• C1-C2 transarticular screw fixation for atlantoaxial instability due to rheumatoid arthritis: a seven-year analysis of outcome.

      Nagaria, Jabir; Kelleher, Micheal O; McEvoy, Linda; Edwards, Richard; Kamel, Mahmoud H; Bolger, Ciaran; National Department of Neurosurgery, Beaumont Hospital, Dublin, Ireland. (2009-12-15)
      STUDY DESIGN.: Observational study. Retrospective analysis of prospectively collected data. OBJECTIVE.: The purpose of this article was to report long-term (minimum 7 years) clinical and radiologic outcome of our series of patients with Rheumatoid Arthritis who underwent transarticular screw fixation to treat atlantoaxial subluxation. SUMMARY OF BACKGROUND DATA.: The indications for intervention in patients with atlantoaxial instability are pain, myelopathy, and progressive neurologic deficit. The various treatment options available for these patients are isolated C1-C2 fusion, occipitocervical fusion with or without transoral surgery. Review of current literature suggests that C1-C2 transarticular screw fixation has significant functional benefits, although there is discrepancy in this literature regarding improvement in function following surgery. METHODS.: Myelopathy was assessed using Ranawat myelopathy score and Myelopathy Disability Index. Pain scores were assessed using Visual Analogue Scale. The radiologic imaging was assessed and the following data were extracted; atlanto-dens interval, space available for cord, presence of signal change on T2 weighted image, and fusion rates. RESULTS.: Thirty-seven patients, median age 56, were included in the study. Average duration of neck symptoms was 15.8 months. Average duration of rheumatoid arthritis before surgery was 20.6 years. Preoperative symptoms: suboccipital pain in 26 patients; neck pain, 32; myelopathy, 22; and 5 were asymptomatic. After surgery: suboccipital pain, 2; neck pain, 3; and myelopathy, 10. Ninety percent patients with neck and suboccipital pain improved after surgery in their Visual Analogue pain scores, with all of them having >50% improvement in VAS scores (6.94-2.12 [P < 0.05]).Preoperative Ranawat grade was as follows: grade 1 in 15 patients, grade 2 in 7, and grade 3a in 14, grade 3b in 1.After surgery: grade 1 in 27 patients, grade 2 in 7, grade 3a in 1, and grade 3b in 2. The mean myelopathy score improved after surgery (59.62-32.75, P < 0.05).The space available for the cord was improved in 63%, unchanged in 33%, and worse in 4%.Twenty-seven percent had T2 signal change and 18% had cervicomedullary compression; 97% had bony fusion. BILATERAL SCREWS WERE USED IN 33 PATIENTS AND UNILATERAL SCREWS IN 4 PATIENTS (ABERRANT VERTEBRAL ARTERY).: Computer image guidance was used in 73%. CONCLUSION.: C1-C2 transarticular screw fixation is a safe technique for atlantoaxial subluxation for patients with rheumatoid arthritis. This study clearly demonstrates improvement in Visual Analogue Scale, Ranawat grading and the Myelopathy Disability Index even at long-term follow up.
    • Candida infection of the central nervous system following neurosurgery: a 12-year review.

      O'Brien, Deirdre; Stevens, Niall T; Lim, Chor Hiang; O'Brien, Donncha F; Smyth, Edmond; Fitzpatrick, Fidelma; Humphreys, Hilary; Department of Clinical Microbiology, Beaumont Hospital, Dublin 9, Ireland, de.obrien@svuh.ie. (2011-06)
      Candida infection of the central nervous system (CNS) following neurosurgery is relatively unusual but is associated with significant morbidity and mortality. We present our experience with this infection in adults and discuss clinical characteristics, treatment options, and outcome.
    • Candida infection of the central nervous system following neurosurgery: a 12-year review.

