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Competing Interests: None declared.

Background: Patient delays at the point of their discharge account for more than half a million additional bed days every year in Scotland, United Kingdom. Bottlenecks in discharge medication dispensing contribute to such delays., Aim: To test whether the discharge process could be made more time-efficient by utilising community pharmacy supply of medicines on the day of discharge, rather than hospital pharmacy supply., Setting: Glasgow Royal Infirmary, Scotland., Development: Local community pharmacy staff received training and communication about each patient discharge. Pharmacies could access an immediate discharge letter (IDL) on a shared electronic record. The existing pandemic law allowed medication dispensing from this IDL, without a prescription., Implementation: The programme was implemented from June to November 2020, across three Plan-Do-Study-Act (PDSA) cycles. Comparisons were made between the new community pharmacy model and standard hospital model., Evaluation: Across three PDSA cycles, in total 335 patients had community pharmacy supply compared to 376 patients eligible for hospital pharmacy supply. The median time taken from creation of the IDL to final completion was significantly lower in the new community pharmacy model compared to the hospital pharmacy model; 154 min (interquartile range (IQR) 82-272 min) vs 296 min (IQR 197-1281 min) p value < 0.000 CONCLUSION: A community pharmacy supply model compared to a standard hospital pharmacy model resulted in a median time saving of 142 min per patient. Such a time saving has the potential to deliver a transformational change in patient flow and free up hospital pharmacy staff to deliver other clinical interventions., (© 2023. Crown.)

Background: Immobile patients with cerebral palsy can suffer with painful dislocated hips. Decision-making and surgical management can prove challenging in this cohort of patients, with hips that cannot be reconstructed., Methods: We conduced a retrospective chart review of all patients who underwent prosthetic femoral interposition arthroplasty (PFIA) by two surgeons from 2013 to 2021, for unreconstructable hips. We compared pain and range of motion in preoperative period to the postoperative period. Caregiver reported outcomes were used to assess satisfaction post operatively. During the follow up, radiographs of the PFIA were obtained to assess for proximal migration, heterotopic ossification and loosening of implants., Results: Eleven index surgeries, which met the inclusion criteria, were included in this study. These were performed in eleven patients with an average follow up of 45 months. Regarding pain and range of motion post-operatively an excellent or good result was seen in nine cases. Two patients were classified as having a fair result with none having a poor result. Most caregivers reported being satisfied or very satisfied with the post-operative outcomes., Conclusion: A prescriptive operative solution to the painful dislocated hip in children with spastic cerebral palsy remains elusive. In this study, we have demonstrated both clinically and radiologically satisfactory results post proximal femoral interposition arthroplasty, for those patients with unreconstructable hips. Patient caregiver reported outcomes, show that the majority of caregivers were satisfied or very satisfied with the outcome of the surgery., (Copyright © 2022 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.)

Functional precision medicine platforms are emerging as promising strategies to improve pre-clinical drug testing and guide clinical decisions. We have developed an organotypic brain slice culture (OBSC)-based platform and multi-parametric algorithm that enable rapid engraftment, treatment, and analysis of uncultured patient brain tumor tissue and patient-derived cell lines. The platform has supported engraftment of every patient tumor tested to this point: high- and low-grade adult and pediatric tumor tissue rapidly establishes on OBSCs among endogenous astrocytes and microglia while maintaining the tumor's original DNA profile. Our algorithm calculates dose-response relationships of both tumor kill and OBSC toxicity, generating summarized drug sensitivity scores on the basis of therapeutic window and allowing us to normalize response profiles across a panel of U.S. Food and Drug Administration (FDA)-approved and exploratory agents. Summarized patient tumor scores after OBSC treatment show positive associations to clinical outcomes, suggesting that the OBSC platform can provide rapid, accurate, functional testing to ultimately guide patient care., Competing Interests: Declaration of interests B.M., X.Z., N.B., A.V., A. Baldwin, S.H., and A.B.S. have submitted a provisional patent application on the basis of the work presented. All other authors declare no competing interest., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Loss of adipose tissue in vertebrate wildlife species is indicative of decreased nutritional and health status and is linked to environmental stress and diseases. Body condition indices (BCI) are commonly used in ecological studies to estimate adipose tissue mass across wildlife populations. However, these indices have poor predictive power, which poses the need for quantitative methods for improved population assessments. Here, we calibrate bioelectrical impedance spectroscopy (BIS) as an alternative approach for assessing the nutritional status of vertebrate wildlife in ecological studies. BIS is a portable technology that can estimate body composition from measurements of body impedance and is widely used in humans. BIS is a predictive technique that requires calibration using a reference body composition method. Using sea turtles as model organisms, we propose a calibration protocol using computed tomography (CT) scans, with the prediction equation being: adipose tissue mass (kg) = body mass - (-0.03 [intercept] - 0.29 * length 2 /resistance at 50 kHz + 1.07 * body mass - 0.11 * time after capture). CT imaging allows for the quantification of body fat. However, processing the images manually is prohibitive due to the extensive time requirement. Using a form of artificial intelligence (AI), we trained a computer model to identify and quantify nonadipose tissue from the CT images, and adipose tissue was determined by the difference in body mass. This process enabled estimating adipose tissue mass from bioelectrical impedance measurements. The predictive performance of the model was built on 2/3 samples and tested against 1/3 samples. Prediction of adipose tissue percentage had greater accuracy when including impedance parameters (mean bias = 0.11%-0.61%) as predictor variables, compared with using body mass alone (mean bias = 6.35%). Our standardized BIS protocol improves on conventional body composition assessment methods (e.g., BCI) by quantifying adipose tissue mass. The protocol can be applied to other species for the validation of BIS and to provide robust information on the nutritional and health status of wildlife, which, in turn, can be used to inform conservation decisions at the management level., Competing Interests: The funders of the study had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The authors declare no conflict of interest., (© 2022 The Authors. Ecology and Evolution published by John Wiley & Sons Ltd.)

