key: cord-006882-t9w1cdr4
authors: nan
title: Royal Academy of Medicine in Ireland
date: 2012-07-22
journal: Ir J Med Sci
DOI: 10.1007/s11845-012-0833-6
sha: 
doc_id: 6882
cord_uid: t9w1cdr4

nan

The Tuberculin-Skin-Test is the most commonly used test to screen for Tuberculosis worldwide. In most cases it is administered by the most junior member of the medical team. There is some anecdotal evidence to suggest that junior doctors have limited knowledge of how to administer and interpret this test correctly. The aim of this audit was to assess the proficiency of Interns and Senior-House-Officers in St. Vincent's University Hospital at performing the Tuberculin-Skin-Test and improve standards.

A multiple choice questionaire was used to assess doctors' knowledge of Tuberculin-Skin-Test administration, interpretation, alternatives and the availability and awareness of information regarding the Tuberculin-Skin-Test within the hospital. 45 interns and Senior-House-Officers were assessed.

Of those questioned 75.6 % correctly identified intradermal as the method of administration. 66.7 % knew to correctly assess the induration at 48-72 h, but only 29 % knew that the induration should be measured across the forearm. Only 11.6 % were aware of the information leaflet within the hospital. 92.9 % of Senior-House-Officers correctly identified intradermal injection as the method of administration.

It is apparent that the Tuberculin-Skin-Test is often administered and/or interpreeted incorrectly. We recommend formal teaching for junior doctors in this area, coupled with improved availability of the information leaflet. Mucinous tubular and spindle cell carcinoma (MTSCC) is an extremely rare type of kidney tumour that has only recently been described, with less than eighty cases in the literature. This was only recognized as a specific entity in the World Health Organization 2004 classification of Renal Cell Carcinoma (RCC). MTSCCs are polymorphic renal neoplasms characterized by small, elongated tubules lined by cuboidal cells with cords of spindled cells separated by pale mucinous stroma.

We report the case of a 57-year old lady who had an incidental finding of a mass in her right kidney. The radiological features were consistent with a RCC and following a multidisciplinary team discussion she underwent a laparoscopic radical nephrectomy.

Macroscopic examination revealed a well circumscribed 6.5 9 6 9 6.5 right lower pole mass. Histologically it was composed of elongated tubules, small tubules and papillary structures with a necrotic centre. The cells demonstrated cuboidal and spindle cell morphology. Histological grade was Fuhrman grade 2. Subsequent CT Thorax Abdomen and Pelvis staged the tumour as pT1b.

The majority of MTSCCs are indolent, and there is only one report of a distant metastasis which responded favourably to adjuvant sunitinib. To date there is no international consensus on long term surveillance of these patients. Due of the favourable prognosis with this type of tumour, MTSCC must be differentiated from papillary renal cell carcinoma to avoid administration of excessive adjuvant treatment to patients. This is the first recorded case of this recently classified, rare tumour in Ireland. This incidental finding of solid pseudopapillary neoplasm (SPN) was discovered when a 59-year-old female underwent a chest X-ray to investigate a wheeze. A subsequent CT abdomen revealed a 10 cm well circumscribed mass adjacent to the tail of the pancreas. This neoplasm had reached a significant size of 10 cm appreciable on radiological imaging and yet was asymptomatic and not palpable on physical examination.

Laparatomy revealed a highly haemorrhagic and calcified mass emanating from the pancreas. This was adherent to the omentum, distal pancreas and splenic vessels. Distal pancreatectomy was performed with en bloc resection of the mass. Repeated CT scans at 3, 6 and 12 months failed to demonstrate recurrence.

Solid pseudopapillary neoplasms are rare entities accounting for between 0.13 and 2.7 percent of pancreatic tumours. This neoplasm has a predilection for females under the age of 35.

These tumours are indolent and usually reach a large size before detection. Diagnosis is confirmed on histology and complete surgical excision of localised tumours is curative. We aimed to assess the prevalence of smoking among patients with vascular disease and the role of the health care profession in encouraging smoking cessation. 100 patients who attended the vascular outpatient department were surveyed over a 2 month period in 2011. Patients gave verbal consent to partake in the audit and the surveyor entered the responses into a standardised questionnaire response sheet.

29 % of patients were current smokers, 39 % ex-smokers and 32 % had no history of smoking. 38 % smoke over 30 cigarettes per day and 66 % had a smoking history spanning over 30 years. Just 58 % of smokers who are under the care of the vascular service have been advised to give up smoking in the past by a healthcare professional.

Smoking has long been established as a major modifiable risk factor for the development of atherosclerosis however 29 % of patients attending the vascular service continue to smoke. Just half of patients who were offered smoking cessation advice found it was effective. Therefore a system needs to be put in place where all vascular patients are advised of the benefits of smoking cessation and the manner in which information is dispensed needs to be revised.

To Investigate the Optimum Location for the Teaching of Procedural Skills to Medical Students English N, O'Flynn S

Introduction: Procedural skill training is a vital component of medical education. Traditionally it has been teaching hospital based however general practice rotations may provide greater opportunities than previously thought. Aims: This study aimed to ascertain whether a General Practice setting or a teaching hospital setting provided a better environment for acquiring procedural skills in terms of opportunity to practice and the variety of skills performed. The correlation between end of year OSCE results and the amount of procedural skill exposure was also looked at. Methods: A cross-sectional quantitative study which included all 107 3rd year medical students at UCC was conducted. A log book listing 28 procedural skills was made available to all students before beginning both General practice and teaching hospital rotations. Students were instructed to indicate on the log when they performed any of these skills and in which location. Logs were returned to medical school. Data was obtained and analysis performed using SPSS17. Results: A response rate of 80 % was achieved. 92.9 % of students performed more skills at the GP setting. 40.5 % (n = 34) did not perform any skills while in a teaching hospital 0.17 skills were performed significantly more frequently in a GP setting while 5 were performed more frequently in a teaching hospital. Students who performed a high number of skills in one location were no more likely to perform a high number in the other. Conclusions: Students were able to take greater advantage of procedural skills opportunities in a GP setting. As this was the students first clinical year it is likely that the one-to-one teaching scenario provided them with a more suitable location to practice skills for the first time. This study also highlighted the diverse nature of procedural skills which a general practice setting can provide.

Accuracy of Sentinel Node Biopsy in Determining the Requirement for Second Axillary Surgeries in T1-T2 Breast Cancer with Retrospective Application of Z0011 Criteria Background: Lymph node status is the most important prognostic marker in breast cancer management. In tandem with breast conser-vative surgery, surgical approaches to the axilla have also become less invasive thus decreasing the morbidity associated with axillary clearance. The ACOSOG Z0011 trial reported no difference in survival in patients undergoing sentinel lymph node biopsy (SLNB) alone versus axillary lymph node dissection (ALND) in T1-T2 tumours. Our aims were to establish whether sentinel lymph node biopsy was a true representative of axillary burden. We also analysed whether retrospective application of criteria from Z0011 trial would have prevented patients undergoing second axillary surgery. Methods: All patients with T1-T2 tumours undergoing sentinel node biopsy were included in our study (n = 1019). Analysis of our prospectively updated breast cancer database was performed. Minitab version 16.0 was used to carry out statistical analysis of the data Results: 1019 SLNB procedures for T1 & T2 tumours were performed over a 7 year period. 730 patients were reported as histologically negative and 289 were positive. Of the lymph node positive group, 223 patients progressed to axillary clearance. Staging of 149 patients remained unchanged with only 74 patients having [2 axillary lymph nodes reported as positive. 72 patients from the SLNB negative group also had an axillary clearance. 5 of these patients had further axillary disease with 1 patient being upstaged having [2 axillary lymph nodes positive. With retrospective application of Z0011 criteria 66 % of patients would have avoided second axillary surgery. Conclusions: Sentinel node biopsy is a strong indicator of axillary tumour burden. This study highlights the accuracy of sentinel lymph node biopsy in staging disease and representing overall tumour burden.

Flaherty RA, Kelly BD, Coyle D, Quinlan MR, D'Arcy FT, Rogers E, Jaffry SQ

We report the first case of a spontaneous right nephrocutaneous fistula (NCF) with an accompanying fistula limb communicating with the right ureter.

A 65-year-old man presented with a groin mass, which was initially diagnosed as a hernia. He was scheduled for an inguinal hernia repair. Upon incision there was extravasation of urine from the wound and the procedure was abandoned. A CT Urogram identified a NCF running from the right lower pole calyx, anterior to the psoas muscle and emerging on the right groin skin with an accompanying fistula limb communicating with the right ureter. During the course of investigation it was discovered that the patient was suffering from chronic indolent calculus pyelonephritis which led to the formation of both aberrant pathways from the kidney and the ureter and that both had calculi located at their origins.

The patient was first treated with a nephrostomy and ureteric stenting to relieve urinary obstruction and after this failed to resolve the fistula, was successfully treated with percutaneous nephrolithotomy for removal of the calculi and fibrin glue injection into the fistula.

This case is one of only a few reported cases of spontaneous nephrocutaneous fistula and the anatomy of the fistulous tract in this case is very unusual and posed a particular challenge for surgical management. This case report further advocates the use of fibrin glue in the management of complicated NCF. This is a retrospective case study. There were six cases of ocular tuberculosis over the 6 year period, one annually, four of whom are women, with ages ranging from 17 to 46 years old. Two were foreign-born. All patients presented with reduced visual acuity. Four developed posterior uveitis, one anterior uveitis and one panuveitis. This was also complicated by vitritis, retinal detachment and retinal vasculitis in four. The median duration of symptoms until commencement of treatment was 3 months. All cases had a positive Mantoux and one case had evidence of pulmonary tuberculosis on chest X-ray. Tuberculosis was isolated in two cases. The intended duration of anti-tuberculous therapy for all patients was 9 months. Vision improved in all cases.

