• An Under-Recognised Cause of Iatrogenic, Severe Metabolic Acidosis

      Spring, A; Owens, R; Fratita, M; O’Dwyer, M (Irish Medical Journal, 2019-04)
      Pyroglutamic acidosis is an uncommonly diagnosed but important cause of a high anion gap metabolic acidosis. Our case report concerns an elderly male admitted to the Intensive Care Unit (ICU) following the acute onset of coma which developed during treatment of a prosthetic joint infection. A diagnosis of pyroglutamic acidosis was ultimately made and later confirmed with laboratory testing. Blood gas analysis revealed a profound high anion gap metabolic acidosis.
    • An unusual cause of granulomatous dermatitis and panniculitis.

      Hackett, C B; Maguire, A; Heffernan, E; Sheahan, K; Collins, P; Department of Dermatology, St Vincent's University Hospital, Elm Park, Dublin, Ireland. c.hackett@svuh.ie (2012-01)
    • An unusual cause of pain post ankle arthrodesis in patients with rheumatoid arthritis.

      Burke, Neil G; Moran, Cathal; Din, Robert; Walsh, James; Quinlan, William R; Department of Orthopaedic Surgery, St Vincent's University Hospital, Dublin,, Ireland. nei1burke@yahoo.co.uk (2012-02-01)
      Rheumatoid arthritis is an autoimmune disease which frequently affects the ankle and foot. End stage ankle arthritis from rheumatic disease is commonly managed by the established practice of ankle arthrodesis. Among the adverse sequelae causing pain following this surgery is infection, pseudo-arthrosis and non-union. Stress fracture of the distal third is a recognised but unusual cause of pain of tibia following ankle arthrodesis. The authors' present three patients with rheumatoid arthritis who sustained a stress fracture of the distal tibia following arthrodesis, and discuss the contributing factors and highlight the need for orthopaedic surgeons to be suspicious of this complication post surgery.
    • An unusual cause of spontaneous pneumothorax: the Mounier-Kuhn syndrome.

      Kent, B D; Sulaiman, I; Akasheh, N B; Nadarajan, P; Moloney, E; Lane, S J; Department of Respiratory Medicine, Pulmonary and Sleep Disorders Unit, St Vincent's University Hospital, Dublin 4. briankent@physicians.ie (2011-05)
      We present the case of a 54-year old woman referred to our service with an unusual presentation of an under-diagnosed condition. A life-long non-smoker, she was referred to respiratory services by our emergency department with a left sided pneumothorax, progressive dyspnoea on exertion, and recurrent chest infections. Subsequent investigation yielded findings consistent with Mounier-Kuhn syndrome (Tracheobronchomegaly), a condition characterised by marked dilatation of the proximal airways, recurrent chest infection, and consequent emphysema and bronchiectasis. Although rarely diagnosed, some degree of Mounier-Kuhn syndrome may occur in up to 1 in 500 adults.
    • An unusual cause of spontaneous pneumothorax: the Mounier-Kuhn syndrome.

      Kent, B D; Sulaiman, I; Akasheh, N B; Nadarajan, P; Moloney, E; Lane, S J; Department of Respiratory Medicine, Pulmonary and Sleep Disorders Unit, St, Vincent's University Hospital, Dublin 4. briankent@physicians.ie (2012-02-01)
      We present the case of a 54-year old woman referred to our service with an unusual presentation of an under-diagnosed condition. A life-long non-smoker, she was referred to respiratory services by our emergency department with a left sided pneumothorax, progressive dyspnoea on exertion, and recurrent chest infections. Subsequent investigation yielded findings consistent with Mounier-Kuhn syndrome (Tracheobronchomegaly), a condition characterised by marked dilatation of the proximal airways, recurrent chest infection, and consequent emphysema and bronchiectasis. Although rarely diagnosed, some degree of Mounier-Kuhn syndrome may occur in up to 1 in 500 adults.
    • Use of a care bundle in the emergency department for acute exacerbations of chronic obstructive pulmonary disease: a feasibility study.

