• Day case shoulder surgery: satisfactory pain control without regional anaesthesia. A prospective analysis of a perioperative protocol.

      Daruwalla, Z J; Halpenny, M; Mullett, H; Department of Orthopaedic Surgery, Beaumont Hospital, Beaumont Road, Dublin 9, Republic of Ireland, zubinjimmydaruwalla@rcsi.ie. (2009-03)
      Pain control is an issue which may limit patients' acceptance of day case shoulder surgery. This study prospectively examined the outcome of a protocol for day case shoulder surgery to determine if satisfactory pain relief could be achieved without regional anaesthesia.
    • "Dead in bed": a tragic complication of type 1 diabetes mellitus.

      O'Reilly, M; O'Sullivan, E P; Davenport, C; Smith, D; Department of Endocrinology and Diabetes Mellitus, Beaumont Hospital and RCSI Medical School, Beaumont, Dublin 9, Ireland. micilino@hotmail.com (2010-12)
      "Dead in bed" is a tragic description of a particular type of sudden death in type 1 diabetes mellitus (DM). Patients are typically found dead in the early morning, lying in an undisturbed bed, having been well the previous evening. The incidence of "dead in bed" syndrome is not known but studies suggest figures of between 4.7 and 27.3% of all unexplained deaths in type 1 DM. The pathogenesis is unclear but patients typically have a preceding history of recurrent severe hypoglycaemia. We describe two cases of "dead in bed" syndrome which occurred at our institution within a 12-month period.
    • A deceiving wheeze.

      Chotirmall, S H; Branagan, P; Logan, M P; O'Neill, S J; Department of Respiratory Medicine, Beaumont Hospital, Dublin 9, Republic of Ireland, schotirmall@rcsi.ie. (2009-08-07)
      'Wheeze' is a common symptom in both paediatric and adult populations. Unexplained wheeze is concerning and warrants investigation. We present a case of a young girl with childhood asthma suffering with 'persistent wheeze'. This was explained by the presence of a dual aortic arch which only became apparent during her teenage years. This report serves as a reminder to all clinicians that "not all that wheezes is asthma".
    • Deep full thickness burn to a finger from a topical wart treatment

      Tong, E; Dorairaj, J; O’Sullivan, JB; Kneafsey, B (Irish Medical Journal, 2015-10)
      We present a case of a deep full thickness burn from topical formic acid. Our patient developed a burn over her proximal interphalangeal joint (PIPJ) of her finger, secondary to inappropriate application of an anti-wart treatment. The burn required extensive debridement, and the resultant defect was reconstructed using a subcutaneous flap from the adjacent finger (a reverse cross finger flap). She was reviewed six months post-surgery, and overall she has a sub-optimal result. This incident was referred to the Irish Medicines Board who have since reviewed the case and ordered the manufacturer to alter their usage instructions.
    • Defining familial ALS: A worldwide survey

      Byrne, S; Hardiman, O (2011-11)
    • Delayed acute hospital discharge and healthcare-associated infection: the forgotten risk factor.

      McNicholas, S; Andrews, C; Boland, K; Shields, M; Doherty, G A; Murray, F E; Smyth, E G; Humphreys, H; Fitzpatrick, F; Department of Microbiology, Beaumont Hospital, Dublin, Ireland; Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland. (2011-06)
    • Delayed diagnosis in a sight-threatening lesion.

      O'Neill, E; Connell, P; Rawluk, D; Logan, P; Department of Ophthalmology, Beaumont Hospital, Dublin 9, Ireland. (2009-06)
      Acute chiasmal compression has several aetiologies including pituitary apoplexy, a medical emergency caused by acute haemorrhagic or ischemic infarction in pituitary macroadenomas. Clinical diagnosis can often be difficult as the patient is frequently unaware of an existing adenoma. Delayed diagnosis may lead to increased morbidity and mortality.
    • Delays in the stroke thrombolysis pathway - Identifying areas for improvement