Ocular tuberculosis is rare in developed countries, with prevalence ranging from \1 to 7 %. However, it is important to be considered in all cases of uveitis. Despite the use of PCR, most cases are presumptive. This leads to delayed commencement of therapy causing further complications. A high index of suspicion is required. We describe the case of a 45-year-old gentleman who presented to our Emergency Department (ED) with a very unusual complication of central venous catheterisation. This resulted in spontaneous extrusion of a retained intravenous guide wire from the base of the occiput. This has been described only once previously in the literature, but not at such a delayed time interval from insertion [1] .

This 45-year-old gentleman presented to the ED reporting that he felt the point of a sharp object irritate his finger in his midline occipital area. He had successfully retrieved approximately 3 cm of a thin metal wire. He had a history of Rheumatic fever and had undergone an elective aortic valve replacement 5 years previously, necessitating central venous cannulation. He had remained asymptomatic up to this time.

Plain radiography of his neck revealed a short segment of wire in the posterior spinal musculature. This segment of wire (approximately 25 cm) was removed manually with minimal force and minor manipulation. The procedure was uncomplicated and the patient was discharged shortly afterwards.

Retained foreign bodies may migrate slowly over many years eventually extruding from the body, without any serious complications. Events such as retained or lost guide-wires are rare. This phenomenon may become more frequent with increasing complexity of medical care and with increasing use of CV catheters in the treatment of sepsis and other emergent critical conditions. Physicians should be aware of the possibility of retained foreign bodies and should be somewhat re-assured by reports of simple uncomplicated removal. We present the case of a 79-year-old gentleman who was recently admitted with symptomatic right heart failure and new onset atrial fibrillation. Our patient had been treated in the community for symptoms suggestive of CCF but had not previously been investigated. Of note, he has no history of a chronic inflammatory condition and no symptoms suggestive of an underlying neoplastic process. On presentation he was also noted to have evidence of an arthropathy affecting his knees and ankles and bipedal oedema. Renal function was abnormal with a urea of 17.9 and a creatinine of 116. Urinalysis was positive for protein and 24 h urine collection for protein is ongoing. Liver enzymes were also elevated and revealed a cholestatic picture.

Echocardiogram showed a reduced ejection fraction of 30 % and findings consistent with amyloidosis. Biopsy of abdominal fat pad at time of writing is pending.

Amyloidosis refers to an uncommon group of disorders characterised by extracellular tissue deposition of a variety of proteins in an abnormal fibrillar pattern which are resistant to degradation. It can occur alone (primary) or can complicate many chronic inflammatory conditions (secondary).

The major sites for clinically reported amyloid deposition are the kidneys, heart and liver. Clinically patients present more often with right heart failure; pulmonary oedema is rare. Amyloid infiltration results in increased echogenicity on echocardiogram and gives a ''sparkling'' appearance to the myocardium. Biopsy is diagnostic.

This was achieved using a retrospective review of all children receiving GH therapy (n = 53) over a 5-year period (October 2006-October 2011).

33 of 53 patients on GH therapy had GHD. Of these, 18 had IGHD (15 male) and 15 had CPHD (8 male). All had appropriate work-up and follow-up. Age at presentation to endocrinology was older in the IGHD group (mean 8.2 years) than in those with CPHD (mean 4.4 years). 17/18 children with IGHD presented with short stature, compared to only 4 with CPHD; the remainder presenting with clinical features of other pituitary hormone deficiencies. The mean height centile at diagnosis was lower in the IGHD group (0.4th) versus the CPHD group (9th). MRI brain/pituitary was abnormal in the majority of patients (14/15) with CPHD, compared with 1/18 with IGHD. Both groups responded well to treatment and height increased by one centile on average at 12 months.

All patients diagnosed with GHD at Temple St had appropriate work-up and follow-up. Children with IGHD presented later than those with CPHD, and had shorter height centiles at diagnosis. There was a strong male predominance in children presenting with IGHD, which may reflect psychosocial factors. Structural pituitary abnormalities were more common in those with CPHD, and their clinical presentation was more varied. Response to therapy was similar in both groups. Background: Out of hospital cardiac arrests have poor survival rates approx 1-9 %. Improving outcomes in Ireland have been seen in the past decade. Better outcomes are seen if arrest is witnessed and when bystander Basic Life Support was initiated. Worse prognosis is seen in a rural setting due to delay in paramedic response times and in administration of advanced cardiac life support. Case report: A 60-year-old Donegal Male experienced chest pain in his rural home and subsequently cardiac arrested. His spouse, whom 3 months prior had trained in Basic Life Support as part of a FAS course contacted the 'out of hours' GP and Ambulance service and commenced CPR. The GP failed to reach the house and the first ambulance broke down. On arrival of second ambulance, one person CPR had been administered for [40 min. Paramedics delivered 10 DC shocks and intubated the patient. In the Regional hospital PC was admitted to the Intensive Care Unit for 11 days being managed with Acute Respiratory Distress Syndrome (ARDS). Transoesophageal echocardiogram on day of admission showed EF 45 %. CT Brain carried out showed no acute pathology. Once stable, angiography was carried out showing multivessel disease. Discussion at St James's Hospital (SJH) Cardio-Thoracic Conference resulted in plan for transfer and PCI. In SJH pressure wire study of Left Anterior Descending (LAD) coronary artery was positive and stenting (Drug-eluting) commenced. LAD 96 stents, Left Circumflex 92 stents and Right Coronary Artery (RCA) 92 stents. Patient is currently well with no overt signs of hypoxic brain injury and is enrolled in cardiac rehabilitation programme.

Discussion: This is an incredible case of an out of hospital cardiac arrest. Elapsed time in the chain of survival events would predict a negative outcome. However, adequate CPR was administered preventing long term brain injury and certain death. This highlights the need for a greater community-based CPR skill base. Recently Citalopram and Escitalopram have been reported to cause dose dependent QTc prolongation. Prescribing guidelines have since changed including contraindication of co-prescription with other QTc prolonging agents. Domperidone is a dopamine antagonist widely used as an anti emetic. QTc prolongation and ventricular arrhythmias have also recently been highlighted with Domperidone and, since November 2011, caution advised when prescribing Domperidone, particularly in patients [60 years of age, or at doses [30 mg/day. In this audit, we aimed to study whether information on QTc prolongation affects prescribing practice by looking at the prescription of a commonly used medical drug, with recently highlighted QTc effects, and its co-prescription with psychotropics.

A list of drugs with substantial evidence for QTc prolonging effects was obtained. A kardex review was completed from acute medical and surgical; long stay and rehabilitation wards. Kardexes with Domperidone were reviewed for dose, age, gender and co-prescription of other QTc prolonging agents.

Of 820 surveyed kardexes, 10 % (n = 81) were prescribed Domperidone. 63 % were[65 years. 38 % were on[60 mg/day. Coprescription with another QTc prolonging agent seen in 37 % of cases; of these 77 % were psychotropics, most commonly Citalopram (n = 8). Four patients were co-prescribed [1 QTc prolonging agent.

QTc prolonging agents were commonly co-prescribed with Domperidone, which continues to be used even in at-risk groups. Psychotropics were the most likely class to be concurrently prescribed. Further work in this area is necessary to inform clinical psychiatric practice and encourage responsiveness to new evidence regarding cardiac risk.

The Development of a Mathematical Model to Predict the Time to Osteoporosis (TTO) Using DEXA Scanning Background: Dual-Energy X-Ray absorptiometry (DEXA) is the gold standard used for measuring bone mineral density and such readings are currently used to predict osteoporosis and osteoporotic fractures. However, no similar prediction model has been developed to identify the time it will take to become osteoporotic based on DEXA scanning.

Objective: The aim of this study was to develop a mathematical model to determine the TTO based on two or more DEXA scans with TTO defined as the age at which the patient will enter the osteoporotic T-score range. Methods: Fifty patients who had previously undertaken five DEXA scans were identified from the DEXA database. T-scores were graphed against patient age using GraphPad Prism software. Straight line curves for the most recent scans and cumulative scans were generated with the age at which the curve intersects T = -2.5 being classed as TTO.

Results: The mathematical model developed successfully predicted the time to osteoporosis for each patient, as well as creating a cumulative osteoporotic trend based on total DEXA scans performed. Additionally, if the patient was classified as osteoporotic following DEXA scanning, the model also successfully predicted the Time out of Osteoporosis. Implication: The TTO provides a simple and informative parameter of DEXA scanning that a patient can immediately comprehend and understand, while also providing a more simple measure to monitor response to therapy. Based on the results presented TTO can be incorporated into future DEXA scans result summaries. Further research will involve validation of this tool.

An Audit of Clinical Outcomes in Transcervical Resection of the Endometrium Compared to Outpatient Balloon Thermablation Anglim BC, Von Bunau G Department of Gynaecology, Adelaide and Meath Children's Hospital, Tallaght, Dublin Thermablation was introduced to the Coombe in November 2009 and thus far it has provided a quick and effective means of treating women with menorrhagia refractive to medical treatment.

