• Intravenous, contrast-enhanced MR colonography using air as endoluminal contrast agent: Impact on colorectal polyp detection.

      Keeling, Aoife N; Morrin, Martina M; McKenzie, Charles; Farrell, Richard J; Sheth, Sunil G; Ngo, Long; Bloch, B Nicolas; Pedrosa, Ivan; Rofsky, Neil M; Department of Radiology, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland. (2010-12-03)
      PURPOSE: To compare diagnostic accuracy and patient tolerance of MR colonography with intravenous contrast and luminal air (MRC) to conventional colonoscopy (CC). MATERIALS AND METHODS: IRB approval and written informed consent were obtained. Forty-six patients, both screening and symptomatic, underwent MRC followed by CC. The MRC technique employed 3D T1W spoiled gradient echo sequences performed after the administration of gadopenetate dimeglumine, with parallel imaging. The diagnostic accuracy and tolerance of patients for MRC was compared to CC. RESULTS: Twenty-four polyps were detected in eighteen patients with CC (5 polyps ≥10mm, 4 polyps 6-9mm, 15 polyps ≤5mm). MRC was 66.7% (12/18) sensitive and 96.4% (27/28) specific for polyp detection on a per-patient basis. When analyzed by polyp size, sensitivity and specificity of MRC was 100% (5/5) and 100% (19/19), respectively, for lesions greater than 10mm, 100% (4/4) and 100% (20/20) for lesions 6-9mm, and sensitivity of 20% (3/15) lesions less than 5mm. The sensitivity and specificity of MRC for detecting significant lesions (>6mm) was 100% (9/9) and 100% (15/15), respectively. Regarding tolerance of the exams, there were no significant differences between MRC and CC. Thirty-five percent (n=16) of patients preferred MRC as a future screening test compared to 33% (n=15) for CC. CONCLUSION: MRC using air as an intraluminal contrast agent is a feasible and well-tolerated technique for detecting colonic polyps ≥6mm in size. Further studies are warranted.
    • 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.
    • Invasive Group A streptococcal disease in Ireland, 2004 to 2010.

      Martin, J; Murchan, S; O'Flanagan, D; Fitzpatrick, F; Health Protection Surveillance Centre, Dublin, Ireland. Jennifer_martin@health.gov.ie (2011)
      Invasive group A streptococcal infections (iGAS) are a major clinical and public health challenge. iGAS is a notifiable disease in Ireland since 2004. The aim of this paper is to describe the epidemiology of iGAS in Ireland for the first time over the seven-year period from 2004 to 2010. The Irish national electronic infectious disease reporting system was used by laboratories to enter the source of iGAS isolates, and by departments of public health to enter clinical and epidemiological details. We extracted and analysed data from 1 January 2004 to 31 December 2010. Over the study period, 400 iGAS cases were notified. The annual incidence of iGAS doubled, from 0.8 per 100,000 population in 2004 to 1.6 in 2008, and then remained the same in 2009 and 2010. The reported average annual incidence rates were highest among children up to five years of age (2.3/100,000) and adults aged over 60 years (3.2/100,000). The most common risk factors associated with iGAS were skin lesions or wounds. Of the 174 people for whom clinical syndrome information was available, 28 (16%) cases presented with streptococcal toxic shock syndrome and 19 (11%) with necrotising fasciitis. Of the 141 cases for whom seven-day outcomes were recorded, 11 people died with iGAS identified as the main cause of death (seven-day case fatality rate 8%). The notification rate of iGAS in Ireland was lower than that reported in the United Kingdom, Nordic countries and North America but higher than southern and eastern European countries. The reasons for lower notification rates in Ireland compared with other countries may be due to a real difference in incidence, possibly due to prescribing practices, or due to artefacts resulting from the specific Irish case definition and/or low reporting in the early stages of a new surveillance system. iGAS disease remains an uncommon but potentially severe disease in Ireland. Ongoing surveillance is required in order to undertake appropriate control measures and gain a greater understanding of this disease.
    • Invasive intracerebral fungal infection in a leukaemic patient.

