• 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
    • Referral letters to the emergency department: is the medication list accurate?

      McCullagh, M; O'Kelly, P; Gilligan, P (Irish Medical Journal, 2015-02)
      Medication errors are common when patients transfer across healthcare boundaries. This study was designed to investigate the quality of information on medicines provided by general practitioners (GPs) on emergency department (ED) referral letters. A convenience sample of referral letters to the ED of a teaching hospital was reviewed. The medication list and/or patient's drug allergy status were noted. Medicines reconciliation including patient (or carer) interview was conducted to determine the patient's actual home medication list. This was compared with the GP list and any discrepancies were identified and addressed. A total of 92 referral letters were included in the analysis of which 60 were computer-generated and 32 were hand-written. GPs provided dose and frequency of administration information in 47 (51%) of the letters sampled i.e. 44 (71%) computer-generated versus 3 (10%) hand-written; p < 0.001. In addition, the patient was taking their medicines exactly as per the GP list in 20 (22%) of cases. The patient's drug allergy status was documented in 13 (14%) of the letters.
    • Potential pitfalls with the treatment of acquired methaemoglobinaemia

      Cassidy, N; Duggan, E (Irish Medical Journal, 2015-01)
      We read with interest the article by Nee and Fitzgerald. 1 We welcome the call for continued vigilance for methaemoglobinaemia (MetHb) secondary to amyl nitrite abuse; however we would like to emphasise some potential pitfalls associated with the management of acquired MetHb.
    • The appropriateness of a proton pump inhibitor prescription.

      Moran, N; Jones, E; O'Toole, A; Murray, F (Irish Medical Journal, 2014-11)
      Proton pump inhibitors (PPIs) are one of the most commonly prescribed groups of drug in Ireland, at great expense to the Irish healthcare executive. This study aims to evaluate the appropriateness of PPI prescriptions on admission and discharge in a tertiary referral hospital. All non-elective admissions in the Emergency Department in one week were included in the study. 102 patients in total were included, with 36 (35.4%) treated with a PPI on admission. Of these, only 3 (8.3%) had a clear indication noted as per current NICE guidelines. 18 new in-hospital PPI prescriptions were documented. 11 (61%) of which were present on discharge prescriptions. Continuing PPI prescription on discharge into the community may be inappropriate, costly and potentially harmful. Brief interventions aimed at reducing inappropriate PPI prescriptions have been shown to be effective at reducing the cost and potential harm of unnecessary treatment.
    • Malformation risks of antiepileptic drug monotherapies in pregnancy: updated results from the UK and Ireland Epilepsy and Pregnancy Registers.

      Campbell, E; Kennedy, F; Russell, A; Smithson, W H; Parsons, L; Morrison, P J; Liggan, B; Irwin, B; Delanty, N; Hunt, S J; et al. (2014-09)
      Antiepileptic drug (AED) exposure during pregnancy increases the risk of major congenital malformations (MCMs). The magnitude of this risk varies by AED exposure. Here we provide updated results from the UK Epilepsy and Pregnancy Register of the risk of MCMs after monotherapy exposure to valproate, carbamazepine and lamotrigine.
    • Juxta-articular myxoma: an unusual benign mesenchymal lesion, readily mistaken for malignancy

      Beggan, C; Davies, K; Kinsella, J; Leader, M (Irish Medical Journal, 2014-07)
      Myxomas are benign tumours of mesenchymal origin. We describe the 1st reported case of paraspinal juxta-articular myxoma. Juxta-articular myxomas show increased cellularity and distinction from cellular myxoma is required. The differential also includes malignant myxofibrosarcoma. For patient prognosis and management it is essential to separate these entities. Complete surgical excision is the mainstay of treatment as local recurrences may occur.
    • Introducing a specialist drug Kardex can significantly change prescribing practices for VTE in cancer patients

      Coleman, N; Young, R; Greally, M; O Riordan, L; Breathnach, O; Grogan, L (Irish Medical Journal, 2014-06)
      We read with interest the results of the ENDORSE Study 1 . This study clearly demonstrated a high prevalence of risk for venous thromboembolism (VTE) and a low rate of prophylaxis use, particularly in medical patients. Of those at-risk medical and surgical patients with no contraindication to VTE prophylaxis, overall 57% received recommended VTE prophylaxis, with 64% surgical and 47% medical patients, receiving the recommended prophylaxis, respectively. We note that with regard to risk factors present prior to admission, active malignancy was an issue in only 6.7% (n=19) of the patients included in the study, and as inpatients only 2 patients (0.7%) underwent cancer therapy. As such, cancer patients are perhaps underrepresented in this cohort. Cancer is a well-known risk factor for the development of VTE, and VTE is a common and life-threatening condition in cancer patients, resulting in a shorter life expectancy than either cancer patients without VTE or noncancer patients with VTE 2,3 . Effective thromboprophylaxis reduces the risk for VTE and improves outcomes.
    • The use and limitations of SMS reminders to improve outpatient attendance rates

