• B-type natriuretic peptide measurement in primary care; magnitude of associations with cardiovascular risk factors and their therapies. Observations from the STOP-HF (St. Vincent's Screening TO Prevent Heart Failure) study.

      Conlon, Carmel M; Dawkins, Ian; O'Loughlin, Christina; Gibson, Denise; Kelleher, Cecily C; Ledwidge, Mark; McDonald, Kenneth; Department of Cardiology, St. Vincent's University Hospital, Dublin, Ireland. (2012-02-01)
      BACKGROUND: An effective prevention strategy for heart failure in primary care requires a reliable screening tool for asymptomatic ventricular dysfunction. Preliminary data indicate that B-type natriuretic peptide (BNP) may be suitable for this task. However, for the most effective use of this peptide, the interrelationships between associated risk factors and their therapies on BNP, and in particular their magnitude of effect, needs to be established in a large primary care population. Therefore, the objective of the study was to establish the extent of the association between BNP, cardiovascular risk factors and their therapies. METHODS: BNP measurement and clinical review was preformed on 1122 primary care patients with cardiovascular risk factors. Multivariate analyses identified significant associates of BNP concentrations which were further explored to establish the magnitude of their association. RESULTS: Associates of BNP were age (1.36-fold increase in BNP/decade), female (1.28), beta-blockers (1.90), myocardial infarction (1.36), arrhythmia (1.98), diastolic blood pressure; all p<0.01. A novel method was devised that plotted median BNP per sliding decade of age for the various combinations of these principal associates. CONCLUSIONS: The data presented underline the importance of considering several clinical and therapeutic factors when interpreting BNP concentrations. Most of these variables were associated with increased concentrations, which may in part explain the observed false-positive rates for detecting ventricular dysfunction using this peptide. Furthermore, the design of studies or protocols using BNP as an endpoint or a clinical tool should take particular account of these associations. This analysis provides the foundation for age, risk factor and therapy adjusted reference ranges for BNP in this setting.
    • Back pain following a lumbar puncture: what's unusual about that?

      Sinokrot, O; Doyle, A; Lonergan, R; Fitzgerald, S; McGuigan, C (Irish Medical Journal, 2015-05)
      A 50 year old male presents with progressive back pain. Osteomyelitis and discitis are rare but important complications of minimally invasive procedures such as bedside lumbar puncture. It is imperative to consider P. acnes as the pathogen in the setting of instrumentation.
    • Bacterial colonization of colonic crypt mucous gel and disease activity in ulcerative colitis.

      Rowan, Fiachra; Docherty, Neil G; Murphy, Madeline; Murphy, T Brendan; Coffey, J Calvin; O'Connell, P Ronan; Department of Surgery, St. Vincent's University Hospital, UCD School of Medicine , and Medical Science, Dublin, Ireland. (2012-02-01)
      OBJECTIVE: To optimize total bacterial 16S rRNA quantification in microdissected colonic crypts in healthy controls and patients with ulcerative colitis (UC) and to characterize the findings with disease activity. BACKGROUND: Microscopic and molecular techniques have recently converged to allow bacterial enumeration in remote anatomic locations [eg, crypt-associated mucous gel (CAMG)]. The aims of this study were to combine laser capture microdissection (LCM) and 16S rRNA-based quantitative polymerase chain reaction (qPCR) to determine total bacterial copy number in CAMG both in health and in UC and to characterize the findings with disease activity. METHODS: LCM was used to microdissect CAMG from colonic mucosal biopsies from controls (n = 20) and patients with acute (n = 10) or subacute (n = 10) UC. Pan-bacterial 16S rRNA copy number per millimeter square in samples from 6 locations across the large bowel was obtained by qPCR using Desulfovibrio desulfuricans as a reference strain. Copy numbers were correlated with the UC disease activity index (UCDAI) and the simple clinical colitis activity index (SCCAI). RESULTS: Bacterial colonization of CAMG was detectable in all groups. Copy numbers were significantly reduced in acute UC. In subacute colitis, there was a positive correlation between copy number and UCDAI and SCCAI in the ascending, transverse and sigmoid colon. CONCLUSIONS: This study describes a sensitive method of quantitatively assessing bacterial colonization of the colonic CAMG. A positive correlation was found between CAMG bacterial load and subacute disease activity in UC, whereas detectable bacterial load was reduced in acute UC.
    • Bacterial lipopolysaccharide promotes profibrotic activation of intestinal fibroblasts.