      Brewer, L; Arize, C; Williams, D (Irish Medical Journal, 2014-05)
      Despite international consensus on the benefits of thrombolysis for ischaemic stroke (IS), it remains underused. Guidelines now recommend a door-to-needle time of d60 minutes. We reviewed the rate and timeliness of thrombolysis for IS at our hospital. 323 stroke patients presented between January 2011 and April 2012.Thirty patients (10.6% of IS) were thrombolysed, mean age was 68.5 years (42 to 88) and 19 patients (63%) were male. Thirty-six patients (12.7% of IS) were not thrombolysed despite arriving within the time-window and symptom resolution was the commonest reason (15 patients; 42%). Despite most thrombolysed patients (42%) presenting to the Emergency Department during daytime working hours, there were delays at each step of the acute care pathway. The mean time for stroke team review was 23 minutes (5-50). The mean door-to-CT and the door-to-needle times were 60 minutes (25-95) and 92 minutes (46-130) respectively. In parallel with national stroke incentives, local audit can highlight barriers to uptake and efficiency within thrombolysis services.
    • The {Delta}Np63 Proteins Are Key Allies of BRCA1 in the Prevention of Basal-Like Breast Cancer.

      Buckley, Niamh E; Conlon, Susan J; Jirstrom, Karin; Kay, Elaine W; Crawford, Nyree T; O'Grady, Anthony; Sheehan, Katherine; Mc Dade, Simon S; Wang, Ching-Wei; McCance, Dennis J; et al. (2011-03-01)
      Little is known about the origin of basal-like breast cancers, an aggressive disease that is highly similar to BRCA1-mutant breast cancers. p63 family proteins that are structurally related to the p53 suppressor protein are known to function in stem cell regulation and stratified epithelia development in multiple tissues, and p63 expression may be a marker of basal-like breast cancers. Here we report that ΔNp63 isoforms of p63 are transcriptional targets for positive regulation by BRCA1. Our analyses of breast cancer tissue microarrays and BRCA1-modulated breast cancer cell lines do not support earlier reports that p63 is a marker of basal-like or BRCA1 mutant cancers. Nevertheless, we found that BRCA1 interacts with the specific p63 isoform ΔNp63γ along with transcription factor isoforms AP-2α and AP-2γ. BRCA1 required ΔNp63γ and AP-2γ to localize to an intronic enhancer region within the p63 gene to upregulate transcription of the ΔNp63 isoforms. In mammary stem/progenitor cells, siRNA-mediated knockdown of ΔNp63 expression resulted in genomic instability, increased cell proliferation, loss of DNA damage checkpoint control, and impaired growth control. Together, our findings establish that transcriptional upregulation of ΔNp63 proteins is critical for BRCA1 suppressor function and that defects in BRCA1-ΔNp63 signaling are key events in the pathogenesis of basal-like breast cancer. Cancer Res; 71(5); 1933-44. ©2011 AACR.
    • Demodex-associated bacterial proteins induce neutrophil activation.

      Medical Mycology Unit, Department of Biology, National University of Ireland, Maynooth, Co. Kildare, Ireland. Respiratory Research Division, Department of, Medicine, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin 9,, Ireland. (2012-02-01)
      Background: Patients with rosacea demonstrate a higher density of Demodex mites in their skin than controls. A bacterium isolated from a Demodex mite from a patient with papulopustular rosacea (PPR) was previously shown to provoke an immune response in patients with PPR or ocular rosacea thus suggesting a possible role for bacterial proteins in the etiology of this condition. Objectives: To examine the response of neutrophils to proteins derived from a bacterium isolated from a Demodex mite. Methods: Bacterial cells were lysed and proteins were partially purified by AKTA-FPLC. Isolated neutrophils were exposed to bacterial proteins and monitored for alterations in migration, degranulation and cytokine production. Results: Neutrophils exposed to proteins from Bacillus cells demonstrated increased levels of migration and elevated release of MMP-9, an enzyme known to degrade collagen and cathelicidin, an antimicrobial peptide. In addition neutrophils exposed to the bacterial proteins demonstrated elevated rates of Il-8 and TNF-alpha production. Conclusions: Proteins produced by a bacterium isolated from a Demodex mite have the ability to increase the migration, degranulation and cytokine production abilities of neutrophils. These results suggest that bacteria may play a role in the inflammatory erythema associated with rosacea.
    • Detailed immunohistochemical (IHC) evaluation of novel markers associated with urothelial differentiation in a comprehensive spectrum of variants of urothelial carcinoma (UCa): A study of 80 cases

