• Barriers and facilitators to implementing addiction medicine fellowships: a qualitative study with fellows, medical students, residents and preceptors.

      Klimas, J; Small, W; Ahamad, K; Cullen, W; Mead, A; Rieb, L; Wood, E; McNeil, R (Biomed Central, 2017)
      Although progress in science has driven advances in addiction medicine, this subject has not been adequately taught to medical trainees and physicians. As a result, there has been poor integration of evidence-based practices in addiction medicine into physician training which has impeded addiction treatment and care. Recently, a number of training initiatives have emerged internationally, including the addiction medicine fellowships in Vancouver, Canada. This study was undertaken to examine barriers and facilitators of implementing addiction medicine fellowships.
    • Bedside detection of low systemic flow in the very low birth weight infant on day 1 of life.

      Miletin, J; Pichova, K; Dempsey, E M; Department of Paediatrics and Newborn Medicine, Coombe Women and Infants, University Hospital, Dolphin's Barn, Dublin 8, Ireland. miletinj@yahoo.com (2012-02-01)
      We aimed to assess the relationship between the clinical and biochemical parameters of perfusion and superior vena cava (SVC) flow in a prospective observational cohort study of very low birth weight (VLBW) infants. Newborns with congenital heart disease were excluded. Echocardiographic evaluation of SVC flow was performed in the first 24 h of life. Capillary refill time (forehead, sternum and toe), mean blood pressure, urine output and serum lactate concentration were also measured simultaneously. Thirty-eight VLBW infants were examined. Eight patients (21%) had SVC flow less than 40 ml/kg/min. There was a poor correlation between the capillary refill time (in all sites), mean blood pressure, urine output and SVC flow. The correlation coefficient for the serum lactate concentration was r = -0.28, p = 0.15. The median serum lactate concentration was 3.5 (range 2.8-8.5) vs. 2.7 (range 1.2-6.9) mmol/l (p = 0.01) in low flow versus normal flow states. A serum lactate concentration of >2.8 was 100% sensitive and 60% specific for detecting a low flow state. Combining a capillary refill time of >4 s with a serum lactate concentration of >4 mmol/l had a specificity of 97% for detecting a low SVC flow state. Serum lactate concentrations are higher in low SVC flow states. A capillary refill time of >4 s combined with serum lactate concentrations >4 mmol/l increased the specificity and positive and negative predictive values of detecting a low SVC flow state.
    • Behavioural change in relation to alcohol exposure in early pregnancy and impact on perinatal outcomes--a prospective cohort study.

      Murphy, Deirdre J; Mullally, Aoife; Cleary, Brian J; Fahey, Tom; Barry, Joe; Academic Department of Obstetrics & Gynaecology, Coombe Women and Infants University Hospital & Trinity College Dublin, Dublin, Dublin 8, Republic of Ireland. deirdre.j.murphy@tcd.ie (2013)
      There has been limited research addressing whether behavioural change in relation to alcohol exposure in pregnancy results in better perinatal outcomes.
    • Body Mass Index (BMI) in women booking for antenatal care: comparison between selfreported and digital measurements.

      Fattah, Chro; Farah, Nadine; O'Toole, Fiona; Barry, Sinead; Stuart, Bernard; Turner, Michael J; UCD School of Medicine and Medical Science, Coombe Women and Infants University, Hospital, Dublin, Ireland. (2012-02-01)
      OBJECTIVE: We set out to compare measurement of Body Mass Index (BMI) with selfreporting in women early in pregnancy. STUDY DESIGN: We studied 100 women booking for antenatal care in the first trimester with a normal ongoing pregnancy. Selfreported maternal weight and height were recorded and the Body Mass Index was calculated. Afterwards maternal weight and height were digitally measured and actual BMI was calculated. RESULTS: If selfreporting is used for BMI classification, we found that 22% of women were classified incorrectly when BMI was measured. 12% of the women who were classified as having a normal selfreported BMI were overweight and 5% classified as overweight were obese. Similar findings have been reported outside pregnancy. CONCLUSIONS: These findings have implications for clinical practice, and for research studies exploring the relationship between maternal adiposity and pregnancy complications.
    • Body mass index and blood pressure measurement during pregnancy.

