• Psychiatry in Ireland: A Lot Done, More to Do

      Kelly, B.D.; Department of Psychiatry, Trinity Centre for Health Sciences (Irish Medical Journal, 2019-10)
      Four decades ago, in April 1979, Time magazine printed a dramatic cover story titled “Psychiatry’s depression”, diagnosing psychiatry with “a bad case of mid-life blues” 1. The magazine pointed to a lack of knowledge about the biology of mental illness, recruitment problems into the profession, uncertainties about treatments, and the inadequacy of community care. Precisely forty years later, in April 2019, the Economist magazine, in a very similar tone, referred to “today’s crisis in the psychiatric profession” 2 and, the following month, the New Yorker cited many of the same problems again in an article about “psychiatry’s fraught history” 3.
    • Incidence of Asymptomatic Chiari Malformation

      O’Reilly, E.M; Torreggiani, W (Irish Medical Journal, 2019-07)
      Aim The aim of this study is to define the incidence of asymptomatic Chiari malformation in an Irish population. Methods MRIs performed over 24 months were analysed. Exclusion criteria include: space occupying lesion, hydrocephalus, Chiari symptoms and inadequate views. Data were analysed to give incidence of asymptomatic Chiari and to analyze the relationship between symptom and position of the cerebellar tonsils (Chi square and Fishers exact test). Results Sample Characteristics: 147 patients (Male = 65: Female = 82), age range 15 to 93 years (M age = 53.35, SD= 16.67). 2%had a Chiari malformation (n=2). There was no significant association between symptom and tonsil position (Fishers exact test, ² (8) = 9.98, p = .23.) Conclusion This study shows an asymptomatic Chiari Malformation rate of 2%. This study supports the idea that in asymptomatic patients, a tonsil herniation of up to 5 millimeters may be an incidental and inconsequent finding.
    • Hip Fracture and the Weekend Effect in an Irish Trauma Hospital

      Downey, C; Flannery, S; Izydorczyk, A; Quinlan, J.F. (2019-06)
      We examined the relationship between the 1-year mortality (OYM) rate and (i) those admitted at the weekend, (ii) those who underwent surgery at the weekend and (iii) those admitted during the NCHD changeover months (January & July) for the management of hip fracture in Tallaght University Hospital (TUH).
    • Where does Pelvic and Acetabular Fracture Treatment fit into the Newly Proposed Major Trauma Model in Ireland?

      Fenelon, C; Murphy, E.P; O’Daly, B.J; Leonard, M (Irish Medical Journal, 2019-04)
      Major trauma continues to be the biggest cause of death in people aged between 5 and 45 years of age. Suboptimal trauma management results in greater ongoing costs to patients, hospitals and society. Trauma networks in the United States, Australia and more recently the United Kingdom have proven successful in significantly reducing morbidity and mortality. In the UK, analysis by the Trauma Audit Research Network (TARN) has shown that a major trauma patient has a 19% increase in the odds of survival following major trauma since its introduction in 2012. No integrated trauma network yet exists in Ireland but a recent report “A Trauma System for Ireland” published in January of 2018 outlined plans of how such a trauma network would be introduced. The report called for the introduction of two regional trauma networks, a central and south network, with one major trauma centre for each. However, the report made no mention of where the treatment of pelvic and acetabular fractures fell within it.
    • Infliximab Induced Cardiac Tamponade

      O’Morain, N; Kumar, L; O’Carroll-Lolait, C; Alakkari, A; Ryan, B (Irish Medical Journal, 2019-03)
      Biologic therapies are increasingly used in the treatment of Inflammatory Bowel Disease. Reactions to infusion therapy are not uncommon but are mostly benign and self-limiting. Rarely, life-threatening complications can occur.
    • Are we Over-Imaging the Obese Patient with Suspected Pulmonary Embolus in Ireland

      Gargan, M.L; O'Sullivan, M.; Hunter, K.; Buckley, O.; Torreggiani, W.C (Irish Medical Journal, 2019-02)
      To assess if there was a significant difference in the number of positive studies for pulmonary embolism between obese and non obese patients.
    • “Semenly” Harmless Back Pain: An Unusual Presentation of a Subcutaneous Abscess

      Dunne, L; Murphy, E; Rutledge, R (Irish Medical Journal, 2019-01)
      We report, with review of the literature, the case of a patient who developed a subcutaneous abscess after intravenously injecting his own semen in an attempt to treat longstanding back pain. He had devised this “cure” independent of medical advice.
    • Proficiency-based progression training: an 'end to end' model for decreasing error applied to achievement of effective epidural analgesia during labour: a randomised control study.

