• Day-surgery patients anesthetized with propofol have less postoperative pain than those anesthetized with sevoflurane.

      Tan, Terry; Bhinder, Rajesh; Carey, Michael; Briggs, Liam; Department of Anaesthesia and Perioperative Medicine, Coombe Women and Infants, University Hospital, Cork St., Dublin 8, Ireland. tutan@me.com (2012-02-01)
      BACKGROUND: There have been recent studies suggesting that patients anesthetized with propofol have less postoperative pain compared with patients anesthetized with volatile anesthetics. METHODS: In this randomized, double-blind study, 80 patients undergoing day-case diagnostic laparoscopic gynecological surgery were either anesthetized with IV propofol or sevoflurane. The primary outcome measured was pain on a visual analog scale. RESULTS: Patients anesthetized with propofol had less pain compared with patients anesthetized with sevoflurane (P = 0.01). There was no difference in any of the other measured clinical outcomes. CONCLUSIONS: The patients anesthetized with propofol appeared to have less pain than patients anesthetized with sevoflurane.
    • Delivery outcomes for nulliparous women at the extremes of maternal age - a cohort study.

      Vaughan, DA; Cleary, Bj; Murphy, Dj; Coombe Women and Infants University Hospital, Dublin, Ireland. (2013-06-12)
      OBJECTIVE: To examine the associations between extremes of maternal age (≤17 years or ≥40 years) and delivery outcomes. DESIGN: Retrospective cohort study. SETTING: Urban maternity hospital in Ireland. POPULATION: A total of 36 916 nulliparous women with singleton pregnancies who delivered between 2000 and 2011. METHODS: The study population was subdivided into five maternal age groups based on age at first booking visit: ≤17 years, 18-19 years, 20-34 years, 35-39 years and women aged ≥40 years. Logistic regression analyses were performed to examine the associations between extremes of maternal age and delivery outcomes, adjusting for potential confounding factors. MAIN OUTCOME MEASURES: Preterm birth, admission to the neonatal unit, congenital anomaly, caesarean section. RESULTS: Compared with maternal age 20-34 years, age ≤17 years was a risk factor for preterm birth (adjusted odds ratio [adjOR] 1.83, 95% confidence interval [95% CI] 1.33-2.52). Babies born to mothers ≥40 years were more likely to require admission to the neonatal unit (adjOR 1.35, 95% CI 1.06-1.72) and to have a congenital anomaly (adjOR 1.71, 95% CI 1.07-2.76). The overall caesarean section rate in nulliparous women was 23.9% with marked differences at the extremes of maternal age; 10.7% at age ≤17 years (adjOR 0.46, 95% CI 0.34-0.62) and 54.4% at age ≥40 years (adjOR 3.24, 95% CI 2.67-3.94). CONCLUSIONS: Extremes of maternal age need to be recognised as risk factors for adverse delivery outcomes. Low caesarean section rates in younger women suggest that a reduction in overall caesarean section rates may be possible.
    • Differences in nulliparous caesarean section rates across models of care: a decomposition analysis.

      Brick, Aoife; Layte, Richard; Nolan, Anne; Turner, Michael J (BMC health services research, 2016)
      To evaluate the extent of the difference in elective (ELCS) and emergency (EMCS) caesarean section (CS) rates between nulliparous women in public maternity hospitals in Ireland by model of care, and to quantify the contribution of maternal, clinical, and hospital characteristics in explaining the difference in the rates.
    • Early pregnancy azathioprine use and pregnancy outcomes.

