• Needs of informal caregivers across the caregiving course in amyotrophic lateral sclerosis: a qualitative analysis.

      Galvin, Miriam; Carney, Sile; Corr, Bernie; Mays, Iain; Pender, Niall; Hardiman, Orla (BMJ Open, 2018-01-27)
      Amyotrophic lateral sclerosis (ALS), also known as motor neuron disease (MND), is a debilitating terminal condition. Informal caregivers are key figures in ALS care provision. The physical, psychological and emotional impact of providing care in the home requires appropriate assistance and support. The objective of this analysis is to explore the needs of informal ALS caregivers across the caregiving course.
    • Isolated Unilateral Pulmonary Artery Agenesis complicated by Symptomatic Aspergilloma

      Daly, A; Gunaratnam, C; Redmond, K C; Eaton, D (Irish Medical Journal, 2017-11)
      Isolated unilateral pulmonary artery agenesis is a rare diagnosis. Poor blood flow to the lung parenchyma renders the tissue susceptible to opportunistic infections. We present the unusual case of isolated unilateral pulmonary artery agenesis complicated by aspergilloma. Management options and considerations are discussed.
    • The Avocado Hand

      Rahmani, G; Martin-Smith, J; Sullivan, P (Irish Medical Journal, 2017-11)
      Accidental self-inflicted knife injuries to digits are a common cause of tendon and nerve injury requiring hand surgery. There has been an apparent increase in avocado related hand injuries. Classically, the patients hold the avocado in their non-dominant hand while using a knife to cut/peel the fruit with their dominant hand. The mechanism of injury is usually a stabbing injury to the non-dominant hand as the knife slips past the stone, through the soft avocado fruit. Despite their apparent increased incidence, we could not find any cases in the literature which describe the “avocado hand”. We present a case of a 32-year-old woman who sustained a significant hand injury while preparing an avocado. She required exploration and repair of a digital nerve under regional anaesthesia and has since made a full recovery.
    • Dysphagia in the Elderly Following Anterior Cervical Surgery: A Multidisciplinary Approach

      Osuafor, C N.; Greene, B; El-Kininy, N; Donegan, C (Irish Medical Journal, 2017-11)
      Dysphagia is a risk factor for adverse health outcomes like aspiration, recurrent chest infections and malnutrition. Here, we describe a case of an 82-year-old lady who presented with a two-month history of dysphagia after an anterior odontoid screw fixation for a type II odontoid process fracture. This case highlights the importance of a multidisciplinary approach to patient care.
    • Hospital Resource Utilisation by Patients with Community-Acquired Pneumonia

      McCarthy, S; O’Donnell, S; Costello, R W; Humphreys, H (Irish Medical Journal, 2017-09)
      Little data is available on the resource utilisation of patients admitted with Community-Acquired Pneumonia (CAP) in Ireland. A retrospective review of 50 randomly-selected patients admitted to Beaumont Hospital with CAP was undertaken. The mean length of stay of patients with CAP was 12 days (+/- 16 days). All patients were emergency admissions, all had a chest x-ray, a C-reactive protein blood test, and occupied a public bed at some point during admission. Common antimicrobial therapies were intravenous (IV) amoxicillin/clavulanic acid and oral clarithromycin; 60% received physiotherapy. The estimated mean cost of CAP per patient was €14,802.17. Costs arising from admission to hospital with CAP are substantial, but efforts can be undertaken to ensure that resources are used efficiently to improve patient care such as discharge planning and fewer in-hospital ward transfers
    • Impact of somatic PI3K pathway and ERBB family mutations on pathological complete response (pCR) in HER2-positive breast cancer patients who received neoadjuvant HER2-targeted therapies.

      Toomey, Sinead; Eustace, Alexander J; Fay, Joanna; Sheehan, Katherine M; Carr, Aoife; Milewska, Malgorzata; Madden, Stephen F; Teiserskiene, Ausra; Kay, Elaine W; O'Donovan, Norma; et al. (BioMed Central, 2017-07-27)
      The Cancer Genome Atlas analysis revealed that somatic EGFR, receptor tyrosine-protein kinase erbB-2 (ERBB2), Erb-B2 receptor tyrosine kinase 3 (ERBB3) and Erb-B2 receptor tyrosine kinase 4 (ERBB4) gene mutations (ERBB family mutations) occur alone or co-occur with somatic mutations in the gene encoding the phosphatidylinositol 3-kinase (PI3K) catalytic subunit (PIK3CA) in 19% of human epidermal growth factor receptor 2 (HER2)-positive breast cancers. Because ERBB family mutations can activate the PI3K/AKT pathway and likely have similar canonical signalling effects to PI3K pathway mutations, we investigated their combined impact on response to neoadjuvant HER2-targeted therapies.
    • 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).
    • Home enteral nutrition recipients: patient perspectives on training, complications and satisfaction