Ventilation system performance in high-rise multi-unit residential buildings (MURBs) has a significant impact on resident wellbeing. While the importance of ventilation is well established, it is commonly overlooked since underperformance often goes undetected. This article presents a review and synthesis of ventilation system performance in high-rise MURBs located in cold climates as it relates to the three pillars of sustainability: economic (capital and operational cost), social (airflow control, indoor environmental quality, and occupant behavior and interactions), and ecological (energy and carbon). A meta-analysis revealed previous ventilation system designs generally prioritized economic sustainability, specifically, capital cost. However, priorities have recently shifted toward social and ecological sustainability. While this shift is positive, there is insufficient empirical evidence showing which ventilation system most effectively supports it. The decentralized heat/energy recovery ventilator (HRV/ERV) system shows the potential to improve upon the social and ecological sustainability of previous designs, such as the centralized pressurized corridor system, but the interconnected nature of performance metrics can cause improvements to one to negatively impact others. Therefore, further research is required to enhance ventilation system performance in cold climate, high-rise MURBs, and facilitate decision-making while designing and retrofitting these systems., (© 2022 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Physical activity (PA) is recommended in the management of patients with pulmonary fibrosis (PF) to improve health outcomes. Dance is one such form of PA which is meaningful, valuable, enjoyable and has demonstrated positive physical and mental health effects., Methods: With pre-post design, 16 patients, members of the Irish Lung Fibrosis Association, were enrolled in this study. Once weekly, 75-min dance sessions were delivered for eight weeks via Zoom by an experienced choreographer. Participants completed Chronic Respiratory Questionnaire Self-Administered Standardised Format (CRQ-SAS) and European Quality of Life 5 Dimensions 3 Level Version (EQ-5D-3L) to assess self-rated quality of life. A paired-sample t-test was employed to assess the mean differences between the pre-and post-intervention scores., Results: Most patients (78.57%) were aged over 60 years; with 71.43% diagnosed with pulmonary fibrosis more than 3 years ago. We performed an analysis of 10/16 participants who completed the intervention (5 males, 5 females). On CRQ-SAS scale we found, (a) dyspnoea-small to moderate magnitude improvement of 0.5-1.0 among 50%, (b) fatigue-small to moderate magnitude improvement of 0.5-1.0 among 40%, (c) emotional function-small to high magnitude improvement of 0.5-2.0 among 50%, (d) mastery-small magnitude improvement of 0.5 among 20%. Participants reported their health moderate to best on Visual Analogue Scale of EQ-5D-3L which improved by 1-3 scale among 40%. Mental health improved as percentage of not feeling anxious or depressed rose post event from 42.86% to 72.73%., Conclusion: Our findings demonstrate that a virtual dance intervention is acceptable, enjoyable and feasible for improving health outcomes among PF patients. More organised and continuous events in future may reveal cost-benefit ratio and impact on health outcomes.

Background: The SARS-CoV-2 pandemic has had profound implications on healthcare institutions., Aims: This study aims to assess and compare referral patterns during COVID-19 to corresponding dates for the preceding 3 years (2017-2019), in order to preemptively coordinate the logistics of the surgical unit for similar future experiences., Methods: Retrospective review for our institution, a national tertiary referral centre for spine pathology. Two distinct time-points were chosen to represent the varied levels of social restriction during the current pandemic: (i) study period 1 (SP1) from 11 November 2020 to 08 June 2020 represents a national lockdown, and (ii) study period 2 (SP2) from 09 June 2020 to 09 September 2020 indicates an easing of restrictions. Both periods were compared to corresponding dates (CP1: 11 March-08 June and CP2 09 June-09 September) for the preceding 3 years (2017-2019). Data collected included age, gender, and mechanism of injury (MOI) for descriptive analyses. MOIs were categorised into disc disease, cyclist, road-traffic-accident (RTA), falls < 2 m, falls > 2 m, malignancy, sporting injuries, and miscellaneous., Results: All MOI categories witnessed a reduction in referral numbers during SP1: disc disease (-29%), cyclist (-5%), RTAs (-66%), falls < 2 m (-39%), falls > 2 m (-17%), malignancy (-33%), sporting injuries (-100%), and miscellaneous (-58%). Four of 8 categories (RTAs, falls < 2 m, malignancy, miscellaneous) showed a trend towards return of pre-lockdown values during SP2. Two categories (disc disease, falls > 2 m) showed a further reduction (-34%, -27%) during SP2. One category (sporting injuries) portrayed a complete return to normal values during SP2 while a notable increase in cyclist-related referrals was witnessed (+ 63%) when compared with corresponding dates of previous years., Conclusion: Spinal injury continues to occur across almost all categories, albeit at considerably reduced numbers. RTAs and falls remained the most common MOI. Awareness needs to be drawn to the reduction of malignancy-related referrals to dissuade people with such symptoms from avoiding presentation to hospital over periods of social restrictions., (© 2021. The Author(s).)

Objectives: The importance of palliative care in those with advanced fibrotic interstitial lung diseases (F-ILD) is recognised, but the palliative care requirements of patients and caregivers affected by F-ILD regardless of disease course are not established. We set out to explore this and identify optimal solutions in meeting the needs of a F-ILD population in Ireland., Methods: Implementing a World-Café qualitative research approach, we captured insights evolving, iteratively in interactive small group discussions in response to six predefined topics on palliative care and planning for the future. Thirty-nine stakeholders participated in the World-Café including 12 patients, 13 caregivers, 9 healthcare professionals, 4 industry representatives and 1 representative of the clergy., Results: Palliative care emerged as fundamental to the care and treatment of F-ILDs, regardless of disease progression. Unmet palliative care needs were identified as psychological and social support, disease education, inclusion of caregivers and practical/legal advice for disease progression and end-of-life planning. Participants identified diagnosis as a particularly distressing time for patients and families. They called for the introduction of palliative care discussions at this early-stage alongside improvements in integrated care, specifically increasing the involvement of primary care practitioners in referrals to palliative services., Conclusion: Patients and caregivers need discussions on palliative care associated with F-ILD to be included at the point of diagnosis. This approach may address persisting inadequacies in service provision previously identified over the course of the last decade in the UK, Ireland and European F-ILD patient charters., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Aim To gain an understanding of the impact of COVID-19 on the daily life, healthcare needs, mental wellbeing and outlook of patients with Interstitial Lung Disease (ILD) and their caregivers. Methods ILD patients and caregivers were invited to participate in a quantitative survey. Respondents could self-select to then participate in in-depth structured telephone interviews. Survey data was compared to Department of Health COVID-19 public opinion tracker findings for the comparable time period. Results There were 170 survey respones (111 patients and 59 caregivers) and 14 in-depth interview participants. 32% (n=36) of patients and 42% (n=25) of caregivers expressed extreme worry regarding COVID-19 on a 1-10 scale. 83% (n=92) of patients expressed concern about safe hospital access, 33% (n=37) had received a telephone consultation with their clinician, 43% (n=48) reported test delays, 47% (n=52) were exercising less, 23% (n=26) reported worse sleep and 15% (n=17) reported being financially worse off. Carers reported that sleep was worse for 58% (n=34), 42% (n=25) reported being worse off financially, and 40% (n=24) reported a worse diet. Worry (66%, n=39), stress (51%, n=30), anxiety (49%, n=29) were commonly reported by carers. Discussion ILD patients and caregivers reported higher levels of worry regarding COVID-19 compared to the general public. Alternative pathways for quality ILD patient care and interventions to reduce the burden of care on ILD caregivers are required., Competing Interests: The authors have no conflicts of interest to declare.

