RSS 1.0Mater Misericordiae Hospital
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Bilateral Plantar FibromatosisPlantar fibromastosis is a hyperproliferative disorder of the plantar fascia which predominantly affects males over the age of fifty. Its etiology is incompletely understood; however up to 42% of affected patients also have a diagnosis of Diabetes Mellitus.
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Operative Management of Perinatal Lumbar Disc Herniation and Cauda Equina Syndrome: A Case SeriesPerinatal lumbar discectomy for lumbar disc herniation or cauda equina syndrome is a rare clinical scenario. This case series outlines the surgical management of this clinical scenario at a national tertiary referral centre over a 10-year period
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Maximising Refractive Outcomes with an Extended Depth of Focus IOL.To assess the impact of the magnitude of preoperative and postoperative corneal astigmatism on refractive outcomes in patients undergoing cataract surgery or lens exchange with an extended depth of focus intraocular lens. To compare visual outcomes of steep and temporal on-axis corneal incisions. Department of Ophthalmology, Blackrock Clinic, Dublin, Ireland. Prospective cohort analysis. Fifty-three consecutive adult patients (94 eyes) undergoing routine phacoemulsification with Symfony IOL implantation were analysed. Exclusion criteria: targets for mini-monovision, incomplete data, other ocular pathology. Data were prospectively collected on pre- and postoperative refraction, keratometry, distance vision, near vision, surgical wound site and Surgically Induced Astigmatism (SIA).
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The Case for Shared Medical and Psychiatric Units: Are They Needed and How They Could Run?A diagnosis of major mental illness is associated with a 15-20 year reduction in life expectancy. Individuals with mental illness face many difficulties accessing and receiving healthcare, many of these barriers exist in secondary care. On medical and surgical wards, the majority of mental healthcare is delivered by consultation liaison services. Hospital based psychiatry is increasingly important; well designed services are often cost-effective and can reduce patient’s length of stay. Some individual’s care needs, however, exceed the capacity of such a service. There is a significant unmet need for individuals with severe co-morbid mental and physical illness, due to their increased lengths of stay, costs and readmission rate. In these cases ‘both medical and psychiatric safety features form a prerequisite for the physical settings’ 4. This paper examines the need for shared care units (SCU), with additional mental health input. A Vision for Change proposes one adult liaison mental health services for 300,000 people and a national 6-10 bed neuropsychiatry unit. While the proposed neuropsychiatry unit does not currently exist it would only address a small proportion of the individuals who could benefit from a SCU. In Ireland there are currently just over 10,000 acute inpatient beds. Overall 52.5 people per 100,000 require inpatients mental health services. Based on these numbers there is a need for 5 inpatient beds nationally where medical and psychiatric needs can be addressed simultaneously. This calculation however falsely assumes no association between physical and mental health morbidity. In reality a bidirectional association is well established. Psychological morbidity is higher in medical inpatients. A study of general medical and trauma orthopedic admissions, showed that 64% of those over 70 had significant psychiatric morbidity including 8% with delusions and 6% with hallucinations. Patients with major mental illnesses have increased levels of mortality, even in highly income countries greatly reduced life expentancy Kishi and Kanthol suggest that one percent of patients admitted to general hospital would benefit from a SCU4. Compounding this association between physical and psychological illness is the fact that Ireland’s population is aging, older patients have higher rates of inpatient care for both physical and mental health reasons. A review of four studies of such wards demonstrated that SCUs reduce psychiatric symptoms, shorten in length of stay, improve functional outcomes and a decrease the need for long-term care. A medical and mental health unit for older individuals with delirium and dementia has been trialed in the UK with initially favorable and cost effective results11. We identify three cohorts of patients who may benefit from this service. The interventions such a ward could deliver are examined and some of the potential practical considerations are discussed. Key potential benefits that this shared model could provide are highlighted.
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Sarcomatoid Carcinoma of the Prostate Presenting in a 44 Year OldWe present the case of a 44-year-old man diagnosed with metastatic sarcomatoid carcinoma of the prostate. The pathogenesis and optimal treatment of this rare and aggressive subtype of prostate cancer are not fully clear. The patient was managed using a multimodality approach of chemotherapy, hormonal blockade and radiation therapy, with palliative intent.