A retrospective audit was carried out over a 2 year period in Tallaght hospital from November 2009 to October 2011. The aim of the study was to compare the efficacy of balloon thermablation compared to transcervical resection of the endometrium (TCRE) with or without mirena coil insertion, in the treatment of menorrhagia. 48 patients in total were studied, 24 of which underwent a TCRE, and 24 of which underwent balloon thermablation. Out of those who underwent a TCRE 16 had successful treatment of the menorrhagia and 6 and 12 weekly follow up, 5 had continued menorrhagia which may require a future hysterectomy, however one of which was due to a large fibroid, and one patient described a reduction in menorrhagia however an increase in dysmenorrheoa. Out of those who underwent thermablation 15 were treated successfully, 6 had continued menorrhagia to be considered for hysterectomy, 2 had reduced bleeding but increased dysmenorrhoea and one patients symptoms had resolved however she then developed Idiopathic Thrombocytopenia Purpura which led to a recommencement of symptoms.

One can therefore conclude that there are both pros and cons to both procedures, TCRE being less expensive, however it requires general anaesthesia and may require mirena insertion. Thermablation is more expensive however it is a quick outpatient procedure (2 min, 8 s) and is done under local anaesthetic.

Akinmoluwa S, Tormey S Department of Breast Surgery, Mid-Western Regional Hospital, Limerick Breast pain is a common problem especially among women of reproductive age. It accounts for a great percentage of GP visits by young women. It represents a huge proportion of GP referrals to the breast clinic.

The palpable effects of this include, among others, an increase in waiting time, increase in healthcare cost, stress on the limited resources and ultimately a decrease in quality of care. In this era of unfavorable economic climate, it is prudent to sanitise our healthcare systems by way of identifying and eliminating practices that have not been proven to alter the course of care.

In this study, I reviewed the number of breast pain cases referred to Ms Tormey's breast clinic in the month of March. The objective of this study is to determine whether or not all breast pain complaints should be referred for specialist review. To achieve this objective, I reviewed all the cases of breast pain referred to the breast clinic in March.

The table represents my findings. It is evident from the study that hormonal mastalgia accounts for majority of breast pain complaints in women of reproductive age while a few other cases are attributed to musculoskeletal and other benign disorders. These women, with no risk factors, only need reassurance and pain relief. They do not require specialist intervention. 

Alrashed D

Introduction: Anaemia is a common finding in the elderly population. It may be a sign of chronic disease, underlying malignancy, nutritional status, or blood loss. Depending on the classification of anaemia, further investigations such as haematinics and endoscopy may be warranted, as replacing the haemoglobin deficit is never a definitive treatment.

Objective: To determine the prevalence of anaemia in a population of elderly in-patients and whether further screening was performed.

Methods: This was a cross-sectional review of all patients 65 years and older under a gastroenterology, a rheumatology, and three geriatrics services at a large teaching hospital. Patients' full blood counts were reviewed during their current admission. Anaemic patients were then categorised based on anaemia subtype and whether haematinics were investigated. Results: Out of 116 patients under the five teams, 83 were 65 years and older. 37 out of 83 of these elderly patients were anaemic. None of these subjects had Microcytic anaemia during their current admission. 27 out of 37 of these patients had Normocytic anaemia. 10 out of 37 of anaemic patients had Macrocytic anaemia. Haematinics were investigated in 17 out of 37, including 13 out of 17 patients with normocytic anaemia and 4 out of 10 patients with macrocytic anaemia. One patient had abnormal haematinics after being investigated for macrocytic anaemia. Conclusion: Anaemia was very prevalent in the patients selected for this audit, with the normocytic subtype being the commonest. Haematinics were investigated in half those patients.

Anglim B, Murphy C

Aims: To determine the nature of surgical management of ovarian cysts in the adolescent and paediatric population over a 5 year period. Methods: A retrospective audit was carried out over a 5 year period in Tallaght Hospital from January 2007 to December 2011. This audit reviewed cases of ovarian cystectomy, oopherectomy and salpingooopherectomy using both a hospital online database and records of theatre procedures to identify these patients.

Results: A total of 103 cases were identified. The commonest presentation was due to pelvic pain. There was a total of 43 ovarian cystectomies, 7 fimbrial cystectomies, 8 oopherectomies, 1 bilateral oopherectomy, and 4 salpingo-oopherectomies. A total of 13 appendicectomies were performed in conjunction with these. Histology varied from functional and non functional cysts to dermoids and cystadenomas. There were a total of 30 functional cysts, 13 of which were hemorrhagic. There were 7 follicular cysts, 5 fimbrial cysts, 4 paratubal cysts, 8 dermoid cysts, 2 endometrial cysts, 9 cystadenomas, 6 ovarian torsions and 2 fimbrial torsions. Of the total amount of procedures performed 24 were done by a paediatric surgeon, and 52 by a gynaecologist. Notably there were fewer cases of benign histology in those procedure performed by gynaecologists.

Conclusions: Adnexal surgery is commonly performed in adolescents and children. Pathology is frequently benign. There may be a role for more conservative management. We suggest that imaging of the pelvis and tumour markers should be used more frequently in the pre-operative period. Protocols may be developed for future implementation.

Anglim BC, Crowley P

Day surgery is an efficient way of using hospital beds, provided patients are discharged as planned on the day of surgery. Unplanned overnight stay following day surgery places an extra burden on a hospital with the busiest Accident and Emergency Department in Ireland.

A retrospective audit was carried out of one years day case admissions to determine the incidence and causes of unintended or unplanned overnight stay. 692 women were admitted as day cases over the period of 1st July 2009 to June 30th 2010. A total of 129 diagnostic laparoscopies, 67 operative laparoscopies, 23 diagnostic hysteroscopies, Ninety-three operative hysteroscopies, 4 tension free vaginal tapes (TVT) and 26 miscellaneous minor procedure were carried out during this time period. 20 women (2.89 %) were retained overnight. The main reason for overnight stay was excessive post-operative pain. Additional reasons included voiding difficulties, reactions to spinal anaesthetic, asymptomatic tachycardia and the need for intravenous antibiotics. There was no evidence of inappropriate selection amongst the laparoscopies and hysteroscopies, however 50 % of the patients undergoing TVT required admission. One can conclude from this study that most patients were appropriately selected for day case admission. Patients undergoing TVT surgery should be scheduled for a 24 h hospital stay. A vulval clinic is an ideal and efficient way of detecting patients with vulval cancer. Once potential patients have been flagged by general practice clinicians or other specialities within the hospital, immediate steps can be taken to rule out malignancy.

A retrospective audit was carried over a 10 month period on a new vulval clinic which commenced in Tallaght Hospital on 26/01/2011. The aim of the study was to determine the need for a specialised vulval clinic for detection of vulval cancer. A total of 29 patients were referred to the four clinics which took place over this time frame. The majority of referrals were from general practice, other referrals were from dermatology, gynaecology and colposcopy clinics. The main reason for referral was vulval pruritis and pain. Nine patients were referred with suspicious lesions on clinical examination. A total of 18 biopsies were taken, two of which showed Vulval Intraepithelial Neoplasia (VIN). Amongst the other biopsies were 4 cases of lichen sclerosis and the remaining 12 biopsies showed non specific dermatitis. One can conclude from this study that a combined dermatological-gynaecological clinic would be of benefit. In addition a 6.9 % detection rate of VIN was achieved and therefore highlights the necessity of this clinic.

The Prevalence of Renal Disease in Patients Aged Above 65 with Normal Serum Creatinine Balasubramanian I, Peters C, Lyons D and O'Connor M Department of Ageing and Therapeutics, Mid-Western Regional Hospital, Limerick

Background: The prevalence of chronic kidney disease (CKD) increases with age. Older patients have lower lean muscle mass and therefore using serum creatinine alone as marker of renal function can lead to underdiagnosis of CKD. Objective: The aim of this study was to review the prevalence of CKD amongst a cohort of elderly patients with normal serum creatinine. Methods: Doctot application on the smartphone was used to calculate eGFR in a cohort of patients over 65 years with a normal serum creatinine on admission. 40 patients were included. This application is based on the MDRD formula (includes age, sex, ethnicity and serum creatinine). Patients were then classed into the various stages of CKD. Results: Of the 40 patients reviewed, 35 had renal disease. Interestingly, only 5 had a diagnosis of renal impairment recorded in the medical notes. 20 of the 35 patients had stage 1 CKD and the other 15 had stage 2 CKD. 18 of the 35 patients with renal impairment especially stage 2, were found to be frail females over 75 years. This group also had a number of co-morbidities including diabetes and hypertension. Conclusion: eGFR is better than serum creatinine alone for assessment of renal function in the elderly. It is important not only for diagnosis but also for appropriate medical investigation and drug prescribing. As the MDRD formula excludes BMI, further research is warranted to compare measurement of eGFR using MDRD formula with The Cockcroft and Gault equation in this older population. Chronic obstructive pulmonary disease (COPD) is increasingly prevalent worldwide and the main responsibility for it's prevention and management lies with general practitioners. The aim of this audit was to analyse current standards of care of COPD patients in a suburbanrural general practice by examining ICGP criteria and comparing results with best practice guidelines.

The existing coded population of active patients with COPD were telephoned and consent was obtained to ask a set of questions designed to examine certain criteria chosen from the ICGP COPD Quick Reference Guide [1] . . Of the patients included in the audit (n = 39), 64 % of patients were male, the mean age was 71 years (SD = 11.6) and 82 % were General Medical Service (GMS) patients.