      O'Brien, Deirdre; Lim, Chor Hiang; Farrell, Michael; O'Marcaigh, Aengus; Rawluk, Daniel; Fitzpatrick, Fidelma; Smyth, Edmond; Department of Clinical Microbiology, Beaumont Hospital, Dublin 9, Ireland. de.obrien@svuh.ie (2012-06)
      Intracerebral abscesses secondary to Zygomycosis are potentially fatal. A 12-year-old girl with acute promyelocytic leukaemia was successfully treated for intracerebral abscess caused by Zygomycosis with complete surgical excision and combination antifungal therapy.
    • Inverted formin 2 mutations with variable expression in patients with sporadic and hereditary focal and segmental glomerulosclerosis.

      Gbadegesin, Rasheed A; Lavin, Peter J; Hall, Gentzon; Bartkowiak, Bartlomiej; Homstad, Alison; Jiang, Ruiji; Wu, Guanghong; Byrd, Alison; Lynn, Kelvin; Wolfish, Norman; et al. (2012-01)
      Focal and segmental glomerulosclerosis (FSGS) is a major cause of end-stage kidney disease. Recent advances in molecular genetics show that defects in the podocyte play a major role in its pathogenesis and mutations in inverted formin 2 (INF2) cause autosomal dominant FSGS. In order to delineate the role of INF2 mutations in familial and sporadic FSGS, we sought to identify variants in a large cohort of patients with FSGS. A secondary objective was to define an approach for genetic screening in families with autosomal dominant disease. A total of 248 individuals were identified with FSGS, of whom 31 had idiopathic disease. The remaining patients clustered into 64 families encompassing 15 from autosomal recessive and 49 from autosomal dominant kindreds. There were missense mutations in 8 of the 49 families with autosomal dominant disease. Three of the detected variants were novel and all mutations were confined to exon 4 of INF2, a regulatory region responsible for 90% of all changes reported in FSGS due to INF2 mutations. Thus, in our series, INF2 mutations were responsible for 16% of all cases of autosomal dominant FSGS, with these mutations clustered in exon 4. Hence, screening for these mutations may represent a rapid, non-invasive and cost-effective method for the diagnosis of autosomal dominant FSGS.
    • Investigation of sleep disturbance in chronic low back pain: an age- and gender-matched case-control study over a 7-night period.

      van de Water, Alexander T M; Eadie, Jennifer; Hurley, Deirdre A; School of Public Health, Physiotherapy and Population Science, Health Sciences Centre, University College Dublin, Dublin 4, Ireland. (2011-12)
      Sleep disturbance is frequently reported by people with chronic low back pain (>12 weeks; CLBP), but few studies have comprehensively investigated sleep in this population. This study investigated differences in subjectively and objectively measured sleep patterns of people with CLBP, and compared this to age- and gender matched controls. Thirty-two consenting participants (n = 16 with CLBP, n = 16 matched controls), aged 24-65 years (43.8% male) underwent an interview regarding sleep influencing variables, completed the Pittsburgh Sleep Quality Index, Insomnia Severity Index, Pittsburgh Sleep Diary, SF36-v2, Hospital Anxiety and Depression Scale, Oswestry Disability Index, Numerical Pain Rating Scales, and underwent seven consecutive nights of actigraphic measurement in the home environment. Compared to controls, people with CLBP had, on self-report measures, significantly poorer sleep quality [Pittsburgh Sleep Quality Index (range 0-21) mean (SD) 10.9 (4.2)], clinical insomnia [Insomnia Severity Index mean (range 0-28) 13.7 (7.6)], lower sleep efficiency, longer sleep onset latency, more time awake after sleep onset, and more awakenings during sleep (p < 0.05). However, no significant differences between groups were found on objective actigraphy (p > 0.05). The findings provide some evidence to support self-reported sleep assessment as an outcome measure in CLBP research, while further research is needed to determine the validity of objective sleep measurement in this population.
    • An investigation of the subtype diversity of clinical isolates of Irish Clostridium difficile ribotypes 027 and 078 by repetitive-extragenic palindromic PCR.

