women with a cytologic diagnosis of atypical squamous cells of undetermined significance

OBJECTIVE

Our purpose was to determine the clinical value of human papillomavirus deoxyribonucleic acid testing with the hybrid capture test, specifically to examine whether human papillomavirus testing could identify which women with Papanicolaou smears read as atypical squamous cells of undetermined significance were most likely to have histologically confirmed cervical intraepithelial neoplasia.

STUDY DESIGN

Hybrid capture testing for 14 human papillomavirus types, repeat Papanicolaou smears, and colposcopically directed biopsies were performed concurrently on 217 women referred to a student health colposcopy clinic with a previous Papanicolaou smear read as atypical squamous cells of undetermined significance.

RESULTS

Human papillomavirus deoxyribonucleic acid positivity was associated with an eightfold increased likelihood of histologic confirmation of cervical intraepithelial neoplasia. The sensitivity of hybrid capture for any cervical intraepithelial neoplasia was 86% (43/50) and for grade 2 or 3 was 93% (14/15), whereas the corresponding values for the repeat Papanicolaou smear were 60% (30/50) and 73% (11/15), respectively. Moreover, high viral levels of human papillomavirus types known to be associated with cervical cancer were strongly predictive of high-grade cervical intraepithelial neoplasia.

CONCLUSIONS

Testing for human papillomavirus deoxyribonucleic acid with hybrid capture appears to offer an effective means by which patients whose cervical Papanicolaou smears have been read as atypical squamous cells of undetermined significance could be triaged for colposcopy. In particular, sensitivity for high-grade cervical intraepithelial neoplasia could be maintained and specificity markedly improved by referring only those patients who had elevated levels of human papillomavirus deoxyribonucleic acid of cancer-associated viral types.

Under-reporting of suicide in an Irish county

It is clearly important to have accurate figures on suicides, but official statistics may not always reflect the true numbers of suicides. In this paper, the authors describe how the files of all deaths reported to the coroners of County Mayo, Ireland, for the period 1978-1992 were examined. Those deaths considered to be suicide by the authors were abstracted. Of these deaths, it was found that 7.3% had not been officially registered. The remainder were coded to three different categories in official returns: suicide, undetermined, and accident. In all, 35% of deaths were, in the author's opinion, miscoded or unregistered. The authors compared these three groups on a number of demographic variables with the expectation that if suicide deaths were being miscoded to undetermined and accident, no significant difference would be found between the three groups. This was found to be the case other than for mode of death. The authors found the greatest miscoding was for deaths due to drowning. The authors recommended that changes be made in the reporting and coding system for suicide deaths in Ireland.

Home glucose monitoring in type 2 diabetes: is it a waste of time?

A cross-sectional study to assess home glucose monitoring practices was conducted in 200 non-insulin-treated diabetic patients consecutively attending our hospital clinic. Of the 200, 97 (48%) patients (Group 1) regularly monitored urine (n = 74), blood (n = 19) or both (n = 4); 103 (52%) patients (Group 2) performed no home monitoring. The two groups were similar in terms of age, sex, duration of diabetes and type of treatment. The prevalence of diabetic complications was also closely comparable and only peripheral neuropathy differed between the groups, being more common in Group 1 (n = 12) than Group 2 (n = 4); p < 0.05. There was also no significant difference between the HbA1 concentration (mean +/- SD) in Group 1 (9.7 +/- 2.2%) and Group 2 (9.4 +/- 2.0%). The mean frequency of home monitoring was four tests weekly, but only 21 (22%) kept a written record and 60 (62%) would never alter their treatment on the basis of their results. Almost a third of patients could not interpret the results of monitoring or give the normal range of values. Home glucose monitoring, particularly of urine, is widely practised in Type 2 diabetes, at considerable overall expense. However, convincing evidence of its value in helping patients improve their blood glucose control or preventing the complications of the disease is lacking.

Non-starch polysaccharide/dietary fibre supplementation using small meals in long-stay frail elderly patients

Small meals of high non-starch polysaccharide (NSP)/dietary fibre cakes were offered to clinically stable continuing-care elderly patients, replacing the standard provision of low NSP/dietary fibre commercial cakes in an attempt to improve their well being. The study design was comprised of a 4 week control period, a 4 week intervention period, when modified cakes were offered, and finally a second 4 week control period. During intervention, an additional 33% NSP or 23% dietary fibre was offered, but only 7.7% and between 3.5% and 5.6% were consumed, respectively. Anthropometric measurements and bowel frequency did not change throughout the study but a decrease in aperient use was noted. From this study it was concluded that more comprehensive changes in food provision are required to achieve the current recommended consumption of NSP/dietary fibre in continuing-care elderly patients.

