• Antibiotic prophylaxis for transrectal ultrasound biopsy of the prostate in Ireland.

      Smyth, L G; Mulvin, D W; Department of Urology, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland. elizabethsmyth@rcsi.ie (2012-03)
      Prostate cancer is the most common solid cancer affecting men in Ireland. Transrectal ultrasound (TRUS) biopsies of the prostate are routinely performed to diagnose prostate cancer. They are, in general, a safe procedure but are associated with a significant risk of infective complications ranging from fever, urinary tract infection to severe urosepsis. At present, there are no recommended national guidelines on the use of antibiotic prophylaxis to minimise the risk of infective complications post-TRUS biopsy.
    • Aortic plaque rupture in the setting of acute lower limb ischemia.

      O'Donnell, David H; Moloney, Michael A; Killeen, Ronan P; Sheehan, Stephen; Brophy, David P; Department of Radiology, St Vincent's University Hospital, Dublin, Ireland. (2012-02-01)
      Acute aortic plaque rupture is an uncommon cause of acute lower limb ischemia. The authors report sequence computed tomographic imaging of a distal aortic plaque rupture in a young man with bilateral lower limb complications. Clinical awareness, prompt recognition and imaging, and appropriate treatment of this uncommon condition are necessary to improve patient outcomes.
    • Application of the GRAPPA psoriatic arthritis treatment recommendations in clinical practice.

      Mumtaz, Aizad; FitzGerald, Oliver; Bone and Joint Unit, Dublin Academic Health Care, St Vincent's University, Hospital, Elm Park, Dublin 4, Ireland. (2012-02-01)
      Psoriatic disease presents with a complex array of clinical features, including peripheral synovitis and skin psoriasis, but there is also variable involvement of the nail, dactylitis, enthesitis, and spinal disease. Composite assessment of disease activity and response taking into account the impact of the disease as a whole on an individual's health and quality of life is of vital importance. Following an extensive literature review, discussions, and consensus, the Group for Research in Psoriasis and Psoriatic Arthritis (GRAPPA) published guidelines to help clinicians make treatment decisions. The utility of these guidelines in routine clinical practice is further enhanced by incorporating them into a Composite Psoriatic Disease Activity Index (CPDAI). The potential application of the CPDAI in typical psoriatic disease patients is presented and discussed. Validation and possible modification of a composite disease activity and responder index is currently being undertaken by GRAPPA.
    • Are beta2-agonists responsible for increased mortality in heart failure?

      Bermingham, Margaret; O'Callaghan, Eleanor; Dawkins, Ian; Miwa, Saki; Samsudin, Shazzarina; McDonald, Kenneth; Ledwidge, Mark; Heart Failure Unit, St Vincent's University Hospital, Elm Park, Dublin 4,, Ireland. (2012-02-01)
      AIMS: Previous large-scale, retrospective studies have shown increased mortality in heart failure (HF) patients using beta2-agonists (B2As). We further examined the relationship between B2A use and mortality in a well-characterized population by adjusting for natriuretic peptide levels as a measure of HF severity. METHODS AND RESULTS: This was a retrospective cohort study of patients attending an HF Disease Management Programme with mean follow-up of 2.9 +/- 2.4 years. Chart review confirmed B2A use, dose and duration of use, and documented pulmonary function evaluation. The primary endpoint was the effect of B2A use compared with no B2A use on mortality using unadjusted and adjusted Kaplan-Meier survival curves. Data were available for 1294 patients (age 70.6 +/- 11.5 years) of whom 64% were male and 22.2% were taking B2As. beta2-Agonist users were older, more likely to be male, to have smoked, to have chronic obstructive pulmonary disease (COPD) and asthma, and less likely to take beta-blockers. Multivariable associates of mortality included: B-type natriuretic peptide (BNP), coronary artery disease, age, and beta-blocker use. Unadjusted mortality rates for B2A users were found to be significantly higher than non-B2A users [hazard ratio (HR) 1.304, 95% confidence interval (CI) 1.030-1.652, P= 0.028]. However, when adjusted for age, sex, medication, co-morbidity, smoking, COPD, and BNP differences, overall mortality rates were similar [HR 1.043, 95% CI (0.771-1.412), P= 0.783]. CONCLUSION: Unlike previous reports, this retrospective evaluation of B2A therapy in HF patients shows no relationship with long-term mortality when adjusted for population differences including BNP. Large, prospective studies are required to define the risk/benefit ratio of B2As in patients with heart failure.
    • Are natural killer cells protecting the metabolically healthy obese patient?