      Solomon, K; Murray, S; Scott, L; McDermott, S; Drudy, D; Martin, A; O'Donoghue, C; Skally, M; Burns, K; Fenelon, L; et al. (2011-08)
      A repetitive-extragenic palindromic PCR (rep-PCR) subtyping method (DiversiLab) in conjunction with ribotyping, toxinotyping and antimicrobial-susceptibility testing was used to detect subtypes within Clostridium difficile ribotypes 027 and 078. Clinical isolates of ribotypes 027 (toxinotype III) (n = 30) and 078 (toxinotype V) (n = 23) were provided by health-care facilities across the Republic of Ireland over 2 months in 2006 and 1 month in 2009. Ribotype 027 isolates were significantly more related to each other (9 different subtype profiles) when compared to ribotype 078 isolates (14 different profiles) (P = 0.001; cut-off >90 % similarity). Almost half of ribotype 078 isolates (45.5 %) showed no relationship to each other. The clonality of ribotype 027 isolates suggests effective adaptation to the human niche, whereas the considerable genetic diversity within ribotype 078 isolates suggests that they may have originated from a variety of sources. Subtyping correlated well with antimicrobial susceptibility, in particular clindamycin susceptibility for ribotype 027, but diverse antimicrobial-susceptibility profiles were seen in ribotype 078 isolates, even within a single health-care facility. Between 2006 and 2009, a change in the predominant subtype of ribotype 027 was seen, with the recent clone representing half of all ribotype 027 isolates studied. This strain exhibited 89 % similarity to a rep-PCR profile of the North American NAP-1 strain.
    • The involvement of glycosaminoglycans in airway disease associated with cystic fibrosis.

      Reeves, Emer P; Bergin, David A; Murray, Michelle A; McElvaney, Noel G; Respiratory Research Division, Department of Medicine, Royal College of Surgeons , in Ireland, Education and Research Centre, Beaumont Hospital, Dublin, Ireland., emerreeves@rcsi.ie (2012-02-01)
      Individuals with cystic fibrosis (CF) present with severe airway destruction and extensive bronchiectasis. It has been assumed that these structural airway changes have occurred secondary to infection and inflammation, but recent studies suggest that glycosaminoglycan (GAG) remodelling may be an important independent parallel process. Evidence is accumulating that not only the concentration, but also sulphation of GAGs is markedly increased in CF bronchial cells and tissues. Increased expression of GAGs and, in particular, heparan sulphate, has been linked to a sustained inflammatory response and neutrophil recruitment to the CF airways. This present review discusses the biological role of GAGs in the lung, as well as their involvement in CF respiratory disease, and their potential as therapeutic targets.
    • Iodinated contrast media alter immune responses in pro-inflammatory states.

      O'Donnell, David H; Moloney, Michael A; Bouchier-Hayes, David J; Lee, Michael J; Department of Radiology and Vascular Surgery, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin, Ireland. (2010-07)
      Hypertonic saline causes a transient elevation of blood osmolality and has been shown to alter cellular inflammatory responses in pro-inflammatory states. Intravascular administration of iodine contrast media also causes a transient elevation of blood osmolarity.
    • The Irish epilepsy surgery experience: Long-term follow-up.

      Dunlea, Orla; Doherty, Colin P; Farrell, Michael; Fitzsimons, Mary; O'Brien, Donncha; Murphy, Kevin; MacMackin, Deirdre; Pender, Niall; Staunton, Hugh; Phillips, Jack; et al. (2010-05)
      To assess the long-term seizure outcome of Irish patients who underwent resective surgery for refractory epilepsy since 1975. We also wished to determine the impact of pathology and surgical technique (with particular reference to neocorticectomy) on seizure outcome.
    • Is hair loss a reality in neuro-interventional radiology?