      Cleary, Brian J; Kallen, Bengt; Pharmacy Department, Coombe Women and Infants University Hospital, Dublin 8,, Ireland. bcleary@coombe.ie (2012-02-01)
      BACKGROUND: Azathioprine (AZA) is used during pregnancy by women with inflammatory bowel disease (IBD), other autoimmune disorders, malignancy, and organ transplantation. Previous studies have demonstrated potential risks. METHODS: The Swedish Medical Birth Register was used to identify 476 women who reported the use of AZA in early pregnancy. The effect of AZA exposure on pregnancy outcomes was studied after adjustment for maternal characteristics that could act as confounders. RESULTS: The most common indication for AZA use was IBD. The rate of congenital malformations was 6.2% in the AZA group and 4.7% among all infants born (adjusted OR: 1.41, 95% CI: 0.98-2.04). An association between early pregnancy AZA exposure and ventricular/atrial septal defects was found (adjusted OR: 3.18, 95% CI: 1.45-6.04). Exposed infants were also more likely to be preterm, to weigh <2500 gm, and to be small for gestational age compared to all infants born. This effect remained for preterm birth and low birth weight when infants of women with IBD but without AZA exposure were used as a comparison group. A trend toward an increased risk of congenital malformations was found among infants of women with IBD using AZA compared to women with IBD not using AZA (adjusted OR: 1.42, 95% CI: 0.93-2.18). CONCLUSIONS: Infants exposed to AZA in early pregnancy may be at a moderately increased risk of congenital malformations, specifically ventricular/atrial septal defects. There is also an increased risk of growth restriction and preterm delivery. These associations may be confounded by the severity of maternal illness.
    • The efficacy of fibrinogen concentrate compared with cryoprecipitate in major obstetric haemorrhage - an observational study.

      Ahmed, S; Harrity, C; Johnson, S; Varadkar, S; McMorrow, S; Fanning, R; Flynn, C M; O' Riordan, J M; Byrne, B M; Department of Obstetrics and Gynaecology, Coombe Women and Infants University Hospital, Dublin, Ireland. (2012-10)
      Fibrinogen replacement is critical in major obstetric haemorrhage (MOH). Purified, pasteurised fibrinogen concentrate appears to have benefit over cryoprecipitate in ease of administration and safety but is unlicensed in pregnancy. In July 2009, the Irish Blood Transfusion Service replaced cryoprecipitate with fibrinogen.
    • An emergency department intervention to protect an overlooked group of children at risk of significant harm.

      Kaye, P; Taylor, C; Barley, K; Powell-Chandler, A; Emergency Department, Royal United Hospital, Coombe Park, Bath, UK., philip_bath@hotmail.com (2012-02-01)
      BACKGROUND: Parental psychiatric disorder, especially depression, personality disorder and deliberate self-harm, is known to put children at greater risk of mental illness, neglect or physical, emotional and sexual abuse. Without a reliable procedure to identify children of parents presenting with these mental health problems, children at high risk of significant harm can be easily overlooked. Although deliberate self-harm constitutes a significant proportion of emergency presentations, there are no guidelines which address the emergency physician's role in identifying and assessing risk to children of these patients. METHODS: A robust system was jointly developed with the local social services child protection team to identify and risk-stratify children of parents with mental illness. This allows us to intervene when we identify children at immediate risk of harm and to ensure that social services are aware of potential risk to all children in this group. The referral process was audited repeatedly to refine the agreed protocol. RESULTS: The proportion of patients asked by the emergency department personnel about dependent children increased and the quality of information received by the social services child protection team improved. CONCLUSIONS: All emergency departments should acknowledge the inadequacy of information available to them regarding patients' children and consider a policy of referral to social services for all children of parents with mental health presentations. This process can only be developed through close liaison within the multidisciplinary child protection team.
    • Endosomal gene expression: a new indicator for prostate cancer patient prognosis?