      Burke, J P; Cunningham, M F; Watson, R W G; Docherty, N G; Coffey, J C; O'Connell, P R; Department of Surgery, St Vincent's University Hospital, Dublin, Ireland. (2012-02-01)
      BACKGROUND: Fibroblasts play a critical role in intestinal wound healing. Lipopolysaccharide (LPS) is a cell wall component of commensal gut bacteria. The effects of LPS on intestinal fibroblast activation were characterized. METHODS: Expression of the LPS receptor, toll-like receptor (TLR) 4, was assessed in cultured primary human intestinal fibroblasts using flow cytometry and confocal microscopy. Fibroblasts were treated with LPS and/or transforming growth factor (TGF) beta1. Nuclear factor kappaB (NFkappaB) pathway activation was assessed by inhibitory kappaBalpha (IkappaBalpha) degradation and NFkappaB promoter activity. Fibroblast contractility was measured using a fibroblast-populated collagen lattice. Smad-7, a negative regulator of TGF-beta1 signalling, and connective tissue growth factor (CTGF) expression were assessed using reverse transcriptase-polymerase chain reaction and western blot. The NFkappaB pathway was inhibited by IkappaBalpha transfection. RESULTS: TLR-4 was present on the surface of intestinal fibroblasts. LPS treatment of fibroblasts induced IkappaBalpha degradation, enhanced NFkappaB promoter activity and increased collagen contraction. Pretreatment with LPS (before TGF-beta1) significantly increased CTGF production relative to treatment with TGF-beta1 alone. LPS reduced whereas TGF-beta1 increased smad-7 expression. Transfection with an IkappaBalpha plasmid enhanced basal smad-7 expression. CONCLUSION: Intestinal fibroblasts express TLR-4 and respond to LPS by activating NFkappaB and inducing collagen contraction. LPS acts in concert with TGF-beta1 to induce CTGF. LPS reduces the expression of the TGF-beta1 inhibitor, smad-7.
    • Blockade of Toll-like receptor 2 prevents spontaneous cytokine release from rheumatoid arthritis ex vivo synovial explant cultures.

      Ultaigh, Sinéad Nic An; Saber, Tajvur P; McCormick, Jennifer; Connolly, Mary; Dellacasagrande, Jerome; Keogh, Brian; McCormack, William; Reilly, Mary; O'Neill, Luke A; McGuirk, Peter; et al. (2011)
      The aim of this study was to examine the effect of blocking Toll-like receptor 2 (TLR2) in rheumatoid arthritis (RA) synovial cells.
    • CA 15-3: uses and limitation as a biomarker for breast cancer.

      Duffy, Michael J; Evoy, Denis; McDermott, Enda W; Department of Pathology and Laboratory Medicine, St Vincent's University, Hospital, Dublin 4, Ireland. Michael.J.Duffy@ucd.ie (2012-02-01)
      CA 15-3 which detects soluble forms of MUC-1 protein is the most widely used serum marker in patients with breast cancer. Its main use is for monitoring therapy in patients with metastatic disease. In monitoring therapy in this setting, CA 15-3 should not be used alone but measured in conjunction with diagnostic imaging, clinical history and physical examination. CA 15-3 is particularly valuable for treatment monitoring in patients that have disease that cannot be evaluated using existing radiological procedures. CA 15-3 may also be used in the postoperative surveillance of asymptomatic women who have undergone surgery for invasive breast cancer. In this setting, serial determination can provide median lead-times of 5-6 months in the early detection of recurrent/metastatic breast cancer. It is unclear however, whether administering systemic therapy based on this lead-time improves patient outcome. Consequently, expert panels disagree on the utility of regularly measuring CA 15-3 in the postoperative surveillance of asymptomatic women following a diagnosis of breast cancer. The main limitation of CA 15-3 as a marker for breast cancer is that serum levels are rarely increased in patients with early or localized disease.
    • Can delayed time to referral to a tertiary level urologist with an abnormal PSA level affect subsequent Gleason grade in the opportunistically screened population?