      Kallidaikurichi Srinivasan, Karthikeyan; Gallagher, Anthony; O'Brien, Niall; Sudir, Vinod; Barrett, Nick; O'Connor, Raymund; Holt, Francesca; Lee, Peter; O'Donnell, Brian; Shorten, George (2018-10-15)
      Background: Training procedural skills using proficiency-based progression (PBP) methodology has consistently resulted in error reduction. We hypothesised that implementation of metric-based PBP training and a valid assessment tool would decrease the failure rate of epidural analgesia during labour when compared to standard simulation-based training. Methods: Detailed, procedure-specific metrics for labour epidural catheter placement were developed based on carefully elicited expert input. Proficiency was defined using criteria derived from clinical performance of experienced practitioners. A PBP curriculum was developed to train medical personnel on these specific metrics and to eliminate errors in a simulation environment.Seventeen novice anaesthetic trainees were randomly allocated to undergo PBP training (Group P) or simulation only training (Group S). Following training, data from the first 10 labour epidurals performed by each participant were recorded. The primary outcome measure was epidural failure rate. Results: A total of 74 metrics were developed and validated. The inter-rater reliability (IRR) of the derived assessment tool was 0.88. Of 17 trainees recruited, eight were randomly allocated to group S and six to group P (three trainees did not complete the study). Data from 140 clinical procedures were collected. The incidence of epidural failure was reduced by 54% with PBP training (28.7% in Group S vs 13.3% in Group P, absolute risk reduction 15.4% with 95% CI 2% to 28.8%, p=0.04). Conclusion: Procedure-specific metrics developed for labour epidural catheter placement discriminated the performance of experts and novices with an IRR of 0.88. Proficiency-based progression training resulted in a lower incidence of epidural failure compared to simulation only training.
    • National Survey Of The Aetiological Assessment Service Of Permanent Childhood Hearing Loss In Ireland

      Balfe, J; Van Der Spek, N; Waldron, D (Irish Medical Journal, 2018-09)
      Best practice indicates that all children who are identified with permanent childhood hearing loss (PCHL) should have access to prompt paediatric assessment to determine the need for aetiological investigations[i]. Early paediatric assessment allows the identification and management of potentially treatable causes e.g. congenital CMV (cCMV) infection and provides an opportunity to prevent or reduce disability. It also allows the identification of associated co-morbidities including potentially fatal cardiac arrhythmias. The role of the paediatrician also includes liaison with agencies including tertiary specialist services, education, disability services and other community based organisations
    • Subtrochanteric Femur Fractures in an Irish Trauma Centre over 9 years: How the Impact of Hospital Coding on Diagnosis of Subtrochanteric Femur Fractures Leads to Inaccurate Occurrence Rates

      Coveney, EI; Harriz, E; Gibney, B; Quinlan, JF (Irish Medical Journal, 2018-06)
      Our aim was to assess the occurrence rates of subtrochanteric femur fractures in an orthopaedic tertiary referral centre and to assess the correlation of patient’s actual diagnosis with national hospital inpatient enquiry data.
    • A Combination of Surgery And Methotrexate for Successful Treatment of a Caesarean Scar Ectopic Pregnancy.

      Tadesse, WG; Von Bunau, G (Irish Medical Journal, 2018-06)
      Caesarean scar ectopic pregnancy (CSEP) is one of the rarest forms of ectopic pregnancies. With rising caesarean delivery (CD) rates worldwide, there is an increase in the incidence of CSEP. Patients usually present with painless vaginal bleeding and often misdiagnosed as spontaneous miscarriage. The use of ultrasonography with colour flow Doppler helps in the differential diagnosis. Different treatment options are described in the literature, although there is insufficient evidence regarding the best approach. We report the diagnosis and management of a case of CSEP in a woman with four previous CD who presented with vaginal bleeding and lower abdominal cramps at six weeks of gestation. She was treated with laparoscopic and ultrasound guided aspiration of the gestational sac and local injection of methotrexate supplemented by intramuscular methotrexate injection.
    • Extramammary Paget ’s disease Of Glans Penis: A Rare Case Report