      Johnson, Ian R D; Parkinson-Lawrence, Emma J; Keegan, Helen; Spillane, Cathy D; Barry-O'Crowley, Jacqui; Watson, William R; Selemidis, Stavros; Butler, Lisa M; O'Leary, John J; Brooks, Doug A (Impact Publishers, 2015-11-10)
      Prostate cancer continues to be a major cause of morbidity and mortality in men, but a method for accurate prognosis in these patients is yet to be developed. The recent discovery of altered endosomal biogenesis in prostate cancer has identified a fundamental change in the cell biology of this cancer, which holds great promise for the identification of novel biomarkers that can predict disease outcomes. Here we have identified significantly altered expression of endosomal genes in prostate cancer compared to non-malignant tissue in mRNA microarrays and confirmed these findings by qRT-PCR on fresh-frozen tissue. Importantly, we identified endosomal gene expression patterns that were predictive of patient outcomes. Two endosomal tri-gene signatures were identified from a previously published microarray cohort and had a significant capacity to stratify patient outcomes. The expression of APPL1, RAB5A, EEA1, PDCD6IP, NOX4 and SORT1 were altered in malignant patient tissue, when compared to indolent and normal prostate tissue. These findings support the initiation of a case-control study using larger cohorts of prostate tissue, with documented patient outcomes, to determine if different combinations of these new biomarkers can accurately predict disease status and clinical progression in prostate cancer patients.
    • Epidural analgesia practices for labour: results of a 2005 national survey in Ireland.

      Fanning, Rebecca A; Briggs, Liam P; Carey, Michael F; Department of Perioperative Medicine, Coombe Women and Infants University, Hospital, Dublin, Ireland. rebecca.fanning@gmail.com (2012-02-01)
      BACKGROUND AND OBJECTIVE: The last 25 years have seen changes in the management of epidural analgesia for labour, including the advent of low-dose epidural analgesia, the development of new local anaesthetic agents, various regimes for maintaining epidural analgesia and the practice of combined spinal-epidural analgesia. We conducted a survey of Irish obstetric anaesthetists to obtain information regarding the conduct and management of obstetric epidural analgesia in Ireland in 2005. The specific objective of this survey was to discover whether new developments in obstetric anaesthesia have been incorporated into clinical practice. METHODS: A postal survey was sent to all anaesthetists with a clinical commitment for obstetric anaesthesia in the sites approved for training by the College of Anaesthetists, Ireland. RESULTS: Fifty-three per cent of anaesthetists surveyed responded. The majority of anaesthetists (98%) use low-dose epidural analgesia for the maintenance of analgesia. Only 11% use it for test-dosing and 32% for the induction of analgesia. The combined spinal-epidural analgesia method is used by 49%, but two-thirds of those who use it perform fewer than five per month. Patient-controlled epidural analgesia was in use at only one site. CONCLUSION: It appears that Irish obstetric anaesthetists have adopted the low-dose epidural analgesia trend for the maintenance of labour analgesia. This practice is not as widespread, however, for test dosing, the induction of analgesia dose or in the administration of intermittent epidural boluses to maintain analgesia when higher concentrations are used. Since its introduction in 2000, levobupivacaine has become the most popular local anaesthetic agent.
    • Establishing the accuracy and acceptability of abdominal ultrasound to define the foetal head position in the second stage of labour: a validation study.

      Ramphul, Meenakshi; Kennelly, Mairead; Murphy, Deirdre J; Academic Department of Obstetrics & Gynaecology, Trinity College Dublin & Coombe Women & Infant's University Hospital, Dublin 8, Ireland. ramphulm@tcd.ie (2012-09)
      To compare the diagnosis of the foetal head position in the second stage of labour by ultrasound scan performed by a novice sonographer and by clinical assessment, to that of an expert sonographer (gold standard); and to evaluate the acceptability of ultrasound in the second stage of labour to women and clinicians.
    • Evidence-based planning and costing palliative care services for children: novel multi-method epidemiological and economic exemplar

