• Factors influencing career choice after initial training in surgery.

      McHugh, Seamus; Corrigan, Mark; Sheikh, Athar; Lehane, Elaine; Tanner, William; Hill, Arnold; Department of Surgery, Beaumont Hospital, Dublin, Ireland. seamusmchugh@rcsi.ie (2011-03)
      Irish general surgery faces a recruitment crisis with only 87 of 145 (60%) basic surgical training (BST) places filled in 2009. We assessed basic surgical trainees to identify objective, and potentially modifiable, factors that influence ultimate recruitment into a general surgical career.
    • Factors influencing career choice after initial training in surgery.

      McHugh, Seamus; Corrigan, Mark; Sheikh, Athar; Lehane, Elaine; Tanner, William; Hill, Arnold; Department of Surgery, Beaumont Hospital, Dublin, Ireland. seamusmchugh@rcsi.ie (2012-02-01)
      INTRODUCTION: Irish general surgery faces a recruitment crisis with only 87 of 145 (60%) basic surgical training (BST) places filled in 2009. We assessed basic surgical trainees to identify objective, and potentially modifiable, factors that influence ultimate recruitment into a general surgical career. METHODS: Candidates commencing BST training during a 5-year period between 2004 and 2008 were included in a quantitative study. In addition a total of 2,536 candidates, representing all those who commenced surgical training in Ireland since 1960 were identified through the Royal College of Surgeons in Ireland (RCSI) database and invited to complete an online survey. Statistical analysis was performed using SPSS version 15, with p < 0.05 considered significant. RESULTS: During the 5-year quantitative study period there were 381 BST trainees. Gender was a significant predictor of career choice with women more likely to ultimately choose a nonsurgical career after initial surgical training (p = 0.049). Passing surgical membership examinations (MRCS) also was predictive of remaining in surgery (p = 0.005). Training region was not a significant predictor of ultimate career choice. There were 418 survey respondents. The influence of role models was most commonly cited as influencing candidates in choosing to commence surgical training. Candidates who rated "academic opportunity" (p = 0.023) and "intellectual challenge" (p = 0.047) as factors that influenced their decision to commence surgical training were more likely to ultimately continue their careers in a surgical speciality. CONCLUSIONS: This study describes the career pathway of surgical trainees and confirms the importance of academic achievement in discriminating between candidates applying for surgical training schemes.
    • Factors predicting adherence with psychiatric follow-up appointments for patients assessed by the liaison psychiatric team in the emergency department.

      Agyapong, Vincent I O; Rogers, Cathy; Machale, Siobhan; Cotter, David; St. Patrick's University Hospital, Dublin, Ireland. israelhans@hotmail.com (2010)
      Several factors may predict adherence with psychiatric follow-up appointment for patients seen in the emergency department (ED) by liaison psychiatric teams. Awareness of these factors would allow for interventions targeted at vulnerable groups.
    • Factors that predict failure in home management of an acute exacerbation of COPD.

      Dunican, Eleanor M; Deering, Brenda M; Ryan, Dorothy M; McCormack, Niamh M; Costello, Richard W; Department of Respiratory Medicine, Beaumont Hospital, Dublin 9, Ireland. rcostello@rcsi.ie. (2011-04)
    • Felbamate in an adult population with severe refractory epilepsy.

      Kearney, H; Delanty, N; Department of Neurology, Beaumont Hospital, Beaumont, Dublin. hughkearney@yahoo.com (2011-04-05)
      Felbamate (FBM) is efficacious in treating patients with refractory epilepsy but was withdrawn due to cases of aplastic anaemia, hepatic failure and five reported deaths. FBM is currently used in specialist centres and is only being used in one Irish centre to date. This papers aim is to review the efficacy and safety experience of FBM in Irish adult patients with refractory epilepsy. A retrospective chart review was done on patients' medical records. Patients were subdivided into responders and non responders based on change in seizure frequency and side effects were recorded for all. Of the 13 patients on FBM nine patients responded to FBM, four patients did not. FBM is a safe and efficacious alternative in an Irish adult population with refractory epilepsy. However close monitoring is still required given the potential fatal side effects that are possible with this anticonvulsant.
    • Financial impact of accurate discharge coding in a liaison psychiatry service.