      O'Brien, Deirdre; Stevens, Niall T; Lim, Chor Hiang; O'Brien, Donncha F; Smyth, Edmond; Fitzpatrick, Fidelma; Humphreys, Hilary; Department of Clinical Microbiology, Beaumont Hospital, Dublin 9, Ireland., de.obrien@svuh.ie (2012-02-01)
      BACKGROUND: Candida infection of the central nervous system (CNS) following neurosurgery is relatively unusual but is associated with significant morbidity and mortality. We present our experience with this infection in adults and discuss clinical characteristics, treatment options, and outcome. METHODS: All episodes of Candida isolated from the central nervous system were identified by searching our laboratory database. Review of the cases was performed by means of a retrospective chart review. RESULTS: Eleven episodes of Candida CSF infection following neurosurgery were identified over a 12-year period. Candida albicans was the predominant species isolated (n = 8, 73%). All infections were associated with foreign intracranial material, nine with external ventricular drains (82%), one with a ventriculoperitoneal shunt, one with a lumbar drain, and one with Gliadel wafers (1,3-bis [2-chloroethyl]-1-nitrosurea). Fluconazole or liposomal amphotericin B were the most common anti-fungal agents used. The mortality rate identified in our series was 27%. CONCLUSIONS: Candida infection following neurosurgery remains a relatively rare occurrence but one that causes significant mortality. These are complex infections, the management of which benefits from a close liaison between the clinical microbiologist and neurosurgeon. Prompt initiation of antifungal agents and removal of infected devices offers the best hope of a cure.
    • Candida parapsilosis meningitis associated with Gliadel (BCNU) wafer implants.

      O'brien, Deirdre; Cotter, Meaghan; Hiang Lim, Chor; Sattar, Muhammad T; Smyth, Edmond; Fitzpatrick, Fidelm; Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland. (2010-12-15)
      A 58-year old male presented with meningitis associated with subgaleal and subdural collections 6 weeks following a temporal craniotomy for resection of recurrent glioblastoma multiforme and Gliadel wafer implantation. Candida parapsilosis was cultured from cerebrospinal fluid (CSF) and Gliadel wafers removed during surgical debridement. He was successfully treated with liposomal amphotericin B. To our knowledge, this is the first reported case of Candida parapsilosis meningitis secondary to Gliadel wafer placement.
    • Candida parapsilosis meningitis associated with Gliadel (BCNU) wafer implants.

      O'Brien, Deirdre; Cotter, Meaghan; Lim, Chor Hiang; Sattar, Muhammad T; Smyth, Edmond; Fitzpatrick, Fidelm; Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland., de.obrien@svuh.ie (2012-02-01)
      A 58-year old male presented with meningitis associated with subgaleal and subdural collections 6 weeks following a temporal craniotomy for resection of recurrent glioblastoma multiforme and Gliadel wafer implantation. Candida parapsilosis was cultured from cerebrospinal fluid (CSF) and Gliadel wafers removed during surgical debridement. He was successfully treated with liposomal amphotericin B. To our knowledge, this is the first reported case of Candida parapsilosis meningitis secondary to Gliadel wafer placement.
    • Cannabis misinterpretation and misadventure in a coroner's court.

      Tormey, William Patrick; Chemical Pathology, Beaumont Hospital, Dublin 9, Ireland. billtomey@gmail.com (2012-10)
      A 37-year-old, one-pack-per-day tobacco smoker collapsed and died at home. At autopsy, he had an occluded left anterior descending coronary artery. Δ(9)-Tetrahydrocannabinol-carboxylic acid was found in his urine but no cannabinoids were detected in his blood. Misadventure was the inquest verdict on the basis of the urinary cannabis, with acute myocardial infarction as the primary cause and cannabis as the secondary cause of death. Such a conclusion is a misinterpretation of the evidence when the time duration for cannabis as a trigger for myocardial infarction is at most two hours. The absence of cannabis in the blood likely places the time since inhalation at more than two hours. The role of tobacco smoking as a trigger was ignored. Cotinine, the biochemical marker of tobacco smoke, should be added to the standard toxicological screen in the guidelines on autopsy practice of the Royal College of Pathologists.
    • Cannabis smoking and myocardial infarction.

      Tormey, W; Moore, T; Gulmann, C; University of Ulster, Biomedical Science, Coleraine, Northern Ireland Beaumont, Hospital, Pathology, Dublin, Ireland Email: billtormey@gmail.com. (2012-02-01)
    • Cannabis use and childhood trauma interact additively to increase the risk of psychotic symptoms in adolescence.