      McCarthy, Cormac; Brennan, John R; Brown, Lindsay; Donaghy, Deirdre; Jones, Patricia; Whelan, Rory; McCormack, Niamh; Callanan, Ian; Ryan, John; McDonnell, Timothy J (2013)
      Aim: To determine the efficacy and usefulness of a chronic obstructive pulmonary disease (COPD) care bundle designed for the initial management of acute exacerbations of COPD and to assess whether it improves quality of care and provides better outcomes. Introduction: The level of care provided in the emergency department (ED) for COPD exacerbations varies greatly, and there is a need for a more systematic, consistent, evidence-based quality improvement approach to improve outcomes and costs. Methods: A prospective before and after study was carried out in a university teaching hospital. Fifty consecutive patients were identified in the ED with COPD exacerbations and their management was reviewed. Following the education of ED staff and the implementation of a COPD care bundle, the outcome for 51 consecutive patients was analyzed. This COPD care bundle consisted of ten elements considered essential to the management of COPD exacerbations and was scored 0–10 according to the number of items on the checklist implemented correctly. Results: Following implementation, the mean bundle score out of 10 improved from 4.6 to 7 (P,0.001). There was a significant decrease in the unnecessary use of intravenous corticosteroids from 60% to 32% (P=0.003) and also a marked improvement in the use of oxygen therapy, with appropriate treatment increasing from 76% to 96% (P=0.003). Prophylaxis for venous thromboembolism also improved from 54% to 73% (P=0.054). The 30-day readmission rate did not significantly improve. Conclusion: The use of a bundle improves the delivery of care for COPD exacerbations in the ED. There is more appropriate use of therapeutic interventions, especially oxygen therapy and intravenous corticosteroids.
    • Use of an electrothermal bipolar sealing device in ligation of major mesenteric vessels during laparoscopic colorectal resection.

      Martin, S T; Heeney, A; Pierce, C; O'Connell, P R; Hyland, J M; Winter, Desmond C; Department of Colorectal Surgery, St. Vincent's University Hospital, Elm Park,, Dublin 4, Ireland. (2012-02-01)
      BACKGROUND: A variety of approaches are available for division of major vascular structures during laparoscopic colorectal resection. Ultrasonic coagulating shears (UCS), vascular staplers, plastic or titanium clips and electrothermal bipolar vessel sealing (EBVS) are currently available. We report our experience with an EBVS device, LigaSure (Covidien AG), used in division of the ileocolic, middle colic and inferior mesenteric arteries during laparoscopic colorectal resection. METHODS: We report the immediate outcome of 802 consecutive unselected patients who underwent elective laparoscopic colorectal cancer resection performed with use of the LigaSure (5 and 10 mm) at our institution over a 5-year period. Operative procedures included right hemicolectomy (n = 180), left hemicolectomy (n = 96), sigmoid colectomy (n = 347) and anterior resection (n = 179). Data were collected from a prospectively maintained cancer database and operative records. The procedures were performed primarily by three consultant surgeons with an interest in laparoscopic colorectal resection. RESULTS: Of 802 cases in which the LigaSure device was employed to divide major vascular structures, immediate effective vessel sealing was achieved in 99.8% (n = 800). Two patients experienced related adverse events both following division of the inferior mesenteric artery with a 5 mm LigaSure. Both patients had immediate uncontrolled haemorrhage that required laparotomy. CONCLUSIONS: Use of the LigaSure device to seal and divide the major mesenteric vessels during laparoscopic colorectal resection is very effective, with a high success rate of 99.8%. Caution should be exercised in elderly atherosclerotic patients, particularly when using the 5-mm LigaSure device.
    • The use of bone morphogenetic protein 7 in fracture non-unions.

