Bedside Ultrasound in the Emergency Department Enables Rapid Diagnosis of PUJ Obstruction Syndrome

Presentation A 27-year-old male presented to the Emergency Department with acute severe left flank pain following ingestion of 5 pints of beer. Approximately 20 bouts of similar episodes over the past year, in the setting of alcohol ingestion. Despite attending GP, no diagnosis reached yet. Diagnosis "Pelvo-ureteric junction (PUJ) obstruction Syndrome". Bedside ultrasound in the Emergency Department during the acute pain crisis: massive hydronephrosis left kidney. Finding confirmed on CT scan. Subsequent 99m-Tec renogram showed markedly decreased renal function on the left. Treatment Interval Pyeloplasty two months later. Conclusion Delayed recognition is the norm for PUJ obstruction syndrome, as CT/MRI/US studies often do not display hydronephrosis if the patient is asymptomatic. We could not find any reports in the literature of diagnosing PUJ obstruction syndrome using bedside ultrasound in the Emergency Department. We advise acquiring rapid bedside ultrasound imaging in suspected cases of PUJ obstruction syndrome, enabling earlier diagnosis.

Children with congenital colorectal malformations during the UK Sars-CoV-2 pandemic lockdown: an assessment of telemedicine and impact on health

PURPOSE

This pilot study was designed to assess bowel function and quality of life (QoL) in children and adolescents with congenital colorectal malformations (CCM) during the first UK COVID lockdown period.

METHODS

Changes in health were assessed through semi-structured interviews, gastrointestinal functional outcomes using Krickenbeck scoring and QoL by the modified disease-specific HAQL (Hirschsprung's disease anorectal malformation quality of life questionnaire). The State-Trait Anxiety Inventory (STAI)™ for adults was used to assess parental anxiety.

RESULTS

Thirty-two families were interviewed; 19 (59%) reported no change in their child's health during the lockdown, 5 (16%) a deterioration and 8 (25%) an improvement. Neither the severity of the CCM, nor the degree of bowel dysfunction, correlated with any deterioration. The HAQL score was not correlated to a change in health. Anxiety scores ranged from no anxiety to clinical concerns. Telemedicine was well accepted by 28/32 parents (88%); however, in-person appointments were preferred if there were clinical concerns.

CONCLUSION

In the follow-up of children and adolescents with CCM during the first UK lockdown using telemedicine we found that over half had stable health conditions. Patients needing additional care could not be predicted by the severity of their disease or their bowel function alone.

Inadvertent Antegrade Urethral Placement of a Suprapubic Catheter

Presentation A 55-year-old male patient with neuropathic bladder secondary to multiple sclerosis (MS) presented to the EmergencyDepartment (ED) with abdominal pain and no output from his suprapubic catheter (SPC) that was changed 24 hourspreviously. Diagnosis On examination, the SPC-tip was clearly visible at the external urethral meatus. Treatment The patient was managed by gently deflating the anchoring balloon, exchanging the SPC and a period of observationto ensure adequate catheter drainage. Conclusion Important learning points from this case are to observe urine draining after routine SPC change and to examine thegenitalia when a misplaced SPC is suspected.

A prolonged outbreak of invasive meningococcal disease in an extended Irish Traveller family across three Health Service Executive (HSE) areas in Ireland, 2010 to 2013

Between March 2010 and November 2013 eight laboratory-confirmed cases of serogroup B, invasive meningococcal disease (IMD) were identified in an extended Irish Traveller family across three Health Service Executive (HSE) areas of Ireland. Cases were aged between 5 and 46 months, and were either a cousin or sibling of another case. All eight cases survived. Chemoprophylaxis was given to relevant nuclear family members and close contacts on each occasion, but failed to prevent further cases. Neisseria meningitidis isolates from six cases were highly related, belonging to the ST-41/44 clonal complex, and shared the porA designation 7–2,4. In November 2013, the outbreak control team recommended that directly observed ciprofloxacin chemoprophylaxis be administered simultaneously to the extended family, and that the four component meningococcal B (4CMenB) vaccine be administered to family members aged 2 months to 23 years inclusive and relevant close contacts of the eighth case. Subsequently these recommendations were implemented at three regional clinics. Additionally pharyngeal swabs (n=112) were collected to assess carriage rates of N. meningitidis in this extended family. Pharyngeal carriage of N. meningitidis was detected in 15 (13%) family members. From the epidemiological investigation and carriage study overcrowding was the most likely risk factor identified in this outbreak. To date, the combination of directly observed ciprofloxacin chemoprophylaxis and use of 4CMenB vaccine have controlled the outbreak with no further cases diagnosed.

