• Bilateral adrenal haemorrhage secondary to intra-abdominal sepsis: a case report.

      Egan, Aoife M; Larkin, John O; Ryan, Ronan S; Waldron, Ronan; Department of Surgery, Mayo General Hospital, Castlebar, Co. Mayo, Ireland and, 2Department of Radiology, Mayo General Hospital,Castlebar, Co. Mayo, Ireland., aoife.egan@gmail.com (2012-01-31)
      INTRODUCTION: Bilateral adrenal haemorrhage is a rare cause of adrenal failure. Clinical features are non-specific and therefore a high index of suspicion must be maintained in patients at risk. Predisposing factors include infection, malignancy and the post-operative state. CASE PRESENTATION: We report the case of a patient who underwent a left hemicolectomy with primary anastomosis and formation of a defunctioning loop ileostomy for an obstructing colon carcinoma at the splenic flexure. En-bloc splenectomy was performed to ensure an oncologic resection. The patient developed a purulent abdominal collection post-operatively and became septic with hypotension and pyrexia. This precipitated acute bilateral adrenal haemorrhage with consequent adrenal insufficiency. Clinical suspicion was confirmed by radiological findings and a co-syntropin test. Following drainage of the collection, antibiotic therapy and corticosteroid replacement, the patient made an excellent recovery. CONCLUSION: This case highlights the importance of prompt diagnosis and treatment of adrenal failure. In their absence, this condition can rapidly lead to death of the patient.
    • Day of surgery admission for the elective surgical in-patient: successful implementation of the Elective Surgery Programme.

      Concannon, E S; Hogan, A M; Flood, L; Khan, W; Waldron, R; Barry, K; Department of Surgery, Mayo General Hospital, Castlebar, County Mayo, Ireland, lizconcannon@gmail.com. (Springer, 2012-09-11)
      BACKGROUND AND AIMS: The aim of this prospective cross-sectional study was to determine the impact of (1) ring fencing in-patient general surgical beds and (2) introducing a pre-operative assessment clinic (PAC) on the day of surgery admission (DOSA) rate in a single Irish institution. The secondary aim was to analyse the impact of an increased rate of DOSA on cost efficiency and patient satisfaction. METHODS: An 18-month period was examined following ring-fencing of elective and emergency surgical beds. A PAC was established during the study period. Prospectively collected data pertaining to all surgical admissions were retrieved using patient administration system software (Powerterm Pro, Eircom Software) and a database of performance information from Irish Public Health Services (HealthStat). RESULTS: Ring-fencing and PAC establishment was associated with a significant increase in the overall DOSA rate from 56 to 85 %, surpassing the national target rate of DOSA (75 %). Data relating specifically to general surgery admissions mirrored this increase in DOSA rate from a median of 5 patients per month, before the advent of ring-fencing and PAC, to 42 patients per month (p < 0.0387). 100 patient surveys demonstrated high levels of satisfaction with DOSA, with a preference compared to admission one night pre-operatively. Cost analysis demonstrated overall savings of 340,370 Euro from this change in practice. CONCLUSION: The present study supports the practice of DOSA through the introduction of ring-fenced surgical beds and PAC. This has been shown to improve hospital resource utilisation and streamline surgical service provision in these economically challenging times.
    • Delayed presentation of carotid artery dissection following major orthopaedic trauma resulting in dense hemiparesis.

      Edmundson, S P; Hirpara, K M; Ryan, R S; O'Malley, T; O'Grady, P; Department of Trauma and Orthopaedics, Mayo General Hospital, Westport Road,, Castlebar, County Mayo, Ireland. stevenedmundson@yahoo.co.uk (2012-01-31)
      We report a 30-year-old patient who was involved in a high-velocity road traffic accident and developed a left-sided hemiparesis, which was noted in the post-operative period following bilateral femoral intramedullary nailing. CT scanning of the brain revealed infarcts in the right frontal and parietal lobes in the distribution of the right middle cerebral artery. CT angiography showed occlusion of the right internal carotid artery consistent with internal carotid artery dissection. He was anticoagulated and nine months later was able to walk independently. An awareness of this injury is needed to diagnose blunt trauma to the internal carotid artery. Even in the absence of obvious neck trauma, carotid artery dissection should be suspected in patients with a neurological deficit in the peri-operative period.
    • The effectiveness of methicillin-resistant Staphylococcus aureus colonisation screening in asymptomatic healthcare workers in an Irish orthopaedic unit.

