Is Increasing Life Expectancy Leading To More Complexity?

Life expectancy is increasing in Ireland, but whether this has resulted in healthier life years among the elderly and its impact (if any) on hospital services is unknown. The purpose of the study was to use routinely available data to explore the relationship of age and indicators of clinical complexity in acute hospitals over ten years. The study included all in-patients aged 65+ years from the Hospital In-Patient Enquiry (HIPE) discharged between 2005 and 2014. Indicators of complexity included the Charlson index, overall length of stay (LOS), intensive care unit LOS and deaths in hospital, analysed by the major clinical classification software (CCS). Over the period, the number and rate of admissions increased, especially among those aged 85+. Indicators of patient complexity increased and LOS decreased. In-hospital mortality decreased from 5.9% to 4.7%. Hospitals appear to be managing the emergency care of the older and more complex patient more efficiently and with better outcomes.

Return to work after burns: a qualitative research study

As yet no qualitative research studies looking at return to work following burns have been published. The aim of this study was to investigate the "hows" and "whys" of return to work, by purposively selecting a cross-section of burns patients who returned to the same/similar job, those who returned to work but either on a part-time basis or in a different role/job and those who became or remained unemployed, and using semi-structured interviews to explore their experiences. Using matrix analysis methodology, and with the general themes that emerged from these transcripts, it was possible to place patients into 5 broad groups, the "defeated", the "burdened", the "affected", the "unchanged" and the "stronger". We anticipate that use of these general groups will be useful in targeting multi-disciplinary return to work strategies, and discuss how this qualitative research has changed practice at the Queen Victoria Hospital Burns Centre.

Evaluation of the utility of the HemoCue 301 haemoglobinometer for blood donor screening

BACKGROUND AND OBJECTIVES

Reliable blood donor screening requires more accurate measure of haemoglobin (Hb) than by either copper sulphate or the haemoglobin colour scale. The HemoCue haemoglobinometer has established a method for this, but it is considerably more expensive; a modified version (HemoCue 301) has now been developed with a cheaper reagent-free cuvette for use in budget-restricted situations. This report describes evaluation of the performance, the assessment of reproducibility and accuracy of this modified analyser against the reference technique for Hb measurement.

MATERIALS AND METHODS

Over 300 routine blood samples from specimens received routinely in a hospital laboratory were tested in accordance with the International Committee for Standardization in Haematology (ICSH) protocol. Accuracy and linearity were confirmed by the reference method with the WHO international haemoglobincyanide reference standard. Tests were also performed on selected samples for checking interference by biochemical abnormalities and leucocytosis. The effects of various sample storage conditions prior to testing were also tested.

RESULTS

Ninety per cent of results were within 4% of true values, 96% within 6% and in only three cases was the deviation > 10%, due to interference by bilirubinaemia and/or C-reactive protein. At an Hb value of 120 g/l for donor selection, there were no cases where the method would have been misleading.

CONCLUSION

HemoCue 301 provides a simple and reliable anaemia screen method, conforming to the requirements of CLIA'88 regulations; it is reliable for discriminating Hb values for donor acceptance. The main advantage is that the cuvettes are significantly cheaper than the previous models, and will not deteriorate in adverse climatic conditions.

A framework for the design of ambulance sirens

Ambulance sirens are essential for assisting the safe and rapid arrival of an ambulance at the scene of an emergency. In this study, the parameters upon which sirens may be designed were examined and a framework for emergency vehicle siren design was proposed. Validity for the framework was supported through acoustic measurements and the evaluation of ambulance transit times over 240 emergency runs using two different siren systems. Modifying existing siren sounds to add high frequency content would improve vehicle penetration, detectability and sound localization cues, and mounting the siren behind the radiator grill, rather than on the light bar or under the wheel arch, would provide less unwanted noise while maintaining or improving the effective distance in front of the vehicle. Ultimately, these considerations will benefit any new attempt to design auditory warnings for the emergency services.

Primary care anticoagulant management using near patient testing

BACKGROUND

Indications for anticoagulant treatment are increasing and new approaches to anticoagulant services require a shift from hospital to primary care.

AIM

To pragmatically test the validity and effectiveness of primary care anticoagulant management using near patient testing.

METHODS

Twelve CoaguCheck monitors were supplied to 16 rural practices that had previously provided supervision of anticoagulant therapy. Practices were required to record data for eligible patients from September 1998 to April 1999 and to forward one blood sample per week to the regional hospital laboratory for parallel testing.

