• Nasogastric intubation causes gastroesophageal reflux in patients undergoing elective laparotomy.

      Manning, B J; Winter, D C; McGreal, G; Kirwan, W O; Redmond, H P; Department of Surgery, University College Cork, and Cork University Hospital,, Cork, Ireland. (2012-02-03)
      BACKGROUND: The routine use of nasogastric tubes in patients undergoing elective abdominal operation is associated with an increased incidence of postoperative fever, atelectasis, and pneumonia. Previous studies have shown that nasogastric tubes have no significant effect on the incidence of gastroesophageal reflux or on lower esophageal sphincter pressure in healthy volunteers. We hypothesized that nasogastric intubation in patients undergoing laparotomy reduces lower esophageal sphincter pressure and promotes gastroesophageal reflux in the perioperative period. METHODS: A prospective randomized case-control study was undertaken in which 15 consenting patients, admitted electively for bowel surgery, were randomized into 2 groups. Group 1 underwent nasogastric intubation after induction of anesthesia, and Group 2 did not. All patients had manometry and pH probes placed with the aid of endoscopic vision at the lower esophageal sphincter and distal esophagus, respectively. Nasogastric tubes, where present, were left on free drainage, and sphincter pressures and pH were recorded continuously during a 24-hour period. Data were analyzed with 1-way analysis of variance. RESULTS: The mean number of reflux episodes (defined as pH < 4) in the nasogastric tube group was 137 compared with a median of 8 episodes in the group managed without nasogastric tubes (P =.006). The median duration of the longest episode of reflux was 132 minutes in Group 1 and 1 minute in Group 2 (P =.001). A mean of 13.3 episodes of reflux lasted longer than 5 minutes in Group 1, with pH less than 4 for 37.4% of the 24 hours. This was in contrast to Group 2 where a mean of 0.13 episodes lasted longer than 5 minutes (P =.001) and pH less than 4 for 0.2% of total time (P =.001). The mean lower esophageal sphincter pressures were lower in Group 1. CONCLUSIONS. These findings demonstrate that patients undergoing elective laparotomy with routine nasogastric tube placement have significant gastroesophageal reflux in the perioperative period and a reduced ability to clear refluxed acid from the distal esophagus. Due to the associated risk of postoperative pulmonary complications, we recommend that nasogastric intubation be performed on a selective rather than routine basis.
    • National Perinatal Epidemiology Centre: severe maternal morbidity report 2011.

      National Perinatal Epidemiology Centre; UCC (2013-03)
      This is the first national audit of severe maternal morbidity in Ireland. Between 1st January 2011 and the 31st December 2011, anonymised data on severe maternal morbidity were collected from 19 of the 20 maternity units in Ireland (this includes one private and 18 public maternity units). In total, 67,806 maternities were reported from the 19 participating maternity units, representing 93% of maternities in Ireland for the calendar year 2011. Severe maternal morbidity was classified as the presence of one or more of 15 categories of maternal morbidity including: major obstetric haemorrhage (MOH), eclampsia, renal/liver dysfunction, cardiac arrest, pulmonary oedema, acute respiratory dysfunction, coma, cerebrovascular accident, status epilepticus, septicaemic shock, anaesthetic complications, pulmonary embolism, peripartum hysterectomy, admission to intensive care and interventional radiology. Major obstetric haemorrhage was defined as an estimated blood loss of ≥ 2,500ml, and or a transfusion of ≥ 5 units of blood and or documented treatment for coagulopathy. The methodology for case ascertainment and morbidity inclusion criteria, adapted by the National Perinatal epidemiology Centre (NPEC), was based on the Scottish Confidential Audit of Severe Maternal Morbidity (SCASMM) and are described in Appendix B. As such, use of this validated data collection tool with the kind permission of the Reproductive Health Programme of the National Health Service (NHS) Quality Improvement Scotland, facilitated international comparison with a relatively similar health care provision service and pregnant population. Although severe maternal morbidity may reflect the complexity of the pregnant population, evaluation of such cases has been acknowledged as a surrogate measure of quality care in the maternity services.
    • The natural history of hepatitis C virus infection.