      O'hEireamhoin, Sven; Quinlan, John F; Rourke, Kieran O; Department of Trauma and Orthopaedics, St. Vincent's University Hospital, Elm Park, Dublin, Ireland. svenerwin@hotmail.com (2011-02)
      To assess the rate of clinical and radiological union with the use of bone morphogenetic protein 7 (BMP-7) in a range of fractures.
    • Use of faecal markers in screening for colorectal neoplasia: a European group on tumor markers position paper.

      Duffy, Michael J; van Rossum, Leo G M; van Turenhout, Sietze T; Malminiemi, Outi; Sturgeon, Catherine; Lamerz, Rolf; Nicolini, Andrea; Haglund, Caj; Holubec, Lubos; Fraser, Callum G; et al. (2012-02-01)
      Several randomized controlled trials have shown that population-based screening using faecal occult blood testing (FOBT) can reduce mortality from colorectal neoplasia. Based on this evidence, a number of countries have introduced screening for colorectal cancer (CRC) and high-risk adenoma and many others are considering its introduction. The aim of this article is to critically review the current status of faecal markers as population-based screening tests for these neoplasia. Most of the available faecal tests involve the measurement of either occult blood or a panel of DNA markers. Occult blood may be measured using either the guaiac faecal occult blood test (gFOBT) or a faecal immunochemical test (iFOBT). Although iFOBT may require a greater initial investment, they have several advantages over gFOBT, including greater analytical sensitivity and specificity. Their use results in improved clinical performance and higher uptake rates. Importantly for population screening, some of the iFOBTs can be automated and provide an adjustable cutoff for faecal haemoglobin concentration. However, samples for iFOBT, may be less stable after collection than for gFOBT. For new centres undertaking FOBT for colorectal neoplasia, the European Group on Tumour Markers recommends use of a quantitative iFOBT with an adjustable cutoff point and high throughput analysis. All participants with positive FOBT results should be offered colonoscopy. The panel recommends further research into increasing the stability of iFOBT and the development of improved and affordable DNA and proteomic-based tests, which reduce current false negative rates, simplify sample transport and enable automated analysis.
    • Use of molecular markers for predicting therapy response in cancer patients.

      Duffy, Michael J; O'Donovan, Norma; Crown, John; Department of Pathology and Laboratory Medicine, St. Vincent's University, Hospital, Dublin, Ireland. Michael.J.Duffy@ucd.ie (2012-02-01)
      Predictive markers are factors that are associated with upfront response or resistance to a particular therapy. Predictive markers are important in oncology as tumors of the same tissue of origin vary widely in their response to most available systemic therapies. Currently recommended oncological predictive markers include both estrogen and progesterone receptors for identifying patients with breast cancers likely to benefit from hormone therapy, HER-2 for the identification of breast cancer patients likely to benefit from trastuzumab, specific K-RAS mutations for the identification of patients with advanced colorectal cancer unlikely to benefit from either cetuximab or panitumumab and specific EGFR mutations for selecting patients with advanced non-small-cell lung cancer for treatment with tyrosine kinase inhibitors such as gefitinib and erlotinib. The availability of predictive markers should increase drug efficacy and decrease toxicity, thus leading to a more personalized approach to cancer treatment.
    • Using atypical symptoms and red flags to identify non-demyelinating disease.

      Kelly, Siobhan B; Chaila, Elijah; Kinsella, Katie; Duggan, Marguerite; Walsh, Cathal; Tubridy, Niall; Hutchinson, Michael; Department of Neurology, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland. (2012-01)
      Red flags and atypical symptoms have been described as being useful in suggesting alternative diagnoses to multiple sclerosis (MS) and clinically isolated syndrome (CIS); however, their diagnostic utility has not been assessed. The aim of this study was to establish the predictive value of red flags and the typicality/atypicality of symptoms at presentation in relation to the final diagnosis of patients referred with suspected MS.
    • Vaginal haemangioendothelioma: an unusual tumour.