      Jordan, Iain; Barry, Helen; Clancy, Maurice; O'Toole, Desmond; Machale, Siobhan; Royal College of Surgeons in Ireland, Education and Research Centre, Beaumont Hospital, Dublin 9, Ireland. iainjordan@gmail.com (2012-12)
      Previous research has shown that patients seen by liaison psychiatry services are a complex and expensive patient group and that the psychiatric co-morbidities of hospital inpatients are poorly attested at discharge for assignment to diagnosis-related groups (DRGs). The aim of this study was to investigate the accuracy of discharge coding in a neuropsychiatry liaison population. We also aimed to establish whether or not, had the correct diagnosis been assigned, additional funding would have been allocated to the hospital.
    • The financial imperative of physicians to control demand of laboratory testing.

      Murphy, R K J; McHugh, S; O'Farrell, N; Dougherty, B; Sheikh, A; Corrigan, M; Hill, A D K; Beaumont Hospital, Beaumont, Dublin 9. murphyr@wudosis.wustl.edu (2012-02-01)
      It is an integral component of doctor's duty of care to understand the significant impact laboratory testing has on the expense an ultimate quality of healthcare patients receive, yet the costs of these tests are poorly perceived. Utilising semi-structured interviews and questionnaires, we assessed surgeon's perceived costs of two commonly encountered clinical scenarios requiring out of hours laboratory testing. Of the 35 participants only 23.3% (n = 7) accurately estimated the overall cost. The most expensive test was "Type and Screen" at Euro 83, with 77.3% (n = 17) underestimating the cost. Non-consultant hospital doctors qualified for 3 years were more likely to underestimate on-call costs (p = 0.042). It is of utmost importance to improve the knowledge of all surgeons of the financial implications of investigations. Through education we can potentially reduce un-warranted costs and fulfill our duty of care in the most cost efficient manner.
    • Flank hernia secondary to phenol nerve block.

      Al-Hilli, Z; Deasy, J; Keaveny, J; Department of General Surgery, Beaumont Hospital, Dublin 9, Ireland. (2010-09)
      The management of patients with chronic pain is challenging. The aim of treatment is alleviation of symptoms in an attempt to increase functional capacity. Interventional procedures, such as chemical neurolysis are adopted when other techniques fail to provide adequate pain control.
    • Flow crossmatch results in combination with 2 different single antigen assays provide greater resolution in predicting renal graft survival

      Keegan, D; Kelly, J; O'Neill, D; Keogan, M (Wiley-Blackwell, 2011-09)
      Detection of HLA-specific antibodies pre-transplant helps prevent graft rejection, and aids risk assessment of donor-recipient pairs. Initial enthusiasm and widespread adoption of Luminex single antigen (SAB) assays has been tempered by conflicting reports of their clinical relevance. Aims: To assess effects of Luminex-detected antibodies on long-term graftsurvival, alone or in combination with a second Luminex assay and flow cytometry cross-matching. Methods: Day of transplant sera from 204 sensitized renal transplant recipients were retrospectively analysed for the presence of donor-specific HLA antibodies (DSA) using HLA One Lambda Labscreen® (Canoga Park, CA) and Genprobe Lifecodes® (Stamford, CT) SAB. Results: 122 patients (55%) had detectable DSA. When all antibodies were considered positive, there was no statistically significant difference in graft survival (>80% in both groups). This confirmed the suspicion that not all antibodies detected are clinically relevant, and that the non-significant subset of antibodies detected was masking clinically relevant antibodies. When only antibodies detectable by both methods are considered true positives, the result was highly significant (p<0.001). Survival rates in negative patients were >80% ten years post-transplant, and patients with single technique antibodies also had excellent graft survival after ten years (>80%). In contrast, graft survival in patients with antibodies confirmed by both Luminex assays was <80% approximately 2 years post-transplant, dropping to approximately 50% after ten years. When flow-cytometry crossmatch results were correlated with SAB results, patients with confirmed antibodies and a positive crossmatch had significantly worse outcomes than confirmed antibody positive/crossmatch negative patients (graft survival at 2 years 64% vs >90%; p<0.002). Conclusions: SAB assays alone are inadequate to risk assess a donorrecipient pair. However, when used in combination together with flowcytometry crossmatching, they facilitate detailed risk assessment.
    • Formative evaluation of a telemedicine model for delivering clinical neurophysiology services part I: utility, technical performance and service provider perspective.

