• A Geospatial Analysis of Adult Major Trauma Transit Time in Dublin

      Kelly, O.; O'Reilly, M; Collins, N. (Irish Medical Journal, 2019-09)
      To estimate ambulance transit time of Major Trauma patients from scene to Emergency Department (ED) in order to inform future trauma network design.
    • The co-design, implementation and evaluation of a serious board game 'PlayDecide patient safety' to educate junior doctors about patient safety and the importance of reporting safety concerns.

      Ward, Marie; Ní Shé, Éidín; De Brún, Aoife; Korpos, Christian; Hamza, Moayed; Burke, Elaine; Duffy, Ann; Egan, Karen; Geary, Una; Holland, Catherine; et al. (2019-06-25)
      A serious game based on the PlayDecide framework was co-designed and implemented in two large urban acute teaching hospitals. To evaluate the educational value of the game voting on the position statements was recorded at the end of each game by a facilitator who also took notes after the game of key themes that emerged from the discussion. A sample of players were invited on a voluntary basis to take part in semi-structured interviews after playing the game using Flanagan's Critical Incident Technique. A paper-based questionnaire on 'Safety Concerns' was developed and administered to assess pre-and post-playing the game reporting behaviour. Dissemination workshops were held with senior clinicians to promote more inclusive leadership behaviours and responsiveness to junior doctors raising of safety concerns from senior clinicians.
    • Thinking forward: promising but unproven ideas for future intensive care.

      Marini, John J; DeBacker, Daniel; Gattinoni, Luciano; Ince, Can; Martin-Loeches, Ignacio; Singer, Pierre; Singer, Mervyn; Westphal, Martin; Vincent, Jean-Louis (2019-06-14)
      Progress toward determining the true worth of ongoing practices or value of recent innovations can be glacially slow when we insist on following the conventional stepwise scientific pathway. Moreover, a widely accepted but flawed conceptual paradigm often proves difficult to challenge, modify or reject. Yet, most experienced clinicians, educators and clinical scientists privately entertain untested ideas about how care could or should be improved, even if the supporting evidence base is currently thin or non-existent. This symposium encouraged experts to share such intriguing but unproven concepts, each based upon what the speaker considered a logical but unproven rationale. Such free interchange invited dialog that pointed toward new or neglected lines of research needed to improve care of the critically ill. In this summary of those presentations, a brief background outlines the rationale for each novel and deliberately provocative unconfirmed idea endorsed by the presenter.
    • Influenza and associated co-infections in critically ill immunosuppressed patients.

      Martin-Loeches, Ignacio; Lemiale, Virginie; Geoghegan, Pierce; McMahon, Mary AISLING; Pickkers, Peter; Soares, Marcio; Perner, Anders; Meyhoff, Tine Sylvest; Bukan, Ramin Brandt; Rello, Jordi; et al. (2019-05-02)
      Background It is unclear whether influenza infection and associated co-infection are associated with patient-important outcomes in critically ill immunocompromised patients with acute respiratory failure. Methods Preplanned secondary analysis of EFRAIM, a prospective cohort study of 68 hospitals in 16 countries. We included 1611 patients aged 18 years or older with non-AIDS-related immunocompromise, who were admitted to the ICU with acute hypoxemic respiratory failure. The main exposure of interest was influenza infection status. The primary outcome of interest was all-cause hospital mortality, and secondary outcomes ICU length of stay (LOS) and 90-day mortality. Results Influenza infection status was categorized into four groups: patients with influenza alone (n = 95, 5.8%), patients with influenza plus pulmonary co-infection (n = 58, 3.6%), patients with non-influenza pulmonary infection (n = 820, 50.9%), and patients without pulmonary infection (n = 638, 39.6%). Influenza infection status was associated with a requirement for intubation and with LOS in ICU (P < 0.001). Patients with influenza plus co-infection had the highest rates of intubation and longest ICU LOS. On crude analysis, influenza infection status was associated with ICU mortality (P < 0.001) but not hospital mortality (P = 0.09). Patients with influenza plus co-infection and patients with non-influenza infection alone had similar ICU mortality (41% and 37% respectively) that was higher than patients with influenza alone or those without infection (33% and 26% respectively). A propensity score-matched analysis did not show a difference in hospital mortality attributable to influenza infection (OR = 1.01, 95%CI 0.90–1.13, P = 0.85). Age, severity scores, ARDS, and performance status were all associated with ICU, hospital, and 90-day mortality. Conclusions Category of infectious etiology of respiratory failure (influenza, non-influenza, influenza plus co-infection, and non-infectious) was associated with ICU but not hospital mortality. In a propensity score-matched analysis, influenza infection was not associated with the primary outcome of hospital mortality. Overall, influenza infection alone may not be an independent risk factor for hospital mortality in immunosuppressed patients.
    • Clinical and genetic landscape of treatment naive cervical cancer: Alterations in PIK3CA and in epigenetic modulators associated with sub-optimal outcome.