      Lynch, Lydia A; O'Connell, Jean M; Kwasnik, Anna K; Cawood, Thomas J; O'Farrelly, Cliona; O'Shea, Donal B; Department of Obesity and Immunology, St. Vincent's University Hospital, Dublin, , Ireland. Lydia.lynch@ucd.ie (2012-02-01)
      With the emerging obesity pandemic, identifying those who appear to be protected from adverse consequences such as type 2 diabetes and certain malignancies will become important. We propose that the circulating immune system plays a role in the development of these comorbidities. Clinical data and blood samples were collected from 52 patients with severe obesity attending a hospital weight-management clinic and 11 lean healthy controls. Patients were classified into metabolically "healthy obese" (n = 26; mean age 42.6 years, mean BMI 46.8 kg/m(2)) or "unhealthy obese" (n = 26; mean age 45 years, mean BMI 47.5 kg/m(2)) groups, based upon standard cutoff points for blood pressure, lipid profile, and fasting glucose. Circulating lymphoid populations and phenotypes were assessed by flow cytometry. Obese patients had significantly less circulating natural killer (NK) and cytotoxic T lymphocytes (CTL) compared to lean controls. There were significantly higher levels of NK cells and CTLs in the healthy obese group compared to the unhealthy obese group (NK: 11.7% vs. 6.5%, P < 0.0001, CD8 13.4% vs. 9.3%, P = 0.04), independent of age and BMI and these NK cells were also less activated in the healthy compared to the unhealthy group (CD69, 4.1% vs. 11.8%, P = 0.03). This is the first time that quantitative differences in the circulating immune system of obese patients with similar BMI but different metabolic profiles have been described. The significantly higher levels of CTLs and NK cells, which express fewer inhibitory molecules, could protect against malignancy, infection, and metabolic disease seen in obesity.
    • Artificial hydroureteronephrosis to facilitate MR urography during pregnancy.

      Connolly, S S; Browne, L P; Collins, C D; Lennon, G M; Department of Urology, St Vincent's University Hospital, University College, Dublin, Dublin 4, Ireland. steconnolly@rcsi.ie (2012-02-01)
      INTRODUCTION: Insertion of a percutaneous nephrostomy (PCN) catheter decompresses the upper urinary tract, thereby removing the hydroureteronephrosis upon which magnetic resonance (MR) urography is dependent for diagnosing the precise level and cause of ureteric obstruction. METHOD: We present the case of a young woman who required PCN insertion during pregnancy. RESULT: Only when unenhanced T2-weighted MR urography was repeated after the creation of an artificial hydronephrosis by an injection of sterile saline via the PCN catheter was the diagnosis of stone in the mid-ureter later made possible. CONCLUSION: This case highlights an easy solution to a limitation with the use of MR urography during pregnancy, when a physiological hydroureteronephrosis has been relieved by the insertion of a PCN catheter.
    • Aspirin versus warfarin in atrial fibrillation: decision analysis may help patients' choice.

      Romero-Ortuno, Roman; O'Shea, Diarmuid; St Vincent's University Hospital, Department of Medicine for the Elderly, Elm Park, Dublin 4, Ireland. romeror@tcd.ie (2012-03)
      the primary prevention of ischaemic stroke in chronic non-valvular atrial fibrillation (AF) typically involves consideration of aspirin or warfarin. CHA(2)DS(2)-VASc estimates annual stroke rates for untreated AF patients, which are reduced by 60% with warfarin and by 20% with aspirin. HAS-BLED estimates annual rates of major bleeding on warfarin. The latter risk with aspirin is 0.5-1.2% per year.
    • Association between vitamin D status and physical function in the severely obese.