      Kenny-Walsh, E; Department of Hepatology, Cork University Hospital and University College Cork,, Cork, Ireland. (2012-02-03)
      The natural history of HCV infection remains ill-defined. The knowledge accumulated on the progression of HCV to date is important, however. It is now abundantly clear that the progression of disease is generally slow, and the development of cirrhosis and its complications is a possibility, not a probability as hitherto thought. Predicting the outcome remains a quandary for clinicians. Ultimately it will be possible to define the natural history of hepatitis C infection through a combination of research in the fields of virology, immunology, and molecular biology and by monitoring the biochemical and histologic progress of the disease. Only then will it be possible to intervene appropriately and develop new therapies to prevent the progression to cirrhosis and hepatocellular carcinoma.
    • Near field communications technology and the potential to reduce medication errors through multidisciplinary application

      O’Connell, Emer; Pegler, Joe; Lehane, Elaine; Livingstone, Vicki; McCarthy, Nora; Sahm, Laura J.; Tabirca, Sabin; O’Driscoll, Aoife; Corrigan, Mark (2016-07)
      Patient safety requires optimal management of medications. Electronic systems are encouraged to reduce medication errors. Near field communications (NFC) is an emerging technology that may be used to develop novel medication management systems.
    • Nebulized hypertonic saline via positive expiratory pressure versus via jet nebulizer in patients with severe cystic fibrosis.

      O'Connell, Oisin J; O'Farrell, Carmel; Harrison, Mike J; Eustace, Joseph A; Henry, Michael T; Plant, Barry J; Cork Adult Cystic Fibrosis Centre, Department of Respiratory Medicine, Cork University Hospital, University College Cork, Wilton, Cork, Ireland. (2011-06)
      Nebulized hypertonic saline is a highly effective therapy for patients with cystic fibrosis (CF), yet 10% of patients are intolerant of hypertonic saline administered via jet nebulizer. Positive expiratory pressure (PEP) nebulizers splint open the airways and offers a more controlled rate of nebulization.
    • Necrotising fasciitis secondary to intra-abdominal sepsis.

      O'Leary, D P; Myers, E; Clover, A J P; O'Shaughnessy, M; McCourt, M (Springer, 2011-05)
    • The need for HPV vaccination.

      O'Connor, M B; O'Connor, C (2009-06)
    • Nephrotic syndrome: cause of an abnormal response to the rapid ACTH stimulation test.

      Brennan, Aoife; O'Connor, Kieran A; Plant, William D; O'Halloran, Domhnaill J; Cork University Hospital, Wilton, Cork, Ireland. itsaoife@eircom.ie (2012-02-03)
    • Neuraxial dimensions.

      O'Sullivan, M; O'Donnell, B D (2011-02)
    • Neuraxial opioid-induced pruritus: a review.

      Szarvas, Szilvia; Harmon, Dominic; Murphy, Damian; Department of Anaesthesia and Intensive Care Medicine, Cork University Hospital, , Wilton Road, Cork, Ireland. szarvasszilvia@hotmail.com (2012-02-03)
      When intrathecal and epidural opioids are administered, pruritus occurs as an unwanted and troublesome side effect. The reported incidence varies between 30% and 100%. The exact mechanisms of neuraxial opioid-induced pruritus remain unclear. Postulated mechanisms include the presence of an "itch center" in the central nervous system, medullary dorsal horn activation, and antagonism of inhibitory transmitters. The treatment of intrathecal opioid-induced pruritus remains a challenge. Many pharmacological therapies, including antihistamines, 5-HT(3)-receptor antagonists, opiate-antagonists, propofol, nonsteroid antiinflammatory drugs, and droperidol, have been studied. In this review, we will summarize pathophysiological and pharmacological advances that will improve understanding and ultimately the management of this troublesome problem.
    • Neurogenic bladder

      O Mahony, Eileen; Cork University Hospital (2014)
    • Neurology referrals to a liaison psychiatry service.

      Fitzgerald, P; Herlihy, D; Sweeney, B; Cassidy, E M; Department of Psychiatry, Cork University Hospital, Wilton, Cork. (2012-02-03)
      The objective of the present study was to assess the activity of the Liaison Psychiatry service of Cork University Hospital in relation to all in-patient neurology referrals over a 12-month period. Of 1685 neurology admissions, 106 (6%) were referred to liaison psychiatry for assessment. 91 referrals (86%) met criteria for a psychiatric disorder according to DSM-IV, the commonest being major depression (24%) and somatoform disorder (23%). Patients with multiple sclerosis or epilepsy comprised nearly half of all referrals (48 cases; 45%). Approximately 20% of M.S. in-patients (21 cases) were referred for psychiatric assessment, with the corresponding figure in epilepsy being 25% (18 cases). Although only 106 (6%) neurology in-patients were referred to liaison psychiatry, psychiatric diagnoses were documented in 327 (20%) discharge forms, presumably reflecting previous diagnosis. The above findings indicate that psychiatric illness is common among neurology inpatients screened by liaison psychiatry yet referral rates are relatively low in terms of the overall number of neurology in-patients. Psychiatric disorders were diagnosed in 86% of referrals indicating high concordance between neurologists and liaison psychiatry regarding the presence of a psychiatric disorder.
    • Neuronal phosphorylated RNA-dependent protein kinase in Creutzfeldt-Jakob disease.

