Peritonsillar Abscess at a Dedicated Otolaryngology Emergency Department

Aim Peritonsillar abscess (PTA) is the most common suppurative complication of acute tonsillitis. It requires urgent specialist treatment due to the risk of progression to airway compromise. We aimed to review referral pathways to a dedicated otolaryngology emergency department (ORL-ED), identify causative organisms and discuss COVID-19 implications. Methods A retrospective review of patients presenting to the ORL-ED between January 2018 and December 2019 was undertaken. Data extracted included demographics, referral source, treatment, microbiology results and length of stay. Statistical analysis of seasonal variation of presentation and causative organisms employed Chi-Square and Fisher's Exact Test, respectively. Results There were 53 PTA presentations. 51 were admitted accounting for 44.3% (51/115) of ED admissions. The median patient age was 31 years (IQR 20-40yrs). GP referral accounted for 48/53 (90.6%). There was no statistically significant seasonality (χ2=5.94, p=0.11) in presentation. Microbiology samples were available for 44 patients. Streptococcus was identified in 19/44 (43.2%) patients. 85% (45/53) of patients received Co-amoxiclav. Discussion PTA is a perennial condition with diverse causative organisms. Antibiotic choice should reflect this. The majority of patients are referred from primary care, emphasising the role of the GP in initial diagnosis and the importance of clinical education in this regard.

Collaborating to Compete: Blood Profiling Atlas in Cancer (BloodPAC) Consortium

The cancer community understands the value of blood profiling measurements in assessing and monitoring cancer. We describe an effort among academic, government, biotechnology, diagnostic, and pharmaceutical companies called the Blood Profiling Atlas in Cancer (BloodPAC) Project. BloodPAC will aggregate, make freely available, and harmonize for further analyses, raw datasets, relevant associated clinical data (e.g., clinical diagnosis, treatment history, and outcomes), and sample preparation and handling protocols to accelerate the development of blood profiling assays.

Perampanel: An audit of clinical experience using the epilepsy electronic patient record

Perampanel is a non-competitive antagonist of AMPA glutamate receptors on post synaptic neurons. The aim of this study was to conduct an audit of the experience of perampanel treatment in Ireland based on the interrogation of the national epilepsy electronic patient record (EPR). A retrospective audit was compiled which reviewed the progress of patients who had been treated across two regional epilepsy centres. The EPR was used to identify patients and collect information relevant to their perampanel therapy. Collected data was entered into a statistical package for social sciences for analysis using descriptive statistics. Seventy patients were identified for inclusion in this audit. Partial onset epilepsy was the predominant epilepsy syndrome treated with perampanel. Eight milligrams daily was the maximum dose achieved in 31.45% (n=22). Complex partial seizures demonstrated the best seizure response to perampanel, which was optimal at doses of 4mgs to 8mgs once daily. Treatment was discontinued primarily due to side effect profile (28.5%; n=20). The common side effects reported were behavioural alteration, sedation and dizziness. Abnormal thoughts were identified in 4.2% (n=3). Overall perampanel has been shown to be an effective adjunct. The EPR was demonstrated as an effective tool for audit and research.

Towards the development of integrated epilepsy services: an audit of documented epilepsy care

Effective chronic disease management (CDM) requires the ready availability and communication of accurate, clinical disease specific information. Using epilepsy as a probe into CDM, we report on the availability and reliability of clinical information in the primary care records of people with epilepsy (PWE). The medical records of 374 PWE from 53 general practices in the Mid-West region of Ireland were examined. Confirmation of an epilepsy diagnosis by a neurologist was documented for 132 (35%) patients. 282 (75%) patients had no documented evidence of receiving specialist neurology review while 149 (40%) had not been reviewed by their GP in the previous two years for their epilepsy. Significant variation in documentation of epilepsy specific information together with an inadequacy and inconsistency of existing epilepsy services was highlighted.

The health care journeys experienced by people with epilepsy in Ireland: what are the implications for future service reform and development?

Opportunities exist to significantly improve the quality and efficiency of epilepsy care in Ireland. Historically, epilepsy research has focused on quantitative methodologies that often fail to capture the invaluable insight of patient experiences as they negotiate their health care needs. Using a phenomenological approach, we conducted one-to-one interviews with people with epilepsy, reporting on their understanding of their health care journey from onset of symptoms through to their first interaction with specialist epilepsy services. Following analysis of the data, five major themes emerged: delayed access to specialist epilepsy review; uncertainty regarding the competency and function of primary care services; significant unmet needs for female patients with epilepsy; disorganization of existing epilepsy services; and unmet patient information needs. The findings reveal important insights into the challenges experienced by people with epilepsy in Ireland and identify the opportunities for future service reorganization to improve the quality and efficiency of care provided.

