Advancing early detection of suicide? A national study examining socio-demographic factors, antecedent stressors and long-term history of self-harm

BACKGROUND

A range of factors including mental disorders, adverse events and history of self-harm are associated with suicide risk. Further examination is needed of the characteristics of suicides which occur without established risk factors, using national surveillance systems.

METHODS

Data on all suicides in Ireland from 2015 to 2017 were drawn from the Irish Probable Suicide Deaths Study (IPSDS). Variables examined included socio-demographics, psychiatric history and precipitant stressors. Suicide data were linked with data on prior self-harm from the National Self-Harm Registry Ireland (NSHRI). Latent Class Analysis (LCA) was used to identify sub-groups of suicide cases.

RESULTS

Of the 1809 individuals who died by suicide, 401 (22.2 %) had a history of hospital-treated self-harm. Four distinct profiles of suicides were identified. One group was marked by high levels of prior self-harm and mental health conditions. Two of the groups included few individuals with a history of self-harm but had notably high levels of mental health conditions. These two groups had relatively high levels of reported chronic pain or illness but differed in terms of socio-demographics. The final group, predominantly male, had markedly low levels of mental health conditions or self-harm but high levels of personal stressors and substance use.

LIMITATIONS

The use of coronial data may be limited by bias in the collecting of information from the deceased's family members.

CONCLUSIONS

A sub-group of suicide cases exists without any psychiatric or self-harm history but with salient occupational or health-related proximal stressors. Suicide prevention interventions should include occupational settings and should promote mental health literacy.

Evaluation of a national clinical programme for the management of self-harm in hospital emergency departments: impact on patient outcomes and the provision of care

BACKGROUND

Emergency departments are important points of intervention, to reduce the risk of further self-harm and suicide. A national programme to standardise the management of people presenting to the emergency department with self-harm and suicidal ideation (NCPSHI) was introduced in Ireland in 2014. The aim of this study was to evaluate the impact of the NCPSHI on patient outcomes and provision of care.

METHODS

Data on self-harm presentations were obtained from the National Self-Harm Registry Ireland from 2012 to 2017. The impacts of the NCPSHI on study outcomes (3-month self-harm repetition, biopsychosocial assessment provision, admission, post-discharge referral, and self-discharge) were examined at an individual and aggregate (hospital) level, using a before and after study design and interrupted time series analyses, respectively. The 15 hospitals that implemented the programme by January 2015 (of a total of 24 between 2015 and 2017) were included in the analyses.

RESULTS

There were 31,970 self-harm presentations during the study period. In hospitals with no service for self-harm (n = 4), risk of patients not being assessed reduced from 31.8 to 24.7% following the introduction of the NCPSHI. Mental health referral in this hospital group increased from 42.2 to 59.0% and medical admission decreased from 27.5 to 24.3%. Signs of a reduction in self-harm repetition were observed for this hospital group, from 35.1 to 30.4% among individuals with a history of self-harm, but statistical evidence was weak. In hospitals with a pre-existing liaison psychiatry service (n = 7), risk of self-discharge was lower post-NCPSHI (17.8% vs. 14.8%). In hospitals with liaison nurse(s) pre-NCPSHI (n = 4), medical admission reduced (27.5% vs. 24.3%) and there was an increase in self-harm repetition (from 5.2 to 7.8%. for those without a self-harm history).

CONCLUSION

The NCPSHI was associated with improvements in the provision of care across hospital groups, particularly those with no prior service for self-harm, highlighting the need to consider pre-existing context in implementation planning. Our evaluation emphasises the need for proper resourcing to support the implementation of clinical guidelines on the provision of care for people presenting to hospital with self-harm.

Gate-controlled suppression of light-driven proton transport through graphene electrodes

Recent experiments demonstrated that proton transport through graphene electrodes can be accelerated by over an order of magnitude with low intensity illumination. Here we show that this photo-effect can be suppressed for a tuneable fraction of the infra-red spectrum by applying a voltage bias. Using photocurrent measurements and Raman spectroscopy, we show that such fraction can be selected by tuning the Fermi energy of electrons in graphene with a bias, a phenomenon controlled by Pauli blocking of photo-excited electrons. These findings demonstrate a dependence between graphene's electronic and proton transport properties and provide fundamental insights into molecularly thin electrode-electrolyte interfaces and their interaction with light.

Proton transport through nanoscale corrugations in two-dimensional crystals

Defect-free graphene is impermeable to all atoms1-5 and ions6,7 under ambient conditions. Experiments that can resolve gas flows of a few atoms per hour through micrometre-sized membranes found that monocrystalline graphene is completely impermeable to helium, the smallest atom2,5. Such membranes were also shown to be impermeable to all ions, including the smallest one, lithium6,7. By contrast, graphene was reported to be highly permeable to protons, nuclei of hydrogen atoms8,9. There is no consensus, however, either on the mechanism behind the unexpectedly high proton permeability10-14 or even on whether it requires defects in graphene's crystal lattice6,8,15-17. Here, using high-resolution scanning electrochemical cell microscopy, we show that, although proton permeation through mechanically exfoliated monolayers of graphene and hexagonal boron nitride cannot be attributed to any structural defects, nanoscale non-flatness of two-dimensional membranes greatly facilitates proton transport. The spatial distribution of proton currents visualized by scanning electrochemical cell microscopy reveals marked inhomogeneities that are strongly correlated with nanoscale wrinkles and other features where strain is accumulated. Our results highlight nanoscale morphology as an important parameter enabling proton transport through two-dimensional crystals, mostly considered and modelled as flat, and indicate that strain and curvature can be used as additional degrees of freedom to control the proton permeability of two-dimensional materials.