Background: Daily home-based spirometry in idiopathic pulmonary fibrosis (IPF) has been shown to be feasible and clinically informative. The patientMpower app facilitates home-based spirometry along with home-based monitoring of IPF-related symptoms. The patientMpower app can be downloaded to the user's mobile phone or tablet device, enabling the recording of objective and subjective data., Objective: The aim of this paper is to report on the 1-year experience of using patientMpower with home-based spirometry by 36 participants with self-reported pulmonary fibrosis (PF) treated with usual care., Methods: Self-selecting participants enrolled in this community-based participatory research program through a patient advocacy group in their country: Irish Lung Fibrosis Association in Ireland and PF Warriors in the United States. Disease severity was comparable with a baseline mean predicted forced vital capacity (FVC) of 64% and 62% in the Irish and US participants, respectively. Both groups of participants were allocated to identical, in-country, open-label, single-group observational studies and were provided with a Bluetooth-active Spirobank Smart spirometer integrated directly with patientMpower. Data collected via patientMpower included seated FVC (daily), breathlessness grade (modified Medical Research Council scale score), step count, medication adherence, and symptoms and impact of IPF on daily life, which were measured by a patient-reported outcome measure (PROM) scale that was specifically developed for IPF. Longitudinal patient-reported data on oximetry and oxygen consumption were also collected., Results: A large majority of the 36 participants reported that their experience using patientMpower was positive, and they wanted to continue its use after the initial 6-week observation. Out of 36 participants, 21 (58%) recorded home-based spirometry without prompting for ≥180 days, and 9 (25%) participants continued with recording home-based spirometry for ≥360 days., Conclusions: The patientMpower app with associated Bluetooth-connected devices (eg, spirometer and pulse oximeter) offers an acceptable and accessible approach to collecting patient-reported objective and subjective data in fibrotic lung conditions., (©Colin Edwards, Eamonn Costello, Nicola Cassidy, Bill Vick, Anne-Marie Russell. Originally published in JMIR mHealth and uHealth (http://mhealth.jmir.org), 20.11.2020.)

Bones do not normally have lymphatics. However, individuals with generalized lymphatic anomaly (GLA) or Gorham-Stout disease (GSD) develop ectopic lymphatics in bone. Despite growing interest in the development of tissue-specific lymphatics, the cellular origin of bone lymphatic endothelial cells (bLECs) is not known and the development of bone lymphatics has not been fully characterized. Here, we describe the development of bone lymphatics in mouse models of GLA and GSD. Through lineage-tracing experiments, we show that bLECs arise from pre-existing Prox1-positive LECs. We show that bone lymphatics develop in a stepwise manner where regional lymphatics grow, breach the periosteum and then invade bone. We also show that the development of bone lymphatics is impaired in mice that lack osteoclasts. Last, we show that rapamycin can suppress the growth of bone lymphatics in our models of GLA and GSD. In summary, we show that bLECs can arise from pre-existing LECs and that rapamycin can prevent the growth of bone lymphatics., Competing Interests: Competing interestsM.T.D. is the Director of Research for the Lymphatic Malformation Institute. The other authors declare no competing or financial interests., (© 2020. Published by The Company of Biologists Ltd.)

Background: Adolescent idiopathic scoliosis (AIS), with an incidence of 3%, is a common deformity. Correction of severe curvature of the deformity has attracted much investigation to achieve safe, reproducible results. We present our experience with a novel device for the correction of deformities across a spectrum of curve types, the rod link reducer. This system allows direct visualization of a mass derotation to achieve deformity correction., Methods: Prospective cohort study of patients with severe AIS treated in our institution during 2017 with major TL/L curves. Pre- and postoperative Cobb angles and coronal balance; operative time; and estimated blood loss, fusion levels, and screw density were recorded. Our results were split between those with a Lenke A/B classification and Lenke C, with a goal of correction of curve in the former and achieving good coronal balance with a preservation of distal motion segments in the latter., Results: There were 31 patients enrolled in our series. Within the Lenke A/B group, there were 18 patients, achieving a mean correction of 56% (SD 10%) and a correction of a mean coronal balance of 14.5 mm (SD 12.5 mm) of C7 from the CSVL to 10.9 mm (SD 10.6 mm). Our screw density was 1.3 screws (SD 0.1) per vertebrae fused. Our operative time was 185 min (SD 38 min). Average recorded blood loss was 721 ml (SD 289). In our Lenke C cohort, preoperative and postoperative mean Cobb angles (SD) were 73.3 (13.4) and 33.8 (11.9), respectively, with an average correction of 54% (SD 11%). The mean (SD) operative time was 03:35 (SD 00:35). Fusion levels were over a mean of 12.1 (SD 1.7) vertebrae, with a screw density of 1.3 (SD 0.1) per level. Mean intraoperative blood loss was 829 ml (SD 355). No patient received an allogenic blood transfusion. There were no adverse neurological events in this patient cohort., Conclusions: The link rod system allows for excellent correction of spinal deformity and a short operative time.

Background: Culture yield in osteomyelitis and septic arthritis is low, emphasising the role for molecular techniques., Aims: The purpose of this study was to review the laboratory investigation of childhood osteomyelitis and septic arthritis., Methods: A retrospective review was undertaken in an acute tertiary referral paediatric hospital from January 2010 to December 2016. Cases were only included if they had a positive culture or bacterial PCR result from a bone/joint specimen or blood culture, or had radiographic evidence of osteomyelitis., Results: Seventy-eight patients met the case definition; 52 (66%) were male. The median age was 4.8 years. Blood cultures were positive in 16 of 56 cases (29%), with 11 deemed clinically significant (Staphylococcus aureus = 8, group A Streptococcus = 3). Thirty-seven of 78 (47%) bone/joint samples were positive by culture with S. aureus (n = 16), coagulase-negative Staphylococcus (n = 9) and group A Streptococcus (n = 4), being the most common organisms. Sixteen culture-negative samples were sent for bacterial PCR, and four were positive (Kingella kingae = 2, Streptococcus pneumoniae = 1, group A Streptococcus = 1)., Conclusions: Sequential culture and PCR testing can improve the detection rate of causative organisms in paediatric bone and joint infections, particularly for fastidious microorganisms such as K. kingae. PCR testing can be reserved for cases where culture is negative after 48 h. These results have been used to develop a standardised diagnostic test panel for bone and joint infections at our institution.