Do statistics lie? Suicide in Kildare--and in Ireland

This study, reporting a ten-year investigation of suicide in Kildare, found that the suicide rate based on clinical assessment of coroner's records was very close to the Central Statistics Office (CSO) figure for Kildare and for Ireland as a whole for the same period. Dublin data for 1977-1981 confirmed these findings. Since in the 1960s similar clinical assessment concluded that CSO rates underestimated suicide by a factor of two or over, we believe that changes in CSO coding procedures whereby more deaths are now coded to suicide than was the case in the past have resulted in current CSO data reflecting accurately the rate of clinical suicide. There has been more than a three-fold increase in CSO suicide rates in Ireland between 1968 and 1987. Even allowing for improved CSO practices there still remains a considerable excess of suicide deaths which indicates a doubling of 'real' suicide in Ireland over these twenty years.

Immunohistological features in the synovium obtained from clinically uninvolved knee joints of patients with rheumatoid arthritis

The spectrum of immunohistological change in the affected joints of patients with rheumatoid arthritis has been well described. In this study, the immunohistological features in synovial membrane obtained from apparently uninvolved knee joints of 16 patients with active untreated rheumatoid arthritis were examined and compared to tissue from control subjects. Synovial tissue was obtained by needle biopsy. Hyperplasia of the synovial lining layer, present in 69%, was the most frequently observed abnormality in synovium obtained from uninvolved joints. Perivascular mononuclear cell infiltration was present in 31% and consisted predominantly of helper T-cells. Increased vascularity and fibrin deposition were not notable features. Clinically overt synovitis emerged in only two patients during a follow-up period of up to 36 months. In conclusion, a considerable degree of histological change was observed in the apparently uninvolved knee joints of patients with active rheumatoid arthritis. The presence of subclinical synovitis challenges current concepts of disease activity and clinical remission. Further study is required to determine whether the features described may be associated with progressive joint erosion.

Primary amyloidosis of lower urinary tract

Primary amyloidosis of the lower urinary tract is a rare condition with an excellent prognosis in most cases. Three patients with this condition are described. In the cases of localized amyloidosis of the urethra and urinary bladder, the clinical presentation mimicked cancer of the respective sites. This was also true in the case of primary systemic amyloidosis involving the bladder. If significant associated systemic or local disease can be excluded, management is symptomatic and expectant.

Immunohistochemical Cal9-9 in primary colonic polyps and polyps synchronous with colorectal cancer

A prospective study was undertaken to examine the immunohistochemical expression of tumor antigen Cal9-9 in 56 colorectal cancers and 95 colonic adenomas, divided into 65 primary polyps and 30 polyps synchronous with colorectal cancer. Seventy five per cent of tumours were positive for Cal9-9. Antigen was expressed more frequently in advanced Duke's C and D and poorly differentiated colorectal cancer. Overall 51% of adenomas were positive for Cal9-9. Antigen expression correlated significantly with increasing size (p less than 0.001), synchronicity with colorectal cancer (p less than 0.001), severe dysplasia (p less than 0.001) and villous typing (p less than 0.003). Discriminate analysis using the first three variables correctly classified 79% of positive and 89% of negative Cal9-9 results. The similar frequency of antigen expression seen in colorectal cancers and their synchronous adenoma suggests a field change in the tumour bearing colon. Adenomas positive for Cal9-9 may have a greater malignant potential for carcinomatous change.

How to write an abstract of a paper or a report to be presented at the annual meeting of the American Academy of Optometry

Although the General Papers Program (held on Saturday, Monday and Tuesday afternoons at the Annual Meeting of the Academy) has expanded to a format in which 20-minute papers and 10-minute reports are presented simultaneously in 4 or 5 rooms the committee continues to receive abstracts for approximately 25 percent more papers and reports than the program can accommodate. The committee's task of selecting papers and reports is complicated by the failure of many writers of abstracts to include sufficient and pertinent information in their abstracts. This presentation lists the essential elements of an acceptable abstract, and tabulates the reasons for non-acceptance of abstracts.