      Harley, M; Kelleher, I; Clarke, M; Lynch, F; Arseneault, L; Connor, D; Fitzpatrick, C; Cannon, M; Department of Psychiatry, Royal College of Surgeons in Ireland and Beaumont Hospital, Dublin, Ireland. (2010-10)
      Adolescent cannabis use has been shown in many studies to increase the risk of later psychosis. Childhood trauma is associated with both substance misuse and risk for psychosis. In this study our aim was to investigate whether there is a significant interaction between cannabis use and childhood trauma in increasing the risk for experiencing psychotic symptoms during adolescence.
    • Cannabis, possible cardiac deaths and the coroner in Ireland.

      Tormey, W P; Department of Biomedical Sciences, University of Ulster, Coleraine, Northern Ireland, UK, billtormey@gmail.com. (2012-01-10)
      BACKGROUND: The elevated risk of triggering a myocardial infarction by smoking cannabis is limited to the first 2 h after smoking. AIM: To examine the possible role of cannabis in cardiac deaths. CASES AND RESULTS: From 3,193 coroners' cases over 2 years, there were 13 cases where the clinical information was compatible with a primary cardiac cause of death. An inquest was held in three cases. Myocardial infarction was the primary cause of death in 54%. Other causes were sudden adult death syndrome, sudden death in epilepsy, and poisoning by alcohol and diazepam. Cannabis was mentioned once only on a death certificate, but not as a cause of death. Blood delta9-tetrahydrocannabinol-carboxylic acid was recorded in one case and in no case was plasma tetrahydrocannabinol (THC) measured. CONCLUSIONS: To attribute sudden cardiac death to cannabis, plasma THC should be measured in the toxicology screen in coroners' cases where urine cannabinoids are positive. A positive urine cannabinoids immunoassay alone is insufficient evidence in the linkage of acute cardiac death and cannabis.
    • Cardiovascular and Interventional Radiological Society of Europe commentary on the treatment of chronic cerebrospinal venous insufficiency.

      Reekers, J A; Lee, M J; Belli, A M; Barkhof, F; Department of Radiology, AMC, University of Amsterdam, Amsterdam, The Netherlands. j.a.reekers@amc.uva.nl (2011-02)
      Chronic cerebrospinal venous insufficiency (CCSVI) is a putative new theory that has been suggested by some to have a direct causative relation with the symptomatology associated with multiple sclerosis (MS) [1]. The core foundation of this theory is that there is abnormal venous drainage from the brain due to outflow obstruction in the draining jugular vein and/or azygos veins. This abnormal venous drainage, which is characterised by special ultrasound criteria, called the "venous hemodynamic insufficiency severity score" (VHISS), is said to cause intracerebral flow disturbance or outflow problems that lead to periventricular deposits [2]. In the CCSVI theory, these deposits have a great similarity to the iron deposits seen around the veins in the legs in patients with chronic deep vein thrombosis. Zamboni, who first described this new theory, has promoted balloon dilatation to treat the outflow problems, thereby curing CCSVI and by the same token alleviating MS complaints. However, this theory does not fit into the existing bulk of scientific data concerning the pathophysiology of MS. In contrast, there is increasing worldwide acceptance of CCSVI and the associated balloon dilatation treatment, even though there is no supporting scientific evidence. Furthermore, most of the information we have comes from one source only. The treatment is called "liberation treatment," and the results of the treatment can be watched on YouTube. There are well-documented testimonies by MS patients who have gained improvement in their personal quality of life (QOL) after treatment. However, there are no data available from patients who underwent unsuccessful treatments with which to obtain a more balanced view. The current forum for the reporting of success in treating CCSVI and thus MS seems to be the Internet. At the CIRCE office and the MS Centre in Amsterdam, we receive approximately 10 to 20 inquiries a month about this treatment. In addition, many interventional radiologists, who are directly approached by MS patients, contact the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) for advice. Worldwide, several centres are actively promoting and performing balloon dilatation, with or without stenting, for CCSVI. Thus far, no trial data are available, and there is currently no randomized controlled trial (RCT) in progress Therefore, the basis for this new treatment rests on anecdotal evidence and successful testimonies by patients on the Internet. CIRSE believes that this is not a sound basis on which to offer a new treatment, which could have possible procedure-related complications, to an often desperate patient population.
    • Caring for dementia carers: the role of general practitioners in Ireland.