      Breen, Patricia; Murphy, Kevin; Browne, Geraldine; Molloy, Fiona; Reid, Valerie; Doherty, Colin; Delanty, Norman; Connolly, Sean; Fitzsimons, Mary; Epilepsy Programme, Beaumont Hospital, Dublin 9, Ireland. maryfitzsimons@beaumont.ie (2010)
      Formative evaluation is conducted in the early stages of system implementation to assess how it works in practice and to identify opportunities for improving technical and process performance. A formative evaluation of a teleneurophysiology service was conducted to examine its technical and sociological dimensions.
    • Formative evaluation of a telemedicine model for delivering clinical neurophysiology services part II: the referring clinician and patient perspective.

      Breen, Patricia; Murphy, Kevin; Browne, Geraldine; Molloy, Fiona; Reid, Valerie; Doherty, Colin; Delanty, Norman; Connolly, Sean; Fitzsimons, Mary; Epilepsy Programme, Beaumont Hospital, Dublin 9, Ireland. (2010)
      Feedback from service users will provide insight into opportunities for improvement so that performance can be optimised. In the context of a formative evaluation referring clinician and patient satisfaction with a teleneurophysiology service was examined during a 20 week pilot period.
    • Four country healthcare-associated infection prevalence survey: pneumonia and lower respiratory tract infections.

      Humphreys, H; Newcombe, R G; Enstone, J; Smyth, E T M; McIlvenny, G; Davies, E; Spencer, R; Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Education and Research Centre, Beaumont Hospital, PO Box 9063, Dublin 9, Ireland. hhumphreys@rcsi.ie (2010-03)
      In 2006, the Hospital Infection Society was funded by the respective health services in England, Wales, Northern Ireland and the Republic of Ireland to conduct a prevalence survey of healthcare-associated infection (HCAI). Here, we report the prevalence of pneumonia and lower respiratory tract infection other than pneumonia (LRTIOP) in these four countries. The prevalence of all HCAIs was 7.59% (5743 out of 75 694). Nine hundred (15.7%) of these infections were pneumonia, and 402 (7.0%) were LRTIOP. The prevalence of both infections was higher for males than for females, and increased threefold from those aged <35 to those aged >85 years (P<0.001). At the time of the survey or in the preceding seven days, 23.7% and 18.2% of patients with pneumonia and LRTIOP, respectively, were mechanically ventilated compared to 5.2% of patients in the whole study population. Meticillin-resistant Staphylococcus aureus (MRSA) was the cause of pneumonia and LRTIOP in 7.6% and 18.1% of patients, respectively (P<0.001). More patients with LRTIOP (4.2%) had concurrent diarrhoea due to Clostridium difficile compared to patients with pneumonia (2.4%), but this did not reach statistical significance. Other HCAIs were present in 137 (15.2%) of patients with pneumonia and 66 (16.4%) of those with LRTIOP. The results suggest that reducing instrumentation, such as mechanical ventilation where possible, should help reduce infection. The higher prevalence of MRSA as a cause of LRTIOP suggests a lack of specificity in identifying the microbial cause and the association with C. difficile emphasises the need for better use of antibiotics.
    • Full capacity protocol: an end to double standards in acute hospital care provision.