Extracellular matrix (ECM)-derived implants hold great promise for tissue repair, but new strategies are required to produce efficiently decellularized scaffolds with the necessary porosity and mechanical properties to facilitate regeneration. In this study, we demonstrate that it is possible to produce highly porous, elastic, articular cartilage (AC) ECM-derived scaffolds that are efficiently decellularized, nonimmunogenic, and chondro-permissive. Pepsin solubilized porcine AC was cross-linked with glyoxal, lyophilized and then subjected to dehydrothermal treatment. The resulting scaffolds were predominantly collagenous in nature, with the majority of sulphated glycosaminoglycan (sGAG) and DNA removed during scaffold fabrication. Four scaffold variants were produced to examine the effect of both ECM (10 or 20 mg/mL) and glyoxal (5 or 10 mM) concentration on the mechanical and biological properties of the resulting construct. When seeded with human infrapatellar fat pad-derived stromal cells, the scaffolds with the lowest concentration of both ECM and glyoxal were found to promote the development of a more hyaline-like cartilage tissue, as evident by increased sGAG and type II collagen deposition. Furthermore, when cultured in the presence of human macrophages, it was found that these ECM-derived scaffolds did not induce the production of key proinflammatory cytokines, which is critical to success of an implantable biomaterial. Together these findings demonstrate that the novel combination of solubilized AC ECM and glyoxal crosslinking can be used to produce highly porous scaffolds that are sufficiently decellularized, highly elastic, chondro-permissive and do not illicit a detrimental immune response when cultured in the presence of human macrophages., (© 2019 Wiley Periodicals, Inc.)

Cystinosis is an autosomal recessive storage disease due to impaired transport of cystine out of lysosomes. Since the accumulation of intracellular cystine affects all organs and tissues, the management of cystinosis requires a specialized multidisciplinary team consisting of pediatricians, nephrologists, nutritionists, ophthalmologists, endocrinologists, neurologists' geneticists, and orthopedic surgeons. Treatment with cysteamine can delay or prevent most clinical manifestations of cystinosis, except the renal Fanconi syndrome. Virtually all individuals with classical, nephropathic cystinosis suffer from cystinosis metabolic bone disease (CMBD), related to the renal Fanconi syndrome in infancy and progressive chronic kidney disease (CKD) later in life. Manifestations of CMBD include hypophosphatemic rickets in infancy, and renal osteodystrophy associated with CKD resulting in bone deformities, osteomalacia, osteoporosis, fractures, and short stature. Assessment of CMBD involves monitoring growth, leg deformities, blood levels of phosphate, electrolytes, bicarbonate, calcium, and alkaline phosphatase, periodically obtaining bone radiographs, determining levels of critical hormones and vitamins, such as thyroid hormone, parathyroid hormone, 25(OH) vitamin D, and testosterone in males, and surveillance for nonrenal complications of cystinosis such as myopathy. Treatment includes replacement of urinary losses, cystine depletion with oral cysteamine, vitamin D, hormone replacement, physical therapy, and corrective orthopedic surgery. The recommendations in this article came from an expert meeting on CMBD that took place in Salzburg, Austria, in December 2016., (© 2019 The Authors. Journal of Inherited Metabolic Disease published by John Wiley & Sons Ltd on behalf of SSIEM.)

This paper explores commonalities in the experience and unmet needs of idiopathic pulmonary fibrosis (IPF) patients and carers in Europe throughout the care pathway, focusing specifically on the unmet communication needs of patients and carers. Four patient organisations/groups in Europe held focus groups (Italy (seven patients and four carers); Belgium (six patients); Ireland (23 patients and 10 carers); and England, UK (five patients and three carers)). A focus group schedule was provided and translated into the language of each focus group by the European Lung Foundation (ELF). Content analysis was conducted by the ELF and verified by the authors of the paper. Three main themes emerged: professional-patient, professional-professional and patient-patient communication. Within these themes, eight priority areas were highlighted by two or more of the focus groups. In addition, 17 suggested action points were identified. Patients and carers in Europe have unmet communication needs, which could be met by specialist physicians and specialist centres providing more effective information and signposting to support services, including support groups and patient organisations., Competing Interests: Conflict of interest: S. Masefield is a former employee of the European Lung Foundation. Conflict of interest: N. Cassidy reports grants from Boehringer Ingelheim Ltd, Roche Products Ireland and Three Lakes Partners to ILFA outside the submitted work. Conflict of interest: P. Powell is an employee of the European Lung Foundation. Conflict of interest: A. Wells reports personal fees for consultancy and speaking from Boehringer Ingelheim and Roche outside the submitted work.

Introduction Perinatal lumbar discectomy for lumbar disc herniation or cauda equina syndrome is a rare clinical scenario. This case series outlines the surgical management of this clinical scenario at a national tertiary referral centre over a 10-year period Methods A retrospective review of all females who underwent discectomy / decompression for lumbar disc herniation or cauda equina syndrome in the perinatal period at a national tertiary referral centre for spine surgery over a 10-year period between January 2008 to December 2017. Results 6 cases required surgical intervention. All patients were successfully managed with surgical decompressive procedures and recovered well in the postoperative period without complication. Conclusions The principles of management remain the same in the pregnant and non-pregnant populations, although treatment options are complicated by the desire to avoid risk to the developing foetus. Surgical intervention is safe to both mother and baby and if performed promptly is associated with an excellent functional outcome., Competing Interests: The authors declare no conflict of interest.