      Mohan, H; Shireen, R; Hayes, B; Canney, A; Mooney, E E; Murphy, J; Department of Gynaecology, St Vincent's University Hospital, Elm Park, Dublin 4, , Ireland. eibhlinmohan@hotmail.com (2012-02-01)
      Vaginal tumours are uncommon and this is a particularly rare case of a vaginal haemangioendothelioma in a 38-year-old woman. Initial presentation consisted of symptoms similar to uterovaginal prolapse with "something coming down". Examination under anaesthesia demonstrated a necrotic anterior vaginal wall tumour. Histology of the lesion revealed a haemangioendothelioma which had some features of haemangiopericytoma. While the natural history of vaginal haemangioendothelioma is uncertain, as a group, they have a propensity for local recurrence. To our knowledge this is the third reported case of a vaginal haemangioendothelioma. Management of this tumour is challenging given the paucity of literature on this tumour. There is a need to add rare tumours to our "knowledge bank" to guide management of these unusual tumours.
    • The value of appropriate assessment prior to specialist referral in men with prostatic symptoms.

      Quinlan, M R; O'Daly, B J; O'Brien, M F; Gardner, S; Lennon, G; Mulvin, D W; Quinlan, D M; Department of Urology, St Vincent's University Hospital, Dublin 4, Republic of, Ireland. lynagh@hotmail.com (2012-02-01)
      BACKGROUND: Referrals to Urology OPD of men with a likely diagnosis of BPH are common. AIMS: To review referrals to OPD of men with lower urinary tract symptoms (LUTS) to establish how many could have been managed without specialist assessment. METHODS: We reviewed records of 200 male patients referred to OPD with LUTS. We assessed whether the referral source had performed digital rectal examination (DRE), International Prostate Symptom Score (IPSS), Bother Score or PSA level. RESULTS: 74% of patients were referred by GPs. In 31.5% of cases DRE was performed prior to referral. One GP had completed an IPSS, none a Bother Score. 96% had a PSA checked before OPD. Ultimately, 88.5% of our patients were diagnosed with BPH. CONCLUSIONS: With better pre-assessment in the form of DRE, IPSS and Bother Score, allied to a PSA check, many patients with LUTS could be managed in a primary care setting.
    • The value of level III clearance in patients with axillary and sentinel node positive breast cancer.

      Dillon, Mary F; Advani, Vriti; Masterson, Catherine; O'Loughlin, Christina; Quinn, Cecily M; O'Higgins, Niall; Evoy, Denis; McDermott, Enda W; Department of Surgery, St Vincent's University Hospital, Elm Park, Dublin,, Ireland. maryfdillon@hotmail.com (2012-02-01)
      BACKGROUND: The value of level III axillary clearance is contentious, with great variance worldwide in the extent and levels of clearance performed. OBJECTIVE: To determine rates of level III positivity in patients undergoing level I-III axillary clearance, and identify which patients are at highest risk of involved level III nodes. METHODS: From a database of 2850 patients derived from symptomatic and population-based screening service, 1179 patients who underwent level I-III clearance between the years 1999-2007 were identified. The pathology, surgical details, and prior sentinel nodes biopsies of patients were recorded. RESULTS: Eleven hundred seventy nine patients had level I-III axillary clearance. Of the patients, 63% (n = 747) were node positive. Of patients with node positive disease, 23% (n = 168) were level II positive and 19% (n = 141) were level III positive. Two hundred fifty patients had positive sentinel node biopsies prior to axillary clearance. Of these, 12% (n = 30) and 9% (n = 22) were level II and level III positive, respectively. On multivariate analysis, factors predictive of level III involvement in patients with node positive disease were tumor size (P < 0.001, OR = 1.36; 95% CI: 1.2-1.5), invasive lobular disease (P < 0.001, OR = 3.6; 95% CI: 1.9-6.95), extranodal extension (P < 0.001, OR = 0.27; 95% CI: 0.18-0.4), and lymphovascular invasion (P = 0.04, OR = 0.58; 95% CI: 0.35-1). Lobular invasive disease (P = 0.049, OR = 4.1; 95% CI: 1-16.8), extranodal spread (P = 0.003, OR = 0.18; 95% CI: 0.06-0.57), and having more than one positive sentinel node (P = 0.009, OR = 4.9; 95% CI: 1.5-16.1) were predictive of level III involvement in patients with sentinel node positive disease. CONCLUSION: Level III clearance has a selective but definite role to play in patients who have node positive breast carcinoma. Pathological characteristics of the primary tumor are of particular use in identifying those who are at various risk of level III nodal involvement.
    • Varicella-zoster virus immunity in dermatological patients on systemic immunosuppressant treatment.