There was poor recording of smoking status, high uptake of influenza vaccines compared to international figures, a lower uptake of pneumococcal vaccinations and an increased need for osteoporosis prophylaxis. Vaccination reminders, smoking cessation advice and information leaflets have been posted to these patients. Development of protocols for coding and management have been implemented.

In conclusion, general practitioners must focus on ensuring optimum managment of COPD in the community. Clinical audit is a useful tool to initiate change. We assessed the accuracy of continuous non-invasive haemoglobin measurement using the SpHb Pulse Co-Oximeter Ò when compared to traditional laboratory haemoglobin assessment in an outpatient antenatal population.

A total of 125 women were recruited. Traditional laboratory haemoglobin samples were taken and quantified in the hospital laboratory. The SpHb Pulse Co-Oximeter Ò was calibrated and the mean of three non-invasive measurements of haemoglobin were recorded prior to venipuncture. Bland-Altman plots were used to determine acceptability of the new non-invasive test as a replacement for invasive testing in a clinical setting.

The mean gestation at haemoglobin estimation was 20.8 (8.6) weeks. Laboratory haemoglobin values ranged from 8.8 to 15.1 g/dL with a mean of 12.1 (1.0) g/dL. The range for the SpHb Pulse Co-Oximeter Ò assessment was 9.1 to 15.8 g/dL with a mean of 12.6 (1.3) g/dL.

Non-invasive haemoglobin measurement provides a clinically acceptable accuracy compared to traditional haemoglobin testing. pressure wound therapy (NPWT). In this review we examine the role of NPWT in wound healing, compare the products available to clinicians in Irish hospitals and explore cost implications today. We achieved this through review of online data, peer reviewed articles regarding efficacy, collection and assessment of data from suppliers of NPWT and examining the use and cost of NPWT in the Mater Misericordiae University Hospital. We summarise the mechanism of action of NPWT, patient selection and indications for its use. The products available on the Irish market are compared.

Through examination of these elements we clarify a role of NPWT in management of complex wounds and identify flaws in the management of this service that are both wasteful of money and hospital services and create barriers to discharge. Potential strategies to correct the issues identified are detailed, for example, funding of the product by the treating hospital rather than by local authorities in the community or selection of less costly devices in negotiation with suppliers by local health authorities. The solutions we outline will potentially have a financial benefit to the hospital, will lead to the more efficacious running of the hospital system and as such will benefit the patient.

We conclude that this is a fundamental service and that there are alternative approaches to implementing use of the product in a more efficacious manner.

Poster 10 Q Fever: Questions to be Answered?

Brandon L, Bannon C, Fleming C Department of Infectious Diseases, University Hospital Galway Q fever, an aptly named condition, describes infection with gramnegative bacteria Coxiella burnetti. Q denotes a question, and there are many to be answered in this rare, but not unknown, condition.

Take Mr. M.C, a 45-year-old farm worker, who had an aortic valve replacement in 1994, for congenital Aortic Valvular disease. He next presented to Medical Services in 1999, with fevers, sweats, fatigue and weight loss. Investigations at the time diagnosed Autoimmune Hepatitis, following liver biopsy. He commenced prednisolone and azathioprine.

In 2002, again symptomatic, he had another aortic valve replacement. Post-operatively, he required 6 weeks of antibiotics for a culture negative valvular infection. In 2003, still on immunosuppression, he developed culture negative meningitis, requiring 2 weeks of antibiotics. Azathioprine was discontinued. A renal biopsy revealed proliferative glomerular nephritis in 2004, carried out for macroscopic haematuria. He commenced high dose prednisolone and cyclophosphamide.

Throughout this time, he regularly presented to Medical personnel with high fevers, up to 40 C, present since 1999. They responded to steroids but relapsed on doses below 40 mg. In 2004, the fevers were investigated with a TOE, and vegetations seen on the aortic graft. He was diagnosed with culture negative Bacterial Endocarditis, and subsequently tested positive for Q fever.

This case highlights the Q behind Q fever, and raises important issues for medical personnel. When should we remember it? When should we test for it? And what can we do to ensure high risk populations dont slip through the cracks, as this gentleman did? Previous point prevalence studies of antimicrobial use in SCH have consistently produced the same conclusions and recommendations pertaining to prescribing habits, highlighting doctors' failure to meet ideal standards of antimicrobial prescription. The aim of this study was to assess antimicrobial prescribing habits from the doctors' point of view, to compare this to available prescription data and to raise awareness of the principles of prudent antimicrobial prescribing.

A multiple choice questionnaire was used to examine antimicrobial prescribing habits with regard to documentation of indication, documentation of a stop/review date, awareness of local empiric guidelines and other principles of prudent antimicrobial prescribing. 40 trainee and consultant doctors were surveyed.

Of those questioned, 38 % claimed they always ensure that an indication for commencing antimicrobial treatment is documented in the patient's healthcare record. Only 10 % always document a stop/ review date when prescribing antimicrobials, while 69 % indicated that they had failed to do this at least once in the preceding month. 20 % of those surveyed sometimes or never consult local guidelines. When switching patients from intravenous to oral therapy, 90 % believed oral bioavailability to be an important factor, with only 45 % citing cost as being relevant.

Identifying doctors self-reporting of their deficits allows us to target appropriate interventions to these deficits. Our survey identifies areas where awareness of diverted resources and safety issues could be used as a fulcrum for changing prescribing practices. We recommend formal teaching for doctors in this area, with particular emphasis on prudent prescribing and the correct use of empiric guidelines. Venous thromboembolism (VTE) is a cause of inpatient morbidity and mortality which may be reduced by appropriate thromboprophylaxis. It is well established that VTE risk assessment and thromboprophylaxis prescribing may often be inadequate. Recently it has been estimated that as many as 14,000 deaths per year due to hospital-acquired VTE in England may have been prevented with appropriate prophylaxis [1] . In the current study, a cross section of inpatients was examined to establish concordance with current evidence-based guidelines for VTE prophylaxis.

Data was collected from inpatient charts and drug kardexes relating to patients on three medical wards. Laboratory data was also obtained from the hospital IT system. Data relating to patient mobility was obtained from medical charts, nursing staff, observation, and the patient themselves.

Sixty-three medical patients and 8 surgical patients (including one patient under obstetrics and gynaecology) were included in the study. 13 (61.9 %) out of 21 at-risk medical patients who were suitable candidates for thromboprophylaxis had sub-cutaneous heparin prescribed, whereas 2 out of 2 of the suitable at-risk surgical patients were prescribed thromboprophylaxis. 4 medical patients (6.35 %) and 4 surgical patients (50 %) were prescribed anti-embolism compression stockings.

Prescribing of thromboprophylaxis is relatively thorough in this patient population although it remains less than optimal. There exists some evidence of disagreement amongst clinicians regarding the optimum VTE prophylaxis strategy [1] . Implementation of hospitalspecific guidelines regarding thromboprophylaxis is recommended in keeping with recognised guidelines [2] . 

Ali Sheikh A, Chandra R, Gardezi A, O'Hare J Mid-Western Regional Hospital, Limerick

Background: Good documentation represents good medical practice. Objectives: To assess our current standard of documentation of allergy in admission notes, synchronicity with risk alert bands, information given by the patient, documentation on the front allergy alert section of medical notes and drug kardex. Methodology: We assessed five parameters i.e. drug kardex, alert band, medical and admission notes and gathered information from each patient staying in medical and surgical services. There were 371 patients in hospital. Results: 19 % of the patients admitted under medical and surgical teams had allergy or allergies to different drugs. 21 % had single allergy, whereas 81 % had multiple allergies. Penicillin allergy was the commonest 7.2 % followed by Opioids 3.7 %. Furthermore, it is found that recording of allergies was under par as 24 % was on front page and 50 % appeared in medical notes. More than half of allergy information was found on drug kardex 77 %, patient knowledge 77 % and allergy bands 67 %. It is well documented that use of Elastic Compression Stockings (ECS) prevents Post Thrombotic Syndrome in patients with prior Deep Venous Thrombosis (DVT). A 50 % reduction in these complications has been noted, with 2 year duration of therapy suggested [1] . The advice given to patients, their understanding of the benefits of this therapy and adherence issues has not been documented at Sligo General Hospital (SGH), this research aimed to address this.

A short patient questionnaire was undertaken. This consisted of demographic information, and questions regarding the advice and use of ECS. The population consisted of patients with prior DVT attending the warfarin clinic at SGH. This data collection took place from October 2011-February 2012. The questionnaires were collated and results identified using Microsoft Excel with simple statistical analysis.

Eleven patients were included in the study, 36 % were not advised to wear ECS, and only 27 % wore the ECS daily. Reasons for nonadherence include; difficulty fitting, discomfort and no benefit noted. Improvement in adherence could be achieved if advice was given promoting use, the benefits explained, optimal frequency/duration of use advised and correct measurement. As research strongly supports use of ECS, it is essential adherence is encouraged to reduce the risk of post-thrombotic syndrome and future DVT. Opiate injecting drug use is a well-established phenomenon in inner city Dublin. The complications arising from this practice affect a predominantly young cohort of patients, who under different circumstances would be expected to enjoy good health. Acute infections, acute vascular issues such as pseudoaneurysm, and chronic medical conditions such as Hepatitis C and HIV are well recognised and frequently encountered by medical physicians who care for these patients.