      Hogan, Jennifer L; Maguire, Patrick; Farah, Nadine; Kennelly, Mairead M; Stuart, Bernard; Turner, Michael J; Coombe Women and Infants University Hospital, Dublin, Ireland., Jennifer.Hogan@ucdconnect.ie (2012-02-01)
      OBJECTIVE: The accurate measurement of blood pressure requires the use of a large cuff in subjects with a high mid-arm circumference (MAC). This prospective study examined the need for a large cuff during pregnancy and its correlation with maternal obesity. METHODS: Maternal body mass index (BMI), fat mass, and MAC were measured. RESULTS: Of 179 women studied, 15.6% were obese. With a BMI of level 1 obesity, 44% needed a large cuff and with a BMI of level 2 obesity 100% needed a large cuff. CONCLUSION: All women booking for antenatal care should have their MAC measured to avoid the overdiagnosis of pregnancy hypertension.
    • Body Mass Index and spontaneous miscarriage.

      Turner, Michael J; Fattah, Chro; O'Connor, Norah; Farah, Nadine; Kennelly, Mairead; Stuart, Bernard; UCD Centre for Human Reproduction, Coombe Women and Infants University Hospital, , Dublin 8, Ireland. michael.turner@ucd.ie (2012-02-01)
      OBJECTIVE: We compared the incidence of spontaneous miscarriage in women categorised as obese, based on a Body Mass Index (BMI) >29.9 kg/m(2), with women in other BMI categories. STUDY DESIGN: In a prospective observational study conducted in a university teaching hospital, women were enrolled at their convenience in the first trimester after a sonogram confirmed an ongoing singleton pregnancy with fetal heart activity present. Maternal height and weight were measured digitally and BMI calculated. Maternal body composition was measured by advanced bioelectrical impedance analysis. RESULTS: In 1200 women, the overall miscarriage rate was 2.8% (n=33). The mean gestational age at enrolment was 9.9 weeks. In the obese category (n=217), the miscarriage rate was 2.3% compared with 3.3% in the overweight category (n=329), and 2.3% in the normal BMI group (n=621). There was no difference in the mean body composition parameters, particularly fat mass parameters, between those women who miscarried and those who did not. CONCLUSIONS: In women with sonographic evidence of fetal heart activity in the first trimester, the rate of spontaneous miscarriage is low and is not increased in women with BMI>29.9 kg/m(2) compared to women in the normal BMI category.
    • Burden of Severe Respiratory Syncytial Virus Disease Among 33-35 Weeks' Gestational Age Infants Born During Multiple Respiratory Syncytial Virus Seasons.

      Anderson, Evan J; Carbonell-Estrany, Xavier; Blanken, Maarten; Lanari, Marcello; Sheridan-Pereira, Margaret; Rodgers-Gray, Barry; Fullarton, John; Rouffiac, Elisabeth; Vo, Pamela; Notario, Gerard; Campbell, Fiona; Paes, Bosco (Wolters Kluwer Health, 2017-02)
      Moderate-late preterm infants, 33-35 weeks' gestational age (wGA), are at increased risk for respiratory syncytial virus hospitalization (RSVH). The objective of this study is to quantify the burden of RSVH in moderate-late preterm infants.
    • A case of toxoplasmosis causing severe ventriculomegaly in association with reproductive immunotherapy.

      O'Connor, C; Stuart, B; Turner, M J; Kennelly, M M; UCD Centre for Human Reproduction, Coombe Women and Infants University Hospital, Dublin, Ireland. drclare.oconnor@gmail.com (2012-08)
    • Catching moving targets: cancer stem cell hierarchies, therapy-resistance & considerations for clinical intervention.

      Gasch, Claudia; Ffrench, Brendan; O'Leary, John J; Gallagher, Michael F (BioMed Central, 2017)
      It is widely believed that targeting the tumour-initiating cancer stem cell (CSC) component of malignancy has great therapeutic potential, particularly in therapy-resistant disease. However, despite concerted efforts, CSC-targeting strategies have not been efficiently translated to the clinic. This is partly due to our incomplete understanding of the mechanisms underlying CSC therapy-resistance. In particular, the relationship between therapy-resistance and the organisation of CSCs as Stem-Progenitor-Differentiated cell hierarchies has not been widely studied. In this review we argue that modern clinical strategies should appreciate that the CSC hierarchy is a dynamic target that contains sensitive and resistant components and expresses a collection of therapy-resisting mechanisms. We propose that the CSC hierarchy at primary presentation changes in response to clinical intervention, resulting in a recurrent malignancy that should be targeted differently. As such, addressing the hierarchical organisation of CSCs into our bench-side theory should expedite translation of CSC-targeting to bed-side practice. In conclusion, we discuss strategies through which we can catch these moving clinical targets to specifically compromise therapy-resistant disease.
    • Cerebral tissue oxygenation index and superior vena cava blood flow in the very low birth weight infant.