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Transcatheter Mitral Valve-in-Ring ImplantationFailed surgical mitral valve repair using an annuloplasty ring has traditionally been treated with surgical valve replacement or repair1. For patients at high risk for repeat open heart surgery, placement of a trans-catheter aortic valve (i.e., TAVI valve) within the mitral ring (i.e., Mitral-Valve-in-Ring, MViR) has emerged as a novel alternative treatment strategy2-5 . We describe our experience of a failed mitral valve repair that was successfully treated with a TAVI valve delivered via the trans-septal approach, and summarise the data relating to this emerging treatment strategy.
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Iatrogenic Bowel Injury at Exchange of Supra-Pubic CatheterSuprapubic catheter insertion and exchange is a common urological procedure, but it is not without risks and complications. While bowel perforation is a recognised complication at suprapubic catheter insertion, it is not commonly reported at suprapubic catheter exchange. We report our experience of recognition, diagnosis and subsequent successful management of the most important complication related to suprapubic catheters.
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Is The Consent Process Appropriate - The Interns’ Perspective?Consent is an integral component to any medical procedure involving a competent patient, a communicating doctor, and transfer of information about the procedure. The aim of this study was to assess interns’ experience of the consent process.
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Outcomes of a Clinical Leadership Training Program Amongst Hospital DoctorsTo evaluate the effectiveness of formal leadership training amongst medical trainees and to review the current literature in this area
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Bacteraemia in the ED: Are We Meeting Targets?When sepsis is identified early in the Emergency Department (ED) and its severe form is treated aggressively with the protocolised care bundle of early goal directed therapy (EGDT), improvements in mortality are significant1,2. Surviving sepsis guidelines recommend the administration of effective intravenous antimicrobials within the first hour of recognition of septic shock and severe sepsis without septic shock3. The Mater University Hospital has antimicrobial guidelines to guide empiric prescribing in adult sepsis available on the hospital intranet and on a smartphone app.
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A Borderline Ovarian Tumour in a Patient with Classic Bladder Exstrophy; a Case Report.A 37-year-old Romanian lady presented with a large pelvic mass, urosepsis and deteriorating renal function. She had undergone separation from her conjoined twin. Imaging revealed grossly abnormal anatomy and a suspicious pelvic mass. Examination was consistent with classic bladder exstrophy. Postoperative histology showed borderline ovarian tumour (BTO)
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New Delhi Metallo-Β-Lactamase-Producing Carbapenem-Resistant Enterobacteriacae Isolated From Bronchial Washings.The prevalence of Carbapenem resistance among Enterobacteriacae species is increasing and poses a potential major public health risk. In recent years, several new carbapenemases have been identified, including New Delhi metallo-β-lactamase (NDM). A 78-year-old non-smoking female with prior medical history of type 2 diabetes mellitus, gastroesophageal reflux disease (GERD) and prior coronary artery bypass grafting was referred to our respiratory outpatient service for evaluation of a chronic cough and dyspnoea in 2013. Clinical examination revealed bibasal pulmonary crepitations but was otherwise unremarkable. Computed tomography of the chest demonstrated atelectasis of the lingula and right middle lobe. She underwent bronchoscopy, which demonstrated laryngeal mucosa inflammation, consistent with her GERD. There was no growth on bacterial, fungal or mycobacterial bronchial washings cultures.
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Epithelioid Angiomyolipoma – a case report and review of the literatureHerein we present the case of a 43-year-old female in whom a left renal mass was identified incidentally on imaging performed for staging of a newly diagnosed breast carcinoma. The mass was resected and histologic examination and immunohistochemistry confirmed a diagnosis of epithelioid angiomyolipoma
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Survey of Bereaved Relatives: VOICES MaJamThe report presents findings and recommendations from the largest survey of bereaved relatives undertaken by two adult acute hospitals in Ireland in conjunction with their academic partners TCD and UCD. The findings provide significant insight into the quality of care delivered at end of life from the perspective of bereaved relatives. This report will be of interest to all healthcare staff involved in improving end-of-life care in acute hospitals and other healthcare settings.