We present the case of a lady in her thirties with a long history of opiate injecting drug use. Approximately 6 months prior to presentation, she underwent left sided pseudoaneurysm repair. She presented to the Emergency Department in a drowsy opiate induced state. On waking, she stated that she had lost some needles while injecting into her groins. Plain radiology of Pelvis revealed the two ''lost'' needles ( Fig. 1) . On closer questioning she admitted to significant manipulation of the needle injecting path and angle in the weeks prior to presentation. She had attributed this to her previous surgery and the duration of her injecting drug use.

Follow-up Duplex sonography revealed bilateral intact femoral arteries. Further surgical management was non-operative with the focus on addiction counselling and further attempts at facilitating cessation of heroin use.

Bilateral ''lost'' needles is an unusual complication of injecting drug use and certainly would not rank as one of the protean manifestations of such practices. The aim of the study was to investigate patients' recall of their surgery and influencing factors. A questionnaire was given to patients at outpatient follow up and surgical details were recorded. 165 patients completed the questionnaire. The median age was 59 years (range 28-85) and the median follow up was 26 months (range 1-168). The extent of surgery did influence patients' recall with those having an ALND (n = 51, 31 %) having significantly more accurate recall of their surgery as opposed to those who had SLNB (n = 114, 69 %), p = 0.007. The presence of ongoing postoperative symptoms also significantly improved recall, p = 0.004. Almost half the patients who had SLNB (46.5 %) could not accurately remember the extent of the surgery they had but 55.3 % were more careful of their arm or would not allow cannulation. The patient's consent process influenced patient accuracy. Patients who filled the consent at both the outpatient consultation and in the hospital were significantly more accurate than those who had signed the consent at the clinic or hospital alone, p = 0.01.

Patients who have minimally invasive surgery, such as SLNB are not accurate at recalling their surgery. This misinformation results in confusion over the subsequent vigilance of their upper limb. The consent process may have a role in improving patient recall. Introduction: Waiting times can exceed 100 days for general surgical clinics and can reach up to 18 months in different surgical specialities. Many outpatient slots are lost by patients who do not attend (DNA) to their scheduled appointment. We sought to ascertain whether a reminder text message (RTM) could decrease the number of patients who DNA to surgical outpatients. Methods: A single text message was sent to patients 4 days before their scheduled appointment, reminding them of the date and time of their upcoming surgical outpatient visit. This incentive was initiated in January 2011. Outpatient appointment scheduling and attendances for a single surgical team were analysed over a 1 year period, encompassing two 6 month periods before and after implementation of the RTM service. Data was exported to SPSS v17 for statistical analysis with p \ 0.05 considered statistically significant. Results: Over the 12 month period there were 1,287 scheduled outpatient appointments for the surgical service, with 653 attending prior to the implementation of the reminder text message service and the remaining 634 attending in the 6 months following its implementation. The percentage of DNA patients did not differ significantly (21. Classically, Focussed Assessment with Sonography in Trauma (FAST) addresses a yes/no binary question as to whether fluid is present in the context of trauma. FAST generally concentrates on four areas: perihepatic, peri-splenic, pelvic and a sub-xiphoid view of the pericardium. We report on two patients who were the victims of trauma. Both patients had normal haemodynamic parameters. In both patients, the initial FAST ultrasound scan was technically negative but it exhibited other signs of intraperitoneal injury. In the first case, a young gentleman sustained a penetrating injury to his right upper quadrant area. Morison's pouch (the interface between the liver and the right kidney) did not exhibit any fluid. There was, however, a thin anechoic strip around the gallbladder. CT confirmed the suspicion of peri-cholecystic fluid and this patient required urgent laparotomy and repair of his hepatobiliary injury. In the second case, a gentleman in his thirties sustained a blunt injury to his left upper quadrant. Ultrasonography exhibited heterogeneous echogenicity of the spleen. This patient proceeded to have urgent laparotomy and splenectomy for this shatter-type injury.

As experience with FAST techniques grows, the binary question of whether intra-peritoneal fluid is present becomes more nuanced. The objective of this audit was to review the hospitals compliance with hospital guidelines, to get an overview of how fluids are being prescribed in the hospital and to produce quality improvement plans.

Thirty Drug Kardexs were chosen randomly from wards around the hospital, both medical and surgical. If a Kardex was found to have no fluid prescription, an alternative Kardex was chosen in its place.

Note was taken on whether the prescription had the patient name and hospital number, the date, name, dosage and strength of the prescription, the route of administration and the frequency and rate of administration.

The main areas of non-compliance were found to be: Name: only 34 (30.4 %)orders out of 112 had the name on the order Medical Record Number: only 34 (30.4 %)orders out of 112 had the MRN on the order, and the route of administration was not present on any of the 112 orders checked.

In conclusion, this audit would suggest that there is a lack of compliance with detailing the patients name and MRN on fluid orders, that the route of administration was not written on any Kardex, however the back page of each is exclusively dedicated to IV fluid prescription and also that non-approved abbreviations are being used when prescribing fluid orders. Spontaneous hip fractures, or fractures without a fall have been described in up to 6 % (1, 2) of cases of hip fracture. An upsurge in such cases was recently observed in our emergency department. We present these in the form of a retrospective case series. Patient 1 is a 43-year-old ex intravenous drug user who presented with non-traumatic right-sided hip pain over a period of weeks. Initial plain films did not reveal fracture. Over 1 week her symptoms deteriorated to the extent that she became unable to weight-bear. Patient 2 is a 66-year-old gentleman with increasing left sided hip pain following a seemingly innocuous fall 3 months prior to index presentation. Again initial radiographs did not reveal an abnormality. Patient 3 is an 83-year-old bed-bound nursing home resident with end-stage Alzheimer's disease. She was noted by nursing staff to have bilateral hip symptoms post seizure. The patient was unable to mobilise independently and had not fallen out of bed at any stage. Patient 4 is a 29-year-old lady who presented with unilateral sacroiliac pain following a recent intensive exercise program including kickboxing 1 week previously.

In each of these cases, subsequent review and plain films demonstrated fracture and in one case bilateral fractures secondary to seizure were demonstrated.

Our cases highlight the need for diagnostic vigilance and a structured approach in dealing with possible radiologically occult hip fractures, even in patients with no proximate antecedent history of trauma. Delerium, or acute confusional state, is a common presentation to our Emergency Departments, and occurs in up to 30 % of hospitalised patients. We describe the case of acute deterioration in mental status, on a background of Alzheimer's Disease, with an interesting aetiology. Mr K's family sought emergency medical review of 5 days deterioration; withdrawal, somnolence and general disorientation. He is a 73-year old with moderate Alzheimer's disease. History and initial investigations were unremarkable. He was mildly dehydrated and physical exam showed only mild truncal ataxia. Further investigations to elucidate cause included lumbar puncture, MRI brain and immunological and vasculitic parameters. Serology revealed Human Immunodeficiency Virus (HIV) infection with acute seroconversion pattern. A history obtained with help of his family identified several casual heterosexual partners within past year. This included a contact who may be an intravenous drug user, with involvement in commercial sex work.

Symptoms abated within a week of admission, following pattern of HIV viral load. He has subsequently commenced antiretroviral therapy. This case highlights several areas of interest. Sexual history is often overlooked in the older patient, which can be deleterious to outcomes. Trends of HIV infection in Ireland include primary infection in the older person, in addition to greater longevity of people infected in earlier adult life. We would advocate opt-out testing within the Emergency Department, and this is currently under study in our tertiary emergency department.

Comparison of Comorbidities in Patients with Pre-Diabetes to those with Diabetes Mellitus Type 2 The management of type 2 diabetes and its complications are well researched. The prevalence of these complications in pre-diabetes has not been researched to the same extent. There has been no research comparing the prevalence of complications in pre-diabetes and type 2 diabetes in Ireland.

A cross sectional study performed on 309 pre-diabetes and 309 type 2 diabetes patients, selected from the Diabetes Interest Group database (a database of the diabetic patients in 30 general practices in Cork region) using stratified sampling for age and gender. A questionnaire was designed and completed in each practice assessing the presence of diabetes related complications in pre-diabetes and type 2 diabetes patients. Data was analyzed on SPSS. The prevalence of complications was determined and the Chi square test performed to see is there a statistically significant difference in the prevalence of these complications between pre-diabetic and type 2 diabetic patients.

The prevalence of ischaemic heart disease and autonomic neuropathy is actually higher in pre-diabetes but the prevalence of renal disease and cerebrovascular disease is higher in type 2 diabetes. None of these differences in prevalence are statistically significant. The prevalence of peripheral vascular disease, eye disease and peripheral neuropathy is higher in type 2 diabetes, this difference being statistically significant.

The prevalence of many of the complications in pre-diabetes is as high as in type 2 diabetes which may have implications for the screening and management of these conditions and the related comorbidities.

The Both groups were evenly matched. The median age was 73 and median Homocysteine level was 11 (range 5-34.9). Results: In Group B, Immediate clinical improvement was equivalent between the normal homocysteine group and treated HyhC group. Median time to Binary Restenosis in HyhC was 29 months and in Normal Homocysteine was 50 months. p = 0.4335. Secondary endpoints and all cause survival showed no significant difference. Pre-Treatment Multivariate Logistic Regression for group A; depicts that HyhC is the main culprit of Graft occlusion and limb loss p \ 0.0001. Multivariate Logistic Regression for treatment group reports that corrected HyhC is no longer a significant factor of operative outcome. Conclusion: Patients with treated HyhC have similar outcomes compared to those with normal homocysteine. It is therefore crucial to measure homocysteine in all patients with CLI and correct aggressively prior to intervention to improve outcomes.