      Moran, M; Miletin, J; Pichova, K; Dempsey, E M; Department of Pediatrics and Newborn Medicine, Coombe Women and Infants, University Hospital, Dublin 8, Ireland. (2012-02-01)
      BACKGROUND: Superior vena cava (SVC) flow assesses blood flow from the upper body, including the brain. Near infrared spectroscopy (NIRS) provides information on brain perfusion and oxygenation. AIM: To assess the relationship between cerebral tissue oxygenation index (cTOI) and cardiac output measures in the very low birth weight (VLBW) infant in the first day of life. METHODS: A prospective observational cohort study. Neonates with birth weight less than 1500 g (VLBW) were eligible for enrollment. Newborns with congenital heart disease, major congenital malformations and greater than Papile grade1 Intraventricular Haemorrhage on day 1 of life were excluded. Echocardiographic evaluation of SVC flow was performed in the first 24 h of life. Low SVC flow states were defined as a flow less than 40 mL/kg/min. cTOI was measured using NIRO 200 Hamamatsu. RESULTS: Twenty-seven VLBW neonates had both echocardiography and NIRS performed. The median (range) gestation was 29/40 (25 + 3 to 31 + 5 weeks) and median birth weight was 1.2 kg (0.57-1.48 kg). The mean (SD) TOI was 68.1 (7.9)%. The mean (SD) SVC flow was 70.36(39.5) mLs/kg/min. The correlation coefficient of cerebral tissue oxygenation and SVC flow was r = 0.53, p-value 0.005. There was a poor correlation between right and left ventricular output and cTOI which is not surprising considering the influence of intra- and extracardiac shunts. CONCLUSION: There is a positive relationship between cerebral TOI values and SVC flow in the very low birth infant on day one of life.
    • Chlamydia trachomatis detection in cervical PreservCyt specimens from an Irish urban female population.

      Keegan, H; Ryan, F; Malkin, A; Griffin, M; Lambkin, H; Department of Pathology, Coombe Women's Hospital, Dublin, Ireland., keeganh28@gmail.com (2012-02-01)
      OBJECTIVE: The aim of this study was to determine the prevalence of cervical Chlamydia trachomatis infection by polymerase chain reaction (PCR) in urban women undergoing routine cervical cytological screening and to investigate the relationship with age, cytology, smoking status and concurrent human papillomavirus (HPV) infection. METHODS: A total of 996 women (age range 16-69 years) attending general practitioners for routine liquid-based cervical smear screening in the Dublin area were recruited in the study of prevalence of C. trachomatis. Informed consent was obtained and liquid-based cytology (LBC) specimens were sent for cytological screening. DNA was extracted from residual LBC and tested for C. trachomatis by PCR using the highly sensitive C. trachomatis plasmid (CTP) primers and for HPV infection using the MY09/11 primers directed to the HPV L1 gene in a multiplex format. RESULTS: The overall prevalence of C. trachomatis was 5.4%. Prevalence was highest in the <25 years age group (10%). Coinfection with HPV and C. trachomatis occurred in 1% of the screening population. A higher rate of smoking was observed in women positive for C. trachomatis, HPV infections or those with abnormal cervical cytology. Chlamydia trachomatis infection was not associated with abnormal cytology. CONCLUSIONS: Women (5.4%) presenting for routine cervical screening are infected with C. trachomatis. Opportunistic screening for C. trachomatis from PreservCyt sample taken at the time of cervical cytological screening may be a possible strategy to screen for C. trachomatis in the Irish female population.
    • Chronic illness and multimorbidity among problem drug users: a comparative cross sectional pilot study in primary care.

      Cullen, Walter; O'Brien, Sarah; O'Carroll, Austin; O'Kelly, Fergus D; Bury, Gerard; UCD School of Medicine and Medical Science, Coombe Healthcare Centre, Dublin,, Ireland. walter.cullen@ucd.ie (2012-02-01)
      BACKGROUND: Although multimorbidity has important implications for patient care in general practice, limited research has examined chronic illness and health service utilisation among problem drug users. This study aimed to determine chronic illness prevalence and health service utilisation among problem drug users attending primary care for methadone treatment, to compare these rates with matched 'controls' and to develop and pilot test a valid study instrument. METHODS: A cross-sectional study of patients attending three large urban general practices in Dublin, Ireland for methadone treatment was conducted, and this sample was compared with a control group matched by practice, age, gender and General Medical Services (GMS) status. RESULTS: Data were collected on 114 patients. Fifty-seven patients were on methadone treatment, of whom 52(91%) had at least one chronic illness (other then substance use) and 39(68%) were prescribed at least one regular medication. Frequent utilisation of primary care services and secondary care services in the previous six months was observed among patients on methadone treatment and controls, although the former had significantly higher chronic illness prevalence and primary care contact rates. The study instrument facilitated data collection that was feasible and with minimal inter-observer variation. CONCLUSION: Multimorbidity is common among problem drug users attending general practice for methadone treatment. Primary care may therefore have an important role in primary and secondary prevention of chronic illnesses among this population. This study offers a feasible study instrument for further work on this issue. (238 words).
    • A cohort study of maternal and neonatal morbidity in relation to use of sequential instruments at operative vaginal delivery.