RESULTS

Nine practices returned data on 122 patients. Indications for anticoagulation Included atrial fibrillation (n = 56), valve replacement (n = 12) and deep venous thrombosis or pulmonary embolus (n=12). Regression of the mean of 185 paired readings against their difference confirmed the validity of the CoaguCheck monitor (r2 = 0.00 [95% CI -0.38 to 0.38]). There were 692 International Normalised Ratio (INR) tests performed representing an average of 5.7 tests per patient. The desired therapeutic range was provided for 609 (88%) of these tests; 294 (48.3%) were within the desired therapeutic range. Results differed significantly between practices.

CONCLUSIONS

This study confirmed the validity of anticoagulant management using the CoaguCheck monitor in primary care.

Indicators of deprivation, voting patterns, and health status at area level in the Republic of Ireland

STUDY OBJECTIVE

To determine what relation, if any, exists between mortality patterns, indicators of deprivation, general lifestyle and social attitudes, as exemplified by general election voting pattern, in the Republic of Ireland. A relation has been demonstrated previously between voting and mortality patterns in the United Kingdom.

DESIGN

Cross sectional ecological study using three data sources. Standardised mortality ratios (SMR) were based on mortality rates at county level and 1996 census data from the Central Statistics Office, 1997 general election first preference voting data in all 41 constituencies were aggregated to county level. Selected reported measures of health status, lifestyle and social circumstances are from the first ever National survey on lifestyles, attitudes and nutrition (SLAN). This study comprised adults over 18 years sampled by post using the electoral register from 273 representative district electoral divisions. Univariate inter-relations were examined at individual level for the dataset as a whole, adjusting for age and at aggregated level for 26 county borough areas, which included the two largest cities and for 22 county areas, which afforded correlation with voting pattern, using the method of Pearson's correlation coefficient.

PARTICIPANTS

1,806,932 votes were cast nationally at the 1997 general election, representing a voter turnout of 65.92 %. There was an overall response rate of 62% to SLAN comprising 6539 adults (47% male). The demographic pattern of survey respondents was consistent with that of the general population over 18 years.

MAIN RESULTS

At individual level there was a large number of highly significant inter-relations between indicators of deprivation, various measures of self rated health status and lifestyle factors. Aggregated at 26 county level percentage unemployed (r=0.408, p=0.038), and level of education (r=0.475, p=0.014) related significantly to SMR and inversely to both fruit and vegetable consumption (r= -0.672, p=0.001) and excess alcohol consumption among men (r= -595, p=0.003). Those rating their health as fair or poor were more likely to report a poor quality of life (r=0.487, p=0.022), to have none or primary school education only (r=0.428, p=0.047), or to have a means tested medical services card (r=0.428, p=0.047). There was no significant relation between SMR and voting pattern for the two main political parties (67.28% first preferences) but a significant relation with left wing voting (r=0.446, p=0.037). Fianna Fail voting pattern was inversely related to level of dissatisfaction with health (r= -0.59, p<0.05). There was a positive significant relation between left wing voting and dissatisfaction with health (r=0.51, p<0.02) and rate of smoking (r=0.47, p=0.03). Smoking pattern also related positively to rates of voter abstention (r=0.526, p=0.12).

CONCLUSIONS

These data are consistent with those in other countries in showing a relation between deprivation indicators and lifestyle, but differ in that no relation with SMR and the votes cast for the main parties was seen in a country with a mainly centre right voting pattern. The relation between left wing voting pattern and some indicators of deprivation and lifestyle suggest that party political voting patterns and affiliations could be a useful indicator of vertical social capital. However, its variability as a measure across countries suggests that the inter-relation between sociocultural and economic factors and the consequent influence on health status is not straightforward.

Tuberculosis incidence in Northern Ireland and the Republic of Ireland--a collaborative study

We examined the incidence of tuberculosis in the Republic of Ireland and Northern Ireland for 1991 using the Census of Population for both jurisdictions, data from a National Survey of Tuberculosis for 1991 for the Republic and examination of nominal notification data for Northern Ireland. We showed that there is a significantly higher incidence of TB in the Republic of Ireland. More cases were reported (p < 1.0 x 10(-7)) as were more bacteriologically proven cases (p < 1.0 x 10(-7)). The difference was true for each of the following age groups (< 15 years, 15-35 years, 35-54 years and > 55 years) but it is noteworthy that areas in the Republic which make use of neonatal BCG vaccine did not have a significantly different rate of tuberculosis for individuals less than 15 years (p = 0.34) compared to Northern Ireland.