      Edmundson, S P; Hirpara, K M; Bennett, D; Department of Trauma and Orthopaedics, Mayo General Hospital, Castlebar, County, Mayo, Ireland. stevenedmundson@yahoo.co.uk (2012-01-31)
      Methicillin-resistant Staphylococcus aureus (MRSA) infections are associated with increased mortality, costs and length of stay compared to non-MRSA infections. This observational 4-year study analyses the impact of screening and treating orthopaedic healthcare workers for MRSA colonisation. A total of 1,011 swabs were taken from 566 healthcare workers. Positive healthcare workers were treated with topical mupirocin to both anterior nares. The prevalence of MRSA colonisation on initial testing was 4.77%. The rate of positive MRSA colonisation of those tested on more than one occasion fell from 5.88% to 2.71% (p = 0.055) on subsequent screening. All healthcare workers receiving treatment were successfully cleared of colonisation; however, some required more than one course of treatment. These results show that there could be a role for screening and treating orthopaedic staff for MRSA colonisation as part of a strategy to reduce the prevalence of MRSA infections in orthopaedic units.
    • Fertility preservation in young females with non-gynaecologic malignancy: an emerging speciality.

      Smyth, C; Robertson, I; Higgins, L; Memeh, K; O'Leary, M; Keane, M; Khan, W; Barry, K; Department of Surgery, Mayo General Hospital, Castlebar, Co Mayo, Ireland. (Springer, 2013-06-06)
      BACKGROUND: As new treatment and research advances continue to improve the prognosis of cancer patients, oncologists and surgeons are increasingly faced with the issue of fertility protection and preservation. Cancer patients are frequently exposed to gonadotoxic chemotherapy and radiation therapy as a component of their treatment regimens. There are currently various anticipatory techniques available to women who wish to retain future reproductive ability, the most successful of which involves oocyte retrieval followed by in vitro fertilisation and embryo cryopreservation. Innovative methods include oocyte cryopreservation, ovarian follicle cryopreservation and oophoropexy. AIM: The aim of this study was to examine our combined experiences at Mayo General Hospital of treating female patients (<30 years) with non-gynaecologic malignancy and requiring referral to the HARI Unit during a 6-year period (2007-2012). Emphasis was placed on reviewing the fertility-preservation options available. METHODS: The hospital inpatient enquiry system was inspected for all cases of non-gynaecologic malignancy referred for fertility preservation from 2007 to 2012. RESULTS: Three cases of non-gynaecologic malignancy in young females, with an intention to protect and preserve future fertility were identified. The primary treatment plan did not initially incorporate input from a gynaecology or fertility specialist. It was after concerted inquiry and reflection by both physician and patient that oncofertility consultation was sought. CONCLUSION: The responsibility is on both physicians and surgeons to consider a more holistic approach to cancer care in young female patients, which focuses not only on the elimination of malignancy but also on preservation of fertility and quality of life.
    • Higher specialist training in paediatrics 2005-2010.The graduates reflections

      O’Neill, MB; Freyne, B; Nicholson, AJ (Irish Medical Journal, 2013-09)
      This study of paediatric trainees, who were awarded their CSCST from 2005 to 2010, evaluated their training experience and assessed whether the curriculum goals were achieved. From an incomplete database 23 (57.7%) graduates based in Ireland and 3(19%) based abroad responded. Twenty one (81%) of respondents were currently working in Ireland as consultants, 20(80%) had a post membership qualification and 23 (92%) had travelled abroad for fellowships. Positive experiences included clinical training (44%), positive role models (44%), quality of the training days (52%).Negative experiences included lack of protected time for research (52%), excessive clinical service (28%), and poor monitoring of trainers (20%). Mean Likert scores for curriculum competencies were clinical care 4.9, clinical knowledge 5, application of evidence 3.7, academic supervisor skills3.3, knowledge of public health 3.2, health economics 2.2, and healthcare systems modification 2.3. The curriculum deficiencies can be addressed through the diploma in Leadership and Quality in Healthcare which has been developed by the Health Service Executive and the College of Physicians but an adequate database of graduates needs to be maintained.
    • The impact of changes in work practice and service delivery on surgical infection rates in a general surgical unit