      Sheil, F; Davis, S; Lowery, AJ; Hill, ADK (Irish Medical Journal, 2014-06)
      Missed appointments and non-attendance at outpatient clinics are a major cause of inefficiency in the health service. It is estimated that this problem currently costs the Health Service Executive (HSE) up to 33 million annually; each individual non-attendance costs 80 and adds a burden to lengthening waiting lists and a potential delay in assessment and treatment of the non-attending patient. Outpatient Breast Services are currently under particular pressure with a 60% increase in referrals to the Symptomatic Breast Units (SBU) since services were centralised under the auspices of the NCCP in 2007 1 .
    • Access to in-patient stroke services and multidisciplinary team (MDT) rehabilitation: current demands and capacity

      O’Sullivan, EJ; Williams, DJ; Shanahan-O’Connell, J; Kirrane, K; Armitage, D; Leahy, W; O’Flaherty, E; Horgan, NF (Irish Medical Journal, 2014-06)
      The objective of this project was to analyse the current access to in-patient stroke services and MDT rehabilitation in an acute stroke centre and to compare these services to the recommended â National Clinical Guidelines and Recommendations for the Care of People with Stroke and TIAâ (IHF 2010). A retrospective chart review was carried out, recording activity statistics of all patients admitted with acute stroke over a three-month period. 73 patients (male=40, 54.8%) were included. Patients were discharged from the stroke service after a mean stay of 20.2 days (SD.= 19.3). 76.7% (N=56) of patients were admitted to the acute stroke unit (ASU). The mean length of time from admission to first assessment 3.4 days (SD.=2.68), with an average of 138 minutes of treatment received per day across all disciplines. This is compared to the IHFâ s recommendation of patients being assessed within 24-48 hours of admission and receiving 180 minutes of treatment across all disciplines. As demands for stroke MDT services increase, it is important to recognise the benefits of increasing staff and resources to maintain and continue to improve standards of care
    • Delays in the stroke thrombolysis pathway - Identifying areas for improvement

      Brewer, L; Arize, C; Williams, D (Irish Medical Journal, 2014-05)
      Despite international consensus on the benefits of thrombolysis for ischaemic stroke (IS), it remains underused. Guidelines now recommend a door-to-needle time of d60 minutes. We reviewed the rate and timeliness of thrombolysis for IS at our hospital. 323 stroke patients presented between January 2011 and April 2012.Thirty patients (10.6% of IS) were thrombolysed, mean age was 68.5 years (42 to 88) and 19 patients (63%) were male. Thirty-six patients (12.7% of IS) were not thrombolysed despite arriving within the time-window and symptom resolution was the commonest reason (15 patients; 42%). Despite most thrombolysed patients (42%) presenting to the Emergency Department during daytime working hours, there were delays at each step of the acute care pathway. The mean time for stroke team review was 23 minutes (5-50). The mean door-to-CT and the door-to-needle times were 60 minutes (25-95) and 92 minutes (46-130) respectively. In parallel with national stroke incentives, local audit can highlight barriers to uptake and efficiency within thrombolysis services.
    • Management of parenteral nutrition associated hyperglycaemia: A comparison of subcutaneous and intravenous insulin regimen

      Neff, K; Donegan, D; MacMahon, J; O’Hanlon, C; Keane, N; Agha, A; Thompson, C; Smith, D (Irish Medical Jorunal, 2014-05)
      PN is associated with significant hyperglycaemia, which may be detrimental to clinical outcome. There are few data on the management of this phenomenon outside of intensive care units. In our unit, we studied the efficacy of protocol-based intravenous insulin delivery as compared to subcutaneous insulin prescribed individually outside of the critical care setting. In a retrospective review over a two-year period, we compared patients with PN-associated hyperglycaemia who had received both modes of insulin therapy. A total of 122 who developed PN-associated hyperglycaemia were identified. Those on the intravenous insulin regimen were within glycaemic target for more time than those on the subcutaneous regimen (62% Vs 43%, p=0.008). We therefore conclude that outside of the critical care setting, intravenous insulin delivers better glycaemic control and should therefore be considered optimum therapy for patients with PN-associated hyperglycaemia.
    • Beware: unilateral Reinkes oedema of the larynx

      Kharytaniuk, N; Walshe, P (Irish Medical Journal, 2014-05)
      A thirty year-old man presented with hoarseness of recent onset. The underlying cause was a glottic schwannoma, which led to development of unilateral Reinke’s oedema. Schwannomas arising in the paraglottic space are rare.