      Boland, Karen; Maher, Niamh; O'Hanlon, Carmel; O'Sullivan, Maria; Rice, Niamh; Smyth, Martina; Reynolds, John V (BMJ, 2016-10)
      The equitable provision of home enteral nutrition (HEN) in the community can have a transformative effect on patient experience and family life for adults and children alike. While optimising quality of life in HEN patients can be challenging, the initiation of HEN positively impacts this measure of healthcare provision.1 Quality of life scores have been shown to improve in the weeks after hospital discharge, and HEN is physically well tolerated. However, it may be associated with psychological distress, and sometimes reluctance among HEN patients to leave their homes.2 Globally, HEN can attenuate cumulative projected patient care costs through a reduction in hospital admission and complications including hospital acquired infections.3 In an era where the cost of disease related malnutrition and associated prolonged hospital stay is being tackled in our healthcare systems, the role of HEN is set to expand. This is a treatment which has clear clinical and social benefits, and may restore some independence to patients and their families. Rather than the indications for HEN being focused on specific diagnoses, the provision of months of quality life at home for patients is adequate justification for its prescription.4 Previously, a review of HEN service provision in 39 cases demonstrated that patients want structured follow-up after hospital discharge, and in particular, would like one point of contact for HEN education and discharge.5 Management structures, funding challenges and the need for further education, particularly within the primary care setting may limit optimal use of HEN. The Irish Society for Clinical Nutrition and Metabolism (IrSPEN) aims to develop a national guideline document, drawing on international best practice, forming a template and standards for local policy development in the area of HEN service provision, training and follow-up. The first step in guideline development was to investigate patient experience for adults and children alike. Care needs and supports may differ in these distinct populations. The unmet needs of carers of older adults on HEN have been documented,6 although multidisciplinary interventions and evolution of standards for successful discharge will benefit all affected patients and their families. The aim of this study, therefore, was to survey domiciliary HEN clients, to document and analyse user experience, attitudes and complications associated with HEN.
    • DVT presentations to an emergency department: a study of guideline based care and decision making

      Lillis, D; Lloyd, C; O’Kelly, P; Kelada, S; Kelly, S; Gilligan, P (Irish Medical Journal, 2016-02)
      Pre-test probability scoring and blood tests for deep venous thrombosis (DVT) assessment are sensitive, but not specific leading to increased demands on radiology services. Three hundred and eighty-five patients presenting to an Emergency Department (ED), with suspected DVT, were studied to explore our actual work-up of patients with possible DVT relating to risk stratification, further investigation and follow up. Of the 205 patients with an initially negative scan, 36 (17.6%) were brought for review to the ED Consultant clinic. Thirty-four (16.6%) patients underwent repeat compression ultrasound with 5 (2.4%) demonstrating a DVT on the second scan. Repeat compression ultrasound scans were performed on 34 (16.6%) patients with an initially negative scan, with essentially the same diagnostic yield as other larger studies where 100% of such patients had repeat scanning. Where there is ongoing concern, repeat above-knee compression ultrasound within one week will pick up a small number of deep venous thromboses.
    • Vaccination in Renal Transplant Patients (VcRtp study)

      Rathore, F; Berzan, E; Magee, C (Irish Medical Journal, 2016-02)
      Adverse outcomes of influenza & pneumococcal infections in solid organ transplant recipients have been well documented. Vaccinations are therefore recommended by multiple guidelines. Despite emerging evidence of the safety & effectiveness among immunosuppressed patients, most vaccines are still underutilized, we conducted a survey among the renal transplant patients in Beaumont Hospital to determine the awareness and uptake of vaccinations. Questionnaires were handed to patients during a clinic visit over a span of 2 weeks and 250 questionnaires were posted out to randomly selected transplant patients, The Questionnaire addressed various aspects including the awareness of importance of vaccinations, source of information, if they were up to date with the vaccines & where did they receive it?
    • Secondary prevention after ischaemic stroke: the ASPIRE-S study

      Brewer, Linda; Mellon, Lisa; Hall, Patricia; Dolan, Eamon; Horgan, Frances; Shelley, Emer; Hickey, Anne; Williams, David (BMC Neurology, 2015-10-23)
    • Deep full thickness burn to a finger from a topical wart treatment