An analysis of hospital-treated attempted hanging and drowning in Ireland, 2007-2019

Background

Highly lethal of methods of self-harm, such as attempted hanging and drowning, are a major public health concern due to their high associated risk of completed suicide. This study aims to describe hospital presentations for attempted hanging and drowning in Ireland and explore the factors associated with self-harm and repeat self-harm by these methods.

Methods

Data on all self-harm presentations to Irish hospitals (2007-2019) were obtained from the National Self-Harm Registry Ireland, a national surveillance system of hospital-treated self-harm. Multivariable logistic regression was used to explore factors associated with any presentation for attempted hanging and drowning and factors associated with repetition of attempted hanging and drowning.

Results

There were 9,719 and 4,637 attempted hanging and drowning hospital presentations, respectively, in Ireland in 2007-2019. The odds of presentations being due to hanging, rather than due to any other self-harm method, were highest for males (aOR 2.88, 95% CI: 2.76-3.02), children aged <15 (aOR 1.32, 1.17-1.48) and in summer (aOR 1.09, 1.02-1.14). The odds of presentations being due to drowning, rather than due to any other self-harm method, were highest for those aged ≥55 (aOR 1.60, 1.43-1.78), homeless individuals (aOR 2.59, 2.32-2.89) and in autumn (aOR 1.15, 1.06-1.25). Repetition of attempted hanging was positively associated with homelessness (aOR 2.47, 2.02-3.04) and acute alcohol ingestion (aOR 1.12, 1.02-1.23). Similar associations were observed for repetition of attempted drowning.

Conclusions

This study identifies key population groups for whom the risk of self-harm, or repeat self-harm, by hanging and drowning is greatest. Universal, targeted and indicated interventions are needed to address the determinants of highly lethal methods of self-harm. Biopsychosocial assessments of those presenting after attempted hanging and drowning are essential, in view of their high risk of repeat self-harm and suicide.

Key messages

Wien effect in interfacial water dissociation through proton-permeable graphene electrodes

Strong electric fields can accelerate molecular dissociation reactions. The phenomenon known as the Wien effect was previously observed using high-voltage electrolysis cells that produced fields of about 10⁷ V m^-1, sufficient to accelerate the dissociation of weakly bound molecules (e.g., organics and weak electrolytes). The observation of the Wien effect for the common case of water dissociation (H₂O [Formula: see text] H⁺ + OH^-) has remained elusive. Here we study the dissociation of interfacial water adjacent to proton-permeable graphene electrodes and observe strong acceleration of the reaction in fields reaching above 10⁸ V m^-1. The use of graphene electrodes allows measuring the proton currents arising exclusively from the dissociation of interfacial water, while the electric field driving the reaction is monitored through the carrier density induced in graphene by the same field. The observed exponential increase in proton currents is in quantitative agreement with Onsager's theory. Our results also demonstrate that graphene electrodes can be valuable for the investigation of various interfacial phenomena involving proton transport.

Risk of repetition and subsequent self-harm following presentation to hospital with suicidal ideation: A longitudinal registry study

BACKGROUND

Few studies have focused on those who present to hospital with suicidal thoughts (suicidal ideation). The aim of this study was to establish the risk of repeat presentation to hospital following suicidal ideation and to identify factors which were associated with further ideation or subsequent self-harm.

METHODS

Data were obtained from the Northern Ireland Registry of Self-harm. Risk of repeat presentation following hospital-presenting ideation was analysed using Kaplan Meier analyses, specifically cox proportional hazard models.

FINDINGS

During the period April 2014 to March 2019, a total of 14,695 presentations to hospital due to suicidal ideation were made in Northern Ireland. The cumulative incidence of repeat presentation to hospital was 40·5% within five years, with an 18·3% risk of subsequent self-harm. Previous ideation had the strongest association with repeat presentation. There was evidence of recidivism considering further ideation, with an increased risk according to number of previous presentations. In contrast, risk of subsequent self-harm was highest after the first or second presentation. Male gender and alcohol were associated with further ideation, while females and young people were more likely to re-present with self-harm.

INTERPRETATION

The findings indicate that individuals who present to hospital with suicidal ideation are at risk of repeat presentation and future self-harm, however clinical guidelines do not specifically address hospital-presenting ideation. The transition from ideation to suicidal behaviour is important to consider and research could inform effective screening and early intervention measures.

ROLE OF FUNDING

The Northern Ireland Registry of Self-harm is funded by the Public Health Agency, Northern Ireland.

Review of external referrals to a regional stroke centre: it is not just about thrombectomy

AIMS

To determine the experience of a regional stroke referral centre of external referrals for endovascular thrombectomy (EVT) in patients with symptoms of acute ischaemic stroke (AIS) and large vessel occlusion (LVO).

MATERIALS AND METHODS

Data were collected prospectively over two 4-month periods (2017-2018) on consecutive external referrals for EVT. Baseline demographics, imaging findings, and key time parameters were recorded. Reasons for not transferring patients and for not performing EVT were recorded. Key time intervals were calculated and compared between the transferred and non-transferred group with and without intracranial occlusion and between the transferred patients who underwent thrombectomy and those who did not.

RESULTS

Two hundred and sixty-two patients were referred. Sixty-one percent (n=159) were accepted and transferred for treatment. Of those transferred, 86% (n=136) had EVT. Fourteen percent (n=23) were unsuitable for EVT on arrival due to no vessel occlusion (48% n=11), poor Alberta Stroke Program Early CT Score (ASPECTS)/established infarct (30%, n=7) haemorrhage (9%, n=2), and clinical recovery (13% n=3). One hundred and three patients (39%) were ineligible for EVT following phone discussion due to absence of intracranial occlusion (59%, n=61), low ASPECTS (22%, n=23), distal occlusion (4%, n=4), low/improving National Institutes of Health Stroke Scale (NIHSS; 10.7%, n=11), and poor modified Rankin Scale (mRS) at baseline (3%, n=3). Patients with LVO but not transferred had longer onset to hospital arrival time compared with those transferred 151.5 versus 91 minutes (p<0.005), with a trend also toward a longer door to CT/CTA 40 minutes versus 30 minutes (p=0.142).