Neonatal BCG vaccination in Ireland: evidence of its efficacy in the prevention of childhood tuberculosis

Data from the 1986 and 1991 National Tuberculosis Survey were used, together with the Census of Population for those years, to try and determine whether bacille Calmette-Guerin (BCG) vaccination policy had any influence on the reported incidence of tuberculosis in the Republic of Ireland. The age-specific incidence of tuberculosis for the country as a whole and for local areas, was determined with respect to neonatal BCG vaccination. Based on these data, the reported incidence of tuberculosis in people aged 15 yrs or younger in areas without a policy of neonatal BCG was shown to be significantly higher compared to areas that use neonatal BCG vaccination (p = 1.5x10(-5) in 1986; and p = 1.0x10(-7) for 1991). It was estimated that some 646 vaccinations needed to be given to prevent one case of tuberculosis in 1986, and that the figure for 1991 was 551 vaccinations. This evidence supports a policy of continued neonatal bacille Calmette-Guerin vaccination in the population of the Republic of Ireland at present.

Neonatal BCG vaccination in Ireland: evidence of its efficacy in the prevention of childhood tuberculosis

Data from the 1986 and 1991 National Tuberculosis Survey were used, together with the Census of Population for those years, to try and determine whether bacille Calmette-Guerin (BCG) vaccination policy had any influence on the reported incidence of tuberculosis in the Republic of Ireland. The age-specific incidence of tuberculosis for the country as a whole and for local areas, was determined with respect to neonatal BCG vaccination. Based on these data, the reported incidence of tuberculosis in people aged 15 yrs or younger in areas without a policy of neonatal BCG was shown to be significantly higher compared to areas that use neonatal BCG vaccination (p = 1.5x10(-5) in 1986; and p = 1.0x10(-7) for 1991). It was estimated that some 646 vaccinations needed to be given to prevent one case of tuberculosis in 1986, and that the figure for 1991 was 551 vaccinations. This evidence supports a policy of continued neonatal bacille Calmette-Guerin vaccination in the population of the Republic of Ireland at present.

The effect of a cervical collar on the tidal volume of anaesthetised adult patients

Semi-rigid cervical collars may be used to assist the stabilisation of the cervical spine during transport in patients suffering from major trauma. We have attempted to evaluate the effect of one such collar on airway patency in the presence of depressed airway reflexes. Thirty-eight patients undergoing anaesthesia via face mask with spontaneous ventilation were studied. Tidal volume was measured with the airway in three different positions, both with and without a collar. The collar made no statistically significant difference to tidal volume in any position. Changing support of the airway increased tidal volume both with and without the collar. Patients fitted with an incorrectly sized collar may develop upper airway obstruction in the presence of impaired consciousness. Experience should be gained in the correct fitting of semi-rigid collars.

Interaction between baricity (glucose concentration) and other factors influencing intrathecal drug spread

The effects of intrathecal injection of 0.5% bupivacaine in solutions containing various concentrations of glucose have been studied in four groups of 20 patients. When solutions containing 0.8% glucose were injected at the L3-4 interspace the median maximum extent of block was higher, and the range of blocks wider, with the 8% solutions. All patients receiving 0.8% glucose had blocks between the T5 and T10 dermatomes, confirming previous work on the benefits of this concentration of glucose. In the two other groups 0.5% bupivacaine containing 0 or 0.8% glucose was injected at the L2-3 interspace. In both groups of patients a wider range of blocks, with a median maximum extent that was higher, was produced. These results demonstrate how glucose concentration may be used to influence the spread of intrathecal solutions and how other factors can obscure the effect of glucose concentration.

Comparison of extradural and intravenous diamorphine as a supplement to extradural bupivacaine

The influence of route of administration (extradural as compared with intravenous) of diamorphine 0.5 mg/hour as a supplement to extradural bupivacaine (0.125% at 15 ml/hour) was investigated in two groups of 20 patients who underwent major abdominal gynaecological surgery. Significantly more patients in the intravenous group withdrew because of inadequate analgesia (p less than 0.05). Those in the extradural group were significantly more drowsy throughout the study (p less than 0.01), but no major side effects were encountered.