      Tong, E; Dorairaj, J; O’Sullivan, JB; Kneafsey, B (Irish Medical Journal, 2015-10)
      We present a case of a deep full thickness burn from topical formic acid. Our patient developed a burn over her proximal interphalangeal joint (PIPJ) of her finger, secondary to inappropriate application of an anti-wart treatment. The burn required extensive debridement, and the resultant defect was reconstructed using a subcutaneous flap from the adjacent finger (a reverse cross finger flap). She was reviewed six months post-surgery, and overall she has a sub-optimal result. This incident was referred to the Irish Medicines Board who have since reviewed the case and ordered the manufacturer to alter their usage instructions.
    • Evaluation of presenting symptoms and long-term outcomes of patients requiring excision of a transobturator tape (TOT)

      Forde, JC; Davis, NF; Creagh, TA (Irish Medical Journal (IMJ), 2015-10)
      The transobturator tape (TOT) is an effective treatment for stress urinary incontinence (SUI). Erosion of TOT mesh is a recognised complication requiring excision. A retrospective analysis of 228 females undergoing a TOT procedure over 4 years identified 16 patients (7%) that underwent excision of eroded mesh. Mean age of patients requiring excision was 48.8 years and mean weight was 72.7kg. Mean time to re-presentation was 14.5 months. Presenting symptoms included dyspareunia in 9 patients (56.2%), dysuria in 3 (18.7%), persistent incontinence in 3 (18.7%) and groin pain in one patient. Ten patients (62.5%) had a prior urogynecological procedure. After excision of eroded tape-mesh, 7 (43.7%) required a rectus fascial sling and 4 (25%) underwent repeat TOT for recurrence of SUI. Five patients (31.2%) required no further surgery. At present 10 patients (62.5%) report resolution of SUI, 4 (25%) report mild SUI and 2 (12.5%) patients have moderate/severe SUI. Resolution of symptoms occurred in the majority of patients after excision of eroded mesh and an additional anti-incontinence procedure
    • Using social media to increase accessibility to online teaching resources

      O’Kelly, B; McHugh, S; McHugh, T; Fady, N; Boyle, E; Hill, ADK (Irish Medical Journal, 2015-09)
      The key learning points of Surgical Grand Rounds (SGR) are often not accessible at times of exam revision for students. We sought to use Twitter as an online teaching repository. A SGR Twitter profile was created. 23 SGR presentations were made accessible on Twitter over a 3 month period. 93 students were invited to complete a questionnaire assessing usage of the repository. 84 (90%) in total responded, of these, 25 (80.6%) felt that the online provision of SGR through twitter was “useful”. The majority (71%) felt that the online content was easily accessible. The novel use of social media is a useful adjunctive educational tool in accessing an online repository of SGR presentations.
    • Home enteral feeding

      Corrigan, Grainne (Nursing in General Practice, 2015-09)
      Enteral nutrition is a well-established therapy for patients with a functioning gastrointestinal tract who require nutrition support due to inadequate or unsafe oral intake to treat or prevent malnutrition.1 Common indications for patients going home on enteral feeding include dysphagia due to neurological conditions, cancer, gastrointestinal obstruction or surgery and those with higher nutritional requirements (eg Cystic Fibrosis). Home Enteral Nutrition (HEN) provides patients with adequate and safe nutrition while allowing them to return to a familiar environment and for some, a degree of independence.2 HEN may be the sole source of nutrition for some patients, or be supplemental to diet for others. It may be given continuously via a pump or by boluses via a syringe, or a combination of both, during the day or overnight. Various enteral feeding tubes are available and are typically classified by site of insertion and location of the distal tip of the feeding tube. (See Table 1) The organisation of HEN usually occurs in the hospital setting and involves the dietitian, medical team, social worker, nursing staff and liaison with community personnel such as the Director of Public Health Nursing (DPHN), the public health nurse (PHN), the general practice and the community dietitian.
    • Breaking barriers to successful implementation of day case laparoscopic cholecystectomy