Epilepsy care in general practice

Epilepsy care in Ireland is shared between primary, secondary and tertiary care services with the General Practitioner (GP) managing the process. Barriers to effective epilepsy care in Irish general practice remain undocumented although sub-optimal and fragmented services are frequently anecdotally reported. This survey of Irish GPs reports on such barriers to epilepsy care and on the Information & Communication Technology (ICT) issues potentially relevant to the use of an epilepsy specific Electronic Patient Record (EPR). The response rate was 247/700 (35.3%). Respondents supported the concept of shared care for epilepsy 237 (96%) however they were very dissatisfied with existing neurology services, including pathways of referral 207 (84%) and access to specialist neurology advice and investigations 232 (94%). They reported that neurology services and investigations may be accessed more expeditiously by patients with private health insurance than those without 178 (72%). Consequently many patients are referred to the emergency department for assessment and treatment 180 (73%). A deficit in epilepsy care expertise among GPs was acknowledged 86 (35%). While computerisation of GP practices appears widespread 230 (93%), just over half the respondents utilise available electronic functionalities specific to chronic disease management. GP specific electronic systems infrequently link or communicate with external electronic sources 133 (54%). While the current pathways of care for epilepsy in Ireland appear fragmented and inadequate, further investigations to determine the quality and cost effectiveness of the current service are required.

Reliability of a repeated-sprint test for field-hockey

The purpose of this study was to assess the reliability of a repeated-sprint test, specifically designed for field-hockey, as it was based directly on the time-motion analysis of elite level competition. The test consisted of 6 x 30-m over-ground sprints departing on 25s, with an active recovery (approximately 3.1-3.3 ms(-1)) between sprints. Ten highly trained, male, field-hockey players (mean+/-S.D.: age, 23+/-3 years; body mass, 78.1+/-7.1 kg) participated in this study. Following familiarisation, the subjects performed the repeated-sprint test on two occasions, 7 days apart. The reliability of the test variables was assessed by the typical error of measurement (TE). The total sprint time was very reliable (T(1): 26.79+/-0.76 s versus T2: 26.83+/-0.74 s), as the TE was 0.7% (95% CL, 0.5-1.2%). However, the percent sprint decrement was less reliable (T1: 5.6+/-0.9% versus T2: 5.8+/-1.0%), with the TE being 14.9% (95% CL, 10.8-31.3%). In summary, it is suggested that this field-hockey-specific, repeated-sprint test is very reliable when the results are presented as the total sprint time.

Customer needs, expectations, and satisfaction with clinical neurophysiology services in Ireland: a case for tele-neurophysiology development

Although equitable access to services should be based on need, geographical location of patients and their clinicians can give rise to inequalities in healthcare delivery. Development of tele-medicine services can improve equity of access. The specialty of Clinical Neurophysiology (CN), currently under-developed in Ireland provides an example of such potential. This study aimed to determine the needs, expectations, and satisfaction of CN customers, namely patients and referring clinicians. The goal was to examine geographical impediments to access that might be addressed by the introduction of tele-neurophysiology. Two customer surveys were conducted: CN referring clinicians and CN patients. Thirty-one North Western Health Board (NWHB) consultant clinicians responded to a postal survey. Distance and delays caused by long waiting lists were felt to deter or make CN referral irrelevant. Ninety-seven percent believed the lack of a local service negatively impacts on patient management and 93% would welcome the introduction of a tele-neurophysiology service. The geographical location of patient's residence and/or the location of the referring clinician's practice influenced waiting lists for CN. Fifty-eight (105/182) percent of patients living in a region with a CN service compared to 39% (50/128) of those living in a region with no service received an appointment within one month. In addition to the current insufficient CN service capacity in Ireland, these surveys highlighted geographical inequities. Tele-neurophysiology has the potential to speed-up diagnosis, result in more patients being appropriately investigated and be fairer to patients.

