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We thank Salama S et al [...]

Dear Editor We applaud Martin et al for their investigation of analgesic options in anterior cruciate ligament (ACL) reconstruction, a painful and common procedure.[1][1] Analgesia aside, clinical evaluation of functional outcomes is an important consideration in examining any regional block and in

To the Editor:We read with interest the comparison by Sehgal IS et al. of the benefits of pressure support (PSV) and adaptive support ventilation (ASV) in patients presenting with acute exacerbatio...

Purpose: The purpose of this study was to examine the route to diagnosis of persons with Amyotrophic Lateral Sclerosis (ALS) in Nova Scotia. Methods: Nova Scotia clients of the ALS Society of New Brunswick and Nova Scotia described their perspective on their route to a firm diagnosis of ALS, including processes that worked effectively as well as barriers to expedited care. Clients were selected from all who had been diagnosed in the previous two years and who were able and will- ing to participate in the interview. Results: Fifteen interviews were completed. From two to 42 months elapsed between the time of initial symptoms and firm diagnosis of ALS being made. The path to diagnosis was ≤6 months for five individuals and was ≥18 months for five others. Mean duration of time elapsed between the first symptoms and the firm diagnosis was 14.4 months with a median of 11 months. Conclusions: Persons with ALS in Nova Scotia have similar paths to diagnosis compared to those in other countries. Considerable delays occurred in persons with initial bulbar symptoms and in those cases where ALS was not con- sidered a diagnostic possibility early in the course, due to lack of provider awareness or atypical initial symptoms and signs.

Background and Purpose— In children with stroke, poor motor outcome is associated with early Wallerian degeneration of the corticospinal tract that is seen on diffusion-weighted MRI. In this study we test the hypothesis that early diffusion changes also occur in the corticospinal tract (CST) of adults after stroke and that these lesions are associated with poor outcome. Methods— In this retrospective study, we assessed images from a serial MRI study of adults with acute middle cerebral/internal carotid artery stroke. MRI-negative TIA patients served as controls. Custom software measured signal along the CST on different sequences, including the apparent diffusion coefficient (ADC). Visual detection of abnormal signal by blinded neuroradiologists was also evaluated. We then determined associations between CST signal changes and 3-month motor outcome (NIHSS score). Results— Thirty-eight patients (20 stroke/18 control) were included. ADC measures were much more accurate than other MRI sequences for detection of degeneration in the CST. The ADC decreased in a time-dependent fashion in the CST of patients with poor motor outcome but not in those with good outcome. Changes in ADC were maximal at 7 days. Neuroradiologists could visually detect these changes with accuracy comparable to the software method. Conclusion— CST ADC decreases after acute stroke in patients with poor motor outcome and may represent early Wallerian degeneration. Recognition of this imaging marker may improve early outcome prediction and patient selection for rehabilitation and neuroprotection trials.

Background Intensive care unit (ICU) re-admission identifies a high-risk group in terms of hospital mortality, length of stay, and resource utilization. Only hospital and ICU mortality are well described in the literature on critically ill patients needing re-admission. Methods With ethical committee approval, from a prospectively collected database of all admissions to a combined medical and surgical ICU from January 1 to December 31, 2004, we identified all ICU re-admissions from within the hospital and analysed the factors associated with increased incidence of re-admission. At 2–3 yr after discharge, we evaluated the functional outcome of the surviving re-admitted patients as Glasgow Outcome Score (GOS) and Karnofsky index and identified determinants of both mortality and good functional outcome. Results Seventy-three (7.4%) of the 1061 patients who survived their first ICU stay were re-admitted during the study period. Of the 73 re-admitted patients, 14 died in ICU, 17 died later in the same hospital stay, and 10 died in the interim. Thus, 32 (43.8%) were alive 2–3 yr after discharge. The median [IQR] GOS of the survivors was 4 (see Mackle and colleagues in One year outcome of intensive care patients with decompensated alcoholic liver disease. Br J Anaesth 2006; 97: 496–8 and Jennett and Bond in Assessment of outcome after severe brain damage. A practical scale. Lancet 1975; 1: 480–4) and their median Karnofsky index was 70 [70–90] at follow-up. The only independent predictors of favourable functional outcome at follow-up were lower Apache 2 scores on both first ICU admission and on re-admission. Conclusions Although the ICU, hospital, and subsequent mortalities are high in patients after ICU re-admission, most survivors at 2–3 yr had by then made a good functional recovery and were independent.