      Piggott, R; Hogan, A; Concannon, E; Sharkey, M; Waldron, R; Khan, W; Barry, K (Irish Medical Journal (IMJ), 2013-10)
      Ring-fencing of elective orthopaedic beds has been shown to significantly reduce surgical site infection (SSI) rates. There are fewer studies in general surgical practice. Comparison of overall surgical workload in 2007 and 2011 was performed. Data pertaining to SSI were collected and analysis of this prospectively maintained database was performed on all SSI diagnosed in 2007 and 2011. There was a significant reduction in the crude SSI rate from 117 cases in 2007 (8%) to 42 cases in 2011 (3.5%). A statistically significant reduction in SSI rate for elective surgery was observed, 7.6% vs. 2.5% (p<0.001 Chi-square test). Apart from the introduction of ring fencing, all other contributory variables remained unchanged. Ring-fencing of inpatient general surgical beds has been associated with a significant reduction in SSI rates. These data provide timely supportive evidence that ring-fencing of inpatient beds is an appropriate patient-orientated strategy.
    • Investigation of paramedics' compliance with clinical practice guidelines for the management of chest pain.

      Figgis, Ken; Slevin, Oliver; Cunningham, J Brian; Emergency Department, Mayo General Hospital, Castlebar, Mayo, UK., kfiggis@hotmail.com (2012-01-31)
      BACKGROUND: Acute coronary syndromes remain a leading cause of preventable early deaths. However, previous studies have indicated that paramedics' compliance with chest pain protocols is suboptimal and that many patients do not receive the benefits of appropriate prehospital treatment. AIMS: To evaluate paramedics' level of compliance with national clinical practice guidelines and to investigate why, in certain circumstances, they may deviate from the clinical guidelines. SETTING: The Health Service Executive Mid-Western Regional Ambulance Service which serves a mixed urban and rural population across three counties in the west of Ireland. METHOD: A retrospective review of completed ambulance Patient Care Report Forms was conducted for all adult patients with non-traumatic chest pain treated between 1 December 2007 and 31 March 2008. During the same study period, paramedics were asked to complete a prospective questionnaire survey investigating the rationale behind their treatment decisions, their estimation of patient risk and their attitudes towards the clinical practice guidelines and training. RESULTS: 382 completed Patient Care Report Forms were identified for patients with chest pain, of whom 84.8% received ECG monitoring, 75.9% were given oxygen, 44.8% were treated with sublingual glyceryl trinitrate (GTN) and 50.8% were treated with aspirin. Only 20.4% of patients had a prehospital 12-lead ECG recorded. 58 completed questionnaires were returned (response rate 15%); 64% of respondents said they had received insufficient training to identify ECG abnormalities. CONCLUSIONS: Prehospital treatment with oxygen, aspirin, sublingual GTN and ECG monitoring remains underused by paramedics, even though only a small number of patients had documented contraindications to their use. The small number of patients who received a prehospital 12-lead ECG is a cause of particular concern and suggests that incomplete patient assessment may contribute to undertreatment. Further provision of training and equipment is necessary to enable paramedics to more accurately assess and treat patients with acute coronary syndromes.
    • Is overexpression of HER-2 a predictor of prognosis in colorectal cancer?

