• 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.
    • Beaumont Rapid Assessment Team (BRAT) service R\V

      Ward, Peter; Murphy, Carole; Beaumont Hospital, Dublin (Health Service Executive (HSE), 2014-02-28)
    • An audit of meal service and provision in a large teaching hospital in Dublin.

      Corrigan, G; Connolly, N; Deeney O; Fanning E; Guiden H; Hannon R; O'Hanlon C; McElligott K; McMahon S; Moreau C; et al. (Health Service Executive (HSE), 2014-02-28)
    • Affects of dysphagia and gastrostomy feeding on quality of life for people with motor neurone disease [poster]

      Doyle, L; McElligott, K; aDepartment of Speech & Language Therapy, bDepartment of Nutrition & Dietetics, Beaumont Hospital, Dublin, Ireland (Health Service Executive (HSE), 2014-02-28)
    • Laparoscopic hemicolectomy for cutaneous malignant melanoma metastasis to the ileocaecal valve

      Boland, T; Burke, J; Morrin, M; Deasy, J (Irish Medical Journal (IMJ), 2014-02)
      Colonic tumours are most frequently primary and lesions secondary to metastasis are uncommon. Malignant melanoma is an aggressive cancer, with a tendency to metastasize and recur. This report describes the case of a 66-year-old man who underwent wide local excision and adjuvant therapy for malignant melanoma three years prior to presentation with loose stools, abdominal cramps and iron deficiency anaemia. CT colonography showed a 6cm ileocaecal mass, and following a laparoscopic right hemicolectomy, histological examination revealed a metastatic melanoma to the ileocaecal valve. Subsequent positron emission tomography showed no residual metastatic disease. Malignant melanoma metastasis to the colon is a rare clinical entity. Metastectomy via laparoscopic right hemicolectomy is an appropriate and effective treatment.
    • Autotransplantation of a single functioning kidney following rupture of renal artery aneurysm

      Sullivan, JF; Forde, JC; Daly, P; Shields, W; O’Kelly, F; Quinlan, DM; Hickey, DP (Irish Medical Journal (IMJ), 2014-02)
      Renal artery aneurysms (RAA) are the second most common visceral artery aneurysm. In cases of rupture they pose a significant and emergent surgical challenge. Extracorporeal arterial reconstruction and autotransplantation is often necessary in certain complex cases that are not amenable to aneurysm repair in vivo. We report a case of a 35 year old female with a RAA in a solitary functioning kidney, requiring ex vivo reconstruction and autotransplantation to the iliac vessels
    • Organ donation following the circulatory determination of death

      O’Rourke, J; Zimmermann, JA; Shields, W; McLaughlin, D; Cunningham, P; Magee, C; Hickey, DP (Irish Medical Journal, 2014-01)
      Organ Donation following the Circulatory determination of Death was introduced in Beaumont Hospital during 2011. The Intensive Care Society of Ireland formally endorsed a national DCD clinical practice guideline in 2012. This retrospective audit covers a 2-year period during which eleven patients were considered suitable for DCD and where consent was obtained. Nine patients died within the ninety-minute period following the withdrawal of life sustaining therapies and subsequently donated organs (82%). Eighteen kidneys were recovered and seventeen patients received renal transplants - one patient received a nephron-dosing dual renal transplant. Lungs were recovered on two occasions and one patient received a lung transplant. Heart valves were recovered on one occasion. To date sixteen of seventeen recipient patients have functioning renal transplants (94%). In conclusion, this model of deceased donation has proven acceptable to families, nursing and medical staff and the outcomes reported are consistent with international best practice.
    • Arrest in hospital: A study of in hospital cardiac arrest outcomes