      Reynolds, I; Bolger, J; Al-Hilli, Z; Hill, ADK (Irish Medical Journal, 2015-07)
      Laparoscopic cholecystectomy is a common procedure performed in both emergency and elective settings. Our aim was to analyse the trends in laparoscopic surgery in Ireland in the public and private healthcare systems. In particular we studied the trend in day case laparoscopic cholecystectomy. National HIPE data for the years 2010-2012 was obtained. Similar datasets were obtained from the three main health insurers. 19,214 laparoscopic cholecystectomies were carried out in Ireland over the 3-year period. More procedures were performed in the public system than the private system from 2010-2012. There was a steady increase in surgeries performed in the public sector, while the private sector remained static. Although the ALOS was significantly higher in the public sector, there was an increase in the rate of day case procedures from 416 (13%) to 762 (21.9%). The day case rates in private hospitals increased only slightly from 29 (5.1%) in 2010 to 40 (5.9%) in 2012. Day case laparoscopic cholecystectomy has been shown to be a safe procedure, however significant barriers remain in place to the implementation of successful day case units nationwide.
    • Paediatric cyclical Cushing's disease due to corticotroph cell hyperplasia.

      Noctor, E; Gupta, S; Brown, T; Farrell, M; Javadpour, M; Costigan, C; Agha, A (BioMed Central, 2015-06)
      Cushing's disease is very rare in the paediatric population. Although uncommon, corticotroph hyperplasia causing Cushing's syndrome has been described in the adult population, but appears to be extremely rare in children. Likewise, cyclical cortisol hypersecretion, while accounting for 15 % of adult cases of Cushing's disease, has only rarely been described in the paediatric population. Here, we describe a very rare case of a 13-year old boy with cyclical cortisol hypersecretion secondary to corticotroph cell hyperplasia.
    • Attitudes of Hospital Healthcare Workers towards Influenza Vaccination in a Tertiary Hospital Setting

      Muhammad, HSS; Gueret, P; Hayes, B (Irish Medical Journal, 2015-06)
      The rate of uptake of seasonal influenza vaccination worldwide by healthcare workers (HCWs) has been suboptimal. Nationally, uptake among hospital HCWs was less than 20%% prior to 2014. Indeed in our hospital following the 2010/2011 influenza season, a significant number of staff chose to have their vaccinations after the usual campaign period. The Occupational Health Department (OHD) undertook a questionnaire survey to determine the reason(s) for their late presentation. This was not anonymised, with a 21.7% participation rate (119 replied out of 548). We found 86(72.3%) HCWs believed influenza to be a serious illness, 84(70.6%) wanted to protect their family members and friends, and 64(53.8%) their patients from the infection. Nevertheless, 77(64.7%) were influenced by the recent media attention on the H1N1 influenza pandemic. We conclude external factors such as the arrival of the H1N1 pandemic continue to play an important role in influencing HCWsâ attitudes towards receiving the vaccine.
    • HLA testing for coeliac disease in Ireland?

      Kutty, J; Hussey, S; Broderick, AM; Quinn, S; Bourke, B (Irish Medical Journal, 2015-05)
      Recent studies have shown a worldwide prevalence of coeliac disease (CD) of around 1% and one of the highest prevalence rates (1 in 300) has been found in the West of Ireland. 1,2 The incidence of coeliac disease appears to be increasing. For example, a greater than 6-fold increase over a 20 year period was evident in a recent retrospective Scottish study. 3 Children with selective IgA deficiency, Down syndrome, Type I diabetes mellitus and autoimmune diseases are at increased risk of CD. Those with a family history are particularly vulnerable with as many as 1 in 10 first-degree, and 1 in 40 second-degree relatives affected. 1 The presenting features of coeliac disease are heterogeneous. The most commonly described symptoms include diarrhoea, excessive flatulence, weight loss, failure to thrive, abdominal distension, pain, bloating, vomiting and anorexia. Irritability is a particularly consistent finding in symptomatic coeliac disease in childhood and CD can also present with many other systemic symptoms such as iron deficiency, anaemia, fatigue, short stature, abnormal liver enzyme tests, osteopenia and dermatitis herpetiformis. However, it must also be remembered that the vast majority of affected individuals manifest few or no symptoms at all
    • Hodgkin lymphoma in a patient with chronic lymphocytic leukaemia a rare presentation of Richter's transformation

      De La Harpe, P; Egan, C; Leader, M; Murphy, PT; Quinn, J (Irish Medical Journal, 2015-04)
      Richter's transformation of chronic lymphocytic leukaemia (CLL) to high-grade B-cell Non-Hodgkin lymphoma occurs in < 5% of CLL cases. Transformation of CLL to Hodgkin Lymphoma is a much rarer event and here we describe a patient who developed Richterâ s transformation into a Hodgkin Lymphoma presenting as rapidly progressive hepatosplenomegaly