• A Life-Saving Palsy: Hereditary Neuropathy with Liability to Pressure Palsies (HNPP) Presenting As Hand Weakness during Cardiopulmonary Resuscitation (CPR) Training

      Hughes, H; Tubridy, N; Connolly, S; St. Vincent’s University Hospital, Dublin (Irish Medical Journal, 2018-09)
      Hereditary neuropathy with liability to pressure palsies (HNPP), is an uncommon condition characterised by recurrent episodes of painless, focal motor and sensory peripheral neuropathies, often preceded by nerve compression 1, 2. Despite the rarity of the condition, HNPP should form part of the differential diagnosis in patients presenting with this picture.
    • Maternal Early Warning Scores (MEWS)

      Nair, Shrijit; Dockrell, Lucy; Mac Colgain, Siaghal; St. Vincent’s University Hospital (World Federation of Societies of Anesthesiologists, 2018-07)
      According to Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries in the UK (MBRRACE-UK) report 2016, maternal mortality rate is 8.5 per 100,000 maternities. More than 50% of maternal deaths are potentially preventable.Nine pregnant women develop severe maternal morbidity for every maternal death. Evolving morbidity can be difficult to recognise in the obstetric population because of the normal changes in peripartum physiology. Delays in recognition of patient deterioration and initiation of treatment lead to worse outcomes.2 Early Warning Systems (EWS) have been used since 1999 in the general patient population to identify clinical deterioration. The Maternal Early Warning System (MEWS) has been advocated with the aim to reduce maternal morbidity and mortality, and improve clinical outcomes. The MEWS tracks physiological parameters and evolving morbidity and once a predetermined threshold has been reached, it triggers evaluation by a healthcare professional.
    • Quality Improvement of Clinical Handover in a Liaison Psychiatry Department: A Three-Phase Audit

      Alexander, L; Bechan, N; Brady, S; Douglas, L; Moore, S; Shelley, R (Irish Medical Journal, 2018-06)
      Clinical handover has been identified as a period of high risk in healthcare, with increased incidence of adverse outcomes and near-misses. The purpose of handover is to communicate relevant information between medical professionals, with emphasis on completing management tasks and preventing patients from ‘falling through the cracks’1. Poor handover practices contribute to catastrophic but avoidable adverse events in healthcare. In Ireland, one such high profile incident has been a particular catalyst in the development of comprehensive handover guidelines in maternity settings2. Other specialities have yet to follow suit and there remains a dearth of guidance on handover practices, particularly guidance that can be applied to highly specialised and logistically unique areas, such as psychiatry
    • Overnight Emergency CT Imaging: A 10-Year Experience at an Irish Tertiary Referral Hospital.

      Hynes J; Redmond CE; Healy GM; Cronin, J; Heffernan, EJ (Irish Medical Journal, 2018-01)
      In recent years there has been increased utilisation of computed tomography (CT) imaging in developed countries, however there is a paucity of data regarding the utilisation of CT in the emergency overnight setting. We retrospectively analysed trends in ‘overnight’ (midnight to 8am) CT utilisation over a ten-year period at a single Irish tertiary referral hospital. Over the study period, we observed a significant increase in the proportion of CT imaging that was carried out overnight. There was no significant variation in the yield of pathological findings over the study period, which remained low (64% of CT studies were normal or had non-critical findings). The multiple factors which have contributed to the increased utilization of overnight emergency CT in recent years, the potential for reporting errors overnight and the implications therein for patient safety warrant consideration.
    • Isolation and gene expression profiling of intestinal epithelial cells: crypt isolation by calcium chelation from in vivo samples.

      Balfe, Aine; Lennon, Grainne; Lavelle, Aonghus; Docherty, Neil G; Coffey, J Calvin; Sheahan, Kieran; Winter, Desmond C; O'Connell, P Ronan (Clinical and Experimental Gastroenterology, 2018)
      The epithelial layer within the colon represents a physical barrier between the luminal contents and its underlying mucosa. It plays a pivotal role in mucosal homeostasis, and both tolerance and anti-pathogenic immune responses. Identifying signals of inflammation initiation and responses to stimuli from within the epithelial layer is critical to understanding the molecular pathways underlying disease pathology. This study validated a method to isolate and analyze epithelial populations, enabling investigations of epithelial function and response in a variety of disease setting.
    • Immune checkpoint inhibitor PD-1 pathway is down-regulated in synovium at various stages of rheumatoid arthritis disease progression.