      Gavagan, L; Ti, J; Thornton, J; Department of Radiology, Beaumont Hospital, Dublin, Ireland., lindagavagan@beaumont.ie (2012-02-01)
      Reports in the literature of radiation-induced hair loss are becoming increasingly common. This work describes a retrospective dose study of patients (n = 958) undergoing diagnostic (primarily cerebral angiograms) and therapeutic (primarily cerebral embolisation) procedures in a neuro-interventional suite. A comparison of patient doses as dose area product (DAP) readings from a single-plane image intensifier system (mean DAP value of 8772 cGy cm(2)) were compared with patient doses from a flat panel biplane system (mean DAP value of 7855 cGy cm(2)). Over 80 % of patients requiring neuro-interventional procedures were found to undergo two procedures or more. An estimated 7 % of therapeutic procedures were found to reach the International Commission on Radiological Protection threshold for temporary epilation.
    • Is the contribution of alcohol to fatal traumatic brain injuries being underestimated in the acute hospital setting?

      O'Toole, O; Mahon, C; Lynch, K; Brett, F M; Department of Neuropathology, Beaumont Hospital, Beaumont, Dublin. (2011-04-05)
      Alcohol consumption in Ireland has nearly doubled during the period 1989-2001. To evaluate the relationship of alcohol to fatal head injuries in the acute hospital setting we created a data base of all fatal traumatic brain injuries in the Department of Neuropathology at Beaumont Hospital over a ten year period (1997-2006 inclusive). 498 cases were identified (351 males: 147 females). Fatalities were highest in males aged 19-25 years (N=101) and 51-70 years (N=109). Falls (N=210) and road traffic accidents (N=183) were the commonest modes of presentation. 36/210 (17%) falls had positive blood alcohol testing, 9/210 (4.3%) had documentation of alcohol in notes but no testing, 35/210 (16.7%) tested negative for alcohol and 130/210 (61.9%) were not tested. The RTA group (N=183) comprised drivers (n=79), passengers (n=47) and pedestrians (n=57). 65/79 (82.2%) of drivers were males aged 19-25 years. Blood alcohol was only available in 27/79 (34.1%) drivers and was positive in 13/27 (48.1%). 14/75 (18.7%) pedestrians were tested for alcohol, 4/14 (28.6%) were positive. Overall 142/183 (77.6%) of the RTA group were not tested. The contribution of alcohol to fatal traumatic brain injuries is probably being underestimated due to omission of blood alcohol concentration testing on admission to hospital. Absence of national guidelines on blood alcohol testing in the emergency department compounds the problem.
    • Is the quality of endoscopic research improving? A 20-year review.

      Anwar, Malik M; Harewood, Gavin C; Zeb, Faisal; Slattery, Eoin; Hamed, Mohamed A (2011-06)
    • Is there a requirement for axillary lymph node dissection following identification of micro-metastasis or isolated tumour cells at sentinel node biopsy for breast cancer?

      Joyce, D P; Solon, J G; Prichard, R S; Power, C; Hill, A D K; Department of Surgery, Royal College of Surgeons in Ireland and Beaumont Hospital, Beaumont Road, Dublin 9, Ireland. (2012-02-29)
      INTRODUCTION: Recent decades have seen a significant shift towards conservative management of the axilla. Increasingly, immunohistochemical analysis of sentinel nodes leads to the detection of small tumour deposits, the significance of which remains uncertain. The aims of this study are to examine patients whose sentinel lymph nodes are positive for macro-metastasis, micro-metastasis or isolated tumour cells (ITCs) and to determine the rate of further nodal disease after axillary lymph node dissection (ALND). METHODS: A retrospective analysis of all patients undergoing a sentinel lymph node biopsy (SLNB) between January 2007 and December 2010 in a tertiary referral breast unit was performed. Patients who underwent an axillary lymph node dissection for macro-metastasis, micro-metastasis or ITCs were identified. Demographics, histological data and the rate of further axillary disease were examined. RESULTS: In total, 664 breast cancer patients attended the symptomatic breast unit during the study period, 360 of whom underwent a SLNB. Seventy patients had a SLNB positive for macro-metastasis. All of these patients underwent ALND. A positive SLNB with either micro-metastasis or ITCs was identified in 58 patients. Only 41 of the 58 patients went on to have an ALND, due primarily to variations in surgeons' preferences. Nineteen patients with micro-metastasis underwent an ALND. Four patients had further axillary disease (21%). Twenty-two patients had ITCs identified, of whom only one had further disease (4.5%). No statistically significant difference was found between the two groups in terms of tumour size, grade, lymphovascular invasion or oestrogen receptor status. CONCLUSION: ALND should be considered in patients with micro-metastasis at SLNB. It should rarely be employed in the setting of SLNB positive for ITCs.
    • 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.
    • IVC filter limb penetration of the caval wall during retroperitoneal surgery/lymph node dissection.