      Ahern, T; Khattak, A; O'Malley, E; Dunlevy, C; Kilbane, M; Woods, C; McKenna, M J; O'Shea, D; Weight Management Service (T.A., A.K., E.O., C.D., C.W., D.O.), St Columcille's Hospital, Loughlinstown, County Dublin, Ireland; Obesity Research Group, Education and Research Centre (T.A., A.K., C.W., D.O.), Department of Endocrinology (T.A., A.K., C.W., M.J.M., D.O.), and Metabolism Laboratory (M.K., M.J.M.), St Vincent's University Hospital, Elm Park, Dublin 4, Ireland. (2014-07)
      Mortality is 85% higher in severely obese subjects (body mass index [BMI] > 40 kg/m(2)) than in subjects with a healthy BMI; poor physical function may be contributory. Hypovitaminosis D is common in obese subjects and is associated with physical dysfunction in the elderly.
    • Association of artificial turf and concussion in competitive contact sports: a systematic review and meta-analysis.

      O' Leary, Frank; Acampora, Nic; Hand, Fiona; O' Donovan, James (2020-05-26)
      Objective: To determine the incidence of head injuries and concussion in contact sports, comparing natural grass with artificial turf surfaces. Design: Systematic review and meta-analysis via the RevMan V.5.3 software. Eligibility criteria for selecting studies: All studies describing competitive contact sports played on both natural grass and artificial turf. The primary outcome measured was occurrence of head injury and concussion. Data sources: The databases include PubMed, Embase, Cochrane, Medline and Sport Discus. The last search took place on 23 May 2019. The Newcastle-Ottawa Quality Assessment Scale evaluated the methodological quality of the selected studies with a funnel plot designed to determine publication bias. Study screening and data extraction were performed by two independent reviewers. Results: Initial screening generated 42 publications, with 12 meeting criteria for inclusion. Eight studies described concussion only. The rate ratio (RR) of head injury and concussion was less on artificial turf compared with natural grass (RR=0.89, 95% CI 0.77 to 1.04) as was the rate ratio of concussion only (RR=0.72, 95% CI 0.58 to 0.89). Conclusion: Analysis of published data demonstrates a decreased incidence of head injury and concussion when contact sports are played on artificial turf. This difference was most marked for sports such as rugby and American football. However, artificial turf has no association with the incidence of head injury or concussion while playing soccer. Keywords: concussion; contact sports; environment; head; injuries.
    • Association of oesophageal hypertension with Bradycardia Mediated Deglutition Syncope

      Lim, RY; Mulcahy, H; Keane, D (Irish Medical Journal, 2015-12)
      Swallow syncope is a rare form of situational syncope. We report a case of swallow syncope with invasive confirmation of esophageal hypertension (spasm) and invasive confirmation of a bradycardia mechanism. Awareness of this uncommon disorder is important as a treatable cause of syncope.
    • Association of synovial tissue polyfunctional T-cells with DAPSA in psoriatic arthritis.