CONCLUSION

These data provide valuable insights into the service provision of a comprehensive stroke network. The present rates of EVT and futile transfers are modest compared to published data. Access to neuroradiology and specialised stroke assessment is crucial to optimise time to treatment.

Psychosocial, psychiatric and work-related risk factors associated with suicide in Ireland: optimised methodological approach of a case-control psychological autopsy study

BACKGROUND

Suicide has profound effects on families and communities, but is a statistically rare event. Psychological autopsies using a case-control design allow researchers to examine risk factors for suicide, using a variety of sources to detail the psychological and social characteristics of decedents and to compare them to controls. The Suicide Support and Information System Case Control study (SSIS-ACE) aimed to compare psychosocial, psychiatric and work-related risk factors across three groups of subjects: suicide decedents, patients presenting to hospital with a high-risk self-harm episode, and general practice controls.

METHODS

The study design includes two inter-related studies; one main case-control study: comparing suicide cases to general practice (GP) controls, and one comparative study: comparing suicide cases to patients presenting with high-risk self-harm. Consecutive cases of suicide and probable suicide are identified through coroners' registration of deaths in the defined region (Cork City and County, Ireland) and are frequency-matched for age group and gender with GP patient controls recruited from the same GP practice as the deceased. Data sources for suicide cases include coroners' records, interviews with health care professionals and proxy informants; data sources for GP controls and for high-risk self-harm controls include interviews with control, with proxy informants and with health care professionals. Interviews are semi-structured and consist of quantitative and qualitative parts. The quantitative parts include a range of validated questionnaires addressing psychiatric, psychosocial and occupational factors. The study adopts several methodological innovations, including accessing multiple data sources for suicide cases and controls simultaneously, recruiting proxy informants to examine consistency across sources.

CONCLUSIONS

The study allows for the investigation of consistency across different data sources and contributes to the methodological advancement of psychological autopsy research. The study will also inform clinical and public health practice. The comparison between suicide cases and controls will allow investigation of risk and protective factors for suicide more generally, while the comparison with high-risk self-harm patients will help to identify the factors associated specifically with a fatal outcome to a self-harm episode. A further enhancement is the particular focus on specific work-related risk factors for suicide.

A Standardized Aspiration-First Approach for Thrombectomy to Increase Speed and Improve Recanalization Rates

BACKGROUND AND PURPOSE

Direct aspiration is a recognized technique for revascularization in large-vessel ischemic strokes. There is ongoing debate regarding its efficacy compared with stent retrievers. Every delay in achieving revascularization and a decrease in reperfusion rates reduces the likelihood of patients achieving functional independence. We propose a standardized setup technique for aspiration-first for all anterior circulation thrombectomy procedures for increasing speed and recanalization rates.

MATERIALS AND METHODS

We analyzed 127 consecutive patients treated by a standardized approach to thrombectomy with an intention to perform aspiration-first compared with 127 consecutive patients treated with a stent retriever-first approach. Key time metrics evaluated included groin to first angiogram, first angiogram to reperfusion, groin to first reperfusion, and length of the procedure. The degree of successful recanalization (TICI 2b-3) and the number of passes were compared between the 2 groups.

RESULTS

In 127 patients who underwent the standardized technique, the median time from groin puncture to first reperfusion was 18 minutes compared with 26 minutes (P < .001). The duration of the procedure was shorter compared with the stent retriever group (26 minutes in the aspiration first group versus 47 minutes, P < .001) and required fewer passes (mean, 2.4 versus 3.1; P < .05). A higher proportion of patients had a TICI score of 2b-3 in the aspiration-first group compared with stent retriever group (96.1% versus 85.8%, P < .005).

CONCLUSIONS

Our study highlights the increasing speed and recanalization rates achieved with fewer passes in a standardized approach to thrombectomy with an intention to attempt aspiration-first. Any attempt to reduce revascularization time and increase successful recanalization should be used.

Method of self-harm and risk of self-harm repetition: findings from a national self-harm registry

BACKGROUND

Risk of self-harm repetition has consistently been shown to be higher following self-cutting compared to intentional drug overdose (IDO) and other self-harm methods. The utility of previous evidence is limited due to the large heterogeneous method categories studied. This study examined risk of hospital presented self-harm repetition according to specific characteristics of self-harm methods.

METHODS

Data on consecutive self-harm presentations to hospital emergency departments (2010-2016) were obtained from the National Self-Harm Registry Ireland. Associations between self-harm method and repetition were analysed using survival analyses.

RESULTS

Overall, 65,690 self-harm presentations were made involving 46,661 individuals. Self-harm methods associated with increased repetition risk included minor self-cutting, severe self-cutting, multiple drug IDOs involving psychotropic drugs and self-harm by blunt object. Minor self-cutting was the method associated with highest repetition risk (adjusted hazard ratio (AHR) 1.38, 95% CI 1.31-1.45). Risk of repetition was comparable following IDOs of four or more drugs involving psychotropic drugs (AHR = 1.29, 95% CI 1.20-1.39), severe self-cutting (AHR 1.25, 95% CI 1.16-1.34) and blunt object (AHR = 1.23, 95% CI 1.07-1.42).

LIMITATIONS

Information was not available on suicide or other causes of mortality.