      Annaiah, C; Paner, G P; Gulmann, C; Rao, P; Ro, J Y; Hansel, D E; Shen, S S; Lopez-Beltran, A; Arora, K; Parakh, R S; et al. (2011-02)
    • Development and independent validation of a prognostic assay for stage II colon cancer using formalin-fixed paraffin-embedded tissue.

      Kennedy, Richard D; Bylesjo, Max; Kerr, Peter; Davison, Timothy; Black, Julie M; Kay, Elaine W; Holt, Robert J; Proutski, Vitali; Ahdesmaki, Miika; Farztdinov, Vadim; et al. (2011-12-10)
      Current prognostic factors are poor at identifying patients at risk of disease recurrence after surgery for stage II colon cancer. Here we describe a DNA microarray-based prognostic assay using clinically relevant formalin-fixed paraffin-embedded (FFPE) samples.
    • Development of an adhesive surgical ward round checklist: a technique to improve patient safety.

      Dhillon, P; Murphy, R K J; Ali, H; Burukan, Z; Corrigan, M A; Sheikh, A; Hill, A D K; Beaumont Hospital, Beaumont, Dublin 9. Paul.dhillon@gmail.com (2012-02-01)
      Checklists have been shown to improve patient outcomes. Checklist use is seen in the pre-operative to post-operative phases of the patient pathway. An adhesive checklist was developed for ward rounds due to the positive impact it could have on improving patient safety. Over an eight day period data were collected from five consultant-led teams that were randomly selected from the surgical department and divided into sticker groups and control groups. Across the board percentage adherence to the Good Surgical Practice Guidelines (GSPG) was markedly higher in the sticker study group, 1186 (91%) in comparison with the control group 718 (55%). There was significant improvement of documentation across all areas measured. An adhesive checklist for ward round note taking is a simple and cost-effective way to improve documentation, communication, hand-over, and patient safety. Successfully implemented in a tertiary level centre in Dublin, Ireland it is easily transferable to other surgical departments globally.
    • Development of key performance indicators for emergency departments in Ireland using an electronic modified-Delphi consensus approach.

      Wakai, Abel; O'Sullivan, Ronan; Staunton, Paul; Walsh, Cathal; Hickey, Fergal; Plunkett, Patrick K; aEmergency Care Research Unit (ECRU), Department of Emergency Medicine, Midland Regional Hospital, Tullamore bEmergency Department, Our Lady's Children's Hospital, Crumlin cDepartment of Paediatrics, University College Dublin (UCD) dDepartment of Emergency Medicine, Beaumont Hospital eDepartment of Statistics, Trinity College, Dublin fDepartment of Emergency Medicine, Sligo General Hospital, Sligo gDepartment of Emergency Medicine, St James's Hospital/School of Medicine, Faculty of Health Sciences, Trinity College, Dublin, Ireland. (2012-02-29)
      OBJECTIVE: The objective of this study was to develop a consensus among emergency medicine (EM) specialists working in Ireland for emergency department (ED) key performance indicators (KPIs). METHODS: The method employed was a three-round electronic modified-Delphi process. An online questionnaire with 54 potential KPIs was set up for round 1 of the Delphi process. The Delphi panel consisted of all registered EM specialists in Ireland. Each indicator on the questionnaire was rated using a five-point Likert-type rating scale. Agreement was defined as at least 70% of the responders rating an indicator as 'agree' or 'strongly agree' on the rating scale. Data were analysed using standard descriptive statistics. Data were also analysed as the mean of the Likert rating with 95% confidence intervals (95% CIs). Sensitivity of the ratings was examined for robustness by bootstrapping the original sample. Statistical analyses were carried out using SPSS version 16.0. RESULTS: The response rates in rounds 1, 2 and 3 were 86, 88 and 88%, respectively. Ninety-seven potential indicators reached agreement after the three rounds. In the context of the Donabedian structure-process-outcome framework of performance indicators, 41 (42%) of the agreed indicators were structure indicators, 52 (54%) were process indicators and four (4%) were outcome indicators. Overall, the top-three highest rated indicators were: presence of a dedicated ED clinical information system (4.7; 95% CI 4.6-4.9), ED compliance with minimum design standards (4.7; 95% CI 4.5-4.8) and time from ED arrival to first ECG in suspected cardiac chest pain (4.7; 95% CI 4.5-4.9). The top-three highest rated indicators specific to clinical care of children in EDs were: time to administration of antibiotics in children with suspected bacterial meningitis (4.6; 95% CI 4.5-4.8), separate area available within EDs (seeing both adults and children) to assess children (4.4; 95% CI 4.2-4.6) and time to administration of analgesia in children with forearm fractures (4.4; 95% CI 4.2-4.7). CONCLUSION: Employing a Delphi consensus process, it was possible to reach a consensus among EM specialists in Ireland on a suite of 97 KPIs for EDs.
    • Developmental trajectories of fronto-executive functions in 22q11.2 deletion syndrome: A preliminary study