Background: Antifibrotics are recommended for the treatment of individuals with idiopathic pulmonary fibrosis (IPF), but treatment use remains at ∼60%., Objective: To investigate the views of individuals with IPF and pulmonologists on the diagnosis and management of IPF to understand treatment patterns., Methods: Interviews and/or online surveys were completed by patients and pulmonologists from Canada, France, Germany, Italy, Spain, and the UK. Responses from physicians were analyzed by time between diagnosis and treatment initiation in the majority of patients with IPF (group A, > 4 months; group B, ≤4 months). Statistical comparisons between physicians were undertaken using z tests, with p < 0.05 considered statistically significant., Results: The physicians in group A saw fewer patients, were less comfortable discussing the IPF prognosis with patients, and had less belief in the benefits of antifibrotic treatments than the physicians in group B. These physicians' attitudes contrasted with those of the patients, who wanted more information about the IPF prognosis and pharmacological treatment options at diagnosis and were more concerned about preventing disease progression than avoiding medication side effects. Differences between countries were found regarding physicians' comfort in discussing the prognosis at diagnosis and access to care., Conclusions: Several barriers to antifibrotic treatment, principally reflecting the differing views and values of patients and physicians, were identified in this study, suggesting a need for better patient-physician communication about pharmacological therapy for IPF., (© 2018 S. Karger AG, Basel.)

Introduction: We report a rare case of cervical spine trauma through a cervical disc replacement and adjacent multilevel disc fusions. Cervical disc replacement (CDR) is a viable option for the surgical treatment of degenerative disc disease however long term follow up data regarding this operative technique is poor specifically relating to traumatic complications. We know of no previous reports of bilateral cervical pedicle fractures occurring adjacent to CDR and anterior cervical spine instrumentation., Presentation of Case: A 46 year-old with a history of C6C7 CDR and C4-6 anterior cervical decompression and fusion was an unrestrained driver involved in a road traffic accident and suffered bilateral C7 pedicle fractures and a right C6C7 facet joint fracture-subluxation without neurological deficit. Reduction and fixation via a posterior approach achieved a satisfactory alignment and the patient made an uneventful recovery., Discussion: A significant force coupled with cervical fixation resulted in a bilateral pedicle fracture of the cervical spine with preserved neurological function., Conclusion: The protective role of the CDR has not been previously demonstrated but may have played a role in this case. The authors believe the challenges encountered in the treatment of this patient provide valuable lessons in the management of complex cervical spine trauma in the setting of previous instrumentation., (Copyright © 2018. Published by Elsevier Ltd.)

Chlorinated ethenes (CEs) are legacy contaminants whose chemical footprint is expected to persist in aquifers around the world for many decades to come. These organohalides have been reported in river systems with concerning prevalence and are thought to be significant chemical stressors in urban water ecosystems. The aquifer-river interface (known as the hyporheic zone) is a critical pathway for CE discharge to surface water bodies in groundwater baseflow. This pore water system may represent a natural bioreactor where anoxic and oxic biotransformation process act in synergy to reduce or even eliminate contaminant fluxes to surface water. Here, we critically review current process understanding of anaerobic CE respiration in the competitive framework of hyporheic zone biogeochemical cycling fuelled by in-situ fermentation of natural organic matter. We conceptualise anoxic-oxic interface development for metabolic and co-metabolic mineralisation by a range of aerobic bacteria with a focus on vinyl chloride degradation pathways. The superimposition of microbial metabolic processes occurring in sediment biofilms and bulk solute transport delivering reactants produces a scale dependence in contaminant transformation rates. Process interpretation is often confounded by the natural geological heterogeneity typical of most riverbed environments. We discuss insights from recent field experience of CE plumes discharging to surface water and present a range of practical monitoring technologies which address this inherent complexity at different spatial scales. Future research must address key dynamics which link supply of limiting reactants, residence times and microbial ecophysiology to better understand the natural attenuation capacity of hyporheic systems., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Progressive fibrotic interstitial lung diseases (ILDs) are characterised by major reductions in quality of life and survival and have similarities to certain malignancies. However, palliative care expertise is conspicuously inaccessible to many patients with ILD. Unmet patient and caregiver needs include effective pharmacological and psychosocial interventions to improve quality of life throughout the disease course, sensitive advanced care planning, and timely patient-centred end-of-life care. The incorrect perception that palliative care is synonymous with end-of-life care, with no role earlier in the course of ILD, has created a culture of neglect. Interventions that aim to improve life expectancy are often prioritised without rigorous assessment of the individual's health and psychosocial needs, thereby inadvertently reducing quality of life. As in malignant disorders, radical interventions to slow disease progression and palliative measures to improve quality of life should both be prioritised. Efficient patient-centred models of palliative care must be validated, taking into account religious and cultural differences, as well as variability of resources. Effective implementation of palliative care for ILD will require multidisciplinary participation from clinicians, specialist nurses, psychologists, social workers, and, in some countries, non-governmental faith and community-based organisations with access to palliative care expertise., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Introduction: Farming is a major industry in Ireland, employing 6% of the workforce but accounts for 40% of workplace fatalities (Meredith, 2008). 1 The use of machinery and proximity to large livestock poses significant risk for spinal injuries. This study reviews mechanism of injury, injuries sustained, and the treatment undertaken., Results: Of 31 patients, 26 sustained high-energy injuries with machinery and livestock implicated in the majority of accidents. 77% sustained poly-trauma and 52% had permanent neurological injury., Conclusions: The proximity to heavy machinery and livestock pose significant risk for spinal injuries. This study should encourage increased efforts to improve farm safety.