We evaluated various aspects of grand rounds videoconferenced from a tertiary care hospital to a regional hospital in Nova Scotia. During a five-month study period, 29 rounds were broadcast (19 in medicine and 10 in cardiology). The total recorded attendance at the remote site was 103, comprising 70 specialists, nine family physicians and 24 other health-care professionals. We received 55 evaluations, a response rate of 53%. On a five-point Likert scale (on which higher scores indicated better quality), mean ratings by remote-site participants of the technical quality of the videoconference were 3.0-3.5, with the lowest ratings being for ability to hear the discussion (3.0) and to see visual aids (3.1). Mean ratings for content, presentation, discussion and educational value were 3.8 or higher. Of the 49 physicians who presented the rounds, we received evaluations from 41, a response rate of 84%. The presenters rated all aspects of the videoconference and interaction with remote sites at 3.8 or lower. The lowest ratings were for ability to see the remote sites (3.0) and the usefulness of the discussion (3.4). We received 278 evaluations from participants at the presenting site, an estimated response rate of about 55%. The results indicated no adverse opinions of the effect of videoconferencing (mean scores 3.1-3.3). The estimated costs of videoconferencing one grand round to one site and four sites were C$723 and C$1515, respectively. The study confirmed that videoconferenced rounds can provide satisfactory continuing medical education to community specialists, which is an especially important consideration as maintenance of certification becomes mandatory.

Irish ICUs typically have bed occupancy rates approaching 100%, with 75 to 80% being the recommended level [1]. Detection of excessive demand from simple databases can thus be difficult: expedited turnover and cancellations of elective surgery often ensue, leaving occupancy rates unchanged. We hypothesised that excessive demand would produce higher readmission rates, thus illustrating the strain imposed on ICU resources during the H1N1 influenza pandemic.

Cocaine misuse is increasing and it is evidently considered a relatively safe drug of abuse in Ireland. To address this perception, we reviewed the database of an 18-bed Dublin intensive care unit, covering all admissions from 2003 to 2007. We identified cocaine-related cases, measuring hospital mortality and long-term survival in early 2009. Cocaine-related admissions increased from around one annually in 2003-05 to 10 in 2007. Their median (IQR [range]) age was 25 (21-35 [17-47]) years and 78% were male. The median (IQR [range]) APACHE II score was 16 (11-27 [5-36]) and length of intensive care stay was 5 (3-9 [1-16]) days. Ten patients died during their hospital stay. A further five had died by the time of follow-up, a median of 24 months later. One was untraceable. Cocaine toxicity necessitating intensive care is increasingly common in Dublin. Hospital mortality in this series was 52%. These findings may help to inform public attitudes to cocaine.

Patients who have overdosed on drugs commonly present to emergency departments, with only the most severe cases requiring intensive care unit (ICU) admission. Such patients typically survive hospitalisation. We studied their longer term functional outcomes and recovery patterns which have not been well described. All patients admitted to the 18-bed ICU of a university-affiliated teaching hospital following drug overdoses between 1 January 2004 and 31 December 2006 were identified. With ethical approval, we evaluated the functional outcome and recovery patterns of the surviving patients 31 months after presentation, by telephone or personal interview. These were recorded as Glasgow outcome score, Karnofsky performance index and present work status. During the three years studied, 43 patients were identified as being admitted to our ICU because of an overdose. The average age was 34 years, 72% were male and the mean APACHE II score was 16.7. Of these, 32 were discharged from hospital alive. Follow-up data was attained on all of them. At a median of 31 months follow-up, a further eight had died. Of the 24 surviving there were 13 unemployed, seven employed and four in custody. The median Glasgow outcome score of survivors was 4.5, their Karnofsky score 80. Admission to ICU for treatment of overdose is associated with a very high risk of death in both the short- and long-term. While excellent functional recovery is achievable, 16% of survivors were held in custody and 54% unemployed.

[1] Dust is the Number 1 environmental hazard on the Moon, yet its movements and adhesive properties are little understood. Matchbox-sized, 270-gram Dust Detector Experiments (DDEs) measured contrasting effects triggered by rocket exhausts of Lunar Modules (LM) after deployment 17 m and 130 m from Apollo 11 and 12 LMs. Apollo 11 Lunar Seismometer was contaminated, overheated and terminated after 21 days operation. Apollo 12 hardware was splashed with collateral lunar dust during deployment. DDE horizontal solar cell was cleansed of nominally 0.3 mg cm−2 dust by 80% promptly at LM ascent and totally within 7 minutes. A vertical cell facing East was half-cleaned promptly then totally over hundreds of hours. Each cell cooled slightly. For the first time lunar electrostatic adhesive forces on smooth silicon were directly measured by comparison with lunar gravity. Analyses imply this adhesive force weakens as solar angle of incidence decreases. If valid, future lunar astronauts may have greater problems with dust adhesion in the middle half of the day than faced by Apollo missions in early morning. A sunproof shed may provide dust-free working environments on the Moon. Low-cost laboratory tests with DDEs and simulated lunar dust can use DDE benchmark lunar data quickly, optimising theoretical modelling and planning of future lunar expeditions, human and robotic.