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The Hidden Burden of Outpatient Repeat PSA Testing in a Prospective CohortPSA testing is widespread throughout Europe for diagnostic purposes and follow up. We performed a prospective outpatient cohort study of 250 men (2013-2015) in two hospital sites. Included were those men being followed up by urology with PSA blood testing. First appointments and those men in whom non-PSA tests were ordered by urology were excluded. The median age was 67.2yrs (46-88). Eighty-one point two percent of samples had a combination of 21 different serology tests at an added cost of >€18,000. Abnormal serology resulted in 53 referrals. Twenty-six-six percentof correspondence referenced abnormal serology other than PSA. Follow up of non-PSA test results poses a challenge in an outpatient setting with failure to appropriately follow-up on abnormal results, increased costs, and medico-legal implications. There is currently no Irish legislature in place to safeguard hospital physicians. This study quantifies the levels of expenditure, resources and risk associated with ambulant PSA testing.
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Post Traumatic Tension Pneumocephalus: The Mount Fuji SignPneumocephalus is defined as the presence of intracranial air. This is most commonly secondary to a traumatic head injury. Tension pneumocephalus presents radiologically with compression of the frontal lobes and widening of the interhemispheric space between the frontal lobes. It is often termed the Mount Fuji sign due to a perceived similarity with an iconic mountain peak in Japan. We present the case of a 52-year-old gentleman who presented to the emergency department shortly before 8am on a Saturday morning following an assault. He was alert and ambulatory with no clinical evidence of raised intracranial pressure. A plain radiograph of the facial bones showed significant pneumocephalus. A later CT was consistent with a tension pneumocephalus which usually necessitates urgent decompression.The patient showed no clinical signs or symptoms of raised intracranial pressure and was managed conservatively. He was discharged home 16 days later with no neurological deficit
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A role for susceptibility weighted imaging in progressive multifocal leukoencephalopathyWe report a radiologic finding on magnetic resonance imaging (MRI) of the brain of two cases of progressive multifocal leukoencephalopathy (PML) of hypointense signal of subcortical U-fibres on susceptibility weighted (SW) sequence. The first case is a 50-year-old man recently treated with chemotherapy including rituximab for non-Hodgkin's lymphoma. The second case is a 64-year-old woman with human immunodeficiency virus (HIV) infection. Iron deposition is a likely causative factor. We propose that SWI may be especially useful in the assessment of indeterminate cases to reduce the likelihood of a missed diagnosis of PML
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Multidisciplinary emergent removal of a metal penoscrotal constriction deviceStrangulation of the genital organs is a rare presentation to the emergency department which requires urgent intervention to avoid long term complications. Penoscrotal constriction devices are either used for autoerotic stimulus or to increase sexual performance by maintaining an erection for a longer period. We report a case of a man who presented with penile strangulation following the application of a titanium penoscrotal constriction ring during sexual intercourse seven hours previously. The Fire Brigade department attended with an electric operated angle grinder to facilitate removal of the ring as standard medical equipment (orthopaedic saws, bolt and bone cutters) were insufficient. Fully functional recovery was achieved.
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Improving time to surgery for hip fracture patients. Impact of the introduction of an emergency theatreHip fractures are a major cause of morbidity and mortality1. Surgery performed on the day of or after admission is associated with improved outcome2,3. An audit cycle was performed examining time to surgery for hip fracture patients. Our initial audit identified lack of theatre space as one factor delaying surgery. A dedicated daytime emergency theatre was subsequently opened and a re-audit was performed to assess its impact on time to surgery. Following the opening of the theatre, the proportion of patients with a delay to hip fracture surgery greater than 36 hours was reduced from 49% to 26% with lack of theatre space accounting for 23% (3 of 13) of delayed cases versus 28.6% (9 of 32) previously. 44% of hip fracture surgeries were performed in the emergency theatre during daytime hours, whilst in-hospital mortality rose from 4.6% to 6%. We conclude that access to an emergency theatre during daytime hours reduced inappropriate delays to hip fracture surgery.
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Diagnosing Lynch SyndromeLynch Syndrome, also known as Hereditary Non-Polyposis Colorectal Cancer (HNPCC), is a hereditary condition that increases an individual’s risk of developing a constellation of cancers. These most commonly arise in the colon, but also involve other solid organs such as the endometrium and ovaries in women, the stomach, brain and the skin. Ireland’s small population offers an opportunity to identify all those with Lynch Syndrome (LS) in the country, which would represent a powerful preventive opportunity to meaningfully impact on the incidence of cancer in Ireland.