      Scholl, Suzy; Popovic, Marina; de la Rochefordiere, Anne; Girard, Elodie; Dureau, Sylvain; Mandic, Aljosa; Koprivsek, Katarina; Samet, Nina; Craina, Marius; Margan, Madalin; et al. (2019-04-02)
      Background: There is a lack of information as to which molecular processes, present at diagnosis, favor tumour escape from standard-of-care treatments in cervical cancer (CC). RAIDs consortium (www.raids-fp7.eu), conducted a prospectively monitored trial, [BioRAIDs (NCT02428842)] with the objectives to generate high quality samples and molecular assessments to stratify patient populations and to identify molecular patterns associated with poor outcome. Methods: Between 2013 and 2017, RAIDs collected a prospective CC sample and clinical dataset involving 419 participant patients from 18 centers in seven EU countries. Next Generation Sequencing has so far been carried out on a total of 182 samples from 377 evaluable (48%) patients, allowing to define dominant genetic alterations. Reverse phase protein expression arrays (RPPA) was applied to group patients into clusters. Activation of key genetic pathways and protein expression signatures were tested for associations with outcome. Findings: At a median follow up (FU) of 22 months, progression-free survival rates of this FIGO stage IB1-IV population, treated predominantly (87%) by chemoradiation, were65•4% [CI95%: 60•2-71.1]. Dominant oncogenic alterations were seen in PIK3CA (40%), while dominant suppressor gene alterations were seen in KMT2D (15%) and KMT2C (16%). Cumulative frequency of loss-of-function (LOF) mutations in any epigenetic modulator gene alteration was 47% and it was associated with PIK3CA gene alterations in 32%. Patients with tumours harboring alterations in both pathways had a significantly poorer PFS. A new finding was the detection of a high frequency of gains of TLR4 gene amplifications (10%), as well as amplifications, mutations, and non-frame-shift deletions of Androgen receptor (AR) gene in 7% of patients. Finally, RPPA protein expression analysis defined three expression clusters. Interpretation: Our data suggests that patient population may be stratified into four different treatment strategies based on molecular markers at the outset. FUND: European Union's Seventh Program grant agreement No 304810.
    • Current advances in the treatment of giant cell arteritis: the role of biologics.

      Low, Candice; Conway, Richard (Therapeutic Advances in Musculoskeletal Disease, 2019-01-01)
      Giant cell arteritis (GCA) is the most common form of systemic vasculitis. It is a potentially severe disease with 25% of patients suffering vision loss or stroke. Our treatment paradigm is based on glucocorticoids. Glucocorticoids are required in high doses for prolonged periods and subsequently are associated with a significant amount of treatment-related morbidity. Alternative treatment options are urgently needed to minimize these glucocorticoid adverse events. Many other agents, such as methotrexate and tumour necrosis factor alpha inhibitors have been used in GCA, with limited or no evidence of benefit. Our emerging understanding of the pathogenic processes involved in GCA has led to an increased interest in the use of biologic agents to treat the disease. Two randomized controlled trials have recently reported dramatic effects of the use of the interleukin-6 targeted biologic tocilizumab in GCA, with significant increases in remission rates and decreases in glucocorticoid burden. While encouraging, longer-term and additional outcomes are awaited to clarify the exact positioning of tocilizumab in the treatment approach. Emerging data for other biologic agents, particularly abatacept and ustekinumab, are also encouraging but less well advanced. We are at the dawn of a new era in GCA treatment, but uncertainties and opportunities abound.
    • National Medicines Information Centre VOLUME 24 NUMBER 4 2018

      National Medicines Information Centre (National Medicines Information Centre St James Hospital, 2018-08)
      Newsletter of the National Medicines Information Centre
    • National Medicines Information Centre VOLUME 24 NUMBER 3 2018

      National Medicines Information Centre (National Medicines Information Centre St James Hospital, 2018-08)
      Newsletter of the National Medicines Information Centre
    • Transcriptome level analysis in Rett syndrome using human samples from different tissues.