      Paquet, Claire; Bose, Anindita; Polivka, Marc; Peoc'h, Katell; Brouland, Jean Philippe; Keohane, Catherine; Hugon, Jacques; Gray, Françoise; Service Central d'Anatomie et de Cytologie Pathologiques, APHP, Hôpital Lariboisière-Université Paris VII, France. (2009-02)
      The mechanisms of neuronal apoptosis in Creutzfeldt-Jakob disease (CJD) and their relationship to accumulated prion protein (PrP) are unclear. A recent cell culture study showed that intracytoplasmic PrP may induce phosphorylated RNA-dependent protein kinase (PKR(p))-mediated cell stress. The double-stranded RNA protein kinase PKR is a proapoptotic and stress kinase that accumulates in degenerating neurons in Alzheimer disease. To determine whether neuronal apoptosis in human CJD is associated with activation of the PKR(p) signaling pathway, we assessed in situ end labeling and immunocytochemistry for PrP, glial fibrillary acidic protein, CD68, activated caspase 3, and phosphorylated PKR (Thr451) in samples of frontal, occipital, and temporal cortex, striatum, and cerebellum from 6 patients with sporadic CJD and 5 controls. Neuronal immunostaining for activated PKR was found in all CJD cases. The most staining was in nuclei and, in contrast to findings in Alzheimer disease, cytoplasmic labeling was not detected. Both the number and distribution of PKR(p)-positive neurons correlated closely with the extent of neuronal apoptosis, spongiosis, astrocytosis, and microglial activation and with the phenotype and disease severity. There was no correlation with the type, topography, or amount of extracellular PrP deposits. These findings suggest that neuronal apoptosis in human CJD may result from PKR(p)-mediated cell stress and are consistent with recent studies supporting a pathogenic role for intracellular or transmembrane PrP.
    • Neuropathy in the hemodialysis population: a review of neurophysiology referrals in a tertiary center.

      O'Regan, John; Walsh, Richard; Kelly, Dearbhla; Plant, Liam; Eustace, Joseph; McNamara, Brian; Department of Nephrology, Cork University Hospital, Cork, Ireland. oregan10@gmail.com (2012)
      This was a retrospective observational study of neurophysiology referrals over 8 years from a tertiary referral center in Ireland. A total of 68 of the 73 referrals yielded one or more abnormalities. Thirty-nine (53%) patients had one or more mononeuropathies; iatrogenic mononeuropathies believed to be associated with arterio-venous fistula creation occurred in 15 patients. Polyneuropathy was identified in 43 patients (59%). Access to an experienced neurophysiology department offers valuable insight into dialysis-associated neuropathies, especially when associated with arterio-venous fistulae.
    • Neurosurgical management of L-asparaginase induced haemorrhagic stroke.

      Ogbodo, Elisha; Kaliaperumal, Chandrasekaran; O'Sullivan, Michael; Department of Neurosurgery, Cork University Hospital, Cork, Ireland. (2012)
      The authors describe a case of L-asparaginase induced intracranial thrombosis and subsequent haemorrhage in a newly diagnosed 30-year-old man with acute lymphoblastic leukaemia who was successfully managed by surgical intervention. At presentation, he had a Glasgow Coma Score of 7/15, was aphasic and had dense right hemiplegia. Neuroimaging revealed an acute anterior left middle cerebral artery infarct with parenchymal haemorrhagic conversion, mass effect and subfalcine herniation. He subsequently underwent left frontal craniotomy and evacuation of large frontal haematoma and decompressive craniectomy for cerebral oedema. Six months postoperatively he underwent titanium cranioplasty. He had made good clinical recovery and is currently mobilising independently with mild occasional episodes of expressive dysphasia, difficulty with fine motor movement on the right side, and has remained seizure free. This is the first documented case of L-asparaginase induced haemorrhagic stroke managed by neurosurgical intervention. The authors emphasise the possible role of surgery in managing chemotherapy induced intracranial complications.
    • A neurosurgical presentation of patent foramen ovale with atrial septal aneurysm

      Walsh, K.; Kaliaperumal, C.; Wyse, G.; Kaar, G. (2012-01-10)
    • Neutrophil-induced transmigration of tumour cells treated with tumour-conditioned medium is facilitated by granulocyte-macrophage colony-stimulating factor.