Describing readmissions to an Ebola case management centre (CMC), Sierra Leone, 2014

Case management centres (CMCs) are part of the outbreak control plan for Ebola virus disease (EVD). A CMC in Sierra Leone had 33% (138/419) of primary admissions discharged as EVD negative (not a case). Fifteen of these were readmitted within 21 days, nine of which were EVD positive. All readmissions had contact with an Ebola case in the community in the previous 21 days indicating that the infection was likely acquired outside the CMC.

Describing readmissions to an Ebola case management centre (CMC), Sierra Leone, 2014

Case management centres (CMCs) are part of the outbreak control plan for Ebola virus disease (EVD). A CMC in Sierra Leone had 33% (138/419) of primary admissions discharged as EVD negative (not a case). Fifteen of these were readmitted within 21 days, nine of which were EVD positive. All readmissions had contact with an Ebola case in the community in the previous 21 days indicating that the infection was likely acquired outside the CMC.

Staff support for the Health Service Executive (HSE) global health programme

The Global Health programme (GHP) within the Health Service Executive (HSE) aims to improve health in developing countries by creating partnerships between Irish and developing world healthcare institutions. To ascertain the level of interest among HSE staff for the GHP a web-based survey was conducted. 1,028 responses were received. Medical professionals, 202 (27.7%) composed the largest category of respondents. The majority, 503 (69.3%) of respondents wished to actively participate in the GHP. 237 (23.1%) staff had previous experience of working in the developing world. This survey highlighted a number of themes respondents considered important for successful partnerships including: reciprocal staff exchange, joint scientific research, the avoidance of "brain drain" and utilising the Internet to link institutions. Less than 1% (2/203) of comments expressed a negative view of the GHP.

Use of a geographic information system to map cases of measles in real-time during an outbreak in Dublin, Ireland, 2011

In 2011, there was a large measles outbreak in Dublin. Nationally 285 cases were notified to the end of December 2011, and 250 (88%) were located in the Dublin region. After the first case was notified in week 6, numbers gradually increased, with 25 notified in June and a peak of 53 cases in August. Following public health intervention including a measles-mumps-rubella (MMR) vaccination campaign, no cases were reported in the Dublin region in December 2011. Most cases (82%) were children aged between 6 months and 14 years, and 46 cases (18%) were under 12 months-old. This is the first outbreak in Dublin to utilise a geographic information system for plotting measles cases on a digital map in real time. This approach, in combination with the analysis of case notifications, assisted the department of public health in demonstrating the extent of the outbreak. The digital mapping documented the evolution of two distinct clusters of 87 (35%) cases. These measles cases were infected with genotype D4-Manchester recently associated with large outbreaks across Europe. The two clusters occurred in socio-economically disadvantaged areas and were attributable to inadequate measles vaccination coverage due in part to the interruption of a school-based MMR2 vaccination programme.

DIALYSIS: PROLONGING LIFE OR PROLONGING DYING? ETHICAL, LEGAL AND PROFESSIONAL CONSIDERATIONS FOR END OF LIFE DECISION MAKING