      Murphy, Deirdre J; Macleod, Maureen; Bahl, Rachna; Strachan, Bryony; Academic Department of Obstetrics & Gynaecology, Coombe Women & Infants, University Hospital & Trinity College, University of Dublin, Dublin 8, Ireland., deirdre.j.murphy@tcd.ie (2012-02-01)
      OBJECTIVE: To evaluate the risk factors and maternal and neonatal morbidity associated with sequential use of instruments (vacuum and forceps) at operative vaginal delivery. STUDY DESIGN: A cohort study of 1360 nulliparous women delivered by a single instrument (vacuum or forceps) or by both instruments, within two university teaching hospitals in Scotland and England. Outcomes were compared for use of sequential instruments versus use of any single instrument. A sub-group analysis compared sequential instruments versus forceps alone. Outcomes of interest included anal sphincter tears, postpartum haemorrhage, urinary retention, urinary incontinence, prolonged hospital admission, neonatal trauma, low Apgar scores, abnormal cord bloods and admission to the neonatal intensive care unit (NICU). RESULTS: Use of sequential instruments at operative vaginal delivery was associated with fetal malpositions, Odds Ratio (OR) 1.8 (95% Confidence Interval (CI) 1.3-2.6), and large neonatal head circumference (>37 cm) (OR 5.0, 95% CI 2.6-9.7) but not with maternal obesity or grade of operator. Sequential use of instruments was associated with greater maternal and neonatal morbidity than single instrument use (anal sphincter tear 17.4% versus 8.4%, adjusted OR 2.1, 95% CI 1.2-3.3; umbilical artery pH <7.10, 13.8% versus 5.0%, adjusted OR 3.3, 95% CI 1.7-6.2). Sequential instrument use had greater morbidity than single instrument use with forceps alone (anal sphincter tear OR 1.8, 95% CI 1.1-2.9; umbilical artery pH <7.10 OR 3.0, 95% CI 1.7-5.5). CONCLUSIONS: The use of sequential instruments significantly increases maternal and neonatal morbidity. Obstetricians need training in the appropriate selection and use of instruments with the aim of completing delivery safely with one instrument.
    • Comparison in maternal body composition between Caucasian Irish and Indian women.

      Farah, N; Murphy, M; Ramphul, M; O'Connor, N; Kennelly, M M; Turner, M J; UCD Centre for Human Reproduction, Coombe Women and Infants University Hospital, , Dublin, Ireland. nadine.farah@ucd.ie (2012-02-01)
      The use of body mass index (BMI) for the diagnosis of obesity has limitations, especially when comparing ethnic groups with different body proportions. The aim of this prospective study was to compare maternal body composition in early pregnancy between Caucasian Irish and Indian women. A total of 81 Indian women and 81 Irish Caucasian women were matched for age, parity and BMI. Maternal weight and height were measured, and body composition analysed using bioelectrical impedance. The Irish women were taller and weighed more than the Indian women (p<0.001). At any given BMI, the Indian women had a higher total body fat percentage, visceral fat level and high fat percentage than the Irish women (p=0.024, 0.001 and 0.001, respectively). Our findings suggest that lower BMI cut-offs should be used for screening for gestational diabetes mellitus in Indian women attending our antenatal services.
    • A comparison of blood pressure measurements in newborns.

      O'Shea, Joyce; Dempsey, Eugene M; Department of Newborn Medicine, Coombe Women's Hospital, Dublin, Ireland. (2012-02-01)
      Blood pressure monitoring is an essential component of neonatal intensive care. We compared invasive and noninvasive (Dinamap, Marquette, and Dash) recordings in newborns and also noninvasive values obtained from upper and lower limbs. Infants' blood pressure was recorded every 6 hours for 72 hours using three noninvasive devices and compared with invasive readings taken simultaneously. Twenty-five babies were enrolled in the study, with birth weights of 560 to 4500 g and gestation 24 + 1 to 40 + 5 weeks. Three hundred thirty-two recordings were obtained. Comparison between invasive and noninvasive readings revealed that all three noninvasive monitors overread mean blood pressure. There was no significant difference between the cuff recordings obtained from the upper or lower limbs. All three noninvasive devices overestimated mean blood pressure values compared with invasive monitoring. Clinicians may be falsely reassured by noninvasive monitoring. Mean blood pressure values obtained from the upper and lower limb are similar.
    • Comparison of HPV detection technologies: Hybrid capture 2, PreTect HPV-Proofer and analysis of HPV DNA viral load in HPV16, HPV18 and HPV33 E6/E7 mRNA positive specimens.