The Efficacy of Clinical Guidelines in Promoting Co-Prescription of Bone Protection with Glucocorticoids among Hospital Doctors Treating Inpatients Background: Therapeutic glucocorticoids (GC) rapidly decrease bone mineral density, inducing a catabolic shift by promoting osteoclast differentiation and activation and by inhibiting osteocytes. Current guidelines (1) direct that bisphosphonates (BP's) and calcium carbonate 1,200 mg (Ca ++ CO 3 -) with vitamin D 3 (vit. D 3 ) should be given at initiation of GC therapy as it is known that bone catabolism occurs early with steroid usage. We circulated these guidelines within our hospital after auditing the existing practice of the hospitals doctors and 1 year later we sought to measure the efficacy of our intervention by completing an audit loop. Methods: A cross sectional audit was performed of all adult medical and surgical inpatients in a tertiary referral centre teaching hospital. It was noted if inpatients had been prescribed GC and if concurrent anti osteoporotic medication had been prescribed. Subsequent to the initial audit, guidelines promoting the use of BP's, Ca ++ CO 3 and vit. D 3 when prescribing GC's were advertised on hospital notice boards, in hospital bulletins, hospital prescribing guidelines and on the hospital website. One year after publishing the new guidelines the audit loop was completed by performing a similar cross sectional audit. Results: All inpatient medical records (n = 417) were reviewed in Jan 2010 of whom 52 % were female and 58 % were older than 65. 66/417 (16 %) inpatients were prescribed GC's. Ca ++ CO 3 with vit. D 3 was prescribed for 20 % of patients on GC's with 2 % also receiving BP therapy. 3 % of patients were also receiving-post menopausal hormone replacement therapy. In Nov 2011 1 year after guideline publication all 452 inpatient medical records (n = 452) were reviewed of whom 63 % were female and 60 % were older than 65. 55/452 (12 %) inpatients were prescribed GC's. Ca ++ CO 3 with vit. D 3 was prescribed for 55 % of patients on systemic steroids with 20 % also receiving BP therapy. Creation and circulation of hospital guidelines resulted in an improvement in the co-prescription of Ca ++ CO 3 and vit. D 3 and BP's with GC's by the order of 2.35 and 10 respectively. However 45 % of patients on systemic steroids received no bone protection and 80 % received suboptimal bone protection from steroid induced osteoporosis. Conclusion: Publication and advertisement of current bone protection guidelines when prescribing systemic steroids resulted in a substantial but suboptimal improvement by hospital doctors in our hospital in the co-prescription of bone protecting drugs to prevent steroid induced osteoporosis. In this audit it appears that the majority of prescribers do recognise the necessity to protect bone health when a patient requires steroids. However a substantial number of patients did not receive any bone protection. It is our perception that most physicians are not aware that short courses of steroids reduce bone mineral density and therefore greater efforts must be made to enhance doctor awareness of the necessity for bone protection to be prescribed at initiation of systemic steroids. There is a trend towards longer total survival for Jetflow TCVCs. These results suggest a potential advantage from using this line type, however, further study and formal cost analysis needs to be undertaken prior to changing our practice. With increasing resource restrictions, appropriate ordering of blood tests is vital for medical economic viability. This study evaluated the pattern and cost of thyroid function test (TFT) requests and aimed to determine if TSH alone identifies thyroid abnormalities.

A retrospective review of TFTs performed on in-and-out-patients at a 350-bedded regional hospital was undertaken in January 2011, evaluating the number, results and costs of TSH, T4 and T3 levels.

4055 TSH, 3959 T4 and 28 T3 were ordered. 3456/4055 patients (85.2 %) were euthyroid. TSH abnormalities occurred in 526/4055 (13.0 %) ( Table 1) Only 82/4055 (2.0 %) patients had a normal TSH despite an abnormal T3 or T4 level. 57/82 (69.5 %) of these patients had known thyroid disease, undergoing treatment with thyroxine or thyroidblocking medications. 9/82 (10.9 %) had T4 levels \1 nmol/l outside the normal range and asymptomatic so were considered to be euthyroid. 16/82 (19.5 %) had a variety of diagnoses, for example, pituitary disease. TFT reagents alone cost €10,600.

Ir J Med Sci (2012) 181 (Suppl 3):S83-S107

This study has identified that non-selective requests for T4 and T3 add little diagnostic value, except in certain circumstances like treatment of thyroid disease, in pregnancy or if pituitary disease is suspected. Optimising TFTs requests could save in the region of €42,000/per annum. TSH alone would appear to be adequate for the majority of patients.

Case Study: Neurodegenerative Disorders

We present a case with an unusual combination of neurodegenerative disorders.

A fit and healthy 60-year-old man, with no history of medical or psychiatric illness deteriorated progressively over a 10 year span, presenting initially with speech and language difficulties, followed by development of extra-pyramidal signs non responsive to levodopa.

Neurological Permacol Ò mesh is an acellular porcine-derived dermal collagen surgical implant used in a wide variety of surgical reconstructions and repairs. We describe two cases where Permacol Ò mesh was used to anchor the contents of the femoral triangle in patients undergoing radical block nodal dissection as part of the surgical management for metastatic penile squamous cell carcinoma, one of whom had an atrophied sartorius muscle due to previous infection with Poliomyelitis. Both patients underwent successful inguinal node dissections and femoral triangle repairs, with Permacol Ò proving to be an effective means of protecting the femoral vessels in both patients despite complications related to wound healing secondary to a fixed flexion deformity in one patient. A 65-year-old gentleman, with a past history of vestibular schwannoma requiring a ventriculoperitoneal shunt (VPS) was admitted with acute diverticulitis. His condition worsened and required a laparotomy for bowel perforation and faecal peritonitis. This case reports the successful perioperative management of the patient with a VPS in situ in the setting of an emergency abdominal surgery.

VPS placement is an effective treatment of hydrocephalus, diverting cerebrospinal fluid (CSF) into the peritoneal cavity. Unfortunately, the shunt devices have a high incidence of malfunction mainly due to catheter obstruction or infection and are associated with various complications, 25 % of which are abdominal [1] . Incidental pathology unrelated to the VP shunt can also occur such as appendicitis [2] , endometriosis [3] and diverticulitis as in this case.

No standard current set of guidelines for perioperative management of VPS exists for patients undergoing general gastrointestinal or urologic procedures with varying degrees of contamination [4] .

This case reports successful and conservative management of a patient with a VP shunt that underwent contaminated abdominal surgery.

There is no consensus on the management of VPS in patients undergoing elective or emergent abdominal surgery and further studies are required in this area.

The Use of Antithrombotic Therapy on Management of Atrial Fibrillation in an Irish General Practice Malomo K 1 , Breen N 2 , Dunne L 3 , Farrell G 3 , Bryne P 3 1 UCD (University College Dublin), Ireland, Now Intern, Mid-Western Regional Hospital, Limerick; 2 General Practice, Dublin, Ireland; 3 Pottersway Medical Centre, Bunclody, Ireland Background and objective: Atrial fibrillation (AF) is a common cardiac arrhythmia associated with increased risk of stroke events [1] . To assess the use of antithrombotic therapy in patients with known AF attending an Irish General Practice (IGP) and use of stratification schemes to assess their suitability for oral anticoagulant therapy. Methods and subject: Permission to carry out the study was sort from University-College-Dublin ethics committee. There were 161 patients with AF attending the IGP identified using the computerized disease coding system WHO International Classification of Disease (ICD-10). Thirty patients were diagnosed between 01/01/2009 and 21/01/2011 and their data from the computerized medical notes was used to calculate CHADS 2 , CHA2DS 2 -VASc, HAS-BLED scores and identify antithrombotic therapy they were using. Results: There were 30 AF patients. Sixty-three percent (n = 19) were males and 37 % (n = 11) were females (ratio 1.7:1). Twentythree percent (n = 7) of patients were aged \65 years, 27 % (n = 8) 65-74 years inclusive and 50 % (n = 15) =/[75 years. Two patients with CHADS 2 score zero were on warfarin although one of them had CHA 2 DS 2 VASc Score of one. Sixty-percent (n = 18) were on warfarin alone, 20 % (n = 6) aspirin alone, 14 % (n = 4) warfarin plus aspirin, 3 % (n = 1) aspirin plus clopidogrel and 3 % (n = 1) on warfarin plus clopidogrel. Seven patients were not on warfarin for various reasons. The HAS-BLED score revealed 7 patients at low risk, 12 moderate risk and 11 at high risk of bleeding. Implications: Ninety-three percent of patients were correctly managed and two patients were on warfarin with CHADS 2 scores of zero. The use of evidence based management guidelines is necessary to manage patients. Keywords: Atrial fibrillation, CHADS 2 score, CHA 2 DS 2 VASc score, HAS-BLED score Meckel's Diverticulum is the most common congenital abnormality of the gastrointestinal tract. Only 16 % of Meckel's Diverticulum are symptomatic [1] . It can cause complications such as ulceration, obstruction, intussusception, haemorrhage and perforation and these complications are more common in the paediatric age group. A 16-year-old has a lifetime risk of 3.7 of developing a complication, this falls to zero over time [2] . Adults most commonly present with bleeding [1] .