      Shovlin, Stephen; Tropea, Daniela (Orphanet Journal of Rare Diseases, 2018-07-11)
      The mechanisms of neuro-genetic disorders have been mostly investigated in the brain, however, for some pathologies, transcriptomic analysis in multiple tissues represent an opportunity and a challenge to understand the consequences of the genetic mutation. This is the case for Rett Syndrome (RTT): a neurodevelopmental disorder predominantly affecting females that is characterised by a loss of purposeful movements and language accompanied by gait abnormalities and hand stereotypies. Although the genetic aetiology is largely associated to Methyl CpG binding protein 2 (MECP2) mutations, linking the pathophysiology of RTT and its clinical symptoms to direct molecular mechanisms has been difficult. One approach used to study the consequences of MECP2 dysfunction in patients, is to perform transcriptomic analysis in tissues derived from RTT patients or Induced Pluripotent Stem cells. The growing affordability and efficiency of this approach has led to a far greater understanding of the complexities of RTT syndrome but is also raised questions about previously held convictions such as the regulatory role of MECP2, the effects of different molecular mechanisms in different tissues and role of X Chromosome Inactivation in RTT. In this review we consider the results of a number of different transcriptomic analyses in different patients-derived preparations to unveil specific trends in differential gene expression across the studies. Although the analyses present limitations- such as the limited sample size- overlaps exist across these studies, and they report dysregulations in three main categories: dendritic connectivity and synapse maturation, mitochondrial dysfunction, and glial cell activity. These observations have a direct application to the disorder and give insights on the altered mechanisms in RTT, with implications on potential diagnostic criteria and treatments.
    • Factors Associated with Maternal Wellbeing at Four Months Post-Partum in Ireland.

      Bennett, Annemarie E; Kearney, John M; 1 Department of Clinical Medicine, Trinity Centre for Health Sciences, St. James' Hospital Campus, Dublin 8, Ireland. 2 School of Biological Sciences, Dublin Institute of Technology, Kevin Street, Dublin 8, Ireland. (MDPI, 2018-05-14)
      This study aimed to examine factors associated with maternal wellbeing at four months post-partum in the Irish context. Socio-demographic, health behaviour and infant feeding data were collected in pregnancy, at birth and at 17 weeks post-partum. Maternal distress, body image and resilience were measured at 17 weeks post-partum. Binary logistic regression predicted maternal distress and statistical significance was taken at p < 0.05. One hundred and seventy-two women were followed-up in pregnancy, at birth and at 17 weeks post-partum. Three in five (61.6%, n106) initiated breastfeeding. At 17 weeks post-partum, 23.8% (n41) were exclusively or partially breastfeeding and over a third (36.0%, n62) of all mothers were at risk of distress. In multivariate analyses, independent predictors of distress included: low maternal resilience (p < 0.01, odds ratio (OR): 7.22 (95% confidence interval [CI]: 2.49–20.95)); unsatisfactory partner support (p = 0.02, OR: 3.89 (95% CI: 1.20–12.65)); older age (p = 0.02, OR: 1.11 (95% CI: 1.02–1.21)); and breastfeeding (p = 0.01, OR: 2.89 (95% CI: 1.29–6.47)). Routine assessment of emotional wellbeing and targeted interventions are needed to promote a more healthful transition to motherhood among women in Ireland.
    • Acquired Factor Xiii Deficiency: An Uncommon But Easily Missed Cause Of Severe Bleeding