Needs analysis for tele-neurophysiology in the Irish North-Western Health Board

No clinical neurophysiology (CN) service is currently provided by the North-Western Health Board (NWHB) region in Ireland. Digital technology associated with CN is compatible with tele-neurophysiology service development and may increase the efficiency of patient care in remote areas. This study was conducted to assess the need for CN in the NWHB with a view to implementing a tele-neurophysiology service for the region. A retrospective audit of investigations performed at six CN departments in Dublin compared patient groups from regions with (Eastern Regional Health Authority--ERHA) and without (NWHB) local CN departments. 4954 records were audited. CN activity was lower than internationally expected (ERHA group 52% of expected, NWHB group 23% of expected). The 2 groups differ in the specialty of referring clinician (p < 0.0001). NWHB patients are more likely to be referred by clinicians outside their region (p < 0.0001) and wait longer for appointment (p < 0.0001). While there is an unmet demand for CN services in Ireland generally, the population of the NWHB is further disadvantaged. Tele-neurophysiology has the potential to provide fairer access to CN services across the country. The data from this study provide a baseline against which the outcome of investment in CN can be monitored and evaluated.

Effect of wearing an ice cooling jacket on repeat sprint performance in warm/humid conditions

OBJECTIVE

To examine the effect of cooling the skin with an ice jacket before and between exercise bouts (to simulate quarter and half time breaks) on prolonged repeat sprint exercise performance in warm/humid conditions.

METHODS

After an initial familiarisation session, seven trained male hockey players performed two testing sessions (seven days apart), comprising an 80 minute intermittent, repeat sprint cycling exercise protocol inside a climate chamber set at 30 degrees C and 60% relative humidity. On one occasion a skin cooling procedure was implemented (in random counterbalanced order), with subjects wearing an ice cooling jacket both before (for five minutes) and in the recovery periods (2 x 5 min and 1 x 10 min) during the test. Measures of performance (work done and power output on each sprint), heart rates, blood lactate concentrations, core (rectal) and skin temperatures, sweat loss, perceived exertion, and ratings of thirst, thermal discomfort, and fatigue were obtained in both trials.

RESULTS

In the cooling condition, chest (torso) skin temperature, thermal discomfort, and rating of thirst were all significantly lower (p<0.05), but no significant difference (p>0.05) was observed between conditions for measures of work done, power output, heart rate, blood lactate concentration, core or mean skin temperature, perceived exertion, sweat loss, or ratings of fatigue. However, high effect sizes indicated trends to lowered lactate concentrations, sweat loss, and mean skin temperatures in the cooling condition.

CONCLUSIONS

The intermittent use of an ice cooling jacket, both before and during a repeat sprint cycling protocol in warm/humid conditions, did not improve physical performance, although the perception of thermal load was reduced. Longer periods of cooling both before and during exercise (to lower mean skin temperature by a greater degree than observed here) may be necessary to produce such a change.

Gender and the integration of acoustic dimensions of prosody: implications for clinical studies

This study was conducted to detect the existence of a relationship between spectral and temporal prosodic cues and to examine gender differences in any such relationship. The rationale for the investigation was to gain a greater understanding of normal prosody and the requirements for control groups in clinical studies of prosody. Ten male and 10 female speakers with no known speech or neurological deficits participated in the study. They performed a reading task which involved delivering 10 sentences first with a declarative and then repeated with an interrogative intonation (20 sentences per speaker). Intrasubject and intersubject analyses of the speech data revealed a dependence of pitch on duration that differed between male and female speakers. Significant differences between the genders were also found in speech rate, pitch range, and pitch slope. The findings suggest that an integrated treatment of acoustic cues may provide a more invariant feature of normal prosody against which clinical groups may be compared. The data also imply that in clinical studies of the production of prosody gender should be carefully controlled.

Accuracy and validity of stereology as a quantitative method for assessment of human temporal lobe volumes acquired by magnetic resonance imaging

The object of this study was to compare the accuracy and validity of stereology as a method for determining whole temporal lobe volume with the more established technique of semi-automated thresholding and tracing. Ten, fixed, post-mortem human brains, were imaged using a three dimensional (3D) acquisition protocol. The volume of the left temporal lobe, dissected from each brain, was determined by fluid displacement. Each volume was compared to measurements obtained from magnetic resonance images (MRI) of the post-mortem brain using each of the two segmentation methods. Post-acquisition processing was performed using MEASURE software. Three investigators performed each measurement three times using each method, yielding a total of 180 measurements. Stereology took, on average, half the time of thresholding/tracing. Using a clinically acceptable variation for 95% of repeat measures; both intra-observer and inter-observer variation were acceptable for each technique. However, validity, as demonstrated by graphs of agreement against water displacement showed that the "limits of agreement" using stereology were within the acceptable range, while those using the thresholding/tracing technique were not. Quantitative estimates of variation and a graphical representation of the limits of agreement show that stereology is at least as precise as the thresholding/tracing method but is superior in terms of speed and validity. This has broad implications for published estimates of brain region volumes in human diseases such as epilepsy, dementia and other neurodegenerative disorders.