      Howley, S A; Prasad, S E; Pender, N P; Murphy, K C (2011-01)
      22qll.2 deletion syndrome (22qllDS) is associated with borderline-mild intellectual disability and specific neurocognitive deficits, particularly in prefrontally-mediated executive functions (EF). There is evidence for white matter abnormalities in frontal cortical regions in 22qllDS, however little is known about the development of EF across the age range. Forty-eight individuals with 22qllDS were divided into 3 age groups: Child (7 male; n = 16; 6–11 years; M (SD) age = 8.4 (1.7); mean FSIQ = 72.9); Adolescent (7 male; n = 15; 12–15 years; M (SD) age = 13.1 (0.8); mean FSIQ = 68.0) and Adult (7 male; n = 17; 16–45 years; M (SD) age = 28.8 (11.5); mean FSIQ = 69.6). Forty healthy controls were also recruited and divided into the same 3 age groups: Child (6 male; 6–11 years, n = 12; M (SD) age = 9.3 (1.7); mean FSIQ = 99.1); Adolescent (6 male; 12–15 years; n = 12; M (SD) age = 13.2 (1.1); mean FSIQ = 100.9) and Adult (6 male; 16–45 years; n = 16; M (SD) age = 28.8 (9.4); mean FSIQ = 109). All participants completed standardised tests of a range of executive functions, specifically working memory, planning, problem-solving, strategy formation, cognitive flexibility and inhibition, and cross-sectional developmental trajectories of each function were constructed. No age-mediated improvements on EF tasks were observed in the 22qllDS groups, with the exception of verbal working memory. The control group exhibited significant age-mediated improvements in working memory, strategy formation and planning efficiency. These findings support the hypothesis that 22qllDS individuals experience atypical development of neuroanatomical regions and networks associated with EF in typical individuals. Future longitudinal work is required to examine intra-individual development of executive and non-executive cognitive processes.
    • Diagnosis and management of asthma in older adults.

      Chotirmall, Sanjay Haresh; Watts, Michael; Branagan, Peter; Donegan, Ciaran F; Moore, Allan; McElvaney, Noel Gerard; Department of Medicine, Respiratory Research Division, Education & Research Centre, Beaumont Hospital, Dublin 9, Republic of Ireland. schotirmall@rcsi.ie (2009-05)
      Despite comprehensive guidelines established by the European Global Initiative for Asthma and the U.S. National Asthma Education and Prevention Program on the diagnosis and management of asthma, its mortality in older adults continues to rise. Diagnostic and therapeutic problems contribute to older patients being inadequately treated. The diagnosis of asthma rests on the history and characteristic pulmonary function testing (PFT) with the demonstration of reversible airway obstruction, but there are unique problems in performing this test in older patients and in its interpretation. This review aims to address the difficulties in performing and interpreting PFT in older patients because of the effects of age-related changes in lung function on respiratory physiology. The concept of "airway remodeling" resulting in "fixed obstructive" PFT and the relevance of atopy in older people with asthma are assessed. There are certain therapeutic issues unique to older patients with asthma, including the increased probability of adverse effects in the setting of multiple comorbidities and issues surrounding effective drug delivery. The use of beta 2-agonist, anticholinergic, corticosteroid, and anti-immunoglobulin E treatments are discussed in the context of these therapeutic issues.
    • Diagnostic yield of catheter cerebral angiography in a single institution