      Gilligan, P; Quin, G; Emergency Department, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland., peadargilligan@beaumont.ie (2012-02-01)
    • Functional study of elafin cleaved by Pseudomonas aeruginosa metalloproteinases.

      Guyot, Nicolas; Bergsson, Gudmundur; Butler, Marcus W; Greene, Catherine M; Weldon, Sinéad; Kessler, Efrat; Levine, Rodney L; O'Neill, Shane J; Taggart, Clifford C; McElvaney, Noel G; et al. (2010-06)
      Elafin is a 6-kDa innate immune protein present at several epithelial surfaces including the pulmonary epithelium. It is a canonical protease inhibitor of two neutrophil serine proteases [neutrophil elastase (NE) and proteinase 3] with the capacity to covalently bind extracellular matrix proteins by transglutamination. In addition to these properties, elafin also possesses antimicrobial and immunomodulatory activities. The aim of the present study was to investigate the effect of Pseudomonas aeruginosa proteases on elafin function. We found that P. aeruginosa PAO1-conditioned medium and two purified Pseudomonas metalloproteases, pseudolysin (elastase) and aeruginolysin (alkaline protease), are able to cleave recombinant elafin. Pseudolysin was shown to inactivate the anti-NE activity of elafin by cleaving its protease-binding loop. Interestingly, antibacterial properties of elafin against PAO1 were found to be unaffected after pseudolysin treatment. In contrast to pseudolysin, aeruginolysin failed to inactivate the inhibitory properties of elafin against NE. Aeruginolysin cleaves elafin at the amino-terminal Lys6-Gly7 peptide bond, resulting in a decreased ability to covalently bind purified fibronectin following transglutaminase activity. In conclusion, this study provides evidence that elafin is susceptible to proteolytic cleavage at alternative sites by P. aeruginosa metalloproteinases, which can affect different biological functions of elafin.
    • Gain of chromosome arm 1q in atypical meningioma correlates with shorter progression-free survival.

      Pathology Service and Cancer Center, Massachusetts General Hospital, Boston, MA, , USA; Neuropathology Department, Beaumont Hospital, Dublin, Ireland; Department of, Pathology, Harvard Medical School, Boston, MA, USA Department of Biostatistics,, Harvard School of Public Health, Boston, MA; Neuropathology Department, Cork, University Hospital, Cork, Ireland. (2012-02-01)
      Aims: Atypical (WHO grade II) meningiomas have moderately high recurrence rates; even for completely resected tumours, approximately one-third will recur. Post-operative radiotherapy (RT) may aid local control and improve survival, but carries the risk of side effects. More accurate prediction of recurrence risk is therefore needed for patients with atypical meningioma. Previously, we used high-resolution array CGH to identify genetic variations in 47 primary atypical meningiomas and found that approximately 60% of tumors show gain of 1q at 1q25.1 and 1q25.3 to 1q32.1 and that 1q gain appeared to correlate with shorter progression-free survival. This study aimed to validate and extend these findings in an independent sample. Methods: 86 completely resected atypical meningiomas (with 25 recurrences) from two neurosurgical centres in Ireland were identified and clinical follow up was obtained. Utilizing a dual-colour interphase FISH assay, 1q gain was assessed using BAC probes directed against 1q25.1 and 1q32.1. Results: The results confirm the high prevalence of 1q gain at these loci in atypical meningiomas. We further show that gain at 1q32.1 and age each correlate with progression-free survival in patients who have undergone complete surgical resection of atypical meningiomas. Conclusions: These independent findings suggest that assessment of 1q copy number status can add clinically useful information for the management of patients with atypical meningiomas.
    • Gait impairment in cervical spondylotic myelopathy: comparison with age- and gender-matched healthy controls.