An international survey of long-term video/EEG services

To determine current practices in the provision of video-EEG services, the authors conducted an international survey by post. The aim of the survey was to evaluate, by reference to other centres, how and why certain things are done, be assured that their own center is providing a quality service, identify weaknesses in their service, and from this, set improvement goals and objectives. A purposive sampling method was used by sending questionnaires to 78 hospitals where it was believed a long-term video-EEG monitoring service existed. Completed survey questionnaires were returned from 42 centers. Although the survey mechanism may have resulted in self-selection bias, evaluation of the responses provides information on patient management, staffing levels, equipment, and equipment management. Ultimately, these data may aid in identifying a minimum set of requirements for the provision of a video-EEG telemetry service.

The application of d.c. electrical stimulation in evoking and recording gustatory brain potentials

Evidence exists which supports the hypothesis that electrical stimulation of appropriate parameters can fulfil the fundamental requirements for an effective evoked potential taste stimulus. Nevertheless, it had previously been considered that electrical taste stimulation is inadequate for evoking gustatory brain potentials. Consequently, the majority of the earlier attempts to record gustatory evoked potentials (GEPs) reported in the literature have employed chemical stimulus techniques. The design of an electrical taste stimulator and its interface to an evoked potential recording unit is described. The first human brain potentials recorded with this system are presented, among which are those attributable to taste pathway activation. Following future work to unequivocally confirm that taste evoked brain potentials are achievable with this system, it has potential to become a clinically valuable tool.

Discrimination of prosody and music by normal children

Prosody or the melody of speech is the process used to alter the meaning (linguistic prosody) or emotional force (affective prosody) of a sentence. The components of prosody are rhythm, pitch, tone and stress and they are articulated by modulation of the acoustic correlates of prosody; frequency, duration and amplitude. Little is known about the development of prosody in normal children other than that it appears to be a precursor to the further acquisition of normal language. In order to examine the development of the perception of prosody in normal children, a group of 40 neurologically normal children aged between 5 and 9 years were subjected to a number of prosodic recognition tasks. The objective was to modify a number of existing tasks and to devise a number of new ones to test both linguistic and affective prosody and the appreciation of affective cues in music. The results indicate a step-wise improvement in perceptual contours up to 8.5 years old. However the perception of emotion in music appears highly developed early on in development. This study provides normative data and is the first report of a comparison between the development of prosodic and musical appreciation in this age group of normal children.

Prosodic preservation in Landau-Kleffner syndrome: a case report

Landau-Kleffner syndrome (LKS) is a rare acquired condition of auditory verbal agnosia and convulsive disorder in children. It has been proposed that there is a functional relationship between electrical disturbance and the speech defect. Prosody or the melody of language, as described by Monrad-Krohn (1947), is one aspect of non-verbal communication which is distributed bilaterally in the brain. Prosodic parameters of expression and perception in one 7.5-year-old child were tested to see if they were preserved as a means of communication. The child was observed during video-electroencephalogram (EEG) monitoring over a 48-hour period. All utterances were recorded and subject to analysis for the salience and variation of acoustic correlates of prosody. Prosodic comprehension was measured using specific perceptual tasks previously presented to normal children between the ages of 5.5 and 8.5. Despite being unable to meaningfully use or perceive phonemes, the child was able to use variations in fundamental frequency, duration and intensity of utterances, to convey both emotional and propositional intent. Similarly, the child was able to discriminate prosodic contours of a male adult voice to an age equivalent to 5.5 to 6.5 years. This argues in favour of the notion for educating such children not only through the visual channel but also through the auditory channel.