      Wu, Q D; Wang, J H; Bouchier-Hayes, D; Redmond, H P; Department of Surgery, Cork University Hospital, University College Cork,, Ireland. (2012-02-03)
      OBJECTIVE: To investigate the effect of different cytokines that are present in tumour-conditioned medium on human neutrophil (PMN)-induced tumour cell transmigration. DESIGN: Laboratory study. SETTING: University hospital, Ireland. MATERIAL: Isolated human PMN and cultured human breast tumour cell line, MDA-MB-231. Interventions: Human PMN treated with either tumour-conditioned medium or different media neutralised with monoclonal antibodies (MoAb), and MDA-MB-231 cells were plated on macrovascular and microvascular endothelial monolayers in collagen-coated transwells to assess migration of tumour cells. MAIN OUTCOME MEASURES: Cytokines present in tumour-conditioned medium, PMN cytocidal function and receptor expression, and tumour cell transmigration. RESULTS: tumour-conditioned medium contained high concentrations of granulocyte-macrophage colony-stimulating factor (GM-CSF), vascular endothelial growth factor (VEGF), and interleukin 8 (IL-8), but not granulocyte colony-stimulating factor (G-CSF) and interleukin 3 (IL-3). Anti-GM-CSF MoAb significantly reduced PMN-induced transmigration of tumour cells treated with tumour-conditioned medium (p < 0.05), whereas anti-VEGF and anti-IL-8 MoAbs did not affect their migration. In addition, anti-GM-CSF MoAb, but not anti-VEGF or anti-IL-8 MoAb, reduced PMN CD11b and CD18 overexpression induced by tumour-conditioned medium (p < 0.05). CONCLUSION: These results indicate that the GM-CSF that is present in tumour-conditioned medium may be involved, at least in part, in alterations in PMN function mediated by the medium and subsequently PMN-induced transmigration of tumour cells.
    • New lessons: Classic treatments in convulsive status epilepticus.

      Renganathan, R; Conlon, N; Sweeney, B; Department of Neurology, Cork University Hospital, Cork. howrurenga@yahoo.com (2012-02-03)
      Convulsive status epilepticus is a relatively common life-threatening illness requiring prompt intervention. There has been much debate about the appropriate protocol for management of convulsive status epilepticus. Published data on the management of this condition in Ireland is limited. Our aim was to establish if there was a structured, evidence-based or consensus-based protocol being implemented in the management of status epilepticus in our centre. We retrospectively audited all charts with a diagnosis of 'Status Epilepticus' admitted to our hospital from January 1998 to December 2002. A total of 95 episodes of convulsive status epilepticus were recorded. 34 charts were reviewed. Benzodiazepines were the drug class of first choice in 96% of patients. However, the doses of benzodiazepines used varied widely. The most frequent dose of phenytoin used was 1 gram. No one received continuous EEG monitoring during treatment of refractory status epilepticus. Overall mortality was 18%. The results of this study show that there is no consistent protocol was being followed for the management of convulsive status epilepticus in our centre. The drugs of first choice varied between diazepam and lorazepam in most cases. Although phenytoin was used as second line drug, the dose used was frequently suboptimal. We have developed a protocol for the management for convulsive status in our centre.
    • New onset seizures in the elderly: aetiology and prognosis.

      Timmons, S; Sweeney, B; Hyland, M; O'Mahony, D; Twomey, C; Department of Neurology, Cork University Hospital, Wilton, Ireland., suzannea@eircom.net (2012-02-03)
      Late onset epilepsy is increasing in incidence. These patients often have significant underlying morbidity. This retrospective study in a tertiary referral centre identified 68 patients aged 65 years or older, with new onset seizures over a four-year period. 81% of patients (n = 55) were followed up at an average of 2.7 years post diagnosis. 38% of patients had evidence of cerebrovascular disease (CT visualised focal infarction, haemorrhage or small vessel ischaemia in 32%, clinical diagnosis with normal CT brain in 6%). No patient was found to have a space-occupying lesion. Of the 55 patients followed up, 45% of these had died at a mean age of 82 years old and 1.9 years post diagnosis (range 12 hours to 5 years). Three patients died as a direct result of seizures (trauma and sepsis). 14 patients died of clearly unrelated causes. Eight patients died from underlying vascular disease or Alzheimer's dementia. Patients who died during follow-up were on average 3.4 years older at the time of diagnosis than survivors (p< 0.05). Patients with atrial fibrillation at the time of diagnosis, had increased mortality (relative risk 2.53; 95% C.I. 1.19 - 5.36), but they were older than those without atrial fibrillation. At the time of follow up, 92% of those taking anti-convulsants were maintained seizure free on anticonvulsant monotherapy.