We have a case of a 37-year-old male who presented with a 3 day history of abdominal pain, constipation and anorexia. On examination he had RIF tenderness, but no signs of peritonism. A provisional diagnosis of appendicitis was made. The patient was taken to theatre the next morning for laparoscopy and appendicectomy. The appendix was normal and surgery proceeded to laparotomy. An inflamed and perforated Meckel's Diverticulum was found. A terminal ileum resection with side to side anastomosis was performed. The patient made an uneventful recovery and was discharged to OPD follow up. This case illustrates the importance of further evaluation following normal laparoscopy in the case of the ill patient. References: Neonatal Graves disease is a rare condition, caused by transplacental transfer of thyroid stimulating antibodies from mother to fetus. 0.2 % of pregnant women have Graves disease and 1.5 % of their offspring will have overt hyperthyroidism. A further 3 % will have biochemical thyrotoxicosis without symptoms. This is the case of a baby girl with neonatal Graves disease. Her antenatal course was uncomplicated until 39 weeks gestation. At this point, her mother became clinically thyrotoxic. Maternal blood tests showed an elevated free thyroxine level (50 pmol/L) and positive thyroid receptor antibodies. A diagnosis of Graves Disease was made. She was commenced on treatment but remained thyrotoxic at the time of delivery. The baby was healthy at birth. However, thyroid function tests on day 2 of life showed an elevated free thyroxine (40 pmol/L) and thyroid receptor antibodies were positive. Clinically, she remained asymptomatic and examination was normal. Treatment with carbimazole was commenced and the dose titrated to maintain her euthyroid.

Most neonates affected by neonatal Graves disease will have biochemical thyrotoxicosis but are clinically asymptomatic. The minority will be severely affected with goitre, eye signs, weight loss, tachycardia, arrhythmias and heart failure. It is a transient disorder, limited by clearance of maternal thyroid receptor antibodies and is usually self-limiting over 3-12 weeks. Mortality rates of up to 20 % are reported in untreated cases, usually from arrhythmias and heart failure.

This case emphasises the importance of close monitoring of pregnant women with a history of thyroid disorders, before and during their pregnancy, as well as monitoring their babies in the neonatal period. Fibreoptic bronchoscopy is considered a safe diagnostic tool [1] . It is suggested however that post-bronchoscopy complication rate increases with age [2] . We decided to study the complication rate and the outcomes of bronchoscopy in patients over the age of 80 years in our institution. A retrospective review of the case notes of patients aged greater than 80 years who underwent bronchoscopy between September 2009 and November 2011 was carried out. Data on complications experienced during and after bronchoscopy and the influence of the results on subsequent management of patients were collated and analysed.

Ninety-six patients were included. The mean age was 82.8 years (SD 2.98). Thirty subjects (31.25 %) had a documented lung disease. Fifty-nine patients (61.45 %) were current or ex-smokers. Indications for bronchoscopy were; to evaluate for malignancy (93.8 %) and to evaluate for TB (6.2 %). Post bronchoscopy complications were noted in eight (8.2 %) cases including hypoxia (3.1 %), infection (2.1 %), tachycardia (1 %) haemoptysis (1 %) and pneumothorax (1 %). Six patients required treatment including nebulised bronchodilators (2.1 %), antibiotics (2.1 %), and oxygen therapy (2.1 %). Malignancy was diagnosed in twenty cases (20.8 %). Clinically significant pathogens were detected in six cases (6.2 %). As a result of bronchoscopy fourteen patients (14.6 %) had alterations to their drug therapy, three (3.1 %) received lung cancer treatment with curative intent, eighteen (18.8 %) had palliative care input, seventeen (17.7 %) were referred for further investigation and thirty-seven (38.6 %) had no change to their management.

In conclusion, bronchoscopy is relatively safe and has good diagnostic utility in patients aged more than 80 years. Patient records were identified from a database of patients who underwent a spinal MRI to investigate spinal metastatic disease between November 2006 and April 2009. An analysis of the management of those diagnosed with MSCC, specifically radiotherapy and/or surgical intervention was performed. Three hundred and sixtyone patient records were identified with one hundred and seventy-one patients having metastatic spinal column disease. Of these, thirty-four had MRI evidence of metastatic spinal cord compression.

Radiotherapy alone was the most common therapy employed for patients with MSCC. A multidisciplinary team approach was not taken in the majority of cases. A surgical opinion was sought in the minority of cases. This is not congruous with NICE guidelines as a management protocol.

The complexity of management decisions for metastatic spinal cord compression demands a multi-disciplinary approach. Current practise in this major supra-regional cancer centre does not routinely employ this approach. A surgical opinion is sought in the minority of cases. This reflects the national trend with some centres having no spinal surgeons as staff. We recommend the establishment of a care pathway in order to comply with best evidence based practise as outlined by the 2008 NICE guidelines.

PET CT as a staging modality in primary cervical cancer; to establish the correlation between histological subtype and FDG-18 avidity of the primary lesion Purpose: PET CT has become one of the mainstays of diagnostic imaging both in staging and prognosis of cervical cancer. We wanted to establish the link between FDG-18 uptake in the primary lesion and correlation with specific histological subtypes of cervical cancer including squamous cell carcinoma, adenocarcinoma and other rarer subtypes such as clear cell and adeno-squamous carcinoma.

Methods and materials: The main audit involved working out the FDG uptake in the primary lesions from the cervical cancer database of patients. The patient list was derived from a database of patients collated by the gynaecological services at SJH of all patients who received workup and treatment for cervical cancer from 2006-2011. The computer system at SJH was employed for analysing PET-CT reports and histology reports. Microsoft excel was used to store this information parameters and complete statistics on the data. Results: The results of this study are to follow. Conclusion: There is a correlation between FDG avidity and histological subtype of cervical cancer and this provides valuable information on the reliability of PET-CT findings in a specific cohort of patients with cervical cancer. We present the case of a 44-year-old male with a primary piriform fossa squamous cell carcinoma (SCC) who attended for staging Positron Emission Tomography/Computerised Tomography (PET/ CT) scan. Distant to the primary lesion, focused F 18 fluorodeoxyglucose (FDG) uptake was noted in the left iliac bone, without underlying abnormality on the accompanying CT scan. Low grade uptake was also noted in subcentimetre upper mediastinal nodes, without any underlying lung parenchymal abnormality. These nodes were felt to be inflammatory or reactive in origin. Though an unusual pattern for metastatic head and neck SCC, the left iliac bone lesion was concerning for malignancy. Thus, a percutaneous biopsy of this region was performed under image guidance. Histology revealed non caseating epithelioid granulomata consistent with sarcoidosis. The patient was subsequently able to have potentially curative treatment of his head and neck primary. Discussion: Sarcoidosis is a chronic inflammatory multisystem condition characterised by the presence of non-caseating granulomas in affected organ tissues. It commonly affects young and middle aged adults with a slightly higher prevalence in women. The disease shows a predilection for adults under 40, peaking between 20 and 29, with a second peak in women over 50 [1] . Despite its unknown aetiology, it is felt that T lymphocytes play a central role in the development of sarcoidosis, as they likely propagate an excessive cellular immune reaction. It has been shown that abnormalities with the CD4/CD8 ratio and production of T helper 1 and 17 (Th 1/Th 17) cytokines such as interferon and Tumour Necrosis Factor (TNF) are found in sites of disease activity [2] . The importance of TNF in sarcoidosis is demonstrated by the efficacy of anti-TNF medications such as pentoxifylline and infliximab [3] .

It is estimated that bone lesions occur in 1-13 % of sarcoidosis patients [4] . These figures are however based on radiographic data and are likely an underestimate as the majority of bone lesions would be asymptomatic [5] . Varying osseous manifestations of sarcoid have been described; punched out lytic lesions, lace-like destruction and subperiosteal resorption mimicking hyperparathyroidism. Commonly, the small bones of the hands and feet (predominantly the middle and distal phalanges) are involved often bilaterally and symmetrically. While pulmonary involvement occurs in 90 % of patients with sarcoidosis [6] , bony involvement is rare without other clinical manifestations of the disorder [4] . Indeed our patient had low grade subcentimetre mediastinal nodes.

The FDG avidity of sarcoid is a well documented phenomenon. Indistinguishable from metastatic disease on F 18 FDG PET scan alone it can lead to false-positive appearance of metastatic disease on PET/ CT. Furthermore one-third of PET/CT positive sarcoidosis have osseous abnormalities on PET/CT the majority of which will not be evident on low dose CT [7] .

This case serves to remind us of the diagnostic limitations of F 18 FDG PET in the differentiation of inflammatory and metastatic processes. In a patient with an unusual pattern of 'metastatic' disease tissue diagnosis is a necessity. Distinct islet auto antibodies against antigens insulin, GAD65, IA2 and ZnT8 have been identified. The presence of autoantibodies has been shown to be predictive of reduced beta cell mass. International data suggests that 85-90 % of patients with newly diagnosed T1DM are positive for at least one of the above antibodies. Our aim is to study the prevalence of autoantibody positivity in our population of children with newly diagnosed T1DM over a 5 year period (2007) (2008) (2009) (2010) (2011) .

Details of all children newly diagnosed with T1DM were collected using the Endocrinology department database and chart review was undertaken. Children diagnosed elsewhere whose care was transferred to our centre and children who had Non Type 1 diabetes were excluded.