      Wade, Sarah M; Canavan, Mary; McGarry, Trudy; Low, Candice; Wade, Siobhan C; Mullan, Ronan H; Veale, Douglas J; Fearon, Ursula (2019-01-09)
      PsA synovial tissue infiltrating CD4+ T-cells expressed higher levels of interleukin (IL)-17A, interferon gamma (IFN-γ), GM-CSF and CD161, with parallel enrichment of Th1, Th17 and exTh17 T-helper subsets (all p<0.05). Interestingly, a significant proportion of synovial T-cell subsets were triple-positive for GM-CSF, tumour necrosis factor (-TNF), -IL-17 or IFN-γ compared with matched blood (all p<0.05). Importantly, frequencies of polyfunctional T-cells correlated with DAPSA: Th1-GM-CSF+/TNF+/IFN-γ+ (r=0.7, p<0.01), Th17-GM-CSF+/TNF+/IL-17+ (r=0.6, p<0.057) and exTh17-GM-CSF+/TNF+/IFN-γ+ (r=0.7, p=0.0096), with no associations observed for single cytokine-producing T-cells. Following ex vivo culture of PsA synovial tissue cell suspensions, polyfunctional GM-CSF+TNFα+IL-17A+ or/IFN-γ+-producing T-cells (p<0.05), but not single cytokine-producing T-cells, were inhibited with a PDE4 inhibitor. Conclusion: These data demonstrate enrichment of polyfunctional T-cells in PsA synovial tissue which were strongly associated with DAPSA and ex vivo therapeutic response.
    • Atypical melanocytic naevi following melanotan´fi injection

      C Reid; T Fitzgerald; A Fabre (Irish Medical Journal, 2013-05)
    • Audit of an inpatient liaison psychiatry consultation service.

      Lyne, John; Hill, Michelle; Burke, Patricia; Ryan, Martina; St Vincent's University Hospital, Dublin, Ireland. johnlyne@mail.com (2012-02-01)
      PURPOSE: The purpose of this paper is to examine an audit that was performed of all patients referred to a liaison psychiatry inpatient consultation service which sought to establish a baseline for demographics, type of referral, and management of referrals, with a view to introducing improved evidence-based treatments. It also aims to examine timeliness of response to referrals benchmarked against published standards. DESIGN/METHODOLOGY/APPROACH: All inpatient referrals to a liaison psychiatry service were recorded over a six-month period, including demographics, diagnosis, management and timeliness of response to referrals. The data were retrospectively analysed and compared against international standards. FINDINGS: A total of 172 referrals were received in the six months. Commonest referral reasons included assessments regarding depressive disorders (23.8 per cent), delirium/other cognitive disorders (19.2 per cent), alcohol-related disorders (18.6 per cent), anxiety disorders (14.5 per cent), and risk management (12.2 per cent). Evidence-based practices were not utilised effectively for a number of different types of presentations. A total of 40.1 per cent of referrals were seen on the same day, 75.4 per cent by the end of the next day, and 93.4 per cent by the end of the following day. PRACTICAL IMPLICATIONS: Use of a hospital protocol for management of delirium may improve outcomes for these patients. Evidence-based techniques, such as brief intervention therapies, may be beneficial for referrals involving alcohol dependence. Referrals were seen reasonably quickly, but there is room for improvement when compared with published standards. ORIGINALITY/VALUE: This paper provides valuable information for those involved in management of liaison psychiatry consultation services, providing ideas for development and implementation of evidence based practices.
    • An audit of hospital based outpatient infusions and a pilot program of community-based monoclonal antibody infusions.

      Doran, J-P; Alraqi, S; Callanan, I; FitzGerald, O; Bresnihan, B; Veale, D J; Department of Rheumatology, St Vincent's University Hospital, Dublin, Ireland., johnpauldoran@gmail.com (2012-02-01)
      INTRODUCTION: Infliximab, a chimeric monoclonal antibody to tumour necrosis factor alpha, is administered as an intravenous infusion requiring a costly hospital day case or inpatient admission. METHODS: An audit of all current therapies given by intravenous infusions in an outpatient setting in St Vincent's University Hospital (SVUH) was undertaken. Furthermore, in conjunction with TCP homecare, we established in a general practise health clinic, the first Irish community infusion centre for the administration of infliximab in August 2006. RESULTS: All outpatient departments indicated that they would favour a centralized hospital infusion unit. There were no adverse events and the mean global satisfaction improved in the community infliximab infusion pilot programme of seven patients. CONCLUSION: This study suggests efficiencies in providing centralized infusion facilities, while the community based infusion of infliximab is feasible and safe in this small cohort and identifies the community infusion unit as a viable and cost efficient alternative for administration of infliximab.
    • An Audit of the Effectiveness of Large Group Neurology Tutorials for Irish Undergraduate Medical Students