      Hackett, C B; Wall, D; Fitzgerald, S F; Rogers, S; Kirby, B; Department of Dermatology, St Vincent's University Hospital, Elm Park, Dublin 4, , Ireland. c.hackett@svuh.ie (2012-02-01)
      BACKGROUND: Primary varicella infection is caused by varicella-zoster virus (VZV). It is a common childhood infection, which is usually benign but can occasionally cause morbidity and mortality. In immunosuppressed adults, atypical presentation and disseminated disease can occur with significant morbidity and mortality. A VZV vaccine is available. OBJECTIVES: This study was designed to measure the prevalence of immunity to VZV and to determine the predictive value of a self-reported history of varicella infection in a population of dermatological patients receiving systemic immunosuppressant therapy. We sought to assess the need for routine serological testing for varicella-zoster immunity in this cohort. METHODS: Serological testing for VZV immunity was done on 228 patients receiving systemic immunosuppressive treatment for a dermatological condition. Information regarding a history of previous primary VZV infection was obtained from each patient. RESULTS: Two hundred and twenty-eight patients had VZV serology performed. The mean age of the patients was 49.6 years. The prevalence of VZV seropositivity in this cohort was 98.7%. One hundred and two patients (44.7%) reported having a definite history of primary VZV. The sensitivity of a self-reported history of VZV infection was 45.3% with a specificity of 100%. The positive and negative predictive values of a self-reported history of VZV for serologically confirmed immunity were 100% and 2.3%, respectively. CONCLUSIONS: The prevalence of VZV IgG antibodies in our cohort of Irish dermatology patients receiving immunosuppressive therapy is 98.7%. A recalled history of varicella infection is a good predictor of serological immunity. This study has shown that there are VZV-susceptible individuals within our cohort. These patients did not have a clear history of previous infection. We recommend serological testing of patients without a clear history of infection prior to the commencement of immunosuppressive therapy and vaccination of patients with negative serology.
    • Vertroplasty for spinal fracture.

      O'Sullivan, M; Ryan, J (2011-05)
    • Very late bare-metal stent thrombosis, rare but stormy!

      Ali, Mohammed; McDonald, Ken; Department of Cardiology, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland. mtali100@gmail.com (2011-08)
      Recurrent in-stent thrombosis is rarely reported, with catastrophic clinical consequences of either acute coronary syndrome or death. We present a case of recurrent in-stent thrombosis with its outcome and a concise literature review.
    • Video-assisted lobectomy for endobronchial leiomyoma.

      Bartosik, Waldemar; Crowther, Stephen; Narski, Maciej; Fabre, Aurélie; Department of Thoracic Surgery, Saint Vincent's University Hospital, Elm Park, Dublin 4, Ireland. w_bartosik@o2.pl (2011-02)
      Endobronchial leiomyomas are rare tumours arising from the smooth muscle on the bronchial tree. We describe a patient with a six-month history of chest infections, who was treated surgically with a video-assisted thoracic surgery (VATS) lobectomy. The pathology revealed an endobronchial leiomyoma that coexisted with postobstructive pulmonary non-necrotising granulomas.
    • Vitamin D nutrient intake for all life stages

      McKenna, M; McCarthy, R; Kilbane, M (Irish Medical Journal, 2011-05-25)
    • A Web-Based Electronic Neurology Referral System: A Solution for anOverburdened Healthcare System

      Williams, L; O’Riordan, S; McGuigan, C; Hutchinson, M; Tubridy, N (Irish Medical Journal (IMJ), 2012-10)