      O'Kelly, Fardod; Thomas, Arun; Murray, Denise; Galvin, David; Mulvin, David; Quinlan, David M; Department of Urological Surgery, St. Vincent's University Hospital, Elm Park, Dublin, Ireland. fokelly@rcsi.ie (2013-09)
      There is growing conflict in the literature describing the effect of delayed treatment on outcomes following radical prostatectomy. There is also evidence to suggest progression of low-risk prostate cancer to develop higher grades and volumes of prostate cancer during active surveillance. It is unknown as to what affect a delay in referral of those men with abnormal screened-PSA levels have on subsequent Gleason grade.
    • Can individualized weight monitoring using the HeartPhone algorithm improve sensitivity for clinical deterioration of heart failure?

      Ledwidge, Mark T; O'Hanlon, Rory; Lalor, Lorraine; Travers, Bronagh; Edwards, Nuala; Kelly, Deirdre; Voon, Victor; McDonald, Kenneth M; Heart Failure Unit, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland. mark@heartbeat-trust.org (2013-04)
      Previous studies have demonstrated poor sensitivity of guideline weight monitoring in predicting clinical deterioration of heart failure (HF). This study aimed to evaluate patterns of remotely transmitted daily weights in a high-risk HF population and also to compare guideline weight monitoring and an individualized weight monitoring algorithm.
    • Can we avoid surgery in elderly patients with renal masses by using the Charlson comorbidity index?

      O'Connor, Kevin M; Davis, Niall; Lennon, Gerry M; Quinlan, David M; Mulvin, David W; Department of Urology, St. Vincent's University Hospital, Dublin, Ireland., kevinoconnor@rcsi.ie (2012-02-01)
      OBJECTIVE To determine the safety of surveillance for localized contrast-enhancing renal masses in elderly patients whose comorbidities precluded invasive management; to provide an insight into the natural history of small enhancing renal masses; and to aid the clinician in identifying those patients who are most suitable for a non-interventional approach. PATIENTS AND METHODS We conducted a retrospective chart review of 26 consecutive patients (16 men and 10 women), who were followed for > or =1 year, with localized solid enhancing renal masses between 1998 and 2006. These patients were unfit or unwilling to undergo radical or partial nephrectomy. None had their tumours surgically removed. Study variables included age, presentation, tumour size, growth rate, Charlson comorbidity index (CMI) and available pathological data. RESULTS The mean (range) patient age was 78.14 (63-89) year, with a mean follow-up of 28.1 (12-72) months. The mean tumour size was 4.25 (2.5-8.7) cm at diagnosis. The tumour growth rate was 0.44 cm/year; among smaller masses (T1a) it was 0.15 cm/year, vs 0.64 cm/year in the larger masses (T1b and T2). The mean CMI was 2.96. There were 11 deaths overall; 10 patients died from unrelated illnesses. One death was directly attributable to metastatic renal cancer; this patient had an initial tumour diameter of 5.4 cm and a CMI of 6. All patients who died had a CMI of > or =3. CONCLUSIONS Elderly patients with small renal tumours (T1a) and comorbidity scores of > or =3 were more likely to die as a result of their comorbidities rather than the renal tumour. Surveillance of small renal masses appears to be a safe alternative in elderly patients who are poor surgical candidates, where the overall growth rate appears to be slow.
    • Can we reduce preventable heart failure readmissions in patients enrolled in a Disease Management Programme?

      Phelan, D; Smyth, L; Ryder, M; Murphy, N; O'Loughlin, C; Conlon, C; Ledwidge, M; McDonald, K; Heart Failure Unit, St Vincent's University Hospital, Elm Park, Dublin 4,, Ireland. (2012-02-01)
      BACKGROUND: Disease Management Programmes (DMPs) are successful in reducing hospital readmissions in heart failure (HF). However, there remain a number of patients enrolled in a DMP who are readmitted with HF. The primary aim of the study was to determine the proportion of preventable readmissions (PR). The secondary aim was to recognise patient characteristics which would identify certain patients at risk of having a PR. METHODS: A retrospective chart search was performed on patients readmitted over a 1-year period. RESULTS: 38.5% of readmissions were classified as PR. None of these patients made prior contact with the DMP. Admission levels of BNP, potassium, urea and creatinine were significantly lower in the PR group. CONCLUSION: DMP have proven benefits in reducing hospital readmission nonetheless a significant proportion of these readmissions are preventable. Further work is required to prospectively analyse why these patients fail to contact the DMP.
    • Canis Caveat (Beware of the Dog) - Septic Shock Due To Capnocytophaga Canimorsus Contracted From A Dog Bite

      O’Shaughnessy, SM; Broderick, L; Walsh, J; Schaffer, K; Westbrook, A; St. Vincent’s University Hospital (Irish Medical Journal, 2018-11)
      We describe the case of a 61-year-old immunocompetent male who developed septic shock and multiorgan failure due to Capnocytophaga canimorsus (C. canimorsus) bloodstream infection, sustained from a dog bite. Unusually, this patient developed acute liver failure and splenic infarction in addition to many of the better-known clinical sequelae of C. canimorsus infection.
    • Cardiac carcinoid: tricuspid delayed hyperenhancement on cardiac 64-slice multidetector CT and magnetic resonance imaging.