CONCLUSIONS

Self-harm method and the associated risk of repetition should form a core part of biopsychosocial assessments and should inform follow-up care for self-harm patients. The observed differences in repetition associated with specific characteristics of IDO underline the importance of safety planning and monitoring prescribing for people who have engaged in IDO.

Self-Harm, Methadone Use and Drug-Related Deaths amongst Those Registered As Being of No Fixed Abode or Homeless in Ireland

This work aims to contribute to the evidence base regarding the health of those who experience homelessness in Ireland by collating data on methadone use, drug-related deaths and emergency department presentations due to self-harm. Data from the Central Methadone Treatment List (CTL), National Self-Harm Registry Ireland and the National Drug-Related Deaths Index were analysed. The percentage on the CTL registered as being of no fixed abode (NFA) or homeless increased from 2% to 7% from 2011-2014. The absolute number of presentations with deliberate self-harm from those of NFA increased by 49% from 2007-2014. The number of drug-related deaths amongst those of NFA or homeless and who died in Dublin fluctuated from 2004-13 with an overall upward trend. There is an urgent need to adequately resource and coordinate those services which aim to address factors (social and health inequalities, mental ill-health and addiction) which lead people into - and prevent them exiting from - homelessness.

A computerized 360° feedback tool for personal and organizational development in general practice

360° feedback techniques (‘do we see ourselves as others see us?’) have been used extensively in the business sector for personal development. This paper describes a collaborative project in the UK in which the technique was contextualized for use in general practice, both as a personal development tool for individuals and as a practice development tool for the organization.

The application is based on questionnaires for completion by practice clinicians, members of staff and patients. These questionnaires investigate perceptions about (a) standards of performance (individual or organizational) in a number of competency areas (patient care, management, team-work, professional standards and consulting); and (b) the importance of these areas in terms of overall effectiveness/efficiency.

An iterative design was used to develop a computer program to aid data collection, automate data analysis and produce individualized results for participants/participating practices. The output identifies areas of effective performance and areas in need of improvement.

The application was piloted and evaluated in seven practices, results being fed back to participants by primary care facilitators. All practices found the 360° output valuable.

The computerized ‘Insight’ tool developed is sophisticated yet easy to use, having wide application in the areas of peer appraisal, practice planning and development.

Variation between hospitals in inpatient admission practices for self-harm patients and its impact on repeat presentation

PURPOSE

Self-harm patient management varies markedly between hospitals, with fourfold differences in the proportion of patients who are admitted to a medical or psychiatric inpatient bed. The current study aimed to investigate whether differences in admission practices are associated with patient outcomes (repeat self-harm) while accounting for differences in patient case mix.

METHODS

Data came from the National Self-Harm Registry Ireland. A prospective cohort of 43,595 self-harm patients presenting to hospital between 2007 and 2012 were included. As well as conventional regression analysis, instrumental variable (IV) methods utilising between hospital differences in rates of hospital admission were used in an attempt to gain unbiased estimates of the association of admission with risk of repeat self-harm.

RESULTS

The proportion of self-harm patients admitted to a medical bed varied from 10 to 74 % between hospitals. Conventional regression and IV analysis suggested medical admission was not associated with risk of repeat self-harm. Psychiatric inpatient admission was associated with an increased risk of repeat self-harm in both conventional and IV analyses. This increased risk persisted in analyses stratified by gender and when restricted to self-poisoning patients only.

CONCLUSIONS

No strong evidence was found to suggest medical admission reduces the risk of repeat self-harm. Models of health service provision that encourage prompt mental health assessment in the emergency department and avoid unnecessary medical admission of self-harm patients appear warranted. Psychiatric inpatient admission may be associated with a heightened risk of repeat self-harm in some patients, but these findings could be biased by residual confounding and require replication.

Gait abnormalities in older people--comparison of inter-professional assessment

Gait abnormalities are common in older people but relatively under-diagnosed. We investigated the prevalence of gait abnormalities among patients presenting to a geriatric medicine day hospital, classified them according to whether they were lower, middle or higher level gait disorders and compared inter-professional (physician and physiotherapist) assessments for this classification. Prospective independent assessment by a physician and a senior physiotherapist of 50 consecutive patients presenting to a day hospital. Presence of a gait abnormality was determined and then classified. Levels of agreement were determined between the two professions. There was 98% agreement that a gait abnormality existed in 43 people. In classifying the gait abnormality there was complete agreement in over two-thirds of cases (67.4%). There was further agreement of higher level gait disorders (but disagreement in the sub-classification) in 11.6% of cases. Given the high prevalence of gait abnormality presenting to the day hospital, screening for gait and balance disorders should be of paramount importance. While levels of agreement between the two professions were high, disagreement existed in approximately one-third of cases. Agreement among professionals essential for appropriate tailoring of treatment and intervention.

Neonatal transportation: the effects of a national neonatal transportation programme

BACKGROUND

The transport of critically ill newborns by specialised transport teams has been shown to be associated with a significant improvement in their clinical condition on arrival at the receiving hospital.

AIM

To determine if the National Neonatal Transport Programme introduced in 2001 improved clinical condition of newborns at the end of transfer.

METHODS

A retrospective study of all 176 patients transported by the National Neonatal Transport Programme between March 2001 and March 2002.

RESULTS

Before transfer, 17% of patients were hypothermic, 2% hypoglycaemic and 11% acidotic as were 7%, 3% and 5% respectively at the end of transfer. A review of 172 neonatal transports between 1987 and 1989 revealed that 21% of patients were hypothermic, 13% hypoglycaemic and 20% acidotic at the end of transfer.