      Keegan, Helen; Mc Inerney, Jamie; Pilkington, Loretto; Gronn, Petter; Silva, Ivan; Karlsen, Frank; Bolger, Noel; Logan, Catriona; Furuberg, Liv; O'Leary, John; Martin, Cara; Department of Pathology, Coombe Women and Infants University Hospital, Dublin 8, , Ireland. keeganh28@gmail.com (2012-02-01)
      Human papillomavirus (HPV) testing using molecular methods in liquid based cytology (LBC) specimens may be useful as an adjunct to cervical screening by cytology. We compared the positivity rate of the commercially available HPV DNA method hybrid capture 2 (hc2) and the commercially available E6/E7 mRNA method PreTect HPV-Proofer in cytological specimens (n=299). LBC specimens collected (n=299) represented the following cervical cytological disease categories: Normal (n=60), borderline nuclear abnormalities (BNA) (n=34), CIN1 (n=121), CIN2 (n=60), CIN3 (n=24). Overall, 69% (205/299) of the cases were positive by hc2 and 38% (112/299) of the cases were positive by PreTect HPV-Proofer. Concordance rates between the two tests were highest in the high-grade cytology cases (CIN2: 67% and CIN3: 83%) and the normal cytology cases (88%) and lowest in the BNA and CIN1 categories (56% and 52%). HPV DNA viral load analyses were carried out on HPV16 (n=55), HPV18 (n=9) and HPV33 (n=13) samples that were positive by PreTect HPV-Proofer. The sensitivity and specificity of PreTect HPV-Proofer and the hc2 DNA test for the detection of high-grade cytology (i.e. CIN2+) were 71.4% and 75.8% vs 100% and 43.7%, respectively. The relatively low detection rate observed by PreTect HPV-Proofer in the whole range of cytological positive cases, combined with a relatively higher specificity and PPV, suggests that PreTect HPV-Proofer may be more useful than hc2 for triage and in predicting high-grade disease.
    • A comparison of maternal and paternal body mass index in early pregnancy.

      Kelly, Ross; Farah, Nadine; O'Connor, Norah; Kennelly, Mairead; Stuart, Bernard; Turner, Michael J; UCD Centre for Human Reproduction, Coombe Women and Infants University Hospital, Dublin, Ireland. (2011-04)
       Our findings show a high level of obesity in fathers-to-be, which has implications not only for the men themselves but also their families. We suggest that public health interventions directed at obesity during pregnancy should include both parents-to-be.
    • A complication after a previous caesarean section.

      Barrett, Niamh; Sheehan, Sharon R; Murphy, Deirdre J; Coombe Women and Infants' University Hospital, Dublin 8, Ireland. (2012-02-01)
    • Continuation of metformin in the first trimester of women with polycystic ovarian syndrome is not associated with increased perinatal morbidity.

      Bolton, S; Cleary, B; Walsh, J; Dempsey, E; Turner, M J; UCD School of Medicine and Medical Science, Coombe Women's Hospital, Dublin 8,, Ireland. (2012-02-01)
      This study aimed to assess the perinatal outcome, especially foetal growth, following the continuation of metformin during the first trimester of pregnancy. All women with polycystic ovary syndrome (PCOS) treated with metformin in the first trimester and who delivered a baby weighing 500 g or more between 2003 and 2005 were studied. Subjects were matched for age and parity with randomly selected controls. The perinatal outcomes studied were: growth parameters, gestational age, congenital defects, hypoglycaemia and neonatal unit admission. Sixty-six pregnancies were compared with 66 controls; all had singleton deliveries. There was no difference in mean birth weight between the metformin and the control groups (p=0.84). The percentage of small (<10th centile) and large (>90th centile) for gestational age babies was lower in the metformin group. In the metformin group, there were no major congenital malformations and 24% of the babies were admitted to the neonatal intensive care unit (NICU) compared with 27% of the babies in the control group (non-significant). Neonatal hypoglycaemia was less common in the metformin group (18.5% vs. 24.5%) and fewer babies required intravenous glucose therapy (6.3% vs. 12%). We found no evidence that the continuation of metformin in the first trimester of pregnancy was associated with an adverse foetal outcome.