      Martos, R; Ridge, C; Quinn, M; Dodd, J; Department of Cardiology, St. Vincent's University Hospital, Dublin, Ireland., ramonmartos2003@yahoo.co.uk (2012-02-01)
      INTRODUCTION: Carcinoid heart disease is a rare condition in adults. Its diagnosis can be easily missed in a patient presenting to a primary care setting. We revised the advantages of using coronary multidetector computed tomography (MDCT) and cardiac magnetic resonance imaging (MRI) in diagnosing this condition. MATERIALS AND METHODS: We studied a 65-year-old patient with carcinoid heart disease and right heart failure using transthoracic Doppler-echocardiogram, cardiac MDCT and MRI. Cardiac echocardiogram revealed marked thickening and retraction of the tricuspid leaflets with dilated right atrium and ventricle. Cardiac MDCT and MRI demonstrated fixation and retraction of the tricuspid leaflets with delayed contrast hyperenhancement of the tricuspid annulus. CONCLUSION: This case demonstrates fascinating imaging findings of cardiac carcinoid disease and highlights the increasing utility of contrast-enhanced MRI and cardiac MDCT in the diagnosis of this interesting condition.
    • Cardiac tumors: optimal cardiac MR sequences and spectrum of imaging appearances.

      O'Donnell, David H; Abbara, Suhny; Chaithiraphan, Vithaya; Yared, Kibar; Killeen, Ronan P; Cury, Ricardo C; Dodd, Jonathan D; Cardiac CT and MRI Program, Department of Radiology and Cardiology, St. Vincent's, University Hospital, Elm Park, Dublin 4, Ireland. (2012-02-01)
      OBJECTIVE: This article reviews the optimal cardiac MRI sequences for and the spectrum of imaging appearances of cardiac tumors. CONCLUSION: Recent technologic advances in cardiac MRI have resulted in the rapid acquisition of images of the heart with high spatial and temporal resolution and excellent myocardial tissue characterization. Cardiac MRI provides optimal assessment of the location, functional characteristics, and soft-tissue features of cardiac tumors, allowing accurate differentiation of benign and malignant lesions.
    • Cardiovascular disease and risk factors in patients with psoriasis and psoriatic arthritis.

      Tobin, Anne-Marie; Veale, Douglas J; Fitzgerald, Oliver; Rogers, Sarah; Collins, Paul; O'Shea, Donal; Kirby, Brian; Department of Dermatology, St. Vincent's University Hospital, Elm Park, Dublin 4,, Ireland. tobin.annemarie@gmail.com (2012-02-01)
      OBJECTIVE: Patients with psoriasis and psoriatic arthritis (PsA) have an increased incidence of cardiovascular disease (CVD) and cardiovascular risk factors such as smoking, hypertension, and metabolic syndrome compared to the normal population. Patients with psoriasis and PsA may also have increased risk from nonconventional risk factors such as raised levels of homocysteine and excessive alcohol consumption. We conducted a comprehensive review of the literature on CVD and all cardiovascular risk factors in patients with psoriasis and PsA. METHODS: Data sources: All studies identified from a Medline (www.ncbi.nlm.nih.gov) search pertaining to CVD, individual risk factors in psoriasis, and PsA were included. Study selection: Studies included a healthy reference population, were published between 1975 and 2009, and were written in English. RESULTS: Our search yielded 14 studies that documented rates of CVD in patients with psoriasis and PsA compared to controls. Substantial evidence points to elevated risk of CVD in patients with psoriasis and PsA. CONCLUSION: It remains difficult to conclude if risk factors are caused by psoriasis or share a common pathogenesis. Physicians treating patients with psoriasis and PsA must be aware of all potential cardiovascular risk factors in their patients.
    • Cardiovascular disease in obstructive sleep apnoea syndrome: the role of intermittent hypoxia and inflammation.