Changes in performance, muscle metabolites, enzymes and fibre types after short sprint training

In contrast to endurance training, little research has been carried out to investigate the effects of short (< 10 s) sprint training on performance, muscle metabolism and fibre types. Nine fit male subjects performed a mean of 16 outdoor sprint running training sessions over 6 weeks. Distances sprinted were 30-80 m at 90-100% maximum speed and between 20 and 40 sprints were performed in each session. Endurance (maximal oxygen consumption; VO2max), sprint (10 m and 40 m times), sustained sprint (supramaximal treadmill run) and repeated sprint (6 x 40 m sprints, 24 s recovery between each) performance tests were performed before and after training. Muscle biopsy samples (vastus lateralis) were also taken to examine changes in metabolites, enzyme activities and fibre types. After training, significant improvements were seen in 40 m time (P < 0.01), supramaximal treadmill run time (P < 0.05), repeated sprint performance (P < 0.05) and VO2max (P < 0.01). Resting muscle concentrations of ATP and phosphocreatine did not change. Phosphorylase activity increased (P < 0.025), citrate synthase activity decreased (P < 0.01), but no significant changes were recorded in myokinase and phosphofructokinase activities. The proportion of type II muscle fibres increased significantly (P < 0.05). These results demonstrate that 6 weeks of short sprint training can improve endurance, sprint and repeated sprint ability in fit subjects. Increases in the proportion of type II muscle fibres are also possible with this type of training.

Muscle phosphocreatine repletion following single and repeated short sprint efforts

Phosphocreatine (PCr) repletion following either single (1x6 s, n=7) or repeated (5x6 s, departing every 30 s, n=8) maximal short sprint cycling efforts was measured in separate groups of trained subjects. Muscle biopsies (vastus lateralis) were taken pre-exercise before warming up, and then at 10 s, 30 s and 3 min post-exercise. After the 1 x 6 s sprint PCr concentration was respectively, 55% (10 s; P<0.01), 69% (30 s; P<0.01) and 90% (3 min; NS) of the pre-exercise value (mean+/-SD) (81.1+/-7.4 mmol x kg(-1) DM), whereas after the 5x6 s sprints, PCr concentration was, respectively, 27% (10 s; P<0.01), 45% (30 s; P<0.01) and 84% (3 min; P<0.01) of the pre-exercise value (77.1+/-4.9 mmol x kg(-1) DM). PCr concentration was correlated with muscle lactate at 30 s (r=-0.82; P<0.05) and 3 min of recovery (r=-0.94; P<0.01) for the 1x6 s sprint, but not for the 5x6 s sprints. The extent of PCr repletion was significantly greater after the 5x6 s sprints than the 1x6 s sprint between both 10 s and 30 s and 30 s and 3 min, despite lower PCr levels at 10 s, 30 s and 3 min following the 5x6 s sprints. Full repletion of PCr is likely to take longer after repeated sprints than single short sprints because of a greater degree of PCr depletion, such that replenishment must commence from lower PCr levels rather than because of slower rates of repletion.

Image processing of videofluoroscopy of patients with velopharyngeal insufficiency and hypernasal speech

Eleven patients with hypernasal speech and velopharyngeal insufficiency (VPI), together with five normals, were evaluated by videofluoroscopy to assess velopharyngeal movement, velar lift and lateral pharyngeal wall movement. Computer processing of the images obtained was used to compensate for initial poor quality images by contrast and edge enhancement techniques and to provide objective measurement of the movements involved. It was demonstrated that objective computer aided analysis of videofluoroscopic images is feasible and may provide additional subtle diagnostic information when nasendoscopy is unavailable. In addition, results obtained showed an increased degree of velar lift and lateral pharyngeal wall movement for the more severely affected patients. These suggest a compensatory mechanism in operation for the more severe cases of VPI.

Model for a controlled-release drug delivery safety system with permeable and erodible coatings

Models of drug delivery devices that employ erodible permeable coatings must take care to avoid the unacceptably high rate of release that arises as the erodible coating disappears and the barrier to drug release vanishes. One solution to this safety problem has been to exhaust the drug reservoir just before this condition occurs. This design has the disadvantage of placing demands of high accuracy on the quality control in the fabrication of the device. A drug delivery system of cylindrical symmetry is proposed that uses two permeable coatings on a drug-containing core. Only the outer of the two coatings is erodible; the inner safety coating and the core are inert. Calculations are performed to design the device that can yield constant drug delivery rates while avoiding the possibility of explosive late drug release.