      Fogarty, H; Byrne, M; O’Connell, NM; Ryan, K; White, B; O’Donnell, JS; Lavin, M (Irish Medical Journal, 2018-05)
      Factor XIII (FXIII) is a plasma clotting protein involved in clot stabilization. Severe FXIII deficiency may present with severe, even fatal bleeding. Critically however, routine coagulation assays may be normal and only specific FXIII assays will detect the abnormality. Herein we discuss a case report of a patient with acquired FXIII deficiency in order to highlight the clinical challenges associated with establishing the diagnosis and discuss the treatment approach. A 70-year-old man presented with a gluteal haematoma despite no preceding personal history of bleeding. Extensive initial haemostatic investigations were normal until a specific FXIII assay showed a marked reduction in FXIII levels. With directed treatment, bleeding episodes ceased and remission was achieved. Clinical awareness of FXIII deficiency is important, so appropriate testing can be implemented in patients with unexplained bleeding diatheses, particularly those in whom bleeding responds poorly to standard replacement therapy.
    • Therapeutics Today May 2018 Number 5

      National Medicines Information Centre, St. James’s Hospital (SJH) Dublin 8 (National Medicines Information Centre, St. James’s Hospital (SJH) Dublin 8, 2018-05)
    • The ‘Medication Safety Minute’− Microlearning in Medicine

      Relihan, Eileen (2018-04-06)
      Summary of an initiative of St. James’s Hospital (SJH) medication safety programme to highlighting prescribing safety issues. The project the ‘Medication Safety Minute' was based on the concept of ‘bite-sized learning’. The aim was to deliver a message which could be which could be read and understood in one minute or less. The project was selected for the HSE excellence awards showcase.
    • Therapeutics Today April 2018 Number 4

      National Medicines Information Centre, St. James’s Hospital; Dept of Therapeutics Trinity College, Trinity Centre, SJH (National Medicines Information Centre, St. James’s Hospital, 2018-04)
      Newsletter of the National Medicines Information Centre, St. James’s Hospital.
    • Methaemoglobinaemia: A Blue Light Emergency

      Uí Bhroin, S; McNamara, R; Kidney, E (Irish Medical Journal, 2018-03)
      Methaemoglobinaemia is a rare but potentially fatal condition. It occurs when the haem molecule of haemoglobin is oxidized from ferrous to ferric form1,2. Methaemoglobin has decreased oxygen carrying capacity. It also causes leftward shift of the oxygen dissociation curve, thus impairing tissue oxygenation1,2. Methaemoglobinaemia can be congenital or, more commonly, acquired3. Many toxins have been implicated in acquired methaemoglobinaemia including local anaesthetics, metoclopramide, cocaine and volatile nitrites4,5.
    • Outcomes of a Community-Based Paediatric Weight Management Programme in an Irish Midlands Setting

      Bennett, AE, N Canning, K Younger 2, MAT Flynn 1; Johnston Molloy, C; Glennon-Slattery, C; Loane, D (Irish Medical Journal, 2018-02)
      Ongoing investigation is needed into feasible approaches which reduce excess weight in childhood. This study aimed to assess the effectiveness of an adapted version of the Scottish Childhood Overweight Treatment Trial (SCOTT) in an Irish primary care setting. Families were offered monthly dietitian-led sessions for six months. These sessions targeted dietary habits, family meals, screen time and exercise. Of the 95 children (mean age 7.6 years) referred, 90.5% (n86) were obese and 9.5% (n9) were overweight. Fifty-one (53.7%) families opted into the programme from referral, and 18 completed the programme (64.7% attrition). Statistically significant reductions in body mass index (BMI) were observed between sessions one and six (25.7±4.2kg/m2 and 25.3±4.8kg/m2, respectively, p<0.01). BMI z-score modestly decreased by 0.2 (p=0.01). Despite these reductions, issues with programme referral, attrition and long-term effectiveness were evident. Further investigation into strategies which reduce paediatric overweight is warranted.
    • Portal Hypertensive Colopathy with Pelvic Varices presenting as Severe Lower GI Bleed treated with TIPSS