Background Context: Plasmablastic lymphoma (PBL) is a rare aggressive variant of diffuse large B-cell lymphoma., Purpose: We describe a rare case of an aggressive PBL presenting as acute spinal cord compression requiring thoracic decompression and fusion, in a case of previously undiagnosed human immunodeficiency virus (HIV) infection., Study Design: A case report., Patient Sample: A patient with PBL of the thoracic spine., Outcome Measures: Preoperative magnetic resonance imaging, pathologic findings from the operative specimen, and serum HIV testing confirmed the diagnosis., Methods: We present the case of a 33-year-old Caucasian woman with a 10-day history of thoracic back pain and a 1-day history of sudden-onset bilateral lower limb weakness and paresthesia from below the level of the umbilicus (American Spinal Injury Association [ASIA] Grade C). Magnetic resonance imaging demonstrated an extradural mass extending from T3 to T6 within the left posterior canal, resulting in significant cord compression. A complete debulking of the tumor mass and an instrumented posterior thoracic fusion was performed., Results: Histopathologic examination of the specimen revealed tumor cells of PBL, and subsequent HIV testing was positive. She was treated with intravenous and intrathecal chemotherapy to prevent recurrence. Her lower limb neurologic status improved to ASIA Grade D over the subsequent 2 weeks., Conclusions: We report the case of an aggressive PBL presenting as acute spinal cord compression requiring urgent surgical intervention, on a background of undiagnosed HIV infection., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Integrated approaches for the identification of pollutant linkages between aquifers and streams are of crucial importance for evaluating the environmental risks posed by industrial contaminants like trichloroethene (TCE). This study presents a systematic, multi-scale approach to characterising groundwater TCE discharge to a 'gaining' UK lowland stream receiving baseflow from a major Permo-Triassic sandstone aquifer. Beginning with a limited number of initial monitoring points, we aim to provide a 'first pass' mechanistic understanding of the plume's fate at the aquifer/stream interface using a novel combination of streambed diffusion samplers, riparian monitoring wells and drive-point mini-piezometers in a spatially nested sampling configuration. Our results indicate the potential discharge zone of the plume to extend along a stream reach of 120 m in length, delineated by a network of 60 in-situ diffusion samplers. Within this section, a 40 m long sub-reach of higher concentration (>10 μg L(-1)) was identified; centred on a meander bend in the floodplain. 25 multi-level mini-piezometers installed to target this down-scaled reach revealed even higher TCE concentrations (20-40 μg L(-1)), significantly above alluvial groundwater samples (<6 μg L(-1)) from 15 riparian monitoring wells. Significant lateral and vertical spatial heterogeneity in TCE concentrations within the top 1m of the streambed was observed with the decimetre-scale vertical resolution provided by multi-level mini-piezometers. It appears that the distribution of fine-grained material in the Holocene deposits of the riparian floodplain and below the channel is exerting significant local-scale geological controls on the location and magnitude of the TCE discharge. Large-scale in-situ biodegradation of the plume was not evident during the monitoring campaigns. However, detections of cis-1,2-dichloroethene and vinyl chloride in discrete sections of the sediment profile indicate that shallow (e.g., <20 cm) TCE transformation may be significant at a local scale in the streambed deposits. Our findings highlight the need for efficient multi-scale monitoring strategies in geologically heterogeneous lowland stream/aquifer systems in order to more adequately quantify the risk to surface water ecological receptors posed by point-source groundwater contaminants like TCE., (Copyright © 2013 Elsevier B.V. All rights reserved.)

Study Design: This article presents a case of Paget's disease of the cervical spine., Objectives: To report a very rare case of Paget's disease of the cervical spine and review the literature., Methods: We report a case of Paget's disease of the cervical spine in a 51-year-old male presenting with neck pain post RTA. Routine radiographs revealed enlarged sclerotic bodies of C2-C5 with normal alignment. CT revealed a fracture of the lateral mass of C2 with extensive sclerotic changes in the bodies of C2-C5 with periosteal apposition, endosteal resorption "pumice stone" type focal periosteal apposition consistent with Paget's disease. Laboratory investigations were consistent with a diagnosis of Paget's disease. Isotope bone scan revealed isolated uptake in the cervical spine. He was commenced on biosphosphonate therapy. Following 12 weeks of immobilisation his orthosis was removed and rehabilitation commenced., Results: At 12-month follow-up he is asymptomatic with no radiological change., Conclusion: This case illustrates the investigation and successful management of a very rare case of Paget's disease of the cervical spine.

Unlabelled: Synchrotron-based X-ray fluorescence microscopy (XFM) can localise chemical elements at a subcellular level. 99mTechnetium stannous (TcSn) colloid is taken up by phagocytes via a Complement Receptor 3 mediated phagocytic process. In the current study, XFM was used to examine the intracellular trafficking of TcSn colloid in neutrophils. XFM was performed on TcSn colloid, and neutrophils labelled with TcSn colloid, in whole blood. We developed a set of pixel by pixel analysis and mapping techniques incorporating cluster analysis that allowed us to differentiate neutrophils and artefactual contaminants, and we examined the changes in element distribution that accompany neutrophil phagocytosis of TcSn colloid. Sn became associated with half the neutrophils. Within cells, Sn colocalised with iron (Fe) and sulphur (S), and was negatively associated with calcium (Ca). Despite the high sensitivity of XFM, Tc was not detected. XFM can help clarify the intracellular processes that accompany neutrophil phagocytosis. The subcellular colocalisation of Sn with Fe is consistent with fusion of the colloid-containing phagosome with neutrophil granules. The association of Sn with S suggests that proteins rich in S-containing amino acids are present in the phagosome. The negative colocalisation with Ca indicates that ongoing maturation of the TcSn colloid phagosome is no longer calcium dependent one hour after phagocytosis., Electronic Supplementary Material: The online version of this article (doi:10.1007/s10867-011-9233-9) contains supplementary material, which is available to authorized users.

Introduction: Medication errors are widely reported for hospitalised patients, but limited data are available for medication errors that occur in community-based and clinical settings. Epidemiological data from poisons information centres enable characterisation of trends in medication errors occurring across the healthcare spectrum., Aim: The objective of this study was to characterise the epidemiology and type of medication errors reported to the National Poisons Information Centre (NPIC) of Ireland., Methods: A 3-year prospective study on medication errors reported to the NPIC was conducted from 1 January 2007 to 31 December 2009 inclusive. Data on patient demographics, enquiry source, location, pharmaceutical agent(s), type of medication error, and treatment advice were collated from standardised call report forms. Medication errors were categorised as (i) prescribing error (i.e. physician error), (ii) dispensing error (i.e. pharmacy error), and (iii) administration error involving the wrong medication, the wrong dose, wrong route, or the wrong time., Results: Medication errors were reported for 2348 individuals, representing 9.56% of total enquiries to the NPIC over 3 years. In total, 1220 children and adolescents under 18 years of age and 1128 adults (≥ 18 years old) experienced a medication error. The majority of enquiries were received from healthcare professionals, but members of the public accounted for 31.3% (n = 736) of enquiries. Most medication errors occurred in a domestic setting (n = 2135), but a small number occurred in healthcare facilities: nursing homes (n = 110, 4.68%), hospitals (n = 53, 2.26%), and general practitioner surgeries (n = 32, 1.36%). In children, medication errors with non-prescription pharmaceuticals predominated (n = 722) and anti-pyretics and non-opioid analgesics, anti-bacterials, and cough and cold preparations were the main pharmaceutical classes involved. Medication errors with prescription medication predominated for adults (n = 866) and the major medication classes included anti-pyretics and non-opioid analgesics, psychoanaleptics, and psychleptic agents. Approximately 97% (n = 2279) of medication errors were as a result of drug administration errors (comprising a double dose [n = 1040], wrong dose [n = 395], wrong medication [n = 597], wrong route [n = 133], and wrong time [n = 110]). Prescribing and dispensing errors accounted for 0.68% (n = 16) and 2.26% (n = 53) of errors, respectively., Conclusion: Empirical data from poisons information centres facilitate the characterisation of medication errors occurring in the community and across the healthcare spectrum. Poison centre data facilitate the detection of subtle trends in medication errors and can contribute to pharmacovigilance. Collaboration between pharmaceutical manufacturers, consumers, medical, and regulatory communities is needed to advance patient safety and reduce medication errors.