      O'Connor, C; Department of Surgery, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland, o_connor_ciara@hotmail.com. (2011-01-29)
      BACKGROUND: Dementia patients in Ireland live 8 years on average after diagnosis and health policy aims to ensure patients are cared for in the home for as long as possible. AIM: To assess the role of general practitioners in Ireland caring for dementia carers. METHODS: A PubMed search (1980-2010) was performed using MeSH terms "caregivers or carers", "Dementia or Alzheimer's disease", "family physician or general practitioner". An English language restriction was imposed and the search continued to June 24th 2010. RESULTS: Psychosocial multidisciplinary interventions that unite education, skills training, management of psychological problems and family support in the community are effective in managing the problems of carers and should be facilitated by general practitioners. CONCLUSIONS: Dementia carers form an important yet understated patient group who present unique challenges for general practitioners in Ireland.
    • Caring for dementia carers: the role of general practitioners in Ireland.

      O'Connor, C; Department of Surgery, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland., o_connor_ciara@hotmail.com (2012-02-01)
      BACKGROUND: Dementia patients in Ireland live 8 years on average after diagnosis and health policy aims to ensure patients are cared for in the home for as long as possible. AIM: To assess the role of general practitioners in Ireland caring for dementia carers. METHODS: A PubMed search (1980-2010) was performed using MeSH terms "caregivers or carers", "Dementia or Alzheimer's disease", "family physician or general practitioner". An English language restriction was imposed and the search continued to June 24th 2010. RESULTS: Psychosocial multidisciplinary interventions that unite education, skills training, management of psychological problems and family support in the community are effective in managing the problems of carers and should be facilitated by general practitioners. CONCLUSIONS: Dementia carers form an important yet understated patient group who present unique challenges for general practitioners in Ireland.
    • A Case of Autoimmune Pancreatitis Presenting as a Deterioration in Glycaemic Control in a Patient with Pre-Existing Type 2 Diabetes

      Forde, H; Slattery, D; Swan, N; Smith, D (Irish Medical Journal, 2017-05)
      Autoimmune pancreatitis (AIP) was first described in 1961 and accounts for 5-6% of cases of chronic pancreatitis, though the prevalence is increasing with increasing awareness of the disease1,2. There are two types of autoimmune pancreatitis with different clinical and pathological features. Type 1 AIP is an IgG4 related disease and tends to occur in elderly patients in the 7th decade, with a male preponderance3. Type 1 AIP is associated with other organ involvement and commonly affects the biliary system3. In contrast, Type 2 AIP occurs in patients in the 5th-6th decade of life and other organ involvement is uncommon3. Both types of AIP respond well to steroids with reported remission rates of 99% and 92% for Type 1 and Type 2 AIP respectively4. Case report: A 69-year-old man was referred to the diabetes clinic with poor glycaemic control despite escalation of oral hypoglycaemic therapy. He had been diagnosed with Type 2 diabetes mellitus (T2DM) 1 year previously, having presented with polyuria, one stone weight loss and a HbA1c of 12%. His past medical history included asthma, benign prostatic hypertrophy, treated hypertension, B12 deficiency and gallstone cholecystitis. At presentation to the diabetes clinic, his BMI was 24kg/m2 with a HbA1c of 8.1% on Gliclazide 120mg daily and Pioglitazone 15mg daily. A previous trial of Metformin and Saxagliptin had been ineffective at lowering blood glucose levels. He was commenced on Insulin Detemir once daily to optimise diabetes control. In view of the significant weight loss and hyperglycaemia despite multiple agents, computerised tomography (CT) of the pancreas was arranged. This revealed pancreatic duct dilatation within an atrophic pancreatic tail. Magnetic Resonance Cholangiopancreatography (MRCP) demonstrated a prominence in the pancreatic head and neck region which appeared malignant when further imaged with endoscopic ultrasound (EUS).
    • A case of dapsone induced methaemoglobinaemia.