      Noyes, Jane; Edwards, Rhiannon Tudor; Hastings, Richard P; Hain, Richard; Totsika, Vasiliki; Bennett, Virginia; Hobson, Lucie; Davies, Gareth R; Humphreys, Ciarán; Devins, Mary; et al. (2013-04-25)
      Abstract Background Children’s palliative care is a relatively new clinical specialty. Its nature is multi-dimensional and its delivery necessarily multi-professional. Numerous diverse public and not-for-profit organisations typically provide services and support. Because services are not centrally coordinated, they are provided in a manner that is inconsistent and incoherent. Since the first children’s hospice opened in 1982, the epidemiology of life-limiting conditions has changed with more children living longer, and many requiring transfer to adult services. Very little is known about the number of children living within any given geographical locality, costs of care, or experiences of children with ongoing palliative care needs and their families. We integrated evidence, and undertook and used novel methodological epidemiological work to develop the first evidence-based and costed commissioning exemplar. Methods Multi-method epidemiological and economic exemplar from a health and not-for-profit organisation perspective, to estimate numbers of children under 19 years with life-limiting conditions, cost current services, determine child/parent care preferences, and cost choice of end-of-life care at home. Results The exemplar locality (North Wales) had important gaps in service provision and the clinical network. The estimated annual total cost of current children’s palliative care was about £5.5 million; average annual care cost per child was £22,771 using 2007 prevalence estimates and £2,437- £11,045 using new 2012/13 population-based prevalence estimates. Using population-based prevalence, we estimate 2271 children with a life-limiting condition in the general exemplar population and around 501 children per year with ongoing palliative care needs in contact with hospital services. Around 24 children with a wide range of life-limiting conditions require end-of-life care per year. Choice of end-of-life care at home was requested, which is not currently universally available. We estimated a minimum (based on 1 week of end-of-life care) additional cost of £336,000 per year to provide end-of-life support at home. Were end-of-life care to span 4 weeks, the total annual additional costs increases to £536,500 (2010/11 prices). Conclusions Findings make a significant contribution to population-based needs assessment and commissioning methodology in children’s palliative care. Further work is needed to determine with greater precision which children in the total population require access to services and when. Half of children who died 2002-7 did not have conditions that met the globally used children's palliative care condition categories, which need revision in light of findings.
    • Gene expression profiling in cervical cancer: identification of novel markers for disease diagnosis and therapy.

      Martin, Cara M; Astbury, Katharine; McEvoy, Lynda; O'Toole, Sharon; Sheils, Orla; O'Leary, John J; Department of Pathology, Coombe Women's Hospital, Dublin, Ireland. (2012-02-01)
      Cervical cancer, a potentially preventable disease, remains the second most common malignancy in women worldwide. Human papillomavirus is the single most important etiological agent in cervical cancer. HPV contributes to neoplastic progression through the action of two viral oncoproteins E6 and E7, which interfere with critical cell cycle pathways, p53, and retinoblastoma. However, evidence suggests that HPV infection alone is insufficient to induce malignant changes and other host genetic variations are important in the development of cervical cancer. Advances in molecular biology and high throughput gene expression profiling technologies have heralded a new era in biomarker discovery and identification of molecular targets related to carcinogenesis. These advancements have improved our understanding of carcinogenesis and will facilitate screening, early detection, management, and personalised targeted therapy. In this chapter, we have described the use of high density microarrays to assess gene expression profiles in cervical cancer. Using this approach we have identified a number of novel genes which are differentially expressed in cervical cancer, including several genes involved in cell cycle regulation. These include p16ink4a, MCM 3 and 5, CDC6, Geminin, Cyclins A-D, TOPO2A, CDCA1, and BIRC5. We have validated expression of mRNA using real-time PCR and protein by immunohistochemistry.
    • Hepatitis C: is there a case for universal screening in pregnancy?

      Martyn, F; Phelan, O; O'Connell, M; Department of Obstetrics & Gynaecology, Coombe Women & Infant's University, Hospital, Dolphin's Barn, Dublin 8. f_martyn@yahoo.com (2012-02-01)
      Hepatitis C (HCV) is not routinely screened for antenatally in all maternity hospitals. Most hospitals adopt a policy of targeted screening. The policy in the Coombe Women and Infants University Hospital in Dublin changed from targeted screening in 2006 to universal screening in 2007. We audited the two consecutive years. The prevalence of HCV in our antenatal population was 1.4% for 2006 (67/4666) when targeted screening applied and in 2007--0.71% (66/9222) when universal screening came into affect. One woman in 2007 would not have been detected by targeted screening--1.49% (1/67). Fifty five percent (37/67) of women were HCV-RNA positive in 2006 and 57.5% (38/66) were positive in 2007. We conclude that there were similar detection rates for HCV in 2006 and 2007 and that universal screening is not required if inclusive criteria for selective screening are employed but is of use in research context.
    • Hepatitis C: is there a case for universal screening in pregnancy?