      Inder, M S; O’Kelly, F; Sheikh, M; O’Hare, K; Barbara, M L; Thornhill, J A (Irish Medical Journal, 2018-06)
      We present the case of an 83-year-old man with Extramammary Paget’s disease (EMPD) of the penis. He underwent a total penectomy and histopathology confirms the association of underlying invasive high grade urothelial carcinoma. Penile EMPD is rare and can be misinterpreted for benign skin conditions. A high index of suspicion is required for correct diagnosis and appropriate treatment.
    • Patterns of Mortality in Modern Stroke Care

      Dalton, M; Coughlan, T; Cogan, N; Greene, S; McCabe, DJH; McCarthy, A; Murphy, S; Walsh, R; O’Neill, D; Kennelly, S; et al. (Irish Medical Journal, 2018-05)
      Stroke is a leading cause of death. We looked at the causes (direct and indirect) of in-hospital mortality in a modern stroke unit over a two-year period.
    • Individualized dosing with axitinib: rationale and practical guidance.

      Schmidinger, Manuela; Danesi, Romano; Jones, Robert; McDermott, Ray; Pyle, Lynda; Rini, Brian; Négrier, Sylvie; 1 Clinical Division of Oncology, Department of Medicine I & Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria. 2 Department of Clinical & Experimental Medicine, University of Pisa, Pisa, Italy. 3 Institute of Cancer Sciences, University of Glasgow, The Beatson West of Scotland Cancer Centre, Glasgow, UK. 4 Department of Medical Oncology, St Vincent's University Hospital & The Adelaide & Meath Hospital, Dublin, Ireland. 5 Renal Cancer Unit, Department of Medicine, Royal Marsden Hospital, London, UK. 6 Department of Hematology & Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA. 7 Medical Oncology Department, University of Lyon, Centre Léon Bérard, Lyon, France. (Future Science Group, 2018-04-01)
      Axitinib is a potent, selective, vascular endothelial growth factor receptor inhibitor with demonstrated efficacy as second-line treatment for metastatic renal cell carcinoma. Analyses of axitinib drug exposures have demonstrated high interpatient variability in patients receiving the 5 mg twice-daily (b.i.d.) starting dose. Clinical criteria can be used to assess whether individual patients may benefit further from dose modifications, based on their safety and tolerability data. This review provides practical guidance on the 'flexible dosing' method, to help physicians identify who would benefit from dose escalations, dose reductions or continuation with manageable toxicity at the 5 mg b.i.d. dose. This flexible approach allows patients to achieve the best possible outcomes without compromising safety.
    • Involuntary psychiatric admission based on risk rather than need for treatment: report from the Dublin Involuntary Admission Study (DIAS).

      Kelly, BD; Curley, A; Duffy, RM (Irish Medical Journal, 2018-04)
      Involuntary psychiatric admission in Ireland is based on the presence of mental disorder plus serious risk to self/others and/or need for treatment. This study aimed to examine differences between use of risk and treatment criteria, about which very little is known.
    • Single Centre Experience – Clinical Presentation and Frequency of Paediatric Diabetic Ketoacidosis (DKA) At Diagnosis over a 5-Year Period

      McKenna, A; Sandys, N; Ryder, K; Metwally, N; Brennan, A; O’Regan, M; Hoey, MCV; Roche, EF (Irish Medical Journal, 2018-03)
      Type 1 diabetes (T1D) symptoms are subtle and easily overlooked. Delayed diagnosis can result in Diabetic ketoacidosis (DKA), a life threatening complication with lasting consequences. We sought to define the presenting features of T1D and DKA frequency, in children <15 years diagnosed in a single national tertiary centre, and identify predictive factors for DKA. A review of T1D incident cases was undertaken from 2008-2012 using the National Diabetes Register (ICDNR) and clinical case notes. Data were compared with a 1997/8 national study. We found DKA at presentation in 28.7 % of children and 15.5% had moderate/severe DKA. Commonest symptoms were polydipsia, polyuria, weight loss, and lethargy. Median symptom duration was 17 days. Clinical presentation was similar and frequency of DKA at T1D diagnosis remains high. The proportion with moderate/severe DKA is lower than the 25% previously reported (p=0.038). National monitoring and targeted action to reduce DKA at diagnosis is required.
    • Peripherally Inserted Central Catheters (PICCs) and Potential Cost Savings and Shortened Bed Stays In an Acute Hospital Setting.