One hundred and thirty-six children were diagnosed with T1DM in our centre, of which 37 (27 %) presented in diabetic ketoacidosis. Age at diagnosis ranged between 10 months and 15.7 years. The male to female ratio was 1:2. Other autoimmune conditions (coeliac disease, hypothyroidism, Addison's) were present in 11 %. Ninety-six percent (n = 130) were tested for one of the three antibodies. 76 % were positive for at least one antibody, 30 % positive for two, 5 % positive for all three antibodies. The most common antibody found was anti GAD (60 %).

Positive autoantibodies are helpful in confirming the presence of T1DM and their absence in raising the possibility of monogenic diabetes. The absence of pancreatic islet autoantibodies at diagnosis can be predictive for maintained beta cell function during the 2 years after diagnosis. Maternal obesity, based on a Body Mass Index (BMI)[29.9 kg/m 2 , is associated with increased pregnancy complications. Moderate exercise during pregnancy is associated with decreased complications such as pre-eclampsia [1] and gestational diabetes mellitus [2] and has a beneficial effect on mood with those who exercise experiencing fewer symptoms of depression and anxiety both during and after pregnancy [3] . The purpose of this study was to determine if obese women exercise less during pregnancy.

We recruited 110 women at their convenience after a routine scan confirmed an early ongoing pregnancy. Maternal height and weight were measured accurately and BMI calculated. Women completed the International Physical Activity Questionnaire.

Of the 110 studied in early pregnancy, 10.9 % took no exercise, 58.2 % walked only, 21.8 % undertook moderate exercise and 9.1 % undertook vigorous exercise. Of the obese women (n = 20), only 10 % reported moderate-vigorous exercise in early pregnancy compared with 34.5 % in women from the normal BMI category (n = 55). Also 15 % of the obese group reported doing no exercise compared with 10 % of those with a normal BMI. Women with a BMI of 30 or more were found to sit for an average of 453 min per day whereas those with a normal BMI sit for 320 min per day on average. Although BMI increases with age and parity, these variables were not found to influence exercise levels in early pregnancy.

Exercise may be physically challenging in obese women, particularly if morbidly obese, but due to its beneficial effects it should be encouraged antenatally in all pregnant women irrespective of their BMI category. References: Angiogram showed an absence of coronary artery disease and echocardiogram ruled out structural abnormality. Exercise Stress test showed short runs of VT in recovery. Further tests included Ajmaline and Adrenaline Challenges. Cardiac MRI showed right ventricular outflow tract scarring consistent with either a primary diagnosis of ARVC or secondary with that of myocarditis. Sarcoidosis was outruled by further laboratory and radiological means. Non-sustained runs of VT on telemetry were noted and a dual chamber Implantable Cardiac Defibrillator was placed.

On discharge, medication included Atenolol 100 mg daily and patient will undergo Genetic Screening. Follow up for the siblings included phenotyping and MRI. Discussion: History, presentation and pathology uncovered are consistent with a diagnosis of ARVC. Suspected paternal inheritance of an autosomal dominant genetic defect predisposed to the ventricular arrhythmias which at first, manifested as self-limiting palpitations however, later caused a near fatal event. Long term management may include cardiac transplantation.

Prevalence of diagnosed atrial fibrillation in adults: national implications of rhythm management and stroke prevention: the anticoagulation and risk factors in atrial fibrillation (ATRIA) study

Complications of fiberoptic bronchoscopy at a University Hospital

The relationship between age and process of care and patient tolerance of bronchoscopy

Central skeletal sarcoidosis mimicking metastatic disease

Sarcoidosis is a Th1/Th17 multisystem disorder

Osseous sarcoidosis treated with tumour necrosis factor-inhibitors: case report and review of literature. Spine (Phila Pa 1976)

Musculoskeletal manifestations of sarcoidosis

Multiple atypical bone involvement in sarcoidosis

Imaging in sarcoidosis. Semin Respir Crit Carre Med

F-18 FDG PET/CT for detecting bane and bone marrow involvement in sarcoidosis patients

Poster 42

Diaphragmatic Rupture: Delayed Diagnosis and its Consequences-A Case Report

Diaphragmatic rupture: a frequently missed injury in blunt thoracoabdominal trauma patients

Diaphragmatic rupture due to blunt trauma: sensitivity of plain chest radiographs

The Introduction: Lymphoscintigraphy has been shown to be accurate in identifying sites of potential nodal metastases in melanoma patients. Recent guidelines published by the EORTC-EANM have defined specific criteria with relation to performing lymphoscintigraphy in melanoma patients. Methods: The aim of this study was to audit all patients with malignant melanoma who underwent Sentinel Lymph Node Biopsy (SLNBx) and lymphoscintigraphy in University College Hospital Galway between 2005-2010. Results were compared with EORTC-EANM recommendations. Results: 189 melanoma patients underwent SLNBx during the study period. 121 patients had preoperative lymphoscintigraphy using intradermal injections of technetium 99 m. Sentinel nodes were identified in 102 of 121 patients (84.3 %) on lymphoscintigraphy. 66.94 % of lymphoscintigrams were reported on the same day as the procedure, 23.97 % after 1 day and 9.09 % greater than 1 day postop. Obligatory imaging, as defined in the EORTC-EANM guidelines, was obtained in 91 % of all patients undergoing lymphoscintigraphy. No nodal uptake was reported in 18 patients, 14 of whom received imaging in accordance with the guidelines. The location of those melanomas with no nodal uptake was 44.4 % on the head and neck, and 38.9 % on the trunk. The overall rate of false-negative lymphatic mapping and sentinel node biopsy was 5.2 %. In patients receiving lymphoscintigraphy the false negative rate was 3.7 versus 7.9 % in patients who did not have lymphoscintigraphy. Conclusion: Preoperative lymphoscintigraphy is an essential adjunct in identifying the sentinel lymph node in clinically node negative melanoma patients and should adhere to EORTC-EANM guidelines. Conflict of interest: None. On examination, she was alert, HR 160, BP 105/60. She was tachypnoeic, but reported this to be her baseline. There was a palpable, non-reducible mass in the left upper quadrant. A chest X-ray showed loops of bowel above the diaphragm. Ultrasound showed an abscess in the rectus sheath, which drained mucopurulent fluid.MB opted not to have the diaphragm repaired, despite medical advice. She was readmitted 2 weeks later with a recurrence of the abscess. Her clinical condition deteriorated, with severe abdominal pain, and oxygen saturations of 70 %. An emergency laparotomy was performed, which showed an obstructing lesion in the descending colon, with large and small bowel above the diaphragm. She had an extended right hemicolectomy, with restoration of bowel to the abdominal cavity and mesh repair of the diaphragm. Histology showed an descending colon adenocarcinoma, T3N0M0.Traumatic diaphragmatic rupture is a rare problem, occurring in 1-8 % of blunt and penetrating traumas. (1) Plain films and CT scans are not always diagnostic in the acute phase, due to concomitant injuries. (2) Repair is essential once diagnosis has been reached to avoid herniation of abdominal viscera. Patients with ongoing dyspnoea after blunt trauma may benefit from a repeat chest X-ray. 

A 75-year-old retired veterinary surgeon was referred to tertiary referral with a 2 months history of a painless enlarging neck mass. Clinical examination showed a right side neck mass approximately 7 cm 9 5 cm in size which extended through both anterior and posterior triangles. Cervical lymphadenopathy was not appreciated and the patient was clinically euthyroid. Patient was admitted under the care of the maxillofacial service, where he underwent a needle core biopsy of the neck mass. This was returned showing poorly differentiated spindle cell tumour with large pleomorphic nuclei and abundant abnormal mitoses. The immunoprofile was consistent with metastatic poorly differentiated sarcomatoid carcinoma and the differential diagnosis included origin fro the kidney, lung or thyroid.The case was discussed at the Head and Neck MDM and a consensus was reached that the patient as developed a sarcoma of the neck, with a level 5 neck dissection the most appropriated intervention.Intraoperatively, following the removal of the neck mass it was noted that the right lobe of the thyroid was enlarged. An intra-op FNA was performed on the mass in the right lobe of the thyroid. The FNA was returned showing bizarre giant cells, suggestive of malignancy. Ultimately the patient underwent a total thyroidectomy but, despite surgery the patient died 19 weeks post-operatively. Using feedback from the pilot study and analysis of the preexamination Consultant and Registrar-led teaching schedule for students a further 'Intern-led' tutorial timetable was structured. It allowed for a weekly maximum of 9 h of teaching dependent on demand and intern availability. Programme duration was 10 weeks, January to March 2012. Group sizes were a maximum of 8 students. Tutorials were all at the patient bedside. Feedback forms were distributed at the end of the programme.Sixty-four tutorials were given in total. Seventy feedback forms were returned. Mean number of tutorials attended per student was 5.8. Students rated statements 1-5 (1-Strongly Disagree, 2-Disagree, 3-Neutral, 4-Agree, 5-Strongly Agree). Median scores were used. Scoring showed improvements were made from last year in terms of level of intern preparation for tutorials and importantly, the students own subjective view of their level of preparation for forthcoming examinations. Most importantly, students agreed that tutorials improved their history taking skills and strongly agreed that their examination skills improved. Matching feedback from the pilot study, students strongly agreed that intern-led teaching is an appropriate adjunct to the final year programme.Of the 47 Intern working in St James's Hospital, 22 participated. Seventeen of these had received tutorials on the pilot programme. Of the 25 that did not participate, many had never received formal intern teaching.The feedback obtained from the pilot study was invaluable in organising and delivering this teaching programme. Ongoing improvements will be made for next year based on this Audit. This also highlights that the intern-teaching tool is extremely beneficial, yet largely underused.