      Martyn, F; Phelan, O; O'Connell, M; Department of Obstetrics & Gynaecology, Coombe Women & Infant's University Hospital, Dolphin's Barn, Dublin 8. f_martyn@yahoo.com (2011-05)
      Hepatitis C (HCV) is not routinely screened for antenatally in all maternity hospitals. Most hospitals adopt a policy of targeted screening. The policy in the Coombe Women and Infants University Hospital in Dublin changed from targeted screening in 2006 to universal screening in 2007. We audited the two consecutive years. The prevalence of HCV in our antenatal population was 1.4% for 2006 (67/4666) when targeted screening applied and in 2007--0.71% (66/9222) when universal screening came into affect. One woman in 2007 would not have been detected by targeted screening--1.49% (1/67). Fifty five percent (37/67) of women were HCV-RNA positive in 2006 and 57.5% (38/66) were positive in 2007. We conclude that there were similar detection rates for HCV in 2006 and 2007 and that universal screening is not required if inclusive criteria for selective screening are employed but is of use in research context.
    • How many joints does the 5th toe have? A review of 606 patients of 655 foot radiographs.

      Moulton, Lawrence Stephen; Prasad, Seema; Lamb, Robert G; Sirikonda, Siva P; Department of Orthopaedics, Royal United Hospital Bath NHS Trust, Coombe Park, Bath, United Kingdom. Lawrence.moulton@doctors.net.uk (Elsevier, 2012-12)
      It is a common understanding that the fifth toe has three bones with two interphalangeal joints. However, our experience shows that a significant number have only two phalanges with one interphalangeal joint.
    • How Much Greater is Obstetric Intervention in Women with Medical Disorders in Pregnancy When Compared to the General Population?

      Keane, R.; Manning, C.; Lynch, C.; Regan, C.; Byrne, B. (Irish Medical Journal, 2019-10)
      The purpose of this study was to compare obstetric and neonatal outcomes between women attending a specialised maternal medicine service and the general obstetric population.
    • Human papillomavirus vaccination in the prevention of cervical neoplasia.

      Astbury, Katharine; Turner, Michael J; Department of Obstetrics and Gynaecology, Coombe Women's Hospital, Dublin,, Ireland. kathastbury@gmail.com (2012-02-01)
      Cervical cancer remains a major cause of morbidity and mortality for women worldwide. Although the introduction of comprehensive screening programs has reduced the disease incidence in developed countries, it remains a major problem in the developing world. The recent licensing of 2 vaccines against human papillomavirus (HPV) type 16 and HPV-18, the viruses responsible for 70% of cervical cancer cases, offers the hope of disease prevention. In this article, we review the role of HPV in the etiology of cervical cancer and the evidence to support the introduction of vaccination programs in young women and discuss the potential obstacles to widespread vaccination. In addition, we discuss the issues that remain to be elucidated, including the potential need for booster doses of the vaccine and the role of concomitant vaccination in men.
    • Identifying novel hypoxia-associated markers of chemoresistance in ovarian cancer.

      McEvoy, Lynda M; O'Toole, Sharon A; Spillane, Cathy D; Martin, Cara M; Gallagher, Michael F; Stordal, Britta; Blackshields, Gordon; Sheils, Orla; O'Leary, John J (Springer, 2015)
      Ovarian cancer is associated with poor long-term survival due to late diagnosis and development of chemoresistance. Tumour hypoxia is associated with many features of tumour aggressiveness including increased cellular proliferation, inhibition of apoptosis, increased invasion and metastasis, and chemoresistance, mostly mediated through hypoxia-inducible factor (HIF)-1α. While HIF-1α has been associated with platinum resistance in a variety of cancers, including ovarian, relatively little is known about the importance of the duration of hypoxia. Similarly, the gene pathways activated in ovarian cancer which cause chemoresistance as a result of hypoxia are poorly understood. This study aimed to firstly investigate the effect of hypoxia duration on resistance to cisplatin in an ovarian cancer chemoresistance cell line model and to identify genes whose expression was associated with hypoxia-induced chemoresistance.
    • Impact of a personal learning plan supported by an induction meeting on academic performance in undergraduate Obstetrics and Gynaecology: a cluster randomised controlled trial