      Garvey, J F; Taylor, C T; McNicholas, W T; Respiratory Sleep Disorders Unit, St. Vincent's University Hospital, Dublin,, Ireland. (2012-02-01)
      There is increasing evidence that intermittent hypoxia plays a role in the development of cardiovascular risk in obstructive sleep apnoea syndrome (OSAS) through the activation of inflammatory pathways. The development of translational models of intermittent hypoxia has allowed investigation of its role in the activation of inflammatory mechanisms and promotion of cardiovascular disease in OSAS. There are noticeable differences in the response to intermittent hypoxia between body tissues but the hypoxia-sensitive transcription factors hypoxia-inducible factor-1 and nuclear factor-kappaB appear to play a key role in mediating the inflammatory and cardiovascular consequences of OSAS. Expanding our understanding of these pathways, the cross-talk between them and the activation of inflammatory mechanisms by intermittent hypoxia in OSAS will provide new avenues of therapeutic opportunity for the disease.
    • Cardiovascular flashlight. Detection of cardiac tumour-surface thrombus: utilization of cardiac magnetic resonance imaging avascular tissue nulling sequence.

      O'Neill, Ailbhe; Ridge, Carole; Cury, Ricardo C; Quinn, Martin; Keane, David; Dodd, Jonathan D; Department of Radiology, St Vincent's University Hospital, Elm Park, Dublin 4,, Ireland. (2012-02-01)
    • Caring for cancer patients on non-specialist wards.

      Gill, Finola; Duffy, Anita; Oncology and Cancer Support Services, St. Vincent's University Hospital, Dublin. (2012-02-01)
      As cancer is the leading cause of death worldwide, every nurse will be required to care for patients with the condition at some point in his/her career. However, non-specialized oncology nurses are often ill-prepared to nurse patients suffering from cancer. This literature review aims to provide an overview of current trends and developments in cancer care nursing in an attempt to identify the range of previous research pertaining to caring for patients with cancer on non-specialist wards. The review finds that non-specialized cancer nurses report a lack of education and training with regard to cancer care and cancer treatments, which acts as a barrier to providing quality nursing care. Emotional and communication issues with patients and their families can also cause non-specialist nurses significant distress. International research has shown that specialist oncology nurses make a considerable difference to physical and psychosocial patient care. It is therefore paramount that non-speciality nurses' educational needs are met to develop clinical competence and to provide supportive holistic care for both patients and their families.
    • A case of "refractory" lupus erythematosus profundus responsive to rituximab [case report].

      McArdle, Adrian; Baker, Joshua F; St Vincent's University Hospital, Elm Park, Dublin 4, Ireland. (2012-02-01)
      Lupus erythematosus profundus is a rare complication of systemic lupus erythematosus characterized by the presence of deep, tender subcutaneous nodules. A 22-year-old African-American female with extensive lupus profundus resistant to conventional therapies was treated with two infusions of the anti-CD20 monoclonal antibody, rituximab, at a dosage of 1,000 mg each. The patient demonstrated a remarkable clinical response as indicated by the disappearance of the nodules. B-cell depletion therapy with rituximab used alone or in combination with other therapies may be a viable option in patients with lupus profundus refractory to current therapies.
    • A case-control study of visual acuity in onychocryptosis.

      Hogan, Aisling M; Broe, David; Stunnell, Helen; Bobart, Andra; Ridgway, Paul F; St. Vincent's University Hospital, Adelaide & Meath Hospital, incorporating the, National Children's Hospital, Dublin, Ireland. (2012-02-01)
      BACKGROUND: There are many theories surrounding the etiology of ingrown toenails (IGTN). Few factors have been formally assessed, but it is widely accepted that a poor nail cutting technique has a causative role. AIM: To investigate the hypothesis that decreased visual acuity may lead to inadequate nail cutting and the formation of IGTN. METHODS: A prospective case-control study was performed. Near and distance visual acuity were tested on a population with IGTN (n = 19) and compared with that of an age- and sex-matched control cohort (n = 24) who underwent epidermal cyst excision in the same tertiary referral center. Comparisons of visual acuity were made between groups by Mann-Whitney U-test. Differences were taken to be significant if P < 0.05. Institutional Review Board approval was sought and granted. RESULTS: No significant difference in visual acuity (near or distance) was demonstrated between patients with IGTN and the control group (P = 0.33). CONCLUSION: Visual acuity does not appear to play a significant role in the development of IGTN.