      Guo, Yanxia; Walsh, Alice M; Canavan, Mary; Wechalekar, Mihir D; Cole, Suzanne; Yin, Xuefeng; Scott, Brittney; Loza, Mathew; Orr, Carl; McGarry, Trudy; et al. (PLoS One, 2018)
      Immune checkpoint blockade with therapeutic anti-cytotoxic T lymphocyte-associated antigen (CTLA)-4 (Ipilimumab) and anti-programmed death (PD)-1 (Nivolumab and Pembrolizumab) antibodies alone or in combination has shown remarkable efficacy in multiple cancer types, concomitant with immune-related adverse events, including arthralgia and inflammatory arthritis (IA) in some patients. Herein, using Nivolumab (anti-PD-1 antagonist)-responsive genes along with transcriptomics of synovial tissue from multiple stages of rheumatoid arthritis (RA) disease progression, we have interrogated the activity status of PD-1 pathway during RA development. We demonstrate that the expression of PD-1 was increased in early and established RA synovial tissue compared to normal and OA synovium, whereas that of its ligands, programmed death ligand-1 (PD-L1) and PD-L2, was increased at all the stages of RA disease progression, namely arthralgia, IA/undifferentiated arthritis, early RA and established RA. Further, we show that RA patients expressed PD-1 on a majority of synovial tissue infiltrating CD4+ and CD8+ T cells. Moreover, enrichment of Nivolumab gene signature was observed in IA and RA, indicating that the PD-1 pathway was downregulated during RA disease progression. Furthermore, serum soluble (s) PD-1 levels were increased in autoantibody positive early RA patients. Interestingly, most of the early RA synovium tissue sections showed negative PD-L1 staining by immunohistochemistry. Therefore, downregulation in PD-1 inhibitory signaling in RA could be attributed to increased serum sPD-1 and decreased synovial tissue PD-L1 levels. Taken together, these data suggest that agonistic PD1 antibody-based therapeutics may show efficacy in RA treatment and interception.
    • Age Adjusted D-Dimer for exclusion of Pulmonary Embolism: a retrospective cohort study.

      Monks, D; Neill, A; Barton, D; Moughty, A; McFeely, A; Timmons, A; Hatton, S; McMorrow, D (Irish Medical Journal, 2017-08)
      D-Dimer (DD) will increase with age and recent studies have shown the upper limit of normal can be raised in those who are low risk and over 50. We studied age adjusted D-dimer (AADD) levels to assess whether pulmonary embolism (PE) could be safely excluded. This study analysed the Emergency Department (ED) Computed Tomographic Pulmonary Angiography (CTPA) requests. There were 756 requests. The parameters studied were; age, DD value, calculated AADD, CT result and Simplified Geneva Score (SGS). The primary outcome was the diagnostic performance of AADD. One hundred and eighty-five patients were included in the final cohort. Twenty-one patients had a negative DD after age adjustment. Of these one had a PE, corresponding to a failure rate of 4.76% (1 in 22). The sensitivity of AADD was 0.96 (95% CI 0.76 to 0.99) and its specificity was 0.12 (95% CI 0.08- 0.19). AADD demonstrated a reduction in false positives with one false negative, giving rise to a failure rate higher than that of other larger studies. Further study is indicated to accurately define the diagnostic characteristics for the Irish context.
    • Impact of receptor phenotype on nodal burden in patients with breast cancer who have undergone neoadjuvant chemotherapy

      Boland, M. R.; McVeigh, T. P.; O'Flaherty, N.; Gullo, G.; Keane, M.; Quinn, C. M.; McDermott, E. W.; Lowery, A. J.; Kerin, M. J.; Prichard, R. S.; et al. (BSJ Open, 2017-07-31)
      Optimal evaluation and management of the axilla following neoadjuvant chemotherapy(NAC) in patients with node-positive breast cancer remains controversial. The aim of this study wasto examine the impact of receptor phenotype in patients with nodal metastases who undergo NAC to seewhether this approach can identify those who may be suitable for conservative axillary management.Methods: Between 2009 and 2014, all patients with breast cancer and biopsy-proven nodal diseasewho received NAC were identied from prospectively developed databases. Details of patients who hadaxillary lymph node dissection (ALND) following NAC were recorded and rates of pathological completeresponse (pCR) were evaluated for receptor phenotype.
    • Long-term follow-up of patients with spontaneous clearance of hepatitis C: does viral clearance mean cure?