      Kavanagh, Dara O; Chambers, Gillian; O'Grady, Liam; Barry, Kevin M; Waldron, Ronan P; Bennani, Fadel; Eustace, Paul W; Tobbia, Iqdam; Department of Surgery, Mayo General Hospital, Castlebar, Co Mayo, Ireland., dara_kav@hotmail.com (2012-01-31)
      BACKGROUND: The development of novel chemotherapeutic agents in colorectal cancer has improved survival. Following initial response to chemotherapeutic strategies many patients develop refractory disease. This poses a significant challenge common to many cancer subtypes. Newer agents such as Bevacizumab have successfully targeted the tyrosine kinase receptor epidermal growth factor receptor in metastatic colorectal cancer. Human epidermal growth factor receptor-2 is another member of the tyrosine kinase receptor family which has been successfully targeted in breast cancer. This may play a role in colorectal cancer. We conducted a clinicopathological study to determine if overexpression of human epidermal growth factor receptor-2 is a predictor of outcome in a cohort of patients with colorectal cancer. METHODS: Clinicopathological data and paraffin-embedded specimens were collected on 132 consecutive patients who underwent colorectal resections over a 24-month period at Mayo General Hospital. Twenty-six contained non-malignant disease. Her-2/neu protein overexpression was detected using immunohistochemistry (IHC). The HER-2 4B5 Ventana monoclonal antibody was used. Fluorescent insitu hybridisation (FISH) was performed using INFORM HER-2/Neu Plus. Results were correlated with established clinical and pathological predictors of outcome including TNM stage. Statistical analysis was performed using SPSS version 11.5. RESULTS: 114 were HER-2/Neu negative using IHC, 7 showed barely perceptible positivity (1+), 9 showed moderate staining (2+) and 2 were strongly positive (3+). There was no correlation with gender, age, grade, Dukes' stage, TNM stage, time to recurrence and 5-year survival (p > 0.05). FISH was applied to all 2+ and 3+ cases as well as some negative cases selected at random. Three were amplified (2 were 3+ and 1 was 2+). Similarly, HER-2 gene overexpression did not correlate with established prognostic indicators. CONCLUSION: HER-2 protein is over expressed in 11% of colorectal cancer patients. The gene encoding HER-2 is amplified in 3% of cases. Overexpression of HER-2 is not a predictor of outcome. However, patients who over express HER-2 may respond to Herceptin therapy.
    • Isolated pancreatic metastases from a bronchogenic small cell carcinoma.

      Walshe, T; Martin, S T; Khan, M F; Egan, A; Ryan, R S; Tobbia, I; Waldron, R; Department of Surgery, Mayo General Hospital, Castlebar, Co Mayo., walshetriona@hotmail.com (2012-01-31)
      We describe the case of a 60 year old female smoker who presented with a three month history of weight loss (14 Kg), generalized abdominal discomfort and malaise. Chest radiography demonstrated a mass projected inferior to the hilum of the right lung. Computed Tomography of thorax confirmed a lobulated lesion in the right infrahilar region and subsequent staging abdominal CT demonstrated a low density lesion in the neck of the pancreas. Percutaneous Ultrasound guided pancreatic biopsy was performed, histology of which demonstrated pancreatic tissue containing a highly necrotic small cell undifferentiated carcinoma consistent with metastatic small cell carcinoma of the bronchus.
    • Management of the Acute Appendix Mass: A Survey of Surgical Practice

      Irfan, M; Hogan, AM; Gately, R; Lowery, AJ; Waldron, R; Khan, W; Barry, K (Irish Medical Journal (IMJ), 2012-10)
    • Management of the acute scrotum in a district general hospital: 10-year experience.

      Tajchner, Lukas; Larkin, John O; Bourke, Michael G; Waldron, Ronan; Barry, Kevin; Eustace, Paul W; Department of Surgery, Mayo General Hospital, Castlebar, Co. Mayo, Republic of, Ireland. (2012-01-31)
      The acutely painful scrotum is a common urologic emergency. The primary objective of management is to avoid testicular loss. This requires a high index of clinical suspicion and prompt surgical intervention. In our series conducted between January 1996 and December 2005, 119 patients (age range: 4-62 years) underwent emergency operative exploration for acute scrotal pain. The most common finding was torted cyst of Morgagni (63/119, 52.9%), followed by testicular torsion (41/119, 34.4%). The majority of testicular torsions occurred in the pubertal group (22/41, 53.6%). Only one patient in this group had an unsalvageable testis necessitating orchidectomy, a testicular loss rate in torsion of 2.4%. There were no postoperative wound infections or scrotal haematomas. Testicular salvage depends critically on early surgical intervention, so the delay incurred in diagnostic imaging may extend the period of ischaemia. Furthermore, all radiological investigations have a certain false-negative rate. We advocate immediate surgical exploration of the acute scrotum. We report a low orchidectomy rate (2.4%) in testicular torsion.
    • Measuring emergency department nurses' attitudes towards deliberate self-harm using the Self-Harm Antipathy Scale.