Background: Occasionally, mycologist assistance is requested to reliably identify mushroom species in symptomatic cases where there is a concern that a toxic species is involved. The aim of this study was to describe the epidemiology of mushroom poisoning in Ireland, to describe the working arrangement between the National Poisons Information Centre (NPIC) and professional mycologists and to present a case series detailing the circumstances when mycologists were consulted., Methods: Computerised records from 1 January 2004 to 31 December 2009 were retrospectively reviewed and data on patient demographics, circumstances, and mushroom species collated. In 1999, the NPIC established a national registry of volunteer professional mycologists who are available 24 h/day for mushroom identification. The NPIC staff liaises directly with the mycologist and arranges transport of mushroom material. Digital photographic images are requested if there is likely to be a delay in arranging transportation of mushroom material, and the images are subsequently emailed to a mycologist. Five cases of suspected mushroom poisoning were chosen to demonstrate the inter-professional collaboration between the NPIC and mycologists., Results: From 2004 to 2009, the NPIC was consulted about 70 cases of suspected mushroom exposures. Forty-five children ingested unknown mushrooms, 12 adults and 2 children ingested hallucinogenic mushrooms and 11 adults ingested wild toxic mushrooms that were incorrectly identified or confused with edible species. The mycologists were consulted 10 times since 1999. In this series, Amanita species were identified in two cases. In three cases, the species identified were Clitocybe nebularis, Coprinus comatus and Panaeolina foenisecii, respectively, and serious poisoning was excluded. Incorrect mushroom identification by a health care professional using the Internet occurred in two cases. The mycologists assisted Poisons Information Centres in Northern Ireland and the United Kingdom in two cases. Digital photographs facilitated tentative mushroom identification in two cases., Conclusion: Poison information centres should maintain a registry of expert mycologists who are available for consultation following potentially serious mushroom intoxications. Health care workers should not attempt to identify toxic mushroom species using the Internet as erroneous identification can occur. Digital photography may help with mushroom identification when there is likely to be a delay organising a physical examination of mushroom tissue.

Background: The National Poisons Information Service and the Association of Clinical Biochemists in the United Kingdom published guidelines on laboratory analyses for poisoned patients in 2002. In 2003, U.S. guidelines were prepared by an expert panel of analytical toxicologists and emergency department (ED) physicians. Some professional associations in different countries quote these guidelines but there are no data to support adherence to these recommendations in the medical literature., Objective: To analyze the availability of 15 quantitative laboratory analyses, specifically relating to the management of the poisoned patient, in Ireland., Methods: A questionnaire relating to the provision of toxicological analyses was compiled and distributed to 39 acute care hospital laboratories in Ireland. The availability of 15 quantitative analyses (carbamazepine, carboxyhemoglobin, digoxin, ethanol, ethylene glycol, iron, lithium, methemoglobin, methanol, paracetamol, paraquat, phenobarbital, salicylate, theophylline, and valproic acid), specifically relating to the management of the poisoned patient, was analyzed. The reporting units for these analyses were also collected. The acute care hospitals were sorted into groups according to their number of ED attendances: A) <20,000, B) 20,000-30,000, C) 30,000-40,000, D) 40,000-50,000, and E) >50,000 based on ED activity data for 2008. The median number of assays provided by each hospital group was calculated., Results: The response rate was 100%, allowing complete national data to be ascertained. Hospital laboratories provided a more comprehensive testing service when ED attendances exceeded 30,000 per annum. Sixteen hospital laboratories (41.0%) performed at least 10 of the 15 toxicological investigations. The most widely available assay was paracetamol (74.4%, n = 29) and the least widely available assays were methanol, ethylene glycol, and paraquat (2.6%, n = 1). Only one hospital laboratory provided all 15 analyses. Hospital laboratories in groups A and B carried out a median number of 3/15 assays (range 0-8) and 4/15 assays (range 0-10), respectively. Hospital laboratories where ED attendances exceeded 30,000 per annum carried out a median number of 11/15 toxicological assays (range 1-15). There was a lack of consistency in the reporting units with both molar and mass units used., Conclusion: There is wide availability of toxicological analyses among hospital laboratories in Ireland. Most analyses were provided with 24-h availability. Hospitals with ED attendances in excess of 30,000 provided a more comprehensive laboratory service with respect to the number of analyses performed. The lack of consistency with units used by Irish hospital laboratories could present challenges with the reporting and interpretation of quantitative results. This study could be carried out in other countries to establish what analyses are available for the treatment of poisoned patients.

Data regarding the incidence, morbidity, and mortality of poisoning in older adults are limited. A retrospective review of enquiries to the National Poisons Information Centre, involving adults aged over-65 years, was conducted from 2001-2003 inclusive. Information on poisoning circumstances, patient demographics, type and number of agent(s), symptoms, enquiry source, location, and route of exposure was collated. 575 adults over-65 years of age were poisoned during the study period. 37.2% (n=214) of poisonings were intentional, 54.4% (n=313) were unintentional, in 5.6% (n=32) of cases the circumstances were unknown, and 2.8% (n=16) were requests for information only. 70.3% (n=404) of poisonings involved pharmaceuticals, 29.0% (n=167) chemicals, and 0.7% (n=4) foreign bodies. The principal pharmaceuticals included cardiovascular drugs, hypnotics/sedatives, and antidepressants. 145 (25%) patients were poisoned with multiple pharmaceutical agents. Overall, 301 (52.3%/) older adults were symptomatic and there were 5 fatalities. Substantial morbidity and mortality occurred following poisoning in older adults. Poison prevention strategies are needed to reduce toxic exposures.