      Kearney, H; Krakar, A; Drazyk, A; Maloney, E; Callanan, I; Tubridy, N (Irish Medical Journal, 2016-07)
      The aim of this audit was to determine the effectiveness of large group tutorials for teaching neurology to medical students. Students were asked to complete a questionnaire rating their confidence on a ten point Likert scale in a number of domains in the undergraduate education guidelines from the Association of British Neurologists (ABN). We then arranged a series of interactive large group tutorials for the class and repeated the questionnaire one month after teaching. In the three core domains of neurological: history taking, examination and differential diagnosis, none of the students rated their confidence as nine or ten out of ten prior to teaching. This increased to 6% for history taking, 12 % in examination and 25% for differential diagnosis after eight weeks of tutorials. This audit demonstrates that in our centre, large group tutorials were an effective means of teaching, as measured by the ABN guidelines in undergraduate neurology.
    • Autobuttressing of colorectal anastomoses using a mesenteric flap.

      Mohan, H M; Winter, D C (2013-12)
      Anastomotic leakage is a common and dreaded complication of colorectal surgery. Many different approaches have been tried to attempt to reduce leakage and associated morbidity. The concept of reinforcement of an anastomosis by buttressing is well established. Techniques described include using sutures, native omentum, animal or synthetic material. We report a technique for buttressing using a mesenteric flap to envelope the anastomosis. The primary rationale is to reduce clinical sequelae of anastomotic leakage by promoting local containment, as well as providing a scaffold for healing. Using autologous tissue provides a safe, time-efficient and cost-effective buttress without the risks of infection or reaction associated with foreign material. A mesenteric flap is particularly useful in patients in whom omentum is not available due to previous surgery, or to fill the dead space posterior to a low anastomosis within the pelvis.
    • Axillary fine needle aspiration cytology for pre-operative staging of patients with screen-detected invasive breast carcinoma.

      Hayes, Brian D; Feeley, Linda; Quinn, Cecily M; Kennedy, M M; O'Doherty, Ann; Flanagan, Fidelma; O'Connell, Anna Marie; Department of Histopathology, St Vincent's University Hospital, Dublin 4,, Ireland. brian_hayes@ireland.com (2012-02-01)
      INTRODUCTION: Fine needle aspiration cytology (FNAC) of radiologically abnormal axillary lymph nodes in patients with breast cancer can identify patients suitable for primary axillary clearance (AC) rather than sentinel node biopsy, enabling surgical axillary staging by a single operation. This study assessed the accuracy of FNAC in predicting positive axillary lymph nodes. METHODS: 161 patients with screen-detected invasive carcinoma and who had pre-operative FNAC of a radiologically abnormal axillary lymph node were identified from two screening units, The axillary FNAC reports were correlated with sentinel node biopsy and AC reports, and sensitivity, specificity, positive (PPV) and negative (NPV) predictive values were calculated. RESULTS: FNAC had a moderate sensitivity (66.3%) and NPV (71.8%), and a high specificity (98.7%) and PPV (98.3%). Most patients (86%) had a single axillary operation. The sensitivity was highest in grade 3 (81.8%) and ductal type (77.8%) tumours. The sensitivity was lower in tumours of special type (34.8%), grade 1 tumours (50%) and those without lymphovascular invasion (LVI) (55.9%). The NPV was highest in pT1 (86.7%) and in grade 1 (84.5%) tumours, and lowest (44%) in tumours with LVI. The PPV was 100% in grade 1 and 3 tumours, stage pT2 and pT3 tumours and those without LVI, and was high (>96%) in all other groups. In lymph-node-positive patients, the mean number of lymph nodes involved was higher in the case of a positive (6.4) than negative FNAC (4.4). CONCLUSIONS: FNAC of ultrasonically abnormal axillary lymph nodes achieved surgical staging by a single operation in most patients with screen-detected invasive breast carcinoma, with moderate sensitivity and high specificity.
    • 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.