      Bruton, K A; Zahreen, Z; Ti, J P; Thornton, J; Lynch, B; Saunders, D; Ganesan, V; King, M (Wiley-Blackwell, 2011-01)
      Introduction: Catheter cerebral angiography (CA) is the criterion standard in cerebrovascular imaging of childhood arterial ischaemic stroke (AIS). However, recent data on the prevalence and classification of cerebral arteriopathy is based on non-invasive vascular imaging modalities, most commonly magnetic resonance angiography (MRA). Aim: To describe CA findings in a series of children with AIS attending a single institution between 1989 and 2010 and to compare the diagnosis assigned at the time with current arteriopathy definitions. Method: Review of case records and neuroimaging. Children with known predisposing conditions were excluded. Arteriopathies were defined according to the criteria of Sebire et al. (2004). Results: Thirty children with AIS (11 males, 19 females) had CA performed (ages 8mo to 15y, median 6y 10mo). Fifteen patients presented with left-sided symptoms, 13 right-sided symptoms, one quadraparesis and one cerebellar signs. Four patients had seizures at presentation. CT was performed in 25 out of 30, 13 were abnormal. MRI was performed in 23 out of 30, all abnormal. MRA was performed in 16 out of 30, nine were abnormal. CA was performed in 30 out of 30, 19 were abnormal. Comparison of MRA with CA studies led to revision of diagnosis in 2 out of 16 owing to detectable lesion on CA (dissection, transient cerebral arteriopathy (TCA)). Subsequent review of CA studies resulted in revision of diagnosis in six out of 30 cases (occlusion – normal, vasculitis – TCA, normal – TCA, occlusion – TCA, unilateral moyamoya – vasculitis, moyamoya – fibromuscular dysplasia). Conclusions: CA provided additional information to MRA in 12.5% of cases. There is significant interobserver variation in interpretation of CA. Reference: 1. Sebire et al. Current opinion in paediatrics. 2004; 16: 617–622.
    • Did Not Wait Patient Management Strategy (DNW PMS) Study.

      Emergency Department, Beaumont Hospital, Beaumont Road, Dublin, Ireland. (2012-02-01)
      Objectives This study was undertaken to assess the usefulness of senior emergency medicine specialists' review of all 'did not wait' (DNW) patients' triage notes and the recall of at-risk patients. Methods A prospective study of all DNW patients was performed from 1 January to 31 December 2008. Following a daily review of charts of those who failed to wait to be seen, those patients considered to be at risk of adverse outcome were contacted by the liaison team and advised to return. Data were gathered on all DNW patients on the Oracle database and interrogated using the Diver solution. Results 2872 (6.3%) of 45 959 patients did not wait to be seen. 107 (3.7%) were recalled on the basis of senior emergency medicine doctor review of the patients' triage notes. Variables found to be associated with increased likelihood of being recalled included triage category (p<0.001), male sex (p<0.004) and certain clinical presentations. The presenting complaints associated with being recalled were chest pain (p<0.001) and alcohol/drug overdose (p=0.001). 9.4% of DNW patients required admission following recall. Conclusion The systematic senior doctor review of triage notes led to 3.7% of patients who failed to wait being recalled. 9.4% of those recalled required acute admission. The daily review of DNW patients' triage notes and the recalling of at-risk patients is a valuable addition to our risk management strategy.