      Conlon, Mary; O'Tuathail, Claire; Mayo Mental Health Services, Mayo General Hospital, Castlebar, Co. Mayo, Ireland. (2012-01-31)
      The emergency department is an important gateway for the treatment of self-harm patients. Nurses' attitudes towards patients who self-harm can be negative and often nurses experience frustration, helplessness, ambivalence and antipathy. Patients are often dissatisfied with the care provided, and meeting with positive or negative attitudes greatly influences whether they seek additional help. A quantitative design was utilised to measure emergency department nurses' attitudes towards deliberate self-harm. The 'Self-Harm Antipathy Scale', a validated questionnaire, was administered to a random sample of nurses in four emergency departments in the Republic of Ireland. A total of 87 questionnaires were returned (87% response rate). Results reveal that nurses show slightly negative antipathy overall, indicating positive attitudes towards self-harming patients. Attitudes were significantly different in accordance with a nurse's age. Education and social judgment also contribute to the way nurses view, interact and make moral decisions regarding self-harm patients. Evidence indicates there is need to improve the training, supervision and support of nurses caring for patients who self-harm, and that practical strategies should be implemented to manage the alienation process and inform practice.
    • Mesenteric venous thrombosis secondary to an unsuspected JAK2 V617F-positive myeloproliferative disorder.

      Department of Surgery, Mayo General Hospital, Mayo, Ireland,, mikebourkecork@yahoo.co.uk. (2012-01-31)
      BACKGROUND: Mesenteric venous thrombosis (MVT) is a rare but potentially fatal cause of mesenteric ischaemia. It presents insidiously and often diagnosis is made at emergency surgery. In half of the cases MVT develops without a causative factor, while in cases in which a pro-thrombotic state is found to exist MVT may be the first clinically detected consequence of that state. The myeloproliferative disorders (MPD) are known to contribute to the development of pro-thrombotic states. Recently, the JAK2 V617F mutation has been associated with the MPDs. CONCLUSION: We describe a case of MVT occurring secondary to an unsuspected MPD, in which the patient was subsequently found to carry this mutation. We highlight the necessity to screen for this mutation in cases of intra-abdominal thromboses so that appropriate systemic anticoagulation may be instituted, and the patient may be followed so as to detect the development of an overt MPD.
    • Modern management of pyogenic hepatic abscess: a case series and review of the literature.

      Heneghan, Helen M; Healy, Nuala A; Martin, Sean T; Ryan, Ronan S; Nolan, Niamh; Traynor, Oscar; Waldron, Ronan; Department of Surgery, Mayo General Hospital, Castlebar, Mayo, Ireland., helenheneghan@hotmail.com. (2012-01-31)
      BACKGROUND: Pyogenic hepatic abscesses are relatively rare, though untreated are uniformly fatal. A recent paradigm shift in the management of liver abscesses, facilitated by advances in diagnostic and interventional radiology, has decreased mortality rates. The aim of this study was to review our experience in managing pyogenic liver abscess, review the literature in this field, and propose guidelines to aid in the current management of this complex disease. METHODS: Demographic and clinical details of all patients admitted to a single institution with liver abscess over a 5 year period were reviewed. Clinical presentation, aetiology, diagnostic work-up, treatment, morbidity and mortality data were collated. RESULTS: Over a 5 year period 11 patients presented to a single institution with pyogenic hepatic abscess (55% males, mean age 60.3 years). Common clinical features at presentation were non-specific constitutional symptoms and signs. Aetiology was predominantly gallstones (45%) or diverticular disease (27%). In addition to empiric antimicrobial therapy, all patients underwent radiologically guided percutaneous drainage of the liver abscess at diagnosis and only 2 patients required surgical intervention, including one 16-year old female who underwent hemi-hepatectomy for a complex and rare Actinomycotic abscess. There were no mortalities after minimum follow-up of one year. CONCLUSIONS: Pyogenic liver abscesses are uncommon, and mortality has decreased over the last two decades. Antimicrobial therapy and radiological intervention form the mainstay of modern treatment. Surgical intervention should be considered for patients with large, complex, septated or multiple abscesses, underlying disease or in whom percutaneous drainage has failed.
    • Mortality in perforated duodenal ulcer depends upon pre-operative risk: a retrospective 10-year study.