      Goh, Gerard S; Slattery, Michael M; Given, Mark F; Little, David; Lee, Michael J; Departments of Radiology Surgery, Beaumont Hospital, Beaumont, Dublin, Ireland. ggoh@doctor.com (2012-12)
      Optional inferior vena cava (IVC) filters are being increasingly used for protection against pulmonary embolism in patients with deep vein thrombosis where anticoagulation is contraindicated. We describe two cases during retroperitoneal surgery where the IVC filters were found to have perforated the cava wall and were subsequently removed intra-operatively. Cava wall penetration by filter limbs poses a significant danger during retroperitoneal lymph node dissection and filters should be removed preoperatively.
    • JNK mitogen-activated protein kinase limits calcium-dependent chloride secretion across colonic epithelial cells.

      Donnellan, Fergal; Keating, Niamh; Geoghegan, Paul; Murray, Frank E; Harvey, Brian J P; Keely, Stephen J; Dept. of Molecular Medicine, Royal College of Surgeons in Ireland, RCSI Education and Research Ctr., Smurfit Bldg., Beaumont Hospital, Dublin 9, Ireland. (2010-01)
      Neuroimmune agonists induce epithelial Cl(-) secretion through elevations in intracellular Ca2+ or cAMP. Previously, we demonstrated that epidermal growth factor receptor (EGFR) transactivation and subsequent ERK MAPK activation limits secretory responses to Ca2+-dependent, but not cAMP-dependent, agonists. Although JNK MAPKs are also expressed in epithelial cells, their role in regulating transport function is unknown. Here, we investigated the potential role for JNK in regulating Cl(-) secretion in T(84) colonic epithelial cells. Western blot analysis revealed that a prototypical Ca2+-dependent secretagogue, carbachol (CCh; 100 microM), induced phosphorylation of both the 46-kDa and 54-kDa isoforms of JNK. This effect was mimicked by thapsigargin (TG), which specifically elevates intracellular Ca2+, but not by forskolin (FSK; 10 microM), which elevates cAMP. CCh-induced JNK phosphorylation was attenuated by the EGFR inhibitor, tyrphostin-AG1478 (1 microM). Pretreatment of voltage-clamped T(84) cells with SP600125 (2 microM), a specific JNK inhibitor, potentiated secretory responses to both CCh and TG but not to FSK. The effects of SP600125 on CCh-induced secretion were not additive with those of the ERK inhibitor, PD98059. Finally, in apically permeabilized T(84) cell monolayers, SP600125 potentiated CCh-induced K+ conductances but not Na+/K+ATPase activity. These data demonstrate a novel role for JNK MAPK in regulating Ca2+ but not cAMP-dependent epithelial Cl(-) secretion. JNK activation is mediated by EGFR transactivation and exerts its antisecretory effects through inhibition of basolateral K+ channels. These data further our understanding of mechanisms regulating epithelial secretion and underscore the potential for exploitation of MAPK-dependent signaling in treatment of intestinal transport disorders.