      O'Dwyer, D; McElvaney, N G; Department of Respiratory Medicine, Beaumont Hospital, Dublin, Ireland. daviodwyer@gmail.com (2008-09)
      We present a case of dapsone induced methaemoglobinaemia that occurred in a patient who presented to the Emergency Department of a University Hospital. It is an uncommon condition that requires specific and urgent treatment in severe cases.
    • A case of desensitization, transplantation, and allograft dysfunction.

      Magee, Colm; Clarkson, Michael; Rennke, Helmut; Department of Nephrology, Beaumont Hospital, Dublin, Ireland. cmagee99@gmail.com (2008-09)
    • A Case of Hemorrhagic Necrosis of Ectopic Liver Tissue within the Gallbladder Wall.

      Nagar, Sapna; Koffron, Alan; Raofi, Vandad; Department of Surgery, William Beaumont Hospital, Royal Oak, MI 48073, USA. (2012-02-01)
      Ectopic liver tissue is a rare clinical entity that is mostly asymptomatic and found incidentally. In certain situations, however, patients may present with symptoms of abdominal pain secondary to torsion, compression, obstruction of adjacent organs, or rupture secondary to malignant transformation. Herein, we report a case of a 25-year-old female that presented with acute onset of epigastric pain found to have ectopic liver tissue near the gallbladder complicated by acute hemorrhage necessitating operative intervention in the way of laparoscopic excision and cholecystectomy. The patient's postoperative course was uneventful. Gross pathology demonstrated a 1.2 x 2.8 x 4.5 cm firm purple ovoid structure that histologically revealed extensive hemorrhagic necrosis of benign ectopic liver tissue.
    • A case of progressive hypertension preceding gemcitabine-associated thrombotic microangiopathy complicated by acute kidney injury and stroke.

      Phelan, Paul J; Liew, Aaron; Magee, Colm; Department of Nephrology, Beaumont Hospital, Dublin 9, Ireland. paulphel@gmail.com (2009)
      Gemcitabine-associated thrombotic microangiopathy is being increasingly recognized as a serious complication of treatment. We report a normotensive patient who developed progressive hypertension after commencing gemcitabine therapy. She also developed subtle changes in her platelet count and serum creatinine months before her emergent presentation. Clinicians should be aware of new onset or worsening hypertension and 'mild' biochemical changes in gemcitabine-treated patients.
    • A case of progressive multifocal leukoencephalopathy in a patient with sarcoidosis.

      St Vincent's University Hospital, Elm Park, Dublin 4, Department of Radiology, St, Vincent's University Hospital, Elm Park, Dublin 4, Department of Opthalmology,, Blackrock Clinic, Dublin 4, Department of Neuropathology and Department of, Neurosurgery, Beaumont Hospital, Dublin 9, Ireland. (2012-02-01)
    • A case of stiff-person syndrome, type 1 diabetes, celiac disease and dermatitis herpetiformis.

      O'Sullivan, Eoin P; Behan, Lucy-Ann; King, Tom F J; Hardiman, Orla; Smith, Diarmuid; Department of Diabetes and Endocrinology, Beaumont Hospital, Dublin 9, Ireland. eoinosullivan@beaumont.ie (2009-05)
      Antibodies against glutamic acid decarboxylase (GAD) are involved in the pathophysiology of stiff-person syndrome (SPS) and type 1 diabetes. GAD catalyses the conversion of glutamate to gamma-aminobutyric acid (GABA). GABA acts as a neurotransmitter between neurones, while in pancreatic beta cells it plays an integral role in normal insulin secretion, hence the clinical presentation of muscular spasms in SPS and insulin deficiency in diabetes. Despite this apparent major overlap in pathophysiology, SPS only rarely occurs in individuals with type 1 diabetes. We report the case of a 41-year-old man presenting with a simultaneous diagnosis of both these conditions. His case is unusual in that it is the first reported case in the literature of these conditions occurring in someone with celiac disease (CD) and dermatitis herpetiformis. We discuss why SPS and type 1 diabetes co-exist in only a minority of cases and speculate on the underlying mechanism of the association with CD and dermatitis herpetiformis in our patient.