      O’Brien, C; Mc Marrow, J; O’Dwyer, E; Govender, P; Torreggiani, WC (Irish Medical Journal, 2018-01)
      Peripheral inserted central catheters (PICCs) have increasingly become the mainstay of patients requiring prolonged treatment with antibiotics, transfusions, oncologic IV therapy and total parental nutrition. They may also be used in delivering a number of other medications to patients. In recent years, bed occupancy rates have become hugely pressurized in many hospitals and any potential solutions to free up beds is welcome. Recent introductions of doctor or nurse led intravenous (IV) outpatient based treatment teams has been having a direct effect on early discharge of patients and in some cases avoiding admission completely. The ability to deliver outpatient intravenous treatment is facilitated by the placement of PICCs allowing safe and targeted treatment of patients over a prolonged period of time. We carried out a retrospective study of 2,404 patients referred for PICCs from 2009 to 2015 in a university teaching hospital. There was an exponential increase in the number of PICCs requested from 2011 to 2015 with a 64% increase from 2012 to 2013. The clear increase in demand for PICCs in our institution is directly linked to the advent of outpatient intravenous antibiotic services. In this paper, we assess the impact that the use of PICCs combined with intravenous outpatient treatment may have on cost and hospital bed demand. We advocate that a more widespread implementation of this service throughout Ireland may result in significant cost savings as well as decreasing the number of patients on hospital trollies.
    • Oral Cancer Awareness of Non-Consultant Hospital Doctors in Irish Hospitals

      Shanahan, D; Healy, CM (Irish Medical Journal, 2018-01)
      The incidence of oral cancer is rising in Ireland. The aim of this study is to assess the level of awareness of oral cancer amongst non-consultant hospital doctors (NCHDs) in Ireland, so any knowledge deficits can be identified and addressed. Data was collected by means of an anonymous online questionnaire, which was distributed via a private social media page for NCHDs in Ireland. It was completed by 221 participants, of which over 80% recorded that they do not regularly examine patients’ oral mucosa. Sixty percent were ‘unsure’, and 21%, ‘very unsure’, about diagnosing oral cancer based on clinical appearance. Nor were respondents able to identify confidently the various potential risk factors for oral cancer. Eighty-four percent of NCHDs requested further education on the topic. The response rate of the study was low, and further investigation is required to determine if the findings of this study are representative of the wider NCHD community. The chief recommendation of this paper is to provide more education about oral cancer, at both medical undergraduate and postgraduate levels, and to increase awareness of the condition amongst hospital doctors.
    • Primary Renal Carcinoid - A Case Report

      O’Sullivan, M; Gargan, ML; Flynn, R; Crowther, S; Torreggiani, W (Irish Medical Journal, 2018-01)
      Carcinoid tumours in the abdomen are uncommon, but typically occur in the gastrointestinal tract. Primary renal carcinoid is an extremely rare tumour, poorly described in the literature. We describe an unusual case where an atypical renal mass on imaging led to a preoperative diagnosis of renal carcinoid on imaging guiding biopsy.
    • Hidradenitis Suppurativa and Crohn’s Disease: A Case Series

      Kirthi, S; Hellen, R; O’Connor, R; Connolly, M; Tobin, AM; McNamara, D (Irish Medical Journal, 2017-09)
      Hidradenitis Suppurativa (HS) is characterized by chronic recurrent abscesses, nodules and draining sinus tracts with scar formation. Cutaneous Crohn’s Disease (CD) may also present similarly. We wished to identify and describe an Irish cohort with combined HS and CD, with a view to a better recognition of clinical manifestations and understanding of the pathophysiology underlying these two overlapping conditions. Cases were identified using the HIPE Code at Tallaght Hospital from 1990-2014 and retrospective review was performed. Seven patients with both HS and CD were identified, 5(71%) female. The median age of diagnosis with both conditions was 37 years. In all cases, CD had preceded the diagnosis of HS. All patients smoked. Six had an increased BMI and 43% had additional autoimmune conditions. All patients required treatment with a TNF-alpha inhibitor for HS with 5 of 6 subjects having reduced frequency of flare ups and clinically less active HS on follow up