CONCLUSIONS

The National Neonatal Transport Programme has resulted in improved clinical condition of newborns at the end of transfer when compared to their condition before transfer and compared to outcomes prior to the introduction of the programme.

A link between diabetes and atherosclerosis: Glucose regulates expression of CD36 at the level of translation

Both the risk and the rate of development of atherosclerosis are increased in diabetics, but the mechanisms involved are unknown. Here we report a glucose-mediated increase in CD36 mRNA translation efficiency that results in increased expression of the macrophage scavenger receptor CD36. Expression of CD36 was increased in endarterectomy lesions from patients with a history of hyperglycemia. Macrophages that were differentiated from human peripheral blood monocytes in the presence of high glucose concentrations showed increased expression of cell-surface CD36 secondary to an increase in translational efficiency of CD36 mRNA. We obtained similar data from primary cells isolated from human vascular lesions, and we found that glucose sensitivity is a function of ribosomal reinitiation following translation of an upstream open reading frame (uORF). Increased translation of macrophage CD36 transcript under high glucose conditions provides a mechanism for accelerated atherosclerosis in diabetics.

The effects of peripheral vascular disease on gait

This study was designed to determine whether patients with peripheral vascular disease (PVD) have gait abnormalities. A previous study on humans with PVD found no abnormalities whereas significant gait changes were seen with a rat model of PVD. The study population was comprised of 10 controls and 9 subjects with PVD (all male). The PVD group had documented pain in one or both legs while walking. Subjects ranged in age from 55-92 years of age, with a mean age of 69 in the PVD group and 70 in the control group. The GaitMat II system was used to measure both spatial and temporal variables of gait. Subjects walked across the mat, four to six times, at their comfortable walking speed. The PVD group then walked on a treadmill until they experienced moderate claudication pain and felt they had to stop (pain levels between 6 and 8, with maximal pain at level 10). Control group walked on a treadmill for 10 minutes without pain. All subjects repeated the gait tests on the GaitMat H system immediately after treadmill walking. Claudication pain persisted in the PVD group during the second gait test. The PVD group was not different than control group in any of the measured variables on the first test (p values from .35 to .99). Difference scores (post- minus pre-treadmill walking)for PVD group were significantly different than those for control group on 8 of 11 variables (p values <.005). The primary response in PVD subjects was reduced walking speed (1.02+/-0.16 to 0.94+/-0.16 m/s) and reduced step length (0.60+/-0.08 to 0.57+/-0.09 m/s), whereas control subjects increased their speed (1.09+/-0.17 to 1.19+/-0.19 m/s) and step length (0.63+/-0.10 to 0.67+/-0.10 m/s). No asymmetries in gait were measured in either group, either before or after treadmill walking. In conclusion, PVD subjects were not different in gait while rested, but responded to claudication pain by reducing preferred walking speed and step size.

Mother-to-child transmission of human immunodeficiency virus (HIV) in Ireland: a prospective study

Symptomatic HIV infection was first diagnosed in an Irish child in 1985. A prospective study was initiated to determine the vertical transmission rate (VTR) of HIV and the average age of infant seroreversion and to monitor clinical, immunologic and virologic evidence for HIV infection in seroreverters. Ninety three HIV positive infants have been prospectively identified since 1985. The predominant underlying maternal risk factor for HIV infection is intravenous drug use (IVDU) (96 per cent). Of 93 infants, median gestational age was 40 weeks and median birth weight 3125 grams. Ninety-four per cent of infants were bottle fed. Currently 72 (77 per cent) infants are uninfected, 12 (13 per cent) are infected, 4 (4.5 per cent) are indeterminate and 5 (5.5 per cent) have been lost to follow up. The intermediate estimate of vertical transmission rate (VTR) is 14.3 per cent. The median age at documented seroreversion was 12 months. There are no significant differences between infected and non-infected children in male/female ratio, gestational age, mode of delivery or birth weight. Strategies to reduce the transmission of HIV among drug users in combination with routine antenatal screening and antiretroviral prophylaxis of vertical transmission are all measures which can reduce HIV infection in our children.

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.

Intratumoral chemotherapy with fluorouracil/epinephrine injectable gel: a nonsurgical treatment of cutaneous squamous cell carcinoma

BACKGROUND

We attempted to originate a nonsurgical treatment alternative for cutaneous squamous cell carcinoma (SCC), and we evaluated intratumoral modified-release chemotherapy with fluorouracil/epinephrine injectable gel (5-FU/epi gel).

OBJECTIVE

To assess the safety and efficacy, we conducted an open-label pilot study of 5-FU/epi gel in 25 patients with biopsy-proven SCC lesions on the face, head, neck, trunk, arms, and hands.

METHODS

Each tumor site was injected intradermally with up to 1.0 ml of 5-FU/epi gel. One SCC per patient was treated weekly for up to 6 weeks, then observed for 4 months at which time the tumor site and margins were excised for histologic examination.

RESULTS

Overall, 96% (22 of 23) of evaluable treated tumors had histologically confirmed complete tumor clearing. No clinically significant systemic reactions or unexplained treatment-related adverse medical events occurred. The evaluations of the cosmetic appearance of the treated sites, judged subjectively by clinicians and patients, were mostly good to excellent and generally in close agreement.

CONCLUSION

Treatment of superficial SCC with 5-FU/epi injectable gel results in a high rate of histologically confirmed complete tumor responses and may provide a nonsurgical treatment alternative in selected patients.

The human side of reengineering

This article on the human side of reengineering describes the issues and concerns faced by healthcare executives who are considering or who already are involved in a reengineering project. It offers a practical approach to understanding issues such as the importance of assessing the culture and its readiness for change, the importance of human resource policy development prior to initiating a reengineering project, and how to ensure buy-in and support from the healthcare organization and its community.