Comparison of extradural ropivacaine and bupivacaine

Ropivacaine, a new long acting amide type local anaesthetic, was compared with bupivacaine in a randomized double-blind study. One hundred and ten patients undergoing extradural anaesthesia received a test dose of 3 ml of 1% lignocaine with adrenaline which was followed by 15 ml of one of five solutions: 0.5, 0.75 or 1.0% ropivacaine or 0.5 or 0.75% bupivacaine. There was little difference between the groups with respect to speed of onset or sensory block. The duration of analgesia was increased by increasing the concentration of both drugs, but this had minimal effect on onset time or extent of block. When the same concentration of each drug was administered, there were inconsistent differences in duration of sensory block, none of which was statistically significant. Increasing concentration of both drugs resulted in greater degree and longer duration of motor block. Ropivacaine produced a slower onset, shorter duration and less intense motor block than the same concentration of bupivacaine. The cardiovascular changes were similar in all groups.

Ethyl chloride and venepuncture pain: a comparison with intradermal lidocaine

One hundred and twenty unpremedicated patients undergoing gynaecological surgery were randomly allocated to one of three equal treatment groups to assess the effectiveness of ethyl chloride in producing instant skin anaesthesia to prevent the pain of venepuncture from a 20 G cannula. They received either no anaesthetic, 0.2 ml one per cent lidocaine plain intradermally or a ten-second spray of ethyl chloride at the cannulation site. Ethyl chloride produced skin anaesthesia that significantly reduced the pain of venepuncture. However, it was not as effective as intradermal lidocaine. It had no effect on vein visualisation or ease of cannulation. Ethyl chloride can be recommended as a method of producing instant skin anaesthesia.

Evaluation of the efficacy of elastic compression stockings in prevention of hypotension during epidural anaesthesia for elective caesarean section

The ability of graduated compression elastic stockings to prevent hypotension during elective epidural caesarean section was evaluated. Twenty women were randomly assigned to two groups of ten, one group being fitted with the stockings. The incidence and degree of hypotension were the same in both groups. Graduated compression elastic stockings are of no benefit in reducing the incidence of maternal hypotension during caesarean section.

Comparison of the cognitive effects of premedication with hyoscine and atropine

An investigation was carried out comparing the nature and duration of the cognitive effects of atropine and hyoscine. Thirty patients undergoing a minor gynaecological operation were randomly assigned to one of three groups to receive hyoscine, atropine or placebo as premedication. A battery of psychological tests was administered before premedication, 30 min after premedication, and 1 and 3 h following operation. The tests included orientation questions, simple tasks such as reciting the alphabet, memory tests, a reaction-time test and two tests of visuo-motor co-ordination. The results showed that hyoscine had detrimental effects on memory and on motor tasks compared with placebo, while atropine did not. In addition, the effects on motor performance had not disappeared 3 h after operation.

Stabilization of atlantoaxial subluxation in the dog, using the nuchal ligament

A technique for the stabilization of atlantoaxial subluxation in the dog was developed. The technique involved use of the nuchal ligament as a means of securing the spinous process of the axis to the dorsal arch of the atlas. Two cases were typical atlantoaxial subluxation in toy-breed dogs, and 2 cases were traumatic subluxation secondary to fracture of the axis in dogs of large breeds. On the basis of the results in these cases, it was concluded that the technique has advantages over techniques in which wire or nonmetallic suture material is utilized for stabilization.

Cadmium exposure and renal accumulation in an Australian urban population

An indication of the degree of cadmium exposure and renal accumulation in an Australian population (Brisbane) has been obtained from cadmium determinations of urine from 98 patients and post-mortem kidney specimens from 91 patients. Urinary excretion of cadmium from normal or unexposed adults and lead exposed adults was consistent with normal values from other developed countries. There was no apparent relationship between cadmium and lead excretion levels for individual urine specimens. Renal cadmium concentrations were used to estimate the average total cadmium content for a "standard man" and renal cortex concentrations. The results were similar to reported studies from the United Kingdom and Europe, but lower than those from Japan. Daily intake of cadmium was estimated to be 30 to 50 mug, which compares favourably with the FAO/WHO1 "provisional tolerable weekly intake" of 0-4 to 0-5 mg cadmium per adult per week. It is concluded that Australian populations exposed to potential sources of industrial and environmental cadmium contamination should be investigated.