We report 2 cases demonstrating that localization of internal mammary (IM) sentinel lymph nodes with lymphoscintigraphy using peritumoral injection of Tc-99m antimony sulfide colloid, followed by resection using minimal access surgery, can reveal nodal metastatic disease in patients with clinically node-negative breast cancer when axillary sentinel nodes are not affected by metastatic disease. When this is found, it changes staging and can affect prognosis and treatment. These cases confirm that the technique used is sampling true sentinel IM nodes, that is nodes that receive direct lymph flow from the breast cancer, and confirm the importance of sampling IM sentinel lymph nodes. Unless techniques are used that are specifically designed to identify IM node drainage from the breast cancer site itself, with subsequent directed surgical removal of sentinel IM nodes, some patients with breast cancer will not be staged correctly.

Calcium hydroxide (Ca(OH)(2)) has been used extensively to induce dentine regeneration through formation of dentine bridges at sites of pulp exposure after dental tissue injury, however, the biological processes underpinning these events are unclear. We hypothesise that growth factors and other bio-active molecules, sequestered within dentine matrix, may be released by the action of Ca(OH)(2) and signal gene expression in pulp cells, which mediates the changes in cell behaviour observed during regeneration. Powdered sound, human dentine samples were extracted with either 0.02 m Ca(OH)(2), pH 11.7 or 10% EDTA, pH 7.2 ( a control known extractant of bio-active and other ECM molecules from dentine) over a 14-day period. Extracts were compared for non-collagenous protein (NCP) and glycosaminoglycan (GAG) content using dye binding assays and protein compositions were analysed by 1D-polyacrylamide gel electrophoresis (1D-PAGE) and TGF-beta1 ELISA. The effects of extracts on TGF-beta1, Collagen-1alpha and Nestin gene expression were analysed using semi-quantitative RT-PCR in the dental MDPC-23, OD-21 and fibroblastic Swiss 3T3 cell lines following 24h of exposure. Ca(OH)(2) solubilised NCPs and GAGs from the dentine ECM, although with a lower yield than the EDTA solution and with different kinetics. 1D-PAGE analysis demonstrated some differences in profiles for proteins solubilised from dentine by Ca(OH)(2) and EDTA. Both solutions released TGF-beta1 from the dentine with higher concentrations present in the EDTA (1.395 +/- 0.036 ng/mg) versus the Ca(OH)(2) (0.364 +/- 0.012 ng/mg) extract. Notably, both extracts induced similar gene expression profiles in all cell lines. These data provide a rational explanation for the action of Ca(OH)(2) during pulp capping in which the cellular activities involved in dentine bridge formation may be mediated through release of growth factors and other bio-active molecules from the dentine by Ca(OH)(2).

Introduction: [(99m)Tc]-technetium stannous colloid (TcSnC)-labeled white cells are used to image inflammation. Neutrophil labeling with TcSnC is probably phagocytic, but the phagocytic receptor involved is not known. We hypothesised that complement receptor 3 (CR3) plays a key role. Phagocytic labeling could theoretically result in neutrophil activation or priming, affecting the behaviour of labeled cells. Fluorescence-activated cell sorter (FACS) analysis side scatter measurements can assess neutrophil activation and priming., Methods: We tested whether TcSnC neutrophil labeling is CR3-mediated by assessing if neutrophil uptake of TcSnC was inhibited by a monoclonal antibody (mAb) directed at the CD11b component of CR3. We tested if TcSnC-labeled neutrophils show altered activation or priming status, comparing FACS side scatter in labeled and unlabeled neutrophils and examining the effect of lipopolysaccharide (LPS), a known priming agent., Results: Anti-CD11b mAb reduced neutrophil uptake of TcSnC in a dose-dependent fashion. Labeled neutrophils did not show significantly increased side scatter compared to controls. LPS significantly increased side scatter in control cells and labeled neutrophils. However, the increase was significantly greater in labeled neutrophils than unlabeled cells., Conclusions: Neutrophil labeling with TcSnC is related to the function of CR3, a receptor which plays a central role in phagocytosis. TcSnC labeling did not significantly activate or prime neutrophils. However, labeled neutrophils showed a greater priming response to LPS. This could result in labeled neutrophils demonstrating increased adhesion on activated endothelium at sites of infection.

Decanting of chemicals from their original containers is a hazardous practice that can result in inadvertent poisoning. We conducted a four-year prospective observational study to analyse the epidemiology of accidental poisoning with decanted chemicals. 157 patients were poisoned following accidental exposure to chemicals transferred to innocuous containers. 106 patients attended hospital emergency departments, 17 attended a general practitioner and 34 were instructed to seek medical advice if symptomatic. 112 patients developed clinical features, 9 patients required admission to intensive care and 4 of these needed intubation and ventilation. There was 1 fatality following inadvertent ingestion of paraquat. The predominant symptoms were gastrointestinal upset and a burning sensation in the mouth, throat, and stomach. Decanted chemicals included household, industrial, automobile, and agricultural products. Caustic agents accounted for approximately 33% of decanted chemicals. Decanting of chemicals into innocuous containers results in significant morbidity, mortality, and cost to the health service.

Bupropion is a monocyclic antidepressant structurally related to amphetamine. Zyban, a sustained-release formulation of bupropion hydrochloride, was recently released in Ireland, as a smoking cessation aid. In the initial 6 months since it's introduction, 12 overdose cases have been reported to The National Poisons Information Centre. 8 patients developed symptoms of toxicity. Common features included tachycardia, drowsiness, hallucinations and convulsions. Two patients developed severe cardiac arrhythmias, including one patient who was resuscitated following a cardiac arrest. All patients recovered without sequelae. We report a case of a 31 year old female who required admission to the Intensive Care Unit for ventilation and full supportive therapy, following ingestion of 13.5g bupropion. Recurrent seizures were treated with diazepam and broad complex tachycardia was successfully treated with adenosine. Zyban caused significant neurological and cardiovascular toxicity in overdose. The potential toxic effects should be considered when prescribing it as a smoking cessation aid.

Femoral fractures resulting from birth injuries are rare. The authors undertook a study to assess their incidence and outcome. Seven patients from a total of 55,296 live births suffered 8 femoral fractures (incidence 0.13 per 1,000 live births). Twin pregnancies, breech presentations, prematurity, and disuse osteoporosis were associated with the occurrence of a fracture. The typical injury pattern was a spiral fracture of the proximal half of the femur, which was held in an extended position. A variety of treatment modalities were used, including gallows traction, spica cast, and Pavlik harness. All patients in this study, regardless of treatment, had a satisfactory clinical outcome, with no evidence of limb length discrepancy or angular deformity on follow-up.