There are over 7,000 people on dialysis in Australia and this is predicted to increase due to the ageing population and the high incidence of diabetes mellitus. Discontinuation of dialysis is the second most frequent cause of death in dialysis patients in Australia. Risk factors for the discontinuation of dialysis include: co-morbidities (especially diabetes mellitus) and being older. Because the decision to discontinue dialysis is a major life choice, collaborative decision making should be encouraged, and the patient needs assurances of the continuation of care and kindness, a palliative care plan, and the alleviation of suffering. Patients decide to discontinue dialysis because of an unacceptable quality of life, depression and a chronic failure to thrive. Health professionals need to support end of life decision making using an ethical decision framework. A review of current literature was undertaken and revealed a paucity of information in regard to palliation in those with end stage renal disease who had discontinued dialysis. The fear of dying, pain, suffering, and abandonment that a patient and/or their family may perceive as being associated with death may create barriers to decisions to discontinue with dialysis treatments. Therefore health care personnel should provide information with honesty to allow patients to predict their quality of life and death. Support for the patient and family during the dying period should be multi-disciplinary, with clear and timely communication between all members of the team.

High dependency care: impact of lack of facilities for high-risk surgical patients

BACKGROUND

The difference between the level of care available on general ward areas and intensive care units (ICUs) has resulted in the development of high dependency units (HDUs).

AIMS

This study examined the current perioperative management techniques and clinical care settings of high-risk surgical patients in a hospital without a HDU.

METHODS

A prospective audit of high-risk surgical patients was performed over an eight-week period. Using a pre-operative questionnaire, the anaesthetist categorised patient suitability for one of three post-operative care areas. In addition, desired and actual post-operative monitoring, pain management and organ support were indicated.

RESULTS

Seven (25%) of 28 patients admitted to ICU were rated HDU suitable indicating inappropriate use of resources, while 27 (75%) of 36 patients admitted to the general ward were categorised as fulfilling HDU admission criteria. A total of 21/27 (78%) and 12/27 (44%) of this latter group had alteration of idealised post-operative pain management and haemodynamic invasive monitoring plans respectively.

CONCLUSIONS

The absence of an intermediate care area facility in a tertiary hospital without an acute pain team impacts on the type of perioperative care provided to patients and the optimal use of resources.

Application of Ugi reactions in synthesis of divalent neoglycoconjugates: evidence that the sugars are presented in restricted conformation

[reaction: see text]. The Ugi reaction has been used to prepare divalent galactose derivatives. NMR analysis shows that a divalent neoglycoconjugate, where the glycopeptides are bridged by a terephthaloyl group, is an 83:17 mixture of two conformers; the amide groups of the major isomer have E-anti conformations. The spatial relationship and the relative orientation of the sugars are restricted, which may have consequences for the recognition of this and related structures in biological systems.

Design of an interface to allow microfluidic electrophoresis chips to drink from the fire hose of the external environment

An interface design is presented that facilitates automated sample introduction into an electrokinetic microchip, without perturbing the liquids within the microfluidic device. The design utilizes an interface flow channel with a volume flow resistance that is 0.54-4.1 x 10(6) times lower than the volume flow resistance of the electrokinetic fluid manifold used for mixing, reaction, separation, and analysis. A channel, 300 microm deep, 1 mm wide and 15-20 mm long, was etched in glass substrates to create the sample introduction channel (SIC) for a manifold of electrokinetic flow channels in the range of 10-13 microm depth and 36-275 microm width. Volume flow rates of up to 1 mL/min were pumped through the SIC without perturbing the solutions within the electrokinetic channel manifold. Calculations support this observation, suggesting a leakage flow to electroosmotic flow ratio of 0.1:1% in the electrokinetic channels, arising from 66-700 microL/min pressure-driven flow rates in the SIC. Peak heights for capillary electrophoresis separations in the electrokinetic flow manifold showed no dependence on whether the SIC pump was on or off. On-chip mixing, reaction and separation of anti-ovalbumin and ovalbumin could be performed with good quantitative results, independent of the SIC pump operation. Reproducibility of injection performance, estimated from peak height variations, ranged from 1.5-4%, depending upon the device design and the sample composition.