      Iqbal, M; McCormick, P A; Cannon, M; Murphy, N; Flanagan, P; Hegarty, J E; Thornton, L (Irish Medical Journal, 2017-06)
      Up to 40% of patients with hepatitis C virus (HCV) antibodies are negative for HCV RNA at initial evaluation. If there is a risk of viral re-activation, long term follow-up is required with attendant financial, psychological and medical implications. We investigated the risk of re-activation in the Irish anti-D cohort. Information was obtained from the national hepatitis C database which includes data on patients infected by anti-D immunoglobulin in two large outbreaks, 1977-9 and 1991-94. As part of a screening programme, starting in 1994, 64,907 females exposed to anti-D immunoglobulin were evaluated. Three hundred and forty-seven were found to be antibody positive but HCV RNA negative at initial assessment. 93% had subsequent RNA tests. There was no evidence of HCV recurrence in patients whose infection resolved spontaneously. It appears that two initial sequential negative results for HCV RNA are sufficient to confirm spontaneous viral clearance and probable cure of hepatitis C virus infection.
    • Ireland's recent contribution to the radiological literature; a bibliometric analysis

      Redmond, CE; Healy, GM; Ryan, DT; Conway, R; Murphy, CF; Ni Leidhin, C; Power, J; Brophy, DP; Heffernan, EJ (Irish Medical Journal, 2017-04)
      The aim of this study was to identify and analyse all articles published by Irish radiology departments in the medical literature since the year 2000. The PubMed database was searched to identify and review all articles published by radiologists based in the Republic of Ireland or Northern Ireland. Citation counts were then obtained and the top ten most cited articles were identified. There were 781 articles published during the study period. Of these, 558 (71%) were published in radiology journals and the remaining 223 (29%) were published in general medical journals. Abdominal radiology was the most represented sub-specialty (33% of all articles). There was a general trend of increased publications per year. Only 75 (9.6%) of articles were collaborative efforts by more than one radiology department. Irish radiology departments have a considerable research output and this has increased since the year 2000. More collaborative research between Irish radiology departments is encouraged
    • Identifying Incomplete Atypical Femoral Fractures With Single-Energy Absorptiometry: Declining Prevalence

      McKenna, Malachi; McKiernan, Fergus; McGowan, Bernie; Silke, Carmel; Bennett, Kathleen; Van Der Kamp, Susan; Ward, Paul; Hurson, Conor; Heffernan, Eric (Journal of Endocrine Society, 2017-03)
      Atypical femur fractures (AFFs) are associated with long-term bisphosphonate (BP) therapy. Early identification of AFF prior to their completion provides an opportunity to intervene, potentially reducing morbidity associated with these fractures. Single-energy X-ray absorptiometry (SE) is an imaging method recently shown to detect incomplete AFF (iAFF) prior to fracture completion.
    • Giant desmoid tumour of the thorax following latissimus dorsi and implant breast reconstruction: case report and review of the literature

      Collins, AM; Granahan, AM; Healy, DG; Lawlor, CA; O’Neill, SP (Irish Medical Journal, 2017-03)
      The case of a giant thoracic desmoid tumour in a 44-year-old woman, who presented two years following a breast reconstruction with a latissimus dorsi (LD) flap and implant, is reported. Clinical findings included a rapidly growing, painless mass. Computed tomography (CT) suggested skin and intercostal soft tissue invasion. The tumour was resected en bloc with the LD muscle, implant capsule and underlying rib segments. The resultant thoracic and abdominal wall defects were reconstructed with Dualmesh® and polypropylene meshes respectively. There was no evidence of recurrence at thirty-six months follow-up.
    • Shock, Cardiac Arrest, and Resuscitation.

      Lin, Yan-Ren; Ng, Kee-Chong; Exadaktylos, Aristomenis K; Ryan, John M; Wu, Han-Ping (Hindawi Publishing Corp., 2017)
    • St Vincent’s University Hospital Make Bold Move by Banning Soap

      Murphy, Lisa (St Vincent's University Hospital, 2017)
    • Emergence and spread of a human-transmissible multidrug-resistant nontuberculous mycobacterium.