      Malone, Ailish; Meldrum, Dara; Bolger, Ciaran; Physiotherapy Department, Beaumont Hospital, Dublin 9, Ireland. ailishmcd@gmail.com (2012-12)
      Gait impairment is a primary symptom of cervical spondylotic myelopathy (CSM); however, little is known about specific kinetic and kinematic gait parameters. The objectives of the study were: (1) to compare gait patterns of people with untreated CSM to those of age- and gender-matched healthy controls; (2) to examine the effect of gait speed on kinematic and kinetic parameters.
    • Gelastic seizures without hypothalamic hamartoma

      O'Connor, G; Chaila, E; Mullins, G; Delanty, N (Wiley-Blackwell, 2011-08)
      Purpose: Gelastic epilepsy is a well recognized epilepsy syndrome, and is associated in almost all cases with the presence of a hypothalamic hamartoma. However, the epileptologist should be alert to alternative causes for such presentations. We present two cases from our service of gelastic seizures in the absence of hypothalamic hamartoma. Method: We reviewed the clinical features in both cases. Both patients were male and right-handed. The duration of epilepsy was similar in both cases, with onset in late adolescence. In both cases, epilepsy was refractory to treatment with antiepileptic medications. Clinical examination was unremarkable in both men. Both patients were investigated with video EEG monitoring and imaging to localize a seizure focus. Results: Video EEG monitoring in both cases suggested a right frontal focus for seizure onset. MRI in one patient revealed a right frontal mass lesion, and in the other, a right frontal cortical dysplasia. There was no evidence of a hypothalamic lesion in either case. After discussion, both cases were felt to be suitable for neurosurgical intervention. Conclusion: Gelastic epilepsy without hypothalamic hamartoma is rare, but some cases reported have had a right frontal focus for seizure onset. Causes reported in such cases have included tumors and cortical dysplasia. Many of the cases reported have had a good response to surgical intervention. In gelastic epilepsy, the clinician should be aware of causes other than hypothalamic hamartomata. Investigations should be directed towards confirming a seizure focus with a view to offering surgical intervention.
    • Gene targeted therapeutics for liver disease in alpha-1 antitrypsin deficiency.

      McLean, Caitriona; Greene, Catherine M; McElvaney, Noel G; Respiratory Research Division, Dept. Medicine, Royal College of Surgeons in Ireland, Education and Research Centre, Beaumont Hospital, Dublin 9, Ireland. (2009)
      Alpha-1 antitrypsin (A1AT) is a 52 kDa serine protease inhibitor that is synthesized in and secreted from the liver. Although it is present in all tissues in the body the present consensus is that its main role is to inhibit neutrophil elastase in the lung. A1AT deficiency occurs due to mutations of the A1AT gene that reduce serum A1AT levels to <35% of normal. The most clinically significant form of A1AT deficiency is caused by the Z mutation (Glu342Lys). ZA1AT polymerizes in the endoplasmic reticulum of liver cells and the resulting accumulation of the mutant protein can lead to liver disease, while the reduction in circulating A1AT can result in lung disease including early onset emphysema. There is currently no available treatment for the liver disease other than transplantation and therapies for the lung manifestations of the disease remain limited. Gene therapy is an evolving field which may be of use as a treatment for A1AT deficiency. As the liver disease associated with A1AT deficiency may represent a gain of function possible gene therapies for this condition include the use of ribozymes, peptide nucleic acids (PNAs) and RNA interference (RNAi), which by decreasing the amount of aberrant protein in cells may impact on the pathogenesis of the condition.
    • Genome-wide mapping for clinically relevant predictors of lamotrigine- and phenytoin-induced hypersensitivity reactions.

      McCormack, Mark; Urban, Thomas J; Shianna, Kevin V; Walley, Nicole; Pandolfo, Massimo; Depondt, Chantal; Chaila, Elijah; O'Conner, Gerard D; Kasperavičiūtė, Dalia; Radtke, Rodney A; et al. (2012-03)
      An association between carbamazepine-induced hypersensitivity and HLA-A*3101 has been reported in populations of both European and Asian descent. We aimed to investigate HLA-A*3101 and other common variants across the genome as markers for cutaneous adverse drug reactions (cADRs) attributed to lamotrigine and phenytoin.