Comparative studies on peptides representing the so-called tachykinin-like region of the Alzheimer Abeta peptide [Abeta(25-35)]

In an attempt to answer the question of whether or not the so-called tachykinin-like region of the Alzheimer beta-amyloid protein [Abeta(25-35)] can act as a tachykinin, the sequences Abeta(25-35), Abeta(25-35)amide and their norleucine-35 and phenylalanine-31 analogues were synthesized. These peptides were examined with ligand binding studies, electron microscopy, CD and NMR. In all cases some differences were found between the Abeta(25-35) analogue and the corresponding Phe31 peptide. In addition, in ligand displacement studies on tachykinin NK1 receptors, only the Phe31 analogue showed activity comparable to that of genuine tachykinins. We conclude that peptides based on Abeta(25-35) but with a Phe residue at position 31 do display properties typical of a tachykinin, but that peptides with Ile at this position do not.

Micromachined analytical devices: microchips for semen testing

Micromachined devices (microchips) have been designed and tested for a range of clinically important assays. In this study we compare sperm motility determined using disposable glass microchips and a conventional Makler chamber. The 17 x 14 mm glass microchips contained three etched test structures each comprising either duplicate or quadruplicate analytical microchannels. Semen samples with sperm counts ranging from 21 to 78 million sperm per ml and forward progression scores of from 1+ to 3+ were evaluated and swimming times ranging from 360 s (3.3+ progression) to 770 s (1+,2 forward progression) observed in the microchips. Motility determined by the time taken for sperm to swim to the end of a microchannel (100 microns wide x 40 microns deep x 10 mm long) in the microchip correlated with forward progression of the sperm determined by the conventional Makler chamber method. This study demonstrates the feasibility of microchips for sperm motility testing and suggests that this technique would be applicable to the study of other types of motile cells.

Propranolol reduces the anxiety associated with day case surgery

OBJECTIVE

To find out if propranolol, a non-cardioselective beta-blocker, can reduce the anxiety associated with day case surgery.

DESIGN

Prospective randomized double blind trial.

SETTING

University hospital, Ireland.

SUBJECTS

An unselected group of 53 patients undergoing day case surgery.

INTERVENTION

Subjects randomised to receive either propranolol (10 mg) or placebo on the morning of operation.

MAIN OUTCOME MEASURES

Blood pressure; pulse, anxiety, pain score and patient satisfaction.

RESULTS

Mean (SD) Hospital Anxiety and Depression score was significantly lower in the propranolol group than in the control group (2.5 (0.7) compared with 4.6 (0.7), p < 0.0001) before discharge.

CONCLUSION

A low dose of propranolol given on the morning of day case surgery significantly reduced patients' anxiety.

Anaesthesia for thyroplasty

The purpose of this report is to describe the anaesthetic considerations for layngoplastic procedures. Thyroplasty is a procedure which restores the voice in unilateral vocal cord paralysis. The procedure employs an external approach via a window cut at the appropriate level in the thyroid ala. A wedge of silastic is inserted against the inner perichondrium, thereby displacing the vocal cord medially and permitting voice production. Correct placement of the implant is assessed by asking the patient to phonate; patient cooperation is therefore necessary at certain times during the procedure. We describe our management of a patient undergoing thyroplasty. The use of a benzodiazepine agonist-antagonist combination provided both optimal operating conditions and patient comfort.

Purtscher's retinopathy and fat embolism

A 19-year-old woman who sustained multiple trauma but no head injury developed fulminant fat embolism syndrome (FES). Her neurological deterioration was associated with cerebral oedema and the concomitant Purtscher's type retinopathy. We suggest that the pathogenesis of the retinopathy and of the cerebral oedema are the same and that Purtscher's retinopathy and retinopathy of the FES are indistinguishable.

Epidural buprenorphine for pain relief after major abdominal surgery. A controlled comparison with epidural morphine

In a controlled trial epidural buprenorphine was compared with epidural morphine as the sole means of analgesia after major abdominal surgery. Bolus injections of buprenorphine 60 micrograms in 10 ml or morphine 2 mg in 10 ml of normal saline were given on demand for the first 48 hours postoperatively. Both drugs produced significant reduction in pain scores as assessed by the linear visual analogue scale and both produced prolonged analgesia at this dosage, which could be extended by further 'top-ups'. The authors conclude that, for postoperative epidural analgesia, buprenorphine may be the opiate of choice and the reasons for this are discussed.