The Dublin outcome for low birth-weight infants

This report describes outcomes for all infants with birth weight 501-1750 grams born in the three major maternity hospitals in Dublin between 1.1.90 to 31.12.91. 37,958 mothers delivered 38,498 infants during this period, consisting of approximately 36% of all deliveries in Ireland. 633 (1.6%) of all infants born weighed 501-1750 grms. 102 (16%) were stillborn and 28 of the 531 live born infants had lethal malformations. 30% of women received two or more doses of antenatal steroids before delivery and a highly significant negative correlation occurred between the need for ventilation after birth and antenatal steroids. 56.4% of babies were delivered by caesarean section as compared with 10.8% of the hospital population. Of 503 liveborn infants without lethal malformation. 426 (85%) survived to 28 days and 419 (83%) to discharge home. 15% were growth retarded. 46% of infants were ventilated, mean duration of ventilation was 7 days. 25% of infants had an intraventricular haemorrhage, 10% necrotising enterocolitis and 19% culture proven sepsis. 15% of survivors developed broncho pulmonary dysplasia and 12% retinopathy of prematurity. This paper describes important information for mortality, morbidity and interventions among a large population of low birth weight infants in Ireland and can be used as a basis against which to compare future alterations in practice. It demonstrates a clear benefit for antenatal steroids in decreasing the need for ventilation and the importance of ensuring their utilisation antenatally where possible.

Effective systems documentation: essential for safety management

The rapid pace of change in healthcare has caused critical engineering systems in hospitals and other healthcare facilities systems to be altered and upgraded on a virtually continuous basis. Changes to these systems, which include heating, ventilating, and air conditioning (HVAC), medical gases, normal and emergency electrical systems, plumbing, and fire protection systems, often are not properly documented. As a result, healthcare facilities may, over time, be exposed to increased risk. Such a situation compromises an organization's high level of patient and staff safety; it also may cause problems during a Joint Commission on Accreditation of Healthcare Organizations review of environment of care. This article outlines seven specific questions safety officers should review to determine if their facility needs a thorough systems assessment.

Characterization of [3H]SK&F 108566 as a radioligand for angiotensin type-1 receptor

Rat aortic smooth muscle cells were used as a model system to characterize the binding properties of [3H]SK&F 108566, an angiotensin type-1 (AT1) receptor antagonist. The binding was specific, saturable and reversible. The association and dissociation rates of [3H]SK&F 108566 binding to smooth muscle cells were monophasic and Scatchard analysis of equilibrium binding data yielded a linear plot indicating a homogenous population of binding sites. The maximum binding (Bmax) and apparent dissociation constant (Kd) were 22,000 +/- 6000 sites/cell and 0.83 +/- 0.08nM respectively. The pharmacological specificity of [3H]SK&F 108566 binding to smooth muscle cells is consistent with that observed for AT1 and confirms AT1 receptor specificity of this radioligand. High affinity binding was observed in membranes prepared from bovine adrenal cortex, rat liver and rat kidney glomeruli. COS cells transfected with cDNA encoding human AT1 angiotensin II receptors also displayed high affinity binding site for [3H]SK&F 108566. No specific binding could be detected on membranes prepared from bovine cerebellum, a tissue rich in the angiotensin type-2 (AT2) receptor. These observations indicate that [3H]SK&F 108566 binds to sites which have pharmacological characteristics of angiotensin II AT1 subtype receptors and can be used as a subtype-selective radioligand to characterize AII receptors in various systems.

Characterization of bovine ovary angiotensin II receptors using subtype-selective antagonists

Angiotensin-II (AII) receptors have been classified as AT1 and AT2 subtypes based on selective antagonists. AII binding sites in bovine ovary membranes were characterized using the radiolabeled AII antagonist, [125I]Sar1,Ile8-AII ([125I]SIA). The binding was specific and saturable with dissociation constant (Kd) and maximum binding (Bmax) of 0.18 +/- 0.08 nmol/l and 32.5 +/- 1.3 fmol/mg, respectively. Pretreatment of ovarian membranes with dithiothreitol (10 mumol/l) doubled the specific binding of [125I]SIA twofold to 63.5 +/- 2.8 fmol/mg. Guanine nucleotide had no significant effect on the affinity of agonist (AII) to compete for [125I]SIA binding. AII and a series of AII-related analogs were used in competition binding experiments, and the data were compared with those obtained with membranes prepared from bovine adrenal cortex and bovine cerebellum. The membranes from ovary and cerebellum showed similar binding characteristics, but they differed from those of adrenal cortex. CGP42112A and WL-19, AT2-subtype selective antagonists, inhibited [125I]SIA binding to ovarian membrane with IC50 values of 28 +/- 4 and 26.7 +/- 2.8 nmol/l, respectively. SK&F 108566 and DuP 753, AT1-subtype-selective antagonists, had very little effect on [125I]SIA binding to ovarian membranes. These data directly demonstrate that bovine ovary membranes have predominantly AT2-subtype AII receptors.