      Murphy, SF; Durand, M; McMorrow, JP; Meaney, JF; Guiney, M (Irish Medical Journal, 2018-02)
      We present the case of a 71-year-old lady with a background of significant alcohol intake who presented with frank lower gastrointestinal (GI) bleeding, lower abdominal pain and haemoglobin 6.3g/dL. CT abdominal angiogram showed right-sided colonic thickening, atrophic liver and enlarged superior mesenteric vein (SMV) and right-sided pelvic varix. This lead to a diagnosis of portal hypertensive colopathy secondary to alcoholic liver cirrhosis. The patient failed conservative management and underwent a Transjugular Intrahepatic Portosystemic Shunt (TIPSS) procedure. This lead to an immediate resolution of her lower-GI bleeding. Repeat CT at three weeks showed a decompressed SMV and resolution of the right-sided pelvic varix. The patient was discharged after three months following optimization of medical condition and social circumstances.
    • Improving the quality of radiation oncology: 10years' experience of QUATRO audits in the IAEA Europe Region.

      Izewska, Joanna; Coffey, Mary; Scalliet, Pierre; Zubizarreta, Eduardo; Santos, Tania; Vouldis, Ioannis; Dunscombe, Peter; 1 International Atomic Energy Agency, Vienna International Centre, Vienna, Austria. Electronic address: j.izewska@iaea.org. 2 Discipline of Radiation Therapy, School of Medicine, Trinity Centre for Health Sciences, St. James' Hospital, Dublin, Ireland. 3 Department of Radiotherapy, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium. 4 International Atomic Energy Agency, Vienna International Centre, Vienna, Austria. 5 University of Calgary, Canada. (Elsevier, 2018-01-01)
      The IAEA has developed a methodology for comprehensive quality audits of radiotherapy practices called Quality Assurance Team for Radiation Oncology (QUATRO). This study explores the factors that impacted quality of care among QUATRO audited centres in the IAEA Europe Region. The 31 QUATRO reports collected over 10years include extensive data describing the quality of radiotherapy at the audited centres. A coding key was developed to aggregate and review these data in terms of recommendations for improvement and positive findings (commendations). Overall 759 recommendations and 600 commendations were given. Eight centres recognized as centres of competence differed from other centres mostly because they operated complete quality management systems and were adequately staffed. Other centres had excessive staff workloads and many gaps in the process of care. Insufficient equipment levels were prevalent. Patient centredness, communication, dosimetry, quality control and radiation protection were frequently commended by QUATRO. This analysis points to barriers to quality care such as insufficient staffing, education/training, equipment and lack of quality management. It highlights the correlation between the human resources availability and quality of care. It has also identified common action items for enhancing quality of radiotherapy programmes in the Region.
    • Laryngeal Chondrosarcoma: A rare cause of critical upper airway obstruction.

      Tuite, K; Oosthuizen, J.C; Subramaniam, T; Kinsella, J.B (Irish Medical Journal, 2018-01)
      Laryngeal cancers are rare, encompassing around one percent of all cancers. Suspicion should be raised if a patient presents with classical signs and symptoms; i.e. dysphonia, inspiratory stridor, dysphagia, odynophagia, neck mass, or persistent cough. Laryngeal chondrosarcoma is a rare form of laryngeal cancer, the diagnosis of which can be difficult. The case in question describes an unusual presentation of one such case, and its subsequent investigation, management and outcome.
    • Interventions to Improve the Treatment of Malaria in an Acute Teaching Hospital in Ireland

      O’Connor, R; Morley, D; Relihan, E; Broderick, A; Merry, C; Bergin, C (Irish Medical Journal, 2017-11)
      Malaria is the most serious parasitic infection. At our institution over a two year period there were treatment errors in 18% (n=3) of cases. The aim of this multidisciplinary study was to ensure appropriate and timely treatment of malaria by implementation of a cluster of interventions: reconfiguration of existing guidelines, provision of prescribing information; delivery of education sessions to front-line staff and enabling rapid access to medication. Staff feedback was assessed through a questionnaire. Perceived benefits gained included awareness of guidelines (91%, n= 39), how to diagnose (81%, n =35), how to treat (86%, n=37), that treatment must be prompt (77%, n=33) and where to find treatment out of hours (84%, n=36). ‘Others’ perceived benefits (5% n= 2) noted referred to treatment in pregnancy. Going forward, a programme of on-going staff education, repeated audits of guideline compliance and promotion of reporting of medication errors should help ensure that these benefits are sustained