      Bryant, Josephine M; Grogono, Dorothy M; Rodriguez-Rincon, Daniela; Everall, Isobel; Brown, Karen P; Moreno, Pablo; Verma, Deepshikha; Hill, Emily; Drijkoningen, Judith; Gilligan, Peter; et al. (2016-11-11)
      Lung infections with Mycobacterium abscessus, a species of multidrug resistant nontuberculous mycobacteria, are emerging as an important global threat to individuals with cystic fibrosis (CF) where they accelerate inflammatory lung damage leading to increased morbidity and mortality. Previously, M. abscessus was thought to be independently acquired by susceptible individuals from the environment. However, using whole genome analysis of a global collection of clinical isolates, we show that the majority of M. abscessus infections are acquired through transmission, potentially via fomites and aerosols, of recently emerged dominant circulating clones that have spread globally. We demonstrate that these clones are associated with worse clinical outcomes, show increased virulence in cell-based and mouse infection models, and thus represent an urgent international infection challenge.
    • Preclinical validation of the small molecule drug quininib as a novel therapeutic for colorectal cancer.

      Murphy, Adrian G; Casey, Rory; Maguire, Aoife; Tosetto, Miriam; Butler, Clare T; Conroy, Emer; Reynolds, Alison L; Sheahan, Kieran; O'donoghue, Diarmuid; Gallagher, William M; et al. (Nature Publishing Group, 2016-10-14)
      Colorectal cancer (CRC) is a leading cause of cancer deaths. Molecularly targeted therapies (e.g. bevacizumab) have improved survival rates but drug resistance ultimately develops and newer therapies are required. We identified quininib as a small molecule drug with anti-angiogenic activity using in vitro, ex vivo and in vivo screening models. Quininib (2-[(E)-2-(Quinolin-2-yl) vinyl] phenol), is a small molecule drug (molecular weight 283.75 g/mol), which significantly inhibited blood vessel development in zebrafish embryos (p < 0.001). In vitro, quininib reduced endothelial tubule formation (p < 0.001), cell migration was unaffected by quininib and cell survival was reduced by quininib (p < 0.001). Using ex vivo human CRC explants, quininib significantly reduced the secretions of IL-6, IL-8, VEGF, ENA-78, GRO-α, TNF, IL-1β and MCP-1 ex vivo (all values p < 0.01). Quininib is well tolerated in mice when administered at 50 mg/kg intraperitoneally every 3 days and significantly reduced tumour growth of HT-29-luc2 CRC tumour xenografts compared to vehicle control. In addition, quininib reduced the signal from a α
    • 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.
    • Cycling Injuries Presenting to an Irish Emergency Department

      J Foley, J; Cronin, J; Gheorghescu, A; Chetrit, D; Evoy, D; Ryan, J (Irish Medical Journal, 2016-06)
      There is little published data on cycling injuries in Ireland and the present study aims to describe the cycling related injuries presenting to the emergency department (ED), of a tertiary urban university hospital. This is a retrospective review of cycling-related injuries presenting to the ED of St. Vincent’s University Hospital (SVUH) from 1st of January to 31st of December 2014. There were 534 cycling related injuries presenting to the ED during the study period. Just over 71% of the patients were male, and 14.8% of patients presented following a collision with a motor vehicle. Forty patients required admission to hospital following their injury with 6 of these patients spending time in the intensive care unit. Cycling is now a very popular means of transport and exercise activity in Ireland and using hospital based data, it is possible that EDs may provide a vector for guiding injury prevention strategies in the future
    • Acute pain assessment

      Clear, Elaine (Nursing in General Practice, 2016-05)
      The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” (IASP, 1997). This definition of pain emphasises that it is neither a sensory nor an emotional experience, but a combination of both. It is a subjective experience influenced by physical, psychological and environmental factors that is assessed from a biopsychosocial perspective. The gold standard in assessing pain however is always what the patient says it is.
    • ESGAR consensus statement on liver MR imaging and clinical use of liver-specific contrast agents.

      Neri, E; Bali, M A; Ba-Ssalamah, A; Boraschi, P; Brancatelli, G; Alves, F Caseiro; Grazioli, L; Helmberger, T; Lee, J M; Manfredi, R; et al. (Springer, 2016-04)
      To develop a consensus and provide updated recommendations on liver MR imaging and the clinical use of liver-specific contrast agents.