Homologous desensitization of calcitonin gene-related peptide response in rat glomerular mesangial cells in culture

Addition of calcitonin gene-related peptide (CGRP) to rat glomerular mesangial cells in culture resulted in an increase in cyclic adenosine monophosphate (cAMP) accumulation in a concentration-dependent fashion with an EC50 of approximately 3 nM. Inclusion of CGRP8-37, a CGRP1 selective antagonist shifted CGRP concentration-response curve to the right, suggesting the presence of CGRP1 subtype receptors in these cells. Pretreatment of these cells with CGRP followed by washing and rechallenge with CGRP or isoproterenol or forskolin resulted in selective attenuation of CGRP-mediated cAMP accumulation by 55-60% without affecting isoproterenol or forskolin-mediated accumulation, suggesting that CGRP pretreatment of mesangial cells induced homologous desensitization. CGRP-mediated desensitization of cAMP accumulation was found to be both concentration- and time-dependent. Desensitization did not affect the EC50 of CGRP for stimulation of cAMP accumulation, but resulted in a 55-60% reduction in maximal response. CGRP-mediated desensitization was fast, with half-maximal desensitization occurring as early as 5 min after pretreatment with CGRP. In addition, CGRP-mediated desensitization was blocked by the CGRP receptor antagonist, CGRP8-37, when included in the pretreatment protocol. These data suggest that rat mesangial cells display CGRP1 subtype receptors and that prolonged pretreatment of these cells with CGRP resulted in homologous desensitization.

Adopting an information management approach to the design and implementation of information systems

As the NHS adopts an information management approach to coordinated handling of total information resources, methods of systems analysis and design require assessment to ensure that they are appropriate. Mandatory use of Structured Systems Analysis and Design Methodology (SSADM) may be encouraging a damagingly narrow view of information systems. Research is described in which an holistic view of information systems is applied, allowing the needs of information users to play a stronger role in determining how information will be supplied to them. The techniques may also assist the training activities associated with implementing new systems.

Cloning and characterization of a human angiotensin II type 1 receptor

A human liver cDNA library was screened using a rat type 1 angiotensin II receptor cDNA coding sequence as a probe. cDNA clones were isolated which encoded a protein of 359 amino acids that shared 94.4% and 95.3% identify to rat and bovine type 1 angiotensin II receptors, respectively. Ligand binding studies of the cloned receptor expressed in COS cells suggested that it is pharmacologically a type 1 angiotensin II receptor subtype. Electrophysiological studies of the receptor expressed in Xenopus laevis oocytes revealed that it could functionally couple to a second messenger system leading to the mobilization of intracellular stores of calcium. Southern and Northern blot analyses indicated that the cloned receptor is represented as a single copy in the human genome and is expressed in many tissues of different histogenic origin with the exception of brain, where mRNA transcripts were barely detectable.

Pharmacological characterization of the nonpeptide angiotensin II receptor antagonist, SK&F 108566

The angiotensin II (AII) antagonist activity of (E)-alpha-[[2-butyl-1-[(4-carboxyphenyl)methyl]-1H-imidazol-5- yl]methylene]-2-thiophenepropanoic acid (SK&F 108566), was examined in a number of in vitro and in vivo assays. In rat and human adrenal cortical membranes, SK&F 108566 displaced specifically bound [125I]AII with IC50 of 9.2 and 3.9 nM, respectively. SK&F 108566 also inhibited [125I]AII binding to human liver membranes (IC50 = 1.7 nM) and to rat mesenteric artery membranes (IC50 = 1.5 nM). In rabbit aortic smooth muscle cells, SK&F 108566 caused a concentration-dependent inhibition of AII-induced increases in intracellular Ca++ levels. In rabbit aortic rings, SK&F 108566 produced parallel rightward shifts in the AII concentration-response curve without affecting the maximal contractile response. Schild analysis of the data yielded a KB value of 0.26 nM and a slope not different from 1, indicative of competition antagonism. SK&F 108566 had no effect on the contractile responses to KCl, norepinephrine or endothelin in rabbit aorta. In conscious normotensive rats, i.v. administration of SK&F 108566 (0.01-0.3 mg/kg) produced dose-dependent parallel shifts in the AII pressor dose-response curve. Administration of SK&F 108566 (3-10 mg/kg) intraduodenally or intragastrically to conscious normotensive rats resulted in a dose-dependent inhibition of the pressor response to AII (250 ng/kg, i.v.). At 10 mg/kg, i.d., significant inhibition of the pressor response to AII was observed for 3 hr. In this same rat model, SK&F 108566 had no effect on base-line pressure or on the pressor response to norepinephrine or vasopressin. The data demonstrate that SK&F 108566 is a potent, highly selective, competitive nonpeptide AII antagonist.(ABSTRACT TRUNCATED AT 250 WORDS)

Identification and characterization of calcitonin gene-related peptide receptors in porcine renal medullary membranes

Membranes prepared from the medullary region of the porcine kidney displayed high affinity, high density (Kd, 0.12 nM; binding capacity, 127 fmol/mg protein) receptors for calcitonin gene-related peptide (CGRP). Human CGRP (hCGRP), rat CGRP (rCGRP), and the hCGRP analog [hCGRP-(8-37)] competed for the binding of [125I]hCGRP, whereas salmon calcitonin (sCT) and CGRP-(22-37) were very weak in displacing [125I]hCGRP binding. In accordance with these binding data, CGRP stimulated adenylate cyclase activity in these membrane preparations in a concentration-dependent manner, with an EC50 similar to that of the Kd for binding. In the same preparations, sCT was ineffective in stimulating adenylate cyclase activity, suggesting that porcine kidney medullary membranes possess receptors specific for CGRP. Further hCGRP-(8-37), a CGRP antagonist, inhibited CGRP-stimulated adenylate cyclase activity in a competitive manner. Covalent cross-linking of [125I]hCGRP to these membranes resulted in the specific labeling of one major band at approximately 30,000 mol wt and two minor bands at about 58,000 and 78,000 mol wt. The presence of CGRP receptors and their coupling to adenylate cyclase suggest a role for CGRP in kidney function, such as local regulation of the microcirculation, electrolyte transport, or water homeostasis in the porcine kidney.