      Larkin, J O; Bourke, M G; Muhammed, A; Waldron, R; Barry, K; Eustace, P W; Department of Surgery, Mayo General Hospital, Castlebar, Co., Mayo, Ireland., larkin.dundalk@gmail.com (2012-01-31)
      INTRODUCTION: Most patients presenting with acutely perforated duodenal ulcer undergo operation, but conservative treatment may be indicated when an ulcer has spontaneously sealed with minimal/localised peritoneal irritation or when the patient's premorbid performance status is poor. We retrospectively reviewed our experience with operative and conservative management of perforated duodenal ulcers over a 10-year period and analysed outcome according to American Society of Anesthesiologists (ASA) score. METHODS: The records of all patients presenting with perforated duodenal ulcer to the Department of Surgery, Mayo General Hospital, between January 1998 and December 2007 were reviewed. Age, gender, co-morbidity, ASA-score, clinical presentation, mode of management, operative procedures, morbidity and mortality were considered. RESULTS: Of 76 patients included, 48 (44 operative, 4 conservative) were ASA I-III, with no mortality irrespective of treatment. Amongst 28 patients with ASA-score IV/V, mortality was 54.5% (6/11) following operative management and 52.9% (9/17) with conservative management. CONCLUSION: In patients with a perforated duodenal ulcer and ASA-score I-III, postoperative outcome is uniformly favourable. We recommend these patients have repair with peritoneal lavage performed, routinely followed postoperatively by empirical triple therapy. Given that mortality is equivalent between ASA IV/V patients whether managed operatively or conservatively, we suggest that both management options are equally justifiable.
    • The non specialist paediatric training registrar in the healthcare system

      O’Neill, MB; A Kumar, A (Irish Medical Journal (IMJ), 2012-07)
    • Operative surgical yield from general surgical outpatient clinics; Time to change the way we practice?

      Irfan, M; McGovern, M; Robertson, I; Waldron, R; Khan, I; Khan, W; Barry, K (Irish Medical Journal (IMJ), 2013-07)
      The aim of this study was to compare the number of patients attending surgical outpatient clinics in a general hospital to the number of resulting elective procedures scheduled in a single year. Patients initially assessed at private consulting rooms are not included in this study. The number of surgical outpatient appointments issued in 2011 totalled 6503 with non-attendances running at 1489(22.9%).The number of elective surgical theatre cases performed in 2011(i.e. the surgical yield from that period) came to 1078 with an additional 1470 patients referred for endoscopy and 475 patients referred for minor operations. Operative surgical yield from the currently structured outpatient clinic model is low, with the number of theatre cases coming to only 16.58% of the original number of outpatient appointments issued. Recommendations for the improvement of outpatient services are made. These findings are relevant in the context of streamlining access to surgical services.
    • Opportunity Costs in Paediatric Training: The Specialist Registrars Experience.

      O’Neill, MB; Nabialek, T; Kandamany, N (Irish Medical Journal, 2017-08)
      In the training process, there is a tension between the work life and home life of trainees. This study explored both the personal impact and the opportunity costs of training from the Specialist Paediatric Registrar (SPR) perspective. The survey explored 1) career progression2) perceived functional effectiveness at work 3) psychological impact of hospital based training and 4) the personal and social cost of training. Fifty-three (71%) SPRs responded of whom 47 (89%)were married or in long term relationships. Seventy-five percent of trainees had a definite career plan with 86% intending to undertake fellowship training. Seventy percent believed they were efficient time managers but 53% had difficulty in making time for academic pursuits and fifty percent experienced negative feelings, which lingered after work and interfered with their relationships at home. Seventy-four percent stated training was undertaken at significant personal cost with only 21% achieving a very satisfactory work/life balance. To address these difficulties trainee wellbeing should be addressed at the Basic Specialist Training (BST) level and the career path clearly explained outlining the challenges that are likely to be encountered.
    • Paediatric surgery - A general hospital experience

      Fahy, E; Ahmed, K; Lowery, AJ; Khan, W; Waldron, R; Barry, K (Irish Medical Journal, 2012-12)