      Fennelly, NK; Mc Phillips, C; Gilligan, P (Irish Medical Journal (IMJ), 2014)
      The effect of advances in cardiac arrest management over the last five decades on in-hospital cardiac arrest survival rates is not clear. Data on 212 arrests between January 2010 and May 2013 were retrospectively analyzed by means of an audit form based upon the Utstein template for in-hospital cardiac arrest, with a view to identifying significant associations between arrest characteristics and return of spontaneous circulation or survival to discharge. Significant associations were identified between return of spontaneous circulation and location (ward, 36patients (38%) vs. ICU, 33 Patients (56%); P=0.032), whether an arrest was witnessed or not (82 patients (52%) vs. 9 patients (30%); P = 0.029), whether the initial rhythm was shockable or non-shockable (28 patients (85%) vs. 38patients (31 %); P<0.001), whether the first dose of adrenaline was administered within 2 minutes of arrest onset or later (13 patients (54 %) vs.12 patients (28%); P = 0.04).
    • Phase 1 implementation of nutrition screening in a Dublin acute teaching hospital

      Nutrition Screening Steering Group; Beaumont Hospital (Nutrition Screening Steering Group, 2014)
      Nutrition Screening Week results from 2010 and 2011 indicated that one in three to four patients admitted to Irish Hospitals are at risk of disease-related malnutrition, 74-75% of whom are at high risk1. Nutrition screening tools are used to screen for malnutrition risk. One such tool, the Malnutrition Universal Screening Tool (MUST)2 is a practical, easy to use tool that often takes ≤5 minutes to complete. MUST has been validated across care settings and across patient populations, and has been recommended for use in Irish Hospitals by the Department of Health and Children as part of standard care3. The National Institute for Health and Clinical Excellence in the UK has demonstrated significant financial savings associated with the use of routine nutrition screening, in part due to reduced length of hospital stay4. The Irish Society for Clinical Nutrition and Metabolism (IrSPEN) has also demonstrated this5
    • Differences in the structure of outpatient diabetes care between endocrinologist-led and general physician-led services.

      O Donnell, Máire; de Siún, Anna; O Mullane, Monica; Smith, Diarmuid; Bradley, Colin; Finucane, Francis; Dinneen, Sean (2013-11-25)
      Despite a shift in diabetes care internationally from secondary to primary care, diabetes care in the Republic of Ireland remains very hospital-based. Significant variation in the facilities and resources available to hospitals providing outpatient diabetes care have been reported in the UK. The aim of this study was to ascertain the structure of outpatient diabetes care in public hospitals in the Republic of Ireland and whether differences existed in services provided across hospitals.
    • Recurring pulmonary hamartomas: cause for concern?

      Coleman, N; Chotirmall, SH; Forman, E; McCullagh, B; Broe, P; Royston, D; O’Neill, S (Irish Medical Journal (IMJ), 2013-10)
      We report the case of a well-controlled female asthmatic who developed â multiple pulmonary hamartomasâ on three separate occasions over a period of 25 years that necessitated surgical resection. To our knowledge, this is the first report of recurrent hamartomas in a single individual necessitating multiple thoracotomies.
    • Bare below the elbows: A comparative study of a tertiary and district general hospital

      Collins, AM; Connaughton, J; Hill, ADK; Ridgway, PF (Irish Medical Journal (IMJ), 2013-10)
      A Bare Below the Elbows (BBTE) dress code policy has been introduced by the majority of NHS trusts in the UK. The aim of this Irish study was to evaluate the impact of an educational intervention on perception of medical attire. The study was carried out in two centres: a tertiary referral centre (Beaumont Hospital) and a district hospital (MRH, Portlaoise). Two questionnaires, incorporating photographic evaluation of appropriate attire for consultants and junior doctors, were completed pre and post BBTE education. One hundred and five patients participated. Analysis pre BBTE education indicated patients considered formal attire and white coats most appropriate for consultants and junior doctors respectively. Post-intervention analysis revealed a significant reduction in the popularity of both (p <0.001), with scrubs and smart casual attire gaining significant support in both cohorts (p <0.001). Our findings demonstrated that patient opinion on medical attire is malleable. The support of such a policy may be achieved if patients are informed that the aim is to reduce the spread of healthcare-associated infections.