Increased chemokinetic and chemotactic responses of eosinophils in asthmatic patients

The aim of the present study was to investigate the migratory responses of eosinophil and neutrophil granulocytes from asthmatic patients compared with granulocytes from healthy individuals. Twenty-three patients with unstable and severe asthma and blood eosinophilia (greater than 400 x 10(6) cells/l) were selected for the study. Eosinophil and neutrophil chemotactic and chemokinetic responses were tested twice, at the beginning and end of a 5 week treatment period. Lung function was followed by daily measurements of PEF. The eosinophils of the asthmatics demonstrated increased chemokinetic responses to albumin, autologous serum, and normal human serum (NHS), and an increased chemotactic response to NHS at the beginning of the treatment period compared with eosinophils from the references. At the end of the period the eosinophil chemokinetic responses to albumin, autologous serum and NHS were still increased and so was the chemotactic response to zymosan-activated serum (ZAS). The neutrophil migratory responses were not increased compared with those of the references, except for the chemokinetic response to autologous serum, which was increased both at the beginning and end of the treatment period. Patients in whom the eosinophil migratory responses, to most of the agents used, decreased over the treatment period, demonstrated a significantly greater improvement of their lung function at the end of the period compared with patients in whom the eosinophil migratory responses increased. However, no direct relationship between eosinophil migratory responses and lung function of the patients was found. In conclusion, the present investigation demonstrated increased migratory responses of eosinophils from asthmatic patients. This enhanced responsiveness is proposed to be due to priming of the eosinophils in vivo, and might be one mechanism behind the selective recruitment of eosinophils to the lungs of asthmatics.

Blood eosinophil number and activity in relation to lung function in patients with asthma and with eosinophilia

Blood eosinophil count, serum concentrations of eosinophil cationic protein (ECP), eosinophil protein X (EPX), myeloperoxidase (MPO), and peak expiratory flow (PEF) rate were studied in 23 patients with severe labile asthma characterized by eosinophilia at the start and end of a treatment period of 5 weeks. The mean blood eosinophil count was 808 x 10(6)/L at the start of the treatment period. Serum ECP and EPX were significantly raised compared with that of the references, whereas the mean serum MPO level was normal. The mean PEF was significantly and negatively correlated to both blood eosinophil count and serum ECP and EPX, but the predominant correlation was that between blood eosinophil count and PEF. At the end of the treatment period, PEF had increased and the blood eosinophil count and serum ECP and EPX were reduced when these values were compared with the values at the start of the treatment period. There was a significant and negative correlation of mean PEF to serum ECP but not to the blood eosinophil count. In individual subjects, the decreases in the blood eosinophil counts and serum EPX were significantly correlated to the individual increases of mean PEF. In conclusion, the present investigation indicates that in patients with asthma and pronounced eosinophilia, the lung function of the patients was principally related to the number of circulating eosinophils, whereas, when their eosinophilia was reduced to moderate levels, the patient's lung function was closer related to the activity of the eosinophils.

Evaluation of a taurine containing amino acid solution in parenteral nutrition

Vaminolact, an amino acid solution containing taurine, was given to 15 sick newborn babies. They were compared with a group of 10 babies who received a solution that did not contain taurine (Vamin glucose). Efficacy and safety were evaluated by monitoring plasma amino acid patterns, growth patterns, nitrogen balance, and biochemical and haematological profiles. No serious abnormalities in amino acid concentrations were found. After an initial fall the taurine concentration recovered more rapidly in those receiving the taurine supplement, though this difference was not significant. Phenylalanine concentrations were within the reference range in the group receiving Vaminolact, and were significantly lower than in the group receiving Vamin glucose. Metabolic acidosis, which occurred in several subjects in each group, was not a serious problem. Liver function tests remained satisfactory. Nitrogen retention was greater among those receiving Vaminolact than in the control group. Vaminolact is a safe and effective amino acid solution for use in critically ill babies.

Narcotic addiction: the expectant mother and her baby

In a retrospective study of the period 1982-1985, the records of 29 narcotic-addicted mothers and their 42 babies were reviewed. All mothers were from socially deprived backgrounds, had a poor record of ante-natal attendance and had frequent admissions to hospital. Thirteen mothers had a past history of hepatitis B and four were HBsAg positive. The babies had significantly lower mean gestational age and mean birth weight than the control group. Features of withdrawal were recorded in 84% of babies where a history was available. A high incidence of twins (10.5%) was also observed. Testing for HIV antibody in more recent cases has revealed positive results in seven mothers and three babies; one infant has since died from acquired immune deficiency syndrome.

Transportation of newborn infants

The benefit of an organized neonatal transport system is well established. Over a 30 month period, January 1987 to June 1989, 172 babies were transported to the Dublin maternity hospitals. Birth weights ranged from 640 to 5,180g 106 (62%) were less than 37 weeks gestation. Indications for transport included respiratory distress syndrome (54), prematurity only (43), convulsions and/or neurologic dysfunction (23), jaundice (11) and apnoea (11). One hundred and sixty-eight were transferred by ambulance and four by helicopter. Twenty travelled more than 100 miles. Forty (23%) received assisted ventilation during transport. On arrival 37 (21%) had temperature less than 36 degrees C; 22 (13%) had blood sugar less than 2.2 m mol/l and 34 (20%) had arterial ph less than 7.25. Fifty per cent of referral letters had incomplete information. Treatment and care given en route was recorded in only 28 babies. Twenty-four babies (14%) died. Infants who died were more likely to have been of low birth weight, travelled a long distance, been hypothermic, had poor arterial gases, had blood sugars less than 2.2 m mol/l, and had poor referral letters. This review indicates that death and morbidity continue to be associated with the present system of postnatal transfer of newborn infants. The urgent need for an organized neonatal transport service remains unmet.