      Deane, Richard P; Murphy, Deirdre J; Department of Obstetrics & Gynaecology, Trinity College (BioMed Central, 2015)
      BACKGROUND: A personal learning plan (PLP) is an approach to assist medical students maximise their learning experience within clinical rotations. The aim of this study was to investigate whether medical students who created a PLP supported by an induction meeting had an improved academic performance within an undergraduate clinical rotation. METHODS: A cluster randomised controlled study was conducted over a full academic year (2012/13). The intervention was the creation of a PLP by medical students supported by an individual 'one-to-one' induction meeting between each student and a faculty member. Randomisation was by unit of rotation in which students completed the program. There were 2 clusters in the intervention group (n = 71 students) and 2 clusters in the control group (n = 72 students). Primary outcome was the overall examination score. Secondary outcomes were student attendance and student evaluation. RESULTS: There was no difference in overall examination score between the intervention group and control group (mean score 56.3 ± 4.8% versus 56.7 ± 5.6%, p = 0.64). The majority of students in the intervention group (n = 51/71, 85%) reported that the PLP and induction meeting enhanced their learning experience. Attendance at the induction meeting was identified as a key element. CONCLUSIONS: The creation of a PLP supported by an induction meeting was rated highly by students as an approach to enhance their learning experience but did not result in an improved academic performance. Further research is required to establish the role of an interim or exit meeting.
    • The impact of new national guidelines on screening for gestational Diabetes Mellitus

      Ali, FM; Farah, N; O’Dwyer, V; O’Connor, C; Kennelly, MM; Turner, MJ (Irish Medical Journal, 2013-02)
      Gestational diabetes mellitus (GDM) has important maternal and fetal implications. In 2010, the Health Service Executive published guidelines on GDM. We examined the impact of the new guidelines in a large maternity unit. In January 2011, the hospital replaced the 100g Oral Glucose Tolerance Test (OGTT) with the new 75g OGTT. We compared the first 6 months of 2011 with the first 6 months of 2010. The new guidelines were associated with a 22% increase in women screened from 1375 in 2010 to 1679 in 2011 (p<0.001). Of the women screened, the number diagnosed with GDM increased from 10.1% (n=139) to 13.2% (n=221) (p<0.001).The combination of increased screening and a more sensitive OGTT resulted in the number of women diagnosed with GDM increasing 59% from 139 to 221 (p=0.02).This large increase has important resource implications but, if clinical outcomes are improved, there should be a decrease in long-term costs.
    • The impact of new national guidelines on screening for gestational diabetes mellitus.

      Ali, F M; Farah, N; O'Dwyer, V; O'Connor, C; Kennelly, M M; Turner, M J (2013-02)
      Gestational diabetes mellitus (GDM) has important maternal and fetal implications. In 2010, the Health Service Executive published guidelines on GDM. We examined the impact of the new guidelines in a large maternity unit. In January 2011, the hospital replaced the 100 g Oral Glucose Tolerance Test (OGTT) with the new 75 g OGTT. We compared the first 6 months of 2011 with the first 6 months of 2010. The new guidelines were associated with a 22% increase in women screened from 1375 in 2010 to 1679 in 2011 (p < 0.001). Of the women screened, the number diagnosed with GDM increased from 10.1% (n=139) to 13.2% (n=221) (p<0.001).The combination of increased screening and a more sensitive OGTT resulted in the number of women diagnosed with GDM increasing 59% from 139 to 221 (p = 0.02).This large increase has important resource implications but, if clinical outcomes are improved, there should be a decrease in long-term costs.